Spinal subarachnoid haematoma after neuraxial anaesthesia in a patient with polycythaemia vera

Polycythaemia vera is a common haematological proliferative disorder. It is characterised by uncontrolled red cell production with ensuing peri-operative vaso-occlusive and haemorrhagic complications. Spinal haematoma after neuraxial anaesthesia is rare; most cases are associated with technical difficulties or bleeding disorders. Current consensus opinion suggests that neuraxial anaesthesia in patients with polycythaemia vera is safe due to a lower risk of thrombotic events and hypoxaemia compared with general anaesthesia. We report a case of a spinal subarachnoid haematoma after uneventful neuraxial anaesthesia in a patient with optimised polycythaemia vera. Despite an emergent laminectomy, the patient developed permanent motor deficits. This report highlights that although neuraxial anaesthesia is recommended by many authors, patients with polycythaemia vera can paradoxically have an increased haemorrhagic risk from platelet dysfunction and acquired von Willebrand disease. Clinicians proceeding with surgery under neuraxial anaesthesia should appreciate these risks even in patients with normal or apparently elevated thrombotic states. This case also demonstrates that traditional coagulation tests may need to be complemented by pre-operative platelet function tests and screening for von Willebrand disease. Finally, the importance of the patient participation in the choice of the anaesthesia technique cannot be understated, with specific attention paid to this frequently unrecognised risk.

Ecological quality status of the NE sector of the Guanabara Bay (Brazil): A case of living benthic foraminiferal resilience

The ecological quality status of the NE region of the Guanabara Bay (SE Brazil), one of the most important Brazilian embayments, is evaluated. For this purpose, sediment samples from in the inner of the Guanabara Bay (GB) were collected and analyzed (grain-size, mineralogy, geochemistry and living foraminifera). In this study, it is hypothesized that the potentially toxic elements (PTEs) concentrations, in solution and associated with organic matter (_OMPTEs, potential nutrient source), may represent two potential pathways to impact benthic foraminifers. A multiproxy approach applied to complex statistical analyses and ecological indexes shows that the study area is, in general, eutrophic (with high organic matter and low oxygen content), polluted by PTEs and oil. As a consequence, foraminifera are not abundant and their assemblages are poorly diversified and dominated by some stress-tolerant species (i.e., Ammonia tepida, Quinqueloculina seminula, Cribroelphidium excavatum). The results allow us to identify a set of species sensitive to eutrophication and _OMPTEs. Factors such as the increase of organic matter contents and _OMPTEs and, in particular of Zn, Cd and Pb, the oxygen depletion and the presence of oil, altogether contribute to a marked reduction in the abundance and diversity of foraminifera. Ammonia-Elphidium Index and the Foram Stress Index confirm that the NE zone of GB is, in general, "heavily polluted", with "poor ecological quality status" and experiences suboxic to anoxic conditions. In light of it, special attention from public authorities and policymakers is required in order to take immediate actions to enable its environmental recovery.

Advances on assessing nanotoxicity in marine fish - the pros and cons of combining an ex vivo approach and histopathological analysis in gills

The need to overcome logistic and ethical limitations of in vivo nanotoxicity evaluation in marine organisms is essential, mostly when dealing with fish. It is well established that medium/solvent conditions affect dispersion and agglomeration of nanoparticles (NPs), which represents a constraint towards a solid and realistic toxicity appraisal. In this way the pros and cons of an ex vivo approach, using a simplified exposure medium (seawater) and addressing gills histopathology, were explored. The nanotoxic potential of environmentally realistic concentrations of titanium dioxide NPs (TiO₂ NPs) was also assessed, disclosing the morpho-functional effects on the gills and the possible uptake/elimination processes. Excised gills of the Senegalese sole (Solea senegalensis) were directly exposed in artificial seawater to 20 and 200 μg L^-1 TiO₂ NPs, for 2 h and 4 h. Semi-quantitative and quantitative histological analyses were applied. The normal morphology of the gill's epithelia was only slightly altered in the control, reflecting protective mechanisms against the artificiality of the experimental conditions, which, together with the absence of differences in the global histopathological index (I_h), corroborated that the gill's morpho-functional features were not compromised, thereby validating the proposed ex vivo approach. TiO₂ NPs induced moderate severity and dissemination of histopathological lesions. After 2 h, a series of compensatory mechanisms occurred in NP treatments, implying an efficient response of the innate defense system (increasing number of goblet cells) and effective osmoregulatory ability (chloride cells proliferation). After 4 h, gills revealed signs of recovery (normalization of the number of chloride and goblet cells; similar I_h), highlighting the tissue viability and effective elimination and/or neutralization of NPs. The uptake of the TiO₂ NPs seemed to be favored by the higher particle sizes. Overall, the proposed approach emerged as a high-throughput, reliable, accurate and ethically commendable methodology for nanotoxicity assessment in marine fish.

