P6471Pronostic impact of significant valvular disease in long-term survivors of out-of-hospital-cardiac arrest

Background

There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA).

Purpose

To determine whether VHD influence prognosis of OHCA survivors.

Methods

All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed.

Results

A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p<0.001]. Only five patients received surgical or percutaneous treatment for VHD during follow-up, with no deaths in this subgroup. Moderate or severe VHD proved to be an independent predictor of global cardiovascular events and specifically heart failure episodes (Figure 1).

Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254

Figure 1

Conclusion

The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.

Diversity of Saccharomyces cerevisiae yeasts associated to spontaneous and inoculated fermenting grapes from Spanish vineyards

The use of commercial yeast strains is a common practice in winemaking leading to a predictable quality in wine production, avoiding stuck or sluggish fermentations. However, the use of commercial yeasts leads to a consequent reduction in autochthonous microbial diversity. In this study, 1047 isolates from three Spanish appellations of origin were checked for fingerprinting on interdelta polymorphisms and the strain composition and diversity analysed using an extensible open-source platform for processing and analysis of an in-house polymorphism database developed for this study. Ancient vineyards managed with organic practices showed intermediate to low levels of strains diversity indicating the existence of stable populations of Saccharomyces cerevisiae strains. A drastic reduction in the number of different S. cerevisiae strains was observed in vineyards with cellars using a selected autochthonous S. cerevisiae strain for winemaking. Contrary, the use of allochthonous commercial strains in wineries did not seem to affect the native S. cerevisiae strain composition and diversity. SIGNIFICANCE AND IMPACT OF THE STUDY: The aim of this study was to compare different viticulture and oenological practices to determine their influence on the composition and diversity of Saccharomyces cerevisiae strains in wine fermentations. The study shows that the use of autochthonous strains of S. cerevisiae as starters for wine fermentation could have an important incidence on S. cerevisiae strains diversity in surrounding vineyards. The use of autochthonous strains of S. cerevisiae reduced the detected number of S. cerevisiae strains, a fact that was not observed when allochthonous commercial strains were used. Furthermore, vineyards managed with organic practices showed intermediate to low levels of S. cerevisiae strain diversity, whereas conventional practices showed higher levels.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Large-scale implementation of sustainable production practices in the Priorat-Montsant region

The Priorat and Montsant Appellations of Origin are considered to produce some of the finest wines in the Mediterranean area of Spain. Located in the south of Catalonia (North-East Spain), they account for close to 4000 ha cultivated by more than 1300 vine growers under severe Mediterranean climatic conditions and hence threatened by global warming. In this context, sustainable practices are needed for the optimal use of natural resources in order to ensure the durability of high-quality wine production in the region. In addition, these practices allow this region to maintain high levels of biodiversity, a major characteristic of Priorat and Montsant's agricultural landscape, which represents an important touristic attraction. The Project LIFE Priorant+Montsant, funded by the European Union, proposed the implementation of sustainable practices at a regional scale, in order to achieve remarkable reductions of resource consumption in three axes: 1) Irrigation water management, 2) vine fertilization and 3) synthetic pesticide use. Reductions are achieved by providing the necessary technical support to growers to adopt practices, developing optimized strategies and evaluating the viticulture and winery production processes. After the two first seasons of the project, 2017 and 2018, the objectives of reduction of resources consumption have been successfully achieved. A total of 53 vineyard plots, representing the main grape varieties in the region (Grenache, Carignan, Cabernet Sauvignon and Syrah) were classified in eight sub-areas and monitored for water consumption. From pea-size to harvest (phenological stages), weekly measurements of phenology, water potential and meteorological data were collected. Irrigation recommendations were then given to growers, to avoid water potential below − 1.4 MPa. Overall, more than 50 irrigation recommendations were emitted to growers. The water consumption with the optimized irrigation strategy ranged from 10 to 63 litres per ha, the recommended dose saved 20 to 87% of the irrigation water per year, according to previous general recommendations in this region. Regarding fertilization, soil samples were provided by growers and leave samples were taken from vineyards to assess nutrient levels and develop the corresponding recommendation of fertilization, depending on the analysis results. The analyzed soil samples from the different sub-areas were grouped by the Principal Component Analysis, in which the first and second principal components accounted for 31.6% and 11.8% of the variability and were related to soil texture and nutrient content of soils, respectively. Overall, the recommended doses of organic fertilizers saved more than 20% of the usual chemical fertilizer application in the region. The reduction of pesticide use will be achieved through three actions related to three main pests and diseases of grapevine: optimized formulations against powdery mildew, alternative products to reduce copper use against downy mildew and, increase of surface under mating disruption strategy against grape berry moth Lobesia botrana. Before implementing these actions, no vineyards were managed under mating disruption in the Montsant area and 207 ha have been monitored in 2018 after two years. In the Priorat area, more than 200 ha have also adopted this strategy during the project. This action has saved more than 500 application doses of synthetic insecticides in those vineyards. Within the same scope, several formulations will be proved in the following years in order to assess their effectiveness against powdery and downy mildew in further specific field trials. Candidate products will be introduced in Integrated Pest Management strategies to achieve the desired pesticide reduction levels. The results will represent specific regional strategies for irrigation, fertilization and plant protection, and are extensible to most of the vineyards in Priorat and Montsant, as well as to other vitivinicultural regions which similar conditions.

