Nutritional profile and risk assessment of inorganic elements in enteral and parenteral nutrition formulas

The contents of essential (Ca, Fe, K, Na, P, and Zn) and potentially toxic inorganic elements (As, Al, Cd, Cr, Cu, Mn, and Pb) in enteral and parenteral nutrition formulas were evaluated by inductively coupled plasma optical emission spectrometry (ICP OES) and graphite furnace atomic absorption spectrometry (GFAAS). A total of 30 enteral formulas, 23 parenteral solution components, and 3 parenteral solutions were analyzed. The elements Ca and K presented the higher contents (72-2918 mg L-1 and 235-2760 mg L-1) while the lowest concentration levels were found for As and Cd (<0.68 µg L-1 and <0.01-0.62 µg L-1) in the studied samples. The validated analytical methods presented an accuracy of 75-116% and RSD values lower than 9.8%. Calcium gluconate and magnesium sulfate, which are used as raw materials in parenteral solution, are potential sources of Al and Mn contamination. A Hazard Quotient (HQ) >1 was obtained for Al (27 ± 1 µg L-1) in one of the parenteral samples, whereas the established limit is 25 µg L-1. Enteral samples were considered safe for consumption regarding the Al, As, and Cd levels. One healing-specific and pediatric formula contained Pb at levels above 0.25 µg kg-day-1, too high for safe consumption. The enteral formulas (pediatric, diabetes-specific, renal-specific, healing-specific, and standard formula with addition of fiber) presented risks in relation to the consumption of Cr and Mn (>250 µg day-1 and >11 mg day-1). The results indicate the need for strict monitoring, considering that these formulations are often the single patient's food source.

Bioaccessibility and bioavailability of essential and potentially toxic trace elements in potato cultivars: A comprehensive nutritional evaluation

Among the most consumed foods in the world is potato, which occupies the first place as a non-grain commodity, demonstrating the importance of its assessment concerning the population's food safety. In this study, the nutrients Ca, Mg, K, P, Cu, Mn, Fe, and Zn and the potentially toxic trace elements Cd, Cr, and Pb were evaluated considering their total contents, bioaccessible and bioavailable fractions in different potato cultivars, in an unpublished approach in the literature. The in vitro standard gastrointestinal digestion method (INFOGEST) and a model of the intestinal epithelial barrier using the Caco-2 cell line were applied for investigate the presence of metals in potato. For the macroelements, the bioaccessibility (% w/w) varied in the ranges: K (57-72 %), P (59-76 %), Mg (83-103 %), and Ca (30-123 %), whereas for the microelements were: Cu (27-74 %) and Mn (4.22-12.02, 60-119 %). The potentially of trace toxic elements, Cd and Pb, were found in 75 % of the samples, however, all the concentration values were below the maximum levels allowed of 0.10 µg/g. Chromium was determined only in potato peels and has no maximum established level. The bioaccessible and bioavailable fractions of Cd, Cr, and Pb were below the limits of quantification of the spectrometric methods (LOQ - µg/L: 0.063 Cd, 0.65 Cr, and 0.44 Pb). The potato samples were considered safe for consumption regarding the presence of potentially toxic trace elements, with a remarkable nutritional contribution.

Effects of sunflower oil infusions of Asparagopsis taxiformis on in vitro ruminal methane production and biohydrogenation of polyunsaturated fatty acids

Asparagopsis taxiformis inhibits ruminal methane (CH4) production due to its bromoform (CHBr3) content. The immersion of A. taxiformis in edible vegetable oils allows the extraction and stabilization of the highly volatile CHBr3 in the oil phase. The objectives of this study were to explore the effects of adding sunflower oils with increasing concentrations of CHBr3 on in vitro ruminal methanogenesis and biohydrogenation. Five batches of 48-h in vitro incubations were performed in 14 fermentation bottles, using rumen inocula collected shortly after the slaughter of young crossbred bulls and 1 g of dry matter (DM) from a total diet of mixed feed without added oil (control) or with 60 μL of sunflower oil per gram of DM as the substrate. The treatments were the CHBr3 content in the oil added: 0 μg (B0), 25 μg (B25), 50 μg (B50), 75 μg (B75), 100 μg (B100), and 150 μg (B150) of CHBr3 per gram of substrate DM. Organic matter (OM) degradability, total gas, CH4, volatile fatty acids (VFA), long-chain fatty acids, and dimethyl acetals (DMA) were analyzed at the end of each incubation. Data were analyzed with a model considering the treatments as the fixed effect and the run as a random block and using orthogonal contrasts. Degradability of OM was higher in the control group and was unaffected by CHBr3 concentration. Total gas production per gram of degraded OM was unaffected by treatments and averaged 205 ± 29.8 mL/g. Methane (mL) production decreased linearly with increasing CHBr3 concentrations, with 33%, 47%, and 87% reductions for B75, B100, and B150, respectively. Total VFA concentration was unaffected by oil inclusion but was reduced by 20% in CHBr3-containing treatments, although without any dose-response pattern. The molar percentage of acetate decreased linearly, whereas propionate and butyrate increased linearly with the increasing CHBr3 dosage. Including oil in the diet decreased the branched-chain fatty acids and DMA content. Increasing CHBr3 concentrations did not affect branched-chain fatty acids, but linearly increased most of the identified DMA. Adding oil to the control diet increased the 18:2n-6, whereas increasing the concentration of CHBr3 had no effect on 18:2n-6 but decreased linearly the 18:0 and increased the trans-18:1 isomers. The results obtained provide evidence that oil immersions of A. taxiformis can successfully inhibit ruminal production of CH4 in vitro at doses of 100 and 150 μg/g DM, and simultaneously modulate biohydrogenation.

Wildfire and smoke association with COVID-19 cases in the Pantanal wetland, Brazil

OBJECTIVES

In 2020, Brazil experienced two concurrent public health challenges related to respiratory disease: wildfires and increased mortality due to the coronavirus (COVID-19) pandemic. Smoke from these wildfires contributed to a variety of air pollutants, including fine particulate matter (PM2.5). The present study aims to investigate the effects of environmental and socio-economic factors on COVID-19 hospitalisation in the Pantanal.

STUDY DESIGN

Ecological retrospective study.

METHODS

We applied a multilevel negative binomial model to relate monthly hospitalisation data with environmental variables.

