Hydrological, thermal and chemical influence of an intact rock glacier discharge on mountain stream water

Rock glaciers are the most prominent permafrost-related mountain landforms. This study investigates the effects of the discharge from an intact rock glacier on the hydrological, thermal and chemical dynamics of a high-elevation stream in the NW Italian Alps. Despite draining only 39 % of the watershed area, the rock glacier sourced a disproportionately large amount of discharge to the stream, with the highest relative contribution to the catchment streamflow occurring in late summer - early autumn (up to 63 %). However, ice melt was estimated to be only a minor component to the discharge of the rock glacier, due to its insulating coarse debris mantle. The sedimentological characteristics and internal hydrological system of the rock glacier played a major role in its capability to store and transmit relevant amounts of groundwater, especially during the baseflow periods. Besides the hydrological influence, the cold and solute-enriched discharge from the rock glacier significantly lowered the stream water temperature (especially during warm atmospheric periods) as well as increased the concentrations of most solutes in the stream. Furthermore, in the two lobes forming the rock glacier, different internal hydrological systems and flowpaths, likely driven by different permafrost and ice content, caused contrasting hydrological and chemical behaviours. Indeed, higher hydrological contributions and significant seasonal trends in solute concentrations were found in the lobe with higher permafrost and ice content. Our results highlight the relevance of rock glaciers as water resources, despite the minor ice melt contribution, also suggesting their potential, increasing hydrological importance in the light of climate warming.

Controlling anisotropic properties by manipulating the orientation of chiral small molecules

Chiral π-conjugated molecules bring new functionality to technological applications and represent an exciting, rapidly expanding area of research. Their functional properties, such as the absorption and emission of circularly polarized light or the transport of spin-polarized electrons, are highly anisotropic. As a result, the orientation of chiral molecules critically determines the functionality and efficiency of chiral devices. Here we present a strategy to control the orientation of a small chiral molecule (2,2'-dicyano[6]helicene) by the use of organic and inorganic templating layers. Such templating layers can either force 2,2'-dicyano[6]helicene to adopt a face-on orientation and self-assemble into upright supramolecular columns oriented with their helical axis perpendicular to the substrate, or an edge-on orientation with parallel-lying supramolecular columns. Through such control, we show that low- and high-energy chiroptical responses can be independently 'turned on' or 'turned off'. The templating methodologies described here provide a simple way to engineer orientational control and, by association, anisotropic functional properties of chiral molecular systems for a range of emerging technologies.

Smartwatch-based detection of atrial arrhythmia using a deep neural network in a tertiary care hospital

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Smartwatch electrocardiograms (SW ECG) have been identified as a promising noninvasive solution to assess heart rhythm abnormalities, especially atrial arrhythmias (AA) which includes atrial fibrillation, atrial flutter and supraventricular tachycardia. This study evaluates the performance of the detection of AA with a smartwatch and compares the accuracy of two algorithms, the latest version of the original companion application (Apple ECG 2.0 App) and a novel deep neural network (DNN), in a population typical of an electrophysiology department.

Purpose

Determine if a novel DNN can improve the detection of AA on SW ECG in a tertiary care hospital.

Methods

101 patients from the electrophysiology department of one tertiary center were included in this ongoing study. Three simultaneous ECGs were collected for each patient: one 12-lead ECG (Mindray BeneHeart R12) and two SW ECGs (Apple Watch) taken from the left wrist (SWw ECG) and the lower left abdomen (SWa ECG). 12-lead ECGs were adjudicated by a blinded expert electrophysiologist as 52 AA and 49 not AA and considered as gold standard. The SW ECGs were processed by the ECG 2.0 App and the DNN in parallel. The proportions of inconclusive diagnoses returned and the performances were assessed and compared.

Results

Overall, the ECG 2.0 App yielded inconclusive diagnoses for 19% (19/101) of all SWw ECGs while the DNN reduced that number to 0% (0/101). A similar result holds for SWa ECGs (Figure 1). Regarding the detection of AA from SWw ECGs, the ECG 2.0 App had a sensitivity of 81% (95% CI, 67%-90%), a specificity of 97% (95% CI, 87%-100%) and an accuracy of 89% (95% CI, 80%-94%) while the DNN had a sensitivity of 92% (95% CI, 82%-97%), a specificity of 90% (95% CI, 78%-96%) and an accuracy of 91% (95% CI, 84%-95%). For SWa ECGs (Figure 2), the sensitivity of the DNN was found significantly higher compared to the ECG 2.0 App: 96% (95% CI, 89%-98%) vs 76% (95% CI, 61%-87%). Conclusion(s): A novel DNN algorithm decreased the number of inconclusive diagnostics in the detection of AA from SW ECG from around 20% to 0%, which could help limit the overreading time spent by the physicians. Excluding inconclusive diagnostics, we observed no significant difference in performance between the two algorithms except for the sensitivity for SW ECG taken from the abdomen where the DNN outperforms the ECG 2.0 App. Routine application of this SW ECG analysis in tertiary care hospitals offers significant promise in arrhythmia diagnosis.

Simvastatin Prevents Liver Microthrombosis and Sepsis Induced Coagulopathy in a Rat Model of Endotoxemia

Background: Endotoxemia causes endothelial dysfunction and microthrombosis, which are pathogenic mechanisms of coagulopathy and organ failure during sepsis. Simvastatin has potential anti-thrombotic effects on liver endothelial cells. We investigated the hemostatic changes induced by lipopolysaccharide (LPS) and explored the protective effects of simvastatin against liver vascular microthrombosis. Methods and results: We compared male Wistar rats exposed to LPS (5 mg/kg one i.p. dose) or saline in two experimental protocols—placebo (vehicle) and simvastatin (25 mg/kg die, orally, for 3 days before LPS). Morphological studies were performed by light- and electron-microscopy analyses to show intravascular fibrin deposition, vascular endothelial structure and liver damage. Peripheral- and organ-hemostatic profiles were analyzed using whole blood viscoelastometry by ROTEM, liver biopsy and western-blot/immunohistochemistry of thrombomodulin (TM), as well as immunohistochemistry of the von Willebrand factor (VWF). LPS-induced fibrin deposition and liver vascular microthrombosis were combined with a loss of sinusoidal endothelial TM expression and VWF-release. These changes were associated with parenchymal eosinophilia and necrosis. ROTEM analyses displayed hypo-coagulability in the peripheral blood that correlated with the degree of intrahepatic fibrin deposition (p < 0.05). Simvastatin prevented LPS-induced fibrin deposition by preserving TM expression in sinusoidal cells and completely reverted the peripheral hypo-coagulability caused by endotoxemia. These changes were associated with a significant reduction of liver cell necrosis without any effect on eosinophilia. Conclusions: Simvastatin preserves the antithrombotic properties of sinusoidal endothelial cells disrupted by LPS, deserving pharmacological properties to contrast sepsis-associated coagulopathy and hepatic failure elicited by endotoxemia

