Clinical experience with adjustable scleral lenses

PURPOSE

The aim of this study was to evaluate the fitting process of a scleral lens that allows several parameter adjustments during trials and after the initial period of use. In addition, we verified which adjustments were needed and used the most, their indications, and how often these resources were used, and checked the results.

METHODS

Scleral contact lens fittings in a private clinic setting were prospectively analyzed in a sequential, non-randomized, and non-comparative manner. All the patients underwent a complete ophthalmic examination and had an indication for scleral lens use (Zenlens, Alden Optical).

RESULTS

Scleral fit was analyzed in 80 eyes of 45 patients. Regarding diagnosis, 72% of the patients had keratoconus; 12%, radial keratotomy; 5%, post-refractive surgery ectasia; 5%, dry eye; and 3%, high myopia. In 66 (82.5%) of the 80 eyes studied, parameters were modified when the lenses were ordered. The reasons that led to the modifications were apical touch or decreased sagittal height, increased sagittal height, cylindrical over-refraction, poor visual acuity, lens flexure, peripheral touch, 360° edge compression, horizontal edge compression, and vertical edge compression.

CONCLUSION

In this study, the use of Zenlens scleral lenses was shown to be a promising corrective treatment for patients requiring the use of scleral lenses. Although the study suggests a learning curve, as many adjustments were allowed, the lens could be customized according to the patients' needs. This increased the success rates of fitting and wearing, and consequently, use of the lens became a great option for the visual rehabilitation of patients.

Predicting the long-termoutcome of patients admitted with acute heart failure to the emergency department using renal markers

Introduction

Renal dysfunction is one of the most important comorbidities in patients with chronic heart failure (HF) and frequently accentuated in the setting of acute HF (AHF). Serum creatinine and blood urea nitrogen (BUN) have been classically used as markers of renal dysfunction, despite having several limitations. High (BUN)/creatinine ratio has been associated with higher mortality in patients with HF. We aimed to predict the long-term outcome of patients admitted with acute heart failure to the emergency department using renal markers.

Methods

900 patients admitted to our emergency department diagnosed with AHF were retrospectively analysed. Patients were divided into 4 groups according to BUN and SCr on admission:

– BUN ≤33 mg/dL and SCr ≤1.56 mg/dL (group LowBUN/LowCr), n=544;

– BUN ≤33 mg/dL and SCr >1.56 mg/dl (group LowBUN/HighCr), n=25;

– BUN >33 mg/dL and SCr ≤1.56 mg/dL (group HighBUN/LowCr), n=131;

– BUN >33 mg/dL and SCr >1.56 mg/dL (group HighBUN/HighCr), n=200;

The primary end-point of this study was the occurrence of all-cause mortality during follow-up.

Results

The median (IQR) BUN level on admission was 28.0 (20) mg/dL, median (IQR) SCr level on admission was 1.15 (0.73) mg/d, mean age was 81±7 years, 50.8% (n=457) were women and median follow up was 7 months. A total of 41.2% patients were diabetic, 21.7% had at least mild COPD, CAD was present in 28.9% of cases, 44.0% had valvular heart disease and 68.4% patients had atrial fibrillation.

Creatinine, BUN and Cr/BUN ratio predicted survival at 6 months (p<0.05).

Survival was the lowest in the group HighBUN/HighCr and the highest in the group LowBUN/LowCr. As expected, BUN/Cr ratio was the highest in group HighBUN/LowCr and the lowest in group LowBUN/HighCr.

Conclusions

Despite not having the highest BUN/Cr ratio, patients with BUN >33 mg/dL and SCr >1.56 mg/dL showed the worst prognosis.

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Does my TAVR patient have cardiac amyloidosis?

Introduction

Aortic stenosis (AS) is highly age-related, and its prevalence is increasing rapidly in high-income countries. There are 2 major types of amyloid protein responsible for cardiac amyloidosis (CA) - transthyretin (TTR) and immunoglobulin lightchain (AL). Previous cohorts report an incidence ranging from 9 to 16% for the presence of CA in patients with AS referred for TAVR. These patients appear to have a similar prognosis to those with lone AS when undergoing TAVR, but a trend toward worse prognosis if left treated. We aimed to investigate the prevalence of CA in patients with severe AS referred for TAVR in the Portuguese population.

Methods

We prospectively recruited 60 consecutive patients referred for TAVR at our tertiary center between November 2020 and May 2021. 59 patients agreed to participate and signed an informed consent, approved by the local Ethics Commission. All patients performed coronary angiogram, echocardiogram, thoracic abdominal pelvic CT scan, ECG, bone scintigraphy (99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid [DPD]) and blood and urine monoclonal immunoglobulin testing. (Figure 1).

Results

About half (54.2%) of patients were male, average age was 82 years and the prevalence of ischemic heart disease and cardiovascular risk factors was high. About one third of patients had atrial fibrillation and 27.1% were pacemaker carriers. Echocardiographic baseline findings were: maximum aortic valve gradient 72.77±18.18 mmHg; mean aortic valve gradient 43.49±11.60; aortic valve area 0.65±0.15 cm2; interventricular septum thickness 1.30±0.23 cm; left ventricular ejection fraction (LVEF) 52.06±11.35%; E/E' 14.63±7.5; tricuspid annular plane systolic excursion 19.2±4mm; right ventricle/ right atrial gradient 38.1±14.32mmHg.

CA was diagnosed in 6 (10.2%) patients. Perugini grade was 1 (n=3) and 3 (n=3). One patient (Perugini grade = 3) was found to have plasma cell dyscrasia, producing monoclonal IgG Kappa protein. CA patients were all male, older (86.5 vs 81.30 years, p=0.049), more frequently pacemaker carriers (66.7 vs 22.6%, p=0.041) and had a tendency to have a thicker interventricular septum (1.48 vs 1.28 cm, p=0.065).

Conclusions

We show that in the Portuguese population, the prevalence of CA in severe AS patients referred for TAVI is in line with what is observed in other countries. This has important consequences regarding the diagnosis and management of these patients.

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

AB0389 EVOLUTION OF MONOTHERAPY IN RHEUMATOID ARTHRITIS: IMPACT OF THE RISE OF JAK INHIBITOR

Background

According to different international registries, the frequency of use of biological agents in monotherapy in RA ranges from 12 to 39%. Targeted synthetic DMARDs (tsDMARDs-Jaki) have shown great efficacy when used as monotherapy. The rationale for this study is based on the fact that the frequency has increased with the appearance of the Jaki.

Objectives

To estimate the frequency and reason of the use of biological drugs (bDMARDs) or tsDMARDs in monotherapy since 2013 (Year the Jaki were available in Argentina). To describe the frequency of monotherapy by treatment class and analyze the differential characteristics.

Methods

Retrospective and cross-sectional multicenter study (10 reference centers from Argentina). Consecutive patients, ≥18 years, diagnosis of RA (ACR / EULAR 2010), who were under treatment with bDMARDs or tsDMARDs, started after 2013. Socio-demographic, disease and therapeutic data were collected.

Statistical analysis

descriptive statistics, Chi2 test, Fisher’s exact test, Student’s T test and Mann Whitney were performed, according to the nature of the variables. A p <0.05 was considered significant.

Results

Total 505 patients were included, 87.7% women, with a mean age 58 years (SD ± 13.5) and disease duration of 13 years (SD ± 7.8). Treatment: TNF blocker 42.1%, JAKi 30.3%, IL-6 blocker 10.9% and other treatments 16.8%.

Since 2013, the frequency of monotherapy was 49% (95% CI: 45-53), in the last visit the current frequency was 41% (95% CI 37-45),of this 40% received JAKi. JAKi and IL-6 blocker were the treatments that were used more frequently in monotherapy vs combination modality (Figure 1).

Figure 1.

The main causes of monotherapy were intolerance (39.9%), adverse event (22%), physician’s decision (20.2%) and lack of adherence (17.7%) to DMARDs. Patients who were active workers (64% vs 55%, p <0.05), with higher socioeconomic status (31.4% vs 17.2% p <0.01), better mean HAQ at diagnosis (1.1 vs 1.3, p <0.05) an association was observed with monotherapy. In addition, an association was observed with the use of monotherapy in patients in the 2nd biological line or higher vs 1st line (53% vs 33%, p <0.01), lower polypharmacy (45.6% vs 60%, p <0.02) and a shorter mean time of biological treatment (47 months vs 39 months, p <0.01). These variables were entered in a logistic regression model, the results of the independently associated variables are shown in Table 1.

