The InBIO barcoding initiative database: DNA barcodes of Iberian Trichoptera, documenting biodiversity for freshwater biomonitoring in a Mediterranean hotspot

Background

The Trichoptera are an important component of freshwater ecosystems. In the Iberian Peninsula, 380 taxa of caddisflies are known, with nearly 1/3 of the total species being endemic in the region. A reference collection of morphologically identified Trichoptera specimens, representing 142 Iberian taxa, was constructed. The InBIO Barcoding Initiative (IBI) Trichoptera 01 dataset contains records of 438 sequenced specimens. The species of this dataset correspond to about 37% of Iberian Trichoptera species diversity. Specimens were collected between 1975 and 2018 and are deposited in the IBI collection at the CIBIO (Research Center in Biodiversity and Genetic Resources, Portugal) or in the collection Marcos A. González at the University of Santiago de Compostela (Spain).

New information

Twenty-nine species, from nine different families, were new additions to the Barcode of Life Data System (BOLD). A success identification rate of over 80% was achieved when comparing morphological identifications and DNA barcodes for the species analysed. This encouraging step advances incorporation of informed Environmental DNA tools in biomonitoring schemes, given the shortcomings of morphological identifications of larvae and adult Caddisflies in such studies. DNA barcoding was not successful in identifying species in six Trichoptera genera: Hydropsyche (Hydropsychidae), Athripsodes (Leptoceridae), Wormaldia (Philopotamidae), Polycentropus (Polycentropodidae) Rhyacophila (Rhyacophilidae) and Sericostoma (Sericostomatidae). The high levels of intraspecific genetic variability found, combined with a lack of a barcode gap and a challenging morphological identification, rendered these species as needing additional studies to resolve their taxonomy.

The burden of coronary heart disease in simultaneous pancreas-kidney transplantation: coronary angiography as a diagnostic method for all? - a retrospective study

INTRODUCTION

Type 1 diabetes mellitus is associated with an increased risk of coronary artery disease, which is frequently asymptomatic. This risk increases significantly in those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols are still controversial for coronary artery disease in this population.

METHODS

We retrospectively analysed 99 simultaneous pancreas-kidney recipients from our centre from 2011 to 2018 and selected 77 patients who underwent coronary angiography during the pre-transplant evaluation. Our aim was to identify potential risk factors associated with significant lesions on coronary angiography.

RESULTS

Almost half of our cohort of 77 candidates submitted to coronary angiography had coronary artery disease. Of these, nearly 30% underwent revascularization, although only one of them reported symptoms of myocardial ischemia. In a univariate analysis, the presence of smoking habits was the only risk factor for coronary artery disease. We also found that 20 or more years of type 1 diabetes mellitus was significantly associated with the presence of coronaropathy.

DISCUSSION

Selection of diabetic candidates with acceptable cardiac risk before simultaneous pancreas-kidney transplantation is imperative. Given the impact of a correct diagnosis and a low procedural risk, we defend the routine use of coronary angiography as the initial screening method for coronary artery disease in this population. Particularly care must be taken in evaluating asymptomatic patients with long-term type 1 diabetes mellitus and smokers.

Aortic plaques in patients with atrial fibrillation: an often-forgotten risk factor for thromboembolism

Background

CHA2DS2-VASc risk score is the main determinant for maintaining anticoagulation after atrial fibrillation (AF) ablation, irrespective of the procedure outcome. The presence of aortic plaques is included in the score, but isn't regularly assessed previously to AF ablation. This way, risk factors for coronary artery disease (CAD) other than arterial hypertension and diabetes mellitus may influence stroke risk in patients with AF, albeit not being included in the CHA2DS2-VASc score.

Purpose

We sought to evaluate the prevalence of aortic plaques diagnosed during transesophageal echocardiography (TOE) in patients submitted to AF ablation and to assess its determinants and clinical impact on the CHA2DS2-VASc score.

Methods

Retrospective study of patients submitted to AF ablation that performed TOE prior to the procedure, with assessment of aortic plaques. CHA2DS2-VASc risk score was evaluated in the pre-ablation patient evaluation and reassessed after TOE. Demographic, clinical and echocardiographic data, including cardiovascular risk factors, were analyzed. We assessed AF recurrence rate, cerebrovascular events and death during follow-up.

Results

120 patients were submitted to TOE prior to AF ablation from November 2015 to December 2020, mean age 66.6 (±9.55) years, 48% male. In 30 (25%) patients aortic plaques were identified in TOE. Mean CHA2DS2-VASc was 2.2 (±1.47) in pre-ablation evaluation and 2.5 (±1.69) post-TOE, increasing in all patients with aortic plaques and prompting beginning of oral anticoagulation in 5 patients. AF was paroxysmal in 74% and persistent in 26% of patients, mean duration of 6.28 (±3.76) years. Arterial hypertension was present in 79 (66%) of patients, type 2 diabetes mellitus in 24 (20%) and dyslipidemia in 67 (56%). 17 (14%) patients had a prior stroke. During a mean follow-up of 30 (±18.3) months, 32 (27%) patients had AF recurrence and 10 (8%) were submitted to redo procedures. 107 (89%) patients remained under oral anticoagulation, stroke occurred in 1 patient and 2 patients died.

In univariate analysis, age, type 2 diabetes mellitus and dyslipidemia predicted an increase in CHA2DS2-VASc score after TOE (respectively, OR 1.113, 95% CI 1.041–1.190, p-value 0.002; OR 2.907, 95% CI 1.145–7.379, p-value 0.025; and OR 2.442, 95% CI 1.016–5.868, p-value 0.046).

In multivariate analysis, age is the only independent predictor of increased CHA2DS2-VASc score after TOE (OR 1.095, 95% CI 1.013–1.185, p-value 0.023). No risk factor for CAD was independently associated with the presence of aortic plaques (Table 1).

Conclusion

In this population, single CAD risk factors were not independent predictors of aortic plaques. If TOE had not been performed prior to AF ablation, 25% of patients would have had an underestimated CHA2DS2-VASc score and would be off anticoagulation after the procedure, unprotected from thromboembolic events.

Funding Acknowledgement

Type of funding sources: None. Table 1

Predictors of patient and system delay for primary percutaneous coronary intervention

Background

The delay times of the patient and the system for primary percutaneous coronary intervention (p-PCI) have a determining impact on the prognosis of patients with acute myocardial infarction with ST segment elevation (STEMI).

Purpose

To identify the predictors of patient and system delay for p-PCI in the period of 2020 at a reference hospital for p-PCI.

Methods

Patients submitted to p-PCI in the period from March to September 2020 were included and compared with the same period in 2019. We analyzed the differences between the two groups regarding the patient's delay times, time from the onset of symptoms to the first medical contact (FCM) and the system (time from the first contact with the health system to p-ICP). Data collection of the patient's previous history, coronary intervention performed and post-PCI follow-up was performed using the electronic patient record. Univariate analysis and logistic regression models from multivariate analysis were used to determine the predictors of “patient delay” and “system delay” and adjusted for confounding factors. The analysis was performed with a significance level of 5%.

