Improving Guideline-Concordant Care for Febrile Infants Through a Quality Improvement Initiative

OBJECTIVES

We aimed to examine the impact of a quality improvement (QI) collaborative on adherence to specific recommendations within the American Academy of Pediatrics' Clinical Practice Guideline (CPG) for well-appearing febrile infants aged 8 to 60 days.

METHODS

Concurrent with CPG release in August 2021, we initiated a QI collaborative involving 103 general and children's hospitals across the United States and Canada. We developed a multifaceted intervention bundle to improve adherence to CPG recommendations for 4 primary measures and 4 secondary measures, while tracking 5 balancing measures. Primary measures focused on guideline recommendations where deimplementation strategies were indicated. We analyzed data using statistical process control (SPC) with baseline and project enrollment from November 2020 to October 2021 and the intervention from November 2021 to October 2022.

RESULTS

Within the final analysis, there were 17 708 infants included. SPC demonstrated improvement across primary and secondary measures. Specifically, the primary measures of appropriately not obtaining cerebrospinal fluid in qualifying infants and appropriately not administering antibiotics had the highest adherence at the end of the collaborative (92.4% and 90.0% respectively). Secondary measures on parent engagement for emergency department discharge of infants 22 to 28 days and oral antibiotics for infants 29 to 60 days with positive urinalyses demonstrated the greatest changes with collaborative-wide improvements of 16.0% and 20.4% respectively. Balancing measures showed no change in missed invasive bacterial infections.

CONCLUSIONS

A QI collaborative with a multifaceted intervention bundle was associated with improvements in adherence to several recommendations from the AAP CPG for febrile infants.

A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections

BACKGROUND

Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost.

METHODS

We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure.

RESULTS

Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase.

CONCLUSIONS

This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

An assessment of information needs and workflows for emergency service providers and caregivers of children with medical complexity

BACKGROUND

The goal of Project Austin, an initiative to improve emergency care for rural children who are medically complex (CMC), is to provide an Emergency Information Form (EIF) to their parents/caregivers, to local Emergency Medical Services, and Emergency Departments. EIFs are standard forms recommended by the American Academy of Pediatrics that provide pre-planned rapid response instructions, including medical conditions, medications, and care recommendations, for emergency providers. Our objective is to describe the workflows and perceived utility of the provided emergency information forms (EIFs) in the acute medical management of CMC.

METHODS

We sampled from two key stakeholder groups in the acute management of CMC: four focus groups with emergency medical providers from rural and urban settings and eight key informant interviews with parents/caregivers enrolled in an emergency medical management program for CMC. Transcripts were thematically analyzed in NVivo© by two coders using a content analysis approach. The thematic codes were combined into a codebook and revised the themes present through combining relevant themes and developing of sub-themes until they reached consensus.

RESULTS

All parents/caregivers interviewed were enrolled in Project Austin and had an EIF. Emergency medical providers and parents/caregivers supported the usage of EIFs for CMC. Parents/caregivers also felt EIFs made emergency medical providers more prepared for their child. Providers identified that EIFs helped provide individualized care, however they were not confident the data was current and so felt unsure they could rely on the recommendations on the EIF.

CONCLUSION

EIFs are an easy way to engage parents, caregivers, and emergency medical providers about the specifics of a care for CMC during an emergency. Timely updates and electronic access to EIFs could improve their value for medical providers.

Exploring the Readability of Ingredients Lists of Food Labels with Existing Metrics

Healthy diet and dietary behaviors are key components in prevention of chronic disease and management of chronic illness. Nutritional literacy has been associated with dietary behaviors and consumer choice of healthy foods. Nutritional literacy can be measured, for example, by examining consumer food label use, but current research focuses largely on the Nutrition Facts panel of a food product. Ingredients lists are critical for communicating food composition but are relatively unstudied in existing literature. The goal of this work is to measure the readability of ingredients lists on branded food products in the United States using existing metrics. We examined ingredients lists for all 495,646 products listed in the USDA Food Data Central database using four existing readability measures for text written in natural language. Each of these indices approximates the grade level that would be expected to comprehend a text; comparatively, patient consent forms are considered acceptable at an 8^th grade reading level or lower. We report a broad variability for in readability using different metrics: ingredients lists recorded at a 9^th grade reading level or higher to comprehend are found at rates of 16.5% (Automated Reading Index) to 74.9% (Gunning-Fog Index). Ingredients lists recorded at a 10^th grade reading level or higher to comprehend are found at rates of 84.2% (using FRE Index). These results demonstrate the need to further explore how ingredients lists can be measured for readability, both for the purposes of consumer understanding as well as for supporting future nutrition research involving text mining.

On- vs off-hours primary percutaneous coronary intervention: a single-centre experience

Introduction

In ST-segment elevation myocardial infarction (STEMI) patients, emergency medical system delays importantly affect outcomes. The effect of admission time in STEMI patients is dubious when percutaneous coronary intervention (PCI) is the preferred reperfusion strategy.

Aims

The authors aimed to retrospectively describe the association between admission time and STEMI patient's care standards and outcomes.

Methods

Characteristics and outcomes of 1222 consecutive STEMI patients treated in a PCI-centre were collected. On-hours were defined as admission on non-national-holidays from Monday to Friday from 8 AM to 6 PM. Time delays, in-hospital and one-year all-cause mortality were assessed.

Results

A total of 439 patients (36%) were admitted on-hours and 783 patients (64%) were admitted off-hours. Baseline characteristics were well-balanced between groups, including the percentage of patients admitted in cardiogenic shock (on-hours: 4.6% vs off-hours 4%; p=0.62).

Median emergency system dependent time to reperfusion (i.e. first-medical contact to reperfusion) did not differ between the two groups (on-hours: 120 min vs. off-hours 123 min, p=0.54). The authors observed no association between admission time and in-hospital mortality (on-hours: 5% vs. off-hours 4.9%, p=0.90) or 1-year mortality (on-hours: 10% vs. off-hours 10%, p=0.97).

In patients admitted directly in the PCI-centre, median time from first-medical contact to reperfusion (on-hours: 87 min vs off-hours: 88 min, p=0.54), in-hospital mortality (on-hours: 4% vs off-hours: 7%, p=0.30) and 1 year mortality (on-hours: 9% vs off-hours: 13%, p=0.27) did not differ between the two groups.

