P1278 Budget impact of global longitudinal strain for the early detection of cardiotoxicity incorporation in the brazilian private healthcare system

Funding Acknowledgements

Department of Cardiovascular Imaging / Brazilian Society of Cardiology

Objective

To estimate the budget impact of incorporating global longitudinal strain (GLS) for the early detection of cardiotoxicity in patients under cancer treatment, compared to conventional echocardiographic measurements (ECO) in the Brazilian Private Healthcare System (PHS). Methods: The BI was calculated based on a Markov constructed with the following health states: no changes, cardiotoxicity, heart failure, reversibility and death, with annual cycles. Eligible population was estimated through an epidemiological approach, based on the prevalence of cancer, proportion of cancer patients treated with anthracyclines and proportion of patients covered by health plans. The time horizon was 5 years, with perspective of the PHS. One scenario was built considering only the cost of GLS and ECO, whereas the other scenario included direct medical costs related to the management of cardiotoxicity and heart failure. Probabilistic sensitivity analyses were performed to explore uncertainties. Results: The initial eligible population was estimated in 209,657 patients. The scenario considering only GLS and ECO procedures costs resulted in a positive BI, from BRL3.6 million in the first year to R$ 59 million in the fifth year. Considering total costs, the incorporation of GLS has the potential to result in savings to PHS from the fourth year of incorporation. In the fifth year the economy reaches about R$ 9 million. Deterministic results are corroborated by the probabilistic analyses. Conclusion: Cardiotoxicity has a major impact in cancer patients treated with anthracyclines, being associated with increased risk of heart failure and mortality. Since GLS has the potential of early detection of cardiotoxicity, allowing the rapid onset of treatment, the use of GLS has the potential to promote savings for the private healthcare system.

Abstract P1278 Figure. budget impact of GLS

Simultaneous Bilateral Primary Choroidal Melanoma

A case of bilateral primary choroidal melanoma is described. To our knowledge, this is the first reported case in Spain. On admission of a 70-year-old man for a choroidal melanoma in the right eye, an asymptomatic tumor was detected in the periphery of his left eye. A-scan ultrasonography, fluorescein angiography and diascleral transillumination supported the diagnosis of choroidal melanoma in both eyes. The right eye was enucleated. Histology confirmed a choroidal melanoma of the mixed type. The left eye was treated with laser photocoagulation and an episcleral plaque of ruthenium-106. Careful systemic evaluation produced no evidence of a primary tumor or metastatic disease elsewhere in the body. Because of the impossibility, in most cases, of obtaining histological confirmation in both eyes, and the tendency of choroidal melanomas to metastatize late, we suggest that the criteria of independent origin (two separate cell types and tumors separated in time) are not necessary in cases of presumed bilateral choroidal melanoma.

Pyometra and unilateral uterine horn torsion in a sheep

A 13-year-old Romanov sheep presented for evaluation of vaginal discharge, depression and anorexia. Blood work demonstrated mature neutrophilia and marked hyperlactatemia. Transrectal and transabdominal ultrasound revealed echogenic fluid (pus) within the uterus. Purulent uterine fluid culture yield Escherichia coli. A diagnosis of pyometra was made. After medical treatment without clinical improvement, an exploratory laparotomy was performed, and a 360-degree uterine left horn torsion was identified with the pyometra and multiple corpora lutea on both ovaries. Ovariohysterectomy was performed and the ewe recovered uneventfully.

