P383 THIRD–DEGREE ATRIOVENTRICULAR BLOCK AND HYPERCALCEMIA: NOT ALWAYS JUST THE HEART

A 81–year–old lady was admitted to the ER due to anorexia, fever and oliguria. Previous medical history was unknown as she had arrived in Italy one month before and her son was not aware of it. Upon arrival she was soporous and bradicardic. Physical examination consisted of mild pulmonary rales, diffuse abdominal pain and leg edema. ECG showed a third–degree atrioventricular block with narrow QRS and average heart rate of 40 bpm with no signs of ischemia. X–ray showed mild congestion. She was admitted to CCU. Blood tests showed hypoglicemia (53 mg/dL), anemia (Hb 9.9g/dL), low platelet count, renal dysfunction (creatinine 1.43mg/dL), high C–reactive protein, normal potassium but high calcemia (13 mg/dL). To investigate hypercalcemia parathyroid hormone was dosed and was in range, so a CT scan was needed to rule out pancreatitis, cancer or bone lesions. Also a cardiac echo was done: it showed a hypertrophic left ventricle with preserved contractility, no significant valvular dysfunctions, normal right sections with pulmonary hypertension, no pericardial effusion. While performing the subcostal view however multiple formations were seen at the hepatic level. CT scan confirmed multiple pathological conglomerating lymphadenopathies in the abdomen towards the femoral region, reaching 5 cm of diameter; no bone lesions were found. Inguinal lymph node biopsy was performed. Due to persistent complete AV block along with persistent hypercalcemia and hypoglycemia despite medical therapy, considering the electrolyte imbalance not corrigible due to a malignancy a pacemaker was implanted. The result of the lymph node biopsy was consistent with a form of Diffuse Large B–Cell Lymphoma. This case highlights how a 3–rd degree AV block may present with non–specific symptoms. When it is found it may not always represent a pure cardiac problem as sometimes it is the epiphenomenon of a systemic disease. Particularity of this case is that cardiologists are less used to take into consideration calcium balance. Nevertheless, although infrequent, hypercalcemia is a cause of significant conduction disease. After having looked for it, searching for its etiology is mandatory as some could be reversible and thus the AV block as well. For this reason, when a complete AV block is found ruling out hypercalcemia is fundamental, taking into consideration that the conduction disease may represent the first red flag of an unknown malignancy

ECG monitoring of post-stroke occurring arrhythmias: an observational study using 7-day Holter ECG

Post-stroke arrhythmias represent a risk factor for complications and worse prognosis after cerebrovascular events. The aims of the study were to detect the rate of atrial fibrillation (AF) and other cardiac arrhythmias after acute ischemic stroke, by using a 7-day Holter ECG which has proved to be superior to the standard 24-h recording, and to evaluate the possible association between brain lesions and arrhythmias. One hundred and twenty patients with cryptogenic ischemic stroke underwent clinical and neuroimaging assessment and were monitored with a 7-day Holter ECG. Analysis of the rhythm recorded over 7 days was compared to analysis limited at the first 24 h of monitoring. 7-day Holter ECG detected AF in 4% of patients, supraventricular extrasystole (SVEB) in 94%, ventricular extrasystole (VEB) in 88%, short supraventricular runs (SVRs) in 54%, supraventricular tachycardia in 20%, and bradycardia in 6%. Compared to the first 24 h of monitoring, 7-Holter ECG showed a significant higher detection for all arrhythmias (AF p = 0.02; bradycardia p = 0.03; tachycardia p = 0.0001; SVEB p = 0.0002; VEB p = 0.0001; SVRs p = 0.0001). Patients with SVRs and bradycardia were older (p = 0.0001; p = 0.035) and had higher CHA₂DS₂VASc scores (p = 0.004; p = 0.026) respectively, in the comparison with patients without these two arrhythmias. An association was found between SVEB and parietal (p = 0.013) and temporal (p = 0.013) lobe lesions, whereas VEB correlated with insular involvement (p = 0.002). 7-day Holter ECG monitoring proved to be superior as compared to 24-h recording for the detection of all arrhythmias, some of which (SVEB and VEB) were associated with specific brain areas involvement. Therefore, 7-day Holter ECG should be required as an effective first-line approach to improve both diagnosis and therapeutic management after stroke.

