Prevalence and predictors of chronic thromboembolic pulmonary hypertension following severe forms of acute pulmonary embolism

INTRODUCTION AND OBJECTIVES

The true prevalence of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) in the Portuguese population remains unknown. We aimed to assess the prevalence and predictors of CTEPH two years after a symptomatic high- (HR) or intermediate-high risk (IHR) PE.

METHODS

We conducted a retrospective cohort study of patients admitted with PE between 2014 and 2019 to a Portuguese referral center for pulmonary hypertension.

RESULTS

In this single-center registry of 969 patients admitted with PE (annual incidence of 46/100000 population), 194 had HR (5.4%) and IHR (14.7%) PE. After excluding patients who died or had no follow-up in the first three months, 129 patients were included in the analysis. The overall prevalence of suspected CTEPH by clinical assessment, Doppler echocardiography and V/Q lung scan was 6.2% (eight patients). CTEPH was confirmed by right heart catheterization in four of these (3.1%). Increased pulmonary artery systolic pressure (PASP) at admission (OR 1.12; 95% CI 1.04-1.22; p=0.005) and the presence of varicose veins in the lower limbs (OR 7.47; 95% CI 1.53-36.41; p=0.013) were predictors of CTEPH. PASP >60 mmHg at admission identified patients with CTEPH at follow-up with sensitivity and specificity of 83.3% and 76.3%, respectively. All patients diagnosed with CTEPH had at least two radiological findings suggestive of CTEPH at the index event.

CONCLUSIONS

In our cohort, the prevalence of CTEPH in survivors of severe forms of acute PE was 6.2%. PASP above 60 mmHg and supporting radiological findings on the index computed tomography scan are highly suggestive of acute-on-chronic CTEPH.

Thermodilution vs indirect fick cardiac output measurement in clinical practice: insights from a tertiary centre

Introduction

Thermodilution (TD) and indirect Fick (IF) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches concerning agreement and comparative prognostic value as applied in medical practice.

Purpose

To assess agreement between TD and IF methods and to compare how well these methods predict mortality.

Methods

Retrospective cohort study including all consecutive right heart catheterizations performed in a referral pulmonary hypertension (PH) centre from 2010 to 2018. Cardiac index (CI) was calculated by indexed CO to body surface area. PH was classified according to the new definition of the 6st World Symposium on Pulmonary Hypertension 2018 [mean pulmonary arterial pressure (mPAP) >20 mmHg]. Patients with cardiac or extra-cardiac shunts or significant (moderate to severe or severe) tricuspid regurgitation were excluded. All-cause mortality over 1 year after right heart catheterization was recorded. Logistic regression was used to identify predictors of the adverse event.

Results

From a total of 569 procedures, 424 fulfilled the inclusion criteria: mean age 56.7±15.4 years, 67.3% female. Haemodynamic parameters were diagnosed of PH in 86.2% of cases: mPAP 35.3±15.3 mmHg, 83.6% pre-capillary subtype, 42.9% belonging to group 4 (chronic thromboembolic pulmonary hypertension) and 26.6% to group 1 (pulmonary arterial hypertension). Mean values of CO and CI were, respectively, 4.5±2.8 L/min and 2.5±0.8 L/min/m2 measured by TD and 4.6±2.4 L/min and 2.6±1.3 L/min/m2 measured by IF method. There was a median difference (IF minus TD) of - 0.03 / min to CO and - 0.05 L/min/m2 to CI but both meausres correlated only modestly (r=0.6 to TD and r=0.5 to IF). One-year all-cause mortality rate was 5.4% (median time to death was 50.5 days). Lower values of CO and CI assessed by TD were significantly associated with all-cause mortality occurrence (CO TD: 4.5±1.3 L/min versus 3.6±1.0 L/min, p<0.01; CI TD: 2.6±0.7 L/min/m2 versus 2.1±0.4 L/min/m2, p<0.01). No association was observed between CO (p=0.31) and CI (p=0.42) measured by IF method and the adverse event. Logistic regression identified 2 independent predictors of all-cause mortality: TD CO (OR 0.55, 95% CI 0.38–0.79, p<0.01) and TD CI (OR 0.34, 95% CI 0.17–0.67, p<0.01). Similar results were obtained when patients diagnosed with PH were independently analyzed.

