Dental Surgical Activity in Hospitals during COVID-19: A Nationwide Observational Cohort Study

INTRODUCTION

The number of surgical extractions performed in hospitals in England remains unclear. This study reports the volume of surgical extractions conducted in hospitals and change in activity during the COVID-19 pandemic.

METHODS

We conducted a nationwide observational cohort study using Hospital Episode Statistics (HES) in England for patients undergoing surgical removal of a tooth (defined using OPSC-4 code F09) between April 1, 2015, and December 31, 2020. Procedures were stratified by age, gender, and urgency (elective or nonelective), reported using descriptive statistics, number, and percentage. We conducted post hoc modeling to predict surgical activity to December 2023. In addition, we contrasted this with aggregate national data on simple dental extraction procedures and drainage of dental abscesses in hospital as well as dental activity in general practice.

RESULTS

We identified a total of 569,938 episodes for the surgical removal of a tooth (females 57%). Of these, 493,056/569,938 (87%) were for adults and 76,882/569,938 (13%) children ≤18 years. Surgical extractions were most frequent in adult females. Elective cases accounted for 96% (n = 548,805/569,938) of procedures. The median number of procedures carried out per quarter was 27,256, dropping to 12,003 during the COVID-19 pandemic, representing a 56% reduction in activity. This amounted to around 61,058 cancelled procedures. Modeling predicts that this activity has not returned to prepandemic levels.

CONCLUSIONS

The number of surgical extractions taking place in hospitals during the pandemic fell by 56%. The true impact of this reduction is unknown, but delayed treatment increases the risk of complications, including life-threatening infections.

KNOWLEDGE TRANSFER STATEMENT

The result of this study provides an evidence-based overview of the trends relating to surgical extractions of teeth in England taking place in hospitals. This information can be used to inform service and workforce planning to meet the needs of patients requiring surgical extractions. The data also provide an insight into the oral health needs of the population in England.

Proposed mechanisms of action of herbal drugs and their biologically active constituents in the treatment of coughs: an overview

Various medicinal plants find their use in cough treatment, based on traditions and long-term experience. Pharmacological principles of their action, however, are much less known. Herbal drugs usually contain a mixture of potentially active compounds, which can manifest diverse effects. Expectorant or antitussive effects, which can be accompanied by others, such as anti-inflammatory or antibacterial, are probably the most important in the treatment of coughs. The aim of this review is to summarize the current state of knowledge of the effects of medicinal plants or their constituents on cough, based on reliable pharmacological studies. First, a comprehensive description of each effect is provided in order to explain the possible mechanism of action in detail. Next, the results related to individual plants and substances are summarized and critically discussed based on pharmacological in vivo and in vitro investigation.

Postoperative transfusion hemoglobin threshold and functional recovery after high-risk oncologic surgery: A randomized controlled pilot study

BACKGROUND

Robust evidence to inform best transfusion management after major oncologic surgery, where postoperative recovery might impact treatment regimens for cancer, is lacking. We conducted a study to validate the feasibility of a larger trial comparing liberal versus restrictive red blood cells (RBC) transfusion strategies after major oncologic surgery.

STUDY DESIGN AND METHODS

This was a two-center, randomized, controlled, study of patients admitted to the intensive care unit after major oncologic surgery. Patients whose hemoglobin level dropped below 9.5 g/dL, were randomly assigned to immediately receive a 1-unit RBC transfusion (liberal) or delayed until the hemoglobin level dropped below 7.5 g/dL (restrictive). The primary outcome was the median hemoglobin level between randomization to day 30 post-surgery. Disability-free survival was evaluated by the WHODAS 2.0 questionnaire.

RESULTS

30 patients were randomized (15 patients/group) in 15 months with a mean recruitment rate of 1.8 patients per month. The median hemoglobin level was significantly higher in the liberal group than in the restrictive group: 10.1 g/dL (IQR 9.6-10.5) versus 8.8 g/dL (IQR 8.3-9.4), p < .001, and RBC transfusion rates were 100% versus 66.7%, p = .04. The disability-free survival was similar between groups: 26.7% versus 20%, p = 1.

DISCUSSION

Our results support the feasibility of a phase 3 randomized controlled trial comparing the impact of liberal versus restrictive transfusion strategies on the functional recovery of critically ill patients following major oncologic surgery.

