Age shock index as an early predictor of cardiovascular death in acute coronary syndrome patients

BACKGROUND

The shock index (SI), reflecting heart rate (HR) to SBP ratio, is established for predicting adverse outcomes in acute coronary syndrome (ACS) patients. Exploring the age shock index (ASI), obtained by multiplying SI with age, could offer further insights into ACS prognosis.

OBJECTIVES

Assess ASI's effectiveness in predicting in-hospital death in individuals with ACS.

METHODS

This study encompassed patients with acute myocardial infarction, drawn from a national registry spanning October 2010 to January 2022. The optimal ASI threshold was established using receiver operating characteristic (ROC) curve analysis. The primary outcome was in-hospital mortality.

RESULTS

A total of 27 312 patients were enrolled, exhibiting a mean age of 66 ± 13 years, with 72.3% being male and 47.5% having ST-elevation myocardial infarction. ROC analysis yielded an area under the curve (AUC) of 0.80, identifying the optimal ASI cutoff as 44. Multivariate regression analysis, adjusting for potential confounders, established ASI ≥ 44 as an independent predictor of in-hospital death [hazard ratio: 3.09, 95% confidence interval: 2.56-3.71, P  < 0.001]. Furthermore, ASI emerged as a notably superior predictor of in-hospital death compared to the SI (AUC ASI  = 0.80 vs. AUC SI  = 0.72, P  < 0.0001), though it did not outperform the Global Registry of Acute Coronary Events (GRACE) score (AUC ASI  = 0.80 vs. AUC GRACE  = 0.85, P  < 0.001) or thrombolysis in myocardial infarction (TIMI) risk index (AUC ASI  = 0.80 vs. AUC TIMI  = 0.84, P  < 0.001).

CONCLUSION

The ASI offers an expedient mean to promptly identify ACS patients at elevated risk of in-hospital death. Its simplicity and effectiveness could render it a valuable tool for early risk stratification in this population.

Image based prognosis in head and neck cancer using convolutional neural networks: a case study in reproducibility and optimization

In the past decade, there has been a sharp increase in publications describing applications of convolutional neural networks (CNNs) in medical image analysis. However, recent reviews have warned of the lack of reproducibility of most such studies, which has impeded closer examination of the models and, in turn, their implementation in healthcare. On the other hand, the performance of these models is highly dependent on decisions on architecture and image pre-processing. In this work, we assess the reproducibility of three studies that use CNNs for head and neck cancer outcome prediction by attempting to reproduce the published results. In addition, we propose a new network structure and assess the impact of image pre-processing and model selection criteria on performance. We used two publicly available datasets: one with 298 patients for training and validation and another with 137 patients from a different institute for testing. All three studies failed to report elements required to reproduce their results thoroughly, mainly the image pre-processing steps and the random seed. Our model either outperforms or achieves similar performance to the existing models with considerably fewer parameters. We also observed that the pre-processing efforts significantly impact the model's performance and that some model selection criteria may lead to suboptimal models. Although there have been improvements in the reproducibility of deep learning models, our work suggests that wider implementation of reporting standards is required to avoid a reproducibility crisis.

Representational horizon and visual space orientation: An investigation into the role of visual contextual cues on spatial mislocalisations

The perceived offset position of a moving target has been found to be displaced forward, in the direction of motion (Representational Momentum; RM), downward, in the direction of gravity (Representational Gravity; RG), and, recently, further displaced along the horizon implied by the visual context (Representational Horizon; RH). The latter, while still underexplored, offers the prospect to clarify the role of visual contextual cues in spatial orientation and in the perception of dynamic events. As such, the present work sets forth to ascertain the robustness of Representational Horizon across varying types of visual contexts, particularly between interior and exterior scenes, and to clarify to what degree it reflects a perceptual or response phenomenon. To that end, participants were shown targets, moving along one out of several possible trajectories, overlaid on a randomly chosen background depicting either an interior or exterior scene rotated -22.5º, 0º, or 22.5º in relation to the actual vertical. Upon the vanishing of the target, participants were required to indicate its last seen location with a computer mouse. For half the participants, the background vanished with the target while for the remaining it was kept visible until a response was provided. Spatial localisations were subjected to a discrete Fourier decomposition procedure to obtain independent estimates of RM, RG, and RH. Outcomes showed that RH's direction was biased towards the horizon implied by the visual context, but solely for exterior scenes, and irrespective of its presence or absence during the spatial localisation response, supporting its perceptual/representational nature.

