Elexacaftor/Tezacaftor/Ivacaftor, a game-changer in Cystic Fibrosis: The Portuguese experience

BACKGROUND

Phase 3 trials of elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) combination treatment in people with cystic fibrosis (CF) with ≥1 F508del-CFTR allele showed profound short-term effects on lung function, weight, and pulmonary exacerbations (PEx). The authors conducted a 12-month study to add evidence on the real-world long-term effectiveness and safety of CFTR modulator therapy with ELX/TEZ/IVA in Portuguese CF adult population.

METHODS

Ambispective, multicentre, observational, real-life study involving all the Portuguese CF Reference Centres. Adult patients on treatment with ELX/TEZ/IVA combination outside clinical trials were included. Demographics, efficacy, and safety variables on the first 12 months of treatment were compared with the pre-treatment year.

RESULTS

132 adult people with CF were included, of which 119 completed 12 months treatment (mean duration of treatment 21.5 months). Mean age was 31.7 ± 11.0 years, 53% patients were homozygous for the F508del variant, baseline sweat chloride was 86.7 ± 25.9mmol/L and pre-treatment percent-predicted FEV1 was 77.9 ± 19.7%. At 1 year, mean absolute change from baseline in FEV1 was +0.46L (95% CI: 0.37, 0.55; p<0.001) and +13.9 percentage points (95% CI: 11.5, 16.2; p<0.001). PEx episodes decreased by 78% (p<0.001) and hospitalizations for PEx decreased by 91.4% (p<0.001). Body mass index (BMI) increased 1.2 Kg/m2 (95% CI: 0.9, 1.5; p<0.001). Mean sweat chloride variation was -44.5 mmol/L (95% CI: -49.8, -39.2; p<0.001). No correlation was found between sweat chloride and lung function (r= -0.116, p= 0.335). There were no major safety concerns. Of note, headache was reported in 7.6% and neuropsychiatric manifestations occurred in 12.6% treated patients, being anxiety and depressive disorders the most common.

CONCLUSIONS

ELX/TEZ/IVA treatment in Portuguese adults with CF was associated with significant improvement in lung function, a drop in PEx and PEx-related hospitalizations and increase in BMI at 12 months and was well tolerated. These results add knowledge to our understanding of clinical benefits and tolerability of ELX/TEZ/IVA. Careful evaluation of adverse effects of ELX/TEZ/IVA therapy and its determinants, mainly concerning mental health, are a research priority.

Drug-Drug Interaction between Oral Zamicastat and Continuous Epoprostenol Infusion at Steady-State Conditions in Healthy Subjects

This study intended to evaluate the interactions between zamicastat and epoprostenol in healthy human subjects. This was a single-center, open-label, two-period study. In period 1, epoprostenol 8 ng/kg/min was administered alone. In period 2, epoprostenol 8 ng/kg/min was administered following an 8-day treatment with zamicastat. Since the initial dose of epoprostenol showed to be insufficiently tolerated, it was decreased to 6 ng/kg/min. Blood samples were collected to determine the metabolites of epoprostenol and concentrations of zamicastat and its metabolites. A total of 54 subjects were enrolled and data from 28 subjects were available for pharmacokinetic analysis. The epoprostenol plus zamicastat-to-epoprostenol geometric means ratio (GMR) and corresponding 90% confidence interval (CI) for Cav,ss and area under the plasma concentration-time curve from time 0 up to 16 h at steady state (AUC0-16,ss) of the metabolites of epoprostenol were within the acceptance bioequivalence range (80.00%-125.00%). The intrasubject coefficient of variation (ISCV) was below 10% for both parameters, on both metabolites. For zamicastat AUC0-τ,ss, the zamicastat plus epoprostenol-to-zamicastat GMR and corresponding 90% CI were within the bioequivalence acceptance range, while for zamicastat Cmax,ss, the lower limit of the 90% CI was slightly below the acceptance range. For zamicastat metabolites, Cmax,ss and AUC0-τ,ss and the zamicastat plus epoprostenol-to-zamicastat GMR were below the acceptance bioequivalence range. ISCV was between 30% and 41% for Cmax,ss and between 21% and 41% for AUC0-τ,ss, for zamicastat and both metabolites. This study showed that the administration of zamicastat did not significantly modify the cardiovascular effects of epoprostenol and that the interactions between zamicastat and epoprostenol are not expected to be clinically relevant.

An individual-based model to explore the impact of psychological stress on immune infiltration into tumour spheroids

In recentin vitroexperiments on co-culture between breast tumour spheroids and activated immune cells, it was observed that the introduction of the stress hormone cortisol resulted in a decreased immune cell infiltration into the spheroids. Moreover, the presence of cortisol deregulated the normal levels of the pro- and anti-inflammatory cytokines IFN-γand IL-10. We present an individual-based model to explore the interaction dynamics between tumour and immune cells under psychological stress conditions. With our model, we explore the processes underlying the emergence of different levels of immune infiltration, with particular focus on the biological mechanisms regulated by IFN-γand IL-10. The set-up of numerical simulations is defined to mimic the scenarios considered in the experimental study. Similarly to the experimental quantitative analysis, we compute a score that quantifies the level of immune cell infiltration into the tumour. The results of numerical simulations indicate that the motility of immune cells, their capability to infiltrate through tumour cells, their growth rate and the interplay between these cell parameters can affect the level of immune cell infiltration in different ways. Ultimately, numerical simulations of this model support a deeper understanding of the impact of biological stress-induced mechanisms on immune infiltration.

