Persisting Symptomatic Severe Secondary Mitral Regurgitation in Heart Failure Patients

Aims We aimed to assess the rate of persisting severe symptomatic secondary mitral regurgitation (MR) in a newly diagnosed heart failure (HF) population following optimisation of guideline directed medical therapy (GDMT), cardiac resynchronisation therapy (CRT) and revascularisation. Methods We assessed all new patients referred to our hospital group’s HF clinics. We retrospectively reviewed these patients at HF clinic enrolment, HF programme completion, as well as most recent follow up. Results Of the 242 new patients referred to our HF clinics, there were 10 patients (4.1%) who had either persisting symptomatic severe secondary MR at HF programme completion, or had undergone mitral valve surgery. There were no percutaneous mitral valve repairs at the time of these patients’ referrals. The rates of ACE/ARB/ARNI, BB and MRA use were 87.8%, 94.1%, and 49.8% in those with mid ranged, or reduced ejection fraction. The rates of ICD and CRT therapy were 15.1% and 4.4% at follow up. Patients with severe MR had higher time adjusted rates of death or hospitalization for heart failure. Conclusion In a well-treated newly diagnosed HF population, repeat assessment at HF programme completion suggests 4.1% of patients have a persisting indication for percutaneous mitral valve repair based on persisting severe symptomatic secondary MR.

A Review of a Tertiary Referral Centre's CT Coronary Angiography Programme

Aims To investigate the implication of outpatient CT coronary angiogram (CTCA) waiting times on patient outcomes and service provision. Methods All outpatient CTCAs requested for stable chest pain during 2017 in our catchment area were included. Rate of major adverse cardiovascular events (MACE), presentations with chest pain to the emergency department (ED), cardiology outpatient attendance, time interval in alteration of Coronary artery disease (CAD) prognostic treatment, rate of angiography and percutaneous coronary intervention (PCI) were noted. Results 172 CTCAs were included. 11 (6.4%) presented to ED with chest pain. 38 (22.1%) attended outpatients prior to scan completion. 17 (9.9%) required alteration of prognostic treatment, taking on average 10.4 (+/-4.5) months to occur. 21 (12.2%) underwent coronary angiography and 7 (4.1%) had PCI, which took on average 9.9 (+/-6.6) months. One non-fatal MI requiring CABG was noted. Conclusion The low rate of MACE and revascularisation likely represents appropriately low risk patient selection for CTCA. Presentation to clinic prior to scan completion highlights a need for better administration support.

P6444Cardiovascular secondary prevention setting and lipid controlu, update data from PINNACLE BRAZIL REGISTRY

Introduction

Lipid control is highly effective and improves clinical outcomes in coronary artery disease (CAD) patients, thus is one of the pillars of the cardiovascular secondary prevention.

Purpose

The aim of this preliminary analysis was to describe the lipid management in CAD patients in Brazil after one year of the clinical practice registry.

Methods

Patients with documented CAD were included by using electronic case report form based on the ACC PINNACLE Registry. The registry has been enrolling patients from general practitioners and specialists. Patients data were evaluated after 01 year of follow-up on regular clinical appointments and the differences on clinical practice were evaluated

Results

Currently, PINNACLE-Brazil enrolled individuals, with 2234 (29.4%) patients with CAD. Prescription of statin therapy was identified in 85.6% baseline and 78.3% follow-up. CAD patients with LDL-c <100 mg/dL were 47.3% baseline and 38.5% follow-up and at least one lipid profile assessment occurred in 60.9% baseline and 51.2% follow-up. CAD patients who have an LDL-c result <100 mg/dL, or >100 mg/dL with a documented plan to achieve LDL-c <100 mg/dL, were 48.1% (baseline) and 38.5% (follow-up).

