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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Erector spinae plane block for surgery of esophageal atresia in a preterm neonate

Pain management during and after thoracotomy is challenging in premature neonates. Ultrasound-guided fascial plane block techniques, such as the erector spinae plane block are a relatively new regional anesthesia technique and have emerged as an alternative to thoracic epidural due to its clinical effectiveness, ease of administration and theoretically being safer to perform. The relative ease of identifying anatomical landmarks compared to the paravertebral block, as well as its safety profile compared to an epidural, may have contributed to the erector spinae plane Bs growing popularity. Currently, however, the published evidence for the efficacy of regional anesthesia techniques in low birth weight newborns undergoing this surgery is limited to few isolated case reports. Herein we describe the use of unilateral erector spinae plane block as part of anesthesia and postoperative analgesia management of surgical correction of esophageal atresia in a preterm neonate.

The workload-indexed blood pressure response predicts cardiovascular events and all-cause mortality in coronary artery disease

Background

Abnormal blood arterial pressure response to exercise (BPR) is a cardiovascular (CV) risk factor (CVRF). The concept of pathological BPR, believed to be an excessive raise or decrease, has been challenged. The workload-indexed blood pressure response (WBPR) recently emerged in an attempt to normalize hypertensive responses to exercise. However, it remains to be explored its value in high-risk CV subjects.

Purpose

Evaluation of the predictive value of WBPR in the occurrence of CV events and death in coronary artery disease (CAD) patients.

Methods

A cohort of 318 patients with known CAD, who underwent Bruce protocol treadmill testing between 2009–2010, were retrospectively followed to 11/2021 (9.9±2.3 years) to assess the predictive value of WBPR for the occurrence of death and CV events. The WBPR is the ratio between systolic blood pressure variation from rest to peak exercise (ΔSBP) and metabolic equivalent of task (MET-1). High and low WBPR groups were created based on median value for this sample (5.2 mmHg/MET). Data presented: mean ± standard deviation; 95% confidence interval (CI) for hazard ratios (HR); significance between groups p<0.05.

Results

Low vs high WBPR groups were similar at baseline for sex (88% male, p=0.67), hypertension (63%, p=0.18), diabetes (32%, p=0.34); dyslipidemia (72%, p=0.62), myocardial infarction (75%, p=0.39) and heart failure (HF) (9.9%, p=0.07), with exception for overweight/obesity (90% vs 82%, p=0.009) and age (57±11 vs 61±8 years, p=0.009) that were higher in the high-WBPR group. No significant differences were found between groups for medication at baseline, including anti-hypertensive, anti-thrombotic or anti-ischemic drugs. In the follow-up period occurred 43 deaths (12 CV deaths), 58 reinfarctions, 94 worsening/de novo HF and 29 strokes. A non-linear J-shaped relationship was observed between WBPR and most events. In the event-free survival analyses using Cox regression, the high-WBPR group was associated with all death (HR 2.0 (CI 1.0–3.9, p=0.042), reinfarction (HR 2.3 (CI 1.2–4.1, p=0.008), and worsening/de novo HF (HR 1.7 (CI 1.0–2.9, p=0.043) after adjusting for baseline age, CVRFs and medication. In receiver operating characteristic curves, adding WBPR to a model with other cardiac stress variables (double product, ST-T changes, symptoms, and test positivity) significantly improved the power to predict all death, with an area under curve of 0.73 (CI 0.66–0.80, p=0.037).

Conclusions

Data shows that WBPR is a powerful independent predictor of future cardiovascular events and deaths in CAD patients. This highlights cardiac exercise stress testing as an important risk assessment tool in secondary prevention of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

On the body-mind nexus in chronic musculoskeletal pain: A scoping review

BACKGROUND AND OBJECTIVE

Bodily experience disturbances are frequent among chronic musculoskeletal pain patients and associated with important pain-related psychosocial outcomes (e.g., disability, quality of life). However, the relationship between bodily experience and the psychological dimensions of chronic pain (e.g., affective, cognitive) has only recently garnered attention. This scoping review aimed to identify trends and gaps in research on the nexus between body awareness, body image, and body schema, and psychological processes/outcomes in adults with chronic musculoskeletal pain to inform future directions for research and practice.

DATABASES AND DATA TREATMENT

This study was guided by Arksey and O'Malley's guidelines and PRISMA-ScR recommendations. Keywords related to body awareness/body image/body schema and pain were searched on PsycInfo and PubMed from database inception until February 16, 2021; 2045 articles were screened, and 41 met the inclusion criteria (i.e., primary quantitative studies investigating body awareness/body image/body schema in relation to pain-related psychological outcomes/processes in chronic musculoskeletal pain).

