Antifungal effect of (R) and (S)-citronellal enantiomers and their predictive mechanism of action on Candida albicans from voriconazole-resistant onychomycoses

Onychomycosis is the most common disease affecting the nail unit and accounts for at least 50% of all nail diseases. In addition, Candida albicans is responsible for approximately 70% of onychomycoses caused by yeasts. This study investigated the antifungal effect of (R) and (S)-citronellal enantiomers, as well as its predictive mechanism of action on C. albicans from voriconazole-resistant onychomycoses. For this purpose, in vitro broth microdilution and molecular docking techniques were applied in a predictive and complementary manner to the mechanisms of action. The main results of this study indicate that C. albicans was resistant to voriconazole and sensitive to the enantiomers (R) and (S)-citronellal at a dose of 256 and 32 µg/mL respectively. In addition, there was an increase in the minimum inhibitory concentration (MIC) of the enantiomers in the presence of sorbitol and ergosterol, indicating that these molecules possibly affect the integrity of the cell wall and cell membrane of C. albicans. Molecular docking with key biosynthesis proteins and maintenance of the fungal cell wall and plasma membrane demonstrated the possibility of (R) and (S)-citronellal interacting with two important enzymes: 1,3-β-glucan synthase and lanosterol 14α-demethylase. Therefore, the findings of this study indicate that the (R) and (S)-citronellal enantiomers are fungicidal on C. albicans from onychomycoses and probably these substances cause damage to the cell wall and cell membrane of these micro-organisms possibly by interacting with enzymes in the biosynthesis of these fungal structures.

Effect of Salivary Flow on Bleached Enamel Roughness and Mineral Content: an In Situ and In Vitro Study

This study aimed to evaluate the effect of human saliva in vitro and salivary flow in situ on the roughness and mineral content of bleached enamel. Dental specimens were divided into five groups (n=15): not bleached (NB); bleached (35% hydrogen peroxide) and exposed to distilled water (DW); human saliva in vitro (IV); normal salivary flow in situ (NSF); and low salivary flow (LSF) in situ. Enamel roughness (Ra, Rz) and calcium/phosphorus contents were evaluated with laser profilometry and energy-dispersive spectroscopy, respectively, at baseline (T1), after bleaching (T2), and after seven days (T3). Salivary pH and buffer capacity were evaluated with colorimetric strips and salivary calcium and phosphorus with absorbance spectrophotometry. Data were analyzed with non-parametric tests and linear regression (α=0.05). After contact with saliva, Ra and Rz of LSF=DW>IV=NSF=NB was found. For DW and LSF, the roughness of T1<T2=T3 was found. For IV, T1<T3<T2; for NSF, T1=T3<T2. Enamel calcium/phosphorus content did not change with bleaching or with saliva contact (p≥0.05). Buffer capacity and calcium concentration did not differ between LSF and NSF. Phosphorus was higher, and pH was lower in LSF. Ra and Rz were, respectively, 0.14 and 1.95 lower with NSF than LSF. The conclusions were that NSF in situ and human saliva in vitro recovered original enamel roughness. The experimental conditions did not affect enamel mineral content. Recovery of bleached enamel roughness was higher in NSF when compared to LSF, regardless of salivary pH, calcium and phosphorus concentrations, and buffer capacity.

Significance and distribution of aortic valve calcium score before TAVI

Introduction

Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected.

Results

A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%.

Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p&lt;0.001) (Figs. 1 and 2).

11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p&lt;0.001) and mean gradients (r=0.387, p&lt;0.001) and aortic valve area (r=−0.120, p=0.047) was demonstrated. Valvular calcification was not significantly different in P with reduced ejection fraction (&lt;50%) (p=0.388).

Conclusion

There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known.

Funding Acknowledgement

Type of funding sources: None.

Artificial intelligence-enabled comprehensive coronary phenotyping in patients with suspected CAD

Introduction

The capabilities of artificial intelligence (AI) are rapidly progressing and the research community is getting increasingly interested in its possibilities. AI algorithms are able to work continuously and at high speed, reducing human workload and saving time that physicians can spend on more complex data or rarer cases. However, many clinical AI applications are currently only used in a research setting and lack proper testing and validation.

Objectives

This study aimed to determine the accuracy and performance of a novel AI-based software tool for CCTA analysis compared to conventional expert evaluation.

Methods

We evaluated 100 CCTA exams from a cohort of symptomatic patients with mild-to-moderately abnormal non-invasive ischemia test. Stenosis severity assessed by AI-based analysis (automatic evaluation, AEv) was compared with a level III expert CCTA interpretation (manual evaluation, MEv). AI-based analysis reported exact % stenosis and obstructive CAD was considered if maximal stenosis was ≥50%. Plaque phenotype was also estimated using AI algorithms.

Results

The study cohort was as follows: 52% male, mean age 68±10 years. The prevalence of hypertension, dyslipidemia and diabetes was 77%, 81% and 23%, respectively, and 10-year cardiovascular risk was 19±10% as predicted by Framingham risk score. Typical angina was present in 33%, of which 67% had a Canadian Cardiovascular Society angina grade ≥2.

Overall prevalence of obstructive CAD determined by MEv and AEv was 25% and 21%, respectively, with a significant association between both assessments (p&lt;0.001). When compared to MEv as reference, AEv method performed with a sensitivity, specificity, positive and negative predictive values of 0.56, 0.91, 0.58 and 0.86, respectively. Area under the curve was 0.871 (p&lt;0.001) demonstrating high accuracy.

AEv atherosclerosis quantification revealed significant differences between patients with and without obstructive CAD according to MEv: median total plaque volume (569 vs 115 mm3, p&lt;0.001), calcified plaque volume (297 vs 19 mm3, p&lt;0.001), non-calcified plaque volume (235 vs 71 mm, p&lt;0.001), low-density non-calcified plaque volume (2.8 vs 1.0 mm3, p=0.023) and percent atheroma volume (16.1 vs 3.8 mm3, p&lt;0.001).

Conclusion

In patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy using AEv as a gatekeeper is effective, providing a quantitative stenosis evaluation with similar diagnostic performance for obstructive CAD when compared to MEv. AI-enabled approach additionally allows a fully automated quantification of coronary plaque volumes and composition, which would further enhance risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Epicardial fat volume improves prediction of adverse clinical events

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive.

Objectives

To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA).

­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months.

Results

72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p &lt;0.001), male sex (135 ± 50 vs 78 ± 30, p &lt;0.001), body mass index (rs= 0.32, p= 0.008) and TFV (rs= 0.27, p= 0.025). A positive correlation with CAC (rs= 0.47, p &lt;0.001) and a significant association with CAD (116 ± 50 vs 90 ± 37, p= 0.029) and obstructive CAD (141 ± 60 vs 97 ± 39, p= 0.031) were demonstrated. Composite endpoint was observed in 13 pts (18%). After adjusting for all considered confounders, EFV remained an independent predictor of adverse events (OR: 1.015, 95%CI: 1.003-1.027, p= 0.041). ROC analysis of EFV (AUC 0.751, p = 0.005) allowed to estimate that EFV &gt;124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively.

