Vision System for a Forestry Navigation Machine

This article presents the development of a vision system designed to enhance the autonomous navigation capabilities of robots in complex forest environments. Leveraging RGBD and thermic cameras, specifically the Intel RealSense 435i and FLIR ADK, the system integrates diverse visual sensors with advanced image processing algorithms. This integration enables robots to make real-time decisions, recognize obstacles, and dynamically adjust their trajectories during operation. The article focuses on the architectural aspects of the system, emphasizing the role of sensors and the formulation of algorithms crucial for ensuring safety during robot navigation in challenging forest terrains. Additionally, the article discusses the training of two datasets specifically tailored to forest environments, aiming to evaluate their impact on autonomous navigation. Tests conducted in real forest conditions affirm the effectiveness of the developed vision system. The results underscore the system's pivotal contribution to the autonomous navigation of robots in forest environments.

Sensor Integration in a Forestry Machine

This paper presents the integration of multimodal sensor systems for an autonomous forestry machine. The utilized technology is housed in a single enclosure which consolidates a set of components responsible for executing machine control actions and comprehending its behavior in various scenarios. This sensor box, named Sentry, will subsequently be connected to a forestry machine from MDB, model LV600 PRO. The article outlines previous work in this field and then details the integration and operation of the equipment, integrated into the forest machine, providing descriptions of the adopted architecture at both the hardware and software levels. The gathered data enables the assessment of the forestry machine's orientation and position based on the information collected by the sensors. Finally, practical experiments are presented to demonstrate the system's behavior and to analyze the methods to be employed for autonomous navigation, thereby assessing the performance of the established architecture. The novel aspects of this work include the physical and digital integration of a multimodal sensor system on a forestry machine, its use in a real case scenario, namely, forest vegetation removal, and the strategies adopted to improve the machine localization and navigation performance on unstructured environments.

A 12-week lifestyle intervention: effects on fatigue, fear, and nutritional status in children with a Fontan circulation

Introduction

Children and adolescents with a Fontan circulation are less physically active compared to healthy peers. In the current study, effects of a 12-week lifestyle intervention on fatigue, fears regarding exercise, caloric intake, rest energy expenditure (REE), and body composition were measured in children with a Fontan circulation.

Methods

This study was a semi-cross-over randomized controlled trial. The lifestyle intervention consisted of a 12-week high-weight resistance training (three supervised training sessions a week) supported by high-protein diet (>2 g/kg) and tailored recommended caloric intake. Fatigue (measured by the validated PedsQol Multidimensional Fatigue Scale), fears regarding exercise (measured on a fear thermometer), REE (measured using indirect calorimetry), caloric intake and body composition using air displacement plethysmography, and four-skinfold method were measured before and after the intervention and control period.

Results

Twenty-seven pediatric Fontan patients, median age 12.9 years (IQR: 10.5-16.2), of the included 28 patients successfully completed the program. Before training, both child- and parent-reported levels of fatigue were significantly worse on all domains (general, sleep/rest, and cognitive fatigue) compared to healthy peers. After training, parent-reported fatigue significantly improved on the general and cognitive fatigue domains [effect size +16 points (7-25), p < 0.001, and +10 points (2-17), p = 0.015, compared to the control period]. Before training, fear regarding exercise scored on the fear thermometer was low for both children and parents (median score 1 and 2, respectively, on a scale of 0-8). After training, child-reported fear decreased further compared to the control period [effect size -1.4 points (-2.3 to -0.6), p = 0.001]. At baseline, children had increased REE +12% compared to reference values, which did not change after exercise. Children ate an average of 637 calories below recommended intake based on REE, caloric deficit became smaller after the intervention, and protein intake increased compared to the control period [-388 calories (-674 to -102), p = 0.008, and +15 g (0.4-30), p = 0.044]. Body fat percentage did not change significantly.

Conclusion

A 12-week lifestyle intervention improved parent-reported fatigue symptoms in the children, further decreased child-reported fears, and increased caloric and protein intake.

Complete Distal Rupture of the Rectus Femoris in an Elite Football Player: A Non-operative Treatment

Although muscle injuries represent the most frequent injury in professional football, isolated complete distal ruptures of the rectus femoris (RF) muscle are rare, and there is no consensus on their treatment and return to play (RTP). In this article, we report a clinical case of successful non-surgical management of an RF grade 4c muscle injury in a professional football player, in which the athlete was able to RTP 21 weeks after the injury, had no re-injury >1 year after RTP, and is playing at an elite level in the Portuguese Football First League.

Emergence of chaotic cluster synchronization in heterogeneous networks

Many real-world complex systems rely on cluster synchronization to function properly. A cluster of nodes exhibits synchronous behavior, while others behave erratically. Predicting the emergence of these clusters and understanding the mechanism behind their structure and variation in response to a parameter change is a daunting task in networks that lack symmetry. We unravel the mechanism for the emergence of cluster synchronization in heterogeneous random networks. We develop heterogeneous mean-field approximation together with a self-consistent theory to determine the onset and stability of the cluster. Our analysis shows that cluster synchronization occurs in a wide variety of heterogeneous networks, node dynamics, and coupling functions. The results could lead to a new understanding of the dynamical behavior of networks ranging from neural to social.

Trends in trust of professional groups in Portugal during COVID-19

We repeated a Portuguese study, 5 months after a first evaluation, to observe any change in the average levels of trust of professional groups during the COVID-19 pandemic. From our sample of the Portuguese population, 1455 completed the questionnaire from June through September 2020, and 1156 during 2 months, February and March 2021. We found a trend toward higher trust of medical doctors, nurses, and researchers. Analysis of changes between the two pandemic periods (first and second lockdown) showed a statistically significant increase in trust in nurses (t =  - 2.01; p = 0.04) and researchers (t =  - 2.40; p = 0.02), and the opposite trend for journalists and politicians. This study shows a trend in increasing trust of the Portuguese people toward science-based activities during the COVID-19 pandemic.

Exponentially Long Transient Time to Synchronization of Coupled Chaotic Circle Maps in Dense Random Networks

We study the transition to synchronization in large, dense networks of chaotic circle maps, where an exact solution of the mean-field dynamics in the infinite network and all-to-all coupling limit is known. In dense networks of finite size and link probability of smaller than one, the incoherent state is meta-stable for coupling strengths that are larger than the mean-field critical coupling. We observe chaotic transients with exponentially distributed escape times and study the scaling behavior of the mean time to synchronization.

