Preliminary results from REALITY: a nation-wide study of a database with 1.8 million real-life patients to study atherosclerotic cardiovascular disease and familial hypercholesterolemia in Spain

Introduction

Ischemic heart disease and stroke are the leading causes of premature death worldwide. Atherosclerotic cardiovascular disease (ASCVD) is the main determining factor for these and other life-threatening pathologies, such as peripheral artery disease (PAD). LDL-lowering therapies are the gold standard to prevent ASCVD. These treatments are also used for familial hypercholesterolemia (FH), a genetic disorder manifesting with high LDL levels. It is crucial to evaluate the management and level of LDL control in “real-life” patients with ASCVD and FH, but so far very few large-scale studies have focussed on these issues. REALITY is an observational retrospective study of ASCVD and FH in Spain.

Purpose

The goals of REALITY included the analysis of the demographic and clinical characteristics, comorbidities, and concomitant medication of patients with ASCVD and/or FH by a multidisciplinary group of experts. The lipid-lowering therapies used in Spain were assessed, and patient LDL levels were evaluated according to treatment intensity during the two-year follow-up period.

Methods

Electronic medical records were retrieved from the BIG-PAC® database that includes anonymized data of patients from seven health areas in Spain. The study population included patients presenting a new or recurrent episode of ASCVD (n=26,976) or a new diagnosis of FH (n=572) during the recruitment period (from 01/01/2017 to 31/12/2018). The index date was defined as the date of the event/diagnosis, and a 2-year follow-up was established.

Results

The average age was 69.9±11.5 for ASCVD patients and 60.1±12 for FH patients (59.4% and 48.6% males, respectively). The average Charlson index was 2.2±1.6 in ASCVD and 1.2±1.4 in FH. The comorbidities most frequently observed in ASCVD vs. FH were hypercholesterolaemia (55% vs. 100%), arterial hypertension (65% vs. 54%), diabetes mellitus (31% vs. 29%) and obesity (31% vs. 21%). Around 25% and 6% of patients with ASCVD and FH, respectively, presented CV events in the follow-up. During the 24-month period, the highest rate of ischemic heart disease was observed in patients with LDL levels of 55–69 mg/dL, whereas LDL levels below 55 mg/dL were associated with the highest incidence of PAD. The highest lipid biochemical reductions in ASCVD vs. FH were observed in total cholesterol (−52±17.4 vs. −53.5±21.3 mg/dL), triglycerides (−53±7.9 vs. −54.2±8.8 mg/dL) and LDL (−27.4±10.4 vs. −29±12.3 mg/dL). HDL levels showed an average increase of 8.5±2 vs. 9.3±2.5 mg/dL. Treatment intensity correlated with reduction of LDL levels in all ASCVD disease subgroups and FH patients (Table 1).

Conclusions

The results of REALITY provide an estimated clinical picture of ASCVD and FH in Spain. The impact of therapeutical approaches on LDL levels and the prevention of CV events were evaluated by a multidisciplinary group of experts. The findings of the study will help lower the burden of ASCVD and FH in Spain.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): REALITY study was sponsored by Novartis. Statistical analysis of the BIG-PAC® database was performed by Atrys Health. Medical writing and editing were provided by Medical Science Consulting. All funded by Novartis.

The REALITY project: analysis of a national database with 1.8 million real-life patients to study atherosclerotic cardiovascular disease and familial hypercholesterolemia in Spain

Introduction

Atherosclerotic cardiovascular disease (ASCVD), hypercholesterolaemia, and familial hypercholesterolaemia (FH) are associated with high mortality, morbidity and direct/indirect economic costs worldwide. However, information about patient characteristics, clinical practice, treatment effectiveness, and economic costs is limited in Spain. To address this issue, a multidisciplinary working group of cardiologists, hospital pharmacists, family physicians, internal medicine specialists, and neurologists took part in the nationwide, observational, retrospective REALITY study. Using information from the Spanish National Health System (SNHS), the group will describe the treatment patterns and clinical profiles of patients with ASCVD and/or FH in Spain.

Methods and results

REALITY will access 1.8 million electronic medical records in the BIG-PAC® database, which collects anonymised data (in compliance with Organic Law 3/2018 of 5 December) from SNHS primary care centres and hospitals across seven regional health areas in Spain. REALITY was approved by the Hospital of Terrassa Ethics Committee on 17/11/2020. Patients presenting a new/recurrent episode of ASCVD or diagnosed with FH from 01/01/2017 to 31/12/2018 were recruited. The index date was the date of the event/diagnosis, and a two-year follow-up was established. Patients were classified as FH or ASCVD on the basis of their primary diagnosis (five subgroups: stable/unstable angina, acute myocardial infarction, ischemic stroke, transient ischemic attack, and peripheral arterial disease). Primary objectives were to determine demographic and clinical characteristics, comorbidities, and concomitant medication. Secondary objectives were to determine the lipid-lowering therapy applied, persistence of medication and modifications, the rationale for switching therapy, and treatment adherence (including data from non-adherent patients). Endpoints were low-density lipoprotein (LDL) levels, prevalence and incidence of new events, use of healthcare resources (e.g., medical visits or tests, coronary artery bypass surgery, hospitalizations, etc.), and healthcare costs. Using the aforementioned variables, these endpoints were analysed globally according to disease classification. Exploratory objectives included estimation of the percentage of statin-intolerant patients, and a subanalysis of costs according to the intensity of the lipid-lowering treatment and LDL levels.