P975Safety and clinical outcomes of rotational atherectomy: an eleven-year centre experience

Introduction

Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality.

Objectives

To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure.

Methods

Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year.

Results

246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach.

Conclusions

RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

P117 Predictive factors of outcome in poor grade subarachnoid haemorrhage (SAH)

Objectives

To study the factors associated with outcome in poor grade SAH in a busy tertiary centre.

Design

Retrospective records review.

Subjects

All Patients with SAH WFNS grades IV and V admitted Jan 2016-Dec 2017.

Methods

We admitted 379 SAH patients, 84 (22%) were poor grade (n=84, 33M/51F mean age 60.7±1.4 y). Outcome was assessed by Modified Rankin Scale (mRS) scores before surgery and at latest follow up (3–6 months). mRS was dichotomised as good (0–3) and poor (4–6).Spearman’s rank-order test evaluated correlation between latest mRS and all other variables (WFNS grade, GCS, Motor score of GCS, age, sex, smoking, hypertension, intraventricular haemorrhage (IVH) and intracerebral haemorrhages (ICH)).

Results

63 patients (75%) had poor outcome, of which 46 (55%) died (44 with 30 days), versus 21 (25%) had good outcome. Spearman’s correlation analysis revealed that patients with smaller aneurysms (3.3±0.4 mm in good outcome patients vs 11.3±1.2 mm in poor outcome) (rs=0.37, p=0.009), who are younger (rs=0.24, p=0.03), have higher GCS (rs=−0.24, p=0.03), higher motor score (rs=0.25, p=0.02), lower WFNS grade (rs=0.3, p=0.007) and received coiling of aneurysms vs no treatment (rs=−0.39, p<0.0001) had better outcome. There was no significant correlation in outcome with ICH, IVH, external ventricular drain insertion, location of aneurysms, smoking, hypertension, other co-morbidities or sex.

Conclusions

In poor grade SAH, younger patients with smaller aneurysms, higher GCS and higher motor score who received endovascular coiling had better outcome.

WP1-23 Vascular collagen 4A1 in subcortical white matter of older people and primates

Objectives

To test whether collagen 4A1 in cerebral small arteries associated with age, hypertension or small vessel disease (SVD).

Design

Neuropathology cohort study.

Subjects

Older people age >65 years with minimal Alzheimer’s Disease.

Methods

We examined subcortical white matter in archived brain tissue from older people (n=34, 15F/19M, median age 84, range 65–99 y) and from experimental non-human primates (NHP, Macaca mulatta) that were young adults (n=9, age 6.2–8.3 y) or older adults (n=8, age 17.0–22.7 y). Some of the primates (5 young, 3 older) were chronically hypertensive. Vascular collagen 4A1 immunohistochemical labelling was examined qualitatively and quantified as percent area fraction.

Results

Collagen 4A1 labelling was common in arterial myocytes and in the adventitial layer in human and primate brain arteries, as well as in basement membrane, which frequently exhibited replication. Among older people, collagen 4A1 associated with neuropathological SVD severity (sclerotic index; r=−0.461, p=0.0409, least squares) and with radiological SVD severity (leukoaraiosis; p=0.0455, 1-way ANOVA) but not with age or clinical history of hypertension. In NHP, age but not hypertension was significantly associated with collagen-4A1 labelling (p=0.0396, 0.232 respectively, 2-way ANOVA).