RESULTS

We showed that monthly PM2.5 concentration levels had the greatest influence on the increase in hospitalisations by COVID-19 in the elderly (23 % increase). The Gini index, a coefficient that reflects income inequalities, also had a positive association with COVID-19 hospitalisations (18 % increase). Higher temperatures and humidity were protective factors, showing a 15 % and 14 % decrease in hospitalisations, respectively. The results of the present study suggest that high PM2.5 exposure contributed to the increase in COVID-19 hospitalisations, as did the social inequalities of each municipality.

CONCLUSIONS

The present study highlights the importance of gathering evidence supported by multiple information sources to guide decision-making and identify populations needing better public health systems.

Childhood social adversity and clustering of health risk behaviours during early adolescence in a population-based birth cohort

OBJECTIVES

This study aimed to prospectively explore the association between early lifetime exposure to psychosocial adversity and engagement in health risk behaviours (HRBs) during early adolescence.

STUDY DESIGN

This was a prospective study.

METHODS

This study used data from the baseline (2005-2006), third (2016-2017) and fourth waves (2018-2020) of the Generation XXI birth cohort. Socio-economic circumstances (SECs) at baseline, adverse childhood experiences (ACEs; e.g. abuse, neglect, household dysfunction) at age 10 years and HRBs (i.e. alcohol consumption, smoking, physical exercise level, sedentary behaviours, sleep duration and eating behaviours) at age 13 years were measured. Patterns of HRBs were obtained using latent class analysis. Latent class regression analysis was used to estimate the likelihood of being engaged in HRBs according to the extent of exposure to ACEs (i.e. 0 ACEs, 1-3 ACEs, 4-5 ACEs and ≥6 ACEs) and negative family SECs.

RESULTS

Adolescents whose mothers had a low level of education (adjusted odds ratio [aOR] = 2.72 [95% confidence interval {CI}, 2.33-3.18]), low occupational status (aOR = 3.21 [95% CI, 2.68-3.85]) and low income (aOR = 2.70 [95% CI, 2.23-3.28]) were more likely to be engaged in HRBs than their peers with higher SECs. Adolescents who experienced more ACEs were at a significantly increased risk of involvement in HRBs (aOR = 1.86 [95% CI, 1.33-2.63] for 4-5 ACEs vs aOR 2.41 [95% CI, 1.72-3.43] for ≥6 ACEs). No significant gender differences were observed.

CONCLUSIONS

Adolescents from families with low SECs were more likely than their more affluent counterparts to be engaged in HRBs. Furthermore, more ACEs contributed to widening health inequalities.

The new WHO air quality guidelines for PM2.5: predicament for small/medium cities

The global burden of disease estimated that approximately 7.1 million deaths worldwide were related to air pollution in 2016. However, only a limited number of small- and middle-sized cities have air quality monitoring networks. To date, air quality in terms of particulate matter is still mainly focused on mass concentration, with limited compositional monitoring even in mega cities, despite evidence indicating differential toxicity of particulate matter. As this evidence is far from conclusive, we conducted PM_2.5 bioaccessibility studies of potentially harmful elements in a medium-sized city, Londrina, Brazil. The data was interpreted in terms of source apportionment, the health risk evaluation and the bioaccessibility of inorganic contents in an artificial lysosomal fluid. The daily average concentration of PM_2.5 was below the WHO guideline, however, the chemical health assessment indicated a considerable health risk. The in vitro evaluation showed different potential mobility when compared to previous studies in large-sized cities, those with 1 million inhabitants or more (Curitiba and Manaus). The new WHO guideline for PM_2.5 mass concentration puts additional pressure on cities where air pollution monitoring is limited and/or neglected, because decision making is mainly revenue-driven and not socioeconomic-driven. Given the further emerging evidence that PM chemical composition is as, or even more, important than mass concentration levels, the research reported in the paper could pave the way for the necessary inter- and intra-city collaborations that are needed to address this global health challenge.

Reliability and validity of the Chester step test in patients with interstitial lung disease

BACKGROUND

The Chester Step Test (CST) is a simple and inexpensive field test, which requires minimal physical space to assess exercise capacity. Such characteristics make the CST suitable to be used in different settings, however, its measurement properties in patients with interstitial lung diseases (ILD) are unknown.

METHODS

A cross-sectional study was conducted in patients with ILD. First, a CST-1 and a 6-minute walk test (6MWT) were performed. After 48-72 hours, a CST-2 was repeated. A 2nd rater was present in one of the sessions. Relative reliability was measured using intraclass correlation coefficient (ICC1,1 and ICC2,1). Absolute reliability was determined using standard error of measurement (SEM), minimal detectable change at 95% confidence interval (MDC95) and the Bland-Altman method. The values of SEM and MDC95 were also expressed as a percentage of the mean. Construct validity was explored using Spearman correlation coefficient (rs) between the number of steps taken in the best CST and the distance performed in the 6MWT.

RESULTS

Sixty-six patients with ILD (65.5±12.9 years; 48.5%men; FVC 79.4±18.8pp; DLCO 49.0±18.3pp) participated in the study. Relative (ICC 0.95-1.0) and absolute reliability were excellent without evidence of systematic bias. The SEM and MDC95 were 11.8 (14.7%) and 32.6 steps (40.7%), respectively. The correlation between CST and 6MWT was significant, positive, and high (rs=0.85, p=0.001).

CONCLUSION

The CST is a reliable and valid test and might be especially useful to assess exercise capacity in patients with ILD in limited space environments.

Red and brown seaweeds extracts: A source of biologically active compounds

The biological activities of Porphyra sp., Gracilaria gracilis, Alaria esculenta and Saccharina latissima extracts prepared by enzymatic and ball milling-assisted methods and hot water were evaluated. Enzyme-assisted methods allowed the highest extraction yields. Alcalase-assisted extraction (EAA) was the most effective in the recovery of polyphenolic compounds and Porphyra sp. had the highest content. The efficiency of flavonoids extraction was highly dependent on the used method. Globally, Porphyra sp. and EAA extracts exhibited the highest antioxidant and chelating activities. The highest α-amylase inhibitory activity was determined in HW Porphyra sp. extract while EAA A. esculenta extract had the highest α-glucosidase inhibitory activity. The highest ACE inhibitory activity was obtained in EAA from S. latissima. None of the extracts showed antimicrobial activity against the tested bacteria. The results showed that Porphyra sp. and S. latissima are potentially useful as ingredient in functional foods and nutraceuticals.

