Coffee consumption and cardiovascular health in the general population

Background

Coffee, next to water the most widespread beverage, is attributed both harmful and protective characteristics concerning cardiovascular health. This study aimed to evaluate associations of coffee consumption with cardiac biomarkers, echocardiographic, and electrocardiographic parameters as well as major cardiovascular diseases.

Methods and results

We performed a cross-sectional analysis of 9,009 participants a large German population-based cohort study, enrolled between 2016 and 2018 median age 63 [IQR: 55; 69] years. Coffee consumption was classified into three groups: <3 cups/day (low), 3–4 cups/day (moderate), >4 cups/day (high). In linear regression analyses adjusted for age, sex, body mass index, diabetes, hypertension, and smoking, moderate and high coffee consumption were associated with LDL-cholesterol (β=2.08; 95% CI: 0.14, 4.03, p=0.036; β=5.69; 95% CI: 2.91, 8.47; p<0.001). Moderate and high coffee consumption were negatively associated with systolic (β=−1.6; 95% CI: −2.66, −0.54; p=0.003; β=−2.63; 95% CI: −4.15, −1.12; p=0.001) and diastolic blood pressure (β=−0.8; 95% CI: −1.38, −0.22; p=0.007; β=1.28; 95% CI: −2.11, −0.45; p=0.002). Different levels of coffee consumption did neither correlate with any investigated electrocardiographic or echocardiographic parameter nor with prevalent major cardiovascular diseases, including prior myocardial infarction and heart failure.

Conclusions

In this cross-sectional analysis, moderate and high coffee consumption was positively associated with LDL-cholesterol and negatively associated with systolic and diastolic blood pressure. However, major cardiovascular diseases including heart failure and its diagnostic precursors were not associated with coffee consumption, connoting a neutral role of coffee in the context of cardiovascular health.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft [Grant Number TH1106/5-1; AA93/2-1]The Foundation Leducq [Grant Number 16 CVD 03]

Exploring circulating biomarkers for risk prediction of incident atrial fibrillation – insights from the BiomarCaRE project

Background

Atrial fibrillation (AF) remains a major health issue in Europe and worldwide. Risk prediction is crucial to identify at-risk individuals and prevent subsequent complications of AF such as stroke and heart failure. Biomarker-enriched, personalized risk prediction offers great potential for population-wide prevention beyond traditional cardiovascular risk factors.

Purpose

We aimed to identify robust predictors for incident AF using classical regressions and machine learning (ML) techniques within a broad spectrum of candidate variables.

Methods

Three European community cohorts from the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) consortium were included to explore the predictive utility of 14 biomarkers mirroring distinct pathophysiological pathways of AF including lipids, inflammation (C-reactive protein [CRP]), renal, and myocardium-specific markers (N-terminal pro B-type natriuretic peptide [NT-proBNP], high-sensitivity troponin I [hsTnI]) within a population-based sample of 42,280 individuals free of AF at baseline. Investigated biomarkers were examined in relation to incident AF using Cox regressions adjusted for multiple cardiovascular risk factors, and additionally by C-indices and net reclassification improvement (NRI) when compared to a reference model incorporating clinical variables. Their predictive utility for incident AF was further analyzed using different ML methods, including Least Absolute Shrinkage and Selection Operator (LASSO) and Random Survival Forest (RSF).

Results

Of 42,280 individuals (21,843 women [51.7%]; median [interquartile range, IQR] age, 52.2 [42.6, 62.0] years), 1496 (3.5%) developed AF during a median follow-up time of 5.7 years. In multivariable-adjusted Cox regression analysis, NT-proBNP was the strongest circulating predictor of incident AF (hazard ratio [HR] per standard deviation [SD] 1.93, 95% CI 1.82–2.04; P<0.001). Further, hsTnI (HR per SD 1.18, 95% CI 1.13–1.22; P<0.001), cystatin C (HR per SD 1.16, 95% CI 1.10–1.23; P<0.001) and CRP (HR per SD 1.08, 95% CI 1.02–1.14, P=0.012) correlated positively with new-onset AF. NT-proBNP enhanced model discrimination (ΔC-index 0.037, 95% CI 0.029–0.044) markedly and yielded the best reclassification improvement (NRI 0.237, 95% CI 0.187–0.287) when compared to the clinical model. Neither the addition of hsTnI to NT-proBNP, nor a model comprising all investigated biomarkers further increased discrimination or reclassification substantially. In different ML models, NT-proBNP and age were the strongest predictors of incident AF.

Conclusions

Using a dual approach with both classical regressions and modern ML methods, NT-proBNP consistently remained the strongest blood-based predictor of incident AF with relevant discriminative ability and reclassification yield beyond classical cardiovascular risk factors. The clinical benefit of these findings for AF risk prediction needs to be tested prospectively.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): BiomarCaRE (FP7, HEALTH-F2-2011-278913)European Union's Horizon 2020 research and innovation programme (grant agreement number 847770, AFFECT-EU)

Moving towards the ecological intensification of tree plantations

The growing demand for timber and the boom in massive tree-planting programs could mean the spreading of mismanaged tree plantations worldwide. Here, we apply the concept of ecological intensification to forestry systems as a viable biodiversity-focused strategy that could be critical to develop productive, yet sustainable, tree plantations. Tree plantations can be highly productive if tree species are properly combined to complement their ecological functions. Simultaneously considering soil biodiversity and animal-mediated biocontrol will be critical to minimize the reliance on external inputs. Integrating genetic, functional, and demographic diversity across heterogeneous landscapes should improve resilience under climate change. Designing ecologically intensified plantations will mean breaking the timber productivity versus conservation dichotomy and assuring the maintenance of key ecosystem services at safe levels.