RESULTS

The referred bodily experience constructs have been inconsistently defined. Body awareness was the most investigated construct, with consistent operationalization strategies. The links between body schema/body image and pain-related psychological processes/outcomes are still under-investigated. Most studies examined the role of bodily experience as a correlate/predictor of psychological outcomes/processes; overall, a better relationship with one's own body was associated with better pain-related psychological outcomes/processes.

CONCLUSIONS

Our findings emphasize the relevance of further investigating body-mind relations in musculoskeletal pain and the development of therapies designed to improve the bodily experience within multidisciplinary treatment programs. Suggestions for future research are discussed.

MRI differentiation of low-grade and high-grade chondrosarcoma of the shoulder girdle, chest wall and pelvis: a pictorial review based on 111 consecutive cases

Approximately 40% of conventional chondrosarcomas arise from the shoulder girdle, chest wall and pelvis. This pictorial review describes the MRI features which may aid in the differentiation of Grade 1 chondrosarcoma (Gd1-CS) from high-grade chondrosarcoma (HG-CS) and dedifferentiated chondrosarcoma (DD-CS) in these locations, based on literature review and assessment of 111 consecutive cases presenting to the senior authors institution over a 13-year period. Of the 111 patients reviewed (71 males and 40 females; mean age 54.3 years; range 17-92 years), 27 were Gd1-CS, 72 were HG-CS and 12 were DD-CS. Tumours arising from the scapula, acetabulum, pubis/ischium and sacrum were more likely to be HG-CS, as were intramedullary tumours. MRI features associated with HG-CS and DD-CS included cortical destruction, bone oedema, soft tissue oedema, tumour necrosis, intermediate T2W SI and joint invasion. The presence of a soft tissue mass became a significant differentiating feature for tumours arising within the medullary cavity, but this was location-specific and did not differentiate between Gd1-CS and HG-CS/DD-CS arising from the sternum or clavicle.

Cauda equina syndrome following combined spinal-epidural anesthesia with levobupivacaine for cesarean section

Cauda equina syndrome (CES) is a rare but possible complication of neuroaxial anesthesia. Damage to the nerve roots may occur due to compression, inflammation, stretching, direct trauma, spinal ischemia or neurotoxicity, usually with lidocaine or bupivacaine. We describe a case of a 33-year-old patient that underwent an uneventful cesarean section with a combined spinal-epidural technique anesthesia, with levobupivacaine. 48 h after the procedure, she presented diminished muscular strength and abolished osteotendinous reflexes in the left lower limb, limited flexion of the right hallux, urinary retention and saddle anesthesia. Imaging exams excluded hematoma, thickening or compression of the cauda equina nerve roots. CES was suspected and treatment was initiated. 9-month follow up revealed diminished osteotendinous reflexes on the left lower limb and perianal hypoesthesia. Despite being unusual, neurological complications require prompt recognition and management to avoid permanent damage.

The incidence and diagnostic relevance of pathological fracture in conventional central chondrosarcoma

OBJECTIVE

To determine the incidence and diagnostic relevance of pathological fracture in patients with conventional central chondrosarcoma (CC-CS).

MATERIALS AND METHODS

Retrospective review of patients with CC-CS diagnosed between January 2007 and December 2019. Data collected included age, sex, skeletal location and the presence of pathological fracture at presentation. Histological tumour grade based on surgical resection or needle biopsy was classified as atypical cartilaginous tumour (ACT)/grade 1 CS (ACT/Gd1 CS), high-grade CS (HG-CS) and dedifferentiated CS (DD-CS). The presence of pathological fracture was correlated with age, skeletal location and tumour grade.

RESULTS

Three hundred seventeen patients were included (177 males and 140 females with mean age 55.8 years, range 9-91 years). Mean age of patients without pathological fracture was 54.4 years and those with pathological fracture 62.9 years (p = 0.002). The major long bones were involved in 171 cases, the flat bones in 112 cases, the mobile spine in 7 cases and the small bones of the hands and feet in 27 cases. There were 81 ACT/Gd 1 CS, 168 HGCS and 68 DD-CS. Pathological fracture was evident at presentation in 51 (16.1%) cases, the commonest bones involved being the femur (n = 21; 41.2%), humerus (n = 10; 19.6%) and acetabulum (n = 7; 13.7%). Pathological facture occurred in 7 cases of ACT/Gd 1 CS (13.7%), 23 cases of HGCS (45.1%) and 21 cases of DD-CS (41.2%) (p = 0.001). Following multivariate analysis, both older age and histological grade were independently significant factors.

CONCLUSIONS

Pathological fracture was seen in 16.1% of patients with CC-CS. Pathological fractures in the femur, humerus and acetabulum very likely indicate higher tumour grade.