Utility of the Age Shock Index in 27312 patients with an acute coronary syndrome

Introduction

The Shock Index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), represents a bedside reflection of the integrated response from the cardiovascular and autonomic systems and has been reported to predict adverse prognosis in patients with acute coronary syndromes (ACS).

Age Shock Index (ASI), the product of SI multiplied with age, could also be useful in this setting, but its prognostic value is yet to be determined in ACS patients.

Methods

Acute myocardial infarction patients included in a national registry between October 2010 and January 2022. Optimal shock index cutoff was determined according to ROC curve analysis. Patients were categorized into two groups based on their initial ASI. Baseline characteristics, management and outcomes were compared between the two groups. The primary outcome was in-hospital cardiovascular death.

Results

A total of 27312 patients were included with a mean age of 66±13 years, 72.3% male, 47.5% with ST-elevation myocardial infarction. Based on ROC analysis, which showed AUC=0.80, the optimal ASI cutoff was 44 (with a sensitivity of 73% and a specificity of 74%); 19997 patients (73.2%) had an ASI &lt;44 and 26.8% had an ASI ≥44. The former group was older (mean age of 75±10.0 vs 63±13.0 years, p&lt;0.001), and had more comorbidities: arterial hypertension (77.3% vs 66.3%, p&lt;0.001), diabetes mellitus (39.8% vs 28.1%, p&lt;0.001), peripheral artery disease (7.1% vs 4.4%, p&lt;0.001) and previous history of heart failure (11.0% vs 4.3%, p&lt;0.001).

Patients with ASI ≥44 had higher Killip class at admission and worse left ventricular ejection fraction on discharge (46.0±13.0 vs 53.0±11.0, p&lt;0.001).

In a multivariate regression analysis, after adjusting for possible confounders, ASI ≥44 was an independent predictor of cardiovascular death (HR 3.09, 95% CI: 2.56–3.71, p&lt;0.001).

ASI was a significantly better predictor of cardiovascular death than Shock Index (AUCASI = 0,80 vs AUCSI = 0.72, p&lt;0,0001), but not in comparison to GRACE score (AUCASI=0.80 vs AUCGRACE=0.85, p&lt;0.001) and TIMI (score AUCASI=0.80 vs AUCGRACE=0.84, p&lt;0.001).

At one year, using a Kaplan Meyer survival analysis, mortality was higher in patients with ASI ≥44 (log rank p&lt;0.001)

Conclusion

ASI can identify almost immediately ACS patients at high risk of cardiovascular death, and combined with its simple use, makes it a practical tool for early risk stratification in these patients.

Funding Acknowledgement

Type of funding sources: None.

Exploring the pH-dependent kinetics, thermodynamics and photochemistry of a flavylium-based pseudorotaxane

Flavylium-based molecular switches are attractive molecular components to devise stimuli-responsive host-guest systems such as rotaxanes and pseudorotaxanes. These compounds display a pH-dependent reaction network of several species that reversibly interconvert within different time scales. Therefore, to explore and take profit of exceptional stimuli-responsive properties of these systems, detailed kinetic and thermodynamic characterizations are often required. In this work, we present the results of such characterization for a new flavylium compound decorated with a trimethylalkylammonium substituent designed to form a pseudorotaxane with cucurbit[7]uril (CB7). The formation of the pseudorotaxane was characterized in detail, and the thermodynamic and kinetic aspects of the flavylium interconversion reactions in the assembly were investigated and compared with the free molecular switch.

Large-Amplitude Conformational Changes in Self-Assembled Multi-Stranded Aromatic Sheets

The orchestration of ever larger conformational changes is made possible by the development of increasingly complex foldamers. Aromatic sheets, a rare motif in synthetic foldamer structures, have been designed so as to form discrete stacks of intercalated aromatic strands through the self‐assembly of two identical subunits. Ion‐mobility ESI‐MS confirms the formation of compact dimers. X‐ray crystallography reveals the existence of two distinct conformational dimeric states that require large changes to interconvert. Molecular dynamics simulation validates the stability of the two conformations and the possibility of their interconversion.