Evaluation of COVID-19 impact on DELAYing diagnostic-therapeutic pathways of lung cancer patients in Italy (COVID-DELAY study): fewer cases and higher stages from a real-world scenario

Introduction

COVID-19 has disrupted the global health care system since March 2020. Lung cancer (LC) patients (pts) represent a vulnerable population highly affected by the pandemic. This multicenter Italian study aimed to evaluate whether the COVID-19 outbreak had an impact on access to cancer diagnosis and treatment of LC pts compared with pre-pandemic time.

Methods

Consecutive newly diagnosed LC pts referred to 25 Italian Oncology Departments between March and December 2020 were included. Access rate and temporal intervals between date of symptoms onset and diagnostic and therapeutic services were compared with the same period in 2019. Differences between the 2 years were analyzed using the chi-square test for categorical variables and the Mann–Whitney U test for continuous variables.

Results

A slight reduction (−6.9%) in newly diagnosed LC cases was observed in 2020 compared with 2019 (1523 versus 1637, P = 0.09). Newly diagnosed LC pts in 2020 were more likely to be diagnosed with stage IV disease (P < 0.01) and to be current smokers (someone who has smoked more than 100 cigarettes, including hand-rolled cigarettes, cigars, cigarillos, in their lifetime and has smoked in the last 28 days) (P < 0.01). The drop in terms of new diagnoses was greater in the lockdown period (percentage drop −12% versus −3.2%) compared with the other months included. More LC pts were referred to a low/medium volume hospital in 2020 compared with 2019 (P = 0.01). No differences emerged in terms of interval between symptoms onset and radiological diagnosis (P = 0.94), symptoms onset and cytohistological diagnosis (P = 0.92), symptoms onset and treatment start (P = 0.40), and treatment start and first radiological revaluation (P = 0.36).

Conclusions

Our study pointed out a reduction of new diagnoses with a shift towards higher stage at diagnosis for LC pts in 2020. Despite this, the measures adopted by Italian Oncology Departments ensured the maintenance of the diagnostic-therapeutic pathways of LC pts.

•

The COVID-19 outbreak had an impact on access to lung cancer (LC) diagnosis and treatment.

•

A slight reduction (−6.9%) in newly diagnosed LC cases was observed in 2020 compared with 2019.

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Newly diagnosed LC pts in 2020 were more likely to be diagnosed with stage IV disease.

•

The Italian Oncology Departments ensured the maintenance of the diagnostic-therapeutic pathways of LC pts.

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A reverse migration from high-volume to low-volume cancer centers was noted during the pandemic.

Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology

BACKGROUND & AIMS

Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model.

METHODS

In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses.

RESULTS

In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD.

CONCLUSIONS

In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed.

LAY SUMMARY

While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.

On the factors influencing the chiroptical response of conjugated polymer thin films

We study the influence of the physical and chemical structure on the chiroptical response of fluorene-based polymeric systems, namely poly(9,9-dioctylfluorene) (PFO) and the donor-acceptor type copolymer poly(9,9-dioctylfluorene-alt-benzothiadiazole) (F8BT). We reveal the significance of electric-magnetic coupling, at both short (molecular-level) and intermediate (delocalised over multiple polymer chains) length scales, on the magnitude of the dissymmetry. These findings provide a framework for the design of new materials with an enhanced chiroptical response.

Safety, feasibility and prognostic value of stress perfusion CMR in patients with pacemaker

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Several studies have shown the excellent prognostic value of stress cardiovascular magnetic resonance (CMR). However, its prognostic value in patients with pacemaker (PM) remains unknown because most studies excluded PM patients.

PURPOSE

This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in patients with PM.

METHODS

Consecutive patients with MR-conditional pacemakers referred for stress perfusion CMR at 1.5 T were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Cox regressions analyses were performed to determine the prognostic value of CMR-parameters. The quality of CMR was rated by two observers blinded to clinical details. Data on pacemaker and leads were collected pre- and post-CMR.

RESULTS

Of 224 patients who completed the stress CMR protocol, 2 patients had inconclusive stress CMR due to artefact and 203 patients (72.9% male, mean age 71.4 ± 8.7 years) completed the follow-up (median [interquartile range], 7.0 [5.2-7.3] years). Among those, 23 experienced a MACE (11.3%). Stress CMR was well tolerated with no major adverse events. All scans were completed successfully with no significant change in lead thresholds or pacing parameters. Overall, the image quality was rated good or excellent in 84.1% of segments. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 11.80 [95% CI, 4.63-30.30]; and HR: 6.74 [95% CI, 2.47-18.40], both p &lt; 0.001; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 5.24 [95% CI, 2.61-14.40]; and HR: 2.98 [95% CI, 2.25-4.02]; both p &lt; 0.001; respectively). In patients with ischemia, CMR-related coronary revascularization showed no benefit in reducing MACE (p = 0.25).

CONCLUSION

Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.

Seasonal variations in the optical characteristics of dissolved organic matter in glacial pond water

Large amounts of dissolved organic matter (DOM) are stored in mountain glaciers. However, few researches have analysed the optical characteristics of DOM in surface waters fed by mountain glaciers and their seasonal variations. In a pond fed by a glacier we observed simultaneous decreases in the dissolved organic carbon, and increases in both absorbance at 254 nm and specific absorption coefficient (SUVA₂₅₄) during the ice-free season 2015. This behaviour differs from the typical behaviour of lake/pond water in summer, and from the trends observed in a nearby pond not fed by a glacier. The trends of DOM properties, main ions and water stable isotopes at the glacier-fed pond could be attributed to transient modifications of the subglacial hydrological system. Flushing of previously isolated pools of subglacially stored water, containing terrestrial DOM derived from glacially-overridden soil and vegetation, would be driven by intense rainfall events during the melting season. These findings suggest that heavy rainfall events during the melting season have the capability to transiently modify the characteristics of DOM in a glacial pond. These events may be further exacerbated in the future, as summer rainfall events in the Alps are predicted to increase due to global warming.