ANKRD11 pathogenic variants and 16q24.3 microdeletions share an altered DNA methylation signature in patients with KBG syndrome

Pathogenic variants in ANKRD11 or microdeletions at 16q24.3 are the cause of KBG syndrome (KBGS), a neurodevelopmental syndrome characterized by intellectual disability, dental and skeletal anomalies, and characteristic facies. The ANKRD11 gene encodes the ankyrin repeat-containing protein 11A transcriptional regulator, expressed in the brain and implicated in neural development. Syndromic conditions caused by pathogenic variants in epigenetic regulatory genes show unique patterns of DNA methylation (DNAm) in peripheral blood termed DNAm signatures. Given ANKRD11’s role in chromatin modification, we tested whether pathogenic ANKRD11 variants underlying KBGS are associated with a DNAm signature. We profiled whole-blood DNAm in 21 individuals with ANKRD11 variants, 2 individuals with microdeletions at 16q24.3, and 28 typically developing individuals, using Illumina’s Infinium EPIC array. We identified 95 differentially methylated CpG sites that distinguished individuals with KBGS and pathogenic variants in ANKRD11 (n = 14) from typically developing controls (n = 28) and was also validated in seven additional individuals with pathogenic ANKRD11 variants. We generated a machine learning model from the KBGS DNAm signature and classified the DNAm profiles of 4 individuals with variants of uncertain significance (VUS) in ANKRD11. We identified an intermediate classification score for an inherited missense variant transmitted from a clinically unaffected mother to her affected child. In conclusion, we show the DNAm profile of two individuals with 16q24.3 microdeletions, was indistinguishable from the DNAm profile of individuals with pathogenic variants in ANKRD11 and we demonstrate the diagnostic utility of the new KBGS signature by classifying the DNAm profiles of individuals with VUS in ANKRD11.

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

Background

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

Methods

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

Results

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

Conclusions

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

CDK13-related disorder: Report of a series of 18 previously unpublished individuals and description of an epigenetic signature

PURPOSE

Rare genetic variants in CDK13 are responsible for CDK13-related disorder (CDK13-RD), with main clinical features being developmental delay or intellectual disability, facial features, behavioral problems, congenital heart defect, and seizures. In this paper, we report 18 novel individuals with CDK13-RD and provide characterization of genome-wide DNA methylation.

METHODS

We obtained clinical phenotype and neuropsychological data for 18 and 10 individuals, respectively, and compared this series with the literature. We also compared peripheral blood DNA methylation profiles in individuals with CDK13-RD, controls, and other neurodevelopmental disorders episignatures. Finally, we developed a support vector machine-based classifier distinguishing CDK13-RD and non-CDK13-RD samples.

RESULTS

We reported health and developmental parameters, clinical data, and neuropsychological profile of individuals with CDK13-RD. Genome-wide differential methylation analysis revealed a global hypomethylated profile in individuals with CDK13-RD in a highly sensitive and specific model that could aid in reclassifying variants of uncertain significance.

CONCLUSION

We describe the novel features such as anxiety disorder, cryptorchidism, and disrupted sleep in CDK13-RD. We define a CDK13-RD DNA methylation episignature as a diagnostic tool and a defining functional feature of the evolving clinical presentation of this disorder. We also show overlap of the CDK13 DNA methylation profile in an individual with a functionally and clinically related CCNK-related disorder.

Impact of an Operating Room Nurse Preoperative Dialogue on Anxiety, Satisfaction and Early Postoperative Outcomes in Patients Undergoing Major Visceral Surgery-A Single Center, Open-Label, Randomized Controlled Trial

Background: Anxiety is common before surgery and known to negatively impact recovery from surgery. The aim of this study was to evaluate the impact of a preoperative nurse dialogue on a patient’s anxiety, satisfaction and early postoperative outcomes. Method: This 1:1 randomized controlled trial compared patients undergoing major visceral surgery after a semistructured preoperative nurse dialogue (interventional group: IG) to a control group (CG) without nursing intervention prior to surgery. Anxiety was measured with the autoevaluation scale State-Trait Anxiety Inventory (STAI, Y-form) pre and postoperatively. The European Organization for Research and Treatment of Cancer (EORTC) In-Patsat32 questionnaire was used to assess patient satisfaction at discharge. Further outcomes included postoperative pain (visual analogue scale: VAS 0−10), postoperative nausea and vomiting (PONV), opiate consumption and length of stay (LOS). Results: Over a period of 6 months, 35 participants were randomized to either group with no drop-out or loss to follow-up (total n = 70). The median score of preoperative anxiety was 40 (IQR 33−55) in the IG vs. 61 (IQR 52−68) in the CG (p < 0.001). Postoperative anxiety levels were comparable 34 (IQR 25−46) vs. 32 (IQR 25−44) for IG and CG, respectively (p = 0.579). The IG did not present higher overall satisfaction (90 ± 15 vs. 82.9 ± 16, p = 0.057), and pain at Day 2 was similar (1.3 ± 1.7 vs. 2 ± 1.9, p = 0.077), while opiate consumption, PONV levels and LOS were comparable. Conclusion: A preoperative dialogue with a patient-centered approach helped to reduce preoperative anxiety in patients undergoing major visceral surgery.