Return to Play After the Diagnosis of Reactive Arthritis in a Professional Football Player

In professional football, most of the injuries are traumatic; however, these athletes may suffer from rheumatologic diseases, that may present as sports-related injuries. Reactive arthritis (ReA) is classified as a sub-group of the spondyloarthritis family and is relatively rare. In this article, we highlight the successful return to play (RTP) process after the ReA diagnosis in an elite football player in the Portuguese first league. The athlete was able to RTP four months and one week after the diagnosis, had no ReA recurrence nor re-injury >8 months after RTP, and is playing at an elite level.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

Analytical performance of the FDA-cleared Parsortix® PC1 system

Introduction

The Parsortix® PC1 system, Food and Drug Administration (FDA) cleared for use in metastatic breast cancer (MBC) patients, is an epitope-independent microfluidic device for the capture and harvest of circulating tumor cells from whole blood based on cell size and deformability. This report details the analytical characterization of linearity, detection limit, precision, and reproducibility for this device.

Methods

System performance was determined using K2-EDTA blood samples collected from self-declared healthy female volunteers (HVs) and MBC patients spiked with prelabeled cultured breast cancer cell lines (SKBR3, MCF7, or Hs578T). Samples were processed on Parsortix® PC1 systems and captured cells were harvested and enumerated.

Results

The system captured and harvested live SKBR3, MCF7, and Hs578T cells and fixed SKBR3 cells linearly between 2 and ~100 cells, with average harvest rates of 69%, 73%, 79%, and 90%, respectively. To harvest ≥1 cell ≥95% of the time, the system required 3, 5 or 4 live SKBR3, MCF7 or Hs578T cells, respectively. Average harvest rates from precision studies using 5, 10, and ~50 live cells spiked into blood for each cell line ranged from 63.5% to 76.2%, with repeatability and reproducibility percent coefficient of variation (%CV) estimates ranging from 12.3% to 32.4% and 13.3% to 34.1%, respectively. Average harvest rates using ~20 fixed SKBR3 cells spiked into HV and MBC patient blood samples were 75.0% ± 16.1% (%CV = 22.3%) and 68.4% ± 14.3% (%CV = 21.1%), respectively.

Conclusions

These evaluations demonstrate the Parsortix® PC1 system linearly and reproducibly harvests tumor cells from blood over a range of 1 to ~100 cells.

Maternofetal outcomes in early-onset gestational diabetes: does weight gain matter?

AIM

Women with early-onset gestational diabetes mellitus (GDM) have overall lower gestational weight gain (GWG) compared to those with later-onset GDM, albeit with usually worse maternofetal outcomes. We intent to investigate the association between inadequate GWG and maternofetal outcomes in pregnant women with early-onset GDM.

METHODS

We performed a retrospective study of women with early-onset GDM based on the National Registry of GDM. Three study groups were defined according to the recommendations of the Institute of Medicine for GWG: excessive GWG (eGWG), adequate (aGWG) or insufficient (iGWG).

RESULTS

A total of 8040 pregnant women were included: 27% (n = 2170) eGWG, 31% (n = 2492) aGWG and 42% (n = 3378) iGWG. Preeclampsia (4.3 vs 3 vs 1.6%, p < 0.001), polyhydramnios (3.1 vs 2.3 vs 1.8%, p = 0.008) and cesarean section (37.4 vs 34.1 vs 29.5%, p < 0.001) were significantly more frequent among women with eGWG. Additionally, there was a higher frequency of macrosomia (8.1 vs 3.6 vs 2.4%, p < 0.001), large-for-gestational-age (8.2 vs 3.7 vs 2.6%, p < 0.001) and birth trauma (2.6 vs 1.5 vs 1.1%, p < 0.001) in this group. On the other hand, fetal death (0.2 vs 0.2 vs 0.5%, p = 0.04), small-for-gestational-age (9 vs 10.3 vs 14.9, p < 0.001) and preterm delivery (5.6 vs 7.1 vs 7.5%, p = 0.03) were more frequent in iGWG group.

CONCLUSIONS

Over two-thirds of pregnant women with early-onset GDM had inappropriate GWG, which was significantly associated with adverse maternofetal outcomes. Weight management must be a focus of special attention in women with early-onset GDM, beyond glycemic control, to achieve healthy pregnancy outcomes.

Prevalence and predictors of anti-SARS-CoV-2 serology in a highly vulnerable population of Rio de Janeiro: A population-based serosurvey

Background

COVID-19 serosurveys allow for the monitoring of the level of SARS-CoV-2 transmission and support data-driven decisions. We estimated the seroprevalence of anti-SARS-CoV-2 antibodies in a large favela complex in Rio de Janeiro, Brazil.

Methods

A population-based panel study was conducted in Complexo de Manguinhos (16 favelas) with a probabilistic sampling of participants aged ≥1 year who were randomly selected from a census of individuals registered in primary health care clinics that serve the area. Participants answered a structured interview and provided blood samples for serology. Multilevel regression models (with random intercepts to account for participants’ favela of residence) were used to assess factors associated with having anti-S IgG antibodies. Secondary analyses estimated seroprevalence using an additional anti-N IgG assay.

Findings

4,033 participants were included (from Sep/2020 to Feb/2021, 22 epidemic weeks), the median age was 39·8 years (IQR:21·8-57·7), 61% were female, 41% were mixed-race (Pardo) and 23% Black. Overall prevalence was 49·0% (95%CI:46·8%-51·2%) which varied across favelas (from 68·3% to 31·4%). Lower prevalence estimates were found when using the anti-N IgG assay. Odds of having anti-S IgG antibodies were highest for young adults, and those reporting larger household size, poor adherence to social distancing and use of public transportation.

Interpretation

We found a significantly higher prevalence of anti-S IgG antibodies than initially anticipated. Disparities in estimates obtained using different serological assays highlight the need for cautious interpretation of serosurveys estimates given the heterogeneity of exposure in communities, loss of immunological biomarkers, serological antigen target, and variant-specific test affinity.

Funding

Fundação Oswaldo Cruz, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação de Amparo a Pesquisa do Estado do Rio de Janeiro (FAPERJ), the European Union's Horizon 2020 research and innovation programme, Royal Society, Serrapilheira Institute, and FAPESP.

Emergent hypernetworks in weakly coupled oscillators

Networks of weakly coupled oscillators had a profound impact on our understanding of complex systems. Studies on model reconstruction from data have shown prevalent contributions from hypernetworks with triplet and higher interactions among oscillators, in spite that such models were originally defined as oscillator networks with pairwise interactions. Here, we show that hypernetworks can spontaneously emerge even in the presence of pairwise albeit nonlinear coupling given certain triplet frequency resonance conditions. The results are demonstrated in experiments with electrochemical oscillators and in simulations with integrate-and-fire neurons. By developing a comprehensive theory, we uncover the mechanism for emergent hypernetworks by identifying appearing and forbidden frequency resonant conditions. Furthermore, it is shown that microscopic linear (difference) coupling among units results in coupled mean fields, which have sufficient nonlinearity to facilitate hypernetworks. Our findings shed light on the apparent abundance of hypernetworks and provide a constructive way to predict and engineer their emergence.

