An α-helical peptide-based plasmonic biosensor for highly specific detection of α-synuclein toxic oligomers

BACKGROUND

α-Synuclein (αS) aggregation is the main neurological hallmark of a group of neurodegenerative disorders, collectively referred to as synucleinopathies, of which Parkinson's disease (PD) is the most prevalent. αS oligomers are elevated in the cerebrospinal fluid (CSF) of PD patients, standing as a biomarker for disease diagnosis. However, methods for early PD detection are still lacking. We have recently identified the amphipathic 22-residue peptide PSMα3 as a high-affinity binder of αS toxic oligomers. PSMα3 displayed excellent selectivity and reproducibility, binding to αS toxic oligomers with affinities in the low nanomolar range and without detectable cross-reactivity with functional monomeric αS.

RESULTS

In this work, we leveraged these PSMα3 unique properties to design a plasmonic-based biosensor for the direct detection of toxic oligomers under label-free conditions.

SIGNIFICANCE AND NOVELTY

We describe the integration of the peptide in a lab-on-a-chip plasmonic platform suitable for point-of-care measurements of αS toxic oligomers in CSF samples in real-time and at an affordable cost, providing an innovative biosensor for PD early diagnosis in the clinic.

A Targetable N-Terminal Motif Orchestrates α-Synuclein Oligomer-to-Fibril Conversion

Oligomeric species populated during α-synuclein aggregation are considered key drivers of neurodegeneration in Parkinson's disease. However, the development of oligomer-targeting therapeutics is constrained by our limited knowledge of their structure and the molecular determinants driving their conversion to fibrils. Phenol-soluble modulin α3 (PSMα3) is a nanomolar peptide binder of α-synuclein oligomers that inhibits aggregation by blocking oligomer-to-fibril conversion. Here, we investigate the binding of PSMα3 to α-synuclein oligomers to discover the mechanistic basis of this protective activity. We find that PSMα3 selectively targets an α-synuclein N-terminal motif (residues 36-61) that populates a distinct conformation in the mono- and oligomeric states. This α-synuclein region plays a pivotal role in oligomer-to-fibril conversion as its absence renders the central NAC domain insufficient to prompt this structural transition. The hereditary mutation G51D, associated with early onset Parkinson's disease, causes a conformational fluctuation in this region, leading to delayed oligomer-to-fibril conversion and an accumulation of oligomers that are resistant to remodeling by molecular chaperones. Overall, our findings unveil a new targetable region in α-synuclein oligomers, advance our comprehension of oligomer-to-amyloid fibril conversion, and reveal a new facet of α-synuclein pathogenic mutations.

Characterisation of Portuguese radiotherapy departments: Organisation, occupational exposure values and diagnostic reference levels for breast and prostate computed tomography planning

INTRODUCTION

Portugal currently hosts 24 active radiotherapy departments, 8 public and 16 privates, presenting potential radiation exposure risks to multidisciplinary teams. Patients in these treatments also face ionising radiation during treatment planning and verification.

METHODS

Authorisation and ethical approval were secured for a national online survey, disseminated to radiotherapy departments across Portugal. The survey encompassed three sections: equipment, staff, and radiographer role characterisation; occupational exposure values for one month; and exposure parameters, including computed tomography (CT) dose values [CT dose index (CTDIvol) and dose length product (DLP)] for breast and prostate cancer CT planning. Local Diagnostic Reference Levels (DRLs) derived were based on the 75th percentile of median dose values.

RESULTS

The study garnered a 50% response rate from public institutions, 12,5% from private and 25% from all active radiotherapy institutions in Portugal. All departments employ Three-Dimensional Conformal Radiation Therapy (3D-CRT) and incorporate Intensity Modulated Radiation Therapy (IMRT) and/or Volumetric Modulated Arc Therapy (VMAT) irradiation techniques. Additionally, half of the departments also perform Brachytherapy (BT). Radiographers demonstrated an occupational dose of zero mSv. CT planning dose values were 13 mGy and 512 mGy cm for breast CT and 16 mGy and 689 mGy cm for prostate CT, pertaining to CTDIvol and DLP, respectively.

CONCLUSION

Most aspects of national radiotherapy characterisation align with the established literature. Occupational exposure values exhibited consistency across radiotherapy modalities. An approach to national DRLs was formulated for breast and prostate CT planning, yielding values congruent with recent European studies.

IMPLICATIONS FOR PRACTICE

This study offers vital insights for analysing occupational contexts and risk prevention, serving as the initial characterisation of the national radiotherapy landscape. It also pioneers the calculation of DRLs for CT planning in radiotherapy to optimise procedures.

aSynPEP-DB: a database of biogenic peptides for inhibiting α-synuclein aggregation

Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder, yet effective treatments able to stop or delay disease progression remain elusive. The aggregation of a presynaptic protein, α-synuclein (aSyn), is the primary neurological hallmark of PD and, thus, a promising target for therapeutic intervention. However, the lack of consensus on the molecular properties required to specifically bind the toxic species formed during aSyn aggregation has hindered the development of therapeutic molecules. Recently, we defined and experimentally validated a peptide architecture that demonstrated high affinity and selectivity in binding to aSyn toxic oligomers and fibrils, effectively preventing aSyn pathogenic aggregation. Human peptides with such properties may have neuroprotective activities and hold a huge therapeutic interest. Driven by this idea, here, we developed a discriminative algorithm for the screening of human endogenous neuropeptides, antimicrobial peptides and diet-derived bioactive peptides with the potential to inhibit aSyn aggregation. We identified over 100 unique biogenic peptide candidates and ensembled a comprehensive database (aSynPEP-DB) that collects their physicochemical features, source datasets and additional therapeutic-relevant information, including their sites of expression and associated pathways. Besides, we provide access to the discriminative algorithm to extend its application to the screening of artificial peptides or new peptide datasets. aSynPEP-DB is a unique repository of peptides with the potential to modulate aSyn aggregation, serving as a platform for the identification of previously unexplored therapeutic agents. Database URL:  https://asynpepdb.ppmclab.com/.

Arabidopsis metacaspase MC1 localizes in stress granules, clears protein aggregates, and delays senescence

Stress granules (SGs) are highly conserved cytoplasmic condensates that assemble in response to stress and contribute to maintaining protein homeostasis. These membraneless organelles are dynamic, disassembling once the stress is no longer present. Persistence of SGs due to mutations or chronic stress has been often related to age-dependent protein-misfolding diseases in animals. Here, we find that the metacaspase MC1 is dynamically recruited into SGs upon proteotoxic stress in Arabidopsis (Arabidopsis thaliana). Two predicted disordered regions, the prodomain and the 360 loop, mediate MC1 recruitment to and release from SGs. Importantly, we show that MC1 has the capacity to clear toxic protein aggregates in vivo and in vitro, acting as a disaggregase. Finally, we demonstrate that overexpressing MC1 delays senescence and this phenotype is dependent on the presence of the 360 loop and an intact catalytic domain. Together, our data indicate that MC1 regulates senescence through its recruitment into SGs and this function could potentially be linked to its remarkable protein aggregate-clearing activity.

Efficacy and safety of dolutegravir/rilpivirine in real-world clinical practice. GeSIDA study 1119

INTRODUCTION

Dolutegravir/rilpivirine (DTG/RPV) is an effective antiretroviral (ART) regimen endorsed by clinical trials as a switch therapy. The aim of our study was to analyse the efficacy and safety of DTG/RPV in real-world clinical practice.

METHODS

Observational, multicentre study of patients who started DTG/RPV. Efficacy, adverse events and metabolic changes at 48 weeks were analysed.

