Associations between psychological distress in adolescence and menstrual symptoms across life: Longitudinal evidence from the 1970 British Cohort Study

PURPOSE

This study aimed to investigate the association between psychological distress (PD) at age 16 and menstrual symptoms experienced across women's life.

METHODS

Up to 2584 females from the 1970 British Cohort Study, a study of individuals born within one week in 1970, were included. PD at age 16 was measured with the 12-item General Health Questionnaire. Three categories were derived: low PD (<11), moderate PD (11-15), and severe PD (>15). Five menstrual health symptoms were self-reported at each age (16, 30 and 42 years). Binomial logistic regressions examined associations between PD at age 16 and each individual symptom, adjusted for age of menarche, sleep and appetite problems, physical activity levels and socioeconomic position.

RESULTS

The most prevalent symptoms were "pain" (61 %), "painful period" (10 %) and "heavy period" (33 %) at ages 16, 30 and 42, respectively. At age 16, those with severe PD were more likely to experience depression (OR: 2.92; 95% CI: 2.31, 3.70)), irritability (1.67; 1.33, 2.11), menstrual pain (1.34; 1.01, 1.80), and headaches (1.29; 1.02, 1.63). A weak association was found between severe PD at age 16 and pre-menstrual tension at age 30 (1.72; 1.01, 2.83). At age 42, those with severe PD at age 16 were more likely to experience pre-menstrual tension (1.89; 1.46, 2.44), painful periods (1.64; 1.27, 2.11), and heavy periods (1.28; 1.00, 1.62).

DISCUSSION

Menstruating females with higher levels of PD in adolescence have an increased risk of menstrual symptoms across adolescence, early and mid-adulthood. Our findings suggest the need to consider early-life psychological interventions to improve women's menstrual experiences across their reproductive years.

Exposure to PM2.5 and cardiovascular diseases in Portugal – the contribute of PMCardImpact project

 

Particulate matter with a diameter of 2.5 μm or less (PM2.5) are one of the air pollutants more detrimental to human health, being responsible for around 400 000 premature deaths in Europe every year. The cardiovascular diseases (CVD) and air pollution are linked, with existing evidence of a causal relationship between exposure to particulate matter and cardiovascular morbidity and mortality. Under the scope of PMCardImpact, a national funded project, data collected from Portuguese air monitoring platform (2005-2021) (&gt;60 stations) was used to estimate the attributable number of cases of acute myocardial infarction. The air monitoring data and parameters such as exposure-response factors will support the risk assessment in AirQ+ software (WHO Regional Office for Europe). Preliminary results showed that exceedances of Air Quality Directive in Portugal ranged between 0.1 % and 10.2% for PM10 and PM2.5 in 2019. Results obtained will include the number of cases of CVD attributable to exposure to PM2.5 in the Portuguese population. Four scenarios of exposure will be considered for presenting the results: current scenario of exposure, new WHO Air Quality guidelines, European Commission Air Quality Directive and lastly, a worst-case scenario. This assessment will be the starting point for calculation of the burden of disease of CVD that exposure to PM2.5 represent in Portugal. With a view to promote the science to policy interface, PMCardImpact project will make available to policy makers the needed supporting information to act, including actionable knowledge on air pollution trends and related health effects, to implement reducing air pollution policies.

This work is funded by FCT/MCTES through national funds to PMCardImpact (EXPL/SAU-PUB/0944/2021) and CESAM (UIDP/50017/2020 + UIDB/50017/2020 + LA/P/0094/2020).

Key messages

• PMCardImpact will make available to policy makers the needed supporting information to act to implement reducing air pollution policies.

• Risk assessment will allow to determine the number of CVD cases attributable to air pollution.

Air pollution and health – the importance of air monitoring and burden of disease for attaining SDGs

Pollution is the worldwide largest environmental cause of disease and premature death, being also considered a risk for planetary health, a cause of ecosystems destruction and intimately linked to global climate change. Pollution is considered costly, with attributable diseases resulting in health-care costs that are responsible for 1.7% of annual health spending in high-income countries. Moreover, in utero and early childhood exposures are responsible for health effects in children. The importance of air pollution as a cause of disease is well reflected in the Sustainable Development Goals (SDG), mainly in the SDG 3, SDG 11, and SDG 15, but indirectly in all the SDGs. To tackle this issue, an integrative and holistic approach linking human and environmental health such as One Health is needed, to provide evidence-based data to support the establishment of reduced air pollutants’ maximum admissible levels. A case-study developed in Portugal in the scope of PMCardImpact project, regarding the exposure of population to particulate matter with a diameter of 2.5 μm or less (PM2.5) and the associated number of cases of cardiovascular diseases will be presented herewith. Four scenarios of exposure will be considered for presenting the results: current scenario of exposure, new WHO Air Quality guidelines, European Commission Air Quality Directive and lastly, a worst-case scenario. This assessment is the starting point for calculation of the burden of disease of CVD that exposure to PM2.5 represent in Portugal. With a view to promote the science to policy interface, PMCardImpact project will make available to policy makers the needed supporting information to act, including actionable knowledge on air pollution trends and related health effects, to implement reducing air pollution policies.

This work is funded by FCT/MCTES through national funds to PMCardImpact (EXPL/SAU-PUB/0944/2021) and CESAM (UIDP/50017/2020 + UIDB/50017/2020 + LA/P/0094/2020).