Characterization of alkylsilane self-assembled monolayers by molecular simulation

Self-assembled monolayers (SAM) of dodecyltrichlorosilane (DTS) and octadecyltrichlorosilane (OTS) on silica are studied by molecular dynamics simulations at 298 K and 1 bar. The coverage (number of alkylsilane molecules per surface area) is systematically varied. The results yield insight into the properties of the alkylsilane SAMs, which complement experimental studies from the literature. Relationships are reported between thickness, tilt angle, and coverage of alkylsilane SAMs, which also hold for alkylsilanes other than DTS and OTS. They are interpreted based on the information on molecular ordering in the SAMs taken form the simulation data. System size and simulation time are much larger than in most former simulation works on the topic. This reduces the influence of the initial configuration as well as the periodic boundary conditions and hence minimizes the risk of artificial ordering. At the same time, more reliable statistics for the calculated properties can be provided. The evaluation of experimental data in the field is often based on strongly simplified models. The present simulation results suggest that some of these lead to errors, concerning the interpretation of experimental results, which could be avoided by introducing more realistic models.

Potential of Spartina maritima in restored salt marshes for phytoremediation of metals in a highly polluted estuary

Sedimentary abiotic environment, and concentration and stock of nine metals were analyzed in vegetation and sediments to evaluate the phytoremediation capacity of restored Spartina maritima prairies in the highly polluted Odiel Marshes (SW Iberian Peninsula). Samples were collected in two 10 -m long rows parallel to the tidal line at two sediments depths (0-2 cm and 2-20 cm). Metal concentrations were measured by inductively coupled plasma spectroscopy. Iron, aluminum, copper, and zinc were the most concentrated metals. Every metal, except nickel, showed higher concentration in the root zone than at the sediment surface, with values as high as ca. 70 g Fe kg(-1). The highest metal concentrations in S. maritima tissues were recorded in its roots (maximum for iron in Spartina roots: 4160.2 +/- 945.3 mg kg(-1)). Concentrations of aluminum and iron in leaves and roots were higher than in superficial sediments. Rhizosediments showed higher concentrations of every metal than plant tissues, except for nickel. Sediment metal stock in the first 20 cm deep was ca. 170.89 t ha(-1). Restored S. maritima prairies, with relative cover of 62 +/- 6%, accumulated ca. 22 kg metals ha(-1). Our results show S. maritima to be an useful biotool for phytoremediation projects in European salt marshes.

Ecotypic variations in phosphoenolpyruvate carboxylase activity of the cordgrass Spartina densiflora throughout its latitudinal distribution range

This study compared the specific activity of phosphoenolpyruvate carboxylase (PEPC) of Spartina densiflora Brongn., collected from four populations along its latitudinal distribution range. Spartina densiflora is a halophyte with C(4) photosynthesis that has a very wide latitudinal distribution, from Patagonia to the southwest Iberian Peninsula. The basis of intraspecific differences in PEPC activity were analysed by recording the phosphorylation state and amount of the enzyme, comparing leaf anatomy and evaluating leaf gas exchange. S. densiflora individuals from Patagonia had 60% higher PEPC specific activity than plants from the other three populations due to higher levels of PEPC protein that coincided with lower activation mediated by phosphorylation, yielding similar net photosynthesis rate (c. 29 micromol CO(2)xm(-2)xs(-1)). Patagonian plants had a higher area of photosynthetic mesophyll relative to total chlorophyll than plants from north Argentina and the southwest Iberian Peninsula. Ecotypic differentiation in PEPC activity and leaf anatomy were found, distinguishing a higher-latitude ecotype from lower-latitude populations. The higher PEPC protein levels of the Patagonian ecotype seemed to be a response to lower light activation level of the enzyme, as judged by the low PEPC phosphorylation state.

Identification of adsorption sites in Cu-BTC by experimentation and molecular simulation

The adsorption of several quadrupolar and nonpolar gases on the Metal Organic Framework Cu-BTC has been studied by combining experimental measurements and Monte Carlo simulations. Four main adsorption sites for this structure have been identified: site I close to the copper atoms, site I' in the bigger cavities, site II located in the small octahedral cages, and site III at the windows of the four open faces of the octahedral cage. Our simulations identify the octahedral cages (sites II and III) and the big cages (site I') as the preferred positions for adsorption, while site I, near the copper atoms, remains empty over the entire range of pressures analyzed due to its reduced accessibility. The occupation of the different sites for ethane and propane in Cu-BTC proceeds similarly as for methane, and shows small differences for O2 and N2 that can be attributed to the quadrupole moment of these molecules. Site II is filled predominantly for methane (the nonpolar molecule), whereas for N2, the occupation of II and I' can be considered almost equivalent. The molecular sitting for O2 shows an intermediate behavior between those observed for methane and for N2. The differences between simulated and experimental data at elevated temperatures for propane are tentatively attributed to a reversible change in the lattice parameters of Cu-BTC by dehydration and by temperature, blocking the accessibility to site III and reducing that to site I'. Adsorption parameters of the investigated molecules have been determined from the simulations.