Networks with higher-order interactions are relevant to variety of real-world applications, they can be good description of data even if the system has only pairwise interactions. The authors uncover the hypernetwork emergence in coupled nonlinear oscillators and electrochemical experiments.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Deep generative model for therapeutic targets using transcriptomic disease-associated data-USP7 case study

The generation of candidate hit molecules with the potential to be used in cancer treatment is a challenging task. In this context, computational methods based on deep learning have been employed to improve in silico drug design methodologies. Nonetheless, the applied strategies have focused solely on the chemical aspect of the generation of compounds, disregarding the likely biological consequences for the organism's dynamics. Herein, we propose a method to implement targeted molecular generation that employs biological information, namely, disease-associated gene expression data, to conduct the process of identifying interesting hits. When applied to the generation of USP7 putative inhibitors, the framework managed to generate promising compounds, with more than 90% of them containing drug-like properties and essential active groups for the interaction with the target. Hence, this work provides a novel and reliable method for generating new promising compounds focused on the biological context of the disease.

Prognostic value of exercise stress echocardiography in patients with known coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Background

Exercise stress echocardiography (EE) is useful for diagnosis and risk stratification in patients (pts) with suspected coronary artery disease (CAD). Pts with known CAD carry a high risk of events. Our aim was to assess the utility of EE in predicting outcomes in this population.

Methods

Single center retrospective study of consecutive pts with known CAD who performed an EE between 2018 and 2019. The primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up.

Results

A total of 76 pts were included (mean age 59±9 years; 87% male). Fifty-nine (78%) pts had history of ACS, 51 (67%) of percutaneous coronary intervention (PCI) and 14 (18%) of coronary artery bypass graft. The majority of pts had 2 or more vessel disease (42 pts; 55%).

The main reason for performing EE was new onset of chest pain (38 pts; 50%) followed by functional assessment of coronary stenoses after incomplete revascularization (29 pts; 38%). The majority of pts had a preserved left ventricular ejection fraction (67; 88%). The exam was performed under beta-blocker effect in 35 (46%) pts.

The results of EE were positive for myocardial ischemia in 7 (9%) pts, negative in 37 (49%) pts and inconclusive in 32 (42%) pts. Mean exercise time was 8±3 minutes and mean METs achieved was 9.4±2.6. ST-segment depression fulfilling electrocardiographic criteria for ischemia occurred in 17 (22%) pts. Eleven (14%) pts complained of chest pain during the exam.

During a median follow up of 22 months (IQR 15-26), the primary endpoint occurred in 9 pts (admission for ACS in 5 pts; revascularization for chronic coronary syndrome in 4 pts). No cardiovascular death occurred. The positive predictive value of EE for the primary endpoint was 57.1% and the negative predictive value (NPV) 97.3%.

In a survival analysis, the predictors of the primary endpoint were lower exercise time, lower METs achieved, untreated significant coronary lesions and a positive EE (figure).

After adjustment in a multivariate analysis, a positive EE was an independent predictor of the primary endpoint (HR 4.6, 95%CI: 1.1-16.7, p=.044).

Conclusion

In pts with known CAD, EE had a high NPV and a positive result was an independent predictor of future cardiovascular events.

A left systolic dysfunction study in a group of breast cancer patients and its clinical impact

Funding Acknowledgements

Type of funding sources: None.

Background

 Cancer therapy-related cardiac dysfunction (CTRCD) is one of the major complications being reported in patients with breast cancer (BC) under chemotherapy, in particular with anthracyclines (A) or trastuzumab (T). CTRCD is defined as a reduction of left ventricular ejection fraction (LVEF) &gt;10% to a value &lt;50% or as a relative reduction of global longitudinal strain (GLS) &gt;15%.

Purpose

We aim to evaluate the frequency of CTRCD and its clinical impact on BC patients.

Methods

 Retrospective study of patients with BC treated with A and/or T between Jan 2017 and Dec 2018 who underwent a  transthoracic echocardiography (TTE) before, during, and after chemotherapy. We analysed their baseline characteristics and outcomes based on the type of treatment received, and focusing specially on parameters of ventricular function.

Results

 We included 128 females with median age of 54 ± 11 years-old, treated with A (78; 60.9%), T (14; 10.9%) or A followed by T (36; 28.1%).

At the end of A therapy, there was a significant decrease in LVEF (64,2 ± 5,4% vs 62.6 ± 5,3%, p &lt; 0.05) and in GLS (-20,7 ± 1.9% vs -18.8 ± 2.2%, p &lt; 0.001) compared to baseline. No change in tricuspid annular systolic velocity (S") (p = 0,842) was observed. At 2 years of follow-up, this group of patients had no significant difference in LVEF (64,58 ± 5,58 vs 62,63 ± 6,48, p = 0,053) but maintained a significant lower GLS (-20,84 ± 2,13 vs -18,51± 2,52, p &lt; 0,001) compared to baseline. A significant decrease in S’ (14,36 ± 2,55 vs 13,25 ± 2,26, p &lt; 0,05) was observed.

During T therapy, there was a significant decrease in LVEF (65,04 ± 5,41 vs 59,30 ± 6,21, p &lt; 0,001), in GLS (-21,21 ± 2,75 vs -17,89 ± 2,77, p &lt; 0,001) and in S’ (14,39 ± 3,05 vs 12,19 ± 1,62, p &lt; 0,001) compared to baseline. At the end of T therapy (with or without A), this group of patients maintained a significant decrease in LVEF (65,11 ± 5,65 vs 61,29 ± 6,39, P &lt; 0,001) and in GLS (-21.41%±2,86 vs -19.54%±3,50, p &lt; 0,01). S’ returned to normal values (p = 0,10). At 2 years of follow-up, this group of patients maintained a significant decrease in LVEF (65,00 ± 5,99 vs 61,18 ± 6,30, p &lt; 0,05) but GLS (p = 0,235) returned to normal values. No change in S’ was observed (p =0,379).

During a mean follow-up of 38 months, 35 (27%) patients developed CTRCD with a higher prevalence in patients who took A followed by T (18; 14%), 9 (7%) presented with clinical heart failure, 1 (1%) needed hospitalization, 5 (4%) needed to temporarily suspend treatment and 3 (2%) needed to definitely stop treatment.

Conclusions

 Treatment with A was associated with a decrease in LV systolic function at the end of therapy. A decrease in right ventricular (RV) systolic function was observed at 2 years of follow-up. Treatment with T was associated with a decrease in RV and LV systolic function during therapy. CTRCD occurred in 27%, mainly on patients with both A and T therapy, a frequency within literature data. CTRCD had clinical impact leading to HF and suspension of chemotherapy.

Cancer therapeutics-related cardiac dysfunction: what is the role of cardioprotective medication?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cancer therapy-related cardiac dysfunction (CTRCD) is one of the major complications being reported in patients with breast cancer (BC) under chemotherapy, in particular with anthracyclines (A) or trastuzumab (T). Guidelines recommend regular left ventricular ejection fraction (LVEF) assessments and CTRCD management with cardioprotective medication (CPM). However, while secondary prevention has already entered clinical practice, primary prevention is still in the research domain.