Results

We included in the study 255 patients who underwent p-PCI, of which 122 in the period from 2020 and 133 in the period from 2019. Regarding the characteristics of the population, there were no significant differences between the two periods. Regarding the patient's delay time, there were no statistically significant differences. The variable first medical contact with a non p-PCI center was the only variable associated with system delay>90 minutes in the multivariate analysis, OR (6.18: 95% CI, 1.91–20), p=0.002. There was a statistically significant association between the period of 2020 (pandemic period) and total ischemia time, but with a negative effect, dependent variable adjusted for confounding factors [adjusted OR: −0.10; 95% CI: −107.61 to −5.57; p=0.03].

Conclusion

In this study, the patient's admission to a non p-PCI centers was identified as the only predictor of longer delay until p-PCI (system delay). However, these results should serve as a contribution to decision making in order to mitigate risks, regardless of any associated catastrophe and eventually alert the population not to neglect the symptoms suspected of acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: None.

DNA Barcoding of Portuguese Lacewings (Neuroptera) and Snakeflies (Raphidioptera) (Insecta, Neuropterida)

The orders Neuroptera and Raphidioptera include the species of insects known as lacewings and snakeflies, respectively. In Portugal, these groups account for over 100 species, some of which are very difficult to identify by morphological analysis. This work is the first to sample and DNA sequence lacewings and snakeflies of Portugal. A reference collection was built with captured specimens that were identified morphologically. DNA barcode sequences of 658 bp were obtained from 243 specimens of 54 species. The results showed that most species can be successfully identified through DNA barcoding, with the exception of seven species of Chrysopidae (Neuroptera). Additionally, the first published distribution data are presented for Portugal for the neuropterans Gymnocnemiavariegata (Schneider, 1845) and Myrmecaelurus (Myrmecaelurus) trigrammus (Pallas, 1771).

Rapid atrial fibrillation increases cardiac biomarkers: decision to perform coronary angiography based on novel high-sensitivity Troponin I peak

Funding Acknowledgements

Type of funding sources: None.

Background

Since January 2018 the availability of high sensitivity Troponin I (hsTnI) has improved ischemia diagnosis. In patients with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, evidence to support the rentability of this approach is sparse.

Purpose

Evaluate if hsTnI in patients with rapid AF and elevated cardiac biomarkers has a good discriminative power to predict a positive coronary angiography.

Methods

We retrospectively studied consecutive patients admitted to the emergency department (ED) between January 2018 and December 2019 with rapid AF that underwent coronary angiography and had multiple hsTnI values obtained. We analysed risk factors, initial and peak hsTnI, time from ED admission to peak hsTnI and ST-T segment abnormalities (ST depression and/or T wave inversion). We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography. Univariable and multivariable analysis was performed to obtain the Odds Ratio (OR, 95% CI, p-value) for significant coronary artery disease (CAD).

Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of peak hsTnI as predictor of a positive coronary angiography. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value.

Results

From 1407 patients admitted to the ED with rapid AF, 30 patients, 60% male, median age 74 (IQR 61.25-80.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 17 (57%) patients.

Age, ST-T segment abnormalities and peak hsTnI were predictors of significant CAD, respectively 1.203, 1.064-1.361, 0.003; 25.00, 3.522-177.477, 0.001; and 1.000, 1.000-1.001, 0.015.

Optimal cut-point value for predicting the presence of significant coronary artery stenosis at coronary angiography was a peak hsTnI of 359 pg/mL (AUC 0.869, p-value 0.001, 95% CI 0.742-0.995). The two groups with hsTnI < 359 and hsTnI >359 differed in age and ST-T segment abnormalities (see Table).

After adjustment, peak hsTnI >359 pg/mL was the only independent predictor of significant CAD (23.894, 1.310-435.669, 0.032).

Conclusion

In this group of patients with rapid AF, peak hsTnI >359 pg/mL was the only independent predictor of significant coronary artery disease. Therefore, those patients should undergo coronary angiography. Abstract Figure.

Optimal percentage of biventricular pacing to obtain CRT response: how high is high enough

Funding Acknowledgements

Type of funding sources: None.

Background

The greatest benefit with cardiac resynchronization therapy (CRT) is achieved when biventricular pacing (BivP) percentage (%) is close to 100%. However, in some patients that goal can be challenging to obtain.

Purpose

Determine whether a lower BivP% could lead to similar CRT response and events, as compared with patients with BivP% >98%.

Methods

Patients with CRT followed up in a remote-monitoring network were retrospectively analyzed. BivP% was assessed and response to CRT was defined as an absolute increase in left ventricle ejection fraction (LVEF) >5% or a relative increase in LVEF >15%.

Low BivP% was defined as <98%. Clinical, echocardiographic data and all-cause death during follow-up were evaluated. ROC curve and AUC were obtained to determine the discriminative power of BivP% as predictor of CRT response. Optimal cut-point value was obtained and patients were divided according to this value. Kaplan-Meyer survival function was used to compare survival in the different groups and the Log-rank test was used for comparison between the groups.

Results

88 patients, 76% male, median age 73.5 (IQR 65.75-79.25) years were included. A CRT-D was implanted in 69%. Etiology was ischemic in 44%. 93% were under beta-blockers. Median LVEF before CRT was 27% (IQR 20.25-32). 

44 patients (50%) had low BivP% (median 91%, IQR 96-99), 55% due to atrial fibrillation and 52% due to frequent premature ventricular complexes. After optimization of medical therapy, device programming and/or interventional procedures, we obtained a BivP >98% in 26 out of the 44 patients (59%). However, in 18 patients (20%) BivP% was <98% (median 95, IQR 92.25-96). 66% patients were CRT responders. Median follow-up was 36 (IQR 23.75-84) months. During follow-up, all-cause mortality was 27% (24 patients).

Optimal cut-point value for predicting CRT response was 91% BivP% (AUC 0.644, p-value 0.047, 95% CI 0.496-0.792). The characteristics of the two groups didn’t differ significantly (Table).

Survival was significantly higher in patients with BivP% >91% (Log-rank 3.667, p-value 0.050) – Figure.

Conclusion

In this population, BivP% >91% was sufficient to achieve CRT-response and was associated with a better survival. BivP% <91%(n = 4)BivP% >91%(n = 84)p-valueAge in years, median (IQR)72.50 (70.50-73.75)74.00 (65.00-80.00)0.666CRT-D, n (%)3 (75.0)58 (69.0)0.999Ischemic cardiopathy, n (%)3 (75.0)35 (41.7)0.311LVEF before CRT, median (IQR)27 (19-39)27 (20-32)0.795Beta-blockers, n (%)4 (100.0)78 (95.1)0.999Abstract Figure.

Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes

Importance

Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned.

Objective

To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography.

Design, Setting, and Participants

This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018.

Main Outcomes and Measures

Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year.

Results

Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status.

Conclusions and Relevance

Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.

Predictors of relapse after improved ejection fraction in patients with heart failure

Background

Patients with systolic dysfunction with improvement in left ventricular ejection fraction (LVEF) present a more favorable clinical profile when compared to those that maintain dysfunction. However, little is known about the characteristics of patients who “relapse” after LVEF improvement.

Purpose

Evaluate prevalence, clinical characteristics and outcomes of patients in whom ejection fraction declined after previous improvement.

Methods

We retrospectively studied patients followed at a heart failure (HF) clinic with LVEF improvement after an initial diagnosis of HF with reduced ejection fraction (EF), which was defined as having an LVEF >40% on follow-up. We then evaluated the presence of LVEF “relapse” in these patients – a decline in LVEF to <50% or <40%, in cases where it recovered to preserved EF or to mid-range EF, respectively. We analysed patient demographics, clinical parameters and outcomes and used logistic regression to assess the predictors of LVEF “relapse”.