Table 1.VariablepORCI 95%Employment status (active).0,1911,3270,8682,029Socioeconomic level (medium-high stratum)0,0022,151,3233,494HAQ at diagnosis, M (SD)0,0190,7040,5240,944First Line of biological treatment or Jaki (yes)0,020,4590,30,7Polypharmacy (>4 drugs) (yes)0,0180,6030,3950,918bDMARDs or tsDMARDs exposure time (months)0,0540,9940,9871

Conclusion

The frequency of monotherapy, since the Jaki’s emergence, was 49% (all follow-up) and 41% (current-last visit). Intolerance to cDMARDs doctor and the patient decision were the main cause. The monotherapy use pattern was greater in those who received JAKi and anti IL6. The use of monotherapy was associated with work activity, socioeconomic status, and functional capacity at diagnosis. An association was also observed with less polypharmacy.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–699.

[2]Emery P, Sebba A, Huizinga TW. Ann Rheum Dis.2013;72(12):1897–904.

[3]F. Sommerfleck et al. Rev Arg Reumatol. 2013;24(4): 30-36

[4]Aletaha D, Neogi T, Silman AJ,et al. Arthritis Rheum 2010. 2010;62(9):2569–81.

Disclosure of Interests

Rodrigo Garcia Salinas Speakers bureau: Abbvie, Lilly, BMS, Jassen, Novartis, boehringer ingelheim, Consultant of: Lilly, Jassen, Grant/research support from: Abbvie, Fernando Sommerfleck Speakers bureau: Abbvie, Janssen, Novartis, Grant/research support from: Abbvie, Alfredo Vargas Caselles: None declared, Luis Palomino Romero: None declared, Javier Rosa: None declared, Mariana Benegas: None declared, Etel Saturansky: None declared, Pamela Giorgis: None declared, Florencia Martinez: None declared, Marcelo Abdala: None declared, Jimena Sanchez Alcover: None declared, Emma Estela Civit De Garignani: None declared, Gabriela Vanesa Espasa: None declared, Verónica Inés Bellomio: None declared, Juan Manuel Bande: None declared, Silvia Papasidero: None declared, Veronica Saurit: None declared, Leticia Ibañez Zurlo: None declared, Emilio Buschiazzo: None declared

POS0508 PREDICTORS OF PERSISTENT DISEASE IN EARLY ARTHRITIS: 12 MONTHS RESULTS

Background

Early arthritis is an inflammatory disease with the potential to progress to persistent arthritis, such as established Rheumatoid Arthritis (RA) or other articular disease, to resolve spontaneously or remain undifferentiated for indefinite periods of time.

Objectives

To identify predictors of persistent RA after 12 months follow up in the Argentinean early arthritis clinic (CONAART).

Methods

We conducted an observational, prospective longitudinal study, including patients with early arthritis (at least 1 swollen joint with <2 years of evolution) who had at least one year of follow-up.

Sociodemographic and clinical data and characteristics of the disease were recorded at baseline, at 3, 6 and 12 months. After 1 year of follow-up, each patient was classified according to diagnosis: self-limited arthritis, persistent non-erosive arthritis, or persistent erosive arthritis.

The association between the different predictors of diagnosis at 12 months was evaluated using multiple logistic regression, adjusted by potential confounders. Rheumatoid Factor (RF) and Anti Citrullinated Peptide Antibodies (ACPA) were included in separate models in order to avoid multicollinearity. A value of p<0.05 was considered significant.

Results

We included 839 patients, 83% females, mean age of 57±14 years and mean disease duration of 8.2±6.2 months; 67.5% were rheumatoid factor positive and 59% ACPA positive. Disease characteristics at baseline were DAS28 5.1±1.4, swollen joints 6±5, erythrocyte sedimentation rate (ESR) 34±25 mm/h, C Reactive Protein (CRP) 4±6 and Health Assessment Questionnaire-Argentinean (HAQ-A) 1.2±0.8.

After 12 months follow up, 11% of the patients were diagnosed as self-limited disease, whereas 89% were diagnosed as persistent disease. For the persistent disease, 34% presented radiograph erosions and therefore were catalogued as persistent erosive disease.

The seropositivity for both, RF and ACPA, together with baseline DAS28, were the variables independently associated with the development of persistent disease at 12 months. [Model 1a: RF OR 2.33 (95% CI 1.44, 3.78) and DAS28 1.27 (1.06, 1.52); Model 2a: ACPA 2.61 (1.38, 4.93) and DAS28 1.59 (1.24, 2.04)]. (Table 1).

Table 1.

Predictors of Persistent Rheumatoid Arthritis at 12 months

OutcomesPersistent RAPersistent RAPersistent RAPersistent RAOR (95 IC)OR (95 IC)OR (95 IC)OR (95 IC)Model 1aModel 1bModel 2aModel 2bn708708507507Age (years)0.99 (0.98, 1.01)0.99 (0.98, 1.01)0.99 (0.97, 1.01)0.99 (0.97, 1.01)Female gender1.06 (0.57, 2.00)1.06 (0.56, 1.99)0.72 (0.30, 1.71)0.72 (0.30, 1.70)RF positive2.33 (1.44, 3.78)***2.45 (1.52, 3.98)***--ACPA positive--2.61 (1.38, 4.93)**2.63 (1.39, 4.98)**DAS28 at baseline1.27 (1.06, 1.52)**1.59 (1.24, 2.04)***Categorical DAS28  MDA (vs LDA)-1.81 (0.85, 3.86)^-2.86 (1.68, 6.99)*  HDA (vs LDA)-2.83 (1.30, 6.15)^-6.39 (2.42, 16.82)***

^ p<0.1, * p<0.05, ** p<0.01, *** p<0.001

RF, Rheumatoid Factor; ACPA, Anti Citrullinates Protein Antigen; DAS28, Disease activity Score-28; LDA, low disease activity; MDA, moderate disease activity; HDA, high disease activity.

In the patient prediction model, it can be observed that a patient with female gender, ACPA negative, and a low activity at baseline (DAS28 <3.1) presents a 62.3% of likelihood of developing persistent arthritis after 12 months, while a male patient, ACPA positive, with a high baseline activity level, the probability of having persistent disease rises to 97.5%. (Figure 1)

Figure 1.

Matrix prediction model. Probability of diagnosis of Persistent Rheumatoid Arthritis after 12 months of follow-up. Colors represents predictive probability of achieving the outcome as follow: grey: 0-69.9%; blue: 70.0-89.9%; purple: 90.0-100%.

DAS28, Disease Activity Score 28; LDA, low disease activity; MDA, Moderate Disease Activity; HDA, High Disease Activity.

Conclusion

Predictors of persistent arthritis after 12 months of follow up since AT diagnosis were RF and ACPA seropositivity and higher baseline disease activity level.

Disclosure of Interests

None declared.

OP0260 RESPONSIVENESS OF A COMBINED POWER DOPPLER AND GREYSCALE ULTRASOUND SCORE FOR ASSESSING SYNOVITIS AT JOINT LEVEL IN PSORIATIC ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO csDMARDs: DATA FROM THE ULTIMATE TRIAL

Background

Power Doppler ultrasound (PDUS) is a sensitive non-invasive imaging tool that allows the visualisation of articular and periarticular inflammation in patients with psoriatic arthritis (PsA).1 ULTIMATE (NCT02662985) was the first large randomised clinical trial that showed the responsiveness of the Global OMERACT-EULAR ultrasound synovitis score (GLOESS) in PsA and confirmed the rapid and continued benefits of secukinumab through 52 weeks.2,3

Objectives

To report the distribution of ultrasound-detected synovitis at joint level, by degree of severity at baseline and over time, and the contribution of each core component of GLOESS, synovial hypertrophy (SH) by greyscale (GS; B-mode) and power Doppler (PD) signal, to responsiveness.3

Methods

This was a 52-week study with a 12-week double-blind, placebo-controlled treatment period followed by a 12-week open-label period and a 6-month open-label extension secukinumab treatment period.3 The number of joints with synovitis measured by GLOESS2 was assessed up to Week 52. The assessments included distribution of synovitis based on composite PDUS score across 24 pairs of joints (with worse score of the pair of the joints used) by grade of severity (0-3) and change from baseline to Week 52 in each core component of GLOESS.3-5 Data are presented as observed.

