P5522ST elevation myocardial infarction networks: relationship of hub-spoke distance with transfer time and clinical outcomes in rescue PCI

Background

In the establishment of ST elevation myocardial infarction (STEMI) systems of care, transfer times between primary care units (PCU) and the cardiac catheterization lab (CCL) are pillars to therapeutic success. Objective: To analyze the relationship between PCU-CCL distance with transport time and main clinical outcomes in STEMI patients (p) treated with pharmaco-invasive therapy (PIT) and referred for rescue PCI after failed fibrinolysis.

Methods

Between January 2010 and December 2018, of the 2241 patients who received tenecteplase in PCU inserted in a large city STEMI network, 801 (35.7%) evolved without reperfusion criteria after 90 minutes (persistence of chest pain, less than 50% reduction on ST elevation or hemodynamic instability), being urgently transferred to the CCL. The PCU were divided according to the distance to the tertiary center in Group 1: between 5 and 9km (N=208p), Group 2: between 16 and 18km (N=315p) and Group 3: between 22 and 30km=266p). Considering an alpha of 0.05, sample size n=801 and an effect size of 0.11, a power of 0.80 was obtained.

Results

The groups were comparable for baseline features (Table 1). Group 2 (intermediate distances) had the highest median transport time (G1 260 interquartile 145–437 min vs G2 355 interquartile 206–573 min vs G3 241 interquartile 125–418 min; p<0.01 for G2). There were no differences between the groups regarding cardiogenic shock (G1 24.5% vs G2 23.3% vs G3 24.1%, p=0.9) or in-hospital death (G1 17.4% vs G2 12.3% vs G3 13.0%, p=0.2).

Table 1. Group's baseline features G1: Short distances G2: Intermediate distances G3: Long distances p value (5–9 km) N=208 (16–18 km) N=315 (22–30 km) N=266 Age (median) 57.5 (51–64) 57 (49–66) 59 (52–67) 0.27 Female 29.7% 28.3% 35.1% 0.19 Hypertension 67.3% 60.9% 64.4% 0.31 Diabetes 37.0% 32.1% 37.8% 0.30 Renal failure 10.3% 9.7% 6.3% 0.21 Anterior STEMI 56.1% 58.4% 62.4% 0.36 Pain-to-needle time (median min) 197.5 (137–330) 195 (120–295) 195 (125–345) 0.38

Conclusion

In STEMI patients with failed fibrinolysis treated with pharmaco-invasive therapy, the PCU-CCL distance was not related to transfer time or to outcomes of in-hospital death and cardiogenic shock. The longer transport time of hospitals located at intermediate distance can possibly reflect local logistical difficulties and are not due to hub-spoke distance. Continuous improvement in structuring and coordination of public STEMI networks is aimed.

Human Immunodeficiency Virus (HIV) 2 Superinfection in a Patient Receiving Antiretroviral Therapy With Longstanding HIV-1 Viral Load Suppression

Dual human immunodeficiency virus (HIV) 1 and HIV-2 superinfections are rare but challenging. A HIV-1–infected patient receiving effective antiretroviral therapy was investigated for a severe CD4⁺ cell count decline. HIV-2 superinfection was diagnosed and genotypic test revealed mutations conferring resistance to most drug class, limiting options for treatment.

Contribuição à identificação de compostos purínicos e pirimidínicos de interesse biológico

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Micropatterned Silica Films with Nanohydroxyapatite for Y-TZP Implants