POS0179 IMPLICATIONS OF BRAIN ACTIVITY IN THE TREATMENT DECISION OF KNEE OSTEOARTHRITIS

Background

Chronic pain related to knee osteoarthritis (KOA) is a common health problem and functional magnetic resonance imaging (fMRI) is a useful technique which can determine different brain activation (1).

Objectives

The main purpose of our study was to observe whether there is different risk to central sensitization and different brain activation in patients with KOA according to the treatment followed (conservative (CNV) Vs. total knee replacement (TKR))

Methods

Patients diagnosed of primary KOA following a CNV treatment or undergoing TKR were recruited. The two groups were matched by age, sex and BMI. Clinical central sensitization was considered if patients presented spread tenderness, evaluated with an algometer, in more than 1 site of the extended peripatellar map (2) (notice that pain at points 3, 7 and 8 were not counted) fMRI testing involved pressure painful stimulation to the articular interline and to a commonly sensitized site (tibial surface, point 10).To evaluate the associations between central sensitization and the risk to undergo a TKR; logistic regression was performed to estimate OR and 95% confidence intervals (95%CI). Models were adjusted by sex, age and BMI (R (R v.3.5.2).Whole-brain activation maps were compared between groups using Statistical Parametric Mapping software (SPM12 http://www.fil.ion.ucl.ac.uk/spm).

Results

Women have a significant higher risk to present central sensitization than men (OD 12,11 (95% CI 4,32-33,95) p-value:2,09*106), but no differences were observed between CNV and TKR group (OR TKR 0,69 (95% CI 0,24-1,98)) (Table 1). The differences observed in brain activation between the treatment groups in the interline fMRI test (point 7) did not correspond to any specific brain area. However, TKR group showed a higher activation that implicated the region of the amygdala and anterior hippocampus during the tibial fMRI test (point 10).

Table 1.

Central sensitization Odds Ratio (OR) with 95% Confidence Interval (95%CI)

O.R. (95% CI)p-valueTreatment0.69 (0.24- 1.98)0,494Sex12.11 (4.32- 33.95)2,09*10-6Age0.72 (0.26- 1.97)0,525BMI1.88 (0.69- 5.17)0,219

Conclusion

Presenting central sensitization is not a risk for KOA patients to undergo a TKR, but the mechanism underlaying sensitization in both treatment groups might be different, with amygdala playing an important role in TKR patients. The amygdala is an important element of the brain systems that both express emotions and modulate pain. The activation of the amygdala in response to pressure stimulation on a sensitized knee site is interpreted as a failure of the descending pain inhibitory systems, and the occurrence of a major emotional response during the painful experience in patients that ultimately received TKR.

References

[1]Pujol, J. et al., 2017. Brain imaging of pain sensitization in patients with knee osteoarthritis. Pain, 158(9), pp.1831–1838.

[2]Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, Graven-Nielsen T. Sensitization in patients with painful knee osteoarthritis. Pain 2010;149:573-8

Extended peripatellar map including the points tested for tenderness, and brain areas differently activated between both treatments groups during painful stimulation to point 7 (interline) and point 10 (tibial surface, a commonly sensitized site).

Disclosure of Interests

None declared

Association of glycated haemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE consortium

Background

Glycated haemoglobin A1c (HbA1c) is used to monitor the quality of diabetes treatment; however, its role in predicting cardiovascular outcomes in the general population remains uncertain.

Purpose

The additional use of glycated haemoglobin A1c (HbA1c) as a biomarker might highlight subjects of the general population with an increased risk for cardiovascular outcomes with cardiovascular disease, cardiovascular mortality or overall-mortality.

Methods

Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analysed. HbA1c was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular diseases (CVD), and overall mortality in the study population, in non-diabetic (N=32,477), and diabetic participants (N=3,703).

Results

Kaplan-Meier curves showed higher event rates with increasing continuous log-transformed HbA1c levels. Cox regression analysis revealed significant associations between HbA1c (in mmol/mol) log-transformed divided by interquartile range and the examined outcomes, with a hazard ratio (HR) of 1.12 (95% confidence interval (CI): 1.04–1.20, p=0.0019) for cardiovascular mortality, 1.10 (95% CI: 1.04–1.16, p<0.001) for CVD, and 1.09 (95% CI: 1.05–1.14, p<0.001) for overall mortality per one unit increase.

An increased risk of CVD was observed in subjects without diabetes with increased HbA1c levels (HR 1.09; 95% CI: 1.01–1.16, p=0.021). An HbA1c cut-off value of 39.89 mmol/mol (5.8%), 36.62 mmol/mol (5.5%), and 38.80 mmol/mol (5.7%) for cardiovascular mortality, CVD, and overall mortality, respectively, was determined for selecting individuals at an increased risk.

Conclusion

HbA1c was demonstrated to be an independent prognostic biomarker for all investigated outcomes in the general European population. An approximately linear relationship was observed between an increase of HbA1c levels and the outcomes. Elevated HbA1c levels were also associated with the outcomes in participants without diabetes (i.e. HbA1c levels <6.5% (<48mmol/mol) which underlines the importance of HbA1c levels in the overall population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union Seventh Framework ProgrammeEuropean Union FP 7 project CHANCES Kaplan-Meier curves for the outcomesPenalised cubic splines HbA1c/time event

Volatile and Semi-Volatile Organic Compounds May Help Reduce Pollinator-Prey Overlap in the Carnivorous Plant Drosophyllum lusitanicum (Drosophyllaceae)