Survival analysis showed no survival benefit of on-hours PCI over off-hours PCI (HR 1.01; 95% CI [0.77–1.46], p=0.95).

Conclusion

In a contemporary well-organized emergency network, STEMI patients admission time in the PCI-centre was not associated with reperfusion delays or increased mortality.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve

ST-segment elevation myocardial infarction: are women being discriminated?

Background

Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PCI) have improved, a gender disparity exists, with women showing higher mortality.

Objectives

To assess gender differences in presentation, management and in-hospital, at 30-days, 6-months and 1-year after STEMI mortality.

Methods

We collected data from 809 consecutive patients treated with primary PCI and compared the females versus males.

Results

Women were older than man (69,1±14,6 vs. 58,5±12,7 years; p<0.001) with higher prevalence of age over 75 years (36.7% vs. 11.7%; p<0.001), diabetes (30,6% vs. 18,5%; p=0.001), hypertension (60.5% vs. 45.9%; p=0.001), chronic kidney disease (3.4% vs. 0.6%; p=0.010) and acute ischemic stroke (6.8% vs. 3.0%; p=0.021). At presentation, women had more atypical symptoms, less chest pain (90.3% vs. 95.6%; p=0.014) and greater clinical severity (cardiogenic shock (10.7% vs. 5.4%; p=0.011). There were no differences in the symptom-first medical contact me (95.0 min vs. 80.5 min; p=0.215); however, women had longer time until reperfusion (264.0 min vs. 212.5 min; p=0.001) and were less likely to receive optimal medical therapy (aspirin-93.1% vs. 99.2%; p<0.001; P2Y12 inhibitors 91.9% vs. 98.2%; p<0.001; beta-blockers-90.8% vs. 95.1%; p=0.032; ACEIs- 88.1% vs. 94.8%; p=0.003). In-hospital mortality (9.6% vs. 3.5%; p=0.001), at 30-days (11.3% vs. 4.0%; p<0.001), 6-months (14.1% vs. 4.7%; p<0.001) and 1-year (16.4% vs. 6.3%; p<0.001) was significantly higher in women. The multivariate analysis identified age over 75 years (HR=4.25; 95% CI [1.67–10.77]; p=0.002), Killip class II (HR=8.80; 95% CI [2.72–28.41]; p<0.001), III (HR=5.88; 95% CI [0.99–34.80]; p=0.051) and IV (HR=9.60; 95% CI [1.86–48.59]; p=0.007), acute kidney injury (HR=2.47; 95% CI [1.00–6.13]; p=0.051) and days of hospitalization (HR=1.04; 95% CI [1.01–1.08]; p=0.030) but not female gender (HR=0.83; 95% CI [0.33–2.10]; p=0.690) as independent prognostic factors of mortality.

Conclusions

Compared to men, women with STEMI undergoing primary PCI have higher mortality rates. Our results suggest that this is not due to the gender itself, but due to the women worse risk profile, the higher reperfusion time related with system delays and the minor probability of receiving the recommended therapy. Efforts should be made to reduce these gender differences.

Funding Acknowledgement

Type of funding sources: None.

The Predictive role of speckle-tracking and left ventricular ejection fraction estimation using 2D and 3D echocardiography in the detection of chemotherapy related cardiotoxicity

Background

2D left ventricular ejection fraction (LVEF) estimation through echocardiography has been the classic parameter for cancer therapy–related cardiac dysfunction (CTrCD) detection. However, it is hypothesized that other parameters can be used in order to detect early stages of subclinical cardiotoxicity when LVEF is still preserved. Therefore, 3D LVEF and 2D and 3D strain parameters assessments have been evaluated in patients submitted to anthracyclines treatment.

Objectives

To compare 2D and 3D LVEF and strain parameters estimation using echocardiography regarding its ability to predict and detect subclinical and clinical cardiotoxicity during and after anthracyclines treatment.

Search methods and criteria

A systematic review was done and search was performed on PubMed and EMBASE from January 1st of 2000 to October 31th of 2020. Observational studies comparing 2D and 3D echocardiographic exams performed in adult patients submitted to anthracyclines were analyzed. Studies that evaluated survivors of pediatric cancer were excluded. 11 studies were included (n=844 patients).

Main results

2D and 3D LVEF decreased throughout the echocardiographic assessments of 7 studies, but 2D LVEF drops were not statistically significant in 4 studies and 3 studies showed that 3D LVEF detected a superior number of patients with abnormal LVEF. Compared to 3D LVEF,

2D GLS decreased at an earlier point of treatment and detected a superior number of patients with subclinical LV dysfunction. Despite 2D and 3D GLS decreased throughout treatment, 3D GLS measurements were consistently lower and had higher relative variation. All 3D strain parameters decreased during and after the treatment and have higher relative variations than 2D GLS, with the exception of 1 study. 3D GLS reference values are not yet recognized by guidelines, so subclinical LV dysfunction was not evaluated.

Conclusions

LVEF estimation through 3D proved to be a better parameter for CTrCD detection vs 2D imaging. GLS is superior to 3D LVEF in detecting earlier LV changes, even if calculated using 2D echocardiography. Moreover, GLS reduction can be a predictor of subsequent LVEF decrease. 3DE is a growing potential technique and may be superior to 2DE in detecting and predicting subclinical LVEF dysfunction and CTrCD, respectively. Though 3D strain parameters presented promising results, more studies are needed to prove its incremental value over 2D strain echocardiography

Funding Acknowledgement

Type of funding sources: None.

Managing bifurcations: are two stents better than one?

Introduction

Bifurcation percutaneous coronary intervention (PCI) is associated with a higher degree of complexity when compared with non-bifurcation procedures. Although 1-stent PCI remains the standard approach for most bifurcation lesions, data is constantly being published on 2-stent PCI.

Aim

To evaluate and compare the characteristics and outcomes of patients that underwent bifurcation PCI with one or two stents.

Methods

Single center, retrospective observational study including all patients who underwent bifurcation PCI between January 2015-December 2018. We defined two groups: 1-stent PCI group (1s-PCI) and 2-stent PCI group (2s-PCI). The 2s-PCI group included PCI patients with all the different techniques used in our center: provisional stenting with 2 stents, Cullote, crushing stent and DK Crush.

