Using single-species and algal communities to determine long-term adverse effects of silver nanoparticles on freshwater phytoplankton

The physical and chemical properties of silver nanoparticles (AgNPs) have led to their increasing use in various fields such as medicine, food, and industry. Evidence has proven that AgNPs cause adverse effects in aquatic ecosystems, especially when the release of Ag is prolonged in time. Several studies have shown short-term adverse effects of AgNPs on freshwater phytoplankton, but few studies have analysed the impact of long-term exposures on these populations. Our studies were carried out to assess the effects of AgNPs on growth rate, photosynthesis activity, and reactive oxygen species (ROS) generation on the freshwater green algae Scenedesmus armatus and the cyanobacteria Microcystis aeruginosa, and additionally on microcystin (MC-LR) generation from these cyanobacteria. The tests were conducted both in single-species cultures and in phytoplanktonic communities exposed to 1 ngL-1 AgNPs for 28 days. The results showed that cell growth rate of both single-species cultures decreased significantly at the beginning and progressively reached control-like values at 28 days post-exposure. This effect was similar for the community-cultured cyanobacteria, but not for the green algae, which maintained a sustained decrease in growth rate. While gross photosynthesis (Pg) increased in both strains exposed in single cultures, dark respiration (R) and net photosynthesis (Pn) decreased in S. armatus and M. aeruginosa, respectively. These effects were mitigated when both strains were exposed under community culture conditions. Similarly, the ROS generation shown by both strains exposed in single-species cultures was mitigated when exposure occurred in community cultures. MC-LR production and release were significantly decreased in both single-species and community exposures. These results can supply helpful information to further investigate the potential risks of AgNPs and ultimately help policymakers make better-informed decisions about their utilization for environmental restoration.

Left atrial appendage occlusion for recurrent stroke while on oral anticoagulation: a case series

Background

Clinical practice guidelines recommend oral anticoagulation (OAC) for stroke prevention in selected patients with atrial fibrillation (AF). However, some patients still experience thrombo-embolic events despite adequate anticoagulation. The optimal management of these cases remains uncertain, leading to practice pattern variability. We present a series of three cases illustrating the use of left atrial appendage occlusion (LAAO) as an adjunctive stroke prevention strategy in AF patients with recurrent thrombo-embolic events despite adequate anticoagulation.

Case summary

Case one describes an 89-year-old female on apixaban who presented with a thrombus and underwent successful mechanical thrombectomy. Left atrial appendage occlusion was performed, and no subsequent thrombo-embolic events were reported. Case 2 involves a 72-year-old female on full-dose apixaban who experienced recurrent strokes despite adequate anticoagulation. Thrombectomy was performed twice, and complications arose during LAAO. The patient was discharged on warfarin + clopidogrel and remained event-free at the six-month follow-up. Case 3 features an 88-year-old female on rivaroxaban who experienced recurrent cerebral ischaemic events and gastrointestinal bleeding. Left atrial appendage occlusion using an Amplatzer Amulet™ device was successful, and the patient remained event-free at the one-year follow-up.

Discussion

This case series emphasizes the complexity of stroke prevention in AF patients and underscores the need for an individualized approach. Incorporating LAAO alongside OAC can provide additional stroke protection for patients with inadequate response to anticoagulation. Further randomized controlled trials are needed to evaluate the efficacy and safety of this approach. In light of the limited evidence available, these cases contribute to the growing body of knowledge on the potential role of LAAO in secondary stroke prevention in AF patients with recurrent thrombo-embolic events despite appropriate anticoagulation.

Comparison between epileptic seizure prediction and forecasting based on machine learning

Epilepsy affects around 1% of the population worldwide. Anti-epileptic drugs are an excellent option for controlling seizure occurrence but do not work for around one-third of patients. Warning devices employing seizure prediction or forecasting algorithms could bring patients new-found comfort and quality of life. These algorithms would attempt to detect a seizure's preictal period, a transitional moment between regular brain activity and the seizure, and relay this information to the user. Over the years, many seizure prediction studies using Electroencephalogram-based methodologies have been developed, triggering an alarm when detecting the preictal period. Recent studies have suggested a shift in view from prediction to forecasting. Seizure forecasting takes a probabilistic approach to the problem in question instead of the crisp approach of seizure prediction. In this field of study, the triggered alarm to symbolize the detection of a preictal period is substituted by a constant risk assessment analysis. The present work aims to explore methodologies capable of seizure forecasting and establish a comparison with seizure prediction results. Using 40 patients from the EPILEPSIAE database, we developed several patient-specific prediction and forecasting algorithms with different classifiers (a Logistic Regression, a 15 Support Vector Machines ensemble, and a 15 Shallow Neural Networks ensemble). Results show an increase of the seizure sensitivity in forecasting relative to prediction of up to 146% and in the number of patients that displayed an improvement over chance of up to 300%. These results suggest that a seizure forecasting methodology may be more suitable for seizure warning devices than a seizure prediction one.

Adverse effects of iron-based nanoparticles on freshwater phytoplankton Scenedesmus armatus and Microcystis aeruginosa strains

Zero-valent nano-iron particles (nZVI) are increasingly present in freshwater aquatic environments due to their numerous applications in environmental remediation. However, despite the broad benefits associated with the use and development of nZVI nanoparticles, the potential risks of introducing them into the aquatic environment need to be considered. Special attention should be focused on primary producer organisms, the basal trophic level, whose impact affects the rest of the food web. Although there are numerous acute studies on the acute effects of these nanoparticles on photosynthetic primary producers, few studies focus on long-term exposures. The present study aimed at assessing the effects of nZVI on growth rate, photosynthesis activity, and reactive oxygen activity (ROS) on the freshwater green algae Scenedesmus armatus and the cyanobacteria Microcystis aeruginosa. Moreover, microcystin production was also evaluated. These parameters were assessed on both organisms singly exposed to 72 h-effective nZVI concentration for 10% maximal response for 28 days. The results showed that the cell growth rate of S. armatus was initially significantly altered and progressively reached control-like values at 28 days post-exposure, while M. aeruginosa did not show any significant difference concerning control values at any time. In both strains dark respiration (R) increased, unlike net photosynthesis (Pn), while gross photosynthesis (Pg) only slightly increased at 7 days of exposure and then became equal to control values at 28 days of exposure. The nZVI nanoparticles generated ROS progressively during the 28 days of exposure in both strains, although their formation was significantly higher on green algae than on cyanobacteria. These data can provide additional information to further investigate the potential risks of nZVI and ultimately help decision-makers make better informed decisions regarding the use of nZVI for environmental remediation.

Quantitative evaluation of transdermal drug delivery patches on human skin with in vivo THz-TDS

Transdermal drug delivery (TDD) has been widely used in medical treatments due to various advantages, including delivering drugs at a consistent rate. However, variations in skin hydration can have a significant effect on the permeability of chemicals. Therefore, it is essential to study the changes in skin hydration induced by TDD patches for better control of the delivery rate. In this work, in vivo terahertz (THz) spectroscopy is conducted to quantitatively monitor human skin after the application of patches with different backing materials and propylene glycol concentrations. Changes in skin hydration and skin response to occlusion induced by other patches are investigated and compared. Our work demonstrates the potential application of in vivo THz measurements in label-free, non-invasive evaluation of transdermal patches on human skin and further reveals the mechanism behind the effect.