Most carnivorous plants show a conspicuous separation between flowers and leaf-traps, which has been interpreted as an adaptive response to minimize pollinator-prey conflicts which will reduce fitness. Here, we used the carnivorous subshrub Drosophyllum lusitanicum (Drosophyllaceae) to explore if and how carnivorous plants with minimal physical separation of flower and trap avoid or reduce a likely conflict of pollinator and prey. We carried out an extensive field survey in the Aljibe Mountains, at the European side of the Strait of Gibraltar, of pollinating and prey insects of D. lusitanicum. We also performed a detailed analysis of flower and leaf volatile and semi-volatile organic compounds (VOCs and SVOCs, respectively) by direct thermal desorption-gas chromatography/mass spectrometry (TD-GC/MS) to ascertain whether this species shows different VOC/SVOC profiles in flowers and leaf-traps that might attract pollinators and prey, respectively. Our results show a low overlap between pollinator and prey groups as well as clear differences in the relative abundance of VOCs and SVOCs between flowers and leaf-traps. Coleopterans and hymenopterans were the most represented groups of floral visitors, whereas dipterans were the most diverse group of prey insects. Regarding VOCs and SVOCs, while aldehydes and carboxylic acids presented higher relative contents in leaf-traps, alkanes and plumbagin were the main VOC/SVOC compounds detected in flowers. We conclude that D. lusitanicum, despite its minimal flower-trap separation, does not seem to present a marked pollinator-prey conflict. Differences in the VOCs and SVOCs produced by flowers and leaf-traps may help explain the conspicuous differences between pollinator and prey guilds.

Head-to-head comparison of the incremental value of the three established risk markers hs-troponin I, hs-C-reactive protein and NT-proBNP in secondary prevention of coronary artery disease

Background

Risk stratification among patients with coronary artery disease (CAD) and acute coronary syndrome (ACS) is of considerable interest due to the potential to guide secondary preventive therapies. Cardiac troponins as well as the inflammatory biomarker C-reactive protein (CRP) and natriuretic peptides have now emerged as useful blood-based biomarkers for risk stratification concerning incident cardiac events. Nevertheless, it has not been tested, whether one of these biomarkers yields predictive value beyond the others. Thus, we evaluated the head-to-head potential of high-sensitivity troponin I (hsTnI), high-sensitivity (hs) CRP and NT-proBNP as prognostic biomarkers for adverse outcome in patients with manifest CAD.

Methods

Plasma levels of hsTnI, hsCRP and NT-proBNP were measured in a cohort of 2,193 patients with documented CAD –including 837 patients with ACS and 1,356 patients with stable angina pectoris (SAP). Cardiovascular death and/or non-fatal acute myocardial infarction (MI) were defined as the main outcome measures. The association of circulating biomarker levels, used after log-transformation, with cardiovascular mortality and non-fatal MI during follow-up was assessed by Cox proportional hazards analyses adjusted according to three different models including cardiovascular risk factors and either the biomarkers hsCRP, NT-proBNP or hsTnI. Additionally, the net reclassification index (NRI) was calculated using the category five-year event probabilities for two models.

Results

During a median follow-up of 3.8 years, a total of 231 events were registered (10.5%). All three biomarkers reliably predicted cardiovascular death and/or MI, as evidenced by survival curves stratified for tertiles of circulating levels.

In Cox regression analyses with adjustments for sex, age, and conventional cardiovascular risk factors, the hazard ratio (HR) per standard deviation (SD) for the prediction of cardiovascular (CV) death and/or non-fatal MI during follow-up was 1.39 [95% CI: 1.24–1.57, p<0.001] for hsTnI, 1.41 [95% CI: 1.24–1.60, p<0.001] for hsCRP, and 1.64 [95% CI: 1.39–1.92, p<0.001] for NT-proBNP. Nevertheless, upon further adjustment for the other two biomarkers, the significance of the association for hsTnI got lost, association for hsCRP attenuated, and only NT-proBNP kept its predictive value and was still strongly associated with the combined endpoint (1.47 [95% CI: 1.19–1.82, p<0.001]), but also with CV death alone (2.42 [95% CI: 1.86–3.15, p<0.001]). Moreover, only NT-proBNP significantly improved C-statistics and net reclassification index (NRI) for the prediction of cardiovascular death.

Conclusions

NT-proBNP reliably predicted cardiovascular death and myocardial infarction in patients with manifest CAD and provides incremental value beyond hsCRP and hsTnI.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “Stiftung Rheinland-Pfalz für Innovation”, Ministry for Science and Education

OP0276 CLINICAL PATTERNS AND FOLLOW-UP OF INFLAMMATORY ARTHRITIS AND OTHER IMMUNE-RELATED ADVERSE EVENTS INDUCED BY CHECKPOINT INHIBITORS. A MULTICENTER STUDY

Background:

Immune checkpoint inhibitors (ICI), such as anti-CTLA-4and anti-PD1/PD-L1 monoclonal antibodies, have produced impressive clinical results in different types of cancer. However, immune-related adverse events (irAEs) may develop a wide spectrum of disabling syndromes. Knowledge of different rheumatic irAEs induced by ICI is increasing over the last years, however clinical patterns, time to onset of different irAEs according to treatment and follow-up are less well known.

Objectives:

To describe different clinical patterns of rheumatic irAEs induced by ICI and their rheumatic and oncologic outcomes.

Methods:

We included consecutive patients with rheumatic irAEs from 3 different referral centers in Barcelona with special emphasis in articular irAEs. Four main clinical syndromes were identified: inflammatory arthritis (IA), non-inflammatory arthralgias (NIA), psoriatic arthritis (PsA)-like and polymialgia (PMR)-like. We conducted a baseline visit and then follow-up in order to determine their clinical pattern, treatment response and outcome. Longitudinal visits were done from January 2017 to January 2020. Patients with other non–articular diagnosis were not included in the follow-up analysis.