At the outer edge of STEMI time: even after 12 hours, the clock keeps ticking

Introduction

Although primary percutaneous coronary intervention (pPCI) is not a class I recommendation in all patients (pts) presenting within 12 to 48h of symptom onset (late ST-segment Elevation Myocardial Infarction, STEMI), there is increasing evidence supporting its routine use in this population. Data on long-term clinical outcomes is sparse.

Objective

To evaluate long-term MACE in late-STEMI pts submitted to pPCI and compare with clinical outcomes of early reperfusion groups.

Methods

Retrospective analysis of consecutive pts submitted to pPCI due to STEMI between 2010 and 2015 in a pPCI centre. Included pts were stratified in 5 groups according to symptom-to-balloon time (SBT): &lt;3h; 3–6h; 6–12h; 12–24h; 24–48h. Of a total of 903 pts, 19 pts were excluded due to SBT &gt;48h. Long-term events were established as 5y mortality and 5y-MACE (a composite endpoint of death, re-infarction, heart failure hospital admission and ischemic stroke). The cumulative incidence of long-term outcomes was calculated by the Cox regression analysis and presented according to the Kaplan-Meier method.

Results

Of the 884 pts included in the study, stratification according to SBT was: pPCI&lt;3h (47.4%), pPCI 3–6h (24.9%), pPCI 6–12h (16.5%), pPCI 12–24h (8.0%), and pPCI 24–48h (3.2%). These groups showed no significant difference in terms of demographic characteristics (age, CV risk factors, previous coronary disease or heart failure), clinical severity (systolic arterial pressure, Killip-Kimball class, left ventricle ejection fraction) and angiography findings (multivessel disease, complete revascularization and PCI success). After a median follow-up of 76 (56; 98) months, 5-year mortality was 20.6% (182 pts) and 5-year MACE was 23.3% (206 pts). MACE was associated with increased median SBT: 5.0 (2.0; 9.0) hours vs 4.0 (2.0; 6.5) hours, p&lt;0.001. Of the MACE components, the only that showed a significant association with higher median SBT was mortality: 5.0 (2.0; 10.0) hours vs 4.0 (2.0; 6.0), p&lt;0.001. Differences in long-term outcomes were significant when considering SBT stratified by revascularization time (Figure 1).

Conclusions

As expected, there is a clinical benefit of early reperfusion for long-term cardiovascular events. Within the late-STEMI group, there seems to be a clear distinction between pPCI&lt;24h and &gt;24h, although the clinical benefit of pPCI timing most probably acts a continuum.

Funding Acknowledgement

Type of funding sources: None.

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

 

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

Aim

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

Study population

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

Results

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

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

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

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

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

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

Introduction

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

Purpose

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

Methods

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

Results

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

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

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Noncompliance to iodine supplementation recommendation is a risk factor for iodine insufficiency in Portuguese pregnant women: results from the IoMum cohort

PURPOSE

After a recommendation for iodine supplementation in pregnancy has been issued in 2013 in Portugal, there were no studies covering iodine status in pregnancy in the country. The aim of this study was to assess iodine status in pregnant women in Porto region and its association with iodine supplementation.

METHODS

A cross-sectional study was conducted at Centro Hospitalar Universitário São João, Porto, from April 2018 to April 2019. Pregnant women attending the 1st trimester ultrasound scan were invited to participate. Exclusion criteria were levothyroxine use, gestational age < 10 and ≥ 14 weeks, non-evolutive pregnancy at recruitment and non-signing of informed consent. Urinary iodine concentration (UIC) was measured in random spot urine by inductively coupled plasma-mass spectrometry.

RESULTS

Median UIC was 104 μg/L (IQR 62-189) in the overall population (n = 481) of which 19% had UIC < 50 µg/L. Forty three percent (n = 206) were not taking an iodine-containing supplement (ICS) and median UIC values were 146 µg/L (IQR 81-260) and 74 µg/L (IQR 42-113) in ICS users and non-users, respectively (p < 0.001). Not using an ICS was an independent risk factor for iodine insufficiency [adjusted OR (95% CI) = 6.00 (2.74, 13.16); p < 0.001]. Iodised salt use was associated with increased median iodine-to-creatinine ratio (p < 0.014).

CONCLUSIONS

A low compliance to iodine supplementation recommendation in pregnancy accounted for a mild-to-moderately iodine deficiency. Our results evidence the need to support iodine supplementation among pregnant women in countries with low household coverage of iodised salt. Trial registration number NCT04010708, registered on the 8th July 2019.

AB0437 MONTELUKAST AS A TREATMENT FOR REFRACTORY CUTANEOUS LUPUS ERYTHEMATOSUS: A CASE SERIES AND PROOF-OF-CONCEPT STUDY

Background

Treatment of cutaneous lupus relies mostly in avoidance of exposure to sunlight, steroids and hydroxychloroquine. A diverse array of cytokines and chemokines released by resident and migrating inflammatory cells have been implicated in the pathogenesis of skin damage in patients with systemic lupus erythematosus (SLE). Leukotrienes are potent lipid mediators involved in hypersensitivity reactions but very few data exist on their involvement in SLE.

