The cytomegalovirus gB/MF59 vaccine candidate induces antibodies against an antigenic domain controlling cell-to-cell spread

Vaccination against human cytomegalovirus (CMV) infection remains high priority. A recombinant form of a protein essential for CMV entry, glycoprotein B (gB), demonstrated partial protection in a clinical trial (NCT00299260) when delivered with the MF59 adjuvant. Although the antibody titre against gB correlated with protection poor neutralising responses against the 5 known antigenic domains (AD) of gB were evident. Here, we show that vaccination of CMV seronegative patients induces an antibody response against a region of gB we term AD-6. Responses to the polypeptide AD-6 are detected in >70% of vaccine recipients yet in <5% of naturally infected people. An AD-6 antibody binds to gB and to infected cells but not the virion directly. Consistent with this, the AD-6 antibody is non-neutralising but, instead, prevents cell-cell spread of CMV in vitro. The discovery of AD-6 responses has the potential to explain part of the protection mediated by gB vaccines against CMV following transplantation.

Percutaneous coronary intervention in elderly patients with chronic kidney disease and non-ST segment elevation acute coronary syndrome – is it worth it?

 

ESC guidelines recommend revascularization in patients (pts) with chronic kidney disease (CKD) irrespective of age. However, elderly pts are usually underrepresented in the available data on percutaneous coronary intervention (PCI). Thus, the decision on whether to perform PCI in these pts is usually at the discretion of the cardiology team.

Aim

To evaluate the impact of PCI vs conservative approach (CA) in elderly pts (&gt;80 years) with CKD and unstable angina (UA)/non-ST segment elevation myocardial infarction (NSTEMI) who were enrolled in the Portuguese National Registry of Acute Coronary Syndromes. To determine impact of CKD in in-hospital (IH) and long-term outcomes, including MACE (myocardial infarction, stroke and death) and death at 1 year.

Study population

Elderly pts admitted with UA and NSTEMI, from 2010 until 2021. There were three different groups: Group 1 – eGFR ≥60 ml/min/1.73 m2; Group 2 – eGFR between 30 and 59 ml/min/1.73 m2 and Group 3 – eGFR &lt;30 ml/min/1.73 m2. Pts with ST-segment elevation myocardial infarction and cardiogenic shock were excluded.

Results

A total of 2443 pts, of which 921 (37,7%) were submitted to PCI. 50,2% (n=1126,) were from the group 1, 38,5% (n=941) from group 2 and 11.3% (n=276) from group 3.

Regarding overall population, pts submitted to PCI were mainly male (60,4%) with a mean age of 84±3 years old. They had previous history of PCI (21,6% vs 15,1% p&lt;0.001), less history of heart failure (HF), stroke or dementia (8,5% vs 16,5%; 8,1 vs 13.3% and 2,1 vs 5,9%, p&lt;0.001). At presentation they had more angina (88,8% vs 81,2% p&lt;0.001), less NT-proBNP levels (387 vs 561 p&lt;0.001) and were more frequently in KK class I (75,6% vs 70,2% p=0.004). They developed less HF (21% vs 27%, p&lt;0.001) and MACE (5,7% vs 9,1% p=0.003). Pts in the group 3 were less submitted to PCI (27,5% vs 38,2% vs 39,6% p&lt;0.001) and had more MACE and cardiovascular death when comparing to group 2 and 1 (16,1% vs 8,7% vs 5,3% and 10,5% vs 5,5% vs 2,6% p&lt;0.001 respectively).

Comparing PCI vs CA in each group, there was no difference in IH outcomes between both strategies in group 3. The same was not true for groups 1 and 2, in which PCI seemed to favor overall outcomes (p=0.001 and p=0.015 respectively).

The predictors of IH death and MACE were: age (OR 1.068 p=0.010), dementia (OR 2,376 p=0.015), KK class &gt;1 (OR 2,243, p&lt;0.001), atrial fibrilhation (OR 1.605, p=0.046), not having PCI (OR 0.309, p&lt;0.001), eGFR &lt;30 (OR 3.51, p&lt;0.001) and PCI in pts with eGFR &lt;30 (OR 2.923, p=0.019).

Interestingly, survival analysis showed that pts submitted to PCI in all 3 groups (including group 3) had a longer 1-year survival (p&lt;0.001, p&lt;0.001 and p&lt;0.004).

Conclusions

PCI performance in elderly pts with CKD should be individualized. In our population, especially in group 3, the performance of PCI is associated with a higher IH mortality, however, after surviving hospitalization, these pts seem to have a benefit in 1 year survival.

Funding Acknowledgement

Type of funding sources: None.

Should we stay or should we go: assessment of the need for the implantation of a definite pacemaker in a population of acute coronary syndrome that evolved in advanced atrioventricular block

Introduction

The incidence of advanced atrioventricular block (AVB) secondary to acute coronary syndrome (ACS) has been decreasing in the era of percutaneous revascularization and in most cases is transitory and does not require pacemaker (PM) implantation.

Purpose

Our aim was to assess the characteristics of patients with AVB as a consequence of the ACS and compare those with and without PM implantation, in what regards in-hospital and at 1 year outcomes.

Methods

We performed a retrospective analysis of all patients admitted with AVB secondary to ACS in Portugal between October of 2010 and August of 2021 with data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS). Medical records were analysed for demographic, procedural data and outcomes.

Results

Sex hundred and seventy one (671) patients with AVB secondary to ACS were admitted, which corresponded to 2.2% of the total cohort. The mean age was 70±13 with a male preponderance (66%). The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 76.4%, non-STEMI (NSTEMI) in 22.1%, and unstable angina (UA) in 1.5%. Of the patients admitted with AVB, 8.6% implanted a permanent PM. The was no clinically relevant differences in both groups in what regards to medical priors or medication. Regarding the location of the infarction, an Anterior STEMI was the diagnosis of admission in 36.8% (vs 14.5%; OR 3.45, CI 95% 1.31–9.06, p&lt;0.05) of patients that implanted a PM, and the left descending artery was more frequently the culprit artery, and an Inferior STEMI was the diagnosis of 63.2% (vs 83.7%; OR 0.31, CI 95% 0.12–0.82, p&lt;0.05) of patients and a right coronary artery was more frequently the culprit artery.