Conclusions

The power of the “real-life” data from the BIG-PAC® database and the multidisciplinary approach used in this study will facilitate a wide range of analyses/subanalyses of various clinical issues, including treatment, disease burden, and economic costs. This study will give healthcare practitioners and policy makers valuable data for cardiovascular secondary prevention, control, and strategies to improve management.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The REALITY study is sponsored by Novartis. Statistical analysis of the BIG-PAC® database was performed by Atrys Health. Medical writing and editing were provided by Medical Science Consulting. All funded by Novartis.

Paternal low protein diet perturbs inter-generational metabolic homeostasis in a tissue-specific manner in mice

The underlying mechanisms driving paternally-programmed metabolic disease in offspring remain poorly defined. We fed male C57BL/6 mice either a control normal protein diet (NPD; 18% protein) or an isocaloric low protein diet (LPD; 9% protein) for a minimum of 8 weeks. Using artificial insemination, in combination with vasectomised male mating, we generated offspring using either NPD or LPD sperm but in the presence of NPD or LPD seminal plasma. Offspring from either LPD sperm or seminal fluid display elevated body weight and tissue dyslipidaemia from just 3 weeks of age. These changes become more pronounced in adulthood, occurring in conjunction with altered hepatic metabolic and inflammatory pathway gene expression. Second generation offspring also display differential tissue lipid abundance, with profiles similar to those of first generation adults. These findings demonstrate that offspring metabolic homeostasis is perturbed in response to a suboptimal paternal diet with the effects still evident within a second generation.

Poor paternal diet leads to changes in offspring tissue lipid abundance that is still evident in a second generation.

Characteristics of stroke units and stroke teams in Spain in 2018. Pre2Ictus project

INTRODUCTION

The aim of this work is to describe the characteristics of stroke units and stroke teams in Spain.

METHODS

We performed a cross-sectional study based on an ad-hoc questionnaire designed by 5 experts and addressed to neurologists leading stroke units/teams that had been operational for ≥ 1 year.

RESULTS

The survey was completed by 43 stroke units (61% of units in Spain) and 14 stroke teams. A mean (standard deviation) of 4 (3) neurologists were assigned to each stroke unit/team; 98% of stroke units (and 38% of stroke teams) have an on-call neurologist available 24 hours a day, 98% of units (79% of stroke teams) included specialised nurses, 86% of units (71% of stroke teams) included a social worker, and 81% of units (71% of stroke teams) included a rehabilitation physician. Most stroke units (80%) had 4--6 beds with continuous non-invasive monitoring. The mean number of unmonitored beds was 14 (8) for stroke units and 12 (7) for stroke teams. The mean duration of non-invasive monitoring was 3 (1) days. All stroke units and 86% of stroke teams had intravenous thrombolysis available, and 81% of stroke units and 21% of stroke teams were able to perform mechanical thrombectomy, whereas the remaining centres had referral pathways in place. Telestroke systems were in place at 44% of stroke units, providing support to a mean of 4 (3) centres. Activity is recorded in clinical registries by 77% of stroke units and 50% of stroke teams, but less than 75% of data is completed in 25% of cases.

CONCLUSIONS

Most stroke units/teams comply with the current recommendations. The systematic use of clinical registries should be improved to further improve patient care.

Proprotein convertase subtilisin/kexin type 9 inhibitors in secondary prevention of vascular events in patients with stroke: Consensus document and practice guidance

INTRODUCTION

Patients with history of stroke or transient ischaemic attack present considerable risk of future vascular events. Reducing levels of low-density lipoprotein (LDL) cholesterol decreases the incidence of new vascular events, although in a substantial number of patients, the currently available lipid-lowering therapies fail to achieve the therapeutic goals recommended in clinical guidelines. The aim of this consensus statement is to provide updated information on the role of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab in the secondary prevention of vascular events in patients with history of ischaemic stroke.

METHODS

A literature review was performed to identify the main evidence on the use of PCSK9 inhibitors in these patients and the recommended therapeutic targets of LDL cholesterol. The results were discussed in 2 consensus meetings that constituted the basis for the drafting of the document.

CONCLUSIONS

PCSK9 inhibitors are effective in reducing vascular risk in secondary prevention; evolocumab specifically has achieved this reduction in patients with history of ischaemic stroke. Moreover, both alirocumab and evolocumab present good safety profiles, even in patients achieving LDL cholesterol levels <20 mg/dL, and no signs of cognitive impairment have been observed in patients treated with evolocumab who achieved very low levels of LDL cholesterol. In the light of this evidence, we provide practical recommendations about the use of PCSK9 inhibitors in secondary prevention of vascular events in patients with history of ischaemic stroke and follow-up of these patients.