Results

A total of 166 patients (mean age, 46.7 years; males, 45.2%) were enrolled, of which 90% (75/83) of secukinumab and 83% (69/83) of placebo-secukinumab participants completed 52 weeks. The mean (SD) number of PDUS detected synovitis at baseline was 9.2 (4.9) and 10.2 (5.2) in the secukinumab and placebo group, respectively. The most frequent locations with synovitis at baseline were: wrist, metatarsophalangeal (MTP), knees and metacarpophalangeal (MCP) joints (Table 1). An early and continued improvement in GLOESS was observed in both secukinumab and placebo-secukinumab groups after switching to active therapy, as previously reported at Week 12 and through Week 52.2,3 Among the two core components of GLOESS, SH was mainly responsible for the change in GLOESS from baseline to Week 52, in contrast with PD signal in this dataset. The distribution of synovitis by grade of severity showed that MTP joints, wrist, knee, MCP1/2 and tibiotalar joints mostly contributed to the composite PDUS at Week 12 (Figure 1). Similar patterns were observed through 52 weeks.

Table 1.

Proportion of patients with PDUS detected synovitis at baseline*

Synovitis joint, data presented as n (%)Secukinumab (N=83)Placebo (N=83)Wrist66 (80)66 (80)MTP256 (68)65 (78)MTP158 (70)60 (72)MTP352 (63)60 (72)MTP446 (55)59 (71)Knee50 (60)47 (57.)MCP136 (43)52 (63)MCP235 (42)41 (49)MTP530 (36)41 (49)

*Data for top nine pairs of joints with most frequently detected power Doppler ultrasound (PDUS) synovitis are presented here. Synovitis was scored by a OMERACT-EULAR synovitis composite score >0 for each paired joint (irrespective of right or left side). The OMERACT-EULAR composite PDUS score (for individual joints) ranged from 0 to 3 and was composed of the two core components synovial hypertrophy and power Doppler.

N, total number of randomised patients; n, number of evaluable patients

Conclusion

The distribution of synovitis at baseline reflected a predominance of small joints (feet and hands) and large joints (wrist and knee) and were mostly responsive to secukinumab over time in the ULTIMATE trial. Synovial hypertrophy was the most responsive core component of GLOESS driving an early and continued reduction of synovitis with secukinumab through Week 52. This finding could be useful to select a restricted number of joints in future ultrasound trials in PsA.

References

[1]D’Agostino MA and Coates LC. J Rheumatol. 2019;46:337–9.

[2]D’Agostino MA et al. Arthritis Rheumatol. 2021;73(10).

[3]D’Agostino MA, et al. Rheumatology (Oxford) 2021;keab628.

[4]D’Agostino MA and Coates LC. RMD Open 2017;3:e000428.

[5]Uson J, et al. Rheumatol Clin. 2018;14:27–35.

Disclosure of Interests

Maria-Antonietta D’Agostino Speakers bureau: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Consultant of: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Maarten Boers Consultant of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Carlos Gamez: None declared, LUCIO VENTURA: None declared, Javier Rosa Speakers bureau: Abbvie, Pfizer, Lilly, Janssen, Novartis and BMS, Ilaria Padovano: None declared, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Grant/research support from: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Arnd Kleyer Speakers bureau: Abbvie, Lilly, Novartis, MEDAC; Janssen, Consultant of: Abbvie, Lilly, UCB, Novartis, BMS, Sanofi, Galapagos, Catherine Bakewell Speakers bureau: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Consultant of: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Punit Goyanka Employee of: Novartis, Philip G Conaghan Speakers bureau: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Roche and UCB

POS0025 PREVALENCE OF ATTENTION DEFICIT HYPERACTIVITY DISORDER AMONG ADULT PATIENTS WITH FIBROMYALGIA

Background

Fibromyalgia (FM) and attention deficit hyperactivity disorder (ADHD) share some clinical features, and a reduced dopamine function has been proposed for both disorders. ADHD is a chronic condition, marked by persistent inattention, impaired concentration, hyperactivity, impulsivity, emotional lability, anxiety and disorganized behaviour. High rates of comorbidity between ADHD and FM have been reported, as well as some evidence that patients with both conditions experience heightened disease severity.

Objectives

Our purpose was to determine the prevalence of ADHD symptoms in patients with FM and to assess the relationship with disease impact.

Methods

Consecutive patients, older than 18 years, with diagnosis of FM (ACR 2016 criteria) without known cognitive impairment, seen at the Rheumatology Unit between April 2018 and December 2019, were included. At inclusion visit the collected data included Revised Fibromyalgia Impact Questionnaire (FIQ-R) and Health Assessment Questionnaire, Argentine version (HAQ-A). During the Neurology visit, the following tests were performed: Montreal Cognitive Assessment (MoCA) test for evaluating the presence of cognitive impairment, Conners Continuous Performance Test II (CPT II) for the assessment of ADHD, and Wender-Utah Rating Scale (WURS) to retrospectively assess childhood ADHD symptoms. Univariate analysis was performed using t-tests for normally distributed continuous variables, and Wilcoxon rank sum test for non-normally distributed continuous variables. A chi-square or Fisher test was used when appropriate for categorical variables. Predictors that were found to be related to ADHD (p ≤ 0.20) were then entered into a multivariable logistic regression model.

Results

60 patients with FM and 71 matched controls without FM or known cognitive impairment were included. FM patients’ characteristics are shown in Table 1. 61.7% (n=37) of the patients with FM tested positive for adult ADHD. In 48.6% (18/37) of them, the diagnosis had been missed in childhood. Participants with both FM and a positive adult ADHD screening test did not score significantly higher on the FIQ-R (52.3, SD= 16.1 vs. 47.9, SD= 12.3; p= 0.2693) and HAQ-A (0.693, SD= 0.455 vs. 0.521, SD= 0.428; p=0.1523) compared with patients without ADHD. Retrospectively assessed childhood ADHD was significantly associated with adult persistence (OR 55.1, CI=3.6 to 842.6, p=0.004).

Table 1.

Clinical and demographic characteristics of patients with FM.

Characteristicsn=60Female, n (%)53 (88.3)Age (years), mean (SD)58.3 (14.2)Time from diagnosis (years), mean (SD)5.2 (5)Scholarity (years), mean (SD)12.9 (3.4)HAQ-A, mean (SD)0.627 (0.449)FIQ-R, mean (SD)50.6 (14.8)Cognitive complaint, n (%)34 (56.7)Depression, n (%)35 (58.3)Anxiety, n (%)27 (45)Concomitant personality disorders39 (65)

Patients with FM had significantly higher prevalence of cognitive impairment (43.3% vs. 16.9%; p<0.0001), childhood ADHD symptoms (31.7% vs. 14.1%; p=0.016) and adult ADHD symptoms (61.7% vs. 23.9%; p<0.0001) than the control group (Figure 1).

Figure 1.

Percentage of FM patients with cognitive impairment, childhood and adult ADHD. Comparison with the control population.

Conclusion

The co-occurrence of adult ADHD in FM was highly prevalent. In nearly half of the patients the diagnosis had been overlooked during childhood and it was associated with adult persistence. The prevalence of cognitive impairment, and childhood and adult ADHD was higher in patients with FM compared with the control group. ADHD was not associated with the FM impact. Evaluation of ADHD symptoms in patients with FM is important for recognition and treatment of this comorbidity.

References

[1]Stefano P et al. J Psychiatr Res. 2021 Apr;136:537-542.

[2]Karas H et a.l Int J Psychiatry Clin Pract. 2020 Sep;24(3):257-263.

[3]Kessler RC et al. Biol Psychiatry. 2005 Jun 1;57(11):1442-51.

Acknowledgements

The authors thank the patients who agreed to participate in

this study.

Disclosure of Interests

None declared

Early systolic lengthening in patients with ST-elevation myocardial infarction: a novel tool for risk stratification

Funding Acknowledgements

Type of funding sources: None.

Background

After an ST-elevation myocardial infarction (STEMI), the risk of subsequent cardiovascular events is high. Risk stratification at index hospitalization remains a core challenge, especially in patients with subtle changes in LV function. Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force and it has been correlated with infarct size and prognosis in STEMI patients with mildly impaired LV function. In this study, we aimed to evaluate the correlation of ESL with common echocardiographic parameters and its prognostic value in STEMI patients with preserved LV function.

