Achondroplasia Foramen Magnum Score: screening infants for stenosis

BACKGROUND

Achondroplasia is associated with foramen magnum stenosis (FMS) and significant risk of morbidity and sudden death in infants. A sensitive and reliable method of detecting infants who require decompressive surgery is required. This study aims to describe the incidence and severity of FMS in an unselected, sequential series of infants using a novel MRI score and retrospectively correlate severity with clinical examination and cardiorespiratory sleep (CRS) studies.

METHODS

The Achondroplasia Foramen Magnum Score (AFMS) was developed and scores were retrospectively correlated with clinical and CRS data over a 3-year period.

RESULTS

Of 36 infants (M:F, 18:18), 2 (5.6%) did not have FMS (AFMS0); 13 (36.1%) had FMS with preservation of the cerebrospinal fluid (CSF) spaces (AFMS1); 3 (8.3%) had FMS with loss of the CSF space but no spinal cord distortion (AFMS2); 13 (36.1%) had FMS with flattening of the cervical cord without signal change (AFMS3); and 5 (13.9%) had FMS resulting in cervical cord signal change (AFMS4). Mean Total Apnea and Hypopnea Index (TAHI) for AFMS0-4 was 3.4, 6.41, 2.97, 10.5 and 25.8, respectively. Severe TAHI had a specificity of 89% but only a 59% sensitivity for AFMS3-4. Neurological examination was normal in 34/36 (94%) patients. Overall, 9/36 (25%) infants required neurosurgery with minimal surgical complications.

CONCLUSIONS

Clinical examination and CRS have a low sensitivity for predicting the effects of foramen stenosis on the spinal cord. Routine screening with MRI using AFMS can aid in detecting early spinal cord changes and has the potential to reduce infant morbidity and mortality.

Long-term effects of elevated CO2 on the population dynamics of the seagrass Cymodocea nodosa: Evidence from volcanic seeps

Population reconstruction techniques was used to assess for the first time the population dynamics of a seagrass, Cymodocea nodosa, exposed to long-term elevated CO₂ near three volcanic seeps and compared them with reference sites away from the seeps. Under high CO₂, the density of shoots and of individuals (apical shoots), and the vertical and horizontal elongation and production rates, were higher than at the reference sites. Nitrogen limitation effects on rhizome elongation and production rates and on biomass were more evident than CO₂ as these were highest at the location where the limitation of nitrogen was highest. At the seep where the availability of CO₂ was highest and nitrogen lowest, density of shoots and individuals were highest, probably due to CO₂ effects on shoot differentiation and induced reproductive output, respectively. At the three seeps, there was higher short- and long-term shoot recruitment than at the reference sites, and growth rates was around zero, indicating that elevated CO₂ increases the turnover of C. nodosa shoots.

Are we aiming for different metabolic targets in heart failure patients?

Introduction

Metabolic control plays an important role on major cardiovascular events (MACE) prevention. The 2019 ESC guidelines on dyslipidaemia management recommend tighter LDL-cholesterol (LDL-C) control in order to prevent cardiovascular events. However, it is not yet proven that thigh control of dyslipidaemia, glycaemic levels and body mass index (BMI) in Heart Failure (HF) patients (pts) have an impact on prognosis.

Objective

To evaluate the impact of LDL-C, HbA1c and BMI values on HF pts mortality and MACE rates.

Methods

Single centre study that included consecutive pts hospitalized for acute / decompensated chronic HF in a tertiary Hospital between January 2016 to December 2018 and followed for 12 months. The impact of LDL-C, HbA1c and BMI on mortality and MACE was assessed using Cox regression and Kaplan-Meier curve, after adjustment for age, sex, functional class and ejection fraction. A safety cut-off was established when any of these variables was deemed protective using ROC curve analysis.

