Early intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. However, the specific timing of intervention for asymptomatic patients with severe AS remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic patients with AS.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for both interventional or observational studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

Results

Thirteen studies were included in which two were randomised clinical trials. A total of 4,679 patients were included, providing a 1,268 pooled death events (327 in early AVR and 941 in WW). Our meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group, although with a moderate amount of heterogeneity between studies in the magnitude of the effect (pooled odds ratio [OR], 0.41; 95% confidence interval [CI] 0.34, 0.50, P<0.01; I2=60%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I 2=64%) and heart failure hospitalisations (pooled OR 0.19; 95% CI [0.10, 0.39], P<0.01, I2=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI [0.73, 2.29], P=0.36, I2=0%) and myocardial infarction (pooled OR 0.49; 95% CI [0.19, 1.27], P=0.14, I2=0%).

Conclusions

Our pooled data suggest that an early-AVR strategy is preferable for asymptomatic patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.

Meta-analysis comparing outcomes in patients undergoing transcatheter aortic valve implantation with versus without percutaneous coronary intervention

Background

Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear.

Purpose

To compare the outcomes of PCI prior to TAVI in patients with significant coronary artery disease and severe aortic stenosis.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both retrospective and prospective studies comparing TAVI with PCI versus TAVI alone. Random-effects meta-analysis was performed.

Results

Eleven studies were included in which one was a randomized clinical trial. A total of 2530 patients were included, providing a 145 pooled death events (64 in TAVI with PCI and 81 in TAVI only). In terms of 30-day clinical outcomes, our pooled analysis revealed a similar all-cause mortality (pooled OR, 1.24; 95% CI [0.80, 1.93], P=0.34; I2=27% - Figure), cardiovascular mortality (pooled OR, 1.44; 95% CI [0.56, 3.75], P=0.45; I2=57%) and stroke (pooled OR, 1.07; 95% CI [0.53, 2.13], P=0.86; I2=0%). However, our analysis revealed a higher rate of myocardial infarction (pooled OR, 4.28; 95% CI [1.56, 11.69], P<0.01; I2=0%) and major bleeding events (pooled OR, 1.40; 95% CI [1.02, 1.93], P=0.04; I2=0%) in the TAVI with PCI group. A 1-year clinical outcomes analysis revealed a trend for lower all-cause mortality in TAVI only group (pooled OR, 1.37; 95% CI [0.98, 1.91], P=0.06; I2=0%), similar cardiovascular death rate (pooled OR, 1.15; 95% CI [0.70, 1.89], P=0.59; I2=6%) and major bleeding events (pooled OR, 1.62; 95% CI [0.95, 2.76], P=0.07; I2=0%).

Conclusion

Our pooled data suggests that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage.

Funding Acknowledgement

Type of funding sources: None.

Maximum dose sacubitril/valsartan in heart failure with reduced ejection fraction: does atrial fibrillation compromise the benefits?

Background

In the PARADIGM-HF trial, sacubitril/valsartan (SV) was shown to be superior to enalapril in reducing hospitalizations for worsening heart failure (HF), cardiovascular mortality, and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). The 2021 ESC Guidelines recommends SV as a replacement for angiotensin-converting-enzyme inhibitors to reduce the risk of HF hospitalization and death. There is little information regarding the effects of SV according to atrial fibrillation (AF) status.

Purpose

The aim of this study was to compare the effects of maximum dose SV regarding symptomatic improvement, change in natriuretic peptides levels (NP) and left ventricular ejection fraction (LVEF) in patients with HFrEF with and without AF.

Methods

Retrospective analysis of 137 patients with HFrEF on maximum dose SV (97/103mg twice daily). Patients were divided into two groups according to AF status. Age, gender, relevant comorbidities, usual medication, baseline symptomatic status, NP levels and LVEF were assessed using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Variation in NYHA class, NP levels and LVEF between baseline and 6-month follow-up was evaluated and compared between groups.

