Higher baseline resting metabolic rate is associated with 1-year frailty decline among older adults residing in an urban area

BACKGROUND

Dysregulated energy metabolism is one hypothesized mechanism underlying frailty. Resting energy expenditure, as reflected by resting metabolic rate (RMR), makes up the largest component of total energy expenditure. Prior work relating RMR to frailty has largely been done in cross section with mixed results. We investigated whether and how RMR related to 1-year frailty change while adjusting for body composition.

METHODS

N = 116 urban, predominantly African-American older adults were recruited between 2011 and 2019. One-year frailty phenotype (0-5) was regressed on baseline RMR, frailty phenotype, demographics and body composition (DEXA) in an ordinal logistic regression model. Multimorbidity (Charlson comorbidity scale, polypharmacy) and cognitive function (Montreal Cognitive Assessment) were separately added to the model to assess for change to the RMR-frailty relationship. The model was then stratified by baseline frailty status (non-frail, pre-frail) to explore differential RMR effects across frailty.

RESULTS

Higher baseline RMR was associated with worse 1-year frailty (odds ratio = 1.006 for each kcal/day, p = 0.001) independent of baseline frailty, demographics, and body composition. Lower fat-free mass (odds ratio = 0.88 per kg mass, p = 0.008) was independently associated with worse 1-year frailty scores. Neither multimorbidity nor cognitive function altered these relationships. The associations between worse 1-year frailty and higher baseline RMR (odds ratio = 1.009, p < 0.001) and lower baseline fat-free mass (odds ratio = 0.81, p = 0.006) were strongest among those who were pre-frail at baseline.

DISCUSSION

We are among the first to relate RMR to 1-year change in frailty scores. Those with higher baseline RMR and lower fat-free mass had worse 1-year frailty scores, but these relationships were strongest among adults who were pre-frail at baseline. These relationships were not explained by chronic disease or impaired cognition. These results provide new evidence suggesting higher resting energy expenditure is associated with accelerate frailty decline.

It's about time: small mammal communities and Lyme disease emergence

Theory predicts that biodiversity changes due to climate warming can mediate the rate of disease emergence. The mechanisms linking biodiversity-disease relationships have been described both theoretically and empirically but remain poorly understood. We investigated the relations between host diversity and abundance and Lyme disease risk in southern Quebec, a region where Lyme disease is rapidly emerging. We found that both the abundance of small mammal hosts and the relative abundance of the tick's natural host, the white-footed mouse (Peromyscus leucopus), influenced measures of disease risk in tick vectors (Borrelia burgdorferi infection abundance and prevalence in tick vectors). Our results suggest that the increase in Lyme disease risk is modulated by regional processes involving the abundance and composition of small mammal assemblages. However, the nature and strength of these relationships was dependent both on time and geographic area. The strong effect of P. leucopus abundance on disease risk we report here is of significant concern, as this competent host is predicted to increase in abundance and occurrence in the region, with the northern shift in the range of North American species under climate warming.

Herbivore-Dependent Induced Volatiles in Pear Plants Cause Differential Attractive Response by Lacewing Larvae

Biological control may benefit from the behavioral manipulation of natural enemies using volatile organic compounds (VOCs). Among these, herbivore-induced plant volatiles (HIPVs) provide potential tools for attracting or retaining predators and parasitoids of insect pests. This work aimed to characterize the VOCs emitted by pear plants in response to attack by Cacopsylla bidens (Hemiptera: Psyllidae), a major pest in pear orchards, to compare these with VOCs induced by a leaf chewing insect, Argyrotaenia sphaleropa (Lepidoptera: Tortricidae), and to evaluate the behavioral response of Chrysoperla externa (Neuroptera: Chrysopidae) to HIPVs from pear plants damaged by either herbivore. The results demonstrated that plants damaged by the pear psylla emitted VOC blends with increased amounts of aliphatic aldehydes. Leafroller damage resulted in increased amounts of benzeneacetonitrile, (E)-4,8-dimethylnona-1,3,7-triene, β-ocimene and caryophyllene. In olfactometer bioassays, larvae of C. externa were attracted to herbivore-damaged plants when contrasted with undamaged plants. When plant odors from psylla-damaged were contrasted with those of leafroller-damaged plants, C.externa preferred the former, also showing shorter response lag-times and higher response rates when psylla-damaged plants were present. Our results suggest that pear plants respond to herbivory by modifying their volatile profile, and that psylla-induced volatiles may be used as prey-specific chemical cues by chrysopid larvae. Our study is the first to report HIPVs in pear plants attacked by C. bidens, as well as the attraction of C. externa to psyllid-induced volatiles.

Artificial intelligence-guided, single-lead EKG may be a game-changer for symptom-to-balloon time reduction in ST-elevated myocardial infarction

Background

Over decades, efforts to shave off life-saving minutes from ST-Elevated Myocardial Infarction (STEMI) care centred on reducing door-to-needle and door-to-balloon times. We firmly believe that symptom-to-balloon time should prove a better focus to this end. Challenges come with this goal as it heavily relies on a patient's perception and initiative to seek care, which we deem intelligent and wearable Artificial Intelligence (AI)-driven Single Lead EKG technologies as an attractive solution in modern-day cardiology.

Purpose

To provide an accurate, accessible, and cost-effective AI-driven Single Lead STEMI detection algorithm that can be embedded into wearable devices and employed in a self-administered fashion.

Methods

Database: EKG records from Mexico, Colombia, Argentina, and Brazil from April 2014 to December 2019. Dataset: A total of 11,567 12-lead EKG records of 10[s] length with a sampling frequency of 500 Hz, including the following balanced classes: angiographically confirmed and unconfirmed STEMI, branch blocks, non-specific ST-T abnormalities, normal and abnormal (200+ CPT codes, excluding those mentioned above). Cardiologists manually checked the label of each record to ensure precision. Pre-processing: We discard the first and last 250 samples as they may contain a standardisation pulse. The study applied a digital low pass filter of order 5 with a frequency cut-off of 35 Hz. The mean was subtracted from each Lead. Classification: The determined classes were “STEMI” (Including STEMI in different locations of the myocardium – anterior, inferior, and lateral); and “Not-STEMI” (Combination of randomly sample, branch blocks, non-specific ST-T changes, and abnormal records – 25% of each). Training and Testing: A 1-D Convolutional Neural Network was trained and tested with a dataset proportion of 90/10, respectively. A different model was trained and tested for each Lead, using the central 4,500 samples of the records. The last dense layer outputs a probability for each report of being STEMI or Not-STEMI. Lead V2 showed the best overall results. The model was further tested through the same methodology using the best Lead with a subset of the previous data, excluding the unconfirmed STEMI EKG records (Total 7,230 12-lead EKG records for Confirmed Only STEMI dataset). Performance metrics were reported for each experiment and compared.

Results

Combined STEMI data: Accuracy: 91.2%; Sensitivity: 89.6%; Specificity: 92.9%. Confirmed STEMI Only dataset: Accuracy: 92.4%; Sensitivity: 93.4%; Specificity: 91.4% (Figure 1).

Conclusion

By assiduously improving the quality of the model's input, we continue to assess our algorithm's performance and reliability for future clinical validation as a potential remote monitoring and early STEMI detection device.

Funding Acknowledgement

Type of funding sources: None.

Type III collagen formation is significantly associated with risk of outcome in HFpEF patients but loses its significant association with underlying AF

Introduction

Heart failure with preserved ejection fraction (HFpEF) is the most common type of heart failure, associated with high morbidity and mortality. Atrial fibrillation (AF) has been associated with structural remodelling and fibrosis and can coexist with HFpEF. Type III collagen is the second most abundant collagen in the heart wall and has been associated with cardiac fibrosis. It has been previously shown that type III collagen formation, measured by PRO-C3, is prognostic for all-cause mortality in HFpEF.

Purpose

In this study, we aimed at investigating if the prognostic power of PRO-C3 in relation to all-cause mortality would be affected by underlying AF in HFpEF patients.

Methods

The analysis included 166 individuals with hypertensive HFpEF. The patients were classified in three groups according to NYHA classification, 43.2% in NYHA Class II, 52.5% NYHA Class III and 2.5% NYHA Class IV. A previous history of AF was present in 53.4% of the patients. Cardiac function was assessed by echocardiography and standard clinical measures. Type III collagen formation was evaluated by means of ELISA with the biomarker PRO-C3, which targets the released N-terminal pro-peptide of type III collagen.

Results

Levels of PRO-C3 were significantly elevated in HFpEF patients with AF (p=0.0063). PRO-C3 was significantly predictive of all-cause mortality in HFpEF patients (AUC=0.643, p=0.0053), but lost its significant association when factoring in AF (AUC=0.581, p=0.235). There was an increased risk of all-cause mortality (p=0.0089) but not statistically significant differences in HFpEF patients with AF (p=0.178) with increasing tertiles of PRO-C3.

Conclusions

Type III collagen formation as measured by PRO-C3, was increased in patients with HFpEF and previously diagnosed AF. However, while PRO-C3 can be predictive of all-cause mortality in HFpEF patients, it lacks predicting ability when AF is considered. The presented data suggest a potential role of increased type III collagen formation in HFpEF patients with adverse outcomes, which is consistent with the presence of increased fibrosis, and can potentially be used as a tool of risk stratification.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Nordic Bioscience A/S

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Background

Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated.

Purpose

By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool.

Methods

11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports.

Results

Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1).

Conclusion

Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures.

Funding Acknowledgement

Type of funding sources: None.

No need for a cardiologist for AMI diagnosis – progress of transforming a behemoth telemedicine program with artificial intelligence

Background

The Latin American Telemedicine Infarct Network (LATIN) Telemedicine is a mammoth hub and spoke model that provides an umbrella of AMI protection for 100 million patients. In the program, 826,043 patients had a telemedicine encounter; 7,400 with AMI were diagnosed; 4,332 of them managed with guidelines-based strategies. We have gradually begun implementing a system for using Artificial Intelligence (AI) algorithms embedded into EKGs for rapid and accurate STEMI detection and validated the results with a cardiologist's interpretations.

Purpose

To test whether an AI-driven EKG algorithm can effectively substitute a cardiologist for STEMI telemedicine protocols.

Methods

The AI algorithm construction was in the following fashion. Sample: a selection of 8,511 EKG and 90,592 classified heartbeats. Pre-processing: segmentation of each EKG into individual heartbeats. Training & testing: 90% and 10% of the total dataset, respectively. Classification: 1-D Convolutional Neural Network; the study constructed classes for each heartbeat. The algorithm was next deployed on a consecutive series of LATIN EKG records to diagnose STEMI. We afterwards compared the algorithm's results with eight expert cardiologists' interpretations of the same sample.

Results

This study achieved a concordance of 91% between the AI algorithm and cardiologist interpretation (Figure 1).

Conclusions

The initial results with AI algorithms for STEMI diagnosis are encouraging and may provide the base work for new tools for cardiologists to improve their efficiency. Moreover, implementing this innovative tool may overcome current limitations associated with the telemedical management of this disease.

Funding Acknowledgement

Type of funding sources: None.

Molecular characterization of thioester-containing proteins in Biomphalaria glabrata and their differential gene expression upon Schistosoma mansoni exposure

Schistosomiasis is a disease caused by trematode parasites of the genus Schistosoma that affects approximately 200 million people worldwide. Schistosomiasis has been a persistent problem in endemic areas as there is no vaccine available, currently used anti-helmintic medications do not prevent reinfection, and most concerning, drug resistance has been documented in laboratory and field isolates. Thus, alternative approaches to curtail this human disease are warranted. Understanding the immunobiology of the obligate intermediate host of these parasites, which include the freshwater snail Biomphalaria glabrata, may facilitate the development of novel methods to stop or reduce transmission to humans. Molecules from the thioester-containing protein (TEP) superfamily have been shown to be involved in immunological functions in many animals including corals and humans. In this study we identified, characterized, and compared TEP transcripts and their expression upon S. mansoni exposure in resistant and susceptible strains of B. glabrata snails. Results showed the expression of 11 unique TEPs in B. glabrata snails. These transcripts present high sequence identity at the nucleotide and putative amino acid levels between susceptible and resistant strains. Further analysis revealed differences in several TEPs’ constitutive expression levels between resistant and susceptible snail strains, with C3-1, C3-3, and CD109 having higher constitutive expression levels in the resistant (BS90) strain, whereas C3-2 and TEP-1 showed higher constitutive expression levels in the susceptible (NMRI) strain. Furthermore, TEP-specific response to S. mansoni miracidia exposure reiterated their differential expression, with resistant snails upregulating the expression of both TEP-4 and TEP-3 at 2 h and 48 h post-exposure, respectively. Further understanding the diverse TEP genes and their functions in invertebrate animal vectors will not only expand our knowledge in regard to this ancient family of immune proteins, but also offer the opportunity to identify novel molecular targets that could aid in the efforts to develop control methods to reduce schistosomiasis transmission.

