[Cognitive impairment in the elderly patient with symptomatic severe aortic stenosis. Therapeutic decisions and impact on one-year mortality]

INTRODUCTION

Interventional treatment of severe aortic stenosis includes valve replacement by surgery or transcatheter - transcatheter aortic valve implantation (TAVI). In order to make an adequate selection and to rule out patients with little/no therapeutic benefit, it is recommended to assess comorbidities, frailty and cognitive impairment.

AIMS

a) To determine the prevalence of cognitive impairment in older patients with severe aortic stenosis; b) to analyse its influence on decision-making (surgery, TAVI or conservative treatment); and c) to analyse its impact on mortality at one year.

MATERIAL AND METHODS

Prospective, longitudinal epidemiological study of patients aged 75 years and older with severe aortic stenosis treated by the Heart-Team.

VARIABLES

sociodemographic, clinical, cardiological, functional and mental variables; cognitive impairment assessed by applying the Mini-Mental State Examination (MMSE).

RESULTS

We included 300 patients in the study (83.99 ± 4.02 years old; 61.2%, women). Prevalence of cognitive impairment of 15.3%, which was associated with albumin level - odds ratio (OR): 0.082; p = 0.011 - and Barthel (OR: 0.962; p = 0.02) and Lawton (OR: 0.787; p = 0.025) index scores. Surgery was chosen in 24.7% of cases; TAVI in 63.3%; and conservative treatment in 12%. This decision was associated with the score on the Barthel (OR: 0.93; p = 0.012) and Lawton indices (OR: 0.678; p = 0.014), the Short Physical Performance Battery (OR: 0.75; p = 0.037) and the MMSE (OR: 0.691; p < 0.001). Mortality at one year was 14%, and higher in patients with MMSE scores <24 (23.5% vs. 12.8%; p = 0.094).

CONCLUSIONS

Cognitive impairment is a very common geriatric syndrome in older patients with severe aortic stenosis that is associated with functional disability in activities of daily living. Cognitive impairment has a high impact on decision-making and appears to be a variable associated with increased mortality.

The IFMIF-DONES Project: Design Status and Main Achievements Within the EUROfusion FP8 Work Programme

International Fusion Materials Irradiation Facility-DEMO-Oriented NEutron Source (IFMIF-DONES) is a high-intensity neutron irradiation facility for qualification of fusion reactor materials, which is being designed as part of the European roadmap to fusion-generated electricity. Its main purpose is to study the behavior of materials properties under irradiation in a neutron flux able to simulate the same effects in terms of relevant nuclear responses as those expected in the first wall of the DEMO reactor which is envisaged to follow ITER. It is thus a key facility to support the design, licensing and safe operation of DEMO as well as of the fusion power plants that will be developed afterwards. The start of its construction is foreseen in the next few years. In this contribution, an overview of the IFMIF-DONES neutron source is presented together with a snapshot of the current engineering design status and of the relevant key results achieved within the EUROfusion Work Package Early Neutron Source (WPENS) as part of the 2014–2020 EURATOM Research and Training Programme, complementary to the EU Horizon 2020 Framework Programme (FP8). Moreover, some information on the future developments of the project are given.

Expected-value bias in mid-trimester preterm birth screening

OBJECTIVES

Cervical length (CL) measurement ≤ 25 mm on mid-trimester ultrasound scan is a known risk factor for preterm birth, for which vaginal progesterone is recommended. The aims of this study were to evaluate whether CL measurement is affected by observer bias and to assess the impact on short cervix prevalence of masking CL measurement during routine mid-trimester ultrasound scan.

METHODS

This was a flash study designed for a 2-month period (October and November 2018) at Cruces University Hospital (Bizkaia, Spain), in which all CL measurements from routine mid-trimester scans were masked. During the study period, there was no modification of the routine screening method, and women with a short cervix were prescribed 200 mg vaginal progesterone daily as per usual. The control group included women examined in a 2-month period (April and May 2018) prior to the study, in which CL measurements were taken as usual by a non-blinded operator. The primary outcome was the prevalence of short cervix in each group.