Results

98 patients were studied, 70 (71%) male, median age 69 (58–76) years.

Fifty-four (55%) patients had recovered EF (>50%) and in 44 (45%) it had improved to mid-range values. In 36 (37%) occurred LVEF “relapse”: in 10 (10%) patients to an EF 40–50% and in 88 (90%) to an EF<40%.

Ischemic cardiomyopathy and non-ischemic dilated cardiomyopathy were the main HF aetiologies (38% and 35%, respectively).

During a median follow-up of 7 years, 39 (40%) patients had at least one HF hospitalization. Global mortality was 30%, with no significant statistical difference between the two groups.

In univariate analysis, HF duration, type 2 diabetes mellitus (T2DM), left main or left anterior descending coronary (LAD) disease, valvular heart disease (VHD) and chronic kidney disease (CKD) predicted LVEF “relapse”.

In multivariate analysis, T2DM, left main or LAD disease and VHD were the only predictors of LVEF “relapse” (Table).

Conclusion

In this group of patients, LVEF “relapse” after it had initially improved was frequent and was predicted by the presence of T2DM, left main or LAD disease and VHD. Despite improved systolic function, these patients remain at high risk, thus the need to maintain treatment.

Funding Acknowledgement

Type of funding source: None

P1506Prolonged and recurrent hospital admissions predict risk of cardiac implantable electronic device infections in hospitalized patients with bacteriaemia

Background

As the use of Cardiac Implantable Electronic Devices (CIED) is expanding, the burden of device-related infections, particularly infectious endocarditis, is also increasing. Furthermore, with the increase in life expectancy, these devices are being implanted in patients who are older, with more serious co-morbidities and who are frequently hospitalized.

Purpose

To assess incidence and predisposing factors for infective endocarditis (IE) in hospitalized patients with CIED and nosocomial bacteraemia.

Methods

We performed a retrospective analysis of all hospitalized patients with CIED and positive blood cultures admitted to the Cardiology department between January 2012 and February 2019. Endocarditis was defined according to modified Duke criteria. We analyzed clinical parameters, device- and procedure-related characteristics, length of hospital stay and hospitalizations in the previous year.

Results

25 patients had positive blood cultures, 4 patients (16.0%) were diagnosed with infective endocarditis (median age 59.25 years, 75.0% male).

Patients characteristics are displayed in the Table.

In univariable analysis, the number and presence of hospitalizations in the previous year and the length of hospital stay was significantly associated with the possibility of endocarditis (respectively, OR 3.411, 95% CI 1.164-9.998, p-value 0.025; OR 18.000, 95% CI 1.375-235.686, p-value 0.028; and OR 1.047, 95% IC 1.001-1.096, p-value 0.046).

Conclusion

In this group of patients with positive blood cultures during hospitalization, the possibility of CIED infection was predicted by the length of hospital stay and the presence and number of hospitalizations in the previous year.

With CIED-IE Without CIED-IE p-value Age in years, median (IQR) 63 (16) 76 (16) 0.002 Heart failure, n (%) 4 (100%) 10 (47.6%) 0.105 LVEF in %, median (IQR) 21 (9) 51 (30) 0.008 LV dilation, n (%) 4 (100%) 8 (38.1%) 0.039 Device revision/upgrade/substitution, n (%) 2 (50.0%) 6 (28.57%) 0.570 LOS in days, median (IQR) 58.5 (83) 20 (15) 0.004 Hospital admissions in the previous year, n (%) 3 (75.0%) 3 (14.3%) 0.031 No. of hospital admissions in the previous year, mean (standard deviation) 1.67 (1.528) 0.29 (0.784) 0.005 Use of central venous access, n (%) 4 (100%) 4 (19.05%) 0.008 LOS – Length of Stay; LV – Left Ventricle; LVEF – Left Ventricle Ejection Fraction

Nucleolin-based targeting strategies for cancer therapy: from targeted drug delivery to cytotoxic ligands

Cancer is currently the second leading cause of death worldwide and current therapeutic approaches remain ineffective in several cases. Therefore, there is a need to develop more efficacious therapeutic agents, especially for subtypes of cancer lacking targeted therapies. Limited drug penetration into tumors impairs the efficacy of therapies targeting cancer cells. One of the strategies to overcome this problem is targeting the more accessible tumor vasculature via molecules such as nucleolin, which is expressed at the surface of cancer and angiogenic endothelial cells, thus enabling a dual cellular targeting strategy. In this review, we present and discuss nucleolin-based targeting strategies that have been developed for cancer therapy, with a special focus on recent antibody-based approaches.

Gramene 2018: unifying comparative genomics and pathway resources for plant research

Gramene (http://www.gramene.org) is a knowledgebase for comparative functional analysis in major crops and model plant species. The current release, #54, includes over 1.7 million genes from 44 reference genomes, most of which were organized into 62,367 gene families through orthologous and paralogous gene classification, whole-genome alignments, and synteny. Additional gene annotations include ontology-based protein structure and function; genetic, epigenetic, and phenotypic diversity; and pathway associations. Gramene's Plant Reactome provides a knowledgebase of cellular-level plant pathway networks. Specifically, it uses curated rice reference pathways to derive pathway projections for an additional 66 species based on gene orthology, and facilitates display of gene expression, gene-gene interactions, and user-defined omics data in the context of these pathways. As a community portal, Gramene integrates best-of-class software and infrastructure components including the Ensembl genome browser, Reactome pathway browser, and Expression Atlas widgets, and undergoes periodic data and software upgrades. Via powerful, intuitive search interfaces, users can easily query across various portals and interactively analyze search results by clicking on diverse features such as genomic context, highly augmented gene trees, gene expression anatomograms, associated pathways, and external informatics resources. All data in Gramene are accessible through both visual and programmatic interfaces.

Impact of Routine Fractional Flow Reserve on Management Decision and 1-Year Clinical Outcome of Patients With Acute Coronary Syndromes: PRIME-FFR (Insights From the POST-IT [Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease] and R3F [French FFR Registry] Integrated Multicenter Registries - Implementation of FFR [Fractional Flow Reserve] in Routine Practice)

BACKGROUND

Fractional flow reserve (FFR) is not firmly established as a guide to treatment in patients with acute coronary syndromes (ACS). Primary goals were to evaluate the impact of integrating FFR on management decisions and on clinical outcome of patients with ACS undergoing coronary angiography, as compared with patients with stable coronary artery disease.