Conclusion

The preliminary results of PINNACLE-Brazil show that, despite the relatively high prescription rate of statin therapy, LDL-c targeted level for CVD secondary prevention has not been achieved in the majority of patients after 01 year of follow-up. Nationwide knowledge translation initiatives are needed to improve the CVD burden in Brazil

Acknowledgement/Funding

ACC Foundation

Age at Menarche and Time Spent in Education: A Mendelian Randomization Study

Menarche signifies the primary event in female puberty and is associated with changes in self-identity. It is not clear whether earlier puberty causes girls to spend less time in education. Observational studies on this topic are likely to be affected by confounding environmental factors. The Mendelian randomization (MR) approach addresses these issues by using genetic variants (such as single nucleotide polymorphisms, SNPs) as proxies for the risk factor of interest. We use this technique to explore whether there is a causal effect of age at menarche on time spent in education. Instruments and SNP-age at menarche estimates are identified from a Genome Wide Association Study (GWAS) meta-analysis of 182,416 women of European descent. The effects of instruments on time spent in education are estimated using a GWAS meta-analysis of 118,443 women performed by the Social Science Genetic Association Consortium (SSGAC). In our main analysis, we demonstrate a small but statistically significant causal effect of age at menarche on time spent in education: a 1 year increase in age at menarche is associated with 0.14 years (53 days) increase in time spent in education (95% CI 0.10–0.21 years, p = 3.5 × 10⁻⁸). The causal effect is confirmed in sensitivity analyses. In identifying this positive causal effect of age at menarche on time spent in education, we offer further insight into the social effects of puberty in girls.

Opisthorchis felineus negatively associates with skin test reactivity in Russia-EuroPrevall-International Cooperation study

BACKGROUND

Most studies on the relationship between helminth infections and atopic disorders have been conducted in (sub)tropical developing countries where exposure to multiple parasites and lifestyle can confound the relationship. We aimed to study the relationship between infection with the fish-borne helminth Opishorchis felineus and specific IgE, skin prick testing, and atopic symptoms in Western Siberia, with lifestyle and hygiene standards of a developed country.

METHODS

Schoolchildren aged 7-11 years were sampled from one urban and two rural regions. Skin prick tests (SPT) and specific IgE (sIgE) against food and aeroallergens were measured, and data on allergic symptoms and on demographic and socioeconomic factors were collected by questionnaire. Diagnosis of opisthorchiasis was based on PCR performed on stool samples.

RESULTS

Of the 732 children included, 34.9% had opisthorchiasis. The sensitization to any allergen when estimated by positive SPT was 12.8%, while much higher, 24.0%, when measured by sIgE. Atopic symptoms in the past year (flexural eczema and/or rhinoconjunctivitis) were reported in 12.4% of the children. SPT was positively related to flexural eczema and rhinoconjunctivitis, but not to wheezing. Opisthorchiasis showed association with lower SPT response, as well as borderline association with low IgE reactivity to any allergen. However, the effect of opisthorchiasis on SPT response was not mediated by IgE, suggesting that opisthorchiasis influences SPT response through another mechanism. Opisthorchiasis also showed borderline association with lower atopic symptoms.

CONCLUSIONS

There is a negative association between a chronic helminth infection and skin prick test reactivity even in a developed country.

PTTG1IP and MAML3, novel genomewide association study genes for severity of hyperresponsiveness in adult asthma

BACKGROUND

The severity of bronchial hyperresponsiveness (BHR) is a fundamental feature of asthma. The severity of BHR varies between asthmatics and is associated with lack of asthma control. The mechanisms underlying this trait are still unclear. This study aimed to identify genes associated with BHR severity, using a genomewide association study (GWAS) on the slope of BHR in adult asthmatics.

METHODS

We performed a GWAS on BHR severity in adult asthmatics from the Dutch Asthma GWAS cohort (n = 650), adjusting for smoking and inhaled corticosteroid use, and verified results in three other cohorts. Furthermore, we performed eQTL and co-expression analyses in lung tissue.

RESULTS

In the discovery cohort, one genomewide significant hit located in phosphodiesterase 4D, cAMP-specif (PDE4D) and 26 SNPs with P-values < 1*10^-5 were found. None of our findings replicated in adult and childhood replication cohorts jointly. In adult cohorts separately, rs1344110 in pituitary tumour-transforming 1 interacting protein (PTTG1IP) and rs345983 in Mastermind-like 3 (MAML3) replicated nominally; minor alleles of rs345983 and rs1344110 were associated with less severe BHR and higher lung tissue gene expression. PTTG1IP showed significant co-expression with pituitary tumour-transforming 1, the binding factor of PTTG1lP, and with vimentin and E-cadherin1. MAML3 co-expressed significantly with Mastermind-like 2 (MAML2), both involved in Notch signalling.

