Dupilumab in patients with atopic dermatitis: assessing treatment response, clinical features and potential biomarkers in real-life

Summary

Background. The clinical and pathophysiological heterogeneity of atopic dermatitis (AD) endophenotypes is associated with wide diversity in response to therapy. The aim of this study was to evaluate the response to dupilumab in a group of AD patients and identify clinical/immunological features associated with different patterns of response. Methods. A retrospective observational study was performed, including 30 adults with AD who completed 12 months treatment with dupilumab, in a Portuguese Immunoallergology Department. Demographic, clinical, and immunological data were analyzed, including total serum IgE, sensitization to aeroallergens, peripheral eosinophilia and inflammatory biomarkers (sedimentation rate, C-reactive protein and lactate dehydrogenase-LDH). Patients who achieved EASI-75/EASI ≤ 7, SCORAD-75/SCORAD ≤ 24, NRS-pruritus ≤ 4 or DLQI≤5 at 6 months of treatment were considered responders and those that achieved all these goals at 16 weeks were considered super-responders. Results. Clinical evaluation revealed a significant reduction in median SCORAD, EASI, DLQI, NRS-pruritus and NRS-sleep over 12 months on dupilumab (p less than 0.01), in parallel with decrease in serum Th2 pathway biomarkers and LDH. All patients responded to dupilumab, and 26.7% were super-responders, supporting that dupilumab is highly effective in moderate to severe Th2-high AD. Conclusions. In this cohort, none of the evaluated biomarkers at baseline were associated with a better/earlier clinical response to dupilumab. Dupilumab treatment for 52 weeks resulted in a significant and sustained reduction in blood levels of total IgE and allergen-specific IgE to aeroallergens. The potential long-term clinical benefit of these effects, even after discontinuing dupilumab therapy in patients with AD, should be explored to a greater extent.

Early morphological and neurochemical changes of the bed nucleus of stria terminalis (BNST) in gestational protein-restricted male offspring

BACKGROUND

The bed nucleus of the stria terminalis (BNST) is a structure with a peculiar neurochemical composition involved in modulating anxietylike behavior and fear.

AIM

The present study investigated the effects on the BNST neurochemical composition and neuronal structure in critical moments of the postnatal period in gestational protein-restricted male rats' offspring.

METHODS

Dams were maintained during the pregnancy on isocaloric rodent laboratory chow with standard protein content [NP, 17%] or low protein content [LP, 6%]. BNST from male NP and age-matched LP offspring was studied using the isotropic fractionator method, Neuronal 3D reconstruction, dendritic-tree analysis, blotting analysis, and high-performance liquid chromatography.

RESULTS

Serum corticosterone levels were higher in male LP offspring than NP rats in 14-day-old offspring, without any difference in 7-day-old progeny. The BNST total cell number and anterodorsal BNST division volume in LP progeny were significantly reduced on the 14th postnatal day compared with NP offspring. The BNST HPLC analysis from 7 days-old LP revealed increased norepinephrine levels compared to NP progeny. The BNST blot analysis from 7-day-old LP revealed reduced levels of GR and BDNF associated with enhanced CRF1 expression compared to NP offspring. 14-day-old LP offspring showed reduced expression of MR and 5HT1A associated with decreased DOPAC and DOPA turnover levels relative to NP rats. In Conclusion, the BNST cellular and neurochemical changes may represent adaptation during development in response to elevated fetal exposure to maternal corticosteroid levels. In this way, gestational malnutrition alters the BNST content and structure and contributes to already-known behavioral changes.

The genetic landscape of mitochondrial diseases in the next-generation sequencing era: a Portuguese cohort study

Introduction: Rare disorders that are genetically and clinically heterogeneous, such as mitochondrial diseases (MDs), have a challenging diagnosis. Nuclear genes codify most proteins involved in mitochondrial biogenesis, despite all mitochondria having their own DNA. The development of next-generation sequencing (NGS) technologies has revolutionized the understanding of many genes involved in the pathogenesis of MDs. In this new genetic era, using the NGS approach, we aimed to identify the genetic etiology for a suspected MD in a cohort of 450 Portuguese patients. Methods: We examined 450 patients using a combined NGS strategy, starting with the analysis of a targeted mitochondrial panel of 213 nuclear genes, and then proceeding to analyze the whole mitochondrial DNA. Results and Discussion: In this study, we identified disease-related variants in 134 (30%) analyzed patients, 88 with nuclear DNA (nDNA) and 46 with mitochondrial DNA (mtDNA) variants, most of them being pediatric patients (66%), of which 77% were identified in nDNA and 23% in mtDNA. The molecular analysis of this cohort revealed 72 already described pathogenic and 20 novel, probably pathogenic, variants, as well as 62 variants of unknown significance. For this cohort of patients with suspected MDs, the use of a customized gene panel provided a molecular diagnosis in a timely and cost-effective manner. Patients who cannot be diagnosed after this initial approach will be further selected for whole-exome sequencing. Conclusion: As a national laboratory for the study and research of MDs, we demonstrated the power of NGS to achieve a molecular etiology, expanding the mutational spectrum and proposing accurate genetic counseling in this group of heterogeneous diseases without therapeutic options.

[Clinical characteristics and follow-up of 60 patients with recent diagnosis of giant cell arteritis, NEWTON study]

INTRODUCTION

The management of giant cell arteritis (GCA) has evolved with the arrival of tocilizumab (TCZ) and the use of PET/CT. Our objective is to describe the characteristics and followup of patients with recent diagnosis of GCA in current care.

PATIENTS AND METHODS

The NEWTON cohort is a monocentric retrospective cohort based on data collected from 60 GCA patients diagnosed between 2017 and 2022 according to the ACR/EULAR 2022 criteria.

RESULTS

The median age at diagnosis was 73 [68.75; 81] years old. At diagnosis, the main manifestations were unusual temporal headaches in 48 (80 %) and an inflammatory syndrome in 50 (83 %) patients. Temporal artery biopsy confirmed the diagnosis in 49/58 (84 %) patients. Doppler of the temporal arteries found a halo in 12/23 (52 %) patients. The PET/CT found hypermetabolism in 19/43 (44 %) patients. Prednisone was stopped in 17.5 [12.75; 24.25] months. During follow-up, 22 (37 %) patients received TCZ. At least one complication of corticosteroid therapy was observed in 22 (37 %) patients. After a median follow-up of 24 [12; 42] months, 25 (42 %) patients relapsed. At the end of the follow-up, 29 (48.3 %) patients were weaned from corticosteroid therapy and 15 (25 %) were on TCZ.

CONCLUSION

Despite the increasing use of TCZ in the therapeutic arsenal and of the PET/CT in the imaging tools of GCA patients, relapses and complications of corticosteroid therapy remain frequent, observed in more than a third of patients.