The presence of cardiovascular shock and in-hospital death was significantly more frequent in the group that did not implant a PM (OR 0.40; CI 95% 0.17–0.95, p&lt;0.05 and OR 0.33; CI 0.12–0.92, p&lt;0.05 respectively) and the implantation of PM was a negative predictor of in-hospital death (OR 0.28; CI 95% 0.08–0.93, p&lt;0.05).

The follow up at 1 year was performed in two hundred and sixty three (263) patients, 10.6% with an implanted PM. The survival analysis demonstrated increased mortality and a combined end-point of death and readmissions in the population of AVB that did not implant PM compared with a population who did not present with AVB (p&lt;0.05) with the Kaplan Meier curves widening significantly (Figure 1). This difference was not observed compared with an AVB population that implanted PM.

Conclusions

In patients with AVB secondary to ACS, the implantation of a PM might have been withheld in more severe patients, accounting for the increased mortality observed, and this population has worse outcomes at 1 year, leaving open to the hypothesis if either due to a more severe clinical status or the recurrence of AVB.

Funding Acknowledgement

Type of funding sources: None.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Lung ultrasound: an additional tool in COVID-19

Lung ultrasound is a well-defined diagnostic modality in the point of care emergency medicine concept. In the context of the coronavirus disease 2019 (COVID-19) pandemic, the lung ultrasound assumed an essential role in this disease, with a valid correlation of the imaging results with computed tomography. Recognize how the diagnostic possibilities of ultrasound in the approach of COVID-19 and its differential diagnoses are fundamental.

475 A rare cause of right ventricular mass

Introduction

Intracardiac masses are always a challenging diagnosis, especially when it involves the right side of the heart. There are multiples etiologies that can be responsible for these masses, namely thrombosis, neoplasm or vegetations. Occasionally, these may be related to an autoimmune process not yet discovered.

Case Report

17-year-old male, with a previous history of genital ulcers, medicated with penicillin with complete resolution of symptoms.

In January 2019, he started an history of recurrent fever, associated with right anterior thoracalgia, weight loss and oral afthosis. He went to the emergency department several times, where he was medicated with antibiotic, with partial symptom relief.

Three months later, he returned to medical attention due to an episode of abundant hemoptysis, followed by hematemesis and cough. At hospital admission, he was hemodynamically stable, tachycardic (100/min) and with occasional episodes of cough. Cardiac and pulmonary auscultation were unremarkable. Thoracic CT revealed the presence of pulmonary thromboembolism (PTE) and a large mass in the right ventricle (RV). It was performed an echocardiogram (echo) that confirmed the presence of a large mass in the RV (50x53mm) from which a projecting hypermobile mass appeared to prolapse into the right atrium.

Taking into account the diagnosis of PTE and the presence of a right ventricular mass, the patient was hospitalized and started anticoagulation. The case was immediately discussed with cardiac surgery, that confirmed that there was no surgical indication. During hospitalization, there were no more episodes of hemoptysis or hematemesis.Consecutive echos were performed, that did not reveal a significant decrease in mass dimensions despite anticoagulation. Viral serologies and autoimmunity panel were all negative. Cardiac RMI was performed raising the suspicion of a possible mass covered with thrombus.

After discussion with rheumatology, and according to clinical signs, the hypothesis of vasculitis was placed, and the patient started treatment with steroids. This treatment had to be suspended after a few days due to an infectious intercurrence. After a course of antibiotic therapy, the patient started therapy with cyclophosphamide with good clinical and echocardiographic response (reduced mass dimensions).

It was admitted Behçet’s disease with cardiac complications, and the patient was referred to the rheumatology consultation.

Conclusion

Behçet’s disease is a multi-system, chronic disorder that behaves like vasculitis.There are some typical clinical manifestations associated with this disease, such as oral and genital afthosis, uveitis, arthritis, skin lesions and nervous system involvement.Presentations with cardiac symptoms are one of the extremely rare manifestations of this disease, posing a challenge for the treating physician.

Abstract 475 Figure. Right ventricular mass

107 Low-flow low-gradient aortic stenosis: aortic valve area estimated by continuity equation versus simplified method of projected aortic valve area

Introduction

The evaluation of real severity of "low-flow low-gradient" aortic stenosis (LFLG AS) is particularly challenging. TOPAS study demonstrated that projected aortic valve area at a normal transvalvular flow rate (AVAproj) derived from dobutamine stress echocardiography (DSE) is superior to the traditional Doppler indices to discriminate true severe-AS and pseudosevere-AS.

Purpose

To compare two echocardiographic methods to estimate severity of LFLG AS with DSE (aortic valve area (AVA) estimated by continuity equation (AVA-CE) and simplified method of AVAproj) in patients (pts) with low transvalvular flow rate (&lt;250mL/seg).

Methods

Unicentric, retrospective study, that included pts with LFLG AS undergoing DSE with low dose dobutamine protocol, during Nov 2013-Dec 2018 period. Evaluation at rest and peak DSE of vital signs, mean transaortic gradient, aortic VTI, LVOT VTI and VTI ratio, valvulo-arterial impedance (ZVA), AVA-CE, simplified method of AVAproj and global longitudinal strain (GLS).

Results

A total of 27 DSE were performed in 23 different pts, mean age of 76 ± 8 years, 82% male. At rest 55% in sinus rhythm, mean heart rate (HR) was 76 ± 12 bpm, mean systolic arterial pressure (SAP) was 122 ± 22 mmHg, mean ZVA 4.3 ± 2 mmHg/ml/m2; mean diameter of LVOT was 21,7 ± 2,6cm, mean of mean aortic gradients 21 ± 7 mmHg, 67% of pts had a VTI ratio at rest compatible with severe AS and remaining compatible with moderate AS. Estimated mean AVA-CE was 0.86 ± 0.29 cm2 with 67% of pts classified as severe AS. Mean left ventricular ejection fraction at rest was 31 ± 9%, systolic volume index 28,7 ± 8 mL/m2 and GLS -5,9%.