SPECC1L Mutations Are Not Common in Sporadic Cases of Opitz G/BBB Syndrome

Opitz G/BBB syndrome (OS) is a rare genetic developmental condition characterized by congenital defects along the midline of the body. The main clinical signs are represented by hypertelorism, laryngo–tracheo–esophageal defects and hypospadias. The X-linked form of the disease is associated with mutations in the MID1 gene located in Xp22 whereas mutations in the SPECC1L gene in 22q11 have been linked to few cases of the autosomal dominant form of this disorder, as well as to other genetic syndromes. In this study, we have undertaken a mutation screening of the SPECC1L gene in samples of sporadic OS cases in which mutations in the MID1 gene were excluded. The heterozygous missense variants identified are already reported in variant databases raising the issue of their pathogenetic meaning. Recently, it was reported that some clinical manifestations peculiar to OS signs are not observed in patients carrying mutations in the SPECC1L gene, leading to the proposal of the designation of ‘SPECC1L syndrome’ to refer to this disorder. Our study confirms that patients with diagnosis of OS, mainly characterized by the presence of hypospadias and laryngo–tracheo–esophageal defects, do not carry pathogenic SPECC1L mutations. In addition, SPECC1L syndrome-associated mutations are clustered in two specific domains of the protein, whereas the missense variants detected in our work lies elsewhere and the impact of these variants in the function of this protein is difficult to ascertain with the current knowledge and will require further investigations. Nonetheless, our study provides further insight into the SPECC1L syndrome classification.

Sex disparities in lipid-lowering therapy and dyslipidemia control in a coronary rehabilitation program

Introduction

Lipid control is one of the most important secondary cardiovascular prevention targets. Although cardiovascular disease is the most common cause of death for both genders, several studies have consistently shown that women are less likely to receive guideline-recommended secondary prevention medications after an acute coronary syndrome (ACS).

Purpose

To compare sex disparities in dyslipidemia control in a secondary prevention population with ACS in light of the ESC Dyslipidemia Guidelines.

Methods

We retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an ACS from January 2011 to October 2019. Clinical data was collected at presentation and during 12 months follow-up. Doses of atorvastatin ≥40 mg, rosuvastatin ≥20 mg or a combination of a statin and ezetimibe were considered high-intensity LDL-lowering therapy (HIT).

Results

Of a total of 881 patients enrolled, mean age 55.0±10.0 year-old, 16.1% were female. At baseline there were no differences respecting clinical features between genders. At admission, 51.4% of patients had ST-elevation myocardial infarction and, concerning to cardiovascular risk factors, 63% patients had dyslipidemia, 46% had hypertension, 19% were diabetic, 76% were smokers or previous smokers, 27% had family history of coronary disease and 12% had previous coronary disease (ACS or &gt;50% coronary artery stenosis). At hospital admission, females and males had similar mean LDL-levels [120.7 vs 118.1 mg/dL, t(708)=0.691, p=0.496]. The vast majority of patients from both genders were prescribed with statins on hospital discharge (99.5%) and maintain it during follow-up (99.3%). Female patients received more HIT during follow-up (67.8% vs 53.9% at baseline, p=0.015; 75.6% vs 59.0% after CRP, p=0.003; and 79.8% vs 65.1% at 1-year-follow-up, p=0.007). During follow-up, at the end of the CRP (about 3 months after event), male patients exhibit a better control of LDL [82.0 vs 75.6 mg/dL, t(597)=2.4, p=0.016)] with 12.8% vs 16.4% below 55 mg/dL and 29.8% vs 44.5% below 70 mg/dL (p=0.008). At 1-year follow-up, both genders exhibited similar LDL-control due to a worsening control of the male population (81.9 vs 80.6 mg/dL, t(540)=0.52, p=0.605). Only 13.3% of females had LDL below 55 mg/dL (vs 12.9%, p=0.921) and 32.5% below 70 mg/dL (vs 37.0%, p=0.432).

Conclusion

This real-life study showed that guideline recommended LDL target is not achieved in the majority of patients, even under a structured CRP. Unlike other reports, there were more women receiving potent anti-dyslipidemic therapy. Nevertheless, women showed a poor control of LDL-concentration after three months of ACS and a similar control after 1-year; this highlights the uncertainties concerning the efficacy of lipid-lowering therapy in women, an underrepresented population in clinical trials.

Funding Acknowledgement

Type of funding sources: None.

Emergent coronary angiography in a 90-plus population – outcomes at 5-years follow-up

Introduction

Elderly people represents a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Several data suggest the benefit of an early revascularization in ST-elevation (STE)-ACS or non-STE-ACS with positive troponin. However questions persist considering the unavoidable adverse prognosis, patient's functional and cognitive status, comorbidities and preferences.