Conclusion

EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

Left ventricular noncompaction: the importance of identifying high-risk patients within the scope of left ventricular hypertrabeculation

Introduction

Prominent left ventricular (LV) trabeculation is frequently encountered, however LV noncompaction (LVNC) criteria are not always fulfilled. The clinical and prognostic significance of these findings remains unclear.

Objectives

To characterize the patients (P) with echocardiographic suspicion of LVNC and to assess clinical outcomes.

Methods

Retrospective single-centre study that included all echocardiograms between January 2018 and June 2020 perceiving LV hypertrabeculation. The cohort underwent diagnostic assessment for LVNC by Chin and Jenni criteria. Baseline characteristics were evaluated. Composite endpoint of cardiovascular death, heart failure (HF) hospitalization, ventricular arrythmias (VA) and nonfatal stroke was considered.

Results

51P, 75% male, mean age 50±18 years. 35P (69%) had associated heart conditions, of which 57% had other known cardiomyopathy (mainly dilated cardiomyopathy), 14% congenital, 26% ischemic and 3% valvular heart disease. 2P were in postpartum period and 1P was an athlete. Family history of cardiomyopathy was present in 8P (16%). 12P underwent genetic testing, with TTN and MYH7 mutations being the most frequently detected. Prior clinical HF was reported in 53%, previous stroke in 14%, and non-sustained and sustained VA in 24% and 4%, respectively. Mean NYHA classification was 1.8±0.7, with 31% being asymptomatic.

The prevalence of LVNC by Chin criteria was 31% and by Jenni criteria was 55%. 32P (63%) met at least one LVNC criteria. This group was younger (45±18 vs 59±15, p=0.004), had higher NT-proBNP levels (3644±2819 vs 389±640, p=0.048) and QRS fragmentation (59% vs 21%, p=0.027). Significantly higher LV end-diastolic volume (84 (41) vs 64 (28)ml/m2, p=0.008) and end-systolic volume (51 (37) vs 35 (20)ml/m2, p=0.004), along with lower LV ejection fraction (39±12 vs 49±13%, p=0.009) and global longitudinal strain (−11±5 vs −17±4%, p=0.003) were noticed. P who met LVNC criteria also had higher number of affected LV segments (6.4±1.8 vs 4.2±1.6, p&lt;0.001).

Over a mean follow-up of 18±9 months, the incidence of composite endpoint was 35%. Univariate Cox analysis showed a significant association between the presence of LVNC criteria and adverse outcomes (HR: 5.108, 95% CI: 1.682–11.236, p=0.030) (Fig. 1).

Conclusion

LV hypertrabeculation can be encountered in a variety of clinical scenarios and often overlaps with other heart diseases. P satisfying criteria for LVNC had more impairment in LV performance and worse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Impact of COVID-19 in adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 13 000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Aims

To evaluate the impact of COVID-19 in adult patients with congenital heart disease in our tertiary centre

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to February 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified 36 patients (pts) with COVID-19 infection. Symptoms were present in 31 (86%). The median age was 39 (32–49) years, 58% were females. Seven P (19%) had complex cyanotic disease; three (8%) Tetralogy of Fallot; three (8%) transposition of great arteries (one after Senning procedure and 2 after arterial switch); six (14%) right ventricle obstacle; two (8%) atrioventricular canal defect; four (11%) atrial septal defect; five (14%) ventricular septal defect; five (14%) aortic coarctation; two aortopathies (one submitted do David procedure); one subaortic stenosis; two (6%) had Eisenmenger syndrome. The majority (61%) of P had previous surgery and 58% were at New York Heart Association class of I. Mild symptoms were reported by 24 P (67%). Seven adults experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, although none required mechanical ventilation. One death was reported. There was a significant association between the gravity of CHD and hospitalizations (p=0.012).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Exercise end-tidal carbon dioxide pressure: a new prognostic marker after acute myocardial infarction?

Funding Acknowledgements

Type of funding sources: None.

Background

Although several cardiopulmonary exercise testing (CPET) parameters have already proved to predict prognosis, there is increasing interest in finding variables that do not require maximal effort. End-tidal carbon dioxide pressure (PETCO2), an indirect indicator of cardiac output, is one of such variables. Studies in heart failure populations already suggest its role as a prognostic factor. However, data concerning other populations are still scarce.

Purpose

To assess the association between exercise PETCO2, cardiac biomarkers and systolic function following acute myocardial infarction (AMI) and to evaluate its potential prognostic role in this population.

Methods

A retrospective single-centre analysis was conducted including patients who underwent symptom-limited CPET early after AMI. We assessed PETCO2 at baseline (PETCO2-B), at anaerobic threshold (PETCO2-AT) and at peak exercise and calculated the difference between PETCO2-AT and PETCO2-B (PETCO2-difference). We analysed their association with B-natriuretic peptide (BNP), maximal troponin after AMI as well as with left ventricular ejection fraction (LVEF) 1 year after.

Results

We included 40 patients with a mean age of 56 years (87.5% male), assessed with CPET a median of 3 months after AMI (80% of which were ST-elevation myocardial infarctions). Average respiratory exchange ratio was 1,1 with 48% of patients not reaching maximal effort. Mean PETCO2-AT was 37mmHg, with a mean increase from baseline of 6mmHg (PETCO2-difference). There was a significant positive correlation between all the PETCO2 variables measured and BNP values at time of AMI and on follow-up (best correlation for PETCO2-AT with BNP at AMI hospitalization, r = 0.608, p &lt; 0.001). Maximal troponin was not correlated with PETCO2. Both PETCO2-AT and PETCO2-difference were significantly and positively correlated with LVEF 1-year post-AMI (r = 0.421, p = 0.040 and r = 0.511, p = 0.011, respectively).

Conclusion

PETCO2-AT and PETCO2-difference are both correlated with BNP, an established prognostic marker, and with medium-term systolic function after AMI, suggesting their potential prognostic role in this population. Further studies with larger samples are required to confirm the results of this pilot study and assess PETCO2 as a definite predictor of prognosis after AMI.

Left ventricular remodelling patterns after MitraClip implantation: Do ischemic patients have the same benefit?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Percutaneous mitral valve repair has shown to prevent and even reverse adverse LV remodelling in most patients with moderate to severe mitral regurgitation (MR). This effect is, however, highly variable and may differ according to the MR etiology.

Objectives

 The aim of the present study is to evaluate cardiac remodelling patterns and clinical outcomes after MitraClip implantation (MI) in ischemic and non-ischemic patients (P).

Methods

 A standardized registry was prospectively performed between 2013 and 2019 for all P who underwent MitraClip insertion in a single terciary care centre. Transthoracic echocardiographic information was assessed at baseline and 1, 6, 12 and 18 months after MI. Student’s t-test was used to assess the procedure’s effect on several variables. Clinical outcomes were compared with the use of Fisher’s exact test or the chi-square test, as appropriate.