The multifaceted spectrum of liver cirrhosis in older hospitalised patients: analysis of the REPOSI registry

BACKGROUND

Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce.

OBJECTIVES

To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties.

METHODS

A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed.

RESULTS

LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age-sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10-1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37-3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P < 0.05) compared to FIT. D&M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P < 0.01; post-discharge: 41% vs 12%/15%, P < 0.01) and less rehospitalisation (10% vs 32%/34%, P < 0.01) compared to PSS and FIT.

CONCLUSIONS

LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features.

Fullerene Desymmetrization as a Means to Achieve Single-Enantiomer Electron Acceptors with Maximized Chiroptical Responsiveness

Solubilized fullerene derivatives have revolutionized the development of organic photovoltaic devices, acting as excellent electron acceptors. The addition of solubilizing addends to the fullerene cage results in a large number of isomers, which are generally employed as isomeric mixtures. Moreover, a significant number of these isomers are chiral, which further adds to the isomeric complexity. The opportunities presented by single-isomer, and particularly single-enantiomer, fullerenes in organic electronic materials and devices are poorly understood however. Here, ten pairs of enantiomers are separated from the 19 structural isomers of bis[60]phenyl-C61-butyric acid methyl ester, using them to elucidate important chiroptical relationships and demonstrating their application to a circularly polarized light (CPL)-detecting device. Larger chiroptical responses are found, occurring through the inherent chirality of the fullerene. When used in a single-enantiomer organic field-effect transistor, the potential to discriminate CPL with a fast light response time and with a very high photocurrent dissymmetry factor (g_ph  = 1.27 ± 0.06) is demonstrated. This study thus provides key strategies to design fullerenes with large chiroptical responses for use as chiral components of organic electronic devices. It is anticipated that this data will position chiral fullerenes as an exciting material class for the growing field of chiral electronic technologies.

COVID-19 et troubles du rythme

Lors de la pandémie due au virus SARS-CoV2 les troubles du rythme n’ont pas été au premier plan. Cependant, le virus semble atteindre de nombreux organes et le tropisme cardiaque est maintenant bien connu. Les connaissances dans ce domaine sont encore loin d’être exhaustives, mais plusieurs séries publiées concernant les patients atteints de la COVID-19 retrouvent une proportion significative de troubles du rythme, dont certains pouvant potentiellement mener à une issue fatale. Ces troubles du rythmes sont principalement supraventriculaires à type de fibrillation atriale (FA) ou flutter, mais également ventriculaire avec des tachycardies ventriculaires (TV) fibrillation ventriculaire (FV) et plus rarement torsades de pointe (TdP). Les causes en sont multiples, du fait de l’atteinte multiorgane du virus et des interactions médicamenteuses potentielles. Par ailleurs, la question de la surveillance de troubles du rythme pouvant émerger à moyen et long terme après une infection reste à explorer.

Natural optical activity as the origin of the large chiroptical properties in π-conjugated polymer thin films

Polymer thin films that emit and absorb circularly polarised light have been demonstrated with the promise of achieving important technological advances; from efficient, high-performance displays, to 3D imaging and all-organic spintronic devices. However, the origin of the large chiroptical effects in such films has, until now, remained elusive. We investigate the emergence of such phenomena in achiral polymers blended with a chiral small-molecule additive (1-aza[6]helicene) and intrinsically chiral-sidechain polymers using a combination of spectroscopic methods and structural probes. We show that – under conditions relevant for device fabrication – the large chiroptical effects are caused by magneto-electric coupling (natural optical activity), not structural chirality as previously assumed, and may occur because of local order in a cylinder blue phase-type organisation. This disruptive mechanistic insight into chiral polymer thin films will offer new approaches towards chiroptical materials development after almost three decades of research in this area.

Polymer thin films that emit and absorb circularly polarised light are promising in achieving important technological advances, but the origin of the large chiroptical effects in such films has remained elusive. Here the authors demonstrate that in non-aligned polymer thin films, large chiroptical effects are caused by magneto-electric coupling, not structural chirality as previously assumed.

[Infections in interventional electrophysiology]

The implantation of pacemakers and defibrillators carries the highest risk of infection in interventional electrophysiology. The use of implantable cardiac devices is continually increasing with almost 2 million devices implanted worldwide each year. The recipients' profile may also be associated with an increased risk of infection. Several measures can be implemented to reduce the risk of device-related infection. Systematic antibiotic prophylaxis has proven to be beneficial provided that prescription modalities are respected, especially with respect to the selection of the appropriate molecule and timing of administration prior to the procedure. Despite all the precautions taken during surgery (asepsis, prophylactic antibiotic therapy….) the estimated rate of peri-procedural infection is around 2%. Device related infections are associated with a high rate of morbidity and mortality as well as substantial healthcare costs. Staphylococcus aureus (SA) and epidermidis (SE) are the pathogenic agents involved in most cases. Prevention is crucial given the difficulties in treating such infections because of the near-systematic need to remove the device and antibiotic resistance. Leadless pacemakers and subcutaneous defibrillators are potential alternatives to implantable endocardial devices, albeit with certain limitations. A group of experts has recently issued consensus paper on the prevention, diagnosis and treatment of infections associated with endocardial implantable cardiac devices.

222AI-based strategy enables faster Holter ECG analysis with equivalent clinical accuracy compared to a classical strategy

BACKGROUND

Analysis of Holter recordings can be challenging and time-consuming, therefore requiring significant clinical resources in order to achieve a high-quality diagnosis. Such resources depend largely on the qualifications of the person conducting the analysis and the duration of the recordings. A novel Holter analysis platform has been developed, based on deep neural networks trained with a dataset of one million ECGs, to allow fast and reliable Holter recording analysis.

PURPOSE

This study sought to compare the performance of an artificial intelligence (AI)-based Holter analysis platform using deep learning tools with a classical one used on a daily basis in hospitals (the reference). The main endpoints evaluated were duration to complete the analysis by the physician operating it as well as diagnostic accuracy of each strategy, when platforms are used by electrophysiologists (EPs).