Evolutionary dynamics of glucose-deprived cancer cells: insights from experimentally informed mathematical modelling

Glucose is a primary energy source for cancer cells. Several lines of evidence support the idea that monocarboxylate transporters, such as MCT1, elicit metabolic reprogramming of cancer cells in glucose-poor environments, allowing them to re-use lactate, a by-product of glucose metabolism, as an alternative energy source with serious consequences for disease progression. We employ a synergistic experimental and mathematical modelling approach to explore the evolutionary processes at the root of cancer cell adaptation to glucose deprivation, with particular focus on the mechanisms underlying the increase in MCT1 expression observed in glucose-deprived aggressive cancer cells. Data from in vitro experiments on breast cancer cells are used to inform and calibrate a mathematical model that comprises a partial integro-differential equation for the dynamics of a population of cancer cells structured by the level of MCT1 expression. Analytical and numerical results of this model suggest that environment-induced changes in MCT1 expression mediated by lactate-associated signalling pathways enable a prompt adaptive response of glucose-deprived cancer cells, while fluctuations in MCT1 expression due to epigenetic changes create the substrate for environmental selection to act upon, speeding up the selective sweep underlying cancer cell adaptation to glucose deprivation, and may constitute a long-term bet-hedging mechanism.

Predictive Potential of Cmax Bioequivalence in Pilot Bioavailability/Bioequivalence Studies, through the Alternative ƒ2 Similarity Factor Method

Pilot bioavailability/bioequivalence (BA/BE) studies are downsized trials that can be conducted prior to the definitive pivotal trial. In these trials, 12 to 18 subjects are usually enrolled, although, in principle, a sample size is not formally calculated. In a previous work, authors recommended the use of an alternative approach to the average bioequivalence methodology to evaluate pilot studies' data, using the geometric mean (Gmean) ƒ2 factor with a cut off of 35, which has shown to be an appropriate method to assess the potential bioequivalence for the maximum observed concentration (Cmax) metric under the assumptions of a true Test-to-Reference Geometric Mean Ratio (GMR) of 100% and an inter-occasion variability (IOV) in the range of 10% to 45%. In this work, the authors evaluated the proposed ƒ2 factor in comparison with the standard average bioequivalence in more extreme scenarios, using a true GMR of 90% or 111% for truly bioequivalent formulations, and 80% or 125% for truly bioinequivalent formulations, in order to better derive conclusions on the potential of this analysis method. Several scenarios of pilot BA/BE crossover studies were simulated through population pharmacokinetic modelling, accounting for different IOV levels. A redefined decision tree is proposed, suggesting a fixed sample size of 20 subjects for pilot studies in the case of intra-subject coefficient of variation (ISCV%) > 20% or unknown variability, and suggesting the assessment of study results through the average bioequivalence analysis, and additionally through Gmean ƒ2 factor method in the case of the 90% confidence interval (CI) for GMR is outside the regulatory acceptance bioequivalence interval of [80.00-125.00]%. Using this alternative approach, the certainty levels to proceed with pivotal studies, depending on Gmean ƒ2 values and variability scenarios tested (20-60% IOV), were assessed, which is expected to be helpful in terms of the decision to proceed with pivotal bioequivalence studies.

Preliminary evidence that Merkel cells exert chemosensory functions in human epidermis

The mechanotransduction of light-touch sensory stimuli is considered to be the main physiological function of epidermal Merkel cells (MCs). Recently, however, MCs have been demonstrated to be also thermo-sensitive, suggesting that their role in skin physiologically extends well beyond mechanosensation. Here, we demonstrate that in healthy human skin epidermal MCs express functional olfactory receptors, namely OR2AT4, just like neighbouring keratinocytes. Selective stimulation of OR2AT4 by topical application of the synthetic odorant, Sandalore®, significantly increased Piccolo protein expression in MCs, as assessed by quantitative immunohistomorphometry, indicating increased vesicle trafficking and recycling, and significantly reduced nerve growth factor (NGF) immunoreactivity within MCs, possibly indicating increased neurotrophin release upon OR2AT4 activation. Live-cell imaging showed that Sandalore® rapidly induces a loss of FFN206-dependent fluorescence in MCs, suggesting OR2AT4-dependent MC depolarization and subsequent vesicle secretion. Yet, in contrast to keratinocytes, OR2AT4 stimulation by Sandalore® altered neither the number nor the proliferation status of MCs. These preliminary ex vivo findings demonstrate that epidermal MCs also exert OR-dependent chemosensory functions in human skin, and invite one to explore whether these newly identified properties are dysregulated in selected skin disorders, for example, in pruritic dermatoses, and if these novel MC functions can be therapeutically targeted to maintain/promote skin health.

Productivity gains in vegetables from rice husk biochar application in nutrient-poor soils in Timor-Leste

Response to fertilisation with biochar is greatest in field crops on acidic tropical soils, but limited information is available for vegetable crops. As a case-study using vegetable production in Timor-Leste, we assessed if biochar alleviates nutritional constraints to vegetables in low-nutrient soils. Field trials on vegetable crops were conducted with fertiliser combinations of rice husk biochar, phosphate and local fertiliser at three sites. A pot soil incubation trial of biochar was undertaken with soil from the acid site, where rice husk biochar had a larger effect on productivity than the other fertilisers in chili pepper, tomato and soybean with an average yield increase with biochar of 230% over control. Combining phosphate with biochar augmented the yield over biochar alone in chili pepper, tomato and soybean. At neutral and alkaline sites, fertilisation with biochar lifted mean yield over the control. Soil constraints alleviated by fertiliser were primarily from P and Zn deficiencies. Marked increases in vegetable yields, among the highest globally, were achieved with fertilisation with biochar individually and in combination with phosphate in low nutrient soil in Timor-Leste. Clearly, rice husk biochar is a promising avenue to fertilise the soil with P and Zn and increase crop productivity in Timor-Leste.

Managing Nanomaterials in the Workplace by Using the Control Banding Approach

Nanomaterials offer new technical and commercial opportunities. However, they may also pose risks to consumers and the environment and raise concerns about occupational health and safety. An overview of the standardization in the area of nanomaterials is presented. Focus is given to the standard ISO/TS 12901-2:2014, which describes the use of a control banding approach for controlling the risks associated with occupational exposures to nano-objects and their aggregates and agglomerates greater than 100 nm. The article also presents a case study on a textile finishing company that implements two chemical finishes containing nanomaterials. A risk analysis was conducted to assess the hazards associated with workers handling nanomaterials. Control banding was applied, and measures such as appropriate ventilation and use of protective equipment are proposed to mitigate risks. In some cases, additional measures, such as a closed booth and smoke extractor, are required. The safety data sheets are a primary source of information on how to handle and care for products containing nanomaterials, but the information provided is still limited in terms of the specific hazards and risks posed by nanomaterials.