Results

Comparison between groups is presented in Table 1. In our studied population, ischemic aetiology was more common in the sinus rhythm group (49.5% vs 30.4%; p 0.034). There were no significant differences between groups regarding age, gender, hypertension, diabetes, and beta-blocker and mineralocorticoid receptor antagonist usage. At baseline, the AF group had higher NT-proBNP levels [median 1421 mg/dL (IQR 743–3087) vs 467 mg/dL (IQR 140–797); p<0.001]. There were no significant differences regarding baseline NYHA class or LVEF. After 6 months of follow-up, reductions in NYHA class [−1 (IQR −2, −1) for AF; −1 (IQR −1, 0) for SR; p=0.437] and NT-proBNP levels [−358 mg/dL (IQR −2275, −47) for AF; −162 mg/dL (IQR −364, 27) for SR; p=0.156], as well as LVEF improvement [11% (IQR 3–15) for AF; 12% (IQR 7–21) for SR; p=0.201], displayed no statistically significant differences between the two groups.

Conclusions

Our study shows that the beneficial effects of SV on symptomatic status, NP levels and LVEF were not compromised by the presence of AF at baseline.

Funding Acknowledgement

Type of funding sources: None.

Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

Background

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation.

Purpose

To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed.

Results

Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P<0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P<0.01; I2=27%).

Conclusions

Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention.

Funding Acknowledgement

Type of funding sources: None.

Factors associated with perceived performance drops and musculoskeletal injuries in Brazilian recreational triathletes

OBJECTIVE

The aim of the study was to investigate sleep characteristics, use of supplements, and training volume of recreational triathletes, and to verify possible associations with perceived performance drops and occurrence of injuries.

MATERIALS AND METHODS

Recreational triathletes (n=942) answered a questionnaire inquiring about their demographic characteristics, performance, injuries and training volume.

RESULTS

When comparing athletes who slept more (9-10 hours) with those who slept less, less sleep was associated with a higher prevalence of perceived performance drops. Regarding difficulties in initiating sleep, the absence of initiating difficulties (p<0.001) was a protective factor against perceived performance drops. Regarding weekly training volume, compared to those who trained more than 20 hours, training less than 3 hours (p<0.001), 3-5 hours (p<0.001), or 12-14 hours (p<0.001) were protective factors against perceived performance drops. Concerning training volume and injuries, we found that compared to those who trained more than 20 hours, training 18-20 hours (p<0.001), 15-17 hours (p<0.001), 12-14 hours (p<0.001), 6-8 hours (p<0.001), or 3-5 hours (p<0.001) were protective factors against injuries.

CONCLUSIONS

Triathletes with a lower sleep quantity and those who have difficulties initiating sleep frequently experience drops in performance. Training volumes can influence both performance and the likelihood of injuries.

Distant supervision for imaging-based cancer sub-typing in Intrahepatic Cholangiocarcinoma

Finding effective ways to perform cancer sub-typing is currently a trending research topic for therapy opti-mization and personalized medicine. Stemming from genomic field, several algorithms have been proposed. In the context of texture analysis, limited efforts have been attempted, yet imaging information is known to entail useful knowledge for clinical practice. We propose a distant supervision model for imaging-based cancer sub-typing in Intrahepatic Cholangiocar-cinoma patients. A clinically informed stratification of patients is built and homogeneous groups of patients are characterized in terms of survival probabilities, qualitative cancer variables and radiomic feature description. Moreover, the contributions of the information derived from the ICC area and from the peri tumoral area are evaluated. The findings suggest the reliability of the proposed model in the context of cancer research and testify the importance of accounting for data coming from both the tumour and the tumour-tissue interface. Clinical relevance - In order to accurately predict cancer prognosis for patients affected by ICC, radiomic variables of both core cancer and surrounding area should be exploited and employed in a model able to manage complex information.

The Histopathological Growth Pattern of Colorectal Liver Metastases Impacts Local Recurrence Risk and the Adequate Width of the Surgical Margin

BACKGROUND

The histopathological growth pattern (HGP) of colorectal liver metastases (CLM) has been associated with prognosis. This study was designed to elucidate if the HGP is associated with local recurrence risk and impacts the adequate width of surgical margin.

METHODS

All consecutive patients resected for CLM in 2018-2019 were considered. HGP was prospectively classified as follows: desmoplastic, pushing, and replacement. Surgical margin was classified as follows: R0 (margin ≥ 1 mm), R1vasc (0-mm margin, tumor detachment from intrahepatic vessels), and R1par (tumor exposure along transection plane). R0 resections were further distinguished in R0min (1-mm margin) and R0wide (> 1-mm margin).