METHODS

For this prospective evaluation, a total of 159 Holter recordings (24-hour) were selected from a large Holter dataset from 1 hospital, with a relatively high prevalence of electrical rhythm and conduction disorders. Recordings were analysed by four EPs using independently both the AI-based and classical analysis platforms. All four EPs had no previous experience with the AI-based platform, except for an introductory 6-hour training session. Three EPs had multiple years of experience with the traditional platform, while one EP had limited experience. For each recording, in addition to the analysis duration, diagnostic accuracy was evaluated through the analysis of the presence or absence of predefined cardiac arrhythmias and conduction disorders (prevalence): pauses (25.2%), ventricular tachycardia (VT, 30.2%), atrial fibrillation (AF, 26.4%), high grade atrioventricular block (AVB, 10.1%) and burden of premature ventricular complex larger than 10% (PVC, 23.9%). Definite diagnostics were established by an expert EP after a careful examination of all available analysis reports. 

RESULTS

Time required for the AI-based analysis was on average 42% shorter compared to the traditional platform (6.65 min vs 11.5 min, p &lt; 0.0001). Regarding accuracy to detect electrical disorders, there was no statistically significant differences between AI-based and classical platforms (AF: 98.7% vs 96.9%, Pause: 99.4% vs 100%, PVC: 98.7% vs 98.7%, VT: 92.5% vs 96.2%, AVB: 98.7% vs 94.3%). CONCLUSION: These preliminary findings suggest that an AI-based strategy to analyse Holter recordings may be highly accurate in detecting cardiac electrical abnormalities, with significant time savings compared to a classical strategy, even for users with no previous experience with the novel AI-based platform. An AI-based Holter analysis platform may contribute to a broader and more resource-efficient adoption of Holter monitoring.

Abstract Figure. analysis duration using each strategy

[Transcatheter aortic valve implantation and conduction disturbances]

Transcatheter aortic valve implantation (TAVI) is currently becoming the treatment of choice for patients with calcific aortic stenosis. Despite several technical improvements, the incidence of conduction disturbances has not diminished and remains TAVI's major complication. These disturbances include the occurrence of left bundle branch block and/or high-grade atrioventricular block often requiring pacemaker implantation. The proximity of the aortic valve to the conduction system (conduction pathways) accounts for the occurrence of these complications. Several factors have been identified as carrying a high risk of conduction disturbances like the presence of pre-existing right bundle branch block, the type of valve implanted, the volume of aortic and mitral calcifications, the size of the annulus and the depth of valve implantation. Left bundle branch block is the most frequent post TAVI conduction disturbance. Whereas the therapeutic strategy for persistent complete atrioventricular block is simple, it becomes complex in the presence of fluctuating changes in PR interval and left bundle branch block duration. The QRS width threshold value (150-160 ms) indicative of the need for pacemaker implantation is still being debated. Although there are currently no recommendations regarding the management of these conduction disturbances, the extension of TAVI indications to patient at low surgical risk calls for a standardization of our practice. However, a decision algorithm was recently proposed by a group of experts composed of interventional cardiologists, electrophysiologists and cardiac surgeons. There are still uncertainties about the appropriate timing of pacemaker implantation and the management of new onset left bundle branch block.

P1018Evolution of atrioventricular conduction disorders after TAVI

Background

The evolution of atrioventricular block (AVB) after Trans Aortic Valve Implantation (TAVI) is poorly understood, and indications of pacemaker (PM) implantation after TAVI not well defined. Modern PM algorithms can help studying the evolution of these AV conduction disorders after TAVI. SafeR® mode (Sorin® PM) allows to monitor precisely the AV conduction and to store AVB episodes in the PM memory as intracardiac electrograms, which can be re-read and validated afterwards.

Methods

From November 2015 and January 2017, all patients implanted in one of the 19 French enrolling centers with a Sorin® PM set in SafeR® mode after TAVI could be prospectively included in the study. All the PM interrogation files were centrally collected. The primary endpoint (PE) was the presence of at least one episode of high grade AVB (HG-AVB) beyond day 7 (D7) to one year after the TAVI. It could be validated either by the presence of a HG-AVB on EKG or telemetry, or by the confirmation of a HG-AVB in the PM memory files.

Results

273 patients were included in the study, the PE was assessable in 197 patients. PE was validated in 74.6% patients. In univariate analysis, the use of an oversized prothesis or balloon, and all early episodes of HG-AVB (all those occurring up to D7) influence the validation of the PE. Other AV conduction disorders have no influence on the PE (Table). In multivariate analysis, only HG-AVB occurring between D2 and D7 has a significant influence on the PE.

Factors influencing HG-AVB after TAVI Studied factor HG-AVB episode(s) during the one year follow up No HG-AVB episode during the one year follow up p value RBBB before TAVI (%) 41 34 0,346 Low implantation (>6mm) (%) 59 37 0,156 Use of Autoexpansive Valve (%) 62 62 0,990 Oversizing (%) 19 6 0,022 HG-AVB per TAVI (%) 56 30 0,001 HG-AVB D0-D1 (%) 53 24 0,001 HG-AVB D2-D7 (%) 68 34 0,001 New or wiser LBBB and improvement of PR interval after TAVI (%) 30 39 0,253 Influence of predefined factors on the Primary Endpoint.

Conclusion

The analysis of the SafeR® algorithm files in patients implanted with a PM after TAVI show a high incidence of HG-AVB during the one year follow up. In multivariate analysis, only HG-AVB occurring between D2 and D7 significantly influence the PE, confirming that AV conduction disorders occurring during the first 24 hours may spontaneously normalize.

Acknowledgement/Funding

Microport CRM

Influence of permafrost, rock and ice glaciers on chemistry of high-elevation ponds (NW Italian Alps)

Permafrost degradation, rock-glacier thawing, and glacier retreat are influencing surface water quality at high elevations. However, there is a lack of knowledge on the dominant geochemical reactions occurring in different cryospheric conditions and how these reactions change during the ice-free season. In the Col d'Olen area (LTER site, NW Italian Alps), four ponds with similar sizes, located in basins with different cryospheric features (glacier, permafrost, rock glacier, none of these), are present in a geographically limited area. All ponds were sampled weekly in 2015 and partially in 2014. Major ions, selected trace elements, and biotic parameters (dissolved organic carbon-DOC, fluorescence index-FI, and nitrate) are examined to evidence the effect of different cryospheric features on water characteristics. Where cryospheric conditions occur chemical weathering is more intensive, with strong seasonal increase of major ions. Sulphide oxidation dominates in glacier and permafrost lying on acid rocks, probably driven by enhanced weathering of freshly exposed rocks in subglacial environment and recently deglaciated areas, and active layer thickness increase. Differently, carbonation dominates for the rock glacier lying on ultramafic rocks. There, high Ni concentrations originate from dissolution of Mg-bearing rocks in the landform. In all settings, pH neutralisation occurs because of the presence of secondary carbonate lithology and ultramafic rocks. Nitrate highest concentrations and changes occur in cryospheric settings while DOC and FI do not show strong differences and seasonal variations. The establishment of more frequent monitoring for water quality in high-elevated surface waters is necessary to provide greater statistical power to detect changes on longer time scales.