POS0707 POTENTIAL USE OF BELIMUMAB IN LUPUS PATIENTS FROM ARGENTINE COHORT ACCORDING DISEASE ACTIVITY STATE

Background

The goal of targeted treatment in patients with Systemic Lupus Erythematosus (SLE) is to achieve clinical remission or low disease activity, with the best quality of life, low damage rates and better survival 1-4. RELESSAR is a multicenter, cross-sectional study registry of ≥18 years SLE (ACR 97) patients 5.

Objectives

To describe demographic, clinical characteristics and treatments in SLE patients according to disease activity state. To evaluate the proportion of SLE and refractory SLE patients that are potentially candidates for Belimumab treatment (Active SLE despite standard treatment including increased acDNA autoantibodies and low complement).

Methods

We evaluated demographic and clinical data, treatments, score of damage (SLICC), activity (SLEDAI) and comorbidity (Charlson), hospital admissions and severe infections. The patients were compared according to disease activity: remission (SLEDAI = 0 and without corticosteroids), low disease activity (LDA, SLEDAI> 0 and ≤4 and without corticosteroids) and non-optimal control (SLEDAI> 4 and any dose of corticosteroids). Refractory SLE was defined according to Rituximab (RTX) use, non-response to cyclophosphamide or two or more immunosuppressant or splenectomized patients. Potential use of Belimumab according approved prescription in Argentina was analyzed.

Results

Overall, 1277 patients were analyzed: 299 (23.4%) were in remission, 162 (12.7%) in LDA and 816 (63.9%) with non-optimal control of the disease.

Patients in non-optimal control group were younger, less frequently female and they showed less time of disease and lower socioeconomic status (p < 0.001). They were also more prevalent mestizos (p= 0.004), had higher SLEDAI and SLICC indexes (p <0.001) and higher use of immunosuppressant therapy (p <0.001). There was no difference regarding biologic treatment (RTX p= 0.547 and Belimumab p= 0.08). This group had higher proportion of hospital admissions and severe infections (p<0.001, respectively).

Two hundred and one SLE patients fulfilled the use of Belimumab prescription criteria but only 45/201 patients (22,3%) received it in the last visit. Malar rash was the only clinical variable associated with the use of Belimumab (72.7% vs 29.8% p= 0.005).

Seventy-six patients classified as refractory SLE (15.7%) and 56/76 (75.7%) never received Belimumab. Patients on Belimumab therapy were associated to treatment with lower doses of corticoids (p= 0.018) and lower rate of hospital admission caused by SLE flare (p= 0.027).

Conclusion

A high percentage of patients had uncontrolled disease upon entry into the registry and were potential candidates for treatment with Belimumab. The patients who received biologic treatment showed the benefit of requiring fewer doses of corticosteroids and having a lower rate of hospitalizations.

References

[1]Mok CC. Treat-to-target in systemic lupus erythematosus: Are we there yet? Expert Rev Clin Pharmacol. 2016;9(5).

[2]Morand EF, Mosca M. Treat to target, remission and low disease activity in SLE. Vol. 31, Best Practice and Research: Clinical Rheumatology. 2017.

[3]Golder V, Tsang-A-Sjoe MWP. Treatment targets in SLE: Remission and low disease activity state. Rheumatol (United Kingdom). 2020;59.

[4]Ruiz-Irastorza G, Bertsias G. Treating systemic lupus erythematosus in the 21st century: new drugs and new perspectives on old drugs. Vol. 59, Rheumatology (United Kingdom). 2021.

[5]Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum [Internet]. 1997;40(9):1725. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9324032

Disclosure of Interests

Rosana Quintana: None declared, Lucila Garcia: None declared, Paula Alba: None declared, Susana Roverano: None declared, Analia Alvarez: None declared, Cesar Graf: None declared, Cecilia Pisoni: None declared, Alberto Spindler: None declared, Catalina Gomez: None declared, Heber Matias Figueredo: None declared, Silvia Papasidero: None declared, Raul Horacio Paniego: None declared, Maria DeLaVega: None declared, Emma Estela Civit De Garignani: None declared, Luciana Gonzalez Lucero: None declared, Victoria Martire: None declared, Rodrigo Águila Maldonado: None declared, Sergio Gordon: None declared, Carla Gobbi: None declared, Romina Nieto: None declared, Gretel Rausch: None declared, Vanina Góngora: None declared, Maria Agustina D´Amico: None declared, Diana Dubinsky: None declared, Alberto Omar Orden: None declared, Johana Zacariaz: None declared, Julia Romero: None declared, Mariana Alejandra Pera: None declared, Oscar Rillo: None declared, Roberto Baez: None declared, Valeria Arturi: None declared, Andrea Gonzalez: None declared, Florencia Vivero: None declared, Marcela Schmid: None declared, Victor Caputo: None declared, Maria Silvia Larroude: None declared, Graciela Gomez: None declared, Graciela Rodriguez: None declared, Josefina Marin: None declared, Maria Victoria Collado: None declared, Marisa Jorfen: None declared, Zaida Bedran: None declared, Judith Sarano: None declared, David Zelaya: None declared, MONICA SACNUN: None declared, Pablo Finucci: None declared, Romina Rojas Tessel: None declared, Maria Emilia Sattler: None declared, MAXIMILIANO MACHADO ESCOBAR: None declared, Pablo Astesana: None declared, Ursula Vanesa Paris: None declared, Alberto Allievi: None declared, Juan Manuel Vandale: None declared, Bernardo Pons-Estel: None declared, Guillermo Pons-Estel: None declared, Mercedes García Grant/research support from: GSK grant

POS0438 IDENTIFICATION OF ANTI-CYTOKINE AUTOANTIBODIES WITH POTENTIAL TO PREDICT FLARE IN RHEUMATOID ARTHRITIS PATIENTS UNDERGOING BIOLOGICAL THERAPIES: A DISCOVERY STUDY

Background

The presence of anti-cytokine autoantibodies (ACAAs) seems to be a physiologic mechanism to control the immune response and regulate cytokine activity. Biological therapies also regulate cytokine activities and have greatly improved the quality of life of RA patients. However, alteration of the cytokine network by the use of these treatments may lead to a disbalance in the regulatory system of ACAAs. We hypothesize the ACAAs network may influence the course of immune response in RA patients and may be useful to predict the therapy efficacy.

Objectives

We aimed to explore the potential of circulating ACAAs to predict flare in a cohort of RA patients treated with biological therapy.

Methods

We employed sera at baseline from 194 RA patients of the clinical trial OPTIBIO1 (A Coruña), whose primary endpoint is to evaluate the usefulness of standardized protocol strategies of dose reduction in patients with RA in clinical remission treated with biologics. These patients were treated with TNF inhibitors (Etanercept, N=47; Infliximab, N=12; Adalimumab, N=35; Certolizumab (CTZ), N=17; Golimumab, N=5), Tocilizumab (TCZ, N=60) and Abatacept (ABA, N=18). Patients were in clinical remission (DAS 28 <2.6 or SDAI <5 or ACR/EULAR 2011 criteria) at least from 6 months. Patients were followed during a minimum period of one year and maximum period of 3 years. Flare was considered when remission criteria were not fulfilled. The bead-based antigen array MILLIPLEX MAP Human Cytokine Autoantibody Magnetic Bead Panel was used for the simultaneous detection and quantification in sera of anti-BAFF, anti-G-CSF, anti-IFNβ, anti-IFNγ, anti-IL-1α, anti-IL-6, anti-IL-8, anti-IL-10, anti-IL-12 (p40), anti-IL-15, anti-IL-17A, anti-IL-17F, anti-IL-18, anti-IL-22, and anti-TNFα. Non-parametrical tests, ROC curves and logistic regressions were performed for the statistical data analysis using SPSS. P-value < 0.05 was considered statistically significant.

Results

The levels of anti-17A and anti-IL-1α were increased in the sera from patients who suffered a flare during the follow-up period (N= 76), compared to those who remained in remission (N= 118), showing an area under the curve (AUC) of 0.586 and 0.594, respectively. Segregating by treatment, the levels of anti-17A were specifically increased in those relapsing patients under CTZ (N=6), ABA (N=12) and TCZ (N=20) treatment. The AUC of anti-17A within these three therapies was 0.867, 0.903 and 0.682, respectively. Logistic regression analysis also associated the levels of anti-17A with the risk of suffering a flare in TCZ-treated patients (OR=1.11; p=0.015, for 100 MFI increase). In addition, the TCZ-treated patients who suffered a flare also showed higher levels of anti-IL17F, anti-IL-1α, and anti-IL-18 compared to those that remained in remission, showing AUCs of 0.689, 0.657 and 0.698, respectively. Anti-IL-18 was also associated with the risk of flare in these patients (OR=1.65; p=0.028, for 100 MFI increase). The presence of these three ACAAs was also higher in the TCZ-treated patients who suffered a flare compared to those in remission.

Conclusion

Although further validation of our results is needed, we present a ground-breaking study showing the potential of anti-IL17A, anti-IL-1α, and anti-IL18 to predict flare in RA patients under biological therapies.

References

[1]Bejerano C, et al. Clinical evaluation usefulness of standardized protocol strategies of dose reduction in patients with RA in clinical remission treated with biologic therapies. The Optibio Study. Arthritis Rheumatol. 2016; 68 (suppl 10): 649.

Table 1.

Table showing a summary of the results. CI: confidence interval

• Treatments• ACAAs• AUC (CI 95%; p)Allanti-IL17A0.586 (0.504-0.668; 0.044)anti-IL-1α0.594 (0.512-0.676; 0.028)CTZanti-IL17A0.867 (0.675,1.000; 0.017)ABAanti-IL17A0.903 (0.761-1.000; 0.007)TCZanti-IL-1α0.657 (0.494-0.820; 0.049)anti-IL-17F0.689 (0.551-0.827; 0.018)anti-IL17A0.682 (0.528-0.835; 0.023)anti-IL180.698 (0.545-0.850; 0.013)

Disclosure of Interests

None declared.

Use of verbal de-escalation in reducing need for mechanical restraint in patients with psychotic disorders during non-voluntary transfers from home to the psychiatric emergency department

Introduction

Little is known about the need for mechanical restraint during non-voluntary transfers from patient’s homes to the psychiatric emergency department in patients diagnosed with Paranoid Schizophrenia. Although there is no evidence of its efficacy, one of the main tools used for the reduction of mechanical restraints is verbal de-escalation training.

Objectives

The aim is to describe which symptoms predispose to mechanical restrain in patients with Paranoid Schizophrenia transferred in a non-voluntary manner from home to the psychiatric emergency department, and the effect on reducing mechanical restraints after receiving verbal de-escalation training.

Methods

All patients with Paranoid Schizophrenia who, after being visited by a home psychiatry team, have required non-voluntary transfer from their homes to the psychiatric emergency department were selected (N = 442).

Results

Young age, being male, having a poor adherence to treatment, higher scores for de following variables; Excitement, Grandiosity, Suspiciousness, Hostility, Abstract thinking, Motor tension, Uncooperativeness, Poor attention, Lack of insight and Poor impulse control as well as lower scores in motor retardation on the PANSS, are related to a higher frequency of mechanical restrain (P<0,005). Before the verbal de-escalation training, 43.9% of the transferred patients required mechanical restraint, after the training, the need for restraints was reduced to 25.5% (P<0.001).

Conclusions

Training in verbal de-escalation has allowed an important reduction in mechanical restraints in patients with schizophrenia who have required non-voluntary transfers from home to the psychiatric emergency department.

Disclosure

No significant relationships.

Antithrombotic Treatment after Carotid Stenting in Patients with Concomitant Atrial Fibrillation

BACKGROUND AND PURPOSE

Antithrombotic therapy following carotid artery stent placement with concomitant atrial fibrillation is not well-established. Our aim was to assess the safety and efficacy of the combination of direct oral anticoagulants and a P2Y12 inhibitor at 30 days after carotid artery stent placement in patients with atrial fibrillation.

MATERIALS AND METHODS

We designed an observational single-center study including patients who underwent carotid artery stent placement with concomitant atrial fibrillation. We studied 3 groups according to antithrombotic therapy: 1) the direct oral anticoagulants plus clopidogrel (DC) group: receiving direct oral anticoagulants plus a P2Y12 inhibitor; 2) the triple therapy group: anticoagulation and dual antiplatelet therapy; and 3) the dual antiplatelet therapy group: following dual antiplatelet therapy alone. The safety outcome was a major or clinically relevant non-major bleeding event at the first month. The efficacy outcomes were the thromboembolic events (myocardial infarction, stroke, systemic embolism, or stent thrombosis).

RESULTS

Of 959 patients with carotid artery stent placement, 91 met the inclusion criteria, including 24 patients in the DC group, 42 patients in the triple therapy group, and 25 in the dual antiplatelet therapy group. The mean age was 72.27 (SD, 8.1 ) years, with similar baseline characteristics. The median CHA₂DS₂-VASc score for each group was 6 (interquartile range  = 5-6), 5 (interquartile range = 4-6), and 5 (interquartile range = 4-6), respectively. The median HAS-BLED score was 4 in the 3 groups (P = .17). The primary safety end point was 23.8% in the triple therapy group compared with 4% in the dual antiplatelet therapy group (P = .032), with no bleeding events in the DC group (P = .007). There was 1 stent thrombosis in DC group and a cardioembolic stroke in the dual antiplatelet therapy group (P = .41).