Conclusions

In this small cohort, vascular collagen 4A1 was related to SVD severity in older humans, in accord with genetic associations of COL4A1 with SVD phenotypes.

P112 Management and outcome of subarachnoid haemorrhage (SAH) in older people: a centre series

Objectives

To study the management and factors associated with outcomes in SAH in elderly over 80 years of age.

Design

Retrospective records review.

Subjects

All Patients with SAH confirmed on head CT admitted Jan 2012-Dec 2017.

Methods

We admitted 1079 patients with SAH, 32 were aged ≥80 y (3%). We subdivided the patients into a poor outcome group (POG) (Modified Rankin Scale (mRS) 4–6), (n=24, 14F/10M, mean age 83.7±0.7 y) and good outcome group (GOG) (mRS 0–3) (n=8, 7F/1M, mean age 82.6±0.6 y). Spearman’s rank-order test evaluated correlation between outcome (mRS) and all other variables (WFNS grade, GCS, Motor score of GCS, age, sex, smoking, hypertension, intraventricular haemorrhage (IVH) and intracerebral haemorrhages (ICH)).

Results

9 patients (38%) of POG were WFNS grades IV – V versus 1 patient (13%) in GOG. More POG than GOG patients had IVH (83% vs 38%, rs=−0.44 p=0.011). 20% of POG had ICH vs none in GOG. GOG patients had better GCS (rs=−0.37, p=0.04), lower WFNS grade (rs=0.43, p=0.01) and did not need external ventricular drain (EVD) (rs=0.51, p=0.003). There was no significant correlation between outcome and sex, smoking, hypertension, size of aneurysm (4.9 mm ±1.0 in GOG vs 5.4 mm ±1.1 in POG, rs=−0.29, p=0.28), percentage receiving coiling or clipping, GCS motor score, procedure complications and general medical complications.

Conclusions

75% of patients’ aged ≥80 y with SAH had poor outcome. WFNS grade (I-III), higher GCS patients who did not need EVD had better outcome.

TM3-6 Symptomatic intracranial arachnoid cysts: a centre series

Objectives

To study the presentation, management and outcomes of symptomatic intracranial arachnoid cysts.

Design

Retrospective records review.

Subjects

All cases coded as intracranial cysts.

Methods

Patients admitted between Jan-2012 and Sep 2017. Of 56 cases, only 24 were arachnoid cysts. Median age 57 (range 8–81). Mean 49.1±5.0 years, 8 males and 16 females.

Results

Males were significantly younger (34.3±9.1 vs 56.5±5.2 year-old, p=0.03) and outnumbered females. Mean size of cysts was 58.8±6.1 mm (range 18.5–126 mm). Five were located frontally, one fronto-temporal and another fronto-parietal, two parietal and two parieto-occipital, two within third ventricle, one intraventricular, one supra sellar and one intra sellar while eight were posterior fossa. 12 patients had headache, five presented with cognitive and memory issues, five had visual problems, four with limb weakness and two had cerebellar signs. Eight had open fenestration, five endoscopic fenestration, four had aspiration with reservoir, two aspiration only, two marsupialisation, two received ICP monitor and one had no treatment. One reservoir was aspirated three times and another open fenestration had another surgical fenestration. Two had transient infection, two needed VP shunts and one had cysto-peritoneal shunt. mRS (0–2) improved significantly after the treatment (62.5% pre-surgery to 91.7% post-surgery, p=0.016).

Conclusions

Symptomatic arachnoid cysts are more common in young males. In the literature, the most common location is middle cranial fossa which is not the case in symptomatic arachnoid cysts as in our series. Although intervention is variable, they are associated with very good outcomes.

WM1-4 Decompressive craniectomy versus strokectomy for malignant middle cerebral artery (MCA) infarction

Objectives

To compare the outcomes of decompressive craniectomy (DC) with craniotomy and debulikng of stroke tissue (Strokectomy (SC)) for malignant MCA infarction at our centre.