Cost-effectiveness of implementing a digital psychosocial intervention for patients with psychotic spectrum disorders in low- and middle-income countries in Southeast Europe: Economic evaluation alongside a cluster randomised trial

Background

DIALOG+ is a digital psychosocial intervention aimed at making routine meetings between patients and clinicians therapeutically effective. This study aimed to evaluate the cost-effectiveness of implementing DIALOG+ treatment for patients with psychotic disorders in five low- and middle-income countries in Southeast Europe alongside a cluster randomised trial.

Methods

Resource use and quality of life data were collected alongside the multi-country cluster randomised trial of 468 participants with psychotic disorders. Due to COVID-19 interruptions of the trial’s original 12-month intervention period, adjusted costs and quality-adjusted life years (QALYs) were estimated at the participant level using a mixed-effects model over the first 6 months only. We estimated the incremental cost-effectiveness ratio (ICER) with uncertainty presented using a cost-effectiveness plane and a cost-effectiveness acceptability curve. Seven sensitivity analyses were conducted to check the robustness of the findings.

Results

The average cost of delivering DIALOG+ was €91.11 per participant. DIALOG+ was associated with an incremental health gain of 0.0032 QALYs (95% CI –0.0015, 0.0079), incremental costs of €84.17 (95% CI –8.18, 176.52), and an estimated ICER of €26,347.61. The probability of DIALOG+ being cost-effective against three times the weighted gross domestic product (GDP) per capita for the five participating countries was 18.9%.

Conclusion

Evidence from the cost-effectiveness analyses in this study suggested that DIALOG+ involved relatively low costs. However, it is not likely to be cost-effective in the five participating countries compared with standard care against a willingness-to-pay threshold of three times the weighted GDP per capita per QALY gained.

Improving treatment of patients with psychosis in low-and-middle-income countries in Southeast Europe: Results from a hybrid effectiveness-implementation, pragmatic, cluster-randomized clinical trial (IMPULSE)

Background

In Southeast Europe (SEE) standard treatment of patients with psychosis is largely based on pharmacotherapy with psychosocial interventions rarely available. DIALOG+ is a digital psychosocial intervention designed to make routine care therapeutically effective. This trial simultaneously examined effectiveness of DIALOG+ versus standard care on clinical and social outcomes (Aim 1) and explored intervention fidelity (Aim 2).

Methods

A hybrid type II effectiveness–implementation, cluster-randomized trial was conducted in five SEE countries: Bosnia and Herzegovina, Kosovo*, Montenegro, North Macedonia, and Serbia. The intervention was offered to patients six times across 12 months instead of routine care. The outcomes were subjective quality of life (primary), clinical symptoms, satisfaction with services, and economic costs. Intervention fidelity was operationalized as adherence to the protocol in terms of frequency, duration, content, and coverage. Data were analyzed using multilevel regression.

Results

A total of 81 clinicians and 468 patients with psychosis were randomized to DIALOG+ or standard care. The intervention was delivered with high fidelity. The average number of delivered sessions was 5.5 (SD = 2.3) across 12 months. Patients in the intervention arm had better quality of life (MANSA) at 6 months (p = 0.03). No difference was found for other outcomes at 6 months. Due to disruptions caused by the COVID-19 pandemic, 12-month data were not interpretable.

Conclusions

DIALOG+ improved subjective quality of life of individuals with psychosis at 6 months (after four sessions), albeit with small effect size. The intervention has the potential to contribute to holistic care of patients with psychosis.

Treatment of lean PCOS teenagers: a follow-up comparison between Myo-Inositol and oral contraceptives

OBJECTIVE

Polycystic ovary syndrome (PCOS) is an endocrinological and metabolic disorder widely diffused and diagnosed in women of reproductive age. The pathology exhibits alteration of the reproductive functions, including conditions as hyperandrogenism, menstrual cycle irregularity, type 2 diabetes. These conditions are visible in the patients through phenotypical manifestations as hirsutism, acne, and obesity. Even if the syndrome is characterized by common features among both adult and adolescent women, the diagnostic criteria are different for the two age categories and to date still controversial. We investigated different treatments in PCOS adolescents with non-severe metabolic conditions, to evaluate which could be the appropriate therapeutical approach for these patients.

PATIENTS AND METHODS

We enrolled lean teenagers with PCOS, and we divided the patients in two age ranges: 13-16 years old and 17-19 years old. They were treated for 3 months either with oral contraceptive pills (OCP) drospirenone/ethinylestradiol (group A), myo-Inositol (myo-Ins) (group B), or OCP plus myo-Ins (group C). Data were analyzed with a descriptive statistics summarizing quantitative variables including median, 25th and 75th percentiles.