Results

1s-PCI group included 376 individuals and 2s-PCI group included 26. Overall baseline clinical characteristics were balanced between groups. There was no statistically significant difference in age (mean 64 vs 66; p=0.388), gender (79% vs 85% males; p=0.622) and comorbidities (hypertension, diabetes mellitus, hypercholesterolemia, chronic kidney disease, smoking and previous history of coronary artery disease). Also, there was no difference in clinical status (NSTEMI 36% vs 38%; stable disease 32% vs 42%; STEMI 28% vs 19%; unstable angina 5% vs 0%; p=0.419). Coronary angiography and lesion distribution were similar in both groups (p=0.367). However, radiation dose (median 90.5 [IQR=79] vs 156 [IQR=84] mGy cm2; p<0,001) and contrast volume (median 150 [IQR=100] vs 156 [IQR=83] ml; p<0,001) were significantly higher in 2s-PCI group. At 12-month follow-up, mortality rate was higher in 1s-PCI group, but without statistical significance (8% vs 4%; p=0.71); the same is true for acute myocardial infarction at 12 months (3% vs 0%; p=0.368). Target-lesion failure was only reported in 4 patients in the 1s-PCI group. Survival tests showed no significant difference between groups (χ2(1,n=402)=0.634; p=0.426).

Conclusion

Individuals that underwent 1s-PCI were overall similar to those who underwent 2s-PCI. Predictably, deploying more than 1 stent required more contrast volume and implied a higher radiation dose. We should note that our studied is greatly limited by the 2s-PCI group size, which may justify the lack of difference in the evaluated outcomes.

Funding Acknowledgement

Type of funding sources: None.

Impact of a cardio-oncology rehabilitation program in patients with breast cancer undergoing cardiotoxic treatment

Background

Cancer treatment–related cardiotoxicity (CTrCD) is commonly associated with anthracyclines and anti-HER2 agents which are widely used for the treatment of breast cancer. In order to mitgate CTrCD, exercise-based cardio-oncology rehabilitation (COR) involving a structured exercise program has been proposed.

Objectives

To evaluate the impact of a cardiac-rehabilitation program in breast cancer patients submitted to chemotherapy with known cardiotoxicity.

Methods

A systematic review was performed. Two databases were searched, PubMed and SCOPUS. All randomized or controlled trials and other prospective studies published between 2000 and March 2020 which evaluate the impact of an aerobic exercise program on cardiorespiratory fitness (CRF), health-related quality of life (QOL), vascular/endothelial function as well as cardiac assessment namely through the evaluation of left ventricular function and cardiac biomarkers in patients undergoing anthracycline and/or anti-HER2 treatments were included.

Main results

Fourteen studies were included enrolling 578 breast cancer patients with a mean age of 48.80 years. Regarding the impact of exercise in CRF, 5 studies (n=176) reported a significant improvement of VO2 max. and 4 studies of VO2max./kg (n=137). The peak power output was also improved in 4 studies (n=95) in the exercise-group. Considering the assessment of QOL, 3 studies (n=180) revealed significant differences favoring the exercise-group. The results regarding the evaluation of the LVEF were not clear: 2 studies (n=48) reported a significant decrease on LVEF when compared to baseline at the end of the intervention in both groups, despite the exercise program. However, 2 studies (n=97) showed a significant increase on LVEF in the exercise-group. Three studies (n=82) did not found significant differences in global longitudinal strain between groups. Limited evidence was found in vascular and endothelial functon. In 2 studies (n=50), endothelial function measured by brachial artery flow-mediated dilatation significantly improved in the exercise-group. Two studies (n=98) reported no significant impact of exercise on atenuating the increase of cTnI and BNP levels in the course of chemotherapy. On the other hand, when considering NT-proBNP, an increase in its levels was attenuated in the exercise-group.

Conclusions

This study confirms that exercise-based COR seems to be an effective approach to improve several cardiovascular outcomes and quality of life in breast cancer patients.

Funding Acknowledgement

Type of funding sources: None.

Temporal characterization of ventricular function and deformation after Takotsubo syndrome using cardiovascular magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

The time course of ventricular recovery in Takotsubo Syndrome (TS) patients(pts) is still not well characterized. Quantification of myocardial deformation using Cardiovascular Magnetic Resonance Feature-Tracking (CMR-FT) may be a useful method to better characterize ventricular recovery during TS.

AIM

To assess the time course of ventricular function using CMR-FT myocardial strain in patients (pts) with an episode of TS.

METHODS

We performed a single-center, retrospective cohort study including 130 pts admitted with TS over a 10-year period. From this cohort, 39 (30%) pts were selected and age and sex-matched with 16 healthy controls for a comparative analysis of myocardial strain using CMR-FT. TS pts were divided in 3 homogeneous subgroups according to the time from index-event and the CMR acquisition: Group 1(G1): <8 days; Group 2(G2): 8 to 30 days; Group 3 (G3): >30 days.

One operator blinded for the study group performed the analysis. Left ventricle (LV) radial strain (RS), longitudinal strain (LS) and right ventricle (RV) LS were quantified.

RESULTS

The mean age of TS group was 66 years and 90% were female. The median ejection fraction (EF) at admission was 38%; 82% displayed an apical ballooning (AB) pattern. Around 19% had at least 1 in-hospital complication and 1.5% died during hospitalization. A significant increase use of CMR was observed over the years (p = 0.001).

Myocardial deformation analysis showed a significant group interaction for LV LS and RS. Specifically, the global values of G1 LV LS and RS were significantly decreased when compared with G3 (LS:-15vs-20%;p = 0.002; RS:40vs61%; p < 0.001) and controls (LS:-15vs-22%;p < 0.001; RS: 40vs70; p < 0.001). There were no significant differences in the RV LS across groups.

The CMR-quantified EF was significantly decreased in G1 when compared with G3 (52vs64%; p < 0.003) and controls (52vs64%; p < 0.001). Differences between G1 and G2 were found in LV RS (LS:40vs57%; p < 0.001) and EF (52vs62%; p < 0.001). No differences were observed for any parameters between G3 and controls.