CONCLUSIONS

Among patients with carotid artery stent placement with atrial fibrillation, triple therapy confers a high bleeding risk. A regimen of direct oral anticoagulants plus a P2Y12 inhibitor might confer a good safety profile with significantly lower rates of bleeding and optimal efficacy.

Differences in mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine immunogenicity among patients undergoing dialysis

BACKGROUND

Differences in immunogenicity between mRNA SARS-CoV-2 vaccines have not been well characterized in patients undergoing dialysis. We compared the serologic response in patients undergoing maintenance hemodialysis after vaccination against SARS-CoV-2 with BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna).

METHODS

We conducted a prospective observational cohort study at 2 academic centres in Toronto, Canada, from Feb. 2, 2021, to July 20, 2021, which included 129 and 95 patients who received the BNT162b2 and mRNA-1273 SARS-CoV-2 vaccines, respectively. We measured SARS-CoV-2 immunoglobulin G antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD) and nucleocapsid protein (anti-NP) at 6-7 and 12 weeks after the second dose of vaccine and compared those levels with the median convalescent serum antibody levels from 211 controls who were previously infected with SARS-CoV-2.

RESULTS

At 6-7 weeks after 2-dose vaccination, we found that 51 of 70 patients (73%) who received BNT162b2 and 83 of 87 (95%) who received mRNA-1273 attained convalescent levels of anti-spike antibody (p < 0.001). In those who received BNT162b2, 35 of 70 (50%) reached the convalescent level for anti-RBD compared with 69 of 87 (79%) who received mRNA-1273 (p < 0.001). At 12 weeks after the second dose, anti-spike and anti-RBD levels were significantly lower in patients who received BNT162b2 than in those who received mRNA-1273. For anti-spike, 70 of 122 patients (57.4%) who received BNT162b2 maintained the convalescent level versus 68 of 71 (96%) of those who received mRNA-1273 (p < 0.001). For anti-RBD, 47 of 122 patients (38.5%) who received BNT162b2 maintained the anti-RBD convalescent level versus 45 of 71 (63%) of those who received mRNA-1273 (p = 0.002).

INTERPRETATION

In patients undergoing hemodialysis, mRNA-1273 elicited a stronger humoral response than BNT162b2. Given the rapid decline in immunogenicity at 12 weeks in patients who received BNT162b2, a third dose is recommended in patients undergoing dialysis as a primary series, similar to recommendations for other vulnerable populations.

Association of soluble ST2 and right ventricular dysfunction with mortality in chronic hemodialysis patients

Background

End stage kidney disease (ESKD), is a triggering and facilitating factor for cardiac remodelling (i.e., morphologic hypertrophy and/or dilatation associated with deterioration of systolic and/or diastolic function) that contribute to heart failure (HF). RV dysfunction (RVD) has been demonstrated to predict mortality in ESKD patients.

Purpose

The present study aimed to investigate the potential associations between RVD and circulating biomarkers of myocardial inflammation and fibrosis with all-cause mortality in HD patients.

Method

We performed a retrospective single-centre cohort study of prevalent patients admitted in a chronic HD program for more than 3 months. Clinical characteristics and echocardiographic parameters were assessed in all patients. Pre-dialysis blood samples for measurement of inflammatory (e.g., C reactive protein, interleukin-1, interleukin-18) and fibrotic (e.g., soluble suppression of tumorigenesis-2 [sST2], galectin-3, C-terminal pro-peptide of procollagen type I and N-terminal pro-peptide of procollagen type III) biomarkers were collected. RVD was defined using tricuspid annular plane systolic excursion (TAPSE) &lt;1.7 cm or pulsed Doppler peak annular velocity (S') &lt;9.5 cm/s. The ability of sST2 to discriminate between mortality was assessed using AuROC curve.

Results

We enrolled forty-eight patients, mean patients age was 74 (64 – 79)years, and 62.5% were males. 95.8% of the patients had high blood pressure, and at least 70.8% had HF criteria. About 52.1% of the patients were on OnLine HDF. Regarding the echocardiogram parameters, 56.3% had no functional heart disease, 10.4% had LVD (LVEF ≤45% and diastolic dysfunction ≥ grade 2), and 33.3% had RVD (TAPSE &lt;17mm and/or S'&lt;9.5cm/s), with or without LVD. Mortality was higher 45.5% (log-rank, p=0.003) in patients with RVD as diagnosed by S' than in patients without RVD. No difference in mortality was observed for RVD defined by TAPSE. There were no differences in the morphology and function parameters of the left ventricle between patients with and without RVD. From all biomarkers measured only sST2 was associated with RVD. Indeed, an age- and sex-adjusted analyses showed that doubling of sST2 was inversely associated with a decreased in S' (estimate = −2.03, 95% CI [−3.04 to −1.00] cm/s; P=0.002). Mortality was increased in patients with sST2 ≥40.45 ng/mL compared to patients with sST2 &lt;40.45 ng/mL (66.7% vs. 18.9%, log-rank; p=0.004).

Conclusion

This preliminary data would suggest that patients on chronic HD, circulating levels of sST2 were independently associated with RVD. In addition, elevated sST2 levels and RVD were associated with increased all-cause mortality. The myocardial pro-remodelling effect of sST2 in HD patients with RVD warrants further investigation.

Funding Acknowledgement

Type of funding sources: None.

Impact of previous cardiac conditions in prognosis and clinical management of patient with COVID-19 infection

Background

Recent studies suggest a higher mortality rate because of COVID-19 in patients with previous cardiac conditions compared to those without. Given the limited resources of intensive care units (ICU) during the pandemic outbreak, this fact has important implications.

Purpose

The main purpose of this study was to compare the 30-day mortality of the COVID-19 infection in patients with and without previous cardiac conditions. The secondary end point was to assess the differences in clinical severity of the infection (as development of Acute Respiratory Distress Syndrome – ARDS) and ICU admission amongst these patients.

Methods

A total of 1708 consecutive patients were prospectively included. The inclusion criteria were: a confirmed positive diagnosis of COVID-19 infection by PCR and being admitted to our centre between 18th and 23rd March 2020 and 22nd August and 9th January 2021. Patients were classified in two groups according to the presence of previous cardiac conditions (defined as previous history of myocardial infarction, heart failure and atrial fibrillation). Other comorbidities were extensively explored and Charlson Comorbidity Index was calculated. A propensity-score matching was performed and 145 patients with previous cardiac conditions were matched with 145 patients without.

Results

The group of patients with a previous cardiac condition included 421 patients (24.6%). The crude analysis showed a higher 30-day mortality rate among patients with previous cardiac affections (35.6% vs. 14.6%, p&lt;0.001). They were also less likely to be admitted to the ICU (9.8% vs. 6.2%, p=0.022) and had a higher prevalence ARDS (48.9% vs. 33.9%, p&lt;0.001). In the matched cohort, there were no significant differences between both groups regarding mortality (24.8% in the group of patients with previous cardiac conditions vs. 31.0%, p=0.272) nor ARDS prevalence (50.3% vs. 53.1%, p=0.655). There was a trend toward patients with previous cardiac conditions to be less likely to be admitted to the ICU (4.8% vs. 9.7%, p=0.090).

Conclusions

Patients with a personal history of previous cardiac conditions were less likely to be admitted to the ICU. However, our results show that when comparing cohorts with similar comorbidity burden, a previous cardiopathy “per se” does not significantly increase the risk of death in patients with a concomitant COVID infection.

Funding Acknowledgement

Type of funding sources: None. Mortality unmatched vs matched cohort

Endotrophin is significantly associated with disease severity and increased risk of adverse outcome in HFpEF but not in HFrEF patients

Introduction

The global burden of heart failure (HF), with either reduced (HFrEF) or preserved (HFpEF) ejection fraction, has increased dramatically over the past years, and HFpEF is projected to become the dominant type of HF. Fibrogenesis, promoted by fibroblast activity, plays an important role in the pathology of HF regardless of subtype, causing impaired cardiac function. Endotrophin is a bioactive molecule released from collagen type VI during its maturation, and it is a marker of fibroblast activity. The aim of this post-hoc analysis was to confirm the previously observed prognostic potential of endotrophin (measured by PRO-C6) for adverse outcome in HFpEF and to test its prognostic abilities in HFrEF.

Methods

234 patients with hypertension and either HFrEF (30.3%) or HFpEF (69.7%) were included for analysis. 43.2% were NYHA Class II, 52.5% NYHA Class III and 2.5% NYHA Class IV. 53.4% of patients had a previous history of atrial fibrillation. The cohort did not include diabetic patients. Cardiac function was assessed by echocardiography and standard clinical measures, including left ventricle ejection fraction (EF), blood pressure (BP) and measurement of N-terminal natriuretic brain-peptide (NT-proBNP). Circulating endotrophin was quantified at baseline in serum by means of an enzyme-linked immunosorbent assay, PRO-C6.

Results

PRO-C6 levels increased significantly with disease severity in HFpEF patients (NYHA Class III vs II, p=0.0003), but not in HFrEF patients (NYHA Class III vs II, p=0.33). In HFpEF patients, PRO-C6 was able to discriminate between patients that were hospitalized for HF (AUC=0.69, p&lt;0.001), died from cardiovascular (CV) causes (AUC=0.74, p&lt;0.001), or by any other cause (AUC=0.73, p&lt;0.001). PRO-C6 was not associated with none of these outcomes in HFrEF patients (AUC=0.56, p=0.42; AUC=0.53, p=0.73; AUC=0.56, p=0.53, respectively). Adding PRO-C6 to a risk prediction model containing age, sex, body mass index and systolic BP significantly increased the discriminatory power of the model for mortality (deltaAUC=0.037, p=0.04). When looking at patients stratified in PRO-C6 tertiles, patients in the upper tertile had a significantly higher risk of mortality (p&lt;0.0001, hazard ratios 3 vs 1=4.1, 3 vs 2=3.5, respectively) and HF hospitalization (p&lt;0.0001, hazard ratio 3 vs 1=4.4, 3 vs 2=1.6, respectively) compared to tertiles 1 and 2.

Conclusion

In this population of hypertensive HF patients, circulating endotrophin, measured by PRO-C6, was increased with increasing disease severity, and associated with a higher risk of adverse outcome in HFpEF, but not in HFrEF patients. The data presented here suggest a potential role of endotrophin in HFpEF pathophysiology and further underline the differences between HFpEF and HFrEF. These data confirm previous observations, and strengthen the usefulness of endotrophin, measured by the PRO-C6 biomarker, as a prognostic tool aiding in assessment of HFpEF patients.

Funding Acknowledgement

Type of funding sources: None.

Prognostic factors at admission on patients with cancer and COVID-19: Analysis of HOPE registry data

Background

Previous works seem to agree in the higher mortality of cancer patients with COVID-19. Identifying potential prognostic factors upon admission could help identify patients with a poor prognosis.

Methods

We aimed to explore the characteristics and evolution of COVID-19 cancer patients admitted to hospital in a multicenter international registry (HOPE COVID-19).

Our primary objective is to define those characteristics that allow us to identify cancer patients with a worse prognosis (mortality within 30 days after the diagnosis of COVID-19).

Results

5838 patients have been collected in this registry, of whom 770 had cancer among their antecedents. In hospital mortality reached 258 patients (33.51%). The median was 75 years (65–82). Regarding the distribution by sex, 34.55% of the patients (266/770) were women.

The distribution by type of cancer: genitourinary 238/745 (31.95%), digestive 124/745 (16.54%), hematologic 95/745 (12.75%).

In multivariate regression analysis, factors that are independently associated with mortality at admission are: renal impairment (OR 3.45, CI 97.5% 1.85–6.58), heart disease (2.32, 1.47–3.66), liver disease (4.69, 1.94–11.62), partial dependence (2.41, 1.34–4.33), total dependence (7.21, 2.60–21.82), fatigue (1.84, 1.16–2.93), arthromialgias (0.45, 0.26–0.78), SatO2 < 92% (4.58, 2.97–7.17), elevated LDH (2.61, 1.51–4.69) and abnormal decreased Blood Pressure (3.57, 1.81–7.15). Analitical parameters are also significant altered.

Conclusion

In patients with cancer from the HOPE registry, 30-day mortality from any cause is high and is associated with easily identifiable clinical factors upon arrival at the hospital. Identifying these patients can help initiate more intensive treatments from the start and evaluate the prognosis of these patients.

Evaluation of the SARS-CoV-2 Antibody Response to the BNT162b2 Vaccine in Patients Undergoing Hemodialysis

IMPORTANCE

Patients undergoing hemodialysis have a high mortality rate associated with COVID-19, and this patient population often has a poor response to vaccinations. Randomized clinical trials for COVID-19 vaccines included few patients with kidney disease; therefore, vaccine immunogenicity is uncertain in this population.