Sensing a binding event through charge transport variations using an aromatic oligoamide capsule

The selective binding properties of a 13-mer oligoamide foldamer capsule composed of 4 different aromatic subunits are reported. The capsule was designed to recognize dicarboxylic acids through multiple-point interactions owing to a combination of protonation/deprotonation events, H-bonding, and geometrical constraints imparted by the rigidity of the foldamer backbone. Compared to tartaric acid, binding of 2,2-difluorosuccinic acid or 2,2,3,3-tetrafluorosuccinic acid resulted in symmetry breaking due to deprotonation of only one of the two carboxylic acid groups of the encapsulated species as shown by NMR studies in solution and by single-crystal X-ray diffraction in the solid state. An analogous 14-mer foldamer capsule terminated with a thiol anchoring group was used to probe the complexation event in self-assembled monolayers on Au substrates. Ellipsometry and polarization-modulation infrared absorption-reflection spectroscopy studies were consistent with the formation of a single molecule layer of the foldamer capsule oriented vertically with respect to the surface. The latter underwent smooth complexation of 2,2-difluorosuccinic acid with deprotonation of one of the two carboxylic acid groups. A significant (80-fold) difference in the charge transport properties of the monolayer upon encapsulation of the dicarboxylic acid was evidenced from conducting-AFM measurements (S = 1.1 × 10-9 vs. 1.4 × 10-11 ohm-1 for the empty and complexed capsule, respectively). The modulation in conductivity was assigned to protonation of the aromatic foldamer backbone.

Selective Coordination of Cu2+ and Subsequent Anion Detection Based on a Naphthalimide-Triazine-(DPA)2 Chemosensor

A new fluorescent chemosensor for copper (II) and subsequent anion sensing was designed and fully characterized. The sensor consisted of a 1,8-naphthalimide core, bearing two terminal dipicolylamine (DPA) receptor units for binding metal cations, and an ethoxyethanol moiety for enhanced water solubility. The DPA units are connected to position 4 of the fluorophore via a triazine-ethylenediamine spacer. Fluorescence titration studies of the chemosensor revealed a high selectivity for Cu²⁺ over other divalent ions, the emissions were strongly quenched upon binding, and a stability constant of 5.52 log units was obtained. Given the distance from DPA chelating units and the fluorophore, quenching from the Cu²⁺ complexation suggests an electron transfer or an electronic energy transfer mechanism. Furthermore, the Cu²⁺-sensor complex proved to be capable of sensing anionic phosphate derivatives through the displacement of the Cu²⁺ cation, which translated into a full recovery of the luminescence from the naphthalimide. Super-resolution fluorescence microscopy studies performed in HeLa cells showed there was a high intracellular uptake of the chemosensor. Incubation in Cu²⁺ spiked media revealed a strong fluorescent signal from mitochondria and cell membranes, which is consistent with a high concentration of ATP at these intracellular sites.

Monitoring inorganic pyrophosphatase activity with the fluorescent dizinc(ii) complex of a macrocycle bearing one dansylamidoethyl antenna

The dizinc(ii) complexes of L were used for the recognition of anions by fluorescence spectroscopy (L is a heteroditopic hexaazamacrocycle with two diethylenetriamine coordination heads with 2-methylpyridyl and dansylamido ethyl arms, and m-xylyl spacers). The protonation of L and stability constants of its zinc(ii) complexes were determined in aqueous solution, at 298.2 ± 0.1 K and I = 0.10 ± 0.01 M in KNO₃. At a 2 : 1 Zn²⁺/L ratio, the dinuclear complexes clearly dominate. The ligand alone does not display fluorescence changes upon increasing the pH value, but in the presence of Zn²⁺ the emission reaches a maximum at pH ≅ 7.5, at which 95% of the ligand is in the dinuclear complex form. The emission appears concomitantly with the [Zn₂H_-1L]³⁺ species formation, which supports that the latter complex corresponds to the metal-promoted deprotonation of dansylamide NH. The [Zn₂H_-1L]³⁺ complexes were used for the recognition of phosphate and polyphosphate anions in aqueous solution buffered at pH 7.5 with 2 mM PIPPS, at 298.2 K. The binding of anions causes a decrease of the emission. The association constant determination revealed that HPPi^3- is the strongest bound anion (log K_app = 5.57), followed by HATP^3- (two times weaker), and the remaining anions show lower binding constants, with HPO₄^2- having the weakest uptake by the receptor. The observed selectivity of the [Zn₂H_-1L]³⁺ receptor for PPi in relation to HPO₄^2-, and the fact that the formation of the [Zn₂H_-1L]³⁺ complex is not disturbed by the presence of Mg²⁺, allowed monitoring of the PPi hydrolysis by using inorganic pyrophosphatase in real-time.

