"There's Still Time to be Happy": The Life Trajectories of Portuguese Transgender Women Who Transitioned at 50+ Years

The process of transitioning involves making changes to align one's life with their authentic gender identity. This study explores the life trajectories of three Portuguese transgender women who transitioned later in life (50+ years old) by identifying key chapters in their life courses. Through inductive thematic analysis, six chapters were identified from the participants' interviews: (1) awareness of "something different in me," (2) locked into suffering, (3) finding comfort in something that is socially recognized, (4) "it is enough": it is time to recognize and embrace the woman I am, (5) living my life as a woman, and (6) building and leaving a legacy. Aging and the process of self-discovery played pivotal roles in participants' process of transitioning. The perception of finitude and the limitations associated with the time of life led them to realize that there was no time to waste and a sense of urgency to live authentically.

Global taxonomic, functional, and phylogenetic diversity of bees in apple orchards

An essential prerequisite to safeguard pollinator species is characterisation of the multifaceted diversity of crop pollinators and identification of the drivers of pollinator community changes across biogeographical gradients. The extent to which intensive agriculture is associated with the homogenisation of biological communities at large spatial scales remains poorly understood. In this study, we investigated diversity drivers for 644 bee species/morphospecies in 177 commercial apple orchards across 33 countries and four global biogeographical biomes. Our findings reveal significant taxonomic dissimilarity among biogeographical zones. Interestingly, despite this dissimilarity, species from different zones share similar higher-level phylogenetic groups and similar ecological and behavioural traits (i.e. functional traits), likely due to habitat filtering caused by perennial monoculture systems managed intensively for crop production. Honey bee species dominated orchard communities, while other managed/manageable and wild species were collected in lower numbers. Moreover, the presence of herbaceous, uncultivated open areas and organic management practices were associated with increased wild bee diversity. Overall, our study sheds light on the importance of large-scale analyses contributing to the emerging fields of functional and phylogenetic diversity, which can be related to ecosystem function to promote biodiversity as a key asset in agroecosystems in the face of global change pressures.

Digitization of Pathology Labs: A Review of Lessons Learned

Pathology laboratories are increasingly using digital workflows. This has the potential of increasing laboratory efficiency, but the digitization process also involves major challenges. Several reports have been published describing the individual experiences of specific laboratories with the digitization process. However, a comprehensive overview of the lessons learned is still lacking. We provide an overview of the lessons learned for different aspects of the digitization process, including digital case management, digital slide reading, and computer-aided slide reading. We also cover metrics used for monitoring performance and pitfalls and corresponding values observed in practice. The overview is intended to help pathologists, information technology decision makers, and administrators to benefit from the experiences of others and to implement the digitization process in an optimal way to make their own laboratory future-proof.

Diploid Nuclei Occur throughout the Life Cycles of Pucciniales Fungi

Within Eukaryotes, fungi are the typical representatives of haplontic life cycles. Basidiomycota fungi are dikaryotic in extensive parts of their life cycle, but diploid nuclei are known to form only in basidia. Among Basidiomycota, the Pucciniales are notorious for presenting the most complex life cycles, with high host specialization, and for their expanded genomes. Using cytogenomic (flow cytometry and cell sorting on propidium iodide-stained nuclei) and cytogenetic (FISH with rDNA probe) approaches, we report the widespread occurrence of replicating haploid and diploid nuclei (i.e., 1C, 2C and a small proportion of 4C nuclei) in diverse life cycle stages (pycnial, aecial, uredinial, and telial) of all 35 Pucciniales species analyzed, but not in sister taxa. These results suggest that the Pucciniales life cycle is distinct from any cycle known, i.e., neither haplontic, diplontic nor haplodiplontic, corroborating patchy and disregarded previous evidence. However, the biological basis and significance of this phenomenon remain undisclosed. IMPORTANCE Within Eukaryotes, fungi are the typical representatives of haplontic life cycles, contrasting with plants and animals. As such, fungi thus contain haploid nuclei throughout their life cycles, with sexual reproduction generating a single diploid cell upon karyogamy that immediately undergoes meiosis, thus resuming the haploid cycle. In this work, using cytogenetic and cytogenomic tools, we demonstrate that a vast group of fungi presents diploid nuclei throughout their life cycles, along with haploid nuclei, and that both types of nuclei replicate. Moreover, haploid nuclei are absent from urediniospores. The phenomenon appears to be transversal to the organisms in the order Pucciniales (rust fungi) and it does not occur in neighboring taxa, but a biological explanation or function for it remains elusive.

Explainability and causability in digital pathology

The current move towards digital pathology enables pathologists to use artificial intelligence (AI)-based computer programmes for the advanced analysis of whole slide images. However, currently, the best-performing AI algorithms for image analysis are deemed black boxes since it remains - even to their developers - often unclear why the algorithm delivered a particular result. Especially in medicine, a better understanding of algorithmic decisions is essential to avoid mistakes and adverse effects on patients. This review article aims to provide medical experts with insights on the issue of explainability in digital pathology. A short introduction to the relevant underlying core concepts of machine learning shall nurture the reader's understanding of why explainability is a specific issue in this field. Addressing this issue of explainability, the rapidly evolving research field of explainable AI (XAI) has developed many techniques and methods to make black-box machine-learning systems more transparent. These XAI methods are a first step towards making black-box AI systems understandable by humans. However, we argue that an explanation interface must complement these explainable models to make their results useful to human stakeholders and achieve a high level of causability, i.e. a high level of causal understanding by the user. This is especially relevant in the medical field since explainability and causability play a crucial role also for compliance with regulatory requirements. We conclude by promoting the need for novel user interfaces for AI applications in pathology, which enable contextual understanding and allow the medical expert to ask interactive 'what-if'-questions. In pathology, such user interfaces will not only be important to achieve a high level of causability. They will also be crucial for keeping the human-in-the-loop and bringing medical experts' experience and conceptual knowledge to AI processes.

Improving the Performance of Paper-Based Dipole Antennas by Electromagnetic Flux Concentration

One of the essential issues in modern advanced materials science is to design and manufacture flexible devices, in particular in the framework of the Internet of Things (IoT), to improve integration into applications. An antenna is an essential component of wireless communication modules and, in addition to flexibility, compact dimensions, printability, low cost, and environmentally friendlier production strategies, also represent relevant functional challenges. Concerning the antenna's performance, the optimization of the reflection coefficient and maximum range remain the key goals. In this context, this work reports on screen-printed paper@Ag-based antennas and optimizes their functional properties, with improvements in the reflection coefficient (S₁₁) from -8 to -56 dB and maximum transmission range from 208 to 256 m, with the introduction of a PVA-Fe₃O₄@Ag magnetoactive layer into the antenna's structure. The incorporated magnetic nanostructures allow the optimization of the functional features of antennas with possible applications ranging from broadband arrays to portable wireless devices. In parallel, the use of printing technologies and sustainable materials represents a step toward more sustainable electronics.