During low dose perfusion protocol of dobutamine

100% patients remained asymptomatic, mean HR was 110 ± 25 bpm, mean SAP was 123 ± 26 mmHg, mean ZVA 3.6 ± 1.7 mmHg/mL/m2, mean of mean aortic gradients 28 ± 9mmHg, 37% of pts presented VTI ratio compatible with severe AS and remaining compatible with moderate AS. Mean flow reserve was 16 ± 16% and mean GLS-7.2%. AVA-CE was 1,06 ± 0,35 cm2 with 56% of pts classified as severe AS and mean projected AVA was 1.01 ± 0.22cm2, without significant difference in AVA estimated by the two methods (p = 0.344). Projected AVA allowed re-classification of AS in 22% of pts (5 patients), with 31% of severe AS reclassified as moderate AS while AVA-CE allowed re-classification in 13% (3 patients), with 19% of severe AS reclassified as moderate AS.

Considering medium follow up of 24 months, 6 patients were submitted aortic valve replacement surgery and another 6 patients to transcatheter aortic valve replacement. The simplified projected valve area calculation show no significant therapeutic impact in the selection of this patients.

Conclusion

The simplified projected valve area calculation is technically feasible and accessible. This study shows a good correlation in pts with low cardiac flow. If AVAproj method had been used 2 extra patients would have been reclassified during DSE.

P1808 The impact of valve type in morbimortality of patients with infectious endocarditis

Introduction

Infectious endocarditis (IE) represents one of the main causes of morbimortality in patients (pts) with valvular heart disease. Prosthetic valves infection is usually associated with worse outcomes.

Aim

To compare the clinical features and adverse outcomes of patients with native vs prosthetic valve IE.

Methods

We analysed a population with suspected/confirmed IE, according to Duke criteria, in the last 12 years (2006-2017). The clinical and imaging data were collected as well as complication rates and mortality data.

Results

174 pts, 75% males with mean age of 61 ± 16 years. Native valve EI occurred in 74,1%. of pts. 25,3% had heart failure (HF), 16,1% chronic kidney disease(7,1% on haemodialysis), 12,8% HIV infection, 9,3% active neoplasm and 7,1% were on immunosuppression. 16 pts with native valve disease had previous valvular disease: 1 congenital valve disease, 2 with rheumatic heart disease, 3 with previous IE and 10 with degenerative disease. At admission: 73,1% had fever, 53,2% murmur and 47,9% anemia. The majority (78,4%) had single valve IE and 15,8% had double valve involvement. Aortic valve (AoV) was affected in 54% of the cases and mitral valve involvement was seen in 43,7%. 13,3% had right valve disease. S. Aureus was the most frequent microrganism. Echocardiographic findings: 87,7% had vegetation, 21,2% valve destruction , 5,6% valve obstruction, 14,3% abscess, 3,7% valve aneurysm, 5,6% pseudoaneurysm and 5,6% fistula. Regurgitation was observed in 62,1%. The intrahospitalar mortality was 29,9%.

Comparing both groups, pts with prosthetic IE had more previous history of HF (40,5% vs 20,5% p = 0,009) and diabetes (31,7% vs 15,3% p = 0,020). No differences were found in what concerns microrganisms involved.

Echocardiographically, pts with prosthetic valve had predominantly AoV involvement (81,1% vs 45,5% p &lt; 0,001), less vegetation (75% vs 91,8% p = 0,01) and less regurgitation (45% vs 67,8% p = 0,01). They had more local complications (61% vs 27,7% p&gt; 0,001) like valve obstruction (12,5% vs 3,3% p = 0,043), abscess (32,5% vs 8,3% p&gt; 0,001) or pseudoaneurysm (17,5% vs 1,7% p= 0,001).

In what concerns morbidity burden, developed more HF during hospitalization (56,1% vs 37,7% p= 0,037) as well as more isquemic and haemorragic stroke(85,7% vs 42,3%. P = 0,004 and 28,6% vs 2,4% p = 0,012, respectively). However there were no differences regarding the development of septic shock (p = 0,542) or overall embolization (p = 0,732). At last, no differences were found in intrahospitalar(IH) mortality (p = 0,085), relapse (p = 0,573) or overall survival between both groups (log rank: 1,5, p = 0,217).

Conclusion

Pts with prosthetic valve IE usually have worse outcomes. However,for this population,we conclude that besides having more HF and stroke, there were no differences in what concerns septic shock or overall embolization, as well as IH mortality and survival between both groups.

P846Discriminatory power of the grace score in non-ST segment elevation myocardial infarction in the real world: results from the portuguese registry on acute coronary syndromes

Introduction

Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to the hospital. The Global Registry of Acute Coronary Events (GRACE) risk score was developed in a large multinational registry to predict both mortality and the combined events of death or reinfarction during the hospital stay and 6 months after discharge. Given the substantial regional variation and temporal changes in patient characteristics and management patterns, specially in non-ST segment elevation myocardial infarction (NSTEMI) patients, we sought to validate this risk score in a contemporary Portuguese population.

Purpose

To assess the discriminatory power of the GRACE risk score in a Portuguese contemporary cohort of patients with NSTEMI submitted to invasive strategy, regarding in-hospital mortality and the combined end-point of reinfarction and/or in-hospital mortality.

Methods

We included patients with NSTEMI submitted to coronary angiogram from the Portuguese Registry on Acute Coronary Syndrome (ProACS). For each patient, we calculated the GRACE risk score and classified them in low, intermediate or high risk, according to the cut-offs recommended in the guidelines. The discriminatory capacity of the GRACE risk score was evaluated by the area under the receiver operating characteristic [ROC] curve. The primary endpoint was defined as the occurrence of reinfarction and in-hospital mortality, and the secondary endpoint was in-hospital mortality.

A model with an AUC-ROC between 0.8 and 0.9 was considered to have a good capacity for discrimination.