Conclusions

There is only modest agreement between TD and IF CO and CI estimates. Despite being more time-consuming, TD measurements were predictors of all-cause mortality and present a highest prognostic value. These findings favored their used over IF in clinical practice.

Funding Acknowledgement

Type of funding source: None

Sparse-coding denoising applied to reversible conformational switching of a porphyrin self-assembled monolayer induced by scanning tunnelling microscopy

Scanning tunnelling microscopy (STM) was used to induce conformational molecular switching on a self-assembled monolayer of zinc-octaethylporphyrin on a graphite/tetradecane interface at room temperature. A reversible conformational change controlled by applying a tip voltage was observed. Consecutive STM images acquired at alternating tip voltages showed that at 0.4 V the porphyrin monolayer presents a molecular arrangement formed by alternate rows with two different types of structural conformations and when the potential is increased to 0.7 V the monolayer presents only one type of conformation. In this paper, we characterize these porphyrin conformational dynamics by analyzing the STM images, which were improved for better quality and interpretation by means of a denoising algorithm, adapted to process STM images from state of the art image processing and analysis methods. STM remains the best technique to 'see' and to manipulate the matter at atomic scale. A very sharp tip a few angstroms of the surface can provide images of molecules and atoms with a powerful resolution. However, these images are strongly affected by noise which is necessary to correct and eliminate. This paper is about new computational tools specifically developed to denoise the images acquired with STM. The new algorithms were tested in STM images, obtained at room temperature, of porphyrin monolayer which presents reversible conformational change in function of the tip bias voltage. Images with high resolution, acquired in real time, show that the porphyrins have different molecular arrangements whether the tip voltage is 0.4 V or 0.7 V.

Maintenance programmes for flat roofs in existing buildings

Purpose

The purpose of this paper is to propose a maintenance programme for flat roofs in existing buildings, based on the inspection of 26 buildings in-service conditions, located in the Lisbon region, in Portugal. A proactive maintenance of flat roofs in existing buildings allows reducing their pathology, thus improving their performance and service life.

Design/methodology/approach

The maintenance plan was established based on the degradation state of the maintenance source elements (MSEs) analysed, the aggressiveness of the surrounding environment and the age of the roofs and maintenance actions carried out during the roofing systems’ life cycle.

Findings

The maintenance plan proposed in this study includes the prioritization of the interventions, the definition of the required maintenance operations and the definition of the frequency of the intervention, considering the service lives of the MSEs.

Research limitations/implications

The study addresses only roofs located in the Lisbon area. Even though a relatively large sample of 26 roofs was used, the findings and conclusions can clearly be extrapolated for a much wider scope.

Practical implications

The maintenance plan proposed in this study considers a planning of proactive maintenance operations to continuously and effectively monitor all the relevant MSE.

Originality/value

This plan allows minimizing the incidence and spread of defects, thus enabling the optimization of resources, reducing the costs of the entire maintenance system and improving the quality of the built environment.

Language improvement one week after thrombolysis in acute stroke

OBJECTIVES

Language recovery following acute stroke is difficult to predict due to several evaluation factors and time constraints. We aimed to investigate the predictors of aphasia recovery and to identify the National Institute of Health and Stroke Scale (NIHSS) items that best reflect linguistic performance, 1 week after thrombolysis.

MATERIALS AND METHODS

We retrieved data from a prospective registry of patients with aphasia secondary to left middle cerebral artery (MCA) stroke treated with intravenous thrombolysis. Complete recovery at day 7 (D7) was measured in a composite verbal score (CVS) (Σ Language+Questions+Commands NIHSS scores). Lesion size was categorized by the Alberta Stroke Program Early CT score (ASPECTS) and vascular patency by ultrasound. CVS was correlated with standardized aphasia testing if both were performed within a two-day interval.

