Added value of the measles-rubella supplementary immunization activity in reaching unvaccinated and under-vaccinated children, a cross-sectional study in five Indian districts, 2018-20

INTRODUCTION

Supplementary immunization activities (SIAs) aim to interrupt measles transmission by reaching susceptible children, including children who have not received the recommended two routine doses of MCV before the SIA. However, both strategies may miss the same children if vaccine doses are highly correlated. How well SIAs reach children missed by routine immunization is a key metric in assessing the added value of SIAs.

METHODS

Children aged 9 months to younger than 5 years were enrolled in cross-sectional household serosurveys conducted in five districts in India following the 2017-2019 measles-rubella (MR) SIA. History of measles containing vaccine (MCV) through routine services or SIA was obtained from documents and verbal recall. Receipt of a first or second MCV dose during the SIA was categorized as "added value" of the SIA in reaching un- and under-vaccinated children.

RESULTS

A total of 1,675 children were enrolled in these post-SIA surveys. The percentage of children receiving a 1st or 2nd dose through the SIA ranged from 12.8% in Thiruvananthapuram District to 48.6% in Dibrugarh District. Although the number of zero-dose children prior to the SIA was small in most sites, the proportion reached by the SIA ranged from 45.8% in Thiruvananthapuram District to 94.9% in Dibrugarh District. Fewer than 7% of children remained measles zero-dose after the MR SIA (range: 1.1-6.4%) compared to up to 28% before the SIA (range: 7.3-28.1%).

DISCUSSION

We demonstrated the MR SIA provided considerable added value in terms of measles vaccination coverage, although there was variability across districts due to differences in routine and SIA coverage, and which children were reached by the SIA. Metrics evaluating the added value of an SIA can help to inform the design of vaccination strategies to better reach zero-dose or undervaccinated children.

P1752 Prognostic role of Multilayer Strain Speckle Tracking Echocardiography in patients with severe aortic stenosis treated with Transcatheter Aortic Valve Implantation

Background

Myocardial Strain evaluation helps to assess the efficacy of therapeutic interventions and to predict the prognosis and clinical outcomes. The aim of the present study was to assess whether Multilayer Global longitudinal Strain (GLS) can be useful in estimation of left ventricle (LV) function in patients with severe symptomatic aortic stenosis (AS) who have undergone transcatheter aortic valve implantation (TAVI).

Methods

35 patients with severe AS who successfully underwent TAVI, were enrolled in the study. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function. Occurrence of cardiovascular (CV) events (rehospitalization for HF or CV death) were collected after 24 months follow-up.Results: CV events occurred in 7 patients (20%). Patients were divided in two groups accordingly with CV events occurrence. No differences in baseline, demographic, echocardiographic and procedural characteristics were found. Patients who developed CV events had a more impaired pre-procedural GLS (-10.2 ± 2.4% vs -12.6 ± 2.2%, p = 0.029), mostly due to his subendocardial layer (Endo-LS -10.8 ± 2 vs -13.9 ± 2, p = 0.003). Moreover, by ROC curve analysis, a cut-off value of -12.4% of endo LS was associated with CV events (sensitivity of 83% and specificity of 65 %, AUC 0.8, p = 0.024), with a log-rank p value assessed by survival analysis of 0.044.

Conclusion

Multilayer GLS analysis could provide additional information for prognosis stratification in patients with severe symptomatic AS before TAVI, above and beyond assessment of LVEF alone.

Parameter Event-group (7/35 pz= 20%) Non-event group (28/35 pz= 80%) p Age (y.o) 86 ± 4 80 ± 7 NS LVEDV (ml) 112 ± 34 94 ± 32 NS LVESV (ml) 51.2 ± 6 56.9 ± 6 NS LVEF(%) 55.7 ± 6 56.9 ± 6 NS AVA (cm2) 0.77 ± 0.2 0.73 ± 0.2 NS GLS (%) -10.2 ± 2.4 -12.6 ± 2.2 0.029 Endo-LS (%) -10.8 ± 2 -13.9 ± 2 0.003 Epi-LS (%) -10.2 ± 2 -11.9 ± 2 NS

Abstract P1752 Figure.