Delayed postoperative reactions to metamizole: a diagnostic challenge

Summary

Background. Metamizole, a non-steroidal anti-inflammatory drug from the pyrazolone group, is a frequent cause of immediate hypersensitivity reactions and, more rarely, of delayed drug hypersensitivity reactions. Due to its favorable pharmacokinetic characteristics, metamizole is widely used in the postoperative period for pain control. Methods. Retrospective study of patients referred for allergological study between January 2012 and June2022 for postoperative hypersensitivity reactions. Clinical and diagnostic data were collected through review of patients' medical records. Twenty patients with postoperative hypersensitivity reactions were referred, of which 10 presented delayed reactions. We analyzed the results of skin prick, intradermal and patch tests performed with an intravenous metamizole solution as well as provocation tests performed with metamizole and acetylsalicylic acid. Cross-reactivity to non-steroidal anti-inflammatory drugs was excluded by confirmation of clinical tolerance to non-steroidal anti-inflammatory drugs or by acetylsalicylic acid provocation test. Results. In 7 of the 10 patients a delayed reaction to metamizole was diagnosed. These reactions were characterized as maculopapular exanthema, occurring in multiple postoperative settings. Skin tests were negative, except in one patient with late mild erythema in the ipsilateral upper limb and no reaction at the site of intradermal injection. Delayed hypersensitivity was demonstrated by late positive metamizole provocation tests. Conclusions. This study demonstrated that for a correct diagnosis a high degree of suspicion about possible delayed hypersensitivity drug reactions to metamizole in the postoperative setting is needed. In the investigation, provocation test with metamizole was decisive for diagnostic confirmation.

Modeling Acute Chemoradiotherapy (CRT) Diarrhea Severity Using Automatically Contoured Small Bowel

PURPOSE/OBJECTIVE(S)

Acute severe diarrhea is a common toxicity in rectal cancer patients receiving CRT. A better understanding of the radiation tolerance of the small bowel is needed especially for novel radiation drug combinations. We investigate the dose impact by providing auto-contoured small bowel, using data from the ARISTOTLE phase III trial ISRCTN: 09351447.

MATERIALS/METHODS

A subset of participants (n = 93/564) with locally advanced rectal cancer in the ARISTOTLE trial testing the addition of concurrent irinotecan (n = 48) to neoadjuvant capecitabine (n = 45) CRT (45/25 Gy/fx), in an MRI defined high risk of loco-regional failure. CRT was delivered with conformal techniques. Diarrhea was measured using CTCAE v4.0 weekly. We applied an AI-based auto-contouring model to segment the small bowel on planning CT. The small-bowel DVH parameters were combined with the treatment arm, age, sex and MRI-defined tumor stage in a linear regression (LR) model to predict acute diarrhea severity. Explainable Shapley values (conditional marginalized expectation of a machine learning model per feature) were used to quantify the independent and normalized impact of radiation dose vs Irinotecan on the likelihood of severe diarrhea.

RESULTS

The auto-contouring model accuracy was consistent with clinical practice (mean dice coefficient = 0.739) and clinically acceptable when reviewed by clinicians. The treatment arm, MRI-defined T stage and small-bowel mean dose were found to be independently correlated to the diarrhea severity (p<0.001). V30Gy showed the strongest correlation to diarrhea severity in all the DVH parameters. The LR using the three variables yielded mean AUC scores of 0.898 (95% CI: [0.831,0.958]) on predicting Grade 2 and higher diarrhea, and 0.774 (95% CI: [0.678,0.869]) on predicting Grade 3 diarrhea based on 10-fold cross-validation. Shapley values showed that V30Gy>30.56 cm3 increases the likelihood of more severe diarrhea against the average (grade = 1.03) in the cohort. The impact of irradiation will be larger than the usage of Irinotecan within the patients with V30Gy >160.93 cm3.

CONCLUSION

We accurately modelled acute diarrhea (AUC = 0.90) for rectal cancer patients receiving CRT using AI-contoured small-bowel structures. The treatment arm and small-bowel dose were independently correlated to the diarrhea severity. The explainable model allowed us to quantify the impact of radiation dose, usage of irinotecan, and its combination, with a threshold of V30Gy = 160.93 cm3 yielding an equivalent impact. We will be extending the analysis to the whole trial cohort to improve the statistical power.

Hypersensitivity to Non-Steroidal Anti-Inflammatory Drugs on a pediatric Portuguese cohort

Summary

Background. Non-steroidal anti-inflammatory drugs (NSAID)/analgesics (paracetamol) are among the most common causes of drug hypersensitivity reactions in children, with a reported prevalence of around 0.3% in the pediatric population. Paracetamol and ibuprofen are the most commonly reported culprits in the pediatric population. Our objective was to describe the allergy workup to NSAID/paracetamol of a pediatric population monitored in an allergy outpatient clinic. Methods. Retrospective observational study by consulting the medical records of patients evaluated in a pediatric outpatient clinic with history of NSAID/paracetamol, between January 2016 to August 2022. Results. A total of 43 patients have been evaluated for NSAID/paracetamol suspected allergy: 53.5% females, mean age of 9.8 ± 5.1 years, 47.7% atopic. The drugs reported as culprits were: ibuprofen (75.6%), paracetamol (17.8%), metamizole (4.4%) and naproxen (2.2%) and clinical manifestations were mainly urticaria/angioedema and maculopapular exanthema. Skin tests were performed in 7 patients: paracetamol (n = 5) and metamizole (n = 2), which were all negative. Fourty-six drug provocation tests were performed: 28 with the culprit drug and 18 with an alternative one; only 2 were positive (ibuprofen - culprit NSAID group): one immediate periorbital angioedema and one delayed lip edema with oropharyngeal tightness. Conclusions. The investigation of allergy to NSAID/paracetamol in children remains a challenge. In our population, ibuprofen was the most common NSAID reported. There were only 2 (4.3%) mild reactions on DPT. We could allow the use of the culprit NSAID/analgesic in 11 patients and an alternative one in 9 patients. This study highlights the importance of DPT in children for a correct diagnosis of NSAID hypersensitivity and selection of an alternative drug.

Sources of Sport Satisfaction and Perceived Self-Efficacy Among Youth in a Competitive Environment

Young people's sources of satisfaction in sport are an important indicator of their long-term sport participation. Contextual factors and an individual's internal dispositions act synergistically to determine a positive experience. We studied sources of sport satisfaction and perceived self-efficacy of 1,151 male and female youth athletes (M age = 14.72, SD = 1.56 years) in Brazil who were engaged in school state level competition. The participants responded to questionnaires on their sport satisfaction and perceived self-efficacy. We considered sex, training time, and last game results as independent variables in accessing participant differences in perceived satisfaction. We observed an increasing trend toward more significant satisfaction as sport experience increased. Perceived self-efficacy was a moderator for young participants' self-reported positive experience in sports. Thus, in our offer of evidence on sources of satisfaction in sport and perceived self-efficacy among youth in competition, we found the extent of the sport experience and self-efficacy to be important factors in the developmental pathway.

Hereditary angioedema: 24 years of experience in a Portuguese Reference Center

Summary

Hereditary angioedema (HAE) poses a high burden of disease, being its epidemiological and clinical data heterogeneous among countries, with no recent published studies concerning Portuguese patients. Therefore, we aimed to raise awareness of HAE and to contribute to clinical knowledge. An observational, descriptive, retrospective, and cross-sectional study was performed, that included a cohort of 126 patients followed in a single Portuguese Center. We observed a high prevalence of HAE-C1-INH type II (45.2% of patients). Most HAE patients (67.4%) presented the initial manifestations of the disease before adulthood, at a mean age of 12.6 ± 8.4 years. However, we found a long delay in HAE diagnosis, especially in those without family history (mean 20.7 ± 17.3 years). Stress was the most common trigger, followed by trauma and infection. Symptoms involving different systems were increasingly reported with increased disease duration. Cutaneous symptoms (95.0%) were more frequent, followed by gastrointestinal (80.7%), and respiratory symptoms (50.4%). HAE symptoms led to abdominal surgery in 22 (17.5%) patients and induced laryngeal edema requiring intubation/tracheostomy in 8 (6.3%) patients. Most patients were under long-term prophylaxis, mainly with attenuated androgens (62.7% of patients).The correct distinction between HAE and other common causes of angioedema is critical, allowing reduction of diagnostic delay, improvement of adequate management, and ultimately improving outcomes and quality of life of HAE patients.

