Impact of COVID-19 pandemic on eating styles: A population based-survey during the first lockdown in Italy

Background

The Coronavirus disease (COVID-19) pandemic has had a strong impact on eating behavior. To maintain health and well-being, correct nutrition is essential, especially when the immune system is under pressure.

Objective

The aim of this study was to evaluate the correlation between emotional aspects and the eating behavior of a group of people living in Sicily during the lockdown due to COVID-19.

Methodology

We used a cross-sectional survey design with an anonymous online questionnaire, administered through technological means.

Results

During the COVID-19 pandemic, 91 participants experienced high stress (PSS = 18.14 ± 4.1), and eating was associated with emotional behaviors (DEBQ EM = 41.74 ± 10.9). Stress correlated positively with the emotional and external aspects of eating behaviors.

Conclusion

The present study showed that the COVID-19 lockdown caused high stress with a worsening in eating behaviors. The study participants had difficulty in adequately coping with some emotions and feelings, developing an 'addiction' to food.

P15 AN OLD MYOCARDIAL INFARCTION UNMASKED BY UPGRADE TO HIS BUNDLE PACING: A CASE REPORT

Case Report

We report the clinical case of a 71–year–old man who was implanted with a dual–chamber PMK for complete atrioventricular block in 2012. In 2013 he was treated with two percutaneous coronary intervention (PCI) and stenting of the left anterior descending coronary artery (LAD) and right coronary artery (RCA).In March 2021, he was referred to our hospital for acute heart failure. Transthoracic echocardiography showed diffuse hypokinesis, with a left ventricular ejection fraction (LVEF) of 28% (46% six months earlier). ECG showed atrial flutter and paced ventricular rhythm with notch of the QRS complex in all 12 leads (Figure B). After achieving good clinical compensation with intravenous diuretics, the patient underwent coronary angiography with evidence of an unchanged coronary situation compared with 2013; Given the constant right ventricular pacing in the apex, we considered the LVFE decline as a consequence of pacemaker–induced cardiomyopathy (PICM)5 and a successful upgrade to HB pacing was performed. The surface ECG showed selective HB pacing with QRS width comparable to the native ECG (Figure A) but different morphology, because of evidence of QS complexes in V3–V6 and II, III, aVF (Figure C); physiological pacing obtained with selective HBP had made evident electrocardiographic signs of a previous myocardial infarction (MI).

Discussion

Very difficult is the diagnosis of a previous MI during RV pacing; to date, although considered questionable, we have only the criteria of Kochiadakis and colleagues (Figure 2A): – Notch of 0.04–second duration on the ascending limb of the S–wave of leads V3, V4, or V5 (Cabrera‘s sign). – Notching of the ascending stroke of the R wave in leads I, aVL, or V6 (Chapman‘s sign).– Q waves of 0.03 second duration in leads I, aVL, or V6. – Notch of the first 0.04 seconds of the QRS complex in leads II, III, and aVF. – Q wave of 0.03 seconds duration in leads II, III, and aVF. Occurring through the normal conduction system, HB pacing should generate a physiological myocardial repolarization resulting in a paced QRS complex with morphology and duration equal to the basal ECG, without alterations in the ventricular repolarization phase. As proof of the above, it was possible to appreciate that the transition from RV pacing to selective HB pacing allowed to unmasked the signs of a previous infero–lateral IMA, showing clear QS complexes in II, III, aVF, V3–V6.

Conclusion

Extremely old age should not discourage PM implantation, when indicated; age is obviously predictor of long–term death but is not predictor of precocious mortality. Acute periprocedural complication rate is low and generally comparable to that of younger populations.

C4 PERMANENT HIS BUNDLE PACING USING STYLET–DRIVEN LEAD IN PATIENTS WITH RIGHT ATRIOMEGALY: A SINGLE–CENTER EXPERIENCE

Background

His bundle pacing (HBP) is becoming an increasing widespread approach for physiological pacing. However, successful HBP procedure could be hampered by limited implantation tools especially in challenging anatomies. We aimed to report our experience with HBP technique using a novel stylet–driven lead system in patients with right atriomegaly.

Methods

Consecutive patients with right atrium (RA) volume >25 mL/m2 in men and >21 mL/m2 in women who underwent permanent HBP for standard indications were enrolled from March 2020 to March 2021. The tool of first choice for HBP attempt was a stylet–driven lead (Solia S 60, Biotronik) delivered via a dedicated introducer sheath (Selectra 3D, Biotronik). The acute, 1–month and 6–month procedural success rate was assessed.