Results:

We included 55 patients. A total of 34 patients were male (61.8%) with a mean age of 65.0 ± 11.4 years. Oncologic underlying diagnosis was lung carcinoma in 24 (43.6%) patients, followed by melanoma in 17 (29%), urothelial cancer in 4 (7.3%), breast in 2 (3.6%) and 2 (3.6%) acute myeloid leukemia among others. Seven (12.7%) patients received ICI as combined therapy. Different ICI were used including: Pembrolizumab in 21 (38.2%), Nivolumab 13 (23.6 %), Atezolizumab 6 (10.9%), Nivolumab + ipilimumab 5 (9.0%), Durvalumab 3 (5.5%), Pembrolizumab + epacadostat in 2 (3.6%), 2 anti TIM3, Atezolizumab+ Ibatasertib, Avelumab and Ipilimumab in one case each. 12 out of 55 patients had an underlying rheumatic disease before ICI treatment. Eleven patients developed other irAEs before or at the same time as rheumatic syndromes (mainly colitis and thyroiditis). Main rheumatic irAE included: IA in 23 (41.8%), NIA in 16 (29.1%), PsA-like in 6 (10.9%), PMR-like in 5 (9.1%) among others. Time from ICI to irAEs was 8.3 ± 8.4 months(mo). irAE presented earlier in patients with combined ICI therapy than in patients with monotherapy (6.5 ± 4.0 vs 8.6 ± 8.9 mo, p=NS, Figure 1A). Time (in mo) from ICI initiation to irAE onset was different according to treatments. For Nivolumab 10.0 ± 10.6, Anti TIM3 10.0 ± 1.4, Durvalumab 9.0 ± 2.0, Ipilimumab 7.98 ± 9.21, Pembrolizumab 7.28 ± 7.53, Avelumab 6.0 and Atezolizumab 4.4 ± 5.38 mo (Figure 1B). Time from ICI initiation and onset also differs among rheumatic irAEs (Figure 2). Mean time follow-up was 13.4 ± 10.9 mo. At the last visit, 45% were under GC, mean dose of 3.6 mg/d (range 0-40). DMARD were needed in 15% of patients (6 patients MTX, 1 with LEF and 1 SFZ). At the last visit, 11 (22.9%) patients remain with persistent arthritis, 25% intermittent flares and 52% had a self-limited pattern. Regarding oncologic outcome, 30.2% were on remission, 30.2% in partial response and 39.6% with tumor progression. Eleven (20%) of patients died.

Conclusion:

We described different clinical patterns according treatment and irAEs. Combined ICI therapy and patients treated with Atezolizumab had earlier onset of symptoms. Vasculitis and PMR-like syndromes appear in earlier phases. After a mean follow-up of around 1 year, one-quarter of the patients remain with persistent arthritis and 15% require DMARD therapy.

Disclosure of Interests:

Jose A. Gómez-Puerta Speakers bureau: Abbvie, BMS, GSK, Lilly, Pfizer, Roche, Carolina Perez-Garcia: None declared, David Lobo Prat: None declared, Roberto Gumucio: None declared, Fabiola Ojeda: None declared, Ana Milena Millán Arciniegas: None declared, Sebastian Rodriguez Garcia: None declared, Virginia Ruiz Speakers bureau: Lilly, Pfizer, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche

P3642Predictive value of soluble urokinase-type plasminogen activator receptor for cardiovascular death and non-fatal myocardial infarction in patients with coronary artery disease

Introduction

Stratification for subsequent coronary events among patients with coronary artery disease (CAD) is of considerable interest due to the potential to guide secondary preventive therapies. Soluble urokinase-type plasminogen activator receptor (suPAR) is expressed on various cells involved in atherogenesis and plaque instability, and has been associated with poor clinical outcomes in patients with various conditions.

Purpose

In this study we investigated the potential role of suPAR as a prognostic biomarker for adverse outcome in patients with CAD, and acute coronary syndrome (ACS) in particular.

Methods

Plasma levels of suPAR were measured in a cohort of 1,703 patients (AtheroGene Study) with documented coronary artery disease –including 626 patients with ACS and 1077 patients with stable angina pectoris (SAP). The main outcome measures were defined as cardiovascular death and non-fatal myocardial infarction (MI). Survival curves for the endpoints considered were computed according to thirds of the suPAR distribution. The equality of survival curves was tested using the log-rank test. Multivariable models adjusted for common cardiovascular risk factors and the biomarkers CRP, NT-proBNP and high-sensitivity troponin I (hs-TnI) in particular were also computed.

Results

The prognostic utility of suPAR was evidenced by survival curves stratified for tertiles of circulating suPAR levels –both, in the overall cohort (p=0.00062), and in the ACS cohort (p=0.00099) with a median follow-up of 3,5 years. In multivariable-adjusted Cox regression analyses the hazard ratio (HR) for the prediction of cardiovascular death was 3.60 for log-transformed suPAR levels (p<0.001) in the overall CAD cohort, whereas it was 3.34 (p=0.003) in the ACS cohort. The HR regarding prediction of the combined outcome cardiovascular death and/or non-fatal MI during follow-up was 2.19 (p<0.001) in the overall cohort, and 2.56 (p<0.001) in the ACS cohort. After multivariate adjustment, including conventional cardiovascular risk factors and hs-TnI, suPAR, after log transformation, still enabled a reliable and strong prediction of future cardiovascular death with a HR of 3.17 (p<0.001) in the overall CAD cohort, and a HR of 2.85 (p=0.014) in the ACS cohort.

Conclusions

Our study demonstrates that suPAR has a strong prognostic value independent of hs-TnI in secondary prevention settings, and thereby might represent a valuable biomarker for risk estimation in CAD.