METHODS AND RESULTS

R3F (French FFR Registry) and POST-IT (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease), sharing a common design, were pooled as PRIME-FFR (Insights From the POST-IT and R3F Integrated Multicenter Registries - Implementation of FFR in Routine Practice). Investigators prospectively defined management strategy based on angiography before performing FFR. Final decision after FFR and 1-year clinical outcome were recorded. From 1983 patients, in whom FFR was prospectively used to guide treatment, 533 sustained ACS (excluding acute ST-segment-elevation myocardial infarction). In ACS, FFR was performed in 1.4 lesions per patient, mostly in left anterior descending (58%), with a mean percent stenosis of 58±12% and a mean FFR of 0.82±0.09. In patients with ACS, reclassification by FFR was high and similar to those with non-ACS (38% versus 39%; P=NS). The pattern of reclassification was different, however, with less patients with ACS reclassified from revascularization to medical treatment compared with those with non-ACS (P=0.01). In ACS, 1-year outcome of patients reclassified based on FFR (FFR against angiography) was as good as that of nonreclassified patients (FFR concordant with angiography), with no difference in major cardiovascular event (8.0% versus 11.6%; P=0.20) or symptoms (92.3% versus 94.8% angina free; P=0.25). Moreover, FFR-based deferral to medical treatment was as safe in patients with ACS as in patients with non-ACS (major cardiovascular event, 8.0% versus 8.5%; P=0.83; revascularization, 3.8% versus 5.9%; P=0.24; and freedom from angina, 93.6% versus 90.2%; P=0.35). These findings were confirmed in ACS explored at the culprit lesion. In patients (6%) in whom the information derived from FFR was disregarded, a dire outcome was observed.

CONCLUSIONS

Routine integration of FFR into the decision-making process of ACS patients with obstructive coronary artery disease is associated with a high reclassification rate of treatment (38%). A management strategy guided by FFR, divergent from that suggested by angiography, including revascularization deferral, is safe in ACS.

Transcription Factor Activities Enhance Markers of Drug Sensitivity in Cancer

Transcriptional dysregulation induced by aberrant transcription factors (TF) is a key feature of cancer, but its global influence on drug sensitivity has not been examined. Here, we infer the transcriptional activity of 127 TFs through analysis of RNA-seq gene expression data newly generated for 448 cancer cell lines, combined with publicly available datasets to survey a total of 1,056 cancer cell lines and 9,250 primary tumors. Predicted TF activities are supported by their agreement with independent shRNA essentiality profiles and homozygous gene deletions, and recapitulate mutant-specific mechanisms of transcriptional dysregulation in cancer. By analyzing cell line responses to 265 compounds, we uncovered numerous TFs whose activity interacts with anticancer drugs. Importantly, combining existing pharmacogenomic markers with TF activities often improves the stratification of cell lines in response to drug treatment. Our results, which can be queried freely at dorothea.opentargets.io, offer a broad foundation for discovering opportunities to refine personalized cancer therapies.Significance: Systematic analysis of transcriptional dysregulation in cancer cell lines and patient tumor specimens offers a publicly searchable foundation to discover new opportunities to refine personalized cancer therapies. Cancer Res; 78(3); 769-80. ©2017 AACR.

Abstract SY10-02: Pan-cancer study of recurrent and heterogeneous RNA aberrations and association with whole-genome variants

Whole-exome sequencing studies have transformed our understanding of recurrent somatic mutations that contribute to cancer pathogenesis; however, these studies limit our ability to identify cancer-associated mutations to those that cause protein-coding changes. To more comprehensively catalogue cancer-associated gene alterations, we have extensively characterized tumor transcriptomes from 1,220 donors with matched whole-genome sequence data to identify recurrent RNA-level aberrations. Specifically, we created a unified RNA-Seq analysis pipeline including sequence alignment and quality control and subsequently identified gene alterations through outlier detection from estimated gene expression levels, alternative splicing, alternative transcription starts, and allele-specific expression and through identified RNA-edited sites and gene fusions. Our data represent an extensive catalog of RNA aberrations for each gene across 27 cancer types. We have also tested for genetic associations with these RNA phenotypes. Using an integrative analysis approach, we have mapped genome-wide cis and trans effects on individual RNA phenotypes, considering both common germline variants as well as somatic SNVs in gene promoters, enhancers, and intronic and other regions. Many of the regulatory associations we identify are not accessible by exome sequencing, underlining the importance of whole-genome sequence data. Utilizing this RNA-centric view, we have identified genes that are recurrently altered, yet have not been previously characterized as cancer genes or identified through DNA-level driver gene analysis. To identify further supporting evidence that these recurrent alterations are potential drivers, we identified genes with mutually exclusive RNA-level alterations. Our findings reveal new insights into selective advantages of somatic changes and molecular mechanisms of cancer. This work is by the Transcriptome Working Group of the Pan-Cancer Analysis of Whole Genomes (PCAWG) consortium and authors are listed in alphabetical order.

Citation Format: Samirkumar Amin, Philip Awadalla, Andrew Biankin, Paul Boutros, Alvis Brazma, Angela Norie Brooks, Claudia Calabrese, David Chang, Aurélien Chateigner, Ken Chen, Zechen Chong, Brian Craft, Chad Creighton, Deniz Demircioğlu, Nuno Fonseca, Milana Frenkel-Morgenstern, Gad Getz, Jonathan Göke, Mary Goldman, Liliana Greger, Syed Haider, Yao He, Katherine Hoadley, Yuan Ji, Andre Kahles, Ekta Khurana, Jan Korbel, Kjong Lehmann, Han Liang, Fenglin Liu, Maximillian Marin, Matthew Meyerson, Akinyemi Ojesina, Francis Ouellette, Chandra Pedamallu, Marc Perry, Gunnar Rätsch, Roland Schwarz, Yuichi Shiraishi, Cameron Soulette, Oliver Stegle, Patrick Tan, Alfonso Valencia, Linda Xiang, Christina Yung, Junjun Zhang, Fan Zhang, Zemin Zhang, Jingchun Zhu. Pan-cancer study of recurrent and heterogeneous RNA aberrations and association with whole-genome variants [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr SY10-02. doi:10.1158/1538-7445.AM2017-SY10-02

Autoimmune rheumatic diseases in the intensive care unit: experience from a tertiary referral hospital and review of the literature

Autoimmune rheumatic diseases (AIRD) are not uncommon in the general population and up to one third of hospitalized patients with AIRD may need admission to intensive care unit (ICU). This paper describes the causes of admission, the clinical features and outcome of 24 AIRD patients admitted to a medical ICU from a third level hospital. Thirteen patients had systemic lupus erythematosus (54.2%), three rheumatoid arthritis (12.5%), three pulmonary renal syndrome (12.5%), two dermatopolymyositis (8.3%), two scleroderma (8.3%) and one antiphospholipid syndrome (4.2%). The main causes for ICU admission were rheumatic disease flare-up (37.5%), infection (37.5%) and complications derived from rheumatic disease (29.1%). Mortality during ICU stay was 16.7% (four patients). Excluding shock requiring vasopressor support, no statistical difference was found between survivors and nonsurvivors; although there was a trend to higher test severity scores (APACHE II, ODIN) in nonsurvivors. Our results reveal a lower mortality rate in AIRD patients admitted to the ICU than reported previously. Severity scores such as APACHE II are predictors of mortality in patients with AIRD in the ICU.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome

Background—

Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome.

Methods and Results—

Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P =0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization ( P =0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR.

Conclusions—

Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01835808.

Comparison of GENCODE and RefSeq gene annotation and the impact of reference geneset on variant effect prediction

Background

A vast amount of DNA variation is being identified by increasingly large-scale exome and genome sequencing projects. To be useful, variants require accurate functional annotation and a wide range of tools are available to this end. McCarthy et al recently demonstrated the large differences in prediction of loss-of-function (LoF) variation when RefSeq and Ensembl transcripts are used for annotation, highlighting the importance of the reference transcripts on which variant functional annotation is based.