OBJECTIVE

To evaluate the SARS-CoV-2 antibody response in patients undergoing chronic hemodialysis following 1 vs 2 doses of BNT162b2 COVID-19 vaccination compared with health care workers serving as controls and convalescent serum.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-center cohort study was conducted between February 2 and April 17, 2021, in Toronto, Ontario, Canada. Participants included 142 patients receiving in-center hemodialysis and 35 health care worker controls.

EXPOSURES

BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 IgG antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD), and nucleocapsid protein (anti-NP).

RESULTS

Among the 142 participants undergoing maintenance hemodialysis, 94 (66%) were men; median age was 72 (interquartile range, 62-79) years. SARS-CoV-2 IgG antibodies were measured in 66 patients receiving 1 vaccine dose following a public health policy change, 76 patients receiving 2 vaccine doses, and 35 health care workers receiving 2 vaccine doses. Detectable anti-NP suggestive of natural SARS-CoV-2 infection was detected in 15 of 142 (11%) patients at baseline, and only 3 patients had prior COVID-19 confirmed by reverse transcriptase polymerase chain reaction testing. Two additional patients contracted COVID-19 after receiving 2 doses of vaccine. In 66 patients receiving a single BNT162b2 dose, seroconversion occurred in 53 (80%) for anti-spike and 36 (55%) for anti-RBD by 28 days postdose, but a robust response, defined by reaching the median levels of antibodies in convalescent serum from COVID-19 survivors, was noted in only 15 patients (23%) for anti-spike and 4 (6%) for anti-RBD in convalescent serum from COVID-19 survivors. In patients receiving 2 doses of BNT162b2 vaccine, seroconversion occurred in 69 of 72 (96%) for anti-spike and 63 of 72 (88%) for anti-RBD by 2 weeks following the second dose and median convalescent serum levels were reached in 52 of 72 patients (72%) for anti-spike and 43 of 72 (60%) for anti-RBD. In contrast, all 35 health care workers exceeded the median level of anti-spike and anti-RBD found in convalescent serum 2 to 4 weeks after the second dose.

CONCLUSIONS AND RELEVANCE

This study suggests poor immunogenicity 28 days following a single dose of BNT162b2 vaccine in the hemodialysis population, supporting adherence to recommended vaccination schedules and avoiding delay of the second dose in these at-risk individuals.

Consistent evidence of indirect effects of impulsive delay discounting and negative urgency between childhood adversity and adult substance use in two samples

RATIONALE

Exposure to adverse life experiences (ACEs) is robustly associated with problematic alcohol and other drug use. In addition, both ACEs and substance use have been independently associated with impulsivity.

OBJECTIVE

To examine whether impulsivity is implicated in the link between ACE and adult substance use in two samples.

METHODS

The primary sample was a cohort of community adults (N = 1431) who completed a one-time in-person assessment. A second sample was crowdsourced using Amazon Mechanical Turk (N = 3021). All participants were assessed for ACEs using the Adverse Childhood Experience Questionnaire and for current alcohol and other drug use. Given its multidimensional nature, impulsivity was assessed using the UPPS-P measure of impulsive personality traits, Go/NoGo (GNG) task (in-person community adult sample only), and delay discounting (Monetary Choice Questionnaire [MCQ] in the community adults and Effective Delay-50 [ED₅₀] in the crowdsourced sample. Structural equation modeling was used to examine the hypothesized indirect effects for the measures of impulsivity between ACEs and substance use.

RESULTS

In the community adults, significant indirect effects were observed from ACEs to substance use via UPPS-Negative Urgency (β = 0.07, SE = 0.02, 95% CI [0.04, 0.10]), and the MCQ (β = 0.02 SE = .01, 95% CI [0.01, 0.03]). In the crowdsourced sample, significant indirect effects were observed from ACEs to substance use via UPPS-Negative Urgency (β = 0.05, SE = .01, 95% CI [0.04, 0.07]), UPPS-Premeditation (β = 0.04, SE = .01, 95% CI [0.02, 0.05), and the ED₅₀ (β = 0.02, SE = .01; 95% CI [0.01, 0.03]).

CONCLUSION

These findings provide consistent evidence that decrements in regulation of negative emotions and overvaluation of immediate rewards indirectly link ACE and substance use. These robust cross-sectional findings support the need for elucidating the underlying neural substrates implicated and for longitudinal evaluations.

POS0185 IDENTIFICATION AND VALIDATION OF TWO NOVEL SERUM BIOMARKERS ASSOCIATED WITH THE SEROLOGICAL STATUS OF RHEUMATOID ARTHRITIS PATIENTS

Background:

Despite the diagnostic value of Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibodies (ACPA), more serological markers are needed in order to improve early diagnosis and treatment response of the Rheumatoid Arthritis (RA) patients. Increased knowledge about how these two major autoreactivities arise is crucial for understanding how RA develops and what mechanisms drive pathogenesis.

Objectives:

We aimed to investigate, using a proteomic strategy, novel protein biomarkers associated with RF and/or ACPA that might be useful to stratify seropositive and seronegative RA patients.

Methods:

A shotgun proteomic analysis was performed on 80 sera from the RA cohort of the Rheumatology Unit of the University Hospital of Santiago de Compostela (CHUS). Sera were classified as seropositive or seronegative according to their RF and ACPA values, and were then analyzed employing the iTRAQ labelling technique (Sciex) followed by LC-MALDI-MS/MS analysis (MALDI-TOF). A Multiple Reaction Monitoring (MRM) method was subsequently developed using the Skyline Software for the simultaneous quantification of 26 peptides belonging to ten putative protein biomarkers. The quantitative targeted analysis was performed using peptides with isotope labelled amino acids as internal standards. Serum levels of orosomucoid 1 (ORM1) and haptoglobin (HPT) were measured using commercially available ELISA Kits in the whole RA cohort (n=260) from the Rheumatology Unit of the University Hospital of A Coruña (HUAC).

Results:

For the initial screening, eighty sera were grouped according to the ACPA/RF status in 4 pools (20 patients/pool). Using an iTRAQ technology-based quantitative proteomic approach, the abundance of eleven proteins was altered in the sera from ACPApos/RFpos, 13 proteins in ACPAneg/RFpos and 12 proteins in ACPApos/RFneg, compared to ACPAneg/RFneg. Vitamin D binding protein (VTDB) was the unique protein that resulted increased in all the comparisons. For the biomarker verification phase, all the samples from the CHUS cohort were analyzed individually (n=80). Using the MRM technology, 26 peptides belonging to ten putative protein biomarkers associated with double positivity were simultaneously quantified. The statistical analysis showed a significant modulation of 9 peptides (belonging to 4 different proteins) in ACPApos/RFpos, 7 peptides (5 proteins) in ACPAneg/RFpos, and 9 peptides (6 proteins) in ACPApos/RFneg compared to ACPAneg/RFneg (p<0.05). Two acute phase reactants (ORM1 and HPT) displayed the same modulation in both screening and verification phases, thus confirming their association with the double positivity. Finally, in the biomarker validation phase, a total of 260 patients from CHUAC were included (Table 1). RA patients were classified as follows: (1) 112 patients (43.1%) were ACPApos/RFpos; (2) 73 patients (28.1%) were ACPAneg/RFneg; (3) 51 patients (19.6%) were ACPAneg/RFpos; and (4) 24 patients (9.2%) were ACPApos/RFneg. Serum levels of ORM1 and HPT (Figure 1), measured by commercial immunoassays, confirmed their increased values in double seropositive patients (p=0,0053 ORM1; p=0,0026 HPT). Finally, the increased level of ORM1 resulted associated with RF rather than ACPA status (p=0,0008 ACPAneg/RFpos); whereas HPT was associated with ACPA rather than RF status (p=0,0112 ACPApos/RFneg).

Table 1.

The different phases of RA biomarker development followed in this study.

DISCOVERYPHASEVERIFICATIONPHASEVALIDATIONPHASESource centerCHUSCHUSCHUACN° ofsamplesn= 4n= 80n= 260ACPA+RF+Pool 1ACPA+RF+20ACPA+RF+112ACPA-RF-Pool 2ACPA-RF-20ACPA-RF-73ACPA-RF+Pool 3ACPA-RF+20ACPA-RF+51ACPA+RF-Pool 4ACPA+RF-20ACPA+RF-24N° ofbiomarkersORM1, ORM2, HPT, A2GL, AACT, RBP4, PLMN, IC1, VDBP, APOBORM1, HPT, A2GL, AACTORM1, HPTFigure 1.

Conclusion:

The determination of ORM1 and HPT in sera provides novel information useful for patient stratification, which might improve diagnostic and prognostic approaches and facilitate the development of personalized medicine strategies in RA.

Acknowledgements:

This work is supported by grants from Fondo de Investigación Sanitaria (RD16/0012/0002, PT17/0019/0014) integrated in the National Plan for Scientific Program, Development and Technological Innovation 2013–2016 and funded by the ISCIII-General Subdirection of Assessment and Promotion of Research-European Regional Development Fund (FEDER) “A way of making Europe”.

Disclosure of Interests:

None declared

Robotic-assisted, laparoscopic, and open incisional hernia repair: early outcomes from the Prospective Hernia Study

PURPOSE

To provide a comparative analysis of short-term outcomes after open, laparoscopic, and robotic-assisted (RAS) ventral incisional hernia (VIH) repairs that include subject-reported pain medication usage and hernia-related quality of life (QOL).

METHODS

Subjects were ≥ 18 years old and underwent elective open, laparoscopic or RAS VIH repair without myofascial release. Perioperative clinical outcomes through 30 days were analyzed as were prescription pain medication use and subject-reported responses to the HerQLes Abdominal QOL questionnaire. Observed differences in baseline characteristics were controlled using a weighted propensity score analysis to obviate potential selection bias (inverse probability of treatment weighting, IPTW). A p value < 0.05 was considered statistically significant.

RESULTS

Three hundred and seventy-one subjects (RAS, n = 159; open, n = 130; laparoscopic, n = 82) were enrolled in the study across 17 medical institutions within the United States. Operative times were significantly different between the RAS and laparoscopic groups (126.2 vs 57.2, respectively; p < 0.001). Mean length of stay was comparable for RAS vs laparoscopic (1.4 ± 1.0 vs 1.4 ± 1.1, respectively; p = 0.623) and differed for the RAS vs open groups (1.4 ± 1.0 vs 2.0 ± 1.9, respectively; p < 0.001). Conversion rates differed between RAS and laparoscopic groups (0.6% vs 4.9%; p = 0.004). The number of subjects reporting the need to take prescription pain medication through the 2-4 weeks visit differed between RAS vs open (65.2% vs 79.8%; p < 0.001) and RAS vs laparoscopic (65.2% vs 78.75%; p < 0.001). For those taking prescription pain medication, the mean number of pills taken was comparable for RAS vs open (23.3 vs 20.4; p = 0.079) and RAS vs laparoscopic (23.3 vs 23.3; p = 0.786). Times to return to normal activities and to work, complication rates and HerQLes QOL scores were comparable for the RAS vs open and RAS vs laparoscopic groups. The reoperation rate within 30 days post-procedure was comparable for RAS vs laparoscopic (0.6% vs 0%; p = 0.296) and differed for RAS vs open (0.6% vs 3.1%; p = 0.038).

CONCLUSIONS

Short-term outcomes indicate that open, laparoscopic, and robotic-assisted approaches are effective surgical approaches to VIH repair; however, each repair technique may demonstrate advantages in terms of clinical outcomes. Observed differences in the RAS vs laparoscopic comparison are longer operative time and lower conversion rate in the RAS group. Observed differences in the RAS vs open comparison are shorter LOS and lower reoperation rate through 30 days in the RAS group. The operative time in the RAS vs open comparison is similar. The number of subjects requiring the use of prescription pain medication favored the RAS group in both comparisons; however, among subjects reporting a need for pain medication, there was no difference in the number of prescription pain medication pills taken. While the study adds to the body of evidence evaluating the open, laparoscopic, and RAS approaches, future controlled studies are needed to better understand pain and QOL outcomes related to incisional hernia repair.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02715622.

Prognostic factors at admission on patients with cancer COVID-19: Analysis of hope registry data

Background

Previous works seem to agree in the higher mortality of cancer patients with COVID-19. Identifying potential prognostic factors upon admission could help identify patients with a poor prognosis.

Methods

We aimed to explore the characteristics and evolution of COVID-19 cancer patients admitted to hospital in a multicenter international registry (HOPE COVID-19).

Our primary objective is to define those characteristics that allow us to identify cancer patients with a worse prognosis (mortality within 30 days after the diagnosis of COVID-19).

Results

5838 patients have been collected in this registry, of whom 770 had cancer among their antecedents. In hospital mortality reached 258 patients (33.51%). The median was 75 years (65–82). Regarding the distribution by sex, 34.55% of the patients (266/770) were women.

The distribution by type of cancer: genitourinary 238/745 (31.95%), digestive 124/745 (16.54%), hematologic 95/745 (12.75%).