Treatment of fruit processing wastewater by electrochemical and activated persulfate processes: Toxicological and energetic evaluation

A fruit processing wastewater was submitted to different advanced oxidation processes, namely, electro-Fenton (EF), electrochemical oxidation (EO), activated persulfate (PS), and combined EF/PS. The performance of the treatment processes, at different experimental conditions, regarding organic load removal, biodegradability increment, toxicity reduction, and specific energy consumption (E_sp), was evaluated. At the experimental conditions studied, EO led to the treated solutions with the highest biodegradability increment, from 0.24 to 0.48, and toxicity reduction towards Daphnia magna, from 5.8 to 1.5 toxic units, without requiring the addition of chemicals. Nevertheless, the highest chemical oxygen demand (COD) removals were obtained for EF and combined EF/PS treatments. For the electrochemical processes, an increase in COD removal rate with applied current density (j) was observed. However, the increase in j substantially raised the E_sp. In PS treatment, COD removals above 80% were only achieved for high amounts of added persulfate and iron, which led to less biodegradable and more toxic solutions. Combined EF/PS attained the lowest E_sp values, mainly due to the conductivity increase originated by the persulfate and iron salts addition. Besides the disadvantage of the chemicals added, this combined treatment led to treated solutions with very acidic pH and significant iron content.

Specialty-related asymmetries in treatment and outcomes of younger patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common arrhythmia and one of the most frequent motives for presentation in the emergency department (ED). However, there are still significant inequalities concerning its treatment.

Purpose

We aimed to assess if management and outcomes of patients with AF differed according to the specialty to which they were referred at hospital discharge.

Methods

We conducted a retrospective single-centre analysis including adult patients admitted to the ED in 2016 with the International Classification of Diseases codes correspondent to AF. Patients older than 75 years and those whose electronic medical file was not accessible were excluded. Patient referral at discharge was not based on any pre-specified criteria but rather performed at the discretion of the physician in the ED.

We divided our sample into 3 groups according to whom the patients were referred at hospital discharge: A) patients referred to an electrophysiologist; B) patients referred to a general cardiologist; and C) those referred to a non-cardiologist (general practitioner or internist).

We assessed patient characteristics, delay to first appointment, treatment strategies as well as stroke and all-cause mortality at 3 years of follow-up.

Results

Of the 372 patients initially screened, 184 were excluded due to age over 75 and 85 patients due to inaccessible medical records, resulting in a final sample of 103 patients with a median age of 65 (58-71) years and median CHA2DS2-VASc of 2 (1-3).

At discharge from the index admission, one third of patients were referred to an electrophysiologist (group A), 41% to a general cardiologist (group B) and the remaining 26% to a non-cardiologist (group C). There were no significant differences in baseline characteristics or type of AF between the groups.

The delay from index hospital admission to the first appointment was superior in groups A and B compared with C (3 and 2 vs 0 months, p=0.050).

Patients referred to an electrophysiologist were more frequently started on a rhythm-control strategy compared with those referred to other physicians (71% vs 38% and 26%, p=0.004). Similarly, significantly more patients in group A underwent catheter ablation (47% vs 12% and 4%, p&lt;0.001), around 2 years after the diagnosis (tendentially earlier than those in group B).

At 3 years follow-up, mortality was higher in group C compared with the other groups (15% vs 0 in group A and 2% in group B, p=0.019). Stroke rates did not differ between groups.

Conclusion

In this group of AF patients, referral to an electrophysiologist at discharge was associated with a higher rate of a rhythm-control strategy, including catheter ablation. In the long-term, those patients showed better survival. These results suggest that, in patients under 75 years, an earlier referral to an electrophysiologist might be beneficial.

SELNET clinical practice guidelines for bone sarcoma

Bone sarcoma are infrequent diseases, representing < 0.2% of all adult neoplasms. A multidisciplinary management within reference centers for sarcoma, with discussion of the diagnostic and therapeutic strategies within an expert multidisciplinary tumour board, is essential for these patients, given its heterogeneity and low frequency. This approach leads to an improvement in patient's outcome, as demonstrated in several studies. The Sarcoma European Latin-American Network (SELNET), aims to improve clinical outcome in sarcoma care, with a special focus in Latin-American countries. These Clinical Practice Guidelines (CPG) have been developed and agreed by a multidisciplinary expert group (including medical and radiation oncologist, surgical oncologist, orthopaedic surgeons, radiologist, pathologist, molecular biologist and representatives of patients advocacy groups) of the SELNET consortium, and are conceived to provide the standard approach to diagnosis, treatment and follow-up of bone sarcoma patients in the Latin-American context.

Abuse among Portuguese older people at a time of economic crisis recovery: findings from the Harmed study

This study aimed to assess the prevalence of abuse against Portuguese older people after an economic crisis and to assess how it has influenced health. A cross-sectional study was carried out including 677 older adults (≥60 years) during 2017. Results show that overall, 23.9% of older people reported being a victim of abuse in the last 12 months. The prevalence of psychological abuse was 19.9%, financial abuse 5.8%, physical abuse 2.5% and sexual abuse 1.9%. Older people who report abuse were more likely to have perceived insufficient income and low social support. The abuse was also significantly associated with poor health status and depressive symptoms. Even in an auspicious period, more than a fifth of older people experiences abuse which is associated with social and health vulnerabilities. These results support that an investment should be made in terms of policies toward an age-friendly environment.

Potential Surrogate Outcomes for Kidney Failure in Advanced CKD: Evaluation of Power and Predictive Ability in CKDopps

Rationale & Objective

Potential surrogate end points for kidney failure have been proposed in chronic kidney disease (CKD); however, they must be evaluated to ensure accurate, powerful, and harmonized research, particularly among patients with advanced CKD. The aim of the current study was to investigate the power and predictive ability of surrogate kidney failure end points in a population with moderate-to-advanced CKD.

Study Design

Analysis of longitudinal data of a large multinational CKD observational study (Chronic Kidney Disease Outcomes and Practice Patterns Study).

Setting & Participants

CKD stage 3-5 patients from Brazil, France, Germany, and the United States.

Outcomes

Reaching an estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m² or eGFR decline of ≥40%, and composite end points of these individual end points.

Analytical Approach

Each end point was used as a time-varying indicator in the Cox model to predict the time to kidney replacement therapy (KRT; dialysis or transplant) and was compared by the number of events and prediction accuracy.

Results

8,211 patients had a median baseline eGFR of 27 mL/min/1.73 m² (interquartile range, 21-36 mL/min/1.73 m²) and 1,448 KRT events over a median follow-up of 2.7 years (interquartile range, 1.2-3.0 years). Among CKD stage 4 patients, the eGFR < 15 mL/min/1.73 m² end point had higher prognostic ability than 40% eGFR decline, but the end points were similar for CKD stage 3 patients. The combination of eGFR < 15 mL/min/1.73 m² and 40% eGFR decline had the highest prognostic ability for predicting KRT, regardless of the CKD stage. Including KRT in the composite can increase the number of events and, therefore, the power.

Limitations

Variable visit frequency resulted in variable eGFR measurement frequency.

Conclusions

The composite end point can be useful for CKD progression studies among patients with advanced CKD. Harmonized use of this approach has the potential to accelerate the translation of new discoveries to clinical practice by identifying risk factors and treatments for kidney failure.