Purpose

To evaluate a group of very old patients who underwent emergent coronary angiography (CA).

Methods

We retrospectively analyzed a group of very old patients (≥90 year-old) who underwent emergent CA from January 2008 to September 2020. Clinical features were collected; survival and MACE were compared with an aged-matched control population with ACS not submitted to emergent CA. MACE was defined as a composite of all-cause death, ischemic stroke, ACS or hospitalization for acute heart failure.

Results

A total of 34 patients were enrolled: 56% female, with mean age 92±2 year-old. As for the cardiovascular risk factors, 88% had hypertension, 49% dyslipidaemia, 12% diabetes and 15% were previous smokers. Concerning other comorbidities, 27% had atrial fibrillation, 21% chronic kidney disease, 12% had cerebrovascular disease and median modified Rankin scale for neurologic disability was 2. Almost all patients had STE-ACS, 68% anterior and 29% inferior, inferolateral or inferoposterior infarction; 3% had infarction of indeterminate location. In CA, 65% had multivessel disease, 14% of them involving left main coronary artery; coronary intervention was performed in 71% of patients (mostly stent implantation), the remaining 29% had no invasive treatment. Concerning to clinical status, median troponin was 131 517 ng/L and median BNP 496 pg/mL; 36% of patients evolved in Killip class III or IV and only 32% of patients had normal left ventricular systolic function. Regarding mortality, 38% of patients died in the index-event versus 25% in the aged-matched control group (p=0.319). During five years of follow-up, there was no significant difference in mortality between the two groups (Log Rank, p=0.403) and more than 50% of patients died in two years. Comparing MACE occurrence, both groups were similar (Log Rank, p=0,662), with more than 80% having at least one event in five years.

Conclusion

Very old patients submitted to emergent CA had a high percentage of multivessel disease, left ventricular dysfunction and mortality during hospitalization. Compared to an aged-matched control group, they showed no survival or MACE benefit of emergent CA strategy during a five-years follow-up. Although this is a small study, these findings highlight the efforts that should be made to optimize care in this vulnerable population, under-represented in the clinical trials. Special caution should be given to avoid possible unnecessary discomfort in this setting.

Funding Acknowledgement

Type of funding sources: None. MACE analysis

Mortality after surgery with SARS-CoV-2 infection in England: a population-wide epidemiological study

BACKGROUND

The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.

METHODS

Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001).

CONCLUSIONS

The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

Secondary prevention after acute coronary syndrome - can we achieve dyslipidemia guideline targets?

Funding Acknowledgements

Type of funding sources: None.

Lipid control is one of the most important secondary cardiovascular prevention targets. The 4S trialin 1994 was the first study to demonstrate the benefit of statin therapy in coronary artery disease patients. More recently, the FOURIER trial (2017) and the ODYSSEY Outcomes (2018) demonstrated the cardiovascular benefit of adding a PCSK9 inhibitor to optimized antidyslipidemic therapy.

Owing to the growing number of evidence showing the importance of aggressive lipid control, the European Society of Cardiology (ESC) 2019 Dyslipidemia Guidelines changed the recommendation of LDL targets from below 70 mg/dL to below 55 mg/dL in very high risk patients.

In the light of this new recommendation, we retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an Acute Coronary Syndrome at a tertiary center from May 2008 to June 2019. The CRP consisted in a multi-disciplinary approach to these patients, including 8 to 12 weekly sessions of phase II rehabilitation, exercise prescription, nutrition counselling and life-style intervention, with Cardiology follow-up at the end of the CRP (3 months), 6 months and 12 months after the event. Lipid profile was requested at baseline, 3 months and 12 months after the event. Dyslipidemia was defined using the ESC Guidelines definition.

In total, 989 patients were enrolled: the mean age was 54 ± 10 years and 15% were female. Concerning to cardiovascular risk factors, 56.7% of patients had dyslipidaemia, 41.5% had hypertension, 18.1% were diabetic, 73.1% were smokers or previous smokers, 26.0% had family history of coronary disease and 14.0% had previous coronary disease.

At hospital admission, mean LDL concentration was 121,7 ± 38,8 mg/dL with 2,9% of the patients with values below 55 mg/dL and 7,6% below 70 mg/dL. The vast majority of patients were medicated with statin at hospital discharge and maintained the prescription during the follow-up (97.5% and 97.1%, respectively).

At the end of the CRP, there was a significant decrease of LDL values (p &lt; 0.001) with 18.7% patients with LDL below 55 mg/dL and 46.3% below 70 mg/dL (mean LDL 76.6 ±23.6 mg/dL). At 1-year follow-up, the lipid control was better than at admission, but inferior than at the end of the rehabilitation program, both findings statistically significant (11.0% patients were below 55 mg/dL and 33.1% were below 70 mg/dL, with a mean LDL of 82.7 ± 28.3 mg/dL; p &lt; 0.001).

