Comparable risk of ischemic stroke in patients with screen-detected atrial fibrillation on single timepoint handheld ECG screening to patients with known AF

Aims

To determine risk of ischemic stroke in patients with single timepoint screen-detected atrial fibrillation (AF).

Methods

Cohort of 11,972 consecutive patients aged ≥65 years attending medical outpatient clinics in Hong Kong underwent AF screening using a handheld single-lead ECG (AliveCor) from Dec 2014 to Dec 2017 (NCT02409654). Repeated screening was performed in patients who had >1 clinic visit during the study period. Cohort was divided into 4 exposure groups: (i) new AF detected by initial screening (S1-AF); (ii) new AF detected by subsequent screening or clinically diagnosed during follow up (FU-AF); (iii) known AF and (iv) no initial or subsequent FU-AF (no AF). Exposure in the FU-AF group was handled as a time-dependent variable. All AF exposure groups were further stratified by oral anticoagulant (OAC) use at the end of FU. Cumulative incidence of ischemic stroke was compared between groups during a median FU period of 2.3 (IQR=1.7–3.3) years, using Fine and Gray regression accounting for death as competing risk and using no AF as reference.

Results

Of 11,972 subjects enrolled, 2,236 (18.7%) had known AF and 9,736 (81.3%) underwent 13,571 screening events during the study period. The yield of newly diagnosed AF on initial screening was 2.3% (n=223/9,736), with 71 new AF detected by subsequent screening. During FU, 2.3% (221/9,442) screen-negative patients were diagnosed with AF clinically. Compared to no AF, S1-AF without OAC had the highest ischemic stroke risk (subdistribution hazard ratio (SHR)=2.79; 1.47–5.27), then FU-AF without OAC (SHR=2.66; 1.21–5.82) and known AF without OAC (SHR=1.97; 1.50–2.57). All AF groups taking OAC had similar risk of ischemic stroke as no AF.

Conclusion

This is the first study to report the prognosis of AF detected by single timepoint screening. The prognosis is not benign. Both risks of stroke and benefits from anticoagulation therapy were similar between screen-detected and known AF.

Funding Acknowledgement

Type of funding source: None

[Therapeutic revolution in the treatment of aortic stenosis : transcatheter aortic valve implantation (TAVI )]

Eighteen years after the birth of the concept, TAVI (Transcatheter Aortic Valve Implantation) has established itself as the treatment of choice for symptomatic patients with severe aortic valve stenosis at high surgical risk. Unlike surgical prosthesis, the benefit of which has been validated in observational studies, indications for TAVI are now based on the results of large randomized trials. The TAVI revolution continues today with the miniaturization of the equipment, the development of new closure systems, the availability of a wider range of prosthesis sizes and the growing experience of operators, all contributing to the widening of indications to lower risk patients.

Tumour and pelvic lymph node metabolic activity on FDG-PET/CT to stratify patients for para-aortic surgical staging in locally advanced cervical cancer

PURPOSE

The aim of our study was to comprehensively evaluate the most valuable metabolic parameters of cervical tumours and pelvic lymph nodes (PLN) by FDG-PET/CT to predict para-aortic lymph node (PALN) metastasis and stratify patients for surgical staging.

METHODS

The study included patients with locally advanced cervical cancer, negative PALN uptake on preoperative FDG-PET/CT, and para-aortic lymphadenectomy. Two senior nuclear medicine physicians expert in gynaecologic oncology reviewed all PET/CT exams, and extracted tumour SUVmax, MTV, and TLG, as well as PLN. Prognostic parameters of PALN involvement were identified using ROC curves and logistic regression analysis.