RESULTS

A total of 348 patients were included; median time of HIV infection was 21.1 years, 33.7% were AIDS cases; median nadir CD4 was 160 cells/μL; 90.5% had received ≥3 lines of ART and 179 (53.8%) had prior virological failure. Convenience (43.5%), toxicity/intolerance (28.4%) and interactions (17.0%) were the main reasons for starting DTG/RPV. Previous regimens were protease inhibitors (PI) (31.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI) (20.4%) and integrase strand transfer inhibitors (INSTI) (14.9%). Efficacy (HIV-RNA <50 copies/mL) at 48 weeks was 89.7% (95% CI 86.1-92.6) by intention-to-treat (ITT) and 94.2% (95% CI 91.3-96.4) by on treatment (OT); 10 patients (3.1%) were not suppressed (3 had abandoned ART). There was a mean decrease in triglycerides, total cholesterol, low-density lipoprotein-cholesterol, glutamic-pyruvic transaminase (GPT), gamma-glutamyl transferase (GGT) and alkaline phosphatase; creatinine increased with a decrease in glomerular filtration rate.

CONCLUSIONS

This study confirms the effectiveness, tolerability and safety of DTG/RPV in real-world clinical practice in a different population from clinical trials, with many years of infection, low CD4 nadir, several previous treatment lines, more than half with virological failures, and one-third diagnosed with AIDS. The switch to DTG/RPV was safe with few discontinuations due to adverse effects. Modifications of the lipid and liver profiles were favourable. There were no relevant changes in kidney function.

Plasma position measurements by O-mode and X-mode reflectometry systems in tokamak plasmas

Plasma Position Reflectometry (PPR) is planned to provide plasma position and shape information for plasma operation in future fusion reactors. Its primary function is to calibrate the drift of the magnetic signals due to the integral nature of magnetic measurement. Here, we attempt to measure plasma position using ordinary mode (O-mode) and extraordinary mode (X-mode) reflectometry systems on two tokamaks. A new physical model based on the phase shift is proposed to deduce the relative movement of the cut-off layer without density inversion. We demonstrate the plasma position measurements by absolute measurement from density profile inversion and relative measurement from phase shift. The combination of X-mode and O-mode reflectometers can minimize the limitations of single polarization reflectometry and further increase the accuracy of plasma position measurement. These results could provide an important technical basis for the further development of a real-time control system based on PPR.

Eco-toxicity assessment of industrial by-product-based alkali-activated binders using the sea urchin embryogenesis bioassay

New cement-based materials such as alkali-activated binders (AABs) or geopolymers allow the incorporation of waste or industrial by-products in their formulation, resulting an interesting valorization technique. Therefore, it is essential to inquire about the potential environmental and health impacts throughout their life cycle. In the European context, a minimum aquatic toxicity tests battery has been recommended for construction products, but their potential biological effects on marine ecosystems have not been considered. In this study, three industrial by-products, PAVAL® (PV) aluminum oxide, weathered bottom ash (WBA) resulting from incinerator bottom ash and glass cullet recycling waste (CSP), were evaluated as precursors in the AAB formulation from an environmental point of view. To determine the potential effects on marine environment caused by the leaching of contaminants from these materials into seawater, the leaching test EN-12457-2 and an ecotoxicity test using the model organism sea urchin Paracentrotus lividus were conducted. The percentage of abnormal larval development was selected as endpoint of the toxicity test. Based on the results obtained from the toxicity tests, AABs have less damaging impact (EC₅₀ values: 49.2%-51.9%) on the marine environment in general than raw materials. The results highlight the need to stablish a specific battery of toxicity tests for the environmental assessment of construction products on marine ecosystem.

Radiation protection measures used in Portuguese interventional radiology departments: A national survey

INTRODUCTION

This study aimed to characterise radiation protection (RP) measures used in interventional radiology (IR) departments in Portugal with respect to European and national recommendations.

METHODS

An online national survey was created to characterise the fluoroscopy technology as well as analyse the frequency of body fluoroscopy-guided intervention procedures (FGIP), RP education and training of the staff, and RP measures used daily.

RESULTS

In Portugal, most equipment for FGIP are single-sourced and have a flat panel detector (70%). The most commonly FGIP are percutaneous biliary drainage, percutaneous arterial and venous thrombolysis/thrombectomy, arteriovenous malformations embolization, and percutaneous transluminal balloon angioplasty for arteriovenous fistulas. Only a few staff members had received postgraduate education and training in RP (30%), with most nurses having not received RP education and training (40%). Some of the recommended RP measures lacked harmonisation. Additionally, >50% of the IR departments do not consider examination dose values to identify patients eligible for tissue reactions follow-up.

CONCLUSION

This is the first study to examine the characteristics of IR departments in Portugal. We observed a lack of RP education and training among staff members; further, there was a need to update some RP measures in some IR departments according to the recommendations.

IMPLICATIONS FOR PRACTICE

Our findings will be presented to the participating IR departments in order to update and promote RP best practices. Moreover, our findings will be presented to the national societies of the different professional groups in order to inform strategies for harmonising RP education and training of the staff.

External and internal load during the effort tests in different ages in young futsal players: association between leg power, shot speed and fatigue levels

Futsal is a sports game that features high intensity movements with change of speed or direction, present in several actions during the game. With this study is intended to analyse, compare and evaluate the predictive factor of leg power on shooting speed and fatigue levels in young futsal athletes in order to establish effort patterns in these ages, to prescribe training sessions adequately in terms of external/internal load. The study had 32 participants, male, aged between 12 and 17 years (Mean = 14.56}1.66). Participants were evaluated in relation to their lower limb power through the Chronojump system, the speed was measured through a radar placed on the goal line, and in relation to their fatigue levels through the Running Anaerobic Sprint Test (RAST). To identify the differences between groups, the tests of Kruskal Wallis and Mann Whitney were used, and also a simple linear regression tests for predictive values between variables. In relation to the shots speed, higher values were found in the older groups (P≤0.001), which is directly and significantly related to the higher values of lower limb power, also verified in the older athletes (P≤0.001). In relation to the fatigue levels, it increases as the age of the athletes is higher, verifying that the power of the lower limbs is a predictor variable of the fatigue index (P≤0.001). The analysis conducted indicate that there are significant differences in the association between shooting speed, lower limb power and fatigue indices according to the players levels studied.

Structural differences between hypoxanthine phosphoribosyltransferase family members highlight opportunities for antiparasitic drug design in neglected diseases

Approaches to identify novel druggable targets for treating neglected diseases include computational studies that predict possible interactions of drugs and their molecular targets. Hypoxanthine phosphoribosyltransferase (HPRT) plays a central role in the purine salvage pathway. This enzyme is essential for the survival of the protozoan parasite T. cruzi, the causal agent of Chagas disease, and other parasites related to neglected diseases. Here we found dissimilar functional behaviours between TcHPRT and the human homologue, HsHPRT, in the presence of substrate analogues that can lie in differences in their oligomeric assemblies and structural features. To shed light on this issue, we carried out a comparative structural analysis between both enzymes. Our results show that HsHPRT is considerably more resistant to controlled proteolysis than TcHPRT. Moreover, we observed a variation in the length of two key loops depending on the structural arrangement of each protein (groups D1T1 and D1T1'). Such variations might be involved in inter-subunit communication or influencing the oligomeric state. Besides, to understand the molecular basis that govern D1T1 and D1T1' folding groups, we explored the distribution of charges on the interaction surfaces of TcHPRT and HsHPRT, respectively. To know whether the rigidity degree bears effect on the active site, we studied the flexibility of both proteins. The analysis performed here illuminates the underlying reasons and significance behind each protein's preference for one or the other quaternary arrangement that can be exploited for therapeutic approaches.