Inverting the Handedness of Circularly Polarized Luminescence from Light-Emitting Polymers Using Film Thickness

The emission of circularly polarized light is central to many applications, including data storage, optical quantum computation, biosensing, environmental monitoring, and display technologies. An emerging method to induce (chiral) circularly polarized (CP) electroluminescence from the active layer of polymer light-emitting diodes (polymer OLEDs; PLEDs) involves blending achiral polymers with chiral small-molecule additives, where the handedness/sign of the CP light is controlled by the absolute stereochemistry of the small molecule. Through the in-depth study of such a system we report an interesting chiroptical property: the ability to tune the sign of CP light as a function of active layer thickness for a fixed enantiomer of the chiral additive. We demonstrate that it is possible to achieve both efficient (4.0 cd/A) and bright (8000 cd/m²) CP-PLEDs, with high dissymmetry of emission of both left-handed (LH) and right-handed (RH) light, depending on thickness (thin films, 110 nm: g_EL = 0.51, thick films, 160 nm: g_EL = -1.05, with the terms "thick" and "thin" representing the upper and lower limits of the thickness regime studied), for the same additive enantiomer. We propose that this arises due to an interplay between localized CP emission originating from molecular chirality and CP light amplification or inversion through a chiral medium. We link morphological, spectroscopic, and electronic characterization in thin films and devices with theoretical studies in an effort to determine the factors that underpin these observations. Through the control of active layer thickness and device architecture, this study provides insights into the mechanisms that result in CP luminescence and high performance from CP-PLEDs, as well as demonstrating new opportunities in CP photonic device design.

Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis

BACKGROUND & AIMS

We investigated the effect of albumin treatment (20% solution) on hypoalbuminemia, cardiocirculatory dysfunction, portal hypertension, and systemic inflammation in patients with decompensated cirrhosis with and without bacterial infections.

METHODS

We performed a prospective study to assess the effects of long-term (12 weeks) treatment with low doses (1 g/kg body weight every 2 weeks) and high doses (1.5 g/kg every week) of albumin on serum albumin, plasma renin, cardiocirculatory function, portal pressure, and plasma levels of cytokines, collecting data from 18 patients without bacterial infections (the Pilot-PRECIOSA study). We also assessed the effect of short-term (1 week) treatment with antibiotics alone vs the combination of albumin plus antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) on plasma levels of cytokines in biobanked samples from 78 patients with bacterial infections included in a randomized controlled trial (INFECIR-2 study).

RESULTS

Circulatory dysfunction and systemic inflammation were extremely unstable in many patients included in the Pilot-PRECIOSA study; these patients had intense and reversible peaks in plasma levels of renin and interleukin 6. Long-term high-dose albumin, but not low-dose albumin, was associated with normalization of serum level of albumin, improved stability of the circulation and left ventricular function, and reduced plasma levels of cytokines (interleukin 6, granulocyte colony-stimulating factor, interleukin 1 receptor antagonist, and vascular endothelial growth factor) without significant changes in portal pressure. The immune-modulatory effects of albumin observed in the Pilot-PRECIOSA study were confirmed in the INFECIR-2 study. In this study, patients given albumin had significant reductions in plasma levels of cytokines.

CONCLUSIONS

In an analysis of data from 2 trials (Pilot-PRECIOSA study and INFECIR-2 study), we found that albumin treatment reduced systemic inflammation and cardiocirculatory dysfunction in patients with decompensated cirrhosis. These effects might be responsible for the beneficial effects of albumin therapy on outcomes of patients with decompensated cirrhosis. ClinicalTrials.gov, Numbers: NCT00968695 and NCT03451292.

28 Effect of deuterium oxide on bovine oocyte cryotolerance

It is known that cryopreservation triggers spindle disassembly, increased aneuploidy risk, decreased post-thaw survival, fertilization, and embryo development. We hypothesised that a treatment with D2O before vitrification would slow down oocyte metabolism and reduce ice crystal formation by replacing water inside the cells. The aim of the study was to evaluate the effect of a 4-h treatment with different D2O concentrations (0, 3, 15, and 30%) on cryotolerance of bovine in vitro-matured oocytes. Abattoir-derived bovine oocytes were matured in vitro for 20h in TCM-199 medium with 15% of bovine serum (BS), 0.5µg mL−1 of FSH, 5µg mL−1 of LH, 0.8mM l-glutamine, and 50µg mL−1 of gentamicin at 39°C with 5% of CO2 and randomly divided into 5 experimental groups. A group of non-vitrified oocytes was used as the fresh oocyte control group, whereas the remaining oocytes were incubated for 4h in in vitro maturation medium with 0% (vitrified control; n=205), 3% (n=205), 15% (n=205), and 30% D2O (n=205) before vitrification. The experiment was repeated 4 times. Oocytes were denuded in HEPES-buffered TCM-199 (H199)+5% BS and vitrified using a cryotop freezing straw. The oocytes were incubated in 200μL of H199+20% BS with 7.5% ethylene glycol and 7.5% dimethyl sulfoxide for 3min. After that, oocytes were collected in 50μL of H199+20% fetal bovine serum with 15% ethylene glycol+15% dimethyl sulfoxide and 0.5M sucrose for 20s and plunged into LN2. One month later, oocytes were warmed in thawing media with decreasing concentrations of sucrose (1.35M to 0.31M) and then placed into in vitro maturation medium for 2h before IVF. Matured oocytes were IVF and cultured according to standard procedures (Rubessa et al. 2011 Theriogenology 76, 1347-1355). Cleavage and blastocyst rates were evaluated after 7 days of culture. Data were analysed using the GLM procedure of SPSS (SPSS Inc., Chicago, IL, USA). The least statistical difference post-hoc test was used to perform statistical multiple comparison. The α-level was set at 0.05. As expected, both cleavage [60.5±4.6 (fresh control); 36.9±2.6 (0% D2O); 46.3±3.7 (3% D2O); 31.6±2.4 (15% D2O); and 24.4±2.6 (30% D2O)] and blastocyst rates [25.7±0.8 (fresh control); 9.0±0.8 (0% D2O); 9.0±0.7 (3% D2O); 3.6±0.2 (15% D2O); and 4.3±0.8 (30% D2O)] decreased in all vitrified groups compared with the fresh control group. Within vitrified oocytes, cleavage rate increased (P&lt;0.05) with 3% D2O treatment compared with the other groups. However, pretreatment with higher (15-30%) D2O concentrations decreased (P&lt;0.05) blastocyst rates of vitrified-warmed oocytes. In conclusion, a pretreatment with low concentrations (3%) of D2O improved the cleavage rate of bovine vitrified-warmed oocytes, suggesting a potential beneficial effect, whereas deleterious effects were observed using the higher concentrations. Therefore, further studies are required to assess a potential use of D2O to improve oocyte cryotolerance, likely testing different incubation times.