Results

Two hundred twenty-four patients (71.68±13.45 years, 63.8% males) were included. Eighty-four (37.5%) pts had type 2 diabetes, 39.7% had ischemic heart disease and the median left ventricular ejection fraction was 34% (IQR 25–49.5; 60.3% HFrEF; 13.8% HFmrEF; 22.3% HFpEF). The median BMI was 25.4 kg/m2 (IQR 23.1–30.5), HbA1c, 6.4% (IQR 5.6–6.8) and LDL-C, 89.5 mg/dL (IQR 64–106); 145 (64.7%) pts were medicated with statins. The overall mortality and MACE rates during follow-up were 16.1% and 21.0%, respectively. According to the CV risk classification 39.7% pts were at very high risk and 19.6% pts at high risk. On multivariate analysis HbA1c (HR 1.5 IQR 1.1–1.9; p=0.007) and female sex (HR 9.453 IQR 2.4–37.2; p=0.001) were independent predictors of mortality, whereas LDL-C (OR 1.05 IQR 1.022–1.075; p<0.001) and BMI (OR 1.23 IQR 1.075–1.404; p=0.002) were independent protective factors. LDL-C and BMI had no effect on MACE rates, although HbA1c was an independent predictor of MACE (HR 1.27 IQR 1.03–1.57; p=0.026). For high and very high-risk pts there was still a protective trend on mortality, although non-significant, for higher levels of LDL-C (OR 1.04 IQR 0.99–1.075; P=NS). Protective LDL-C cut-off were estimated for the whole population (LDL-C 88mg/dL; AUC 0.819; sn 56.6%, sp 100%) and for the high and very-high CV risk pts (LDL-C 84mg/dL; AUC 0.815; sn 59.3%; sp 100%). A BMI safety cut-off for mortality of 25.75 kg/m2 was found (AUC 0.627; sn 61.2%; sp 58.3%).

Conclusion

This study supports the theory of the obesity and LDL-C paradox in HF. Lower LDL-C and BMI increased mortality and there is no trade-off effect on MACE rates, supporting the idea that LDL-C and BMI should not be aggressively addressed in HF pts. In our cohort a cut-off level of LDL-C below 88mg/dL is associated with higher mortality. On the other hand, diabetes should be actively treated as HbA1c predicts death and MACE in HF pts.

Funding Acknowledgement

Type of funding source: None

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Introduction

Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy.

Objective

To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting.

Methods

Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression.

Results

100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (<40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures.

The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall.

In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046).

While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF <40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI.

Conclusion

In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Ensuring a Post-COVID Economic Agenda Tackles Global Biodiversity Loss

The COVID-19 pandemic has caused dramatic and unprecedented impacts on both global health and economies. Many governments are now proposing recovery packages to get back to normal, but the 2019 Intergovernmental Science-Policy Platform for Biodiversity and Ecosystem Services Global Assessment indicated that business as usual has created widespread ecosystem degradation. Therefore, a post-COVID world needs to tackle the economic drivers that create ecological disruptions. In this perspective, we discuss a number of tools across a range of actors for both short-term stimulus measures and longer-term revamping of global, national, and local economies that take biodiversity into account. These include measures to shift away from activities that damage biodiversity and toward those supporting ecosystem resilience, including through incentives, regulations, fiscal policy, and employment programs. By treating the crisis as an opportunity to reset the global economy, we have a chance to reverse decades of biodiversity and ecosystem losses.

Pathogenicity reclassification of two BRCA1/BRCA2 exonic duplications after identification of genomic breakpoints and tandem orientation

The genomic consequence and clinical interpretation of large duplications are difficult to infer without determining the location and orientation of the duplicated sequence. We aimed to characterize two intragenic duplications detected in two hereditary breast and ovarian cancer syndrome (HBOC) families, namely BRCA1 exon 4 to 6 and BRCA2 exon 17 to 18, previously detected by multiplex ligation probe amplification and initially classified as variants of unknown significance. Using long range PCR, with duplication-specific primers, we were able to ascertain the genomic breakpoints and observed that the two rearrangements occurred in tandem and in direct orientation. The BRCA1 c.134+440_441+870dup and BRCA2 c.7806-2083_8332-1512dup duplications here identified are predicted to cause frameshifts that create a premature stop codon and were reclassified as pathogenic. Furthermore, both families present phenotypic traits typical of HBOC syndrome. We also observed that the genomic breakpoints of these two duplications occurred within highly homologous Alu elements. Concluding, we characterized two in tandem BRCA1 and BRCA2 duplications that likely occurred by Alu-mediated homologous recombination, allowing identification of the underlying cause of the HBOC syndrome in these families.