RESULTS

A total of 983 CL measurements were analyzed, including 457 in the blinded group and 526 in the control group. The prevalence of short cervix was 2.7% in the non-blinded group and 5.5% in the blinded group (P = 0.024). We identified a statistically significant difference in the incidence of CL of 24-25 mm between the two groups, with a lower prevalence in the non-blinded vs blinded group (0.6% vs 2.4%; P < 0.005). Moreover, the distribution of CL values was normal in the blinded group, in contrast to the non-blinded group, which was characterized by skewed distribution of CL values.

CONCLUSIONS

Expected-value bias exists and should be taken into account when measuring CL in mid-trimester preterm birth screening. Blinding has demonstrated to be an effective strategy to improve the performance of CL screening in clinical practice. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Pathophysiological Role of Genetic Factors Associated With Gestational Diabetes Mellitus

Gestational Diabetes Mellitus (GDM) is a highly prevalent maternal pathology characterized by maternal glucose intolerance during pregnancy that is, associated with severe complications for both mother and offspring. Several risk factors have been related to GDM; one of the most important among them is genetic predisposition. Numerous single nucleotide polymorphisms (SNPs) in genes that act at different levels on various tissues, could cause changes in the expression levels and activity of proteins, which result in glucose and insulin metabolism dysfunction. In this review, we describe various SNPs; which according to literature, increase the risk of developing GDM. These SNPs include: (1) those associated with transcription factors that regulate insulin production and excretion, such as rs7903146 (TCF7L2) and rs5015480 (HHEX); (2) others that cause a decrease in protective hormones against insulin resistance such as rs2241766 (ADIPOQ) and rs6257 (SHBG); (3) SNPs that cause modifications in membrane proteins, generating dysfunction in insulin signaling or cell transport in the case of rs5443 (GNB3) and rs2237892 (KCNQ1); (4) those associated with enzymes such as rs225014 (DIO2) and rs9939609 (FTO) which cause an impaired metabolism, resulting in an insulin resistance state; and (5) other polymorphisms, those are associated with growth factors such as rs2146323 (VEGFA) and rs755622 (MIF) which could cause changes in the expression levels of these proteins, producing endothelial dysfunction and an increase of pro-inflammatory cytokines, characteristic on GDM. While the pathophysiological mechanism is unclear, this review describes various potential effects of these polymorphisms on the predisposition to develop GDM.

Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study

AIMS

Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation.

METHODS AND RESULTS

We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24).

CONCLUSION

In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.

AB1354-HPR CURRENT SITUATION OF TRAINING IN RHEUMATOLOGY IN THE POSTGRADUATE CURRICULUMS OF INTERNAL MEDICINE, FAMILY MEDICINE, GERIATRICS, PAIN MEDICINE AND, PHYSICAL AND REHABILITATION MEDICINE ACROSS COLOMBIA

Background:

Rheumatic diseases are an important complaint in patients, although the incidence is low, they cause disability and impact on the health system. Currently, in Colombia, there are 198 rheumatologist, so it’s important to know how is rheumatology training in specialties related to rheumatology, which are the specialties that the patient with a suspected rheumatic disease will visit at first.

Objectives:

To describe the training status in rheumatology in the postgraduate curriculums of internal medicine, family medicine, geriatrics, pain medicine and, physical and rehabilitation medicine across Colombia.

Methods:

This is a descriptive cross-sectional study. A survey was applied in each participating medical school using the RedCap® platform. The questionnaire included multiple-choice responses and a textbox to complete. The survey was done to the 29 registered medical schools which offer the specializations already mentioned. The program director or an assistant professor was asked to fill the survey out between April 2019 and January 2020. The sample was described through means and standard deviations or frequency and percentages according to the type of variable.