Results

We describe a detailed analysis of the similarities and differences between the gene and transcript annotation in the GENCODE and RefSeq genesets. We demonstrate that the GENCODE Comprehensive set is richer in alternative splicing, novel CDSs, novel exons and has higher genomic coverage than RefSeq, while the GENCODE Basic set is very similar to RefSeq. Using RNAseq data we show that exons and introns unique to one geneset are expressed at a similar level to those common to both. We present evidence that the differences in gene annotation lead to large differences in variant annotation where GENCODE and RefSeq are used as reference transcripts, although this is predominantly confined to non-coding transcripts and UTR sequence, with at most ~30% of LoF variants annotated discordantly. We also describe an investigation of dominant transcript expression, showing that it both supports the utility of the GENCODE Basic set in providing a smaller set of more highly expressed transcripts and provides a useful, biologically-relevant filter for further reducing the complexity of the transcriptome.

Conclusions

The reference transcripts selected for variant functional annotation do have a large effect on the outcome. The GENCODE Comprehensive transcripts contain more exons, have greater genomic coverage and capture many more variants than RefSeq in both genome and exome datasets, while the GENCODE Basic set shows a higher degree of concordance with RefSeq and has fewer unique features. We propose that the GENCODE Comprehensive set has great utility for the discovery of new variants with functional potential, while the GENCODE Basic set is more suitable for applications demanding less complex interpretation of functional variants.

Mitochondrial analysis sheds light on the origin of hair sheep

A total of 180 mtDNA sequences from hair Caribbean (93), West African (73) and Canarian-wooled (14) sheep were analysed to shed light on the origin of hair sheep. A comparison of 360 Iberian sheep sequences retrieved from GenBank was performed to assess a possible European origin of the Caribbean hair sheep. These 180 sequences gave 48 different haplotypes (16 in Caribbean sheep). All Caribbean and Canarian-wooled sequences and 91.8% of the West African samples belonged to haplogroup B. The sheep analysed showed wide haplotypic identity. Caribbean sheep shared roughly two-thirds of their samples with Canarian-wooled and West African samples, respectively. Principal component analysis showed that the Caribbean and the Canarian-wooled sheep clustered together. Additional analyses showed that hair and Iberian sheep had wide genetic identity. It was not possible to ascertain a single Canarian, African or European origin of the Caribbean hair sheep using mtDNA markers only. European, African and Caribbean hair sheep maternal genetic backgrounds likely result from related domestication events.

Evidence for preferential depths of metal retention in roots of salt marsh plants

Depth variation (2-cm resolution) of Fe, Mn, Zn, Cr, Ni, Cu, As and Cd concentrations were determined in belowground biomass of Spartina maritima and Sarcocornia fruticosa and in sediments between roots from two marshes in Tagus (Rosário) and Guadiana (Castro Marim) estuaries in Portugal with different anthropogenic pressures. Levels of metals were also determined in aboveground plant parts. Metal concentrations in belowground material were 2-4 orders of magnitude greater than levels in aboveground plant parts providing evidence of weak upward translocation. Although both studied species showed poor extraction of Cr and Ni from sediments, S. fruticosa exhibited a large capability to remove Zn, Cu, As and Cd from contaminated sediments and stabilised them in belowground biomass. Accumulated metals showed a sub-surface concentration maximum or increase to basal roots. To evaluate whether these preferential layers of accumulation resulted from availability in sediments or controlled by plant activity, Enrichment Factors (EF=[Me](root)/[Metal](sediment)) were calculated for each sediment layer. Maximum values in Rosário plant species (Zn=9.3, Cu=18, As=20, Cd=46) exceeded those obtained in Castro Marim (Zn=1.3, Cu=4.3, As=6.1, Cd=18). Moreover, EFs varied with the depth indicating the presence of preferential layers of metal accumulation in roots of both plants, but depth zonation was not the same as in the sediments. These results suggested that levels in belowground biomass either integrated in time changes that occurred in solid sediments and pore water, or metal uptake by roots was not proportional to levels in sediments. The same sequence of metals transferred from sediment to belowground biomass for the two plants was obtained for the two marshes (Cd > As > Cu, Zn), although metals differed from mining ore to industrial/urban sources.

Mobility of Pb in salt marshes recorded by total content and stable isotopic signature

Total lead and its stable isotopes were analysed in sediment cores, leaves, stem and roots of Sacorconia fruticosa and Spartina maritima sampled from Tagus (contaminated site) and Guadiana (low anthropogenic pressure) salt marshes. Lead concentration in vegetated sediments from the Tagus marsh largely exceeded the levels in non-vegetated sediments. Depth profiles of (206)Pb/(207)Pb and (206)Pb/(208)Pb showed a decrease towards the surface ((206)Pb/(207)Pb=1.160-1.167) as a result of a higher proportion of pollutant Pb components. In contrast, sediments from Guadiana marsh exhibited low Pb concentrations and an uniform isotopic signature ((206)Pb/(207)Pb=1.172+/-0.003) with depth. This suggests a homogeneous mixing of mine-derived particles and pre-industrial sediments with minor inputs of anthropogenic Pb. Lead concentrations in roots of plants from the two marshes were higher than in leaves and stems, indicating limited transfer of Pb to aerial parts. A similar Pb isotopic signature was found in roots and in vegetated sediments, indicating that Pb uptake by plants reflects the input in sediments as determined by a significant anthropogenic contribution of Pb at Tagus and by mineralogical Pb phases at Guadiana. The accumulation in roots from Tagus marsh (max. 2870 microg g(-1) in S. fruticosa and max. 1755 microg g(-1) in S. maritima) clearly points to the dominant role of belowground biomass in the cycling of anthropogenic Pb. The fraction of anthropogenic Pb in belowground biomass was estimated based on the signature of anthropogenic Pb components in sediments ((206)Pb/(207)Pb=1.154). Since no differences exist between Pb signature in roots and upper sediments, the background and anthropogenic levels of Pb in roots were estimated. Interestingly, both background and anthropogenic Pb in roots exhibited a maximum at the same depth, although the proportion of anthropogenic Pb was relatively constant with depth (83+/-4% for S. fruticosa and 74+/-8% for S. maritima).

Acute myocardial infarction in patients aged under 45 years

INTRODUCTION

Coronary artery disease (CAD) becomes an important cause of morbidity and mortality after the age of 45 years.

OBJECTIVE

To evaluate the epidemiology and clinical features of all patients under 45 years old admitted with myocardial infarction.

METHODS

We studied 595 patients admitted with myocardial infarction between January 2000 and December 2002. We analyzed risk factors for CAD, clinical profile, therapeutics and complications (arrhythmic, mechanical and ischemic). The patients were divided into two groups: A--under 45 years old and B-- aged 45 or over.

RESULTS

Group A--56 patients (9.4%); group B--539 patients (90.6 %). There was a higher prevalence of smoking in group A (57% vs. 23.6%; p < 0.01). Hypertension, diabetes and history of CAD were significantly more common in group B. There were no differences in hyperlipidemia (group A: 43% vs. group B: 43.5%). Fibrinolysis was performed in 28 patients (70%) from group A compared to 40 patients (45.9%; p < 0.01) from group B. Use of digitalis and inotropic agents was greater in group B. No differences were found in other pharmacological therapeutics. We found more complications in group B (24% vs. 11%).

CONCLUSIONS

There was a higher prevalence of smoking in patients under 45 years old and of hypertension, diabetes and CAD in patients aged over 45. The high rate of hyperlipidemia in both groups highlights the importance of primary prevention. Fibrinolysis was performed more frequently in younger patients. There were more complications in older patients.