This study showed that global LV LS (r=-0.6, p < 0.001) and RS (r = 0.7, p < 0.001) had a significant correlation with the CMR-quantified EF.

A comparison between the different patterns of TS was also performed (Figure 1). Pts with AB pattern in G1 displayed lower global RS (P = 0.014), although there were no differences regarding global LS. As expected, in the AB group the reduction in myocardial strain was limited to the apical segments.

Despite not being significantly different across groups RV LS was the only CMR-derived predictor of complications during follow-up (OR = 1.17; p = 0.026).

CONCLUSION

This study revealed that after an episode of TS myocardial function quantified either by EF or CMR-FT strain fully recovers between the 8th and 30th day of the event. RV strain was a predictor of complications during follow-up.

Impact of Atrial Fibrillation type in Acute Coronary Syndrome and the antithrombotic strategy

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Atrial fibrillation (AF) is an adverse prognostic factor during acute coronary syndrome (ACS). Current evidence recommends dual antithrombotic therapy (DAT), 1 antiplatelet drug and 1 anticoagulant drug, as the default strategy after nonST elevation ACS.

AIM

To identify the clinical differences and prognosis of AF type-new onset (nAF) or pre-existing (pFA)- during ACS, to evaluate antithrombotic strategy at hospital discharge (HD) and its impact on haemorrhagic and ischemic events.

METHODS

We performed a retrospective observational cohort study including 3241 patients (pts) with ACS (mean age 64 years, 77.5% male) admitted to a single center over a 6-year period, with 12-months follow-up.

RESULTS

AF rhythm was identified in 11.2% pts, of whom 63.2% presented nAF and 36.8% pAF.

When AF types where compared, pts with pAF had a higher prevalence of cardiovascular (Cv) comorbidities, including hypertension (p < 0.001), previous ACS (p = 0.03), valvular disease (p = 0.01) or stroke (p = 0.05), had greater left atrial diameter (p < 0.001) and were less likely to have significant coronary lesions (p = 0.05). Pts with nAF more frequently presented with STelevation ACS (p < 0.001) and had a lower Hemoglobin nadir (p < 0.001). The independent predictors of nAF in ACS were age (OR 1.1, p< =0.001), LVEF ≤ 40% (OR 2.2, p = 0.001), STelevation ACS (OR 2.6, p< =0.001) and previous valvular disease (OR 3.5, p< =0.01). Compared with the population without AF, nAF was a predictor of in-hospital death (OR 2.9, p = 0.027) and in-hospital composite endpoint (death, stroke, reinfarction and cardiogenic shock) (OR 2.5, p = 0.001) in multivariate analysis, but pAF wasn’t. During 12-months follow-up of pts with ACS and AF, there was no difference regarding death or follow-up composite endpoint (death, stroke and ACS) between the AF types.Regarding antithrombotic therapy, nAF pts were less often anticoagulated (p < 0.001) and pAF pts where more often treated with triple antithrombotic therapy (TAT) at HD (<0.001). Most of the pts with TAT stopped the second antiplatelet at agent 6-months (43.8%) or 12 months (25.5%) after HD. During 12-months follow-up, pts discharged with TAT had trend towards more haemorrhagic events (TAT 6.2% vs DAT2.7%,p = 0.69) and both groups had similar ischaemic events (death, ACS, stroke) (TAT 20.9% vs DAT23.7%,p = 0.714). In multivariate analysis the choice of TAT or DAT wasn’t a predictor of ischaemic events.

CONCLUSIONS

In ACS, pts with nAF had worst in-hospital outcomes than pts with pAF. Regarding antithrombotic strategy at HD pts with nFA were less often anticoagulated and less often treated with TAT. In our study the choice between DAT or TAT had no statistical impact on follow-up outcomes.

Syncope: call for the missed diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas.

Purpose

To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope.

Methods

Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation.

Results

In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications.

Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department.

Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance).

Conclusions

Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Asymptomatic severe aortic stenosis: what is the current role of exercise stress test and NT-proBNP in patient risk stratification

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis (AS) is prevalent in the elderly population. When severe and the patient is symptomatic or left ventricular dysfunction arises, the prognosis deteriorates and valve replacement (AVR) is recommended. During the asymptomatic phase regular clinical evaluation is advised to detect early onset of symptoms and/or signs of myocardial maladaptation. Due to the inherent difficulties in the evaluation of symptoms, especially in the elderly, as well as the change in prognosis when symptoms appear (even if not perceived), it is crucial to evaluate the behavior of patients with effort and signs of myocardial injury.

Methods

An observational and retrospective study that included 74 patients followed at the Cardiology Service by severe AS (aortic valve area ≤ 1cm2 and/or aortic transvalvular mean gradient ≥40mmHg), who underwent exercise stress test (EST) and NT-proBNP evaluation for risk stratification. The outcome studied was hospitalization for heart failure (HF), or referral to SV, or death during the follow-up period. Independent predictors were obtained using multivariate Cox regression.

Results

Non-progression or decrease in systolic blood pressure (SBP) in EST is the only independent predictor of a short-term adverse event (p = 0.025). This parameter, NT-proBNP levels and interventricular septal thickness (IVS) were independent predictors of a medium (two (p = 0.025; p = 0.014; p = <0.001), three (p = 0.015; p = 0.007; p = 0.001) and four years (p = 0.007; p = 0.049; p = 0.005)) and a long term adverse event (p = 0.006; p = 0.028; p = 0.005).

Conclusion

In asymptomatic patients with severe AS, no progression or decrease in SBP in EST, increased NT-proBNP levels and thickness of IVS were independent predictors of hospitalization for HF, need for VS or death in short, medium and long term.

Derivation of induced pluripotent stem cells (iPSCs) by retroviral transduction of skin fibroblasts from four patients suffering 7q11.23 microduplication syndrome

Skin fibroblasts were obtained from four patients with 7q11.23 microduplication syndrome carrying the reciprocal rearrangement of Williams-Beuren syndrome at the 7q11.23 genomic region. Induced pluripotent stem cells (iPSCs) were generated by retroviral infection of fibroblasts with polycystronic vectors. The generated iPSC clones ESi058B, ESi057B, ESi070A and ESi071A had the 7q11.23 duplication with no additional genomic alterations, a stable karyotype, expressed pluripotency markers and could differentiate towards the three germ layers in vitro via embryoid body formation and in vivo by teratoma formation. Patient's derived iPSCs are a valuable resource for in vitro modeling of 7q11.23 microduplication syndrome. Resource Table.

