Electroactive poly(vinylidene fluoride-trifluoroethylene)/graphene composites for cardiac tissue engineering applications

Electroactive materials are increasingly being used in strategies to regenerate cardiac tissue. These materials, particularly those with electrical conductivity, are used to actively recreate the electromechanical nature of the cardiac tissue. In the present work, we describe a novel combination of poly(vinylidene fluoride-trifluoroethylene) (P(VDF-TrFE)), a highly electroactive polymer, with graphene (G), exhibiting high electrical conductivity. G/P(VDF-TrFE) films have been characterized in terms of topographical, physico-chemical, mechanical, electrical, and thermal properties, and studied the response of cardiomyocytes adhering to them. The results indicate that the crystallinity and the wettability of the composites remain almost unaffected after G incorporation. In turn, surface roughness, Young modulus, and electric properties are higher in G/P(VDF-TrFE). Finally, the composites are highly biocompatible and able to support cardiomyocyte adhesion and proliferation, particularly surface treated ones, demonstrating the suitability of these materials for cardiac tissue engineering applications.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Belgian guidelines for pathology reporting of neuroendocrine neoplasms of the pancreaticobiliary and gastrointestinal tract

Since neuroendocrine neoplasms are rare tumors, registration of patient data in national and multinational registries is recommended. Indeed, this will facilitate multicenter studies on the epidemiology, efficacy and safety of diagnostic and therapeutic strategies for well-differentiated neuroendocrine tumors as well as for neuroendocrine carcinomas. In Belgium, data on patient and tumor characteristics of all newly diagnosed malignancies have been collected in the Belgian Cancer Registry since 2004 including anonymized full pathological reports. The Digestive Neuroendocrine Tumor (DNET) registry collects information on classification, staging, diagnostic tools and treatment in a prospective national online database. However, the terminology, classification and staging systems of neuroendocrine neoplasms have changed repeatedly over the past 20 years as a result of a better understanding of these rare tumors, by joining forces internationally. These frequent changes make it very difficult to exchange data or perform retrospective analyses. For optimal decision making, for a clear understanding and to allow reclassification according to the latest staging system, several items need to be described in the pathology report. This paper provides an overview of the essential items in reporting neuroendocrine neoplasms of the pancreaticobiliary and gastrointestinal tract.

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

A proof of concept for a deep learning system that can aid embryologists in predicting blastocyst survival after thaw

The ability to understand whether embryos survive the thaw process is crucial to transferring competent embryos that can lead to pregnancy. The objective of this study was to develop a proof of concept deep learning model capable of assisting embryologist assessment of survival of thawed blastocysts prior to embryo transfer. A deep learning model was developed using 652 labeled time-lapse videos of freeze-thaw blastocysts. The model was evaluated against and along embryologists on a test set of 99 freeze-thaw blastocysts, using images obtained at 0.5 h increments from 0 to 3 h post-thaw. The model achieved AUCs of 0.869 (95% CI 0.789, 0.934) and 0.807 (95% CI 0.717, 0.886) and the embryologists achieved average AUCs of 0.829 (95% CI 0.747, 0.896) and 0.850 (95% CI 0.773, 0.908) at 2 h and 3 h, respectively. Combining embryologist predictions with model predictions resulted in a significant increase in AUC of 0.051 (95% CI 0.021, 0.083) at 2 h, and an equivalent increase in AUC of 0.010 (95% CI -0.018, 0.037) at 3 h. This study suggests that a deep learning model can predict in vitro blastocyst survival after thaw in aneuploid embryos. After correlation with clinical outcomes of transferred embryos, this model may help embryologists ascertain which embryos may have failed to survive the thaw process and increase the likelihood of pregnancy by preventing the transfer of non-viable embryos.

Multisectoral approach to address Female Genital Mutilation: a case study from Portugal

Issue

Female genital mutilation (FGM) comprises all procedures that injury female genital organs for non-medical reasons, with several health impacts. Due to global migration, FGM has been increasingly recognised as a healthcare issue in Europe, affecting nearly 1 million women. In Portugal it is estimated that 5483 migrant women have undergone FGM in the Lisbon region. Intervention is required to tackle this issue.

Description

Portugal launched the “Healthy Practices: End of FGM”, a multiagency project targeting Lisbon and Tagus Valley region. Project implementation started in Nov 2018 at 5 local public health units (PHU) and was scaled-up to 5 more in Feb 2020. Project comprises 3 main axes: 1) inclusion in public policy instruments; 2) professionals’ education and awareness; and 3) community intervention. We describe inclusion of FGM in public policy, professionals training and changes in FGM recording before and after intervention.

Results

Between 2018-2022, inclusion of FGM in municipalities’ migration policies doubled. Between 2019-2021, 110 training sessions (n = 1722 professionals) were promoted. During pandemic years, only 344 (2020) and 202 (2021) were trained. Raising awareness and empowerment to risk communities happened mainly through local/online open sessions, workshops, flyer distribution, video projections. These occurred in all 10 PHU, mostly through partnerships with Non-Governmental Organizations and municipalities. According to the Portuguese Health Records, until 2018 there were only 300 women registered with FGM. Between 2019-2021, 363 more were added.

Lessons

The multisectoral approach allowed PHU professionals to collaborate directly with external organizations from different society sectors. COVID-19 pandemic posed a challenge to implementation, especially in the community intervention axis. Notification numbers increased after interventions, though causality could not be established and impact evaluation is yet to be performed.

Key messages

• Multisectoral projects for FGM intervention have specific implementation challenges, including how to justify and evaluate them, that must be considered in each setting.

• Training health professionals might increase identification and notification of FGM, but the impact in preventing FGM in the Portuguese reality is still largely unknown.

POS1152 BONE AND MUSCLE IMPAIRMENT AND HIGHER VISCERAL ADIPOSE TISSUE MASS IN WOMEN WITH LONG-TERM POLYARTICULAR JUVENIL IDIOPATHIC ARTHRITIS

Background

Some studies suggest that patients with juvenile idiopathic arthritis (JIA) may have reduced bone parameters and muscle mass. Despite those considerations, there is no validated consensus about this topic in the literature as the population and the methods for bone and muscle evaluation are often heterogeneous and not standardized.

Objectives

To assess bone parameters and body composition of women with long-term polyarticular JIA and compare them to healthy controls.

Methods

Twenty-seven women with long-term polyarticular JIA were compared with twenty-seven healthy controls, matched by sex, age, and body mass index (BMI). Dual-energy X-ray absorptiometry (DXA) was performed to evaluate the lean mass, body fat percentage (% Fat), and visceral adipose tissue mass (VATm). High resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and tibia was performed to assess trabecular (Tb.) and cortical (Ct.) volumetric bone mineral density (v.BMD) and strength bone parameters (stiffness - S; estimated fail load - FL). Group means were compared using Student’s t-test.

Results

Polyarticular JIA patients have a lower trabecular and cortical volumetric bone density, a lower bone strength, and a lower lean mass compared to healthy controls. Moreover, long-term JIA patients have a higher visceral adipose tissue mass (Table 1).

Table 1.

Bone parameters using high resolution peripheral quantitative computed tomography (HR-pQCT) and body composition in long-term polyarticular patients and healthy controls.

Polyarticular JIA n=27Healthy controls n=27p-valueAge, years31.8 ± 7.633 ± 8.20.597BMI, Kg/m224 ± 4.824.6 ± 4.70.931Disease duration, years22 ± 10-----Remission or low activity, n (%)16 (59)-----Use of prednisone, n (%)5 (18)-----Rheumatoid factor9 (33)0 (0)Lean mass, kg35.7 ± 4.739 ± 7.2<0.001%Fat, %39 ± 837 ± 70.364VATm, kg588 ± 538212 ± 2090.001HR-pQCT at the distal radiusTb.v.BMD, mg HA/cm3125 ± 32159 ± 38<0.001Ct.v.BMD, mg HA/cm3994 ± 461035 ± 43<0.001S, kN/mm64 ± 1178 ± 180.001FL, N3174 ± 8793710 ± 827<0.001HR-pQCT at the distal tibiaTb.vBMD, mg HA/cm3128 ± 48162 ± 320.003Ct.vBMD, mg HA/cm3990 ± 57993 ± 520.811S, kN/mm179 ± 39212 ± 40<0.001FL, N8519 ± 17739675 ± 25250.004

Data expressed as mean ± standard deviation or frequency (percentage). Tb.vBMD – trabecular volumetric bone mineral density, Ct.vBMD – cortical volumetric bone mineral density; S - stiffness; FL - estimated fail load

Conclusion

Pre-menopausal women with long-term polyarticular JIA have an impairment of bone mineral density at peripheral sites in addition to lower muscle mass and higher visceral adipose tissue. These findings may contribute to the increasing osteoporosis/fractures and cardiovascular risk in this population, suggesting that measures should be considered to prevent these damages.

References

[1]Bechtold S, Ripperger P, Dalla Pozza R, Schmidt H, Häfner R, Schwarz HP. Musculoskeletal and functional muscle-bone analysis in children with rheumatic disease using peripheral quantitative computed tomography. Osteoporos Int a J Establ as result Coop between Eur Found Osteoporos Natl Osteoporos Found USA. 2005 Jul;16(7):757–63.