Short-term outcomes in patients with non-ST-segment elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

The proportion of non-ST-segment elevation myocardial infarction (NSTEMI) is increasing among the acute coronary syndromes (ACS). Reinfarction (RI) is a potential complication in high-risk patients with NSTEMI and it will cause an impact on these patients’ prognosis.

Purpose

Identify high-risk patients with RI and their prognosis in the setting of NSTEMI.

Methods

Based on a multicenter retrospective study, data collected from admissions between January 2013 and January 2020. Patients without data on previous cardiovascular history or uncompleted clinical data were excluded. Patients were divided in 2 groups (G): G1 – patients without RI; G2 - patients with RI during hospitalization. Logistic regression and survival analysis were performed.

Results

7180 patients were admitted with NSTEMI, RI occurred in 71 pts (0.99%). Regarding epidemiological and past history G2 was older (71±12 vs 66±12, p=0.001), had higher rates of previous stroke (15.9% vs 7.0%, p 0.003) and peripheric arterial disease (6.3% vs 6.1%, p=0.004). The groups were similar regarding arterial hypertension (p=0.74), diabetes type 2 (p=0.11) and dyslipidaemia (p=0.48).

G2 had higher levels of brain natriuretic peptide (45.5% vs 24.5%, p&lt;0.001) and lower levels of haemoglobin (20.3% vs 7.9%, p&lt;0.001). Patients taking prasugrel (2% vs 0.3%, p=0.002) or ticagrelor (6.1% vs 2.2%, p&lt;0.001) previously to the admission were more susceptible to have RI. Patients with severe left ventricular systolic dysfunction (3.4% vs 2.6%, p&lt;0.001), need of invasive (2.8% vs 0.8%, p&lt;0.001) or non-invasive (4.2% vs 1.3%, p&lt;0.001) ventilation and percutaneous coronary intervention (PCI) (80.3% vs 64.7%, p0.006) had higher rates of RI.

Logist regression confirmed that PCI (p=0.03, OR 2.22, CI 1.08-4.53), previous stroke (p=0.02, OR 0.58, CI 0.37-0.92) and pts previously taking prasugrel (p=0.02, OR 1.85, CI 1.11-3.10) were predictors of RI in the setting of NSTEMI.

Conclusion

RI in the setting of NSTEMI was associated with PCI, previous stroke and pts previously taking prasugrel. One year prognosis was poorer for patients who suffered RI.

Can we prevent the occurrence of stroke in patients admitted with non-ST-segment elevation myocardial infarction?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardio-cerebral vascular diseases are a leading cause of deaths worldwide.

Stroke is a potential complication in high-risk patients who had non-ST-segment elevation myocardial infarction (NSTEMI).

Purpose

Identify high-risk patients with stroke and their prognosis in the setting of NSTEMI.

Methods

Based on a multicenter retrospective study, data collected from admissions between January 2013 and January 2020. Patients without data on previous cardiovascular history or uncompleted clinical data were excluded. Patients were divided in 2 groups (G): G1 – patients who suffered stroke; G2 - patients without stroke. Logistic regression and survival analysis were performed.

Results

7180 patients were admitted with NSTEMI, stroke occurred in 35 patients (0.49%). Regarding epidemiological and past history G1 was older (72±9 vs 66±12, p= 0.004), had more females (54.3% vs 45.75, p&lt;0.001), had higher rates of type 2 diabetes mellitus (51.3% vs 35.2%, p=0.05), previous strokes / transient ischemic attack (24.2% vs 7.0%, p=0.007) and dementia (3.3% vs 0.8%, p&lt;0.001). Arterial hypertension (77.1 vs 72.8%, p=0.56), dyslipidaemia (61.8% vs 63.0%, p=0.88) and smoking (17.6% vs 26.0%, p=0.27) were similar between groups. Patients who presented with chest pain (72.7% vs 92.0%, p&lt;0.001) and patients who were not revascularized were more likely to suffer a stroke (43.3% vs 17.5%, p&lt;0.001).

Logist regression only confirmed that females were more likely to have a stroke (p&lt;0.001, OR 4.13, CI 1.87-9.15) and patients who presented with chest pain (p=0.001, OR 0.23, CI 0.10-0.54). One year event-free survival was higher in patients who did not have stroke (95.3% vs 80.0%, p=0.005, OR 4.50, CI 1.43-14.15)

Conclusion

Since sex gender and form of presentation of NSTEMI are not modifiable factors we cannot prevent strokes from happening in the context of NSTEMI.

Extending MQTT with Real-Time Communication Services Based on SDN

MQTT is one of the most popular application-layer protocols used in the scope of the Internet-of-Things (IoT) and Industrial-Internet-of-Things (IIoT), given its suitability for resource-constrained embedded systems. However, MQTT Quality-of-Service policies do not support timeliness requirements, which is common in IIoT. The literature reports several research works that address this limitation, but they are limited in scope (e.g., improvements in the broker’s internal operation, control of the publisher’s data rate, and path optimizations). Conversely, this paper presents a comprehensive architectural approach, proposing a set of extensions to the MQTT protocol that allow applications to explicitly specify real-time requirements and instantiate corresponding network reservations to enforce the desired temporal behavior. Such reservations are enforced via Software Defined Networking, specifically the OpenFlow protocol, but other protocols that allow bandwidth reservations, e.g., TSN, can also be used. This paper presents the proposed system architecture together with extensive emulation and implementation results that validate the feasibility of the approach, showing that time-sensitive MQTT traffic can be effectively segregated and prioritized to meet application-defined real-time requirements. Using several combinations of network topologies and load levels and comparing to the absence of the proposed real-time mechanisms, both average and worst-case latencies of the time-sensitive traffic decreased to approximately half, while for the normal traffic, they increased by approximately 10%.