RESULTS

We pointed out that the group of 13-16 years old lean teenagers treated with myo-Ins exhibit a significant decrease of weight and body mass index (BMI), and an effective improvement the metabolic and hormonal parameters achieved with a non-pharmacological treatment. In the older teenagers aged 17-19 years, data highlights that myo-Ins treatment in combination with OCP prevents the increases of weight and BMI, improves the metabolic profile of the patients, and strongly ameliorates the hormonal parameters analyzed.

CONCLUSIONS

The results indicate a different scenario in the two age ranges considered and interestingly suggest an important role of myo-Ins in the PCOS context. A therapy based on this natural compound alone or in combination with OCP seems effective to improve both metabolic and hormonal parameters of PCOS adolescents and thus could represent a novel and valid option to consider for the treatment of this syndrome.

VLP-Based COVID-19 Vaccines: An Adaptable Technology against the Threat of New Variants

Virus-like particles (VLPs) are a versatile, safe, and highly immunogenic vaccine platform. Recently, there are developmental vaccines targeting SARS-CoV-2, the causative agent of COVID-19. The COVID-19 pandemic affected humanity worldwide, bringing out incomputable human and financial losses. The race for better, more efficacious vaccines is happening almost simultaneously as the virus increasingly produces variants of concern (VOCs). The VOCs Alpha, Beta, Gamma, and Delta share common mutations mainly in the spike receptor-binding domain (RBD), demonstrating convergent evolution, associated with increased transmissibility and immune evasion. Thus, the identification and understanding of these mutations is crucial for the production of new, optimized vaccines. The use of a very flexible vaccine platform in COVID-19 vaccine development is an important feature that cannot be ignored. Incorporating the spike protein and its variations into VLP vaccines is a desirable strategy as the morphology and size of VLPs allows for better presentation of several different antigens. Furthermore, VLPs elicit robust humoral and cellular immune responses, which are safe, and have been studied not only against SARS-CoV-2 but against other coronaviruses as well. Here, we describe the recent advances and improvements in vaccine development using VLP technology.

Trends in the use of mechanical and bioprosthetic aortic valve replacement in the era of transcatheter aortic valve replacement

Background

The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and co-morbidities, since bioprosthetic AVR (bAVR) as compared to mechanical AVR (mAVR), are associated with a more rapid structural deterioration. However, refinements in bioprosthetic valves and the introduction of transcatheter aortic valve replacement (TAVR) (potential for valve-in-valve procedures), will most likely influence valve selection in the future. The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined.

Purpose

The goal of our study was to assess trends in utilization of bAVR and mAVR in the United States while, assessing in-hospital mortality over time.

Methods

The National Inpatient database (2009–18) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 700,896 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older, [bAVR (69.8 years) vs mAVR (62.7 years) p<0.001]. Heart failure, cardiac arrhythmias, hypertension, diabetes with complications and renal failure were more common in those undergoing a bAVR. Through the course of the study period, the rates of mAVR decreased across all age groups (p trend <0.001), including patients younger than 50 years (p trend <0.001). Both crude (OR = 1.20 95% CI 1.13–1.27) and adjusted (OR = 1.34 95% CI 1.25–1.44) inpatient mortality was higher amongst mAVR recipients.

Conclusions

In the contemporary TAVR era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with significantly less co-morbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding the causes accounting for the higher mortality after mAVR, future research should focus on developing TAVR friendly bAVR; possibly enhancing our ability to perform percutaneous valve-in-valve procedures in the future.

Funding Acknowledgement

Type of funding sources: None.

Clinical characteristics, management, and outcomes of patients with electrical storm: single centre experience

Background

Electrical storm (ES) is a life-threatening condition caused by recurrent malignant ventricular arrhythmia (≥3 episodes of ventricular tachycardia (VT) or ventricular fibrillation within 24 hours). ES patient management is challenging and can involve antiarrhythmic medication, sedation, and invasive procedures such as catheter ablation.

Purpose

The aim of this study is to report the clinical profile and management of ES patients who attended an arrhythmia reference centre.

Methods

Patients who presented with ES at our centre over a five-year period were consecutively enrolled. Patient data were retrospectively collected from hospital records. Patients with in-hospital death were excluded form data analysis.