In conclusion, our real-life observational cohort showed that guideline recommended LDL target is not achieved in most of very high-risk patients even in a structured coronary rehabilitation program. Of note, the number of patients at LDL-target decreased from 3 months to 1-year follow-up. This state the importance of a sustained healthy lifestyle and therapy adherence, with aggressive pharmacologic therapy.

The role of orientation towards sustainability in supply chains

Purpose

The purpose of this paper is to analyse how a company’s orientation enables sustainable practices in its supply chains. Specifically, it focusses on how the strategic orientation of a company may stimulate new behaviours in supply chains.

Design/methodology/approach

Two in-depth qualitative case studies were conducted. Each company’s orientation to sustainable supply chains was studied using cross-case analysis.

Findings

The organisations in this study have a market-driving (i.e. proactive) orientation instead of market-driven (i.e. responsive) behaviour. Using analysis from the process of change for sustainability and explaining some challenges faced by both organisations, findings indicate that a corporate strategy of sustainability modified the companies’ management processes, even for the company that changed its orientation during the time (i.e. sustainability was not the main strategy at first). Practical examples of actions are provided to illustrate the study’s conclusion that a corporate orientation towards sustainability is an enabling factor in developing sustainable supply chain management (SCM).

Research limitations/implications

Strategic management plays an important role in a company’s orientation towards sustainability – internally and throughout its supply chains. Based on the findings, future research should measure the effect of a company’s orientation on sustainable SCM.

Practical implications

This study contributes to the understanding of companies’ strategic orientations and explores ways to introduce sustainability into supply chains.

Originality/value

The paper examines an underexplored debate regarding to how strategic orientations are related to sustainable SCM, focussing on both market-driving (i.e. proactive) and market-driven (i.e. responsive) orientations.

P1310 Prosthetic valve endocarditis or thrombus?

One cause of constitutional syndrome in patients previously submitted to valve replacement surgery is a prosthetic endocarditis; this occurs in 1-6% of valve surgeries and has an adverse prognosis. Although this is a likely etiology, it is important to keep other possibilities in mind. This clinical case is about a 61 years old male, with known history of smoking, atrial fibrillation anticoagulated with warfarin (with low TTR), and rheumatic fever in childhood, with severe aortic stenosis/regurgitation and moderate mitral regurgitation. In August 2018 he was admitted in our hospital with mitral valve endocarditis cause by Streptococcus agalactiae. He was submitted to an aortic and mitral valve replacement surgery with 2 bioprothesis. Three months later he was admitted again with weight loss, fatigue, dyspnea for small efforts and worsening anemia. The first diagnosis hypothesis was prosthetic endocarditis. The echocardiogram showed normo-functioning aortic bioprothesis; obstructive mitral bioprothesis with an image suggestive of a vegetation; and a de novo mass in the left auricle, compatible with a thrombus. This clinical case was discussed in Heart Team: as the patient was clinically stable, it was opted for an initial conservative approach; although there was a strong clinical suspicion that all the clinical case was due to thrombotic manifestations (assuming that the vegetations had a non-infectious origin), he was nonetheless medicated with vancomycin, gentamicin and rifampicin, as the diagnosis of early culture negative prosthetic endocarditis could not be discarded. He was anticoagulated with enoxaparin. In the reevaluation echocardiogram there was a significative reduction of the left atrial thrombus and disappearance of the mitral valve vegetation image, with improvement of the mitral valve prosthetic gradients. The case was discussed again in Heart Team: due to the clinical evolution, the hypothesis that this was all caused by a thrombotic manifestation grew stronger; it was opted not to submit the patient to a new surgery and the antibiotic therapy was suspended. To study the pro-thrombotic state and the constitutional syndrome, a full body CT was requested: "hilar-mediastinal and bilateral hilar adenopathy; right supraclavicular adenopathy; splenomegaly with infarcted area." The right hilar adenopathy was biopsied; the pathologic exam revealed non-small cells lung carcinoma. The patient was discharged, medicated with warfarin and oriented to outpatient Oncology consult. Any cancer can be associated with thrombotic manifestations. In this case, considering the heavy smoking burden, lung cancer is one of the first etiologies to consider. The thrombotic manifestations of the non-small cells lung carcinoma are due to a paraneoplastic mechanism and might precede the cancer diagnosis. This clinical case highlights the importance of thinking of different etiologies in the differential diagnosis of a constitutional syndrome.