Keywords: Sustainable management, Irrigation, Fertilisation, Pesticides, Priorat-Montsant.

Source apportionment and environmental fate of lead chromates in atmospheric dust in arid environments

The environmental fate of lead derived from traffic paint has been poorly studied in developing countries, mainly in arid zones. For this purpose, a developing city located in the Sonoran desert (Hermosillo, Mexico), was chosen to conduct a study. In this paper the lead chromate (crocoite) sources in atmospheric dust were addressed using a combination of Raman microspectroscopy, X-ray diffraction, scanning electron microscopy (SEM), and Pb isotope measurements. A high concentration of Pb and Cr as micro- and nanostructured pigments of crocoite is reported in yellow traffic paint (n=80), road dust (n=146), settled dust in roofs (n=21), and atmospheric dust (n=20) from a developing city located in the Sonoran Desert. 10 samples of peri-urban soils were collected for local geochemical background. The paint photodegradation and erosion of the asphaltic cover are enhanced by the climate, and the presence of the mineral crocoite (PbCrO₄) in road dust with an aerodynamic diameter ranging from 100nm to 2μm suggests its integration into the atmosphere by wind resuspension processes. A positive PbCr correlation (R²=0.977) was found for all studied samples, suggesting a common source. The Pb-isotope data show signatures in atmospheric dust as a product of the mixing of two end members: i) local soils and ii) crocoite crystals as pigments in paint. The presence of lead chromates in atmospheric dust has not been previously documented in Latin America, and it represents an unknown health risk to the exposed population because the identified size of crystals can reach the deepest part of lungs.

Was Aztec and Mixtec turquoise mined in the American Southwest?

Archaeologists have long suggested that prehispanic states in Mesoamerica acquired turquoise through long-distance exchange with groups living in what is now the American Southwest and adjacent parts of northern Mexico. To test this hypothesis, we use lead and strontium isotopic ratios to investigate the geologic provenance of 43 Mesoamerican turquoise artifacts, including 38 mosaic tiles from offerings within the Sacred Precinct of Tenochtitlan (the Mexica or Aztec capital) and 5 tiles associated with Mixteca-style mosaics currently held by the Smithsonian's National Museum of the American Indian. Most of these artifacts have isotopic signatures that differ from turquoise deposits in the American Southwest, but closely match copper deposits and crustal rocks in Mesoamerica. We thus conclude that turquoise used by the Aztecs and Mixtecs likely derives from Mesoamerican sources and was not acquired through long-distance exchange with the Southwest.

Influence of Age on Decision-Making Process to Limit or Withdraw Life-Sustaining Treatment in the Intensive Care Unit - A Single Center Prospective Observational Study

BACKGROUND

The increasing age in the industrialized countries places significant demands on intensive care unit (ICU) resources and this triggers debates about end-of-life care for the elderly.

OBJECTIVES

We sought to determine the impact of age on the decision-making process to limit or withdraw life-sustaining treatment (DWLST) in an ICU in France. We hypothesized that there are differences in the decision-making process for young and old patients.

DESIGN, SETTING, PARTICIPANTS

We prospectively studied end-of-life decision-making for all consecutive admissions (n=390) to a tertiary care university ICU in Toulouse, France over a period of 11 months between January and October 2011.

RESULTS

Among the 390 patients included in the study (age ≥70yo, n=95; age <70yo, n=295) DWLST were more common for patients 70 years or older (43% for age ≥70yo vs. 16% for age <70yo, p <0.0001). Reasons for DWLST were different in the 2 groups, with the 'no alternative treatment options' and 'severity of illness' as the most frequent reasons cited for the younger group whereas it was 'severity of illness' for the older group. 'Advanced age' led to DWLSTs in 43% of the decisions in the group ≥70yo (vs. 0% in the group <70yo, p <0.0001). Multivariate logistic regression showed a high SAPS II score and age ≥70yo as independent risk factors for DWLSTs in the ICU. We did not find age ≥70yo as an independent risk factor for mortality in ICU.

CONCLUSION

We found that age ≥70yo was an independent risk factor for DWLSTs for patients in the ICU, but not for their mortality. Reasons leading to DWLSTs are different according to the age of patients.

Plasma ctDNA RAS mutation analysis for the diagnosis and treatment monitoring of metastatic colorectal cancer patients

Background

RAS assessment is mandatory for therapy decision in metastatic colorectal cancer (mCRC) patients. This determination is based on tumor tissue, however, genotyping of circulating tumor (ct)DNA offers clear advantages as a minimally invasive method that represents tumor heterogeneity. Our study aims to evaluate the use of ctDNA as an alternative for determining baseline RAS status and subsequent monitoring of RAS mutations during therapy as a component of routine clinical practice.