Results

Among the 19.430 patients included in the ProACS between October 2010 and January 2019, we identified 7304 patients with NSTEMI that performed coronary angiogram and had the GRACE score calculated (37.6%). Patients were divided in three groups according to the GRACE score (group 1: 1–108; group 2: 109–140; group 3: 141–372), with 24.9% included in group 1, 33.0% in group 2, and 42.1% in group 3. Most patients were male (73.4%), with a mean age of 66±12 years, and 48.0% were admitted to non-percutaneous coronary intervention centers. In-hospital mortality was 1.0% and the primary endpoint occurred in 2.2% of the patients. The discriminatory capacity of the GRACE score in our population was good regarding in-hospital mortality: the area under the ROC curve was 0.83 (95% confidence interval [CI], 0.783–0.878), with the best cut-off of 148. The discriminatory capacity for the primary end-point was reasonable; the area under the ROC curve was 0.700 (95% CI 0.654–0.745), and the best cut-off was 164.

Conclusions

In our population of patients with NSTEMI submitted to an invasive strategy, the GRACE risk score presented a moderate discriminatory capacity for the occurrence of reinfarction and in-hospital, and a a good discriminatory power for in-hospital mortality.

P5553Right ventricular involvement in hypertrophic cardiomyopathy: insights from a tertiary centre

Introduction

Hypertrophic cardiomyopathy (HCM) is the main cause of sudden cardiac death in the young and a cause of heart failure (HF) and death at any age. Nevertheless, adverse long-term outcomes are not easy to predict.

Objectives

To assess the prevalence and prognostic value of right ventricular (RV) involvement in patients (pts) with HCM.

Methods

Retrospective single-centre study of consecutive pts with HCM evaluated in a specialized consultation. Selected those submitted to cardiac magnetic resonance imaging (CMR) as the gold-standard for RV assessment. The primary endpoint (PE) was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, ventricular arrhythmias with hemodynamic instability and unplanned HF admission.

Results

Of a total of 181 pts, 104 fulfilled the inclusion criteria (mean age at first consultation 62.1±9.7 years, 63.5% male). Septal asymmetric phenotype was the most frequent (73.1%) and 24 pts (23.1%) had rest LV outflow tract obstruction. Mean value of maximum wall thickness was 18.8±4.6 mm. Regarding CMR parameters (Fig A), 5.8% had RV dysfunction and 2.9% RV free wall hypertrophy; no patient presented RV dilation. Late gadolinium enhancement (LGE) of joint points was observed in 47.1%. During follow-up (FU, mean 56.6±29.5 months), survival free of RV dysfunction was 94.3%. Only 5 pts developed RV compromise assessed by echocardiographic parameters: TAPSE 12.0±3.4 mm and pulsed tissue Doppler systolic annular velocity (tricuspid S') wave 7.3±0.9 cm/s. These pts were significantly older (p<0.01) and had higher values of average tissue doppler E/E' ratio at diagnosis (p<0.01). Global RV involvement (at diagnosis or during FU) were associated with increased values of indexed left atrial area (p<0.01), LV dysfunction (p=0.01), LGE of joint points (p=0.01) and higher values of NT-proBNP (p=0.01). In multivariate logistic regression, left atrial enlargement was the only independent predictor of global RV dysfunction (OR 1.9, 95% CI 1.1–3.2, p=0.01) and average E/E' ratio an independent predictor of RV dysfunction during FU (OR 1.3, 95% CI 1.1–1.5, p<0.01). PE rate was 10.6%. It was significantly higher in pts with global RV involvement and there was a significant difference in survival analysis (Fig B). Average E/E' ratio (OR 1.5, 95% CI 1.1–1.9, p=0.01) and RV ejection fraction (OR 0.8, 95% CI 0.7–0.9, p=0.01) were independent predictors of the outcome.

Conclusions

Although not common, RV dysfunction was associated with a higher rate of cardiovascular events. Average E/E' ratio, as a measure of left ventricular filling pressure, was a risk factor for both RV dysfunction and PE. Higher values of RV ejection fraction were protective of adverse events occurrence. Together, these results support a potential role of RV function in the risk stratification of HCM pts.

P6403Predictors of bleeding in elderly patients with myocardial infarction: data from the real world

Background

The population of elderly patients with acute myocardial infarction (MI) is clearly underrepresented in contemporary clinical trials. This population presents a higher risk of both cardiovascular and bleeding events, making the decision of the antithrombotic strategy particularly challenging.

Purpose

To characterize the antithrombotic therapy used in patients with MI and age ≥75 years, and to identify predictors of major bleeding and cardiovascular events in this population.

Methods

Retrospective analysis of patients with a diagnosis of MI and age ≥75 years included in the Portuguese Registry of Acute Coronary Syndromes between October 2010 and January 2018. Logistic regression analysis was used to identify predictors of major bleeding and of the combined endpoint of in-hospital mortality and reinfarction.

Results

The analysis included 17.868 patients of which 30.1% with age ≥75 years. This population had a mean age of 82±5 years, 57% were male and 36% had a diagnosis of STEMI. On admission 10% presented with Killip-Kimball (KK) class III or IV, 14% were on atrial fibrillation (AF), and the mean Hb and creatinine levels were 13±2 g/dl and 1.6±1.2 mg/dl, respectively. In comparison with younger patients, this population had higher Grace and Crusade scores (178 vs 139, and 41 vs 24, respectively). Most elderly patients (74%) underwent coronary angiography (71% by radial artery access) and 75% were submitted to percutaneous revascularization, 9% to surgery, and 1% to an hybrid strategy. Aspirin was used in 96% of patients, clopidogrel in 82%, ticagrelor in 13% (vs 25% of younger patients; p<0.001), and glycoprotein IIb/IIIa inhibitors (GPI) in 11%. Most patients were anticoagulated with enoxaparin (68 vs 56% of younger patients; p<0.001), 22% with unfractionated heparin (vs 30%; p<0.001), and 13% with fondaparinux (vs 14%; p=0.018). Complications were more common in the elderly population, including mechanical complications (1 vs 0.5%), atrioventricular block (5 vs 3%), stroke (1 vs 0.6%), major bleeding (3 vs 1%), in-hospital death (8 vs 2%) and reinfarction (2 vs 1%) (p<0.001 for all).