Analysis of hospitalization trends for ambulatory care sensitive conditions in Piauí/Brazil, 2009-18

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are hospitalizations that can be potentially preventable through care at the first level of contact for health care. In fact, the actions offered in a timely and effective manner can reduce the risk of unnecessary hospitalizations by preventing diseases, controlling acute episodes and managing chronic diseases.

Aim

Analyze the trends in hospitalizations for ACSC in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH) of the public health system (SUS), which comprised all hospitalizations of residents of Piauí, Brazil, in the period from 2009 to 2018. The explanatory variables were the hospitalizations for ACSC groups. For temporal trend analysis, the Prais-Winsten linear regression model was used in the Stata version 14 program.

Results

567,577 were recorded as ACSC, representing 35.3% of the total hospitalizations (1,608,263). Most hospitalizations for ACSC were caused by infectious gastroenteritis (33.5%). The risk of hospitalization for ACSC decreased 36.8%, showing a significant reduction in the trend of the hospitalization rate (Annual Percent Change - APC: -4.6%; 95%CI: -6.4; -2.8). There was a greater decrease in the risk of hospitalization for asthma (70.3%), hypertension (66.4%) and infectious gastroenteritis (61.8%). However, a significant increase was identified for skin infection (6.1 times) and diseases related to prenatal care and childbirth (3.2 times).

Conclusions

The reduction in hospitalizations due to ACSC is a result of the strengthening of Primary Health Care as the Brazilian health system organizer and the implementation of the Mais Médicos Program, which enabled the presence of doctors in family health teams, especially in places that had not previously been attended. It is also necessary to develop new studies to expand the discussions and debates on these findings.

Key messages

Hospitalizations reflect the living conditions of individuals, with social changes being perceived by changes in hospitalization patterns over time. The strengthening of primary care policies in Brazil was able to reduce hospitalizations for ACSC and it is necessary to further strengthen these practices to improve people's health care.

Nurses' production of meaning about National Program for Access and Quality Improvement Primary Care

Introduction

The Brazil's Family Health Strategy (ESF) is one of the initiatives for the strengthening of primary health care (PHC) in Brazil. The ESF is composed of a team of professionals, with the nurse usually adding care and administrative functions. In regard to the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), the nurses have played a prominent role, especially in the external evaluation phase.

Aim

Analyze the meanings produced by nurses about the PMAQ-AB in a state in the northeastern of Brazil.

Methods

A qualitative research was carried out with twenty-five nurses from the health macro-regions of the State of Piauí. Data were collected from four focus groups, with one group in each macro-region, containing at least six and at most seven participants. The meetings were held from September to October 2018, in which semi-structured interview script was used. For the analysis of information, the maps of association of ideas proposed by Spink and Gimenes (1994) were used.

Conclusions

Despite the difficulties and conflicts felt by nurses with the implementation of PMAQ-AB, the program was understood as an agent for transforming in the work process of family health teams. In addition, the realization of this study allowed another space for reflection to the nurses about the program, qualification and financing of PHC, which can contribute to the institutionalization of the culture of monitoring and evaluation and also the consequent strengthening of these services.

Key messages

Based on the expected impacts, we seek collaborate with reflection on the experience and generate consistent and useful information to contribute to the decision-making processes of health policies. The PMAQ-AB was considered a program that was able to induce substantial changes in work processes because it was a way to finance the workforce.

Expenditure trends in ambulatory care sensitive conditions in Piauí, Brazil, 2009 a 2018

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are an indicator that assesses the effectiveness of Primary Health Care. Such hospitalizations burden the public health budget and use the resources that could subsidize other health actions.

Aim

Analyze expenditure trends in hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH). For temporal trend analysis, a linear regression model was built using the Stata version 14 program.