CONCLUSIONS

PTTG1IP and MAML3 are associated with BHR severity in adult asthma. The relevance of these genes is supported by the eQTL analyses and co-expression of PTTG1lP with vimentin and E-cadherin1, and MAML3 with MAML2.

The locus C11orf30 increases susceptibility to poly-sensitization

A number of genetic variants have been associated with allergic sensitization, but whether these are allergen specific or increase susceptibility to poly-sensitization is unknown. Using data from the large multicentre population-based European Community Respiratory Health Survey, we assessed the association between 10 loci and specific IgE and skin prick tests to individual allergens and poly-sensitization. We found that the 10 loci associate with sensitization to different allergens in a nonspecific manner and that one in particular, C11orf30-rs2155219, doubles the risk of poly-sensitization (specific IgE/4 allergens: OR = 1.81, 95% CI 0.80-4.24; skin prick test/4+ allergens: OR = 2.27, 95% CI 1.34-3.95). The association of rs2155219 with higher levels of expression of C11orf30, which may be involved in transcription repression of interferon-stimulated genes, and its association with sensitization to multiple allergens suggest that this locus is highly relevant for atopy.

A Micro-fluidic System for the Evaluation of Blood Compatibility of Polymers

We present a new technique for the evaluation of polymer blood compatibility that makes use of a microchannel array flow analyzer and we describe and characterize the flow dynamics of this instrument. The blood compatibility of four polymers is quantitatively and qualitatively assessed and the results discussed. The blood is allowed to flow through the channels of a polymer coated micro-fluidic chip under adjustable pressure. The chip surface is investigated using optical microscopy during the blood flow and by scanning electron microscopy afterwards. Polymers known for having good blood compatibility exhibited higher flow rate values. Platelets were observed adhering, aggregating and obstructing the channels of the chips coated with polymers known for having poor blood compatibility. This technique has remarkable qualities such as a small blood volume requirement for material tests (100 μL), tuneable flow regimes and the use of human blood.

Exploring the causes of cutaneous B-cell lymphoma: we should learn from the Lyme disease experience

Epidemiological studies rely on the uneven distribution of disease within and between populations and represent a simple but efficient way of studying disease causation. The incidence of non-Hodgkin's lymphomas (NHLs) has increased dramatically over the past few decades and the epidemic calls for epidemiological studies. The study of Munksgaard and colleagues, in this issue of Dermatology, is a good example of an epidemiological study based on the so-called ecological correlation. It focuses on cutaneous B-cell lymphoma (CBCL) and fails to document a correlation between CBCL incidence and Lyme disease as a surrogate indicator for the exposure to tick bites. Although ecological studies neither inform about the time relationship between exposure and disease nor usually allow control for confounding variables, they can provide important information that would guide the direction of further research. There is a number of analytical studies focusing on risk factors for NHLs. One drawback of these studies is that they consider NHLs as a single category. One merit of the paper of Munksgaard et al. is that it focused on a rather specific disease, i.e. CBCL.

Measuring complexity/level of care and appropriateness of resource use in intensive care units

BACKGROUND

Throughout the world, the cost of critical care medicine is increasing more than the overall health care cost. Thus, a higher attention to improve the efficiency of the use of ICU resources is indispensable. The objective of this study was the development of a simple and reliable tool for the evaluation of the appropriateness of ICU utilization.

METHODS

DESIGN

A repeated cross-sectional data collection was performed twice a week, during a 61-day study period.

SETTING

Twenty-three Italian general ICUs.

PATIENTS

All patients present in the 23 ICUs on the 17 index days.

INTERVENTIONS

On each index day, patients were checked for receiving ventilation/CPAP, pulmonary arterial pressure monitoring, intracranial pressure monitoring, vaso-active drug infusion and hemodialysis-ultrafiltration. Simultaneously, each ICU bed was assessed for its technical and personnel facilities in order to estimate the deliverable level of care.

RESULTS

A total of 1250 patients were studied, for a total number of 7533 patient-days. The overall occupancy rate per ICU was 83.8% (-range: 54.4% to 96.1%). The high-level occupancy rate (rate of patients requiring high level of care and actually occupying high-facility beds) was 69.4% (range: 25.0% to 149.0%), while the corresponding low-level occupancy rate was 101.1% (range: 31.3% to 329.4%).