Objectives

Our aim is to report a case series of SLE patients with refractory skin lesions that were successfully treated with sodium montelukast (MLK), a cysteinyl-leukotriene antagonist.

Methods

We present 4 consecutive female SLE patients with refractory skin lesions that were treated with MLK (10mg/d). Skin lesions were scored using CLASI criteria. Peripheral blood mononuclear cells (PBMC) from those 4 SLE patients and 4 healthy age-matched female controls were collected and the relative expression of the 5-lipoxigenase (ALOX5) and 15-lipoxigenase (15LOX1R) genes against a reference gene (GAPDH) was assessed using a quantitative polymerase change reaction (qPCR) protocol.

Results

All four patients experienced improvement of skin lesions 2-4 weeks following initiation of MLK with over 50% reduction in severity using CLASI score. The response was sustained for at least 3 months follow-up and no adverse events were recorded. All but one of the patients relapsed following MLK withdrawal but response was recovered after restart of MLK. Expression of the ALOX5, but not of 15LOX1R, was significantly (p<0.001) increased in PBMC from SLE patients as compared to controls.

Conclusion

This is the first report of a fast and sustained successful response of cutaneous SLE to MLK. There were no safety issues. PBMC from SLE patients showed increased expression of the ALOX5gene. This case series suggests the involvement of MLK in cutaneous lupus and encourage designing a randomized trial.

Disclosure of Interests

None declared

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

SARS-CoV-2 serosurvey among adults involved in healthcare and health research in Guinea-Bissau, West Africa

Objectives

Many African countries have reported fewer COVID-19 cases than countries elsewhere. By the end of 2020, Guinea-Bissau, West Africa, had <2500 PCR-confirmed cases corresponding to 0.1% of the ∼1.8 million national population. We assessed the prevalence of SARS-CoV-2 antibodies in urban Guinea-Bissau to help guide the pandemic response in Guinea-Bissau.

Study design

Cross-sectional assessment of SARS-CoV-2 antibody in a cohort of staff at the Bandim Health Project.

Methods

We measured IgG antibodies using point-of-care rapid tests among 140 staff and associates at a biometric research field station in Bissau, the capital of Guinea-Bissau, during November 2020.

Results

Of 140 participants, 25 (18%) were IgG-positive. Among IgG-positives, 12 (48%) reported an episode of illness since the onset of the pandemic. Twenty-five (18%) participants had been PCR-tested between May and September; 7 (28%) had been PCR-positive. Four of these seven tested IgG-negative in the present study. Five participants reported that somebody had died in their house, corresponding crudely to an annual death rate of 4.5/1000 people; no death was attributed to COVID-19. Outdoor workers had a lower prevalence of IgG-positivity.

Conclusions

In spite of the low official number of COVID-19 cases, our serosurvey found a high prevalence of IgG-positivity. Most IgG-positives had not been ill. The official number of PCR-confirmed COVID-19 cases has thus grossly underestimated the prevalence of COVID-19 during the pandemic. The observed overall mortality rate in households of Bandim Health Project employees was not higher than the official Guinean mortality rate of 9.6/1000 people.

Burden of disease of dietary exposure to aflatoxins in European countries

Aflatoxins (AFTs) are genotoxic and carcinogenic food contaminants causing hepatocellular carcinoma, the third leading cause of cancer deaths worldwide. In 2015, WHO estimated the burden of disease associated with exposure to AFTs and concluded that this exposure corresponds to 636,869 Disability-adjusted Life Years (DALYs) at global level. Particularly for Portugal and recently, there were estimated 0.08-0.30 DALYs/100,000 considering consumption and occurrence in food data, and 1.7 DALYs/100,000 based on human biomonitoring data. The present study considered the exposure data presented in the EFSA scientific opinion “Risk assessment of aflatoxins in food” where data from occurrence of AFTs in food and from food consumption were gathered to estimate the exposure to AFTs in 19 European countries. A deterministic and a bottom-up approach was developed to estimate the health impact of the exposure to AFTs for adult population through the calculation of DALYs associated to the number of estimated extra-cases of hepatocellular carcinoma (HCC). Results showed similar values for all the 19 European countries considered. For adult population and considering the data provided by EFSA using the upper-bound approach (worst-case scenario), the estimated number of DALYs ranged from 0.32 (Spain) to 1.10 (United Kingdom) DALYs/100,000. A total of 11.76 DALYs/100,000 was globally estimated for the considered European countries. The highest burden was estimated for the United Kingdom, that together with The Netherlands, Ireland, Czech Republic, and Austria were the highest contributors to the global estimated European burden associated to the exposure to AFTs. The present study generated reliable and crucial data to characterize the burden associated to exposure to AFTs in the European population. The obtained results constitute an important contribution to define priorities and support the need for further policy actions to protect European citizen's health.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Modified CHA2DS2-VASc can predict mortality in COVID-19 patients admitted to the emergency department

Introduction

CHA2DS2-VASc score is used to determine the thromboembolic risk, but its prognostic value has been demonstrated in several cardiovascular (CV) diseases. Except for female gender, many CV risk factors comprising this score are recognized as risk factors for mortality in COVID-19. Cetinak G. et al demonstrated the ability of modified CHA2DS2-VASc (M-CHA2DS2-VASc) to predict mortality in COVID-19, which is based on changing gender criteria from female to male.