Results:

Data was obtained from all the programs of specialization in internal medicine (n = 29), family medicine (n= 9), pain medicine (n= 8), physical and rehabilitation medicine (n= 6), geriatrics (n= 4). All the programs of internal medicine, geriatrics, and physical/rehabilitation medicine have rheumatology as a mandatory subject within the curriculum, while in family medicine and pain medicine programs: 33% (n= 3), and 57% (n= 4) respectively, does not have a rheumatology training. In internal medicine the average duration of rheumatology training is 56 days (28 to 90 days), in geriatrics, it is 56 days (45-60 days), in family medicine 26.1 days (3 to 30), in medicine physical and rehabilitation medicine 35 days (30 to 60) and in pain medicine 40 days (30 to 60). 93.8% (n= 45) of the programs surveyed have a rheumatologist as a teacher in charge of both, the academic activities and the external rheumatology consultation and in the rest of the programs these activities are done by an specialist in internal medicine, family medicine or pain medicine. The theoretical components most frequently offered in seminars or master classes are: rheumatoid arthritis, lupus, vasculitis, spondyloarthritis, gout, osteoarthritis, sjogren’s syndrome and osteoporosis. The specialization programs have an average of 3 rheumatologists as professors (range 1 to 8). 43.8% of the programs use some virtual resources to complement the teaching in rheumatology such as video conferencing in virtual platform or YouTube (8.3%), online course (6.3%), mobile application (16.7%), others such as moodle and webcast platform (12.5%). 92.9% (n = 52) offer their students an elective rotation in the rheumatology service, in addition to the mandatory one. Finally, 89.6% (n = 43) of the interviewees agree with the way in which the curriculum is structured in their programs, to approach initial diagnostic and therapeutic in patients with suspected or established rheumatic disease. However, 23.2% (n = 13) of the professors of the surveyed programs (6 of internal medicine, 4 of family medicine, 2 of pain medicine and 1 of physical/rehabilitation medicine), consider that the rheumatology subject should not be mandatory within their programs.

Conclusion:

All physicians need to be familiar with rheumatological conditions since the rate of rheumatologists in Colombia is low. Knowing rheumatology is an increasingly important role in a clinical scenario in many postgraduate curriculums as we explain in this study.

References:

[1]Sivera F, et al; Working Group on Training in Rheumatology across Europe. Differences and similarities in rheumatology specialty training programmes across European countries. Ann Rheum Dis. 2015 Jun;74(6):1183-7

Disclosure of Interests:

None declared

THU0467 CONCEPTS AND PERCEPTIONS ABOUT FIBROMYALGIA DIAGNOSIS, MONITORING AND TREATMENT AMONG COLOMBIAN RHEUMATOLOGISTS, PHYSIATRIST AND PAIN PHYSICIAN

Background:

Fibromyalgia is a chronic disease characterized by the presence of widespread and persistent musculoskeletal pain associated with a variety of symptoms. The concepts and perceptions around diagnosis and treatment of fibromyalgia among physicians are not objectively known. The purpose of this study is to obtain objective data through a survey and describe the concepts and perceptions about the diagnosis, treatment and treatment of fibromyalgia among colombian rheumatologists, physiatrist and pain physicians

Objectives:

The main purpose of this study is to obtain objective data on this subject and describe the concepts and perceptions about the diagnosis, treatment and monitoring of FM among colombian rheumatologists, physiatrist and pain physicians.

Methods:

Cross-sectional study. Through a focus group in which two rheumatologists and one expert in qualitative research methods participated, a survey was designed to evaluated the perceptions and concepts that rheumatologists, physiatrist and pain physicians have on the diagnosis and treatment of fibromyalgia. The survey was self-applied anonymously through the internet.

Results:

Survey applied to 139 rheumatologists, 99 physiatrist and 81 pain physicians. 35 rheumatologists (25.2 %), 17 physiatrist (17.1 %) and 58 pain physicians (71.6 %) consider that there is not enough evidence to recognize fibromyalgia as a disease. 45 rheumatologists (32.4 %), 86 physiatrist (86 %) and 73 pain physicians (90.1 %) consider that the 1990 ACR (American college of Rheumatology) criteria are not sufficient to diagnose fibromyalgia, despite the fact more than 90% of them use the criteria as a tool to approach the diagnosis when suspecting fibromyalgia. The most formulated medications for managing fibromyalgia are antidepressants and is used by more than 80% of the respondents, followed by antiepileptics in pain physician (88.9%) but less than physiatrists and rheumatologists (66.6 % and 64.7 % respectively), and analgesic much more for pain physician and physiatry and less for rheumatologists (84 %, 75.7 % and 26.6 % respectively). All respondents consider that the patient with fibromyalgia should have a multidisciplinary approach. Most doctors of the three specialties believe that physiatrist should be the leaders of interdisciplinary management in the treatment of fibromyalgia patients.