The influence of nitrogen position on charge carrier mobility in enantiopure aza[6]helicene crystals

A computational study exploring the influence of the nitrogen position on charge carrier mobility in enantiopure aza[6]helicene crystals

26 Season affects cryotolerance of in vitro-produced buffalo embryos

Buffaloes are tendentially short-day breeders, and seasonality is one of the main factors affecting the feasibility of ovum pickup and in vitro embryo production technology in this species. An improvement of oocyte developmental competence during decreasing daylight months was previously reported in Italian Mediterranean buffalo (Di Francesco et al. 2011 Anim. Reprod. Sci. 123, 48-53). The aim of this work was to evaluate whether season also affects embryo quality and cryotolerance. Abattoir-derived buffalo cumulus-oocyte complexes were collected during the breeding season, characterised by decreasing daylight length (n=349 over 6 replicates), and the non-breeding season, characterised by increasing daylight length (n=770 over 12 replicates). Buffalo cumulus-oocyte complexes were in vitro matured, fertilized, and cultured according to standard procedures (Di Francesco et al. 2011 Anim. Reprod. Sci. 123, 48-53). The embryos obtained by the end of culture (i.e. on Day 7 post-IVF) were scored for quality and developmental stage, and the percentages of total transferable embryos (tight morulae and blastocysts) were recorded. Embryos (n=107 and 110 in the breeding and non-breeding seasons, respectively) were vitrified by cryotop in 16.5% ethylene glycol, 16.5% dimethyl sulfoxide, and 0.5M sucrose (Boccia et al. 2013 Ital. J. Anim. Sci. 12, 492-496). Warming was carried out by plunging the cryotop strip into a 0.25M sucrose solution and transferring the embryos into 0.15M sucrose for 5min. Embryos were then washed and cultured in SOF for 24h to evaluate post-culture viability. The resistance to cryopreservation was evaluated by assessing the survival rate, on the basis of morphological criteria, and development rate (i.e. the percentage of embryos that resumed their development and reached a more advanced developmental stage) after 24h post-warming culture. Data were analysed by Student’s t-test. Both cleavage (82.8±4.3v. 73.1±1.7 in the breeding and non-breeding seasons, respectively; P&lt;0.05) and blastocyst (32.9±3.5v. 18.3±1.7 in the breeding and non-breeding seasons, respectively; P&lt;0.01) rates increased during the breeding season, confirming previous observations. Due to the different efficiency, a higher number of replicates was required during the non-breeding season to obtain an equal number of embryos. In addition, a seasonal effect was recorded on embryo quality, indicated by poorer cryotolerance of in vitro-produced buffalo embryos during the non-breeding season. Indeed, both survival (94.6±2.7% and 74.0±5.5% in the breeding and non-breeding seasons, respectively; P&lt;0.01) and development (67.3±7.6% and 40.0±7.2% in the breeding and non-breeding seasons, respectively; P&lt;0.01) rates of vitrified blastocysts decreased after 24h post-warming culture in the non-breeding season. These findings suggest that the reduced developmental competence of buffalo oocytes during the non-breeding season may also lead to lower blastocyst quality. This is in contrast to the evidence in cattle that embryo quality is mainly determined by culture conditions, whereas blastocyst production depends on oocyte quality.

Management of acute respiratory failure in interstitial lung diseases: overview and clinical insights

Background

Interstitial lung diseases (ILDs) are a heterogeneous group of diseases characterized by widespread fibrotic and inflammatory abnormalities of the lung. Respiratory failure is a common complication in advanced stages or following acute worsening of the underlying disease. Aim of this review is to evaluate the current evidence in determining the best management of acute respiratory failure (ARF) in ILDs.

Methods

A literature search was performed in the Medline/PubMed and EMBASE databases to identify studies that investigated the management of ARF in ILDs (the last search was conducted on November 2017).

Results

In managing ARF, it is important to establish an adequate diagnostic and therapeutic management depending on whether the patient has an underlying known chronic ILD or ARF is presenting in an unknown or de novo ILD. In the first case both primary causes, such as acute exacerbations of the disease, and secondary causes, including concomitant pulmonary infections, fluid overload and pulmonary embolism need to be investigated. In the second case, a diagnostic work-up that includes investigations in regards to ILD etiology, such as autoimmune screening and bronchoalveolar lavage, should be performed, and possible concomitant causes of ARF have to be ruled out.

Oxygen supplementation and ventilatory support need to be titrated according to the severity of ARF and patients’ therapeutic options. High-Flow Nasal oxygen might potentially be an alternative to conventional oxygen therapy in patients requiring both high flows and high oxygen concentrations to correct hypoxemia and control dyspnea, however the evidence is still scarce. Neither Non-Invasive Ventilation (NIV) nor Invasive Mechanical Ventilation (IMV) seem to change the poor outcomes associated to advanced stages of ILDs. However, in selected patients, such as those with less severe ARF, a NIV trial might help in the early recognition of NIV-responder patients, who may present a better short-term prognosis. More invasive techniques, including IMV and Extracorporeal Membrane Oxygenation, should be limited to patients listed for lung transplant or with reversible causes of ARF.