[2]Burnham JM, Shults J, Sembhi H, Zemel BS, Leonard MB. The dysfunctional muscle-bone unit in juvenile idiopathic arthritis. J Musculoskelet Neuronal Interact. 2006;6(4):351–2.

[3]Felin EMO, Prahalad S, Askew EW, Moyer-Mileur LJ. Musculoskeletal abnormalities of the tibia in juvenile rheumatoid arthritis. Arthritis Rheum. 2007 Mar;56(3):984–94.

[4]Roth J, Linge M, Tzaribachev N, Schweizer R, Kuemmerle-Deschner J. Musculoskeletal abnormalities in juvenile idiopathic arthritis - A 4-year longitudinal study. Rheumatology. 2007 Jul;46(7):1180–4.5.

Disclosure of Interests

None declared

POS1285 IMMUNOGENICITY AND SAFETY OF THE CHADOX 1 COVID-19 VACCINE IN PATIENTS WITH AUTOIMMUNE DISEASES AND HEALTHY CONTROLS: DATA FROM SAFER STUDY

Background

Patients with autoimmune inflammatory diseases (AID) have been prioritized for urgent vaccination to mitigate COVID-19 risk. However, few studies in the literature assessed the immunogenicity and safety of the COVID-19 vaccine in patients with AID.

Objectives

In this context, the present study aims to evaluate the immunogenicity and safety of the vaccine against COVID-19 in patients with AID.

Methods

These data are from “Safety and efficacy on COVID-19 Vaccine in Rheumatic Disease” - SAFER study, a Brazilian multicentric prospective phase IV study to evaluate COVID-19 Vaccine in AID, in the real-life, in Brazil. Immunogenicity and adverse events (AE) from a single center were assessed, after 2 doses of ChAdOx1 (Oxford/AstraZeneca), 8 weeks of interval, in patients with AID and healthy controls (HC). Inclusion criteria were age ≥ 18 years and fulfilling criteria according to international classification for AID. Exclusion criteria: pregnancy, previous severe AE to any vaccine, other immunosuppression causes. Stratification of post-vaccination AE was performed using a diary, filled out daily and returned at the end of 28 days for each dose. Participants were followed up through blood collection for measurement of IgG antibodies against SARS-CoV-2 spike receptor-binding domain by chemiluminescence (SARS-CoV-2 IgG II Quant assay, Abbott Laboratories, Abbott Park, IL, USA) at baseline and 28 days after the second dose. The seropositivity was defined for titers ≥50 AU/mL. Quantitative analyses were presented as observed frequency, percentage, central tendency, and variability measurements. The sample’s normal distribution was verified through the Shapiro-Wilk test. The Kruskal-Wallis test and the post-hoc Dwass-Steel-Critchlow-Fligner pairwise comparisons test were used to compare the IgG-S titers between the groups through the evaluation period. Categorical data were addressed using the Fisher´s exact or Chi-squared (χ2) test. An alpha level of 5% significance was used in all analyses.

Results

A total of 377 volunteers with AID and 50 HC were included in the study. Patients with spondyloarthritis (N=64), systemic lupus erythematosus (N=63), rheumatoid arthritis (N=61), primary Sjögren’s syndrome (N=61), vasculitis (N=31), systemic sclerosis (N=14), inflammatory myopathy (N=9), Crohn´s disease (N=49), ulcerative colitis (N=11) and other systemics AID (N=12) were evaluated. Both groups had female predominance (73.5% vs. 74.0%, p=0.937) and were homogeneous for age (43.5 vs. 41.7,p=0.308). The seroconversion among those not reactive (IgG-S negative at baseline) (46 HC and 191 AID), 28 days after second dose was 97.1% for spondyloarthritis (p=0.425), systemic lupus erythematosus 88.2% (0.006), rheumatoid arthritis 93.5% (0.158), primary Sjögren’s syndrome 92.6% (0.133), systemic sclerosis or inflammatory myopathy 47.1% (0.001), inflammatory bowel disease 100% (0.999) and vasculitis 80% (0.006), while in healthy control was 100%. In comparison with HC, there was a statistically significant difference in IgG-S titles only in systemic sclerosis or inflammatory myopathy (1.694 AU/ml vs. 3.719 AU/ml; p=0.006). Both groups only presented mild AE. Pain at the injection (85.7% vs. 78.4%, p=0.239), headache (67.3% vs. 53.8, p=0.074) and fatigue (59.2% Vs. 46.2%, p=0.089) were more common in HC than AID. Overall, reactions like arthralgia (52.6 vs. 22.4%, p<0.001), hematoma (14.1 vs. 4.1%, p=0.05), cutaneous rash (9.5 vs. 0%, p=0.024) were more frequent in AID. Most participants related that they felt safer after receiving a COVID-19 vaccination, and 52.4% did not reported a worse patient global assessment (PGA) index.

Conclusion

In conclusion, our data indicated that ChAdOx1 vaccine is safe and induced high titers and seroconversion rate in AID. More severe AID, such as vasculitis, systemic lupus erythematosous, and systemic sclerosis and myositis showed a lower seroconversion rate. Further analysis will explore the association between immunossupressant and reactivity, and booster dose.

Acknowledgements

Acknowledgements to DECIT/MS and ICEPI/SESA for supporting the study.

Disclosure of Interests

None declared

Electroactive functional microenvironments from bioactive polymers: A new strategy to address cancer

The present work reports on a new approach based on electroactive microenvironments to mitigate skeletal muscle cancer. For that, piezoelectric films based on poly(vinylidene fluoride) have been applied to evaluate the influence of mechano- and/or electrical stimuli on rhabdomyosarcoma (RMS) proliferation. Human embryonal rhabdomyosarcoma (RD) cells were cultured on PVDF pristine films with different surface charge (non-poled, poled+ and poled-) and magnetic composites (10% and 20% Fe₃O₄, and 20% CFO filler content) to allow magneto-mechanical and magnetoelectrical stimulation films. Electrospun PVDF pristine (oriented and randomly) and magnetic (10% Fe₃O₄) fiber mats were also evaluated to take into consideration the morphology effect on cell response. It was found that the mechanical stimuli enhance RMS proliferation whereas the mechano-electrical decreases it. It was also verified that the RD cells proliferate better on randomly oriented fibers, whereas myoblast cells do it better in oriented ones. The obtained results confirm that electroactive microenvironments can be used to develop novel and effective approaches to deal with RMS cancer, that can be extrapolated to others cancer types.

Cardioneuroablation of severe neurally mediated reflex syncope: the experience of two Portuguese centres

Funding Acknowledgements

Type of funding sources: None.

Background

Neurocardiogenic syncope (NCS) is the most frequent aetiology of syncope in young people. Cardioinhibition with asystole and/or transitory atrio-ventricular block induced by a massive vagal reflex is commonly observed in severe cases. According to the current guidelines, cardiac pacing is indicated in patients &gt; 40 years old with severe, recurrent syncope and documented cardioinhibitory reflex. In younger patients there is no recommendation. Although pacing therapy could be effective, complications after pacemaker implantation are commonly seen. Recently, cardioneuroablation (CNA), a technique based on radiofrequency ablation of vagal ganglia, was developed to treat NCS as an alternative to pacemaker implantation in younger patients. However, this method is still evolving, and existing data refer to a small number of patients in a limited number of centres.

Purpose

The aim of our study was to evaluate the efficacy and safety of CNA in patients with highly symptomatic neurocardiogenic syncope.

Methods and Results

A total of 15 patients (11 male; aged 40.0 ± 13.3 years) who underwent CNA in two Portuguese centres between January 2019 and September 2021 were included. All had recurrent syncope with documented pauses at head-up tilt test, Holter or implantable loop recorder. Radiofrequency energy was applied in ganglionated plexi (GP) 1 (between the right upper pulmonary vein and the right atrium) in 14 patients, GP2 (between the superior vena cava and aortic root just above the right upper pulmonary vein) in 9 patients, GP3 (between the inferior vena cava and the right and left atrium) in 5 patients and GP4 (at the insertion of the left pulmonary veins) in 9 patients. The end point of procedure was the inhibition of the vagal response at target sites. Ablation was successfully performed in all patients. One patient had a convulsive episode after the procedure, requiring admission to intensive care but without neurological sequelae. No other major complications occurred. At a mean follow-up of 17.1 ± 12.6 months (range 3-35 months), 13 patients remained free of syncope. Other 2 patients had spontaneous recurrence of syncope (both 9 months after CNA) and underwent a new procedure. These 2 patients had a new symptomatic recurrence and a pacemaker was implanted.

Conclusion

CNA appears to be an effective and safe treatment option for patients with refractory neurocardiogenic syncope and provide a new potential approach without pacemaker implantation.

Family screening in brugada syndrome patients

Background

Brugada syndrome (BS) is a rare inherited channelopathy associated with sudden cardiac death (SCD) and family screening (FS) of index patients (pts) is recommended. However, data about pts identified through FS is lacking.

Aim

To compare index pts to non-index pts identified through systematic FS.

Methods

Single-center retrospective study of BS pts followed by the Arrhythmology Department. FS was offered to 1st degree relatives of all index pts through primary care services and a once-weekly voluntary open appointment. Genetic counselling was performed when indicated. Index and non-index pts were compared regarding baseline characteristics and events during the follow-up (syncope of probable arrhythmic origin, ventricular tachycardia/ventricular fibrillation (VT/VF) and SCD).