Results

We enrolled 24 patients (median age 75 [70–79] years, 85% men) with an average RA volume of 50.7±7.8 mL/m2. At implant, conduction system pacing using stylet–driven lead was achieved in 21 patients (87%): 12 (50%) selective HBP, 6 non–selective HBP (25%) and 3 left bundle branch area pacing (12.5%). In the 3 failures, HBP was further attempted with a different system with final procedural success in 2 cases. In the successful cases, there was a significant reduction of QRS duration between paced and spontaneous beats (152.5 (130–167.5) ms vs 130 (122.5– 137.5) ms, p = 0.003). No lead dislodgment nor significant pacing threshold increase was observed at 1–month (1.30±0.76 V@0.4 vs. 1.32±0.80 V@0.4ms, p > 0.9) and 6–month follow–up (1.30±0.76 V@0.4 vs. 1.38±0.97 V@0.4ms, p = 0.66).

Conclusions

In our experience, the novel stylet–driven lead system showed high implant success rates and capture threshold stability also in patients with right atriomegaly.

P325 CARDIAC SARCOIDOSIS…TYPICAL CLINICAL PRESENTATION

We report the case of a 50–year–old man without previous medical hystory who was admitted to our department for recurrent syncopes for several months. Throughout the 24 hours ECG Holter it has been underlined several advanced atrioventricular block episodes, hence the patient underwent to definitive pacemaker implant. After 3 months, due to sustained ventricular tachycardia, the patient incurred a out–of–hospital cardiac arrest; the patient was subjeced to cardio pulmonary resuscitation with the restoration of the sinus rithm following defibrillation. Unfortunatly, due to the resuscitation maneuvers, sternal fracture resulted. During the hospitalization in the Cardiology department, he underwent coronary angiography wich showed non significant lesions. Cardiac Magnetic Resonance was also performed among the tests. The examination was found to be particularly hard to understand due to the presence of the sternal injury that deformed the pectus and affected dynamics of the right ventricle, causing systolic bulging of the subtricuspid region of the right ventricular wall. During the dynamic sequences, there was a mild bi–ventricular reduction in systolic function. In post contrast imaging, extended transmural LGE of the basal interventricular septum and right ventricular wall, as well as multifocal involvement of the left ventricle were found. Examination was not of univolcal interpretation: the patient was tranferred to another Center to perform MR PET wich was found to be strongy suggestive of sarcoidosis, later confirmed by extra cardiac biopsy. For this reason an ICD upgrade was performed along side the immunosoppressive therapy. Sarcoidosis is an inflammatory disease characterized by the presence of noncaseous granulomas in one or more organs or tissues; at the cardiac level it can “mimic” different cardiomyopathies as an insidious diagnosis. The presence of a post–traumatic pectus excavatum leads to dyskinesia of the rignt venticular wall, reduction of the bi–ventricular systolic funcion combine with an extensive late enhancement could suggest arrhytmogenic dysplasia with bi–ventricular involvement. However, by focusing on the clinical presentation (in particular the onset charaterized by unexplained advanced AV block in a young and healthy subjet and subsequent ventricular arrhytmias), through a multimodal and multidisciplinary imaging approach it was posible to diagnose sarcoidosis with cardiac involvement and refer the patient to adequate therapy.

P327 PULMONARY EMBOLISM FROM RIGHT–SIDED VALVE ENDOCARDITIS REVEALING RECTAL NEOPLAS. A “LUCKY” CASE

We describe a case of a 64–years–old man, outwardly healthy, presented with dyspnoea for 2–3 months and weight loss, coincident Co–Vid. Lung CT scan showed massive PULMONARY EMBOLISM. Echocardiography showed LONE PULMONARY VALVE INFECTIVE ENDOCARDITYS with large mobyle vegetations swinging between RVOT and pulmonary artery. Streptococcus Gallolyticus was identified on blood culture (often related with colorectal neoplasm). Given targeted antibiotic therapy, a surgical opinion was obtained: advised trial of medical management. Patient underwent a colonscopy, because of the causing germ: a neoplasm of rectal posterior side was found, hystological examination revealed an adenocarcinoma. MNR demonstrated a solid rectal lesion protruding in the lumen, infiltrating muscle and adipose tissue, but not pelvic organs. Team discussion with surgeons and oncologists: indication at neoadjuvant therapy before heart valve surgery. After 12 days of antibiotics a new TOE and CT scan were performed and revealed enlargement of valvular vegetations with severe pulmonary regurgitation and also PE warsened. After new surgical opinion, has been given indication of valve replacement. A Magna Ease bioprostetic valve was implanted; the native valve appeared completely destroyed and histological exam showed white fragments including cusps, granulocytes and bacteria, no growth at the culture. No complications obseved in the post operative period, regular echo follow up. The patient underwent neoadjuvant therapy and then surgery to remove the colorectal mass. Lone pulmonary valve infective endocarditis is a rare disease (1–2%), especially without history of immunodeficiency or drug abuse, we should look for a cause of persistent bacteraemia. Bacteraemia is a frequent condition in presence of colorectal neoplasm or IBD, mostly enterococchi or S.Gallolitycus. Septic pulmonary embolism is a frequent complication. Following guidelines, surgery should be considered only if there is no response to antibiotic therapy, extended tricuspid valve vegetations, recurrent pulmonary embolism. Valve vegetations> 10mm are predictor of poor response to ab therapy and pulmonary embolism.