PSXIII-12 Characterization of Physiochemical and Nutrient Profiles of Feedstock and co-Products from Canola bio-oil Processing in Ruminants: Impacted by Source Origin

The objective of this study was to characterize physiochemical and nutrient profiles of feedstock and co-products from canola processing that were impacted by source origin to compare feedstocks and co-products (mash and pellet) from five different bio-oil processing plants with five batches of samples in each processing plant in Canada (CA) and in China (CH) collected by the Canola Council of Canada (CCC). The detailed physicochemical and nutrients parameters for ruminants were determined in chemical composition, TDN and truly digestible nutrients, energy profile (ME, NE), and protein and carbohydrate subfractions and their degradation and digestion in dairy cows. The data were analyzed using the Mixed model procedure in SAS 9.4 with RCBD. The treatment differences were compared using Tukey method. The results showed CP was greater in CH meals (P=0.003). The EE was not different between CA and CH (P &gt;0.05). TDN1x was similar in canola meals regardless of the country (P &gt;0.05). CH meals and feedstock had greater tdCP and tdNDF than CA (P&lt; 0.05), while CA had greater tdNFC (P&lt; 0.05). The energy values of ME3x, NELp3x, NEm3x, and NEg3x were similar in canola meals from both countries (P &gt;0.05). No differences were observed in the energy profile of feedstock between CA and CH (P &gt;0.05). The results also showed that pelleting affected the protein fractionation of CA canola meals (P&lt; 0.05). Canola meals were different between CA and CH in the soluble (PA2) and slowly degradable fractions (PB2) (P&lt; 0.05). The carbohydrate fractions of soluble fiber (CB2), digestible fiber (CB3), and indigestible fiber (CC) were different among CH meals (P&lt; 0.05). CH presented greater water-soluble carbohydrate (CA4, P=0.04) and less CB2 (P=0.01) and CC (P&lt; 0.001) than CA canola meals. Although the seeds were similar within and between counties, the oil-extraction process and pelleting seemed to have generated some different aspects on the meals in both countries.

A Case Report of Anorexia Nervosa - the “perfect“ woman

Introduction

Anorexia nervosa (AN) is an eating behavior disorder characterized by intense fear of gaining weight or persistent behavior that interferes with weight gain, with caloric intake restriction and secondary loss of body weight. It can affect up to 4% of women during their lifetime and is responsible for one of the highest mortality rates from psychiatric disorders.

Objectives

Review of the literature and exposure of a case report of AN in a woman with high level of stress at work.

Methods

Case report and nonsystematic review using databases such as PubMed and UpToDate.

Results

Caucasian woman, 31-year-old, PhD in biology, who works in a multinational company. No personal or family history of psychiatric disorder. She was observed in the psychiatry emergency department, due to low weight, caloric restriction and intense physical exercise, maladaptive personality traits related to perfectionism and control were found. She began follow-up with a multidisciplinary team, but there was a need for hospitalization due to clinical deterioration with BMI of 11. After 6 months, she continued to follow up at the consultations and, despite refusing psychotropic drugs, she maintains psychotherapy and presents clinical improvement (BMI - 17).

Conclusions

Eating behavior disorders are chronic and difficult to treat diseases that are more frequent among people subject to high levels of stress. This case represents a restrictive AN in a woman with multiple risk factors: athlete, perfectionist, with stressful work and life events and restricted interpersonal and affective relationships.

Disclosure

No significant relationships.

Evaluation of antimicrobial activity against Enterococcus faecalis of activated chelating agents in different final rinse protocols: An ex vivo study

Background

To evaluate the antimicrobial activity of the following chelating agents against Enterococcus faecalis using quantitative polymerase chain reaction (qPCR) analysis: 1% peracetic acid (PA), 1% peracetic acid with 0.1% cetrimide (PAC), and 17% ethylenediaminetetraacetic acid (EDTA) activated by passive ultrasonic irrigation (PUI) or with Easy Clean (EC), all followed by 2.5% sodium hypochlorite (NaOCl).

Material and Methods

A total of 80 permanent human mandibular premolars were randomly divided into eight experimental groups according to the chemical solution and agitation protocol used: Group PA + PUI; Group PA + EC; Group PAC + PUI; PAC + EC; group EDTA + PUI; EDTA + EC, all followed by 2.5% NaOCl; and two control groups with saline solution(NaCl): NaCl + PUI and NaCl + EC. Microbial samples were collected before (S1) and after the irrigation protocol (S2). Intracanal E. faecalis reduction analysis was performed by qPCR. Intragroup analysis was performed using the Wilcoxon signed-rank test for paired data, and intergroup analysis was performed using the Wilcoxon Mann-Whitney U test for independent samples. The significance level was set at p< 0.05.

Results

A significant difference was found between S1 and S2 in all groups except NaCl+ EC (p = 0.1602). Comparison between groups showed that PAC + PUI was significantly different from PA +EC (p = 0.0448).

Conclusions

The activated chelating agents were effective against E. faecalis, with significant results compared to the control groups. The peracetic acid with cetrimide activated by PUI showed better results than peracetic acid with EC.

Key words:Easy clean, Final irrigation protocols, Passive ultrasonic irrigation, Peracetic acid.

Association between children’s food insecurity and a Healthy Eating Index in Portuguese children

Background

Evidence on the association between children's food insecurity (FI) and a priori-defined dietary patterns is scarce, particularly in Europe. This study assessed the association between children's FI and a diet quality index in a population-based sample of children.

Methods

A cross-sectional study including 2800 children from the 10-year-old follow-up of a Portuguese birth cohort, the Generation XXI study, was performed. Data on food security status, assessed by the Self-administered Food Security Survey Module for Children (SAFSSMC), dietary intake, assessed by a validated FFQ, and socio-demographic characteristics were collected. An adaptation of the Healthy Eating Index (HEI) was used, by including 7 food groups (fruit and vegetables, dairy products, fish and eggs, meat and meat products, sweet snacks, salty snacks and soft drinks) scored from 1 to 4 according to increasing quartiles of daily consumption. For the last 4 groups, a reverse score was assigned. Scores were summed up (the highest the score, the highest diet quality). Linear and logistic regression models (HEI score and its food groups divided by the sample median) were performed.

Results

The FI prevalence was 9.4%. The median (P25;P75) HEI score was 18.0 (15.0;21.0). Children's FI was inversely associated with diet quality (β=-0.671;95%CI:-1.129;-0.213), independently of maternal education, caregivers' unemployment and child's sex. By using the SAFSSMC raw score, FI increased the odds for lower (below the median) fruit and vegetables intake (OR = 1.069;95%CI:1.002-1.139), and higher intake (above the median) of meat and meat products (OR = 1.075;95%CI:1.011-1.144) and soft drinks (OR = 1.074;95%CI:1.008-1.145), independently of maternal education, caregivers' unemployment, child's sex and the other food groups consumption.