Conclusion:

We present objective information on the perceptions of fibromyalgia among a group of Colombian rheumatologists, physiatrist and pain physician, documenting a frequent use of the ACR 1990 classification criteria. As regards treatment, a high percentage use of antidepressants and antiepileptic. Most believe that physiatrist should be the leaders of interdisciplinary management in the treatment of fibromyalgia patients.

References:

[1]Mu R, Li C, Zhu J-X, Zhang X-Y, Duan T-J, Feng M, et al. National survey of knowledge, attitude and practice of fibromyalgia among rheumatologists in China. Int J Rheum Dis. 2013;16:258–63.

[2]Arshad A, Kong KO. Awareness and perceptions of fibromyalgia syndrome: a survey of Malaysian and Singaporean rheumatologists. Singapore Med J. 2007;48:25–30.

[3]Arshad A, Kong KO, Ooi KK. Awareness and perceptions of fibromyalgia syndrome: a survey of southeast asian rheumatologists. J Clin Rheumatol. 2007;13:59–62.

[4]Bloom S, Ablin JN, Lebel D, Rath E, Faran Y, Daphna-Tekoah S, et al. Awareness of diagnostic and clinical features of fibromyalgia among orthopedic surgeons. Rheumatol Int. 2013;33:927–31.

[5]Clark P, Paiva ES, Ginovker A, Salomón PA. A patient and physician survey of fibromyalgia across Latin America and Europe. BMC Musculoskelet Disord. 2013;14:188.

Disclosure of Interests: :

None declared

Regulatory mechanisms involved in muscle and bone remodeling during refeeding in gilthead sea bream

The tolerance of fish to fasting offers a model to study the regulatory mechanisms and changes produced when feeding is restored. Gilthead sea bream juveniles were exposed to a 21-days fasting period followed by 2 h to 7-days refeeding. Fasting provoked a decrease in body weight, somatic indexes, and muscle gene expression of members of the Gh/Igf system, signaling molecules (akt, tor and downstream effectors), proliferation marker pcna, myogenic regulatory factors, myostatin, and proteolytic molecules such as cathepsins or calpains, while most ubiquitin-proteasome system members increased or remained stable. In bone, downregulated expression of Gh/Igf members and osteogenic factors was observed, whereas expression of the osteoclastic marker ctsk was increased. Refeeding recovered the expression of Gh/Igf system, myogenic and osteogenic factors in a sequence similar to that of development. Akt and Tor phosphorylation raised at 2 and 5 h post-refeeding, much faster than its gene expression increased, which occurred at day 7. The expression in bone and muscle of the inhibitor myostatin (mstn2) showed an inverse profile suggesting an inter-organ coordination that needs to be further explored in fish. Overall, this study provides new information on the molecules involved in the musculoskeletal system remodeling during the early stages of refeeding in fish.

D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry

BACKGROUND

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy.

METHODS

We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel).

RESULTS

In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors.

CONCLUSIONS

Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

Regional report on Angiostrongylus vasorum in Colombia: Genetic similarity to European lineage

The canine lungworm Angiostrongylus vasorum is considered neglected in South America and was only sporadically reported in dogs and wildlife. Gastropods act as obligatory intermediate hosts for this parasitosis. We here analysed Achatina fulica (African giant snail) populations from 5 regions of Colombia for A. vasorum infections. In total, 609 snails were collected from the departments Antioquia, Valle del Cauca and Putumayo. Angiostrongylus vasorum-infected A. fulica were found in all departments with a total prevalence of 3.9%. Larvae originating from Putumayo were molecularly characterized and identified as the European lineage of A. vasorum. This regional report shows for the first time the presence of A. vasorum in intermediate hosts in Colombia and the European genotype in South America.

Lupus nephritis with preserved kidney function associated with poorer cardiovascular risk control: A call for more awareness

BACKGROUND

Despite the improvement in the prognosis of lupus nephritis (LN), the cardiovascular morbimortality remains high. The early recognition and remission of flares, while trying to avoid the metabolic adverse effects of medication, must be mandatory.