Costs and quality of care optimization in the remote monitoring of cardiac implantable electronic devices (CIEDs). A picture from Veneto, Northern Italy

Background

Remote control/monitoring (RC/M) of cardiac implantable electronic devices (CIEDs) is still underutilized, with a significant heterogeneity of use across and within countries. Not all models are equivalent in terms of effectiveness and efficiency.

Purpose

This cost comparative study aimed to analyse different models of following patients with CIEDs in three districts (four implanting facilities) merged into the same administrative area, to assess the impact of RC/M on expenditure, and to propose a common practice with the objectives of standardisation of approach, optimisation of efficiency, and future capillary implementation of RC/M.

Methods

The workload related to CIED-patient follow-ups was assessed in four public hospitals reflecting three different models with different proportions of patients followed by RC/M and different modus operandi. All CIED-patients in charge were scrutinized at 31/08/2019. The workload analysis was based on one-year data, collected retrospectively. Costs were calculated in terms of nursing and physician hours and based on public tariffs. Five variables, identified as drivers of costs, were tested by the simulation model. The main outcome was a total expenditure and cost per patient followed by RC/M compared to the standard care (SC) (in-office only).

Results

A total of 6830 patients with CIEDs were followed, 34.8% by RC/M (five platforms, 19.7% high voltage devices). An additional 25.8% had monitorable devices. The proportion of RC/M-patients across centres was 63.3%, 60.6%, 51% and 2.65%. RC/M resulted more costly than SC in all hospitals. Modelling demonstrated the overall cost in the year 2018 to be €228,075. No single factor optimisation tested separately (number of transmissions, nursing time for each transmission revision, doctor time for transmission processing, nursing time for phone calls, time for single enrolment) was able to reduce the cost per patient below the cost of SC. Providing monitoring to all compatible patients increased the costs of total care to €248,785. After the optimisation of other factors, the additional benefit of extending RC/M to compatible devices was achieved, with the final result of a total expenditure of €128,181 and of €15.97 per RC/M-patient per year vs. €27.93 per SC-patient, below the reimbursement tariff of monitoring recently approved in Veneto (€25.55 per patient/year).

Conclusion

Real-world data from an unselected population confirmed the huge inconsistency in managing patients with CIEDs. RC/M was associated with a significant specific workload. RC/M may be cost-saving compared to the standard in-office follow-up; however, organisation needs to be optimised. Improvement can be achieved by implementing new standards for RC/M procedures using Lean Management tools. A common platform might be of help. Centralisation could represent a further step to ensure high quality service and to save money at the same time.

Funding Acknowledgement

Type of funding source: None

Effects of a Weight-Bearing Exercise Training on Bone Mineral Density and Neuromuscular Function of Osteopenic Women

This study was designed to evaluate whether a weight-bearing exercise training played 3 times a week can have benefits on bone mineral density and neuromuscular function in women with a diagnosis of osteopenia. The study enrolled 22 women aged between 45 and 65, with densitometric diagnosis of osteopenia. The participants were randomly assigned to a group of exercise (n=11) and a control group (n=11). The exercise program lasted for 45 min and consisted of a combination of strength exercises that seek to cause a mechanical osteoblastic stimulus by use of gravity, body weight, fall with antigravity reaction, in combination with exercises for the improvement of balance and coordination. The outcome measures used to assess the result on bone mass are the bone Mineralometric DEXA method for femoral head-neck region and lumbar spine and biochemical markers of bone turnover (resorption and neoformation) and for the evaluation of neuromuscular function was chosen to use surface electromyography (sEMG) as an indicator of overall activity and speed activation of lumbar paravertebral muscles and of the lower limbs antigravity muscles, stabilometric analysis and 6' Walk Test. In addition each person enrolled was given EuroQol and ICF core set of osteoporosis, respectively, to assess the quality of life, as well as activity limitations and participation restrictions associated. In the exercise group, mean values and changes in average rates for the balance, muscle strength, walking ability and quality of life, mean bone mineral content and bone turnover markers, corresponding to the assessments made at 0 (before rehabilitation intervention) and Time 1 (program ended), showed a statistically significant improvement. The results of this study demonstrate that a group rehabilitation program of exercises based on gravitational load, aimed to improve muscle strength and trophism, coordination and balance, can provide advantages of unquestionable importance, not only on the slope of increase bone mass of neuromuscular function and reducing risk of falling, but on health in general.