Antimicrobial potential of known and novel probiotics on in vitro periodontitis biofilms

Several oral diseases are characterized by a shift within the oral microbiome towards a pathogenic, dysbiotic composition. Broad-spectrum antimicrobials are often part of patient care. However, because of the rising antibiotic resistance, alternatives are increasingly desirable. Alternatively, supplying beneficial species through probiotics is increasingly showing favorable results. Unfortunately, these probiotics are rarely evaluated comparatively. In this study, the in vitro effects of three known and three novel Lactobacillus strains, together with four novel Streptococcus salivarius strains were comparatively evaluated for antagonistic effects on proximal agar growth, antimicrobial properties of probiotic supernatant and the probiotic's effects on in vitro periodontal biofilms. Strain-specific effects were observed as differences in efficacy between genera and differences within genera. While some of the Lactobacillus candidates were able to reduce the periodontal pathobiont A. actinomycetemcomitans, the S. salivarius strains were not. However, the S. salivarius strains were more effective against periodontal pathobionts P. intermedia, P. gingivalis, and F. nucleatum. Vexingly, most of the Lactobacillus strains also negatively affected the prevalence of commensal species within the biofilms, while this was lower for S. salivarius strains. Both within lactobacilli and streptococci, some strains showed significantly more inhibition of the pathobionts, indicating the importance of proper strain selection. Additionally, some species showed reductions in non-target species, which can result in unexpected and unexplored effects on the whole microbiome.

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

A Case Report on Metamizole-Induced Agranulocytosis: Is the Benefit Worth the Risk?

Metamizole is a drug with analgesic and antipyretic properties widely available in Portugal. Its use is highly controversial because of the risk of agranulocytosis, a rare but serious adverse event. A 70-year-old female patient with a recent history of treatment with metamizole for post-surgery fever and pain presented to the ED with sustained fever, diarrhea, and painful mouth ulcers. Laboratory tests revealed agranulocytosis. The patient was placed under protective isolation and started treatment with granulocyte-colony stimulating factor (G-CSF) and empiric antibiotic therapy with piperacillin/tazobactam and vancomycin for neutropenic fever. After an extensive workup, no source of infection was identified. During hospitalization, infectious and neoplastic causes of agranulocytosis were investigated, but the results were negative. Metamizole-induced agranulocytosis was suspected. The patient completed a total of three days of G-CSF and eight days of empiric antibiotic therapy with sustained clinical improvement. She was discharged completely asymptomatic and remained clinically stable during follow-up without a resurgence of agranulocytosis. This case report is intended to increase awareness of metamizole-induced agranulocytosis. While this is a well-known side effect, it is also often overlooked. It is paramount that both physicians and patients know how to correctly manage metamizole to prevent and promptly treat agranulocytosis.

Poster No. 044 Cardiovascular risk factors and coronary heart disease in the young – a single centre analysis

Background

Cardiovascular events in the young appear to be increasing. Conversely, this is not the tendency reported in older adults. Identifying risk factors is of the uttermost importance to improve cardiovascular prevention.

Material and methods

Retrospective, single-centre analysis of patients with less than 45 years and suspected coronary heart disease who were subjected to cardiac catheterization in our centre during a 5-year period.

Results and conclusions

A total of 171 patients were included with a median age of 42 ± 6 years of which 82% were male. Overweight (73%), smoking (61%) and dyslipidemia (42%) were the most prevalent cardiovascular risk factors. Coronary heart disease was diagnosed in 67% of patients. After univariate analysis, gender (P = 0.049), age (P = 0.005), smoking (P = 0.032), low-density lipoprotein cholesterol (P = 0.005) and total cholesterol (P = 0.003) were significantly associated with disease in coronary angiography. After multivariate logistic regression, only age (OR = 1.123; CI 95% [1.036–1.217]; P < 0.005) and low-density lipoprotein cholesterol (OR = 1.016; CI 95% [1.004–1.028]; P = 0.009) remained as independent factors of coronary heart disease.

It is known that awareness regarding a healthy lifestyle should be raised in the general population. As several modifiable risk factors have an impact on cardiovascular disease, there is an urgent need to improve primary prevention. Conversely, a more thorough investigation is needed in the cases where no significant coronary disease is found.

According to our analysis, age and low-density lipoprotein cholesterol appear to have a stronger relevance in this young population.

Clinical Case 06—A fatal dance: a case report of a pulmonary embolism with mobile right ventricular thrombus

Presentation

We report a case of a 44-year-old woman with past medical history of dyslipidemia under atorvastatin, overweight and depression, that presented to the emergency department with a 1-month history of dyspnea. On physical examination, blood pressure was within normal range, however she was hypoxemic, needing oxygen via nasal cannula, and tachycardic. Pulmonary auscultation revealed basal crackles. Blood workup showed discrete leukocytosis, increased C-reactive protein, mild hypertransaminasemia and increased troponin and NT-proBNP levels. An EKG revealed sinus tachycardia with 123 beats per minute. A D-shaped left ventricle, an enlarged right ventricle and right heart mobile thrombus were observed in a transthoracic echocardiogram.

Diagnosis

Scoring 2 points on simplified Wells’ Score and with a visible mobile right ventricular thrombus, pulmonary embolism was suspected and further confirmed by computed tomographic pulmonary angiography. Management: In the absence of hemodynamic instability this case fulfils criteria for intermediate-high risk pulmonary embolism. Therefore, anticoagulation with enoxaparin was started under strict electrocardiographic monitoring. Unfortunately, a day later the patient had a sudden cardiac arrest in asystole, with no recuperation after prolonged advanced life support and administration of rescue thrombolysis (alteplase 50mg).

Learning points

Poster No. 045 The role of 24-h Holter monitoring in thrombosis – a single-centre subanalysis in the young

Background

Undercovering the etiology responsible for pathologic states is of the uttermost importance, especially regarding young people. Arterial and venous thromboembolism may have an impact on morbidity and mortality, enhancing the need to prevent recurrences.

Material and methods

Retrospective, single-centre analysis of 24-h Holter monitoring in patients with thrombotic events and less than 40 years during a 5-year period, using IBM® SPSS® software to perform descriptive analysis.

Results and conclusions

Thrombosis was the reason for requesting 24-h Holter monitoring in 7% (n = 41) from a total of 581 exams screened – 68.3% had a stroke, 6% a transient ischemic stroke, 4.9% a pulmonary embolism, 4.9% an intestinal ischemia and 2.4% had both pulmonary embolism and deep vein thrombosis. Patients had a median age of 35 ± 6 years, 63.7% were male and past medical history consisted of cardiovascular risk factors, particularly smoking (36.6%), high blood pressure (19.5%) and dyslipidemia (12.2%).

Merely 4.9% had a diagnostic finding – atrial flutter and second-degree atrioventricular block Mobitz II. On the other hand, autoimmune tests were altered in 12.2% and echocardiogram revealed patent foramen ovale, atrial septum aneurysm and interatrial septum bulging with shunt in 9.8%, 2.4% and 2.4%, respectively. Regarding management, 78% were medicated with aspirin or anticoagulant and 4.9% were submitted to percutaneous closure of patent foramen ovale.

Despite low prevalence of diagnostic findings, Holter monitoring is an important complementary exam that can have therapeutic implications in these cases and, consequently, in preventing new events.

Clinical Case 20—Recurrent intracoronary in-stent restenosis in a young woman

Clinical case

A 39-year-old smoker woman underwent a percutaneous coronary intervention with two Zotarolimus-eluting stents implantation due to right coronary artery occlusion in the context of ST-elevation myocardial infarction (MI). She was medicated with dual antiplatelet therapy and high-intensity statin and stopped smoking.

Nine months later, due to angina symptoms, cardiac catheterization with intravascular ultrasound showed severe restenosis, treated with a drug-coated balloon (DCB).