Results

 46 P, 61% male, mean age 65 ± 14 years. 39% had ischemic MR. Dyslipidemia was more frequent in ischemic P (52% versus 93%, p= 0.002) as well as history of smoking (32% versus 67%, p= 0.022). Atrial fibrillation was significantly associated with non-ischemic etiology (75% versus 44%, p= 0.036). MI success rate was 87% (proper placement and reduction in MR to grade 2 or less), with an average of 1.5 clips. Considering the 37 P that completed 18 months of follow-up (FU), the echocardiographic parameters at baseline were: left ventricular ejection fraction (LVEF) 36 ± 12%, LV end-diastolic dimeter (LVEDD) 68.2 ± 10.2mm, LV end-systolic diameter (LVESD) 52.2 ± 13.5mm and left atrial diameter (LAD) 53.1 ± 6.7mm; there were no significant differences between groups. After MI, a compelling difference in LVEDD was noticeable early in the first month, with significant lower dimensions in non-ischemic P (66.6 ± 11.4 versus 72.8 ± 5.4, p= 0.039). Sustained differences in LVEDD were consistent at 6, 12 and 18 months (62.4 ± 12.3 versus 73.5 ± 7.4, p= 0.025). There was also a reduction in LVESD that became apparent in the sixth month (45.5 ± 15.1 versus 55.3 ± 9.8mm, p= 0.047) and that was sustained after 18 months from MI (45.4 ± 11.7 versus 58.3± 8.9, p= 0.012). No significant differences in LVEF or LAD were noticed over time. Regarding clinical outcomes at 18 months, overall mortality (M) was 24% (9P) and 51% (19P) died or were hospitalized due to heart failure (MH).  No difference was found between groups: M (p= 0.119), MH (p= 0.091).

Conclusion

 This study reports better LV reshape effects after MI in P with non-ischemic etiology, with sustained improvement over time. However, no differences regarding mortality or hospitalization due to HF were apparent at the 18-month FU. Larger long-term studies are required to evaluate these results.

Abstract Figure. LV remodelling pattern

Intersectoral collaboration to promote child development: mapping the relationships

Integrated and intersectoral interventions early in life have the greatest potential to address social inequities, ensuring better opportunities for access to child development support services. The “Projeto Nascente” (Universidade Federal de Minas Gerais and Ministry of Health, Brazil) sought to qualify health and other sectors professionals in actions to promote and monitor early child development, in primary health care. One of its focuses was to stimulate the intersectoral actions to promote child development. The research analyzed the intersectoral network in 31 municipalities in the State of Minas Gerais, Brazil, participating in the 'Projeto Nascente'.

A case study with a qualitative approach was developed using document research on the professionals' perception regarding intersectoral networking. The material was ecomaps elaborated by professionals during the training of the “Projeto Nascente”. The ecomaps represented the local intersectoral networks.

Initially, 29 ecomaps from eleven municipalities were analyzed. Social Protection, Education, Sports, Culture, churches and non-governmental organizations were cited. Other health services were also included. All ecomaps were represented with the family health team in a central position with the other services around them. In municipalities with more than one ecomap, there was no uniformity neither in the services nor in the quality of the relationships represented.

A closer relationship between Education and Social Protection was noticed. However, the quality of the relationships often seemed stressful. Health professionals reported that they invest more energy in relationships than other sectors. Sport and Culture, although less mentioned, seem to be potential partners for new collaborations. The emergence of other health services seems to reflect the fragmentation of the health sector, as well as evidence of the conceptual confusion surrounding intersectoral collaboration.

Key messages

The identification and mapping of the services networking aimed at promoting child development are essential steps in the process of stimulating and reflecting on intersectoral collaboration. The centrality and self-perceived protagonism of the health professionals may not be the best way to involve and count on the participation of other sectors in intersectoral collaboration.

P1377Substrate-based ablation in patients with frequent appropriate ICD therapy and dilated cardiomyopathy: long-term experience with high-density mapping

Recurrent ventricular tachydisrhythmias (VT) episodes have a negative impact in the outcome of patients (P) already with an implantable cardioverter-defibrillator (ICD). Elimination of arrhythmic reentry circuits represents a difficult challenge, mainly due to the induction of intolerable VTs, with multiple ECG morphologies, requiring rapid interruption. Substrate guided ablation has been used as a promising approach strategy to treat recurrent VTs. Aim: to assess long-term results of a VT substrate-based ablation using high-density mapping in P with an ICD, severe left ventricular (LV)  dysfunction and recurrent appropriate ICD therapy. Methods: 16P (12 men, non-ischemic cardiomyopathy 67%, 55 ± 13 years, LV ejection fraction 32 ± 6%) and recurrent appropriate shocks despite antiarrhythmic drug therapy and optimal heart failure medication. All P underwent a protocol of ventricular programmed stimulation (600 ms/S3) to obtain baseline VT documentation. A sinus rhythm (SR) voltage map was created using a 3D electroanatomic mapping system (CARTO) with a high-density mapping catheter (PentaRay) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0,5 mV – dense scar; 0,5-1,5 mV – border zone; ≥1,5 mV – healthy tissue) and provide high-resolution electrophysiological mapping. The substrate modification included catheter elimination of local abnormal ventricular activities (LAVA) - fractionated, splited, low-amplitude/long-lasting, late potentials, pre-systolic potentials - and linear ablation to obtain scars homogenization and scar dechanneling. Pace-mapping techniques were used when capture was possible. LV approach was retrograde in 6 cases, transeptal in 4 and endo-epicardial in 2 cases. In 2P the ablation was performed in the right ventricle. Results: VTs were induced and interrupted with bursts or external DC shocks. LAVA were identified and ablated in all P. Eleven P underwent modification of scar areas. The mean duration of the procedure was 153 mn (103-218 mn), with radiofrequency ranging from 18 to 60 mn (mean 33 min), and a mean fluoroscopy time of 16 mn. Non-inducibility was achieved in 75% of the cases. There was 1 pericardial tamponade drained successfully. During a follow-up of 48 ± 18 months, 75% had no VT recurrences, 2P underwent redo ablation, 1P died from stroke. Conclusion: Catheter ablation of VT based on substrate modification guided by high-density mapping is feasible and safe in P with LV dysfunction. This approach may be of clinical relevance, with potential benefits in reducing VT burden.

P1756 Predictors of outcome in mitral valve repair surgery

Background

Surgical mitral valve repair currently remains a good option in both organic or functional mitral valve regurgitation (MVR). However, a significant number of patients (P) have comorbidities that can contribute to adverse outcomes.

Objective

To determine clinical and echocardiographic predictors of adverse outcomes in P submitted to MV repair surgery in our center, notably MVR recurrence and new MV replacement surgery or all-cause mortality.

Methods

Retrospective analysis of 262 P who underwent MV repair surgery between 2008 and 2017, with a mean follow-up of 30 months. P were included with both organic or functional MV regurgitation. P who underwent simultaneous coronary artery bypass grafting (CABG), atrial fibrillation (AF) surgery and tricuspid valve repair were also included. However, P with simultaneous surgical aortic valve replacement or previous endocarditis were excluded and the remaining 204 P were analysed.