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

Background

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

Purpose

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

Methods

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

Results

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

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

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None. Table 1

Predictors of patient and system delay for primary percutaneous coronary intervention

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

North African dust intrusions and increased risk of respiratory diseases in Southern Portugal

The study of dust intrusions in Portugal is still a subject on which little investigation has been made, especially in terms of their effects. Thus, this work aims to achieve two goals: firstly, to characterize the dust intrusions in the study area; and secondly, to evaluate the possible statistical association between the dust intrusion days and hospital admissions due to respiratory diseases. Dust intrusions in Portugal are prevalent during the summer season. During this season, the dust plumes tend to cover broader areas than in the other seasons and they have origin in the North African countries. In the study area for the period between 2005 and 2015, the relative risk of urgent hospitalizations due to respiratory diseases was 12.6% higher during dust intrusion days. In order to obtain this statistical association, a Distributed Lag Nonlinear Model was developed. With this work, we expect to help the development of further studies regarding North African dust intrusions in Portugal, more precisely their effects on human health.

A New Predictive Equation for Estimating Body Weight in Cirrhotic Patients With Refractory Ascites

Objectives

This study aims to develop a new prediction equation to estimate the dry weight (DW) of patients with refractory cirrhotic ascites since there is a lack of evidence to substantiate the current values used to adjust the wet weight in these patients.

Methods

Cross-sectional study, that included patients with decompensated cirrhosis undergoing large-volume paracentesis. Height (H) was measured and weight, immediately before and after paracentesis. For the prediction of DW, a linear regression model was performed using as predictor variables: gender, H, and pre-paracentesis weight (preW), as response variable: post-paracentesis weight (postW). Three-way interaction was used to test the joint effect of these predictors. The capacity of this model to predict the postW was evaluated by comparing it with the currently used predictions through the intraclass correlation coefficient (ICC) and the mean square error (MSE).

Results

Twenty patients were included, 16 were male. Moderate ascites was the most prevalent grade (n = 18). The mean (range) of ascitic fluid drained was 6.6 (0.45 – 16.0) L, and the difference of Wpre and Wpost was −6.8 (−0.7 – −15.7) kg. The prediction equation developed for estimating DW in male is: DW = −11.4 + 1.2 * Wpre + 0.125 * H −0.002 * Wpre * H, and in female: DW = −40.6 + 1.2 * Wpre + 0.331 * H −0.030 * Wpre * H. ICC values showed that all predictions measures were strongly correlated (r &gt; 0.95). In comparison with current predictions, our model showed the highest ICC (r = 0.97) and the lowest MSE ( = 7.70), comparing with the current predictions (MSE = 18.63, when the preW is adjusted from absolute values and MSE = 12.75 when adjusted from percentage values), indicating more accurate prediction.

Conclusions

This new prediction equation showed high reliability as a weight adjustment tool for patients with refractory cirrhotic ascites. Further research is required to validate this prediction equation.

Funding Sources

Fundo de Incentivo à Pesquisa e Eventos (FIPE) from Hospital de Clínicas de Porto Alegre and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) from Ministry of Education of Brazil.

MO490SYMPTOM BURDEN AND ITS IMPACT ON QUALITY OF LIFE IN PATIENTS WITH MODERATE TO ADVANCED CKD

Background and Aims

It is generally considered that the early stages of CKD are asymptomatic, and that CKD becomes apparent once kidney function is significantly impaired, but large-scale studies in real-world non-dialysis CKD patients under nephrology care are still scarce. We evaluated symptom burden and its impact on quality of life in patients with moderate to advanced CKD.

Method

4423 patients with CKD Stage 3 to 5 from Brazil (N=548), France (N=2691), and the US (N=1184) enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013-2019 completed the Kidney Disease Quality of Life (KDQOL) questionnaire at baseline to assess how much they were bothered by 13 symptoms. Response options ranged from “not at all” to “extremely” bothered. From these Symptoms/Problems of Kidney Disease items, a score was calculated, ranged from 0 to 100, and analyzed in 3 categories: low (≥90), intermediate (66-90), or high symptom burden (&lt;66). Poisson regressions were used to estimate prevalence ratios for each symptom and to study associations between CKD stage and a high symptom burden before and after adjusting for demographics and major comorbidities. Multiple linear regression accounting for clustering at the clinic level was used to examine associations between high symptom burden and physical and mental component summary (PCS and MCS, respectively) scores, with lower scores indicating poorer quality of life.

Results

Patients (mean age 68±13 years, 40% women, mean eGFR at baseline 30.4±12.2 mL/min/1.73m²) were very much to extremely bothered by a number of symptoms, the prevalence of three of which - washed out or drained, nausea or upset stomach, and lack of appetite – significantly increased in more advanced CKD stages before and after adjusting for confounders (Figure). Nearly one in four patients reported a high symptom burden, which was more prevalent in women, those with obesity, anemia, or albumin&lt;3.5 g/dL; it was also more common in France than in the US and Brazil. In adjusted models, as compared to patients with low symptom burden, those with high symptom burden had a worse quality of life with PCS and MCS scores 14.6 (95% confidence interval [95% CI], 15.7 to 13.5) and 7.2 (95% CI, 8.3 to 6.1) points lower, respectively.

Conclusion

Our findings demonstrate a high symptom burden even in nondialysis CKD stages 3-5 with a substantial impact on physical and mental health-related quality of life. Several symptoms, particularly fatigue, and gastrointestinal symptoms, appeared to worsen with increasing CKD stage, independent of patient comorbidities.

MO495UNDERSTANDING INTERNATIONAL VARIATION IN KIDNEY FAILURE INCIDENCE: IMPACT OF DISPARITIES IN RAAS INHIBITOR PRESCRIPTION AND BLOOD PRESSURE CONTROL

Background and Aims

Blood pressure (BP) control and renin-angiotensin-aldosterone system (RAAS) blockade are key measures to slow CKD progression, and the achievement of targets for these measures vary greatly across countries. We sought to evaluate to what extend this might explain international variations in kidney failure incidence.

Method

We used data from the CKD Outcomes and Practice Patterns Study (CKDopps), a cohort study of adult patients recruited from national samples of nephrology clinics. Patients with CKD G3 or G4, from Brazil (n=498), France (n=2702), Germany (n=2314), and the US (n=905) were included. Those neither with hypertension nor with albuminuria were excluded (n=103). We assessed systolic BP and RAAS inhibitor prescription at baseline, and their association with time to kidney failure, defined as an estimated glomerular filtration rate (eGFR) &lt; 15 ml/min/1.73m² or kidney replacement therapy initiation. Death was treated as a competing event. Cox proportional-hazards model was used to estimate cause-specific hazard ratios (cs-HR) and 95% confidence intervals (CI) for kidney failure according to country, before and after adjusting for systolic BP and RAAS inhibitor prescription, as well as demographics, and known risk factors for CKD progression.