Design

Retrospective records review.

Subjects

All Patients with malignant MCA infraction that underwent DC and SC between Jan 2012 and Sep 2017.

Methods

20 patients had DC (11F/9M, mean age 44.7±1.8 y) and four patients had SC (1F/3M) 51.5±5.9 7 y). Outcomes were assessed by Modified Rankin Scale (mRS) scores before surgery and at latest follow up (3–6 months). mRS was dichotomised as good (0–3) and poor (4–6). Craniotomy size was measured by antero-posterior (AP) diameter and compared between the groups.

Results

18 patients (90%) of the DC group had mRS 4–6 before surgery versus 100% in the SC group. Post-surgery 15 patients (75%) of the DC group had poor outcome with 7 mortalities (35%) in comparison to one patient (25%) with poor outcome in the SC group and no mortalities. The average craniotomy size in DC was 120.1±4.1 mm versus 85.5±13.1 mm in the SC, p=0.003 students t test). Six patients of the DC group underwent cranioplasty where two developed post-operative seizures. There was no significant difference in age, sex and side of craniotomy (7 Left/13 Right in DC vs 2 Left/2 Right in SC).

Conclusions

Strokectomy is comparable to decompressive craniectomy in outcomes without taking the extra risks and costs of cranioplasty. Further studies are required to promote this approach.

Evaluation of a single extraction test to estimate the human oral bioaccessibility of potentially toxic elements in soils: Towards more robust risk assessment

Intake of soil by children and adults is a major exposure pathway to contaminants including potentially toxic elements (PTEs). However, only the fraction of PTEs released in stomach and intestine are considered as bioaccessible and results from routine analyses of the total PTE content in soils, therefore, are not necessarily related to the degree of bioaccessibility. Experimental methods to determine bioaccessibility usually are time-consuming and relatively complicated in terms of analytical procedures which limits application in first tier assessments. In this study we evaluated the potential suitability of a recently developed single extract method (ISO-17586:2016) using dilute (0.43M) nitric acid (HNO₃) to mimic the bioaccessible fraction of PTEs in soils. Results from 204 soils from Portugal, Brazil and the Netherlands including all major soil types and a wide range of PTEs' concentrations showed that the extraction efficiency using 0.43M HNO₃ of Ba, Cd, Cu, Ni, Pb and Zn in soils is related to that of in vitro methods including the Simple Bioaccessibility Extraction Test (SBET) and Unified BARGE Method (UBM). Also, differences in the degree of bioaccessibility resulting from differences in parent material, geology and climate conditions did not affect the response of the 0.43M HNO₃ extraction which is a prerequisite to be able to compare results from different soils. The use of 0.43M HNO₃ as a first screening of bioaccessibility therefore offers a robust and representative way to be included in first tier standard soil tests to estimate the oral bioaccessibility.

CAPSULE

The single dilute (0.43M) nitric acid extraction can be used in first tier soil risk assessment to assess both geochemical reactivity and oral bioaccessibility of PTEs.

Epidemiologic Profile of Transplant Patients Treated by the Physiotherapy

Transplant candidates have advanced chronic disease, which often leads to muscular and respiratory impairment contributing to reduced quality of life and daily life activities, and these patients are therefore referred to physiotherapy service. Because of this, it is necessary to know the epidemiologic and functional profile for a better physiotherapeutic approach. Inpatients of kidney, liver, heart, lung and multivisceral transplantation programs were followed up for 1 year. A comparative analysis between groups was performed, taking into account hospital stay time and functional independence measure (FIM). In all, 157 patients (88 post-transplant) were evaluated, with mean age of 54 years, and 99 were men. Prevalence of transplantation included liver: 87 (56%); kidney: 51 (32%); heart: 10 (6%); lung: 8 (5%); multivisceral: 1 (1%). The average length of hospital stay was 23 days for kidney patients, 19 days for lung patients, 18 days for heart patients, 15 days for liver patients, and the 15 days for multivisceral patients. The mean of FIM score was 94 for heart patients; 95 for liver patients, 96 for kidney patients, 99 for lung patients, and 120 for multivisceral patients. The highest incidence of hospitalization was of liver patients, although renal patients had a longer time of hospitalization. FIM score was higher at hospital discharge, if compared with the values at the moment of evaluation, but through the comparison of FIM previous with FIM final scores, the patients still presented functional limitation at the time of hospital discharge. Specific protocols for each transplant group, focused on the improvement of the functionality, are necessary.