Molecular simulations for adsorption and separation of natural gas in IRMOF-1 and Cu-BTC metal-organic frameworks

We use Monte Carlo simulations to study the adsorption and separation of the natural gas components in IRMOF-1 and Cu-BTC metal-organic frameworks. We computed the adsorption isotherms of pure components, binary, and five-component mixtures analyzing the siting of the molecules in the structure for the different loadings. The bulk compositions studied for the mixtures were 50 : 50 and 90 : 10 for CH4-CO2, 90 : 10 for N2-CO2, and 95 : 2.0 : 1.5 : 1.0 : 0.5 for the CH4-C2H6-N2-CO2-C3H8 mixture. We choose this composition because it is similar to an average sample of natural gas. Our simulations show that CO2 is preferentially adsorbed over propane, ethane, methane and N2 in the complete pressure range under study. Longer alkanes are favored over shorter alkanes and the lowest adsorption corresponds to N2. Though IRMOF-1 has a significantly higher adsorption capacity than Cu-BTC, the adsorption selectivity of CO2 over CH4 and N2 is found to be higher in the latter, proving that the separation efficiency is largely affected by the shape, the atomic composition and the type of linkers of the structure.

[Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts]

INTRODUCTION AND OBJECTIVES

Recurrence of infection is observed in a high proportion of patients who have had infective endocarditis in the past. The aim of our study was to evaluate the possible differences between the first and the recurrent episodes of endocarditis, as well as to assess the outcome and prognosis of patients with recurrent endocarditis.

PATIENTS AND METHOD

We reviewed a series of 13 episodes of recurrent endocarditis from among 196 cases of infective endocarditis involving non-drug-addict patients in two hospitals from 1987 to 2000.

RESULTS

There were no differences between recurrent and first episodes of endocarditis according to age, sex, heart valve involved or causal microorganisms. Prosthetic valve endocarditis was more common in patients with recurrent endocarditis (86% versus 27%; p < 0.001). Although there were no differences in the rate of complications or early surgery, overall mortality was significantly higher in patients with recurrent endocarditis (53% versus 27%: p < 0.05). When early and late mortality were analysed separately, the differences did not achieve significance.

CONCLUSIONS

Recurrent endocarditis was frequent in our series (7% of all cases). The features were similar to those of the first episode except for a higher rate of prosthetic valve endocarditis and a higher overall mortality.

Watchful waiting in cases of small abdominal aortic aneurysms- appropriate for all patients?

OBJECTIVE

The purpose of this study was to determine the effect of patient compliance on a program of watchful waiting in cases of small abdominal aortic aneurysms and to document the proportion of patients who become prohibitive operative risks during follow-up.

STUDY DESIGN

A retrospective review was conducted at a regional military veterans medical center. The subjects were 101 male military veterans with abdominal aortic aneurysms measuring less than 5 cm who did not have medical contraindications to operative repair. The main outcome measures were (1) the proportion of patients who missed three scheduled radiologic tests in a row despite written notifications mailed to their homes and (2) the proportion of compliant patients who had medical illnesses and became prohibitive operative risks during follow-up.

