Impact of the first coronavirus-disease pandemic wave on cardiovascular admissions and sudden cardiac death rates in Greece

Background

Various studies suggest a decrease of hospital admissions for acute coronary syndromes (ACS) during COVID-19 outbreak, implying an increase in ACS related pre-hospital-care deaths as a cause of this phenomenon.

Purpose

Aim of this study was to investigate the impact of social containment measures on ACS admission and acute coronary deaths (ACDs) rates in Greece, during COVID-19 first pandemic wave in 2020.

Methods

Data for this analysis were retrieved by the official records of University Forensic and Cardiology Departments and the Forensic Science Services of the most crowded metropolitan areas of Greece (almost 25% of the entire Greek population ≈ 2.5 million people). The study period was defined as the time between March 15 2020, when the Greek state started to implement strict lock-down measures to contain COVID-19 pandemics, until April 14 2020. To compare admission and SCD rates, a corresponding control period a year earlier was chosen. Incidence rates (IRs) (events over days) of ACSs and ACDs in each time-period were assessed along with IRs ratios (IRRs) and 95% CI intervals. Secondary analysis for non-ischemic cardiovascular deaths (CVDs) or violent deaths (VDs) (including road traffic accident deaths) was also performed.

Results

There has been a relative 38.9% reduction in ACS admissions in 2020 [1.8, 95% CI (1.35–2.34) in 2019 vs 1.1, 95% CI (0.76–1.54) in 2020, p=0.02], concordant with a 66% relative reduction of total admissions (p<0.005). Overall, 171 deaths in 2020 vs 208 in 2019 were referred for autopsies in the enrolled forensic departments. Gender and age distribution were not significantly different between case and control periods. There were no statistically significant differences in the frequency of deaths between the two periods examined, with the exception of deaths secondary to road traffic accidents [IR 0.13, 95% CI (0.04–0.34) in 2020 vs 0.67, 95% CI (0.41–1.03) in 2019, p=0.001] and CVDs [IR 0.43, 95% CI (0.23–0.74) in 2020 vs 1.03, 95% CI (0.70–1.47) in 2019, p=0.007] which significantly decreased during COVID-19 pandemic wave. Absolute numbers, percentile changes and IRs are demonstrated in Figure 1 and Table 1.

Conclusions

Our analysis offers evidence over a significant decrease in ACS-related hospitalization rates during COVID-19 first pandemic wave. This decrease is not linked to an increase in pre-hospital, autopsy defined ACDs, as previously thought, implying that many ACS patients may not ask for help on time due to infection fear, being prone however to late-onset complications. Pre-hospital triage and care services, should be appropriately transformed to facilitate and speed-up access of cardiovascular patients to health-care systems during the pandemic.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Development and validation of a reversed-phase high-performance liquid chromatographic method for the quantitation and stability of α-lipoic acid in cosmetic creams

OBJECTIVE

To develop and validate a simple reversed-phase HPLC method for the quantitation and evaluation of stability of α-lipoic acid in cosmetics, according to International Conference on Harmonization (ICH) Guidelines.

METHODS

The chromatography was performed on a reversed-phase Luna C18, analytical column (150 × 4.6 mm id, 5 μm particle size) with a mobile phase of potassium dihydrogen phosphate (pΗ 4.5; 0.05 M) and acetonitrile (60:40, v/v) and a flow rate of 1.0 mL min^-1 with UV detection at 340 nm. Accelerated and long-term stability studies of α-lipoic acid in cosmetic cream were conducted under various degradation conditions including acid, basis, oxidation, and thermal and photolytic degradation, according to European Medicines Agency Guidelines CPMP/ICH/2736/99.

RESULTS

The limit of detection (LOD) for the cosmetic cream was 0.9 μg mL^-1 and the limit of quantitation (LOQ) was 2.8 μg mL^-1 , while the retention time was 7.2 min. The method proved to be linear, precise and accurate. The stability results demonstrated the selectivity of the proposed method to the analysis of α-LA, and the degradation products were determined and evaluated in specific stress conditions in cosmetic creams. The applicability of the method was tested in two different developed cosmetic products (cream with 1.5 % w/w and emulsion with 1.0 % w/w of LA) and proved to be reliable.

CONCLUSION

A reversed-phase HPLC-UV method was developed and fully validated for the analysis of α-lipoic acid in cosmetics. It is the first reported application on the quantitation of lipoic acid in cosmetic creams, while at the same time evaluates the stability in forced degradation conditions, in new cosmetic formulations. It proved to be suitable for the reliable quality control of cosmetic products, with a run time of <8 min that allows for the analysis of large number of samples per day.