Two months later, she was admitted due to non-ST elevation MI and the cardiac catheterization presented thrombotic occlusion of previously implanted stents, treated with balloon dilatation. After two months, she remained with angina and a dobutamine stress echocardiogram showed inferior wall ischemia. The angiographic revision revealed proximal in-stent restenosis, treated with DCB.

About a year later, a fifth coronary angiography was performed due to recurrence of angina. Diffuse in-stent restenosis by neo-atherosclerosis was identified by optical coherence tomography. The lesion was treated with a cutting balloon and Everolimus-eluting stent implantation. The cholesterol-lowering treatment was optimized and the patient remained stable for some months. However, she is currently reporting recurrence of angina. Clinical management and guidance await Heart Team discussion.

Learning points

Understanding Loneliness in Older Adults: Reports from Experts by Experience to Reach Digital Solutions

Loneliness is a subjective experience escalating worldwide and affecting older adults. Digital solutions can play a major role in addressing loneliness, although its use has been facing resistance due to scarce involvement of older adults in its design. MOAI LABS is an ongoing European project that adopts a co-design process to develop digital solutions to address loneliness in older adults. This study reports the experience of loneliness shared by a group of eight community-dwelling older Portuguese adults (aged 64 to 86 years old), who are "experts by experience" (who feel alone). Findings were obtained from two co-creation sessions that were audio-recorded, and transcribed. The data analysis was performed involving the research team and the "experts by experience." Three themes emerged: 1) loneliness as a detrimental "state of the soul"; 2) loneliness reinforced by features of the aging process; and 3) loneliness builds more loneliness. MOAI LABS co-design process of digital solutions will embrace these experiences and involve frontline gerontological social workers who have experience with older adults' loneliness.

Glycerol strengthens probiotic effect of Limosilactobacillus reuteri in oral biofilms: a synergistic synbiotic approach

Both in vitro and in vivo studies have shown that the probiotic Limosilactobacillus reuteri can improve oral health. L. reuteri species are known to produce the antimicrobial 'reuterin' from glycerol. In order to further increase its antimicrobial activity, this study evaluated the effect of the combined use of glycerol and Limosilactobacillus reuteri (ATCC PTA 5289) in view of using a synergistic synbiotic over a probiotic. An antagonistic agar growth and a multispecies biofilm model showed that the antimicrobial potential of the probiotic was significantly enhanced against periodontal pathobionts and anaerobic commensals when supplemented with glycerol. Synbiotic biofilms also showed a significant reduction in inflammatory expression of human oral keratinocytes (HOK-18A), but only when the keratinocytes were preincubated with the probiotic. Probiotic preincubation of keratinocytes or probiotic- and synbiotic treatment of biofilms alone were insufficient to significantly reduce inflammatory expression. Overall, this study shows that combining glycerol with the probiotic L. reuteri into a synergistic synbiotic can greatly improve the effectiveness of the latter. One sentence summary: The use of a synbiotic formulation of Limosilactobacillus reuteri with glycerol over the probiotic improves antimicrobial effects and reduced inflammatory response to oral biofilms. This article is protected by copyright. All rights reserved.

Particle Size, Mass Concentration, and Microbiota in Dental Aerosols

Many dental procedures are considered aerosol-generating procedures that may put the dental operator and patients at risk for cross-infection due to contamination from nasal secretions and saliva. This aerosol, depending on the size of the particles, may stay suspended in the air for hours. The primary objective of the study was to characterize the size and concentrations of particles emitted from 7 different dental procedures, as well as estimate the contribution of the nasal and salivary fluids of the patient to the microbiota in the emitted bioaerosol. This cross-sectional study was conducted in an open-concept dental clinic with multiple operators at the same time. Particle size characterization and mass and particle concentrations were done by using 2 direct reading instruments: Dust-Trak DRX (Model 8534) and optical particle sizer (Model 3330). Active bioaerosol sampling was done before and during procedures. Bayesian modeling (SourceTracker2) of long-reads of the 16S ribosomal DNA was used to estimate the contribution of the patients’ nasal and salivary fluids to the bioaerosol. Aerosols in most dental procedures were sub-PM₁ dominant. Orthodontic debonding and denture adjustment consistently demonstrated more particles in the PM₁, PM_2.5, PM₄, and PM₁₀ ranges. The microbiota in bioaerosol samples were significantly different from saliva and nasal samples in both membership and abundance (P < 0.05) but not different from preoperative ambient air samples. A median of 80.15% of operator exposure was attributable to sources other than the patients’ salivary or nasal fluids. Median operator’s exposure from patients’ fluids ranged from 1.45% to 2.75%. Corridor microbiota showed more patients’ nasal bioaerosols than oral bioaerosols. High-volume saliva ejector and saliva ejector were effective in reducing bioaerosol escape. Patient nasal and salivary fluids are minor contributors to the operator’s bioaerosol exposure, which has important implications for COVID-19. Control of bioaerosolization of nasal fluids warrants further investigation.

Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

Recommendations on compiling test datasets for evaluating artificial intelligence solutions in pathology

Artificial intelligence (AI) solutions that automatically extract information from digital histology images have shown great promise for improving pathological diagnosis. Prior to routine use, it is important to evaluate their predictive performance and obtain regulatory approval. This assessment requires appropriate test datasets. However, compiling such datasets is challenging and specific recommendations are missing. A committee of various stakeholders, including commercial AI developers, pathologists, and researchers, discussed key aspects and conducted extensive literature reviews on test datasets in pathology. Here, we summarize the results and derive general recommendations on compiling test datasets. We address several questions: Which and how many images are needed? How to deal with low-prevalence subsets? How can potential bias be detected? How should datasets be reported? What are the regulatory requirements in different countries? The recommendations are intended to help AI developers demonstrate the utility of their products and to help pathologists and regulatory agencies verify reported performance measures. Further research is needed to formulate criteria for sufficiently representative test datasets so that AI solutions can operate with less user intervention and better support diagnostic workflows in the future.

Cadherin‐3 is a novel oncogenic biomarker with prognostic value in glioblastoma

Glioblastoma (GBM) is the most common and malignant primary brain tumor in adults. The prognosis of patients is very poor, with a median overall survival of ~ 15 months after diagnosis. Cadherin‐3 (also known as P‐cadherin), a cell–cell adhesion molecule encoded by the CDH3 gene, is deregulated in several cancer types, but its relevance in GBM is unknown. In this study, we investigated the functional roles, the associated molecular signatures, and the prognostic value of CDH3/P‐cadherin in this highly malignant brain tumor. CDH3/P‐cadherin mRNA and protein levels were evaluated in human glioma samples. Knockdown and overexpression models of P‐cadherin in GBM were used to evaluate its functional role in vitro and in vivo. CDH3‐associated gene signatures were identified by enrichment analyses and correlations. The impact of CDH3 in the survival of GBM patients was assessed in independent cohorts using both univariable and multivariable models. We found that P‐cadherin protein is expressed in a subset of gliomas, with an increased percentage of positive samples in grade IV tumors. Concordantly, CDH3 mRNA levels in glioma samples from The Cancer Genome Atlas (TCGA) database are increased in high‐grade gliomas. P‐cadherin displays oncogenic functions in multiple knockdown and overexpression GBM cell models by affecting cell viability, cell cycle, cell invasion, migration, and neurosphere formation capacity. Genes that were positively correlated with CDH3 are enriched for oncogenic pathways commonly activated in GBM. In vivo, GBM cells expressing high levels of P‐cadherin generate larger subcutaneous tumors and cause shorter survival of mice in an orthotopic intracranial model. Concomitantly, high CDH3 expression is predictive of shorter overall survival of GBM patients in independent cohorts. Together, our results show that CDH3/P‐cadherin expression is associated with aggressiveness features of GBM and poor patient prognosis, suggesting that it may be a novel therapeutic target for this deadly brain tumor.