Results

Seventy-six patients were included (84% male, mean age 73±10 years). 55% of patients had ischemic heart disease. The mean left ventricle ejection fraction (LVEF) was 33±4%, with 22% of patients having a severe reduction in systolic ventricular function (EF <35%). Baseline characteristics are reported in Table 1. During hospitalisation, 30% of patients underwent coronary angiography and 30% of these had percutaneous coronary revascularization. Patients were managed with pharmacological treatment, including continuous infusion of antiarrhythmic drugs (45% of patients received at least one antiarrhythmic), sedation (12%), and electrolytic solutions (38%). More details on ES management are reported in Table 2. All patients were evaluated for transcatheter ablation. After a mean of 6 days, 25% underwent transcatheter VT ablation during hospitalisation. In 7 patients (9%), catheter ablation was planned and performed during a subsequent hospitalisation.

At discharge, 93% of patients received beta blockers and 68% received amiodarone. Overall, 65% were discharged with at least two antiarrhythmic drugs. The mean length of hospitalisation was 10±9 days, with 6±4 days spent in the intensive care unit. Eighteen patients (23%) had at least one subsequent hospitalisation for ES. After a mean follow-up of 20 months, the cumulative mortality rate was 27%, without a significant difference in mortality rates between ablated and non-ablated patients (27% and 28%, respectively). Baseline mean creatinine levels were higher (1.73±1.1 vs. 1.27±0.1 mg/dl, p<0.05), and LVEF was lower (27±3% vs. 35±17%, p<0.05) in patients who died during follow-up as compared to survivors. A trend toward a longer QTc interval duration (482±47 vs. 467±28 ms) and longer QRS duration (139±36 vs. 131±7 ms) was also found among patients who died during follow-up.

Conclusion

In our centre, ischemic heart disease was the most common heart disease in patients presenting with ES. In more than one third of patients, VT transcatheter ablation was performed as a therapeutic strategy in addition to drug therapy. Among patients who died during the follow-up, baseline creatinine levels were higher and LVEF was lower compared with survivors.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Incidence, predictors and prognostic role of complications occurring during provocative testing with acetylcholine in patients with myocardial ischemia and non-obstructive coronary arteries

Background

Coronary provocative test with acetylcholine (ACh) is of utmost importance and increasingly used in patients with myocardial ischemia and non-obstructive coronary arteries. However, data on safety, predictors and prognostic role of complications during intracoronary provocative testing are scarce.

Purpose

We assessed the safety of ACh provocative test in patients with myocardial ischemia and non-obstructive coronary arteries. Moreover, we evaluated the predictors and the prognostic implications of complications occurring during the provocative test.

Methods

We prospectively enrolled consecutive patients undergoing intracoronary ACh provocative test for suspected myocardial ischaemia with angiographic evidence of non-obstructive coronary arteries. Complications during the ACh test were collected. Occurrence of major adverse cardiac events (MACE), arrhythmic events at 24-hours ECG dynamic Holter monitoring and angina status were assessed at follow-up.

Results

We enrolled 310 patients (mean age 60.6±11.9; 169 [54.5%] chronic coronary syndromes [CCS] and 141 [45.5%] with myocardial infarction and non-obstructive coronary arteries [MINOCA]). The overall incidence of complications was low (9%) with a similar incidence in MINOCA and CCS (10 [7.1%] vs 18 [10.7%], p=0.276, respectively). At multivariate logistic regression analysis, a previous history of paroxysmal atrial fibrillation (Odds Ratio [OR] 12.324, Confidence Interval [CI] 95% [4.641; 32.722], p=0.015) and moderate/severe diastolic dysfunction (OR 3.827, CI95% [1.296; 11.304], p=0.015) were independent predictors for occurrence of complications. The occurrence of complications was not associated with a worse clinical outcome at follow-up (median follow-up 22 months) in terms of both MACE, arrhythmic events and angina burden.

Conclusion

Intracoronary provocative testing with ACh test is safe in patients with myocardial ischemia and non-obstructive coronary arteries, without differences between MINOCA and CCS. History of paroxysmal atrial fibrillation and moderate/severe diastolic dysfunction predicted the occurrence of complications during ACh test. Of importance, our data can reassure clinicians, as the occurrence of complications did not portend a worse prognosis at follow-up in terms of MACE, arrhythmic events and angina burden.

Funding Acknowledgement

Type of funding sources: None. Complications and clinical presentationClinical outcome at follow-up

Does the availability of transcatheter aortic valve replacement impact inpatient outcomes after surgical aortic valve replacement? Analysis of the national inpatient sample

Background

With the introduction of transcatheter aortic valve replacement (TAVR), the treatment of aortic stenosis (AS) has experienced a paradigm shift, altering patient selection for surgical aortic valve replacement (SAVR) over the past decade. What remains to be determined is the impact of a hospital's ability to offer TAVR, in the contemporary era, on inpatient outcomes following SAVR.