Purpose

To evaluate the prognostic value of a M-CHA2DS2-VASc score to predict pulmonary embolism (PE) and mortality in pts with COVID-19 admitted at the emergency department (ED).

Methods

Retrospective study of pts admitted to the ED between June 2020-January 2021, who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. Pts were stratified into 3 M-CHA2DS2-VASc risk groups: lower (0–1), intermediate (2–3) and high risk (≥4). Kruskal-Wallis and X-square test were used to compare score risk groups. Logistic regression was used to determine predictors of PE and mortality. ROC curve was performed to evaluate the discriminative power of the score.

Results

We included 300 pts: median age 71 years, 59% male. Hypertension (59%) chronic kidney disease (CKD, 33%), dyslipidemia (32%) and diabetes (28%) were the most common comorbidities. PE was diagnosed in 46 pts (15%). We found no difference in PE incidence according to M-CHA2DS2-VASc groups (p=0.531) and it showed no predictive value for PE (OR: 1.050, p=0.596). The AUC of M-CHA2DS2-VASc was 0.52, suggesting no discriminative power to predict PE.

Regarding mortality, M-CHA2DS2-VASc score was higher in non-survivors COVID-19 pts than in survivors [4 (IQR 3–5) vs 2 (1–4), respectively, p<0.001]. A multivariate logistic regression analysis was performed for mortality based on M-CHA2DS2-VASC, troponin, CKD and smoking history, and only M-CHA2DS2-VASc was identified as an independent predictor of mortality (OR: 1.406, p=0.007). Kaplan-Meier showed that M-CHA2DS2-VASc score was associated with mortality: the survival rate was 92%, 80% and 63% in the lower, intermediate and higher M-CHA2DS2VASc score risk group (logrank test p<0.001; Fig. A).

Most of the pts in the cohort were hospitalized (83%), but 21 pts (17%) discharged from the ED. Among these pts, 33% (n=17) had low risk, 37% (n=19) intermediate risk and 29% (n=15) high risk for mortality according to the M-CHA2DS2VASc score. The Kaplan-Meier individual survival analysis for hospitalized patients (Fig. B) and for those discharged from the ED (Fig. C) showed that M-CHA2DS2-VASc score had a good discriminative ability to predict short-term mortality for both groups (logrank test p<0.001 and p=0.007, respectively).

Conclusion

Considering the lack of validated scores to predict mortality in COVID-19 pts, the M-CHA2DS2-VASc might be a simple tool to predict short-term mortality in these pts, irrespectively of the need for hospitalization or not.

Funding Acknowledgement

Type of funding sources: None.

CytoPath®Easy processing method validation through cervical self-sampling

Background

Liquid-based cytology is mostly used for the identification of pre-neoplastic and neoplastic cells of cérvix uteri, and many manual and automatic methodologies are available on the market. This study aims to validate a new manual liquid-based processing method - the CytoPath® Easy Kit, for its routine use in some cytology laboratories.

Methods

For this purpose, 45 cervical samples, obtained by self-sampling of women aged 18–58 years old were used: 30 were collected and processed with the CytoPath® Easy Kit and 15 samples were collected and processed by Thinprep®, as a control. Parameters evaluated were cellularity, thickness and cellular overlap of the imprint, undesirable background/debris, morphological preservation and staining properties of the sample. The presence and quantity of metaplastic and/or endocervical cells of the transformation zone was also compared between methods.

Results

The results obtained show that CytoPath® Easy Kit allows the representation of the sample with a very satisfactory cellularity, in a thin layer of cells and without excessive overlap, presenting a reasonably clean background. Statistically, both methods present similar results (P &gt; 0.9999), both globally and for each of the parameters evaluated individually. These results allow to validate the use of this new method in the cytological routine.

Conclusions

This Kit proves to be very useful, allowing the laboratory to screen cervical cytology samples, without the need for large investments and with reliable microscopic results. This has particular interest for laboratories of poor or developing countries as well for services processing small number of samples.

Cardiopulmonary exercise testing in repaired tetralogy of Fallot: a valuable tool for pulmonary regurgitation severity assessment

Funding Acknowledgements

Type of funding sources: None.

Introduction and purpose

The optimal timing for pulmonary valve replacement (PVR) in asymptomatic patients with repaired tetralogy of Fallot (TOF) and pulmonary regurgitation (PR) remains uncertain but is often guided by imaging characterization of the right ventricle. As cardiopulmonary exercise testing (CPET) performance is an accessible prognostic indicator, we assessed which CPET parameters best correlate with pulmonary regurgitation severity to potentially improve identification of high-risk patients.

Methods

A retrospective chart review was done from 2009 to 2018 on adult patients with repaired TOF who underwent maximal effort cardiopulmonary exercise testing with cycle ergometry and with concurrent pulmonary function testing. Demographics, standard measures of CPET interpretation, and major cardiovascular outcomes were collected.

Results

Cardiopulmonary exercise testing was performed in 54 adult repaired TOF patients (59% male), with a mean follow-up of 60 ± 33 months. The mean age was 34 ± 9 years. 30 patients (56%) had severe pulmonary regurgitation and 26 patients (48%) were submitted to PVR, with a 0% mortality rate. PVR was performed a mean 28 ± 7 years after TOF repair surgery. There was moderate to severe right ventricular dysfunction in 11 patients (20%). 12 patients (22%) had a hospitalization for heart failure. Arrhythmic events occurred in 9 patients (17%), mainly atrial fibrillation or atrial flutter (67%). 2 patients (4%) received an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death.