Optimal Relay Network for Aerial Remote Inspections

Unmanned aerial vehicles (UAVs), in particular multirotors, are becoming the de facto tool for aerial sensing and remote inspection. In large industrial facilities, a UAV can transmit an online video stream to inspect difficult-to-access structures, such as chimneys, deposits, and towers. However, the communication range is limited, constraining the UAV operation range. This limitation can be overcome with relaying UAVs placed between the source UAV and the control station, creating a line of communication links. In this work, we assume the use of a digital data packet network technology, namely WiFi, and tackle the problem of defining the exact placement for the relaying UAVs that creates an end-to-end channel with maximal delivery of data packets. We consider asymmetric communication links and we show an increase as large as 15% in end-to-end packet delivery ratio when compared to an equidistant placement. We also discuss the deployment of such a network and propose a fully distributed method that converges to the global optimal relay positions taking, on average, 1.4 times the time taken by a centralized method.

Usability of a telehealth solution based on TV interaction for the elderly: the VITASENIOR-MT case study

Remote monitoring of biometric data in the elderly population is an important asset for improving the quality of life and level of independence of elderly people living alone. However, the design and implementation of health technological solutions often disregard the elderly physiological and psychological abilities, leading to low adoption of these technologies. We evaluate the usability of a remote patient monitoring solution, VITASENIOR-MT, which is based on the interaction with a television set. Twenty senior participants (over 64 years) and a control group of 20 participants underwent systematic tests with the health platform and assessed its usability through several questionnaires. Elderly participants scored high on the usability of the platform, very close to the evaluation of the control group. Sensory, motor and cognitive limitations were the issues that most contributed to the difference in usability assessment between the elderly group and the control group. The solution showed high usability and acceptance regardless of age, digital literacy, education and impairments (sensory, motor and cognitive), which shows its effective viability for use and implementation as a consumer product in the senior market.

Untangling Absorption Mechanisms and Variability in Bioequivalence Studies Using Population Analysis

PURPOSE

Both inter-individual (IIV) and inter-occasion (IOV) variabilities are observed in bioequivalence studies. High IOV may be a cause of problems on the demonstration of bioequivalence, despite strict measures are taken to control it. The objective of this study is to investigate further means of controlling IIV by optimizing study design of crossover studies.

METHODS

Data from 18 bioequivalence studies were used to develop population pharmacokinetics (popPK) models to characterize the absorption and disposition processes of 14 drugs, to estimate IOV for each drug substance and to evaluate possible correlations with biopharmaceutical properties of drug substances, classified in accordance to the Biopharmaceutics Drug Disposition Classification System (BDDCS).

RESULTS

Plasma-pharmacokinetics profiles for the 14 drugs analyzed were successfully described using popPK. The pharmacokinetic parameters that showed greater variability were first-order rate constant of absorption, duration of the zero-order absorption process, relative bioavailability and time of latency. ISCV% estimated for C_max seems to correlate with the log-Dose-Number for Class 1, 2 and 3, despite no direct correlation was observed between popPK model residual variability (RUV) and ISCV%. Nevertheless, higher RUV estimates were observed for Class 2 drugs in comparison to Class 1 and 3.

CONCLUSION

Pharmacokinetic parameters related to drug absorption showed greater variability. Ingestion of the IMP along with 240 mL of water showed to standardize gastric emptying. Given the dependency between C_max variability and dose-solubility ratio, for classes 2 and 4, ad libitum water intake may increase C_max and AUC ISCV%. A water ingestion standardization until the expected T_max of the drug is suggested.

Anaphylactic shock with pulmonary eosinophilic infiltration due to honeybee attack in a donkey: case report

ABSTRACT A case of a donkey attacked by Africanized honeybee is reported here with clinical signs of agitation, dehydration, congestion of the ocular mucous membranes, tongue edema, tachycardia and inspiratory dyspnea, and progression to death. At necropsy, diffuse, severe subcutaneous edema at face and cervical regions and severe diffuse pulmonary hyperemia with abundant edema without parenchymal collapse were observed. Microscopically, marked, diffuse deep dermis and panniculus carnosus edema and marked diffuse alveolar edema, with moderate population of eosinophils predominantly around larger caliber vessels were noted. The final diagnosis of anaphylactic shock was supported by history, clinical signs, and anatomic pathology findings. This is the first report of a honeybee attack with pulmonary eosinophilic infiltration in a mammal.

Antithrombotic strategy in patients with atrial fibrillation and acute coronary syndrome

Background

Atrial fibrillation (AF) is frequent in patients admitted with acute coronary syndromes (ACS). The development of this arrhythmia occurs in 2–21% of patients with non ST-elevation ACS and 21% of ST-elevation ACS. According with the most recent European guidelines, a short period up to 1 week of triple antithrombotic therapy (TAT) is recommended, followed by dual antithrombotic therapy (DAT) using a NOAC and a single antiplatelet agent, preferably clopidogrel.

Objective

To compare the antithrombotic strategy (DAT vs TAT) used and its prognostic value in patients with AF and ACS.

Methods

Retrospective analysis of patients' data admitted with ACS in a multicentric registry between 10/2010–09/2019. TAT was defined as the prescription of dual antiplatelet therapy and one anticoagulant and DAT as one antiplatelet and one anticoagulant. Survival and rehospitalization were evaluated through Kaplan-Meier curve.