Dyslipidemias and stroke prevention: recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

Dyslipidemias and stroke prevention: Recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55 mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

Proprotein convertase subtilisin/kexin type 9 inhibitors in secondary prevention of vascular events in patients with stroke: Consensus document and practice guidance

INTRODUCTION

Patients with history of stroke or transient ischaemic attack present considerable risk of future vascular events. Reducing levels of low-density lipoprotein (LDL) cholesterol decreases the incidence of new vascular events, although in a substantial number of patients, the currently available lipid-lowering therapies fail to achieve the therapeutic goals recommended in clinical guidelines. The aim of this consensus statement is to provide updated information on the role of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab in the secondary prevention of vascular events in patients with history of ischaemic stroke.

METHODS

A literature review was performed to identify the main evidence on the use of PCSK9 inhibitors in these patients and the recommended therapeutic targets of LDL cholesterol. The results were discussed in 2 consensus meetings that constituted the basis for the drafting of the document.

CONCLUSIONS

PCSK9 inhibitors are effective in reducing vascular risk in secondary prevention; evolocumab specifically has achieved this reduction in patients with history of ischaemic stroke. Moreover, both alirocumab and evolocumab present good safety profiles, even in patients achieving LDL cholesterol levels < 20 mg/dL, and no signs of cognitive impairment have been observed in patients treated with evolocumab who achieved very low levels of LDL cholesterol. In the light of this evidence, we provide practical recommendations about the use of PCSK9 inhibitors in secondary prevention of vascular events in patients with history of ischaemic stroke and follow-up of these patients.

Recommendations of the Spanish Society of Neurology for the prevention of stroke. Interventions on lifestyle and air pollution

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.

DEVELOPMENT

We reviewed the most recent studies related to lifestyle and stroke risk, including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.

CONCLUSIONS

Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.

Evaluating the influence of progesterone concentration and time of exposure on in vitro endometrial decidualisation

This study aimed to evaluate the influence of progesterone (concentration and time of exposure) on endometrial decidualisation using an in vitro model cell line: Human Endometrial Stromal Cells (HESCs). HESCs exposed to progesterone (1 and 10 μM) had higher percentages of decidualised cells and higher expression of the decidual marker (Insulin Like Growth Factor Binding Protein 1 (IGFBP1)) compared with those exposed to (0.1 μM). Among those HESCs cultured with 1 μM progesterone for 11 days, the highest rate of morphological differentiation (40-50%) occurred between days 7-9 and IGFBP1 peaked on day 7. The cell-cycle pathway was significantly down-regulated in HESCs exposed to at least 1 μM progesterone regardless of the incubation period. We conclude that exposure to high progesterone concentration for 7-9 days is essential to maximise the process of decidualisation.

Stroke prevention in patients with arterial hypertension: Recommendations of the Spanish Society of Neurology's Stroke Study Group

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology on primary and secondary stroke prevention in patients with arterial hypertension.

DEVELOPMENT

We proposed several questions to identify practical issues for the management of blood pressure (BP) in stroke prevention, analysing the objectives of blood pressure control, which drugs are most appropriate in primary prevention, when antihypertensive treatment should be started after a stroke, what levels we should aim to achieve, and which drugs are most appropriate in secondary stroke prevention. We conducted a systematic review of the PubMed database and analysed the main clinical trials to address these questions and establish a series of recommendations.

CONCLUSIONS

In primary stroke prevention, antihypertensive treatment should be started in patients with BP levels >  140/90 mmHg, with a target BP of < 130/80 mmHg. In secondary stroke prevention, we recommend starting antihypertensive treatment after the acute phase (first 24 hours), with a target BP of < 130/80 mmHg. The use of angiotensin-II receptor antagonists or diuretics alone or in combination with angiotensin-converting enzyme inhibitors is preferable.

Suboptimal mid-luteal progesterone concentrations are associated with aberrant endometrial gene expression, potentially resulting in implantation failure

RESEARCH QUESTION

What is the difference in endometrial transcriptomics between women with normal and with low mid-luteal progesterone during the implantation window?

DESIGN

An endometrial biopsy and serum progesterone concentration were taken from participants during the mid-luteal phase (LH+7 to LH+9). A total of 12 participants were recruited and categorized into two groups based on their progesterone concentrations: normal progesterone (>15 ng/ml, n = 6) and low progesterone (<15 ng/ml, n = 6). Global endometrial gene expression between the two groups was compared by microarray techniques. Principal component analysis was used to display the gene's expression pattern. Pathway and gene ontology enrichment analysis were performed to determine the biological mechanism of progesterone on the endometrium.