RESULTS

One hundred and twenty-five consecutive locally advanced cervical cancer patients were included. The FDG-PET/CT false-negative rate was, respectively, 27.7% (13/47) and 5.1% (4/78) in patients with and without FDG-PET/CT PLN uptake. The AUC of cervical tumour size, SUVmax, MTV, and TLG was, respectively, 0.75 (0.62-0.87), 0.59 (0.44-0.76), 0.75 (0.60-0.90), and 0.71 (0.56-0.86). The AUC of PLN size, SUVmax, SUVmean, PLN SUVmax/Tumour SUVmax ratio, MTV, and TLG was, respectively, 0.57 (0.37-0.78), 0.82 (0.68-0.95), 0.77 (0.61-0.94), 0.85 (0.72-0.98), 0.69 (0.51-0.87), and 0.74 (0.57-0.91). The metabolic parameter showing the best trade-off between sensitivity and specificity to predict PALN involvement was the ratio between PLN and tumour SUVmax.

CONCLUSION

The risk of PALN metastasis in FDG-PET/CT negative PLN patients is very low, so para-aortic lymphadenectomy does not seem justified. In patients with preoperative PLN uptake on FDG-PET/CT, surgical staging led to treatment modification in more than 25% of cases and should therefore be performed. Patients with more than one positive PLN and high PLN metabolic activity are at high risk of para-aortic extension and recurrence. Further prospective evaluation is required to consider intensified treatment modalities without prior PALN dissection.

[Transcatheter aortic valve replacement : from a concept to a medical revolution]

Since the first transcatheter aortic valve implantation (TAVI) in 2002, the paradigm for the treatment of severe aortic stenosis has changed. In the recent past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients but now, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low operative risk. As randomized trials have demonstrated comparable (or better results with TAVI) between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk. Nevertheless, there are still questions regarding TAVI involving paravalvular leak, stroke, pacemaker requirements, and durability, which remain to be more definitively answered before TAVI can routinely be performed in lower risk and younger population. Improvements in patient selection, multimodal imaging, and third generation devices have significantly decreased the incidence of TAVI complications. A role for post-procedure antithrombotic or anticoagulant management remains unanswered. Waiting for current studies to provide us with clear answers to these questions, it is the Heart Team's task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient's preference, and potential for improvement in quality of life.

[The heart team : definition and organization. Point of view of the cardiologist]

The management of complex cardiovascular disease has changed considerably with the development of new care strategies. In cardiology, the «Heart Team» or literally «Equipe du cœur» occupies a prominent place in the latest European and American recommendations, particularly in the management of complex coronary or valvular diseases and in heart failure patients. The concept of «Heart Team» is based on the need for a multidisciplinary holistic approach based on evidence (respect of the recommendations of the scientific societies), the patient as a whole (comorbidities, preferences), risks and long-term benefits of the treatment selected and performed, as well as on the level of local expertise. It aims to determine the best management strategy for the patient, and perhaps to guarantee a better result (prognosis).

[Lower extremity artery disease. Angioplasty and stenting in 2019.]

Lower extremity artery disease (LEAD) is frequent and too often neglected. The ongoing evolution of endovascular techniques has revolutionised its management. Vascular surgery is still recommended in specific clinical situations. It can be performed alone or combined with angioplasty-stenting in a hybrid procedure. Various parameters related to the patient, his pathology and to the medical team must be considered especially as randomized trials comparing devices and techniques are lacking. Technical progress should not mask the high cardiovascular morbi-mortality risk of these patients. Therefore LEAD must be detected as soon as possible and optimally managed by a multidisciplinary team. According to clinical stage and comorbidities, the team can include a general practitioner, an angiologist, a cardiologist, a nephrologist, a diabetologist, an oncologist, a radiologist, a vascular surgeon, a dermatologist, etc. Medical treatment of atherosclerosis and prevention are mandatory, as well as walking exercise. Due to its high cardiovascular and amputation risk, chronic limb-threatening ischemia must be quickly and optimally managed by a multidisciplinary team.

[Diagnostic coronarography]

Coronarography consists in selective angiography of the coronary arteries obtained invasively. It represents the gold standard for the anatomical exploration of the coronary arteries and establishes the first step for the indication of possible percutaneous or surgical revascularisation. According to substantial progress, it represents an essential diagnostic tool frequently used with, despite its invasive characteristic, a very low complication's rate. The present article describes the patient's preparation for this procedure, technical modalities, major indications, contraindications and possible complications.