Results

1067 patients were included, mean age 67±14 years, 72.3% male. Patients who developed de novo AF during hospitalization due to ACS were older (75±12 vs 66±14 years, p&lt;0.001) and with higher prevalence of cardiovascular risk factors and cardiovascular disease. AF was more often in patients with ST elevation ACS (53.4%). During hospitalization, AF patients were more often medicated with aspirin, glycoprotein inhibitor, heparin, fondaparinux and vitamin K antagonists. No difference was found regarding P2Y12 inhibitors. AF patients presented more often obstructive coronary disease (normal coronaries 5.4 vs 8.5%, p&lt;0.001) so they were more often submitted to PCI (79.5 vs 70.9%, p&lt;0.001). AF patients presented with higher rates of adverse in-hospital events as re-infarction, heart failure, shock, ventricular arrhythmias, cardiac arrest, stroke, major bleeding and death (p&lt;0.001). At discharge, AF patients were less prescribed with aspirin or ticagrelor, but the rate of clopidogrel prescription was higher, such as vitamin K antagonists or any of the new anticoagulants. In the AF group, 21.5% patients were discharged with TAT and 30.3% with DAT. Concerning patients discharged with TAT, 1-year follow-up revealed no significant differences in mortality (p=0.578), re-admission for cardiovascular causes (p=0.301) and total re-admission rates (p=0.291). Patients discharged with DAT had similar mortality (p=0.623) and re-admission for cardiovascular causes rates (p=0.138), but significant differences were identified regarding total re-admissions (p=0.024).

Conclusions

In patients with ACS and de novo AF, a low percentage of patients was discharged with oral anticoagulation (51.8%). In those whose anticoagulation was initiated, DAT was the preferred strategy. 1-year outcomes were not different between the antithrombotic strategy, except for all cause re-admission.

Funding Acknowledgement

Type of funding sources: None.

Treatment-induced shrinking of tumour aggregates: a nonlinear volume-filling chemotactic approach

Motivated by experimental observations in 3D/organoid cultures derived from glioblastoma, we propose a novel mechano-transduction mechanism where the introduction of a chemotherapeutic treatment induces mechanical changes at the cell level. We analyse the influence of these individual mechanical changes on the properties of the aggregates obtained at the population level. We employ a nonlinear volume-filling chemotactic system of partial differential equations, where the elastic properties of the cells are taken into account through the so-called squeezing probability, which depends on the concentration of the treatment in the extracellular microenvironment. We explore two scenarios for the effect of the treatment: first, we suppose that the treatment acts only on the mechanical properties of the cells and, in the second one, we assume it also prevents cell proliferation. We perform a linear stability analysis which enables us to identify the ability of the system to create patterns and fully characterize their size. Moreover, we provide numerical simulations in 1D and 2D that illustrate the shrinking of the aggregates due to the presence of the treatment.

Bernard Soulier syndrome: a rare, frequently misdiagnosed and poorly managed bleeding disorder

Bernard Soulier syndrome is a rare, congenital platelet bleeding disorder, with autosomal recessive inheritance. It is characterised by macrothrombocytopenia and platelet dysfunction, leading to mucocutaneous bleeding noted in early childhood. This entity poses an important diagnostic challenge, and blood smear and DNA sequencing are paramount for the correct diagnosis. Differential diagnosis includes May-Hegglin anomaly, Glanzmann Thrombasthenia and von Willebrand disease; it is also often misdiagnosed as idiopathic thrombocytopenic purpura. We report a 68-year-old man diagnosed with von Willebrand disease for three decades, admitted with gastrointestinal bleeding, anaemia and severe thrombocytopenia. Replacement with von Willebrand factor did not stop the haemorrhage, suggesting another aetiology for the bleeding disorder. Corticosteroids and intravenous immune globulin were also ineffective. Genetic sequencing showed a homozygous mutation in GP1BA gene, thus establishing the correct diagnosis.

Sustained ventricular tachycardia as a predictor of major adverse cardiac events in acute coronary syndrome patients

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

Sustained ventricular tachycardia (VT) is a frequent rhythm disturbance during an ischemic event like acute coronary syndrome (ACS). VT was frequently associated with worse prognosis, then is expected, that its presence is related to a higher incidence of major adverse cardiac events (MACE).

Objective

Evaluate if sustained VT was a predictor of MACE in ACS hospitalized patients.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Patients were divided into two groups: A – patients without VT, and B – patients that presented VT on the hospitalization. VT was defined as a register or more of the VT with at least 30 seconds. Were excluded patients without a previous cardiovascular history or clinical data. MACE was defined as re-infarction, congestive heart failure, cardiogenic shock, a mechanical complication of myocardial infarction, completed atrioventricular block, sustained ventricular tachycardia, cardiac arrest, stroke and hospitalization death. Univariate logistic regression was performed to assess if VT in ACS patients was a predictor of MACE.

Results

A total of 29851 patients was analyze and 25725 had information regarding VT. From the group of patients that presented VT, 177 (1.1%) had re-infarction, 2415 (14.1%) had congestive heart failure, 816 (5.0%) had atrial fibrillation, 108 (0.7%) had a mechanical complication of myocardial infarction, 442 (2.7%) had completed atrioventricular block, 458 (2.8%) had cardiac arrest, 101 (0.6%) had stroke and 535 (3.3%) died. VT did not predict re-infarction (p = 0.071), mechanical complication of myocardial infarction (p = 0.979) and stroke (p = 0.500) in ACS hospitalized patients. Logistic regression revealed that VT in ACS patients was a predictor of congestive heart failure (odds ratio (OR) 2.304, p &lt; 0.001, confidence interval (CI) 1.742-3.047), atrial fibrillation (OR 2.078, p &lt; 0.001, CI 1.453-2.973), completed atrioventricular block (OR 1.831, p = 0.012, CI 1.145-2.928), cardiac arrest (OR 15.434, p &lt; 0.001, CI 11.429-20.843) and hospitalization death (OR 6.472, p &lt; 0.001, CI 4.484-9.342).

Conclusions

VT in ACS patients predict MACE, namely congestive heart failure, atrial fibrillation, completed atrioventricular block, cardiac rest and hospitalization death.

Was the atrioventricular block similar in anterior and inferior ST-elevation myocardial infarction?

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

The presence of atrioventricular block (AVB) in ST-elevation myocardial infarction (STEMI) is more frequently registered when is identified in the inferior leads. However, AVB maybe occurs in anterior STEMI, yet the AVB and STEMI localization maybe had different implications.

Objective

Evaluate the impact and prognosis of AVB according to the STEMI localization.