RESULTS

A total of 340 resection areas in 136 patients were analyzed (70 R0min, 143 R0wide, 31 R1vasc, 96 R1par). HGP was desmoplastic in 26 cases, pushing in 221, and replacement in 93. Thirty-six local recurrences occurred (11%, median follow-up 21 months): 1 after R0wide, 4 after R0min, 3 after R1vasc, and 28 after R1par resection. In R1par group, local recurrence rate was high independently of HGP (29%). In R1vasc and R0min groups, local recurrence risk was higher in the replacement group (R1vasc: 29% vs. 4% if pushing/desmoplastic; R0min: 11% vs. 4%). In R0wide group, local recurrence risk was low for all HGP ( < 1%). Independent predictors of local recurrence were replacement HGP (odds ratio = 1.654, P = 0.036), and R1par resection (odds ratio = 57.209, P < 0.001 vs. R0).

CONCLUSIONS

Replacement HGP is associated with an increased risk of local recurrence. In these patients, a wide surgical margin should be pursued, because R1vasc and R0min resections could be insufficient. R1par resection is inadequate, independently of the HGP.

Free-electron lasing with compact beam-driven plasma wakefield accelerator

The possibility to accelerate electron beams to ultra-relativistic velocities over short distances by using plasma-based technology holds the potential for a revolution in the field of particle accelerators^1-4. The compact nature of plasma-based accelerators would allow the realization of table-top machines capable of driving a free-electron laser (FEL)⁵, a formidable tool to investigate matter at the sub-atomic level by generating coherent light pulses with sub-ångström wavelengths and sub-femtosecond durations^6,7. So far, however, the high-energy electron beams required to operate FELs had to be obtained through the use of conventional large-size radio-frequency (RF) accelerators, bound to a sizeable footprint as a result of their limited accelerating fields. Here we report the experimental evidence of FEL lasing by a compact (3-cm) particle-beam-driven plasma accelerator. The accelerated beams are completely characterized in the six-dimensional phase space and have high quality, comparable with state-of-the-art accelerators⁸. This allowed the observation of narrow-band amplified radiation in the infrared range with typical exponential growth of its intensity over six consecutive undulators. This proof-of-principle experiment represents a fundamental milestone in the use of plasma-based accelerators, contributing to the development of next-generation compact facilities for user-oriented applications⁹.

Tachydysrhythmias in patients admitted with COVID-19 pneumonia: prevalence and impact on in-hospital mortality

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality.

Purpose

Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality.

Methods

A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR).

Results

A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p &lt;0.001) and had more hypertension (p 0.034), heart failure (HF) (p &lt;0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA).

Patients with HF had the highest risk of tachyarrhythmia (OR 3.539; 95% CI 2.666-4.698; p &lt;0.001), followed by severe VHD (OR 1.990; 95% CI 1.192-3.365; p 0.009) and CAD (OR 1.575; 95% CI 1.040-2.386; p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819; 95% CI 1.272-2.602; p 0.001)

Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820; 95% CI 2.151-3.695; p &lt;0.001).

Conclusions

Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed.

Prevalence and impact of dysrhythmias in COVID-19 intensive care patients

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias.

Purpose

To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality.

Methods

A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables.

Results

The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016).

When adjusted for confounding variables, prone was the most significant predictor (OR 2.800; 95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484; 95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440; 95% CI 0.950-6.310; p 0.065).

Conclusions

COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias.

P326 SURGICAL VERSUS TRANSCATHETER AORTIC VALVE REPLACEMENT WITH NEWER GENERATION DEVICES IN REAL–WORLD PRACTICE: ONE–YEAR OUTCOMES FROM THE ITALIAN OBSERVANT STUDIES

Objective

To compare the early and 1–year outcomes after transcatheter aortic valve replacement (TAVR) with new–generation devices over surgical replacement (SAVR) among patients with severe aortic stenosis (AS).

Background

TAVR is gaining acceptance for the treatment of lower risk patients with AS after several randomized and observational studies confirmed comparable early results to SAVR. On the other hand, clinical studies have shown that SAVR is still widely used in intermediate and high risk patients. There is need of data from large clinical registries to demonstrate the efficacy and safety of TAVR in the real–world setting, particularly after the introduction of new TAVR technology.

Methods

A total of 5706 AS patients who underwent SAVR and 2989 AS patients who underwent TAVR enrolled in the national, prospective OBSERVANT and OBSERVANT II studies, respectively in 2010–2012 and 2016–2018, were analyzed. Outcomes were adjusted using the propensity score matching. The primary outcomes of interest were all–cause mortality, major adverse cardiac and cerebrovascular events (MACCEs) and hospital readmission due to heart failure at 1–year. Secondary outcomes were major adverse events occurring during the index hospitalization.