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients.

Aim

To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI.

Methods

From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year.

Results

The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029].

Conclusion

We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts.

Funding Acknowledgement

Type of funding source: None

What is the prognosis for patients who develop new-onset atrial fibrillation in the first 48 hours after an acute coronary syndrome?

 

Atrial fibrillation (AF) is a common complication in acute coronary syndrome (ACS). However, treating patients (pts) with new-onset AF (NOAF) after an ACS remains a challenge. Although it seems intuitive that pts who develop AF within the first 48h have increased morbidity and mortality, your prognosis is unclear because there are no robust studies in the literature to confirm this association.

Aim

To characterize the population of pts who developed NOAF in the first 48 hours after an ACS and to compare the prognosis between these pts and pts who didn't develop AF.

Methods

2916 ACS pts admitted consecutively in our coronary care unit during 6 years were analyzed retrospectively. Of these pts, 343 (11.7%) had AF within the first 48h, of which 99 (3.4%) had pre-existing AF and 243 (8.3%) presented NOAF. Pts were divided into two groups: group 1 -ACS pts who developed NOAF in the first 48h (n=243; 8.8%); group 2 – ACS pts who did not develop AF (n=2517; 91.2%). Pts with pre-existing AF were excluded (n=156; 5.4%). Primary endpoint were the occurrence of death at 6 months; follow-up was completed in 95.8% of pts.

Results

Group 1 pts were older (72±12 vs 62±13, p<0.001), with higher proportion of women (30,9% vs 20,9%, p<0.001), hypertensive (78,5% vs 60,7%, p<0.001), smokers (17,4% vs 32,6%, p<0.001), previous CABG (7,9% vs 3,8%, p=0.06) and stroke (10,7% vs 6,8%, p=0.035). Group 1 had a higher proportion of STEMI pts (58,5% vs 46,5%, p<0.001) and, during hospitalization, had more often respiratory infection (p<0.001), malignant arrhythmias (p<0.001), heart failure (p<0.001), stroke (p=0.001), higher values of NT-proBNP (p<0.001) increased C-reactive protein levels (p<0.001), leukocytes (p=0.020), peak of TropI (p=0.029) and creatinine (p<0.001). On echocardiography, group1 had greater LA diameter (45±6 VS 41±5mm, p<0.001), more frequent significant mitral regurgitation (13,9% vs 2,9%, p<0.001), worst LVEF (41±10% vs 46±10%, p<0.001) and a higher value of pulmonary artery pressure (39±12 vs 24±10, p<0.001). Group 1 were less likely to have undergone coronary revascularization (84% vs 74%, p=0.005). In multivariate analysis, age ≥75 (OR 1.05, p<0.001), LVEF ≤40% (OR 2.50, p<0.001), LA diameter (OR 1.59, p=0.027), more significant mitral regurgitation (OR 2.49, p=0.001) and Killip class >1 (OR 1.51, p=0.015) remained independent predictors of NOAF. In multivariate analysis and after adjusting for different baseline characteristics, pts with NOAF have the same risk of 6-months mortality compared to those who didn't develop AF [OR 1.03, p=0.91].

Conclusion

The incidence of NOAF was 8.8% in our population, which is similar to the literature. Age, LVEF, LA diameter, a significant mitral regurgitation and Killip class >1 were independent predictors of NOAF after ACS. Pts with NOAF in the first 48h after an ACS had worse clinical manifestations during hospitalization but no higher 6-months mortality risk.

Funding Acknowledgement

Type of funding source: None

Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma (MEITL) Presenting As An Obstructive Pancreaticoduodenal Mass: A Case Report

Casestudy: A 74-year-old woman of Scottish descent presented with obstructive jaundice and weight loss. Imaging revealed a head of pancreas mass with extrahepatic bile duct dilation. Fine needle aspiration cytology of the mass was non-diagnostic, therefore the patient underwent a pancreaticoduodenectomy. Gross examination revealed a circumferential, necrotic lesion involving the periampullary duodenum with invasion into the pancreas and peri-pancreatic soft tissue. Microscopically, the lesion was composed of diffuse sheets of monomorphic medium-sized cells with fine chromatin, inconspicuous nucleoli, and scant pale cytoplasm. The duodenal mucosa overlying the lesion was ulcerated. Epitheliotropism was noted in the duodenal villi, crypt epithelium and pancreatic duct epithelium. The tumor showed extensive areas of necrosis and conspicuous perineural invasion. The duodenal mucosa uninvolved by the tumor showed no evidence of an underlying enteropathy, such as Celiac disease. By immunohistochemistry, the neoplastic cells were positive for CD45, CD3, CD8, CD56, TIA-1, granzyme B, TCR-BF1, and TCR-gamma, and were negative pan B-cell markers, CD4, CD5, CD25, CD30, EBER, HHV-8, and TCL-1. Molecular studies for T cell clonality revealed clonal TCR-alpha-beta and gamma-delta gene rearrangements. Given the morphologic and immunophenotypic findings, the diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) was rendered. This case is unique with features not typical of MEITL, namely mass-like pancreaticoduodenal presentation resulting in a Whipple resection, extensive necrosis, and perineural invasion.

P1308 A peculiar case of an acute pulmonary embolism

CONCLUSION

We experienced a very uncommon case of a metastatic cardiac tumor from urothelial carcinoma. To the best of our knowledge, only a small number of cases were reported and the reason for the rarity of cardiac metastasis from urothelial carcinoma is unclear. Although the echocardiography has become the gold standard for the diagnosis of intracardiac masses, cardiac MRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, allowing a comprehensive characterization of such lesions.