[Transesophageal echocardiographic evaluation of tricuspid endocarditis from implanted pacemaker: description of two cases]

Two cases of tricuspid valve endocarditis due to staphylococcus epidermidis have been examined in patients with permanent transvenous pacemaker. While transthoracic echocardiography was unable to detect any tricuspidal abnormalities, large vegetations located on the tricuspidal leaflets and the electrocatheter were detected by transesophageal echocardiography. Both cases required surgical removal of the electrostimulation system and valve toilet.

Giant intrapericardial solitary fibrous tumor

A 60-year-old man with a large pericardial effusion was found to have a giant intrapericardial solitary fibrous mesothelioma firmly attached to the ascending aorta and pulmonary trunk. Nine months after excision of the mass the patient is free from symptoms and signs of tumor recurrence. Solitary fibrous mesothelioma is a rare benign tumor and its excision is curative; however, because of the lack of information on its long-term behavior, close noninvasive follow-up of this patient is necessary.

[Pharmacodynamics and pharmacokinetics of flecainide in cardiac pre-excitation of the bundle of Kent]

In order to identify the flecainide plasma concentrations capable to inhibit the abnormal Kent's pathways, 9 patients affected by a Wolff-Parkinson-White syndrome were studied. One of them (a female 21 years old) previously received 200 mg oral flecainide "una tantum", 8 received 100 mg bid for at least 2 weeks. They had a short PR interval and an evident delta wave on the surface ECG, diagnostic for pre-excitation syndrome. The flecainide plasma half-life calculated in 6 patients chronically treated correlated directly and strictly with age. In all patients the flecainide treatment blocked the conduction through the bundle of Kent (normal PR, no delta wave), then the treatment was stopped and the elimination kinetics of flecainide were studied while a Holter 24h ECG monitoring was performed; thus we could extrapolate the flecainide plasma concentrations at which, during the elimination phase, the PR interval became short and the delta wave reappeared. Since short PR and delta wave are the expression of pre-excitation, we were able to determine the minimum concentrations capable to inhibit conduction through the abnormal bundles (290.0 ng ml-1 in the acutely treated patient and average 275.0 ng ml-1 in the chronically treated patients). These plasma levels are near to the lower therapeutic range accepted for ventricular ectopic arrhythmias (200 divided by 800 ng ml-1). Only larger studies will indicate if a relationship exists between the blockade of abnormal pathways and the preventive effect of flecainide on arrhythmias of Wolff-Parkinson-White syndrome. Another open question is whether a simple, non-invasive pharmacodynamic and pharmacokinetic procedure like that one described in the present paper can be used to predict the efficacy of treatment in patients with cardiac pre-excitation.

Relation between myocardial contractility, hypertrophy and pump performance in patients with chronic aortic regurgitation: an echocardiographic study

The aim of this study was to establish prognostic indices and to detect irreversible left ventricular dysfunction before aortic valve replacement in patients with chronic aortic regurgitation. Therefore, we determined the left ventricular pump/contractility relation (expressed as a ration between ejection fraction and peak systolic pressure/end-systolic volume), afterload mismatch (the relation between the ejection fraction and mean systolic wall stress) and the left ventricular end-diastolic radius/posterior wall thickness ratio in 52 patients with chronic aortic regurgitation by means of M-mode echocardiography. These indices were also calculated in 14 patients with idiopathic dilated cardiomyopathy and in 20 normal controls. The indices allowed separation of normals and patients with mild to moderate aortic insufficiency from patients with idiopathic dilated cardiomyopathy indicating that these indices could distinguish between patients with a reversible afterload mismatch and those with irreversible impaired muscle function. The 38 patients with severe aortic insufficiency showed a large overlap between normal and abnormal indices. Twelve of these patients had a pump/contractility index and a ratio between ejection fraction and wall stress similar to that found in patients with idiopathic dilated cardiomyopathy. All these patients, however, had a left ventricular end-diastolic radius/thickness ratio greater than 4 indicating "inadequate hypertrophy". Of these, 3 patients died perioperatively and 4 developed congestive heart failure within 12 months postoperatively. We conclude that an end-diastolic radius/thickness ratio greater than 4 is a sensitive but not a specific preoperative indicator of irreversible left ventricular damage in patients with chronic aortic regurgitation. This index is readily obtained preoperatively by M-mode echocardiography.