Non-ST Elevation Myocardial Infarction With Occluded Culprit Artery: A Continuum of Mortality Risk Across the Spectrum of Acute Myocardial Infarction

BACKGROUND

Non-ST segment elevation myocardial infarction (NSTEMI) patients presenting with occluded culprit artery (OCA) may be at higher risk for worse outcomes. We sought to compare in-hospital (IH) mortality between patients presenting with NSTEMI with and without OCA, and ST-segment elevation myocardial infarction (STEMI).

METHODS

This retrospective analysis studied 14,037 patients enrolled in the Portuguese National Registry of Acute Coronary Syndromes. Three groups were defined: (A) STEMI (n = 8616); (B) OCA-NSTEMI (n = 1309); and (C) non-OCA NSTEMI (n = 4112). Baseline characteristics, therapeutic strategies, and outcomes were compared. Multivariate analysis was performed to assess the risk of IH all-cause mortality across the prespecified groups.

RESULTS

Twenty-four percent of NSTEMI patients presented with OCA. The left circumflex artery was more frequently the culprit artery in group B (12.4% A vs 34.5% B vs 26.0% C; P<.001) and this group was also less likely to receive percutaneous revascularization (95.2% A vs 69.7% B vs 83.2% C; P<.001). The incidence of left ventricular systolic dysfunction was higher in group A and lower in group C (19.9% A vs 12.2% B vs 8.1% C; P<.001). The adjusted risk of IH mortality was significantly higher in group A when compared with group B (3.9% A vs 1.8% B; odds ratio, 2.34; 95% confidence interval, 1.34-4.07; P<.01) and in group B when compared with group C (1.8% B vs 0.9% C; odds ratio, 2.25; 95% confidence interval, 1.17-4.35; P=.02).

CONCLUSION

OCA-NSTEMI patients had worse IH outcomes than non-OCA NSTEMI patients and better IH outcomes than STEMI patients, suggesting the existence of a continuum of increased risk of IH mortality across these groups.

Best Practice Recommendations for the Implementation of a Digital Pathology Workflow in the Anatomic Pathology Laboratory by the European Society of Digital and Integrative Pathology (ESDIP)

The interest in implementing digital pathology (DP) workflows to obtain whole slide image (WSI) files for diagnostic purposes has increased in the last few years. The increasing performance of technical components and the Food and Drug Administration (FDA) approval of systems for primary diagnosis led to increased interest in applying DP workflows. However, despite this revolutionary transition, real world data suggest that a fully digital approach to the histological workflow has been implemented in only a minority of pathology laboratories. The objective of this study is to facilitate the implementation of DP workflows in pathology laboratories, helping those involved in this process of transformation to identify: (a) the scope and the boundaries of the DP transformation; (b) how to introduce automation to reduce errors; (c) how to introduce appropriate quality control to guarantee the safety of the process and (d) the hardware and software needed to implement DP systems inside the pathology laboratory. The European Society of Digital and Integrative Pathology (ESDIP) provided consensus-based recommendations developed through discussion among members of the Scientific Committee. The recommendations are thus based on the expertise of the panel members and on the agreement obtained after virtual meetings. Prior to publication, the recommendations were reviewed by members of the ESDIP Board. The recommendations comprehensively cover every step of the implementation of the digital workflow in the anatomic pathology department, emphasizing the importance of interoperability, automation and tracking of the entire process before the introduction of a scanning facility. Compared to the available national and international guidelines, the present document represents a practical, handy reference for the correct implementation of the digital workflow in Europe.

Real-world comparison of different periprocedural antithrombotic strategies for atrial fibrillation catheter ablation

Introduction

Atrial Fibrillation (AF) catheter ablation carries high bleeding and thromboembolic risks, requiring a detailed assessment of overall risk-benefit profile regarding antithrombotic strategy. Vitamin K Anticoagulant (VKA) and Non-Vitamin K Antagonist Oral Anticoagulant (NOAC) have been used in the latest years in this setting, and with different interruption protocols periprocedural. Our goal was to evaluate the rate of acute adverse events (AAE) and compare them according to antithrombotic strategy used periprocedural, in a real-world basis.

Methods

A single-center retrospective study, including adult patients admitted to first AF catheter ablation, from 2004 to 2020. Different antithrombotic strategies (anticoagulation with VKA uninterrupted, anticoagulation with NOAC uninterrupted, no therapy or antiaggregation/interrupted ACO) were compared concerning the rate of any clinically relevant AAE; the composite of major AAE (hemopericardium and stroke/transient ischemic attack [TIA]) and minor AAE associated with vascular access. Descriptive statistics and logistic regression were used to compare groups according to the antithrombotic strategy with an alpha level of 0.05.

Results

Among the 868 patients included (mean age 59±12 yo, 67,5% [n=586] men), pulmonary vein isolation was performed under uninterrupted anticoagulation in 640 (73,7%), of which 595 patients with NOAC (68,5%) and 45 with VKA (5,2%). AF was paroxysmal, persistent and long-standing persistent in 63,4% (n=550), 21,4% (n=185) and 15,4% (n=133) patients, respectively. Mean CHADS-VASc score was 1,86±1,48. Over time there was a shift in the distribution of the type of antithrombotic therapy used, consistent with changes in recommendations (Graph 1).

The composite outcome occurred in 6,8% (n=62), including hemopericardium in 1,8% (n=16), stroke/TIA in 0,7% (n=6) and events related to vascular access in 1,4% (n=13) [Table 1]. No anticoagulation therapy or antiaggregation/interrupted ACO was more associated to the outcome, driven by major AAE, although the difference did not meet statistical significance (p=0,06) [Table 1]. No difference was found between VKA and NOAC group. Additionally, there was no diference in the incidence of hemorrhagic AAE since the implementation of an uninterrupted anticoagulation strategy periprocedural.

Conclusion

In our population of patients submitted to AF catheter ablation, an uninterrupted anticoagulation strategy is associated with lower rate of AAE, either with VKA or NOAC. Our real-world results are reassuring of the benefit of an uninterrupted strategy, and consistent with recent controlled trials.

Funding Acknowledgement

Type of funding sources: None. Antithrombotic therapies over timeClinically relevant acute adverse events

Is there a real difference in approach between women and men with non-ST-segment elevation myocardial infarction? Insights from a multicentre national registry

 

In patients with non-ST-elevation myocardial infarction (NSTEMI), the early invasive strategy has shown benefit in morbidity and mortality, especially in intermediate-to-high risk patients. However, women still seem to have a lower revascularization rate, regardless of the risk.

The aim of this study is to describe our clinical practice reality about the performance of the invasive strategy between genders among NSTEMI patients, in Portugal.

The authors performed a retrospective analysis of patients admitted with NSTEMI included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and February 2021. A propensity score matching included baseline characteristics and previous history was applied. Comparison tests and log-rank test were performed. A p-value less than 0.05 was considered statistically significant.

A total of 11858 patients with NSTEMI were included, of which 71.3% (n=8450) were men. After the propensity score performing, 4458 patients were analysed, 50.0% (n=2229) men. Table 1 shows the most important baseline characteristics.