Acknowledgement/Funding

Stiftung Rheinland-Pfalz für Innovation, European Union 7th Framework Programme, DZHK e.V., ERA-Net, Abbott Diagnostics

P2675Validation of a 0/1h diagnostic algorithm using a point of care high-sensitivity troponin I assay

Background

The numbers of patients presenting to emergency departments with suspected acute myocardial infarction (AMI) are increasing worldwide. The use of point of care (POC) troponin assays with an increased sensitivity – equal to laboratory-based high-sensitivity immunoassays – might enable faster decision making in this high-risk population.

Objective

To validate a rapid diagnostic algorithm using a novel point of care (POC) high-sensitivity troponin I (hs-TnI) assay in comparison to a laboratory-based hs-TnI assay.

Methods

A diagnostic 0/1h algorithm for the POC hs-TnI assay (PATHFAST hs-cTnI, LSI Medience) was derived in a dataset of 669 patients with suspected AMI, aiming for a negative predictive value (NPV) ≥99.5% for rule-out and a positive predictive value (PPV) ≥75% for rule-in of non-ST-elevation myocardial infarction (NSTEMI). The performance of the developed algorithm was tested in a validation cohort of 610 patients. Diagnostic accuracy of the POC hs-TnI assay was compared to an established hs-TnI assay (Abbott ARCHITECT) using an ESC guideline-recommended 0/1h diagnostic algorithm.

Results

The derived 0/1h algorithm consisted of an admission POC hs-TnI <4 ng/L and a delta from 0h to 1h <3 ng/L for rule-out and an admission POC hs-TnI ≥90 ng/L or a delta from 0h to 1h ≥20 ng/L for rule-in of NSTEMI. Application of the algorithm in the validation cohort showed a NPV of 99.7% (Confidence Interval (CI) 98.1%-100.0%) and 48.0% of patients ruled out, while 14.6% were ruled in with a PPV of 86.5% (CI 77.6%-92.8%). The diagnostic performance of the POC hs-TnI assay was comparable to guideline-recommended use of a laboratory-based hs-TnI assay (Figure 1).

Conclusion

The clinical application of a 0/1h diagnostic algorithm based on a novel POC hs-TnI assay showed good diagnostic performance and was comparable to a laboratory-based hs-TnI assay.

Acknowledgement/Funding

German Center of Cardiovascular Research, Abbott Diagnostics, DIAneering GmbH, German Heart Foundation/ German Foundation of Heart Research

Modeling the Customer Value Generation in the Industry's Supply Chain

This article shows that customer value generation has drivers, which could be different according to each stakeholder within the electricity industry, affecting its growth. Each stakeholder has different interests that affect the decision-making process and the customer value perception in the long term, which impacts on profitability. In order to illustrate how to identify and model key performance drivers to evaluate creating value in the electricity utility industry, this study used a simulation with the system dynamics methodology. Through simulation scenarios, this study shows that, the high customer value perception allows the electricity utilities industry to create more value. This is illustrated with the case of some electricity utilities engaged in the generation and distribution in the Colombian electricity market. The results show a new point of view that contributes to marketers and engineers in the analysis of the relationship between the stakeholders and electricity firms.

P3600High-sensitivity troponin I can predict reduced TIMI coronary grade flow in patients with suspected myocardial infarction

Background

Serial measurements of high-sensitivity troponin (hs-Tn) is recommended for rule-out or rule-in of myocardial infarction (MI) in patients presenting with acute chest pain. Based on dynamic hs-Tn changes invasive angiography is recommended in order to identify a culprit lesion. However, the association of hs-Tn with the intracoronary flow is unknown.

Purpose

We aimed to evaluate the association of hs-TnI with intracoronary flow, measured by the TIMI Coronary Grade Flow in coronary angiography, and its association with outcome.

Methods

1,940 consecutive patients presenting with suspected MI to the emergency department were included. Among those 543 patients underwent coronary angiography. Patients with prior coronary artery bypass graft surgery and patients with chronic total occlusion were excluded from further analysis, resulting in 420 available individuals. TIMI Coronary Grade Flow was scored in accordance with the definition of the TIMI study group. For further analysis two groups were distinguished. Group 1: Minimum TIMI Grade Flow <3 (no complete perfusion in at least one of the coronary arteries) and Group 2: Minimum TIMI Grade Flow = 3 (normal flow in all coronary arteries). Troponin I was measured using the ARCHITECT STAT high sensitive Troponin I immunoassay directly at admission, after 1 and 3 hours. Receiver Operating Characteristic (ROC) curves were used to investigate the association of hs-TnI with a reduced TIMI Grade Flow. Survival curves were produced for a combined endpoint of all-cause mortality, rehospitalisation, PCI and MI after 12 months.

Results

In patients with reduced TIMI Grade Flow the level of hs-TnI was significantly higher at admission (Group 2: 87.3 ng/l vs. Group 1: 15.0 ng/l, p<0.001), after 1 hour (298.3 ng/l vs 18.5 ng/l, p<0.001) and after 3 hours (1,071 ng/l vs. 27.7 ng/l, p<0.001). The prediction of reduced TIMI flow based on the absolute value of hs-TnI improved over time from admission (AUC 0.701, optimal cut off 34.8 ng/l, 95% CI (9.7, 74.6)), to 1 hour (AUC 0.759, optimal cut off 65.1 ng/l, 95% CI (25.1, 279.5)) and 3 hours (AUC 0.777, optimal cut off 90.7 ng/l, 95% CI (14.8, 200)). Using the hs-TnI delta to predict a reduced TIMI Grade Flow improved the accuracy only slightly with time from admission: hs-TnI 0/1h delta (AUC 0.758) vs. 0/3h delta (AUC 0.765). The survival curve for a combined endpoint after one year was significantly reduced in patients with reduced TIMI Grade Flow (Figure 1, p=0.012)

Figure 1

Conclusion

Absolute value and delta change of hs-TnI after 1 and 3 hours help to predict the presence of reduced TIMI Grade Flow in coronary arteries. Patients suffering from a lowered TIMI Grade Flow have higher event rates after 12-months.