Abstract P1310 Figure. Left auricle mass

P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm

P863 Large pericardial effusion two months after transcatheter aortic valve implantation: case report of a post-cardiac injury syndrome

We present a case of a 87-year-old female with a symptomatic severe aortic stenosis (aortic valve area 0.9 cm2, mean transvalvular pressure gradient 44 mmHg). She was refused to surgical aortic valve replacement due to marked aortic root calcification. A transcatheter aortic valve (ACCURATE neo™ 27) was electively implanted. In immediate post-procedure, the patient presented an episode of hypotension, rapidly reverted with supportive treatment. A transthoracic echocardiogram (TTE) showed a circumferential mild pericardial effusion (PE) without prosthetic valve disfunction and with preserved biventricular systolic function. Due to paroxysmal episodes of atrial fibrillation, it was decided to withdraw anti-aggregation and to start anticoagulation. Four days after transcatheter aortic valve implantation (TAVI) the patient presented newer intraventricular and atrioventricular conduction disturbance (left bundle branch block and type-I second-degree atrioventricular block). A definitive pacemaker was implanted without complications. PE maintained stable and seven days after TAVI the patient was discharged from hospital.

Two months after TAVI, the patient was admitted to Intensive care unit (ICU) with increasing asthenia, dyspnea and pleuritic thoracic pain over the preceding two weeks. Laboratory workup exhibited elevation of inflammatory markers (leukocytosis and C-reactive protein). A TTE was performed and showed a large circumferential PE (29 mm) with signs of hemodynamic impact (swinging heart, inferior vena cava dilation with &lt;50% inspiratory collapse, right atrial collapse &gt;1/3 of cardiac cycle, proto-diastolic right ventricular collapse and mitral respiratory flow variation &gt;25%). The patient started treatment with anti-inflammatory drugs (aspirin 1000mg every 8h plus colchicine 0.5mg twice daily) and pericardiocentesis was initially postponed. In spite of clinical and echocardiographic improvement, she maintained elevated inflammatory markers and a moderate PE. Prednisolone 30mg daily was added to initial therapy and serial evaluations showed a pronounced reduction of PE as well as of inflammatory markers. Two weeks after admission to ICU the patient was discharged with a residual PE measuring less than 5mm. The previous recent cardiac intervention and the effective response to anti-inflammatory treatment suggest a post-cardiac injury syndrome.

This case report wants to show that post-cardiac injury syndrome is a diagnosis that should be keep in mind after TAVI.

Abstract P863 Figure. TTE showing large pericardial effusion

Automaticversusmanual oxygen administration in the emergency department

Oxygen is commonly administered in hospitals, with poor adherence to treatment recommendations.

We conducted a multicentre randomised controlled study in patients admitted to the emergency department requiring O2≥3 L·min−1. Patients were randomised to automated closed-loop or manual O2titration during 3 h. Patients were stratified according to arterial carbon dioxide tension (PaCO2) (hypoxaemicPaCO2≤45 mmHg; or hypercapnicPaCO2>45–≤55 mmHg) and study centre. Arterial oxygen saturation measured by pulse oximetry (SpO2) goals were 92–96% for hypoxaemic, or 88–92% for hypercapnic patients. Primary outcome was % time withinSpO2target. Secondary endpoints were hypoxaemia and hyperoxia prevalence, O2weaning, O2duration and hospital length of stay.

187 patients were randomised (93 automated, 94 manual) and baseline characteristics were similar between the groups. Time within theSpO2target was higher under automated titration (81±21%versus51±30%, p<0.001). Time with hypoxaemia (3±9%versus5±12%, p=0.04) and hyperoxia under O2(4±9%versus22±30%, p<0.001) were lower with automated titration. O2could be weaned at the end of the study in 14.1%versus4.3% patients in the automated and manual titration group, respectively (p<0.001). O2duration during the hospital stay was significantly reduced (5.6±5.4versus7.1±6.3 days, p=0.002).

Automated O2titration in the emergency department improved oxygenation parameters and adherence to guidelines, with potential clinical benefits.

Language switching across modalities: Evidence from bimodal bilinguals

This study investigated whether language control during language production in bilinguals generalizes across modalities, and to what extent the language control system is shaped by competition for the same articulators. Using a cued language-switching paradigm, we investigated whether switch costs are observed when hearing signers switch between a spoken and a signed language. The results showed an asymmetrical switch cost for bimodal bilinguals on reaction time (RT) and accuracy, with larger costs for the (dominant) spoken language. Our findings suggest important similarities in the mechanisms underlying language selection in bimodal bilinguals and unimodal bilinguals, with competition occurring at multiple levels other than phonology. (PsycINFO Database Record