We evaluated whether MVR etiology, simultaneous surgery (tricuspid valve repair, AF or CABG), body mass index (BMI), gender, chronic obstructive pulmonary disease (COPD), diabetes mellitus, renal dysfunction (measured by serum creatinine levels), baseline left ventricular ejection fraction (LVEF) and left ventricle end-diastolic diameter (LVED) were predictors of a composite endpoint (follow-up MV replacement surgery or all-cause mortality) and secondary endpoints: MV replacement surgery and all-cause mortality.

Results

204 P who underwent MV repair surgery, 67.2% male, mean age of 62 ± 14 years. 80.4% had organic MVR and 19.6% functional MVR (mostly ischemic – 72.4%). 7P (3.4%) had rheumatic MVR. 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. 30-day mortality was 0%.

The composite endpoint occurred in 40P (20%) and there was MVR recurrence with follow-up MV replacement surgery in 15P (7.5%) and all-cause mortality in 28P (13.7%).

The authors found that elevated serum creatinine levels (OR 4.66; p = 0.003), COPD (OR 3.00; p = 0.035) and functional etiology (OR 2.22; p = 0.049) were predictors of the composite endpoint.

Both COPD (OR 2.823; p = 0.024) and renal dysfunction (OR 6.901; p = 0.001) were also found to be independent predictors of all-cause mortality.

Simultaneous CABG was a predictor of all-cause mortality (OR 2.82; p = 0.024).

Female gender was a predictor of future MV replacement surgery (13.4% vs 4.7%, p = 0.023).

However, echocardiographic variables (baseline LVEF and LVED) were not found to be significant predictors of adverse outcomes in MV repair surgery. Likewise, simultaneous AF or tricuspid valve surgery, rheumatic/ischemic etiology, high BMI or diabetes were not associated with poorer prognosis.

Conclusion

In P undergoing MV repair surgery, renal dysfunction and COPD were independent predictors of all-cause mortality. Functional etiology and simultaneous CABG surgery were also predictors of adverse outcomes.

Baseline LVEF and LVED were not correlated with prognosis.

P229 Primary cardiac angiosarcoma of the right atrium: a rare entity presenting with an atrial arrhythmia

Introduction

Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor.

We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia.

Clinical case

A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain.

Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute.

Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L).

A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia.

The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed:

- Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus).

- Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava.

Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression.

Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped.

The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization.

During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism.

After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month.

Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor.

Abstract P229 Figure. Echocardiogram: right atrium mass

P1330 A rare coronary anomaly in the adult: an extremely large arteriovenous fistula

Introduction

Arteriovenous coronary fistulae are a rare coronary anomaly, which can be congenital or acquired. They can be diagnosed in older adults with heart failure symptoms, atherosclerosis or cardiac arrhythmias.

The authors report the case of an adult patient with an extremely large coronary artery fistula of the left main coronary artery (LMCA).

Clinical case

A 57-year-old caucasian male with known background of arterial hypertension, obesity, pulmonary emphysema and bronchiectasis presented to a Cardiology outpatient appointment with symptoms of congestive heart failure and new-onset atrial fibrillation.

A transthoracic echocardiogram was performed which revealed a possible coronary fistula with multiple rosary-like folds between the LMCA and the coronary sinus. Other echocardiographic findings were left ventricular and biatrial enlargement with biventricular systolic dysfunction (left ventricular ejection fraction 44%) and a GLS of -7.8% as well as mild pericardial effusion.

The patient was referred to our hospital for further diagnostic work-up and clarification of the coronary anatomy.

A cardiac computed tomography (CT) scan was done which showed ectasia and calcification of the LMCA, left anterior descending and circumflex arteries and a large caliber tortuous coronary fistula between the LMCA, the right atrium and the coronary sinus comprised of multiple folds covering from the pulmonary artery to the left atrium.

A coronary artery angiography was also performed, which confirmed the detailed anatomy and dimensions of the coronary fistula.

Follow-up magnetic resonance imaging revealed dilation of both left and right cardiac chambers with no significant shunt (QP/QS = 1)

The patient was started on heart failure medical therapy and was referred to the Cardiac Surgery Department and is currently asymptomatic awaiting for surgical correction of the coronary fistula.

Abstract P1330 Figure. CT scan: large caliber coronary fistula

P1755 Clinical and echocardiographic outcomes of mitral valve repair surgery

Background

Mitral valve regurgitation (MVR) represents the second most frequent valvular heart disease. MV surgical repair is often the preferred treatment when MV anatomy is suitable.

Purpose

To characterize the population who underwent MV repair surgery and evaluate the outcomes of residual MVR, allcause mortality and functional classification.

Methods

Retrospective analysis of 262 patients (P) admitted between 2008 and 2017 for MV repair surgery. P who undergone simultaneous coronary artery bypass graft (CABG) surgery, atrial fibrillation (AF) surgery and tricuspid valve repair were also included. P with endocarditis, P who underwent simultaneous aortic valve replacement and P with rheumatic predominant MV stenosis were excluded, the remaining 204 P were analysed. Clinical and echocardiographic characteristics were evaluated in a mean follow-up of 30 months.

Results

204 P, 67.2% male, mean age 62 + 14 years. The most frequent etiology was organic (80.4%), mostly of degenerative cause. Functional etiology was present in 19.6%, mostly ischemic (72.4%). 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation.

Hypertension was significantly associated with functional etiology (90% vs 72.8%, p = 0.022), as well as hypercholesterolemia (80% vs 48.2%, p &lt; 0.001) and diabetes mellitus (32.5% vs 10.4%, p &lt; 0.001). Baseline left ventricular ejection fraction (LVEF) was &gt;50% in 78.4%, reduced (30-50%) 18.1% and poor (&lt;30%) in 3.4%.

Functional etiology was significantly associated with LVEF &lt;50% (70% vs 9.1%, p &lt; 0.001).

161P (78.9%) had MV prolapse: 120P (74.5%) posterior, 29P (18%) anterior and 7.4% (12P) of both leaflets. P2 was the most frequently involved scallop, in 92P (57.1%), followed by P3, in 41P (25.4%). There was MV chordae rupture in 94P (58.3%).

Post-surgery echocardiography revealed that 93.8% had mild or no residual MVR.

30-day mortality rate was 0%.

There was MVR recurrence with MV replacement surgery in 15P (7.5%), mean time 37.1 months. All-cause mortality was registered in 28P (13.7%), with a mean time of 43.7 months after MV surgery.

Of the P without MVR recurrence or mortality, 111P (70%) were in NYHA class I, 41P (26%) in NYHA class II and 6P (4%) in NYHA class III. 6P were lost to follow-up. Upon echocardiographic revaluation there was no residual MVR in 53P (39%), mild MVR in 67P (49%) and moderate MVR in 16P (11.8%).

Conclusion

In P who underwent MV repair surgery, there was 7.5% recurrence rate with follow-up MV replacement surgery and an all-cause mortality of 13.7%. In a mean follow-up of 30 months, 70% of P were in NYHA I class and there was none or mild residual MVR in 88% of P.

1113 Primary and secondary malignant cardiac tumors - a 22 year case review

Background

Primary cardiac tumors are extremely rare and are usually diagnosed late due to the non-specific symptomatology. Surgery is the main treatment option and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome.