Purpose

Our aim was to evaluate the role of CPM and the risk of CTRCD in BC patients.

Methods

Retrospective study of BC patients treated with A and/or T between Jan 2017 and Dec 2018 who underwent a transthoracic echocardiography (TTE) before, during, and after chemotherapy. Patients with baseline LVEF &lt;50% were excluded. CTRCD is defined as reduction of EF &gt;10% to a value &lt;50% or as relative reduction of global longitudinal strain (GLS) &gt;15%. As CPM we considered angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blocker (ARB) and beta-blockers (BB).

Results

We included 128 patients, all female with median age of 54 ± 11 years-old, treated with A (78; 60.9%), T (14; 10.9%) or A followed by T (36; 28.1%).

At baseline, mean LVEF was 64,7 ± 5,7% and mean GLS was -20,8 ± 2,3.

During a mean follow-up of 38 months, 35 (27%) patients developed CTRCD with a higher prevalence in patients who took A followed by T (18; 14%), 9 (7%) presented with clinical heart failure, 1 (1%) needed hospitalization, 5 (4%) needed to temporarily suspend treatment and 3 (2%) needed to definitely stop treatment. ACEI/ARB therapy was initiated in 12 (34%) and BB therapy was initiated in 10 (29%). Twenty-one (60%) of CTRCD patients recovered. CPM initiation after CTRCD was not associated with a significant higher rate of cardiac function recovery (p = 0,682).

When comparing patients already medicated with CPM before cancer treatment (39; 30,5%) to those naïve of CPM, the first group presented a lower incidence of CTRCD (7% vs 20%) but it was not statistically significant (p = 0,473).

In patients treated with T or A + T, the group of patients treated with CPM before cancer treatment did not present a significantly lower incidence of CTRCD (p = 0,449) compared to patients CPM naïve. Nonetheless, there was a significant higher LVEF in the TTE during T therapy, after chemotherapy and at 2 years of follow-up (P &lt;0,05) in patients treated with CPM before cancer treatment compared to patients CPM naïve.

In patients treated with A (without T) there was no statistically significant difference between the two groups.

Conclusion

 In our study, pre-treatment with CPM was associated with a significant higher LVEF in patients treated with T but no significant association was found with respect to the occurrence of CTRCD. CPM initiation after CTRCD was not associated with a statistically significant cardiac function recovery.

Impact of an inconclusive exercise stress echocardiogram on cardiovascular outcomes

Funding Acknowledgements

Type of funding sources: None.

Background

Exercise stress echocardiography (ESE) is used for the assessment of suspected or known coronary artery disease (CAD); however, a certain percentage of ESE studies are inconclusive. We aim to evaluate the prognostic impact of an inconclusive ESE on cardiovascular outcomes.

Methods

Single-center retrospective study of consecutive patients (pts) who performed an ESE between 2018 and 2019 for diagnosis or stratification of CAD. All pts performed a symptom-limited Bruce protocol. ESE was considered inconclusive when 85% of age-predicted maximum HR was not reached. Primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up.

Results

A total of 141 pts were included (76% male; mean age 60 ± 9 years). ESE was inconclusive in 51 (36%) pts, positive in 11 (8%) and negative in 79 (56%).

The mean exercise time of pts with inconclusive ESE was 7 ± 2 minutes and 76% had normal functional capacity. Fatigue (25 pts; 49%) and lower extremities pain (11 pts; 22%) were the main reasons for ESE stopping. Five pts (10%) complained of chest pain during exam.

Pts with an inconclusive ESE were more diabetic (inconclusive 43%, positive 9%, negative 13%; p=.001), had more chronic obstructive pulmonary disease (COPD) (14%, 0%, 2.5%; p=.026), performed more frequently the exam under beta blocker (BB) therapy (59%, 27%, 18%; p=.041) and had less ST-segment depression fulfilling electrocardiographic criteria for ischemia (10%, 64%, 27%, p&lt;.001). Their functional capacity was worse than negative ESE pts (p&lt;.001).

During a median follow up of 22 months (IQR 15-27), 13 (9.2%) pts had the primary endpoint, including 5 pts (3.5%) with ACS.

Pts with an inconclusive ESE had a lower incidence of the primary outcome than pts with a positive ESE and a higher incidence of events than pts with negative results (figure).

In multivariate analysis, after adjusting for functional capacity and electrocardiographic criteria for ischemia, an inconclusive ESE was an independent predictor of the primary endpoint (HR 9.7, IC95% 1.1-87,6 p= .042)

Conclusions

The frequency of inconclusive ESE is not negligible (36%). These pts had more diabetes and COPD and performed the exam under BB therapy more frequently, highlighting the importance of proper patient selection. An inconclusive ESE was associated to a higher risk of cardiovascular events compared to negative ESE. Abstract Figure.

Prevalence and clinical impact of latent obstruction in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is characterized by varying degrees of left ventricular outflow tract obstruction (LVOTobs). We aim to define the prevalence, clinical profile and impact of LVOTobs under physiological exercise in HCM patients (pts).

METHODS

Single center retrospective study of consecutive HCM pts without LVOTobs at rest (resting gradient &lt;30mmHg), referred for exercise stress echocardiogram (ESE) between 2015 and 2019. Significative latent obstruction was defined as a LVOT gradient ≥50 mmHg during exercise or at early recuperation.

RESULTS

A total of 56 pts were included (64% men, mean age 57 ± 11 years, 61% septal HCM). The majority of pts (47; 84%) were in NYHA I functional class, 20 (36%) had history of syncope or pre-syncope (S/pS) and 7 (13%) had an implantable cardioverter defibrillator (ICD). Twelve (21%) pts had systolic anterior motion (SAM) of the mitral valve at rest.

Thirty-five (63%) pts performed ESE under beta-blocker (BB) therapy. Mean exercise time was 8 ± 3 min. During ESE, 2 (4%) pts developed a LVOT gradient between 30 to 50 mmHg and 17 pts (30%) developed a significative LVOTobs gradient (mean 85 ± 18 mmHg).

Pts with significative latent LVOTobs had more previous complaints of S/pS (59% vs 26%, p=.017), a tendency for a higher NYHA functional class (p=.082) and were more frequently on BB therapy (82% vs 18%, p=.043). Mean septum thickness was similar between groups (17 ± 0.7 vs 16 ± 0.6 mm, p=.536). The presence of SAM at rest was more frequent in the significative latent LVOTobs pts (p&lt;.001). No differences were noted in exercise tolerance (p=.526).

During a median follow-up of 43 (IQR 15-53) months, 7 (41%) pts with significative latent LVOTobs had a pre-syncope, 3 (18%) were diagnosed with atrial fibrillation and 2 (12%) had a cardiovascular admission . There was up-titration/initiation of BB therapy in 5 (29%) pts, referral for septal myectomy in 3 (18%) and ICD implantation for primary prevention in 3 (18%) pts. No proper ICD shocks, sustained ventricular arrythmias or deaths occurred.