Results

US$ 119,559,009.56 (Average = US$ 6,292,579.45/year) was spent on ACSC, representing 17.3% of the total hospitalizations (US$ 690,714,037.24). 2010 was the period with the highest cost (14.8%). In contrast, 2018 was the year with the lowest expenditure (5.8%). 23.7% of the costs went to hospitalizations for gastroenteritis. There was a significant decrease in total expenses with ACSC (β = -1.27; 95%CI: -1.65; -0.89; p < 0.001). There was also a reduction in expenses per individual hospitalized, while in 2009, the average expenditure was US$ 230.97/hospitalization, in 2018 it was US$ 157.30/ hospitalization, representing a significant reduction of 31.9%, (β = -12.4; 95%CI: -18.2; -6.6; p = 0.001). The “asthma” and “hypertension” groups showed the greatest cost reductions, 84.8% and 80.7%, respectively. However, an increase in spending on diseases related to prenatal and childbirth (4.1 times) and skin infection (3.9 times) was identified.

Conclusions

Part of the cost reduction is explained by the reduction of hospitalizations for ACSC. The reduced spending averages are compatible with lower hospitalizations by most expensive groups. Linked to these findings, it is observed that Brazil has faced a period of recession since 2015. To this end, additional research must be carried out to relate the expansion of health coverage with the results presented.

Key messages

The costs of hospitalizations for PHC-sensitive conditions reflect the policy of inducing health system coverage, being lower for greater coverage. The evaluation of the cost of specific groups allows the induction of PHC policies focusing on the specific care for each group with a higher cost so as not to burden the health system.

Resistance training in advanced cancer: a phase II safety and feasibility trial—home versus hospital

Background

Resistance training (RT) is an effective way to increase muscle mass but little is known about its role to prevent sarcopenia in advanced cancer. Furthermore, the preferred setting for this training is not known. Considering home is frequently the place of care and death preferred by cancer patients, it is important to find out whether this would also be the best training setting as opposed to the most common one, hospital.

Objectives

We aimed to test if RT at home and in hospital is feasible (primary outcome) and safe in advanced cancer, with a view to inform a phase III trial.

Methods

Phase II randomised controlled trial including adults (≥18 years) with incurable solid tumours, randomised into one of three arms: (1) supervised RT at home; (2) supervised RT in hospital; (3) standard care with information leaflet. Both training programmes were similar, ran one-to-one with therapists and planned to last 12 weeks (three sessions/week). Feasibility included adherence (proportion of completed sessions) and acceptability (proportion of completed exercises), compared using Fisher’s test.

Results

We included 15 patients (53% men, median age 68), 5 per arm. The home intervention had higher adherence (49% vs 9% in hospital; p<0.001). Acceptability was similar (93% in home and 95% in hospital; p=0.179). No adverse events were recorded.

Conclusions

RT is a safe intervention, more feasible at home than in hospital in advanced cancer. Ways to increase adherence to the home intervention could further improve its potential benefit.

Trial registration number

NCT02930876.

Golden carbon of Sargassum forests revealed as an opportunity for climate change mitigation

Marine climate change mitigation initiatives have recently attracted a great deal of interest in the role of natural carbon sinks, particularly on coastal systems. Brown seaweeds of the genus Sargassum are the largest canopy-forming algae in tropical and subtropical environments, with a wide global distribution on rocky reefs and as floating stands. Because these algae present high amounts of biomass, we suggest their contribution is relevant for global carbon stocks and consequently for mitigating climate change as CO2 remover. We modelled global distributions and quantified carbon stocks as above-ground biomass (AGB) with machine learning algorithms and climate data. Sargassum AGB totaled 13.1 Pg C at the global scale, which is a significant amount of carbon, comparable to other key marine ecosystems, such as mangrove forests, salt marshes and seagrass meadows. However, specific techniques related to bloom production and management, or the utilization of biomass for biomaterials, should be fostered.