P1365 Different response of myocardial contractility by layer following acute pressure unloading after transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic option for severe symptomatic aortic stenosis (AS) with intermediate/high surgical risk. Aim of this study was to examine the acute effect of TAVI in terms of pressure unloading, on left ventricular (LV) mechanics using multilayer global longitudinal strain (GLS) by 2D speckle-tracking echocardiography (ST-E).

Methods

A total of 44 patients (mean age 81.8 ± 2, 34% male) with severe symptomatic AS and preserved LV ejection fraction (LVEF) underwent 2D echocardiography at baseline and 5 ± 2 days after TAVI. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before and after the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function.

Results

By dividing patients in two groups accordingly with LV geometry assessed with regional wall thickness measurement (concentric vs eccentric hypertrophy), better values of Endo-LS were recorded at baseline, in patients with concentric hypertrophy (-12.9 ± 2 vs -11 ± 3, p = 0.048). After TAVI, a significant improvement in Endo-LS was observed, but only in patients with concentric hypertrophy (-12.9 ± 2 vs -14.2 ± 2, p = 0.003).

Conclusion

The improvement in LS was more prominent in the endocardium, which was evident even immediately after TAVI only in patients with concentric hypertrophy. Evaluation of multilayer strain may provide new insights into the positive effects of unloading in patients with AS and may be potentially useful to predict patients with better outcome after TAVI.

Parameter RWT > 0.42 31 pz (70%) RWT ≤ 0.42 13 pz (30%) p Male sex (n, %) 8 (25%) 7 (53%) NS Age (y.o) 81 ± 6 83 ± 7 NS CAD (n, %) 3 (9%) 8 (61%) NS LVEDV (ml) 97 ± 29 134 ± 14 0.002 LVESV (ml) 43 ± 15 72 ± 38 0.001 LVEF(%) 56.2 ± 6 50 ± 12 NS AVA (cm2) 0.8 ± 0.2 0.8 ± 0.3 NS GLS (%) -11.4 ± 3 -10.5 ± 3 NS Endo-LS (%) -12.9 ± 2 -11 ± 3 0.048 Epi-LS (%) -10.8 ± 4 -9.9 ± 3 NS

Abstract P1365 Figure.

P6329123-Iodine Metaiodobenzylguanitidine imaging: a useful prognostic marker of cardiovascular death in heart failure patients

Background

According to guidelines, implantable cardioverter defibrillator (ICD) is recommended in prevention of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Guidelines have several limitations because ICD indication is based mainly on left ventricular ejection fraction (LVEF). Recently, 123-iodine metaiodobenzylguanidine imaging (123-I MIBG) seems to identify, independently from LVEF, pts at high risk of SCD: heart/mediastinum (H/M) ratio<1.6 and summed score (SS)>26.

Purpose

The aim is to assess the role of 123-I MIBG to predict malignant ventricular arrhythmias (VA) in HF pts

Methods

We enrolled 208 pts, admitted to our hospital with diagnosis of HF and LVEF≤35%, NYHA class II and III, who underwent 123-I MIBG imaging. H/M ratio of 1.6 was used as a cut-off to identify high risk (G1) versus low risk pts (G2). All pts underwent ICD implantation. Follow-up was performed at 24 months.

Results

138 patients were included in G1 and 70 patients in G2. All baseline characteristics were similar in the two groups (table 1). At 24 months follow-up VA events were recorded greater in G1 compared to G2 (21% vs 10%, p=0.04).

Table 1 G1 G2 P value H/M ≤1.6 (N=138) H/M >1.6 (N=70) Age (years) 65±12 63±14 0.28 Male, N (%) 108 (78) 64 (91) 0.02 Diabetes mellitus type II, N (%) 54 (39) 14 (20) 0.01 Dyslipidemia, N (%) 58 (42) 30 (42) 0.64 LVEF (%) 30±5 31±4 0.14 Ischaemic CM, N (%) 85 (62) 30 (42) 0.012 Malignant VA, N (%) 30 (21) 7 (10) 0.04 SS 38±9 16±7 0.0001 H/M: heart mediastinum ratio; LVEF: left ventricular ejection fraction; CM: cardiomyopathy; VA: ventricular arrhythmias; SS: summed score.