In multivariate logistic regression analysis, the predictors of major bleeding were diastolic blood pressure (BP) on admission <50 mmHg, maximum creatinine ≥2 mg/dl and the use of GPI. The predictors of the combined endpoint were a diagnosis of STEMI, previous history of cancer, chronic kidney disease or demencia, and the presence on admission of an heart rate <60 bpm, systolic BP <90 mmHg or ≥180 mmHg, KK class > I, AF, left bundle branch block, and left ventricle systolic dysfunction.

Conclusions

This study reflects the contemporary national reality of the management of elderly patients with MI. Overall, this population has a high risk of major bleeding, but several characteristics are associated with an even higher risk, such as the hemodynamic profile, renal function, and the use of GPI.

Nephrocalcinosis and Nephrolithiasis in X-Linked Hypophosphatemic Rickets: Diagnostic Imaging and Risk Factors

Context

Nephrocalcinosis (NC) and nephrolithiasis (NL) are described in hypophosphatemic rickets, but data regarding their prevalence rates and the presence of metabolic risk factors in X-linked hypophosphatemic rickets (XLH) are scarce.

Objective

To determine the prevalence rates of NC and NL and their risk factors in patients with XLH with confirmed PHEX mutations.

Methods

Renal ultrasonography (US) and CT were performed in 16 children and 23 adults. The images were evaluated by two blinded radiologists specializing in US and two specializing in CT. Confirmation of NC was determined with a positive result on both US and CT, whereas the diagnosis of NL was confirmed by CT alone. The presence of hypercalciuria, hypocitraturia, and hyperoxaluria was determined from 24-hour urinary samples from each patient. The glomerular filtration rate was estimated.

Results

NC was identified in 15 patients (38.4%), and stratification by age group showed a higher prevalence of NC in children than in adults (56.2% vs 26.1%). CT identified NL in four adults (10.2%). Patients in the pediatric group required intensive use of phosphate, started treatment earlier, and presented greater phosphaturia than those in the adult group (P < 0.01). In addition to hyperphosphaturia, which was present in all patients with XLH, hypocitraturia was the most common metabolic factor (28.2%), whereas hypercalciuria occurred in two patients (5.1%). None had hyperoxaluria. Most patients had normal renal function.

Conclusions

NC was more prevalent than NL. The main metabolic factor was hyperphosphaturia, and intensive phosphate treatment appears to be a worsening factor for kidney calcification.

Production of bioactive hepcidin by recombinant DNA tagging with an elastin-like recombinamer

With the lack of new chemical antibiotics and increasing pathogen resistance to those available, new alternatives are being explored. Antimicrobial peptides (AMPs) with a broad range of effects, including antibacterial, antifungal, and antiviral actions, have emerged as one of the options. They can be produced by recombinant DNA technology, but the chromatographic methods used for peptide purification are expensive and time consuming. Here, we describe the design, production, purification and assessment of the antibacterial activity of the human peptide hepcidin, using an elastin-like recombinamer as fusion partner. The recombinant protein Hep-A200 was produced in Escherichia coli and purified by a non-chromatographic procedure, exploiting the thermal properties of the A200 elastin-like recombinamer. Recombinant Hep-A200 was found to retain antibacterial activity against Gram-positive and Gram-negative species.

Electroactive biomaterial surface engineering effects on muscle cells differentiation

Even though skeletal muscle cells can naturally regenerate as a response to insignificant tissue damages, more severe injuries can cause irreversible loss of muscle cells mass and/or function. Until now, cell therapies are not a good approach to treat those injuries. Biomaterials such as poly(vinylidene fluoride), PVDF, can improve muscle regeneration by presenting physical cues to muscle cells that mimic the natural regeneration environment. In this way, the ferroelectric and piezoelectric properties of PVDF offer new opportunities for skeletal muscle tissue engineering once the piezoelectricity is an electromechanical effect that can be used to provide electrical signals to the cells, upon mechanical solicitations, similar to the ones found in several body tissues. Thus, previous to dynamic experiments, it is important to determine how the surface properties of the material, both in terms of the poling state (positive or negative net surface charge) and of the morphology (films or fibers) influence myoblast differentiation. It was observed that PVDF promotes myogenic differentiation of C2C12 cells as evidenced by quantitative analysis of myotube fusion, maturation index, length, diameter and number. Charged surfaces improve the fusion of muscle cells into differentiated myotubes, as demonstrated by fusion and maturation index values higher than the control samples. Finally, the use of random and oriented β-PVDF electrospun fibers scaffolds has revealed differences in cell morphology. Contrary to the randomly oriented fibers, oriented PVDF electrospun fibers have promoted the alignment of the cells. It is thus demonstrated that the use of this electroactive polymer represents a suitable approach for the development of electroactive microenvironments for effective muscle tissue engineering.

Pollination and reproductive system of synchronopatric species of Cactaceae (Cactoideae) subject to interspecific flow of pollen: an example of ecological adaptation in the Brazilian Chaco

Three synchronopatric Cactaceae species, Echinopsis rhodotricha, Harrisia balansae and Praecereus saxicola, have mostly nocturnal anthesis and similar flowers, characteristics that motivated us to perform a comparative study of reproductive ecology. Reproductive phenology was sampled monthly from December 2014 to November 2015. We describe floral biology, breeding system via pollination treatments and evaluate floral visitors from focal and filming observations. Pollen grains found on moth proboscis were compared among cactus species under light microscopy. We used fluorescent dye particles to test intra- and interspecific pollen flow. These three species have extended flowering with greater intensity in the wet season, causing high overlap. They have white and hypocrateriformis flowers that open at twilight or nightfall and last about 15 h. H. balansae seems to be self-incompatible, while E. rhodotricha presented self-compatibility. P. saxicola presented self-fertility, but most of the population seems to be self-incompatible. We suggest sphingophily for the three species, but only P. saxicola was visited by Manduca rustica (Sphingidae). However, we observed pollen grains of all three species on the proboscis of moths, especially M. rustica and M. sexta. Prolonged anthesis allowed bees (herein considered as secondary pollinators) to visit flowers of E. rhodotricha and P. saxicola. It can be concluded that the studied species share nocturnal and diurnal pollinators, suggesting interspecific pollen flow, which, however, could not be detected with fluorescent dye particles. In view of the low frequency of primary pollinators, it appears that these three species have different reproductive strategies, ensuring the fruiting and production of viable seeds.