RESULTS

Several key genes related to endometrial receptivity were found to be regulated by progesterone. With regard to gene ontology and pathway analysis, progesterone was shown to be mainly involved in structure morphogenesis predominantly during a process of decidualization, extracellular matrix-receptor interaction and cell adhesion. Distinct differences were observed in the transcriptomic profiles between the two groups, indicating potential impairment of endometrial receptivity in women with suboptimal progesterone concentrations. There was a relatively similar pattern of gene expression between endometrial samples with progesterone concentrations approximately 10 ng/ml and >15 ng/ml. Thus, a progesterone concentration of between 10 and 15 ng/ml appears to be sufficient to induce endometrial receptivity.

CONCLUSIONS

Abnormally low progesterone below the threshold of 10-15 ng/ml during the implantation window results in aberrant endometrial gene expression that may affect implantation potential.

Characteristics of stroke units and stroke teams in Spain in 2018. Pre2Ictus project

INTRODUCTION

The aim of this work is to describe the characteristics of stroke units and stroke teams in Spain.

METHOD

We performed a cross-sectional study based on an ad hoc questionnaire designed by 5 experts and addressed to neurologists leading stroke units/teams that had been operational for ≥ 1 year.

RESULTS

The survey was completed by 43 stroke units (61% of units in Spain) and 14 stroke teams. The mean (SD) number of neurologists assigned to each unit/team is 4±3. 98% of stroke units (and 38% of stroke teams) have a neurologist on-call available 24hours, 365 days. 98% of stroke units (79% of stroke teams) have specialised nurse, 95% of units (71% of stroke teams) auxiliary personnel, 86% of units (71% of stroke teams) social worker, 81% of stroke units (71% of stroke teams) have a rehabilitation physician and 81% of stroke units (86% of stroke teams) a physiotherapist. Most stroke units (80%) have 4-6 beds with continuous non-invasive monitoring. The mean number of unmonitored beds is 14 (8) for stroke units and 12 (7) for stroke teams. The mean duration of non-invasive monitoring is 3 (1) days. All stroke units and 86% of stroke teams have intravenous thrombolysis available, and 81% of stroke units and 21% of stroke teams are able to perform mechanical thrombectomy, whereas the remaining centres have referral pathways in place. Telestroke systems are available at 44% of stroke units, providing support to a mean of 4 (3) centres. Activity is recorded in clinical registries by 77% of stroke units and 50% of stroke teams, but less than 75% of data is completed in 25% of cases.

CONCLUSIONS

Most stroke units/teams comply with the current recommendations. The systematic use of clinical registries should be improved to further improve patient care.

Recommendations of the Spanish Society of Neurology for the prevention of stroke. Interventions on lifestyle and air pollution

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.

DEVELOPMENT

We reviewed the most recent studies related to lifestyle and stroke risk, including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.

CONCLUSIONS

Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.

Stroke prevention in patients with arterial hypertension: Recommendations of the Spanish Society of Neurology's Stroke Study Group

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology on primary and secondary stroke prevention in patients with arterial hypertension.

DEVELOPMENT

We proposed several questions to identify practical issues for the management of blood pressure (BP) in stroke prevention, analysing the objectives of blood pressure control, which drugs are most appropriate in primary prevention, when antihypertensive treatment should be started after a stroke, what levels we should aim to achieve, and which drugs are most appropriate in secondary stroke prevention. We conducted a systematic review of the PubMed database and analysed the main clinical trials to address these questions and establish a series of recommendations.

CONCLUSIONS

In primary stroke prevention, antihypertensive treatment should be started in patients with BP levels >140/90mmHg, with a target BP of <130/80mmHg. In secondary stroke prevention, we recommend starting antihypertensive treatment after the acute phase (first 24hours), with a target BP of <130/80mmHg. The use of angiotensin-II receptor antagonists or diuretics alone or in combination with angiotensin-converting enzyme inhibitors is preferable.

Impact of Neospora caninum Infection on the Bioenergetics and Transcriptome of Cerebrovascular Endothelial Cells

In this work, the effects of the protozoan Neospora caninum on the bioenergetics, chemical composition, and elemental content of human brain microvascular endothelial cells (hBMECs) were investigated. We showed that N. caninum can impair cell mitochondrial (Mt) function and causes an arrest in host cell cycling at S and G2 phases. These adverse effects were also associated with altered expression of genes involved in Mt energy metabolism, suggesting Mt dysfunction caused by N. caninum infection. Fourier Transform Infrared (FTIR) spectroscopy analysis of hBMECs revealed alterations in the FTIR bands as a function of infection, where infected cells showed alterations in the absorption bands of lipid (2924 cm⁻¹), amide I protein (1649 cm⁻¹), amide II protein (1537 cm⁻¹), nucleic acids and carbohydrates (1092 cm⁻¹, 1047 cm⁻¹, and 939 cm⁻¹). By using quantitative synchrotron radiation X-ray fluorescence (μSR-XRF) imaging and quantification of the trace elements Zn, Cu and Fe, we detected an increase in the levels of Zn and Cu from 3 to 24 h post infection (hpi) in infected cells compared to control cells, but there were no changes in the level of Fe. We also used Affymetrix array technology to investigate the global alteration in gene expression of hBMECs and rat brain microvascular endothelial cells (rBMVECs) in response to N. caninum infection at 24 hpi. The result of transcriptome profiling identified differentially expressed genes involved mainly in immune response, lipid metabolism and apoptosis. These data further our understanding of the molecular events that shape the interaction between N. caninum and blood-brain-barrier endothelial cells.