Conclusions

Food insecure children have poorer diet quality, specifically a lower fruit and vegetables consumption, and higher intake of meat and meat products, and soft drinks.

Key messages

FI was reported by 9.4% of children, and poorer diet quality was observed among food insecure children, when compared to food secure ones. Public health interventions targeting food insecure children should be developed to promote healthy dietary habits in the context of populations vulnerable to FI.

PSXIII-12 Exploring nutritional differences of canola seeds and bio-processing co-products (meals, pellets) from different processing plants/companies in Canada and China for dairy cattle

Canola was created as a low erucic acid and low glucosinolate seed, to produce high quality oil for human consumption and meal for use in livestock feed. China is an important user of Canadian canola products (seeds, oil, and meal). The extraction of the oil from the seed produces a co-product called canola meal. This meal is rich in protein and is used as a protein source in animal diets. However, differences in the characteristics of the seeds, or processing methods during oil extraction may affect the quality of this co-product. Plus, the synthesis of tissues and milk is related to the amino acids available to the animal for absorption in the small intestine. This study aimed to determine if there are significant differences in the intestinal digestibility (in vitro) of CP and DM between canola seeds and meals from different companies in Canada and to determine if there are significant differences between them in Canada and China. The three-step procedure was applied on residues from a 12-hour rumen incubation in fistulated dairy cows to estimate the intestinal digestibility of CP and DM. There were significant differences (P &lt; 0.05) for TDDM (Total digestible dry matter) and IDP (intestinal digestibility of protein) of the meals between countries. The samples from China had higher TDDM (83.76% versus 81.53%, P = 0.018), while Canada’s had higher IDP (68.51% versus 65.28%, P = 0.016). No significant differences were observed within countries. Based on the material analyzed during this study, it is safe to affirm that there are no significant differences in the digestibility of DM and CP between Canada and China. It was concluded that the quality of the canola seeds or meals produced in both Canada and China were similar when used in dairy rations.

Key words: canola seeds and bio-processing co-products (meals, pellets), nutritional differences, dairy cows

Oxidative and biochemical profile of Gyr dairy heifers during the peripartum period

ABSTRACT O período de transição em vacas leiteiras aumenta o suprimento de oxigênio aos tecidos e a produção de espécies reativas de oxigênio. Junto com o comprometimento do sistema antioxidante, gera estresse oxidativo, que pode estar ligado ao desenvolvimento de diversas doenças. Este estudo teve como objetivo avaliar o estresse oxidativo em 35 novilhas leiteiras Gir, durante o período periparto. Foram analisados ácido úrico, cobre, ferro, zinco, albumina, bilirrubina total, superóxido dismutase (SOD) e glutationa peroxidase (GSH-Px). Um modelo linear com distribuição de Poisson foi aplicado usando o procedimento GENMOD. A primeira medida (30d antes do parto) foi considerada como referência (T0), e as amostras foram coletadas 16 dias antes do parto (T1) e sete (T2), 14 (T3), 28 (T4) e 42 dias pós-parto (T5). Cobre, zinco e albumina variaram dentro da faixa de referência, apesar de ter havido aumento no cobre de 45,92% no T3. Os níveis de ácido úrico aumentaram durante o período de transição, sem diferença significativa até 16 dias pré-parto, quando foi observado aumento de 67,57%, sendo sua maior concentração observada em T4. A SOD teve um aumento maior (300%) do que a GSH-Px (36%) no final do período experimental, acompanhada por adaptações bioquímicas para garantir uma resposta antioxidante eficaz. Dessa forma, pode-se concluir que o período periparto causa estresse oxidativo em novilhas leiteiras Gir.

Morphological Characteristics of the Sperm of the Peregrine Falcon (Falco peregrinus) during the Reproductive Season

The morphological characteristics of different sperm cells (normal, abnormal, and immature) in the peregrine falcon during the reproductive season were analysed. We also classified the main sperm defects found in semen. Semen samples were collected from mature peregrine falcons via cloacal massage and stained with Diff-Quik stain. The percentages of normal, abnormal, and immature sperm cells were determined by bright-field optical microscopy. The number of normal spermatozoa were greater at the initial stage and subsequently decreased during the middle and later stages of the reproductive season (p < 0.01). In contrast, the percentage of abnormal spermatozoa increased significantly in the middle and end stages of the reproductive season (p < 0.05), whereas the proportion of immature spermatozoa remained stable during the study. Head defects represented the greatest proportion of morphological abnormalities, followed by the defects in the tail and midpiece regions. A small percentage of multiple defects and cytoplasmic droplets were also observed in the falcon spermatozoa. The findings of this study might be important for the development of future conservation protocols for falcon sperm.

SOLVENTES EUTÉTICOS NATURAIS PROFUNDOS (NADES) NO PREPARO DE AMOSTRAS DE ROCHA FOSFÁTICA E SUPLEMENTO MINERAL PARA DETERMINAÇÃO ELEMENTAR POR TÉCNICAS DE PLASMA

NATURAL DEEP EUTECTIC SOLVENTS (NADES) IN SAMPLE PREPARATION OF PHOSPHATE ROCK AND MINERAL SUPPLEMENT FOR ELEMENTARY DETERMINATION BY PLASMA-BASED TECHNIQUES. Natural deep eutectic solvents (NADES) based on xylitol, citric acid, and malic acid were synthesized and used in ultrasound-assisted extraction (UAE) and heating-bath extraction of phosphate rock and mineral supplement samples. Arsenic, Ca, Cd, Cr, Cu, Fe, K, Mg, Mn, Na, P and Zn were determined by inductively coupled plasma mass spectrometry (ICP-MS) and inductively coupled plasma optical emission spectrometry (ICP OES). The results showed the NADES as promising solvents for extraction of inorganic matrices compared to reference values and concentrations obtained using microwave-assisted acid digestion (MW-AD). Significant differences were observed for some elements, suggesting different chemical interactions between the synthesized NADES and each monitored element. For analytes extraction of phosphate rock, UAE presented the best results for As, Cr and P. Zinc was extracted with UAE and heating bath. Concerning mineral supplement, no significant differences were observed for Ca (UAE), Cd (UAE and heating bath), K (UAE and heating bath), Mn (UAE and heating bath), Na (UAE and heating bath), and P (UAE and heating bath). The NADES is a greener and a potentially alternative for the sample preparation compared to the official methods of analysis, can being used as selective extractor solvent in conventional sample preparation methods.