Mutations in EXTL3 Cause Neuro-immuno-skeletal Dysplasia Syndrome

EXTL3 regulates the biosynthesis of heparan sulfate (HS), important for both skeletal development and hematopoiesis, through the formation of HS proteoglycans (HSPGs). By whole-exome sequencing, we identified homozygous missense mutations c.1382C>T, c.1537C>T, c.1970A>G, and c.2008T>G in EXTL3 in nine affected individuals from five unrelated families. Notably, we found the identical homozygous missense mutation c.1382C>T (p.Pro461Leu) in four affected individuals from two unrelated families. Affected individuals presented with variable skeletal abnormalities and neurodevelopmental defects. Severe combined immunodeficiency (SCID) with a complete absence of T cells was observed in three families. EXTL3 was most abundant in hematopoietic stem cells and early progenitor T cells, which is in line with a SCID phenotype at the level of early T cell development in the thymus. To provide further support for the hypothesis that mutations in EXTL3 cause a neuro-immuno-skeletal dysplasia syndrome, and to gain insight into the pathogenesis of the disorder, we analyzed the localization of EXTL3 in fibroblasts derived from affected individuals and determined glycosaminoglycan concentrations in these cells as well as in urine and blood. We observed abnormal glycosaminoglycan concentrations and increased concentrations of the non-sulfated chondroitin disaccharide D0a0 and the disaccharide D0a4 in serum and urine of all analyzed affected individuals. In summary, we show that biallelic mutations in EXTL3 disturb glycosaminoglycan synthesis and thus lead to a recognizable syndrome characterized by variable expression of skeletal, neurological, and immunological abnormalities.

Perspectives on carbon materials as powerful catalysts in continuous anaerobic bioreactors

The catalytic effect of commercial microporous activated carbon (AC) and macroporous carbon nanotubes (CNT) is investigated in reductive bioreactions in continuous high rate anaerobic reactors, using the azo dye Acid Orange 10 (AO10) as model compound as electron acceptor and a mixture of VFA as electron donor. Size and concentration of carbon materials (CM) and hydraulic retention time (HRT) are assessed. CM increased the biological reduction rate of AO10, resulting in significantly higher colour removal, as compared to the control reactors. The highest efficiency, 98%, was achieved with a CNT diameter (d) lower than 0.25 mm, at a CNT concentration of 0.12 g per g of volatile solids (VS), a HRT of 10 h and resulted in a chemical oxygen demand (COD) removal of 85%. Reducing the HRT to 5 h, colour and COD removal in CM-mediated bioreactors were above 90% and 80%, respectively. In the control reactor, thought similar COD removal was achieved, AO10 decolourisation was just approximately 20%, demonstrating the ability of CM to significantly accelerate the reduction reactions in continuous bioreactors. AO10 reduction to the correspondent aromatic amines was proved by high performance liquid chromatography (HPLC). Colour decrease in the reactor treating a real effluent with CNT was the double comparatively to the reactor operated without CNT. The presence of AC in the reactor did not affect the microbial diversity, as compared to the control reactor, evidencing that the efficient reduction of AO10 was mainly due to AC rather than attributed to changes in the composition of the microbial communities.

Farmacovigilância em Portugal: Atividade da Unidade Regional do Centro

<strong>Introduction: </strong>The aim of this study was to characterize the spontaneous reports of adverse events that were received by the Central Portugal Regional Pharmacovigilance Unit.<br /><strong>Material and Methods:</strong> Spontaneous reports received between 01/2001 and 12/2013 were considered. The annual reporting ratios were estimated. The cases were characterized according to their seriousness, previous description, causality assessment, origin and professional group of the reporter, type of adverse event and pharmacotherapeutic groups of the suspected drugs most frequently reported.<br /><strong>Results:</strong> The Pharmacovigilance Unit received 2408 reports that contained 5749 adverse events. In 2013, the reporting rate was estimated at 171 reports per million inhabitants. Fifty-five percent of the reports were assessed as serious. Ninety percent of the cases were assessed as being at least possibly related with the suspected drug. The suspected drugs most frequently reported were antiinfectives for systemic use (n = 809, 33%). The most frequently reported adverse events were “Skin and subcutaneous tissue disorders” (n = 1139, 20%). There were 154 (6.4%) reports resulting in life-threatening situations and/or death, and 88 (3.6%) containing at least one adverse event assessed as serious, unknown and certain or probable.<br /><strong>Discussion:</strong> The present results are in line with those found in other studies, namely the seriousness and type of the adverse eventsand the pharmacotherapeutic groups of the most frequently reported suspected drugs.<br /><strong>Conclusion: </strong>In the last years, the Central Portugal Regional Pharmacovigilance Unit has registered a growth in the reporting rate in general, as well as an increase in the reporting of unknown and serious adverse drug reactions.

[Pharmacovigilance in Portugal: Activity of the Central Pharmacovigilance Unit]

INTRODUCTION

The aim of this study was to characterize the spontaneous reports of adverse events that were received by the Central Portugal Regional Pharmacovigilance Unit.