What if HCM Risk-SCD was assessed with CMR maximum LV wall thickness measurements?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The HCM Risk-SCD estimates the risk of sudden cardiac death at 5 years in patients (pts) with hypertrophic cardiomyopathy (HCM). According to ESC Guidelines, in pts with a 5-year risk of SCD <4%, an implantable cardioverter defibrillator (ICD) is generally not indicated, in pts with a risk of 4 to less than 6%, an ICD may be considered and in pts with a 5-year risk ≥6%, an ICD should be considered. The association between the degree of LVH and sudden cardiac death (SCD) has been based on measurements of maximum LVWT by echocardiography which is part of HCM Risk-SCD score. However, cardiac magnetic resonance (CMR) has shown a superior resolution in characterization of cardiac structures, with additional role in SCD risk stratification. Whether measurements of LVWT by echocardiography and CMR are interchangeable has been brought to question.

Purpose

  We sought to evaluate the incidence of discrepant measurements of maximal LVWT between echocardiography and CMR and determine its implication in HCM Risk-SCD score and ICD indication.

Methods

Unicentric, retrospective analysis of pts submitted to CMR who had HCM as definitive diagnosis, between 1/2013 and 9/2019. CMR and echocardiographic measures were compared, as well as HCM Risk-SCD score calculated with these values (maximum LVWT was the only variable that differed between measures). Subsequently, pts were divided in three groups according to HCM Risk-SCD score: pts with a 5-year risk of SCD <4% (G1), risk of 4 to less than 6% (G2) and risk ≥6% (G3).

Results

Out of the 781 CMR studies evaluated, 59 pts were found to have HCM (7.6%) with mean age of 62 ± 11 years and female predominance (50.8%). 12 pts had obstructive phenotype (20.3%). Mean LVWT was 20.0 ± 4.6mm when measured by CMR and 18.8 ± 4.6mm by echo; when comparing the measures by echo with CMR, there was a positive correlation between them (p < 0.001; r 0.719). Mean HCM Risk-SCD was 2.80 ± 1.51% when measured by CMR and 2.69 ± 1.53% by echo; there was a positive correlation between these measures too (p < 0.001; r 0.963). Maximum LV thickness evaluated by CMR showed a positive correlation (p = 0.006, r 0.384) with the HCM risk-score assessed by CMR. Only 1 pt changed risk group with CMR measurement of maximum LVWT (from G1 to G2). Conclusion: In this cohort, there was a positive, linear relationship between maximum LVWT and HCM Risk-SCD score measured by CMR and echocardiogram. Only 1 pt changed risk stratification group (5-year risk of SCD <4% to 4 to less than 6%).  Although CMR measurements, when interpreted correctly, are more precise compared with echocardiography, in this cohort there was no impact on the patient"s future clinical orientation regarding ICD implantation.

The importance of MRI review following the diagnosis of atypical cartilaginous tumour using image-guided needle biopsy

OBJECTIVE

To evaluate the role of pre-biopsy MRI for management planning in patients with atypical cartilaginous tumours (ACT) diagnosed on image-guided core needle biopsy (IGCNB).

MATERIALS AND METHODS

Retrospective review of patients diagnosed with ACT of the appendicular skeleton based on IGCNB who subsequently underwent surgical curettage or resection. Data collected included age, sex, skeletal location and surgical histology classified as ACT, high-grade chondrosarcoma (HG-CS) and dedifferentiated chondrosarcoma (DD-CS). Pre-biopsy MRI studies were reviewed independently by 2 radiologists blinded to surgical histology results and graded as ACT, HG-CS and DD-CS based on MRI features.

RESULTS

The study included 24 males and 28 females (mean age 42.1 years; range 9-76 years). One patient had 2 lesions treated, making a total of 53 lesions. Tumours were located in the femur in 21 cases, humerus in 17, tibia in 9, radius in 4 and ulna and fibula in 1 each. Surgical histology was ACT in 41 cases, HG-CS in 10 and DD-CS in 2, indicating mismatch between IGCNB and surgical histology in 12/53 cases (22.6%). Predicted MRI grade for the 2 readers was ACT in 39 cases each, HG-CS in 13 and 14 cases and DD-CS in 1 and 0 cases. Sensitivity, specificity and accuracy of MRI for predicting HG-CS/DD-CS were 91%, 93% and 92%, respectively. Inter-observer correlation was very good (kappa = 0.94).

DISCUSSION

Review of MRI findings in patients with ACT diagnosed on IGCNB is vital for identifying patients with a HG-CS/DD-CS and is recommended when planning surgical management or considering repeat IGCNB.