In multivariate regression analysis, factors that are independently associated with mortality at admission are: renal impairment (OR 3.45, CI 97.5% 1.85–6.58), heart disease (2.32, 1.47–3.66), liver disease (4.69, 1.94–11.62), partial dependence (2.41, 1.34–4.33), total dependence (7.21, 2.60–21.82), fatigue (1.84, 1.16–2.93), arthromialgias (0.45, 0.26–0.78), SatO2 < 92% (4.58, 2.97–7.17), elevated LDH (2.61, 1.51–4.69) and abnormal decreased Blood Pressure (3.57, 1.81–7.15). Analitical parameters are also significant altered.

Conclusion

In patients with cancer from the HOPE registry, 30-day mortality from any cause is high and is associated with easily identifiable clinical factors upon arrival at the hospital. Identifying these patients can help initiate more intensive treatments from the start and evaluate the prognosis of these patients.

38 Developmental competence of bovine cumulus–oocyte complexes collected from cows fed rumen-protected methionine and lysine

Supplementation of rumen-protected amino acids (RPAA) has proven to be an effective tool to supply limiting AA in dairy diets. Methionine and lysine are the two most limiting AA for lactating dairy cows. Recently, it has been shown that methionine supplementation seems to affect pre-implantation embryos collected from superovulated cows enhancing their developmental competence because there is strong evidence that endogenous lipid reserves serve as an energy substrate (Acosta et al. 2016 Theriogenology 85, 1669–1679). Moreover, higher concentrations of methionine were determined in the follicular fluid of the first dominant follicle postpartum in cows supplemented with rumen-protected methionine and rumen-protected choline from 21 days before calving to 30 days postpartum and it was assumed that higher methionine concentrations in the follicular fluid could affect oocyte quality (Acosta et al. 2017 Theriogenology 96, 1–9). There is no information available so far regarding the effect of a combined methionine and lysine supplementation (each rumen-protected) on oocyte quality. Therefore, the objective of this study was to evaluate the effect of a combined methionine and lysine supplementation during early to mid-lactation on the developmental competence of oocytes collected from lactating dairy cows (days 0 to 100 p.p.). Thirty pregnant multiparous German Holstein dairy cows were grouped 3 weeks before their expected calving date, receiving identical diets. After calving, they were randomly allocated to 2 groups fed a total mixed ration supplemented with (N=14 cows; RPAA) or without (N=16 cows; CON) LysiGEMTM (encapsulated lysine; Kemin Industries) and Metasmart DryTM (isopropyl ester of the hydroxylated analogue of methionine adsorbed onto a silicon dioxide carrier; Adisseo). Starting from 45 days p.p., animals from both groups were submitted to an ovum pickup (OPU) session once a week for at least 8 weeks. Collected cumulus–oocyte complexes (COC) were subjected to a standard invitro production (IVP) protocol (Stinshoff et al. 2014 Reprod. Fertil. Dev. 26, 502–10) including IVM, IVF, and invitro culture (IVC). Cleavage and developmental rates up to the morula/blastocyst stage were recorded on Days 3, 7, and 8. In total, 1211 follicles have been aspirated from RPAA animals compared with 1413 from CON animals, from which 742 and 885 COC were collected, respectively. The calculated recovery rate based on the number of aspirated follicles and collected COC was similar for both groups (61.3±29.4% vs. 62.6±33.5%). Cleavage and developmental rates based on 240 (RPAA group) and 299 (CON group) COC also showed similar results [RPAA: 84.1±5.9% (202/240), 18.3±4.4% (44/240), 18.8±4.7% (45/240); CON: 81.9±8.6% (245/299), 15.4±8.9% (46/299), 16.7±8.4% (50/299)]. In conclusion, supplementation of RPAA (methionine and lysine) had no beneficial effect on the developmental competence of COC obtained from these animals compared with those collected from cows fed the diet without RPAA supplementation.

Ten-year experience of protocol-based management of small-for-gestational-age fetuses: perinatal outcome in late-pregnancy cases diagnosed after 32 weeks

OBJECTIVE

To report our 10-year experience of protocol-based management of small-for-gestational-age (SGA) fetuses, based on standardized clinical and Doppler criteria, in late-pregnancy cases.

METHODS

A retrospective cohort was constructed of consecutive singleton pregnancies referred for late-onset (> 32 weeks) SGA (defined as estimated fetal weight (EFW) < 10^th centile) that were classified as fetal growth restriction (FGR) or low-risk SGA, based on the severity of smallness (EFW < 3^rd centile) and the presence of Doppler abnormalities (uterine artery pulsatility index (UtA-PI) ≥ 95^th centile or cerebroplacental ratio (CPR) < 5^th centile). Low-risk SGA pregnancies were followed at 2-week intervals and delivered electively at 40 weeks. FGR pregnancies were followed at 1-week intervals, or more frequently if there were signs of fetal deterioration, and were delivered electively after 37 + 0 weeks' gestation. The occurrence of stillbirth and composite adverse outcome (CAO; defined as neonatal death, metabolic acidosis, need for endotracheal intubation or need for admission to the neonatal intensive care unit) was analyzed in low-risk SGA and FGR pregnancies.

RESULTS

A total of 1197 pregnancies with EFW < 10^th centile were identified and classified at diagnosis as low-risk SGA (n = 619; 51.7%) or FGR (n = 578; 48.3%). Of these, 160 were delivered before 37 weeks' gestation; for obstetric reasons in 93 (58.1%) cases, severe pre-eclampsia in 33 (20.6%), FGR with severe hypoxia in 47 (29.4%) and stillbirth in four (2.5%) (indications are non-exclusive). During follow-up, 52/574 (9.1%) low-risk SGA pregnancies were reclassified as FGR, whereas 22/463 (4.8%) FGR pregnancies were reclassified as low-risk SGA. Overall, there were no stillbirths in the low-risk SGA group and four in the FGR group, all of which occurred before 37 weeks. There were no instances of neonatal death in pregnancies delivered ≥ 37 weeks. The risk of CAO was higher in those meeting antenatal criteria for FGR at 37 weeks than in those classified as low-risk SGA (32/493 (6.5%) vs 15/544 (2.8%); odds ratio, 2.5 (95% CI, 1.3-4.6)). In FGR pregnancies, the adjusted odds ratio (95% CI) for CAO was 6.3 (1.8-21.1) in those with EFW < 3^rd centile, while it was 3.2 (1.5-6.8) and 4.2 (1.9-8.9) in those with UtA-PI ≥ 95^th centile and CPR < 5^th centile, respectively, as compared to FGR pregnancies without each of these criteria.

CONCLUSION

Protocol-based risk stratification with different management and monitoring schemes for late pregnancy with a suspected SGA baby, based on clinical and Doppler criteria, enables identification and tailored assessment of high-risk FGR, while allowing expectant management with safe perinatal outcome for low-risk SGA fetuses. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Clinical features and outcomes of adult patients with single ventricle physiology not undergoing Fontan repair

Background

Adult patients with single ventricle (SV) physiology who had not undergone Fontan palliation are uncommon. Little is known about their clinical features and outcomes.

Objective

This study aims to describe the clinical features, cardiovascular outcomes and long-term survival of patients with SV physiology without Fontan palliation.

Methods

Data were collected retrospectively from SV physiology patients followed in adult congenital heart disease (ACHD) units of five tertiary referral centers. None of them had Fontan palliation. Baseline data were recorded on the first visit at ACHD unit. Death was considered as main endpoint. Other outcomes such as atrial or ventricular arrhythmias, endocarditis, ICD or pacemaker implantation, admission for heart failure and heart transplant were also collected and analyzed. Association between clinical/analytical baseline variables and death was also evaluated by univariate Cox regression.

Results

128 patients were included. On the first visit, mean age was 32.3±10.9 years, being the most common defect double inlet left ventricle (63p, 49.2%). The single ventricle had left morphology in 106 cases (82.8%). At baseline mean heaemglobin was 19.1±2.8 g/dl, mean O2 Sat 83±6.9% and 46 patients (36%) had a NYHA status III or IV. 4 different groups were found: a) Unrestricted pulmonary flow with Eisenmenger physiology (24p, 18.8%); b) Restricted forward pulmonary flow with or without pulmonary banding (46p, 35.9%); c) Aortopulmonary shunts as a source of pulmonary flow (20p, 15.5%) and d) cavopulmonary shunt (Glenn) as a definitive palliation (38p, 29.7%). After 7.3±4.1 years follow-up, mortality was 22.7% (29 patients), being sudden death (9p, 7%) the most frequent cause. Survival rate at 5 and 10 years of follow-up were 85% and 76% respectively (Figure 1). About of the rest of the outcomes, highlighting a high rate of atrial tachycardia (38.3%), admission for heart failure (23.4%), stroke (17.2%), endocarditis (9.4%), pacemaker/ICD implantation (11.8%). Baseline variables associated with higher mortality were: older age (HR=1.1 [1.004–1–087]); NYHA III or IV (HR=5.5 [2.4–12.4]); thrombocytopenia (HR=1.01 [1.001–1.003]); anticoagulant treatment (HR=2.6 [1.7–3.9]); glomerular filtration rate below 60 ml/min (HR=3.77 [1.5–9.6]); QRS width (HR=1.03 [1.01–1.05]); atrial arrhythmias (HR=3.1 [1.5–6.5]); moderate or severe AV valve regurgitation (HR=1.5 [1.15–1.97]) and ventricular ejection fraction (HR=0.94 [0.91-0.97]).

Conclusions

Adults survivors with SV physiology without Fontan palliation have a high mortality and frequently suffer from serious cardiovascular events. Several clinical (NYHA status, previous atrial arrhythmias, anticoagulant treatment), analytical (renal function, thrombocytopenia), ECG (QRS width) and echocardiography (AV valve regurgitation and EF) factors can identify patients at higher risk of death.

Figure 1. Survival curve

Funding Acknowledgement

Type of funding source: None

Asymptomatic aortic regurgitation: diastolic function and type-B natriuretic peptide as prognostic factors

Introduction

The indication of valve replacement surgery in patients with severe aortic regurgitation (AR) is mainly based on the presence of symptoms or dilatation/dysfunction of the left ventricle (LV). However, diastolic function and natriuretic peptides have not been related to adverse outcomes in these patients. The aim of this study was to evaluate the prognosis impact of different diastolic function parameters as well as type-B natriuretic peptide (BNP).

Methods

Patients with moderate to severe or severe AR evaluated in the Heart Valve Clinic between 2013–2019 were evaluated. Those patients with classical indications for surgical aortic valve replacement (SAVR) at the moment of inclusion were excluded, as well as those patients with atrial fibrillation. Echocardiographic and analytical data were obtained from the medical history. End-point included cardiovascular mortality, SAVR and heart failure.

Results

A total of 126 patients were included. Median age was 65.0±17.7 years. Among them, 75 (59.5%) were men, 78 (62.4%) hypertensive, 44 (35.3%) suffered from dyslipidemia and 11 (9,6%) had ischaemic cardiomyopathy. During a median follow up of 31±17 months, 24.6% of the patients reached the combined end-point (n=5 developed heart failure, n=28 underwent SAVR, and n=4 died).

Among the diastolic parameters [E wave, A wave, E/A, E/e', left atrial volume and diameter, tricuspid regurgitation (TR) degree and pulmonary systolic pressure (PSP)], only TR degree and PSP were associated with a higher incidence of the combined endpoint: TR degree HR=2,08, p=0,039 and PSP HR= 1,1, p=0,007. BNP also showed prognostic impact for the combined endpoint (HR= 1,002, p=0,011).

Conclusions

In patients with asymptomatic significant AR, severity of TR, PSP and BNP levels are associated with worst prognosis. However, classical echocardiographic diastolic parameters do not show prognosis impact, probably due to the limitations of such parameters to identify diastolic dysfunction and high filling pressures in this population. Our findings support the use of PSP and TR over diastolic function parameters to better stratify left valvular patient risk in clinical practice.

Funding Acknowledgement

Type of funding source: None

MRI detected extaprostatic extension (EPE) in prostate cancer: Do all T3a patients have the same outcomes?

MRI-detected T3a prostate cancer is a heterogeneous disease. This post-hoc analysis of a prospective trial found that patients with T3a disease presenting obliteration of the recto-prostatic angle, contact-asymmetry of neuro-vascular bundle and periprostatic fat invasion, may be at higher risk of biochemical failure and metastases.