Sugar and volatile fatty acids dynamic during anaerobic treatment of olive mill wastewater

Biogas production has been the main route used to exploit olive mill wastewater (OMW), after pretreatment and/or in combination with other effluents, but more recently the production of chemicals and biopolymers by biotechnological routes has deserved increasing attention by the scientific community. The present paper aims to explore the potential of fresh OMW as a source of volatile fatty acids (VFAs) and biogas. The time profile of VFAs production and the corresponding sugar consumption was followed by high-performance liquid chromatography, in batch anaerobic assays. The experimental results have revealed the very high potential of the OMW for the production of VFAs, mainly due to the high sugar concentration in the effluent (37.8 g/L) and its complete conversion into VFAs, in a time period of 2-3 days. The most abundant VFAs were acetic (48-50%), n-butanoic (12-27%), iso-pentanoic (12-14%) and propanoic (5-13%). The ratio of VFA containing even and odd carbon chains increased with the reduction in the initial chemical oxygen demand concentration of the samples used in the experiments. The conversion of the VFAs to biogas was inhibited at concentrations of 3.5 g/L of VFAs.

Ultrasonographic study and Doppler flow velocimetry of maternal kidneys and liver in low-risk pregnancy

OBJECTIVE

Longitudinal study with B-mode ultrasonography and Doppler ultrasonography of maternal kidneys and liver in low-risk pregnancy, to establish and quantify normality parameters, correlating them with physiological changes.

MATERIALS AND METHODS

Twenty-five pregnant women were assessed and selected to participate in the study, each of them undergoing four examinations at the first, second, third trimesters and postpartum.

RESULTS

Findings during pregnancy were the following: increased renal volume, pyelocaliceal dilatation with incidence of 45.4% in the right kidney, and 9% in the left kidney; nephrolithiasis, 18.1% in the right kidney, 13.6% in the left kidney. With pyelocaliceal dilatation, mean values for resistivity index were: 0.68 for renal arteries; 0.66 for segmental arteries; 0.64 for interlobar arteries; 0.64 for arcuate arteries. Without pyelocaliceal dilatation, 0.67 for renal arteries; 0.64 for segmental arteries; 0.63 for interlobar arteries; and 0.61 for arcuate arteries. Portal vein flow velocities presented higher values in pregnancy, with mean value for maximum velocity of 28.9 cm/s, and 22.6 cm/s postpartum. The waveform pattern of the right hepatic vein presented changes persisting in the postpartum period in 31.8% of the patients. Cholelithiasis was observed in 18.1% of the patients.

CONCLUSION

Alterations in renal volume, pyelocaliceal dilatation, nephrolithiasis, cholelithiasis, changes in portal vein flow velocity, alterations in waveform pattern of the right hepatic vein, proved to be significant.

Structural dynamics and physicochemical properties of pDNA/DODAB:MO lipoplexes: effect of pH and anionic lipids in inverted non-lamellar phases versus lamellar phases

Dioctadecyldimethylammonium bromide (DODAB):Monoolein (MO) lipoplexes have mainly been studied within the range of high molar ratios of DODAB, with noticeable transfection efficiencies in the Human Embryonic Kidney (HEK, a.k.a. 293T) cell line. In this work, we intend to study the effect of high MO content on the structure and physicochemical properties of pDNA/DODAB:MO lipoplexes to achieve some correlation with their transfection efficiency. Static/Dynamic Light Scattering and Cryo-TEM imaging were used to characterize the size/morphology of DNA/DODAB:MO lipoplexes at different DODAB:MO contents (2:1, 1:1, 1:2) and charge ratios (CRs) (+/-). Nile Red fluorescence emission was performed to detect changes in microviscosity, hydration and polarity of DNA/DODAB:MO systems. Lipoplexes stability at physiological pH values and in the presence of anionic lipids was evaluated by Förster Resonance Energy Transfer (FRET). Physicochemical/structural data were complemented with transfection studies in HEK cells using the β-galactosidase reporter gene activity assay. This work reports the coexistence of multilamellar and non-lamellar inverted phases in MO-richer lipoplexes (DODAB:MO 1:2 and 1:4), leading to transfection efficiencies comparable to those of multilamellar (DODAB-richer) lipoplexes, but at higher charge ratios [CR (+/-)=6.0] and without dose-effect response. These results may be related to the structural changes of lipoplexes promoted by high MO content.

The skin-to-calyx distance measured by renal ct scan and ultrasound

PURPOSE

We developed a stereotactic device to guide the puncture for percutaneous nephrolithotripsy, which uses the distance from the target calyx to its perpendicular point on skin (SCD) to calculate the needle´s entry angle. This study seeks to validate the use of measurements obtained by ultrasound (US) and computerized tomography (CT) for needle´s entry angle calculation and to study factors that may interfere in this procedure.

MATERIALS AND METHODS

Height, weight, abdominal circumference, CT of the urinary tract in dorsal decubitus (DD) and ventral decubitus (VD), and US of the kidneys in VD were obtained from thirty-five renal calculi patients. SCD obtained were compared and correlated with body-mass index (BMI).

RESULTS

BMI was 28.66 ± 4.6 Kg/m2. SCD on CT in DD was 8.40 ± 2.06cm, in VD was 8.32 ± 1.95cm, in US was 6.74 ± 1.68cm. SCD measured by US and CT were statistically different (p < 0.001), whereas between CT in DD and VD were not. SCD of the lower calyx presented moderate correlation with BMI.