Methods

We retrospectively included all the patients admitted to an intensive care unit with STEMI and a left ventricle ejection fraction ≥55% from January to June of 2016. Patients with inadequate image quality for speckle tracking echocardiographic examination were excluded (n = 14). We evaluated the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)], and ESL duration.

Results

A total of 37 patients were included in the study. Mean age was 63 ± 12 years with a male preponderance (81%). All patients were submitted to complete revascularization. Median values of the ESL index and ESL duration were 7% (IQR, 4%–10%) and 37 msec (IQR, 21–55 msec), respectively. No significant differences were found between ESL index and ESL duration groups, except for a higher prevalence of heart failure at hospitalization in both highest groups, and women were more prevalent in the ESL index higher group (Tables 1 and 2). ESL index was correlated with post-systolic index (PSI) (r2 = 0.34, p = 0.04) and showed a weak correlation with E/A ratio (r2=-0.37, p = 0.02). ESL duration was correlated with ESL index (r2 = 0.76, p &lt; 0.001) and PSI (r2 = 0.43, p = 0.008). During a median follow-up of 3.2 years (interquartile range, 2.9–3.4 years), 7 (18.9%) patients experienced major adverse cardiovascular events (MACE), a composite of heart failure admission, myocardial infarction, and all-cause mortality Both ESL index (HR 2.5; 95%CI 1.2–5.3; P = 0.02) and ESL duration (HR 1.7; 95%CI 1.1–2.7; P = 0.02) were independent predictors of MACE. Both associations remained significant after adjusting for clinical confounders.

Conclusions

In our cohort of STEMI patients with preserved LV function, assessment of ESL yielded important and significant prognostic information on MACE. ESL may be a useful tool to enhance routine risk stratification in this population. Abstract TABLE 1  Abstract TABLE 2

Outcomes of radiofrequency catheter ablation for persistent and long-standing persistent atrial fibrillation

Introduction

Catheter ablation has become the first-line treatment for symptomatic patients with atrial fibrillation (AF). Several approaches of substrate ablation have been used for persistent and long-standing persistent AF and the best protocol procedure is yet to be established. The purpose of this study was to evaluate the outcomes of patients submitted to catheter ablation of persistent and long-standing persistent AF adding extra-pulmonary substrate approaches to pulmonary vein isolation.

Methods

We retrospectively studied 67 consecutive patients referred for the first procedure of catheter ablation of persistent or long-standing persistent AF from May 2016 to October 2018. The first 27 patients were subjected to pulmonary vein isolation and complex fractionated atrial electrograms (CFAE) ablation (group 1) and the last 40 patients were subjected to a tailored approach guided by voltage map areas and CFAE (group 2). Patient characteristics, procedure details and follow-up were assessed, and predictors of recurrence were determined.

Results

Mean age was 59±11 years with 58% being male. During a mean follow-up of 16±6 months 27% of the patients showed AF recurrence. There were no differences in baseline characteristics of group 1 and 2. A higher recurrence rate was found in group 1 by comparison with group 2 (40.7% vs 17.5%, Log Rank X2 = 5.076, P=0.024) (Figure 1). Also, recurrence was associated with a longer AF duration, an increased baseline Brain Natriuretic Peptide (BNP), an increased left atrium (LA) volume, the presence of hyperthyroidism, the absence of sinus rhythm after procedure, the inducibility of AF post-ablation and the absence of an antiarrhythmic drug at hospital discharge. After adjustment for other confounders, the patient group (HR 5.16 [1.23–21.71] P=0.025), a long-standing AF (HR 9.09 [1.41–58.82] P=0.020), the BNP value at admission (HR 1.03 [1.01–1.05] P=0.033) and the LA volume index (HR 1.13 [1.02–1.25] P=0.017) were the only independent predictors of recurrence.

Conclusion

Ablation of persistent and long-standing persistent AF is feasible with good results when a substrate approach is added to pulmonary vein isolation. A tailored approach seems to be more efficient, showing best outcomes in mid-term follow-up. A long-standing AF, higher BNP value and the LA enlargement are important predictors of recurrence and should be used to better select patients and to manage follow-up.

Funding Acknowledgement

Type of funding sources: None.

Estimating pVO2 and prognosis through cardiac exercise stress test in a heart failure population

Background

Compared with the cardiac exercise stress test, more commonly used to assess the presence of ischemia, the cardiopulmonary exercise test has the advantage of providing expired gas analysis. According to current guidelines, cardiopulmonary exercise testing should be considered to stratify the risk of adverse events and to provide measures of survival improvement in heart failure populations. However, cardiac exercise stress test is more readily available and widespread than cardiopulmonary exercise testing. We aimed to compare prognostic information given by estimated pVO2 – which can be obtained from cardiac exercise stress test – and real measured pVO2 – which requires cardiopulmonary exercise test – in a heart failure population.

Methods

We conducted a retrospective analysis of 214 patients with HF underwent cardiac exercise stress test and accessed their 5 year survival. Non-urgent transplanted (UNOS Status 2) patients were censored alive on the date of the transplant. Duringthe cardiopulmonary exercise test, cardiac exercise stress test data simultaneously collected. Based on protocol stage achieved, estimated METs were used to calculate estimated pVO2 (pVO2 = estimated METs x 3.5). Estimated and real pVO2 were correlated using Pearson correlation and the age-adjusted prognostic power of each was determined using Cox proportional hazardsanalysis.

Results

164 patients were male (77%) and the mean age of the population was 56±10 years. 78 (36%) patients had an ischemic etiology. Within 5 years from testing, 46 patients died (21.5%) and 55 patients (26%) were transplanted. Naughton modified (n=165) was the most commonly used protocol, followed by Naughton (n=39) and Bruce (n=10). Estimated pVO2 and measured pVO2 correlated significantly (R=0.66, p&lt;0.01) (Figure 1). Both estimated (HR=0.91, 95% CI 0.86–0.95, p&lt;0.01) and measured pVO2 (HR=0.86, 95% CI 0.80–0.91, p&lt;0.01) strongly predicted prognosis in this population.

Conclusions

Estimated pVO2 correlated with measured pVO2 and strongly predicted prognosis in this heart failure population. Because it can be obtained from conventional cardiac exercise testing, it may become an alternative prognostic tool to cardiopulmonary testing.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Measured vs estimated pVO2

Interventional cardiology in times of COVID-19: impact on a terciary centre

Introduction

Cardiovascular diseases are the leading cause of death worldwide and the pandemic caused by coronavirus disease 2019 (COVID-19) has forced profound changes in the care of patients with cardiac conditions. In Portugal, an increase in mortality beyond that attributed solely to COVID-19 was observed. We aimed to realize how COVID-19 has changed the activity of our Interventional Cardiology Unit.

Methods

We retrospectively assessed all patients submitted to any interventional procedure in 2019 and 2020 in our hospital. A total of 7621 patients and 9163 procedures were evaluated. The mean weekly numbers of coronarography, angioplasty, right heart catheterization and structural heart intervention during 2019 were assessed and were compared with the first COVID-19 wave (comprising March and April 2020) and the second COVID-19 wave (including the time period from October to end of December 2020).

Results

Mean age was 65.2±16.6 years with 72% being male. In the first COVID-19 wave there was a significant reduction in the mean weekly numbers of all procedures, with a 64% decline in coronarographies (30.9±29.3 vs 87.2±12.9, P<0.001), 48% in angiographies (15.7±10.9 vs 30.2±5.7, P=0.004), 51% in right heart catheterizations (5.3±5.9 vs 10.9±4.5, P=0.002) and 57% in structural heart interventions (1.1±1.9 vs 2.6±2, P=0.044). Although there was an evident recovery in activity (figure 1), comparing to 2019, the second wave also showed a significant lower number of procedures, with 24% fewer coronarographies (66.6±20.6 vs 87.2±12.9, P=0.003) and 13% fewer angiographies (26.4±7.6 vs 30.2±5.7, P=0.004). Contrariwise, in the second wave there was no difference in the number of right heart catheterizations (7.3±6.1 vs 10.9±4.5, P=0.055) or structural heart interventions (1.6±1.6 vs 2.6±2, P=0.106).