Tumor Testing for Somatic and Germline BRCA1/BRCA2 Variants in Ovarian Cancer Patients in the Context of Strong Founder Effects

Deleterious variants in the BRCA1/BRCA2 genes and homologous recombination deficiency (HRD) status are considered strong predictors of response to poly (ADP-ribose) polymerase (PARP) inhibitors (PARPi). The introduction of PARPi in clinical practice for the treatment of patients with advanced ovarian cancer imposed changes in the molecular diagnosis of BRCA1/BRCA2 variants. BRCA1/BRCA2 tumor testing by next-generation sequencing (NGS) can detect simultaneously both somatic and germline variants, allowing the identification of more patients with higher likelihood of benefiting from PARPi. Our main goal was to determine the frequency of somatic and germline BRCA1/BRCA2 variants in a series of non-mucinous OC, and to define the best strategy to be implemented in a routine diagnostic setting for the screening of germline/somatic variants in these genes, including the BRCA2 c.156_157insAlu Portuguese founder variant. We observed a frequency of 19.3% of deleterious variants, 13.3% germline, and 5.9% somatic. A higher prevalence of pathogenic variants was observed in patients diagnosed with high-grade serous ovarian cancer (23.2%). Considering the frequencies of the c.3331_3334del and the c.2037delinsCC BRCA1 variants observed in this study (73% of all BRCA1 pathogenic germline variants identified) and the limitations of NGS to detect the BRCA2 c.156_157insAlu variant, it might be cost-effective to test for these founder variants with a specific test prior to tumor screening of the entire coding regions of BRCA1 and BRCA2 by NGS in patients of Portuguese ancestry.

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

Introduction

 The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success.

Objectives

 To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping.

Methods

 Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage &lt;1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis.

Results

 We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%.

Conclusions

 High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation.

Abstract Figure.

P945What is the role of late-potentials determined by signal-averaged ECG in predicting flecainide provocative test in brugada pattern?

Introduction

The sudden cardiac death risk in Brugada Syndrome (BrS) is higher in patients with spontaneous type 1 pattern. Brugada diagnosis is also established in patients with induced type 1 morphology after provocative test with intravenous administration with a sodium blocker channel. Nevertheless, this group of patients is known to be at a lower risk of SCD, and their risk stratification is still a matter of discussion.  Late potentials (LP) detected on signal-averaged ECG (SAECG) on the RVOT have been previously proposed as a predictor factor for BrS, even though data is lacking on its value.

Purpose

To evaluate the association between positive LP (LMS40&gt; 38ms) on SAECG with modified Brugada leads and a positive flecainide test in patients with non-type 1 BrS.

Methods

Retrospective single-center study of non-type 1 BrS patients referred for the performance of a flecainide provocative test. Patients presenting with spontaneous type 1 morphology were excluded from the study. Study of LP on SAECG with modified leads for Brugada were evaluated before administration of flecainide [2mg/kg (maximum150mg), for 10minutes] with determination of filtered QRS duration (fQRS), root mean square voltage of the last 40ms of the QRS complex (RMS40) and duration of low amplitude signals &lt;40μV of the terminal QRS complex (LMS40).

Results

126 patients (47.3 ± 14.1 years, 61.9% males) underwent study with LP SAECG and flecainide test. Among these patients, 7.9% were symptomatic and 16.7% had familiar history of BrS. Flecainide test was positive in 46.8% of patients.

In patients with a positive flecainide test, 64.4% presented LMS40 &gt; 38ms whereas LMS40 &gt; 38ms was present in only 46% of those with a negative flecainide test (p = 0.031). The presence of positive LMS40 was a positive predictor for a positive flecainide test, associated with a two-fold increase likelihood in the induction of a Brugada pattern (OR: 2,12; IC95% 1,025-4,392; P = 0,043).

There was no association between fQRS or RMS40 and a positive flecainide test (p = NS). fQRS &gt; 114ms and RMS40 &lt;20uV was present in 22% and 61% of patients with a positive flecainide test, respectively.

Conclusion

In patient with non-type 1 Brugada syndrome, LMS40 &gt; 38ms in SAECG was a predictor for a positive flecainide test, suggesting that this finding could be helpful on the risk stratification of patients undergoing diagnostic study for Brugada syndrome.