Analysis of volatile organic compounds released from the decay of surrogate human models simulating victims of collapsed buildings by thermal desorption-comprehensive two-dimensional gas chromatography-time of flight mass spectrometry

Field experiments were devised to mimic the entrapment conditions under the rubble of collapsed buildings aiming to investigate the evolution of volatile organic compounds (VOCs) during the early dead body decomposition stage. Three pig carcasses were placed inside concrete tunnels of a search and rescue (SAR) operational field terrain for simulating the entrapment environment after a building collapse. The experimental campaign employed both laboratory and on-site analytical methods running in parallel. The current work focuses only on the results of the laboratory method using thermal desorption coupled to comprehensive two-dimensional gas chromatography with time-of-flight mass spectrometry (TD-GC×GC-TOF MS). The flow-modulated TD-GC×GC-TOF MS provided enhanced separation of the VOC profile and served as a reference method for the evaluation of the on-site analytical methods in the current experimental campaign. Bespoke software was used to deconvolve the VOC profile to extract as much information as possible into peak lists. In total, 288 unique VOCs were identified (i.e., not found in blank samples). The majority were aliphatics (172), aromatics (25) and nitrogen compounds (19), followed by ketones (17), esters (13), alcohols (12), aldehydes (11), sulfur (9), miscellaneous (8) and acid compounds (2). The TD-GC×GC-TOF MS proved to be a sensitive and powerful system for resolving the chemical puzzle of above-ground "scent of death".

Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure

AIM

Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure.

METHODS

We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry.

RESULTS

Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn.

CONCLUSION

Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.

Sex determination by tooth size in a sample of Greek population

Sex assessment from tooth measurements can be of major importance for forensic and bioarchaeological investigations, especially when only teeth or jaws are available. The purpose of this study is to assess the reliability and applicability of establishing sex identity in a sample of Greek population using the discriminant function proposed by Rösing et al. (1995). The study comprised of 172 dental casts derived from two private orthodontic clinics in Athens. The individuals were randomly selected and all had clear medical history. The mesiodistal crown diameters of all the teeth were measured apart from those of the 3rd molars. The values quoted for the sample to which the discriminant function was first applied were similar to those obtained for the Greek sample. The results of the preliminary statistical analysis did not support the use of the specific discriminant function for a reliable determination of sex by means of the mesiodistal diameter of the teeth. However, there was considerable variation between different populations and this might explain the reason for lack of discriminating power of the specific function in the Greek population. In order to investigate whether a better discriminant function could be obtained using the Greek data, separate discriminant function analysis was performed on the same teeth and a different equation emerged without, however, any real improvement in the classification process, with an overall correct classification of 72%. The results showed that there were a considerably higher percentage of females correctly classified than males. The results lead to the conclusion that the use of the mesiodistal diameter of teeth is not as a reliable method as one would have expected for determining sex of human remains from a forensic context. Therefore, this method could be used only in combination with other identification approaches.

Biomarkers of opiate use

The interpretation of toxicological findings is critical for the thorough investigation of the use and abuse of psychoactive substances. A positive analytical result for a sample taken could usually result in criminal proceedings and a punitive outcome for the defendant whose sample was analysed. The detection of markers of illicit opiate misuse is important both in the management of substance misuse and in the postmortem identification of illicit opiate use. The aim of this study was to emphasise the role of opiate biomarkers available at the laboratory and in the clinical environment. Urine remains the biological tool of choice for qualitative detection of illicit drug use in a clinical setting, while quantitative accuracy remains strictly the domain of blood. Accurate interpretation of the screening tests within a clinical setting alongside other relevant information remains the key to the usefulness of any test. Moreover, the finding of a morphine/codeine concentration ratio in blood exceeding unity is a strong evidence that the person had used heroin, as opposed to having taken a prescription analgesic drug containing codeine.

Fundamental issues in forensic semen detection

Sperm detection can be an important factor in confirming sexual assault in cases of rape. A large number of cases received in a forensic laboratory involve sexual offenses, making it necessary to examine exhibits for the presence of seminal stains. The objective of this paper is to provide an overview of the most important methods and tests used in the identification of spermatozoa or constituents of seminal fluid during the investigation of alleged sexual assault cases in forensic medical practice. Furthermore, this paper focusses on the basic knowledge that is necessary to the graduate students who wish to specialize in forensic sciences.