Results

Among 1008 propensity score matched pairs, TAVR was associated with significantly lower 30–day mortality (1.8 vs. 3.5%, p = 0.020), stroke (0.8 vs. 2.3%, p = 0.005), acute kidney injury (0.6 vs. 8.2%, p &lt; 0.001), infectious complications (3.8 vs. 6.5%, p = 0.006) and cardiogenic shock (1.4 vs. 5.1%, p &lt; 0.001) compared to SAVR. Moderate–to–severe paravalvular regurgitation (5.9 vs. 2.0%, p &lt; 0.001), major vascular complications requiring invasive treatment (2.2 vs. 0.1%, p &lt; 0.001) and permanent pacemaker implantation (during the index hospitalization, 13.8 vs. 3.3%, p &lt; 0.001) were more frequent after TAVR. At 1–year, TAVR was associated with lower risk of all–cause death (7.9 vs. 11.5%, p = 0.006), MACCE (12.0 vs. 15.8%, p = 0.011), readmission due to heart failure (10.8 vs. 15.9%, p &lt; 0.001) and stroke (3.2 vs. 5.1%, p = 0.033) compared to SAVR.

Conclusions

In a real–world setting, patients with intermediate operative risk treated with newer generation TAVR devices had a low risk of major adverse events during the index–hospitalization and at 1–year follow–up. TAVR could become the treatment of choice for AS in the elderly provided that its durability is proved by long–term follow–up studies.

Inflammation in acute coronary syndrome: prognostic significance

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with acute coronary syndrome (ACS) the acute phase reactant, C-reactive protein (CRP), might be significantly elevated. Several reports suggest that CRP may play a direct pathophysiological role on the development and progression of atherosclerosis, and CRP values correlate with infarct size when measured by magnetic resonance imaging.

Purpose

The aim of the present study was to evaluate the prognostic value of CRP in patients presenting with an ACS.

Methods

Retrospective analysis of 635 consecutively admitted patients due to ACS in a single coronary intensive care unit. CRP levels were measured at admission. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether CRP was an independent predictor of outcome.

Results

In the studied sample, 75% were male. Median age was 69 [interquartile range (IQR) 57–78]. ST-elevation myocardial infarction (STEMI) occurred in 39.6%, non-ST segment elevation myocardial infarction in 44.9% and unstable angina in 15.5% of the patients. Median left ventricular ejection fraction (LVEF) was 48% (IQR 40–55%) and median CRP level at admission 0.7 mg/dL (IQR 0.5–1.9 mg/dL). Regarding important comorbidities and past medical history, 75.9% had hypertension (HTN), 34.0% diabetes, 20.3% chronic kidney disease (CKD), 68.6% dyslipidaemia and 17.3% heart failure (HF). The median follow-up was 34 months (IQR 22–72). In univariate analysis, CRP was significantly associated with all-cause mortality (HR 1.06 per 1 mg/dL increase, 95% CI 1.04–1.08, p&lt;0.001), as was gender, age, LVEF, STEMI and previous history of diabetes, HTN, CKD or HF. In multivariate analysis, CRP remained significantly associated with the primary endpoint (HR 1.02, 95% CI 1.00–1.05, p=0.033), as did age, LVEF and previous history of HF.

Conclusions

In our study, CRP at admission was an independent risk factor for all-cause mortality following an ACS. This finding indicates that inflammation associated with the acute event has a significant impact in the long-term prognosis. More evidence is needed to determine if treating inflammation (and when, in the course of the disease) could result in better outcomes.

Anger, personality traits and psychopathological symptoms in subjects exposed to negative interpersonal actions in workplaces: an observational study in a large sample attending a Center for Occupational Stress

OBJECTIVE

The association between adverse working conditions and mental disorders is well established. In addition to psychopathological symptoms, this study aimed at investigating anger and personality traits in a clinical sample of subjects referring negative interpersonal experiences in workplaces.

METHODS

1676 workers attending a Centre for Occupational Stress in Milan (from 2014 to 2016) were administered an assessment protocol including SCL-90 for general psychopathology, STAXI for anger intensity and expression, and MMPI-2 for personality traits. A qualitative checklist was used to collect negative experiences in workplaces.