The authors found a significant delay in hospital admission after the onset of symptoms in women (median of 6 hours and 48 minutes) compared to men (median of 5 hours) (p&lt;0.01). Grace score was higher in males (mean 153 points) than in females (mean 145 points) (p&lt;0.01).

The cardiac catheterization was performed in 82.9% (n=3695) of the patients, with no difference between genders (p-value=0.19), as shown in table 2. Among those who underwent cardiac catheterisation, the presence of significant stenosis and coronary occlusion was greater in males, for almost all localizations. The absence of obstructive coronary lesions was more common in females (p-value&lt;0.01).

During hospitalization, sustained ventricular tachycardia was more prevalent in males (p-value =0.01), with no significant difference for other complications or in-hospital mortality.

A 1-year follow-up of 2351 patients (1184 men and 1163 women) was analysed, with survival of 91.2% (n=1080) in men and 91.0% (n=1056) in women, with no significant difference (p-value=0.80).

In conclusion, we observed that women are admitted to the hospital later than men and have a lower Grace score at admission. However, the standardized analysis of the groups allows us to infer that the invasive strategy does not seem to be less frequent or late in women, as observed in other populations. A more recent analysis, including risk groups, would be interesting to clarify the results.

Funding Acknowledgement

Type of funding sources: None.

Unraveling the hepatoprotective effects of blueberries in a hypercaloric diet-induced rat model of prediabetes by metabolomic and transcriptomic approaches

Background

We previously described protective effects of blueberry juice (BJ) against hepatic steatosis evolution in a hypercaloric diet-induced rat model of prediabetes; however, the underlying mechanisms, are still scarcely explored. Herein, we aim to elucidate the molecular pathways underpinning BJ hepatoprotection on the dysmetabolism evolution in a rat model of prediabetes.

Methods

A rat model of evolutive prediabetes [Male Wistar rats, 8 weeks old] was developed by ingestion of a high-sucrose (HSu, 35%) diet for 9 weeks (W9), supplemented with a high-fat diet (HF, 60%) for further 14 weeks (HSuHF, W23), vs control with standard diet. Half of the animals (n = 10/group) daily received BJ (25g/Kg BW, orally) between W9 and W23. Along with metabolic characterization, BJ effects on serum and hepatic metabolic surrogates were elucidated using a 1H NMR based metabolomic approach. Moreover, the liver expression of genes (RT-PCR) involved in insulin signaling, lipid metabolism, inflammatory response and mitochondrial respiration was also explored. Values are means ± S.E.M (ANOVA followed by post-hoc tests).

Results

HSuHF+BJ rats restored hepatic levels of betaine and tend to recover the depletion of glutathione content found in HSuHF animals’ livers. Moreover, BJ positively affected the hepatic mRNA expression of key enzymes and mediators involved in fatty acid oxidation, insulin signalling, inflammatory response, as well as mitochondrial respiratory chain-related genes, which were all downregulated (P &lt; 0.05) in HSuHF animals’ livers.

Conclusions

Altogether, these molecular findings contribute to explain the mechanisms by which BJ elicits protection against hepatic steatosis and mitochondrial dysfunction induced by hypercaloric diets in the frame of prediabetes evolution.

Variations in heterochromatin content reveal important polymorphisms for studies of genetic improvement in garlic (Allium sativum L.)

Allium sativum L. is an herb of the Alliaceae family with a specific taste and aroma and medicinal and nutraceutical properties that are widely marketed in several countries. Brazil is one of the largest importers of garlic in the world, despite of its production is restricted and limited to internal consumption. Thus, explore the genetic diversity of commercial garlic conserved at germplasm banks is essential to generate additional genetic information about its economically important crop. A suitable tool for this purpose is the cytogenetic characterisation of these accessions. This study aimed to characterise the cytogenetic diversity among seven accessions of garlic from a Germplasm Bank in Brazil. The karyotypes were obtained by conventional staining and with chromomycin A3 (CMA) and 4,6-diamidino-2-phenylindole (DAPI) fluorochromes. All accessions analysed showed chromosome number 2n = 16, karyotype formula 6M+2SM, symmetrical karyotypes, reticulate interphase nuclei, and chromosomes with uniform chromatin condensation from prophase to metaphase. The fluorochromes staining showed differences in the amount and distribution of heterochromatin along the chromosomes and between accessions studied. Based on the distribution pattern of these small polymorphisms, it was possible to separate the seven accessions into three groups. It was also possible to differentiate some of the accessions individually. One of the results obtained showed a heteromorphic distension of the nucleolar organiser region observed on the chromosome pairs 6 or 7 with peculiar characteristics. It was suggested for example, that the heteromorphic block of heterochromatin (CMA+++/DAPI-) on chromosome 6 of the "Branco Mineiro Piauí" accession can be used as a marker to identify this genotype or may be associated with some character of economic interest.

Risk factors for the emergence of multidrug-resistant organisms in liver cirrhosis

BACKGROUND

Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC).

OBJECTIVE

Identify risk factors for the occurrence of MDROs in patients with LC.

PATIENTS AND METHODS

Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant.

RESULTS

MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p=0.0312), antibiotic therapy in the last 90 days (p=0.0033) and discharge within preceding 30 days or current hospitalization above 48h (p=0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p=0.0316).

CONCLUSION

MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it.

Comparing single approaches success in index atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial Fibrillation (AF) ablation can be performed by inducing pulmonary vein electrical isolation. There are two widely used approaches: point-by-point and single-shot.  Catheter AF ablation is effective in restoring and maintaining sinus rhythm. However, efficacy is limited by high rate of AF recurrence, after an initially successful procedure.

Purpose

To evaluate AF index ablation successfulness using single-shot techniques and compare them to conventional one (point-by-point using irrigated- tip ablation catheter).

Methods

We analyzed, from a single center, all patients submitted to an index AF ablation procedure and its successfulness. The last was defined as AF, atrial tachycardia or flutter recurrence (with a duration superior to 30seconds) event- free survival, determined by holter and/or event recorder. These exams were performed after 6 and 12months and then annually, until 5years post procedure were accomplished.

Results

From November 2004 to November 2020, 821patients were submitted to first AF ablation (male patients 67,2%(N = 552), mean age of 59 ± 12years old). Paroxysmal AF(PAF) was present in 62,9%(N = 516), with short-duration persistent AF in 21,8%(N = 179) and long-standing persistent in 15,3%(N = 126). Ablation techniques were irrigated tip catheter point-by-point (PbP)ablation in 266 patients (32,4%) and single-shot (SS)techniques on the remaining 555(67,6%), including PVAC in 294(35,8%),225(27,4%) submitted to cryoablation and 36(4,4%) to nMARQ.

Globally, AF ablation had one-year success rate of 72,5%, and 56,2% at 3 years. A significant difference between AF duration type was found: Arrhythmic recurrence risk was 58% higher in persistent AF(PeAF) (HR 1.58;95%IC 1,22-2,04; p &lt; 0.001). In patients presenting with PAF prior to the procedure, success was significantly higher in those submitted to SS technique(HR:0.69;95%CI 0,47-0,90;p = 0.046), while those with PeAF had similar results.