CONCLUSIONS

Our model clearly showed up a certain degree of inappropriateness in the use of ICU resources. Most of the ICUs (69.6%) used a very large proportion of their high-facility beds for patients who did not need high-level care. Being very simple, our method could represent a useful tool for continuous evaluation of the appropriateness of resource utilization in the ICU.

[A case of complete section of the pancreas during closed abdominal trauma]

A review of the literature on pancreatic trauma and its treatment in the light of recent experience is presented. The incidence, mechanism, classification, diagnosis, treatment and complications of pancreatic trauma are discussed. A case of pancreatic transection after blunt abdominal trauma is described.

Moyamoya disease in Brazil

INTRODUCTION

Moyamoya disease was first believed to be confined to Japan, but over the years it has been reported all over the world. We report seven cases from the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo with a review of the previously described cases in Brazil.

MATERIAL AND METHODS

The diagnosis was based on the diagnostic criteria of the Research Committee on Spontaneous Occlusion of the Circle of Willis.

RESULTS

Five patients presented ischemic and two hemorrhagic events. The meta-analysis of the six cases previously described in Brazil showed that only two were true moyamoya disease according to the diagnostic criteria.

CONCLUSION

We can assume that the real frequency of moyamoya disease has been underestimated in Brazil.

Effects of polyunsaturated fatty acids and prostaglandin synthesis on renal function

The effects of polyunsaturated fatty acids (phosphatidylcholine) on renal function in healthy subjects and in patients with chronic renal failure, with liver cirrhosis, and with heart failure were studied. The drug was administered at 3.5 mg/kg i.v. (Linoleic acid 1.24 mg/kg). In all cases, the administration of the drug caused an increased excretion of sodium and especially of water with a reduction in basal urinary hypertonicity. The polyuria was caused by the higher glomerular filtration rate not being counterbalanced by an increase in tubular water reabsorption. The water reabsorption was mostly anisosmotic. The presence of urinary hypertonicity excluded an inhibition of ADH secretion by this drug. The sodium excretion was probably caused by an increase of the glomerular filtration rate whereas no significant changes in the tubular reabsorption of sodium were seen. We found a significant (p 0.05) increase in PGE2 urinary excretion after phosphatidylcholine administration. Lysine - acetylsalicylate injection after phosphatidylcholine, in other trials in the same patients, prevented the effects previously reported. Therefore we suggest that the effects of this drug are mediated by an increased availability of renal prostaglandins.

[Urinary excretion of PGE2 and renal function in acute myocardial infarction]

In 17 hospitalized patients affected by acute myocardial infarction (AMI) PGE2 urinary excretion, renal function and, furthermore, cortisol urinary excretion were tested during a 21 days trial. In 12 patients all the parameters under consideration underwent a similar trend: PGE2 urinary excretion exactly like glomerular filtration rate, Na+ excretion and diuresis tended to be reduced during the first 5 days and they rapidly recovered the normality after this period. Cortisol urinary excretion displayed a characteristic pattern: i.e. the highest values were observed in the first days, followed by a progressive decrease towards physiological levels since the 4th day. Different findings were obtained in 5 cases treated with an antiinflammatory drug (Indoprophen i.m. 200 mg x2 die). In fact the low levels of urinary PGE2 on the first days did not display any increasing and GFR, urinary flow, and Na+ tubular balance underwent irregular and not significant variations. These data suggest that an impaired Prostaglandin synthesis may be related to a compromised renal function often occurring in AMI.

[Effect, on renal function, of a product rich in polyunsaturated fatty acids: results obtained in healthy subjects]

In 7 healthy subjects a 2,5 mg/Kg dose of i.v. phosphatidylcholine a drug with an high content of polyunsaturated fatty acids, caused variations in renal functionality as follows: a statistically significant increase of: urine flow, renal blood flow, glomerular filtration rate and sodium excretion. The above phenomena which resulted in a hypertonic poliuria, were detected during three 30 mins clearance periods. In other 5 subjects, a dose of lysine acetylsalicylate (10,5 mg/Kg) either suppressed the phenomena induced by the previous administration of phosphatidylcholine or prevented them to appear when the drug was given successively. Authors suggest that the data obtained may be ascribed to stimulation of local PG synthesis.