Peak VO2 consumption (pVO2) showed no statistically significant correlation with severity of pulmonary regurgitation (HR 0.26, 95% CI 0.879-1.036, p= 0.262) or PVR (HR 0.92, 95% CI 0.829-1.028, p = 0.914), while percent of predicted pVO2 significantly correlated with severity of pulmonary regurgitation (HR 0.95, 95% CI 0.918-0.993, p = 0.020) and PVR (HR 0.94, 95% CI 0.886-0.992, p = 0.025).

VE/VCO2 slope was not a significant predictor of severity of pulmonary regurgitation (HR 1.03, 95% CI 0.929-1.130, p = 0.622) or PVR (HR 1.04, 95% CI 0.952-1.128, p = 0.414) or) and neither cardiorespiratory optimal point (HR 0.94, 95% CI 0.786-1.120, p = 0.480) nor maximum end-tidal carbon dioxide pressure (PETCO2) (HR 0.93, 95% CI 0.846-1.037, p = 0.213) correlated with severity of pulmonary regurgitation or PVR.

Conclusion

Percent of predicted peak VO2 had the highest predictive power of all CPET parameters analysed in adult repaired TOF patients. Preoperative CPET could be an accessible way to identify high-risk patients earlier for PVR and should therefore be included in the routine assessment of these patients.

The 90s are the new 70s: approach to nonagenarian patients with myocardial infarction: data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS)

Introduction

The approach to Acute Coronary Syndromes is based on robust high quality evidence, currently systematized in European endorsed guidelines. However most trials that support such guidelines excluded or included a small percentage of the very elderly, namely nonagenarian patients, and the clinical decision in this age range is subjected to high interpersonal and inter-hospital variability.

Purpose

Our aim was to assess the approach to nonagenarian patients with Acute Coronary Syndromes (ACS), in what regards the choice of percutaneous coronary intervention or conservative management and determine in-hospital and at 1 year outcomes.

Methods

We performed a 9 year retrospective analysis of all patients with age equal or greater than ninety (90) admitted with ACS in Portugal. Medical records were analysed for demographic, procedural data and outcomes.

Results

Seven hundred and fourteen (714) nonagenarian patients were admitted with ACS, which corresponded to 2.4% of the total cohort. The mean age was 92±2 with a female preponderance (58.7%). There was a high rate of cardiovascular risk factor with hypertension in 81.3%; Dyslipidemia in 46.1% Diabetes Mellitus in 23.4%; and other comorbidities with 21% of prior ACS, 14.4% with Heart Failure, 11% with cerebrovascular events and 15.4% with chronic kidney failure.

The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 43.9%, non- STEMI (NSTEMI) in 45.8%, and unstable angina (UA) in 2%.

Two hundred and sixty-eight (268), 37.8% of the cohort, were submitted to percutaneous coronary intervention (PCI), mainly due to STEMI (68.3%). This cohort were composed of patients with less comorbidities (statistically significant less valvular heart disease, heart failure, peripherical artery disease and dementia although more oncological diseases). There was no difference in the severity of ACS, as categorized by the Kilip Kimbal (KK) classification, mechanical complication or depressed ejection fraction between the 2 groups. (p&gt;0.05 for all)

There was a statistically significant increase of advanced atrioventricular block (10.6 vs 4.4%; p 0.002; Logistic regression OR 3.12; IC95 [1.37–7.15], p 0.007) and major bleeding (1.8 vs 5.5%; p 0.008; Logistic regression OR 3.36; IC95 [1.36–8.32] p 0.009) in the PCI group. There was no difference in in-hospital re-infarction, cardiac arrest, stroke or death. (p&gt;0.05 for all)

The follow up at 1 year was performed in two hundred and fifty-six (256) patients, 30.9% submitted to PCI. Although the survival analysis demonstrated a trend towards improvement in 1-year survival and cardiovascular readmissions in the intervention group, it did not reach statistical significance. (p&gt;0.05 for all)

Conclusions

PCI was performed in about a third of nonagenarians presenting with ACS. Our cohort demonstrated a greater rate of in-hospital complications without a significant in-hospital or at 1 year clinical benefit.