Vascular closure devices in TAVI: MANTA versus ProGlide in a propensity-matched population

Background

Vascular complications increase morbidity and mortality in transcatheter aortic valve implantation (TAVI). A collagen plug-based closure device - MANTA® was recently introduced as an alternative to the suture-mediated ProGlide® vascular closure device (VCD). Data regarding the efficacy and safety comparing both VCD is scarce. The present study sought to compare the effectiveness of both devices.

Methods

Single center retrospective analysis on prospectively collected data of 300 consecutive patients who underwent TAVI using MANTA® or ProGlide® since 2018. A 1:1 propensity-score matched population derived by a multivariate logistic regression model based on age, sex, body mass index, pre-procedural haemoglobin, EuroSCORE II, main access calcification and the sheath-to-artery ratio. The primary endpoint was the composite of major or life-threatening bleeding (VARC-2 definition), femoral artery stenosis/dissection, pseudoaneurysm and need for endovascular/surgical bailout intervention.

Results

The propensity score matching resulted in 129 matched pairs. The median age was 84 years old [IQR 80–87], 42% males with a median EuroSCOREII of 4.29% [IQR 3.05–6.24].

There were no differences in the primary endpoint between MANTA ® and ProGlide® cohorts (3.9% vs 7.8%, p=0.287, respectively). The rates of the primary endpoint with the MANTA® device decreased with center experience, with relatively steep learning curve effect concerning device success.

Major or life-threatening bleeding (3.1% vs 5.4%, p=0.540) and pseudoaneurysm (0.8% vs 2.3%, p=0.622) occurred less frequently in MANTA® cohort, but the differences did not reach statistical significance. Endovascular (stent or balloon) or surgical rescue intervention (9.3% vs 5.4%, p=0.341) and femoral artery stenosis/dissection (6.2% vs 3.1%, p=0.376), were also similar rates. In ProGlide® cohort, to achieve VCD success (without primary endpoint events), 15.5% needed more than 2 devices, significantly different from MANTA ® (p&lt;0,001).

Conclusions

In patients undergoing transfemoral TAVI, the MANTA® VCD showed a similar efficacy and safety compared to the ProGlide® device and it reduced significantly the need of additional VCDs for completion of hemostasis. These results were obtained despite a clear learning curve associated with MANTA.

Funding Acknowledgement

Type of funding source: None

Predicting pacemaker implantation after TAVR with procedural CT

Background and aim

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum.

Methods

Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 TM. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography.

Results

Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05–0.42; p&lt;0.001), independently of the device used (p&lt;0.001). MS length showed strong discriminatory ability for PPMI (c-statistic 0.93; 95% CI 0.88–0.99). Sensitivity/specificity decision plots yielded an MS length of 6.9 mm as the optimal cut-off point for predicting the need for PPMI with a positive and negative predictive value of 91% and 93%, respectively (Figure). There wasn't any calcium accumulation within a specific region of AVC that independently predicted the outcome.

Conclusion

In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type.

Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique.

Funding Acknowledgement

Type of funding source: None

Risk stratification in unprotected left main coronary disease: do we have the tools?

Introduction

The evolution of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) techniques made the choice of the optimal revascularization strategy of unprotected left main coronary disease (ULMD) challenging. Scoring systems are useful tools for the decision-making process and for risk stratification.

Purpose

To evaluate 1) the performance of the SYNTAX score I (SSI) and II (SSII) and Euroscore II (EII) in risk stratification and 2) the outcome predictors of patients (pts) with ULMD, according to the treatment strategy chosen (PCI or CABG).

Methods

Retrospective single centre cohort study of 440 consecutive pts (age 68±11 years; 76.6% male) with significant ULMD (defined as left main coronary artery stenosis &gt;50%, with no patent arterial or venous bypass graft to left anterior descending artery), who were submitted to PCI (n=135) or CABG (n=307), between January 2006 and December 2018. Median follow-up (FU) was 4.0±1.8 years.

The primary outcome was a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and target lesion revascularization (TLR).

Results

During the FU period, there were 112 (25.5%) CV deaths, 26 (5,9%) non-fatal MI and 53 (12.0%) TLR.

Multivariate analysis of pts submitted to PCI showed that SSII and anatomical complete revascularization were independent predictors of the primary outcome (HR 1.045, CI 1.015–1.075, p=0.003 and HR 3,014, CI 1.655–5.489, p&lt;0.0001, respectively). The 63 pts submitted to PCI, who had a SSII favoring CABG, had slightly more adverse events (42.9% vs 41.7%, p=0.889).

In the CABG cohort, only SSII was an independent predictor of the outcome by multivariate analysis (HR 1.061, CI 1.035–1.086, p&lt;0.0001).

The ROC curve analysis for all cohort presented no discriminative capacity for SSI (AUC 0.538, CI 0.482–0.593, p=0.186) and a weak discrimination for SSII (AUC 0.659, CI 0.605–0.713, p&lt;0.0001) and EII (AUC 0.653, CI 0.599–0.707, p&lt;0.0001; Figure 1). The difference between SSII and EII was not statistically significant (DeLong test p=0.828). Similar results were found when analysing the CAGB group, however, in PCI cohort, SII and EII showed an acceptable discriminative capacity (AUC 0.722, CI 0.636–0.809, p&lt;0.0001 and AUC 0.700, CI 0.610–0.791, p&lt;0.0001, respectively).

Conclusion

In a real-world ULMD population, the most common risk scores, mainly those integrating anatomical and clinical features, presented a very modest role in the risk stratification, both in chronic and acute coronary syndromes. However, in pts with ULMD submitted to PCI, those risk scores had a more significant role in the risk stratification of these pts.

Figure 1. SSI, SSII, EII ROC curves for all cohort

Funding Acknowledgement

Type of funding source: None

HIV/AIDS: a 30 year history at the Northern Region of Portugal

Since 1981, when the first cases of human immunodeficiency virus (HIV) infection were diagnosed, the need to monitor what emerged shortly afterwards as an epidemic arose. Portugal was not immune, and over the years different measures have been taken to control the national epidemic. The goal of this research is to contribute to the previous knowledge about the trend of HIV infection at the regional level that allows adequate planning focused on controlling the epidemic. This is an observational, descriptive and cross-sectional study, whose data were anonymized at the source, based on the analysis of cases notified by doctors. The data were analyzed using the software Microsoft® Excel version 16.16.4 and IBM® SPSS® Statistics version 25. To check if there is a proven statistical relationship between the variables, the Chi-Square independence test (X2) was used. The results obtained revealed 14512 accumulated cases, in the different stages of infection, 76.7% of which are male, with a higher incidence between 25-29 years of age. Type HIV-1 covers 97.1% of all cases. From 2013 to 2017 it was observed that 74.2% lived in urban areas. Late diagnosis was found in rural areas, particularly in heterosexual transmission. It was concluded that there are several similarities between data at regional and national levels, such as the occurrence of late diagnosis in the category of heterosexual transmission. Regarding legislative changes, no conclusion can be inferred, although hypotheses were raised that can should be discussed in future studies.