CONCLUSION

SCD obtained by CT in ventral and dorsal decubitus may be used for calculation of the needle´s entry angle. SCD obtained by US cannot be used. A rule for the correlation between BMI and the SCD could not be determined.

Rodent models of heart failure: an updated review

Heart failure (HF) is one of the major health and economic burdens worldwide, and its prevalence is continuously increasing. The study of HF requires reliable animal models to study the chronic changes and pharmacologic interventions in myocardial structure and function and to follow its progression toward HF. Indeed, during the past 40 years, basic and translational scientists have used small animal models to understand the pathophysiology of HF and find more efficient ways of preventing and managing patients suffering from congestive HF (CHF). Each species and each animal model has advantages and disadvantages, and the choice of one model over another should take them into account for a good experimental design. The aim of this review is to describe and highlight the advantages and drawbacks of some commonly used HF rodents models, including both non-genetically and genetically engineered models, with a specific subchapter concerning diastolic HF models.

Potential of human γD-crystallin for hair damage repair: insights into the mechanical properties and biocompatibility

OBJECTIVES

The objective of this work was to develop a new strategy to physically 'repair' chemically damaged hair. Hence the human eye γD-crystallin, a protein from the superfamily characterized structurally by the Greek key motif, was studied. The human γD-crystallin was chosen based on the ability of proteins belonging to this superfamily to be involved in the coating of specific structures. Two crystallins were used on the study, the wild type (Protein Data Bank ID: 1HK0) and the mutant protein. The mutant form was intended to induce a strong and quick protein polymerization as well to have new possible points of anchorage to hair.

METHODS

The ability of both crystallins to bind to damaged hair and even penetrate into its cortex was checked by fluorescence microscopy, confocal microscopy and scanning electron microscopy. Furthermore the reinforcement of hair mechanical resistance, the potential cytotoxic/inflammatory effect of crystallins were studied in order to have a fully comprehension about the protein based formulation.

RESULTS

Although the chemical over-bleaching treatment induced a decrease of 20% on the resistance of the hair, the crystallins which bind and penetrate the hair fibre were able to recover and even to improve its mechanical properties when compared to the virgin hair. Moreover none of the crystallins displayed a toxic effect in fibroblasts for all the range of tested concentrations upon 72 h of exposure. The active aggregation process of mutant crystallin induced an inflammatory response in fibroblasts in the first 24 h of contact, measured by the amount of released pro-inflammatory cytokine IL-6 to the medium. In contrast contact with wild type crystallin did not lead to significant inflammation.

CONCLUSION

Outcome from protein formulation characterization supports the hypothesis that the γD-crystallin it is able to recover and improve the mechanical properties of chemical damaged hair. Therefore it can be considered as a very promising strengthening agent for the development of new restorative hair care products.

Toxicity reduction and biodegradability enhancement of cork processing wastewaters by ozonation

Biodegradability enhancement and detoxification of cork boiling wastewater (CBW) are required for the successful implementation of biological treatment options. We studied the possibility of achieving these goals through ozonation pre-treatment by experimenting on the effect of ozone dose and pH. The CBW used had a pH of 5.81, a chemical oxygen demand (COD) of 1,865 mg L(-1), a biochemical oxygen demand (BOD5) of 498 mg L(-1) and total phenol (TP) and tannin compounds concentrations of 523 and 399 mg L(-1), respectively. The ozone doses ranged from 0.27 to 2.63 for the O3(applied)/COD0 ratios with samples at natural pH and set to 3.33 and 9.96. Ozonation allowed the BOD20/COD ratio (biodegradability index) to increase from 0.37 to 0.63 and a toxicity reduction from 3.08 to 1.24 TU (Microtox). The corresponding removals obtained were 15.2-62.0%, 38.4-83.2% and 56.7-92.1% for COD, TP and colour, respectively. The best outcome of ozonation pre-treatment requires O3(applied)/COD0 ratios over 1.5 and an acid pH. The increase of TP removals with ozone dose at acid pH led to biodegradability enhancement and CBW detoxification. However, for similar conditions the highest COD removals were obtained at alkaline pH due to the hydroxyl radicals' high oxidation ability but lack of selectivity.

Keratin-based peptide: biological evaluation and strengthening properties on relaxed hair

A peptide based on a fragment of hair keratin type II cuticular protein, keratin peptide (KP), was studied as a possible strengthening agent for weakened relaxed hair. The peptide was prepared both in aqueous water formulation (WF) and organic solvent formulations (OF), to determine the effect of organic solvents on peptide interaction with hair and the differences in hair recovery. Both peptide formulations were shown to improve mechanical and thermal properties of weakened hair with peptide in OF showing the stronger effect. As a potential new hair care product, and so would necessitate contact with skin, the cytotoxicity and genotoxicity of the peptide were also evaluated through different methodologies (Alamar Blue assay, 2'-7'-dichlorofluorescein probe, cell morphology and growth and evaluation of DNA damage by an alkaline version of the comet assay) in skin fibroblasts. These tests are indicators of the potential of peptide to cause irritation on skin or to be carcinogenic, respectively. The peptide in WF did not cause cytotoxicity or genotoxicity in any of the concentrations tested. The presence of OF, however, induced a 20% decrease in cell viability in all of the range of concentrations used after 72-h incubation. Moreover, OF inhibited cell growth and was considered genotoxic at first contact with cells. The peptide was therefore considered a promising strengthening agent for hair and was shown to be innocuous when applied in WF.