Conclusions

In our Interventional Cardiology Unit, COVID-19 led to a significant reduction of procedures in the first and second pandemic waves. The effect on the increase in morbidity and mortality has yet to be determined. Health authorities should focus attention in defining measures to amend the consequences of this documented activity reduction.

Funding Acknowledgement

Type of funding sources: None.

Heart failure with reduced ejection fraction: predicting exercise intolerance with echocardiography

Introduction

Cardiopulmonary exercise testing (CPET) is routinely used in the prognostic evaluation of patients with heart failure with reduced ejection fraction (HFrEF). Left ventricular ejection fraction (LVEF) is a strong prognostic marker but have shown a bad correlation with exercise capacity. The aim of this study is to assess the relationship between echocardiographic parameters and exercise capacity in HFrEF patients.

Methods

We retrospectively assessed all patients with HFrEF submitted to CPET and echocardiography between March and September of 2019. 73 patients were eligible for analysis. ANOVA test was used to compare Weber class groups regarding echocardiographic parameters. Multivariate linear regression with a stepwise approach was used to assess independent predictors of peak VO2 uptake. ROC curves were compared to assess the best parameter to discriminate a peak VO2 &lt;10 ml/kg/min (Weber class D).

Results

Mean age was 53.4±11.7 years with 72.6% being male. Mean LVEF was 29.2±7.7% and mean peak VO2 was 13.4±3.8 ml/kg/min. Between the Weber class groups, significant differences were found in left (LV) and right ventricular (RV) longitudinal strain (P&lt;0.001 and P=0.005 respectively), in the left and right atrial reservoir strain (P=0.009 and P&lt;0.001 respectively), in pulmonary velocity acceleration time (P=0.002) and in maximal tricuspid regurgitation velocity (TRmax) (P=0.014). Left ventricular ejection fraction, tricuspid annular plane systolic excursion, and ratio E/e' were not significantly different among exercise capacity groups. Additionally, only RV longitudinal strain (r2=0.225, P=0.008) and TRmax (r2=0.073, P=0.030) were independent predictors of peak VO2. RV longitudinal strain showed the best accuracy in discriminating a Weber class of D (AUC=0.731, 95% CI: 0.613–0.848, P=0.005) with a calculated cut of −8.6% and with a negative predictive value of 95%.

Conclusion

RV longitudinal strain and TRmax seem to be the best echocardiographic predictors of exercise intolerance in patients with HFrEF. Since CPET is not widely available, these echocardiographic parameters can be clinically useful as a surrogate prognostic factor.

Funding Acknowledgement

Type of funding sources: None.

Influence of oceanic and climate conditions on the early life history of European seabass Dicentrarchus labrax

Understanding how marine fish early-life history is affected in the long-term by environmental and oceanographic factors is fundamental given its importance to population dynamics and connectivity. This work aimed at determining the influence of these processes on the interannual variability in hatch day and early-life growth patterns of European seabass, over a seven-year period (2011-2017) in the Atlantic Iberian coast. To accomplish this, otolith microstructure analysis was used to determine seabass hatch day and to develop early-growth correlations. In most years, hatching occurred from February to April, with two exceptions: in 2012, hatching started in early-January, and in 2016 an exceptionally long hatching period was registered. Using generalized additive models (GAM), we observed that sea surface temperature (SST), the North Atlantic Oscillation index (NAOi) and Chlorophyll-a (Chla) were the main drivers behind the inter-annual variability in seabass hatch day. Analysis of correlations between growth increments allowed assessing important periods of seabass growth and how future growth is affected. Since seawater temperature is among the main drivers for seabass recruitment and growth, its life cycle may be hampered due to ocean warming and an increasingly unstable climate, with consequences for the natural marine stocks and their harvest.

POS0984 PREVALENCE OF AXIAL SPONDYLOARTHRITIS AMONG YOUNG PEOPLE CONSULTING BECAUSE OF CHRONIC LOW BACK PAIN IN A UNIVERSITY HOSPITAL IN ARGENTINA

Background:

Axial spondyloarthritis (SpA) is an umbrella term encompassing a number of inflammatory conditions involving the axial skeleton. A substantial delay between disease onset, diagnosis and treatment often occurs, related in part to under-recognition of SpA symptoms. Although several studies have investigated since the publication of the ASAS classification criteria in 2009, the prevalence and incidence of axial SpA in the general population and in patients with SpA-related conditions, the actual prevalence of SpA in many countries (including Argentina) is unknown.

Objectives:

To estimate the prevalence of axial SpA and the amount of undiagnosed axial SpA in people under 45 years of age that contacted the health care system for chronic low back pain.

Methods:

The setting was a university hospital-based health management organization with a population distribution similary to that of Buenos Aires. All electronic medical records of patients < 45 years of age at the time of onset of symptoms (as per the ASAS 2009 criteria) and chronic low back pain for 3 or more months) seen at the university hospital-based health management organization between 2009 and 2019, were reviewed. If the patient fulfilled the ASAS criteria, was classified as having axial SpA [ankylosing spondylitis (AS) or non-radiographic axial SpA (nr-axSpA)]. Among this group, if the diagnosis was already established in the medical records by the treating physicians, these patients were also classified as diagnosed with axial SpA; if not, they were classified as undiagnosed with axial SpA. We are reporting the results of descriptive analysis.

Results:

A total of 796 patients were included (Table 1), 426 were women (53.52%, 95% CI 50.1-57) with a median age of 34 years (IQR 29-40) at initiation of low back pain with a median follow up of 77.7 months (IQR 35.7-136.4). The prevalence of axial SpA among patients with chronic low back pain was 5.78% (n= 46, 95% CI 4.2-7.4). 22 patients had AS (2.76%, 95% CI 1.6-3.9) with a median lag time between the onset of low back pain and diagnosis of 58.7 months (IQR 33.5 - 92). All AS cases were already diagnosed. 24 patients had nr-axSpA (3.02%, 95% CI 1.8 - 4.2). Of those, 14 were diagnosed by treating physicians with a lag time median of 23.2 months (IQR 13.1 - 36.5) between the onset of low back pain and diagnosis. Ten patients fulfilled the ASAS criteria (41.7%, CI 95% 22 - 61.4) but were not diagnosed by the treating physicians (22%, 95% CI 9.82-33.66) among the patients with axial SpA.

Table 1.

Demographic, clinical features and therapeutic characteristics of patients with chroniclow back pain stratified by diagnosis

Axial spondyloarthritisN=46Ankylosing spondylitisN=22Diagnosednr-axSpAN=14Undiagnosednr-axSpAN=10OtherdiagnosisN=749Female, n (%, CI)18(39.13%, 25.04-53.23)4(18.18%, 2.06-34.29)10(71.42%,47.76-95.09)4(40%, 9.63-70.36)407(54.34,50.77-57.9)Age at chronic LBP initiation, years, median (IQR)36(29.25-40)32(32-40)38(22-36.75)39(35.25-41.5)34(29-40)Follow up, median months (IQR)88(33.43-148.66)33.67(23.38-90.34)16.73(7.64-24.02)64.77(11.21-164.7)77.69(35.83-135.32)Inflammatory chronic LBP by any criteria n (%)44 (95.7)21 (95.5)13 (92.8)10 (100)56 (7.5, 5.6-9.4)Seen by a Rheumatologist, n (%)42 (91.3)22 (100)14 (100)6 (60)36 (5.1)Lag time between first LBP to SpA diagnosis, months, median (IQR)34.6 (22.6-63.2)58.7 (33.5 – 92)23.1 (13.1-36.5)--bDMARDs treatment n, (%, CI)15(33; 19.5–48)10(45; 24.4–67.8)5(36; 13–64.9)--Lag time between NSAIDs failure and first bDMARDs, months, median (IQR)2.66(2.05-4.63)2.76(2.07-11.3).2.66(2.04-3.25)--

CI: 95% confidential interval, IQR: interquartile range, bDMARDs: biologic disease modifying anti-rheumaticdrugs, LBP: low back pain

Conclusion:

In our cohort, 5.78% of the patients < 45 years with chronic low back pain had axial SpA (AS: 2.76%; and nr-axSpA: 3.02%). Approximately, one in every five patients had undiagnosed axial SpA. Original manuscript made in collaboration with Novartis Argentina S.A

Disclosure of Interests:

Mayra Alejandra Tobar Jaramillo: None declared, Nicolas Marin Zucaro: None declared, Javier Rosa: None declared, Josefina Marin: None declared, Maria Laura Acosta Felquer: None declared, LEANDRO FERREYRA: None declared, JOHN FREDY JARAMILLO GALLEGO: None declared, Josefina Marcos Employee of: Novartis, Vanesa Duarte Employee of: Novartis, Enrique Soriano Speakers bureau: AbbVie, Amber, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer Inc, Roche, Consultant of: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc, Sandoz, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc, Sandoz.