Methods

Multicenter retrospective study, based on the Portuguese Registry of Acute Coronary Syndrome between 1/10/2010-3/05/2020. Patients were divided into two groups: A – patients with anterior STEMI, and B – patients with inferior STEMI. Were excluded patients without a previous cardiovascular history or clinical data regarding AVB occurrence. Logistic regression was performed to assess AVB as a prognostic marker in STEMI patients.

Results

From 32157 patients, was identified 462 with AVB, 72 in group A (15.6%) and 390 in group B (84.4%). Both groups were similar regarding gender (p = 0.710), age (p = 0.068), body mass index (p = 0.535), admitly directly to cat lab (p = 0.635), initial symptons until first medical contact (p = 0.561), smoker status (p = 0.483), diabetes mellitus (p = 0.331), coronary artery disease (p = 0.053), previous stroke (p = 0.332),  peripheral artery disease (p = 0.348), chronic kidney disease (p = 0.425), systolic blood pressure (p = 0.057), multivessel diasease (p = 0.235), new-onset of atrial fibrillation (p = 0.582), cardiac arrest (p = 0.062) and stroke complication (p = 0.685). Group B had higher left ventricular ejection fraction (LVEF) &gt;50% (16.9 vs 60.7%, p &lt; 0.001). On the other hand, group A had more arterial hypertension (79.7 vs 66.2%, p = 0.027), dislipidaemia (58.2 vs 54.4%, p = 0.038), heart rate at admission (81 ± 20 vs 59 ± 23, p &lt; 0.001), Killip-Kimball class &gt; I (45.7 vs 29.6%, p = 0.008), sinus rhythm at admission (84.5 vs 72.6%, p = 0.035), heart failure complication (65.3 vs 37.1%, p &lt; 0.001), cardiogenic shock complication (42.3 vs 24.7%, p &lt; 0.001), ACS mechanical complication (8.3 vs 3.1%, p = 0.047), sustained ventricular tachycardia during ACS hospitalization (19.4 vs 8.5%, p = 0.005) and hospitalization death (52.9 vs 44.7%, p &lt; 0.001). Logistic regression revealed that AVB in inferior STEMI was a predictor of new-onset of atrial fibrillation (odds ratio (OR) 3.817, p = 0.038, confidence interval (CI) 1.123-12.975), with a R2 Nagelkerke 24.4. Also, revealed that AVB in anterior STEMI was a predictor of death (OR 0.111, p &lt; 0.001, CI 0.034-0.366), with a R2 Nagelkerke 55.2.

Conclusions

AVB in inferior STEMI was a predictor of new-onset of atrial fibrillation and AVB in anterior STEMI was a predictor of death.

Sustained ventricular tachycardia in acute coronary syndromes the Portuguese experience

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

Acute coronary syndromes (ACS) are frequent and are associated with high levels of comorbidities and complications. Ventricular tachycardia (VT) is one of the most danger and stressful situations in ACS.

Objective

Evaluate predictors of ventricular tachycardia in ACS.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Patients were divided in two groups: A – patients without VT, and B – patients that presented VT on the hospitalization. VT was defined as a register or more of the VT with at least 30 seconds. Logistic regression was performed to assess predictors of VT in ACS patients.

Results

25361 in group A (98.6%) and 364 in group B (1.4%). Both groups were similar regarding gender, cardiovascular risk factors, except for dyslipidemia (61.7 vs 51.9%, p &lt; 0.001) and ST-segment elevation myocardial infarction (STEMI) location. Group B was elderly (67 ± 14 vs 70 ± 14, p &lt; 0.001), was admitted directly to the cat lab (10.6 vs 20.4%, p &lt; 0.001), had less time since the onset of symptoms until the admission (383 ± 157 vs 349 ± 121, p = 0.003), but presented higher previous history of heart failure (5.9 vs 10.6%, p &lt; 0.001), peripheral vascular disease (5.5 vs 8.4%, p = 0.015), chronic obstructive pulmonary disease (COPD) (4.4 vs 7.9%, p = 0.001) and dementia (1.7 vs 3.2%, p = 0.038). At admission presented higher levels of STEMI (42 vs 67%, p &lt; 0.001), dyspnea (29 vs 18.1%, p &lt; 0.001), syncope (1.3 vs 6.6%, p &lt; 0.001), cardiac arrest (0.4 vs 4.4%, p &lt; 0.001), Killip-Kimball classification &gt; I (14.8 vs 40.5%, p &lt; 0.001) and atrial fibrillation at admission (AF) (7.1 vs 15.3%, p &lt; 0.001). Ivabradine (3.7 vs 7.6%, p &lt; 0.001), aldosterone receptor antagonists (10.2 vs 24%, p &lt; 0.001), diuretic (28 vs 57.2%, p &lt; 0.001), amiodarone (5.6 vs 53.5%, p &lt; 0.001), digoxin (1.4 vs 4.7%, p &lt; 0.001) were more prevalent used in the admission. Group B exhibited higher multivessel disease (MVD) (51.5 vs 61.5%, p &lt; 0.001), culprit as common coronary trunk (CT) (1.7 vs 4.2%, p = 0.024), hybrid revascularization (0.8 vs 2%, p = 0.032) and left ventricular ejection fraction (LVEF)&lt;50% (38.7 vs 71%, p &lt; 0.001). On the other hand, the used of beta block (81.4 vs 62.3%, p &lt; 0.001), angiotensin-converting-enzyme inhibitor (85.5 vs 74.4%, p &lt; 0.001) and calcium channel blockers (10.1 vs 24%, p &lt; 0.001) since had a protect effect. Regarding reinfarction (0.9 vs 2.5%, p = 0.007), de novo heart failure (15.1 vs 50.3%, p &lt; 0.001), atrioventricular block (2.2 vs 17%, p &lt; 0.001), stroke (1.4 vs 4.9%, p &lt; 0.001) and death (3.4 vs 26.9%, p &lt; 0.001), all were higher in Group B. Logistic regression revealed COPD (odds ratio (OR) 1.9, p = 0.010, confidence interval (CI) 1.17-3.10), STEMI (OR 2.73, p &lt; 0.001, CI 2.00-3.73), AF (OR 2.30, p &lt; 0.001, CI 1.52-3.49), MVD (OR 1.44, p = 0.012, CI 1.08-1.92), CT (OR 2.87, p = 0.003, CI 1.45-5.69) and LVEF &lt; 50%  (OR 3.44, p &lt; 0.001, CI 2.52-4.71) as predictors of VT in ACS.