RESULTS

Of 228 patients included (age average 67.32 years, 131 men), 72% presented some language improvement that was complete in 31%. Total recovery was predicted by ASPECTS (OR=1.65; 95% CI, 1.295-2.108; P < 0.00) and baseline aphasia severity (OR=0.439; 95% CI, 0.242-0.796; P < 0.007). CVS correlated better with standardized aphasia measures (aphasia quotient, severity, comprehension) than NIHSS_Language item.

CONCLUSIONS

Lesion size and initial aphasia severity are the main predictors of aphasia recovery one week after thrombolysis. A NIHSS composite verbal score seems to capture the global linguistic performance better than the language item alone.

Urgent request on avian influenza

Highly pathogenic avian influenza (HPAI) H5N8 is currently causing an epizootic in Europe, infecting many poultry holdings as well as captive and wild bird species in more than 10 countries. Given the clear clinical manifestation, passive surveillance is considered the most effective means of detecting infected wild and domestic birds. Testing samples from new species and non‐previously reported areas is key to determine the geographic spread of HPAIV H5N8 2016 in wild birds. Testing limited numbers of dead wild birds in previously reported areas is useful when it is relevant to know whether the virus is still present in the area or not, e.g. before restrictive measures in poultry are to be lifted. To prevent introduction of HPAIV from wild birds into poultry, strict biosecurity implemented and maintained by the poultry farmers is the most important measure. Providing holding‐specific biosecurity guidance is strongly recommended as it is expected to have a high impact on the achieved biosecurity level of the holding. This is preferably done during peace time to increase preparedness for future outbreaks. The location and size of control and in particular monitoring areas for poultry associated with positive wild bird findings are best based on knowledge of the wider habitat and flight distance of the affected wild bird species. It is recommended to increase awareness among poultry farmers in these established areas in order to enhance passive surveillance and to implement enhanced biosecurity measures including poultry confinement. There is no scientific evidence suggesting a different effectiveness of the protection measures on the introduction into poultry holdings and subsequent spread of HPAIV when applied to H5N8, H5N1 or other notifiable HPAI viruses.

This publication is linked to the following EFSA Supporting Publications article: http://onlinelibrary.wiley.com/doi/10.2903/sp.efsa.2016.EN-1142/full

The portuguese psychiatry in the european setting: Study of a hospital drug formulary in the beginning of the 20th century

The results of an investigation conducted on the Formulario Especial dos Medicamentos para o Hospital de alienados em Rilhafoles (1901), a mental disease drug formulary for the oldest Portuguese psychiatric hospital, are presented. The study considered the Portuguese situation within the European setting.

This study quantifies the number of drugs and pharmaceutical forms and establishes a comparison with the most commonly used international psychiatric medication at the time. The present study aims at contributing to the history of psychiatric drug therapy before the advent of psychoactive drugs. The most commonly used pharmaceutical forms and therapeutic groups in psychiatry are evaluated. Furthermore, we also wish to contribute to the evaluation of how Portugal received and implemented innovations in drug therapy.

Quantitative and qualitative document analysis of the above mentioned formulary, using the comparative method.

The edition of this formulary arose from the need to standardize specific medication for mental patients. In the Formulario, 61 medicinal products are proposed. There were 8 different pharmaceutical forms. The potions were the most commonly referred (32). Hypnotics represented approximately half of the medicinal products (28), followed by hypokinetics (9), and analgesics and antipyretics (8).

The formulary was in line with foreign scientific innovations. Pharmacotherapeutic variety of drugs was short and resorting to non-drug therapies was also usual. The edition of this formulary was mainly due to the work conducted by the psychiatrist Miguel Bombarda (1851–1910), a prominent public figure in medicine and in the political and cultural arena.