Purpose

To review patients (P) with malignant cardiac tumours that were diagnosed by transthoracic echocardiography (TTE) or by transesophageal echocardiogram (TEE) in a tertiary center between 1997 and 2019.

Methods

Retrospective analysis of clinical data from the digital files, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes.

Results

A total of 33 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 21 metastatic tumors (B).

A

Regarding primary cardiac tumors, the most common types were angiosarcomas (6 cases), 2 undifferentiated pleomorphic sarcomas, 1 right ventricle (RV) sarcoma, 1 primary cardiac lymphoma, 1 myxofibrosarcoma and 1 fibrosarcoma.

The mean age of the P at time of diagnosis was 43 ± 15 years, 50% female gender. The most frequent presentation was heart failure symptoms (50% of P) followed by arrhythmias (20%). One patient had a rare presentation with pruritus and polyarthralgias.

On TTE, the most prevalent tumor location was in the right-heart chambers (70%) - mostly the right atrium (50%), with mean dimensions of 40 ± 18 mm x 27 ± 11 mm.

85% of patients had preserved systolic left ventricular function and there was moderate or severe pericardial effusion in 38%.

The most frequent distant metastatic involvement of primary tumors at diagnosis was pulmonary (33%) and hepatic (33%).

50% of P were submitted to tumor resection and 40% were submitted to chemotherapy.

In the case of angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34.

The authors found a mortality rate of 81% in P with primary cardiac tumors, with a median time of follow-up of 6 months (minimum of 20 days and maximum of 18 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a sarcoma of the RV and is still alive and well.

B

Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 6 thymomas, 4 cases of lymphoma, 3 lung carcinomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma and 1 melanoma.

The mean age of P with metastastic involvement of the heart was 57 ± 22 years, 65% male. On TTE/TEE the authors also found a right-sided chambers predominance (60%), with pericardial metastasis in 35%.

As expected, the mortality rate was also extremely high (90%), with a median time of follow up of 1.5 months (minimum of one week, maximum of 44 months)

Conclusion

Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a good outcome.

P5243Indirect costs of acute myocardial infarction in Portugal

Introduction

Cardiovascular diseases are the main cause of death in Portugal. The high incidence of acute myocardial infarction (AMI) is also a major problem, particularly due to the economic burden caused by productivity losses (indirect costs) associated with temporary absence from work, not yet sufficiently studied in Portugal. Our objective was to quantify the indirect costs of AMI in the first year after admission.

Methods

All consecutive patients admitted in a single center with <66 years (official retirement age) during one year that survived to discharge were included in the present study. Employment status on admission was assessed in every patient. For each employed patient, working at the time of admission, the monthly wage was estimated from market wage rates from national public sources (grossed up by social security contributions) according to gender and age. A day-cost was calculated to assess the cost of temporary absence from work. A half-day absence was considered for Cardiology medical appointments and exams. The duration of temporary absence from work was assessed by a first follow-up contact at 30-day and a second follow-up evaluation up to one-year after admission. The cost of temporary absence from work per episode was calculated in this sample and results were applied to the total number of MI in Portugal during the year 2016 (last available national data) and separately according to ST-elevation AMI (STEAMI) or non-ST-elevation acute coronary syndrome (NSTACS).

Results

We included 219 patients (54±7 years, 83% males), from which, 66.2% were working, 16.4% early-retired, 11.9% unemployed and 5.5% in long-term exit from work due to non-cardiac disease. During the one-year follow-up there were no changes in employment status. In our sample, mean monthly labor cost was 1802 euros (69 euros/day). Median number of days absent from work were 34 days (31 days in men and 52 days in women) and a median of 2 half-days were also obtained for Cardiology appointments / exams. We obtained a total cost of 760.521,55 euros. We used available data from 2016 to estimate indirect costs at a national level. There were 4133 patients with <66 years admitted in Portugal due to AMI that survived to discharge. We performed an analysis, using the proportions of 41% of cases with STEAMI and 59% with NSTACS that came out of the Portuguese Registry on Acute Coronary Syndromes and the working patient's proportions in each group. Costs were higher in patients with STEAMI. We estimate an indirect total cost in Portugal of € 10.12 million in the first year after MI.

Conclusions

In Portugal, the costs to society of disability generated losses of productivity are over ten million euros during the first year after AMI. Strategies to improve time of return to work are very important to lower these costs.

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Background

Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently.

Objectives

The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery.

Methods

In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed.

Results

1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (<22 in 88%, 23–32 in 10.2% and >33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p<0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p<0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p<0.01) persisted as independent all-cause mortality predictors.

Conclusion

In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

Oral antioxidant therapy for prevention and treatment of preeclampsia: Meta-analysis of randomized controlled trials

AIMS

To determine whether oral antioxidant therapies, of various types and doses, are able to prevent or treat women with preeclampsia.

DATA SYNTHESIS

The following databases were searched: MEDLINE, CENTRAL, LILACS, and Web of Science. Inclusion criteria were: a) randomized clinical trials; b) oral antioxidant supplementation; c) study in pregnant women; d) control group, treated or not with placebo. Papers were excluded if they evaluated antioxidant nutrient supplementation associated with other non-antioxidant therapies. Data were extracted and the risk of bias of each study was assessed. Heterogeneity was analyzed using the Cochran Q test, and I2 statistics and pre-specified sensitivity analyses were performed. Meta-analyses were conducted on prevention and treatment studies, separately. The primary outcome was the incidence of preeclampsia in prevention trials, and of perinatal death in treatment trials. Twenty-nine studies were included in the analysis, 19 for prevention and 10 for treatment. The antioxidants used in these studies were vitamins C and E, selenium, l-arginine, allicin, lycopene and coenzyme Q10, none of which showed beneficial effects on the prevention of preeclampsia (RR: 0.89, CI 95%: [0.79-1.02], P = 0.09; I² = 39%, P = 0.04) and other outcomes. The antioxidants used in the treatment studies were vitamins C and E, N-acetylcysteine, l-arginine, and resveratrol. A beneficial effect was found in intrauterine growth restriction.

CONCLUSIONS

Antioxidant therapy had no effects in the prevention of preeclampsia but did show beneficial effects in intrauterine growth restriction, when used in the treatment of this condition.

Responses of estuarine nematodes to an increase in nutrient supply: an in situ continuous addition experiment

An experiment was carried out on an estuarine mudflat to assess impacts of inorganic nutrients used to fertilize sugar-cane fields on the surrounding aquatic ecosystem, through changes in the nematode community structure. During 118 days, nine quadrats each 4m(2) were sampled six times after the beginning of fertilizer addition. The fertilizer was introduced weekly in six areas, at two different concentrations (low and high doses), and three areas were used as control. The introduction of nutrients modified key nematode community descriptors. In general, the nematodes were negatively affected over the study period. However, Comesa, Metachromadora, Metalinhomoeus, Spirinia and Terschellingia were considered tolerant, and other genera showed different degrees of sensitivity. Nutrient input also affect the availability and quality of food, changing the nematode trophic structure. The use of inorganic fertilizer should be evaluated with care because of the potential for damage to biological communities of coastal aquatic systems.