Comparing significative latent to non LVOTobs pts, the first ones had more ICD implantation (log rank p =.04) and performed a surgical myectomy more frequently (log rank p= .018) during the follow-up.

CONCLUSION

In our study, significative latent LVOTobs was observed in 30% of pts. Its presence can have clinical implications in HCM pts approach and should be suspected in more symptomatic pts and when SAM is present at rest.

Characterization of temporal trends of systolic and diastolic indexes over time in breast cancer patients treated with trastuzumab

Funding Acknowledgements

Type of funding sources: None.

Background

Trastuzumab therapy increases survival in patients (pts) with HER2 positive breast cancer, however, it is associated with a risk of cardiotoxicity (CT). Our aim was to: 1) assess the temporal evolution of systolic and diastolic left and right ventricular indexes during and after T therapy and 2) study the incidence of CT in this group.

Methods

Retrospective study of breast cancer pts treated with T in a single center, during 2017 and 2018, who underwent a comprehensive echocardiographic examination before, quarterly, and after conclusion of T therapy. Pts with a baseline left ventricular ejection fraction (EF) &lt;50% were excluded. CT was defined as a reduction of EF &gt;10% to a value &lt;50% or as a relative reduction of global longitudinal strain (GLS) of more than 15%.

Results

We included 50 women with mean age of 56 ± 10 years and mean body mass index (BMI) of 27 ± 5 kg/m2. Thirty-six (72%) patients underwent anthracycline chemotherapy prior to T and 44 (88%) had performed radiotherapy.

During treatment with T there was an increase of indexed left ventricle end-diastolic volume (38.6 ± 7.8 to 46.5 ± 10.3 ml/m2, p&lt;.001) and a reduction of LVEF (65.1 ± 5.4 to 59.3 ± 6.2%, p &lt; 0.001), GLS (-21.2 ± 2.7 to -17.9 ± 2.8%, p&lt;.001) and right ventricle S’ (14.4 ± 13.1 to 12.2 ± 1.6 cm/s, p&lt;.001) compared to baseline. There was no change in diastolic function parameters.

CT occurred in 23 (46%) pts, the majority based on GLS criteria (18; 78%). Heart failure symptoms were reported in 4 (8%) of these pts (1 in the GLS group and 3 in the EF group) and 3 (6%) pts had to permanently suspend therapy with T due to CT.

Patients with CT had a lower BMI (25 ± 4 vs 29 ± 4 kg/m2), but were otherwise similar to pts without CT. No association was found between pre-treatment with anthracyclines or radiotherapy with the risk of CT.

An echocardiographic revaluation at 2 years from treatment with T revealed a tendency for LVEF improvement (58.7 ± 7.1 to 61.2 ± 6.3%, p=.059) and a significative recovery of GLS (-17.4 ± 3.5 to -19.1 ± 3.3%, p=.026). No significative variations were found on right ventricular systolic function indexes or on diastolic parameters.

During a follow-up of 43 (IQR 32–47) months, 7 (14%) pts had tumor relapse and 1 (2%) died. CT was not associated with the composite endpoint of tumor relapse or death (p = 0.585).

Conclusion

T therapy is associated with a significative reduction on left and right ventricle systolic indexes during treatment. Although left ventricle systolic function tends to normalize over time, this does not happen with the right ventricle. CT induced by T had clinical impact leading to overt heart failure in 8% of pts and treatment discontinuation in 6% of pts.  A lower BMI was associated with CT, which may be taken into account when defining the treatment strategy.

FLUORO-CT GUIDED BIOPSY OF LUNG NODULES: A STEP BY STEP REVISION

Transthoracic biopsies under fluoro-computer tomography (CT) guidance play an important role on the diagnosis and management of lung nodules, permitting histological examination and differentiation between benign and malignant lesions(1). Furthermore, with recent advances in target therapy, it is increasingly necessary to obtain tumor tissue for the analysis of molecular fingerprints allowing personalized treatment(1). Although many studies report low complication rates for this procedure, they are not negligible, urging the need for a structured and reproducible guide to reduce technique-related complications(1,2).

Unmasking governance failures: The impact of COVID-19 on small-scale fishing communities in South Africa

The COVID-19 pandemic has highlighted the pre-existing vulnerability of the small-scale fisheries sector in South Africa and exposed the structural inequalities and ongoing injustices facing this sector. The failures within the fisheries governance and management system linked to the slow pace of implementing the Small-scale Fisheries Policy of 2012, have further exacerbated their vulnerability. This paper explores the immediate impacts of the COVID-19 pandemic on the small-scale fisheries sector and exposes how governance failures within the fisheries sector have increased their vulnerability. Restrictions on fishing activities and mobility, closure of conservation areas, unfair fines and arrests, loss of markets and barriers to sale of fish products as well as lack of access to water, have had significant impacts on small-scale fishers and coastal communities. The lack of social protection and the limited emergency relief provided by government further exacerbated their precarious position. Despite their vulnerability, fishers have demonstrated a measure of resilience, supporting those in need with food, lobbying government to amend restrictions and recognise their rights, and challenging efforts to fast-track development and exclude their voices. The crisis has highlighted an urgent need for broad, national level transformation to deal with the poverty and injustices facing poor coastal communities, as well as fisheries-specific policy reform.

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.

Smart testing and critical care bed sharing for COVID-19 control

During the early months of the current COVID-19 pandemic, social distancing measures effectively slowed disease transmission in many countries in Europe and Asia, but the same benefits have not been observed in some developing countries such as Brazil. In part, this is due to a failure to organise systematic testing campaigns at nationwide or even regional levels. To gain effective control of the pandemic, decision-makers in developing countries, particularly those with large populations, must overcome difficulties posed by an unequal distribution of wealth combined with low daily testing capacities. The economic infrastructure of these countries, often concentrated in a few cities, forces workers to travel from commuter cities and rural areas, which induces strong nonlinear effects on disease transmission. In the present study, we develop a smart testing strategy to identify geographic regions where COVID-19 testing could most effectively be deployed to limit further disease transmission. By smart testing we mean the testing protocol that is automatically designed by our optimization platform for a given time period, knowing the available number of tests, the current availability of ICU beds and the initial epidemiological situation. The strategy uses readily available anonymised mobility and demographic data integrated with intensive care unit (ICU) occupancy data and city-specific social distancing measures. Taking into account the heterogeneity of ICU bed occupancy in differing regions and the stages of disease evolution, we use a data-driven study of the Brazilian state of Sao Paulo as an example to show that smart testing strategies can rapidly limit transmission while reducing the need for social distancing measures, even when testing capacity is limited.

COVID-19 Pandemic: Effect on Confidence Levels of Portuguese Towards People of Different Professions

BACKGROUND

The COVID-19 pandemic is emerging in a world where science is highly developed. Nevertheless, science is not the only resource that people resort to when they have difficulties. In this pandemic context, some professions became more relevant, including front-line professionals, such as medical doctors and nurses, and those who may have an indirect role. The aim of this study is to understand whether there is a strengthening of people's confidence, in politicians, journalists, science-based activities, and in more mystical dimensions.