Patients and methods

RAS mutational status in plasma was evaluated in mCRC patients by OncoBEAM™ RAS CRC assay. Concordance of results in plasma and tissue was retrospectively evaluated. RAS mutations were also prospectively monitored in longitudinal plasma samples from selected patients.

Results

Analysis of RAS in tissue and plasma samples from 115 mCRC patients showed a 93% overall agreement. Plasma/tissue RAS discrepancies were mainly explained by spatial and temporal tumor heterogeneity. Analysis of clinico-pathological features showed that the site of metastasis (i.e. peritoneal, lung), the histology of the tumor (i.e. mucinous) and administration of treatment previous to blood collection negatively impacted the detection of RAS in ctDNA. In patients with baseline mutant RAS tumors treated with chemotherapy/antiangiogenic, longitudinal analysis of RAS ctDNA mirrored response to treatment, being an early predictor of response. In patients RAS wt, longitudinal monitoring of RAS ctDNA revealed that OncoBEAM was useful to detect emergence of RAS mutations during anti-EGFR treatment.

Conclusion

The high overall agreement in RAS mutational assessment between plasma and tissue supports blood-based testing with OncoBEAM™ as a viable alternative for genotyping RAS of mCRC patients in routine clinical practice. Our study describes practical clinico-pathological specifications to optimize RAS ctDNA determination. Moreover, OncoBEAM™ is useful to monitor RAS in patients undergoing systemic therapy to detect resistance and evaluate the efficacy of particular treatments.

SPECT myocardial perfusion imaging

Aim: To determine the long-term prognostic value of SPECT myocardial perfusion imaging (MPI) for the occurrence of cardiovascular events in diabetic patients. Patients, methods: SPECT MPI of 210 consecutive Caucasian diabetic patients were analysed using Kaplan-Meier event-free survival curves and independent predictors were determined by Cox multivariate analyses. Results: Follow-up was complete in 200 (95%) patients with a median period of 3.0 years (0.8-5.0). The population was composed of 114 (57%) men, age 65 ±10 years, 181 (90.5%) type 2 diabetes mellitus, 50 (25%) with a history of coronary artery disease (CAD) and 98 (49%) presenting chest pain prior to MPI. The prevalence of abnormal MPI was 58%. Patients with a normal MPI had neither cardiac death, nor myocardial infarction, independently of a history of coronary artery disease or chest pain. Among the independent predictors of cardiac death and myocardial infarction, the strongest was abnormal MPI (p <0.0001), followed by history of CAD (Hazard Ratio (HR)=15.9; p=0.0001), diabetic retinopathy (HR=10.0; p=0.001) and inability to exercise (HR=7.7; p=0.02). Patients with normal MPI had a low revascularisation rate of 2.4% during the followup period. Compared to normal MPI, cardiovascular events increased 5.2 fold for reversible defects, 8.5 fold for fixed defects and 20.1 fold for the association of both defects. Conclusion: Diabetic patients with normal MPI had an excellent prognosis independently of history of CAD. On the opposite, an abnormal MPI led to a >5-fold increase in cardiovascular events. This emphasizes the value of SPECT MPI in predicting and risk-stratifying cardiovascular events in diabetic patients.

Underdetection of comorbid drug use at acute psychiatric admission

Aims and Method

The ability of routine clinical practice to detect drug use at acute psychiatric admission was assessed by comparing the results of urinalysis with information on drug use extracted from patient records (n=112).

Results

Urinalysis detected drug use in 23% of the sample. Cannabis was the drug most frequently found. Of the cases of drug use positively identified by urinalysis, 54% were not identified in the notes. Some information on drug use proximal to admission was found in 40% of patient records. Patients asked about proximal drug use were younger than those not asked.

Clinical Implications

All patients should be asked about drug use.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management

OBJECTIVES

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR).

METHODS

To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process.

RECOMMENDATIONS

We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Experimental determination of drift and PM10 cooling tower emissions: Influence of components and operating conditions

Cooling tower emissions have become an increasingly common hazard to the environment (air polluting, ice formation and salts deposition) and to the health (Legionella disease) in the last decades. Several environmental policies have emerged in recent years limiting cooling tower emissions but they have not prevented an increasing intensity of outbreaks. Since the level of emissions depends mainly on cooling tower component design and the operating conditions, this paper deals with an experimental investigation of the amount of emissions, drift and PM₁₀, emitted by a cooling tower with different configurations (drift eliminators and distribution systems) and working under several operating conditions. This objective is met by the measurement of cooling tower source emission parameters by means of the sensitive paper technique. Secondary objectives were to contextualize the observed emission rates according to international regulations. Our measurements showed that the drift rates included in the relevant international standards are significantly higher than the obtained results (an average of 100 times higher) and hence, the environmental problems may occur. Therefore, a revision of the standards is recommended with the aim of reducing the environmental and human health impact. By changing the operating conditions and the distribution system, emissions can be reduced by 52.03% and 82% on average. In the case of drift eliminators, the difference ranges from 18.18% to 98.43% on average. As the emissions level is clearly influenced by operating conditions and components, regulation tests should be referred to default conditions. Finally, guidelines to perform emission tests and a selection criterion of components and conditions for the tested cooling tower are proposed.