Abstract P1308 Figure. pediculated and mobile mass (20x56mm) at

P1314 A singular explanation of stroke in young adults

INTRODUCTION

Although primary cardiac tumors are rare, papillary fibroelastoma (PFE) is the most common benign neoplasm of cardiac valvular structures. Because patients are often asymptomatic the true prevalence is unknown, being most commonly recognized given the evolution of higher-resolution imaging technology. The clinical presentation of PFEs can diverge between being asymptomatic to symptomatic based on the serious complications that can occur, such as acute valve dysfunction or embolization, giving rise to a wide variety of presenting features including neurologic events, acute coronary syndrome, and distal embolic events. The location on the mitral valve does not occur frequently, with rare cases reported in the literature. Here, we present an unusual case of a 32-year-old male with an acute stroke secondary to a PFE in the mitral valve.

CASE REPORT DESCRIPTION

A 32-year-old male patient with a history of crohn"s disease was admitted to our emergency department with a transient sudden-onset aphasia associated with a right hemiparesis. At admission, these symptoms had completely resolved. On further questioning, the patient described another episode of transient right hemiparesis in the last year. On physical examination, the patient"s vital signs were stable. The patient was awake, alert, and oriented with full Glasgow Coma Scale. There was no focal neurological deficit on neurological examination and his cardiovascular examination was normal with no murmurs, added sounds or carotid bruit. A cranial CT showed no signs of acute intracranial disease. Head MRI showed multiple areas of restricted diffusion in the left frontal lobe consistent with acute stroke. As part of the workup to determine the cause of his embolic stroke, a transthoracic echocardiogram and transoesophageal echocardiography were performed, showing a spherical and highly mobilemass attached on the downstream side of the anterior mitral valve leaflet of approximately 1.1 cm in diameter, suggesting the diagnosis of PFE. A bubble study was negative which out ruled patent foramen ovale. After completing the rest of the workup, it was determined that PFE was likely the cause of his stroke. Cardiothoracic surgery was consulted and the patient underwent surgical resection. Histology confirmed the diagnosis of PFE. After 5 years the patient remains asymptomatic, without new embolic events.

DISCUSSION AND CONCLUSIONS

We present a special case that illustrates the importance of diagnosing primary cardiac tumours in a young patient presenting with acute stroke with minimal or no risk factors.Although primary cardiac tumours are rare, diagnosis and treatment at an early stage may prevent serious complications and reduce the morbidity and mortality of embolic stroke.

P226 Caseous calcification of the mitral annulus: a silent cause of intracardiac mass

INTRODUCTION

Caseous calcification of the mitral annulus (CCMA) is a very rare variant of mitral annular calcification with a central liquefaction necrosis, being an uncommon echocardiographic finding (0.5 to 1%) which may be mistaken for an intracardiac tumor, thrombus or vegetation. This chronic degenerative process can occurs at advanced ages, particularly in women, and patients with hypertension, chronic renal failure or calcium metabolism abnormalities. Since patients often remain asymptomatic, conservative treatment for this lesion is generally sufficient.

CASE REPORT

DESCRIPTION

We report a case of an 86-year-old female with a known history of hypertension and diabetes, who was referred to our department in order to investigate the diagnosis of an intracardiac mass visualized through a routine transthoracic echocardiography. She reported effort dyspnea, but refused to have other cardiovascular symptoms.

In order to study this intracardiac mass, the patient was submitted to a transthoracic echocardiogram that showed a rounded mass of 16 × 22 mm in the anterior mitral annulus, mainly in P1 scallop, not causing valve stenosis and with a mild mitral regurgitation. This prompted the need for transesophageal echocardiography which revealed a spheroid mass of heterogeneous content with calcification points, regular edges and with faint central echo-lucent area without acoustic shadowing, attached to the anterior mitral valve leaflet. No communication with any cardiac chamber could be detected. The mass did not determine any restriction to the opening of mitral valve cusps. A cardiac MRI was requested to complete the diagnostic evaluation revealing that the lesion was located at the base of the anterior leaflet. In the T1 and T2 sequences the mass was hypointense, whereas in the perfusion sequence, no contrast penetration was detected in the mass and in the late enhancement. These findings, as well as the presence of a calcified envelope in the cardiac computed tomography scan, confirmed the suspicion of caseous calcification of the mitral annulus.

DISCUSSION

AND CONCLUSIONS

We present an unusual case of caseous calcification of the mitral annulus in which the multi-modal approach was crucial to confirme the diagnosis. Although transthoracic echocardiography can be sensitive in the diagnosis of this entity, the diagnosis may sometimes still be inconclusive. Thus, multi-modality with transesophageal echocardiography, cardiac MRI or CT can lead to a definitive diagnosis, avoiding an mistaken diagnosis with the need of a surgical approach. Since this pathology is most frequently detected in asymptomatic patients, the patients should be treated medically and monitored clinically and echocardiographically for an early recognition of possible complications.

Abstract P226 Figure. Caseous calcification of mitral annulus

P725 An unexpected direction: a case report of a double aortic arch in an asymptomatic woman in adulthood

Introduction

Complete vascular rings represent about 0.5-2% of all congenital cardiovascular malformations, with the double aortic arch (DAA) being the most common of the complete vascular rings, causing tracheoesophageal compression. The right (posterior) arch is usually dominant (70%), although the two arches can have the same size (5%). The left (anterior) arch is dominant in only approximately 25% of cases. In most cases, this anomaly is diagnosed during childhood due to symptoms caused by oesophageal or tracheal compression. For this reason, case reports of adults are rare. This report describes a case of a 61-year-old woman with DAA with dominant left arch, diagnosed accidentallyby thoracic CT angiography.

Case Report Description

A 61 years old woman with a previous story of hypertension and type 1 diabetes presented to the emergency service with dyspnoea and thoracic pain. She also referred a history of intermittent dysphagia and cough with at least 12 years of progression. All the parameters of the physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm with no evidence of acute ischemia and her blood analyses did not show any abnormalitie. She also performed a thoracic CT angiography, which excluded signs of pulmonary embolism, but revealed a vascular ring suggesting a double aortic arch with permeability in both right and left arches as well as their collaterals. The Cardiac MRI was performed with the purpose of excluding ischemia, confirming the double aortic arch with left dominance. The right arch, posterior to the oesophagus and trachea, and the left arch, in an anterior position, showed an anatomic compression of the oesophagus as well as the proximal trachea, capable of eliciting the symptoms mentioned. Other congenital anomalies were excluded. The echocardiography did not demonstrate any additional cardiac malformation. Endoscopy shows a pulsatile extrinsic compression of the esophagus (aortic ring). The patient is currently being studied and closely monitored in the Cardiology consultation.