Funding Acknowledgement

Type of funding source: None

Sustainable plant polyesters as substrates for optical gas sensors

The fast and non-invasive detection of odors and volatile organic compounds (VOCs) by gas sensors and electronic noses is a growing field of interest, mostly due to a large scope of potential applications. Additional drivers for the expansion of the field include the development of alternative and sustainable sensing materials. The discovery that isolated cross-linked polymeric structures of suberin spontaneously self-assemble as a film inspired us to develop new sensing composite materials consisting of suberin and a liquid crystal (LC). Due to their stimuli-responsive and optically active nature, liquid crystals are interesting probes in gas sensing. Herein, we report the isolation and the chemical characterization of two suberin types (from cork and from potato peels) resorting to analyses of gas chromatography–mass spectrometry (GC-MS), solution nuclear magnetic resonance (NMR), and X-ray photoelectron spectroscopy (XPS). The collected data highlighted their compositional and structural differences. Cork suberin showed a higher proportion of longer aliphatic constituents and is more esterified than potato suberin. Accordingly, when casted it formed films with larger surface irregularities and a higher C/O ratio. When either type of suberin was combined with the liquid crystal 5CB, the ensuing hybrid materials showed distinctive morphological and sensing properties towards a set of 12 VOCs (comprising heptane, hexane, chloroform, toluene, dichlormethane, diethylether, ethyl acetate, acetonitrile, acetone, ethanol, methanol, and acetic acid). The optical responses generated by the materials are reversible and reproducible, showing stability for 3 weeks. The individual VOC-sensing responses of the two hybrid materials are discussed taking as basis the chemistry of each suberin type. A support vector machines (SVM) algorithm based on the features of the optical responses was implemented to assess the VOC identification ability of the materials, revealing that the two distinct suberin-based sensors complement each other, since they selectively identify distinct VOCs or VOC groups. It is expected that such new environmentally-friendly gas sensing materials derived from natural diversity can be combined in arrays to enlarge selectivity and sensing capacity.

Comparison of explicit values clarification method (VCM), implicit VCM and no VCM decision aids for men considering prostate cancer screening: protocol of a randomized trial

Background

Screening with prostate-specific antigen (PSA) test for prostate cancer is considered a preference sensitive decision; meaning it does not only depend on what is best from a medical point of view, but also from a patient value standpoint. Decision aids are evidence-based tools which are shown to help people feel clearer about their values; therefore it has been advocated that decision aids should contain a specific values clarification method (VCM). VCMs may be either implicit or explicit, but the evidence concerning the best method is scarce. We aim to compare the perceived clarity of personal values in men considering PSA screening using decision aids with no VCM versus an implicit VCM versus an explicit VCM.

Methods

Male factory employees from an industrial facility in the Northern region of Portugal aged 50 to 69 years old will be randomly assigned to one of three decision aid groups used to support prostate cancer screening decisions: (i) decision aid with information only (control), (ii) decision aid with information plus an implicit VCM, (iii) decision aid with information plus an explicit VCM.

Men will be allowed release time from work to attend a session at their workplace. After a brief oral presentation, those willing to participate in the study will fill the baseline questionnaire, plus a 5 point-Likert scale question about intentions to undergo screening, and will then receive the intervention materials to complete.

We estimated a total sample size of 276 participants; with 92 in each group.

The primary outcome will be the perceived clarity of personal values assessed by the Portuguese validated translation of the three subscales of the Decisional Conflict Scale. Secondary outcomes will be intention to be screened (before and after the intervention), the total score from the Decisional Conflict Scale and the self-report of having or not undergone screening at 6 months.

Discussion

This study will add to the body of evidence on the role of decision aids to support health preference-sensitive choices and provide further insight on the impact of different methods for eliciting people’s values embedded within a decision aid.

Trial registration

NCT03988673 - clinicalTrials.gov (2019/06/17).

Burden of disease associated with dietary exposure to carcinogenic aflatoxins in Portugal using human biomonitoring approach

Human biomonitoring is an important tool to assess human exposure to chemicals, contributing to describe trends of exposure over time and to identify population groups that could be under risk. Aflatoxins are genotoxic and carcinogenic food contaminants causing hepatocellular carcinoma, the third leading cause of cancer deaths worldwide. In Portugal, scarce data are available regarding exposure to aflatoxins and no previous study used human biomonitoring data to comprehensively characterize the associated burden of disease. 24 h urine and first-morning urine paired samples were collected by 94 participants and were analyzed by liquid chromatography-tandem mass spectrometry for the quantitative determination of aflatoxins (B₁, B₂, G₁, G₂ and M₁). Deterministic and probabilistic models were developed to assess the Portuguese exposure to aflatoxins and to estimate the health impact of this exposure, estimating the attributed Disability-Adjusted Life Years (DALYs). Aflatoxins were detected in a maximum of 13% (AFB₁), 16% (AFB₂), 1% (AFG₁), 2% (AFG₂) and 19% (AFM₁) of the urine samples. Data obtained through the probabilistic approach revealed an estimated mean probable daily intake of 13.43 ng/kg body weight per day resulting in 0.13 extra cases of hepatocellular carcinoma, corresponding to mean annual DALYs of 172.8 for the Portuguese population (10291027 inhabitants). The present study generated for the first time and within a human biomonitoring study, reliable and crucial data to characterize the burden associated to the exposure to aflatoxins of the Portuguese population. The obtained results constitute an imperative support to risk managers in the establishment of preventive policy measures that contribute to ensure public health protection.

Phenotype and function of circulating memory T cells in human vitiligo

BACKGROUND

Vitiligo is a chronic inflammatory skin disorder characterized by the loss of melanocytes. While a T helper cell (Th)1/cytotoxic T cell (Tc)1-skewed immune response is now well demonstrated in vitiligo, recent data suggest that the T-cell component could be more complex, involving different combinatorial T-cell subsets.

OBJECTIVES

To analyse the phenotype and function of circulating CD4⁺ and CD8⁺ memory T-cell subsets in patients with stable and active vitiligo, in comparison with patients with psoriasis and healthy controls.