Expression patterns of HLA-DR+ or HLA-DR- on CD4+/CD25++/CD127low regulatory T cells in patients with allergy

BACKGROUND

Allergic rhinoconjunctivitis induced by pollen is a highly prevalent chronic inflammatory disease in Europe. Parietariajudaica is a frequent trigger in the Mediterranean area. The function of regulatory T cells (Treg cells) in allergy has recently been investigated, but further data are necessary to better understand their role and to find new strategies to treat allergic diseases such as allergic rhinoconjunctivitis.

OBJECTIVE

To characterize gene expression of HLA-DR+ or HLA-DR- on peripheral CD4+/CD25++/CD127low Treg cells in patients with allergy.

METHODS

Peripheral Treg cells (CD4+/CD25++/CD127low) were quantified using flow cytometry and sorted according to HLA-DR expression during the pollen season in patients with allergic rhinoconjunctivitis caused by P. judaica. The results were compared with those of nonatopic controls. Expression of associated cytokines and their receptors was measured using quantitative reverse transcription-polymerase chain reaction after extraction of mRNA in sorted populations.

RESULTS

During the pollen season, no significant differences were observed between allergic patients with rhinoconjunctivitis and healthy controls in terms of the absolute number or the percentage of Treg cells in peripheral blood. All patients had a higher number/percentage of HLA-DR- Treg cells than HLA-DR+ Treg cells. In both groups we found high levels of FOXP3 mRNA expression. Despite being lower in number, HLA-DR+ Treg cells presented higher expression of CD28, PRF1, GZMB, and FASL than HLA-DR-Treg cells.

CONCLUSIONS

The most relevant results obtained suggest that HLA-DR+ Treg cells tend to present higher gene expression of molecules associated with contact-dependent cell activation and cytotoxicity.

Triplet-State and Singlet Oxygen Formation in Fluorene-Based Alternating Copolymers

Data are reported on the triplet states of a series of fluorene-based A-alt-B type alternating copolymers based on pulse radiolysis-energy transfer and flash photolysis experiments. From the pulse radiolysis experiments, spectra are given for eight copolymers involving phenylene, thiophene, benzothiadiazole, and oligothienylenevinylene groups. Quantum yields for triplet-state formation (PhiT) have been obtained by flash photolysis following laser excitation and in one case by photoacoustic calorimetry. In addition, yields of sensitized formation of singlet oxygen have been determined by time-resolved phosphorescence and are, in general, in excellent agreement with the PhiT values. In all cases, the presence of thiophene units is seen to increase intersystem-crossing quantum yields, probably because of the presence of the heavy sulfur atom. However, with the poly[2,7-(9,9-bis(2'-ethylhexyl)fluorene)-alt-1,4-phenylene] (PFP), thiophene S,S-dioxide (PFTSO2) and benzothiadiazole (F8BT) copolymers, low yields of triplet formation are observed. With three of the copolymers, the energies of the triplet states have been determined. With PFP, the triplet energy is virtually identical to that of poly[2,7-(9,9-bis(2'-ethylhexyl)fluorene)]. In contrast, with fluorene-thiophene copolymers PFaT and PF3T, the triplet energies are closer to those of thiophene oligomers, indicating that there is significant conjugation between fluorene and thiophene units but also that there is a more localized triplet state than with the homopolymers.

A mechanistic model for m-xylene treatment with a peat-bed biofilter

The painting of vehicles in the automobile industry generates large quantities of gaseous emissions which contain volatile organic compounds (VOC) like xylenes. This polluted air has a high moisture content and a temperature around 15-20 degrees C. It is thus possible to consider its treatment by a biological way. In this paper, laboratory tests are described which led to the choice of packing material to make a biofilter having good removal efficiency. Moreover this technique is known for its simplicity and low energy cost. The maximum treatment capacity was obtained with peat. A mathematical model which makes it possible to specify the different limiting steps of the process was carried out. This considered both physical parameters of the biofilter and properties of the biofilm. By choosing a lower Henry's constant than typical air:water system, we obtain a better simulation of the xylenes concentration according to the biofilter length and applied load.