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

Strauss formula: a great and easy tool to manage congestion in acute heart failure

Background

Approaching the congestive patient is a complex task that requires the combination of different assessment methods. The Strauss formula uses variations in haemoglobin and haematocrit to estimate plasma volume variations (PVV) and haemoconcentration. However, this formula was only validated in outpatients followed with chronic heart failure. We aimed to assess the applicability of this formula to hospitalized patients for acute heart failure (AHF).

Methods

We conducted a single-centre, retrospective, observational study of 302 patients who were admitted to our hospital for AHF during 2016 and were discharged alive. Baseline clinical, laboratory and demographic characteristics were evaluated at admission and the Strauss formula was applied, as PVV (%) = 100 x [(Hb A / Hb D) x (1 − Hct D) / (1 − Hct A)] − 100), where A = admission and D = discharge. At discharge, we considered that a positive change (≥0%) in PV regarding the admission was linked to an increase in PV (haemodilution); a negative change (&lt;0%) correlated to a decrease in the PV (haemoconcentration). The primary endpoint was a composite of cardiovascular death (CV-death) and HF readmission at 3-months.

Results

Mean age was 76±11 years and 57% were male. At baseline, 92% were on clinical-haemodynamic profile B, with a median NT-proBNP of 2157 (IQR 1161–4242) pg/dL, a mean of glomerular filtration rate (GFR) of 63±57 mL/min/m2, a mean haemoglobin of 12±2 g/dL and a mean haematocrit of 38±6%. At discharge, the median plasma volume variation was −1.1% (IQR – 9.6 to 7.8) and the distribution of PVV values in the histogram reveals that a large proportion of patients (44%) increased or maintained plasma volume (PVV ≥0% – haemodilution). The group of patients who decreased plasma volume at discharge was slightly younger (75 vs 78 years, p=0.044), showing higher numerical decreases in NT-proBNP, gamma-glutamyl transferase (gGT) and bilirubin at discharge. A positive change in PV (PVV &gt;0%) during admission almost doubled the risk for readmission and CV-death at 3-months [OR 1.9 (95% CI: 1.1 to 3.1, p=0.026], after adjusting for age and sex.

Conclusions

In this work, we demonstrate that PVV, as calculated by the Strauss formula, increases or is unchanged in 44% of patients admitted with AHF and is strongly associated with a composite of 3-months CV death and HF readmission. Tools to guide the management of residual congestion are of great importance to assess the optimal discharge timing.

Funding Acknowledgement

Type of funding source: None

THU0119 COULD SYNOVITIS AND TENOSYNOVITIS DETECTED BY ULTRASOUND BE CONSIDERED A RISK FACTOR FOR SHORT-TERM FLARE IN RA PATIENTS IN CLINICAL REMISSION

Background:

The clinical value of ultrasound (US) detected synovitis and tenosynovitis as predictors of flares in RA patients in clinical remission is not clear.

Objectives:

To investigate the value of US detected synovitis and tenosynovitis as risk factors for short term flare in RA patients in clinical remission.

Methods:

Consecutive RA patients in clinical remission (DAS28 ERS < 2.6) for at least 3 months, underwent Power Doppler ultrasound (PDUS) examination of: 1st to 6th extensor compartments at the wrist, 2nd to 5th flexor, posterior tibial tendons and peroneals. Regarding joints, carpal joints, 1st to 5th MCP and 2nd to 5th interphalangeal proximal (IPP). Synovitis and tenosynovitis were defined according to OMERACT. Patients were followed for one year. Disease flare was defined as any increase of disease activity generating the need of change in therapy by the attending rheumatologist.

Results:

Ninety patients were included. Patients´ characteristics are shown in the table. After one year of follow-up, 26 patients (29%) experienced a flare. At baseline 39%, 23% and 8% had US detected synovitis, tenosynovitis or both respectively. The presence of US detected tenosynovitis (RR: 4.9; 95% CI: 2.2-10.8), but not of US detected synovitis (RR: 1.3; 95% CI: 0.76-2.2), showed an increased risk of having a flare. In the multivariable analysis, and after adjusting by age, gender, disease duration, DAS28, DMARDs and biologics use, and the US detected synovitis, only subclinical tenosynovitis (OR: 9.8 95% CI: 2.5-39.1; p=0.001) and baseline DAS28 (OR: 5.7, 95% CI: 1.1-31.6; p= 0.047) were significantly associated with an increased risk of flare.

Conclusion:

Subclinical tenosynovitis, but not synovitis, was associated with disease flare in patients with RA in clinical remission. This feature might have physio-pathological implications.

References:

[1]Filippou G, et al. The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study. Ann Rheum Dis 2018;0:1–7.doi:10.1136/annrheumdis-2018-213217

[2]Bellis E, et al. Ultrasound-detected tenosynovitis independently associates with patient-reported flare in patients with rheumatoid arthritis in clinical remission: results from the observational study STARTER of the Italian Society for Rheumatology Rheumatology 2016; 55:1826_1836doi:10.1093/rheumatology/kew258. Advance Access publication 27 June 2016

Table 1.

Demographic and clinical features from RA patients in clinical remission

FeaturePatients with flares (n=26)Patients without flares (n= 64)P valueMean age (SD)63.1 (12.6)57.5 (13.2)0.0679Females, n (%)54 (84)24 (92)0.316Mean Disease duration years (SD)5.5 (5.5)8.4 (5.9)0.0344Positive Rheumatoid Factor, n (%)16 (61.5)40 (62.5)0.802Mean Erythrosedimentation rate (ESR)18.3 (8)14.1 (10.4)0.0680Mean DAS28 ESR (SD)1.9 (0.5)2.2 (0.3)0.0091Mean Swollen joint count (SS)0.15 (0.4)0.15 (0.4)0.9806Mean Patient’s Global VAS (0-10) (SD)1.4 (1.3)1.1 (1.1)0.2471Mean tender joint count (SD)0.2 (0.5)0.2 (0.5)0.9653Treatment with DMARDs, n (%)54 (81)26 (100)0.018Treatment with biologics, n (%)19 (30)3 (11)0.069

Disclosure of Interests:

Johana Zacariaz H: None declared, martin brom: None declared, florencia mollerach: None declared, josefina marin: None declared, leandro ferreyra g: None declared, Javier Rosa Speakers bureau: ABBvie, Pfizer, BMS, Novartis, Janssen, Eli Lilly, enrique soriano Speakers bureau: Abbvie, Pfizer, BMS, Novartis, Janssen, Eli Lilly, UCB, Roche

SAT0144 DOES POLYPHARMACY IN RHEUMATOID ARTHRITIS PATIENTS AFFECT THE TREAT TO TARGET STRATEGY?

Background:

Polypharmacy (PP) is an important risk factor for drug toxicity, delirium, falls, hospitalizations and death. Patients with rheumatoid arthritis (RA) often have comorbid conditions and have PP. Treat to target strategy (T2T) implies a drug escalation and rheumatologists may not apply it in patients with PP.

Objectives:

Our objective was to analyze if PP affects T2T in a real-world scenario.

Methods:

Observational, retrospective cohort study. Patients with a new RA diagnosis (ACR/EULAR 2010 criteria) after 2010, over 18 years old, belonging to a Health Management Organization (HMO) from a university tertiary hospital, with a minimum follow-up period of 2 years, were included. PP was defined as consumption greater than or equal to 5 medications at the time of RA diagnosis, regardless of the medication used for RA, administered for a minimum period of 6 months. T2T strategy was defined as accomplished if an escalation in treatment was done when the patient had moderate or high disease activity at medical visit (by DAS28 and/or CDAI), without a significant improvement with respect to the previous visit. Prevalence of PP at RA diagnosis was calculated and RA patients were divided in those with PP at RA diagnosis time and those without. The first 2 years of disease were analyzed and compare between both groups: clinical and demographic characteristics, percentage of visits where T2T was applied, treatments received during that period. A multivariate logistic regression analysis was performed in order to identify factors associated with no T2T compliance.