[Arterial hypertension and renal denervation : fantasy or reality ?]

Sympathetic hyperactivity is involved in the early stages of hypertension (HTN) and the mechanism persists during the course of HTN until organ damage and significant increase in cardiovascular risk. Radiofrequency renal denervation (RDN) using a percutaneous catheter inserted into the renal artery helps to destroy adventitial sympathetic nerve fibers, interrupting the connections between the renal sympathetic system and the central nervous system. After the first very encouraging clinical results in a small number of patients, the SIMPLICITY HTN-3 study halted the expansion of the technique because of negative results. From there, the technique has been redesigned conceptually as well as technically with the development of a new quadripolar spiral catheter. The first results of the SPYRAL program show this time a proven efficacy in hypertension and a larger study is underway. The results of this trial will help us to decide definitively on the future of this technique. Other pathologies such as heart failure, atrial fibrillation, obstructive sleep apnea and insulin resistance could also be improved by the RDN and studies to demonstrate this are ongoing.

[Percutaneous transluminal coronary angioplasty: from revolution to evolution]

In interventional cardiology, percutaneous transluminal coronary angioplasty (PTCA) definitely represents a revolution in the history of medicine, illustrating the medical community intention to replace aggressive revascularization intervention by less invasive procedure. Rapidly adopted by physicians and patients, its utilization has grown exponentially and in parallel, numerous technical progresses have pushed forward the frontiers of its indications. This article summarizes the principal evolution of this revascularization technique from its beginning until its last innovations, describing some technical characteristics and emphasizing on some changes and extension of its indications.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

Differences in soil organic carbon and soil erosion for native pasture and minimum till agricultural management systems

There is considerable debate over how different agricultural management systems such as minimum tillage and grazing affect soil organic carbon (SOC), soil nitrogen (SN) concentrations and soil erosion over the long-term. In this study SOC, SN and erosion characteristics were compared over a ten year period for two neighbouring sites with longstanding but different land management strategies; one cropped under a minimum tillage (MT) regime and one used for grazing on largely native pasture. Both sites (Hunter Valley, New South Wales, Australia) shared the same soil type (Euchrozem) and climate. SOC and SN were both found to be ~50% higher at the grazing site while erosion was found to be significantly greater (an order of magnitude) at the cropping site despite the application of MT practices. No discernible link between erosion and either SOC, SN or C:N was evident. While both sites have temporally constant SOC, SN and C:N, the MT site offers scope for increased SOC sequestration.

Brentuximab vedotin and ESHAP is highly effective as second-line therapy for Hodgkin lymphoma patients (long-term results of a trial by the Spanish GELTAMO Group)

BACKGROUND

In this work, we assessed the efficacy and safety of brentuximab vedotin (BV) plus ESHAP (BRESHAP) as second-line therapy for Relapsed/Refractory Hodgkin lymphoma (RRHL) to improve the results before autologous stem-cell transplantation (ASCT).

PATIENTS AND METHODS

This was a multicenter, open-label, phase I-II trial of patients with RRHL after first-line chemotherapy. Treatment had three 21-day cycles of etoposide, solumedrol, high-dose AraC, and cisplatin. BV was administered at three dose levels (0.9, 1.2, and 1.8 mg/kg) intravenous on day ‒1 to 3 + 3 cohorts of patients. Final BV dose was 1.8 mg/kg. Responding patients proceeded to ASCT, followed by three BV courses (1.8 mg/kg, every 21 days). Main end points for evaluation were maximum tolerable dose and overall and complete response (CR) before ASCT.