The ELFIN Mission

The Electron Loss and Fields Investigation with a Spatio-Temporal Ambiguity-Resolving option (ELFIN-STAR, or heretoforth simply: ELFIN) mission comprises two identical 3-Unit (3U) CubeSats on a polar (∼93^∘ inclination), nearly circular, low-Earth (∼450 km altitude) orbit. Launched on September 15, 2018, ELFIN is expected to have a >2.5 year lifetime. Its primary science objective is to resolve the mechanism of storm-time relativistic electron precipitation, for which electromagnetic ion cyclotron (EMIC) waves are a prime candidate. From its ionospheric vantage point, ELFIN uses its unique pitch-angle-resolving capability to determine whether measured relativistic electron pitch-angle and energy spectra within the loss cone bear the characteristic signatures of scattering by EMIC waves or whether such scattering may be due to other processes. Pairing identical ELFIN satellites with slowly-variable along-track separation allows disambiguation of spatial and temporal evolution of the precipitation over minutes-to-tens-of-minutes timescales, faster than the orbit period of a single low-altitude satellite (T_orbit ∼ 90 min). Each satellite carries an energetic particle detector for electrons (EPDE) that measures 50 keV to 5 MeV electrons with Δ E/E < 40% and a fluxgate magnetometer (FGM) on a ∼72 cm boom that measures magnetic field waves (e.g., EMIC waves) in the range from DC to 5 Hz Nyquist (nominally) with <0.3 nT/sqrt(Hz) noise at 1 Hz. The spinning satellites (T_spin ∼ 3 s) are equipped with magnetorquers (air coils) that permit spin-up or -down and reorientation maneuvers. Using those, the spin axis is placed normal to the orbit plane (nominally), allowing full pitch-angle resolution twice per spin. An energetic particle detector for ions (EPDI) measures 250 keV - 5 MeV ions, addressing secondary science. Funded initially by CalSpace and the University Nanosat Program, ELFIN was selected for flight with joint support from NSF and NASA between 2014 and 2018 and launched by the ELaNa XVIII program on a Delta II rocket (with IceSatII as the primary). Mission operations are currently funded by NASA. Working under experienced UCLA mentors, with advice from The Aerospace Corporation and NASA personnel, more than 250 undergraduates have matured the ELFIN implementation strategy; developed the instruments, satellite, and ground systems and operate the two satellites. ELFIN's already high potential for cutting-edge science return is compounded by concurrent equatorial Heliophysics missions (THEMIS, Arase, Van Allen Probes, MMS) and ground stations. ELFIN's integrated data analysis approach, rapid dissemination strategies via the SPace Environment Data Analysis System (SPEDAS), and data coordination with the Heliophysics/Geospace System Observatory (H/GSO) optimize science yield, enabling the widest community benefits. Several storm-time events have already been captured and are presented herein to demonstrate ELFIN's data analysis methods and potential. These form the basis of on-going studies to resolve the primary mission science objective. Broad energy precipitation events, precipitation bands, and microbursts, clearly seen both at dawn and dusk, extend from tens of keV to >1 MeV. This broad energy range of precipitation indicates that multiple waves are providing scattering concurrently. Many observed events show significant backscattered fluxes, which in the past were hard to resolve by equatorial spacecraft or non-pitch-angle-resolving ionospheric missions. These observations suggest that the ionosphere plays a significant role in modifying magnetospheric electron fluxes and wave-particle interactions. Routine data captures starting in February 2020 and lasting for at least another year, approximately the remainder of the mission lifetime, are expected to provide a very rich dataset to address questions even beyond the primary mission science objective.

Added prognostic value of longitudinal changes of angiogenic factors in early-onset severe pre-eclampsia: a prospective cohort study

OBJECTIVE

To assess in women with early-onset severe pre-eclampsia whether longitudinal changes in angiogenic factors improve the prediction of adverse outcome.

DESIGN

Prospective cohort study.

SETTING

Maternity units in two Spanish hospitals.

POPULATION

Women with diagnosis of early-onset severe pre-eclampsia.

METHODS

Levels of placental growth factor (PlGF), soluble fms-like tyrosine kinase (sFlt-) and sFlt-1/PlGF ratio were measured at admission and before delivery, and average daily change calculated. The association of longitudinal changes of angiogenic factors with the time interval to delivery and with complications was evaluated by logistic and Cox regression.

MAIN OUTCOME MEASURES

Interval to delivery and composite of adverse outcomes.

RESULTS

We included 63 women, of which 26 (41.3%) had a complication. Longitudinal changes of sFlt-1 were more pronounced in complicated pregnancies (median: 1047 versus 342 pg/ml/day; P = 0.04). On the multivariate analysis, the clinical risk score and sFlt-1 at admission explained 6.2% of the uncertainty for complication; the addition of sFlt-1 longitudinal changes improved this to 25.3% (P = 0.002). The median time from admission to delivery was 4 days (95% CI 1.6-6.04) in those in the highest quartile of sFlt-1 longitudinal changes versus 16 days (95% CI 12.4-19.6) in the remaining women (Log-rank test P < 0.001).

CONCLUSIONS

Longitudinal changes in sFlt-1 maternal levels from admission for confirmed early-onset severe pre-eclampsia add to baseline characteristics in the prediction of adverse outcome and interval to delivery.

TWEETABLE ABSTRACT

In early-onset severe pre-eclampsia, longitudinal changes in sFlt-1 levels improve the prediction of complications and interval to delivery.

Explore, edit and leverage genomic annotations using Python GTF toolkit

MOTIVATION

While Python has become very popular in bioinformatics, a limited number of libraries exist for fast manipulation of gene coordinates in Ensembl GTF format.

RESULTS

We have developed the GTF toolkit Python package (pygtftk), which aims at providing easy and powerful manipulation of gene coordinates in GTF format. For optimal performances, the core engine of pygtftk is a C dynamic library (libgtftk) while the Python API provides usability and readability for developing scripts. Based on this Python package, we have developed the gtftk command line interface that contains 57 sub-commands (v0.9.10) to ease handling of GTF files. These commands may be used to (i) perform basic tasks (e.g. selections, insertions, updates or deletions of features/keys), (ii) select genes/transcripts based on various criteria (e.g. size, exon number, transcription start site location, intron length, GO terms) or (iii) carry out more advanced operations such as coverage analyses of genomic features using bigWig files to create faceted read-coverage diagrams. In conclusion, the pygtftk package greatly simplifies the annotation of GTF files with external information while providing advance tools to perform gene analyses.

AVAILABILITY AND IMPLEMENTATION

pygtftk and gtftk have been tested on Linux and MacOSX and are available from https://github.com/dputhier/pygtftk under the MIT license. The libgtftk dynamic library written in C is available from https://github.com/dputhier/libgtftk.

AB0206 CIRCULATING CENTROMERE PROTEIN F AUTOANTIBODIES FOR PREDICTING CLINICAL RESPONSE TO INFLIXIMAB IN RHEUMATOID ARTHRITIS

Background:

One third of patients with rheumatoid arthritis (RA) respond poorly to TNF inhibitors and related studies are inconsistent in predictive biomarkers. The identification of biomarkers that predict the treatment response prior to drug exposure is a current priority on the RA field. ACPA and RF are ubiquitously tested in RA patients, but other autoantibodies exist and may provide additional information on RA treatment response.

Objectives:

This study aimed to identify circulating autoantibodies for predicting response to infliximab (IFX) in RA.

Methods:

We profiled the autoantibody repertoire of baseline sera from 155 biologic naïve RA patients treated with IFX. The sera were provided by three independent clinical sources and distributed in one exploratory cohort (N=20) collected from Hospital Clínico Universitario of Santiago de Compostela (Spain), one replication cohort (N=61) collected from Hospital Universitario de A Coruña (Spain) and samples from the Swedish Farmacotherapy (SWEFOT) trial (Sweden) (N=74) for clinical validation. The presence of autoantibodies and their levels in serum were analysed in association with EULAR clinical response at 6 months follow-up: good response (GR, N=56), moderate (MR, N=55) and non-response (NR, N=44). A suspension bead array platform built on protein fragments within Human Protein Atlas and selected from an initial untargeted screening using an array containing 42000 antigens was employed to identify the IgG and IgA autoantibodies on the exploratory cohort. A replication and validation phases were carried out on the other two serum sample cohorts. Meta-analysis and Receiver Operating Curves were performed in order to assess the clinical relevance of the findings observed.

Results:

Meta-analysis revealed that the levels in serum of IgG autoantibodies against Centromere protein F (CENPF) are significantly increased in responders (good responders and moderate responders; N=111) to IFX compared to non-responders (N=44) (P=0.018). CENP-F is a proliferation-associated and cell cycle-dependent centromere autoantigen that might be involved in the increased or abnormal cell proliferation that occurs during RA process. The combination of the anti-CENPF antibodies with clinical variables (age, sex, DAS28-ESR) resulted in the best model to discriminate the patients that will respond to IFX, showing an AUC of 0.756 (95% CI [0.639-0.874], P=0.001).

Conclusion:

High serum levels of IgG anti-CENPF antibodies might be potentially useful to identify RA patients more likely to benefit from IFX

Disclosure of Interests:

Lucía Lourido: None declared, Cristina Ruiz-Romero: None declared, flor picchi: None declared, Naomi Diz-Rosales: None declared, Sergio Vilaboa-Galán: None declared, Carlos Fernández-López: None declared, Jose Antonio Pinto Tasende: None declared, Eva Perez-Pampin: None declared, Cristina Regueiro Expósito: None declared, ANTONIO MERA VARELA: None declared, Antonio Gonzalez: None declared, Karen Hambardzumyan: None declared, Saedis Saevarsdottir Employee of: Part-time at deCODE Genetics/Amgen Inc, working on genetic research unrelated to this project, Peter Nilsson: None declared, Francisco J. Blanco Grant/research support from: Sanofi-Aventis, Lilly, Bristol MS, Amgen, Pfizer, Abbvie, TRB Chemedica International, Glaxo SmithKline, Archigen Biotech Limited, Novartis, Nichi-iko pharmaceutical Co, Genentech, Jannsen Research & Development, UCB Biopharma, Centrexion Theurapeutics, Celgene, Roche, Regeneron Pharmaceuticals Inc, Biohope, Corbus Pharmaceutical, Tedec Meiji Pharma, Kiniksa Pharmaceuticals, Ltd, Gilead Sciences Inc, Consultant of: Lilly, Bristol MS, Pfizer

THU0001 GENOME-WIDE ASSOCIATION STUDY ON JOINT EROSIONS IN RHEUMATOID ARTHRITIS SUPPORTS DIFFERENTIAL PATHOLOGICAL MECHANISMS ACCORDING TO ANTI-CCP STATUS

Background:

Joint damage is the pathological hallmark of rheumatoid arthritis (RA). To identify the genetic variation associated with a higher level of erosions has proven elusive.

Objectives:

The objective of the present study was to perform a genome-wide association study on joint damage in a cohort of RA patients of the Spanish population. Our aims were to provide independent validation of previously reported variants and to identify new candidate risk loci. A stratified analysis was performed based on positivity to ACPA status.

Methods:

A total of 1,135 patients diagnosed with RA using the ACR-EULAR criteria recruited by the IMID Consortium were genotyped using a 550,000 single-nucleotide polymorphism array. Additional SNPs were imputed using the 1KG genome data. Joint damage was performed using the S-score, a simplified radiographic erosion score that has a high correlation with the Sharp-van der Hejde score (1). Association testing of SNPs with joint damage was performed via linear regression with the addition of the years of evolution as covariate. The two main components of genetic variation were also added to adjust for potential population stratification. A total of 50 SNPs representing previously reported loci associated with joint damage were selected. Genetic association was also performed at the pathway level using Pascal.

Results:

45 out of 50 SNPs representing 31 previously reported loci for joint damage could be satisfactorily imputed. Association testing of the whole patient cohort replicated the association withIL2RAandTRAF1. Of relevance, after stratifying for anti-CCP five new loci were replicated:KIF5AandSOSTin ACPA-positive RA andCD40, DKK1andTNFin ACPA-negative RA.IL2RAwas only significant in the ACPA-positive group andTRAF1was not significant in either strata. GWAS on the ACPA-positive cohort and on the ACPA-negative group identified n=7 and n=18 loci with P-values < 1x10-5, respectively. From these, however, only 1 SNP showed nominal significant association in the other patient group. Based on this evidence, we performed a pathway-based analysis to understand the biological mechanisms underlying this difference. Pathway analysis showed 52 biological processes associated with joint damage in ACPA-negative RA and 32 pathways in the ACPA-positive group, with only two shared biological processes between the two groups. Fc Gamma receptor mediated phagocytosis was the topmost biological process associated with erosions specifically in ACPA-negative RA and Signalling by Fibroblast Growth Factor mutants was the top process specific for ACPA-positive patients.

Conclusion:

The results from our study provide suggestive evidence that the genetic basis for joint damage is different according to the presence of ACPA. Replication of the new candidate loci in an independent patient cohort is underway.

References:

[1]Lopez-Lasanta, M., Julià, A., Maymó, J., Fernández-Gutierrez, B., Ureña-Garnica, I., Blanco, F. J., ... & Tornero, J. (2015). Variation at interleukin-6 receptor gene is associated to joint damage in rheumatoid arthritis.Arthritis research & therapy,17(1), 242.