RESULTS

During a follow-up (mean +/- SEM) of 34 +/- 2 months, 69 patients (69%) were fully compliant with the watchful waiting program and underwent a mean of 4.5 +/- 0.3 radiologic tests. There were no abdominal aortic aneurysm ruptures in this subgroup. Twenty-five patients (36%) had indications for abdominal aortic aneurysm repair, and 28 (41%) have not met the criteria for repair. Sixteen (23%) of the 69 compliant patients developed prohibitive medical risks during follow-up; eight (50%) of these 16 patients died, all of the causes unrelated to their abdominal aortic aneurysms. Thirty-two (32%) of the 101 study subjects were noncompliant with the watchful waiting program. Twenty-seven (84%) of the noncompliant patients did not keep any scheduled appointments, and five (16%) were lost after one or two examinations. Three of the noncompliant patients experienced documented abdominal aortic aneurysm rupture, and it is suspected in a fourth. Direct contact was made with 28 (88%) of these patients or their families; all acknowledged having received written notifications regarding their watchful waiting program tests and had decided not to continue with surveillance for a variety of socioeconomic reasons. Between the 69 compliant patients and the 32 noncompliant patients, there were no differences with respect to mean age (70 +/- 1 years vs 73 +/- 2 years), distance from home of record to the hospital (62 +/- 14 miles vs 73 +/- 23 miles), or abdominal aortic aneurysm size at initial detection (3.75 +/- 0.5 cm vs 3.8 +/- 0.5 cm).

CONCLUSIONS

Watchful waiting programs are imperfect and highly reliant on the motivation levels and means of the individual patients. Watchful waiting is reasonable among compliant patients with abdominal aortic aneurysms, inasmuch as fewer than half will meet the criteria for intervention within a mean of 3 years. Approximately one fourth of these patients will have medical contraindications to abdominal aortic aneurysm repair during follow-up, and many of these will die of causes other than abdominal aortic aneurysm rupture. In our experience, one third of candidates for watchful waiting programs are unable to participate and are at risk of rupture. These patients need special attention so that the reasons for their noncompliance can be determined, and they may be candidates for earlier intervention.

Endoscopic local injection of ethanolamine oleate and thrombin as an effective treatment for bleeding duodenal ulcer: a controlled trial

The injection of a mixture of ethanolamine oleate and thrombin as an effective treatment for bleeding duodenal ulcer was evaluated in 38 patients entered in a randomised prospective controlled trial. After a one week observation period, 1/19 (5.3%) treated patients and 11/19 (57.9%) control patients had suffered further bleeding (p less than 0.005; CI = 22%-74%). Emergency surgery was required in 1/19 in the treated group compared with 8/19 in the untreated group (CI = 13%-61%; p less than 0.05). The mean (SD) transfusion requirement in the treated group was 1.9 (0.5) U blood compared with 5.3 (0.7) U in the control group. No significant differences related to mortality were detected. In conclusion, local injection therapy is an effective means of haemostasis in patients with bleeding duodenal ulcer who are at risk of further bleeding.

Low dose epirubicin for hypercalcemia associated with renal pelvis carcinoma

We present a case of hypercalcemia associated with a renal pelvis squamous neoplasm. Severe hyperleukocytosis was also present, resembling a leukaemoid reaction. After failure of standard therapy, we performed a trial of low dose epirubicin in this patient, obtaining a short-term clinical remission. Although a palliative non-toxic effect seems to be achievable with this approach, further studies are needed to ascertain the role of chemotherapy in the long-term control of this condition.

A comparative study of eight intraocular lens calculation formulas

A retrospective study of 183 eyes that had undergone extracapsular cataract extraction and posterior chamber intraocular lens (IOL) implantation was undertaken to compare the accuracy of eight IOL power calculation formulas (modified Binkhorst, Colenbrander, Gullstrand, Fyodorov-Galin-Linksz, Gill, Axt, Donzis-Kastle-Gordon and SRK regression). We found that the regression formulas were more accurate than the theoretical formulas, giving enough approximation to the ideal IOL as to assure its clinical use. We prefer the SRK formula because it is easier and it has a constant A that can be adapted in a personalized way to each surgical team.