Abstract Figure. Effect of LMS 40 in flecainide test

P1162Atrial fibrillation and Cardiac resynchronization therapy - is this combination truly bad?

Introduction

 

Cardiac resynchronization therapy (CRT) significantly reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (EF). Atrial fibrillation (AF) is a very common comorbidity in these patients, however, CRT benefit in AF patients has been controversial.

Purpose

 

To compare the prognostic impact of CRT in patients (pts) with and without AF.

Methods

Prospective, single-center study that included pts undergoing CRT implantsince 2015. Clinical and echocardiographicevaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevation ≥10% or LV end-systolic volume (ESV) reduction ≥15% were classified as responders. Patients with EF elevation ≥ 20% or ESV reduction ≥30% were classified as super-responders. All the parameters were compared between patients with and without AF.Prognostic impact of CRT was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 166 patients (31%) had AF (73.5% males, mean age 72.2 ± 10.2 years, 37.3% ischemic, LVEF &lt; 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without AF), except for chronic kidney disease which was more frequent in AF pts(28% vs 17%, p = 0.012). 

The prevalence of complications and surgical revision were similar in both groups.

The CRT response rate was similar in both groups (50% in AF group vs 59.6%, p = NS) as was the super-response rate (22.4% in FA pts vs 31.5%, p = NS).

The 4-year survival rate of patients with AF was similar to non-AF (83.7% vs 84.3%). 

Conclusion

 

Despite the controversy about the efficacy of CRT in AF pts, in our population the long-term survival and CRT response rates were comparable between patients with and without AF.

Abstract Figure.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

Introduction

Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.

Purpose

To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.

Methods

A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p &lt; 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p &lt; 0.05). Major complications were similar between groups.

In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p &lt; 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p &lt; 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).

The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).

Conclusion

For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.

Abstract Figure.

Does the use of health technology assessment have an impact on the utilisation of health care resources? Evidence from two European countries

OBJECTIVES

A centralised approach to health technology assessment (HTA) may facilitate optimal use of HTA resources. A regional approach may increase the chances of local implementation of recommendations. This study aimed to compare assessment procedures in England (centralised HTA approach) with Spain (regional HTA approach) discussing key challenges and opportunities from both approaches.

METHODS

We compared technology assessments of anticancer medicines in the two jurisdictions from 2008 to 2015. To assess the implementation of HTA recommendations, we assessed trends in medicine usage using regression methods. We used IQVIA data, from 2011 to 2016, for a sample of 11 medicines. We used CatSalut data from Catalonia to assess the implementation of local recommendations.

RESULTS

In England, 66 assessments were undertaken by the National Institute for Health and Care Excellence (NICE), using a standardised methodology. In Spain, there were 79 reports undertaken by a range of bodies using a shared process and coordinated through the GENESIS collaboration; the assessment methods used varied substantially. Overall, the recommendations in the two jurisdictions were similar. Regression analyses indicate that where there is a positive recommendation by HTA bodies, the usage of the medicine responds most strongly (p < 0.001) in Catalonia (4.892), followed by England (3.120) and Spain (1.693).

CONCLUSIONS

This study suggests that medicine utilisation does respond to the positive recommendations of HTA bodies. However, if HTA capacity is organised primarily regionally, considerable effort may be required in coordination, to ensure consistent and rigorous assessments and adequate implementation of HTA findings.

Ultrasound analyses of hamstrings muscle morphology changes whit sport

Introduction Physical activities and sports can change muscle morphology. Changes caused by regular physical exercise can be assessed by ultrasound parameters such as the pennation angle, cross-sectional area, echo-intensity and muscle thickness.

Objectives This study aims to characterise and evaluate the morphological changes of the hamstring muscles through ultrasound parameters such as the pennation angle, fascicle length, cross-sectional area, echo-intensity and muscle thickness, and verify the existence of morphological changes between the dominant and non-dominant limb.

Methodology Twenty-two young female divided in two groups (control group=11; athletes group=11) were submitted to an ultrasound examination at 50% of the posterior region of the thigh, for the semimembranosus and long portion of the femoral biceps muscles in the longitudinal and in a panoramic view.