Results

We included 165 pts (61% males, mean age 47±15 years) and 72 (44%) were identified through FS. Non-index pts were diagnosed at a younger age (42±14 vs 51±14 years, p &lt;.001), were more often female (57% vs 25%, p&lt;.001), were diagnosed predominantly through provocative test with ajmaline/flecainide (88% vs 47%, p&lt;.001) and had less documented spontaneous type 1 ECG pattern (17% vs 59%, p&lt;.001). A type 2 pattern was identified in 18 (25%) non-index pts.

Genetic testing was performed in 38 (53%) non-index pts: 6 had a pathogenic SCN5A mutation, 18 a likely pathogenic SCN5A mutation and 12 a mutation of uncertain significance.

At diagnosis, 24 (33%) non-index pts had history of syncope, 3 (4%) had nocturnal agonal respiration and 11 (15%) had palpitations with no differences between both groups (p=.119). Non-index pts were less likely to implant a cardioverterdefibrillator (14% vs 38%, p=.001).

During a median follow-up of 28 (IQR 16–41) months, 10 (6%) pts had an event - 2 (3%) in the non-index group (2 syncope) and 8 (9%) in the index group (1 syncope; 7 VT/VF) - with no significative differences between groups (p=.432). There were nocardiovascular deaths.

Conclusions

FS identified a considerable proportion of BS pts. Non-index pts were younger at the time of the diagnosis and had less spontaneous type 1 pattern. No differences were found in events between index and non-index pts, however, the event rate was low. Systematic FS can identify individuals at risk of SCD earlier, allowing close monitoring and, when indicated, appropriate treatment.

Funding Acknowledgement

Type of funding sources: None.

Electrophysiologic study for risk stratification in Brugada Syndrome: does it still matters?

Background

The value of eletrophisiologic study (EPS) with programmed ventricular stimulation for risk stratification in patients with Brugada Syndrome (BS) remains controversial.

Purpose

The aim of this study is to determine the clinical and electrocardiographic predictors of positive EPS and to evaluate whether the induction of malignant ventricular dysrhythmias in the EPS is a predictor of events

Methods

A retrospective study was carried out of patients with spontaneous type 1 Brugada pattern followed up in Arrhythmology consultation at our Hospital. From this population, patients who underwent EPS for stratification of dysrhythmic risk were selected. Clinical and electrocardiographic variables were analyzed. Hospital records and monitoring data from cardiac devices were consulted. Statistical analysis was performed using SPSS 20.0.

Results

Fourty nine patients were included, with a mean age at the beginning of follow-up of 45±14 years, 40 (82%) of whom were male. In 16 individuals (33%) the EPS was positive with induction of malignant ventricular dysrhythmias. All patients with positive EPS implanted an implantable cardioverter-defibrillator and of the 32 patients with negative EPS, 10 implanted an implantable event recorder. The group of patients with positive EPS had a higher proportion of male patients (88% vs 78%). The median follow-up time was 31 months.

The family history of sudden death, family history of BS, or identification of a genetic variant classified as pathogenic or probably pathogenic did not present any relationship with EPS positivity. Of the analyzed electrocardiographic markers, PR interval (178±29 vs 171±27) and QRS duration (119±24 vs 113±15) tended to be longer in patients with positive EPS. Additionally, it was found that 74% of patients with a QRS of less than 120 ms had a negative EPS.

In the analysis of the value of EPS in the stratification of dysrhythmic risk, it was found that of all the patients who suffered events (4), 75% had positive EPS. Of the patients with negative EPS, only 3% (1) presented events in the follow-up. However, there was no significant association between these variables.

Conclusion

In this population, the analysed clinical elements did not correlate with the EPS result. Although there was no statistical significance, there was a tendency for patients with narrower QRS to be more likely to have negative EPS. Accordingly with published data, it was found that the EPS result was not a predictor of events during the follow-up period, which highlights the difficulty of risk stratification in patients with BS.

Funding Acknowledgement

Type of funding sources: None.

Gender related differences in brugada syndrome

Background

Brugada syndrome (BS) is a heritable channelopathy with male predominance. Males (M) seem to have a higher risk of arrhythmic events, although, there is limited data regarding gender differences in BS.

Aim

To compare the differences between genders in a Portuguese sample of BS patients (pts).

Methods

Single-center retrospective study of BS pts followed by the Arrhythmology Department. Pts were divided according to gender and compared regarding baseline characteristics and electrocardiographic (ECG) parameters that possibly predict the arrhythmic risk (significative S wave in DI, R wave sign, Tpeak-Tend interval and fragmented QRS). The events during follow-up were syncope of probable arrhythmic origin, ventricular tachycardia/ventricular fibrillation (VT/VF) and sudden cardiac death (SCD).

Results

A total of 165 pts were included; 64 (39%) were female (F) and the mean age at diagnosis was 47±15 years. The diagnosis was made by family screening (FS) in 72 (44%) pts. Sixty-seven pts (41%) had spontaneous type 1 pattern, 59 (36%) had history of syncope and 5 (3%) had history of aborted SCD. A positive genetic test was identified in 41 (25%) pts. Sixty-three (38%) pts were referred for an electrophysiological study (EEF) which was positive in 17 (27%) pts. A cardioverter-defibrillator was implanted in 45 (27%) pts. Females were more often diagnosed by FS (64% vs 31%, p &lt;.001), had less type 1 spontaneous pattern (22% vs 53%, p&lt;.001) and had no atrial fibrillation (0% vs 7%, p=.043). They performed EEF less frequently (22% vs 49%, p&lt;.001) and had less spontaneous pattern during treadmill stress test (8% vs 33%, p=.004).

Regarding ECG parameters, females had shorter QRS interval (104±12 vs 115±18 ms, p&lt;0.001), less frequent aVR sign (3% vs 27%, p&lt;0.001), less significative S wave in DI (31% vs 55%, p=0.004), and a tendency for a shorter Tp-Te interval (80 vs 100 ms, p=0.051). Corrected QT interval was longer in females (396 vs 392ms, p=0.044). During a median follow-up of 28 (IQR 16–41) months, 7 pts had VT/VF (2F, 5M) and 3 had syncope (3M), with no differences between gender (p=0.287). There were no cardiovascular deaths.

Conclusion

In BS, female pts are more often diagnosed by FS and have less spontaneous type 1 pattern. Gender appears to affect basal ECG characteristics in BS, namely in parameters that may predict arrhythmic risk. Further studies are important to clarify the role of gender in prognosis and risk stratification of BS pts.

Funding Acknowledgement

Type of funding sources: None.

Impact of atrial fibrillation and biventricular pacing percentage on long-term outcome in patients with heart failure treated with cardiac resynchronization therapy

Introduction

A history of preoperative atrial fibrillation (AF) has been found to be associated with unfavorable outcomes, higher risks of non-response to cardiac resynchronization therapy (CRT) and loss of biventricular pacing (BivP). We aimed to assess the impact of AF and BivP on long-term outcomes in heart failure patients treated with CRT.

Methods

We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the current guidelines. 118 patients were included in our analysis, from whom all data were available. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and 6 months after CRT. Response to CRT was defined as an increase in left ventricular ejection fraction (LVEF) &gt;10%. We considered an effective delivery of BivP &gt;98%. The primary endpoint was the composite endpoint of hospitalization due to HF or death for any cause.

Results

118 patients were included (mean age 69±11 years, 66.1% males, 39.8% ischemic etiology; baseline LVEF was 27,6±6%). Patients were divided into AF (n=42; 35,6%) and sinus rhythm (SR (n=76); 18 patients had permanent AF. AF patients had higher index left atrial volume and left ventricular mass (p&lt;0.001). Mean follow-up time was 43±18 months. BivP percentage was significantly superior in SR than in AF patients (98.1±2.1% vs 94.7±4.5%, p&lt;0.001), with 75% of SR patients having BivP&gt;98% vs 30,3% of AF patients (p&lt;0.001). There were no differences in preoperative parameters between them. The response rate to CRT was higher in SR patients when compared to AF patients (63,2% vs 40,5%, p=0.021). Indeed, the variation of LVEF was higher in SR patients (12±10% vs 7±9%, p=0.012).

During follow-up, there were significant differences between AF and SR patients in the primary endpoint (73,8% vs 42,6%, p&lt;0.001), and mortality for any cause (26,2% vs 9,2% p=0.014; p&lt;0.001). In a multivariate logistic regression analysis pre-procedural AF and BivP (%) were the only independent predictors of primary endpoint (HR 8.949, 95% CI 2.429 – 32.972, p=0.001; HR 0.719, 95% CI 0.526 – 0.982, p=0.038, respectively). Kaplan-Meier curves showed that event survival free was higher in SR patients when compared to AF (69±4 vs 24±3 months, p&lt;0.001)

Conclusion

Pre - procedural AF and BivP are independent predictors of the occurrence of a primary endpoint of hospitalization due to HF or death for any cause in HF patients submitted to CRT.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular dysfunction is a predictor of non-response to cardiac resynchronization therapy

Introduction

Cardiac resynchronization therapy (CRT) has been of great benefit to many heart failure (HF) patients with reduced ejection fraction (EF) and intraventricular conduction delay. However, approximately 30% of patients fail to respond to CRT. We investigated baseline characteristics that might influence response to CRT.