Effects of age, weight, and housing system on prevalence of dead on arrival and carcass condemnation causes in laying hens

Causes of condemnation and dead on arrival (DoA) birds were studied at the slaughterhouse and effects of age, BW, and housing system were investigated. A total of 1,156 (0.18%) birds were found DoA and 20,754 carcasses out of 629,331 (3.30%) were condemned during postmortem inspection. The main reasons for condemnation were peritonitis, septicemia, salpingitis, emaciation, and tumors. The mean percentages of condemnation by septicemia and emaciation differed according to age and BW groups and were more common in batches of younger (≤87 wk) and lighter (≤1.88 kg) birds. Moreover, peritonitis and ascites differed significantly between age groups, occurring more frequently in batches of older hens. The presence of tumors of the reproductive system was more frequently observed in older and heavier hens. This result raises the possibility of tumors being correlated with the higher number of prior ovulatory events. The total condemnation rate was lower in hens from organic systems, followed by free-range, and differed significantly from barns and cage systems. Carcasses with ascites and peritonitis were found more commonly in hens from cages and barns and both differed significantly from organic systems. Salpingitis was statistically more prevalent in barns, presenting differences from organic and free-range systems. Monitoring condemnation causes of end-of-lay hens at slaughter provided a better understanding of health and welfare issues in different housing systems and allowed to identify potential welfare problems, which can be used to improve management and welfare on farms.

Basic life support training with high schools’ teachers in Bahia, Brazil: an experimental study

Background

Early performing of cardiopulmonary resuscitation is the cornerstone of survival in out-of-hospital cardiac arrest, doubling the odds of survival when correctly performed. The American Heart Association and the European Resuscitation Council advocate for training the entire population in order to enable a quick and effective response to out-of-hospital cardiac arrests, improving its outcomes. In primary healthcare settings the health workers can act as trainers, using the family and territorial approach to deliver basic life support (BLS) basis to general population, assuring that key social actors are skilled enough to aid community when needed. This study aims to compare the knowledge and practice skill of high school teachers before and after a BLS training delivered by health workers and students in a primary healthcare setting.

Methods

Teachers of three public high schools in Bahia, Brazil were assessed by a test for theoretical and practical skill in BLS and then trained by a group of primary care workers and students. Training included a 20min lecture and 40min practice session in a simulated scenario. After the training the teachers were assessed with the same test for theoretical and practical skill. A paired-samples T test was used to detect the difference in the mean total score before and after the training, with a significance level of 0.05 (two-sided test) and 95% confidence interval.

Results

The mean total score after the BLS training (8.2 ± 1.5) was significantly higher (p < 0.000) from before training (4.5 ± 1.7).

Conclusions

The high school teachers were unable to deliver proper cardiopulmonary resuscitation before the intervention. Following a BLS training a significant immediate improvement in the knowledge and practical skill was detected. Health workers were able to achieve these results in a primary healthcare setting. Further studies should assess this outcome with larger samples, evaluating the retention of knowledge and skills provided.

Key messages

Basic life support training can be delivered to general population by health workers in primary healthcare settings in order to improve the outcomes to out-of-hospital cardiac arrests. Teachers and health workers can act as key actors in intersetorial health-education initiatives, promoting the health of their communities.

Chondral tumours: discrepancy rate between needle biopsy and surgical histology

OBJECTIVE

To determine the reliability of image-guided core needle biopsy (IGCNB) for the diagnosis and grading of chondral tumours of bone compared with surgical histology.

MATERIALS AND METHODS

Retrospective review of patients with a chondral tumour of bone who underwent IGCNB and surgical resection between January 2007 and December 2017. Data collected included age, sex, skeletal location, technique used for IGCNB, IGCNB result including histological grade and comparison with surgical histology.

RESULTS

A total of 237 patients were included (135 males and 102 females with mean age 53.7 years, range 9-89 years). A total of 174 IGCNBs were CT-guided, 57 ultrasound-guided and 6 fluoroscopic-guided. Two hundred thirty-six of 237 (99.6%) IGCNBs were diagnostic for a chondral tumour, although grade could not be determined in 13 (5.5%) due to necrosis. A positive correlation for tumour grade between IGCNB and surgical histology was achieved in 181 cases (76.4%). In 36 patients (15.2%), IGCNB under-graded the tumour, while in 6 (2.5%), IGCNB over-graded the tumour. Discrepancy between IGCNB and surgical histology was significantly greater for surface/peripheral lesions (p = 0.02) and lesions arising from the flat bones or spine (p = 0.002).

DISCUSSION

IGCNB can achieve a diagnosis of a chondral tumour in a high proportion of cases when compared with final diagnosis from surgical resection specimens. However, correlation of tumour grade between IGCNB and resection histology is less reliable with discordance seen in almost one-quarter of cases, most commonly at non-appendicular sites. Therefore, IGCNB results should not be considered in isolation of imaging and clinical features when planning surgical management.