THU0562 ECONOMIC IMPACT ASSOCIATED WITH COMPLICATIONS OF WOMEN IN REPRODUCTIVE AGE LIVING WITH INFLAMMATORY IMMUNE-MEDIATED DISEASES (PSO, PSA, RA, AXSPA) IN SPAIN

Background:

Cost of the complications that may appear during reproductive age in women living with inflammatory immune-mediated diseases have scarcely been studied.

Objectives:

To obtain an expert consensus in the use of resources associated to complications of women in reproductive age living with immune-mediated diseases: psoriasis (PSO), psoriatic arthritis (PsA), rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) and estimate an economic impact.

Methods:

A cost-analysis was developed to estimate the impact associated with the complications of women of reproductive age with PSO, PsA, RA and axSpA.

The analysis considered the complications during fertility and conception (preconception consultation and assisted reproduction), in pregnancy (miscarriage in the first trimester, late abortion in the second trimester, preeclampsia, delayed or restricted intrauterine growth and threat of premature delivery) and in the postpartum (admissions in neonatology of premature infants).

An online questionnaire was designed for the validation of the inputs used in the cost-analysis. Subsequently, the questionnaire was sent to a multidisciplinary panel composed of, rheumatologist, gynecologists, neonatologists and dermatologist. A consensus meeting was carried out to validate and agree the parameters used in the analysis.

Unitary cost for resources (€,2019) were obtained from national local databases.

The perspective of analysis was the National Healthcare System and the time horizon was one year.

Results:

During fertility and conception, an annual cost per patient of € 229 was estimated for a preconception consultation in a patient with PSO, of € 3,642 for a preconception consultation in patients with PsA, RA and axSpA and € 4,339 for assisted reproduction.

Women with complications in pregnancy had an annual cost per patient of € 1,214 for a miscarriage in the first trimester, € 4,419 for a late abortion in the second trimester, € 11,251 for preeclampsia € 3,183 for delayed or restricted intrauterine growth and € 12,122 for the threat of premature delivery.

In the postpartum complications, an annual cost per patient of € 120,364, € 44,709 and € 5,507 were estimated associated with admissions in neonatology of premature infants of <28 weeks, from 28 to 32 weeks and from 33 to 37 weeks, respectively.

Conclusion:

This modeling provides insight on the economic burden of complications associated with women in reproductive age for immune-mediated diseases (PSO, PsA, RA, axSpA). Individualization of treatment, additional and close monitoring may reduce the risk and burden of these complications.

Disclosure of Interests:

Julia Martínez-Barrio Consultant of: UCB Pharma, Olga Villar Consultant of: UCB Pharma, Oníca Armijo Consultant of: UCB Pharma, María Castellanos Consultant of: UCB Pharma, Natalia Marín Huarte Consultant of: UCB Pharma, María Mareque Consultant of: UCB Pharma, Miguel Angel Casado Consultant of: UCB Pharma, Nuria Martínez Consultant of: UCB Pharma

Will neurological care change over the next 5 years due to the COVID-19 pandemic? Key informant consensus survey

INTRODUCTION

The COVID-19 pandemic will give rise to long-term changes in neurological care, which are not easily predictable.

MATERIAL AND METHODS

A key informant survey was used to enquire about the changes expected in the specialty over the next 5 years. The survey was completed by heads of neurology departments with broad knowledge of the situation, having been active during the pandemic.

RESULTS

Despite a low level of consensus between participants, there was strong (85%) and moderate consensus (70%) about certain subjects, mainly the increase in precautions to be taken, the use of telemedicine and teleconsultations, the reduction of care provided in in-person consultations to avoid the presence of large numbers of people in waiting rooms, the development of remote training solutions, and the changes in monitoring visits during clinical trials. There was consensus that there would be no changes to the indication of complementary testing or neurological examination.

CONCLUSION

The key informant survey identified the foreseeable changes in neurological care after the pandemic.

P867 Mitral stenosis: from mild to severe in less than a year

We report the case of an 82-year-old woman, with personal history of hypertension, diabetes mellitus, dyslipemia and permanent atrial fibrillation. In 2013 aortic valve substitution surgery was performed with a mechanic prosthetic valve. In her last echocardiogram in May 2018 a mild double mitral lesion was detected, with a normal aortic valve functioning.

In March of 2019 she was admitted in hospital with symptoms of heart failure and 38ºC fever.