Conclusion

In this single center analysis almost three-quarters had achieved one-year event-free survival, and more than a half reached long-term freedom from atrial arrhythmia. Patients with paroxysmal atrial fibrillation submitted to single-shot procedure presented with a higher success-rate. Moreover, our study confirmed previous data on the importance of atrial fibrillation classification to postprocedural outcomes. Abstract Figure. Survival Curves

COVID-19 in Gastroenterology Departments: The Impact of the First Wave

Introduction

Coronavirus disease 2019 (COVID-19) is a global pandemic that has severely affected health care systems around the world. During the emergency state declared in Portugal in the months of March and April 2020, there was a severe reduction in medical activity in order to reduce the pressure on health systems. This study aimed to assess the impact of COVID-19 in gastroenterology departments across Portugal and the strategies developed to overcome this challenge.

Methods

This was a cross-sectional study based on an online survey. A detailed questionnaire concerning different aspects of gastroenterology department activity was sent via e-mail to the heads of gastroenterology departments of Portuguese District Hospitals (Núcleo de Gastroenterologia dos Hospitais Distritais). Two periods were assessed, i.e., the emergency state and the recovery period between May and September. The responses were collected between September and October 2020.

Results

A total of 21 hospitals were enrolled (80.8% response rate). Twenty-eight percent of the responders reported healthcare professionals from their unit infected with COVID-19. At least 1 member (mostly fellows) of the department was deployed to another workplace in 66.7% of the hospitals. During the emergency state, 47.6% of the hospitals only performed urgent/emergent endoscopic procedures. In 38.5% of the hospitals the need to ration personal protective equipment led to the suspension of endoscopic training. Regarding the recovery period, nonurgent procedures were restarted in almost all of the centers. The same was reported for the colorectal cancer screening program. Remarkably, 81% of the responders confirmed that they had postponed procedures at patients' request for “fear of getting infected.” Remote consultation was maintained in 81% of the hospitals. Globally, the fellows had resumed their training.

Discussion/Conclusion

This study provides a snapshot of the impact and consequences of the first wave of the COVID-19 pandemic across Portuguese hospitals. It is important to understand how the gastroenterology world dealt with the first impact of COVID-19 and what strategies were implemented in order to better prepare for what might follow.

An outbreak of infective endocarditis during the COVID-19 pandemic? - an observational retrospective single centre study

Funding Acknowledgements

Type of funding sources: None.

Infective endocarditis (IE) is described as an uncommon and challenging infective disease, due to its presentation variability. Its mortality remains high besides the better disease knowledge and therapeutic progress.

The aim of this study was to describe the clinical features and the incidence of IE. Furthermore, we try to identify the risk factors associated with early mortality.

A retrospective study was conducted and all patients diagnosed with definite or possible IE between January 2015 and June 2020, according to the modified Duke criteria, were included. Patient selection and information collection were obtained through medical records. Outcomes were in-hospital and 3 months after discharge mortality.

Group comparisons and multivariate logistic regression analysis were performed. A p-value less than 0.05 is statistically significant.

We analysed 51 patients, which 41 were admitted between 2015 and 2019 with a mean incidence of 8.2 cases per year. In 2020, 10 cases were diagnosed, corresponding to a percentual increase of 143.9%.

Of the 51 patients, 70.6% were male. The mean age was 65 years. Fever was the main presentation feature at admission. We counted 33.3% prosthetic valve endocarditis (PVE) and 5.9% IE device-related. The most common pathogens were Streptococcus gallolyticus (13.7%) and Streptococcus oralis (13.7%). 35 patients (68.6%) had local complications and 26 patients (51%) had systemic complications. One-third of the patients was referenced to surgical treatment. Overall in-hospital mortality was 19.6% and early mortality at 3 months was 27.5%.

In the univariate analysis, early mortality was higher in diabetes mellitus (DM) patients (p < 0.01) and in those who developed sepsis during hospitalization (p = 0.04). In multivariate logistic regression, only DM (OR = 15.8, 95% CI [3.2, 79.0]) was shown to be an independent factor of mortality.

The incidence of IE increased during the first semester of 2020, possibly due to the increased attention given to patients with fever. Diabetes mellitus was found to be the only independent predictor of mortality. More national multicentre studies are needed.

RIGHT VENTRICULAR MYXOMA IN AN ASYMPTOMATIC PATIENT

Myxomas are the most common cardiac tumors; however right ventricular myxomas are very rare. We present the case of an asymptomatic 74 year old female with a right ventricular myxoma originating from the interventricular septum diagnosed during a routine echocardiographic examination. Initially the patient refused surgery due to being asymptomatic, but agreed to be operated two months later. Surgical removal was uneventful, as was the postoperative course. Histopathological analysis confirmed the suspected diagnosis of cardiac myxoma.

Efficacy of a Salt Iodization Program on Iodine Status and Intakes in Schoolchildren of São Miguel Island, Azores, Portugal

INTRODUCTION

Iodine is an essential micronutrient and its deficiency can severely impact children's development. In 2012, the Thyroid Study Group of the Portuguese Society of Endocrinology, Diabetes and Metabolism discovered that the median urinary iodine concentration (mUIC) level in schoolchildren of São Miguel was far too low at 70.9 μg/L. In response, the government implemented a salt iodization program to help normalize levels. This investigation evaluated the efficacy of such an approach.

METHODS

Urinary iodine concentration (UIC) was evaluated in 362 schoolchildren from São Miguel using the fast colorimetric method.

RESULTS

mUIC was 106.7 μg/L, significantly higher than that observed in 2012 (p < 0.001). Over half (55.5%) of the schoolchildren had a UIC >100 μg/L versus 23.0% in 2012 (p < 0.001). 9.4% of schoolchildren had a UIC <50 μg/L, significantly lower than the 30.6% reported in 2012 (p < 0.001).

DISCUSSION/CONCLUSION

Five years after the implementation of the government salt iodization program, the mUIC increased from 70.9 to 106.7 μg/L. This study confirms the efficacy of the adopted measures in schoolchildren population.

The use of flow cytometry for fungal nuclear DNA quantification

Genome size information is sparse across fungi, with information being available for less than 2000 species. So far, most records have been obtained using static, microscope-based cytometry methods or derived from genome sequencing projects. Flow cytometry is now considered the state-of-the-art method for obtaining genome size measurements, and appropriate methods and DNA standards are available, enabling the analysis of most genome size ranges in a rapid, robust and inexpensive way. The average fungal genome size is 60 Mbp, but sizes vary across phylogeny, ranging from 2.2 (Encephalitozoon romaleae) to 3706 Mbp (Jafnea semitosta). In several fungal clades, genome size expansion seems to accompany evolution either to plant mutualism or to plant parasitism (particularly biotrophy), and fungi that interact with plants seem to have larger genomes than saprobes and those that interact with animals. Whereas flow cytometry for nuclear DNA quantification is routinely employed in plant sciences for genome size and ploidy studies, its use in fungal biology is still infrequent. Appropriate standards, methods and best practices are described here, with the aim of stimulating a more generalized and widespread use of flow cytometry for fungal genome size measurement.