Conclusions

COPD, STEMI, AF, MVD, CT and LVEF &lt; 50% were predictors of VT in ACS.

Endocardial left ventricular pacing Where are we a systematic review

Funding Acknowledgements

Type of funding sources: None.

Background

Endocardial left ventricular pacing is a technique used in cardiac resynchronization therapy (CRT), when a coronary sinus implant is not possible, conventional CRT was an unsuccess and in CRT nonresponders. We performed a systemic review to evaluate its risks and benefits.

Objective

Review the evidence regarding the efficacy and safety of endocardial left ventricular pacing.

Methods

A systemic research on MEDLINE and PUBMED with the term "endocardial left ventricular pacing", "biventricular pacing" or "endocardial left pacing". 1038 results were identified, however, just publish papers (excluding abstract) with more than 16 patients was admitted in these analyses. Comparisons pre and post CRT regard New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF) and QRS width was performed. Mean differences (MD) and confidence interval (CI) was used as a measurement of treatment.

Results

Eleven studies were selected, including a total of 560 patients. The studies were performed with different techniques, trans-atrial septal technique, trans-ventricular septal technique and transapical technique. Mean age 66.93 years old, 90.54% male, median ejection fraction of 28.86%, NYHA class of 3.03, QRS width 167,50 mseg. Ischemic etiologic in 43.88%, atrial fibrillation in 45.35% and left bundle branch block in 55.20%. Was reported several complications after the procedure, 8 pocket infection (7 studies), 17 transient ischemic attacks (10 papers), 17 ischemic stroke (all), 35 tromboembolic events (all) and 115 deaths, nevertheless, follow up in the different studies was diverse and heterogeneous. Significant improvement was registered in NYHA class (MD 0.64, CI 0.56-0.72, p &lt; 0.00001, I2 = 89%) (reported in 7 studies), LVEF (MD 6.20, CI 5.09-7.32, p = 0.002, I2 = 69%) %) (reported in 8 studies) and QRS width (MD 31.35, CI 26.11-36.60, p &lt; 0.00001, I2 = 89%) %) (reported in 5 studies), (all p &lt; 0.00001).

Conclusions

Left ventricular endocardial pacing is a feasible alternative to conventional CRT, when the last one is not possible. With clinical, electrocardiogram and echocardiogram improvement in several series. First data regarding this procedure were associated with higher stroke incidence, something contrary to the last study’s results. Nevertheless, at the moment just small series present this technique with heterogenous results and different approaches, being important further investigation.

Septal vs apical defibrillator electrode placement a systematic review

Funding Acknowledgements

Type of funding sources: None.

Background

The optimal right ventricular defibrillator lead placement is still a debatable matter. We attempt to performed a systemic review to evaluate whether septal and apical placement had significant differences in the follow-up with an indication for implantation of these devices.

Objective

Review the evidence regarding the efficacy and safety of right ventricular apical and septal defibrillator lead placement.

Methods

A systemic research on MEDLINE and PUBMED with the term "septal pacing", "apical pacing" "septal defibrillation" or "apical defibrillation". 309 results were identified, however, after a serious analysis, several articles were excluded. Comparisons between apical and septal placement were performed regarding R wave amplitude, pacing threshold at 0.5 ms, lead impedance, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD) and lead complication that produced lead re-placement. Mean differences (MD) and confidence interval (CI) was used as a measurement of treatment.

Results

Six studies were selected, including a total of 2180 patients. The studies were performed with different techniques, analyses and goals. The studies presented heterogeneous and diverse results, with a varied follow-up period, that resulted in the exclusion of one of the studies. Mean age 64.51 years old, 76.86% male, a median ejection fraction of 27.84%, NYHA class of 2.65, ischemic etiologic in 51.10% and a follow-up period of 26.49 months. Septal defibrillator lead placement was established in 772 patients, while the apical defibrillator lead placement was performed in 1399 patients. No differences regarding the lead performance on apical and septal placement were detected regarding the R-wave (MD -0.36, CI -0.75 - +0.03, p = 0.68, I2 = 0%) (reported in 3 studies) and lead impedance (MD -23.83, CI -51.36 - +3.69, p = 0.003, I2 = 82%) (reported in 3 studies). Pacing threshold seems to be favor a septal defibrillator lead implantation (MD -0.05, CI -0.09 - -0.02, p = 0.12, I2 = 53%) (reported in 3 studies). Concerning echocardiography parameters during the follow up period, LVEF (MD -0.83, CI -3.05 - +1.38, p = 0.10, I2 = 57%) (reported in 3 studies) and LVEDD (MD -0.51, CI -2.13 - +1.10, p = 0.20, I2 = 38%) (reported in 3 studies) were not significant influenced for the defibrillator lead placement. Lead complications that provoke a lead replacement was not significant between the lead placement (MD 1.25, CI 0.53 – 2.94, p = 0.71, I2 = 0%) (reported in 3 studies).

Conclusions

Just pacing threshold proved to improve the septal defibrillator lead placement. Neither the other lead parameters or the echocardiography results during the follow-up were influenced by the lead placement. For a definitive conclusion is important to further investigation.

Prognosis of new-onset of atrial fibrillation in acute coronary syndrome: Portuguese experience

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

Acute coronary syndrome (ACS) and atrial fibrillation (AF) are common diseases in developed countries and in some cases, the first episode of AF can occur during the ACS. A stressful event like an ACS can be a trigger for AF, being important to realize its impact and prognosis in the short and long term.

Objective

Evaluate the impact and prognosis of new-onset AF in ACS.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. Patients were divided into two groups: A – patients without new-onset AF, and B – patients that presented new onset of AF. Were excluded patients without a previous cardiovascular history or clinical data during the admission and the follow-up period. Logistic regression was performed to assess if new-onset AF in ACS was a predictor of major adverse cardiac events and mortality. Kaplan-Meier test was performed to establish the survival rates and re-admission for one year of follow up.