Disclosure of Interests:

Antonio Julià: None declared, Francisco Blanco: None declared, Benjamin Fernandez: None declared, Antonio Gonzalez: None declared, Juan D: None declared, Joan Maymó: None declared, Mercedes Alperi-López: None declared, Alejandro Olive: None declared, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche, Victor Martinez Taboada: None declared, Isidoro González-Álvaro Grant/research support from: Roche Laboratories, Consultant of: Lilly, Sanofi, Paid instructor for: Lilly, Speakers bureau: Abbvie, MSD, Roche, Lilly, Antonio Fernandez-Nebro: None declared, Alba Erra: None declared, Simon Sánchez Fernandez: None declared, Núria Palau: None declared, Maria Lopez Lasanta: None declared, Adrià Aterido: None declared, Jesús Tornero: None declared, Sara Marsal: None declared

THU0098 ANTIBODIES AGAINST THREE POST-TRANSLATIONAL PROTEIN MODIFICATIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Autoantibodies to some post-translational modifications (PTMs) of proteins have a relevant role in rheumatoid arthritis (RA). Antibodies to other PMTs such as carbonylation (aCarbo) [1], nitration (aNitra) [2] and homocysteinylation (aHCis) [3] have also been described but they have been scarcely studied.

Objectives:

We aimed to evaluate the presence of antibodies against three poorly studied PTMs in patients with RA and explore their value as biomarkers.

Methods:

Serum samples from 196 healthy controls and RA patients meeting the 1987 ACR classification criteria that had either early RA (< 2 years from symptom onset) (n=182) or established RA (n=143) were analyzed. The antibodies were evaluated by indirect ELISA following the described protocols [1-3]. They include as antigens: HOCl- or ribose- carbonylated bovine type II collagen (HOCl-CII and GLI-CII, respectively) for aCarbo antibodies; homocysteinylated human serum albumin (Hcy-HSA) for aHCis antibodies; andin vitronitrated synovial proteins and synthetic nitrated peptides (3-NT-PS and 3-NT-pep, respectively) for aNitra antibodies. The efficiency of the reactions to produce these PTMs was verified. The study was approved by the CEIC of Galicia. The results were analyzed as differences between the optical densities (OD) obtained without correction, or the specific OD after subtracting reactivity to the native protein.

Results:

The aCarbo antibodies were studied in patients with early RA, as reported [1]. Despite this, uncorrected ODs against the two carbonylated forms of CII were not greater in the patients than in the controls (Table 1). Consequently, the corrected reactivity to GLI-CII that was significantly higher in patients than controls did not reflect aCarbo antibodies but differences in reactivity to native bovine CII.

The other antibodies were analyzed in patients with established RA as previously done [2,3]. However, none of them showed specific reactivity (Table 1). In effect, although an excess of uncorrected reactivity to 3-NT-pep was observed in the patients with RA, it disappeared when corrected (Table 1). Also, the vast majority of patients and controls showed no reactivity to 3-NT-SP (not shown). In turn, the aHCis antibodies were significantly elevated in patients, but only in the uncorrected analysis because the difference disappeared when corrected for reactivity against native HSA (Table 1).

Table 1.

Antibodies against three post-translational protein modifications in RA patients and controls

RAControlsAntigenCorrectionMedian DOIQRMedian DOIQRPHOCl-CIIno0.1410.127/0.1730.1600.141/0.1880.0001HOCl-CIIyes-0.003-0.011/0.008-0.004-0.020/0.0050.02GLI-CIIno0.2340.171/0.2850.2220.163/0.3050.5GLI-CIIyes0.0720.016/0.1150.028-0.010/0.1000.00053-NT-pepno0.2500.201/0.3290.2090.190/0.2300.023-NT-pepyes0.1370.097/0.1850.1130.100/0.1330.1Hcy-HSAno0.1600.145/0.1780.1450.130/0.1550.00011Hcy-HSAyes-0.041-0.074/-0.015-0.038-0.069/-0.200.5

Conclusion:

The presence in RA patients of specific antibodies against the three PTMs has not been replicated. None of the observed reactivities were attributable to the PTMs. If confirmed, these results would indicate that only particular PTMs are relevant for RA and that carbonylation, nitration or homocysteinylation are not among them.

References:

[1]Strollo R, et al. Arthritis Rheum. 2013; 65:1702

[2]Khan F, et al. Clin Chim Acta. 2006; 370:100

[3]Nowakowska-Plaza A, et al. Scand J Rheumatol. 2014; 43:17

Acknowledgments:

Funded by the Instituto de Salud Carlos III projects PI17/01606 and RD16/0012/0014, which are partially co-funded by FEDER

Disclosure of Interests:

None declared

PARE0009 COMMUNITY ADVISORY BOARD INPUT CAN MAKE LAY SUMMARIES OF CLINICAL TRIAL RESULTS MORE UNDERSTANDABLE

Background:

Under European Union (EU) Clinical Trial regulations,1clinical research sponsors (CRSs) must ensure all studies performed in the EU are accompanied by a trial summary for laypersons, published within 1 year of study completion. These lay summaries should disseminate clinical trial results in an easy-to-understand way for trial participants, patient and caregiver communities, and the general public. The European Patients Forum (EPF)2and European Patients’ Academy on Therapeutic Innovation (EUPATI)3encourage CRSs to engage with patient organisations (POs) in the development of lay summaries. This recognises the patients’ contribution to clinical research and supports the development of patient-focused material.

Objectives:

We share learnings from a collaboration between scleroderma POs and a CRS to create the SENSCIS® trial (NCT02597933) written and video lay summaries.

Methods:

A community advisory board (CAB), comprising representatives from 11 scleroderma POs covering a range of countries/regions, was formed based on the EURORDIS charter for collaboration in clinical research.4Through three structured meetings, over a seven-month period, the CAB provided advice on lay summary materials (written and video) drafted by the CRS’ Lay Summary Group (Fig. 1). At each review cycle, the CAB advice was addressed to make content more understandable and more relevant for patients and the general public.

Results:

The CAB advised that the existence of lay summaries is not well known in the patient community and also recommended the development of trial-specific lay summary videos to further improve understandability of the clinical trial results for the general public. Videos are a key channel of communication, enabling access to information for people with specific health needs and lower literacy levels. Following CAB advice, the CRS developed a stand-alone video entitled“What are lay summaries?”and a trial-specific lay summary video. Revisions to lay summary content (written and video) included colour schemes, iconography and language changes to make content more understandable. For videos, adjustments to animation speed, script and voiceover were implemented to improve clarity and flow of information (Fig. 2). Approved final versions of lay summary materials are publicly available on the CRS website. Translation into languages representing trial-site countries is in progress to widen access to non-English speakers and, where possible, local versions are being reviewed by the patient community.

Conclusion:

Structured collection and implementation of CAB advice can make lay summary materials more understandable for the patient community and wider general public.

References:

[1]EU. Summaries of clinical trial results for laypersons. 2018

[2]EPF. EPF position: clinical trial results – communication of the lay summary. 2015

[3]EUPATI. Guidance for patient involvement in ethical review of clinical trials. 2018

[4]EURORDIS. Charter for Collaboration in Clinical Research in Rare Diseases. 2009

Disclosure of Interests:

Joep Welling Speakers bureau: Four times as a patient advocate for employees of BII and BI MIDI with a fixed amount of € 150,00 per occasion., Annelise Roennow: None declared, Maureen Sauvé Grant/research support from: Educational grants from Boehringer Ingelheim and Janssen., EDITH BROWN: None declared, Ilaria Galetti: None declared, Alex Gonzalez Consultant of: Payment made to the patient organisation (Scleroderma Research Foundation) for participation in advisory boards, Alexandra Paula Portales Guiraud: None declared, Ann Kennedy Grant/research support from: AS FESCA aisbl, Catarina Leite: None declared, Robert J. Riggs: None declared, Alison Zheng Grant/research support from: We get grants from Lorem Vascular; BI China,; Jianke Pharmaceutical Co., Ltd.; Kangjing Biological Co., Ltd.; COFCO Coca-Cola to organize national scleroderma meetings, offer patients service, holding academic meetings and other public activities, there is also a small part of the grants used to pay the workers in our organization., Consultant of: I worked as a paid consultant for BI. Pay-per-job., Speakers bureau: I was invited once to be a speaker at BI China’s internal meeting and they paid me., Matea Perkovic Popovic: None declared, Annie Gilbert Consultant of: I have worked as a paid consultant with BI International for over 3 years, since Sept 2016., Lizette Moros Employee of: Lizette Moros is an employee of Boehringer Ingelheim, Kamila Sroka-Saidi Employee of: Paid employee of Boehringer Ingelheim., Thomas Schindler Employee of: Employee of Boehringer Ingelheim Pharma, Henrik Finnern Employee of: Paid employee of Boehringer Ingelheim.

SAT0015 ROCK INHIBITION REDUCES THE SEVERITY OF K/BXN SERUM-TRANSFER INDUCED ARTHRITIS

Background:

Fibroblast-like synoviocytes (FLS) are pivotal in inflammation and joint damage of rheumatoid arthritis (RA). These cells acquire an aggressive and invasive phenotype and secrete inflammatory mediators, metalloproteases and cathepsins that perpetuate inflammation and lead to cartilage and bone damage. We have previously shown that non-canonical Wnt5a pathway is involved in the aggressive phenotype of FLS by increasing their migration and invasion ability, and by stimulating the inflammatory response. The non-canonical Wnt signaling pathway included the planar cell polarity (PCP), with the activation of Rho and Rac GTPases, and the Wnt/Ca2+ pathways. We have also shown that Wnt5a contributes to the aggressive phenotype of RA FLS by binding to RYK receptor, through Rho-ROCK pathway and the activation of MAPKs, ERK and P38, as well as the activation of AKT and GSK3β.

Objectives:

To elucidate the therapeutic potential of the ROCK inhibitor (Y-27632) in the K/BxN serum transfer arthritis model.

Methods:

Two groups of C57BL/6J mice were used, in the control group, mice were treated with physiological serum and in the experimental group with a ROCK inhibitor (Y-27632). Arthritis was induced by intraperitoneal injection of 100 µl of K/BxN serum on days 0 and 2. In the experimental group, mice were treated with intraperitoneal injections of 10 mg/kg from day 0 until sacrifice, on day 10. Control mice were treated with the same volume of physiological serum. Arthritis was assessed by two observers using a semiquantitative clinical score. For histological analysis, it was decided to obtain the right ankle joints and foot. Joints were fixed in formalin for 6h and were decalcified and embedded in paraffin. Sections were stained with hematoxylin and eosin (H&E) and toluidine. Finally, total RNA was obtained from wrist and ankle joints of mice and the expression of inflammatory mediators and metalloproteases was analyzed by real-time PCR.

Results:

Arthritis was induced in C57BL/6J mice, which were treated with Y-27632 (ROCK inhibitor) or with physiological serum. The incidence of arthritis was 100% in both groups of mice and there were no differences in the course of the disease. Clinical score was significantly lower in the Y-27632-treated mice, all along the follow-up, compared with controls. Similar results were observed in the histological analysis. We also analyzed the effect of ROCK inhibitor on the inflammatory response of K/BxN serum-transfer induced arthritis. This analysis revealed that expression of IL6, IL1β, CXCL1, MMP3, MMP9 and MMP13 were significantly decreased in Y-27632-treated mice compared with control mice. In addition, TNF and NOS2 expression was reduced in Y-27632-treated mice to reach the same levels that observed in C57BL/6J mice without arthritis.

Conclusion:

These results indicate that the inhibition of the Rho-ROCK pathway decreases the severity of arthritis in the K/BxN serum transfer model, and point to ROCK as potential therapeutic target for RA. Supported: ISCIII / PI17 / 01660 / RETICS Program, RD16 / 0012/0014 / Cofinanced FEDER.

Disclosure of Interests:

None declared

SAT0037 HIGH AGREEMENT BETWEEN ANTIBODIES AGAINST MALONDIALDEHYDE PROTEIN ADDUCTS AND ANTIBODIES AGAINST MALONDIALDEHYDE-ACETALDEHYDE ADDUCTS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) presents high levels of oxidative stress and reactive species such as malondialdehyde, which modifies proteins forming malondialdehyde adducts (MaP) and, in the presence of acetaldehyde generates adducts called malondialdehyde-acetaldehyde (MaaP). Recently, the presence of malondialdehyde modified proteins in the synovium and antibodies against these adducts (AMaPA) in the serum of patients with RA has been described (1). Previously, a high frequency of antibodies against MaaP (AMaaPA) had been reported in patients with RA (2).

Objectives:

We aimed to confirm the presence of AMaPA in patients with RA and define its relationship with AMaaPA.

Methods:

The sera of 204 healthy controls and 205 patients with established RA that met the 1987 ACR classification criteria and selected to represent the different AMaaPA status were studied. All had information on their status for FR, anti-CCP and AMaaPA antibodies (IgG, IgM and IgA). The AMaPA were determined by indirect ELISA using malondialdehyde-modified serum bovine albumin as antigen and specific secondary antibodies against the IgG and IgM isotypes following the same protocol of the previous study (1). The results were analyzed with the gamma coefficient (γ) for concordance in status and with the Spearman coefficient (ρ) for correlation of titres. The study was approved by the CEIC of Galicia.