METHODS

A cross-sectional study was carried out to understand the levels of confidence of the Portuguese population in several professional groups, measured in two pandemic moments. Participants were recruited to participate in the study through online platforms. The sample was randomly collected from the Portuguese population. The sample was composed of 1455 Portuguese people with a mean age of 44 years, and 1080 were female.

RESULTS

We found high levels of confidence in medical doctors and nurses, as well as in other health professions, science, and education. We detected the opposite trend for politicians and journalists. Measured in two pandemic moments, we found confidence levels in these professionals were lower in September than in July with statistical significance differences [(politicians (t = 3.15, p = 0.00); journalists (t = 2.49, p = 0.01)].

CONCLUSION

It is important to improve a joint action between politicians, journalists, health and science professionals to communicate measures to increase confidence from people. There is a need for the engagement of the population in the adoption of protective measures and contribute to easier control in pandemic situations.

Optimizing blood-brain barrier permeation through deep reinforcement learning for de novo drug design

MOTIVATION

The process of placing new drugs into the market is time-consuming, expensive and complex. The application of computational methods for designing molecules with bespoke properties can contribute to saving resources throughout this process. However, the fundamental properties to be optimized are often not considered or conflicting with each other. In this work, we propose a novel approach to consider both the biological property and the bioavailability of compounds through a deep reinforcement learning framework for the targeted generation of compounds. We aim to obtain a promising set of selective compounds for the adenosine A2A receptor and, simultaneously, that have the necessary properties in terms of solubility and permeability across the blood-brain barrier to reach the site of action. The cornerstone of the framework is based on a recurrent neural network architecture, the Generator. It seeks to learn the building rules of valid molecules to sample new compounds further. Also, two Predictors are trained to estimate the properties of interest of the new molecules. Finally, the fine-tuning of the Generator was performed with reinforcement learning, integrated with multi-objective optimization and exploratory techniques to ensure that the Generator is adequately biased.

RESULTS

The biased Generator can generate an interesting set of molecules, with approximately 85% having the two fundamental properties biased as desired. Thus, this approach has transformed a general molecule generator into a model focused on optimizing specific objectives. Furthermore, the molecules' synthesizability and drug-likeness demonstrate the potential applicability of the de novo drug design in medicinal chemistry.

AVAILABILITY AND IMPLEMENTATION

All code is publicly available in the https://github.com/larngroup/De-Novo-Drug-Design.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

IgG4-related disease with renal and orbital involvement: a clinical case

INTRODUCTION

IgG4-related disease (IgG4-RD) is characterized by the growth of pseudotumors, which can affect almost every organ. Elevated serum IgG4 levels are present in only two-thirds of the patients and are not specific. Diagnosis is difficult and is usually based on a biopsy.

CLINICAL CASE

A 39-year-old man presented complaints of low back pain and fever. A renal computed tomography (CT) scan revealed a voluminous mass next to the right kidney and a biopsy showed an inflammatory process and excluded a neoplasm. A follow-up CT scan at four months revealed total regression without any treatment. Three years later, the patient presented with diplopia and right proptosis. MRI of the orbits revealed a retro-ocular mass; biopsy excluded a malignant process. Infectious, autoimmune or paraneoplastic diseases were also excluded. Although the patient's IgG4 serum levels were normal, histopathological reobservation of the renal biopsy revealed IgG4-positive plasma cells, thus confirming the diagnosis. The patient was prescribed a daily dose of 40 mg of prednisolone and regression of the right orbital lesion was observed.

DISCUSSION

IgG4-RD is a rare and recently described condition. Most anatomic pathology laboratories do not routinely test for it. Spontaneous pseudotumor remission is possible, even when associated with the renal phenotype, although this has not been described until now.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

MO774PREDICTIVE FACTORS FOR PROSTHESIC ARTERIOVENOUS FISTULA OPTION BY DUPLEX DOPPLER ULTRASOUND VASCULAR MAPPING

Background and Aims

Vascular access (VA) remains the lifeline for hemodialysis (HD) patients. Arteriovenous fistulas (AVF) are recommended over prosthesic arteriovenous fistula (PAF). However, the choice of the type of VA still reflects local practice differences and patient-specific demographic and clinical factors. Duplex Doppler ultrasound (DDU) has been shown to be useful in evaluation of both structural and functional aspects of the peripheral vessels, and is emerging as the preferred method for VA planning. Our aim was to find predictive factors for PAF creation in our population, i.e. when AVF was not feasible.

Method

We retrospectively analysed a cohort of chronic kidney disease patients who underwent DDU vascular mapping for preoperative planning of HD access at a tertiary referral centre from 2019 to 2020. All the exams were performed by the same DDU operator. Demographic, clinical and DDU characteristics were studied. Continuous variables were recorded as means (±SD) for normally distributed data or as medians (interquartile ranges) for non-normally distributed data. Comparisons were made using t tests or Wilcoxon rank sum tests as appropriate. Categorical variables were evaluated by frequency distribution and recorded as proportions. Comparisons were made using the x2 test. Unadjusted and adjusted multivariate logistic regression models were fitted to identify risk factors to PAF creation due to not being a good candidate for AVF.

Results

A total of 252 patients were included. The mean age was 65±16 years, 144 (57%) were male, 211 (84%) where white, 40 (16%) were black and 1 (0.4%) was asian. Two hundred and thirty seven (94%) patients were right-handed and 186 (74%) were being evaluated for the first vascular access. The majority had arterial hypertension (HT) (205 (81%)); 98 (39%) had Diabetes Mellitus (DM), 89 (35%) were current or past smoker and 72 (29%) were obese. Most patients were considered appropriate candidates for AVF (207, 82%), whereas 45 (18%) were assigned to PAF. Figure 1 compares the DDU’s arterial indexes of each group. In a multivariate logistic regression model adjusted for age, sex, HT, DM and obesity, black race was found to be a predictor of being a candidate for PAV creation (OR 2.46; CI 95% 1.05-5.71; p-value 0.036).

Conclusion

Our study revealed that black race is an independent factor for PAV creation even after adjusting for classic risk factors as age, DM or HT. Long known insidious factors, such as poor socioeconomic status or poor access to medical care, have been pointed as justifiers to this disparity. However, facing the PAF-associated risks, we believe that further work must be done to clarify potential involved anatomical factors and potential reversible factors. Those patients have been described throughout the literature as presenting with higher risk of VA failure and severe peripheral arterial disease. In parallel we found that radial and ulnar arteries diameters and radial pulse wave velocity (PWV) in DDU were significantly lower in PAV-submitted patients, suggesting distal arterial compromise and stiffness. Our work has some limitations: neither vein parameters nor VA outcomes were analysed. However, it introduces a relationship between the black race and worse arterial indexes, and their impact on the choice of type of VA, as they seem not to be good candidates for AVF.