Exploring cryptic amyloidogenic regions in prion-like proteins from plants

Prion-like domains (PrLDs) are intrinsically disordered regions (IDRs) of low sequence complexity with a similar composition to yeast prion domains. PrLDs-containing proteins have been involved in different organisms' regulatory processes. Regions of moderate amyloid propensity within IDRs have been shown to assemble autonomously into amyloid fibrils. These sequences tend to be rich in polar amino acids and often escape from the detection of classical bioinformatics screenings that look for highly aggregation-prone hydrophobic sequence stretches. We defined them as cryptic amyloidogenic regions (CARs) and recently developed an integrated database that collects thousands of predicted CARs in IDRs. CARs seem to be evolutionary conserved among disordered regions because of their potential to stablish functional contacts with other biomolecules. Here we have focused on identifying and characterizing CARs in prion-like proteins (pCARs) from plants, a lineage that has been poorly studied in comparison with other prionomes. We confirmed the intrinsic amyloid potential for a selected pCAR from Arabidopsis thaliana and explored functional enrichments and compositional bias of pCARs in plant prion-like proteins.

“Blocked broken heart syndrome”: an unusual case of a complete atrioventricular block complicating a Takotsubo cardiomyopathy

Background

Complete heart block is considered a unique and rare complication of Takotsubo cardiomyopathy, an otherwise self-resolving disease. When this occurs, there is a double clinical dilemma: first to find out which triggered the other and second, to decide whether or not to implant a permanent pacemaker.

Case presentation

We present a case of a 77 years-old female patient, with previous medical history of arterial hypertension, diabetes mellitus, dyslipidemia and bifascicular block known since 2013. She came to the emergency department after recurrent syncopal episodes. At admission a complete heart block was diagnosed, and it was implanted a single chamber temporary pacemaker. The patient remained in disproportional acute decompensated heart failure despite pacemaker implantation. She denied chest pain although referring an episode of self-limiting chest pain 2 days before, after an argument with the family. Blood analysis showed an important rise in NTproBNP and troponin levels. Transthoracic echocardiogram showed a dilated left ventricle with akinesia of apical and mid segments, hyperkinesia of basal segments and severely depressed left ventricle ejection fraction. Coronary angiography showed no significant lesions and the diagnosis of Takotsubo cardiomyopathy was suspected. During the following days, she recovered her own intrinsic rhythm. Electrocardiogram evolved with deep T-wave inversion and prolonged QT interval and transthoracic echocardiogram showed resolution of the previous alterations. Despite complete reversion of rhythm alteration, it was decided to implant a permanent pacemaker.

Conclusions

We describe a rare, life-threatening and often underdiagnosed complication of the stress cardiomyopathy. Furthermore, we performed a literature revision of this rare complication and discussed the therapeutic challenge encountered in such patients.

Economics and health economics as a major determinant towards HiAP

 

COVID-19 pandemic response was an opportunity to advocate for HiAP as everyone developed opinions on how policies could affect the different dimensions, including health and economy. Health planning, from the local to the international level, is the main setting where we still need to advocate for the inclusion of all political sectors and actors in order to ensure an effective HiAP implementation. From a more technical perspective, there is still a lot to do when it comes to implementing and improving economic evaluations, including on data on costs, valuing benefits or using cost-effectiveness approaches.

Speakers/Panellists

Nikhil Gokani

EUPHA-LAW

School of Law, University of Essex, Essex, UK

The HFFI, a new frailty index for assessing long-term outcomes in heart failure

Introduction

Patients hospitalized due to heart failure (HF) compose a heterogeneous population whose prognosis is difficult to forecast. Frailty is a well-recognized prognostic marker in multiple chronic diseases, including HF; however, frailty evaluation is often subjective and standardized and objective prediction models are lacking. We aimed to evaluate if an objective and simple index – Heart Failure Frailty Index (HFFI)– can predict long-term outcomes in this population.

Methods

A retrospective analysis of 258 patients admitted to a Cardiology ward due to HF was performed. The variables albumin, C-reactive protein levels, age and body mass index (BMI) were selected for frailty assessment. After attributing points for each variable, according to odds ratio on univariate analysis, the HFFI was calculated (range 0–8), resulting from the sum of the points attributed to each variable. Kaplan-Meyer and Cox-regression analysis were performed to evaluate HFFI association with 24-month mortality (24MM) and 24-month composite endpoint of rehospitalization or death (24MH).

Results

Mean patient age was 75 (±11) years; 51% were men. 45.7% had atrial fibrillation, 15.9% hat history of acute myocardial infarction, 67.8% had hypertension. Mean LVEF was 47% (±17). A LVEF &lt;40% was present in 40% of patients. 24MM was 11.5% and 24 MH was 58%. Patients were considered frail if they had an HFFI ≥3. Kaplan-Meyer curve analysis revealed a significantly lower median time to 24MM in frail patients, as assessed by HFFI, comparing to non-frail patients (585±33 days vs 697±12 days, mortality rate: 25.4% vs 5.7%, χ2=18.156, p&lt;0.001). There was also a significantly lower median time to 24MH in frail patients (336±34 days vs 449±24 days, combined endpoint rate: 76.1% vs 50.3%, χ2=10.884, p=0.001). Cox regression analysis demonstrated that HFFI independently predicts 24MM (HR: 1.364, p=0.002) and 24MH (HR: 1.106, p=0.035), even after adjustment for other prognostic markers, such as history of atrial fibrillation, previous myocardial infarction, diabetes and natriuretic peptides serum level at index event.

Conclusion

HFFI is a simple and objective frailty index correlated with 24MM and 24MH, being an independent prognostic marker in this population. Its use may help to identify patients with a high risk of mortality or readmission, in need of specialized care.

Funding Acknowledgement

Type of funding sources: None.

What are the NEWS in pulmonary embolism risk stratification?

Introduction

The patients with Pulmonary Thromboembolism (PE) stratified as intermediate-high risk with the European Society of Cardiology classification represent an heterogenous population, with the majority having a benign outcome however some evolving in clinical deterioration. Several risk scores have been developed to try and refine the population most at risk but they are deemed sub-optimal.

Purpose

Our aim was to assess the capacity of the National Early Warning Score (NEWS) in predicting a composite end-point of 30-days cardiovascular mortality, rescue thombolysis and/or haemodynamic instability, in a population of intermediate-high risk PE, as compared with other risk evaluation scores as the PESI and SHIeLD scores.

Methods

We performed a retrospective analysis between 2014 and 2019 of all patients admitted for intermediate-high risk PE, in a single expert centre. The patients who underwent fibrinolysis as per clinician discretion (without haemodynamically instability or clinical evidence of clinical deterioration) were excluded. Medical records were analysed for clinical data and outcomes. The predictive accuracy of all scores were assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between NEWS and composite end-point at 30-days was analyzed using a Cox regression model.