Multi-parametric flow cytometric and genetic investigation of the peripheral B cell compartment in human type 1 diabetes

The appearance of circulating islet-specific autoantibodies before disease diagnosis is a hallmark of human type 1 diabetes (T1D), and suggests a role for B cells in the pathogenesis of the disease. Alterations in the peripheral B cell compartment have been reported in T1D patients; however, to date, such studies have produced conflicting results and have been limited by sample size. In this study, we have performed a detailed characterization of the B cell compartment in T1D patients (n = 45) and healthy controls (n = 46), and assessed the secretion of the anti-inflammatory cytokine interleukin (IL)-10 in purified B cells from the same donors. Overall, we found no evidence for a profound alteration of the B cell compartment or in the production of IL-10 in peripheral blood of T1D patients. We also investigated age-related changes in peripheral B cell subsets and confirmed the sharp decrease with age of transitional CD19(+) CD27(-) CD24(hi) CD38(hi) B cells, a subset that has recently been ascribed a putative regulatory function. Genetic analysis of the B cell compartment revealed evidence for association of the IL2-IL21 T1D locus with IL-10 production by both memory B cells (P = 6·4 × 10(-4) ) and islet-specific CD4(+) T cells (P = 2·9 × 10(-3) ). In contrast to previous reports, we found no evidence for an alteration of the B cell compartment in healthy individuals homozygous for the non-synonymous PTPN22 Trp(620) T1D risk allele (rs2476601; Arg(620) Trp). The IL2-IL21 association we have identified, if confirmed, suggests a novel role for B cells in T1D pathogenesis through the production of IL-10, and reinforces the importance of IL-10 production by autoreactive CD4(+) T cells.

Chromatin changes in papillary thyroid carcinomas may predict patient outcome

PURPOSE

New insights in prognostic predictions are urgently needed for papillary thyroid carcinoma (PTC). The present study aimed to investigate whether computerized analysis of chromatin texture allows the identification of PTC patients with a poor prognosis.

METHODS

We randomnly selected paraffin-embedded blocks from surgical specimens of 103 classic cases of PTC. During follow-up, 68 of the patients were classified as free of disease, whereas 35 presented with recurrences. Characteristics of chromatin were obtained from digitized images of at least 100 randomly selected tumor nuclei per patient. An independent series of 30 goiters was used to validate our observations.

RESULTS

Stage, age and distant metastases were found to serve as independent prognostic factors for survival. In addition, multivariate Cox regression confirmed variable cluster prominence as an independent prognostic factor. By comparing malignant and benign nodules, we found that the PTC lesions presented with higher nuclear perimeters, nuclear areas, Minkowski fractal dimensions, optical densities and nuclear longest chords.

CONCLUSION

From our results we conclude that, in conjunction with clinical and histopathological data, morphometric data may provide relevant prognostic information in PTC patients.

Repair of Dimethacrylate-Based Composite Restorations by a Silorane-Based Composite: A One-Year Randomized Clinical Trial

Purpose

To investigate clinical performance of a low-shrinkage silorane-based composite resin when used for repairing conventional dimethacrylate-based composite restorations.

Background

Despite the continued development of resin-based materials, polymerization shrinkage and shrinkage stress still require improvement. A silorane-based monomer system was recently made available for dental restorations. This report refers to the use of this material for making repairs and evaluates the clinical performance of this alternative treatment.

Materials and Methods

One operator repaired the defective dimethacrylate-based composite resin restorations that were randomly assigned to one of two treatment groups: control (n=50) repair with Adper SE Plus (3M/ESPE) and Filtek P60 Posterior Restorative (3M/ESPE), and test (n=50) repair with P90 System Adhesive Self-Etch Primer and Bond (3M/ESPE) and Filtek P90 Low Shrink Posterior Restorative (3M/ESPE). After one week, restorations were finished and polished. Two calibrated examiners (Kw≥0.78) evaluated all repaired restorations, blindly and independently, at baseline and one year. The parameters examined were marginal adaptation, anatomic form, surface roughness, marginal discoloration, postoperative sensitivity, and secondary caries. The restorations were classified as Alpha, Bravo, or Charlie, according to modified US Public Health Service criteria. Mann-Whitney and Wilcoxon tests were used to compare the groups.

Results

Of the 100 restorations repaired in this study, 93 were reexamined at baseline. Dropout from baseline to one-year recall was 11%. No statistically significant differences were found between the materials for all clinical criteria, at baseline or at one-year recall (p&gt;0.05). No statistically significant differences were registered (p&gt;0.05) for each material when compared for all clinical criteria at baseline and at one-year recall.

Conclusions

The hypothesis tested in this randomized controlled clinical trial was accepted. After the one-year evaluations, the silorane-based composite exhibited a similar performance compared with dimethacrylate-based composite when used to make repairs.

Clinical and pathological implications of concurrent autoimmune thyroid disorders and papillary thyroid cancer

Cooccurrences of chronic lymphocytic thyroiditis (CLT) and thyroid cancer (DTC) have been repeatedly reported. Both CLT and DTC, mainly papillary thyroid carcinoma (PTC), share some epidemiological and molecular features. In fact, thyroid lymphocytic inflammatory reaction has been observed in association with PTC at variable frequency, although the precise relationship between the two diseases is still debated. It also remains a matter of debate whether the association with a CLT or even an autoimmune disorder could influence the prognosis of PTC. A better understanding about clinical implications of autoimmunity in concurrent thyroid cancer could raise new insights of thyroid cancer immunotherapy. In addition, elucidating the molecular mechanisms involved in autoimmune disease and concurrent cancer allowed us to identify new therapeutic strategies against thyroid cancer. The objective of this article was to review recent literature on the association of these disorders and its potential significance.

Minimization of transcriptional temporal noise and scale invariance in the yeast genome

The analysis of transcriptional temporal noise could be an interesting means to study gene expression dynamics and stochasticity in eukaryotes. To study the statistical distributions of temporal noise in the eukaryotic model system Saccharomyces cerevisiae, we analyzed microarray data corresponding to one cell cycle for 6200 genes. We found that the temporal noise follows a lognormal distribution with scale invariance at the genome, chromosomal and sub-chromosomal levels. Correlation of temporal noise with the codon adaptation index suggests that at least 70% of all protein-coding genes are a noise minimization core of the genome. Accordingly, a mathematical model of individual gene expression dynamics was proposed, using an operator theoretical approach, which reveals strict conditions for noise variability and a possible global noise minimization/optimization strategy at the genome level. Our model and data show that minimal noise does not correspond to genes obeying a strictly deterministic dynamics. The natural strategy of minimization consists in equating the mean of the absolute value of the relative variation of the expression level (alpha) with noise (eta). We hypothesize that the temporal noise pattern is an emergent property of the genome and shows how the dynamics of gene expression could be related to chromosomal organization.