Combining conventional tree-ring measurements with wood anatomy and strontium isotope analyses enables dendroprovenancing at the local scale

Dendroprovenancing provides critical information regarding the origin of wood, allowing further insights into economic exploitation strategies and source regions of timber products. Traditionally, dendroprovenancing relies on pattern-matching of tree rings, but its spatial resolution is limited by the geographical coverage of species-specific chronologies available for crossdating and, in the case of short-distance trades, by scarce environmental variability. Here, we present an approach to provenance timber with high spatial resolution from forested areas that have been exploited intensively throughout history, with the aim to understand the sustainability of the various woodland management practices used to supply timber products. To this end, we combined tree-ring width (TRW), wood anatomical and geochemical analyses in addition to multivariate statistical validation procedures to trace the origin of living oak trees (Quercus robur) sampled in four stands located within a 30-km radius around the city of Limoges (Haute-Vienne, France). We demonstrate that TRW and wood anatomical variables (and in particular cell density) robustly discriminate the eastern from the western site, while failing to trace the origin of trees from the northern and southern sites. Here, strontium isotopic ratios (⁸⁷Sr/⁸⁶Sr) and Ca concentrations identify clusters of trees which could not be identified with TRW or wood anatomy. Ultimately, our study demonstrates that the coupling of wood anatomy with geochemical signatures allows to correctly pinpoint the origin of trees. Given the small geographic scale of our study and the limited differences in elevation and climate between study sites, our results are particularly promising for future dendroprovenancing studies. We thus conclude that the combination of multiple approaches will not only increase the accuracy of dendroprovenancing studies at local scales, but could also be implemented at much larger scales to identify trends in historic timber supply throughout Europe.

Stable Operation of a Free-Electron Laser Driven by a Plasma Accelerator

The breakthrough provided by plasma-based accelerators enabled unprecedented accelerating fields by boosting electron beams to gigaelectronvolt energies within a few centimeters [1-4]. This, in turn, allows the realization of ultracompact light sources based on free-electron lasers (FELs) [5], as demonstrated by two pioneering experiments that reported the observation of self-amplified spontaneous emission (SASE) driven by plasma-accelerated beams [6,7]. However, the lack of stability and reproducibility due to the intrinsic nature of the SASE process (whose amplification starts from the shot noise of the electron beam) may hinder their effective implementation for user purposes. Here, we report a proof-of-principle experiment using plasma-accelerated beams to generate stable and reproducible FEL light seeded by an external laser. FEL radiation is emitted in the infrared range, showing the typical exponential growth of its energy over six consecutive undulators. Compared to SASE, the seeded FEL pulses have energies 2 orders of magnitude larger and stability that is 3 times higher.

Bridging the gap of axonal regeneration in the central nervous system: A state of the art review on central axonal regeneration

Neuronal regeneration in the central nervous system (CNS) is an important field of research with relevance to all types of neuronal injuries, including neurodegenerative diseases. The glial scar is a result of the astrocyte response to CNS injury. It is made up of many components creating a complex environment in which astrocytes play various key roles. The glial scar is heterogeneous, diverse and its composition depends upon the injury type and location. The heterogeneity of the glial scar observed in different situations of CNS damage and the consequent implications for axon regeneration have not been reviewed in depth. The gap in this knowledge will be addressed in this review which will also focus on our current understanding of central axonal regeneration and the molecular mechanisms involved. The multifactorial context of CNS regeneration is discussed, and we review newly identified roles for components previously thought to solely play an inhibitory role in central regeneration: astrocytes and p75NTR and discuss their potential and relevance for deciding therapeutic interventions. The article ends with a comprehensive review of promising new therapeutic targets identified for axonal regeneration in CNS and a discussion of novel ways of looking at therapeutic interventions for several brain diseases and injuries.

Short introduction to JAHEE and Actions

Reducing health inequalities is on the agenda of many countries. Despite an increasing concern and awareness on health inequalities a wide gap exists in Europe in terms of political response. The main objective of JAHEE was to strengthen a cooperative approach among participating countries and implement concrete actions to reduce health inequalities. The partnership was composed of 24 countries including many strategically most relevant public health institutions in the European Union, which contributed with different backgrounds, skills and know-how to the achievement of the project objectives. The main results will be presented.

Poster No. 012 Premature myocardial infarction: a decade-long analysis of patients admitted to a single-center coronary care unit

Background

Despite being primarily a disease of older patients, acute myocardial infarction (AMI) has been increasingly recognized in young individuals. This study sought to characterize and determine the prognosis of AMI in patients aged ≤ 45 years old.

Methods

We retrospectively analyzed patients consecutively admitted to the coronary care unit with AMI. Two groups were identified: patients aged ≤ 45 and > 45 years old.

Results and conclusions

A total of 5696 AMI patients were included in the analysis: median age of 70 (IQR 19) years and 68.6% (n = 3906) were male; 5.6% (n = 318) of patients were aged ≤ 45 years old.

In contrast to the older patients, those aged ≤ 45 years old were more likely to be male (P < 0.001), presented more often with a history of smoking (P < 0.001), and family history of premature coronary artery disease (P < 0.001), but less often hypertension, hyperlipidemia, and diabetes.

In coronary angiography, most younger patients presented a single-vessel disease (57.1%), more commonly affecting the left anterior descending artery (51.7%); left main involvement was rare (0.8%); and 14.2% presented MINOCA (vs. 11.4% of older patients).

Regarding prognosis, 6.4% (n = 366) of patients died in the hospital and 24.2% (n = 1380) died during the 5-year follow-up. Younger patients had a lower risk of in-hospital mortality (OR 0.22, 95% CI 0.09–541, P = 0.001) and 5-year mortality (OR 0.12, 95% CI 0.06–0.201, P < 0.001), compared to the older patients.

In conclusion, patients with premature AMI have a different proportion of risk factors, less extensive coronary artery disease, and more commonly present MINOCA, compared to the older patients.

Impact of COVID-19 pandemic on inequalities in mortality: an analysis in Piedmont and Emilia-Romagna

Background

Italy was heavily hit by the COVID-19 pandemic. According to official statistics, during 2020 there were more than 75,000 excess deaths compared to the average expected mortality in 2015-2019. General mortality (GM) is a good measure of both the direct and indirect effects of the pandemic because it's exempt from potential bias due to misclassification of events. Evidence shows a greater burden of disease and mortality attributable to COVID-19 among disadvantaged populations, with the risk of an exacerbation of existing health inequalities. We aim to analyse the trend of social inequalities in mortality during the first pandemic year in two Italian regions (Piedmont and Emilia-Romagna) using data from Administrative Population Registries (APR) and statistical databases.

Methods

Data on deaths occurred between Jan 2015 and Jan 2021 in subjects ≥65, stratified by educational level, were obtained from Regional APR and the Census. Using a time series approach, we computed Standardized Mortality Rates (SMR), Relative Index of Inequalities (RII) and Slope Index of Inequalities (SII), adjusted by age, gender, month and region. SMR, RII and SII from March 2020 were forecasted using Holt-Winters method and compared to the observed values in the same period.