Results

Of the 1132 patients assessed and admitted with PE, 116 patients fulfilled all inclusion criteria and none of the exclusion criteria and were analysed. The mean age was 69±16 years at time of diagnosis with a female preponderance (62.9%). Most patients were treated with anticoagulation (97.4%), 68% with low molecular weight heparin and the remaining with unfractionated heparin. The average NEWS score was 7±3, the average PESI score was 110±34 and the average SHIeLD score was 14±13. A primary composite end-point occurred in 18 patients (15.5%). The NEWS score showed the greatest predictive power for the occurrence of an event (OR 1.35; 95% CI 1.11–1.64, p=0.003) compared with the SHIeLD score (OR 1.0; 95% CI 1.00–1.07, p=0.035) and the PESI score (OR 1.02; 95% CI 1.00–1.03, p=0.03); it also showed a greatest discriminative capacity with the ROC curve analysis (Figure 1A) demonstrating an AUC of 0.70, vs 0.65 and 0.62 respectively. The survival analysis demonstrated a Hazard Ratio of 1.29 (95% CI 1.10–1.52; p=0.002) signifying a 29% increased risk of an event per each NEWS class increase, with the Kaplan Meier curves widening significantly in the different terciles of the score (Figure 1B).

Conclusions

In PE patients with intermediate-high risk the NEWS score demonstrated a greater predictive power and discriminative capacity than other commonly used risk scores. The NEWS score may help to identify patients in this risk category who might benefit from a reperfusion strategy, but larger studies are needed to confirm this hypothesis.

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.

Feasibility assessment of the Eye Scan Ultrasound System for cataract characterization and optimal phacoemulsification energy estimation: protocol for a pilot, nonblinded and monocentre study

Background

Cataracts are lens opacifications that are responsible for more than half of blindness cases worldwide, and the only treatment is surgical intervention. Phacoemulsification surgery, the most frequently performed cataract surgery in developed countries, has associated risks, some of which are related to excessive phacoemulsification energy levels and times. The protocol proposed in herein will be used to evaluate the feasibility of a new experimental medical device, the Eye Scan Ultrasound System (ESUS), for the automatic classification of cataract type and severity and quantitative estimation of the optimal phacoemulsification energy.

Methods

The pilot study protocol will be used to evaluate the feasibility and safety of the ESUS in clinical practice. The study will be conducted in subjects with age-related cataracts and on healthy subjects as controls. The procedures include data acquisition with the experimental ESUS, classification based on the Lens Opacity Classification System III (LOCS III, comparator) using a slit lamp, contrast sensitivity test, optical coherence tomography, specular microscopy and surgical parameters.

ESUS works in A-scan pulse-echo mode, with a central frequency of 20 MHz. From the collected signals, acoustic parameters will be extracted and used for automatic cataract characterization and optimal phacoemulsification energy estimation.

The study includes two phases. The data collected in the first phase (40 patients, 2 eyes per patient) will be used to train the ESUS algorithms, while the data collected in the second phase (10 patients, 2 eyes per patient) will be used to assess the classification performance. System safety will be monitored during the study.

Discussion

The present pilot study protocol will evaluate the feasibility and safety of the ESUS for use in clinical practice, and the results will support a larger clinical study for the efficacy assessment of the ESUS as a diagnostic tool. Ultimately, the ESUS is expected to represent a valuable tool for surgical planning by reducing complications associated with excessive levels of phacoemulsification energy and surgical times, which will have a positive impact on healthcare systems and society. The study is not yet recruiting.

Trial registration

ClinicalTrials.gov identifier NCT04461912, registered on July 8, 2020.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

CARs-DB: A Database of Cryptic Amyloidogenic Regions in Intrinsically Disordered Proteins

Proteome-wide analyses suggest that most globular proteins contain at least one amyloidogenic region, whereas these aggregation-prone segments are thought to be underrepresented in intrinsically disordered proteins (IDPs). In recent work, we reported that intrinsically disordered regions (IDRs) indeed sustain a significant amyloid load in the form of cryptic amyloidogenic regions (CARs). CARs are widespread in IDRs, but they are necessarily exposed to solvent, and thus they should be more polar and have a milder aggregation potential than conventional amyloid regions protected inside globular proteins. CARs are connected with IDPs function and, in particular, with the establishment of protein-protein interactions through their IDRs. However, their presence also appears associated with pathologies like cancer or Alzheimer’s disease. Given the relevance of CARs for both IDPs function and malfunction, we developed CARs-DB, a database containing precomputed predictions for all CARs present in the IDPs deposited in the DisProt database. This web tool allows for the fast and comprehensive exploration of previously unnoticed amyloidogenic regions embedded within IDRs sequences and might turn helpful in identifying disordered interacting regions. It contains >8,900 unique CARs identified in a total of 1711 IDRs. CARs-DB is freely available for users and can be accessed at http://carsdb.ppmclab.com. To validate CARs-DB, we demonstrate that two previously undescribed CARs selected from the database display full amyloidogenic potential. Overall, CARs-DB allows easy access to a previously unexplored amyloid sequence space.

A-17 Effects Of Parental Mental Health On Patient and Parent-Reported Anxiety Symptoms Following Concussion In Adolescents

Purpose: Examine the impact of parental mental health history on patient and patent-reported post-concussion symptoms of anxiety. Methods: Participants included 105 adolescents (42.9% male), 12–18 years old, including concussion patients (n = 72, 3.42 ± 1.7 days post-injury) and age-and-sex matched controls (n = 33). Patients and parents completed the Screen for Child Anxiety Disorders, Parent and Child versions (SCARED-P, SCARED-C) and medical histories. T-tests were used to compare control/concussed responses on the SCARED. Logistic regression (LR) was used to evaluate group predictors, as well as high/low (i.e., &gt;21 PCSS total score) concussion symptom groups at 30 days post-injury. Results: Results indicated that concussed SCARED-C (controls: M = 7.88 SD = 7.55, concussed: M = 13.4 SD = 11.42), (t[103] = −2.53, p = 0.01) and SCARED-P (controls: M = 3.55 SD = 3.62, concussed: M = 6.72 SD = 7.12), (t[103] = −2.42, p &lt; 0.01) scores were higher than controls. SCARED-C/SCARED-P scores were not predictive of high/low symptom report at 30 days post-injury, X2(2, n = 59) = 3.46, p = 0.18. The stepwise LR model was significant, X2(1, n = 105) = 7.34, p = 0.007; SCARED-C scores were predictive of concussion group inclusion, SCARED-P scores were not. In analyses of only patients whose parent reported a mental health history (22/105, 21%), there was no significant difference between control and patients on the SCARED-C, t(20) = −1.82, p = 0.08, or SCARED-P, t(20) = −0.34, p = 0.74. SCARED-C/SCARED-P scores did not predict control/concussion group inclusion, X2(2, n = 22) = 5.04, p = 0.08. Conclusions: SCARED-P/SCARED-C scores effectively differentiated between groups: patients and parents reported higher anxiety symptoms. The inclusion of parents with mental health diagnoses precluded the SCARED from differentiating controls from patients.

P-247 Fresh oocyte donation, the use of donor sperm, and the number of usable blastocysts are associated with higher clinical pregnancy rates: results from 1655 cycles

Study question

What are the factors associated with clinical pregnancy in the first single embryo transfer of an oocyte donation treatment?

Summary answer

The number of blastocysts and the use of donor sperm were positively correlated with clinical pregnancy, while the use of vitrified/warmed oocytes was negatively correlated.

What is known already

The use of donor oocytes for in vitro fertilization treatments is often necessary to overcome infertility. The number of donor oocytes allocated to each recipient is a key variable to the cumulative success of these treatments. However, time to pregnancy is another key metric in assisted reproduction, and it is important to achieve a better understanding of the factors influencing the success of the first embryo transfer of an oocyte donation treatment.

Study design, size, duration

A retrospective study was conducted to analyze the outcome of the first single blastocyst transfer of 1665 oocyte donation cycles, from 8 private IVF units, from July 2018 to July 2021. Patients who underwent multiple cycles were only included in the study once, during their first treatment. The endpoint of the study was the clinical pregnancy rate, defined by the presence of a gestational sac confirmed by ultrasound one month after the transfer.