Reduction of the light-onset voltage of light-emitting diodes based on a soluble poly(p-phenylene vinylene) by grafting polar molecules onto indium–tin oxide

We report on the reduction of the light-onset voltage of light-emitting diodes based on poly[(2-methoxy-5-(2′-ethyl-hexyloxy)-1,4-phenylene vinylene] with aluminum cathodes down to 2.2 V by grafting polar molecules onto indium-tin oxide. This value is close to Eg/e=2.13 V, Eg being the energy gap estimated from the absorption onset and e the electron charge, in spite of the poor electron injection ability of the aluminum cathode. In addition, there is a very efficient suppression of the commonly observed low-voltage current peaks.

Ultrastructural and biochemical analysis of the relationship of Crithidia deanei with its endosymbiont

Some protozoa of the Trypanosomatidae family harbor in their cytoplasm bacterial endosymbionts that provide essential nutrients to and induce morphological alterations in the protozoa. In the present study, a close association between endosymbionts and glycosomes, a peroxisome-like organelle where most of the enzymes of the glycolytic pathway are compartmentalized, was identified by conventional transmission electron microscopy in Crithidia deanei. Such an association was further supported by the cytochemical localization of catalase in the glycosome and also confirmed by 3-D reconstruction of the protozoan. The enzymes cytochrome oxidase and succinate dehydrogenase were detected by ultrastructural cytochemistry. A positive reaction was observed in the protozoan mitochondrion but not in the endosymbiont envelope. Enzymatic assays for succinate cytochrome c reductase reinforced these results, as a low enzymatic activity was detected in an endosymbiont-enriched fraction, while high activity was observed in a purified protozoan mitochondrion fraction. We also demonstrated that a purified symbiont fraction was able to hydrolyze ATP. This activity was Mg+2 dependent, since it was highly stimulated by the presence of physiological concentrations of this ion. Taken together, these observations suggest that no electron transporting system is active in the symbionts of Crithidia deanei and that they might obtain energetic molecules derivated from the protozoan glycosomes.

Estimations of intestinal and liver first-pass metabolism in vivo. Studies on gentisamide conjugation in the rat

In this paper a method is introduced to study both intestinal and liver metabolism in the intact rat by cannulation of the jugular vein, carotid artery, pyloric vein (into the portal vein), and bladder. In this preparation, the rat received an initial dose followed by iv (I) and then intraportal (II) infusions. Gentisamide (2,5-dihydroxybenzamide, GAM) was used since it forms monosulfate (GAM-2S and GAM-5S) and monoglucuronide (GAM-5G) conjugates, metabolites that are not further metabolized. After administration of tracer amounts of radiolabeled gentisamide ([3H]GAM), the concentration ratio of [3H]GAM in the portal vein and carotid artery [CPV(I)/CA(I)] during iv infusion, and the ratio of carotid artery concentrations for intraportal to iv infusions [CA(II)/CA(I)] provided the intestine and liver availabilities, respectively; the corresponding extraction ratios for the intestine and liver were 0.26 to 0.27 and 0.37 to 0.41. Similar concentration ratios for the conjugates during iv administration [CPV(I)/CA(I)] showed intestine formation of GAM-5G, and to a lesser extent, GAM-2S, since the ratios exceeded unity; GAM-5S was not formed by the intestine since the ratio was unchanged. The ratio of the carotid arterial concentrations for intraportal to iv infusions that revealed hepatic formation showed similar values (1.77 and 1.71) for GAM-2S and GAM-5S, but variable (decreases and increases) GAM-5G values, whose mean value approximated unity. All findings were consistent with data obtained from the perfused rat liver preparation and the combined perfusion of rat intestine-liver preparation, where GAM-5G and GAM-2S were shown to be formed by the intestine, and where sulfation was the preferred pathway in the liver.(ABSTRACT TRUNCATED AT 250 WORDS)