The incidence of skip metastases on whole bone MRI in high-grade bone sarcomas

INTRODUCTION

Skip metastases have been described with osteosarcoma, Ewing sarcoma and rarely chondrosarcoma. The aim of this study was to determine the incidence of skip metastases on whole bone MRI in all primary high-grade sarcomas of the major long bones.

MATERIALS AND METHOD

Retrospective review of patients from April 2007 to April 2019 with high-grade primary bone sarcomas of the humerus, radius, ulna, femur, tibia or fibula who had whole bone MRI at initial staging. Data collected included age, sex, tumour type, presence and location of skip metastases based on whole bone MRI and presence of distant metastases (the skeleton and lung).

RESULTS

The study included 216 males and 171 females with mean age 30.6 years (range 4-92 years). Tumour types were as follows: High-grade osteosarcoma n = 202, Ewing sarcoma n = 68, high-grade chondrosarcoma n = 44, dedifferentiated chondrosarcoma n = 37, high-grade spindle cell sarcoma n = 29 and angiosarcoma n = 7. Skip lesions were identified in 63 (16.3%). However, after taking into account the presence of distant skeletal (n = 11) and pulmonary (n = 33) metastases, the overall incidence of skip metastases was 6.5%, occurring in 15 (7.5%) high-grade osteosarcomas, 3 (4.5%) Ewing sarcoma, 1 (2.8%) high-grade chondrosarcoma, 4 (10.8%) dedifferentiated chondrosarcomas, and 2 (6.9%) high-grade spindle cell sarcomas. A false positive MRI diagnosis of skip metastasis was made in 4 cases, 3 enchondromata and one focal nodular marrow hyperplasia.

CONCLUSION

The current study has documented the incidence of skip metastases in common types of high-grade primary bone sarcoma. The possibility of false positive skip metastases has also been highlighted.

The horizontal calcaneofibular ligament: a sign of hindfoot valgus on ankle MRI

OBJECTIVE

Hindfoot valgus malalignment has been assessed on coronal MRI by the measurement of the tibio-calcaneal (TC) angle and apparent moment arm (AMA). This study aimed to determine if the calcaneofibular ligament (CFL) angle could be used as a further marker of hindfoot valgus malalignment on routine non-weight-bearing ankle MRI.

MATERIAL AND METHODS

One hundred ninety-five consecutive 3-T ankle MRI studies were identified from the hospital PACS system. The TC and CFL angles could be measured in 155 cases (78%), and the AMA on 153 cases.

RESULTS

The study group comprised 56 males and 72 females with a mean age of 46 years (range 4-89 years). In 27 patients, both ankles had been imaged. The Pearson correlation between the TC and CFL angles was -0.43, with a corresponding p value of 0.001 indicating a strong negative correlation between the TC and CFL angles. The CFL angle was significantly lower in those with hindfoot valgus (113 ± 14) compared with those without (123° ± 15°) (p = 0.001). The optimal cut-off point of the CFL angle for hindfoot valgus was ≤119°, with a sensitivity and specificity of 66% and 63% respectively. The Pearson correlation between the CFL angle and AMA was -0.10, with a corresponding p value of 0.21 indicating a weak negative correlation that did not reach statistical significance.

CONCLUSION

Hindfoot valgus as estimated by the increased TC angle on coronal non-weight-bearing ankle MRI is associated with a reduced CFL angle on sagittal MR images, but is not associated with AMA. Therefore, a horizontal orientation of the CFL on sagittal MR images may be a further useful sign of hindfoot valgus.

Subcutaneous emphysema as a complication of the use of a laryngeal mask in a child

The use of supraglottic airway devices has been increasing in popularity, mostly due to their high success rate and low complications. However, there is very little information available about the potential and group specific concerns regarding their use in children. We present the first description of a child that developed subcutaneous emphysema after the use of a laryngeal mask. We believe that more awareness to the risk of perioperative adverse events with laryngeal mask insertion in the paediatric population is needed.

Fluid around the distal tibialis posterior tendon on ankle MRI: prevalence and clinical relevance

OBJECTIVE

It has been stated that the distal 1-2 cm of the tibialis posterior tendon (TPT) does not have a tendon sheath but rather a paratenon, and that any fluid seen around this segment on ankle MRI is considered to represent paratendonitis. The prevalence and clinical significance of isolated TPT paratendonitis diagnosed on ankle MRI is unknown. This study aims to correlate the presence of isolated distal segment TPT paratendonitis on ankle MRI, with the presence or absence of medial midfoot pain.