METHODS

This is a monocentric, prospective, descriptive and exploratory study. Multiparametric flow cytometry analyses were performed to evaluate the surface expression of homing and T-cell-subset markers together with intracellular cytokine production in peripheral blood mononuclear cells from 60 patients with vitiligo, 25 patients with psoriasis and 28 healthy donors.

RESULTS

Vitiligo peripheral blood circulating effector and central memory T cells expressed similar proportions of skin-homing markers. Decrease in the frequencies of circulating CD4⁺ and CD8⁺ Th1/Tc1, Th17/Tc17, and Th1/Th17 or Tc1/Tc17 effector memory T-cell subsets were observed in patients with vitiligo compared with healthy donors. Similar observations were made in psoriasis. In contrast, vitiligo circulating T cells showed a similar capacity for proinflammatory cytokine production compared with those in psoriasis and healthy controls.

CONCLUSIONS

The decreased frequencies of circulating Th1/Tc1, Th17/Tc17 and Th1/Th17-Tc1/Tc17 cells suggest a possible migration of these T-cell subsets into the skin of patients with vitiligo. These could be targeted to prevent flares of the disease. What is already known about this topic? Vitiligo is a chronic inflammatory skin disorder associated with the loss of melanocytes. Vitiligo is characterized by a T helper cell (Th)1/cytotoxic T cell (Tc)1-skewed immune response in the skin. What does this study add? A thorough analysis of the phenotype and function of circulating memory T cells suggests the migration of Th1/Tc1, Th17/Tc17 and Th1/Th17-Tc1/Tc17 cell subsets in the skin. What is the translational message? A better understanding of the different immune T-cell subsets involved in vitiligo could lead to better therapeutic options. Linked Comment: Matos. Br J Dermatol 2020; 183:803.

Comparative review of imipenem/cilastatin versus meropenem

INTRODUCTION

Carbapenems are broad-spectrum antibacterial molecules. Imipenem-cilastatin and meropenem are the two main molecules used in French healthcare services.

OBJECTIVE

We aimed to evaluate the relative strengths and weaknesses of these two molecules by considering their pharmacokinetic, pharmacodynamic, microbiological, and clinical properties. We demonstrated that imipenem-cilastatin and meropenem are not alike.

METHOD

Review of the literature by querying the MEDLINE network.

RESULTS

Imipenem-cilastatin is the first marketed molecule of the carbapenem class. It is more effective against Gram-positive cocci. Its stability does not allow for long infusions and its main adverse effect on the central nervous system limits its use. Meropenem is more effective against Gram-negative bacilli. Its stability and its milder adverse effects distinguish it from imipenem-cilastatin.

CONCLUSION

Meropenem is preferred for daily use in healthcare services when carbapenems are to be used.

Burden of disease attributable to exposure to aflatoxins in Portugal using Human biomonitoring data

Key messages

Portuguese population is exposed to aflatoxins, chemical food contaminants that may be harmful (carcinogenic, immunotoxic, mutagenic, teratogenic, hepatotoxic) to humans. Human biomonitoring studies provide realistic data on internal exposure at individual level, contributing to a more accurate estimation of the burden derived from this exposure.

Risk assessment of Portuguese population to multiple mycotoxins: the human biomonitoring approach

Key messages

Portuguese population is exposed to mycotoxins, chemical food contaminants that may be harmful (carcinogenic, immunotoxic, mutagenic, teratogenic, hepatotoxic) for human health. Human biomonitoring studies provide realistic data on internal exposure at individual level, allowing a more accurate knowledge of the determinants of exposure to these contaminants.

P975Safety and clinical outcomes of rotational atherectomy: an eleven-year centre experience

Introduction

Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality.

Objectives

To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure.

Methods

Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year.

Results

246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach.

Conclusions

RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

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

Introduction

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

Purpose

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

Methods

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

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

Results

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

Conclusions

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

P3128Unprotected left main revascularization in patients with acute myocardial infarction: insights of a multicenter national registry

Introduction

Unlike stable coronary disease, there is no consensus about the best revascularization strategy for unprotected left main coronary artery (ULMCA) disease associated with acute myocardial infarction (MI). Recent studies have shown that percutaneous coronary intervention (PCI) is technically feasible with acceptable outcomes, making it a reasonable alternative to surgical revascularization (CABG).

Aims

To describe the practice of ULMCA revascularization in MI patients (pts) and its evolution over an 9-year period. To analyze the prognosis of this population and determine the effect of revascularization on outcome.

Methods

Retrospective, multicenter national observational study that included 19 430 MI pts from October 2010 to December 2018. Pts who presented ULMCA as culprit lesion were selected and then compared the subgroup that underwent revascularization by PCI alone versus (vs.) CABG alone. Primary endpoint (PE) was a composite of all-cause death, nonfatal re-MI and nonfatal stroke during hospital stay. Secondary endpoint (SE) was all-cause death rate at 1-year after hospital discharge.