Results

SMRs were higher than expected during the two 2020 epidemic waves (Mar-Apr, Oct-Dec) in both regions. RII didn't increase significantly. Absolute inequalities instead rose in Piedmont during both pandemic waves, mostly among women, and in Emilia-Romagna in March among men.

Conclusions

The impact of the pandemic on inequalities in GM has been at least of the same size of the impact of other mechanisms of unequal mortality. APR coupled with sociodemographic data are a quick and reliable source for assessing the unequal impact of the COVID-19 pandemic on health. Further research is needed to explore mechanisms underlying these effects e.g. inequalities in cause-specific mortality and access to health services.

Key messages

Poster No. 106 Can we optimize d-dimer cut off value to predict pulmonary embolism in covid-19 patients?

Background

Covid-19 is associated with an increased risk of pulmonary embolism (PE) therefore, should the cut off d-dimer value be adjusted for these patients?

Material and methods

Retrospective and observational study to understand if there is a d-dimer cut-off that could guide clinics to perform a thoracic computed tomography angiography (CTA) in patients with covid-19. The population was covid-19 patients admitted to covid-19 dedicated wards of a University Hospital Centre for one year.

Results and conclusions

725 (52%) patients with covid-19 had a d-dimer value dosed during the first 5 days of the disease. Those, 63 (9%) did a CTA with a diagnosis of 16 (25%) PE. Gender was equally represented, median age was 70 years (ID = 3.49) and the majority (94%) survived. Thirteen (81%) patients with PE had a d-dimer value above 2500 ng/mL (OR = 9.244, 95% CI 2.248–9.837), with 7 (54%) with values over 10000 ng/mL, but in 3 (9%) it was under 1500 ng/mL. Seventy-three (63%) of patients with a d-dimer over 1500 ng/mL did not had a thoracic CTA performed. In our population PE was not a frequent outcome. The results are influenced by the low number of thoracic CTA performed because, even tough the cut-off d-dimer value used at our hospital to perform a thoracic CTA to exclude PE is 1500 ng/mL, most patients with that d-dimer value did not take the exam and so PE could not be excluded. Although in most PE cases the d-dimer value was above 2500 ng/mL, the results of our study cannot verify if that is a better cut-off value.

Oral Presentation No. 10 Pharmacological therapy in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): long-term prognosis

Background

The optimal management of myocardial infarction with nonobstructive coronary arteries (MINOCA) is still uncertain. This study sought to determine the association between pharmacological therapies after hospital discharge and the long-term prognosis of MINOCA patients.

Material and methods

We analyzed patients consecutively admitted to the coronary care unit with myocardial infarction (MI). Multivariate analysis was performed to determine which drugs were implicated in the prognosis of MINOCA patients. The primary endpoint was all-cause mortality at 5 years.

Results and conclusions

From a total of 3721 MI patients, MINOCA was identified in 11.6% (n = 430), of whom 56 (13.0%) experienced the primary endpoint. Median age was 66 years (IQR 19), and 51.6% (n = 222) of patients were male.

At discharge, 81.2% of MINOCA patients were prescribed aspirin, 87.4% a statin, 78.6% beta-blockers, and 66.7% angiotensin-converting enzyme inhibitors (ACEI). MINOCA patients were less likely to be prescribed these medications compared to patients with obstructive coronary artery disease (all P < 0.001). 1.4% (n = 6) of MINOCA patients died in the hospital, and the 5-year mortality rate was 13.0% (n = 56). In multivariate Cox regression, treatment with ACEI at discharge was found to be independently associated with a 5-year mortality benefit (HR = 0.29, 95% CI 0.12–0.67, adjusted P = 0.004) in MINOCA patients.

In conclusion, compared with patients with obstructive CAD, patients with MINOCA are less likely to be treated with secondary prevention drugs and are at lower risk of all-cause mortality during long-term follow-up. Treatment with ACEI seems to provide an additional mortality benefit in MINOCA patients.

Cardiac arrhythmias and conduction disorders monitoring after transcatheter aortic valve replacement procedure, using a mobile electrocardiogram 6 lead device

Background

In the early post transcatheter aortic valve replacement (TAVR) discharge era, rate of readmission for permanent pacemaker implantation (PPM-I) due to delayed conduction disturbances (CDs) has significantly increased. This issue has powered post procedural ambulatory electrocardiogram (AECG) monitoring by using implantable cardiac monitors or mobile cardiac telemetry devices, despite several disadvantages as frequent electrode changes and costs.

Purpose

In this scenario we aimed to evaluate the incidence of post-TAVR new onset arrhythmias and delayed CDs, performing an AECG monitoring through a 30s spot digital ECG (AeECG), by using a mobile electrocardiogram 6 lead (ME6L) device in a 30 days period after a TAVR procedure.

Methods

Between March 2021 and February 2022 we consecutively enrolled all patients undergoing a TAVR at the University Hospital of Pisa, excepting who already had a PM. At discharge, all patients received ME6L device and were asked to record a spot eECG for 1 month: 1 eECG per day during the first week and then 1 eECG per week. Clinical and follow-up data were collected and analyzed, and eECG scheduling compliance and quality recordings were explored.

Results

Among 185 consecutive TAVR patients, 12 were excluded due to pre-existing pacing device and 33 due to PPM-I <2 days post TAVR; 3 died before enrollment and 10 refused the enrollment; 18 were excluded because failed the ME6L training phase, 6 for severe postprocedural complications and the last 3 because affected by isolated aortic regurgitation.The remaining ones (100) had 30-day AeECG data. Delayed CDs with a Class I/IIa indications for PPM-Ioccurred in 8 patients with a median of 6 days (range 4–8 days) post-TAVR. New onset documented arrhythmias were AT/AF in 3 patients, isolated PVCs in 10 patients, and competitive transitory junctional rhythm in 2 patients. Delayed PPM-I versus non-delayed PPM-Ipatients were more likely to have a non-self-expandable valve (3 vs 69; p=0.02) and longer PR and QRS intervals at discharge (250.00±53,29 ms vs 179.17±39.17 ms; p=0,003; 125±33.38 ms vs 102.55±30.48 ms; p=0,04). The overall eECG schedule level compliance was 96.5%. Out of a total of 965 sent eECGs, 950 (98,4%) have been correctly recorded and transmitted.

Conclusion

Delayed CDs requiring PPM-I are the most important drawback of TAVR procedure. In our study, AeECG was seen to be safe and helpful in the identification and treatment of delayed CDs requiring PPM-I, with a very high eECG schedule level of compliance and quality. Further prospective studies are needed to better identify patient selection for outpatient monitoring, making safer and safer the early post TAVR discharge approach.

Funding Acknowledgement

Type of funding sources: None.

Comparing the long-term prognosis of myocardial infarction with non-obstructive coronary arteries to myocardial infarction with obstructive coronary artery disease

Background

The long-term survival rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients is lower than in the general population. Nevertheless, there are conflicting results regarding the prognosis of MINOCA patients in comparison to myocardial infarction with obstructive coronary artery disease (MI-CAD) patients.