This investigation aimed at developing micropatterned silica thin films (MSTFs) containing nanohydroxyapatite (nano-HA) microaggregates that were not completely covered by silica so that they could directly interact with the surrounding cells. The objectives were 1) to evaluate the effect of the presence of 2 films (MSTF with or without nano-HA addition) on the characteristic strength (σ₀) and Weibull modulus ( m) of a yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) and 2) to evaluate the effect of these 2 films, as applied onto the Y-TZP surface, on the morphology, orientation, and proliferation of MG63 cells. Sol-gel process and soft lithography were used to apply the MSTF onto the Y-TZP specimens. Three experimental groups were produced: Y-TZP, Y-TZP + MSTF, and Y-TZP + MSTF + sprayed nano-HA. All surfaces were characterized by scanning electron microscopy and energy-dispersive X-ray spectroscopy and tested for 4-point flexural strength ( n = 30) in water at 37 °C. Weibull analysis was used to determine m and σ₀ (maximum likelihood method). In vitro biological behavior was performed with human osteoblast-like cells (MG63). Y-TZP was successfully coated with MSFT and MSFT + nano-HA. Scanning electron microscopy micrographs indicated that the microaggregates of nano-HA were not entirely covered by the silica. There was no statistically significant difference among the experimental groups for σ₀ and m. In the groups containing the films, the cells were elongated and aligned along the lines. The MSFT + nano-HA group showed significantly higher cell metabolic activity than that obtained for the Y-TZP group at day 7. This investigation was successful in producing an MSTF containing nano-HA microaggregates that remained exposed to the environment. The developed films did not jeopardize the structural reliability of a commercial Y-TZP, as confirmed by the Weibull statistics. The MG63 cells seeded over the films became elongated and aligned along the films' micropatterned lines. Y-TZP specimens coated with MSTF and nano-HA showed a higher cell metabolic activity and proliferation after 7 d of culture when compared with uncoated Y-TZP.

Severe asthma in obese patients: Improvement of lung function after treatment with omalizumab

INTRODUCTION

Asthma and obesity have a considerable impact on public health and their prevalence is increasing. Obesity is a known risk factor for asthma and can make it more difficult to control. Omalizumab is recommended in patients with severe allergic persistent asthma. The aim of this study was to assess the impact of omalizumab treatment in obese asthmatic patients with poorly controlled severe persistent asthma.

METHODOLOGY

A non-interventional, prospective study was conducted, in an outpatient asthma clinic. All patients with severe asthma who started treatment with omalizumab were included and followed over 12 months. The study population was divided into two groups (obese and non-obese) for statistical analysis (descriptive and comparative analysis).

RESULTS

Thirty-two patients (19 obese) were followed. After 12 months of omalizumab treatment, there was a statistically significant improvement in body mass index, number of exacerbations in the previous year, rescue medication, disease control and lung function, in the whole population. At the end of the study obese patients had a significantly better lung function (FEV₁) than non-obese.

DISCUSSION

As described in the literature, there was a significant reduction in the number of exacerbations in the previous year, rescue medication and better disease control, in the whole population. In relation to lung function, about which published data are inconsistent, treatment with omalizumab significantly improved it in obese patients.

CONCLUSION

Our study showed that omalizumab significantly improved asthma control, reduced rescue medication and asthma exacerbations in all the population; and for the first time showed that obese patients achieved significantly improved lung function.

Abstract P4-12-06: Cost-effectiveness analysis of pertuzumab plus trastuzumab for advanced HER2-positive breast cancer in Brazil: A public health system perspective

Objectives:

Addition of pertuzumab to trastuzumab and docetaxel (THP) results in significant clinical benefits for women with HER2-positive metastatic breast cancer. Despite evidence of important overall survival and quality of life improvements, for the Brazilian patients depending on the public health system chemotherapy alone (CT) remains the standard treatment. Previous request for trastuzumab incorporation was denied by Brazilian Ministry of Health (MoH) due to high individual costs.

In an innovative way, the Brazilian Society of Clinical Oncology made a price negotiation directly with the pharmaceutical company, aiming to propose a formal request for the incorporation of these technologies to the National Committee for Health Technology Incorporation (CONITEC).

Our objective was to evaluate the cost-effectiveness of THP versus CT in patients with HER2-positive advanced breast cancer, under the perspective of the Brazilian public health system.

Methods:

A cost-effectiveness analysis was conducted using a Markov model over a lifetime horizon. The model considers three health states: 1st-line treatment without progression; disease progression (with chemotherapy or best supportive care) and death. Transition probabilities and mortality rates were extracted from randomized studies. Costs of standard chemotherapy, complications, and surveillance were obtained from price tables regulated by the MoH. Pertuzumab and trastuzumab prices were those negotiated with the manufacturing company. Benefits are presented in life-years (LY) and costs in USD (using exchange rate for Brazilian Real to USD = 3.50). The relation between costs and benefits were used to present the incremental cost-effectiveness ratio (ICER) per life-year saved. We have performed one-way deterministic sensitivity analyses with cost of monoclonal antibodies to define the ideal price in Brazil.