Results

Median age (years) ranged from 67 in Brazil to 75 in Germany; and mean baseline eGFR (ml/min/1.73m²), from 27 in Germany to 33 in France. Prevalence of diabetes ranged from 20% in France to 36% in Brazil, and that of stage A3 albuminuria (&gt;300 mg/g), from 31% in Brazil to 44% in the US. Mean systolic BP (mm Hg) ranged from 132 in Brazil to 143 in France, and the percentage of patients prescribed RAAS inhibitor, from 58% in the US to 81% in Germany. After median follow-up of 4.0 (2.6-5.0) years, 1897 participants progressed to kidney failure and 522 died before meeting this outcome. Two-year crude cumulative incidence of kidney failure was the lowest in France (14%), where patients were recruited at an earlier CKD stage, and similar across Germany (25%), the US (26%), and Brazil (27%); that for all-cause death, the lowest in Brazil (2.5%), followed by France (3.4%), the US (4.4%), and Germany (4.6%). Sequential adjustment for demographics and progression risk factors, in particular baseline eGFR and albuminuria, significantly reduced the gap between France and the other countries (Figure). Despite the associations of systolic BP (cs-HR 1.14, 95%CI 0.95-1.38 for 120-129; 1.18, 95%CI 0.95-1.46 for 130-139; and 1.46, 95%CI 1.23-1.74 for ≥140 versus &lt;120 mm Hg) and RAAS inhibitor prescription (cs-HR 0.81, 95%CI 0.70-0.95 at 6 months of follow-up) with kidney failure, adjustment for these two treatment targets only marginally changed comparisons across studied countries.

Conclusion

In CKD patients under nephrology care, BP control and RAAS inhibitor prescription were associated with lower risk of kidney failure and substantially varied across countries. Despite this variation in practice, BP control and RAAS inhibitor prescription appear to explain little of the differences in risk of kidney failure by country.

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Purpose

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

Methods

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

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

Results

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

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

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

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

Conclusion

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

Assessment of wavefront propagation speed on the right ventricular outflow tract: deceleration zones associated with the presence of low voltage areas

Funding Acknowledgements

Type of funding sources: None.

Background and aims

Activation wavefront is rapid and uniform in normal myocardium. Fibrosis is associated with deceleration zones (DZ) and late activated zones. The presence of low voltage areas (LVAs) in the right ventricular outflow tract (RVOT) of patients with premature ventricular contractions (PVCs) from this origin has been described previously. The aim of this study was to evaluate in sinus rhythm, the RVOT endocardial activation duration (EAD) and the presence of DZs, in patients with PVCs and in controls.

Methods

Consecutive patients with frequent (&gt;10.000/24 h) idiopathic PVCs with inferior axis subjected to ablation that had an activation and voltage map of the RVOT performed in sinus rhythm. A control group of patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. Patients with structural heart disease, previous ablation or conduction disease were excluded. The RVOT EAD was measured as the time interval between the earliest and the latest activated region. Also evaluated the number of 10 ms isochrones throughout the RVOT and the maximal number of 10 ms isochrones within 1 cm, and a DZ was defined as a zone with &gt; 3 isochrones within 1 cm. Low voltage areas (LVA) were defined as areas with local electrogram amplitude &lt;1.5 mV.

Results

42 patients, 29 in the PVC group and 13 control subjects. The site of origin of the PVCs was the RVOT in 23 patients and the LVOT in 6. The characteristics of the two groups are displayed in the Table. Patients with PVCS had longer RVOT EAD, total number of isochrones and presence of DZ was also significantly higher (See table).  LVAs were more frequent in PVCs from the RVOT than from the LVOT (83% vs 33%, p = 0.033). Patients with LVA had longer EAD 60 (52-67) vs 36 (34-40) ms, p &lt; 0.0001 (Figure A) and more DZ than patients without LVA 95% vs 0%, p &lt; 0.0001 (Figure B and C).

Conclusions

The velocity of the wavefront propagation was slower and DZs were more frequently present in patients with PVCs and were associated with presence of LVAs. All sampleN= 42PVCsN = 29ControlsN = 13p-valueAge in years, median (Q1-Q3)56 (35-65)58 (38-66)53 (28-67)0.648Male gender, n (%)19 (45)14 (48)5 (39)0.401Nº points in the map, median (Q1-Q3)410 (338-589)467 (345-660)345 (333-465)0.056Activation duration in ms, median (Q1-Q3)41.8 (36-61)56 (41-66)39 (35-41)0.001Nº isochrones, median (Q1-Q3)4 (4-6)5 (4-6)4 (4-4)0.037Presence of DZs, n (%)20 (48)20 (69)0 (0)&lt;0.0001Presence of LVAs, n(%)21 (50)21 (72)0 (0)&lt;0.0001Abstract Figure.

An insight on psychiatric insight

Introduction

Insight is a complex and multidimensional phenomenon. Metacognition, awareness of illness or anosognosia are some of the terms used to designate this feature of the mental state exam.

Objectives

To attempt to explore the evolution of the concept of insight as a psychiatric symptom over the years and to bring up some up-to-date features on this theme.

Methods

Literature review, using the most relevant papers, with the keywords “psychiatric insight”, “awareness of illness”, “metacognition” and “phenomenology”.

Results

The term ‘insight’ has been described since 1896 when Kraepelin had noticed that patients with dementia praecox were unaware of their condition. Nowadays, it is recognized in several psychiatric disorders, with different meanings in each one. Overall, insight in psychiatry involves an attempt to see one’s thinking and behaviour ‘objectively’ and comparing it to some representation of mental health. Impaired insight has been linked to poor treatment compliance and outcomes, overall symptom severity, higher relapse, lower self-esteem, and impaired psychosocial functioning. White matter and connectivity problems may be related to poorer insight, as well as impaired frontal lobe functioning. In psychotic disorders, lack of insight is a primary symptom with poorer outcomes. Regarding affective disorders, the lower the mood the better the insight. Neuroimaging has been correlating insight with the inferior frontal gyrus, anterior insula, inferior parietal lobule, and ventromedial prefrontal cortex. In everyday practice, there are scales used to assess insight.

Conclusions

Inferences about patients’ insight are important to evaluate severity of illness, suicidal risk, compliance, and response to treatment.

The universe of brief psychosis

Introduction

Nowadays, ‘Acute and transient psychotic disorders’ in ICD-10 and ‘Brief psychotic disorders’ in DSM-5 are both classifications of the same clinical entity. Over the years, several concepts have been formulated to define the same syndrome.

Objectives

To explore the historical evolution of brief psychotic disorders and relate them to current nosologies.

Methods

Literature review, using the most relevant papers, with the keywords “brief psychosis”, “bouffée délirante”, “cycloid psychosis”, “psychogenic psychosis”, “atypical psychosis” and “holodysphrenia”.

Results

Initially, in 1896, Kahlbaum coined the term ‘dysphrenia’, a group of severe form of psychosis that remitted without showing the typical sequence of disease states and without leaving a lasting alteration. Later, Kraepelin included this kind of disorder in manic depressive illness, which he first named as ‘periodic delirium’ and then as ‘delirious mania’. Magnan, in the pre-Kraepelinian era, created the term ‘bouffée délirante’, a sudden onset of delusional ideas with rapid evolution and intense symptomatology with complete remission usually followed after a short time. Later on, Henry Ey grabbed this entity and renewed it, contrasting it to the defined concept of schizophrenia. Other psychiatric schools have proposed numerous designations: ‘cycloid psychosis’ by Kleist from the German school, ‘psychogenic psychosis’ by Wimmer of the Scandinavian school and ‘holodysphrenias’ by Barahona-Fernandes from the Portuguese school. Cultural variants are also observed, as ‘amok’ seen in Malaysia or ‘shinbyung’ in Korea.

Conclusions

The intensity and polymorphism of brief psychosis present a clinical challenge. The historical evolution may be helpful on recognizing this entity in current clinical practice.