Discussion

The most common type of complete vascular ring is the double aortic arch, which accounts for 70% of the complete rings. In most cases, there are two permeable arches, usually with right dominance (70% of the cases). Rarely, both arches are symmetrical. Symptoms usually appear in the fifth month of life. In most cases, only supportive treatment is required.

Conclusion

This case illustrates the atypical features of this congenital malformation, namely the diagnosis during adulthood as well as the left dominance.

Abstract P725 Figure. A double aortic arch

P644 A not so innocent athlete"s heart

We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service.

ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.

P1261 A heart with red flags

A 67 years old woman with a previous history of hypertension, atrial fibrillation (AF) and known severe concentric hypertrophy (more pronounced at the interventricular septum) with moderate pulmonary hypertension and diastolic dysfunction of the left ventricle (LV) resorted to the urgency service for weight loss, asthenia and dyspnea for minor efforts. Her physical examination was innocent. Her ECG showed AF and low voltage in limb and precordial leads. Patient was admitted at the Cardiology Department for investigation. A new TTE revealed fast progression of the hypertrophic pattern (IVS 26 mm, and posterior wall 18 mm) with a rest outflow tract gradient of 18 mmHg; free right ventricular wall was also hypertrophied with 12 mm and a type II diastolic dysfunction was present. A complete investigation for ventricular hypertrophy and constitutional syndrome was done. CMR demonstrated preserved biventricular systolic function, LV hypertrophy with septal predominance (24 mm) with elevated myocardial mass indexed to body mass (114 g/m2) and late difuse subendocardial gadolinium enhancement. (99m)Tc -DPD scintigraphy was negative for ATTR; Anderson-Fabry disease was excluded by genetic testing. Blood analysis revealed a normocytic/ normochromic anemia and a disproportional ratio of free light immunoglobulin chains K/λ, with a predominance of lambda chains. β2-microglobulin was also elevated. 24 hours urine analyses were normal. The hypothesis of non-secretor multiple myeloma (MM) with light chain immunoglobulin amyloidosis (AL) was then admitted. The patient underwent bone marrow and salivary gland biopsies which confirmed MM and deposition of amyloid, respectively. The FISH analyses demonstrated a delection of RB1 gene on 13q14.3 sequence and of TP53 on 17p13.1, both associated with a poorly prognosis in MM. The patient was referred for oncology where she is currently undergoing chemotherapy for MM and AL amyloidosis.

Amyloidosis represents a large spectrum of systemic diseases. Heart failure may be its first sign. This case reflects the diagnostic work-up in the presence of a hypertrophic LV pattern as well as the importance of high clinical suspicious and early diagnosis. While AL amyloidosis occurs in isolation, 10% of patients with multiple myeloma develop systemic AL amyloid with cardiac involvement. The distinction between these entities is not only semantic, but has extremely important prognosis and therapeutic considerations.

P5521Door-to-balloon time and mortality of a PCI centre: how crucial can 30 minutes be for our STEMI patients?

Introduction

STEMI time delays have been presented as an indicator of quality of care. Considering the system delay, the guidelines of European Society of Cardiology (ESC) and American Heart Association (AHA) for the management of STEMI patients (pts) diverge regarding the maximum time from STEMI diagnosis to wire crossing in pts presenting at primary PCI (pPCI) hospitals (≤60min versus ≤90min, respectively).

Objective

To compare the prognosis between pts presenting at pPCI hospital with maximum time from STEMI diagnosis to wire crossing of ≤60min and patients with times between 61 and 90min.

Methods

The records of 1679 STEMI pts admitted consecutively in our coronary care unit during six years were analysed retrospectively. Of this pts, 341 (20%) were admitted directly in a PCI centre and 1338 (80%) were rescued by an emergency medical system or presented to a non-PCI centre. Pts that presented at PCI centre were divided into two groups: group 1 – STEMI pts with maximum time from STEMI diagnosis to wire crossing of ≤60min (n=202,69%); group 2 – STEMI pts with times 61–90 min (n=91,31%). Pts with time from STEMI diagnosis to wire crossing >90min were excluded. Primary endpoints were the occurrence of death at 6 months and 1 year; follow-up was completed in 98% of pts.

Results

Group 2 pts were older (60±14 vs 67±143, p<0.001), with higher proportion of women (14.9% vs 25.3%; p=0.026), hypertension (45.5% vs 61.5%, p=0.035), diabetes (17.1 vs 24.4%, p=0.005) and presented more frequently Killip 4 at admission (2.1% vs 12.5%, p=0.003). Group 1 pts had higher proportion of smokers (62.2% vs 49.4%, p=0.03). Patient delay was statistically higher in group 2 (Mdn (h) 3.8±3.5 vs 5±2, p<0.001), as was the system delay (Mdn (min) 45±9 vs 74±8, p<0.001). In-hospital mortality (3.8% vs 5.1%, p=0.42) wasn't different between groups, but at 1-month (3.8% vs 10.3%, p=0.05), 6-months (4.4% vs 12.8%, p=0.02) and 1-year mortality (5% vs 15.4%, p=0.008) was higher in group 2. In multivariate analysis and after adjusting for different baseline characteristics, pts who complied with the recommended times according to the 2017 ESC guidelines had lower risk mortality at 1 year compared to group 2 [HR 0.42, 95% CI (0.23–0.74), p=0.006].

Conclusion

In patients presenting at this PCI centre, complying with the 2017 ESC STEMI guidelines in order to reduce the system delay to ≤60min was crucial, since pts who were reperfused within this recommended time had lower mortality rates.

P1723Predictors of in-hospital mortality in STEMI patients complicated by cardiogenic shock treated with primary percutaneous coronary intervention

Introduction

Cardiogenic shock (CS) is an uncommon complex syndrome in patients (pts) with acute myocardial infarction (AMI). However, it remains the most serious complication and the most common cause of in-hospital mortality, with mortality rates ranging from 40% to 60%. The majority of pts are thought to develop CS after admission (late CS), but the incidence in a contemporary STEMI cohort admitted for percutaneous coronary intervention (PCI) remains unknown.