An ecological perspective on 'plant carnivory beyond bogs': nutritional benefits of prey capture for the Mediterranean carnivorous plant Drosophyllum lusitanicum

BACKGROUND AND AIMS

Little is known about the evolutionary and ecological drivers of carnivory in plants, particularly for those terrestrial species that do not occur in typical swamp or bog habitats. The Mediterranean endemic Drosophyllum lusitanicum (Drosophyllaceae) is one of very few terrestrial carnivorous plant species outside of Australia to occur in seasonally dry, fire-prone habitats, and is thus an ecological rarity. Here we assess the nutritional benefits of prey capture for D. lusitanicum under differing levels of soil fertility in situ.

METHODS

We measured the total nitrogen and stable nitrogen and carbon isotope ratios of D. lusitanicum leaves, neighbouring non-carnivorous plant leaves, and groups of insect prey in three populations in southern Spain. We calculated trophic enrichment (ε15N) and estimated the proportion of prey-derived nitrogen (%Nprey) in D. lusitanicum leaves, and related these factors to soil chemistry parameters measured at each site.

KEY RESULTS

In all three populations studied, D. lusitanicum plants were significantly isotopically enriched compared with neighbouring non-carnivorous plants. We estimated that D. lusitanicum gain ~36 %Nprey at the Puerto de Gáliz site, ~54 %Nprey at the Sierra Carbonera site and ~75 %Nprey at the Montera del Torero site. Enrichment in N isotope (ε15N) differed considerably among sites; however, it was not found to be significantly related to log10(soil N), log10(soil P) or log10(soil K).

CONCLUSIONS

Drosophyllum lusitanicum individuals gain a significant nutritional benefit from captured prey in their natural habitat, exhibiting proportions of prey-derived nitrogen that are similar to those recorded for carnivorous plants occurring in more mesic environments. This study adds to the growing body of literature confirming that carnivory is a highly beneficial nutritional strategy not only in mesic habitats but also in seasonally dry environments, and provides insights to inform conservation strategies for D. lusitanicum in situ.

Tissue characterization by T1 and T2 mapping cardiovascular magnetic resonance imaging to monitor myocardial inflammation in healing myocarditis

Aims

Monitoring disease activity in myocarditis is important for tailored therapeutic strategies. This study evaluated the ability of T1 and T2 mapping cardiovascular magnetic resonance (CMR) to monitor the course of myocardial inflammation in healing myocarditis.

Methods and Results

Forty-eight patients with strictly defined acute myocarditis underwent CMR at 1.5 T in the acute stage, at 3-months (n = 39), and at 12-months follow-up (FU) (n = 21). Normal values were obtained in a control group of 27 healthy subjects. The CMR protocol included standard ('Lake-Louise') sequences as well as T1 (modified Look-Locker inversion recovery sequence, MOLLI) and T2 (gradient- and spin-echo sequence, GraSE) mapping. T1, T2, and extracellular volume (ECV) maps were generated using an OsiriX plug-in. Native myocardial T1, T2, and ECV values were increased in the acute stage, but declined with healing of myocarditis. The performances of global native T1 and T2 to differentiate acute from healed myocarditis stages were significantly better compared with all other global CMR parameters with AUCs of 0.85 (95% CI, 0.76-0.94) and 0.83 (95% CI, 0.73-0.93). Furthermore, regional native T1 and T2 in myocarditis lesions provided AUCs of 0.97 (95% CI, 0.93-1.02) and 0.93 (95% CI, 0.85-1.01), which were significantly superior to any other global or regional CMR parameter.

Conclusion

Healing of myocarditis can be monitored by native myocardial T1 and T2 measurements without the need for contrast media. Both native myocardial T1 and T2 provide an excellent performance for assessing the stage of myocarditis by CMR.

Defining the role of fire in alleviating seed dormancy in a rare Mediterranean endemic subshrub

Fire is a topical issue in the management of many ecosystems globally that face a drying climate. Understanding the role of fire in such ecosystems is critical to inform appropriate management practices, particularly in the case of rare and ecologically specialized species. The Mediterranean heathlands are highly fire-prone and occur in a biodiversity hotspot increasingly threatened by human activities, and determining the reproductive thresholds of at-risk heathland species is critical to ensuring the success of future conservation initiatives. This study examined the germination biology of the threatened carnivorous subshrub Drosophyllum lusitanicum, with specific focus on the role of fire-related cues (heat and smoke) in combination with seasonal temperatures and moisture conditions to determine how these factors regulate seed dormancy and germination. We found that D. lusitanicum produces water-permeable, physiologically dormant seeds with a fully developed, capitate embryo that when fresh (~1 month old) and without treatment germinate to 20-40 % within 4-8 weeks. Seeds possess a restricted thermal window (15-20 °C) for germination and a neutral photoblastic response. Seed dormancy was overcome through precision nicking of the seed coat (>90 % germination) or by short exposure to dry heat (80 or 100 °C) for 5-30 min (60-100 % germination). We propose seedling emergence from the soil seed bank may be cued by the passage of fire, or by soil disturbance from the movement and browsing of animals. Long-term population viability is likely to be contingent upon appropriate management of the persistent soil seed bank, as well as the adequate management of key ecological disturbances such as fire. Drosophyllum lusitanicum faces an increasingly bleak future in the absence of conservation and management initiatives aimed at reducing habitat fragmentation in heathlands and aligning fire management and livestock practices with biodiversity outcomes.