Subcutaneous immunotherapy with aeroallergens - Safety profile assessment

Summary

Introduction. Severe systemic reactions (SR) to allergen subcutaneous immunotherapy (SCIT) are rare but local reactions (LR) are common. We aimed to characterize the type of reactions and safety profile. Methods. Retrospective analysis of medical record from patients under SCIT between 2013-2016. Results. Total of 7372 SCIT injections in 323 patients: 52% female; mean age 30 years (SD 13); mean treatment time 19 months (SD 13). There were 57 patients (17.6% of population, 70% female) with at least one adverse reaction, for 93 reactions described (1.3% injections). There were 79 LR (1.1% injections) in 46(14.2%) patients: 36 in build-up, 43 in maintenance. There were 14 SR (0.19% injections) in 12(3.7%) patients: 12 in build-up, 2 in maintenance. All SR were grade 1. The majority of reactions were caused by mite SCIT (69.9%). Conclusions. SCIT is safe and well tolerated, with no report of SR grade > 1.

Impact of compliance to chemoradiation on long-term outcomes in squamous cell carcinoma of the anus: results of a post hoc analysis from the randomised phase III ACT II trial

BACKGROUND

Concurrent chemoradiation is standard-of-care for patients with squamous cell carcinoma of the anus. Poor compliance to chemotherapy, radiotherapy treatment interruptions and unplanned breaks may impact adversely on long-term outcomes.

METHODS

The ACT II trial recruited 940 patients with localised squamous cell carcinoma of the anus, and assigned patients to mitomycin (week 1) or cisplatin (weeks 1 and 5), with fluorouracil (weeks 1 and 5) and radiotherapy (50.4 Gy in 28 fractions over 38 days). This post hoc analysis examined the association between baseline factors (age, gender, site, T stage and N stage), and compliance to treatment (radiotherapy and chemotherapy), and their effects on locoregional failure-free survival, progression-free survival (PFS) and overall survival (OS). Compliance was categorised into groups. Radiotherapy: six groups according to total dose and overall treatment time (OTT). Chemotherapy: three groups (A = per-protocol; B = dose reduction or delay; C = omitted).

RESULTS

A total of 931/940 patients were assessable for radiotherapy and 936 for chemotherapy compliance. Baseline glomerular filtration rate <60 ml/min and cisplatin were significantly associated with poor week 5 compliance to chemotherapy (P = 0.003 and 0.02, respectively). Omission of week 5 chemotherapy was associated with significantly worse locoregional failure-free survival [hazard ratio (HR) 2.53 (1.33-4.82) P = 0.005]. Dose reductions/delays or omission of week 5 chemotherapy were associated with significantly worse PFS {HR: 1.56 [95% confidence interval (CI): 1.18-2.06], P = 0.002 and HR: 2.39 (95% CI: 1.44-3.98), P = 0.001, respectively} and OS [HR: 1.92 (95% CI: 1.41-2.63), P < 0.001 and HR: 2.88 (95% CI: 1.63-5.08), P < 0.001, respectively]. Receiving the target radiotherapy dose in >42 days is associated with worse PFS and OS [HR: 1.72 (95% CI: 1.17-2.54), P =0.006].

CONCLUSION

Poor compliance to chemotherapy and radiotherapy were associated with worse locoregional failure-free survival, PFS and OS. Treatment interruptions should be minimised, and OTT and total dose maintained.

CLINICAL TRIAL NUMBER

ISRCTN 26715889.

Monitoring psychoactive substance use at six European festivals through wastewater and pooled urine analysis

The consumption of psychoactive substances is considered a growing problem in many communities. Moreover, new psychoactive substances (NPS) designed as (legal) substitutes to traditional illicit drugs are relatively easily available to the public through e-commerce and retail shops, but there is little knowledge regarding the extent and actual use of these substances. This study aims to gain new and complementary information on NPS and traditional illicit drug use at six music festivals across Europe by investigating wastewater and pooled urine. Samples were collected, between 2015 and 2018, at six music festivals across Europe with approximately 465.000 attendees. Wastewater samples were also collected during a period not coinciding with festivals. A wide-scope screening for 197 NPS, six illicit drugs and known metabolites was applied using different chromatography-mass spectrometric strategies. Several illicit drugs and in total 21 different NPS, mainly synthetic cathinones, phenethylamines and tryptamines, were identified in the samples. Ketamine and the traditional illicit drugs, such as amphetamine-type stimulants, cannabis and cocaine were most abundant and/or frequently detected in the samples collected, suggesting a higher use compared to NPS. The analyses of urine and wastewater is quick and a high number of attendees may be monitored anonymously by analysing only a few samples which allows identifying the local profiles of use of different drugs within a wide panel of psychoactive substances. This approach contributes to the development of an efficient surveillance system which can provide timely insight in the trends of NPS and illicit drugs use.

235Anatomic guided ablation of the right ganglionated plexus is enough for cardiac autonomic denervation in patients with significant bradyarrhythmias

Background

In patients with significant bradyarrhytmias, cardiac denervation is an alternative therapeutic approach. Previous reports proposed different methods (as high frequency ednocardial stimulation of ganglionated plexus and specific atrial electrogram identification) and targets (right and left atrial ganglionated plexus) for adequate denervation. There is no consensus on the best way to perform these procedures, in spite the right atrial ganglia plexus (GP) ablation seeming to be the most contributive to its success.

Purpose

To assess the results of a purely anatomic approach for ablation of just the right atrial plexus in patients with severe vagal bradyarrhytmias.

Methods

We enrolled patients referred for ablation of cardiac parasympathetic ganglia, with or without atrial fibrillation ablation.  We performed eletroanatomic mapping of the right and left atria and used an irrigated tip catheter for ablation, aiming at the anterior right GP at the right pulmonary veins antrum along with ablation at the superior vena cava junction and the inferior right GP at the posterior aspect of the right inferior pulmonary vein along with ablation of the right aspect of the interatrial septum, between the posterior wall and coronary sinus ostium (Figure 1). We assessed the PW and Wenckenback cycle lengths (CL) pre and post procedure in patients with sinus arrest or AV block, respectively, and the patients had new 24h holter readings at least 30 days from the index procedure.

Results

We enrolled 12 patients: 9 males (75%), median age of 49,5 years (IQR 36-61,75). All patients had structurally normal hearts. 7 patients had only ablation of the parasympathetic ganglia and 5 patients had simultaneous pulmonary vein isolation for previously documented atrial fibrillation. 7 patients (58,3%) had sinus bradycardia (2 patients had sinus arrest with pauses of 8 and 13 seconds), 2 patients with cardioinhibitory syncope (with pauses of 23 and 28 seconds) and 3 patients had transient high degree AV block. The ablation procedure led to a median sinus rate acceleration of 15 bpm (IQR 3-29), a median decrease of 320 ms in PW (IQR 23,75-609,5) in patients with sinus arrest and a decrease of 80 ms in wenckenback CL (IQR 60-200) in patients with AV block. With a median follow up of 133,50 days (IQR 36-61,75), no patient had recurrence of symptoms or conduction disturbances.

Conclusions

In selected patients with severe functional paroxysmal bradyarrhytmias, cardiac denervation using an ablation strategy purely based on anatomic aspects and targeting only the right GP, seems to be an effective therapeutic approach.