DNA content of Tetrahymena pyriformis as a biomarker for different toxic agents

The toxicity of different substances was studied on the protozoan Tetrahymena pyriformis, using as an endpoint the DNA content of the macronucleus. Substances from various chemical classes were administered to the Tetrahymena cultures and then the DNA content of the protozoan macronuclei was measured by means of Image Analysis System. The increase in the DNA content of the nuclei is indicative of the stimulation of the mitotic process. Since mitogenic stimuli can substantially alter susceptibility to chemical carcinogenesis, the results of such experiments, which are cheap and easy to run, may contribute to the investigation of the toxic action of several substances on cellular level.

Health impacts of fire smoke inhalation

Most fatalities from fires are not due to burns, but are a result of inhalation of toxic gases produced during combustion. Fire produces a complex toxic environment involving flame, heat, oxygen depletion, smoke and toxic gases. As a wide variety of synthetic materials is used in buildings (insulation, furniture, carpeting, and decorative items) the potential for severe health impacts from inhalation of products of combustion during building fires is continuously increasing. In forest fires the burning of biomass leads to smoke emissions, the composition of which, as well as the relative health impacts from their inhalation, depends on the ecosystem's chemical and physical features and the local environmental parameters. In the present review, health problems that appear to people exposed to fire smoke and especially to firefighters are described and suggestions for fire management and prevention are made.

Environmental aspects of VOCs evolved in the early stages of human decomposition

In the present study, the time profile, measured as "accumulation", of volatile organic compounds (VOCs) produced during the early stages of human decomposition was investigated. A human cadaver was placed in a sealed bag at approximately the 4th day after death. Evolved VOCs were monitored for 24 h by sampling at different time intervals. VOCs produced were analyzed by thermal desorption/gas chromatography/mass spectrometry (TD/GC/MS). Over 30 substances were identified in total. These included mainly aliphatic and aromatic hydrocarbons, oxygenated compounds (alcohols, aldehydes, ketones) and organic sulfides. The last were the most prominent class of compounds identified. Eleven compounds were present in all the sampling cycles and constitute a "common core": ethanol, 2-propanone, dimethyl disulfide, methyl benzene, octane, 2-butanone, methyl ethyl disulfide, dimethyl trisulfide and o-, m- and p-xylenes. The last sampling cycle yielded the most abundant compounds in number and quantities. Inorganic gases such as CO2, CO, NH3 and H2S were also determined. The fundamental physicochemical properties of the evolved VOCs were used for evaluating their environmental impacts. It appears that the decay process, which is a dynamic procedure, can provide chemical signals that might be detected and properly evaluated by experts in the fields of forensic sciences, search and rescue units and environmental scientists.

Toxicological investigation of drug-facilitated sexual assaults

Drug-facilitated sexual assaults have drawn a lot of attention during the last years. The role of the non-forensic doctors in the early recognition and management of such cases is crucial. Diagnosis assisted by samplings must be ascertained without delay, in victims initially brought to the emergency room for a sleepy state, a suspected abuse of drug or a pseudo-alcoholic clinical state. Further, where amnesia is present, it may be prudent to assume that sexual activity has occurred and offer pregnancy and sexually transmitted disease prophylaxis. Forensic doctors should entertain the possibility of poisoning in any presentation involving amnesia. Forensic toxicological laboratories should develop sensitive and specific methods to assure a low threshold of detection of the drugs. The awareness of a delinquent or criminal use of alcohol and/or drugs could permit a better medical recognition, so that proper and timely forensic examination is achieved, and adequate evidence is collected for the establishment of an effective investigation and prosecution.

A study of volatile organic compounds evolved from the decaying human body

Two men were found dead near the island of Samos, Greece, in the Mediterranean sea. The estimated time of death for both victims was 3-4 weeks. Autopsy revealed no remarkable external injuries or acute poisoning. The exact cause of death remained unclear because the bodies had advanced decomposition. Volatile organic compounds (VOCs) evolved from these two corpses were determined by thermal desorption/gas chromatography/mass spectrometry analysis (TD/GC/MS). Over 80 substances have been identified and quantified. The most prominent among them were dimethyl disulfide (13.39 nmol/L), toluene (10.11 nmol/L), hexane (5.58 nmol/L), benzene 1,2,4-trimethyl (4.04 nmol/L), 2-propanone (3.84 nmol/L), 3-pentanone (3.59 nmol/L). Qualitative and quantitative differences among the evolved VOCs and CO2 mean concentration values might indicate different rates of decomposition between the two bodies. The study of the evolved VOCs appears to be a promising adjunct to the forensic pathologist as they may offer important information which can be used in his final evaluation.