Predictors of failure in direct stenting in the real world

INTRODUCTION

Stent implantation without predilation simplifies a large proportion of coronary intervention procedures, with a significant reduction in costs and procedure time.

OBJECTIVES

To determine the variables associated with a higher probability of failure in direct stent implantation in daily practice in a wide range of clinical contexts and types of lesions.

POPULATION AND METHODS

Over a period of 28 months, direct implantation of 931 stents was attempted in our Center (811 patients, 83% male, mean age 62 +/- 12 years; 1.1 stent per patient). In 59 patients (7.3%), balloon predilation was necessary, and the factors associated with direct implant failure were determined.

RESULTS

The vessels treated were: anterior descending (373 lesions: 40.1%), right coronary artery (306 lesions: 32.9%, circumflex (210 lesions: 22.6%), saphenous vein (35 lesions: 3.8%), left main (5 lesions: 0.4%) and internal mammary artery (2 lesions: 0.2%). 54% of the lesions were of type B2/C (ACC/AHA classification). The characteristics significantly associated with, or with statistical tendency towards, a lower success rate in direct stent implantation were: Lesion in the circumflex (11% vs. 5.5%, p = 0.012); reference vessel diameter less than 3.0 mm (9.8% vs. 6.2%, p = 0.097); age over 65 years (8.5% vs. 4.5%, p = 0.017); left main disease, irrespective of the vessel treated (23.5%% vs. 6.5%, p = 0.023); B2/C lesion (7.8%, vs. 4.8%, p = 0.086); calcification (9.9% vs. 4.9%, p = 0.012); vessel angulation greater than 45 degrees (9.9% vs. 4.9%, p = 0.009); and Express stent implant (19.6% vs. 6.0%, p < 0.001). On multivariate analysis, independent predictors of failure in direct stent implantation were: left main lesion (RR 6.6; 95% CI 1.73-24.93; p = 0.013), presence of calcium (RR 1.9; 95% CI 1.02-3.37; p = 0.049), vessel curvature (RR 2.0; 95% CI 1.13-3.64; p = 0.018), reference vessel diameter less than 3 mm (RR 2.2; 95% CI 1.15-4.32; p = 0.023), lesion type B2/C (RR 1.9; 95% CI 1.0-3.52; p = 0.044) and Express stent (RR 2.7; 95% CI 1.07-6.79; p = 0.05).

CONCLUSION

In a large and heterogeneous series of patients, direct stenting was not possible in 7.3% of cases, which required balloon predilation. Certain clinical and angiographic features can predict when this is more like to occur.

Transesophageal echocardiography-guided cardioversion of atrial fibrillation. Selection of a low-risk group for immediate cardioversion

INTRODUCTION

In patients (pts) with atrial fibrillation (AF) of more than 48 hours' duration, electrical cardioversion (ECV) should only be performed after 3 weeks of effective anticoagulation. Transesophageal echocardiography (TEE) allows earlier ECV; however, despite exclusion of thrombi in the atrium and left atrial appendage (LAA), cases of thromboembolism related to ECV have been documented in AF. To define a low-risk group for cardioversion without previous anticoagulation, pts were selected for immediate ECV if no thrombi or dynamic spontaneous echo contrast (auto-contrast) were found after TEE and if LAA velocity was more than 0.25 m/sec.

METHODS AND RESULTS

We performed TEE in 31 consecutive pts referred for ECV for AF of more than 48 hours' duration and without previous anticoagulation. After TEE the pts eligible for immediate ECV began anticoagulation with low molecular weight heparin (enoxaparin), subcutaneously in therapeutic doses, together with warfarin immediately before cardioversion. Enoxaparin was continued until an INR of over 2 was reached. Based on the TEE findings, the pts were divided in 2 groups: immediate ECV, group A, 20 pts with a mean age of 62 +/- 13 years, 6 female; and conventional therapy with warfarin before ECV, group B, 11 pts, mean age of 67 +/- 10 years (p < 0.05), 2 female. None of the pts in either group had mitral stenosis or previous episodes of thromboembolism. The mean transverse diameter of the left atrium in the 31 pts was 47 +/- 4.5 mm, without statistically significant differences between the 2 groups. Of the 11 pts in group B, 3 had a thrombus in the LAA, 6 dynamic spontaneous echo contrast and the remainder LAA velocities of less than 0.25 m/sec. ECV was achieved in all the pts, with no complications. Oral anticoagulation was maintained for at least a month. At one month, sinus rhythm was maintained in 75% of group A and 45% of group B (p < 0.01).

CONCLUSION

In pts with AF of more than 48 hours' duration and no previous history of thromboembolism, the use of our exclusion criteria during TEE enabled stratification of a low-risk population for immediate ECV, which was accomplished effectively and safely in 2/3 of the pts. This strategy is associated with early symptomatic improvement, and may contribute to maintenance of sinus rhythm after one month, which was significantly better than in the pts who had prolonged therapy with warfarin before ECV, despite the differences found in age and left ventricular function.

Tissue Doppler echocardiography for evaluation of patients with ventricular resynchronization therapy

INTRODUCTION AND OBJECTIVE

Ventricular resynchronization therapy optimizes cardiac function and induces reverse remodeling of the left ventricle (LV) in patients (pts) with dilated cardiomyopathy and intraventricular conduction disturbances. Improvement of LV mechanical synchrony seems to be the predominant mechanism. There is a growing interest in objective quantification of desynchronization. This study aims to evaluate the effect of ventricular resynchronization therapy on LV remodeling and on LV desynchronization, assessed by tissue Doppler echocardiography.

PATIENTS

We studied ten pts, eight male, mean age 65 +/- 10 years, with dilated cardiomyopathy, intraventricular conduction disturbances and heart failure, New York Heart Association functional class III or IV. Five pts had coronary artery disease and the others idiopathic dilated cardiomyopathy. All pts had an implanted cardioverter, defibrillator with cardiac resynchronization therapy. The LV pacing electrode was placed in the lateral or posterolateral vein.

METHODS

Before and one month after resynchronization therapy the following parameters were measured with conventional Doppler echocardiography: LV end-diastolic (LVd) and end-systolic (LVs) size, ejection fraction (EF) and mitral regurgitation (MR) area. For diastolic function the maximum velocity of the E wave (MV-E) and A wave (MV-A), E/A ratio, LV filling time (LV-FT) and isovolumetric relaxation time (IVRT) were meadured. Mitral longitudinal motion was studied with pulsed tissue Doppler. Maximum velocity of the systolic S wave (MV-S) and isovolumetric contraction time (IVCT) were measured in the tissue Doppler curve of the septum and lateral, inferior and anterior walls. To evaluate the degree of desynchronization the RV index was calculated for each patient, based on the difference between the maximum and minimum IVCT, normalized for the maximum IVCT.

RESULTS

There was a significant reduction in LVd and MR. EF increased significantly (p = 0.003). There were no differences in diastolic function parameters. MV-S did not increase significantly. IVCT increased significantly at the lateral wall (p = 0.037). The RV index demonstrated a significant reduction in ventricular desynchronization (p = 0.001).

CONCLUSIONS

Ventricular resynchronization therapy induces reverse remodeling and improves LV function in selected pts. Improvement of mechanical LV synchrony seems to be the predominant mechanism. Ventricular desynchronization can be measured by tissue Doppler echocardiography.