Participants/materials, setting, methods

All cycles during the study period, using donor oocytes, resulting in a first fresh or frozen single blastocyst transfer were analyzed. Cases that used PGT-A or sperm from testicular biopsy were excluded. Multiple logistic regression was used to determine the association of the variables: patient age, sperm origin, vitrified/warmed oocytes, fertilization and blastocyst development rate, total number of usable blastocysts obtained, fresh/frozen transfer, and embryonic day at transfer.

Main results and the role of chance

A total of 972 (58.4%) embryo transfers resulted in a clinical pregnancy in the study population. The mean age of the recipient and male partner was 42±4.4 years and 42.1±6.0 years, respectively, and did not differ between positive and negative transfer groups. Statistically significant higher pregnancy rates were observed for day 5 transfers vs. day 6 (59% vs 46%) and fresh vs. vitrified/thawed oocytes (64% vs. 55%). The mean number of zygotes (5.1 vs. 4.8, p = 0.032), the mean fertilization rate (76.3% vs. 72.8%, p = 0.007), the mean usable blastocyst development rate (60.0% vs. 57.7%, p = 0.006) and the mean total number of usable blastocysts (2.9 vs. 2.6, p &lt; 0.001) were higher in clinical pregnancy group.

The results of multiple logistic regression showed that the use of sperm donor increased the chances of achieving a clinical pregnancy rate in the first embryo transfer (OR 1.36, 1.04-1.79), and the use of vitrified/thawed oocytes reduced them (OR 0.69, 0.56-0.85). There was a positive association with a higher number of usable blastocysts obtained in a cycle, and higher pregnancy rates (OR 1.16, 1.07-1.26), presumably by allowing for additional morphological embryo selection.

Limitations, reasons for caution

Certain confounding factors were not accounted for: variability of results between the different IVF units, endometrial preparation protocols, post-warming embryo morphology, sperm analysis diagnostic, as well as variability in recipients’ and donors’ baseline characteristics.

Wider implications of the findings

Factors of an oocyte donation treatment influencing the outcome of the first embryo transfer were identified. A better understanding of these factors, and interactions amongst them, is key to maximize the efficacy of these treatments, and achieve an optimal use of a limited resource such as donated oocytes.

Trial registration number

not applicable

Developing and validating high-value patient digital follow-up services: a pilot study in cardiac surgery

Background

The existing digital healthcare solutions demand a service development approach that assesses needs, experience, and outcomes, to develop high-value digital healthcare services. The objective of this study was to develop a digital transformation of the patients’ follow-up service after cardiac surgery, based on a remote patient monitoring service that would respond to the real context challenges.

Methods

The study followed the Design Science Research methodology framework and incorporated concepts from the Lean startup method to start designing a minimal viable product (MVP) from the available resources. The service was implemented in a pilot study with 29 patients in 4 iterative develop-test-learn cycles, with the engagement of developers, researchers, clinical teams, and patients.

Results

Patients reported outcomes daily for 30 days after surgery through Internet-of-Things (IoT) devices and a mobile app. The service’s evaluation considered experience, feasibility, and effectiveness. It generated high satisfaction and high adherence among users, fewer readmissions, with an average of 7 ± 4.5 clinical actions per patient, primarily due to abnormal systolic blood pressure or wound-related issues.

Conclusions

We propose a 6-step methodology to design and validate a high-value digital health care service based on collaborative learning, real-time development, iterative testing, and value assessment.

The small aromatic compound SynuClean-D inhibits the aggregation and seeded polymerization of multiple α-synuclein strains

Parkinson’s disease is a neurodegenerative disorder characterized by the loss of dopaminergic neurons in the substantia nigra, as well as the accumulation of intraneuronal proteinaceous inclusions known as Lewy bodies and Lewy neurites. The major protein component of Lewy inclusions is the intrinsically disordered protein α-synuclein (α-Syn), which can adopt diverse amyloid structures. Different conformational strains of α-Syn have been proposed to be related to the onset of distinct synucleinopathies; however, how specific amyloid fibrils cause distinctive pathological traits is not clear. Here, we generated three different α-Syn amyloid conformations at different pH and salt concentrations and analyzed the activity of SynuClean-D (SC-D), a small aromatic molecule, on these strains. We show that incubation of α-Syn with SC-D reduced the formation of aggregates and the seeded polymerization of α-Syn in all cases. Moreover, we found that SC-D exhibited a general fibril disaggregation activity. Finally, we demonstrate that treatment with SC-D also reduced strain-specific intracellular accumulation of phosphorylated α-Syn inclusions. Taken together, we conclude that SC-D may be a promising hit compound to inhibit polymorphic α-Syn aggregation.

Oral conditions and salivary analysis in HIV-uninfected subjects using preexposure prophylaxis

Background

New prevention strategies have been advocated to control the progression of HIV/AIDS, such as preexposure prophylaxis (PrEP). The aim of this study is to evaluate the potential changes in the oral and salivary conditions of HIV-uninfected subjects using PrEP.

Material and Methods

Subjects were evaluated before beginning the medication (T0), at the first follow-up (T1), and at the second follow-up (T2). Xerostomia, presence of untreated cavitated caries, oral hygiene habits, taste, gingival and plaque index, stimulated salivary flow rate (SSFR), and salivary concentrations of calcium, glucose, urea, and total proteins were evaluated. Data obtained were analyzed using statistical tests (p<0.05).

Results

Forty-seven participants (41 men; 6 women) were evaluated at T0. Thirty (28 men; 2 women) and 17 men were reassessed at T1 and T2, respectively. There was no difference between the SSFR and oral and salivary conditions between T0, T1, and T2 (p>0.05), except for the salivary calcium concentration, that increased at T2 compared to T1 (p=0.02). There was significant difference between taste and xerostomia at T1 (p=0.017), and the need to drink to swallow at T2 (p=0.015). There was significant correlation between the reported amount of saliva and taste (p=0.039, r=-0.378) at T1.

Conclusions

The prolonged use of PrEP seems to be associated with reports of dry mouth and worsening of taste, possibly associated with increased salivary calcium concentration.

Key words:Antiretroviral agents, pre-exposure prophylaxis, saliva, oral health.

DisProt in 2022: improved quality and accessibility of protein intrinsic disorder annotation

The Database of Intrinsically Disordered Proteins (DisProt, URL: https://disprot.org) is the major repository of manually curated annotations of intrinsically disordered proteins and regions from the literature. We report here recent updates of DisProt version 9, including a restyled web interface, refactored Intrinsically Disordered Proteins Ontology (IDPO), improvements in the curation process and significant content growth of around 30%. Higher quality and consistency of annotations is provided by a newly implemented reviewing process and training of curators. The increased curation capacity is fostered by the integration of DisProt with APICURON, a dedicated resource for the proper attribution and recognition of biocuration efforts. Better interoperability is provided through the adoption of the Minimum Information About Disorder (MIADE) standard, an active collaboration with the Gene Ontology (GO) and Evidence and Conclusion Ontology (ECO) consortia and the support of the ELIXIR infrastructure.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Prediction of the Effect of pH on the Aggregation and Conditional Folding of Intrinsically Disordered Proteins with SolupHred and DispHred

Proteins microenvironments modulate their structures. Binding partners, organic molecules, or dissolved ions can alter the protein's compaction, inducing aggregation or order-disorder conformational transitions. Surprisingly, bioinformatic platforms often disregard the protein context in their modeling. In a recent work, we proposed that modeling how pH affects protein net charge and hydrophobicity might allow us to forecast pH-dependent aggregation and conditional disorder in intrinsically disordered proteins (IDPs). As these approaches showed remarkable success in recapitulating the available bibliographical data, we made these prediction methods available for the scientific community as two user-friendly web servers. SolupHred is the first dedicated software to predict pH-dependent aggregation, and DispHred is the first pH-dependent predictor of protein disorder. Here we dissect the features of these two software applications to train and assist scientists in studying pH-dependent conformational changes in IDPs.