Allosteric Recognition of Homomeric and Heteromeric Pairs of Monosaccharides by a Foldamer Capsule

The recognition of either homomeric or heteromeric pairs of pentoses in an aromatic oligoamide double helical foldamer capsule was evidenced by circular dichroism (CD), NMR spectroscopy, and X-ray crystallography. The cavity of the host was predicted to be large enough to accommodate simultaneously two xylose molecules and to form a 1:2 complex (one container, two saccharides). Solution and solid-state data revealed the selective recognition of the α-4 C1 -d-xylopyranose tautomer, which is bound at two identical sites in the foldamer cavity. A step further was achieved by sequestering a heteromeric pair of pentoses, that is, one molecule of α-4 C1 -d-xylopyranose and one molecule of β-1 C4 -d-arabinopyranose despite the symmetrical nature of the host and despite the similarity of the guests. Subtle induced-fit and allosteric effects are responsible for the outstanding selectivities observed.

Zinc(ii) and copper(ii) complexes as tools to monitor/inhibit protein phosphorylation events

A perspective on the advance of copper(ii) and zinc(ii) complexes of varied ligand architectures as binders of phosphorylated peptides/proteins and as sensors of phosphorylation reactions is presented.

The role of methylation in the copper(ii) coordination properties of a His-containing decapeptide

N-Methylation: a simple strategy to stabilize copper species lacking amidate coordination at neutral pH value.

Evaluation of Noninvasive Prenatal Testing (NIPT) guidelines using the AGREE II instrument

Objective: The rapid increase of cell-free fetal DNA analysis for Down syndrome screening requires evidence-based clinical practice guidelines for noninvasive prenatal testing (NIPT). Several studies show that the quality of many guidelines is low and there are still many health areas where this quality is not systematically evaluated. Given the absence of research, in the NIPT field, we used an internationally validated tool to evaluate a set of three NIPT practice guidelines and to look at dimensions that can be improved.Methods: Four appraisers, experts in prenatal screening, evaluated three main NIPT guidelines published in the last 2 years using the AGREE II (Appraisal of Guidelines for Research and Evaluation II), a tool specifically designed for guideline quality appraisal.Results: Guidelines scored higher in domains related with scope, purpose, and clarity of presentation, and lower in stakeholder involvement and rigor of development. Intradomain items evaluation showed asymmetries between guidelines. The UK-NSC was the guideline with the best scores.Discussion: Several areas of NIPT guidelines, such as stakeholders involvement, selection of supporting evidence, external reviews, updating processes, and competing interests disclosure, can be improved. Appraisers recommend modifications to all NIPT guidelines that can lead to substantial improvements in their methodological quality and subsequently make a contribution to prenatal screening improvement.

Carbohydrate binding through first- and second-sphere coordination within aromatic oligoamide metallofoldamers

Aromatic oligoamide capsules that fold upon metal binding recognize carbohydrate guests in solution as evidenced by CD and NMR titrations. Crystallographic data reveal that, besides their structural role, metal ions also contribute to guest recognition through either first- or second-sphere coordination.

Alkali and alkaline earth metal ion binding by a foldamer capsule: selective recognition of magnesium hydrate

Alkali and alkaline earth metal ion binding by an aromatic oligoamide foldamer was shown to induce its folding into a helical capsule. CD and NMR titrations revealed tight and selective binding of Mg²⁺. Crystallographic studies demonstrated that, depending on the metal, binding may involve the first or second coordination spheres of the metal hydrates.