Morphological and molecular diversity and phylogenetic relationships among anuran trypanosomes from the Amazonia, Atlantic Forest and Pantanal biomes in Brazil

We examined for the presence of trypanosomes in blood samples from 259 anurans (47 species from 8 families), the majority of which were from the Brazilian Amazonia, Atlantic Forest and Pantanal biomes. Trypanosomes were detected by a combination of microhaematocrit and haemoculture methods in 45% of the anurans, and 87 cultures were obtained: 44 from Hylidae, 22 from Leptodactylidae, 15 from Bufonidae, 5 from Leiuperidae and 1 from an unidentified anuran. High morphological diversity (11 morphotypes) was observed among blood trypanosomes from anurans of different species and of the same species as well as among trypanosomes from the same individual. Conversely, morphologically similar trypanosomes were found in anurans from distinct species and biomes. ITS and SSU rDNA polymorphisms revealed high diversity among the 82 isolates examined.† Twenty-nine genotypes could be distinguished, the majority distributed in 11 groups. Phylogenetic relationships based on rDNA sequences indicated that isolates from more phylogenetically related anurans are more closely related. Comparison of anuran trypanosomes from Brazil and other countries revealed several new species among the isolates examined in this study. Phylogenetic relationships suggest that host restriction, host switching and overall ecogeographical structure may have played a role in the evolution of the anuran trypanosomes.

Efficacy and safety of risperidone oral solution in agitation associated with dementia in the elderly

BACKGROUND

Behavioral and psychological symptoms in dementia (BPSD) contribute to caregiver burden and institutionalization of elderly. Neuroleptics are prescribed to control agitation. Side effects of typical neuroleptics are harmful, making atypical neuroleptics an indication.

OBJECTIVES

To evaluate efficacy and tolerability of risperidone oral solution (ROS) given once daily to demented elderly outpatients with BPSD (agitation).

METHOD

Patients (n=26), 76.35+/-8.63 years, Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) criteria for dementia. RSO was given, starting dose of 0.25 mg and increments of 0.25 mg every week. Mini-Mental State Examination (MMSE) assessed cognitive status, Behavioral and Emotional Activities Manifested in Dementia (BEAM-D) and Clinical Global Impression (CGI) measured BPSD, Extrapiramidal Symptom Rating Scale (ESRS) evaluated extrapyramidal symptoms. Cardiovascular side effects were evaluated clinically.

RESULTS

There was a 26% reduction in agitation and no cardiovascular side effects in the range from 1.0 to 1.25 mg. Side effects were more prevalent above 2.5 mg.

CONCLUSION

Risperidone oral solution improved agitation with good tolerability from 0.5 to 1.25 mg. A single dose with increments of 0.25 mg may be more acceptable to patients and caregivers.

Comparison of the cryopreservation of human embryos obtained after intracytoplasmic sperm injection with a slow cooling or an ultrarapid cooling procedure

PURPOSE

Our purpose was to compare an ultrarapid method (URM) modified with dimethyl sulfoxide (Me2SO) to a slow method (SM) with propanediol (PROH) for the cryopreservation of extra human embryos in a program of intracytoplasmic sperm injection (ICSI).

METHODS

The extra embryos of 160 patients were cryopreserved in a prospective and randomized manner (drawing lots) by a modified URM (3 M Me2SO/0.25 M sucrose/thawing in three sucrose gradients) (Group I) or by a SM (1.5 M Propanediol/program 0-Cryologic CL863) (Group II). A total of 103 cycles has been thawed thus far. The number of thawed cycles was 58 for group I and 45 for group II.

RESULTS

The mean age (group I, 31.3 +/- 4.5; group II, 31.9 +/- 4.3) did not differ between the groups (P = 0.38). The number of frozen embryos (group I, 6.6 +/- 3.2; group II, 6.5 +/- 3.2) was similar (P = 0.49) for the two groups, as was the number of thawed embryos (P = 0.52) (group I, 6.5 +/- 2.9; group II, 6.2 +/- 3). The survival rate was higher (P < 0.01) for group II (83.3 +/- 23%) than for group I (69.2 +/- 28.7%). The cleavage rate was also higher (P < 0.01) for group II (56.8 +/- 31%) compared with group I (24.2 +/- 22.4%). The number of embryos transferred did not differ (P = 0.14) between the groups (group I, 3.16 +/- 1.2; group II, 3.5 +/- 1.0). The implantation rate (group I, 6.3%; group II, 13.8%) was significantly different between groups (P = 0.034). Pregnancy rates per thawed and transferred cycle were higher for group II (33.3 and 36.6%, respectively) compared with group I (13.8 and 16%, respectively), and these differences were significant (P = 0.03 and P = 0.03, respectively).

CONCLUSION

The data obtained suggest that the SM is superior to the URM for the cryopreservation of extra embryos after ICSI.

[Effect of supragingival plaque control on subgingival microflora and periodontal tissues]

The aim of this study was to investigate, clinically and microbiologically, forty-four sites in 11 patients presenting with generalized chronic periodontitis. Plaque Index (PI), Gingival Index (GI), Probing Bleeding (PB), Probing Depth (PD) and Insertion Level (IL) were registered. Samples of subgingival plaque were collected in the same sites for cultivation of anaerobic bacteria and determination of microbiological morphotypes using dark field microscopy. Clinical and microbiological data were recorded on the baseline and 4 weeks after the adoption of a program to control supragingival plaque and calculus. The microbiological analysis categorized the degree of development as follows: 0--not detected, 1--scarce, 2--moderate and 3--abundant. The clinical results at the baseline and on the 28th day were, respectively: PI--1.73 +/- 0.10 and 0.30 +/- 0.08; GI--1.73 +/- 0.08 and 1.41 +/- 0.08; PB--0.91 +/- 0.04 and 0.59 +/- 0.07; PD--6.43 +/- 0.20 and 5.77 +/- 0.25; and IL--6.86 +/- 0.32 and 6.52 +/- 0.34. There was significant decrease in PI, GI, PB and PD. However, the difference in IL was not significant. The relative proportions of the microbial morphotypes observed under dark field microscopy at the baseline and on the 28th day were, respectively: coccoid cells--21.16 +/- 3.77 and 36.00 +/- 4.66; mobile bacillus--44.86 +/- 2.65 and 39.50 +/- 2.64; and total treponemes--24.66 +/- 3.08 and 19.25 +/- 2.75. The cultures presented, at the baseline and on the 28th day, respectively: Prevotella intermedia/nigrescens (Pi/n)--1.36 +/- 0.18 and 0.43 +/- 0.11; Porphyromonas gingivalis--0.48 +/- 0.16 and 0.32 +/- 0.13; Actinobacillus actinomycetemcomitans--0.23 +/- 0.09 and 0.23 +/- 0.10; Fusobacterium nucleatum--0.32 +/- 0.14 and 0.41 +/- 0.13; and peptostreptococci--0.82 +/- 0.19 and 0.54 +/- 0.16. There was a significant increase in the number of coccoid cells and a decrease in the number of treponemes and Pi/n.

Zona thinning with noncontact diode laser in patients aged < or = 37 years with no previous failure of implantation: a prospective randomized study

PURPOSE

Zona thinning (ZT) is a technique used to improve pregnancy rates among patients > or = 38 years old and/or patients presenting previous implantation failure. The objective of the study was to determine whether ZT has a beneficial effect on patients younger than 37 years who are undergoing the first ICSI attempt.