Purpose

The goal of this study was to assess inpatient mortality and the use of mechanical aortic valve replacement (mAVR) in patients undergoing SAVR at TAVR versus non-TAVR centers in the United States.

Methods

The National Inpatient Sample (2011–18), a probability sample of inpatient visits in the United States, was used to study trends in admissions for SAVR at TAVR and non-TAVR centers; in-hospital mortality was trended over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 559,365 inpatient visits for SAVR with 75.2% (95% CI 74.2%-76.2%) and 24.7% (95% CI 23.8%-25.8%) receiving bioprosthetic SAVR (bAVR) and mAVR, respectively at TAVR centers and 64.5% (95% CI 63.3%-65.6%) and 35.5% (95% CI 34.4%-36.7%) receiving bAVR and mAVR, respectively at non-TAVR centers. SAVR recipients at non-TAVR centers were older when compared to recipients at TAVR centers (68.3±0.09 vs 66.9±0.11 years p<0.001). Heart failure, cardiac arrhythmias, peripheral vascular disorders, complicated hypertension and diabetes, renal failure and liver disease were more common in patients undergoing SAVR at TAVR-centers. During the study period, both crude (OR = 0.78 95% CI 0.73–0.83) and adjusted (OR = 0.79 95% CI 0.73–0.86) inpatient mortality was lower amongst SAVR recipients at TAVR centers. The utilization rates of mAVR at both TAVR and non-TAVR centers decreased over time amongst all age groups (p trend <0.001).

Conclusions

Patients undergoing SAVR at TAVR centers were younger and had more co-morbidities compared to patients undergoing SAVR at non-TAVR centers. Although patients undergoing SAVR at TAVR centers had significantly more co-morbidities, inpatient mortality was lower at TAVR centers compared to non-TAVR centers. Further research is needed to determine whether the impact of a multidisciplinary cardiac approach resulted in significant differences in patient selection for SAVR, due to the availability of TAVR, influencing patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Long-term exposure to ambient air pollution portends a higher risk of coronary plaque vulnerability and instability in patients with acute coronary syndrome: an optical coherence tomography study

Background

Air pollution is an emerging key player in determining the residual risk of coronary events. However, pathophysiological mechanisms linking air pollution and coronary events have been not adequately investigated.

Purpose

We assessed the relationship between exposure to air pollutants and mechanisms of coronary instability evaluated by optical coherence tomography (OCT) in patients with acute coronary syndrome (ACS).

Methods

ACS patients undergoing OCT imaging were retrospectively selected. Mechanism of culprit lesion instability was classified as plaque rupture (PR) or intact fibrous cap (IFC) by OCT, and the presence of macrophage infiltrates (MØI) and thin-cap fibroatheroma (TCFA) at the culprit site was also assessed. Based on each case's home address, exposure to several pollutants was evaluated, including particulate matter 2.5 (PM2.5), particulate matter 10 (PM10), and carbon monoxide (CO). Only patients with >2 years of available data on air pollution exposure prior to ACS were enrolled.

Results

We included 136 patients [median age 67.0 years (56.2–76.0), 104 (76.5%) male]. Sixty-six patients (48.5%) had PR as mechanism of plaque instability. Patients with PR were exposed to significantly higher PM2.5 levels compared to IFC, and PM2.5 was an independent predictor for PR (OR=1.133, 95% CI [1.020–1.258], p=0.019). Moreover, exposure to higher levels of PM2.5, PM10 and CO was an independent predictor for the presence of TCFA, while PM2.5 and CO levels predicted the presence of MØI. Interestingly, PM2.5, PM10 and CO levels were positively and significantly correlated with serum levels of C-reactive protein. ROC curves were constructed to assess the ability of PM2.5 to predict the presence of plaque rupture, TCFA or MØI. The AUC for PM2.5 to predict plaque rupture was 0.62 (95% CI: 0.52–0.71, p=0.018), for TCFA was 0.71 (95% CI: 0.61–0.80, p<0.001) and for MØI was 0.80 (95% CI: 0.71–0.88, p<0.001). Using a PM2.5 cut-off value of 13.40 μg/m3, the sensitivity and specificity for MØI were 81% and 66%, respectively.