Results:

The AMaPA showed higher titres in the patients with RA than in the controls, the positive frequencies being: 17.1% for IgG AMaPA and 25.4% for IgM AMaPA. An important fraction of the patients with RA showed the same status with the two AMaPA isotypes, as reflected in the significant concordance between them (γ = 0.74, Table 1). When comparing the AMaPA and AMaaPA status in patients with RA, a remarkable concordance was observed among the antibodies of the same isotype, especially between the IgM AMaPA and IgM AMaaPA: γ = 0.83 (Table 1). There were fewer patients with the same status when different antibody isotypes were compared, although some of these comparisons reached statistically significant concordance. However, the titres were not significantly correlated in any of the comparisons, even in those that showed the greatest agreement in status (Table 1).

Table 1.

Relationship of antibodies against malondialdehyde adducts (AMaPA) with other autoantibodies in patients with RA.

AMaPA2nd antibodyϒPρPIgGIgM AMaPA0.741.5E-140.230.3IgMIgM AMaaPA0.833.4E-250.260.1IgGIgG AMaaPA0.652.4E-080.110.7IgMIgA AMaaPA0.420.00170.260.4IgGIgM AMaaPA0.390.000960.080.8IgGIgA AMaaPA0.210.2-0.090.9IgMIgG AMaaPA0.160.30.130.7IgMRF0.480.000011nanaIgMAnti-CCP0.390.00076-0.340.031IgGAnti-CCP0.050.7-0.180.4IgGRF0.020.9nana

In relation to the typical RA autoantibodies, significant concordances were observed between the IgM AMaPA and RF or anti-CCP, although they were lower than those observed with the AMaaPA. In contrast, the IgG AMaPA showed no significant agreement with RF or anti-CCP antibodies. These low levels of concordance were reflected in the lack of significant difference in the prevalence of AMaPA between seronegative and seropositive patients (24.1% vs. 35.4%,P= 0.1).

Conclusion:

The presence of AMaPA in patients with RA has been confirmed, and a high concordance between the AMaPA and AMaaPA status has been observed, especially between those with an IgM isotype. However, the lack of correlation in the titres indicates that these two types of autoantibodies are independent. The potential utility as biomarkers of the AMaPA should be similar to that of the AMaaPA.

References:

[1] Grönwall C, et al. J Autoimmun. 2017, 84:29-45

[2] Thiele GM, et al. Arthritis Rheumatol. 2015, 67:645-55

Acknowledgments:

Funded by the Carlos III Health Institute projects PI17/01606 and RD16/ 0012/0014 that are partially co-funded by FEDER

Disclosure of Interests:

None declared

0551 Longitudinal Measurement Invariance of the Insomnia Severity Index in Veterans with Sleep Apnea

Introduction

The Insomnia Severity Index is a commonly used instrument to assess the presence of insomnia symptoms as well as an outcome measure following an intervention. Longitudinal measurement invariance is a necessary property of an assessment instrument when it is repeated over time. The validity of conclusions regarding change in the construct ‘insomnia severity’ depend on scale equivalence at each measurement timepoint. Assessment of measurement invariance of the ISI in sleep apnea patients has never been performed.

Methods

Veterans with sleep apnea (n=654; AHI=36±28; 93% male; age=52±12; BMI=33±6) completed the ISI on the night of their overnight PSG and again when they picked up their PAP device. Invariance was determined by imposing a series of more restrictive equivalence constraints on a 2-factor model of the ISI. The series of constraints tested for configural, weak, strong and strict invariance. Invariance testing was modeled with exploratory structural equation modeling in Mplus (v. 7.0).

Results

The 2-factor model that emerged from the analysis showed items relating to nighttime symptoms loading on factor 1 and daytime symptoms loading on factor 2. The sleep ‘satisfaction’ item, however, had weak but similar loadings on both factors. The increasingly restrictive constraints imposed on the model revealed no decrement in model fit (RMSEA=.039 to.043; CFI=.987 to .980; TLI=.981-.977; SRMR=.027-.041).

Conclusion

The ISI met strict criteria for longitudinal measurement invariance demonstrating that it is a valid instrument to be used in repeated measures study designs of insomnia in sleep apnea patients. Change over time on the ISI is not due to the changing measurement characteristics of the ISI but to true changes in the ‘insomnia severity’ construct.

Support

None

Impact of mismatches in HbA1c vs glucose values on the diagnostic classification of diabetes and prediabetes

AIMS

To determine whether HbA_1c mismatches (HbA_1c levels that are higher or lower than expected for the average glucose levels in different individuals) could lead to errors if diagnostic classification is based only on HbA_1c levels.

METHODS

In a cross-sectional study, 3106 participants without known diabetes underwent a 75-g oral glucose tolerance test (fasting glucose and 2-h glucose) and a 50-g glucose challenge test (1-h glucose) on separate days. They were classified by oral glucose tolerance test results as having: normal glucose metabolism; prediabetes; or diabetes. Predicted HbA_1c was determined from the linear regression modelling the relationship between observed HbA_1c and average glucose (mean of fasting glucose and 2-h glucose from the oral glucose tolerance test, and 1-h glucose from the glucose challenge test) within oral glucose tolerance test groups. The haemoglobin glycation index was calculated as [observed - predicted HbA_1c ], and divided into low, intermediate and high haemoglobin glycation index mismatch tertiles.

RESULTS

Those participants with higher mismatches were more likely to be black, to be men, to be older, and to have higher BMI (all P<0.001). Using oral glucose tolerance test criteria, the distribution of normal glucose metabolism, prediabetes and diabetes was similar across mismatch tertiles; however, using HbA_1c criteria, the participants with low mismatches were classified as 97% normal glucose metabolism, 3% prediabetes and 0% diabetes, i.e. mostly normal, while those with high mismatches were classified as 13% normal glucose metabolism, 77% prediabetes and 10% diabetes, i.e. mostly abnormal (P<0.001).

CONCLUSIONS

Measuring only HbA_1c could lead to under-diagnosis in people with low mismatches and over-diagnosis in those with high mismatches. Additional oral glucose tolerance tests and/or fasting glucose testing to complement HbA_1c in diagnostic classification should be performed in most individuals.

P726 Cardiac amyloidosis: unmasking the simulator

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case

P754 Severe aortic stenosis with preserved ejection prognostic differences according to flow status and gradient fraction: a Spanish multicentre study

Background and objectives

Low-flow low-gradient (LFLG) aortic stenosis portends bad prognosis in different series. The objective of this study was to evaluate the evolution of this entity in our country.

Methods

We included 1394 consecutive patients evaluated between 2008-2016 with severe AS (AVA &lt;1 cm²) and ejection fraction&gt; 50% from 14 Spanish centres. The results (aortic valve intervention and mortality) were compared using the Kaplan-Meier survival analysis.

Results

Three groups based on gradient and flow status were established (high gradient: HG, normal flow under gradient: NFLG, low gradient low flow: LFLG). No significant demographic or clinical differences between groups were observed. After a follow-up of 61.52 months (IQR 43.5-86.5), 551 (73.8%) HG, 268 (35.4%) with NFLG and 81 (57.9%) LFLG received intervention, with a later surgery/TAVI indication in the LFLG group compared with HG group (p = 0.001) (Figure 1). The analysis of the Kaplan-Meier mortality curves showed no significant differences.

Conclusions

Patients with LFLG aortic stenosis with normal ejection fraction received less and later aortic valve intervention than the HG group with no significant differences in mortality.

Abstract P754 Figure. Time to surgery

1645 Unexpected aortic bioprosthetic valve thrombosis

Introduction

Prosthetic valve thrombosis (PVT) is a rare but feared complication of cardiac valve replacement which usually represents a difficult diagnostic challenge. Although PVT is not frequent in bioprosthetic valves, the advent of transcatheter heart valves and the advances in computed tomography, allowing the detection of subclinical thrombosis, have yielded growing interest in that field, specially taking into account that there is no consensus on optimal antithrombotic approach in these patients.

Clinical Case

A 74-year-old male with prior cardiac antecedents of aortic valve replacement (April 2010) with a bovine pericardial bioprosthesis (Mitroflow 25, Sorin group Inc.), ischemic dilated cardiomyopathy with moderately depressed left ventricle ejection fraction (33%) and carrier of VDD pacemaker due to third degree atrioventricular block was admitted to advanced heart failure unit. During routine follow-up echocardiograms, prosthetic valve presented no signs of dysfunction except slightly increased gradients (image C): max 38 mmHg (normal &lt;36), med 23 mmHg (normal &lt;20). Because of left ventricle dysfunction, high pacing rate (&gt;95%) and dyspnea NYHA class III the patient was referred for upgrade to cardiac resynchronization therapy (CRT).

Computed tomography to asses epicardial venous anatomy prior to CRT implant was performed. In addition to venous distribution, it was described a repletion defect in aortic bioprosthetic valve suggestive of leaflet thrombosis (image A). To complete the study the patient underwent a transesophageal echocardiography (TOE) revealing a swallow’s nest shaped hypoechoic occupation of non-coronary and left aortic leaflets (image B), and 3D effective orifice area of 0,9 cm2.

Oral anticoagulation was started in association to previously taken acetylsalicylic acid (ASA). Control TOE was performed 3 months after diagnosis showing almost complete resolution of thrombi.

During the follow-up a CRT-D was implanted, with significant response in systolic performance, reaching a LVEF of 45%. Interestingly, despite the increase in anterograde aortic flow, progressive decrease of aortic gradients (max 24 mmHg, med 15 mmHg) until normalization was found (image D). Clinical benefit was also patent, being the patient in NYHA class I at the moment.

Discusion

Valve thrombosis could be difficult to diagnose in the presence of left ventricle dysfunction as gradients shall remain low despite an important compromise in valve motion. We present a case of incidental diagnosis of non-obstructive leaflet thrombosis that was managed conservatively with oral anticoagulation and ASA. The descent in transaortic gradients, moreover taking into account the response to CRT increasing LVEF, indicates that gradients slightly increased or in the upper limit of normality should raise suspicion in valve dysfunction in the presence of decreased LVEF.

Abstract 1645 Figure.

58 Effect of different light sources on the developmental capacity of bovine embryos produced invitro

Under natural conditions, mammalian oocytes and zygotes are never exposed to daylight or artificial light. During assisted reproductive procedures such as invitro production (IVP), oocytes and pre-implantation embryos are exposed to light from time to time before being transferred to recipients. The detrimental effect of visible light is not directly related to the intensity and exposure time, but is also a function of the spectral composition of the light. Recently, a green pass light filter was used during all steps of bovine IVP. Results indicated the protective effect of the filter against harmful blue and infrared regions of the light (Korhonen et al. 2009 Hum Reprod. 24, 308-314; https://doi.org/10.1093/humrep/den432). Data regarding either blue or infrared light are missing. Therefore, the effect of environmental light will be examined on the developmental capacity of bovine oocytes and pre-implantation embryos produced invitro. Three different experimental conditions were set during all IVP steps: (i) light from the microscope filtered with a red pass filter, no artificial light, and no daylight, (ii) artificial light without day light, light from the microscope without a filter, and (iii) artificial and daylight, light from the microscope without a filter, as normally used in the laboratory (control). Bovine cumulus-oocyte complexes were recovered from abattoir-derived ovaries by the slicing method. After 24h of maturation, fertilisation was realised and after 19h of co-culture of cumulus-oocyte complexes and sperm, presumptive zygotes were cultured in SOFaa for 8 days. Cleavage and developmental rates were recorded at Day 3 and Day 7/8 (Day 0=IVF, 10 IVP runs). Blastocysts from all groups were individually stored at −80°C until analyses. Then RT-qPCR (at least 12 replicates) was performed as described previously (Stinshoff et al. 2014 Reprod. Fertil. Dev. 26, 502-510; https://doi.org/10.1071/RD12372) for gene transcripts related to cellular stress (BAX, BCL2L1, HSPA1A, SOD1) and embryo developmental capacity (SLC2A3). The morphological quality of expanded blastocyst was assessed via a differential staining procedure (with propidium iodide and Hoechst, 4 replicates) to determine the number of inner cell masses (ICM), trophectoderms (TE), and total cells and to calculate the ICM/TE ratio. Data were analysed by analysis of variance followed by a Tukey test. Cleavage and developmental rates were similar in all groups of embryos (P&gt;0.05). The relative abundance of all analysed gene transcripts was significantly increased (P ≤ 0.05) in blastocysts stemming from settings (i) and (ii) compared with those from the control group. Blastocysts generated using only artificial light or artificial and daylight did show a significantly increased number of ICM and total cells (86.3±3.2, 56.3±1.4; 183.6±4.0, 161.8±2.8) compared with embryos produced under filtered microscope light without any other light (35.3±0.8; 133.8±1.4; P ≤ 0.05). The number of TE cells was similar (P&gt;0.05) in blastocysts of all groups (i: 98.5±1.3; ii: 97.3±2.6; iii (control): 105.5±2.4). These data suggest that day light exposure might influence bovine embryos at the molecular level, whereas the morphological quality seems to be unaffected when compared with embryos exposed to only artificial light.