Methods

We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the guidelines. 118 patients were included in our analysis, from whom all data were available. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and 6 months after CRT implantation. Response to CRT was defined as an increase in left ventricular ejection fraction (LVEF) &gt;10%. Right ventricular systolic dysfunction (RVSD) was defined as S' velocity &lt;9.5 cm/s or tricuspid anular plane systolic excursion (TAPSE) &lt;17 mm. Chronic kidney disease (CKD) was defined as GFR &lt;60 ml/min/1.73m2.

Results

118 patients were included (mean age 69±11 years, 66.1% males, 39.8% ischemic etiology; 35,6% atrial fibrillation, baseline LVEF 27,6±6%). After 6 months of CRT, 65 patients (55.1%) were considered responders. Responders were more frequently female than non responders (43,1% vs 22,6, p=0.02). Atrial fibrillation and CKD were more prevalent in non responders (47,2% vs 26,2%, p=0.018; 62,3% vs 21,5%, p&lt;0.001, respectively). RVSD was present in 60,4% of non responders vs 16,9% of responders (p&lt;0.001). In responder group, the mean S' velocity was 10,9±2,1 cm/s vs 9,1±2,1 cm/s in non responder group, p&lt;0.001. The mean TAPSE was also higher in responder group (20,3±7,2 mm vs 16,5±4,4 mm, p=0.031). On multivariate analysis only RVSD (OR 7,754; 95% CI 2,968 – 20,282 p&lt;0.001] and CKD (OR 5,434; 95% CI 2,109 – 14,002; p&lt;0.001) were independently associated with non-response to CRT.

Conclusion

From a range of preoperative characteristics, multivariate analysis only identified RVSD and CKD as independent predictors of CRT response, with S' &lt;9,5 cm/s and TAPSE &lt;17 mm associated with non-response to CRT. This study highlights the importance of routine RV assessment in order to improve patient selection and optimize CRT response in heat failure patients.

Funding Acknowledgement

Type of funding sources: None.

QRS narrowing predicts left ventricular reverse remodelling after resynchronization therapy in patients with end-stage heart failure

Introduction

Cardiac resynchronization therapy (CRT) is an established treatment for heart failure (HF) patients, however one-third of the patients fail to benefit from CRT. The relationship between the QRS duration, severity of mechanical dyssynchrony and efficacy of CRT is not completely understood. We determined if QRS duration shortening after CRT implantation was predictive of left ventricular reverse remodelling.

Methods

We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the guidelines. 88 patients were included in our analysis, from whom all data were available, and these represent our sample. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and after 6 months of CRT implantation. Response to CRT was defined as a reduction in left ventricular end-diastolic volume (LVEDV) &gt;15%. Linear regression models were used.

Results

88 patients were included (mean age 69±10 years, 62.5% males, 36.4% ischemic etiology). Baseline left ventricular ejection fraction (LVEF) was 27,5±5,8% and LVEDV was 181±69 ml. After 6 months of CRT, 52 patients (59.1%) were considered responders. Baseline LVEDV was superior in responders when compared with non responders (199±85 ml vs 168±53 ml, p=0.038). No significant differences were noted in male gender (p=0.823), ischemic cardiomyopathy (p=0.065), LVEF (p=0.853), atrial fibrillation (p=0.390), left bundle branch block (p=0.950) or biventricular pacing (p=0.154) between them.

QRS duration at baseline was similar between responders and non-responders (165±17 ms vs 163±17 ms, p=0.620). After 6 months of CRT, the reduction of QRS duration in responders was significantly higher than non-responders (p&lt;0.001).

QRS duration was reduced from 165±17 ms to 136±15 ms in responders vs 163±17 ms to 160±17 ms in non-responders, (p&lt;0.001). The change in QRS duration positively correlated with the change in LVEDV (0. 654; p&lt;0.001). Multi-linear regression analysis suggested that QRS duration shortening had a significant effect on LVEDV (y = 14,375 + 1.354 X, R2 0.337, p&lt;0.001)

Conclusion

QRS duration shortening after CRT implantation was predictive of LV reverse remodelling in end-stage heart failure patients. Further prospective studies should be conducted to assess the prognostic value of QRS narrowing in response to CRT.

Funding Acknowledgement

Type of funding sources: None.

AB0848 PARTICIPATION OF UNDERGRADUATE MEDICAL STUDENTS AS INVESTIGATORS IN A RHEUMATOLOGIC COHORT: IMPACT ON DEPRESSION, ANXIETY & STRESS SCALE

Background:

Mental health was widely affected during the new coronavirus pandemic. In addition, some measures adopted by most countries in order to contain the virus spread, such as isolation and social distancing, leading to the interruption of routine activities, including partial or complete interruption of face-to-face classes may be associated with increased stress, depression and anxiety among undergraduate medical students (1). From March to September, 2020, the Brazilian Society of Rheumatology carried out the Mario Pinotti II Project (MPII), a prospective, multicenter, observational cohort study designed to monitor the COVID-19 in patients with rheumatic disease on hydroxychloroquine, using periodic telephone calls performed by undergraduate medical students (2).

Objectives:

To compare the mental health status of medical students who were participating from the MPII with theirs colleagues not involved in this project.

Methods:

A web-based survey via google forms platform was developed by a panel composed of undergraduate medical students, rheumatologists, medical school professors, and a psychology professor. It included details on demographic and life habits data and domains regarding depression, anxiety and stress, using the DASS-21 (Depression, Anxiety & Stress Scale), Brazilian version. Data collection occurred from July 20th to August 31st, 2020. Statistical analysis was performed using the SPSS version 20.0. Univariate and multivariate linear regression analysis were performed to verify associations with the DASS-21, defined as dependent variable. A p-value < 0.05 was deemed as significant. This study was approved by the Institutional Research Ethics Committee.

Results:

A total of 684 undergraduate medical students were included in this study, of whom 228 as MPII volunteers (VG) and 456 as control group (CG). Median age was 23 years (IQ 21-24) and the CG was older than the VG (p<0.03). Most of them were white (68.8%) and women (63%). There were no significant differences regarding comorbidities, ethnicity, smoking status, alcohol intake and physical activity. Older age, male gender, participation of MPII study, absence of a worsening in sleep pattern during the pandemic and a lower number of prior comorbidities were associated with lower DASS21 scores, suggesting a better mental health (Table 1).

Conclusion:

Several aspects may be involved with mental health, including increased emotional maturity, gender and sleep pattern. Although with marginal independent association, medical students with participation in the MPII study had better mental health than their student colleagues not engaged with this research. Our data pointed out that voluntary participation in a research project which foresees interaction by telephone contact with rheumatic patients, professors, rheumatologists, and colleagues is associated with better mental health.

References:

[1]Meo SA, Abukhalaf AA, Alomar AA, Sattar K, Klonoff DC. Covid-19 pandemic: Impact of quarantine on medical students’ mental wellbeing and learning behaviors. Pakistan J Med Sci 2020;36(COVID19-S4):S43–8.

[2]Gomides A, Ferreira G, Kakehas A, Lacerda M, Marques C, Paiva E et al. Impact of chronic use of antimalarials on SARS-COV-2 infection in patients with immune-mediated rheumatic diseases: protocol design for a multicentric observational cohort in Brazil. JMIR Research Protocols, 2020.Preprint

Table 1.

Univariate and multivariate analysis of predictors associated to the DASS-21 in undergraduate medical students during the COVID-19 pandemic

Univariate analysisMultivariate analysisVariableB95%CIp-ValueB95%CIp-ValueAge-0.32-0.61 to -0.030.03-0.47-0.81 to -0.130.008Female gender4.883.021 to 6.76<0.001---Stable love relationship-2.49-4.35 to -0.640.008-2.5-4.4 to -0.590.01Number of previous comorbidities reported4.693.71 to 5.68<0.0014.823.73 to 5.92<0.001MP-II volunteering-2.81-4.74 to -0.860.005---Worsening in sleep pattern6.414.62 to 8.20<0.0015.013.07 to 6.96<0.001

Disclosure of Interests:

None declared

POS1252 COVID-19 IN PATIENTS WITH RHEUMATIC DISEASES ON CHRONIC USE OF HYDROXYCHLOROQUINE IN A LARGE BRAZILIAN COHORT – A 24-WEEK PROSPECTIVE STUDY

Background:

The role of chronic use of hydroxychloroquine (HCQ) in rheumatic disease (RD) patients during the SARS-CoV-2 pandemic is still subject of discussion.

Objectives:

To compare the occurrence of COVID-19 and its outcomes between RD patients on HCQ use with individuals from the same household not taking the drug during community viral transmission in an observational prospective multicenter study in Brazil.

Methods:

Participants were enrolled and monitored through 24-week (From March 29th to Sep 30th, 2020) regularly scheduled phone calls performed by trained medical professionals. Epidemiological and demographic data, as well as RD disease activity status and current treatment data, specific information about COVID-19, hospitalization, need for intensive care, and death was recorded in both groups and stored in the Research Electronic Data Capture (REDCap) database. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. The statistical analysis was performed using IBM-SPSS v.20.0 software. Group comparisons were made using the Man-Whitney, Chi-Square and Fisher Exact Test, as well as multivariate regression models adjusted to confounders. Survival curves were performed using Kaplan-Meier analysis.