A transthoracic echocardiogram was performed, which revealed a vegetation in the native mitral valve that caused a severe mitral stenosis (area 0.64 cm2). In blood cultures Streptococcus gallolyticycus was isolated.

In this situation, a tranesophagical echocardiogram was performed, which confirmed the diagnosis of an infective endocarditis in the native mitral valve. It also showed spontaneous echocontrast as well as a thrombus in the left atrial appendage, despite anticoagulant medication.

Given these findings, antibiotic therapy was initiated and surgery programmed. Substitution of the native mitral valve for a biological prosthesis was made. In the transthoracic echocardiographic control the prosthesis was normal functioning. A colonoscopy was performed taking into account the strong association between Streptococcus gallolyticus and colonic lesions, which showed no abnormal findings. At the discharge the patient had no signs or symptoms suggestive of heart failure or infection.

Streptococcus gallolytycus is included in the D group of Streptococci. Among hospitalized patients, this group accounts for approximately 5% of streptococcal bloodstream isolates. For humans, the gastrointestinal tract is the most frequent entry point, other potential sources include the hepatobiliary tree and the urinary tract. Clinical manifestations include bacteremia and endocarditis, which is usually highly destructive and frequently bivalvular. Bone infection, meningitis or peritonitis can also be present. Due to the frequent association between this microorganism and colonic neoplasm, colonoscopy is necessary to dismiss pathological findings. Typically D Streptococci can be treated with penicillins, ceftriaxone, carbapenems, vancomycin, daptomycin, and linezolid. The preferred regimen for streptococcal prosthetic valve endocarditis includes a beta-lactam combined with an aminoglycoside, to achieve synergistic effect.

Abstract P867 Figure. Mitral stenosis

Metallome of cerebrovascular endothelial cells infected with Toxoplasma gondii using μ-XRF imaging and inductively coupled plasma mass spectrometry

In this study, we measured the levels of elements in human brain microvascular endothelial cells (ECs) infected with T. gondii. ECs were infected with tachyzoites of the RH strain, and at 6, 24, and 48 hours post infection (hpi), the intracellular concentrations of elements were determined using a synchrotron-microfocus X-ray fluorescence microscopy (μ-XRF) system. This method enabled the quantification of the concentrations of Zn and Ca in infected and uninfected (control) ECs at sub-micron spatial resolution. T. gondii-hosting ECs contained less Zn than uninfected cells only at 48 hpi (p < 0.01). The level of Ca was not significantly different between infected and control cells (p > 0.05). Inductively Coupled Plasma Mass Spectrometry (ICP-MS) analysis revealed infection-specific metallome profiles characterized by significant increases in the intracellular levels of Zn, Fe, Mn and Cu at 48 hpi (p < 0.01), and significant reductions in the extracellular concentrations of Co, Cu, Mo, V, and Ag at 24 hpi (p < 0.05) compared with control cells. Zn constituted the largest part (74%) of the total metal composition (metallome) of the parasite. Gene expression analysis showed infection-specific upregulation in the expression of five genes, MT1JP, MT1M, MT1E, MT1F, and MT1X, belonging to the metallothionein gene family. These results point to a possible correlation between T. gondii infection and increased expression of MT1 isoforms and altered intracellular levels of elements, especially Zn and Fe. Taken together, a combined μ-XRF and ICP-MS approach is promising for studies of the role of elements in mediating host-parasite interaction.

Broad band high resolution rotational spectroscopy for Laboratory Astrophysics

We present a new experimental setup devoted to the study of gas phase molecules and processes using broad band high spectral resolution rotational spectroscopy. A reactor chamber has been equipped with radio receivers similar to those used by radio astronomers to search for molecular emission in space. The whole Q (31.5-50 GHz) and W bands (72-116.5 GHz) are available for rotational spectroscopy observations. The receivers are equipped with 16×2.5 GHz Fast Fourier Transform spectrometers with a spectral resolution of 38.14 kHz allowing the simultaneous observation of the complete Q band and one third of the W band. The whole W band can be observed in three settings in which the Q band is always observed. Species such as CH3CN, OCS, and SO2 are detected, together with many of their isotopologues and vibrationally excited states, in very short observing times. The system permits automatic overnight observations and integration times as long as 2.4×105 seconds have been reached. The chamber is equipped with a radiofrequency source to produce cold plasmas and with four ultraviolet lamps to study photochemical processes. Plasmas of CH4, N2, CH3CN, NH3, O2, and H2, among other species, have been generated and the molecular products easily identified by their rotational spectrum, and mass spectrometry and optical spectroscopy. Finally, the rotational spectrum of the lowest energy conformer of CH3CH2NHCHO (N-Ethylformamide), a molecule previously characterized in microwave rotational spectroscopy, has been measured up to 116.5 GHz allowing the accurate determination of its rotational and distortion constants and its search in space.