Key messages

Late diagnosis in rural areas. Late diagnosis in heterosexual transmission.

Predictive equations of maximum respiratory mouth pressures: A systematic review

BACKGROUND

Maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures are commonly used to detect respiratory muscle weakness resorting to predictive equations established for healthy people. There are several predictive equations, but they are widespread in the literature. This study aimed to review the existent predictive equations of maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures for adults. Additionally, we aimed to identify which ones were generated based on international standards.

METHODS

A systematic review of predictive equations of Pimax and Pemax for healthy adults was conducted. A comprehensive search was performed of Cochrane Library, EBSCO, PubMed, Scopus and Web of Science to identify studies that presented at least one equation for Pimax or Pemax developed for healthy adults. The quality of studies was assessed by two reviewers with the Quality Assessment of Diagnostic Accuracy Studies (Quadas-2).

RESULTS

Risk of bias was high in 8 of the 20 studies included. Forty-two Pimax and 34 Pemax equations were found, mostly using the variables age (n=39), weight (n=20) and height (n=8). These equations explained 3 to 96% of the Pimax/Pemax variance. They were developed with individuals from 11 countries (Portugal not included). Twelve Pimax and eight Pemax equations complied with international standards.

CONCLUSIONS

This review gathered the predictive equations that have been developed for both Pimax and Pemax, however most were generated from unstandardized procedures. Future studies should explore the suitability of these equations for populations for which specific ones are not available, such as the Portuguese population, and develop new equations if necessary.

Atomic Absorption Spectrometry Methods to Access the Metal Solubility of Aerosols in Artificial Lung Fluid

Recent studies to quantify the health risks that fine particulate matter with an aerodynamic less than 2.5 µm (PM_2.5) pose use in vitro approaches. One of these approaches is to incubate PM_2.5 in artificial lysosomal fluid for a given period at body temperature. These body fluids used have a high ionic strength and as such can be challenging samples to analyze with atomic spectroscopy techniques. As PM_2.5 is a primary health hazard because it is tiny enough to penetrate deep into the lungs and could, in addition, dissolve in the lung fluid it is important to quantify elements of toxic and/or carcinogenic concerns, reliably and accurately. Sophisticated instrumentation and expensive pre-treatment of challenging samples are not always available, especially in developing countries. To evaluate the applicability of graphite furnace atomic absorption spectrometry (GFAAS) without Zeeman correction capability to detect trace quantities of heavy metals leached from PM_2.5 on to artificial lung fluid, univariate and multivariate approaches have been used for optimization purposes. The limits of quantification, LOQ, obtained by the optimized method were: 2 µg L^-1 (Cu), 3 µg L^-1 (Cr), 1 µg L^-1 (Mn), and 10 µg L^-1 (Pb). The addition/recovery experiments had a mean accuracy of: (Cu) 99 ± 7%; 110 ± 8% (Cr); 95 ± 9% (Mn), and 96 ± 11% (Pb). The average soluble fractions of PM_2.5 incubated in artificial lysosomal fluid (ALF) for 1 h were: 1.2 ± 0.01 ng m^-3 Cu, 0.4 ± 0.01 ng m^-3 Cr, 0.6 ± 0.01 ng m^-3 Mn, and 4.8 ± 0.03 ng m^-3 Pb. Using historical elemental averages of PM_2.5 in Curitiba (Cu 3.3 ng m^-3, Cr 2.1 ng m^-3, Mn 6.1 ng m^-3, Pb 21 ng m^-3), the percentage bioaccessibility were determined to be Cu 38%, Cr 20%, Mn 10%, and Pb 23%. The elemental values of the atmospheric soluble fraction of Cu, Cr, and Mn were below the inhalation risk concentrations. However, for Pb, the atmospheric soluble fraction exceeded the inhalation unit risk of 0.012 ng m^-3. This robust and straightforward GF AAS method is pivotal for low and middle-income countries were most air pollution adverse effects occur and established lower-cost technologies are likely unavailable.

Fauna flebotomínica e soroprevalência para leishmaniose visceral canina em área urbana na região Centro-Oeste do Brasil

RESUMO A leishmaniose visceral americana (LVA) é uma zoonose de transmissão vetorial na qual o cão tem papel importante na epidemiologia da doença. No Brasil, a elevada prevalência da infecção em cães está diretamente correlacionada com o aumento no risco de ocorrência de casos de LVA. O objetivo deste estudo foi investigar a fauna flebotomínica e verificar a soroprevalência da leishmaniose visceral canina (LVC) na localidade Pedra 90, no município de Cuiabá. Para o levantamento entomológico, armadilhas CDC foram utilizadas de agosto de 2014 a julho de 2015. Na avaliação sorológica dos cães, o teste imunocromatográfico DPP LVC foi utilizado para a triagem das amostras, enquanto o ensaio imunoenzimático (EIE) para o diagnóstico da LVC (Bio-Manguinhos) foi empregado como teste confirmatório. O trabalho vem acrescentar à fauna flebotomínica do município de Cuiabá as espécies Lu. andersoni, Lu. braziliensis, Lu. bourrouli e Lu. scaffi, não registradas em publicações anteriores. Além disso, entre as espécies de flebotomíneos com importância médica, Lu. cruzi, Lu. flaviscutellata e Lu. whitmani foram capturadas. No inquérito canino, a prevalência de LVC observada na localidade Pedra 90 foi de 1,14%, indicando que a região pode ser considerada como área de transmissão.

Confirmatory Factor Analysis of the Postpartum Depression Screening Scale-21 in a Sample of Portuguese Women

Introduction

The postpartum depression screening scale (PDSS; Beck & Gable, 2002) is a widely used measure to assess women's depressive symptoms after their children's birth. Pereira et al. adapted, validated and developed a short-version of PDSS for Portuguese women (PDSS-21).

Objective

To examine the factor structure of the PDSS–21, using confirmatory factor analysis (CFA) in a sample of Portuguese women in the postpartum period.