Results:

A total of 10,427 participants mean age (SD) of 44.04 (14.98) years were enrolled, including 6004 (57.6%) rheumatic disease patients, of whom 70.8% had systemic lupus erythematosus (SLE), 6.7% rheumatoid arthritis (RA), 4% primary Sjögren’s syndrome (pSS), 1.8% mixed connective tissue disease (DMTC), 1% systemic sclerosis (SSc) and others (15.9), including overlap syndromes. In total, 1,132 (10.8%) participants fulfilled criteria for COVID-19, being 6.7% RD patients and 4.1% controls (p=0.002). A recent influenza vaccination had a protective role (p<0.001). Moderate and severe COVID-19 included the need for hospitalization, intensive care, mechanical ventilation or death. Infection severity was not different between groups (p=0.391) (Table 1). After adjustments for multiple confounders, the main risk factors significantly associated with COVID-19 were higher education level (OR=1.29 95%CI 1.05-1.59), being healthcare professionals (OR=1.91; 95%CI 1.45-2.53), presence of two comorbidities (OR=1.31; 95%CI 1.01-1.66) and three or more comorbidities associated (OR=1.69; 95%CI 1.23-2.32). Interestingly, age >=65 years (OR=0.20; 95%CI 0.11-0.34) was negatively associated. Regarding RD, the risk factors associated with COVID-19 diagnosys were SLE (OR= 2.37; 95%CI 1.92-293), SSc (OR=2.25; 95%CI 1.05-4.83) and rituximab use (OR=1.92; 95%CI 1.13-3.26). In addition, age >=65 years (OR=5.47; 95%CI 1.7-19.4) and heart disease (OR=2.60; 95%CI 1.06-6.38) were associated with hospitalization. Seven female RD patients died, six with SLE and one with pSS, and the presence of two or more comorbidities were associated with higher mortality rate.

Conclusion:

Chronic HCQ use did not prevent COVID-19 in RD compared to their household cohabitants. Health care profession, presence of comorbidities LES, SSc and rituximab were identified as main risk factors for COVID-19 and aging and heart disease as higher risk for hospitalization. Our data suggest these outcomes could be considered to manage them in clinical practice.

Table 1.

Frequency and severity of COVID-19 in patients with rheumatic diseases on chronic use of hydroxychloroquine compared to their household controls

COVID-19 outcomesTotal(%)GroupsPPatients(%)Controls (%)DiagnosisNo9256 (89.1)5300 (88.3)3956 (90.2)0.002Yes1132 (10.9)704 (11.7)428 (9.8)SeverityMild1059 (93.6)662 (94.0)397 (92.8)0.391Moderate52 (4.6)32 (4.5)20 (4.7)Severe21 (1.9)10 (1.4)11 (2.6)

HCQ: hydroxychloroquine.

Moderate and severe COVID-19 included the need for any of the following: hospitalization, intensive care, mechanical ventilation or death.

Acknowledgements:

To the Brazilian Society of Rheumatology for technical support and rapid nationwide mobilization.

To all the 395 interviewers (medical students and physicians) who collaborated in the study and the participants

To CNPq (Number 403442/2020-6)

Disclosure of Interests:

None declared

POS0013 MUSCULOSKELETAL MANIFESTATIONS IN PATIENTS WITH ENDOCRINE DISEASES IN TERTIARY SERVICE

Background:

Musculoskeletal diseases represent about 50 to 70% of the frequency of chronic diseases according to previous studies (SOUZA, OLIVEIRA, 2015). Chronic pain is often associated with these diseases and is an important cause of care in the health service. Thus, medical professionals are required to adequately manage their patients. Despite the lack of knowledge of some, endocrine diseases are basic diseases linked to musculoskeletal manifestations.

Thus, secondary arthropathies of the non-rheumatologic origin or osteoarticular complaints that simulate or show rheumatic diseases can be seen in patients with endocrine diseases during their evolution or in the initial phase along with other systemic symptoms.

Based on this concept, the musculoskeletal manifestations presented by patients with endocrine disorders in tertiary health service were monitored and evaluated.

Objectives:

The objective of this study is to characterize the musculoskeletal manifestations in patients with endocrine diseases: type 1 and type 2 diabetes mellitus; hypothyroidism; hyperthyroidism and pituitary diseases and to clinically classify the patients based on physical and imaging findings.

Methods:

A cross-sectional and descriptive study, where clinical screening was performed at the endocrinology outpatient clinic, in which patients with musculoskeletal complaints were identified. These patients were referred for evaluation with a rheumatologist with clinical, laboratory and imaging investigation for the diagnosis of rheumatic disease. A questionnaire with epidemiological and clinical data was applied.

Results:

In this study, 325 patients with endocrine diseases were interviewed, 53 ± 16.4 years old, 258 (80%) were female and 64 (20%) males. Of the interviewed patients, 236 (72.8%) reported musculoskeletal pain, being that 196 (75.9%) of the women and 33% of the men indicated this type of symptom. Regarding endocrine diseases, the most frequent was Diabetes Mellitus type 2 with 158 patients (48.6%), and 75% of these people have chronic musculoskeletal pain, most 5 to 7 times a week, showing an intrinsic character of this disease with pain complaints from a large part of this population. It was also identified the prevalence of 25% of Hypothyroidism, 12% of Diabetes type 1, 9% of Hyperthyroidism and less expressive amounts of other endocrine diseases such as Acromegaly (2.1%), Gigantism (0.3%) and similar. About 63% of those who have pain are not followed up in the service of rheumatology, 42% of these have already indicated these pains to their endocrinologist, however they have not had their complaint properly flagged. Of these patients, 94 (29%) use Antihypertensives and 25% Oral Antidiabetics. The most notable diagnoses in rheumatology are: Rheumatoid Arthritis (29%); Osteoarthritis (27%); Osteoporosis and Fibromyalgia both with 20.6% of diagnoses and Psoriatic Arthritis and GOUT with 6%. The main regions that are subject to pain are the Hands (52%); Knees (40%); Spine and feet with 30% each.

Conclusion:

Although there is a demand of more confirmatory studies, our preliminary results showed the mutuality between endocrine diseases and musculoskeletal manifestations and, therefore, that rheumatological findings are increasingly frequent in this population. The high prevalence of these symptoms secondary to endocrine diseases raises serious questions in order to improve the quality of life of these patients, and also to increase the number of researches in this field, because the pathophysiological mechanisms of this association are not well elucidated and, from this, expand this information to professionals who may not be aware of this relationship.

References:

[1]SOUZA, Cesario da Silva; OLIVEIRA, Anamaria Siriani. Prevalência de encaminhamentos às doenças musculoesqueléticas segundo a classificação estatística internacional de doenças (CID-10): reflexões para formação do fisioterapeuta na área de musculoesquelética. Fisioterapia e Pesquisa v. 22, n. 1, p. 48–53, 2015.

Disclosure of Interests:

None declared.

Device therapy guided by implantable loop recorders: predictors of bradyarrhythmic events

Background

Implantable loop recorders (ILR) improved diagnostic yield in unexplained syncope patients (pts). Data on possible predictive factors for bradycardia requiring device implantation in these pts is limited. We aim to identify clinical predictors for device implantation due to a significant bradyarrhythmia in patients who underwent ILR insertion for the study of syncopal/presyncopal (S/pS) events.

Methods

Single-center retrospective study of patients who implanted an ILR for the study of unexplained S/pS episodes between 2013 and 2018. The primary endpoint was a documented bradyarrhythmia requiring device implantation during the follow-up.

Results

A total of 251 pts were included. Mean age was 68±15 years and 53% were female. The majority of pts (220; 88%) had normal ejection fraction. Fifty-two (21%) pts had atrial fibrillation (AF). Regarding basal electrocardiographic characteristics, 34 (14%) pts had 1st degree auriculo-ventricular block (AVB), 31 (12%) pts had left bundle branch block (L-BBB), 22 (9%) pts had R-BBB and 13 (5%) pts had bifascicular block.

During a median follow-up of 20 (IQR 9–34) months, 74 (29%) pts required device implantation because of a significant bradyarrhythmia (92% pacemaker, 4% CRT, 4% ICD). Median duration from ILR until device implantation was 5 (IQR 1–10) months. The indications were sick-sinus-syndrome in 47 (64%) pts, advanced AV block in 23 (31%) pts and symptomatic slow AF in 4 (5%) pts.

Patients who required device implantation were older (73±12 vs 66±15 years, p &lt;0.001), had more hypertension (73% vs 59% p=0.048), a higher prevalence of AF (34% vs 15% p=0.001) and a lower glomerular filtration rate (GFR&lt;60 ml/min: 32% vs 21%, p=0.047). They also had more 1st AVB (22% vs 11%, p=0.026) and intraventricular conduction disturbances (38% vs 25%, p=0.025). There was a trend for a higher device implantation in pts with concomitant 1st AVB and left anterior fascicular block (7% vs 2%, p=0.063)

In a logistic regression model, age &gt;75 years (HR: 1.7; 95% CI: 1.1–2.8) and the presence of AF (HR: 1.8; 95% CI: 1.1–3.0) were independent predictors for device implantation.

Conclusion

An older age and the presence of AF were independent predictors for device therapy in pts who implanted an ILR for the study of S/pS. These factors may identify a higher risk group and should be considered in the initial workup of these pts.