Conclusions

We provide novel insights into the missing link between air pollution and increased risk of coronary events. In particular, exposure to higher concentrations of air pollutants is a risk factor for vulnerable plaque features and for plaque rupture as mechanism of coronary instability mediated by systemic and local plaque inflammation. Of importance, the thresholds of air pollutants that predicted the presence of vulnerable plaque features are far lower than commonly accepted safety thresholds used to start preventive measures for public health, suggesting that further efforts are needed in order to reduce the adverse effects on the cardiovascular system.

Funding Acknowledgement

Type of funding sources: None. Air pollutants exposure and OCT featuresROC curve analysis

Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid (99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation

BACKGROUND

To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients.

METHODS

Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years.

RESULTS

Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period.

CONCLUSIONS

99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.

Naturally occurring hypothermia promotes survival in severe anaphylaxis

Although hypothermia has received substantial attention as an indicator of severity in anaphylaxis, it has been neglected from the perspective of whether it could act as a disease-modifying factor in this condition. Here, the impact of naturally occurring (spontaneous) hypothermia on anaphylaxis was evaluated in a murine model of ovalbumin (OVA)-induced allergy. Nonextreme changes in the ambient temperature (T_a) were used to modulate the magnitude of spontaneous hypothermia. At a T_a of 24°C, challenge with OVA intraperitoneally or intravenously resulted in a rapid, transient fall in body core temperature, which reached its nadir 4-6°C below baseline in 30 min. This hypothermic response was largely attenuated when the mice were kept at a T_a of 34°C. The T_a-dependent attenuation of hypothermia resulted in a survival rate of only 30%, as opposed to survival of 100% in the condition that favored the development of hypothermia. The protective effect of hypothermia did not involve changes in the rate of mast cell degranulation, as assessed by the concentration of mast cell protease-1 in bodily fluids. On the other hand, hypothermia improved oxygenation of the brain and kidneys, as indicated by higher NAD⁺/NADH ratios. Therefore, it is plausible to propose that naturally occurring hypothermia makes organs more resistant to the anaphylactic insult.

Short communication: Seroprevalence of paratuberculosis in Italian water buffaloes (Bubalus bubalis) in the region of Campania

Paratuberculosis is a chronic enteric disease affecting virtually all ruminants, but only anecdotal information is currently available about the occurrence of this disease in water buffaloes (Bubalus bubalis). We carried out a survey study aimed at determining the prevalence of paratuberculosis in 2 provinces in the region of Campania, Italy, where about half of all Italian buffaloes are reared. From May 2017 to December 2018, we collected 201,175 individual serum samples from 995 buffalo herds. The sera were collected from animals over 24 mo old and were tested using a commercial ELISA test. The herd-level apparent prevalence result was 54.7%, and the animal-level apparent prevalence was 1.8%. The herd-level true prevalence was estimated using a Bayesian approach, demonstrating a high herd-level prevalence of paratuberculosis in water buffaloes from the Campania area. These findings suggest that the urgent adoption of paratuberculosis herd-control programs for water buffaloes in this area would be beneficial.

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases

BACKGROUND

Lemierre syndrome is characterized by head/neck vein thrombosis and septic embolism usually complicating an acute oropharyngeal bacterial infection in adolescents and young adults. We described the course of Lemierre syndrome in the contemporary era.

METHODS

In our individual-level analysis of 712 patients (2000-2017), we included cases described as Lemierre syndrome if these criteria were met: (i) primary site of bacterial infection in the head/neck; (ii) objectively confirmed local thrombotic complications or septic embolism. The study outcomes were new or recurrent venous thromboembolism or peripheral septic lesions, major bleeding, all-cause death and clinical sequelae.

RESULTS

The median age was 21 (Q1-Q3: 17-33) years, and 295 (41%) were female. At diagnosis, acute thrombosis of head/neck veins was detected in 597 (84%) patients, septic embolism in 582 (82%) and both in 468 (80%). After diagnosis and during in-hospital follow-up, new venous thromboembolism occurred in 34 (5.2%, 95% CI 3.8-7.2%) patients, new peripheral septic lesions became evident in 76 (11.7%; 9.4-14.3%). The rate of either was lower in patients who received anticoagulation (OR: 0.59; 0.36-0.94), higher in those with initial intracranial involvement (OR: 2.35; 1.45-3.80). Major bleeding occurred in 19 patients (2.9%; 1.9-4.5%), and 26 died (4.0%; 2.7-5.8%). Clinical sequelae were reported in 65 (10.4%, 8.2-13.0%) individuals, often consisting of cranial nerve palsy (n = 24) and orthopaedic limitations (n = 19).