A3D 2.0 Update for the Prediction and Optimization of Protein Solubility

Protein aggregation propensity is a property imprinted in protein sequences and structures, being associated with the onset of human diseases and limiting the implementation of protein-based biotherapies. Computational approaches stand as cost-effective alternatives for reducing protein aggregation and increasing protein solubility. AGGRESCAN 3D (A3D) is a structure-based predictor of aggregation that takes into account the conformational context of a protein, aiming to identify aggregation-prone regions exposed in protein surfaces. Here we inspect the updated 2.0 version of the algorithm, which extends the application of A3D to previously inaccessible proteins and incorporates new modules to assist protein redesign. Among these features, the new server includes stability calculations and the possibility to optimize protein solubility using an experimentally validated computational pipeline. Finally, we employ defined examples to navigate the A3D RESTful service, a routine to handle extensive protein collections. Altogether, this chapter is conceived to train and assist A3D non-experts in the study of aggregation-prone regions and protein solubility redesign.

Integrating ecosystem services into sustainable landscape management: A collaborative approach

The Paiva River is considered one of the least polluted rivers in Europe and its watershed has a high conservation value. However, the Paiva River basin suffers pressures related with recurrent disturbances in land use, such as forest fires, agricultural activities, urbanization and pressures that affect the natural hydromorphological conditions and the continuity of watercourses. Blue and Green Infrastructures (BGINs) emerge to improve biodiversity, sustainability and the supply of ecosystem services while improving socioeconomic aspects. Thus, this article aims to identify priority areas in the basin, for intervention with these infrastructures. For that, a spatial multicriteria decision analysis (MDCA) was carried out according to several data related to the Paiva River Basin. As local politicians and responsible entities for the natural resources management are the main experts on the problems and their possible solutions at the local level, they were involved in this decision-making model. Therefore, these specialized stakeholders did the weighting assignment according to the most or least importance of the same for the work. The map of priority locations to implement BGINs was obtained in the sequel. To the top 5 priority areas, stakeholders attributed the best solutions based on nature. The most recommended BGINs were recovery/maintenance of riparian vegetation and conservation and reforestation of the native forest, both presented in four of the five areas, and introduction of fuel management strips presented in three of the five areas. Thus, we concluded that it is extremely important to include the communities and the competent entities of nature and environment management in scientific projects related to conservation, forming a synergy that makes it possible to combine scientific knowledge with local experience acquired in the field. This project uses a very flexible methodology of local data and can be a great example to be implemented in other hydrographic basins anywhere in the world.

DispHScan: A Multi-Sequence Web Tool for Predicting Protein Disorder as a Function of pH

Proteins are exposed to fluctuating environmental conditions in their cellular context and during their biotechnological production. Disordered regions are susceptible to these fluctuations and may experience solvent-dependent conformational switches that affect their local dynamism and activity. In a recent study, we modeled the influence of pH in the conformational state of IDPs by exploiting a charge–hydrophobicity diagram that considered the effect of solution pH on both variables. However, it was not possible to predict context-dependent transitions for multiple sequences, precluding proteome-wide analysis or the screening of collections of mutants. In this article, we present DispHScan, the first computational tool dedicated to predicting pH-induced disorder–order transitions in large protein datasets. The DispHScan web server allows the users to run pH-dependent disorder predictions of multiple sequences and identify context-dependent conformational transitions. It might provide new insights on the role of pH-modulated conditional disorder in the physiology and pathology of different organisms. The DispHScan web server is freely available for academic users, it is platform-independent and does not require previous registration.

COVID-19 vaccination: what are the costs we should include?

As for previous communicable diseases, the vaccine against SARS-CoV-2 can be a truly “game-changing” factor to tackle the COVID-19 pandemic. A lot has been discussed about what is the less expensive vaccine and how health expenditures might be overrun with pandemic containment measures. There are interesting questions on cost estimation of this technology that should be discussed. The focus has been mainly on vaccine costs rather than on immunization delivery costs, which might also represent an important constraint. This includes human resources, equipment or maintenance which cannot be ignored. Such programs are highly dependent on labor supply, as well as on opportunity costs of reallocating an important share of health care workers for COVID-19 vaccination. On the other hand, costs regarding prevented health care use on COVID-19, from testing to intensive care unit, cannot be neglected, with associated opportunity costs as well. However, prevention of potentially needed measures such as lockdowns with effects in all spheres of society, such as economy and education, are of utmost relevance and are not commonly accounted for in health technology assessments. Furthermore, vaccines have important effects that are not commonly present in prescription drugs such as herd effect, protection against comorbidities or others to be explored in such a recent disease. Only a few efforts for COVID-19 vaccines' economic evaluations exist. However, at the same time, vaccines (and the rollout of vaccination programs) continue to be developed and improved. Therefore, such assessments will be important for studying boosters or revaccinations later on, but also for future pandemic preparedness. Moreover, such efforts on estimating vaccination cost-effectiveness, considering a wide range of costs, might be essential for sub-population prioritization.

Building a roadmap for the evaluation of a National Health Plan: the experience of Portugal

Issue

The National Health Plan (PNS) 2012-2016 (extended until 2020) is the Portuguese strategic health document that presents the direction of intervention within the Health System. A final evaluation of PNS was foreseen, with National Institute of Health Dr Ricardo Jorge (INSA) being responsible for carrying out this task. The experience gained by INSA in defining a roadmap to be used in this process can be important in steering other actors to policy evaluation.

Description of the problem

In order to analyze the impact of policies, it is necessary to collect evidence that can evaluate the results achieved, and more importantly, identify gaps in implementation and evaluation issues. Herein, we aim to present the methodological approach developed to pave the way to the final assessment of PNS.

Results

As part of the Biennial Collaborative Agreement 2016-2017, WHO sponsored a high-level technical consultative process with relevant experts to address the condition for defining the work plan. It was devised to undertake: i) A scoping review based upon data collected from PNS implementation evidence mapping; ii) A qualitative analysis of the perception from main stakeholders on PNS impact and their expectations. Thus, a matrix of evidence was built to analyze the alignment of PNS at national and local levels, and with the main health framework targets and indicators. Also, online surveys and face-to-face interviews were done with key stakeholders in order to identify evidence gaps and critical factors for the successful PNS implementation, among others.

Lessons

To characterize its implementation and impact on citizens' health, a sound PNS evaluation should be guided by clear assessment questions, supported by validated tools and complemented by international guidance. In addition, a long-term consultative process with key stakeholder support is required to properly identify opportunities, priorities, and outcomes.

Key messages

Institutionalization of an evaluation process as part of public policies life cycle is a powerfull tool to foster learning and crucial to achievement of proposed goals. A clear structure to support the policy evaluation approach is mandatory to guarantee impartiality, independence and transparency on the overall process.

Health impact assessment of a voluntary protocol to decrease salt in bread: what can we learn?

Issue

Hypertension (HT) is a major and modifiable risk factor for cardiovascular diseases (CVD), which can be caused by excessive salt intake. Portugal has one of the highest mortality rate due to CVD in Europe, mainly due to HT. Thus, reduction of salt intake from food products is one of major strategies advocated to modify blood pressure (BP) and its impact on HT.