METHODS

A retrospective database of 195 consecutive 3 T ankle MRI studies was assessed for the presence of isolated TPT paratendonitis. Relevant clinical notes were available in 159 of these cases, and were reviewed for the absence or presence of medial midfoot pain.

RESULTS

Of 133 patients with both ankle MRI studies and clinical notes available, 53 (33.3%) patients had isolated TPT paratendonitis based on MRI. Of these, 37 (69.8%) had reported no medial foot pain on review of clinical records, while medial foot pain was recorded in 16 cases (30.2%). The comparison of TPT paratendonitis with clinically evident medial midfoot pain showed no statistically significant association (p = 0.19).

CONCLUSION

Fluid signal intensity around the distal 1-2 cm of the TPT is a relatively common finding on ankle MRI. Therefore, care should be taken when reporting ankle MRI studies not to overstate the relevance of this finding.

ADVANCES IN KNOWLEDGE

There was no statistically significant relationship between medial midfoot pain and the presence of isolated TPT paratendonitis.

Plasmodium malariae in a Spanish traveller returning from Colombia

Plasmodium malariae is a rare cause of malaria in the WHO region of America, accounting for <0.1% of cases. We described a malaria case caused by Plasmodium malariae in a Spanish traveller returning from Colombia.

Leptospirosis in Spanish travelers returning from Chiang Mai: A case series

BACKGROUND

Leptospirosis is an important zoonosis worldwide, nevertheless is often poor recognized in non tropical settings. In Thailand is becoming an emerging disease and Chiang Mai could become a popular spot to acquire the disease amongst travelers.

METHODS

We describe three cases of imported leptospirosis undifferentiated fever after travelling to Thailand during the summer of 2015 diagnosed at two Spanish hospitals.

RESULTS

Our three patients probably acquired leptospirosis while swimming in freshwater around Chiang Mai, a Thailand's northern region with moderate incidence of leptopirosis. Travelers had normal white blood cell counts and low platelets, suggesting leptospirosis after ruling out other imported diseases such as malaria, dengue or typhoid.

CONCLUSION

As recent findings point out, low platelets and normal white blood cell counts are clinical features that could help the clinician to suspect Leptospirosis infection. It should be always considered as a cause of fever, particularly if travelers come from a tropical country and have had contact with water or flooding, especially during rainy season.

The potential use of shear viscosity to monitor polymer conditioning of sewage sludge digestates

The work assessed the use of shear viscosity at 0.1 s^-1 ( [Formula: see text] ) as a parameter to detect changes in the conditioning and dewatering of digestates. Total and soluble fractions of organic matter of digestate samples before and after storage were also assessed in regards to their conditioning and dewatering performance. Digestate from a conventional mesophilic anaerobic digestion (CMAD) and advanced anaerobic digestion (AAD) plants were used. Linear regression and correlation analysis of 29 different parameters showed that soluble and total fractions of organic matter (N_org, Sc, Sp, Tp, TKN/COD, tCOD and sCOD) during plant operation and storage conditions correlated (r between 0.80 and 0.99) with the variation in polymer dose, floc strength and CST of conditioned digestate samples. The variations occurred within the content of soluble and total fractions of organic matter, and showed to correlate with both conditioning requirements and the variation in [Formula: see text] . The work concluded that [Formula: see text] measurements of unconditioned digestate samples have the potential to be used as a parameter to monitor conditioning requirements during digestate storage or during process changes. It was found important to analyse soluble and total fractions of organic matter in order to understand the changes in [Formula: see text] within specific process conditions.

[Traveller's diarrhoea]

Traveller's diarrhoea (TD) is acquired primarily through ingestion of food and drinks contaminated with pathogens that cause diarrhoea. They can be bacteria, protozoa, helminths, and viruses. Globally, the most common causes of TD are two pathotypes of Escherichia coli (enterotoxigenic and enteroaggregative) and Campylobacter, although there are significant variations by geographic area visited. Most TD occurs in individuals traveling to low-middle income countries. The type of travel, length of stay, traveller's age, and the presence of certain underlying conditions are important risk factors to consider for the acquisition of TD. While TD is usually a mild and self-limiting disease, half of travellers with TD experience some limitation of activities during their trip, while up to 10% will experience persistent diarrhoea or other complications. The purpose of this article is to provide an updated microbiological, epidemiological, and clinical profile of traveller's diarrhoea, including known risk factors, as well as to make recommendations on the prevention and treatment of TD.

High-voltage electrical burns due to copper theft - Case series

Electrical burns are among the most devastating trauma inflicted on the human body. These burns have a higher morbidity, length of stay and a much higher risk of amputation than any other type of burn. Electrical burns affect mostly young, working males because they are more frequently the result of a work accident. However, possibly due to the worldwide economic crisis, we are experiencing a new phenomenon: the theft of high-voltage copper wiring.