Zinc: a multipurpose trace element

Zinc (Zn) is one of the most important trace elements in the body and it is essential as a catalytic, structural and regulatory ion. It is involved in homeostasis, in immune responses, in oxidative stress, in apoptosis and in ageing. Zinc-binding proteins (metallothioneins, MTs), are protective in situations of stress and in situations of exposure to toxic metals, infections and low Zn nutrition. Metallothioneins play a key role in Zn-related cell homeostasis due to their high affinity for Zn, which is in turn relevant against oxidative stress and immune responses, including natural killer (NK) cell activity and ageing, since NK activity and Zn ion bioavailability decrease in ageing. Physiological supplementation of Zn in ageing and in age-related degenerative diseases corrects immune defects, reduces infection relapse and prevents ageing. Zinc is not stored in the body and excess intakes result in reduced absorption and increased excretion. Nevertheless, there are cases of acute and chronic Zn poisoning.

Adverse effects of anabolic steroids in athletes. A constant threat

Anabolic-androgenic steroids (AAS) are used as ergogenic aids by athletes and non-athletes to enhance performance by augmenting muscular development and strength. AAS administration is often associated with various adverse effects that are generally dose related. High and multi-doses of AAS used for athletic enhancement can lead to serious and irreversible organ damage. Among the most common adverse effects of AAS are some degree of reduced fertility and gynecomastia in males and masculinization in women and children. Other adverse effects include hypertension and atherosclerosis, blood clotting, jaundice, hepatic neoplasms and carcinoma, tendon damage, psychiatric and behavioral disorders. More specifically, this article reviews the reproductive, hepatic, cardiovascular, hematological, cerebrovascular, musculoskeletal, endocrine, renal, immunologic and psychologic effects. Drug-prevention counseling to athletes is highlighted and the use of anabolic steroids is must be avoided, emphasizing that sports goals may be met within the framework of honest competition, free of doping substances.

Clinical Diagnoses and Autopsy Findings: A Retrospective Analysis of 252 Cases in Greece

Context.—Despite medical and technologic advances, clinicians may misdiagnose a patient's situation and the cause of death. Autopsy may be valuable in uncovering the most frequent diagnostic pitfalls and helping clinicians to learn and to develop the medical art and science.

Objective.—To compare the clinical diagnoses with postmortem findings and evaluate the frequency of diagnostic errors assessed by autopsies.

Design.—Retrospective analysis of the protocols of 252 consecutive cases of adult patients autopsied in the Department of Forensic Medicine and Toxicology of Athens Medical School during the period 1999–2003. The outcome measures included concordance between diagnosis before death and at autopsy, sex, age, and length of hospitalization of the patient.

Results.—In 73 cases (29%), the autopsy findings confirmed the clinical diagnosis and the cause of death suggested by the clinicians. In 45 cases (19%), the clinical diagnosis and the cause of death suggested by the clinicians were discordant with the autopsy findings. In 105 cases (42%), the autopsy requests did not include any suggestion about the cause of the patient's death. In 7 cases (3%), several diagnoses were suggested by the clinicians, and in 16 cases (6%), the comparison between clinical and postmortem diagnosis was not possible. The most frequently misdiagnosed diseases were coronary disease and pulmonary embolism.

Conclusions.—It is concluded from this study that autopsies may reveal unexpected findings that are of critical importance and that a continued emphasis on autopsy evaluation is necessary to improve the quality of patient care.

Genotype-phenotype assessment in autosomal recessive arrhythmogenic right ventricular cardiomyopathy (Naxos disease) caused by a deletion in plakoglobin

OBJECTIVES

The purpose of this study was to examine the genotype-phenotype relation with respect to penetrance, age and severity of expression, disease progression and prognosis in a recessively inherited arrhythmogenic right ventricular cardiomyopathy (ARVC).

BACKGROUND

Naxos disease is a recessively inherited ARVC caused by a mutation in the gene encoding plakoglobin (cell adhesion protein) in which the cardiac phenotype is associated with palmoplantar keratoderma and woolly hair.