Description of the problem

The Portuguese population has excessive daily salt intake mainly due to bread consumption. Thus, in 2017 a voluntary ‘Protocol' was signed between stakeholders with the goal to reduce salt content in bread by 2021. Herein, using a Health Impact Assessment (HIA) approach we aimed to estimate the potential effect in BP from the implementation of this ‘Protocol'. Thus, two national surveys were used to find average values of salt intake and BP on population, while estimates of BP reduction were calculated based upon meta-analysis data.

Results

It was expected that the implementation of the ‘Protocol' could reduce salt ingestion and have a higher BP effect, mostly in more vulnerable populations. In fact, results showed that individuals with low educational level, men, aged and residents in the South region of Portugal were the ones that could more benefit from the ‘Protocol' implementation. However, this study found that the effects were be very low for all groups analysed, suggesting that only slight health gains can occur.

Lessons

The ‘Protocol' as a voluntary agreement is not sufficient to attain the public health targets devised. Following the HIA framework, further complementary and intersectoral integrated measures, through the use of compulsory food and fiscal policies preferably extended to other highly consumed food products, were thus recommended. HIA could be used as a comprehensive tool to assess health impacts, supporting at each national context the design and implementation of effective strategies to promote salt intake reduction and effectively prevent hypertension.

Key messages

The systematic use of HIA to design the appropriate policy framework and to inform adequately political decision-making is crucial to promote health and prevent Non-Communicable Diseases. Voluntary agreements should be complemented by other integrated measures to improve the efficacy of policies aiming to reduce salt intake and prevent hypertension.

BAUN score, a better predictive model of in-hospital and long-term outcomes in acute heart failure?

Introduction

Patients hospitalized due to acute heart failure (AHF) compose a heterogeneous population whose prognosis is difficult to forecast. Previously, BAUN score has proven to be able to accurately predict in-hospital mortality (IHM) in AHF. We aimed to evaluate BAUN score performance in the prediction of long-term outcomes in this population, comparing it to the recently validated Get With The Guidelines (GWTG) score.

Methods

A retrospective analysis of 1052 patients admitted to a Cardiology ward due to AHF was performed. 268 patients were excluded due to data omission or therapy with sacubitril/valsartan. Using the variables systolic blood pressure, urea, brain natriuretic peptide and sodium at admission, BAUN score was calculated, ranging from 0–28 points. GWTG score was also calculated at the index event. ROC curve analysis was used to compare the predictive value of the two scores for IHM. Kaplan-Meyer and Cox-regression analysis were performed to evaluate BAUN score prediction ability for 24-month mortality (24-MM) and for the composite endpoint of 24-month rehospitalization or death (24-MH).

Results

Mean patient age was 77 (±10) years; 51% were men. Mean left ventricle ejection fraction (EF) was 49% (±16.4). An EF&lt;40% was present in 31% of patients. IHM, 24-MM and 24-HM were 6.5%, 17.1% and 57.8%, respectively. Mean BAUN score was 7 (±5.64). Mean GWTG score was 49.7 (±9.8). ROC curve analysis for IHM prediction revealed a better performance of the BAUN score (AUC: 0.738p, &lt;0.001) in comparison with GWTG score (AUC: 0.687, p&lt;0.001). Patients were stratified into subgroups according to BAUN risk score – very-high risk (≥22), high risk (16–21), intermediate risk (5–15) and low risk (&lt;5). Kaplan-Meyer analysis revealed a significant difference in 24-MM according to risk subgroup (very high: 35%, high: 26.7%, intermediate: 19.5%, low risk: 12.7%, χ2=16.304, p=0.001). When stratified by non-reduced or reduced EF (≥40% or &lt;40%), there was still a significant mortality difference in subgroups with reduced (p=0.007) and borderline significant in patients with nonreduced EF (p=0.05). Kaplan-Meyer analysis also revealed a significant difference between subgroup risk for 24-MH (51%; 63.8%; 63.3% and 75%, respectively, for low, intermediate, high and very-high risk, χ2=21.237, p&lt;0.001). Cox regression analysis demonstrated that BAUN score independently predicts 24-MM (HR: 1.056, p=0.043) and 24-MH (HR: 1.033, p=0.048), even after adjustment for other prognostic markers, such as atrial fibrillation, coronary artery disease, previous myocardial infarction, age, EF and GWTG score.

Conclusion

BAUN outperforms GWTG score for IHM prediction in AHF. It also independently predicts 24-MM and 24-MH. Its use may identify patients with high risk of mortality/readmission, in need of specialized care, and those patients with low risk of death, who might be candidates for lenient surveillance.

Funding Acknowledgement

Type of funding sources: None.

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

Comparison of the GRACE score, TIMI score and a New Laboratorial Score to predict adverse outcomes in acute coronary syndrome

Introduction

Acute coronary syndrome (ACS) is a clinical entity which includes a heterogeneous group of patients with different outcomes. Risk scores are in this setting a resourceful tool to identify the subset of patients with a worse prognosis, in order to plan therapeutic and surveillance strategies.

Aim

To create a risk score – Laboratory Risk Score (LRS) – which exclusively includes analytical and echocardiographic parameters, as a predictor of adverse outcomes (in-hospital mortality and 1-year mortality), and compare it with other well-known scores: GRACE Score (GS) and TIMI-score (TS).

Methods

A retrospective cohort study was conducted, which included patients admitted in the Cardiology Department with the diagnosis of ACS. In order to calculate the new LRS, the authors attributed the value of 1 to each of the satisfied condition from the following: leucocytes &gt;11,7g/L, hemoglobin &lt;13.3g/dL, red cell distribution width &gt;14%, prothrombinemia &lt;90%, glycaemia at admission &gt;143mg/dL, urea &gt;53.5mg/dL, creatinine &gt;1.16mg/dL, reactive C-protein &gt;1.0mg/dL, maximum troponin &gt;35.0ng/dL, natriuretic brain peptide &gt;416 pg/dL and left ventricular ejection fraction &lt;40%. LRS resulted from the sum of the satisfied conditions.

ROC curves for LRS, GS and TS to predict in-hospital mortality and to predict 1-year mortality were constructed. The statistical analysis was performed in SPSS and Medcalc. p value &lt;0.05 was considered statistically significant.

Results

1714 patients (70.4% male, average age 69±13 years-old) were included in this study. Intra-hospital mortality rate was 6.8% and 1-year mortality rate after de discharge was 4.8%.

The areas under the ROC curves for predicting in-hospital mortality were the following: 0,790 (LRS, p&lt;0,001), 0,793 (GS, p&lt;0.01), 0.817 (TS, p&lt;0.001). For predicting 1-year mortality, the areas under the ROC curves were: 0,715 (LRS, p&lt;0,001), 0,761 (GS, p&lt;0,001), 0.742 (TS, p&lt;0.001). Pairwise comparison of ROC curves showed no significant differences between the scores.

Conclusion

The above-mentioned risk scores, including the new LRS, are obtained with non-invasive and widely available parameters and displayed a good performance in predicting in-hospital and 1-year mortality. Pairwise comparison of ROC curves demonstrated that the new laboratorial score was not inferior predicting adverse outcomes. The SRL is an easily obtained score, that shows a statistical significance in predicting mortality, especially the prediction of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: None.

Global longitudinal strain as a predictor of cardiovascular events and mortality in patients with ischemic heart disease and heart failure with preserved/mid-range ejection fraction

Introduction

Global longitudinal strain (GLS) is considered a more sensitive marker of systolic dysfunction than other measures commonly used in clinical practice, such as left ventricle ejection fraction (EF). Our objective was to evaluate the impact of reduced GLS in death and cardiovascular events in patients hospitalized due to heart failure with mid-range or preserved ejection fraction, with previous history of acute myocardial infarction.