Recognition of phosphopeptides by a dinuclear copper(ii) macrocyclic complex in a water : methanol 50 : 50 v/v solution

A new triethylbenzene-derived tetraazamacrocycle containing pyridyl spacers, L, was prepared and its dinuclear copper(ii) complex was used as a receptor for the recognition of phosphorylated peptides in aqueous solution. A detailed study of the acid-base behaviour of L and its copper(ii) complexation properties as well as of the cascade species with phosphorylated anions including two peptidic substrates was carried out in a H₂O/MeOH (50 : 50 v/v) solution using different techniques, such as potentiometry, X-band EPR and DFT calculations. The association constants of the dinuclear receptor with the phosphorylated peptides and other anionic species revealed a clear preference towards phenylic phosphorylated substrates, with values ranging 3.96-5.35 log units. Single-crystal X-ray diffraction determination of the dicopper(ii) complex of L showed the copper centres at a distance of 5.812(1) Å from one another, with the phosphate group of the PhPO₄^2- substrate well accommodated between them. X-band EPR studies indicated a similar structure for this cascade complex and for the other cascade complexes with the phosphorylated anions studied. DFT studies of the [Cu₂L(μ-OH)]³⁺ complex revealed a different conformation of the ligand that brings the two copper centres at a very short distance of 3.94 Å aided by the presence of a bridging hydroxide anion that provides a CuOCu angle of 167.3°. This complex is EPR silent, in line with the singlet ground state obtained using CASSCF(2,2) calculations and DFT calculations with the broken-symmetry approach. This species coexists in solution with a complex in a different conformation, and having a CuCu distance of 6.63 Å, in lower percentage.

Eslicarbazepine acetate as adjunctive therapy in clinical practice: ESLADOBA study

OBJECTIVE

To assess seizure control and tolerability of eslicarbazepine acetate (ESL) as adjunctive therapy to one baseline antiepileptic drug (AED), in adults with partial-onset seizures (POS) with or without secondary generalization.

METHODS

Multicenter, non-interventional, prospective cohort study conducted between March 2012 and September 2014 at 12 neurology departments in Portugal. Adults with POS not controlled with one AED who had initiated ESL as adjunctive treatment were enrolled. Retention rate was defined at the final visit (Vfinal) 6-9 months of follow-up. Proportion of responders, seizure-free, changes in seizure frequency were evaluated using patients' diaries. Clinical Global Impression of Change (CGI-C) and Clinical Global Impression of Severity (CGI-S) were assessed by the neurologist.

RESULTS

Fifty-two patients (48.1% male) were included with mean age 41.5±13.3 years. Mean epilepsy duration was 18.5±14.8 years; mean seizure frequency in the four previous weeks to baseline was 7.5±12.7. At Vfinal, retention rate was 73.0%; responder rate and seizure-free rates were 71.1% and 39.5%, respectively. The median relative reduction in seizure frequency between baseline and Vfinal was 82.2%. A reduction in epilepsy severity (CGI-S) was observed in 42.1%. According to CGI-C, 73.6% patients had their epilepsy "much improved" or "very much improved". Twelve patients (23.1%) had at least one adverse event (AE), two (3.9%) had one serious AE, and five (9.6%) discontinued due to AE.

CONCLUSIONS

Eslicarbazepine acetate showed good retention rates, elicited a significant reduction in seizure frequency, and was well tolerated when used in the clinical practice.

Implementing Case Management in Portuguese Mental Health Services: Conceptual Background

Case management implementation processes are one of the best examples on how an evidence-based practice can influence health services organisation. This practice helped shaping mental health teams, increasing their multidisciplinarity and interdisciplinary work in the last decades. Examples from several countries show how effectiveness research blends into health policy development to meet different needs in each health system, thus influencing case management inception and improvement of care. Portugal followed its own path in case management implementation, determined mostly by mental health services organisation and closely linked with the capacity to implement a national mental health policy in the last years.