Results

204 pts with ULMCA as culprit lesion were selected (1.1% of all pts): 77.9% male, mean age 69±12 years, 97 (47.5%) underwent CABG alone, 92 (45.1%) PCI alone, 10 (4.9%) no revascularization and 5 (2.5%) both strategies. At admission, pts undergoing PCI alone presented more frequently with ST-segment elevation, persistent chest pain, cardiogenic shock and higher values of GRACE risk score. During hospital stay, severe left ventricular (LV) systolic dysfunction (<30%), need for mechanical ventilation, sustained ventricular tachycardia and aborted cardiac sudden death were also more common in these pts. Concerning PE, global rate was 18.5% (27 deaths, 6 nonfatal re-MI and 2 nonfatal stroke). It was significantly higher in pts undergoing PCI alone (32.6% vs. 3.1%, p<0.01). After adjustment, surgical revascularization had 98% lower odds of PE occurrence compared to PCI (OR 0.02, 95% CI 0.002–0.22, p<0.01). Cardiogenic shock at admission (OR 5.06, 95% CI 1.21–21.11, p=0.03) and severe LV systolic dysfunction (OR 7.77, 95% CI 1.49–40.56, p=0.02) were also independent predictors of adverse outcome. One-year all-cause death rate was 4.9%, with no significant difference at survival curves between PCI vs. CABG (Log-Rank p=0.96).Over the 9-year, there was not a significant change in the use of one revascularization technique over the other.

Conclusions

MI with ULMCA as culprit lesion is infrequent and associated with a high rate of adverse events during hospital stay. PCI was preferred in higher risk pts but, even after adjustment, it was associated with a less favorable short-term outcome compared to surgical strategy. Nevertheless, long-term prognosis was excellent in hospital survivors with no difference between both techniques. Randomized trials are needed to determine the ideal revascularization strategy for these pts.

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

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

P03.13 Evaluation of PIK3CA mutational status in glioma molecular subgroups

BACKGROUND

Gliomas are the most common and lethal malignant tumors of central nervous system. In 2016, World Health Organization (WHO) classification included IDH mutations and 1p/19q codeletion as diagnostic criteria to define glioma entities. However, new biomarkers for diagnosis, prognosis and response to therapy are needed. In this context, PIK3CA mutations have been described as constitutive mutations, which highlights their relevance in gliomas. Here we clarified the clinical relevance of PIK3CA mutations according to the 2016 WHO classification, the potential impact on diagnosis, prognosis, response to therapy, as well as their correlation with EGFR amplification and PTEN deletion.

MATERIAL AND METHODS

A cohort of 444 adult diffuse glioma samples from Instituto Português de Oncologia Lisboa Francisco Gentil (IPOLFG) was classified according to the 2016 WHO Classification. The mutational status of exon 9 and 20 of PIK3CA was evaluated in molecular subgroups of gliomas by Sanger sequencing. PTEN deletion and EGFR amplification were identified by Fluorescent in situ hybridization (FISH).

RESULTS

PIK3CA mutations showed a higher frequency in the subgroup of gliomas with IDH mutations and 1p/19q codeletion - oligodendrogliomas (10%). In Glioblastoma (GBM) IDH-mutant and IDH-wildtype these oncogenic mutations were observed in 9% and 3% of cases, respectively. Similar results were obtained using The Cancer Genome Atlas (TCGA) data, which was 8% and 2%, respectively. H1047R and E542K were the most frequent mutations identified in the glioma molecular subgroups. Importantly, we found 3 unreported pathogenic variants in exon 20 of PIK3CA (c.3112T>C, c.2988T>C, c.3040C>T) and one polymorphic variant (c.3210A>G). In addition, PIK3CA mutations, PTEN deletion and EGFR amplification were not mutually exclusive alterations in glioma molecular subgroups. For the first time in gliomas, it was identified the rs45455192 polymorphism at a frequency of 16% in astrocytomas IDH-mutant, 24% in oligodendrogliomas and 18% in both molecular subgroups of GBM, although this polymorphism did not have prognostic value. The analysis of PIK3CA mutations in glioma recurrences showed that these mutations are maintained during glioma progression.

CONCLUSION

In two independent cohorts (IPOLFG and TCGA), it was obtained similar frequencies of PIK3CA mutations in GBM molecular subgroups. In addition, these mutations are more relevant in less aggressive gliomas (IDH-mutated and 1p/19q codeleted). These alterations seem to be important in tumor maintenance and progression, which makes this gene a potential therapeutic target. In the future, we will investigate the effect of the in vitro pharmacological inhibition of PIK3CA in GBM mutant cell lines.

Mytilus galloprovincialis CYP1A-like mRNAs reveal closer proximity of mytilid CYP1A to the eumetazoan CYP2 family

Due to the role of Cytochrome P450, Family 1, Subfamily A (CYP1A) in the detoxification of many polycyclic aromatic hydrocarbons (PAHs), there has been an effort to characterise the gene and the products from its expression in organisms that are relevant for biomonitoring and toxicity testing procedures. Nonetheless, the existence of functional homologues in aquatic invertebrates is not entirely consensual, especially in bivalve molluscs, which pose as one of the most important models for aquatic toxicologists, especially mytilids. After isolation and sequencing of CYP1A-like mRNA from the Mediterranean mussel, Mytilus galloprovincialis, phylogenetics incorporating homologues from molluscs and other eumetazoans, vertebrates included, yielded notorious similarity to sequences belonging to the CYP2 Family. Altogether, the findings further indicate that CYP1A-like CYPs may be absent in bivalves, in lieu of Families CYP2, 3 and 4, suggesting caution when interpreting data from common biomarkers of exposure to aromatic hydrocarbons that have been developed for CYP1A activity and expression in higher deuterostomes.