RESULTS

Patients reported they were exposed to "threats to the task or the professional career" more than to "attacks to the person". Over 80% scored above the cutoff in all the subscales of the SCL-90, with highest scores in Depression, Obsessive-Compulsive Disorder, Anxiety, Somatization and Paranoia. 60% scored above the 90th percentile in the AX/in subscale, showing intense anger feelings that they mostly suppress. Abnormal elevations at the MMPI scales of Hypochondria, Depression, Hysteria, and Paranoia were found in over 50% of the sample. Women reported higher psychological difficulties and internalized anger than men. Anger towards objects and people, instead, was more common in males. No differences were observed by work sector or employment status.

CONCLUSIONS

In addition to severe psychological difficulties, individuals reporting negative interpersonal experiences in workplaces have high levels of internalized anger and a distinctive profile of personality traits. While a deeper investigation is needed, anger expression should be considered in future treatment programs.

Acute intestinal ischemia in patients with COVID-19: single-centre experience and literature review

OBJECTIVE

Acute Intestinal ischemia (AII) may involve the small and/or large bowel after any process affecting intestinal blood flow. COVID-19-related gastrointestinal manifestations, including AII, have been attributed to pharmacologic effects, metabolic disorders in ICU patients and other opportunistic colonic pathogens. AII in COVID-19 patients may be due also to "viral enteropathy" and  SARS-CoV-2-induced small vessel thrombosis. A critical appraisal of personal experience regarding COVID-19 and AII was carried out comparing this with a systematic literature review of published series.

PATIENTS AND METHODS

  A retrospective observational clinical cohort study and a systematic literature review including only COVID-19 positive patients with acute arterial or venous intestinal ischemia were performed. The primary endpoint of the study was the mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay.

RESULTS

Patient mean age was 62.9±14.9, with a prevalence of male gender (23 male, 72% vs. 9 female, 28%). The mean Charlson Comorbidity Index was 3.1±2.7. Surgery was performed in 24/32 patients (75.0%), with a mean delay time from admission to surgery of 6.0 ±5.6 days. Small bowel ischemia was confirmed to be the most common finding at surgical exploration (22/24, 91.7%). Acute abdomen at admission to the ED (Group 1) was observed in 10 (31.2%) cases, while 16 (50%) patients developed an acute abdomen condition during hospitalization (Group 2) for SARS-CoV-2 infection.

CONCLUSIONS

Our literature review showed how intestinal ischemia in patients with SARS-CoV-2 has been reported all over the world. The majority of the patients have a high CCI with multiple comorbidities, above all hypertension and cardiovascular disease. GI symptoms were not always present at the admission. A high level of suspicion for intestinal ischemia should be maintained in COVID-19 patients presenting with GI symptoms or with incremental abdominal pain. Nevertheless, a prompt thromboelastogram and laboratory test may confirm the need of improving and fastening the use of anticoagulants and trigger an extended indication for early abdominal CECT in patients with suggestive symptoms or biochemical markers of intestinal ischemia.

Emergency hernia repair in the elderly: multivariate analysis of morbidity and mortality from an Italian registry

PURPOSE

The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed.

METHODS

This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed.

RESULTS

259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality CONCLUSION: Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation.

Are antigen tests useful as screening for the identification of SARS-CoV-2 in emergency rooms?

Background

A quick and accurate case identification in the Emergency Department (ED) during the SARS-CoV-2 pandemic is crucial for clinical management and to prevent spread of infections. The gold standard for diagnosing SARS-CoV-2 infection is the real-time reverse transcription polymerase chain reaction (RT-PCR) test in upper airways swabs. However, the procedure is available in few specialized laboratories and requires an average sample processing time of about 6 hours from its inception. The development of reliable but cheaper and faster point-of-care tests was expected to be useful either for population-screening or as first aid tests in the ED. Rapid antigenic diagnostic tests (Ag-RDTs), directly detect SARS-CoV-2 proteins produced by the replicating virus in respiratory specimens, were proved to be candidates in both cases. However, data on their effectiveness are still few and controversial. The aim of the study is to establish the accuracy of antigen tests to identify SARS-CoV-2 in a high prevalence setting.

Methods

Results of 324 patients, consecutively admitted to the ED of San Luigi Gonzaga University Hospital in Orbassano (Turin, Italy) between 26 October and 10 November 2020 and subjected to both molecular and antigen tests, were compared.