Results

9687 patients suffered ACS and had follow-up at 1 year, 9264 in group A (95.6%) and 423 in group B (4.4%). Both groups were similar regarding dyslipidemia, diabetes mellitus, previous coronary artery disease, multivessel disease after the cardiac catheterization. Group A had more smokers (28.2 vs 17.8%, p &lt; 0.001) and left ventricular ejection fraction (LVEF) &gt;50% (69.2 vs 45.1%, p &lt; 0.001). On the other hand, group B was elderly (67 ± 14 vs 75 ± 12, p &lt; 0.001), female (26.9 vs 34.0%, p &lt; 0.001), arterial hypertension (70.5 vs 77.5%, p = 0.005), was more admitted directly to the cat lab (12.5 vs 17.7%, p = 0.002), ST-segment elevation myocardial infarction (40.2 vs 49.9%, p &lt; 0.001), Killip-Kimball classification &gt; I (12.8 vs 34.8%, p &lt; 0.001) and hybrid revascularization (0.7 vs 2.4%, p = 0.002). Logistic regression revealed that new-onset of AF in ACS patients was a predictor of congestive heart failure (odds ratio (OR) 1.75, p &lt; 0.001, confidence interval (CI) 1.47-2.09), cardiogenic shock (OR 3.08, p &lt; 0.001, CI 2.37-4.01), sustained ventricular tachycardia (OR 2.29, p &lt; 0.001, CI 1.61-3.25) and intrahospital mortality (OR 1.99, p &lt; 0.001, CI 1.51-2.63). Nevertheless, new-onset of AF was not associated with re-infarction (p = 0.361), mechanical complications (p = 0.319), atrioventricular block (p = 0.574), stroke (p = 0.131) and cardiac arrest (p = 0.060) during the hospitalization for ACS. Mortality rates at one year of follow-up showed significant differences, p &lt; 0.001, between the two groups (Figure 1). Similar results were found concerning re-admission for all causes, p = 0.021 (Figure 2), on the other causes, re-admission for cardiovascular causes do not reveal to be significant, p = 0.515.

Conclusions

New-onset of AF in ACS was a predictor of congestive heart failure, cardiogenic shock, sustained ventricular tachycardia and intrahospital mortality. AF was associated with higher mortality rates and re-admission for all causes at one year follow up.

Atrioventricular block in acute coronary syndrome: Portuguese experience

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Portuguese Registry of Acute Coronary Syndromes

Background

The atrioventricular block (AVB) occurrence in acute coronary syndrome (ACS) is a potentially life-threatening complication, that demand a rapid and efficient response regarding reperfusion time and rhythm stabilization.

Objective

Evaluate the impact and prognosis of AVB in ACS patients, as well as predictors of AVB.

Methods

Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-3/05/2020. Patients were divided into two groups: A – patients without AVB, and B – patients that presented AVB. Were excluded patients without a previous cardiovascular history or clinical data regarding AVB occurrence. Logistic regression was performed to assess predictors of AVB in ACS patients.

Results

From 32157 patients, 23774 was included, 23148 in group A (97.4%) and 626 in group B (2.6%). Both groups were similar regarding initial symptons until first medical contact (p = 0.410), smoker status (p = 0.222), arterial hypertension (p = 0.776), diabetes mellitus (p = 0.508), peripheral artery disease (p = 0.479), chronic kidney disease (p = 0.467) and re-infarction during the hospitalization for ACS (p = 0.145). Group A had higher body mass index (27.4 ± 4.4 vs 26.9 ± 4.6, p = 0.005), dislipidaemia (59.6 vs 51.4%, p &lt; 0.001), coronary artery disease (18.9 vs 13.0, p &lt; 0.001), heart rate (78 ± 19 vs 65 ± 25, p &lt; 0.001), systolic blood pressure (139 ± 29 vs 119 ± 32, p &lt; 0.001) and left ventricular ejection fraction (LVEF) &gt;50% (60.1 vs 51.7%, p &lt; 0.001). On the other hand, group B was elderly (66 ± 13 vs 71 ± 13, p &lt; 0.001), female (27.4 vs 32.4%, p &lt; 0.001), previous stroke (6.9 vs 10.9%, p &lt; 0.001), neoplasia (4.9 vs 6.8%, p = 0.031), ST-segment elevation myocardial infarction (46.2 vs 75.4%, p &lt; 0.001), syncope as major symptom (1.3 vs 10.0%, p &lt; 0.001), Killip-Kimball class &gt; I (15.4 vs 31.6%, p &lt; 0.001), multivessel diasease (52.1 vs 61.4%, p &lt; 0.001), heart failure complication (15.5 vs 40.6%, p &lt; 0.001), cardiogenic shock complication (3.8 vs 24.6%, p &lt; 0.001), new-onset of atrial fibrillation (4.2 vs 14.1%, p &lt; 0.001), ACS mechanical complication (0.6 vs 3.2%, p &lt; 0.001), sustained ventricular tachycardia during ACS hospitalization (1.3 vs 10.0%, p &lt; 0.001), cardiac arrest (2.7 vs 13.3%, p &lt; 0.001), stroke complication (0.6 vs 1.9%, p &lt; 0.001) and hospitalization death (3.5 vs 19.0%, p &lt; 0.001). Logistic regression revealed that female gender (odds ratio (OR) 1.422, p = 0.015, confidence interval (CI) 1.072-1.885), age ≥75 years old (OR 1.560, p = 0.002, CI 1.174-2.073), heart rate &lt;60 (OR 6.692, p &lt; 0.001, CI 5.180-8.644) and Killip-Kimball class &gt; I (OR 3.264, p &lt; 0.001, CI 2.446-5.356) were predictors of AVB in ACS patients.

Conclusions

Female gender, age ≥75 years old, heart rate &lt;60 and Killip-Kimball class &gt; I were predictors of AVB in ACS patients.