Effects of cardiac resynchronization therapy on right ventricular function--evaluation with tissue Doppler echocardiography

INTRODUCTION AND OBJECTIVE

Ventricular resynchronization therapy improves cardiac function in patients (pts) with dilated cardiomyopathy and intraventricular conduction disturbances. The effects of ventricular resynchronization on right ventricular function have been poorly studied. Tricuspid annular motion can be studied with tissue Doppler echocardiography, which enables quantitative assessment of right ventricular function. The aim of this study was to evaluate the effects of ventricular resynchronization on right ventricular function with pulsed tissue Doppler.

PATIENTS

We studied ten pts, eight male, mean age 65 +/- 10 years, with dilated cardiomyopathy, intraventricular conduction disturbances and heart failure, New York Heart Association functional class III or IV. Five pts had coronary artery disease and the others idiopathic dilated cardiomyopathy. All pts had an implanted cardioverter-defibrillator with ventricular resynchronization.

METHODS

Before and one month after device implantation right ventricular function was evaluated with pulsed wave tissue Doppler study of tricuspid annular motion. The maximum velocity of the S wave (MV-S), E wave (MV-E), and A wave (MV-A), E/A ratio, isovolumetric contraction time (IVCT) and ejection time (ET) were determined. Right ventricular size and left ventricular ejection fraction (EF) were measured. Functional class before and after implantation was assessed.

RESULTS

MV-S, MV-E and MV-A did not change significantly. The E/A ratio decreased significantly (p = 0.017). There were no differences in IVCT and ET, nor in right ventricular size before and after resynchronization. EF improved in all but one patient (p = 0.003). All pts had an improvement in functional class, except the one without increased EF.

CONCLUSIONS

Ventricular resynchronization therapy does not appear to have a deleterious effect on right ventricular function in pts with dilated cardiomyopathy and intraventricular conduction disturbances. The main beneficial effect of this type of therapy appears to be improvement in left ventricular function.

Non invasive hemodynamic monitorization for AV interval optimization in patients with ventricular resynchronization therapy

INTRODUCTION AND OBJECTIVE

In patients (pts) with dilated cardiomyopathy and intraventricular conduction disturbances, resynchronization therapy improves cardiac function and functional capacity. Determination of the optimal AV interval is essential to optimize the therapy results and various methods have been used in daily practice to obtain such an interval. The aim of this work is to assess optimal AV determined by impedance cardiography and compare it to the interval previously obtained by transmitral flow Doppler echocardiography.

PATIENTS

Seven pts were evaluated, five men, mean age of 61 +/- 10 years, with dilated cardiomyopathy, intra-ventricular conduction disturbances and heart failure, New York Heart Association functional class III or IV. Four pts had ischemic cardiomyopathy and three idiopathic. All pts had an implanted cardioverter-defibrillator with cardiac resynchronization.

METHODS

The optimal AV delay was estimated by transmitral flow pulsed Doppler using the method previously described by Ritter. Subsequently, cardiac output (CO) was determined by impedance cardiography. CO was estimated for different AV delays, beginning with 80 ms until occurrence of fusion QRS. The optimal AV delay was defined as the value corresponding to the highest measured CO. The ideal AV interval was compared between the two methods used.

RESULTS

The AV delay determined by echocardiography varied between 120 and 170 ms (134 +/- 17 ms). The optimum AV delay based on CO estimation varied between 110 and 190 ms (137 +/- 26 ms). There was a correlation between the delays determined by the two methods (r = 0.844; p = 0.017).

CONCLUSIONS

In pts undergoing ventricular resynchronization therapy, AV delay optimization based on CO determined by impedance cardiography is comparable to that measured by transmitral flow pulsed Doppler. However, impedance cardiography seems a more objective and simpler technique.

Hyperhomocysteinemia--case report

The authors present the case of a 25-year-old female patient, white, with mental retardation and proptosis, and a history of repeated cerebrovascular events. During investigation elevated levels of homocysteinemia and homocystinuria were demonstrated. The authors present a review of related literature.

Combined percutaneous treatment for pulmonary valve stenosis and atrial septal defect in an adult patient

Pulmonary valve stenosis and atrial septal defect are common forms of congenital heart disease; however, their association is relatively rare. When the two conditions are present simultaneously, significant left-to-right shunt is often prevented by the outflow obstruction, which protects the pulmonary bed until adulthood. This work describes a case of simultaneous percutaneous treatment of both congenital malformations. Although these procedures have been applied in isolation as methods of treatment, this case demonstrates the feasibility and effectiveness of a combined percutaneous treatment.

Leiomyosarcoma of the inferior vena cava--a very rare case report

The authors present a case report of a patient with abdominal pain that began 6 months before hospital admission. Ambulatory abdominal echography and computed tomography (CT) revealed partial thrombosis of the inferior vena cava (IVC) with right atrial extension. During hospitalization, magnetic resonance imaging (MRI) revealed aspects suggesting a tumoral lesion of the right atrium, rather than a thrombus, with tumoral extension to the IVC. The echocardiogram showed images suggesting a right atrial tumor. Transesophageal echocardiography confirmed the diagnosis. During surgery, an IVC tumor was found invading the right atrium, which histopathology confirmed as a leiomyosarcoma. The authors present this case because this type of tumor is rare (21 cases worldwide at this anatomic site), it is difficult to diagnose, and its management has not been adequately described. The authors review the literature relevant to this case.

Presence of international multiresistant clones of Streptococcus pneumoniae in Colombia

In Colombia, penicillin resistance of Streptococcus pneumoniae invasive isolates recovered from children less than 5 years old has increased from 10% in 1994 to 49.4% in 1999, suggesting the circulation of international resistant clones in the country. A total of 167 S. pneumoniae invasive isolates with diminished susceptibility to penicillin (DSP) were studied. The techniques used were pulsed-field gel electrophoresis (PFGE) and restriction fragment length polymorphism (RFLP) of penicillin-binding proteins (PBPs) genes (2B, 2X, and 1A). Forty-nine serotype 23F isolates were grouped in two clusters: 15 (31%) multiresistant isolates showed PFGE pattern A and PBP I profile, thus making them indistinguishable from Spain23F-1 clone, and 34 (69%) with PFGE pattern C, PBP II profile, and intermediate level resistance (ILR) to penicillin and TMP-SMX, features unique to a Colombian clone. Fifty-five serotype 14 isolates were assigned to PFGE B pattern, PBP III profile, having high-level resistance to penicillin, and TMP-SMX, similar to the France9V variant 14. This same pattern was present in five capsular type 9V isolates. Four serotype 14 isolates were assigned to PFGE pattern F, and appeared to be similar to Slovakia(14)-10 PFGE pattern, although they had different PBP profiles. Nine capsular type 6B and one 6A isolates belonged to PFGE pattern M, similar to Spain6B-2, although they showed different PBP profiles. The remaining 44 isolates, corresponding to serotypes 14, 6B, 19F, and 34, showed variable PFGE and PBP patterns. These results show that as many as two international clones may be circulating in Colombia as well as a unique, widely distributed 23F clone with ILR to penicillin. Additionally, some Colombian isolates capsular type 14 and 6B might be related to Slovakia(14)-10 Spain6B-2 clones, respectively.