Starch characterization in seven raw, boiled and roasted chestnuts (Castanea sativa Mill.) cultivars from Portugal

Changes occurring in seven chestnut (Castanea sativa sp.) cultivars, caused by boiling and roasting, on starch content, cell and starch granules dimension were evaluated, and morphological changes were characterized by scanning electron microscopy. Three clear patterns of variation were detected after processing, namely: i) decrease of starch content with processing; ii) starch increase with the applied treatments; iii) increase of starch with boiling and decrease with roasting. Starch granules of raw chestnuts presented round, oval or elliptical form, external smooth surface and eccentric hilum, with rather ellipsoid-shaped growth rings. Processing resulted in modifications of the granules, with fusion of individual granules, and gelatinization taking place with the formation of elongated clusters. The present results indicate that boiling and roasting, besides changing the starch content of chestnut, causes important modifications in the starch granules, which can affect the sensory, rheological and chemical characteristics of chestnuts.

Implementation of multivariate techniques for the selection of volatile compounds as indicators of sensory quality of raw beef

This study was performed in order to select volatile compounds to predict the off-odour and overall assessment of raw beef's freshness Maronesa breed, using multivariate analysis. M. longissimus dorsi packed in vacuum and MAP (70 % O2/20 % CO2/10 % N2) stored at 4 ºC were examined for off-odour perception as well as the overall assessment of freshness at 10 and 21 days post mortem. The results achieved in this study demonstrated that the selected volatile compounds could be considered as volatile indicators of beef spoilage, enclosing information for discrimination of Maronesa beef samples in sensory classes of odour corresponding to unspoiled and spoiled levels. Fifty-four volatile compounds were detected. A significant increase of aldehydes, ketones and alcohols were observed during storage in MAP. 2 and 3-methylbutanal, 2 and 3-methylbutanol, 1-pentanol, 1-hexanol, 2,3-octanedione, 3,5-octanedione, octanal and nonanal were suggested as indicators of beef spoilage. 3-methylpentane was considered as a marker in the first stages of spoilage in beef, decreasing during storage. Data were examined using PCR and PLSR models for different optimal subsets of volatile compounds. The simplicity and usefulness of the technique in using 0/1 data in preserving high levels of accuracy was also prevalent. The powerful analytical methodologies for reducing variables and the choice of optimal subsets could be advantageous in both basic research and the routine quality control of chilled beef.

Impact of isoniazid preventive therapy on mortality among children less than 5 years old following exposure to tuberculosis at home in Guinea-Bissau: a prospective cohort study

OBJECTIVE

In a cohort of children less than 5 years old exposed to adult intrathoracic tuberculosis (TB) in 1996-1998, we found 66% increased mortality compared with community controls. In 2005, we implemented isoniazid preventive therapy (IPT) for children exposed to TB at home, and the present study evaluates the effect of this intervention on mortality.

SETTING

This prospective cohort study was conducted in six suburban areas included in the demographic surveillance system of the Bandim Health Project in Bissau, the capital city of Guinea-Bissau.

PARTICIPANTS

All children less than 5 years of age and living in the same house as an adult with intrathoracic TB registered for treatment in the study area between 2005 and 2007 were evaluated for inclusion in the IPT programme. MAIN OUTCOME MEASURES (END POINTS): The all-cause mortality rate ratio (MRR) between exposed children on IPT, exposed without IPT and unexposed community control children.

RESULTS

A total of 1396 children were identified as living in the same houses as 416 adult TB cases; of those, 691 were enrolled in the IPT programme. Compared with community controls, the IPT children had an MRR of 0.30 (95%CI 0.1 to 1.2). The MRR comparing exposed children with and without IPT was 0.21 (0.0 to 1.1). The relative mortality in IPT children compared with community controls in 2005-2008 differed significantly from the relative mortality of exposed untreated children compared with the community controls in 1996-1998 (test of interaction, p=0.01).

CONCLUSIONS

In 2005-2008, exposed children on IPT had 70% lower mortality than the community control children, though not significantly. Relative to the community control children, the mortality among TB-exposed children on IPT in 2005-2008 was significantly lower than the mortality among TB-exposed children not on IPT in 1996-1998.

Utility of the plasma level of suPAR in monitoring risk of mortality during TB treatment

Objective

To investigate whether changes in the plasma level of soluble urokinase plasminogen activator receptor (suPAR) can be used to monitor tuberculosis (TB) treatment efficacy.

Design

This prospective cohort study included 278 patients diagnosed with active pulmonary TB and followed throughout the 8-month treatment period.