Abstract Figure 1: Abl of right ganglionated plex

AB0062 CHARACTERIZATION OF IL-12 AND IL-23 REDUCTION BY TOFACITINIB IN MDCS

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory auto-immune disease characterized by an excessive production of pathogenic mediators that cause inflammation of the skin, peripheral joints, entheses and the spine. Among these, interleukin (IL)-23, IL-12, the IL-17 family and TNF constitute key players in PsA pathogenesis.1,2IL-23, consisting of IL23A (IL-23p19) and IL12B (IL-12p40) subunits, is predominantly produced by myeloid dendritic cells (mDCs). While the p19 subunit is unique to IL-23, the p40 subunit is shared with IL-12. Together, IL-12 and IL-23 play a crucial role in promoting the differentiation of naïve T lymphocytes into T helper (Th) interferon (IFN)-γ-producing Th1 or IL17-producing Th17 cells, respectively.3

Small-molecule inhibitors, such as the JAK/STAT inhibitor Tofacitinib, have recently shown promising therapeutic potential in PsA clinical trials.4The inhibition of JAKs by Tofacitinib results in the direct suppression of multiple intracellular signaling pathways which constitute key hubs in the cytokine network.5However, whether Tofacitinib is able directly target IL-12/IL-23 production by mDCs has not yet been documented. Suppression of these canonical inflammatory pathways would provide further evidence that Tofacitinib is an effective drug in halting both innate and adaptive immune responses.

Objectives:

To evaluate the transcriptional and molecular events underlining IL-12 and IL-23 regulation by Tofacitinib in mDCs.

Methods:

Peripheral blood mononuclear cells from healthy donors were isolated by Ficoll gradient. Monocytes and myeloid dendritic cells (mDCs) were isolated by using magnetic beads on autoMACS. Monocytes were cultured for 6 days in the presence of IL-4 and granulocyte-macrophage colony-stimulating factor (GM-CSF) to generate monocyte-derived dendritic cells (moDCs). MoDCs were harvested, washed and put to rest for 1 day prior to stimulation, while mDCs were stimulated on the same day of isolation. Both moDCs and mDCs were pre-treated with Tofacitinib and then stimulated with either lipopolysaccharide (LPS) or combination of LPS with IFN-γ for 4 hours. Cytokines were measured using enzyme-linked immunosorbent assay (ELISA) and gene expression was assessed using quantitative polymerase chain reaction (qPCR).

Results:

Treatment of both mDCs and moDCs with Tofacitinib led to a decreased mRNA expression of IL-12 p40 (IL12B) in the presence of TLR4 and IFNγ co-stimulation. The decreasedIL12BmRNA expression also resulted in lower production of IL-12 p40 and IL-23 proteins in mDCs.

Conclusion:

In this work, we demonstrated for the first time that Tofacitinib can suppress the production of IL-23/IL-12 p40 subunit in mDCs, upon the condition that an active type II IFN signalling is also present in these cells. This observation indicates that specific factors, such as endogenous IFN-γ levels in the serum of PsA patients, can possibly predict differential responses to Tofacitinib treatment.

References:

[1]Gaffen SL. et al. The IL-23-IL-17 immune axis: from mechanisms to therapeutic testing. Nat Rev Immunol. 2014 Sep;14(9):585-600

[2]Bravo A, Kavanaugh A. Bedside to bench: defining the immunopathogenesis of psoriatic arthritis. Nat Rev Rheumatol. 2019 Nov;15(11):645-656

[3]Floss DM. et al. Insights into IL-23 biology: From structure to function. Cytokine Growth Factor Rev. 2015 Oct;26(5):569-78

[4]Berekmeri A. et al. Tofacitinib for the treatment of psoriasis and psoriatic arthritis. Expert Rev Clin Immunol. 2018 Sep;14(9):719-730

[5]T Virtanen A. et al. Selective JAKinibs: Prospects in Inflammatory and Autoimmune Diseases. BioDrugs. 2019 Feb;33(1):15-32

Disclosure of Interests:

None declared

AB0561 AUTOMATIC QUANTIFICATION OF INTERSTITIAL LUNG DISEASE FROM CHEST COMPUTED TOMOGRAPHY IN SYSTEMIC SCLERODERMA

Background:

Scleroderma-associated interstitial lung disease (SSc-ILD) is often observed in patients with systemic scleroderma (SSc) and its diagnosis contributes to early treatment decisions1,2.

Objectives:

The present study aims to automatically quantify SSc-ILD from high-resolution chest-computed tomography (HRCT) and to evaluate the association between interstitial lung disease (ILD) extension and lung function impairment.

Methods:

Ninety-four patients with SSc and 27 lung-healthy subjects matched for gender, weight, height, and age underwent HRCT, spirometry and carbon monoxide diffusion capacity (DLCO). SSc-ILD was determined as the tissue mass present between -500 and +100 Hounsfield Units normalized by the total lung tissue mass (TLM). Cut off was the highest value obtained in the control group (25% of TLM). All data are presented as mean and standard deviations (Table I). An ANOVA test followed by Bonferroni post-hoc correction was used for comparisons among groups.

Results:

From 94 patients with SSc, 64 were classified as having pulmonary involvement (SSc-ILD) and 30 as not having pulmonary involvement (SSc No-ILD). In SSc-ILD subjects, there was a significant reduction in forced vital capacity (FVC), carbon monoxide diffusion capacity (DLCO) and carbon monoxide diffusion capacity normalized by alveolar ventilation (DLCO/A) when compared with SSc No-ILD and control group.

Conclusion:

The proposed method allows the automatic quantification of SSc-ILD from HRCT and ILD extent is associated with pulmonary function impairment.

References:

[1]Doyle TJ, Dellaripa PF. Lung Manifestations in the Rheumatic Diseases. CHEST. 2017 Dec;152(6):1283–95.

[2]Saketkoo LA, Magnus JH, Doyle MK. The primary care physician in the early diagnosis of systemic sclerosis: the cornerstone of recognition and hope. The American Journal of the Medical Sciences. 2014 Jan;347(1):54–63.

Table 1.

Demographic variables, pulmonary function tests and densitovolumetry considering scleroderma patients with less or greater pulmonary involvement.

Control GroupN = 27SSc No-ILDN = 30SSc-ILDN = 64p-valueDemographic DataFemales16 (59.2)28 (93.3)58 (90.1)-Age (years)37.9 ± 14.851.2 ± 12.256 ± 14<0.011a,bBMI (kg/m2)26.7 ± 5.124.1 ± 5.025.9 ± 5.7-Lung Function FVC (% predicted)100.2 ± 9.299.9 ± 19.869.8 ± 16.7<0.001b,c DLco (% predicted)103 ± 13.383.8 ± 14.263.4 ± 20.3<0.002a,b,cDLco/A (% predicted)112.7 ± 17.485.7 ± 12.979.2 ± 20.6<0.001a,bDensitovolumetryTLV mL4675 ± 9864471 ± 9163492 ± 1120<0.001b,cLung Tissue Mass (g)793 ± 125756 ± 159731 ± 155- ILD Extent (% LTM)17 ± 222.9 ± 1.232.6 ± 8<0.003a,b,c

a: Statistically significant difference between No-ILD SSc and control group; b and c: Statistically significant difference between SSc-ILD vs control group and SSc No-ILD, respectively.