METHODS

A total of 103 patients submitted to ICSI for the first time and those aged < or = 37 years were divided in a prospective and randomized manner into two groups: group I, patients submitted to ZT (n = 51) (a laser diode with 1.48-micron wavelength (Fertilaser) was used for the procedure); group II, patients with no ZT (n = 52). In both groups, embryo transfer was performed on the second day.

RESULTS

The age of group I patients (31.8 +/- 3.6) did not differ (P = 0.53) from that of group II patients (31.4 +/- 3.6). The number of metaphase II oocytes was similar (P = 0.76) for the two groups (group I = 9.12 +/- 5.27; group II = 8.67 +/- 5.02). The average number of embryos available per transfer of group I (6.14 +/- 4.02) did not differ (P = 0.69) from that of group II (5.75 +/- 3.83). The number of embryos transferred was similar (P = 0.61) for the two groups (group I = 2.76 +/- 0.9; group II = 2.87 +/- 0.79). The thickness of the zona pellucida of group I embryos (16.6 +/- 2.2 microns) did not differ (P = 0.08) from that of group II embryos (17.1 +/- 1.7 microns). The rate of embryo implantation (20.8%) and the rate of clinical pregnancy per embryo transfer (40.3%) were higher for group II than for group I (17.7% and 33.3%, respectively), but the difference was not significant (P = 0.55 and P = 0.54).

CONCLUSIONS

These results suggest that ZT in the population aged < or = 37 years and with no previous failure of implantation may have no impact on intracytoplasmic sperm injection success rates.

Antidepressant efficacy of sertraline and imipramine for the treatment of major depression in elderly outpatients

CONTEXT

Most double-blind studies of efficacy and tolerability of sertraline as compared to tricyclics in the treatment of late-life major depression have used amitriptyline as a standard, leading to the inevitable conclusion that the former drug is better tolerated than the latter, with both being equally efficacious.

OBJECTIVE

To compare the antidepressant efficacy and tolerability of sertraline (50 mg/day) and imipramine (150 mg/day) in the first 6 weeks of the treatment of major depression in the elderly.

DESIGN

A randomized double-blind parallel study with 6 weeks of follow-up.

SETTING

The psychogeriatric clinic at the Institute of Psychiatry, Hospital das Clínicas, Faculty of Medicine of the University of São Paulo.

PARTICIPANTS

55 severe and moderately depressed non-demented outpatients aged 60 years or more.

INTERVENTION

Patients were assigned to sertraline 50 mg/day or imipramine 150 mg/day.

MAIN MEASUREMENTS

CAMDEX interview. Psychiatric diagnosis followed the guidelines for "Major Depressive Episode" according to DSM-IV criteria. Severity of symptoms was evaluated using the "CGI" and "MADRS" scales. Cognitive state was assessed using the Mini-Mental State Examination. Side effects were assessed using the "Safetee-Up" schedule.

RESULTS

Both groups had a significant decrease in depressive symptoms according to the MADRS scores after 6 weeks of treatment (P = 0.01). No significant differences between groups were detected regarding treatment outcome (t = 0.4; P = 0.7). Although the dropout rate was greater in the imipramine group, the overall tolerability among patients who completed the 6-week trial was similar in both test groups.

CONCLUSIONS

Both sertraline and imipramine exhibited good efficacy and an acceptable side-effect profile for elderly depressed patients after 6 weeks of antidepressant treatment.

[Recommendations for the diagnosis and treatment of unstable angina and non-Q-wave myocardial infarction (proposed revision)]

The optimal diagnostic and treatment strategies for unstable angina/non-Q-wave myocardial infarction patients will continue to be redefined as rapid progress is made in the understanding, and treatment of this syndrome. The recommendations presented here reflect, in part, discussions at the International Cardiology Forum in September 1998. Although areas of controversy remain, we have summarized major points on which a consensus could be reached and for which the weight of the clinical evidence supports a change in practice.

[The use of Abciximab in patients with acute myocardial infarction undergoing direct percutaneous coronary revascularization]

OBJECTIVE

To evaluate the initial experience, in our Centre, with Abciximab in patients with acute myocardial infarction undergoing direct percutaneous transluminal coronary angioplasty (PTCA).

METHODS

Between October 1996 and May 1998, 65 patients (51 males, mean age 56.9 +/- 11 years) underwent direct PTCA for acute myocardial infarction. In thirty-seven patients the myocardial infarction was anterior and 40 had multivessels disease. Mainly to compare the incidence of bleeding complications we considered 2 groups: Group A--17 patients submitted to PTCA without the use of Abciximab, and Group B--48 patients submitted to PTCA and to a bolus followed by a 12 hour infusion of Abciximab. All the patients were treated with aspirin and heparin (5,000 to 15,000 U according to ACT) and ticlopidine in case of stent implantation.

RESULTS

Percutaneous coronary revascularization was successfully achieved in 92.3% of the patients. The total number of bleeding complications was ten cases (20.8%) in Group B and 1 case (5.8%) in Group A. Most of the bleeding complications in the Abciximab Group were minor and related to the femoral vascular access site (9 cases--18.7%) and were easily resolved with local measures (8 cases). There were also 3 cases of hematemesis and one of oral bleeding, all well tolerated. Major bleeding complications were identified in only one patient of the Abciximab Group related to the vascular access site, however there was an absolutely similar case in Group A (2% versus 5.8%).

CONCLUSIONS

Although bleeding complications were more frequent in patients receiving Abciximab, mostly related to the vascular access site, they were transient and well tolerated.

Clinical experience with ultrarapid cryopreservation of human embryos resulting from intracytoplasmic sperm injection: brief communication

A total of 41 patients requested thawing of supernumerary embryos in an intracytoplasmic sperm injection (ICSI) programme. Mean patient age was 30.8 +/- 3.8 years. Embryo freezing by the ultrarapid method was performed at room temperature in 3 mol/l DMSO and 0.25 mol/l sucrose. Total freezing time was 2.5 min including filling of the straw. In the thawing process, the embryos were removed from liquid N(2), left at room temperature for 30 s, immersed for 40 s at 30 degrees C, and then successively transferred at room temperature for 10 min to each of three sucrose solutions of decreasing concentration. The embryos were kept in culture and only those that presented cleavage after 24 h were transferred. Embryos from 42 cycles were thawed and a total of 24 transfers was performed. The mean number of thawed embryos was 5.0 +/- 3.2 per cycle and the mean number of transferred embryos was 2.83 +/- 1.3. The clinical pregnancy rate per cycle obtained after the thawing process was 16. 6%. The clinical pregnancy rate per transfer was 29.2% and the implantation rate was 13.2%. The abortion rate was 14.3%. Six deliveries have been performed, with the birth of seven infants.

Penicillin-binding proteins of pathogenic Escherichia coli strains

The penicillin-binding proteins of 11 pathogenic Escherichia coli strains, including enteropathogenic, enterotoxigenic, enteroinvasive, enteroaggregative, and enterohemorrhagic E. coli, were detected in gels following the labeling of isolated cell envelopes with [3H]benzylpenicillin. The electrophoretic profiles, sensitivities to and morphological changes induced by beta-lactam antibiotics showed that the penicillin-binding proteins of most pathogenic E. coli possess structural and physiological functions similar to those of E. coli K12.