Oral-disease prevention in children with cancer: testing preventive protocol effectiveness

Mucositis, gingivitis, herpetic stomatitis and candidiasis are a potential source of systemic infection in patients undergoing chemotherapy. Their severity and incidence may be reduced with procedures based on the prevention and elimination of sources causing oral infection and irritation.

OBJECTIVE

The purpose of this investigation was to evaluate the effectiveness of an Oral Disease Preventive Protocol in children with cancer, subjected to chemotherapy and prior to application of dentobacterial infection control.

MATERIAL AND METHODS

A controlled clinical test was run, with random assignations, on twelve 5-to-12-year-old patients diagnosed with Acute Lymphoblastic Leukemia (ALL) or Lymphoma, evaluated for twelve months, with a total of 154 evaluations. Five patients were boosted with oral physiotherapy, with non-alcoholic 0.05% fluoride mouthwashes, with topical application of myconazole oral gel; seven patients were given instructions on oral physiotherapy.

RESULTS

There were no significant differences between the groups under evaluation (p>0.05). Of the oral complications evaluated, gingivitis registered the highest percentage (60%), followed by mucositis (18%) and candida albicans infection (7%). Most affected were the submandibular and cervical ganglions (59% and 41%, respectively).

CONCLUSIONS

Prior control of sources causing oral infection and irritation effectively prevents complications during non-surgical cancer therapy.

Atrial flutter ablation with a new radiofrequency catheter

OBJECTIVE

To assess the performance of a new radiofrequency catheter, specially designed for inferior vena cava-tricuspid annulus (IVC-TA) isthmus ablation, in the treatment of atrial flutter.

PATIENTS

IVC-TA isthmus ablation was performed in thirteen patients, eleven men and two women, aged 60 +/- 12, with a diagnosis of typical atrial flutter, symptomatic despite anti-arrhythmic therapy. The flutter was present for more than one year in seven patients and was paroxysmal in the remainder. The echocardiogram showed atrial enlargement in six patients. Atrial flutter was an isolated phenomenon in seven patients and in the remainder was associated with arterial hypertension (two patients), ischemic heart disease (two patients) and dilated cardiomyopathy (two patients).

METHODS

In the electrophysiologic study four diagnostic catheters were used, including one duodecapolar for mapping the tricuspid annulus. In the patients who presented with sinus rhythm, atrial flutter was induced with programmed atrial stimulation, and then the atrial activation circuit was mapped. To demonstrate the entrainment phenomenon the IVC-TA isthmus was over-stimulated, to prove that this was the slow zone of the circuit. The radiofrequency energy was applied in the IVC-TA isthmus with the Medtronic Cosio-Fluttr ablation catheter, for 60 sec per application, with temperature control and with a maximum energy output of 50 W. Criteria for success were not only the disappearance of the atrial flutter during the application of radiofrequency energy, but also the demonstration of bi-directional IVC-TA isthmus block.

RESULTS

The primary success rate was 100%. The mean procedure time was 110 +/- 22 min, mean fluoroscopy time was 23 +/- 4 min and the number of radiofrequency energy pulses was 9 +/- 3. There were no complications. The patients were followed for a mean time of 8 +/- 4 months and atrial flutter recurred in only one patient (8%).

CONCLUSIONS

Atrial flutter ablation with the new Medtronic Cosio-Fluttr catheter, specially designed for the application of radiofrequency at the IVC-TA isthmus, is a safe procedure and has a high success rate. It simplifies ablation, decreasing the number of radiofrequency energy pulses, without using long sheaths and keeping short procedure and fluoroscopy times.

[Deciding about pacing mode in sinus node dysfunction: should carotid sinus massage be performed and in which circumstances?]

OBJECTIVE

To state the incidence of carotid sinus syndrome (CSS) with atrioventricular node manifestation in patients with sinus node dysfunction (SND) and indication for a definitive pacemaker (PM), we propose a new protocol between atrial pacing AAI and double chamber DDD.

POPULATION AND METHODS

69 patients (PTS) (male 71%), median age 65 +/- 10 years, with SND (normal PQ and no intraventricular conduction defect), that had a PM implant following the protocol that included carotid sinus massage for the pacing decision, were followed prospectively between December 1995 and November 1999. During the protocol we implanted DDD PM in PTS with Wenckebach less than 130 or Wenckebach equal/over 130 and CSS. At least, in PTS with Wenckebach equal/over 130 and no CSS we implanted AAI PM. The follow-up was between 4 months and 4 years, with clinical evaluation in the first and fourth months and then half yearly, with carotid sinus massage in the first evaluation.

RESULTS

About 1/4 of the 69 patients followed had SND without carotid sinus syndrome, or atrioventricular node repercussion; the SND involved the atrioventricular node in 56% of the patients, and there was a relation between the SND and carotid sinus syndrome in 18.8%. The follow-up revealed, in all patients, a complete remission of the symptoms, and when we repeated the carotid sinus massage in the first evaluation, there was a response like in the surgery room, in all patients.

CONCLUSIONS

There is a significant number of patients with SND and carotid sinus syndrome. The carotid sinus massage performed in the surgery room does not influence the test sensitivity and specificity in the diagnosis of carotid sinus syndrome. The authors think that carotid sinus massage should be considered in the protocol that defines the pacing mode, in patients with SND, and that influence the choice of pacemaker in 18.8% of patients.

Pneumococcal surface protein A of invasive Streptococcus pneumoniae isolates from Colombian children

Pneumococcal surface protein A (PspA) elicits protection in mice against fatal bacteremia and sepsis caused by genetically diverse pneumococci and protects against carriage and lung infection. We determined the PspA families of invasive isolates of Streptococcus pneumoniae recovered from Colombian children <5 years of age. That 97.5% of Colombian isolates belong to PspA families 1 and 2 supports the hypothesis that a human PspA vaccine covering a few PspA families could be broadly effective.

[A seroepidemiological survey on the island of São Luis during a dengue epidemic in Maranhão]

The island of São Luis in the State of Maranhão, constituted by the municipalities of São Luis-SL (835,428 inhabitants), São José de Ribamar-SJR (60,633 inhabitants) and Paço do Lumiar-PL (80,274 inhabitants), has been suffering dengue (DEN) fever epidemics since 1995, caused by DEN-1. In 1996, from August through October, an aleatory sero-epidemiologic survey was carried out in order to estimate the incidence of DEN infection and to analyze other clinical and epidemiological parameters. A questionnaire was applied and serum samples were simultaneously obtained. Serum samples were tested by hemagglutination inhibition (HI). Results were analyzed using Lotus 123, Epi-info 6.0, Excel 5.0 and STATA softwares. A total of 1,217 serum samples were obtained (101 of PL, 100 of SJR and 1017 of SL). The rate of DEN was 55.4% in PL, 28% in SJR and 41.4% in SL, suggesting the occurrence of 401,933 infections. No difference was seen between males and females, but infection occurred more in the upper social class than in poor people (p < 0.003), and was more frequent in adults than in children (p < 0.0004). In SL, the incidence was stratified into seven sanitary districts (SD), and prevalence was found to range from 26.1% in SD4 to 56.8% in SD1 (p < 0.0001). Symptoms were more frequently reported by people whose HI was positive: they included fever, headache, chills, dizziness, retrobulbar pains, muscle and joint pains, nausea, anorexia and skin rash. In spite of the high incidence of infection, no hemorrhagic cases were reported.