Conclusion

Our results seem to confirm that 123-I MIBG uptake is associated with the occurrence of life-threatening VA in HF pts independently from LVEF. The use of 123-I MIBG could be a useful tool in the future to increase the specificity of the pts selection for ICD therapy.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

[Anesthesia in spontaneous ventilation for difficult intubation]

Difficult intubation in children is rare and often predictable during anesthesia consultation. This allows to establish a strategy to provide fiberoptic guided tracheal intubation with spontaneous ventilation in function of age and children pathology. A good knowledge of physiologic and anatomic children particularities, of fiberoptic technique and the respect for some principles lead to ensure the security of this procedure. First principle is to use only one anesthetic inhaled or intravenous agent in order to limit an important decrease of ventilation. The anesthetic technique recommended for pediatric fiberoptic guided intubation is inhaled anesthesia with sevoflurane. But it is possible to use an intravenous agent, like propofol, with a continuous infusion (bolus of 0.1 to 0.3 mg/kg then 0.1-0.3mg/kg per hour for maintenance) or with target controlled infusion (Schnider model, initial concentration 2.5 μg/mL, then increase by 0.5 μg/mL steps) particularly in children older than 5 years with an anesthetic depth control. Whatever the agent, the dose must to be titrated to maintain spontaneous ventilation. Second principle is to combine an airway local anesthesia with general anesthesia to limit airway reactivity. First, a nose topical anesthesia is administered with lidocaine plus naphazoline in children older than 2 years. Then, a laryngeal topical anesthesia is realized with lidocaine 1% (1-2 mL, 2mg/kg) through operating channel of fiberoptic bronchoscope. Finally, third principle is to ensure patient oxygenation with several techniques like use of endoscopic facial mask or nasopharyngeal tube. The use of laryngeal mask is a rescue technique in case of spontaneous ventilation lost. In conclusion, each institution has to establish an algorithm with his own knowledge, constantly feasible and regularly taught.

[Biochemical and metabolic aspects of oxyradical pathology in the hypoxic-ischemic reperfused human skeletal muscle tissue. Clinical markers and therapeutic approach]

BACKGROUND

Following our previous studies on the biomolecular and biochemical aspects of the human tissue oxidative damage due to hypoxia, ischemia and reperfusion, aim of the present work is to evaluate the role played by oxyradical generation in the morphofunctional cellular injury. We evaluated the tissue levels of some metabolic markers (MDA, Catalase, Uric Acid) to obtain a pathogenic picture and then a therapeutic approach closely related to the cellular biodynamics.

METHODS

A skeletal muscle samples were taken during elective knee orthopedic surgery in 20 consecutive patients. The biopsies were taken in normoxic conditions and after 5 +/- 1 and 62 +/- 3 min form tourniquet application and finally 21 +/- 2 min following muscle reperfusion. The samples were assayed for tissue Malondialdeyade (MDA), uric acid and catalase (CAT) contents with HPLC and fluorimetric procedures. All data were evaluated in terms of computerized statistical analysis.

RESULTS

When compared to normoxic tissue (1.24 +/- 0.26 nmoli.mg-1 protein), the MDA levels show a moderate increase in hypoxic (1.66 +/- 0.12) and ischemic tissue (1.78 +/- 0.13), while highly significant is the rise in reperfused muscle MDA content (5.94 +/- 0.15). The uric acid as far as CAT shows no appreciable alterations in hypoxia and ischemia. Following reoxygenation an increase in uric acid contents with a concomitant CAT tissue consumption appear evident.

CONCLUSIONS

The obtained data seem to underline the cytoprotective role played by adaptive changes in the hypoxic and ischemic human cells. On the contrary, the rapid reoxygenation of the ischemic tissue appears to start oxyradical neo-generation. In clinical and therapeutic terms these observations underline a peculiar and different approach to the critically ill patient.