Funding Acknowledgement

Type of funding source: None

Experience report on the training of Brazilian dental managers using active methodologies

This is an account on the training of dental managers in a Social Welfare, not-for-profit, non-governmental institution present in all Brazilian states. Given the continental dimension of Brazil, its regional inequalities and the need for uniformity in the management conduct, as well as in the planning and evaluation of services, it is understood that developing managers' skills and competences is fundamental. Bearing in mind that the model adopted by the company is based on collective health, and its structure is organized in Primary Care, this proposal can be applied by other organizations that offer services of a similar nature. The aim of this study is to describe the training of oral health managers (n = 54) on the themes of sustainability, practices based on evidence/health economics and social determinants - themes that were requested by the managers themselves. Using problem-based learning, active and distance-learning methodologies, three working groups were set up among the managers to go through the contents of the training program, which aimed at training mentors and identifying successful service experiences for sharing. This process peaked at a face-to-face session with all participants where a specialist and their respective mentors presented each topic. The products obtained were: (1) three scientific-economic studies for decision making on the incorporation of hard technologies; (2) a guide to sustainable practices in dentistry and (3) a set of criteria for prioritizing access based on social determinants. In the evaluation of the training, 89% of managers were very satisfied, 8.98% were satisfied and 1.79% were dissatisfied. It is concluded that the methodology used in this process significantly contributed to the development of the company's regional service managers and such improvement stemmed from the empowerment, engagement and alignment of these managers, to which action plans were directed, with measures for monitoring and evaluation.

Key messages

Active methodologies in training contributes to the empowerment, engagement and alignment of dental managers before epidemiological, economic and social challenges faced in the management of services. Trainings where the participants are protagonists in all stages of the educational processes, are those that produce the best results and the highest degree of satisfaction among employees.

Evaluation of the oral health condition of schoolchildren in the south of Brazil

In order to subsidize policies, actions and intersectoral strategies for health promotion, protection and recovery, it is important to establish the distribution of oral diseases in the target population. Thus, the present study aims at identifying the oral health condition of students from a network of schools run by a Social Welfare, not-for-profit, non-governmental institution in Brazil's Southern Region. This is a census approved by a competent Research Ethics Committee, carried out in a school environment in 2018, involving 1,243 children, 1,172 of which at 5 years old and 71 at 12 years old. All had impacts on oral health and caries rates (dmf / DMFT), occlusion (Foster & Hamilton and DAI) and fluorosis (Dean) evaluated by properly trained and calibrated dentists.The most prevalent impact on oral health, at both ages, was “difficulty in eating”. Students aged 12 and 5 years old showed, respectively, 0.28 and 1 tooth with caries experience; 5.8% and 5.3% with some need for treatment and a prevalence of malocclusion of 57.7% and 79%. Fluorosis was investigated only within the 12-year-old students and it was present in 26.8% of them. In view of the results, the planning of oral health actions in the schools of the social institution studied must privilege the actions of promotion, protection and recovery in the scope of malocclusions and strengthen those already implemented for caries disease. At the same time, a health surveillance system should be built and implemented for monitoring and assessment.

Key messages

Identifying the epidemiological profile of the target population contributes to the efficient allocation of financial resources and the establishment of assertive strategies to meet their needs. Epidemiological surveys allow us to know the prevalence and severity of the disease, its distribution and treatment needs, allowing health planning and subsidizing the evaluation of services.

Cardiovascular disease among people living with HIV in Brazil

OBJECTIVES

There is a paucity of data on cardiovascular disease (CVD) among people living with HIV (PLHIV) in resource-limited countries. We assessed factors associated with CVD and the impact of prevalent CVD on all-cause mortality in PLHIV on antiretroviral therapy in Brazil.

METHODS

Competing risk regression to assess factors associated with CVD and all-cause mortality in the HIV-Brazil Cohort Study between 2003 and 2014.

RESULTS

Among 5614 patients, the rate of CVD was 3.5 (95% confidence interval [95% CI] 2.9-4.3) per 1000 person-years. CVD was associated with older age (adjusted hazard ratio [aHR] 6.4 for ≥55 years vs. <35 years, 95% CI: 2.5-16.3, P < 0.01), black race (aHR 1.8 vs. white race, 95% CI: 1.0-3.1, P = 0.04), past CVD (aHR 3.0 vs. no past CVD, 95% CI: 1.4-6.2, P < 0.01), hypertension (aHR 1.8 vs. no hypertension, 95% CI: 1.0-3.1, P = 0.04), high-grade dyslipidemia (aHR 9.3 vs. no high-grade dyslipidemia, 95% CI: 6.0-14.6, P < 0.01), ever smoking (aHR 2.4 vs. never, 95% CI: 1.2-5.0, P = 0.02) and low nadir CD4 cell count (aHR 1.8 for 100-250 cells/mm3 vs. >250 cells/mm3 , 95% CI: 1.0-3.2, P = 0.05). The rate of death was 16.6 (95% CI: 15.1-18.3) per 1000 person-years. Death was strongly associated with having had a past CVD event (aHR 1.7 vs. no past CVD event, 95% CI: 1.1-2.7, P = 0.01).

CONCLUSIONS

Traditional and HIV-specific factors associated with CVD among PLHIV in Brazil are similar to those identified among PLHIV in high-income countries. PLHIV in Brazil with a history of CVD have a high risk of death. CVD care and treatment remain priorities for PLHIV in Brazil as this population ages and antiretroviral therapy use expands.

Self-audits as alternatives to travel-audits for improving data quality in the Caribbean, Central and South America network for HIV epidemiology

INTRODUCTION

Audits play a critical role in maintaining the integrity of observational cohort data. While previous work has validated the audit process, sending trained auditors to sites ("travel-audits") can be costly. We investigate the efficacy of training sites to conduct "self-audits."

METHODS

In 2017, eight research groups in the Caribbean, Central, and South America network for HIV Epidemiology each audited a subset of their patient records randomly selected by the data coordinating center at Vanderbilt. Designated investigators at each site compared abstracted research data to the original clinical source documents and captured audit findings electronically. Additionally, two Vanderbilt investigators performed on-site travel-audits at three randomly selected sites (one adult and two pediatric) in late summer 2017.

RESULTS

Self- and travel-auditors, respectively, reported that 93% and 92% of 8919 data entries, captured across 28 unique clinical variables on 65 patients, were entered correctly. Across all entries, 8409 (94%) received the same assessment from self- and travel-auditors (7988 correct and 421 incorrect). Of 421 entries mutually assessed as "incorrect," 304 (82%) were corrected by both self- and travel-auditors and 250 of these (72%) received the same corrections. Reason for changing antiretroviral therapy (ART) regimen, ART end date, viral load value, CD4%, and HIV diagnosis date had the most mismatched corrections.

CONCLUSIONS

With similar overall error rates, findings suggest that data audits conducted by trained local investigators could provide an alternative to on-site audits by external auditors to ensure continued data quality. However, discrepancies observed between corrections illustrate challenges in determining correct values even with audits.

Pre-exposure prophylaxis in a sexual health clinic for Men who Have Sex with Men in Portugal

Background

Pre-exposure prophylaxis (PrEP) is defined as the use of antiretroviral drugs to prevent HIV acquisition in uninfected individuals. Recognizing the increasing use of informal PrEP in Portugal, CheckpointLX, a community clinic targeted for MSM in Lisbon, Portugal, began offering counselling and follow-up services prior to formal introduction. This study aims to characterize PrEP users attending CheckpointLX before formal PrEP introduction in Portugal, and those who were referred to PrEP in the National Health Service (NHS) following formal approval of PrEP.

Methods

Data was collected by peer counsellors between May 2015 and September 2018 and inserted in a database. Medical care followed EACS recommendations for PrEP eligibility, initiation and follow up. For formal PrEP, the General-Directorate for Health’s PrEP guidelines checklist was used.

Results

Until the end of May 2018, CheckpointLX had a total of 90 appointments for Wild PrEP, of which 64 (71%) were first time visits. As for the 380 service users referred to the NHS, most were Portuguese (N = 318, 84%), and the mean age was 31 (8.9) years old. Condomless sex in the last six months with partners of unknown HIV status was the most common eligibility criteria (N = 59, 83%).

Conclusions

PrEP delivery should be complemented with effective information on the importance of immunization and education on safer practices of drug administration, in the scope of broader preventive sexual health care. Much remains to be done in Portugal to ensure that PrEP is available to those who need it the most. Offering PrEP at community clinics could be a first step.

Key messages

Condomless sex in the last six months with partners of unknown HIV status was the most common eligibility criteria for PrEP. PrEP delivery should be complemented with effective information on the importance of immunization and education on safer practices of drug administration.

Prevalence of gonorrhea and chlamydia in a community clinic for Men who Have Sex with Men in Portugal

Background

Men who have sex with men (MSM) are at greater risk for sexually transmitted infections (STIs). Data on MSM chlamydia and gonorrhea prevalence estimates and associated risk factors is scarce. To our knowledge, this is the first study to describe the prevalence and the determinants of both chlamydia and gonorrhea infections in MSM in Portugal.

Methods

We conducted a cross-sectional study using data from 1,832 visits to CheckpointLX, a community-based center for screening blood-borne viruses and other STIs in MSM.