Plant carnivory beyond bogs: reliance on prey feeding in Drosophyllum lusitanicum (Drosophyllaceae) in dry Mediterranean heathland habitats

Background and Aims

In a cost-benefit framework, plant carnivory is hypothesized to be an adaptation to nutrient-poor soils in sunny, wetland habitats. However, apparent exceptions to this cost-benefit model exist, although they have been rarely studied. One of these exceptions is the carnivorous subshrub Drosophyllum lusitanicum , which thrives in Mediterranean heathlands on dry sandstone soils and has relatively well-developed, xeromorphic roots. Here, the roles of leaf (carnivory) and root (soil) nutrient uptake in growth promotion of this particular species were assessed.

Methods

In a greenhouse experiment, plants were fed with laboratory-reared fruit flies ( Drosophila virilis ) and received two concentrations of soil nutrients in a factorial design. Above-ground plant growth and final above- and below-ground dry biomass after 13 weeks were recorded. Nutrient uptake via roots was also evaluated, using stable nitrogen isotope analysis.

Key Results

Insect feeding resulted in significantly higher growth and above- and below-ground biomass compared with soil fertilization. No additional benefits of fertilization were discernable when plants were insect-fed, indicating that roots were not efficient in nutrient absorption.

Conclusions

The first evidence of strong reliance on insect prey feeding in a dry-soil carnivorous plant with well-developed roots is provided, suggesting that carnivory per se does not preclude persistence in dry habitats. Instead, the combination of carnivory and xeromorphic root features allows Drosophyllum to thrive on non-waterlogged soils. New evidence is added to recent research emphasizing the role of root systems of carnivorous plants in explaining their distribution, partly challenging the cost-benefit hypothesis.

Seed Pubescence and Shape Modulate Adaptive Responses to Fire Cues

Post-fire recruitment by seeds is regarded as an adaptive response in fire-prone ecosystems. Nevertheless, little is known about which heritable seed traits are functional to the main signals of fire (heat and smoke), thus having the potential to evolve. Here, we explored whether three seed traits (pubescence, dormancy and shape) and fire regime modulate seed response to fire cues(heat and smoke). As a model study system, we used Helenium aromaticum (Asteraceae), a native annual forb from the Chilean matorral, where fires are anthropogenic. We related seed trait values with fitness responses (germination and survival) after exposure to heat-shock and smoke experimental treatments on seeds from 10 H. aromaticum wild populations. We performed a phenotypic selection experiment to examine the relationship of seed traits with post-treatment fitness within a population (adaptive hypothesis). We then explored whether fire frequency in natural habitats was associated with trait expression across populations, and with germination and survival responses to experimental fire-cues. We found that populations subjected to higher fire frequency had, in average, more rounded and pubescent seeds than populations from rarely burned areas. Populations with more rounded and pubescent seeds were more resistant to 80°C heat-shock and smoke treatments.There was correlated selection on seed traits: pubescent-rounded or glabrouscent-elongated seeds had the highest probability of germinating after heat-shock treatments. Seed pubescence and shape in H. aromaticum are heritable traits that modulate adaptive responses to fire. Our results provide new insights into the process of plant adaptation to fire and highlight the relevance of human-made fires as a strong evolutionary agent in the Anthropocene.

The predictive value of different equations for estimation of glomerular filtration rate in patients with coronary artery disease - Results from the AtheroGene study

BACKGROUND

Impaired renal function leads to dramatically increased risk for the development and progression of coronary artery disease (CAD). Therefore we aimed to assess the predictive value of different equations for estimated glomerular filtration rate (eGFR) in CAD-patients.

METHODS

From the AtheroGene study 2135 patients were included. eGFR was calculated using the 4-variable Modification of Diet in Renal Disease (4MDRD) equation for serum creatinine (sCr), the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for sCr and cystatin C (CysC) each alone, and in combination (CysC/sCr). eGFR was assessed regarding the combined outcome of cardiovascular death and non-fatal myocardial infarction and regarding complex CAD represented by a SYNTAX score ≥23. Median follow-up was 4.3years.

RESULTS

Only the CKD-EPI equation using CysC could differentiate between eGFR >90ml/min/1.73m(2) vs. eGFR 60-90ml/min/1.73m(2) according to the occurrence of an endpoint event (log-rank test p=0.009). In the Cox regression analysis only eGFR calculated by CKD-EPI equation for CysC (Hazard ratio per 1 standard deviation (HR) 1.27 (95% CI 1.07-1.50); p=0.007) and for CysC/sCr (HR 1.22 (95% CI 1.02-1.46); p=0.026) were predictive regarding the outcome after adjustment for cardiovascular risk factors and Nt-proBNP. Furthermore, only eGFR calculated by CKD-EPI equation for CysC (odds ratio (OR) 1.57 (95% CI 1.36-1.78); p<0.001) and for CysC/sCr (OR 1.32 (95% CI 1.13-1.53); p<0.001) were significantly associated with a SYNTAX score ≥23.

CONCLUSION

In patients with CAD the CKD-EPI equation for CysC and for CysC/sCr provided the best predictive value regarding the prognosis and the severity of CAD.

Attract them anyway: benefits of large, showy flowers in a highly autogamous, carnivorous plant species

Reproductive biology of carnivorous plants has largely been studied on species that rely on insects as pollinators and prey, creating potential conflicts. Autogamous pollination, although present in some carnivorous species, has received less attention. In angiosperms, autogamous self-fertilization is expected to lead to a reduction in flower size, thereby reducing resource allocation to structures that attract pollinators. A notable exception is the carnivorous pyrophyteDrosophyllum lusitanicum(Drosophyllaceae), which has been described as an autogamous selfing species but produces large, yellow flowers. Using a flower removal and a pollination experiment, we assessed, respectively, whether large flowers in this species may serve as an attracting device to prey insects or whether previously reported high selfing rates for this species in peripheral populations may be lower in more central, less isolated populations. We found no differences between flower-removed plants and intact, flowering plants in numbers of prey insects trapped. We also found no indication of reduced potential for autogamous reproduction, in terms of either seed set or seed size. However, our results showed significant increases in seed set of bagged, hand-pollinated flowers and unbagged flowers exposed to insect visitation compared with bagged, non-manipulated flowers that could only self-pollinate autonomously. Considering that the key life-history strategy of this pyrophytic species is to maintain a viable seed bank, any increase in seed set through insect pollinator activity would increase plant fitness. This in turn would explain the maintenance of large, conspicuous flowers in a highly autogamous, carnivorous plant.