RESULTS

A total of 66 patients were recruited (median age 36 years; range 18-66): 40 were primary refractory, 16 early relapse and 10 late relapse. There were 39 severe adverse events were reported in 22 patients, most frequently fever (n = 25, 35% neutropenic), including 3 deaths. Grade 3-4 hematological toxicity presented in 28 cases: neutropenia (n = 21), thrombocytopenia (n = 14), and anemia (n = 7). Grade ≥3-4 extrahematological adverse events (≥5%) were non-neutropenic fever (n = 13) and hypomagnesaemia (n = 3). Sixty-four patients underwent stem-cell mobilization; all collected >2×10e6/kg CD34+ cells (median 5.75; range 2.12-33.4). Overall response before transplant was 91% (CI 84% to 98%), including 70% (CRs 95% CI 59% to 81%). 60 patients were transplanted with no failure engraftments. Post-transplant response was CR in 49 patients (82% CI 73% to 91%) and partial responses in six (10% CI 5% to 15%). After a mean follow-up of 27 months, the 30-month time to treatment to failure was 74% (95% CI 68% to 80%), progression-free survival 71% (95% CI 65% to 77%), and overall survival 91% (CI 84% to 98%).

CONCLUSION

BRESHAP looks a safe and effective pre-transplant induction regimen, does not jeopardize transplant and allows long-term remissions and survival.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

54 Altrenogest supplementation during early pregnancy improves swine embryonic development

Progesterone (P4) is of paramount importance in the establishment and maintenance of pregnancy for mammals. Progesterone stimulates the endometrial secretion of several molecules involved in conceptus growth and development during the peri-implantation period. Indeed, several studies involving ruminants have reported that exogenous P4 supplementation is related to increased early embryo development, higher levels of interferon tau, and improved pregnancy rate. However, there is a lack of information about P4 supplementation during early pregnancy regarding swine embryonic development. Additionally, some of the few studies involving pigs have shown an impaired pregnancy rate when supplementation was performed before Day 6 of pregnancy. Thus, the objective of this study was to evaluate the effects of progesterone/progestin supplementation from Day 6 of pregnancy on total number of embryos (TE), pregnancy rate (PR), embryo development, and maternal serum 17β-oestradiol concentration (17β-E). A total of 31 crossbred, 2 to 6 parity sows were used. All sows were inseminated every 24h through the first oestrus following a 21-day lactation, and ovulation was detected by transrectal real-time ultrasound to determine Day 0 of pregnancy. On Day 6 of pregnancy, animals were randomly allocated to one of the following groups: CON (n=11), non-supplemented sows; RU (n=11), sows supplemented daily with 20mg of Altrenogest-Regumate® from Day 6 to 12 of pregnancy; and PG (n=9), sows supplemented with 2.15 mg/kg of long-acting P4 IM on Day 6 of pregnancy. Sows were treated with altrenogest p.o. as a top dressing over a small portion of feed. Blood samples were collected from 12 sows (4 per group) on Day 12 of pregnancy to measure the level of plasma 17β-E by radioimmunoassay. Sows were slaughtered on Day 28 of pregnancy. The uterus from each sow was collected and embryos were counted to determine TE. Embryos were individually separated from their placentas, weighed, and crown-to-rump length was determined. Data were analysed by the SAS program. All variables were analysed by PROC-MIXED t-test. Statistical difference was considered when P&lt;0.05. The PR did not differ among groups (91, 90, and 88%, for CON, RU, and PG, respectively; P&gt;0.05). No difference was observed among groups for TE and 17β-E level (P&gt;0.05). However, embryonic weight and crown-to-rump length differed among the 3 groups (P&lt;0.001). The RU-treated sows had heavier and bigger embryos when compared with the other groups. In contrast, PG-treated sows had the lowest averages for the same variables (weight: 1.39±0.01, 1.46±0.02, and 1.22±0.01; crown-to-rump: 21.07±0.08, 21.61±0.11, and 20.66±0.11; for CON, RU, and PG, respectively). In conclusion, altrenogest supplementation from Day 6 to 12 of pregnancy increases size and weight of porcine embryos, whereas 2.15mg kg−1 of long-acting P4 on Day 6 of pregnancy decreased these variables when compared with non-supplemented sows. Research was supported by FAPESP Grant 2017/00290-0.