Conclusions

Despite the overall poor prognosis of ARF in ILDs, a personalized approach may positively influence patients’ management, possibly leading to improved outcomes. However, further studies are warranted.

Gastrointestinal Stromal Tumors (GISTs): From Science to Targeted Therapy

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs represent a distinct category of tumors characterized by oncogenic mutations of the KIT receptor tyrosine kinase in a majority of patients. KIT is useful not only for the diagnosis but also for targeted therapy of this disease. Imatinib, a tyrosine kinase inhibitor, is widely used in advanced and metastatic GISTs. This agent revolutionized the treatment strategy of advanced disease and is being tested in the neoadjuvant and adjuvant settings with encouraging results. New therapeutic agents like sunitinib have now been approved, enriching the treatment scenario for imatinib-resistant GISTs. The present review reports on the peculiar characteristics of this disease through its biology and molecular patterns, focusing on the predictive value of KIT mutations and their correlation with clinical outcome as well as on the activity of and resistance to approved targeted drugs.

123 In Vitro Embryo Production in Lyophilized In Vitro Culture Medium as a Method to Increase the Medium's Shelf-Life

The worldwide production of livestock embryos requires stable medium with long shelf life. In this experiment, we evaluated the impact of the freeze-dried in vitro culture (IVC) medium (Mdry) on in vitro embryo production. We compared the standard IVC and Mdry media for cleavage rate and embryo production. Media solutions (10 mL) were aliquoted into 50-mL conical tubes and lyophilized to form a powder concentrate using a Genesis freeze-dryer (VirTis, Gardener, NY, USA). Lyophilization consisted of a constant cooling from 20°C to –10°C at a constant rate of 1°C/min with a 2-h hold at –10°C before sublimation at 0°C. Mdry medium were held at –80°C for 4 months. When the IVC medium was rehydrated, the pH were adjusted to 7.4. Abattoir-derived Holstein oocytes (n = 618, in 7 replicates) were in vitro matured and fertilized with sexed semen, according to standard procedures (Rubessa et al. 2011 Theriogenology 76, 1347-1355). Twenty hours after IVF, presumptive zygotes were cultured in SOF medium with 5% BS at 39°C with 5% CO2, 7% O2, and 88% N2. On Day 7, embryo yields were assessed. All recorded parameters were subjected to a Chi-Square Test 2 × 2. The parameters compared were percent cleavage, blastocysts, and embryos/cleaved. The α level was set at 0.05. All data were expressed as quadratic means and mean standard errors. The results (Table 1) showed not a statistical difference between control and Mdry. The Mdry had a higher percentage of cleaved zygotes (65.4% v. 53.4%) but not enough for a statistical difference. However, when we compared embryo production, there was no difference between treatments. The ratio between blastocysts and cleaved embryos was higher in the control group but not significant according to our selected α level. These results indicate that it is possible lyophilize IVC medium without interfering with the potential quality of the medium. Further studies will be needed to better understand the positive effect of the lyophilization on the cleavage rate. Table 1.Mean (SD in parentheses) percentage cleavage and blastocysts

Antipsychotic prescription and mortality in hospitalized older persons

BACKGROUND

Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients.

METHODS

We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale.

RESULTS

Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5-9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality.

CONCLUSION

We found that the prescription of antipsychotic drugs during hospitalization was not associated with in-hospital or follow-up mortality. Short-term antipsychotic prescriptions (for acutely ill patients) may have a different effect than long-term, repeated prescriptions.

Consensus conference on TIPS management: Techniques, indications, contraindications

The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

The impact of infection by multidrug-resistant agents in patients with cirrhosis. A multicenter prospective study

BACKGROUND & AIMS

Bacterial strains resistant to antibiotics are a serious clinical challenge. We assessed the antibiotic susceptibility of bacteria isolated from infections in patients with cirrhosis by a multicentre investigation.

RESULTS

Three hundred and thirteen culture-positive infections (173 community acquired [CA] and 140 hospital acquired [HA]) were identified in 308 patients. Urinary tract infections, spontaneous bacterial peritonitis and bacteremias were the most frequent. Quinolone-resistant Gram-negative isolates were 48%, 44% were extended-spectrum beta-lactamase producers and 9% carbapenem resistant. In 83/313 culture-positive infections (27%), multidrug-resistant agents (MDRA) were isolated. This prevalence did not differ between CA and HA infections. MDRA were identified in 17 of 37 patients on quinolone prophylaxis, and in 46 of 166 not on prophylaxis (45% vs 27%; P<.03). In 287 cases an empiric antibiotic therapy was undertaken, in 37 (12.9%) this therapy failed. The in-hospital mortality rate of this subset of patients was significantly higher compared to patients who received an effective broad(er)-spectrum therapy (P=.038). During a 3-month follow-up, 56/203 culture-positive patients (27.6%) died, 24/63 who have had MDRA-related infections (38%) and 32/140 who have had antibiotic-susceptible infections (22.8%) (P=.025). Multivariate analysis disclosed MDRA infection, age, hepatocellular carcinoma, bilirubin, international normalized ratio and the occurrence of portal hypertension-related complications independent predictors of death.

CONCLUSIONS

Infection by MDRA is frequent in patients with cirrhosis and the prognosis is severe, especially in patients unresponsive to empiric antibiotic therapy.

E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study

AIMS

The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients.

METHODS

Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up.

RESULTS

A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up.

CONCLUSIONS

This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.

Albumin treatment regimen for type 1 hepatorenal syndrome: a dose-response meta-analysis

Background

Recommended treatment for type 1 hepatorenal syndrome consists of albumin and vasoconstrictor. The optimal albumin dose remains poorly characterized. This meta-analysis aimed to determine the impact of albumin dose on treatment outcomes.

Methods

Clinical studies of type 1 hepatorenal syndrome treatment with albumin and vasoconstrictor were sought. Search terms included: hepatorenal syndrome; albumin; vasoconstrictor; terlipressin; midodrine; octreotide; noradrenaline; and norepinephrine. A meta-analysis was performed of hepatorenal syndrome reversal and survival in relation to albumin dose.