Removal and recovery of Critical Rare Elements from contaminated waters by living Gracilaria gracilis

The experiments performed in this work proved the ability of Gracilaria gracilis to concentrate and recover Critical Rare Elements (CRE) from contaminated waters. The importance of recycling these elements is related to their very limited sources in Nature and progressive use in technologies. Moreover, their mining exploitation has negative environmental impact, and recent studies point them as new emerging pollutants. To the best of our knowledge, this is the first report on the application of living macroalgae for the removal and recovery of CRE. G. gracilis (2.5gL^-1, fresh weight) was exposed to mono- and multi-element saline solutions of 500μgL^-1 of Y, Ce, Nd, Eu and La. Removal was up to 70% in 48h, with bioaccumulation following Elovich kinetic model. In multi-element solutions, selectivity was not observed although removal of lanthanides improved comparatively to single-element solutions. No mortality or adverse effect on growth was registered. The subsequent macroalgae digestion allowed collecting virtually 100% of all elements in a 300-fold more concentrated solution. The overall results suggest the application of living macroalgae as a simple and effective alternative technology for removing and recovering CRE from wastewaters, contributing to an improvement of water quality and CRE recycling.

Addressing the impact of mercury estuarine contamination in the European eel (Anguilla anguilla L., 1758) - An early diagnosis in glass eel stage based on erythrocytic nuclear morphology

The decline of the European eel (Anguilla anguilla L., 1758) population throughout Europe has been partially attributed to pollution. As glass eel estuarine migration may represent a considerable threat, the impact of mercury (Hg) contamination at this stage was evaluated through an in situ experiment (7days). Total Hg (tHg) bioaccumulation was evaluated concomitantly with erythrocytic nuclear morphology alterations: erythrocytic nuclear abnormalities assay (ENA), frequency of immature erythrocytes (IE) and the erythrocytic maturity index (EMI). The ENA results suggested a genotoxic pressure at the most contaminated sites, in line with the tHg increase. The EMI data, together with IE frequency, showed that fish exposed to high levels of Hg exhibited alterations of haematological dynamics, translated into an erythropoiesis increment. Despite the presence of these compensatory mechanisms, the present findings suggest a harmful impact of Hg on genome integrity at this early development stage, potentially affecting eels' condition and ultimately the population sustainability.

Highly efficient upconversion of Er3+ in Yb3+ codoped non-cytotoxic strontium lanthanum aluminate phosphor for low temperature sensors

Er³⁺ and Er³⁺/Yb³⁺ melilite-based SrLaAl₃O₇ (SLA) phosphors were synthesized by a facile Pechine method. The differences in emission intensities of ⁴I_13/2 → ⁴I_15/2 transition in NIR region when excited with Ar⁺ and 980 nm lasers were explained in terms of energy transfer mechanisms. Temperature and power dependence of upconversion bands in the visible region centered at 528, 548 and 660 nm pertaining to ²H_11/2, ⁴S_3/2 and ⁴F_9/2 → ⁴I_15/2 transitions were investigated. Fluorescence intensity ratio (FIR) technique was used to explore temperature sensing behaviour of the thermally coupled levels ²H_11/2/⁴S_3/2 of Er³⁺ ions in the phosphors within the temperature range 14–300 K and the results were extrapolated up to 600 K. Anomalous intensity trend observed in Er³⁺ doped SLA phosphor was discussed using energy level structure. Cytotoxicity of phosphors has been evaluated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay in Bluegill sunfish cells (BF-2). The non-cytotoxic nature and high sensitivity of the present phosphors pay a way for their use in vitro studies and provide potential interest as a thermo graphic phosphor at the contact of biological products.