Results 22 athletes with a mean age of 22.25 years were evaluated. There were significant differences between the two groups in muscle morphology. The athletes group showed a higher value for muscle thickness, cross-sectional area, pennation angle and fascicle length and a lower value for muscle echo-intensity. This group also showed higher values for these parameters when dominant limb is compared with non-dominant.

Conclusion Physical exercise causes changes in muscle morphology and ultrasound is a good method for the musculoskeletal assessment of athlete’s performance, since it is an imaging modality that allows to carry out comparative bilateral studies for athletes performance follow up and for preventive strategies against the sedentarism.

Nutrition of the seagrass Cymodocea nodosa: Pulses of ammonium but not of phosphate are crucial to sustain the species growth

We investigated the nutrient acquisition of the seagrass Cymodocea nodosa and the importance of sediment to water column nutrient pulses, which regularly occur in coastal lagoons forced by incoming flood tides. Ammonium was preferentially taken up and accounted for 60-90% of the total daily N acquisition, whereas amino acid acquisition through belowground plant parts represented the second most important source of N, accounting 8-34%. The uptake of ammonium pulses increased dramatically the daily N acquisition from 9.5 mmol m^-2 day^-1 to 1.33 mmol m^-2 day^-1 at ambient nutrient concentrations, enabling the species to meet its N demand. Roots accounted for 96% of the total phosphate acquisition, with no evidence for P limitation. The ability of seagrasses to adapt to nutrient pulses may be an overlooked nutrition strategy common to many ecosystems where nutrient availability in the water column is low but nutrient pulses occur.

High Nitrogen and Phosphorous Acquisition by Belowground Parts of Caulerpa prolifera (Chlorophyta) Contribute to the Species' Rapid Spread in Ria Formosa Lagoon, Southern Portugal

Despite worldwide proliferation of the genus Caulerpa and subsequent effects on benthic communities, little is known about the nutritional physiology of the Caulerpales. Here, we investigated the uptake rates of ammonium, nitrate, amino acids, and phosphate through the fronds and rhizoids + stolon, the internal translocation of nitrogen, and developed a nitrogen budget for the rapidly spreading Caulerpa prolifera in Ria Formosa lagoon, southern Portugal. Caulerpa prolifera acquired nutrients by both aboveground and belowground parts at similar rates, except nitrate, for which fronds showed 2-fold higher uptake rates. Ammonium was the preferential nitrogen source (81% of the total nitrogen acquisition), and amino acids, which accounted for a significant fraction of total N acquisition (19%), were taken up at faster rates than nitrate. Basipetal translocation of ¹⁵ N incorporated as ammonium was nearly 3-fold higher than acropetal translocation, whereas ¹⁵ N translocation as nitrate and amino acids was smaller but equal in either direction. The estimated total nitrogen acquisition by C. prolifera was 689 μmol · m^-2 · h^-1 , whereas the total nitrogen requirement for growth was 672 μmol · m^-2  · h^-1 . The uptake of ammonium and amino acids by belowground parts accounted for the larger fraction of the total nitrogen acquisition of C. prolifera and is sufficient to satisfy the species nitrogen requirements for growth. This may be one reason explaining the fast spreading of the seaweed in the bare sediments of Ria Formosa where it does not have any macrophyte competitors and the concentration of nutrients is high.

42When to implant CRT-P or CRT-D in the elderly?

Introduction

Cardiac resynchronization therapy (CRT) in elder patients is increasingly common. However, the decision to implant a device with defibrillator in these patients is often complex and it can be limited not only by the shorter life expectancy but also by a lower relative risk of arrhythmic compare to non-arrhythmic death due to other comorbidities. Thus, wether CRT is effective in an elderly population (≥75 years old), or if a defibrillator (CRT-D versus CRT-P) influences outcomes is a pivotal concern needing additional data.

Purpose

To compare the prognostic impact of CRT-P vs CRT-D in old patients (≥ 75 years old) and its impact in the response rate to CRT.