Objective

The aim of the present study was to evaluate pts with STEMI and cardiogenic shock undergoing pPCI, in order to establish the timing of CS onset, mortality rates and predictors of in-hospital mortality.

Methods

The records of 1679 STEMI pts admitted, consecutively, in our coronary care unit during six years were analysed retrospectively. Of this pts, 137 (8%) developed CS based on clinical criteria. Univariate and multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality. Primary endpoint was the occurrence of death at 30 days and 1 year; follow-up was completed in 100% of patients. Statistical analysis was performed using SPSS 20.0.

Results

The sample was formed by 90 (65.7%) men and 47 (34.3%) women, with mean age of 67±15 years. The incidence of CS was 8%. The majority of this pts (48%) were transferred from a non-PCI centre, 27% were rescued by an emergency medical system and 26% were admitted directly at a PCI centre. Around of 39% of pts had to be resuscitated before coronary intervention. Regarding the timing of CS onset, 66% of pts had CS on admission and 34% developed late CS. The left anterior descending artery was the most affected artery (47%), and 55% of the patients had multivessel disease. All-cause in-hospital and 1 year mortality was 45% and 53%, respectively. A multivariate analysis identified age >75 (HR 1.1, p=0.002), eGFR <60 ml/min/1.73 m2 (HR 2.2, p=0.02), left ventricular dysfunction (LVEF<40%) (HR 2.1, p=0.027), resuscitation before PCI (HR 1.2, p=0.045), and Intra-Aortic Balloon Pump (IABP) implantation after PCI (HR 4.4, p=0.026) as independent predictors of in-hospital mortality.

Conclusion

Despite the therapeutic advances and early revascularization have substantially improved the survival of pts with STEMI and CS, the in-hospital mortality is still significant. This study identified age, acute renal failure, left ventricular dysfunction, resuscitation before PCI, and IABP implantation after PCI as independent predictors of in-hospital mortality in patients with cardiogenic shock due to AMI. Consequently, only the timing of IABP insertion was the only modifiable factor predicting in-hospital mortality in our study, and its implantation before PCI can be considered to improve the outcome of these patients. These results should motivate the search for potentially modifiable factors that can lead to better results in the prognosis of these patients.

Direct visualization of the native structure of viroid RNAs at single-molecule resolution by atomic force microscopy

Viroids are small infectious, non-protein-coding circular RNAs that replicate independently and, in some cases, incite diseases in plants. They are classified into two families: Pospiviroidae, composed of species that have a central conserved region (CCR) and replicate in the cell nucleus, and Avsunviroidae, containing species that lack a CCR and whose multimeric replicative intermediates of either polarity generated in plastids self-cleave through hammerhead ribozymes. The compact, rod-like or branched, secondary structures of viroid RNAs have been predicted by RNA folding algorithms and further examined using different in vitro and in vivo experimental techniques. However, direct data about their native tertiary structure remain scarce. Here we have applied atomic force microscopy (AFM) to image at single-molecule resolution different variant RNAs of three representative viroids: potato spindle tuber viroid (PSTVd, family Pospiviroidae), peach latent mosaic viroid and eggplant latent viroid (PLMVd and ELVd, family Avsunviroidae). Our results provide a direct visualization of their native, three-dimensional conformations at 0 and 4 mM Mg2+ and highlight the role that some elements of tertiary structure play in their stabilization. The AFM images show that addition of 4 mM Mg2+ to the folding buffer results in a size contraction in PSTVd and ELVd, as well as in PLMVd when the kissing-loop interaction that stabilizes its 3D structure is preserved.

Applying FAIR Principles to Plant Phenotypic Data Management in GnpIS

GnpIS is a data repository for plant phenomics that stores whole field and greenhouse experimental data including environment measures. It allows long-term access to datasets following the FAIR principles: Findable, Accessible, Interoperable, and Reusable, by using a flexible and original approach. It is based on a generic and ontology driven data model and an innovative software architecture that uncouples data integration, storage, and querying. It takes advantage of international standards including the Crop Ontology, MIAPPE, and the Breeding API. GnpIS allows handling data for a wide range of species and experiment types, including multiannual perennial plants experimental network or annual plant trials with either raw data, i.e., direct measures, or computed traits. It also ensures the integration and the interoperability among phenotyping datasets and with genotyping data. This is achieved through a careful curation and annotation of the key resources conducted in close collaboration with the communities providing data. Our repository follows the Open Science data publication principles by ensuring citability of each dataset. Finally, GnpIS compliance with international standards enables its interoperability with other data repositories hence allowing data links between phenotype and other data types. GnpIS can therefore contribute to emerging international federations of information systems.

Seasonality in Health and Nutrition on a Guatemalan Coffee Plantation

This study, which focuses on a plantation, as well as the study by Bidinger et al., which concerns a village, failed to find the marked seasonal changes in food consumption reported for many other parts of the world. It would be a serious mistake to consider that these studies contradict in any way the findings of those who report seasonal variations They are published, however, as a reminder that generalizations cannot be used to predict specific cases and that, conversely, great caution must be used in generalizing from specific cases. The characteristics of the sites in both studies offer adequate explanation of why they did not fit the expected pattern of seasonal variation despite distinct rainy and dry seasons and harvest and non-harvest periods. It should be noted, however, that both Valverde et al. and Bidinger et al. did observe the anticipated marked seasonal differences in morbidity from diarrhoeal and other infectious diseases.

Superposition principle for the simultaneous optimization of collective responses

We study the dynamics of sets of independent systems, all of which are coupled to the same time-dependent external force. Using optimal control theory, we compute the most efficient temporal pulse shape for this force that can maximize simultaneously the collective response of these systems. This response can be a weighted sum of all amplitudes at the final interaction time. Remarkably, it turns out that for certain systems this optimal force for the collective response can be related to the individual forces that would optimize each system separately. We illustrate this superposition principle for the simultaneous optimization of collective responses with numerical and also analytical solutions for sets of damped linear and nonlinear oscillators. We also apply this principle to predict the optimal temporal profile of a laser pulse that can maximize the final macroscopic polarization (total dipole moment) of a set of quantum mechanical two-level atoms.