Effective prey attraction in the rare Drosophyllum lusitanicum, a flypaper-trap carnivorous plant

PREMISE OF THE STUDY

Carnivorous plants have unusually modified leaves to trap insects as an adaptation to low-nutrient environments. Disparate mechanisms have been suggested as luring traits to attract prey insects into their deadly leaves, ranging from very elaborate to none at all. Drosophyllum lusitanicum is a rare carnivorous plant with a common flypaper-trap mechanism. Here we tested whether Drosophyllum plants lure prey insects into their leaves or they act just as passive traps.

METHODS

We compared prey capture between live, potted plants and Drosophyllum-shaped artificial mimics coated with odorless glue. Since this species is insect-pollinated, we also explored the possible existence of a pollinator-prey conflict by quantifying the similarity between the pollination and prey guilds in a natural population. All experiments were done in southern Spain.

KEY RESULTS

The sticky leaves of Drosophyllum captured significantly more prey than mimics, particularly small dipterans. Prey attraction, likely exerted by scent or visual cues, seems to be unrelated to pollinator attraction by flowers, as inferred from the low similarity between pollinator and prey insect faunas found in this species.

CONCLUSIONS

Our results illustrate the effectiveness of this carnivorous species at attracting insects to their flypaper-trap leaves.

Emerging pollutants in the Esmeraldas watershed in Ecuador: discharge and attenuation of emerging organic pollutants along the San Pedro-Guayllabamba-Esmeraldas rivers

Water quality characteristics and emerging organic pollutants were sampled along the San Pedro-Guayllabamba-Esmeraldas River and its main water pollution streams in the summer of 2013. The annual flow rate of the stream is 22 000 Mm(3) y(-1) and it collects the wastewater of Quito-Ecuador in the Andes and supplies drinking water to the city of Esmeraldas near the Pacific Ocean. The most persistent emerging pollutants were carbamazepine and acesulfame, which were found to be stable along the San Pedro-Guayllabamba-Esmeraldas River, whereas the concentration of most other organic emerging pollutants, such as caffeine, sulfamethoxazole, venlafaxine, O-desmethylvenlafaxine, and steroidal estrogens, was degraded to a large extent along the 300 km flow. The mass rate of the sum of cocaine and benzoylecgonine, its metabolite, was increased along the stream, which may be attributed to coca plantations and wild coca trees. This raises the possibility of using river monitoring as an indirect way to learn about changes in coca plantations in their watersheds. Several organic emerging pollutants, such as venlafaxine, carbamazepine, sulphamethoxazole, and benzoylecgonine, survived even the filtration treatment at the Esmeraldas drinking water system, though all except for benzoylecgonine are found below 20 ng L(-1), and are therefore not likely to cause adverse health effects. The research provides a way to compare drug consumption in a major Latin American city (Quito) and shows that the consumption of most sampled drugs (carbamazepine, venlafaxine, O-desmethylvenlafaxine, sulphamethoxazole, ethinylestradiol) was below their average consumption level in Europe, Israel, and North America.

Dose Rate Dependence of Radiation Induced IgG Membrane Receptor Alteration [1]

Mouse lymph node lymphocytes are irradiated at differ­ent dose rates and the B-cell receptors to anti IgG are tested. The expression of receptors is inhibited by irradia­tion. It is shown that the effectivity of irradiation increases with decreasing dose rate suggesting that membrane dam ­ age may be important for situations of chronic irradiation or implant radiotherapy.

Dose Rate Dependence of Radiation Induced IgG Membrane Receptor Alteration [1]

Mouse lymph node lymphocytes are irradiated at different dose rates and the B-cell receptors to anti IgG are tested. The expression of receptors is inhibited by irradiation. It is shown that the effectivity of irradiation increases with decreasing dose rate suggesting that membrane damage may be important for situations of chronic irradiation or implant radiotherapy.

Population genetic structure of a sandstone specialist and a generalist heath species at two levels of sandstone patchiness across the Strait of Gibraltar

Many habitat specialist species are originally composed of small, discontinuous populations because their habitats are naturally fragmented or patchy. They may have suffered the long-term effects of natural patchiness. Mediterranean heathlands, a representative habitat in the Strait of Gibraltar region, are associated with nutrient-poor, acidic sandstone soils. Sandstone soil patches in the African side of the Strait (Tangier) are, in general, smaller and more scattered than in the European side (Algeciras). In this study, we analyze the effect of this sandstone patchiness on the population genetic diversity and structure of two Erica species from these Mediterranean heathlands that differ in their edaphic specificity, E. australis, sandstone specialist, and E. arborea, generalist. Average levels of within-population genetic diversity and gene flow between populations were significantly lower in Tangier (high sandstone patchiness) than in Algeciras (low patchiness) for the sandstone specialist, whereas no differences between both sides of the Strait were detected in the edaphic generalist. Since most endemic species in Mediterranean heathlands of the Strait of Gibraltar are sandstone specialists, these results highlight an increased vulnerability to loss of genetic diversity and local extinction of the heathland endemic flora in the Tangier side of the Strait of Gibraltar.