Results

Mortality during treatment was higher in the highest inclusion quartile of suPAR (23%) compared to the lowest three quartiles (7%), the risk ratio being 3.1 (95% CI 1.65–6.07). No association between early smear conversion and subsequent mortality or inclusion suPAR was observed. After 1 and 2 months of treatment, an increase in suPAR compared to at diagnosis was associated with a Mortality Rate Ratio (MRR) of 4.5 (95%CI: 1.45–14.1) and 2.1 (95%CI 0.62–6.82), respectively, for the remaining treatment period.

Conclusions

The present study confirmed that elevated suPAR level at time of initiation of TB treatment is associated with increased risk of mortality. Furthermore, increased suPAR levels after one month of treatment was associated with increased risk of mortality during the remaining 7-month treatment period.

Adherence to isoniazid preventive therapy in children exposed to tuberculosis: a prospective study from Guinea-Bissau

OBJECTIVE

To assess adherence to isoniazid preventive therapy (IPT) in children exposed to adult pulmonary tuberculosis (TB) at home.

METHODS

Children were enrolled on IPT if they were aged ≤ 5 years or 5-15 years and presented a tuberculin skin test induration of ≥ 10 mm. Children were included from the demographic surveillance system of the Bandim Health Project in Bissau, Guinea-Bissau. The main outcome measures were adherence, completion rates and side effects during 9 months of IPT. The main outcome was 6 consecutive months of at least 80% adherence.

RESULTS

A total of 2631 children were identified as contacts of adult TB cases. Among the children identified, 1895 (72%) were evaluated for eligibility for IPT, and 820 were enrolled in the study: 609 were aged ≤ 5 years and 211 aged 5-15 years. A total of 79% of the prescribed doses were taken, with 65% of the children taking > 80% of their doses. In all, 51% completed more than 6 consecutive months of IPT.

CONCLUSION

Overall adherence to IPT was better than previously reported from TB-endemic areas, with 76% of the children completing at least 6 months of treatment, with more than 80% adherence.

Is cerebellar volume related to bipolar disorder?

BACKGROUND

Recent data suggest that cerebellum influences emotion modulation in humans. The findings of cerebellar abnormalities in bipolar disorder (BD) are especially intriguing given the link between the cerebellum emotional and behavioral regulation. The purpose of this study was to evaluate cerebellar volume in patients with euthymic BD type I compared to controls. Moreover, we investigated the possible relationship between cerebellar volume and suicidal behavior.

METHODS

Forty-patients with euthymic BD type I, 20 with and 20 without history of suicide attempt, and 22 healthy controls underwent an MRI scan. The participants were interviewed using the Structured Clinical Interview with the DSM-IV axis I (SCID-I), the Hamilton Depression Rating Scale (HDRS), the Young Mania Rating Scale (YMRS) and the Barratt Impulsiveness Scale (BIS-11).

RESULTS

Groups were age, gender and years of schooling-matched. The left cerebellum (p=0.02), right cerebellum (p=0.02) and vermis (p<0.01) were significantly smaller in the BD group; however, there were no volumetric differences between the BD subjects with and without suicidal attempt. There was no correlation between cerebellar measurements and clinical variables.

LIMITATIONS

The main strength is that our sample consisted of patients with euthymic BD type I without any comorbidities, however, these results cannot establish causality as the cross-sectional nature of the study.

CONCLUSIONS

Our findings suggest that the reduction in cerebellar volumes observed in BD type I might be a trait-related characteristic of this disorder. Additional studies with larger samples and subtypes of this heterogeneous disorder are warranted to determine the possible specificity of this cerebellar finding.

The current screening programme for congenital transmission of Chagas disease in Catalonia, Spain

Due to considerable numbers of migrants from Chagas disease-endemic countries living in Catalonia, the Catalonian Health Department has recently implemented a screening programme for preventing congenital transmission, targeting Latin American pregnant women who attend antenatal consultations. Diagnosis of Trypanosoma cruzi infection in women is based on two positive serological tests. Screening of newborns from mothers with positive serology is based on a parasitological test during the first 48 hours of life and/or conventional serological analysis at the age of nine months. If either of these tests is positive, treatment with benznidazole is started following the World Health Organization's recommendations. The epidemiological surveillance of the programme is based on the Microbiological Reporting System of Catalonia, a well established network of laboratories. Once a positive case is reported, the responsible physician is asked to complete a structured epidemiological questionnaire. Clinical and demographic data are registered in the Voluntary Case Registry of Chagas Disease, a database administered by the Catalonian Health Department. It is expected that this programme will improve the understanding of the real burden of Chagas disease in the region. Furthermore, this initiative could encourage the implementation of similar programmes in other regions of Spain and even in other European countries.