Reduced number of Cajal cells in Hirschsprung disease patients' do not relate with postsurgical symptoms

OBJECTIVES: To describe gastrointestinal symptoms and interstitial cells of Cajal (ICC) number in the proximal ganglionated bowel from patients who had surgery for Hirschsprungs disease (HD). METHODS: From 2001 to 2014, 48 children with HD had surgery in a medical school hospital. The files of 24 patients who continue to be followed at this hospital were revised and histological samples corresponding to the proximal ganglionated bowel were selected to ICC count by immunohistochemistry c-Kit. CICs were counted in 10 high-power fields (HPF) and classified into groups, according to Hagger et al. (2000)1: sparse: = 1cell/HPF, few: 2 to 3 cells/HPF, moderate: 4 to 8 cells/HPF and many >8 cells/HPF. RESULTS: Most patients declared symptoms in the postoperative period. The clinical complaints and respective frequencies were: constipation (50%), vomiting (37.5%), retentive fecal incontinence (29.1%), recurrent abdominal pain (25%), abdominal distension (25%), diarrhea (16.6%) and enterocolitis (4.1%). Among symptomatic children, 12 were in the group sparse, 3 in the group few and 4 in the group moderate. There was no difference in ICC count between symptomatic and asymptomatic patients, p=0,721. CONCLUSION: A low number of ICC was found in 80% of the proximal ganglionated intestine from HD patients; this finding was not associated with post-operative complaints and could not be valuable as a predictive indicator of poor post-surgical outcome.

Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease - insights from a nationwide registry

INTRODUCTION AND OBJECTIVES

Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA.

METHODS

The authors analyzed a cohort of patients from a multicenter national registry enrolling patients who suffered their first MI between 2010 and 2017, and underwent coronary angiography revealing absence of stenosis ≥50%. Individual antithrombotic therapy was identified. A logistic regression analysis was applied to search for predictors of DAPT.

RESULTS

From a total of 16 237 patients analyzed, 709 (4.4%) were categorized as MINOCA. Mean age was 64±13 years, 46.3% (n=409) were females. 390 (55.0%) of MINOCA patients were discharged on DAPT. Males (OR 1.67, CI 95 [1.05-2.38], p=0.027), active smokers (OR=1.82, CI 95 [1.05-3.16], p=0.033), previous percutaneous intervention (OR 3.18, CI 95 [1.48-6.81], p=0.003), ST elevation MI (OR 2.70, CI 95 [1.59-4.76], p<0.001) and sinus rhythm at admission (OR=3.94, CI 95 [2.07-7.48], p<0.001) were independent predictors of DAPT use.

CONCLUSION

In this nationwide registry, DAPT was prescribed at discharge in 55% of MINOCA patients. Beyond sinus rhythm, the variables presented as independent predictors for DAPT use identify subgroups of patients who are classified as more prone to thrombotic events. The issue of how to handle antithrombotic agents in MINOCA patients is a topic open for discussion.

BR-BCSC Signature: The Cancer Stem Cell Profile Enriched in Brain Metastases that Predicts a Worse Prognosis in Lymph Node-Positive Breast Cancer

Brain metastases remain an unmet clinical need in breast oncology, being frequently found in HER2-overexpressing and triple-negative carcinomas. These tumors were reported to be highly cancer stem-like cell-enriched, suggesting that brain metastases probably arise by the seeding of cancer cells with stem features. Accordingly, we found that brain-tropic breast cancer cells show increased stem cell activity and tumorigenic capacity in the chick embryo choriallantoic membrane when compared to the parental cell line. These observations were supported by a significant increase in their stem cell frequency and by the enrichment for the breast cancer stem cell (BCSC) phenotype CD44⁺CD24^−/low. Based on this data, the expression of BCSC markers (CD44, CD49f, P-cadherin, EpCAM, and ALDH1) was determined and found to be significantly enriched in breast cancer brain metastases when compared to primary tumors. Therefore, a brain (BR)-BCSC signature was defined (3–5 BCSC markers), which showed to be associated with decreased brain metastases-free and overall survival. Interestingly, this signature significantly predicted a worse prognosis in lymph node-positive patients, acting as an independent prognostic factor. Thus, an enrichment of a BCSC signature was found in brain metastases, which can be used as a new prognostic factor in clinically challenging breast cancer patients.

Intraventricular conduction defects in patients with st-segment elevation myocardial infarction – the paradox of right bundle branch block

 

Intraventricular conduction defects (IVCD) in patients with acute myocardial infarct (AMI) are predictors of a worse prognosis. When acquired they can be the result of an extensive myocardial damage.

Purpose

To assess the impact of IVCD, regardless of being previously known or presumed new, on in-hospital outcomes of patients with AMI with ST segment elevation (STEMI) or undetermined location.

Methods

From a series of patients included in the National Registry of Acute Coronary Syndrome between 10/1/2010 and 9/1/2019, were selected patients with STEMI or undetermined AMI, undergoing coronary angiography.

Results

7805 patients were included: 461 (5.9%) presenting left bundle branch block (LBBB), 374 (4.8%) with right bundle branch block (RBBB) and 6970 (89.3%) with no IVCD. Clinical characteristics as well as in-hospital outcomes are described in the table 1. An unexpected worse prognosis in patients with RBBB has motivated a multivariate analysis. RBBB remained an independent predictor of in-hospital mortality (OR 1.91, 95% CI 1.04–3.50, p=0.038), along with female gender (OR 1.73, 95% CI 1.11–2.68, p=0.015), Killip Class&gt;1 (OR 2.26, 95% CI 1.45–3.53, p&lt;0.001), left ventricular ejection fraction &lt;50% (OR 3.93, 95% CI 2.19–7.05, p&lt;0.001) and left anterior descending artery as the culprit lesion (OR 1.85, 95% CI 1.16–2.91, p=0.009).

Conclusion

In spite of an apparent better clinical profile, in the current large series of unselected STEMI patients, the presence of RBBB is associated with the worst in-hospital outcome. RBBB doubles the risk of death, being an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Prostate cancer with cribriform pattern: Exclusion criterion for active surveillance?

INTRODUCTION

Following the 2014 International Society of Urological Pathology meeting, a rapidly growing body of evidence by several researchers has been demonstrating a poor prognosis in association with cribriform morphology. The aim of our study was to describe the presence of cribriform foci in specimens of radical prostatectomies and to evaluate whether demographic and clinical characteristics are associated with the presence of cribriform pattern.

MATERIALS AND METHODS

This cohort study was based on 70 radical retropubic prostatectomies specimens collected between 2012 and 2016 and evaluated for the association of the cribriform pattern with age, prostate-specific antigen at surgery day, Gleason on biopsy, Gleason after radical prostatectomy, extracapsular extension, vesicles invasion, margins, multiparametric magnetic resonance imaging, and post-operative radiotherapy. Results; From the univariable analysis, biochemical prostatespecific antigen recurrence (p = 0.001), extracapsular extension (p = 0.003), pre-operative prostate-specific antigen (p = 0.017), vesicles invasion, (p = 0.038) and post-operative radiotherapy (p < 0.001) showed an association with the presence of cribriform pattern. There was also a significant difference of cribriform pattern and Gleason 7 in needle biopsy (p = 0.020) and cribriform pattern and Gleason 8 or 9 in radical prostatectomy specimen (p = 0.036).

CONCLUSIONS

In our study, the increase in preoperative prostate-specific antigen had a high association with cribriform pattern. Further evidence is needed to discriminate preoperative prostate specific antigen values that might potentially be associated with the presence of cribriform pattern. Raising our knowledge about the cribriform pattern can be an excellent opportunity to correctly identify and treat patients who will eventually die from prostate cancer, sparing treatment in those who will not.

Estimated Cancer Incidence and Mortality in Europe for the year 2020

Background

Up-to-date cancer burden indicators are essential to support political decision making, to enable epidemiological research and as an information source for citizens. Nevertheless, observed cancer incidence and mortality suffer from an endemic registration delay in the data production workflow. To overcome this, the European Commission's Joint Research Centre in collaboration with the WHO's International Agency for Research on Cancer have computed estimates of cancer incidence and mortality, for the year 2020 and for European countries, in the framework of the European Cancer Information System (ECIS).