Purpose

The aim of this study was to assess the long-term all-cause mortality of MINOCA patients and compare it to MI-CAD patients.

Methods

Retrospective analysis of 2443 consecutively admitted patients for acute myocardial infarction (AMI), in a single coronary intensive care unit. Only patients with 5 years of follow-up and those who died before the 5-year mark were considered. Patients were divided into two groups according to the presence or absence of obstructive coronary artery disease on angiography (≥50% stenosis). Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were compared using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Five-year all-cause mortality was the target endpoint. Five-year survival was modelled through the Cox proportional hazard regression model. The variable of interest (MINOCA vs MI-CAD) and possible confounders that displayed statistically significant differences in the initial demographic analysis were included in univariable Cox regressions, and those with statistically significant associations were included in a multivariable model. Those that displayed non-significant associations in the multivariable model were subsequently removed until we were left with significant associations only, giving us an adjusted hazard ratio.

Results

Comparison between groups is presented in table 1. MINOCA patients were younger and more often women. They were less likely to have smoking habits, diabetes, or a previous history of AMI. They had a lower Killip class, as well as lower troponin I, serum creatinine and low-density lipoprotein cholesterol at admission. On the other hand, they had higher left ventricular ejection fractions. They were also less likely to have beta-blockers or aspirin prescribed at discharge.

All-cause mortality at 5 years was 13.1% among MINOCA patients and 28.3% among MI-CAD patients, with an unadjusted hazard ratio (HR) of 0.421 (95% CI 0.322–0.550), p<0.001. Adjusting for known confounders, the HR was 0.461 (95% CI 0.261–0.816), p=0.008.

Conclusions

Compared with MI-CAD patients, those with MINOCA were slightly younger and had fewer comorbidities. In spite of having a worse long-term prognosis when compared to the general population, MINOCA patients have a significantly higher 5-year survival rate than MI-CAD patients, even after adjustment of confounding factors.

Funding Acknowledgement

Type of funding sources: None.

Early aortic valve replacement in asymptomatic severe aortic stenosis with preserved ejection fraction

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. Specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic AS patients with preserved ejection.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severeAS with preserved ejection fraction criteria. Random-effects meta-analysis was performed.

Results

Eight studies were included in which two were randomized clinical trials. A total of 2672 patients were included, providing a 642 pooled death events (327 in early-AVR and 941 in watchful waiting). In our meta-analysis, early-AVR revealed a significant lower all-cause mortality (pooled OR, 0.39; 95% CI [0.30, 0.51], P<0.01; I2=47%). Additionally, the early-AVR group presented a lower rate of cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I2=64%). Both strategies had similar rate of stroke (pooled OR, 1.30; 95% CI [0.39, 4.27], P=0.67; I2=0%) and myocardial infarction (pooled OR, 0.49; 95% CI [0.14, 1.78], P=0.28; I2=0%). Heart Failure hospitalizations presented a lower trend early-AVR group (pooled OR, 0.22; 95% CI [0.05, 1.08], P=0.36; I2=36%).

Conclusion

Our pooled data suggests that early-AVR strategy is preferable for asymptomatic severe AS patients with preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

Early intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. However, the specific timing of intervention for asymptomatic patients with severe AS remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic patients with AS.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for both interventional or observational studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

Results

Thirteen studies were included in which two were randomised clinical trials. A total of 4,679 patients were included, providing a 1,268 pooled death events (327 in early AVR and 941 in WW). Our meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group, although with a moderate amount of heterogeneity between studies in the magnitude of the effect (pooled odds ratio [OR], 0.41; 95% confidence interval [CI] 0.34, 0.50, P<0.01; I2=60%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I 2=64%) and heart failure hospitalisations (pooled OR 0.19; 95% CI [0.10, 0.39], P<0.01, I2=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI [0.73, 2.29], P=0.36, I2=0%) and myocardial infarction (pooled OR 0.49; 95% CI [0.19, 1.27], P=0.14, I2=0%).

Conclusions

Our pooled data suggest that an early-AVR strategy is preferable for asymptomatic patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.

Meta-analysis comparing outcomes in patients undergoing transcatheter aortic valve implantation with versus without percutaneous coronary intervention

Background

Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear.

Purpose

To compare the outcomes of PCI prior to TAVI in patients with significant coronary artery disease and severe aortic stenosis.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both retrospective and prospective studies comparing TAVI with PCI versus TAVI alone. Random-effects meta-analysis was performed.

Results

Eleven studies were included in which one was a randomized clinical trial. A total of 2530 patients were included, providing a 145 pooled death events (64 in TAVI with PCI and 81 in TAVI only). In terms of 30-day clinical outcomes, our pooled analysis revealed a similar all-cause mortality (pooled OR, 1.24; 95% CI [0.80, 1.93], P=0.34; I2=27% - Figure), cardiovascular mortality (pooled OR, 1.44; 95% CI [0.56, 3.75], P=0.45; I2=57%) and stroke (pooled OR, 1.07; 95% CI [0.53, 2.13], P=0.86; I2=0%). However, our analysis revealed a higher rate of myocardial infarction (pooled OR, 4.28; 95% CI [1.56, 11.69], P<0.01; I2=0%) and major bleeding events (pooled OR, 1.40; 95% CI [1.02, 1.93], P=0.04; I2=0%) in the TAVI with PCI group. A 1-year clinical outcomes analysis revealed a trend for lower all-cause mortality in TAVI only group (pooled OR, 1.37; 95% CI [0.98, 1.91], P=0.06; I2=0%), similar cardiovascular death rate (pooled OR, 1.15; 95% CI [0.70, 1.89], P=0.59; I2=6%) and major bleeding events (pooled OR, 1.62; 95% CI [0.95, 2.76], P=0.07; I2=0%).

Conclusion

Our pooled data suggests that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage.

Funding Acknowledgement

Type of funding sources: None.

Maximum dose sacubitril/valsartan in heart failure with reduced ejection fraction: does atrial fibrillation compromise the benefits?

Background

In the PARADIGM-HF trial, sacubitril/valsartan (SV) was shown to be superior to enalapril in reducing hospitalizations for worsening heart failure (HF), cardiovascular mortality, and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). The 2021 ESC Guidelines recommends SV as a replacement for angiotensin-converting-enzyme inhibitors to reduce the risk of HF hospitalization and death. There is little information regarding the effects of SV according to atrial fibrillation (AF) status.

Purpose

The aim of this study was to compare the effects of maximum dose SV regarding symptomatic improvement, change in natriuretic peptides levels (NP) and left ventricular ejection fraction (LVEF) in patients with HFrEF with and without AF.

Methods

Retrospective analysis of 137 patients with HFrEF on maximum dose SV (97/103mg twice daily). Patients were divided into two groups according to AF status. Age, gender, relevant comorbidities, usual medication, baseline symptomatic status, NP levels and LVEF were assessed using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Variation in NYHA class, NP levels and LVEF between baseline and 6-month follow-up was evaluated and compared between groups.