Results

Overall prevalence of chlamydia or gonorrhea in our sample was 16.05%, with 14.23% coinfection and 40.73% asymptomatic presentation among those testing positive. Anorectal infection was most common for chlamydia (67.26%), followed by urethral (24.78%) and oral (19.47%) infection. Oral infection was most common for gonorrhea (55.63%), followed by anal (51.25%) and urethral (17.50%) infection. In multivariate analyses, young age (U = 94684, p = 0.014), being foreign-born (χ2=11.724, p = 0.003), reporting STI symptoms (χ2=5.316, p = 0.021), inhaled drug use (χ2=4.278, p = 0.039) and having a higher number of concurrent (χ2=18.769, p &lt; 0.001) or total (χ2=5.988, p = 0.050) sexual partners were each associated with higher rates of chlamydia or gonorrhea infection.

Conclusions

Young and migrant MSM are a vulnerable population to STIs, as are those who use inhaled drugs and those with a higher number of concurrent or total sexual partners. Although Portugal has no guidelines on chlamydia and gonorrhea screening, our results point towards a need for greater awareness about the importance of high frequency screening for those at increased risk (i.e. every 3 to 6 months).

Key messages

Higher prevalence was found in young and migrant MSM, those with higher number of concurrent or total sexual partners, and those who use inhaled drugs. There is a need for greater awareness about the importance of high frequency STI screening for MSM at increased risk.

P6579Genetic profile and predictors of positive genetic test in Brugada syndrome

Introduction

Brugada syndrome (BS) is a channelopathy with autosomal dominant transmission, incomplete penetrance and variable expression. There are 18 different gene mutations described in association with this syndrome, however 70% of patients remain without identifiable genetic cause. Genetic testing is appropriated for patients with clinical diagnosis but it is also a very important tool in familiar screening.

Aim

We aim to characterize genetic profile of patients with clinical diagnosis of BS and identify differences between patients with and without causative mutation.

Methods

We included patients followed by the arrhythmology department of our hospital with diagnosis of BS and that have performed genetic test (or patients who were identified through familiar screening and with negative genetic test in the index case). Patients identified through familiar screening with positive genetic test but no spontaneous electrocardiographic pattern, still awaiting pharmacologic provocative test at the time of enrolment – no clinical diagnosis - were excluded. Genetic test was considered positive when we found a pathogenic or probably pathogenic mutation. Mutations in PKP, SLMAP, CACNA, CACNB, SCN10A and CLASP genes considered of uncertain clinical relevance were not included as positive genetic test. We analysed differences between subset of patients with and without causative mutation regarding clinical and electrocardiographic variables. We performed multivariate analysis to find predictors of positive genetic test.

Results

From our 173 patients, 140 met the inclusion criteria and none exclusion criteria so they were enrolled. Patients were 61% male with mean age of 50±15 years old. Mean follow-up was 26±28 months; 24,4% of index cases were positive for causative mutation, 6,8% patients with pathogenic mutation in SCN5A gene and 17,6% with probably pathogenic mutation in SCN5A.

We haven't found significant differences between the 2 groups (negative and positive genetic test) in any clinical variable included. Regarding electrocardiographic variables, patients in whom a mutation was identified had longer PR interval (192±36 vs 170±28, p=0.001), longer QRS (121±19 VS 111±18 p=0.017), particularly when QRS>110ms (p=0,002), and longer QT (398±25 VS 370±45 p=0.015) In multivariate analysis, PR interval (p=0.032) and QRS>110ms (p=0,041) were independent predictors for positive genetic test.

Conclusion

In our BS population, there were no clinical differences between patients with and without causative mutation, also concerning events rate. Patients with positive genetic test have significantly longer PR interval and QRS>110ms than in patients with genetic test negative. Those results can be interpreted in relation to sodium channel disfunction in patients with SCN5A mutation.

Trends and predictors of non-communicable disease multimorbidity among adults living with HIV and receiving antiretroviral therapy in Brazil

INTRODUCTION

People living with HIV (PLHIV) on antiretroviral therapy (ART) experience high rates of non-communicable diseases (NCDs). These co-morbidities often accumulate and older adults may suffer from multimorbidity. Multimorbidity has been associated with loss of quality of life, polypharmacy, and increased risk of frailty and mortality. Little is known of the trends or predictors NCD multimorbidity in PLHIV in low- and middle-income countries.

METHODS

We examined NCD multimorbidity in adult PLHIV initiating ART between 2003 and 2014 using a multi-site, observational cohort in Brazil. NCDs included cardiovascular artery disease, hyperlipidemia (HLD), diabetes, chronic kidney disease, cirrhosis, osteoporosis, osteonecrosis, venous thromboembolism and non-AIDS-defining cancers. Multimorbidity was defined as the incident accumulation of two or more unique NCDs. We used Poisson regression to examine trends and Cox proportional hazard models to examine predictors of multimorbidity.

RESULTS

Of the 6206 adults, 332 (5%) developed multimorbidity during the study period. Parallel to the ageing of the cohort, the prevalence of multimorbidity rose from 3% to 11% during the study period. Older age, female sex (adjusted hazard ratio (aHR) = 1.30 (95% confidence interval (CI) 1.03 to 1.65)) and low CD4 nadir (<100 vs. ≥200 cells/mm3 aHR = 1.52 (95% CI: 1.15 to 2.01)) at cohort entry were significantly associated with increased risk of multimorbidity. Among patients with incident multimorbidity, the most common NCDs were HLD and diabetes; however, osteoporosis was also frequent in women (16 vs. 35% of men and women with multimorbidity respectively).

CONCLUSIONS

Among adult PLHIV in Brazil, NCD multimorbidity increased from 2003 to 2014. Females and adults with low CD4 nadir were at increased risk in adjusted analyses. Further studies examining prevention, screening and management of NCDs in PLHIV in low- and middle-income countries are needed.

Electroactive biomaterial surface engineering effects on muscle cells differentiation

Even though skeletal muscle cells can naturally regenerate as a response to insignificant tissue damages, more severe injuries can cause irreversible loss of muscle cells mass and/or function. Until now, cell therapies are not a good approach to treat those injuries. Biomaterials such as poly(vinylidene fluoride), PVDF, can improve muscle regeneration by presenting physical cues to muscle cells that mimic the natural regeneration environment. In this way, the ferroelectric and piezoelectric properties of PVDF offer new opportunities for skeletal muscle tissue engineering once the piezoelectricity is an electromechanical effect that can be used to provide electrical signals to the cells, upon mechanical solicitations, similar to the ones found in several body tissues. Thus, previous to dynamic experiments, it is important to determine how the surface properties of the material, both in terms of the poling state (positive or negative net surface charge) and of the morphology (films or fibers) influence myoblast differentiation. It was observed that PVDF promotes myogenic differentiation of C2C12 cells as evidenced by quantitative analysis of myotube fusion, maturation index, length, diameter and number. Charged surfaces improve the fusion of muscle cells into differentiated myotubes, as demonstrated by fusion and maturation index values higher than the control samples. Finally, the use of random and oriented β-PVDF electrospun fibers scaffolds has revealed differences in cell morphology. Contrary to the randomly oriented fibers, oriented PVDF electrospun fibers have promoted the alignment of the cells. It is thus demonstrated that the use of this electroactive polymer represents a suitable approach for the development of electroactive microenvironments for effective muscle tissue engineering.

Genotype by environment interaction for yearling weight in Nellore cattle applying reaction norms models

In the present study, a possible existence of genotype × environment interaction was verified for yearling weight in Nellore cattle, utilising a reaction norms model. Therefore, possible changes in the breeding value were evaluated for 46 032 animals, from three distinct herds, according to the environmental gradient variation of the different contemporary groups. Under a Bayesian approach, analyses were carried out utilising INTERGEN software resulting in solutions of contemporary groups dispersed in the environmental gradient from –90 to +100 kg. The estimates of heritability coefficients ranged from 0.19 to 0.63 through the environmental gradient and the genetic correlation between intercept and slope of the reaction norms was 0.76. The genetic correlation considering all animals of the herds in the environmental gradient ranged from 0.83 to 1.0, and the correlation between breeding values of bulls in different environments ranged from 0.79 to 1.0. The results showed no effect of genotype × environment interaction on yearling weight in the herds of this study. However, it is important to verify a possible influence of the genotype × environment in the genetic evaluation of beef cattle, as different environments might cause interference in gene expression and consequently difference in phenotypic response.

Hyperglycemia during tuberculosis treatment increases morbidity and mortality in a contemporary cohort of HIV-infected patients in Rio de Janeiro, Brazil

BACKGROUND

Hyperglycemia occurs in tuberculosis (TB), but the long-term impact is unknown. We estimated the prevalence of hyperglycemia and compared the TB treatment outcomes and 1-year mortality rate according to the glycemic status noted during TB treatment.

METHODS

We conducted a retrospective cohort analysis of adult patients who had TB and HIV coinfection and started receiving TB treatment at the Instituto Nacional de Infectologia Evandro Chagas, Brazil, between 2010-2015. Diabetes Mellitus (DM) and hyperglycemia were defined according to the American Diabetes Association. After excluding for known DM at baseline, the proportion of participants who developed new-onset DM after TB treatment was assessed. TB outcome was classified as successful or adverse (i.e., treatment failure, abandonment, and death). Kaplan-Meier survival curves were compared by the log-rank test based on the glycemic status of patients. Multivariate Cox regression models were used to assess the association between hyperglycemia and 1-year mortality. Two-sided p values <0.05 were considered statistically significant.