Results:

147 patients with RA were included, 86% women, with an average age at diagnosis of 60 years (SD: 15.8). The prevalence of PP at RA diagnosis was 12% (17 patients). Table 1 shows the comparison between patients with and without PP. Patients with PP showed a greater frequency of erosions at baseline and after 2 years of disease, a greater use of corticosteroids at 2 years, higher percentage of hospitalizations and a higher mortality. In the multivariate logistic regression analysis, no compliance of the T2T strategy was only associated with the consumption of corticosteroids at 2 years (OR: 0.36, CI95%: 0.15-0.85; p=0.019) and no association was found with PP at the beginning of the disease.

Table 1.

Demographic and clinical characteristics in patients with and without polypharmacy.)

Patients without Polypharmacy(n= 127)Patients with Polypharmacy(n= 17)PMale sex, n (%)18 (13.8)3 (17.6)0.6Mean age at diagnosis (SD)58.5 (15.6)70.6 (12.2)0.9Positive rheumatoid factor, n (%)87 (66.9)12 (70.5)0.7Positive anti CCP, n (%)109 (85.8)13 (81.2)0.6Erosions at baseline, n (%)25 (19.2)7 (41.1)0.03Active smoker, n (%)28 (21.5)3 (17.6)0.2Past smoker, n (%)23 (17.6)7 (35.2)Charlson score, median (IQR)3 (1-4)4 (4-5)<0.0001Polypharmacy at 2 years, n (%)17 (13.0)46.8 (88.2)<0.0001Rheumatological consultations in 2 years, mean (DE), (IC 95%)8.6 (3.3)(8.0-9.2)8.8 (3.1)(7.2-10.5)0.6Corticosteroid therapy at 2 years, n (%)29 (22.3)8 (47.0)0.02cDMARDs therapy at 2 years, n (%)114 (87.6)13 (76.4)0.2Biologic therapy at 2 years, n (%)13 (10)4 (23.5)0.1Erosions at 2 years, n (%)29 (22.3)9 (52.9)0.007No T2T compliance, n (%)65 (50)5 (29.4)0.1Hospitalizations, n (%)12 (9.2)7 (41.1)<0.0001Mortality, n (%)2 (1.5)2 (11.7)0.01

Conclusion:

The prevalence of PP in our patients with a new RA diagnosis was 12% and was associated with more baseline erosions, a higher consumption of steroids, and a higher frequency of hospitalizations and mortality during the first 2 years of the disease. No relationship between PP and adherence to the T2T strategy was demonstrated. In the multivariate logistic regression analysis, no compliance with the T2T strategy was only associated to the consumption of corticosteroids at 2 years, may be reflecting a poorer disease control.

Disclosure of Interests:

JOHN FREDY JARAMILLO GALLEGO: None declared, Javier Rosa: None declared, Marina Scolnik: None declared, Mayra Alejandra Tobar Jaramillo: None declared, LEANDRO FERREYRA: None declared, Enrique Soriano Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc, Sandoz, Consultant of: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc, Sandoz, Speakers bureau: AbbVie, Amber, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer Inc, Roche

Negative symptom severity at discharge from an index hospitalization and subsequent use of psychiatric care resources: A retrospective 1-year follow-up study on 450 patients with schizophrenia spectrum disorders

Negative symptoms of schizophrenia have a great impact on patients' functioning and are among the most important contributors to subject's disability. However, few studies have assessed the role of type and severity of symptomatology of schizophrenia on the psychiatric care resource utilization. We investigated if the clinical profile of patients at discharge from an index hospitalization might be associated with a different use of psychiatric care resources in the subsequent 1-year period in a large population of patients with schizophrenia spectrum disorders. Clinical records of 450 patients with schizophrenia spectrum disorders admitted in an acute psychiatric inpatient service and subsequently followed in the outpatient services of the same Department were reviewed. Patients with more severe negative symptoms at discharge from hospital showed a higher number and duration of hospitalizations in the 1-year follow-up, as well as a higher number of rehabilitative residential admissions than patients with milder severity of negative symptoms. The same was true for patients with predominant negative symptoms. A global resource utilization index indicated a higher use of psychiatric resources in patients with higher severity of negative symptoms. In conclusion, showing moderate to severe negative symptoms versus positive symptoms at discharge from a hospitalization for an acute exacerbation of schizophrenia spectrum disorder does predict a higher use of psychiatric care resources. This underlines the importance of relieving negative symptoms even in the acute phase of treatment and the need to develop more effective treatments for this symptom dimension.

Current Non-viral siRNA Delivery Systems as a Promising Treatment of Skin Diseases

BACKGROUND

Gene therapy is a new approach to discover and treat many diseases. It has attracted considerable attention from researchers in the last decades. The gene therapy through RNA interference has been considered one of the most recent and revolutionary approaches used in individualized therapy. In the last years, we have witnessed the rapid development in the field of the gene silencing and knockdown by topical siRNA. Its application in gene therapy has become an attractive alternative for drug development.

METHODS

This article will address topical delivery of siRNA as a promising treatment for skin disorders. An update on the advances in siRNA-based nanocarriers as a powerful therapeutic strategy for several skin diseases will be discussed giving emphasis on in vitro evaluations.

RESULTS

Through the in-depth review of the literature on the use of siRNAs for skin diseases we realize how widespread this use is. We have also realized that nanoparticles as non-viral vectors are increasingly being explored. Skin diseases where the use of siRNA has been explored most are skin cancer (melanoma and nonmelanoma), psoriasis, vitiligo, dermatitis and leprosy. But we also report here other diseases where the use of siRNA has been growing as acne, alopecia areata, cutaneous leishmaniasis, mycoses, herpes, epidermolysis bullosa and oculocutaneous albinism. Also highlighted, the first clinical trial of siRNA for cutaneous diseases, aimed at Pathyounychia Congenita.

CONCLUSION

The treatment of skin diseases based on topical delivery of siRNA, which act by inhibiting the expression of target transcripts, offers many potential therapeutic advantages for suppressing genes into the skin.

Tempering aversive/traumatic memories with cannabinoids: a review of evidence from animal and human studies

RATIONALE

Aversive learning and memory are essential to cope with dangerous and stressful stimuli present in an ever-changing environment. When this process is dysfunctional, however, it is associated with posttraumatic stress disorder (PTSD). The endocannabinoid (eCB) system has been implicated in synaptic plasticity associated with physiological and pathological aversive learning and memory.

OBJECTIVE AND METHODS

The objective of this study was to review and discuss evidence on how and where in the brain genetic or pharmacological interventions targeting the eCB system would attenuate aversive/traumatic memories through extinction facilitation in laboratory animals and humans. The effect size of the experimental intervention under investigation was also calculated.

RESULTS

Currently available data indicate that direct or indirect activation of cannabinoid type-1 (CB1) receptor facilitates the extinction of aversive/traumatic memories. Activating CB1 receptors around the formation of aversive/traumatic memories or their reminders can potentiate their subsequent extinction. In most cases, the effect size has been large (Cohen's d ≥ 1.0). The brain areas responsible for the abovementioned effects include the medial prefrontal cortex, amygdala, and/or hippocampus. The potential role of cannabinoid type-2 (CB2) receptors in extinction learning is now under investigation.

CONCLUSION

Drugs augmenting the brain eCB activity can temper the impact of aversive/traumatic experiences by diverse mechanisms depending on the moment of their administration. Considering the pivotal role the extinction process plays in PTSD, the therapeutic potential of these drugs is evident. The sparse number of clinical trials testing these compounds in stress-related disorders is a gap in the literature that needs to be addressed.

The effect of adrenalectomy on exercise response of the renin-angiotensin-aldosterone system and exercise tolerance in primary aldosteronism

Primary aldosteronism (PA) is associated with objectively measured lower physical fitness and blunted response of the renin-angiotensin-aldosterone system to exercise. The purpose of this pilot study was to objectively measure exercise response of the renin-angiotensin-aldosterone system and cardiopulmonary fitness changes after laparoscopic adrenalectomy (ADE) in patients with unilateral PA. We examined a total of 14 patients with confirmed PA before and after ADE, by means of spiroergometry and hormonal evaluation. As expected, after adrenalectomy basal aldosterone (Aldo) levels before exercise decreased significantly, with a concomitant increase in plasma renin (PR). The increase in Aldo (285.9+/-171.3 to 434.1+/-278.2 ng/l; p=0.02) and blunted increase in PR (7.1+/-0.4 to 8.9+/-10.4 pg/ml; NS) post-exercise before ADE became significant after ADE Aldo post-ADE (46.8+/-18.8 to 106.5+/-68.1 ng/l; p<0.0001) and PR post-ADE (20.1+/-14.5 to 33.9+/-30.7 pg/ml; p=0.014). After adrenalectomy, the patients had a non-significant increase in peak workload and VO(2peak). We found normalization of the renin-angiotensin-aldosterone system response to exercise with little changes in cardiopulmonary fitness six months after ADE.