Results

Comparison between groups is presented in Table 1. In our studied population, ischemic aetiology was more common in the sinus rhythm group (49.5% vs 30.4%; p 0.034). There were no significant differences between groups regarding age, gender, hypertension, diabetes, and beta-blocker and mineralocorticoid receptor antagonist usage. At baseline, the AF group had higher NT-proBNP levels [median 1421 mg/dL (IQR 743–3087) vs 467 mg/dL (IQR 140–797); p<0.001]. There were no significant differences regarding baseline NYHA class or LVEF. After 6 months of follow-up, reductions in NYHA class [−1 (IQR −2, −1) for AF; −1 (IQR −1, 0) for SR; p=0.437] and NT-proBNP levels [−358 mg/dL (IQR −2275, −47) for AF; −162 mg/dL (IQR −364, 27) for SR; p=0.156], as well as LVEF improvement [11% (IQR 3–15) for AF; 12% (IQR 7–21) for SR; p=0.201], displayed no statistically significant differences between the two groups.

Conclusions

Our study shows that the beneficial effects of SV on symptomatic status, NP levels and LVEF were not compromised by the presence of AF at baseline.

Funding Acknowledgement

Type of funding sources: None.

Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

Background

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation.

Purpose

To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed.

Results

Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P<0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P<0.01; I2=27%).

Conclusions

Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention.

Funding Acknowledgement

Type of funding sources: None.

Factors associated with perceived performance drops and musculoskeletal injuries in Brazilian recreational triathletes

OBJECTIVE

The aim of the study was to investigate sleep characteristics, use of supplements, and training volume of recreational triathletes, and to verify possible associations with perceived performance drops and occurrence of injuries.

MATERIALS AND METHODS

Recreational triathletes (n=942) answered a questionnaire inquiring about their demographic characteristics, performance, injuries and training volume.

RESULTS

When comparing athletes who slept more (9-10 hours) with those who slept less, less sleep was associated with a higher prevalence of perceived performance drops. Regarding difficulties in initiating sleep, the absence of initiating difficulties (p<0.001) was a protective factor against perceived performance drops. Regarding weekly training volume, compared to those who trained more than 20 hours, training less than 3 hours (p<0.001), 3-5 hours (p<0.001), or 12-14 hours (p<0.001) were protective factors against perceived performance drops. Concerning training volume and injuries, we found that compared to those who trained more than 20 hours, training 18-20 hours (p<0.001), 15-17 hours (p<0.001), 12-14 hours (p<0.001), 6-8 hours (p<0.001), or 3-5 hours (p<0.001) were protective factors against injuries.

CONCLUSIONS

Triathletes with a lower sleep quantity and those who have difficulties initiating sleep frequently experience drops in performance. Training volumes can influence both performance and the likelihood of injuries.

Distant supervision for imaging-based cancer sub-typing in Intrahepatic Cholangiocarcinoma

Finding effective ways to perform cancer sub-typing is currently a trending research topic for therapy opti-mization and personalized medicine. Stemming from genomic field, several algorithms have been proposed. In the context of texture analysis, limited efforts have been attempted, yet imaging information is known to entail useful knowledge for clinical practice. We propose a distant supervision model for imaging-based cancer sub-typing in Intrahepatic Cholangiocar-cinoma patients. A clinically informed stratification of patients is built and homogeneous groups of patients are characterized in terms of survival probabilities, qualitative cancer variables and radiomic feature description. Moreover, the contributions of the information derived from the ICC area and from the peri tumoral area are evaluated. The findings suggest the reliability of the proposed model in the context of cancer research and testify the importance of accounting for data coming from both the tumour and the tumour-tissue interface. Clinical relevance - In order to accurately predict cancer prognosis for patients affected by ICC, radiomic variables of both core cancer and surrounding area should be exploited and employed in a model able to manage complex information.

The Histopathological Growth Pattern of Colorectal Liver Metastases Impacts Local Recurrence Risk and the Adequate Width of the Surgical Margin

BACKGROUND

The histopathological growth pattern (HGP) of colorectal liver metastases (CLM) has been associated with prognosis. This study was designed to elucidate if the HGP is associated with local recurrence risk and impacts the adequate width of surgical margin.

METHODS

All consecutive patients resected for CLM in 2018-2019 were considered. HGP was prospectively classified as follows: desmoplastic, pushing, and replacement. Surgical margin was classified as follows: R0 (margin ≥ 1 mm), R1vasc (0-mm margin, tumor detachment from intrahepatic vessels), and R1par (tumor exposure along transection plane). R0 resections were further distinguished in R0min (1-mm margin) and R0wide (> 1-mm margin).

RESULTS

A total of 340 resection areas in 136 patients were analyzed (70 R0min, 143 R0wide, 31 R1vasc, 96 R1par). HGP was desmoplastic in 26 cases, pushing in 221, and replacement in 93. Thirty-six local recurrences occurred (11%, median follow-up 21 months): 1 after R0wide, 4 after R0min, 3 after R1vasc, and 28 after R1par resection. In R1par group, local recurrence rate was high independently of HGP (29%). In R1vasc and R0min groups, local recurrence risk was higher in the replacement group (R1vasc: 29% vs. 4% if pushing/desmoplastic; R0min: 11% vs. 4%). In R0wide group, local recurrence risk was low for all HGP ( < 1%). Independent predictors of local recurrence were replacement HGP (odds ratio = 1.654, P = 0.036), and R1par resection (odds ratio = 57.209, P < 0.001 vs. R0).

CONCLUSIONS

Replacement HGP is associated with an increased risk of local recurrence. In these patients, a wide surgical margin should be pursued, because R1vasc and R0min resections could be insufficient. R1par resection is inadequate, independently of the HGP.

Free-electron lasing with compact beam-driven plasma wakefield accelerator

The possibility to accelerate electron beams to ultra-relativistic velocities over short distances by using plasma-based technology holds the potential for a revolution in the field of particle accelerators^1-4. The compact nature of plasma-based accelerators would allow the realization of table-top machines capable of driving a free-electron laser (FEL)⁵, a formidable tool to investigate matter at the sub-atomic level by generating coherent light pulses with sub-ångström wavelengths and sub-femtosecond durations^6,7. So far, however, the high-energy electron beams required to operate FELs had to be obtained through the use of conventional large-size radio-frequency (RF) accelerators, bound to a sizeable footprint as a result of their limited accelerating fields. Here we report the experimental evidence of FEL lasing by a compact (3-cm) particle-beam-driven plasma accelerator. The accelerated beams are completely characterized in the six-dimensional phase space and have high quality, comparable with state-of-the-art accelerators⁸. This allowed the observation of narrow-band amplified radiation in the infrared range with typical exponential growth of its intensity over six consecutive undulators. This proof-of-principle experiment represents a fundamental milestone in the use of plasma-based accelerators, contributing to the development of next-generation compact facilities for user-oriented applications⁹.

Tachydysrhythmias in patients admitted with COVID-19 pneumonia: prevalence and impact on in-hospital mortality

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality.

Purpose

Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality.

Methods

A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR).

Results

A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p &lt;0.001) and had more hypertension (p 0.034), heart failure (HF) (p &lt;0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA).