MO773THE VASCULAR REALITY BEHIND ULTRASOUND VASCULAR MAPPING: WHICH FACTORS PREDICT THE BEST CANDIDATES FOR RADIOCEPHALIC ARTERIOVENOUS FISTULA?

Background and Aims

Vascular accesses (VA) are key components for efficient hemodialysis. Arteriovenous fistulas (AVF) are recommended over arteriovenous graft (AVG), but deciding the type and location of a VA is challenging. Preoperative vascular mapping before surgical creation of VA, especially trough ultrasound (US), is helpful in this decision, contributing to improve AVF e AVG outcomes.

Our study aims to identify patient factors associated with appropriate arterial US parameters that predict feasibility for radiocephalic fistula creation.

Method

We analyzed a cohort of chronic kidney disease patients who underwent US vascular mapping for preoperative planning of dialysis access from 2019 to 2020, in a tertiary referral center. Patients were characterized based on its demographical characteristics, and the presence of diabetes, hypertension, obesity, and smoking. Arterial indicators were analyzed by ultrasound techniques in both upper arms, including radial, ulnar and brachial arteries. Those indicators included arterial diameter, calcification, doppler wave form, and pulse wave velocity.

Continuous variables were recorded as means (±SD) for normally distributed data and as medians (interquartile ranges) for nonnormally distributed data. Comparisons were made using t tests or Wilcoxon rank sum tests as appropriate. Categorical variables were examined by frequency distribution and recorded as proportions. Comparisons were made using the x2 test. Unadjusted and adjusted multivariate logistic regression models were fitted to identify predictors for a good candidate for radiocephalic arteriovenous fistula.

Results

A total of 252 patients were included. The mean age was 65±16 years, 144 (57%) were male, 211 (84%) where white, 40 (16%) were black, and 1 (0.4%) was asian. Most had arterial hypertension (205, 81%), 98 (39%) had diabetes mellitus, 89 (35%) were smokers, and 72 (29%) were obese. The majority of patients were attending for the first VA (186; 74%).

Most patients were considered appropriate candidates for arteriovenous fistula creation (207, 82%), whereas 45 (18%) were assigned to PTFE graft. Obesity and male sex were found to be predictors for being a good candidate for radiocephalic arteriovenous fistula in a multivariate logistic regression model adjusted for age, hypertension, and diabetes (OR 3.21, CI 95% 1.63-6.32, p-value 0.001 and OR 2.09, CI 95% 1.07-4.08, p-value 0.031, respectively). Figure 1 presents the arterial indicators analyzed during ultrasound mapping, including both upper limbs.

Conclusion

Our results show that obesity and male sex are predictors for radiocephalic arteriovenous fistula creation. While female sex has long been known to be a risk factor for VA failure, possibly because of worse arterial indicators, an association between obesity and higher probability of distal AVF creation has not been established yet. Comparison between arterial indicators in obese and nonobese patients shows that obese patients generally have better arterial indicators, especially higher pulse wave velocities, and less arterial calcification.

Given that some studies show an association between obesity and shorter fistula survival (due to higher secondary failure rate), our results may come as. A possible explanation for this difference is that obesity may exert a physical protective effect of the forearm vascular bed against iatrogenic damage (blood sampling and vessel cannulation). Besides that, factors other than vascular indicators may contribute to ulterior VA failure, like the proinflammatory state in obese patients and its consequent myointimal hyperplasia.

However, our conclusions are based on preoperative findings, and not on VA outcomes, especially its patency and complications. Moreover, which further help to determine the better location for a VA creation, were not evaluated in this study.

HOXB7 Overexpression Leads Triple-Negative Breast Cancer Cells to a Less Aggressive Phenotype

HOX genes appear to play a role in breast cancer progression in a molecular subtype-dependent way. The altered expression of HOXB7, for example, was reported to promote breast cancer progression in specific subtypes. Here we induced HOXB7 overexpression in MDA-MB-231 cells, a cellular model of the Triple-Negative breast cancer molecular subtype, and evaluated the phenotypic changes in cell viability, morphogenesis, migration, invasion, and colony formation. During the phenotypic characterization of the HOXB7-overexpressing cells, we consistently found less aggressive behavior represented by lower cell viability, inhibition of cell migration, invasion, and attachment-independent colony formation capacities added to the more compact and organized spheroid growth in 3D cultures. We then evaluated the expression of putative downstream targets and their direct binding to HOXB7 comparing ChIP-qPCR data generated from HOXB7-overexpressing cells and controls. In the manipulated cells, we found enriched biding of HOXB7 to CTNNB1, EGFR, FGF2, CDH1, DNMT3B, TGFB2, and COMMD7. Taken together, these results highlight the plasticity of the HOXB7 function in breast cancer, according to the cellular genetic background and expression levels, and provide evidence that in Triple-Negative breast cancer cells, HOXB7 overexpression has the potential to promote less aggressive phenotypes.

Voriconazole-induced periostitis

Voriconazole is a fluorinated drug from the triazole group that is widely used in the prophylaxis and treatment of fungal infections in immunosuppressed patients. Chronic use of this medication can generate, as an adverse effect, a multifocal, asymmetric, diffuse and nodular periosteal reaction, associated with severe and disabling skeletal pain and elevated alkaline phosphatase and serum fluoride. Radiography is the imaging technique of choice for periostitis diagnosis. In general, clinical manifestations and radiographic findings disappear, when the drug is discontinued. We report the clinical case of a 44 year-old woman diagnosed with acute myeloid leukemia, who developed an invasive fungal infection treated with voriconazole after a stem cell transplant. Nine months after starting antifungal treatment, she manifested symptoms and radiological signs compatible with periostitis. Due to clinical suspicion, we decided to suspend voriconazole, with consequent resolution of clinical manifestations and radiological findings.

Diversity oriented Deep Reinforcement Learning for targeted molecule generation

In this work, we explore the potential of deep learning to streamline the process of identifying new potential drugs through the computational generation of molecules with interesting biological properties. Two deep neural networks compose our targeted generation framework: the Generator, which is trained to learn the building rules of valid molecules employing SMILES strings notation, and the Predictor which evaluates the newly generated compounds by predicting their affinity for the desired target. Then, the Generator is optimized through Reinforcement Learning to produce molecules with bespoken properties. The innovation of this approach is the exploratory strategy applied during the reinforcement training process that seeks to add novelty to the generated compounds. This training strategy employs two Generators interchangeably to sample new SMILES: the initially trained model that will remain fixed and a copy of the previous one that will be updated during the training to uncover the most promising molecules. The evolution of the reward assigned by the Predictor determines how often each one is employed to select the next token of the molecule. This strategy establishes a compromise between the need to acquire more information about the chemical space and the need to sample new molecules, with the experience gained so far. To demonstrate the effectiveness of the method, the Generator is trained to design molecules with an optimized coefficient of partition and also high inhibitory power against the Adenosine [Formula: see text] and [Formula: see text] opioid receptors. The results reveal that the model can effectively adjust the newly generated molecules towards the wanted direction. More importantly, it was possible to find promising sets of unique and diverse molecules, which was the main purpose of the newly implemented strategy.