METHODS

Twelve families with Naxos disease underwent cardiac and molecular genetic investigation. Serial cardiac assessment with annual resting 12-lead and 24-h ambulatory electrocardiogram (ECG) and two-dimensional echocardiography was performed during 1 to 16 years, median 7 +/- 6 years in all 78 surviving members.

RESULTS

Twenty-eight surviving members were homozygous and 40 were heterozygous for the mutation. All adults who were homozygous (n = 26) fulfilled the diagnostic criteria for ARVC, the youngest by the age of 13 years. In eight who were heterozygous, minor ECG or echocardiographic abnormalities were observed. Of the 26 subjects who were affected homozygotes, 92% showed ECG abnormalities, 92% ventricular arrhythmias, 100% right ventricular structural alterations and 27% left ventricular involvement. During follow-up (10 +/- 6 years), 16 (62%) developed structural progression, 12 (46%) arrhythmic events and 7 (27%) heart failure. The annual disease-related and sudden death mortality was 3% and 2.3%, respectively.

CONCLUSIONS

Autosomal recessive ARVC caused by a mutation in plakoglobin was 100% penetrant by adolescence. Affected subjects who were homozygous experienced progressive disease with adverse prognosis. A minority of subjects who were heterozygous showed minor ECG/echocardiographic changes, but clinically significant disease did not develop.

Putrescine administration reverses cadmium-associated inhibition of liver regeneration

The liver is of central importance in the metabolism of essential and toxic metals such as cadmium. Cadmium pretreatment suppressed the liver regenerative response to partial hepatectomy, due to the inhibition of the enzymatic activity of thymidine kinase. Exogenous putrescine administration has been reported to stimulate liver regeneration in animal models of acute liver failure. The purpose of this study was to document whether the administration of this polyamine enhances the impaired regenerative capacity of hepatocytes in cadmium-pretreated partially hepatectomized rats. The intraperitoneal administration of putrescine (1 or 10 mg/kg body weight), at the time of surgery and at 4 and 8 hr postoperatively partly restored the suppressed hepatocyte deoxyribonucleic acid (DNA) biosynthesis and thymidine kinase activity in cadmium-pretreated partially hepatectomized rats. Mitotic activity and the percentage of hepatocytes positive for proliferating cell nuclear antigen nuclei were in accordance with the liver proliferative status. Our results showed that exogenous putrescine administration is able to improve diminished liver regeneration after partial hepatectomy in this animal model of acute hepatic injury.

Hepatic stimulator substance administration enhances regenerative capacity of hepatocytes in cadmium-pretreated partially hepatectomized rats

The liver is of central importance in the metabolism of essential and toxic metals such as cadmium (Cd). Cd pretreatment suppressed the regenerative capacity of hepatocytes, which normally occurs 24 hr after partial hepatectomy, due to the inhibition of the activity of the enzyme thymidine kinase. The effect of hepatic stimulator substance (HSS) administration (10, 20, and 40 mg protein/kg body weight) on hepatocyte proliferation was investigated in Cd-pretreated partially hepatectomized rats. HSS administration partly restored the suppressed hepatocyte DNA biosynthesis in Cd-pretreated partially hepatectomized rats. The hepatocyte mitotic activity and the percentage of proliferating cell nuclear antigen-positive nuclei were in accordance with the liver proliferative status. The administration of HSS did not affect in a statistically significant manner the activity of the enzyme thymidine kinase in Cd-pretreated partially hepatectomized rats. It is suggested that the administration of HSS ameliorates the diminished hepatocyte regenerative response to partial hepatectomy in this model of acute liver injury, due to Cd intoxication.

Metallothionein expression during liver regeneration after partial hepatectomy in cadmium-pretreated rats

Metallothionein is a low molecular mass protein inducible mainly by heavy metals, having high affinity for binding cadmium, zinc and copper. In the present study we investigated the expression of metallothionein in regenerating liver, at different time intervals, in cadmium pretreated partially hepatectomized rats. Liver metallothionein is highly expressed during regeneration induced by partial hepatectomy in rats, providing zinc within the rapidly growing tissue. Cadmium pretreatment caused inhibition of the first peak of liver regeneration, while metallothionein expression was markedly more prominent in the liver residues of cadmium-pretreated rats. These results demonstrate that although metallothionein able to bind temporarily metal ions as zinc and cadmium has been highly expressed, the liver regenerative process was inhibited possibly due to the effects of cadmium on other pivotal events necessary to the DNA replication.