Patients with HF had the highest risk of tachyarrhythmia (OR 3.539; 95% CI 2.666-4.698; p &lt;0.001), followed by severe VHD (OR 1.990; 95% CI 1.192-3.365; p 0.009) and CAD (OR 1.575; 95% CI 1.040-2.386; p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819; 95% CI 1.272-2.602; p 0.001)

Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820; 95% CI 2.151-3.695; p &lt;0.001).

Conclusions

Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed.

Prevalence and impact of dysrhythmias in COVID-19 intensive care patients

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias.

Purpose

To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality.

Methods

A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables.

Results

The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016).

When adjusted for confounding variables, prone was the most significant predictor (OR 2.800; 95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484; 95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440; 95% CI 0.950-6.310; p 0.065).

Conclusions

COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias.

P326 SURGICAL VERSUS TRANSCATHETER AORTIC VALVE REPLACEMENT WITH NEWER GENERATION DEVICES IN REAL–WORLD PRACTICE: ONE–YEAR OUTCOMES FROM THE ITALIAN OBSERVANT STUDIES

Objective

To compare the early and 1–year outcomes after transcatheter aortic valve replacement (TAVR) with new–generation devices over surgical replacement (SAVR) among patients with severe aortic stenosis (AS).

Background

TAVR is gaining acceptance for the treatment of lower risk patients with AS after several randomized and observational studies confirmed comparable early results to SAVR. On the other hand, clinical studies have shown that SAVR is still widely used in intermediate and high risk patients. There is need of data from large clinical registries to demonstrate the efficacy and safety of TAVR in the real–world setting, particularly after the introduction of new TAVR technology.

Methods

A total of 5706 AS patients who underwent SAVR and 2989 AS patients who underwent TAVR enrolled in the national, prospective OBSERVANT and OBSERVANT II studies, respectively in 2010–2012 and 2016–2018, were analyzed. Outcomes were adjusted using the propensity score matching. The primary outcomes of interest were all–cause mortality, major adverse cardiac and cerebrovascular events (MACCEs) and hospital readmission due to heart failure at 1–year. Secondary outcomes were major adverse events occurring during the index hospitalization.

Results

Among 1008 propensity score matched pairs, TAVR was associated with significantly lower 30–day mortality (1.8 vs. 3.5%, p = 0.020), stroke (0.8 vs. 2.3%, p = 0.005), acute kidney injury (0.6 vs. 8.2%, p &lt; 0.001), infectious complications (3.8 vs. 6.5%, p = 0.006) and cardiogenic shock (1.4 vs. 5.1%, p &lt; 0.001) compared to SAVR. Moderate–to–severe paravalvular regurgitation (5.9 vs. 2.0%, p &lt; 0.001), major vascular complications requiring invasive treatment (2.2 vs. 0.1%, p &lt; 0.001) and permanent pacemaker implantation (during the index hospitalization, 13.8 vs. 3.3%, p &lt; 0.001) were more frequent after TAVR. At 1–year, TAVR was associated with lower risk of all–cause death (7.9 vs. 11.5%, p = 0.006), MACCE (12.0 vs. 15.8%, p = 0.011), readmission due to heart failure (10.8 vs. 15.9%, p &lt; 0.001) and stroke (3.2 vs. 5.1%, p = 0.033) compared to SAVR.

Conclusions

In a real–world setting, patients with intermediate operative risk treated with newer generation TAVR devices had a low risk of major adverse events during the index–hospitalization and at 1–year follow–up. TAVR could become the treatment of choice for AS in the elderly provided that its durability is proved by long–term follow–up studies.

Inflammation in acute coronary syndrome: prognostic significance

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with acute coronary syndrome (ACS) the acute phase reactant, C-reactive protein (CRP), might be significantly elevated. Several reports suggest that CRP may play a direct pathophysiological role on the development and progression of atherosclerosis, and CRP values correlate with infarct size when measured by magnetic resonance imaging.

Purpose

The aim of the present study was to evaluate the prognostic value of CRP in patients presenting with an ACS.

Methods

Retrospective analysis of 635 consecutively admitted patients due to ACS in a single coronary intensive care unit. CRP levels were measured at admission. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether CRP was an independent predictor of outcome.

Results

In the studied sample, 75% were male. Median age was 69 [interquartile range (IQR) 57–78]. ST-elevation myocardial infarction (STEMI) occurred in 39.6%, non-ST segment elevation myocardial infarction in 44.9% and unstable angina in 15.5% of the patients. Median left ventricular ejection fraction (LVEF) was 48% (IQR 40–55%) and median CRP level at admission 0.7 mg/dL (IQR 0.5–1.9 mg/dL). Regarding important comorbidities and past medical history, 75.9% had hypertension (HTN), 34.0% diabetes, 20.3% chronic kidney disease (CKD), 68.6% dyslipidaemia and 17.3% heart failure (HF). The median follow-up was 34 months (IQR 22–72). In univariate analysis, CRP was significantly associated with all-cause mortality (HR 1.06 per 1 mg/dL increase, 95% CI 1.04–1.08, p&lt;0.001), as was gender, age, LVEF, STEMI and previous history of diabetes, HTN, CKD or HF. In multivariate analysis, CRP remained significantly associated with the primary endpoint (HR 1.02, 95% CI 1.00–1.05, p=0.033), as did age, LVEF and previous history of HF.

Conclusions

In our study, CRP at admission was an independent risk factor for all-cause mortality following an ACS. This finding indicates that inflammation associated with the acute event has a significant impact in the long-term prognosis. More evidence is needed to determine if treating inflammation (and when, in the course of the disease) could result in better outcomes.

Anger, personality traits and psychopathological symptoms in subjects exposed to negative interpersonal actions in workplaces: an observational study in a large sample attending a Center for Occupational Stress

OBJECTIVE

The association between adverse working conditions and mental disorders is well established. In addition to psychopathological symptoms, this study aimed at investigating anger and personality traits in a clinical sample of subjects referring negative interpersonal experiences in workplaces.

METHODS

1676 workers attending a Centre for Occupational Stress in Milan (from 2014 to 2016) were administered an assessment protocol including SCL-90 for general psychopathology, STAXI for anger intensity and expression, and MMPI-2 for personality traits. A qualitative checklist was used to collect negative experiences in workplaces.

RESULTS

Patients reported they were exposed to "threats to the task or the professional career" more than to "attacks to the person". Over 80% scored above the cutoff in all the subscales of the SCL-90, with highest scores in Depression, Obsessive-Compulsive Disorder, Anxiety, Somatization and Paranoia. 60% scored above the 90th percentile in the AX/in subscale, showing intense anger feelings that they mostly suppress. Abnormal elevations at the MMPI scales of Hypochondria, Depression, Hysteria, and Paranoia were found in over 50% of the sample. Women reported higher psychological difficulties and internalized anger than men. Anger towards objects and people, instead, was more common in males. No differences were observed by work sector or employment status.

CONCLUSIONS

In addition to severe psychological difficulties, individuals reporting negative interpersonal experiences in workplaces have high levels of internalized anger and a distinctive profile of personality traits. While a deeper investigation is needed, anger expression should be considered in future treatment programs.