Lower physical fitness in patients with primary aldosteronism is linked to the severity of hypertension and kalemia

Hypokalemia as a typical feature of primary aldosteronism (PA) is associated with muscle weakness and could contribute to lower cardiopulmonary fitness. The aim of this study was to describe cardiopulmonary fitness and exercise blood pressure and their determinants during a symptom-limited exercise stress test in patients with PA. We performed a cross-sectional study of patients with confirmed PA who were included before adrenal vein sampling on whom a symptom-limited exercise stress test with expired gas analysis was performed. Patients were switched to the treatment with doxazosin and verapamil at least two weeks before the study. In 27 patients (17 male) the VO(2peak) was 25.4+/-6.0 ml/kg/min which corresponds to 80.8+/-18.9 % of Czech national norm. Linear regression analysis shows that VO(2peak) depends on doxazosin dose (DX) (p=0.001) and kalemia (p=0.02): VO(2peak) = 4.2 - 1.0 * DX + 7.6 * Kalemia. Patients with higher doxazosin doses had a longer history of hypertension and had used more antihypertensives before examination, thus indicating that VO(2peak) also depends on the severity of hypertension. In patients with PA, lower cardiopulmonary fitness depends inversely on the severity of hypertension and on lower plasma potassium level.

Biochemical Testing After Pheochromocytoma Removal: How Early?

Pheochromocytomas are catecholamine-producing tumors with typical clinical presentation. Tumor resection is considered as an appropriate treatment strategy. Due to its unpredictable clinical behavior, biochemical testing is mandatory to confirm the success of tumor removal after surgery. The aim of the study was to investigate the feasibility of a shorter interval of postoperative testing (earlier than the recommended 2-4 weeks according to recently published Guidelines). We investigated 81 patients with pheochromocytoma before and after surgery. Postoperative examination was performed of stable subjects after their transport from the surgical to the internal ward (7.1±2.2 days after surgery). Plasma metanephrines were used for the diagnosis of pheochromocytoma and confirmation of successful tumor removal. All subjects with pheochromocytoma had markedly elevated plasma metanephrines before surgery. No correlation between postoperative interval (the shortest being 3 days) and plasma metanephrine levels was found. Postoperative plasma metanephrine levels did not differ significantly from those taken at the one-year follow-up. In conclusion, we have shown that early postoperative diagnostic workup of subjects with pheochromocytoma is possible and may thus simplify early postoperative management of this clinical condition.

Polychlorinated biphenyls (PCBs) and p,p'-dichlorodiphenyldichloroethylene (DDE) concentrations in maternal and umbilical cord serum in a human cohort from South Portugal

Organochlorine compounds as polychlorinated biphenyls (PCBs) and pp'-dichlorodiphenyldichloroethylene (pp'DDE) are ubiquitous, resistant to degradation and lipophilic compounds, commonly found in the general population. Prenatal exposure to these compounds has been associated to adverse developmental effects. Levels of PCBs and pp'DDE were investigated in maternal and umbilical cord serum of 68 women/newborns pairs from Algarve, South Portugal. Mean sum PCBs congeners and pp'DDE concentrations were 1.62 ± 0.39 ng mL(-1)and 1.11 ± 0.69 ng mL(-1)-for maternal and 1.45 ± 0.25 ng mL(-1) and 0.85 ± 0.50 ng mL(-1)for cord serum, respectively. Congeners distribution pattern followed the order PCB 153>180>130, both for maternal and cord serum). Significant correlations (p<0.05) were found between maternal and cord serum concentrations. The umbilical cord/maternal serum ratio were 0.90 and 0.76, respectively for ΣPCB and pp'DDE Multivariate analyses relate women in urban centers with higher PCB levels, while higher pp'DDE relates to older primiparous women that live at rural areas. PCBs were also correlated to more portions of fat rich foods, while pp'DDE is associated to higher ingestion of vegetables and fruits. Smoking habits only correlated to maternal PCB. The present work provides, to our knowledge and for the first time, baseline human-biomonitoring data and establishes background ranges of PCB and pp'DDE levels in the maternal and umbilical cord serum in the Algarve region. These compounds exhibited the capacity to pass the placenta barrier and target the fetus. Even in non-industrialized areas, and in non-intensive agriculture areas, like the Southern Portugal, there is a need to take measures to eliminate or minimize the risk of organochlorine exposure during pregnancy.

Changes in energy metabolism in pheochromocytoma

CONTEXT

Catecholamine overproduction in pheochromocytoma affects basal metabolism, resulting in weight loss despite normal food intake.

OBJECTIVE

The objective of the study was to evaluate changes in energy metabolism expressed as resting energy expenditure (REE) in patients with pheochromocytoma before and after adrenalectomy and the possible relationship with circulating inflammatory markers.

DESIGN

We measured REE in 17 patients (8 women) with pheochromocytoma by indirect calorimetry (Vmax-Encore 29N system) before and 1 year after adrenalectomy. Body fat percentage was measured with a Bodystat device. Inflammatory markers (leukocytes count and C-reactive protein) and cytokines (TNF-α, IL-6, and IL-8) were analyzed with a Luminex 200.

RESULTS

REE measured in the pheochromocytoma group was 10.4% higher than the predicted value (1731 ± 314 vs 1581 ± 271 kcal/d; P = .004). Adrenalectomy significantly increased body mass index (P =0.004) and the percentage of body fat (P = .01), with a proportional increase in fat distribution (waist circumference, P = .045; hip circumference, P = .001). REE significantly decreased after adrenalectomy (1731 ± 314 vs 1539 ± 215 kcal/d; P = .002), even after adjustments in body surface and body weight (P < .001). After adrenalectomy, we found a significant decrease in leukocyte counts (P = .014) and in the levels of TNF-α (P < .001), IL-6 (P = .048), and IL-8 (P = .007) but not C-reactive protein (P = .09). No significant correlations among calorimetry parameters, hormones, and proinflammatory markers were detected.

CONCLUSIONS

Chronic catecholamine overproduction in pheochromocytoma may lead to a proinflammatory and hypermetabolic state characterized by increased REE. Adrenalectomy leads to the normalization of energy metabolism followed by an increase in body mass index and body fat content and decreases in inflammatory markers and cytokines.

Assessment of essential and nonessential metals and different metal exposure biomarkers in the human placenta in a population from the south of Portugal

The general population is exposed to metals as trace amounts of metallic compounds are present in air, water, and food. Information on background exposures and biomarker concentrations of environmental chemicals in the general Portuguese population is limited. Therefore, the purpose of this study was to determine the levels of important nonessential metals with recognized toxicity cadmium (Cd) and lead (Pb) and essential metals copper (Cu), nickel (Ni), chromium (Cr), and zinc (Zn) in placentas of mothers living in south Portugal (Algarve). Due to the difficulty in establishing the effects of chemicals in a complex and variable environment, this study also aimed to examine the response of biomarkers, such as biochemical changes that occurs at subcellular levels in the presence of contaminants. The investigated biomarkers in placentas indicative of metal exposure or damage included the metallothioneins (MT), delta-aminolevulinic acid dehydratase (ALAD) (specific for Pb), and lipid peroxidation (LPO) as an index of oxidative stress damage. Moreover, HJ-BIPLOT was applied in order to identify and categorize mothers vulnerable to environmental contamination in this region. Metal concentrations in the placenta were not excessive but within the range found in most European studies. In general, the biomarkers MT and LPO were positively correlated with metal levels, while with ALAD the opposite occurred, indicating the selected battery of biomarkers were suitable to study the effects of metals on human placenta. Further, the application of multivariate analysis with HJ-BIPLOT showed that most significant factors contributing to maternal and fetal exposures via placenta were dietary and smoking habits.