[Inverted type transitional cell papilloma of the bladder: apropos of a case]

We present a fresh case of inverted type, transitional cell Papilloma in a 70-year-old woman, with a right laterovesical location. This case was dried up 6 years ago, treated with cytostatics and is currently controlled without relapses. Despite being considered a benign entity, its uncertain evolution and its association with other urothelium tumours call for an attitude of extreme caution.

The effect of endocervical PGE2-gel (Prepidil) gel on plasma levels of 13,14-dihydro-15-keto-PGE2 (PGEM) in women at term

Term pregnant patients undergoing preinduction cervical softening were randomized to receive no treatment (controls) or 0.5 mg PGE2-triacetin gel (Prepidil gel) endocervically. Plasma samples containing PGEM collected 4 hrs post-treatment and converted to the stable bicyclo degradation product (bicyclo-PGEM) were assayed by RIA. Positive clinical effect (responders) during 12 hrs after treatment (Bishop score increase greater than or equal to 3, in labor or delivered) were assessed. All evaluations were blind. In nonresponders (n = 35), the means of the bicyclo-PGEM variables (mean, maximum, area under the curve) were all about 18% higher in gel-treated patients (n = 6) than controls (n.s.). In responders (n = 38), the variables were all about 80% higher in gel-treated women (n = 32) than controls (p less than .01). In controls (n = 35), the responders (n = 6) had 50% higher levels than nonresponders (n.s.). In the gel-treated women (n V 38), responders (n = 32) had about 140% higher levels than nonresponders (less than .01). The results suggest that both exogenous and endogenous bicyclo-PGEM were measured. Differences in pairwise comparisons suggest that there may be substantially less exogenous bicyclo-PGEM in the gel nonresponders than in gel responders or substantially more endogenous bicyclo-PGEM in gel responders than in control-responders.

Growth and Development of Romanomermis culicivorax In Vitro

Various combinations of vertebrate and invertebrate tissue culture and microbiological media were utilized in an attempt to culture Romanomermis culicivorax (Mermithidae: Nematoda) in vitro. Most media were unsuitable and caused nematodes to become lumpy, vacuolated, and granular. Slow and limited growth and development of internal structures of the nematodes were obtained with variously supplemented Grace's tissue culture and Schneider's Drosophila media. In an enriched Grace's medium, development attained by the nematodes after 3-4 wk was comparable to 4-5-day-old parasites grown in vivo in the mosquito host, Culex pipiens. Two molts were observed in vitro. Maximum dimensions in vitro were 7.0-mm length and 87-mum width at the widest point. The stichosome, stichocytes, and trophosome developed prominently. A filiform tail and highly cuticularized tube persisted throughout the culture period in vitro.

Studies on ageing in Turbatrix aceti

Morphologic and physiologic changes which occur during senescence in the free-living nematode Turbatrix aceti are described. With age areas of the interchordal hypodermis containing nerve elements thickened, electron-dense aggregates formed within the pseudocoelom and age pigment granules accumulated within the intestinal epithelium. Specific gravity did not change with age. Old nematodes which had reproduced showed increased osmotic fragility, but this change was not observed in virgin females. The parameters characterizing senescence in T. aceti are compared with those of Caenorhabditis briggsae, another nematode being used as a model to study biological ageing.

Organic Acids of Ditylenchus triformis and Turbatrix aceti

Pyruvic acid, lactic acid and several tricarboxylic acid cycle acids were extracted from Ditylenchus triformis and Turbatrix aceti and identified. Fumaric acid was predominant in both nematodes. Small amounts o f malic and alpha-ketoglutaric acids and intermediate quantities o f lactic, citric, succinic, and pyruvic acids occurred in D. triformis. In T. aceti citric, lactic, and alpha-ketoglutaric acids were less abundant than succinic, malic and pyruvic acids. Only traces of aconitic and oxalacetic acids occurred in both nematodes. All the organic acids detected accounted for only about one per cent of the dry weight of nematodes o f the two species.