Methods

The sample was composed of 208 women (mean age = 32.72; SD = 4.49) who completed the PDSS–21 approximately at the 6th week postpartum. CFA was used to test the model suggested by prior exploratory factor analyses of PDSS–21. AMOS software was used.

Results

After two items were deleted and some errors were correlated, CFA indicated a good fit for the second-order factor (χ2/df = 1.793; CFI = 0.957; GFI = 0.889, rmsea = 0.062; P [rmsea ≤ 0.05] < 0.056). The 19–item PDSS showed excellent internal consistency (α = 0.92) and the four dimensions presented Cronbach's alphas ranging between good (α = 0.83) and excellent (α = 0.93).

Conclusions

These findings suggest that the 19–item PDSS obtained through CFA is a reliable and valid measure to assess depressive symptoms among women in the postpartum period.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Enhancing the assessment of cardiorespiratory fitness using field tests

OBJECTIVE

To establish normative values and reference equations of the 6-minute walk test (6MWT), incremental shuttle walk test (ISWT) and unsupported upper limb exercise test (UULEX) for Portuguese adults.

DESIGN

Cross-sectional study. Descriptive statistics and differences between age decades and genders were explored using univariate general linear models to compute reference values. Reference equations were established with a forward stepwise multiple regression.

SETTING

General community.

PARTICIPANTS

In total, 645 adult volunteers without disabilities [43% male, mean age 55.1 (standard deviation 23.6) years] were recruited from the university campus and surrounding community.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Data on age, gender, height, weight, body mass index and smoking status were collected using a structured questionnaire. Physical activity was evaluated using the Brief Physical Activity Assessment Tool. Participants performed two repetitions of the 6MWT, ISWT and UULEX, and the best repetition was used for analysis.

RESULTS

Overall, performance was better in males than in females, and decreased with age. Participants' performance was significantly reduced after the sixth decade of life compared with the other decades (P<0.001). Reference equations were: 6MWT=226.93-(5.00×age)+(360.41×height), R²=71%; ISWT=393.81-(17.98×age)+(185.64×gender)+(775.88×height), R²=83%; and UULEX=16.71-(0.14×age)+(2.66×gender), R²=57%.

CONCLUSION

Leg or arm exercise field tests are affected significantly by age and gender. These results will aid health professionals to interpret the results of field tests obtained from healthy or diseased adult populations.

Trade-off in plant-ant interactions: seasonal variations

This work evaluated the effect of seasonality on ant-plant interaction in a Seasonally Dry Tropical Forests, using as an ecological model the species Ipomoea carnea subs. fistulosa (Convolvulaceae). We performed systematic collection of ants, herbivores and leaves in marked plants, evaluated the efficiency of herbivorous capture by ants, and the effects of ant presence over the pollinator behavior and plant fitness in dry and rainy seasons. The presence of ants in the plants reduced the number of herbivores (dry season: F2.27=4.7617, p=0.0166; rainy season: F2.27=5.8655, p=0.0078). However, the capture efficiency was negatively affected by the presence of myrmecophilous larvae, so that the average of ants recruited on termite leaves was 2.06 ants per termite, the average recruitment of ants on larval leaves was 22.4 larva ants. In addition, the presence of ants reduced pollinator visits and promoted fruit reduction during the dry season (ANOVA: F = 3.44; p = 0.0653). In conclusion, the association with ants can result in a balance not always favorable to the host plant, and this result actually depends on abiotic (e.g. precipitation) and biotic factors (e.g. ant species composition and abundance, influence of other trophic levels and identity of associated herbivores).

P1715 Aortic stenosis with concomitant LVOTO: an alternative treatment to surgery

The dilemma of the patient with both aortic stenosis (AS) and significant left ventricular outflow tract obstruction (LVOTO) is usually managed through conventional surgery. Patients included in TAVI studies are highly selected, and the presence of LVOTO is a common exclusion criteria. Permanent pacing is referred as a possible treatment in medically refractory symptomatic patients with obstructive hypertrophic cardiomyopathy. We report a case of AS and LVOTO that was submitted to transcatheter aortic valve replacement (TAVR) due to high surgical risk, and submitted to a definitive pacemaker implantation after the procedure.

This case is about a female patient with 82 years old and a history of a severe aortic stenosis with a significant ventricular hypertrophy that causes LVOTO. She had a previous history of hypertension, dyslipidemia, osteoporosis and breast cancer. The patient presented with angina (grade II in Canadian Cardiovascular Society Angina Grade), dyspnea and weakness (classe II of New York Heart Association functional classification). Transthoracic Echocardiography (TTE) presented with severe aortic stenosis with a basal septal ventricular hypertrophy of 18 millimeters, a systolic anterior motion of the mitral valve (SAM) both conditioning LVOTO (maximal gradient of 75 mmHg at rest) and moderate mitral regurgitation (MR). Coronariography showed no coronary lesions. Transfemoral TAVR was successfully implanted under general anesthesia and transesophageal echocardiography monitoring (TOE). During ballooning pre-dilatation a complete atrioventricular block developed. Immediately after the valve implantation TOE showed a well-positioned prothesis without intra or peri-prosthetic regurgitation but with an intraventricular gradient (IVG) above 50mmHg and a moderate to severe MR. SAM, IVG and MR were medically managed and the patient went to the intensive cardiac unit (ICU) with a IVG of 50mmHg and a moderate MR. In the next 24H in the ICU, the patient had a clinical deterioration and TTE found an increased intraventricular gradient (140 mmHg) and a severe mitral regurgitation. It was decided to implant a Dual Chamber pacemaker (DDD PM) and adjust beta-blocker and fluid therapy. A progressive clinical improvement was observed and clinical stabilization attained after 48H. At discharge (7 days after TAVR), TTE showed decreased intraventricular gradients (30 mmHg at rest, 50 mmHg with Valsalva maneuver), telesystolic SAM and a moderate mitral regurgitation. At 6 moths follow up, patient was free of cardiovascular events and had no symptoms of heart failure.

This case shows that TAVR is a safe procedure in patients with LVOTO, but we have to be aware of potentially severe hemodynamic consequences of sudden reduce in after load pressure in these patients. In high risk surgical patients, DDD-PM can accomplish acute and at least medium term clinical and hemodynamic stabilization.