Disclosure of Interests:

None declared

Dispersal mode constrains allocation of carbon and mineral nutrients in seeds of forest and savanna trees

Species vary in seed size and content of stored reserves, which can be related to dispersal strategies and type of habitat in which they are found. We compare seed carbon and nutrient reserves of anemochorous and zoochorous trees from the Cerrado of central Brazil. We measured seed dry mass, lipids, non-structural carbohydrates (starch and total soluble sugars), carbon and mineral nutrients in ten forest and 13 savanna species, each classified as having wind- or animal-dispersed seeds. We used phylogenetically independent contrasts to test for correlations among these traits. Seeds of anemochorous species were lighter, with higher concentrations of C, N, P, Ca and Mg. Lipids were the dominant carbon reserve for most anemochorous species, underpinning the importance of allocation to compact carbon reserves. Starch, lipids or soluble sugars were the major carbon reserve in zoochorous seeds. Savanna and forest species did not differ in seed mass or in total carbon reserves. However, seeds of forest species had higher concentrations of starch than seeds of savanna species. Lipid and starch negatively correlated across species, suggesting a trade-off between starch and lipids as major seed carbon reserves. Calcium was positively correlated with Mn and B, while Mg was positively correlated with C, N, P, K, S, Zn and B. Potassium, S and Cl were positively correlated, while P was positively correlated with Mg and Zn. Dispersal mode rather than vegetation type constrained seed mass and seed storage allocation patterns in forest and savanna trees. We provide evidence that similar mechanisms are involved in seed storage of carbon and mineral nutrients across species.

Atopic Dermatitis Host and Environment Model: Revisiting Therapeutic Options

Summary

Atopic Dermatitis affects both children and adults and is a serious health concern in many countries. AD is a complex disease with host and environmental factors underlying its pathology. Its treatment is multidimensional reflecting the diverse nature of its triggers and includes emollients, topical steroids and calcineurin inhibitors among others. Immunological dysfunction can be addressed broadly with systemic immunosupressors and specifically with monoclonal antibodies. Dupilumab, which targets IL-4 and IL-13 was granted approval for treatment of moderate-to-severe AD. Biologics targeting IgE/Th2 pathways may have its role in patients with overlapping AD and asthma. Psychological distress can exacerbate symptoms and is associated with increased severity of AD. Environmental triggers, such as, allergens can be addressed in selected cases with allergic immunotherapy. In this paper, we discuss AD treatment and propose a new step-by-step approach aiming at maintaining disease control and improving quality of life.

Subcutaneous immunotherapy with aeroallergens Evaluation of adherence in real life

Summary

Introduction. Adherence in allergen immunotherapy is crucial for its efficacy. At least 3 years of treatment are recommended for achieving a long-term modifying effect. Objectives. To assess patient's adherence and to identify determinant factors for allergen subcutaneous immunotherapy (SCIT) suspension in patients with respiratory allergy. Methods. Retrospective analysis of the medical record of patients submitted to SCIT between January 2013 and December 2016 in our Department. Results. 323 patients were included: 52% female; mean age 30±13 years; average treatment time 19±13 months. 52 patients (16%) stopped SCIT: 54% female; mean age 30±9 years; average treatment time 12±6 months; 67% dropped the treatment during the 1st year, 27% in the 2nd and 6% during the 3rd year of treatment. Adherence rate determined was 77%. The most frequent reasons for withdrawal were due to economic reasons (47.9%), followed by patients' perception of no clinical improvement (23%) and change to sublingual immunotherapy (11.6%). Conclusion. Adherence rate in our study was 77%. Economic reasons were the main cause of abandonment in the first year, while the perception of non improvement was the main reason for abandonment in subsequent years. Adequate information on SCIT prescribing and rigorous monitoring of patients during the treatment can improve adherence.

Prevalence of gonorrhea and chlamydia in a community clinic for Men who Have Sex with Men in Portugal

Background

Men who have sex with men (MSM) are at greater risk for sexually transmitted infections (STIs). Data on MSM chlamydia and gonorrhea prevalence estimates and associated risk factors is scarce. To our knowledge, this is the first study to describe the prevalence and the determinants of both chlamydia and gonorrhea infections in MSM in Portugal.

Methods

We conducted a cross-sectional study using data from 1,832 visits to CheckpointLX, a community-based center for screening blood-borne viruses and other STIs in MSM.

Results

Overall prevalence of chlamydia or gonorrhea in our sample was 16.05%, with 14.23% coinfection and 40.73% asymptomatic presentation among those testing positive. Anorectal infection was most common for chlamydia (67.26%), followed by urethral (24.78%) and oral (19.47%) infection. Oral infection was most common for gonorrhea (55.63%), followed by anal (51.25%) and urethral (17.50%) infection. In multivariate analyses, young age (U = 94684, p = 0.014), being foreign-born (χ2=11.724, p = 0.003), reporting STI symptoms (χ2=5.316, p = 0.021), inhaled drug use (χ2=4.278, p = 0.039) and having a higher number of concurrent (χ2=18.769, p &lt; 0.001) or total (χ2=5.988, p = 0.050) sexual partners were each associated with higher rates of chlamydia or gonorrhea infection.

Conclusions

Young and migrant MSM are a vulnerable population to STIs, as are those who use inhaled drugs and those with a higher number of concurrent or total sexual partners. Although Portugal has no guidelines on chlamydia and gonorrhea screening, our results point towards a need for greater awareness about the importance of high frequency screening for those at increased risk (i.e. every 3 to 6 months).

Key messages

Higher prevalence was found in young and migrant MSM, those with higher number of concurrent or total sexual partners, and those who use inhaled drugs. There is a need for greater awareness about the importance of high frequency STI screening for MSM at increased risk.

P6560Delayed ablation of atrioventricular nodal reentry tachycardia as a risk factor for future atrial fibrillation

Introduction

Atrioventricular nodal reentry tachycardia (AVNRT) is the most common type of supraventricular tachycardia. Most of the patients experience recurrent symptoms for years before electrocardiographic documentation and AVNRT ablation. The effects of these ongoing episodes of AVNRT on atrial structure and function, and their influence on new-onset atrial fibrillation (AF) in patients with delayed AVNRT ablation are unknown.

Purpose

To assess if delayed ablation of AVNRT was associated with the development of AF.

Methods

We retrospectively evaluated patients subjected to AVNRT ablation between 2009 and 2016. Patients with history of AF previous to ablation were excluded. We evaluated age at the time of AVNRT ablation, the presence of cardiovascular risk factors, left atrial (LA) dilatation and the presence of frequent premature atrial contractions (PACs) (by 24-hour holter monitoring, defined as >30/h). During follow-up we assessed the occurrence of sustained AF episodes and age at the time of the first AF episode.

Results

We studied 130 patients that underwent AVNRT ablation. Mean follow-up time was 75±27 months and seventeen patients (13%) had new-onset AF during follow-up. Patients who developed AF were more often males (35% vs. 22%, p=0,015), older at the time of AVNRT ablation (60±16 vs. 50±15, p=0,01), had a higher prevalence of hypertension (64% vs. 35%, p=0,03), diabetes mellitus (35% vs. 6%, p=0,02), LA dilation (41% vs. 7%, p=0,01) and frequent PACs (24% vs. 2%, p=0,03). In Univariable Cox regression analysis all these available variables were associated with AF occurrence during follow-up. However, in Multivariable Cox regression analysis, only age at the time of the ablation procedure was independently associated with AF occurrence (Table 1).

Multivariable Analysis HR 95% CI P value Age at ablation 8.762 3.308–23.20 <0.001 Age at the time of the first AF episode 0.113 0.043–0.302 <0.001 LA dilation 0.408 0.113–1.472 0.171 Frequent PACs 1.016 0.156–6.611 0.987

Conclusion

In this group of patients the occurrence of new-onset AF during follow-up was independently associated with delayed AVNRT ablation. These findings suggest that longer atrial exposure to AVNRT episodes before ablation may be associated with LA structural and functional changes leading to higher occurrence of AF.