Transcriptional analysis of adipose tissue during development reveals depot-specific responsiveness to maternal dietary supplementation

Brown adipose tissue (BAT) undergoes pronounced changes after birth coincident with the loss of the BAT-specific uncoupling protein (UCP)1 and rapid fat growth. The extent to which this adaptation may vary between anatomical locations remains unknown, or whether the process is sensitive to maternal dietary supplementation. We, therefore, conducted a data mining based study on the major fat depots (i.e. epicardial, perirenal, sternal (which possess UCP1 at 7 days), subcutaneous and omental) (that do not possess UCP1) of young sheep during the first month of life. Initially we determined what effect adding 3% canola oil to the maternal diet has on mitochondrial protein abundance in those depots which possessed UCP1. This demonstrated that maternal dietary supplementation delayed the loss of mitochondrial proteins, with the amount of cytochrome C actually being increased. Using machine learning algorithms followed by weighted gene co-expression network analysis, we demonstrated that each depot could be segregated into a unique and concise set of modules containing co-expressed genes involved in adipose function. Finally using lipidomic analysis following the maternal dietary intervention, we confirmed the perirenal depot to be most responsive. These insights point at new research avenues for examining interventions to modulate fat development in early life.

Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

INTRODUCTION

There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered.

METHODS

A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review.

RESULTS

These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments.

CONCLUSIONS

This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.

Using radio astronomical receivers for molecular spectroscopic characterization in astrochemical laboratory simulations: A proof of concept

We present a proof of concept on the coupling of radio astronomical receivers and spectrometers with chemical reactors and the performances of the resulting setup for spectroscopy and chemical simulations in laboratory astrophysics. Several experiments including cold plasma generation and UV photochemistry were performed in a 40 cm long gas cell placed in the beam path of the Aries 40 m radio telescope receivers operating in the 41-49 GHz frequency range interfaced with fast Fourier transform spectrometers providing 2 GHz bandwidth and 38 kHz resolution. The impedance matching of the cell windows has been studied using different materials. The choice of the material and its thickness was critical to obtain a sensitivity identical to that of standard radio astronomical observations. Spectroscopic signals arising from very low partial pressures of CH₃OH, CH₃CH₂OH, HCOOH, OCS, CS, SO₂ (<10^-3 mbar) were detected in a few seconds. Fast data acquisition was achieved allowing for kinetic measurements in fragmentation experiments using electron impact or UV irradiation. Time evolution of chemical reactions involving OCS, O₂ and CS₂ was also observed demonstrating that reactive species, such as CS, can be maintained with high abundance in the gas phase during these experiments.

MR Perfusion to Determine the Status of Collaterals in Patients with Acute Ischemic Stroke: A Look Beyond Time Maps

BACKGROUND AND PURPOSE

Patients with acute stroke with robust collateral flow have better clinical outcomes and may benefit from endovascular treatment throughout an extended time window. Using a multiparametric approach, we aimed to identify MR perfusion parameters that can represent the extent of collaterals, approximating DSA.

MATERIALS AND METHODS

Patients with anterior circulation proximal arterial occlusion who had baseline MR perfusion and DSA were evaluated. The volume of arterial tissue delay (ATD) at thresholds of 2-6 seconds (ATD^{2-6 seconds}) and >6 seconds (ATD^{>6 seconds}) in addition to corresponding values of normalized CBV and CBF was calculated using VOI analysis. The association of MR perfusion parameters and the status of collaterals on DSA were assessed by multivariate analyses. Receiver operating characteristic analysis was performed.

RESULTS

Of 108 patients reviewed, 39 met our inclusion criteria. On DSA, 22/39 (56%) patients had good collaterals. Patients with good collaterals had significantly smaller baseline and final infarct volumes, smaller volumes of severe hypoperfusion (ATD^{>6 seconds}), larger volumes of moderate hypoperfusion (ATD^{2-6 seconds}), and higher relative CBF and relative CBV values than patients with insufficient collaterals. Combining the 2 parameters into a Perfusion Collateral Index (volume of ATD^{2-6 seconds} × relative CBV^{2-6 seconds}) yielded the highest accuracy for predicting collateral status: At a threshold of 61.7, this index identified 15/17 (88%) patients with insufficient collaterals and 22/22 (100%) patients with good collaterals, for an overall accuracy of 94.1%.

CONCLUSIONS

The Perfusion Collateral Index can predict the baseline collateral status with 94% diagnostic accuracy compared with DSA.

Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different

Background and Purpose—

Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients.

Methods—

Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel–Haenszel test statistic.

Results—

We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74–1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74–1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25–1.27).

Conclusions—

This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.