CONCLUSIONS

Patients with Lemierre syndrome were characterized by a substantial risk of new thromboembolic complications and death. This risk was higher in the presence of initial intracranial involvement. One-tenth of survivors suffered major clinical sequelae.

Brain-derived neurotrophic factor is associated with coronary macrophage infiltrates in patients with acute coronary syndrome

Background

Brain-derived neurotrophic factor (BDNF) is a neurotrophine that plays a key role in the regulation of both central and peripheral nervous system. Moreover, BDNF is secreted in multiple tissues and exerts systemic, autocrine, and paracrine effects in the cardiovascular system. Of importance, BDNF expression was enhanced in macrophages and smooth muscle cells in atherosclerotic coronary arteries and may be involved in thrombus formation. Thus, BDNF has been suggested as an important link between inflammation and thrombosis, potentially involved in the pathogenesis of acute coronary syndrome (ACS).

Purpose

In our study we aimed at assessing serum levels of BDNF in patients with ACS, evaluating differences according to clinical presentation [ST-segment elevation myocardial infarction (STEMI) vs. Non-ST-segment elevation ACS (NSTE-ACS)]. Moreover, we assessed the presence of optical coherence (OCT)-defined macrophage infiltrates (MØI) in the culprit vessel of ACS patients and evaluated their relationship with BDNF levels.

Methods

ACS patients were prospectively selected. Blood samples were collected at admission and serum levels of BDNF were subsequently assessed. Presence of OCT-defined MØI along the culprit vessel was assessed.

Results

166 ACS patients were enrolled [mean age 65.3±11.9 years, 125 (75.3%) male, 109 STEMI, 57 NSTE-ACS]. Serum levels of BDNF were higher among STEMI patients compared with NSTE-ACS [median (IQR) 2.48 pg/mL (1.54–3.34) vs. 2.12 pg/mL (1.34–2.47), p=0.007], while C-reactive protein levels did not differ between the two groups. OCT assessment was performed in 53 patients and MØI were detected in 27 patients. Of importance, patients with MØI in the culprit vessel had higher levels of BDNF compared with patients without MØI [median (IQR) 2.23 pg/mL (1.38–2.53) vs. 1.41 pg/mL (0.93–2.07), p=0.023], while C-reactive protein levels did not differ between the two groups. Of note, at multivariate regression analysis BDNF levels were independent predictor of MØI [OR: 2.20; 95% CI (1.02–4.74), p=0.043].

Conclusions

Serum levels of BDNF may reliable identify the presence of local macrophage inflammatory infiltrates in patients with ACS. Moreover, BDNF levels are higher in patients with STEMI compared with NSTE-ACS. Taken together, these data suggest that BDNF may represent an interesting link between local inflammatory activation and enhanced thrombosis in ACS.

BDNF serum levels

Funding Acknowledgement

Type of funding source: None

Perilipin-2 is associated with a higher risk of microvascular obstruction in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background

Coronary microvascular obstruction (MVO) is a noxious condition frequently occurring in patients with ST-elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI). However, multiple mechanisms are involved in the pathogenesis of MVO and not yet fully understood. Recent studies suggested that perilipin 2 (PLIN2) may play an important role in lipid metabolism of macrophages resident in atherosclerotic plaques along with a role in enhancing oxidative stress.

Purpose

To study the association between PLIN2 and MVO in STEMI patients undergoing primary PCI. We also assessed the role of PLIN2 to predict future major cardiovascular events (MACEs).

Methods

STEMI patients undergoing primary PCI were enrolled. PLIN2 was dosed within 24 hours from admission in peripheral blood monocytes. MVO was assessed using TIMI flow grade and myocardial blush grade on coronary angiogram after PCI, and patients were stratified accordingly (MVO or noMVO). Major adverse cardiac events (defined as a composite of cardiac death, non-fatal myocardial infarction, re-admission for heart failure and target vessel revascularization) were assessed at clinical follow-up.