Acute intestinal ischemia in patients with COVID-19: single-centre experience and literature review

OBJECTIVE

Acute Intestinal ischemia (AII) may involve the small and/or large bowel after any process affecting intestinal blood flow. COVID-19-related gastrointestinal manifestations, including AII, have been attributed to pharmacologic effects, metabolic disorders in ICU patients and other opportunistic colonic pathogens. AII in COVID-19 patients may be due also to "viral enteropathy" and  SARS-CoV-2-induced small vessel thrombosis. A critical appraisal of personal experience regarding COVID-19 and AII was carried out comparing this with a systematic literature review of published series.

PATIENTS AND METHODS

  A retrospective observational clinical cohort study and a systematic literature review including only COVID-19 positive patients with acute arterial or venous intestinal ischemia were performed. The primary endpoint of the study was the mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay.

RESULTS

Patient mean age was 62.9±14.9, with a prevalence of male gender (23 male, 72% vs. 9 female, 28%). The mean Charlson Comorbidity Index was 3.1±2.7. Surgery was performed in 24/32 patients (75.0%), with a mean delay time from admission to surgery of 6.0 ±5.6 days. Small bowel ischemia was confirmed to be the most common finding at surgical exploration (22/24, 91.7%). Acute abdomen at admission to the ED (Group 1) was observed in 10 (31.2%) cases, while 16 (50%) patients developed an acute abdomen condition during hospitalization (Group 2) for SARS-CoV-2 infection.

CONCLUSIONS

Our literature review showed how intestinal ischemia in patients with SARS-CoV-2 has been reported all over the world. The majority of the patients have a high CCI with multiple comorbidities, above all hypertension and cardiovascular disease. GI symptoms were not always present at the admission. A high level of suspicion for intestinal ischemia should be maintained in COVID-19 patients presenting with GI symptoms or with incremental abdominal pain. Nevertheless, a prompt thromboelastogram and laboratory test may confirm the need of improving and fastening the use of anticoagulants and trigger an extended indication for early abdominal CECT in patients with suggestive symptoms or biochemical markers of intestinal ischemia.

Emergency hernia repair in the elderly: multivariate analysis of morbidity and mortality from an Italian registry

PURPOSE

The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed.

METHODS

This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed.

RESULTS

259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality CONCLUSION: Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation.

Are antigen tests useful as screening for the identification of SARS-CoV-2 in emergency rooms?

Background

A quick and accurate case identification in the Emergency Department (ED) during the SARS-CoV-2 pandemic is crucial for clinical management and to prevent spread of infections. The gold standard for diagnosing SARS-CoV-2 infection is the real-time reverse transcription polymerase chain reaction (RT-PCR) test in upper airways swabs. However, the procedure is available in few specialized laboratories and requires an average sample processing time of about 6 hours from its inception. The development of reliable but cheaper and faster point-of-care tests was expected to be useful either for population-screening or as first aid tests in the ED. Rapid antigenic diagnostic tests (Ag-RDTs), directly detect SARS-CoV-2 proteins produced by the replicating virus in respiratory specimens, were proved to be candidates in both cases. However, data on their effectiveness are still few and controversial. The aim of the study is to establish the accuracy of antigen tests to identify SARS-CoV-2 in a high prevalence setting.

Methods

Results of 324 patients, consecutively admitted to the ED of San Luigi Gonzaga University Hospital in Orbassano (Turin, Italy) between 26 October and 10 November 2020 and subjected to both molecular and antigen tests, were compared.

Results

Using RT-PCR as gold standard, specificity and sensitivity of Ag-RDT were 0.94 (95%CI: 0.90-0.98) and 0.80 (95%CI: 0.75-0.85), respectively. The Ag-RDT positive predictive value was 0.96 (95%CI 0.93- 0.99), and the negative predictive value was 0.72 (95% CI: 0.65-0.79). Patients that tested negative to Ag-RDT but presented with fever and cough or had pneumonia at imaging were more likely to be false negatives. Ag-RDTs best performance occurs in the first days after symptom onset.

Conclusions

These results confirm the limits of antigenic tests as first line screening tests and suggest that the antigenic test should be integrated with clinical judgement, based on physical and instrumental examinations.

Key messages

Antigenic tests have a limited effectiveness as first line screening tests. In a high-prevalence setting these tests incorrectly judge as negative many COVID-19 symptomatic patients, making necessary to integrate their results with clinical judgement.

Estimation of Excess Deaths in Turin from COVID-19 and other causes, October to November 2020

Introduction

Understanding the effect of COVID-19 on mortality during this emergency and evaluating unexplained increases in deaths due to nonspecific outcomes can provide a more complete picture of this period and give better instrument to deal with the pandemy in the future.

Objective

The aim is to evaluate in the city of Turin the excess in the number of deaths from October to November 2020.

Methods

The number of excess deaths was defined as the difference between the deaths observed in the pandemic period of 2020 and the deaths expected for the years 2014-2019.

Results

There were approximately 2047 total all causes deaths in Turin October 1 to November 30 2020, representing 630 more deaths than would typically be expected at that time of year. This excess was higher between men than in women. The number of excess all cause death was higher in 80 years old, less evident between 60-79 years old and very few between under 60 years old. Regarding the place of death, the number of excess all cause death was higher in hospital or in some health institutions for old people. Regarding the causes of deaths the explanation of these excess of deaths was COVID-19 infection only for a part of deaths and there are some excess of deaths not caused by COVID-19. The cause of excess of death not COVID-19 seems to be due to cardiovascular diseases, respiratory diseases, psychiatric disorders, neurological diseases, diabetes or nephrological diseases and to other undefinited causes.

Conclusions

The results showed during pandemic an increase of mortality respect to the expected mortality. Only a part of this excess deaths is due to COVID-19 but there is a relevant percentage of excess of deaths apparentely not due to COVID-19 but probably due to other causes. A better knowledge of these phenomena could help to improve any gaps in territorial assistance and provide indications for the future management of the pandemic in Europe.

Key messages

Increase of mortality in pandemic respect to the expected mortality. There is an excess of deaths apparentely not due to COVID-19.

Impact of the COVID-19 pandemic on emotional status of the adult and older population in Italy. Data from the behavioural risk factor surveillance systems PASSI and PASSI d’Argento, 2020-2021

PASSI and PASSI d'Argento are two nationwide ongoing population-based surveillance systems in Italy which targeting, respectively, adults aged 18-69 and over-65, aim at monitoring people health profile, as per health behaviours and their determinants. The Italian National Institute of Health is in charge of the central coordination, but the Local Health Units (LHUs) develop these surveillances. Specifically trained LHUs personnel conduct phone-interviews on gender and age-representative monthly samples of residents in Italy by using a standardised questionnaire. Within both systems, depressive symptoms are under investigation through the Patient Health Questionnaire-2. Since August 2020 to date, PASSI and PASSI d'Argento annexed a specific COVID module in addition to the standard questionnaires' sections. In this way, we have been studying the impact of the COVID-19 pandemic on economic and working conditions, emotional status and other health-related aspects, as well as those concerning contagion risk perception and its outcomes or citizens compliance with pandemic control measures. In detail, two questions detect the impact of the pandemic on emotional status: ‘intrusive thinking' as dimension of psychological stress associated to experiencing COVID-19 emergency, and ‘degree of concern' about the current situation as a dimension of anxiety. Even if the two items are not precise tools to assess mental health symptoms, they are in the condition to give hints for an estimation of the pandemic impact on the psychological well-being in the general population. Preliminary findings, from the analysis of 5,000 interviews, show quite direct experience of COVID (bereavements in family or COVID-positive friends), worsened economic resources among the working-age individuals, and social isolation in the elderly, as the main determinants of intrusive thinking. Being worried about pandemic also correlates with experience of COVID, showing significant differences by gender.

Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p&lt;0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.

Efficacy and safety of direct oral anticoagulants with diabetes and nonvalvular atrial fibrillation: a systematic review and meta-analysis

Background

Diabetes Mellitus (DM) is an independent risk factor for stroke and atrial fibrillation (AF). Therefore, the risk/benefit profile of the direct oral anticoagulants (DOAC) is of clinical interest.

Purpose

To compare efficacy and safety outcomes of DOAC for nonvalvular AF in patients with DM versus without DM.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in January 2020, for interventional studies comparing DOAC efficacy and safety in patients with AF and diabetes versus without diabetes.

Results

Four randomized clinical trials were included, providing a total of 63987 patients, 18860 with DM and 45127 without DM. In terms of efficacy, our meta-analysis revealed a similar rate of stroke/systemic embolism (pooled OR 1.02 [0.79, 1.31], P=0.87, I2=83%), stroke (pooled OR 1.98 [0.68, 1.40], P=0.90, I2=90%) and all-cause mortality (pooled OR 1.18 [0.97, 1.43], P=0.10, I2=87%), albeit with a significant heterogeneity. However, in direct factor Xa inhibitors sub analysis, diabetic patients had a lower trend of systemic embolism/stroke (pooled OR 0.90 [0.79, 1.02], P=0.09, I2=18%), significantly lower stroke rate (pooled OR 0.82 [0.73, 0.93], P&lt;0.01, I2=0%), but a higher all-cause mortality (pooled OR 1.08 [1.00, 1.16], P&lt;0.01, I2=0%). In terms of safety, the diabetic patients receiving DOAC had higher rates of major bleeding events (pooled OR 1.28 [1.14, 1.45], P&lt;0.01, I2=50%), although with significant heterogeneity. Direct factor Xa inhibitors sub analysis also revealed a higher rate of major bleeding events (pooled OR 1.22 [1.08, 1.38], P&lt;0.01, I2=24%), but a similar intracranial bleeding events (pooled OR 1.03 [0.86, 1.24], P=0.72, I2=0%).

Conclusion

Our pooled analysis suggests that diabetic patients on DOAC have an higher bleeding risk on DOAC, although with a superior embolic protection.

Funding Acknowledgement

Type of funding sources: None. Systemic Embolism/Stroke in DM vs. NonDM

Impact of the COVID-19 pandemic on emergent pacemaker implantation during lockdown and its aftermath

Background

COVID-19 was first considered a pandemic on the 11th of March of 2020 by the World Health Organization. Its impact comprised not only the direct consequences of the disease but a decrease in the follow-up and interventions of patients with cardiovascular (CV) disease. In Portugal and the World, the consequences of this complex paradigm shift on emergent pacemaker implantation rates during and after this pandemic is largely unknown.

Purpose

We sought to analyse the impact of COVID-19 pandemic on emergent pacemaker implantation rate and patient profile in a tertiary hospital during the first Portuguese lockdown and subsequent post-lockdown period.

Methods

We retrospectively reviewed the clinical profile of patients who had pacemakers implanted in our hospital in an urgent/emergent setting from March 18, 2020 to May 17, 2020 (lockdown) and May 19 to July 17, 2020 (post-lockdown). This data was then directly compared to the homologous periods from the year before (H1 and H2, respectively).

Results

A total of 180 patients submitted to emergent pacemaker implantation were included.

The cohort was comprised of 29 patients who had a pacemaker implanted during lockdown, 60 post-lockdown, 38 in H1 (+31% vs lockdown) and 53 in H2. Average age and gender proportion were similar for all groups.

When comparing lockdown and post-lockdown periods, the number of cases significantly increased in the second period (+106.9%) and there was a tendency for a higher number of temporary pacemaker use (3.4% vs 16.7%; p=0.076). Patients admitted during lockdown were 7.57 times more likely to present with hypotension/shock (odds ratio (OR) 7.57; p=0.013).

Regarding lockdown and its homologous 2019 period, there was a decrease in the number of patients admitted (−23.7%). Again, there was a higher tendency for hypotension on presentation during lockdown (p=0.054).

In comparison to its homologous 2019 period, post-lockdown saw a slight increase in the number of patients (+13.2%) and more patients presented with bradycardia (16.7% vs 3.8%; p=0.026).

Also of note, no patients were admitted to the emergency department during lockdown for anomalies detected on ambulatory tests (Holter, electrocardiogram or implanted loop recorder).

Conclusion

During lockdown, clinical presentation was generally more severe, with a greater number of patients presenting with hypotension/shock. In addition, there appears to be a lockdown effect on emergent bradyarrhtmias admissions in the post-lockdown period with a profound impact: higher admission rates and more severe presentations including a higher need of temporary pacemaker. Patients with symptoms suggestive of bradyarrhythmias should be advised to present promptly regardless of the pandemic.

Funding Acknowledgement

Type of funding sources: None. Pacemakers during lockdown/post-lockdownPacemakers implanted by diagnosis

Direct oral anticoagulants compared with vitamin K antagonists for left ventricular thrombi systematic review and meta-analysis

Background

Left ventricular thrombus (LVT) is a serious complication primarily occurring in patients with LV dysfunction following large myocardial infarction. The role of direct oral anticoagulants in this clinical setting remains controversial.

Purpose

To compare DOACs versus vitamin K antagonists (VKA) in LVT treatment.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for interventional or observational studies comparing DOAC with VKA on LVT treatment.

Results

Fourteen publications were included, nine published studies and five conference abstracts, providing 1899 patients, 490 patients on DOACs and 1409 subjects on VKA. In terms of efficacy, DOAC had a lower LVT resolution for all studies included which reported LVT resolution (pooled OR, 0.73; 95% CI, 0.55–0.98; P=0.04; I2=52%), but sensitivity analysis revealed no difference between anticoagulant strategy (pooled OR, 0.78; 95% CI, 0.57–1.05; P=0.10; I2=59%). In terms of systemic embolism or stroke, DOAC had a similar efficacy (pooled OR, 1.06; 95% CI, 0.69–1.63; P=0.78; I2=30%) compared to VKA. In clinically relevant bleeding events analysis, the anticoagulation strategy did not differ in the odds of bleeding (pooled OR, 0.65; 95% CI, 0.37–1.15 P=0.14; I2=0%), with similar findings in net adverse clinical events analysis (pooled OR, 0.66; 95% CI, 0.35–1.25; I2=54%; P=0.20).

Conclusion

Our pooled data suggests DOACs as a safe approach to LVT, despite inconsistent efficacy on LVT resolution.

Funding Acknowledgement

Type of funding sources: None.