RESULTS

We identified 414 euglycemic patients (87.5%), 49 hyperglycemic patients (10.3%), and 10 patients with known DM (2.1%). Diabetic patients were older compared to the euglycemic and hyperglycemic patients (47.9 vs. 37 vs. 39.7 years, respectively, p=0.001). Diabetic patients frequently had cavitation on chest image compared to hyperglycemic and euglycemic patients (50% vs. 23.4% vs. 15.3%, p=0.007, respectively). Hyperglycemic patients had more new-onset DM at follow-up compared to euglycemic (22 vs. 1; p<0001). Hyperglycemia was associated with adverse outcomes (71.4% vs. 24.6%, p<0.0001) compared to euglycemia. Crude 1-year mortality was significantly higher in patients with hyperglycemia compared with euglycemia (48.9% vs. 7.9%; unadjusted HR: 5.79 (3.74-8.96)). In the adjusted Cox models, hyperglycemia remained a significant factor for increased 1-year mortality (adjusted HR: 3.72 (2.17-6.38)].

CONCLUSIONS

Hyperglycemia frequently occurs in HIV-infected patients who commence TB treatment, and it increases the risks of adverse TB outcomes and 1-year mortality. Glucose testing during TB treatment detects patients at risk of adverse outcomes.

Effects of antiretroviral treatment and nadir CD4 count in progression to cardiovascular events and related comorbidities in a HIV Brazilian cohort: a multi-stage approach

The use of highly active antiretroviral therapy has resulted in changes of comorbidity profile in people living with HIV (PLHIV), increasing non-AIDS-related events. The occurrence of cardiovascular events is greater in PLHIV, but the mechanism responsible for it is still controversial. This article aimed to investigate factors associated with the progression to cardiovascular events in PLHIV using HAART. A 15-years cohort study with 1135 PLHIV was conducted in Rio de Janeiro-Brazil. Clinical progression was stratified in five states: No comorbidities (s₁), arterial hypertension (s₂), lipid abnormalities (s₃), hypertension and lipid abnormalities (s₄) and major cardiovascular events (stroke, coronary artery disease, thrombosis or death) (s₅). Semi-Markov models evaluated the effects of cardiovascular traditional factors, treatment and clinical covariates on transitions between these states. Hazard Ratios (HR) and 95% confidence intervals (CI) were provided. In addition to traditional factors (age, sex, educational level and skin color), the development of one comorbidity (lipid abnormalities or hypertension) increased in patients with low nadir CD4 (<50 cells/mm³), (HR = 1.59, CI 1.11-2.28 and 1.36, CI 1.11-1.66, respectively). The risk to experience a second comorbidity (s₃→s₄) increased 75% with low nadir CD4. Age was the only factor that increased the risk of major cardiovascular events once having lipid abnormalities with or without hypertension (s₃,s₄→s₅). The prolonged use of certain antiretroviral drugs (abacavir, didanosine, ritonavir, lopinavir, amprenavir and fosamprenavir) increased the risk of direct transition (s₁→s₅) to major cardiovascular events (HR = 5.29, CI 1.16-24.05). This analysis suggests that prolonged use of certain antiretroviral drugs led directly to major cardiovascular events, while low nadir CD4 only affected the occurrence of lipid abnormalities and hypertension. Management strategies, including rational use of complex exams (such as, computed-tomography angiography), statins and antihypertensives, should be developed based on the distinct roles of antiretroviral use and of HIV infection itself on the progression to cardiovascular events.

Inter- and intra-laboratory standardization of TUNEL assay for assessment of sperm DNA fragmentation

One of the challenges with the sperm DNA fragmentation results is the inconsistency and the large variability in the results obtained by different techniques. The terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay quantifies the incorporation of fluoresceinated dUTP into single- and double-strand DNA breaks by labeling the 3'-OH terminal with TdT. The goal of this study was optimize the TUNEL protocol for assessment of sperm DNA fragmentation by standardization of the method and comparison of the data across two reference laboratories (i) at Basel, Switzerland and (ii) Cleveland Clinic, Ohio, USA. Semen samples from 31 subjects grouped into three cohorts. Sperm DNA fragmentation was data measured by two experienced operators at two different laboratories using identical semen samples, assay kit, protocol and acquisition settings using identical flow cytometers (BD Accuri C6). No significant differences were observed between the duplicates in any of the experiments performed. By including an additional washing step after fixation in paraformaldehyde, a high correlation was seen between the two laboratories (r = 0.94). A strong positive correlation was observed between the average sperm DNA fragmentation rates (r = 0.719). The mean sperm DNA fragmentation measured in each laboratory was similar. Both flow cytometers were identical in their settings and performance. This inter- and intra-laboratory study establishes that TUNEL is a reproducible assay when utilizing a standardized staining protocol and flow cytometer acquisition settings. Standardization and consensual guidelines for TUNEL validate the assay and establishes TUNEL as a robust test for measuring sperm DNA fragmentation especially in a multicenter setting.

Poor retention in early care increases risk of mortality in a Brazilian HIV-infected clinical cohort

Retention in early HIV care has been associated with decreased mortality and improved viral suppression, however the consequences of poor retention in early care in Brazil remain unknown. We assessed the effect of poor retention on mortality in a Brazilian HIV-infected clinical cohort. The analysis included ART-naïve, HIV-infected adults linked to care at the Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz between 2000 and 2010, who did not become pregnant nor participate in a clinical trial during the first two years in care (early care). Poor retention in early care was defined as less than 3 out of 4 six-month intervals with a CD4 or HIV-1 RNA laboratory result during early care. Cox proportional hazards models were used to identify factors associated with mortality, and Kaplan-Meier plots were used to describe the survival probability for participants with poor retention versus good retention. Among 1054 participants with a median (interquartile range) follow-up time of 4.2 years (2.6, 6.3), 20% had poor retention in early care and 8% died. Poor retention in early care [adjusted hazard ratio (aHR) 3.09; 95% CI 1.65-5.79], AIDS defining illness (aHR 1.95; 95% CI 1.20-3.18) and lower education (aHR 2.33; 95% CI 1.45-3.75) were associated with increased mortality risk. Our findings highlight the importance of adopting strategies to improve retention in early HIV care.

Retention in Early Care at an HIV Outpatient Clinic in Rio de Janeiro, Brazil, 2000-2013

Retention in early HIV care has been associated with virologic suppression and improved survival, but remains understudied in Brazil. We estimated retention in early HIV care for the period 2000-2013, and identified socio-demographic and clinical factors associated with good retention in an urban cohort from Rio de Janeiro, Brazil. Antiretroviral therapy-naïve, HIV-infected persons ≥18 years old linked to care between 2000 and 2011 were included. Retention in the first 2 years post-linkage (i.e. early care) was defined by the proportion of 6-month intervals with ≥1 HIV laboratory result. "Good" retention was defined as ≥1 HIV laboratory result recorded in at least three intervals. Overall, 80 % of participants met criteria for good retention and retention significantly improved over the study period. Older age, higher education level and early antiretroviral therapy initiation were associated with good retention. Efforts to improve retention in early care in this population should target younger and less-educated HIV-infected persons.

Tuberculosis is associated with non-tuberculosis-related deaths among HIV/AIDS patients in Rio de Janeiro

SETTING

Human immunodeficiency virus (HIV) infected patients followed in a large cohort in Rio de Janeiro, Brazil.

OBJECTIVE

To evaluate the association of tuberculosis (TB) and other covariables with non-TB-related (NTR) causes of death (CODs).

DESIGN

Patients aged >18 years were followed from 1997 to 2009, until death or 31 December 2009, whichever was earlier. CODs were ascertained using a standardised algorithm. TB diagnosis and prophylaxis followed Brazilian guidelines. Poisson models were used to calculate adjusted rate ratios (aRRs).

RESULTS

Of 2887 patients included in the study, 761 had TB (26.4%). NTR death rates were twice as high among patients with TB (4/100 vs. 2.09/100 patient-years). TB was associated with NTR deaths (aRR 1.4, 95%CI 1.05-1.86, P = 0.01). Highly active antiretroviral treatment (HAART) was protective against NTR (aRR 0.46, 95%CI 0.34-0.61, P < 0.001). Among patients who had never had active TB, prophylaxis was also protective against NTR (aRR 0.45, P = 0.04). The CD4 cell count increase was very modest for both TB and NTR CODs compared to those who did not die (0 vs. 249 cells, P < 0.001).

CONCLUSIONS

TB was significantly associated with increased NTR CODs, indicating rapid progression of disease and increased long-term risk of mortality, probably related to persistent immunodeficiency or incomplete immune recovery. Our results confirm the benefits of HAART and TB prophylaxis.

Quasi-polaritons in Bose-Einstein condensates induced by Casimir-Polder interaction with graphene

We consider the mechanical coupling between a two-dimensional Bose-Einstein condensate and a graphene sheet via the vacuum fluctuations of the electromagnetic field which are at the origin of the so-called Casimir-Polder potential. By deriving a self-consistent set of equations governing the dynamics of the condensate and the flexural (out-of-plane) modes of the graphene, we can show the formation of a new type of purely acoustic quasi-particle excitation, a quasi-polariton resulting from the coherent superposition of quanta of flexural and Bogoliubov modes.