DODAB:monoolein-based lipoplexes as non-viral vectors for transfection of mammalian cells

DNA/Cationic liposome complexes (lipoplexes) have been widely used as non-viral vectors for transfection. Neutral lipids in liposomal formulation are determinant for transfection efficiency using these vectors. In this work, we studied the potential of monoolein (MO) as helper lipid for cellular transfection. Lipoplexes composed of pDNA and dioctadecyldimethylammonium bromide (DODAB)/1-monooleoyl-rac-glycerol (MO) at different molar ratios (4:1, 2:1 and 1:1) and at different cationic lipid/DNA ratios were investigated. The physicochemical properties of the lipoplexes (size, charge and structure), were studied by Dynamic Light Scattering (DLS), Zeta Potential (ζ) and cryo-transmission electron microscopy (cryo-TEM). The effect of MO on pDNA condensation and the effect of heparin and heparan sulphate on the percentage of pDNA release from the lipoplexes were also studied by Ethidium Bromide (EtBr) exclusion assays and electrophoresis. Cytotoxicity and transfection efficiency of these lipoplexes were evaluated using 293T cells and compared with the golden standard helper lipids 1,2-dioleoyl-sn-glycero-3-hosphoethanolamine (DOPE) and cholesterol (Chol) as well as with a commercial transfection agent (Lipofectamine™ LTX). The internalization of transfected fluorescently-labeled pDNA was also visualized using the same cell line. The results demonstrate that the presence of MO not only increases pDNA compactation efficiency, but also affects the physicochemical properties of the lipoplexes, which can interfere with lipoplex-cell interactions. The DODAB:MO formulations tested showed little toxicity and successfully mediated in vitro cell transfection. These results were supported by fluorescence microscopy studies, which illustrated that lipoplexes were able to access the cytosol and deliver pDNA to the nucleus. DODAB:MO-based lipoplexes were thus validated as non-toxic, efficient lipofection vectors for genetic modification of mammalian cells. Understanding the relation between structure and activity of MO-based lipoplexes will further strengthen the development of these novel delivery systems.

Decreased 4-1BB expression on CD4+CD25 high regulatory T cells in peripheral blood of patients with multiple sclerosis

As a tumour necrosis factor receptor superfamily member, 4-1BB (CD137) is preferentially expressed in CD4+CD25+ regulatory T cells (Tregs) and has been suggested to play an important role in regulating the generation or function of Tregs. Recent studies of human Tregs have shown that blood CD4+CD25(high) T cells were much closer to Tregs in terms of their functionality. Furthermore, CD4+CD25(high) Tregs have been found to have a decreased effector function in patients with multiple sclerosis (MS). In this study, we examined the expression of 4-1BB and soluble 4-1BB (s4-1BB) protein levels in the peripheral blood of MS patients. Compared with healthy controls, MS patients had decreased 4-1BB expression in their CD4+C25(high) Tregs and increased plasma s4-1BB protein levels. Moreover, the plasma s4-1BB levels of MS patients were shown to be inversely correlated with the 4-1BB surface expression of CD4+CD25(high) Tregs. The down-regulated 4-1BB expression on CD4+CD25(high) Tregs of MS patients may be involved in the impaired immunoactivity of these Tregs. The elevated s4-1BB levels may, at least in part, function as a self-regulatory attempt to inhibit antigen-driven proliferation of Tregs or their immunosuppressive activity.

Increased Soluble 4-1BB Ligand (4-1BBL) Levels in Peripheral Blood of Patients with Multiple Sclerosis

4-1BB ligand (4-1BBL; CD137L) is a member of the tumour necrosis factor superfamily expressed primarily on antigen presenting cells such as B cells, macrophages and dendritic cells. Its engagement with the receptor 4-1BB (CD137) has been shown to promote T-cell activation and regulate proliferation and survival of T cells. The role of the costimulatory molecule in multiple sclerosis (MS) remains unclear. In this study, the expression of 4-1BBL and soluble 4-1BBL (s4-1BBL) protein levels were analysed in peripheral blood of MS patients. Compared with healthy controls, MS patients had an increase in both plasma s4-1BBL protein levels and expression of 4-1BBL in CD14(+) monocytes. In contrast, myelin basic protein-reactive T-cell proliferation was not found to be inhibited by the use of an anti-4-1BBL antibody. The elevated s4-1BBL protein levels in the MS patients may function as a self-regulatory mechanism of 4-1BB/4-1BBL interaction and costimulation.

Host-feeding patterns of potential human disease vectors in the Paraíba Valley region, State of Säo Paulo, Brazil

Engorged females of Aedes albopictus, Ochlerotatus scapularis, Culex nigripalpus and Culex quinquefasciatus were collected by aspiration and sweep net during two years in Tremembé county, State of Säo Paulo, Brazil. Of the 1,092 specimens analyzed with the precipitin test, 87.6% reacted to one or more of the eight antisera tested. Of the four species for which the host determination was made, the reaction in 98.5% was to a single host. The application of the feeding index for four species of mosquitoes in Tremembe represented an attempt to measure and compare mosquito feeding patterns on these domestic hosts to evaluate the potential risk the region presents for the introduction and dissemination of arthropod-borne diseases. The results of the feeding index showed that Ae. albopictus commonly fed on humans and cattle; Oc. scapularis fed more upon cattleand dogs; Cx. nigripalpus fed on a wide range of hosts, and Cx. quinquefasciatus presented similar behavior but humans and dogs were the most common. The analysis of the feeding index agrees with the reported host feeding patterns of the four species investigated.

[Prevalence of American trypanosomiasis, syphilis, toxoplasmosis, rubella, hepatitis B, hepatitis C, human immunodeficiency virus infection, assayed through serological tests among pregnant patients, from 1996 to 1998, at the Regional University Hospital Norte do Paraná]

In order to evaluate the seroprevalence of the american trypanosomiasis, syphilis, toxoplasmosis, rubella, hepatitis B infection, hepatitis C infection and human immunodeficiency virus infection among pregnant women attended at the Hospital Universitário Regional Norte do Paraná, Londrina State University, Paraná, a retrospective study of the serologic results performed in the prenatal routine during the period of June 1996 to June 1998 was carried out. The rates of seropositivity were as follows: american trypanosomiasis = 0.9%, syphilis = 1.6%, toxoplasmosis = 67% (IgG) and 1.8% (IgM), rubella = 89% (IgG) and 1.2% (IgM), hepatitis B surface antigen = 0.8%, hepatitis C virus = 0.8% and human immunodeficiency virus infection = 0.6%. An association between the increase in the seroprevalence of Chagas' disease and patient age was detected (p=0.006). The results underscore the importance of the serological tests in perinatal care, to prevent both the congenital and perinatally transmitted forms of theses infectious diseases.