Gene pathway development in human epicardial adipose tissue during early life

Studies in rodents and newborn humans demonstrate the influence of brown adipose tissue (BAT) in temperature control and energy balance and a critical role in the regulation of body weight. Here, we obtained samples of epicardial adipose tissue (EAT) from neonates, infants, and children in order to evaluate changes in their transcriptional landscape by applying a systems biology approach. Surprisingly, these analyses revealed that the transition to infancy is a critical stage for changes in the morphology of EAT and is reflected in unique gene expression patterns of a substantial proportion of thermogenic gene transcripts (~10%). Our results also indicated that the pattern of gene expression represents a distinct developmental stage, even after the rebound in abundance of thermogenic genes in later childhood. Using weighted gene coexpression network analyses, we found precise anthropometric-specific correlations with changes in gene expression and the decline of thermogenic capacity within EAT. In addition, these results indicate a sequential order of transcriptional events affecting cellular pathways, which could potentially explain the variation in the amount, or activity, of BAT in adulthood. Together, these results provide a resource to elucidate gene regulatory mechanisms underlying the progressive development of BAT during early life.

The study of progesterone action in human myometrial explants

STUDY HYPOTHESIS

Myometrial explants represent a superior model compared with cell culture models for the study of human myometrial progesterone (P4) signalling in parturition.

STUDY FINDING

Gene expression analysis showed myometrial explants closely resemble the in vivo condition and the anti-inflammatory action of P4 is not lost with labour onset.

WHAT IS KNOWN ALREADY

Circulating P4 levels decline before the onset of parturition in most animals, but not in humans. This has led to the suggestion that there is a functional withdrawal of P4 action at the myometrial level prior to labour onset. However, to date, no evidence of a loss of P4 function has been provided, with studies hampered by a lack of a physiologically relevant model.

STUDY DESIGN, SAMPLES/MATERIALS, METHODS

Myometrial biopsies obtained at Caesarean section were dissected into explants after a portion was immediately snap frozen (t = 0). Microarray analysis was used to compare gene expression of t = 0 with paired (i) explants, (ii) passage 4 myometrial cell cultures or (iii) the hTERT myometrial cell line. Western blotting and chemokine/cytokine assays were used to study P4 signalling in myometrial explants.

MAIN RESULTS AND THE ROLE OF CHANCE

Gene expression comparison of t = 0 to the three models demonstrated that explants more closely resemble the in vivo status. At the protein level, explants maintain both P4 receptor (PR) and glucocorticoid receptor (GR) levels versus t = 0 whereas cells only maintain GR levels. Additionally, treatment with 1 µM P4 led to a reduction in interleukin-1 (IL-1) β-driven cyclooxygenase-2 in explants but not in cells. P4 signalling in explants was PR-mediated and associated with a repression of p65 and c-Jun phosphorylation. Furthermore, the anti-inflammatory action of P4 was maintained after labour onset.

LIMITATIONS/REASONS FOR CAUTION

There is evidence of basal inflammation in the myometrial explant model.

WIDER IMPLICATIONS OF THE FINDINGS

Myometrial explants constitute a novel model to study P4 signalling in the myometrium and can be used to further elucidate the mechanisms of P4 action in human labour.

LARGE SCALE DATA

Data deposited at http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?token=gvmpggkurbgxfqf&acc=GSE77830.

STUDY FUNDING AND COMPETING INTEREST

This work was supported by grants from the Joint Research Committee of the Westminster Medical School Research Trust, Borne (No. 1067412-7; a sub-charity of the Chelsea and Westminster Health Charity) and the Imperial NIHR Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS or the Department of Health. The authors have no conflict of interest.

Access to Endovascular Treatment in Remote Areas

Background and Purpose—

Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model.

Methods—

We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups.

Results—

Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245–435]) and 120 minutes longer in group C (350 minutes [284–408]) compared with group A (230 minutes [160–407]; P <0.001).

Conclusions—

Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Characterization of Gcf2/Lrrfip1 in experimental cerebral ischemia and its role as a modulator of Akt, mTOR and β-catenin signaling pathways

Leucine-rich repeat in Flightless-1 interaction protein 1 (Lrrfip1) is an up-regulated protein after cerebral ischemia whose precise role in the brain both in healthy and ischemic conditions is unclear. Different Lrrfip1 isoforms with distinct roles have been reported in human and mouse species. The present study aimed to analyze the Lrrfip1 transcriptional variants expressed in rat cortex, to characterize their expression patterns and subcellular location after ischemia, and to define their putative role in the brain. Five transcripts were identified and three of them (Lrrfip1, CRA_g and CRA_a' (Fli-I leucine-rich repeat associated protein 1 - Flap-1)) were analyzed by quantitative real-time polymerase chain reaction (qPCR). All the transcripts were up-regulated and showed differential expression patterns after in vivo and in vitro ischemia models. The main isoform, Lrrfip1, was found to be up-regulated from the acute to the late phases of ischemia in the cytoplasm of neurons and astrocytes of the peri-infarct area. This study demonstrates that Lrrfip1 activates β-catenin, Akt, and mammalian target of rapamycin (mTOR) proteins in astrocytes and positively regulates the expression of the excitatory amino acid transporter subtype 2 (GLT-1). Our findings point to Lrrfip1 as a key brain protein that regulates pro-survival pathways and proteins and encourages further studies to elucidate its role in cerebral ischemia as a potential target to prevent brain damage and promote functional recovery after stroke.