Results

Using RT-PCR as gold standard, specificity and sensitivity of Ag-RDT were 0.94 (95%CI: 0.90-0.98) and 0.80 (95%CI: 0.75-0.85), respectively. The Ag-RDT positive predictive value was 0.96 (95%CI 0.93- 0.99), and the negative predictive value was 0.72 (95% CI: 0.65-0.79). Patients that tested negative to Ag-RDT but presented with fever and cough or had pneumonia at imaging were more likely to be false negatives. Ag-RDTs best performance occurs in the first days after symptom onset.

Conclusions

These results confirm the limits of antigenic tests as first line screening tests and suggest that the antigenic test should be integrated with clinical judgement, based on physical and instrumental examinations.

Key messages

Antigenic tests have a limited effectiveness as first line screening tests. In a high-prevalence setting these tests incorrectly judge as negative many COVID-19 symptomatic patients, making necessary to integrate their results with clinical judgement.

Estimation of Excess Deaths in Turin from COVID-19 and other causes, October to November 2020

Introduction

Understanding the effect of COVID-19 on mortality during this emergency and evaluating unexplained increases in deaths due to nonspecific outcomes can provide a more complete picture of this period and give better instrument to deal with the pandemy in the future.

Objective

The aim is to evaluate in the city of Turin the excess in the number of deaths from October to November 2020.

Methods

The number of excess deaths was defined as the difference between the deaths observed in the pandemic period of 2020 and the deaths expected for the years 2014-2019.

Results

There were approximately 2047 total all causes deaths in Turin October 1 to November 30 2020, representing 630 more deaths than would typically be expected at that time of year. This excess was higher between men than in women. The number of excess all cause death was higher in 80 years old, less evident between 60-79 years old and very few between under 60 years old. Regarding the place of death, the number of excess all cause death was higher in hospital or in some health institutions for old people. Regarding the causes of deaths the explanation of these excess of deaths was COVID-19 infection only for a part of deaths and there are some excess of deaths not caused by COVID-19. The cause of excess of death not COVID-19 seems to be due to cardiovascular diseases, respiratory diseases, psychiatric disorders, neurological diseases, diabetes or nephrological diseases and to other undefinited causes.

Conclusions

The results showed during pandemic an increase of mortality respect to the expected mortality. Only a part of this excess deaths is due to COVID-19 but there is a relevant percentage of excess of deaths apparentely not due to COVID-19 but probably due to other causes. A better knowledge of these phenomena could help to improve any gaps in territorial assistance and provide indications for the future management of the pandemic in Europe.

Key messages

Increase of mortality in pandemic respect to the expected mortality. There is an excess of deaths apparentely not due to COVID-19.

Impact of the COVID-19 pandemic on emotional status of the adult and older population in Italy. Data from the behavioural risk factor surveillance systems PASSI and PASSI d’Argento, 2020-2021

PASSI and PASSI d'Argento are two nationwide ongoing population-based surveillance systems in Italy which targeting, respectively, adults aged 18-69 and over-65, aim at monitoring people health profile, as per health behaviours and their determinants. The Italian National Institute of Health is in charge of the central coordination, but the Local Health Units (LHUs) develop these surveillances. Specifically trained LHUs personnel conduct phone-interviews on gender and age-representative monthly samples of residents in Italy by using a standardised questionnaire. Within both systems, depressive symptoms are under investigation through the Patient Health Questionnaire-2. Since August 2020 to date, PASSI and PASSI d'Argento annexed a specific COVID module in addition to the standard questionnaires' sections. In this way, we have been studying the impact of the COVID-19 pandemic on economic and working conditions, emotional status and other health-related aspects, as well as those concerning contagion risk perception and its outcomes or citizens compliance with pandemic control measures. In detail, two questions detect the impact of the pandemic on emotional status: ‘intrusive thinking' as dimension of psychological stress associated to experiencing COVID-19 emergency, and ‘degree of concern' about the current situation as a dimension of anxiety. Even if the two items are not precise tools to assess mental health symptoms, they are in the condition to give hints for an estimation of the pandemic impact on the psychological well-being in the general population. Preliminary findings, from the analysis of 5,000 interviews, show quite direct experience of COVID (bereavements in family or COVID-positive friends), worsened economic resources among the working-age individuals, and social isolation in the elderly, as the main determinants of intrusive thinking. Being worried about pandemic also correlates with experience of COVID, showing significant differences by gender.

Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p&lt;0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.