Results:

Patients with HER2-positive metastatic breast cancer treated with CT were projected to have 1.87 LY, with a total cost of $12,118. THP was projected to increase the life expectancy of these patients by 1.48 years, with an incremental cost of $63,685 per patient. Thus, the ICER was $42,893 per LY-gained.

Conclusions:

The World Health Organization recommendation of three times gross domestic product per capita have defined our cost-effectiveness threshold. Despite the discount price, at a willingness-to-pay (WTP) threshold of $25,615 per LY, THP is not a cost-effective strategy compared to CT. An additional reduction around 58.67% in the pertuzumab price would be necessary to make THP cost-effective in Brazil.

Discussion about the incorporation of trastuzumab to CT using the discount prices is in progress.

Citation Format: Carvalho AC, Vasconcelos VCA, Sasse AD. Cost-effectiveness analysis of pertuzumab plus trastuzumab for advanced HER2-positive breast cancer in Brazil: A public health system perspective [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-06.

Adsorption of H2, O2, H2O, OH and H on monolayer MoS2

Hydrogen and hydrogen-containing gases are commonly used as reductants in chemical vapor deposition growth of MoS₂. Here, we consider the defects resulting from the presence of hydrogen during growth and the resulting electronically active defects. In particular, we find that the interstitial hydrogen defect is a negative-U center with amphoteric donor and acceptor properties. Additionally, we consider the effects of interaction with water and oxygen. The defects are analysed using density functional theory calculations.

Characterization of gelatin and chitosan scaffolds cross-linked by addition of dialdehyde starch

In this study the influence of the addition of dialdehyde starch on the properties of scaffolds based on gelatin and chitosan obtained by the freeze-drying method was investigated. In addition, the adhesion and proliferation of human osteosarcoma SaOS-2 cells on the obtained scaffolds was examined. Chitosan and gelatin were mixed in different weight ratios (75/25, 50/50, 25/75) with 1, 2 and 5 wt% addition of dialdehyde starch. The obtained scaffolds were subjected to mechanical testing, infrared spectroscopy, swelling measurements, low-pressure porosimetry and zeta potential measurement. Internal material structures were observed by scanning electron microscopy. The results showed that the cross-linking process occurred after the addition of dialdehyde starch and resulted in increased mechanical strength, swelling properties, zeta potential and porosity of studied materials. The attachment of SaOS-2 cells to all modified materials was better compared to an unmodified control and the proliferation of these cells was markedly increased on modified scaffolds.

Circulating levels of adiponectin and extent of coronary artery disease in patients undergoing elective coronary angiography

Adiponectin (APN), an adipose tissue-released adipokine with demonstrated anti-inflammatory and anti-atherogenic properties, is encoded by a gene whose polymorphisms are associated with presence of coronary artery disease (CAD). Serum APN levels are inversely related with presence and complexity of CAD. Within this context, we sought to compare levels of total APN and its high molecular weight form (HMW APN) according to clinical presentation and extent of CAD in patients undergoing elective cardiac catheterization. From March 2008 to June 2010, clinical data and blood samples for APN and HMW APN measurements were collected from 415 subjects undergoing cardiac catheterization at two tertiary centers. CAD extent was estimated by the number of coronary arteries with significant stenosis (≥70% obstruction in a major coronary artery) and by Duke Jeopardy Score (DJS). Serum APN levels were similar between groups with stable or unstable CAD (APN 9.20±5.88 vs 9.47±6.23 μg/mL, P=0.738, and HMW APN 5.31±3.72 vs 5.91±4.16 μg/mL, P=0.255), even after stratification by the number of arteries involved (single-vessel vs multivessel disease: APN 9.39±5.76 vs 9.26±6.27 μg/mL, P=0.871; HMW APN 5.29±3.79 vs 5.83±4.04 μg/mL, P=0.306) and DJS score (APN, P=0.718; HMW APN, P=0.276). We conclude that APN and HMW APN serum levels are similar across clinical presentations and different extents of CAD, despite being significantly lower in the presence of obstructive CAD.