AIM

The aim of our study was to assess the cardiovascular (CV) risk profile in a cohort of lupus patients with preserved kidney function after a nephritis episode, compared to patients without a nephritis flare.

METHODS

130 patients diagnosed of SLE (32 with previous nephritis flare and 98 without) were studied in order to evaluate the CV risk profile, despite the preserved kidney function.

RESULTS

The most prevalent risk factors were sedentary lifestyle (57.6%), overweight/obesity (38.3%) and dyslipidemia (36%), followed by smoking (32%) and hypertension (16%). Though more than a half (53.1%) was taking CV medication, a high percentage did not reach a therapeutic target value, especially regarding obesity (11.5%) and cholesterol levels (LDL-C of 16%). The prevalence of dyslipidemia (53.1% vs 30.6%), smoking (46.6% vs 27.5%), left ventricular hypertrophy (LVH) (21.4% vs 6.4%) and lower HDL-C (48.6mg/dL vs 55.4mg/dL) were significantly different in the group with previous nephritis flare. Moreover, young patients with lupus nephritis, received more pulses of corticosteroids and cyclophosphamide, had higher prevalence of hypertension, LVH, higher proteinuria, hospital admissions and waist circumference, constituting the subgroup of patients with greater aggregation of CV risk factors.

CONCLUSIONS

Patients with previous nephritis flare showed a poor control of CV risk factors despite the preserved renal function, these patients would require a closer therapeutic management.

Relationship between peripheral arterial occlusive disease (PAOD) and chronic Chlamydophila (Chlamydia) pneumoniae infection

We carried out a meta-analysis of observational case-control studies published before May 2004 to assess the degree of association between Chlamydophila pneumoniae (Cp) infection and PAOD. A search of the Medline database was performed using atherosclerosis and "Chlamyd* pneumoniae" as keywords. Strict criteria were applied for the selection of case studies, which had to be studies of Cp seroprevalence or of Cp detection in patients versus controls. Forty-three published studies that met these criteria were selected. An association between PAOD and Cp was revealed by immunohistochemical analysis (OR=15.4, 95%CI=5.0–46.9) and nested PCR studies of arterial biopsies (OR=4.3, 95%CI=1.8–10), by PCR study of non-arterial samples (OR=2.9, 95%CI=1.2–7.0), by other direct-detection tests (OR=16.7, 95%CI=7.0–39.8), and by ELISA and MIF tests to detect high IgG (OR=2, 95%CI=1.1–3.5 and OR=1.7, 95%CI=1.0–2.9, respectively) and IgA (OR=1.9, 95%CI=1.1–3.4 and OR=1.5, 95%CI=1.1–2.0, respectively) titers. No significant association was found in simple PCR studies of arterial biopsies, MIF tests to detect low IgG titers or IgM, or ELISA studies to detect IgM. According to this review, the association between Cp infection and PAOD depends on the analytical method adopted. Establishing a relationship between Cp and PAOD will require a case-control study with an adequate number of cases and samples that uses a combination of direct and indirect techniques to identify the presence of the bacterium in different types of sample from the same subjects, correlating the results with the activity of the disease.

Polarized Neutron Study of Ni-Mn-Ga Alloys: Site-Specific Spin Density Affected by Martensitic Transformation

Polarized neutron scattering has been used to obtain the magnetic moment at specific crystallographic sites of the austenitic and martensitic phases of two nonstoichiometric Ni-Mn-Ga single crystals with close composition. These alloys have been chosen because they exhibit different structures in the paramagnetic state and inverse positions of the respective martensitic transformation and Curie temperature. The diffraction analysis revealed a remarkable result: Despite the similar alloy composition, the magnetic moments of Mn are quite different for the two alloys at the same crystallographic position. Furthermore, such a difference enabled us to assess that the exchange coupling between Mn atoms switches from ferro- to antiferromagnetic at a distance between 2.92 and 3.32 Å in the martensite. These results are of great importance to guide first principles calculations that, up to now, have not been contrasted with experiments at the atomic level.