Results

Among 100 STEMI patients (mean age, 65.2±12.0 years, 81 males), 33 (33.0%) had MVO. Patients with MVO were older, had higher troponin I peak, C-reactive protein and lower left ventricular ejection fraction on admission. Patients with MVO had significantly higher levels of PLIN2 (1.03±0.28 vs. 0.90±0.16, p=0.019) compared to noMVO patients. Age [OR (95% CI) per year, 1.045 (1.005–1.087), p=0.026] and PLIN2 [OR (95% CI) per unit, 16.606 (2.027–136.030), p=0.009] were associated with MVO at univariate logistic regression analysis. However, only PLIN2 levels [OR (95% CI) per unit, 12.325 (1.446–105.039), p=0.033] were independently associated with MVO at multivariate analysis. Follow up data were available for 76 patients (76%). After a mean follow up of 182.2±126.6 days, 13 MACEs occurred. Patients with MVO had more MACEs [9 (37.5%) vs. 4 (7.7%), p<0.001] compared to noMVO patients. At univariate Cox regression analysis, MVO [HR (95% CI), 6.792 (2.053–22.460), p=0.002], hypercholesterolemia [HR (95% CI), 3.563 (1.094–11.599), p=0.035] and PLIN2 [HR (95% CI) per unit, 82.991 (9.857–698.746), p<0.001] were predictors for MACEs at follow up. At multivariate analysis only PLIN2 [HR (95% CI) per unit, 26.904 (2.461–294.100), p=0.007] was an independent predictor of MACEs.

Conclusions

In STEMI patients undergoing primary PCI, PLIN2 was independently associated with MVO. PLIN2 was an independent predictor of MACEs at clinical follow-up. These findings suggest that PLIN2 may represent a promising therapeutic target, opening the avenue towards novel therapeutic approaches for MVO.

Funding Acknowledgement

Type of funding source: None

Macrophage infiltrates in coronary plaque erosion portend a worse cardiovascular outcome in patients with acute coronary syndrome

Background

Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS). Inflammatory activation is considered a key mechanism of plaque instability in patients with plaque rupture through the release of metalloproteinases and the inhibition of collagen synthesis that in turns lead to fibrous cap degradation. However, the clinical relevance of macrophage infiltration has never been investigated in patients with PE.

Purpose

In our study, we aimed at assessing the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value.

Methods

ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site and in non-culprit segments along the culprit vessel was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years].

Results

We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. In particular, culprit lesion analysis demonstrated that patients with PE with MØI had a significantly thinner fibrous cap [median (IQR) 100 (60–120) μm vs. 160 (95–190) μm, p<0.001], higher prevalence of thrombus [41 (80.4%) vs. 64 (62.7%), p=0.028], lipid plaque [39 (76.5%) vs. 50 (49.0%), p<0.001], TCFA [20 (39.2%) vs. 14 (13.7%), p=0.001], and a higher maximum lipid arc [median [IQR] 250.0° (177.5°-290.0°) vs. 190.0° (150.0°-260.0°), p=0.018) at the culprit lesion compared with PE without MØI. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p=0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression model, PE with MØI [HR=2.95, 95% CI (1.09–8.02), p=0.034] was an independent predictor of MACEs.

Conclusion

Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with a more aggressive phenotype of coronary atherosclerosis with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. These findings are of the utmost importance in the era of precision medicine because clearly show that macrophage infiltrates may identify patients with a higher cardiovascular risk requiring more aggressive secondary prevention therapies and a closer clinical follow-up.

Prognosis

Funding Acknowledgement

Type of funding source: None

Enhanced morphological transformation of human lung epithelial cells by continuous exposure to cellulose nanocrystals

Cellulose nanocrystals (CNC), also known as nanowhiskers, have recently gained much attention due to their biodegradable nature, advantageous chemical and mechanical properties, economic value and renewability thus making them attractive for a wide range of applications. However, before these materials can be considered for potential uses, investigation of their toxicity is prudent. Although CNC exposures are associated with pulmonary inflammation and damage as well as oxidative stress responses and genotoxicity in vivo, studies evaluating cell transformation or tumorigenic potential of CNC's were not previously conducted. In this study, we aimed to assess the neoplastic-like transformation potential of two forms of CNC derived from wood (powder and gel) in human pulmonary epithelial cells (BEAS-2B) in comparison to fibrous tremolite (TF), known to induce lung cancer. Short-term exposure to CNC or TF induced intracellular ROS increase and DNA damage while long-term exposure resulted in neoplastic-like transformation demonstrated by increased cell proliferation, anchorage-independent growth, migration and invasion. The increased proliferative responses were also in-agreement with observed levels of pro-inflammatory cytokines. Based on the hierarchical clustering analysis (HCA) of the inflammatory cytokine responses, CNC powder was segregated from the control and CNC-gel samples. This suggests that CNC may have the ability to influence neoplastic-like transformation events in pulmonary epithelial cells and that such effects are dependent on the type/form of CNC. Further studies focusing on determining and understanding molecular mechanisms underlying potential CNC cell transformation events and their likelihood to induce tumorigenic effects in vivo are highly warranted.