Inhibition of the STAT3 Protein by a Dinuclear Macrocyclic Complex

A new diethylenetriamine-derived macrocycle bearing 2-methylpyridyl arms and containing m-xylyl spacers, L, was prepared, and its dinuclear copper(II) and zinc(II) complexes were used as receptors for the recognition in aqueous solution of a phosphorylated peptide derived from a sequence of the STAT3 protein. A detailed study of the acid-base behavior of L and of its complexation properties as well as of the association of the phosphorylated peptide to the receptor was carried out by potentiometry in aqueous solution at 298.2 K and I = 0.10 M in KNO3. The data revealed that the receptor forms stable associations with several protonated forms of the substrate, with constant values ranging from 3.32 to 4.25 log units. The affinity of the receptor for the phosphorylated substrate studied is higher at a pH value where the receptor is mainly in the [Cu2L](4+) form and the pY residue of the substrate is in the dianionic form (pH 6.55). These results, also supported by (31)P NMR studies, showed that the phosphopeptide is bound through the phosphoryl group in a bridging mode. Additionally, the receptor inhibited binding between active (phosphorylated) STAT3 and its target DNA sequence in a dose-dependent manner (IC50 63 ± 3.4 μM) in human nuclear extracts in vitro. Treatment of whole cells with the inhibitor revealed that it is bioactive in living cells and has oncostatic properties that could be interesting for the fight against cancer and other pathologies involving the STAT3 protein.

Screening for Fabry disease in left ventricular hypertrophy: documentation of a novel mutation

BACKGROUND

Fabry disease is a lysosomal storage disease caused by enzyme α-galactosidase A deficiency as a result of mutations in the GLA gene. Cardiac involvement is characterized by progressive left ventricular hypertrophy.

OBJECTIVE

To estimate the prevalence of Fabry disease in a population with left ventricular hypertrophy.

METHODS

The patients were assessed for the presence of left ventricular hypertrophy defined as a left ventricular mass index ≥ 96 g/m2 for women or ≥ 116 g/m2 for men. Severe aortic stenosis and arterial hypertension with mild left ventricular hypertrophy were exclusion criteria. All patients included were assessed for enzyme α-galactosidase A activity using dry spot testing. Genetic study was performed whenever the enzyme activity was decreased.

RESULTS

A total of 47 patients with a mean left ventricular mass index of 141.1 g/m2 (± 28.5; 99.2 to 228.5 g/m2] were included. Most of the patients were females (51.1%). Nine (19.1%) showed decreased α-galactosidase A activity, but only one positive genetic test - [GLA] c.785G>T; p.W262L (exon 5), a mutation not previously described in the literature. This clinical investigation was able to establish the association between the mutation and the clinical presentation.

CONCLUSION

In a population of patients with left ventricular hypertrophy, we documented a Fabry disease prevalence of 2.1%. This novel case was defined in the sequence of a mutation of unknown meaning in the GLA gene with further pathogenicity study. Thus, this study permitted the definition of a novel causal mutation for Fabry disease - [GLA] c.785G>T; p.W262L (exon 5).

Sulfate recognition by a hexaaza cryptand receptor

A hexamine macrobicycle with pyrrolyl spacers was evaluated as an anion receptor in its protonated forms. The protonation constants of the receptor, as well as its association constants with Cl(-), NO3(-), AcO(-), ClO4(-), H2PO4(-), and SO4(2-) were determined by potentiometry at 298.2 ± 0.1 K in H2O-MeOH (50 : 50 v/v) and at an ionic strength of 0.10 ± 0.01 M in KTsO. These studies revealed that the Hnpyrr(n+) receptor has a very high effective association constant value for the SO4(2-) at pH 4.0 (log Keff = 6.42), and it is selective for the uptake of this anion in the presence of the other studied anionic substrates. In particular, the receptor showed very high SO4(2-)/NO3(-) selectivity. Using the indicator-displacement approach the receptor is able to signal the presence of sulfate by a change of color. Single crystal X-ray diffraction determination of [(H6pyrr)(SO4)(H2O)3](SO4)2·9.3H2O revealed the presence of one sulfate anion inside the receptor cavity and showed that the encapsulation of the anion is favored by an array of nine hydrogen bonding interactions, including N-HO, C-HO and water-mediated ones.

[Giant tumoral lesion in the left atrium: an uncommon case of undifferentiated cardiac sarcoma]

Primary cardiac tumors are rare, with an incidence ranging from 0.0001% to 0.030%; 80% are benign, while sarcomas account for 95% of malignant tumors. The authors report the case of a 75-year-old patient with a giant mass in the left atrium. The final diagnosis was of an undifferentiated cardiac sarcoma. This tumor represents a real challenge not only for timely diagnosis, but especially the therapeutic approach to adopt.