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

Universal newborn hearing screening: the Belgian experience

Issue

Worldwide 466 million people suffer from hearing loss (HL), of whom 34 million children. Early detection of HL in newborns through screening and subsequent intervention significantly improve their developmental and psychosocial outcome. The WHA adopted a resolution on prevention of deafness and HL (2017), urging the member states 'to develop, implement and monitor screening programs for early identification of ear diseases'. Population based newborn hearing screening (PNHS) by automated otoacoustic emission (AOAE) and/or automated auditory brainstem response (AABR) is considered good practice.

Description of the Problem

Flanders (FL): PNHS by AABR at the age of 2-3 weeks (pass/refer), repeated in case of 'refer'. At 2x 'refer', referral to a tertiary hearing center. French speaking community (FSC): newborns with risk factors for congenital HL are immediately referred to ENT. Others undergo AOAE at day 2-3 (pass/refer with retest in case of 'refer'). At 2x 'refer', referral to ENT for AABR. German speaking community: no data available.

Results

Coverage rate: FL (birth cohort 2014): 96-98%. FSC (birth cohort 2016): 94.9% of newborns without risk factors had a 1st test. 8.7% of newborns with risk factors didn't have any test.

Detection rate/1000 tested newborns

FL: 2.1 newborns with congenital HL. FSC: 2.33 newborns with HL (0.30 perceptive/0.36 permanently conductive/0.75 temporary conductive/0.1 conductive NOS/0.06 mixed type/0.77 NOS).

Lessons

Belgium has at least 2 quality PNHS programs. Due to program differences (different tests/age of testing/registration/financing) in depth comparative analysis on their performance, outcome and cost effectiveness is currently lacking (future perspective).

Key messages

PNHS is common in high income countries, but is not yet integrated worldwide. In the light of the 2017 WHA resolution Belgium might inspire regions and countries starting up PNHS. An in depth comparative analysis of the current Belgian PNHS programs is needed.

Diagnostic challenges in paediatric foreign body aspiration: a case report

Introduction: Foreign body aspiration (FBA) is a potentially fatal paediatric emergency. Our objective was to highlight the importance of a multidisciplinary approach to difficult/doubtful diagnosis. Case Report: 34-month-old girl referred for urgent rigid bronchoscopy after suspected metallic blade ingestion (found chewing on it). She had a previous recurrent history of wheezing. The physical examination revealed face/lip wounds, traces of powder on her teeth but no breathing difficulty. The plain X-Ray revealed radiopaque images of the upper pulmonary field and gastric chamber. In the absence of FBA clinical signs but considering a previous history of bronchial hyperresponsiveness, a direct digital radiographic study was performed. There were no images compatible with foreign bodies: the results were interpreted as artefacts and no bronchoscopy was performed. Conclusions: A careful pre-anaesthetic evaluation, a high level of suspicion and excellent multidisciplinary communication led to the recognition of false radiologic findings. A conservative approach was followed and invasive procedures in a remote location, with high anaesthetic risk for the paediatric population were avoided.

Obstructive Sleep Apnea Syndrome - Predictive Indicators of Severity

Introduction Obstructive Sleep Apnea Syndrome (OSAS) is a public health issue, due to its increasing prevalence and associated morbidity and mortality, worsened by the underestimated diagnosis of this entity in clinical practice.

Objectives To correlate clinical, demographic and anthropometric indicators, and elaborate a predictive equation for OSAS severity and prevalence, in males and females.

Methodology In this cross-sectional study, all the included patients performed a type I Polysomnography in ULSM – HPH Neurophysiology Laboratory, between July 2011 and December 2017. Patient’s weight, height, body mass index (BMI), waist circumference (WC) and neck circumference (NC) were assessed. Daytime excessive sleepiness was rated through the Epworth Sleepiness Scale (ESS). The apnea-hypopnea index and the snoring presence were obtained through the polygraphic recording. Demographic, anthropometric, clinical variables and ESS punctuation were correlated with the presence of OSAS and its severity through a multivariable regression model.

Results The study included 472 patients (275 males and 197 females). OSAS prevalence was 65,7% (75,3% in males and 52,3% in females), being the males related to the most severe forms of OSAS (p &lt; 0,001), the same happening with the age group 60-69 years. OSAS severity correlated directly with NC, WC, BMI and ESS increase. Snoring was present in 92,8% of the cases and did not correlate with OSAS severity. In females, severity correlated directly with age and BMI. Age and NC were identified as the strongest independent OSAS predictors (p-value=0,011 and p-value=0,006, respectively).

Conclusion In this study, OSAS severity predictors were gender, age, NC, WC, BMI, snoring and ESS result (NC and age were the strongest independent predictors). These findings should be confirmed in more robust studies, to identify patients at risk of severe OSAS, to allow earlier diagnostic evaluation and therefore preventing OSAS associated complications.

Evaluation of MMP-10 and TIMP-1 levels associated with Resveratrol supplementation

Introduction Resveratrol (RSV) is a natural phytoalexin present in abundance in grapes, berries, peanuts and red wine. The main benefits of resveratrol ingestion are due to its anti-inflammatory and antioxidant properties. This compound also induces therapeutic benefits in the remodelling of extracellular matrix (ECM), which plays an important role in the regulation of the activity of matrix metalloproteinases (MMPs) and its tissue inhibitors of metalloproteinases (TIMPs). The MMPs are a family of zinc dependent endopeptidases, with an important role in the physiological and pathological remodelling of ECM, once the activity of MMPs can be regulated by TIMPs. This regulation is essential, since if there is an imbalance between the MMPs and TIMPs there’s destruction of the ECM, leading to the development of several pathologies.

Objectives Evaluate RSV potential by determining serum and salivary levels of MMP-10 and TIMP-1.

Methodology The study population included 27 undergraduates between the ages of 18 and 30, divided into a control group (placebo) and an intervention group, supplemented with 100 mg RSV/day, during 30 days. MMP-10 and TIMP-1 levels were determined by slot blot. The results were analysed using a GraphPad Prism version 5 software for Windows (GraphPad Software, San Diego, California, USA).

Results It was verified the existence of a linear correlation between the serum and salivary levels of TIMP-1, as well as a tendency of increase of this biomarker after RSV supplementation. In all indicators studied, supplementation with this compound wasn’t harmful.

Conclusion The rising trend verified at TIMP-1 in both fluids may reflect benefits in the individuals under study, demonstrating that saliva has potential as a study biofluid for this type of biochemical markers. It was also verified that supplementation with this compound did not damage the evaluated parameters and, therefore, the RSV potential shouldn’t be rejected.