Results

Nineteen clinical studies with 574 total patients were included, comprising 8 randomized controlled trials, 8 prospective studies and 3 retrospective studies. The pooled percentage of patients achieving hepatorenal syndrome reversal was 49.5 % (95 % confidence interval, 40.0-59.1 %). Increments of 100 g in cumulative albumin dose were accompanied by significantly increased survival (hazard ratio, 1.15; 95 % confidence interval, 1.02-1.31; p = 0.023). A non-significant increase of similar magnitude in hepatorenal syndrome reversal was also observed (odds ratio, 1.15; 95 % confidence interval, 0.97-1.37; p = 0.10). Expected survival rates at 30 days among patients receiving cumulative albumin doses of 200, 400 and 600 g were 43.2 % (95 % confidence interval, 36.4-51.3 %), 51.4 % (95 % confidence interval, 46.3-57.1 %) and 59.0 % (95 % confidence interval, 51.9-67.2), respectively. Neither survival nor hepatorenal syndrome reversal was significantly affected by vasoconstrictor dose or type, treatment duration, age, baseline serum creatinine, bilirubin or albumin, baseline mean arterial pressure, or study design, size or time period.

Conclusions

This meta-analysis suggests a dose–response relationship between infused albumin and survival in patients with type 1 hepatorenal syndrome. The meta-analysis provides the best current evidence on the potential role of albumin dose selection in improving outcomes of treatment for type 1 HRS and furnishes guidance for the design of future dose-ranging studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0389-9) contains supplementary material, which is available to authorized users.

Gender difference in drug use in hospitalized elderly patients

PURPOSE

The aims of this study were to evaluate whether or not there are gender differences in drug use at hospital admission and prescription at discharge and to evaluate the effect of hospitalization on medication patterns in the elderly.

METHOD

In-patients aged >65years included in the REPOSI registry during a recruitment period of 3years (2008-2010-2012) were analyzed in order to evaluate drug use at hospital admission and prescription at discharge according to gender.

RESULTS

A total of 3473 patients, 52% women and 48% men, were considered. Polypharmacy (>5 drugs) is more frequent in men both at hospital admission and discharge. At hospital discharge, the number of prescriptions increased in both sexes at all age groups. Neuropsychiatric drugs were significantly more prescribed in women (p<0.0001). At admission men were more likely to be on antiplatelets (41.7% vs 36.7%; p=0.0029), ACE-inhibitors (28.7% vs 24.7%; p=0.0072) and statins (22.9% vs 18.3%; p=0.0008). At discharge, antiplatelets (43.7% vs 37.3%; p=0.0003) and statins (25,2% vs 19.6%; p<0.0001) continued to be prescribed more often in men, while women were given beta-blockers more often than men (21.8% vs 18.9%; p=0.0340). Proton pump inhibitors were the most prescribed drugs regardless of gender. At discharge, the medication pattern did not change according to gender.

CONCLUSION

Our study showed a gender difference in overall medications pattern in the hospitalized elderly. Hospitalization, while increasing the number of prescriptions, did not change drug distribution by sex.

Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: A randomized trial

Hepatorenal syndrome (HRS), a serious complication of cirrhosis, is associated with high mortality without treatment. Terlipressin with albumin is effective in the reversal of HRS. Where terlipressin is not available, as in the United States, midodrine and octreotide with albumin are used as an alternative treatment of HRS. The aim was to compare the effectiveness of terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of HRS in a randomized controlled trial. Twenty-seven patients were randomized to receive terlipressin with albumin (TERLI group) and 22 to receive midodrine and octreotide plus albumin (MID/OCT group). The TERLI group received terlipressin by intravenous infusion, initially 3 mg/24 hours, progressively increased to 12 mg/24 hours if there was no response. The MID/OCT group received midodrine orally at an initial dose of 7.5 mg thrice daily, with the dose increased to a maximum of 12.5 mg thrice daily, together with octreotide subcutaneously: initial dose 100 μg thrice daily and up to 200 μg thrice daily. Both groups received albumin intravenously 1 g/kg of body weight on day 1 and 20-40 g/day thereafter. There was a significantly higher rate of recovery of renal function in the TERLI group (19/27, 70.4%) compared to the MID/OCT group (6/21, 28.6%), P = 0.01. Improvement in renal function and lower baseline Model for End-Stage Liver Disease score were associated with better survival.

CONCLUSION

Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS.

Treatment of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is an infection of patients with cirrhosis and ascites. This peculiarity is due to the frequent intestinal translocation that allows bacteria to cross the intestinal barrier, colonizing the ascitic fluid. In cirrhosis, SBP is inferior only to urinary tract infections. It is prevalently sustained by Gram-negative bacteria such as Escherichia coli and Klebsiella. Risk factors for developing SBP are advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels (below 2.5 g/ml), bilirubin over 4 mg/dl, Child-Pugh class C and a previous diagnosis of SBP. Thus, this is an indication for a long-term antibiotic prophylaxis with norfloxacin. Renal failure - especially the hepatorenal syndrome - complicates SBP in about 20% of cases independently of the efficacy of the antibiotic therapy. The mortality of these patients is about 90%. Infusion of albumin significantly reduces the incidence of hepatorenal syndrome and consequently the risk of death. Long-term quinolonic prophylaxis as well as increased antibiotic therapies are causing the emergence of multidrug-resistant agents as frequent causes of SBP. In such cases, the antibiotic sensitivity to quinolones is low, and European recommendations suggest a second-line antibiotic therapy, including meropenem or piperacillin plus tazobactam. Collection of blood, urine and ascitic fluid for cultures is important for bacterial recognition, possibly before starting an empirical antibiotic therapy. Indeed, the probability of positive cultures rapidly vanishes when they are performed during already implemented antibiotic administration. It is important to know that a failure of the first-line therapy is associated with an increased probability of death.

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

BACKGROUND

Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older).

METHODS

Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models.

RESULTS

A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality.

CONCLUSIONS

The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia.

Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study

BACKGROUND

It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF.

METHODS

We retrospectively analyzed the data collected on elderly patients in 66 Italian hospitals, in the frame of the REPOSI project. We analyzed the clinical characteristics of patients with AF and different degrees of CI. Multivariate logistic analysis was used to explore the relationship between variables and mortality.

RESULTS

Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy.

CONCLUSIONS

Elderly hospitalized patients with AF are more likely affected by CI and CKD, two conditions that expose them to a higher mortality risk. Oral anticoagulant therapy, still underused and not optimally enforced, may afford protection from thromboembolic episodes that probably concur to the high mortality.