Methods

Predicted values for the year 2020 are based on the incidence data of more than 150 European population-based cancer registries included in the ECIS, and on the WHO mortality database. According to previously developed and applied methodology, the estimates of 2020 cancer incidence and mortality rates were produced for 40 European countries, on the basis of the most recent time trends of observed data, where possible. Estimated rates were then applied to the projected 2020 population from EUROSTAT, to calculate the predicted number of new cases and deaths for 2020 in each European country.

Results

The number of new cancer cases and deaths in 2020 has been estimated per country by sex and age group, for 25 major cancer sites. The results are included and disseminated through the ECIS web application (https://ecis.jrc.ec.europa.eu/).

Conclusions

The release of up-to-date cancer incidence and mortality estimates is of crucial importance in supporting evidence-based EU cancer policies. The homogeneity of the estimation methods applied throughout Europe guarantees the comparability of the estimated values between countries. Reliable and comparable estimates enable highlighting differences between countries in cancer incidence and mortality, thus facilitating the identification of possible intervention areas.

Key messages

The EC’s JRC, in collaboration with WHO’s IARC, have computed estimates of cancer incidence and mortality for the year 2020 for European countries, in the framework of the ECIS. The number of new cancer cases and deaths in 2020 has been estimated in 40 European countries for 25 major cancer sites and included in the ECIS web application (https://ecis.jrc.ec.europa.eu/).

Burden of cancer and human exposure to chemicals

Cancer has important impacts on the EU's health systems and economies, with around 3 million new patients diagnosed each year. However, up to 40% of cancers are attributed to preventable causes. For these reasons, cancer is one of the main priorities of the EC in the health domain.

The new Europe's Beating Cancer Plan of the EC, to be launched at the end of 2020, aims to support EU Member States to improve cancer control and care, by proposing actions at every key stage of the disease: prevention (lifestyle, pollution, vaccination), diagnosis, treatment and survivorship. Reliable cancer statistics are essential to propel both epidemiological research and political decision making, and provide the supporting evidence to allow assessment of best practices in all those key stages. To this purpose, the European Cancer Information System (ECIS), built on European population-based cancer registries' data, provides the latest information on indicators that quantify the burden of cancer in Europe. It permits the exploration of geographical patterns and temporal trends of incidence, mortality and survival by granting access to harmonised and validated cancer incidence data.

Population-based cancer registries have been essential in many of the epidemiological studies that led to the identification of several carcinogens in the work place as well as those linked to certain lifestyle habits such as tobacco and alcohol consumption. However, In conditions of low exposure, the identification of cancer hazards has remained largely inconclusive, due to the unavailability of sufficient exposure data and appropriate models that can account for multiple exposures over extended periods.

The linkage between cancer registries data and administrative databases, biobanks, environmental data and extensive lifestyle questionnaires could help identifying or consolidate the available information on emerging carcinogens and populations at risk, thus allowing the development of preventable measures.

Pathological and Epidemiological Characterization of First Outbreak of Daylily Rust in Europe and Evaluation of Puccinia hemerocallidis Resistance in Hemerocallis Cultivars

Daylily rust—caused by Puccinia hemerocallidis—was confined to Eastern Asia until the disease was reported in Oceania, Africa, the Americas and Portugal in the 21st century. Although information on rust resistance of American cultivars is available, little is known about the resistance of European bred cultivars, threating the ornamental sector if the fungus spreads to other European countries. Aiming to provide tools to address this, we analyzed the Portuguese pathogens and characterized rust resistance in a selection of cultivars, while optimizing disease rating scales. Morphologic, genetic and cytogenomic characterization of four isolates reveals narrow diversity and raises the question whether the pathogen may have originated in North- or Central America. Daily records of multiple symptomatologic parameters enabled a detailed disease progress analysis, discriminating cultivars according to their resistance levels and revealing susceptibility as the most common state. Among the tested cultivars, 12 out of 17 began to show symptoms between 6–8 dai and were classified as susceptible. Cultivars ‘Stella d’Oro’, ‘Bitsy’ and ‘Cherry Tiger’ behaved as moderately resistant although the occurrence of late sporulation on leaves suggests incomplete resistance and challenges common rating scales. The identification of resistance sources in European breeding lines is crucial for the sustainable future of daylilies.

Left Ventricular Noncompaction: A Rare Cause of Effort Angina Unveiled During Left Heart Catheterization

Effort angina is an under-appreciated presentation of left ventricular non-compaction that frequently leads to a late diagnosis. Cardiac ventriculography can assist in this diagnosis.

P236 Pinball game over

Introduction

Transthoracic echocardiogram (TTE) is recommended for the diagnosis of acute pulmonary embolism (PTE) only in unstable patients, as it lacks specificity and sensitivity in stable ones. However, the rare documentation of intracavitary thrombus confirms the diagnosis and is associated with right ventricular dysfunction and high mortality, up to 42%.

We report a 69year-old female patient with history of hypertension and obesity, presenting at the emergency department with hypothermia (35º C), cyanosis, tiredness and breathless to minimal efforts. At examination she had no measurable blood pressure, low peripheral perfusion, tachycardia, tachypneia and no other abnormalities. Arterial blood gases on 10L/min facemask showed an uncompensated metabolic acidosis with pCO2 27mmHg, HCO3 12mmol/L, hyperlactacidemia and hypoxemia (pO2 57mmHg). Lab results had leucocytosis and neutrophilia, CRP 30mg/L, serum creatinine 2.53mg/dL, K+ 5.1mmol/L and high sensitivity troponin I 305pg/ml. Chest X-ray showed enlargement of the right chambers with a nodular image next to the right hila.

Although sepsis complicating acute pneumonia was firstly assumed and intravenous antibiotics and fluids were rapidly started; persistent hypoxemia with hypocapnia and tachycardia lead to the suspicion of acute PTE and workup proceeded in that direction. A TTE was primarily done because of the renal injury, showing a dilated right ventricle with flattening of the interventricular septum and a large, long, mobile mass in the right atria, protruding to the right ventricle, consistent with a thrombus. As the patient was no more hemodynamic unstable, prompt anticoagulation with low molecular weight heparin (LMWH) was initiated. Lately performed thoracic angio-CT with no contrast showed mild dilation of pulmonary artery and scintigraphy confirmed extensive perfusion defects of the left lung, preserving only posterobasal segment, with normal ventilation.

Additional study revealed a deep venous thrombosis of left popliteal and right gemelar veins and a heterozygosity for two polymorphisms of methyltethahdrofolate reductase enzyme

C677T and A1298C, clinically relevant in the context of patient’s hyperhomocysteinemia.

The patient recovered initially, with compression stockings and anticoagulation. A follow-up TTE showed no remaining intracavitary mass and no signs of right side overload. In the day after, the patient evolved with sudden refractory hypotension and signs of hypoperfusion with cardiorespiratory collapse and death.

Conclusion

The incidence of intracardiac thrombus in the right chambers in a patient with PTE is low (3-23%) and probably underestimated by the absence of early echocardiography in all patients. This case highlights the lability of the clinical evolution of these patients, even tough disappearance of the right atrium thrombus, which is in line with their high early mortality.

Abstract P236 Figure. Imaging study