Abstract P1715 Figure. Echocardiography images

The influence that different urban development models has on PM2.5 elemental and bioaccessible profiles

Limited studies have reported on in-vitro analysis of PM_2.5 but as far as the authors are aware, bioaccessibility of PM_2.5 in artificial lysosomal fluid (ALF) has not been linked to urban development models before. The Brazilian cities Manaus (Amazon) and Curitiba (South region) have different geographical locations, climates, and urban development strategies. Manaus drives its industrialization using the free trade zone policy and Curitiba adopted a services centered economy driven by sustainability. Therefore, these two cities were used to illustrate the influence that these different models have on PM_2.5in vitro profile. We compared PM_2.5 mass concentrations and the average total elemental and bioaccessible profiles for Cu, Cr, Mn, and Pb. The total average elemental concentrations followed Mn > Pb > Cu > Cr in Manaus and Pb > Mn > Cu > Cr in Curitiba. Mn had the lowest solubility while Cu showed the highest bioaccessibility (100%) and was significantly higher in Curitiba than Manaus. Cr and Pb had higher bioaccessibility in Manaus than Curitiba. Despite similar mass concentrations, the public health risk in Manaus was higher than in Curitiba indicating that the free trade zone had a profound effect on the emission levels and sources of airborne PM. These findings illustrate the importance of adopting sustainable air quality strategies in urban planning.

P2550The influence of tonic-clonic seizures on heart rate variability in patients with refractory epilepsy

Background

Heart Rate Variability (HRV) is an increasing area of interest in patients with epilepsy. The effects of epilepsy on the autonomic control of the heart are not completely understood and that autonomic dysfunction has been implicated in some cases of Sudden Unexpected Death in Epilepsy (SUDEP).

Objective

To study the influence of generalized tonic-clonic seizures (GTCS) on HRV of patients with focal refractory epilepsy.

Method

We prospectively evaluated (January 2015 to July 2018) 121 patients admitted to our institution's Epilepsy Monitoring Unit. All patients performed a 48-hour Holter recording. Patients who had GTCS during the recording were included and we selected the first GTCS as the index seizure. HRV (AVNN, SDNN, RMSSD, pNN50, and LF/HF) was evaluated by analyzing 5-min-ECG epochs during inter-ictal and post-ictal periods: baseline, pre-ictal (5 min before the GTCS seizure), post-ictal (5 min after the seizure), and late post-ictal (>5 hours after the seizure). We compared HRV data from these patients with normative values for a healthy population (controlling age and gender). The study was approved by our Institution Ethics Committee and all patients gave informed consent.

Results

Twenty three patients were included (mean age: 38.61±11.58; 70% Female). Thirty percent presented cardiovascular risk factors without known cardiac disease. We found significant differences between the analyzed periods for all but one (LF/HF) HRV metrics (using Friedman test, p<0.05, two-tailed). Specifically during the post-ictal period, we found a significant reduction for AVNN, SDNN, RMSSD and pNN50 (Wilcoxon test, p<0.05; two-tailed). LF/HF was increased during this period, but changes were not statistically significant. There was also a tendency for a reduction of AVNN, SDNN, RMSSD and pNN50 and an increase of LF/HF in our patients during all the analyzed periods when compared to normative healthy population values.

Conclusion

Our work shows reduced HRV after a GTCS in patients with focal resistant epilepsy, both in inter-ictal and post-ictal periods, when compared to normative healthy population values. These results might reflect long term structural changes in autonomic centers. The HRV changes were significant particularly during the post-ictal period, and should prompt further investigation, giving this period is critical for SUDEP.

P5018Prognosis of pulmonary embolism 30-day mortality risk based on five admission parameters: the PoPE score

Background

Pulmonary embolism (PE) is a serious and potentially fatal form of venous thromboembolism. The Pulmonary Embolism Severity Index (PESI), and its simplified version (sPESI), are widely used for risk stratification and mortality prediction, however, the elevated number of parameters make them difficult to use an apply in everyday practice.

Purpose

To provide a simple and easy-to-perform sensible score based on five clinical and metabolic parameters obtained in arterial blood gas (ABG) at admission: Altered Mental State (AMS), Shock Index (SI), Partial Pressure of Oxygen/Fraction of Inspired Oxygen ratio (PaO2/FiO2), blood pH and arterial lactate concentration (Lac), and to compare its performance to predict 30-day (early) mortality.

Material and methods

In retrospective multicentric observational case-control study, 1037 patients with confirmed PE were admitted in a 24-month period. We evaluated medical charts in order to calculate PESI and sPESI risk scores. Multivariate analysis was performed to identify clinical and ABG independent predictors of all-cause mortality. Discriminative power was accessed by Receiver Operating Characteristic (ROC) curve.

Results

A total of 1037 patients were included in the final analysis. Mean age was 69.5 +16.6 years, 39.5% (n=410) were males. Median length of stay was 11.0 [IQR 7.0–18.0] days. Early mortality was 12.6% (n=131). SI and Lac were significantly higher in patients with early mortality (0.81 [IQR 0.66–1.01] vs 0.68 [IQR 0.57–0.82], and 2.63 [IQR 1.60–4.64] mmol/L vs 1.32 [IQR 1.00–1.90] mmol/L, respectively, p<0.0001 for both). PaO2/FiO2and pH were significantly lower in patients with early mortality (231 +120 vs 303 +103, and 7.39 +0.14 vs 7.43 +0.07, respectively, p<0.0001 for both). There was a significantly higher proportion of patients with altered mental status (Glasgow Coma Scale <15) in patients with early mortality (55.0% vs 18.5%, c2(1)=85.3, p<0.0001). Multivariate analysis is summarized in Table 1. Stratified analysis was based on the approximate cut-off value for the last quartile of SI (0.85) and Lac (2.50 mmol/L) and for the first quartile of PaO2/FiO2 (250) and pH (7.35). Based on the similar beta coefficient values for each variable, we attributed 1 point in the presence of each following conditions: GCS <15, SI >0.85, PaO2/FiO2<250, pH <7.35 and Lac >2.50 mmol/L with a total PoPE scorerange 0–5. The PoPE score yielded a good prognostic performance in predicting in-hospital death using ROC analysis (AUC 0.806, 95% CI 0.767–0.845, p<0.0001). The PoPE score performance was superior when compared with PESI (AUC 0.806 vs 0.695, AUC difference 0.111, p<0.0001) and sPESI (AUC 0.806 vs 0.622, p<0.0001) – Figure 1. A PoPEscore of 1 has a sensitivity of 93% and a specificity of 48% in predicting early all-cause mortality.

Conclusions

The PoPE scoreproves an easy and simple tool with good performance which can predict early eraly 30-day mortality in patients admitted for PE.