Methods

A prospective single-center study was conducted of patients indicated for a CRT implant since 2015. Demographic and clinical criteria were evaluated. Transthoracic echocardiography was performed before CRT implant and between 6-12 months post-implant. Patients with an ejection fraction (EF) elevation ≥ 10% or a LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated using the Cox regression and Kaplan-Meier methods. The decision to implant a CRT-P or CRT-D device was made according to clinical decision. Prognostic impact of CRT-P vs CRT-D was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, follow-up duration 18.9 ± 15.8 months). Among these patients, 53.5% had &lt; 75 years old and 46.5% ≥ 75 years. Baseline clinical characteristics were similar, except for a higher prevalence of chronic kidney disease and atrial fibrillation in the elderly population. The proportion of CRT-D/CRT-P was different between these groups (p &lt; 0.001): in the elderly group, more CRT-P were implanted (67.6% vs 32.4 CRT-D) and in the younger group more CRT-D were implanted (77.9% vs 22.1% CRT-P).

The prevalence of complications due to CRT implant was similar in the two groups (4.7% vs 4.2%, p = NS) but the need for surgical revision was less frequent in the elderly group (11.0% vs 5.7%, p = 0.03). The CRT response rate was equivalent in both groups (40.1% vs 59.9%, p = NS), as was the super-response rate (33% in young vs 26.5% in old patients, p = NS).

In the elderly population, the 4-year survival rate was similar between CRT-P and CRT-D patients (75.4% vs 79.8%).

Conclusion

Patients older than 75 years old have similar benefits from the CRT as patients &lt; 75 years, with equivalent response rates to CRT. However, judging from the similar prognostic impact of CRT-P vs CRT-D in this elder population, the implant of a defibrillator should be personalized.

P1059Recurrence of AF after pulmonary vein isolation: how many times?

Introduction

Ablation of atrial fibrillation (AF) by catheter is an effective therapy, particularly in cases of refractoriness to medical therapy. Pulmonary vein isolation (PVI) has a significative long-term recurrence rate of AF, but the recurrence factors after this procedure are poorly defined.

Purpose

To characterize the causes of AF recurrence after PVI and to evaluate complementary strategies that can optimize the therapeutic efficacy.

Methods

A single centre prospective study of patients (pts) with AF submitted consecutively to PVI since September 2004. The variables responsible for the recurrence of AF, the complementary strategies of optimization of AF ablation and the occurrence of other dysrhythmias were evaluated.

Results

A population of 521 pts were submitted to PVI as a primary strategy for AF treatment - 36.1% for paroxysmal AF, 32.5% for persistent AF &lt;1 year, 14.5% persistent AF&gt; 1 year.

Eighty-three pts needed to perform 2 ablations and 10 pts performed 3 ablations. The higher the number of AF ablations, the higher the incidence of atypical atrial flutter (2% in the 1st AF ablation, 17% in the 2nd and 44% after 3 ablations).

In the pts with recurrence of AF undergoing the 2nd ablation, it was verified that most of the pulmonary veins (PV) were not isolated, with an isolation rate of only 34.1% for the right inferior PV; 29.4% for superior PV right, 29.4% lower left VP, 28.2% upper left PV. In this group, in addition to a new PVI in the pts with re-conduction of PV, 45% performed complementary ablation strategies such as: ablation of the cavo-tricuspid isthmus (52.6%); ablation of the left atrium roof line (29%); mitral isthmus ablation line (26%); applications in the scar zone (26%); posterior atrial left line (8%), atrioventricular nodal reentrant atrioventricular ablation (5%), atrial tachycardia ablation (2.6%).

In the pts submitted to the 3rd ablation, again a low PV isolation rate was confirmed: only 44.4% for the both left PV and upper right PV, and 55.6% for the right lower VP. 33.3% also performed cavo-tricuspid isthmus ablation, 22.2% lower mitral isthmus isolation and 22.2% re-isolation of gaps in the roof or intracicritricial line.

Conclusion

This prospective study demonstrates a high rate of PV re-conduction after PVI and its role in AF recurrence. Therefore, the need for a more effective and definitive IVP technique is evident.