Methods

A retrospective analysis of 170 patients admitted to a Cardiology ward due to acute heart failure (AHF) was performed. Patients with reduced EF (Simpson biplane method - EF&lt;40%) were excluded based on echocardiographic evaluation after AHF stabilization. GLS measured by “speckle tracking” technique was calculated for each patient. Measurements were made by the same operator to minimize interoperator variability. Mann-Whitney U test was used for univariate analysis. Kaplan-Meier survival plots and Cox-regression analysis were performed to assess differences in 12-month mortality (12MM) and in the composite endpoint of cardiovascular event or death (12CVM) at 12 months.

Results

A total of 127 patients were included. Mean patient age was 64 (±14) years; 72% were men. 48% of patients had history of ST elevation AMI. Mean EF was 54% (±8) and mean GLS was −14.3 (±3.8). Rates of 12MM and 12CV M were 14.2% and 19.3%, respectively. A statistically significant association between 12MM and 12MCV was found in univariate analysis for GLS (p&lt;0.001). Kaplan-Meyer survival plots revealed that a compromised GLS (&lt;−16) was associated with significantly increased 12MM (23% vs 2.5%, X2: 7.999, p=0.005) and 12CVM (26.6% vs 10%, X2: 4.139, p=0.042). When stratified by mid-range vs preserved EF, GLS &lt;−16 was associated with worse outcomes, although the results did not reach statistical significance (p&gt;0.05). However, when considering a severely compromised GLS (&lt;−13), GLS was significantly associated with increased 12MM (52% vs 8.3%, X2: 5.533, p=0.019) and 12CVM (50% vs 8.3%, X2: 4.970, p=0.026), in the subgroup of patients with heart failure with mid-range EF. Cox-regression analysis demonstrated that GLS was independently associated with 12MM (HR: 0.668p, &lt;0.001) and the 12CVM composite endpoint (HR: 0.819, p=0.008), even after adjustment for other important prognostic markers such as chronic kidney disease, pulmonary disease and diabetes, with significant hazard ratio reduction for each positive point increase in GLS.

Conclusion

GLS is an independent predictor of 12MM and 12CVM in patients hospitalized due to AHF, with an EF ≥40% and previous history of acute myocardial infarction. In the subgroup of patients with heart failure with mid-range EF, a severely compromised GLS (&lt;−13) is a strong predictor of 12MM and 12CVM.

Funding Acknowledgement

Type of funding sources: None.

AHFM score, a predictive model of in-hospital and long-term mortality in heart failure

Introduction

Patients hospitalized due to heart failure (HF) constitute a heterogeneous population whose prognosis is difficult to forecast. The purpose of this study was to create a model based on simple bedside recordable echocardiographic, analytical and objective clinical parameters that could accurately predict mortality and/or rehospitalization risk in different stages of HF course.

Methods

A retrospective analysis of 347 patients admitted to a Cardiology ward due to decompensated HF was performed. The echocardiographic variables pulmonary artery systolic pressure (PSAP) and E/e' ratio, and the analytical/clinical variables systolic blood pressure (SBP), urea and brain natriuretic peptide (BNP) were selected for inclusion. Subgroups were created for each variable and an odds ratio (OR) for the risk of in-hospital mortality (IHM) was calculated. A numerical value proportional to the OR was attributed to each subgroup. A score was created, ranging from 0–47 points, corresponding to the sum of the classification attributed to each variable. ROC curve analysis was used to assess predictive value of the score for IHM. Kaplan-Meyer and Cox-regression plots were used to assess mortality (24MM) and the composite endpoint of HF rehospitalization or death at 24 months (24HM).

Results

Mean patient age was 78 (±9) years; 51% were men. Score variable means were - PSAP: 47 (±15) mmHg; E/e': 16.8 (±7.8); SPB: 138 (±31) mmHg; Urea: 71 (±35) mg/dl; BNP: 911 (±995) pg/ml. Mean ejection fraction (EF) was 48% (±16). 35% of patients had EF&lt;40%. IHM, 24MM and 24HM were 3.5%, 17.1% and 63.6%, respectively. A statistically significant association between IHM and PSAP, E/e', BNP, urea and SBP (p&lt;0.05) was found on univariate analysis. ROC curve analysis of AHFM revealed an AUC of 0.785 (p=0.001) for IHM risk prediction. The cut-off point with most sensitivity (S) and specificity (E) obtained using the Youden index (0.4246) was 18 (S≈75%; E≈67%), associated with significant difference in IHM (1.3% vs 7.6%). IHM by score interval was 1.3%, 3.1% and 25%, respectively, for the intervals 0–18, 19–29 and ≥30. ECHO-AHF score &lt;13 predicted in-hospital survival in all patients. Kaplan Meyer survival analysis by subgroup revealed significant differences in 24MM according to AHFM risk category (13.8% vs 21.9% vs 30.8%, respectively, χ 2= 17.217 p&lt;0.001), but not for 24 MH. Cox-regression analysis demonstrated that AHFM score remained a significant independent predictor of 24MM (HR: 1.067, p=0.05), even after adjustment for other variables, such as coronary disease, chronic kidney disease, atrial fibrillation, EF and diabetes.

Conclusion

AHFM score is an accurate model for predicting IHM and long-term risk of HF death. Its use may help to identify patients with high risk of mortality, in need of specialized care, and those with lower risk of death, who might be candidates for early discharge or lenient follow-up.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular noncompaction and EcoScore: prognostic value of a new echographic risk score

Introduction

Left Ventricular Non-Compaction (LVNC) is a rare and underdiagnosed cardiomyopathy, characterized by hypertrabeculation of the left ventricle. This disease is associated with high rates of morbidity and mortality; however, its main adverse prognostic factors are not well established.

Aim

To create a risk score for LVNC based on echocardiographic criteria (EcoScore) to predict the occurrence of adverse events.

Methods

The authors included patients with the diagnosis of LVNC, according to the Jenni Criteria. Clinical and echocardiographic data were evaluated and the occurrence of the following adverse events was reported: hospitalizations due to supraventricular or ventricular tachyarrythmias and heart failure, acute myocardial infarction, stroke, heart transplant and death. The follow-up time was 24 months. ROC curves to predict the occurrence of at least one adverse event were constructed for each echocardiographic parameter. The optimal cut-off obtained from each ROC curve was then used to attribute points (1 point per parameter). The EcoScore resulted from the sum of the obtained points. The authors finally created a ROC curve to predict the occurrence of any adverse event for the EcoScore. The statistical analysis was performed in SPSS. p value &lt;0.05 was considered statistically significant.

Results

33 patients (48.5% male, age at diagnosis 45.9±21 years) were included in this study. The optimal cut-offs for each parameter obtained from the ROC curves were the following: left ventricle dyastolic diameter &gt;55mm, left atrial diameter &gt;40mm, pulmonary artery systolic pressure &gt;22mmHg and left ventricle ejection fraction &lt;40%. The area under the curve for the EcoScore to predict any adverse event was 0.850 (p=0.017) and an EcoScore &gt;1 had a sensibility of 85.7% and a specificity of 70%.

Conclusion

The EcoScore accurately predicted the occurrence of at least one adverse event in this population. Thus, it could be a good tool in the daily practice to select patients who may benefit from a more aggressive surveillance and treatment.

Funding Acknowledgement

Type of funding sources: None.