MATERIAL AND METHODS

Spontaneous reports received between 01/2001 and 12/2013 were considered. The annual reporting ratios were estimated. The cases were characterized according to their seriousness, previous description, causality assessment, origin and professional group of the reporter, type of adverse event and pharmacotherapeutic groups of the suspected drugs most frequently reported.

RESULTS

The Pharmacovigilance Unit received 2408 reports that contained 5749 adverse events. In 2013, the reporting rate was estimated at 171 reports per million inhabitants. Fifty-five percent of the reports were assessed as serious. Ninety percent of the cases were assessed as being at least possibly related with the suspected drug. The suspected drugs most frequently reported were anti-infectives for systemic use (n = 809, 33%). The most frequently reported adverse events were "Skin and subcutaneous tissue disorders" (n = 1139, 20%). There were 154 (6.4%) reports resulting in life-threatening situations and/or death, and 88 (3.6%) containing at least one adverse event assessed as serious, unknown and certain or probable.

DISCUSSION

The present results are in line with those found in other studies, namely the seriousness and type of the adverse events and the pharmacotherapeutic groups of the most frequently reported suspected drugs.

CONCLUSION

In the last years, the Central Portugal Regional Pharmacovigilance Unit has registered a growth in the reporting rate in general, as well as an increase in the reporting of unknown and serious adverse drug reactions.

Pedigree studies and evaluation of risk factors of breast cancer in Goa

BACKGROUND

Incidence of breast cancer (BC) is increasing in most of the countries, including the areas which have had previously low rates.

AIM

The aim of this prospective study was to analyze the pedigrees of the patients for detecting hereditary factor prevalence and to investigate the possible risk factors associated with BC in a sample population from Goa.

MATERIALS AND METHODS

A prospective analysis was performed for 95 BC patients between 2011 and 2012. For assessing the risk factors, a proforma was designed and the necessary data was collected by interview. The process of collecting family history for drawing the pedigree included interviewing the informant.

STATISTICAL ANALYSIS USED

Online calculators of statistics were used for standard deviation at www.easycalculation.com and fishers test at www.graphpad.com.

RESULTS

High frequency of BC was revealed in the sample population from Goa. This could be attributed to the changes in reproductive patterns, physical inactivity and obesity, or general increase in BC awareness. Factors which did not influence the frequency of BC in the sample population include parity, oral contraceptives, alcohol consumption, occupation, exercise, and nutritional supplement. High incidence of family history of 168/1000 individuals was observed in the present study.

CONCLUSIONS

Proper management of BC is possible after assessment of cumulative risk of BC in females by a thorough study of both environmental and genetic factors. Cumulative risk can be greatly reduced by controlling the environmental risk.

Mutations in tubulin genes are frequent causes of various foetal malformations of cortical development including microlissencephaly

Complex cortical malformations associated with mutations in tubulin genes are commonly referred to as “Tubulinopathies”. To further characterize the mutation frequency and phenotypes associated with tubulin mutations, we studied a cohort of 60 foetal cases. Twenty-six tubulin mutations were identified, of which TUBA1A mutations were the most prevalent (19 cases), followed by TUBB2B (6 cases) and TUBB3 (one case). Three subtypes clearly emerged. The most frequent (n = 13) was microlissencephaly with corpus callosum agenesis, severely hypoplastic brainstem and cerebellum. The cortical plate was either absent (6/13), with a 2–3 layered pattern (5/13) or less frequently thickened (2/13), often associated with neuroglial overmigration (4/13). All cases had voluminous germinal zones and ganglionic eminences. The second subtype was lissencephaly (n = 7), either classical (4/7) or associated with cerebellar hypoplasia (3/7) with corpus callosum agenesis (6/7). All foetuses with lissencephaly and cerebellar hypoplasia carried distinct TUBA1A mutations, while those with classical lissencephaly harbored recurrent mutations in TUBA1A (3 cases) or TUBB2B (1 case). The third group was polymicrogyria-like cortical dysplasia (n = 6), consisting of asymmetric multifocal or generalized polymicrogyria with inconstant corpus callosum agenesis (4/6) and hypoplastic brainstem and cerebellum (3/6). Polymicrogyria was either unlayered or 4-layered with neuronal heterotopias (5/6) and occasional focal neuroglial overmigration (2/6). Three had TUBA1A mutations and 3 TUBB2B mutations. Foetal TUBA1A tubulinopathies most often consist in microlissencephaly or classical lissencephaly with corpus callosum agenesis, but polymicrogyria may also occur. Conversely, TUBB2B mutations are responsible for either polymicrogyria (4/6) or microlissencephaly (2/6).