Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs <7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

Phase III impact of telerehabilitation in patients with coronary heart disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) in coronary heart disease (CAD) has been shown to improve physical capability and health-related quality of life, reducing morbimortality. However, CR accessibility is still low and patient adherence remains poor. It has been hypothesized that using mobile applications to telemonitor exercise-based CR would increase patient adherence to CR, improving results. Hybrid cardiac telerehabilitation (HCTR) is a new concept that includes center and home interventions.

Objectives

Investigate the effects of HCTR program on improving physical activity, quality of life and reducing cardiovascular risk factors among patients with CAD 1 year after CR phase II.

Materials and methods

Longitudinal retrospective study with patients who attended phase 2 CR program (CRP) at a hospital center between august 2018-november 2020. They were divided in 2 groups: group 1 completed conventional CRP (CCRP), 12 weeks of monitored hospital physical exercise and educational sessions; group 2 participated on HCTR program (CCRP associated to a tele-monitorization platform consisting of a mobile application, MOVIDA.eros, with medical prescription of physical exercise and remote interaction). Group 2 maintained use of MOVIDA.eros on phase 3. Evaluations were performed on T0 – phase 2 onset, T1 – end of phase 2, T2 – 1 year after T1, with registration of age, gender, occupation, body mass index (BMI), exercise stress testing, echocardiogram (evaluation of left ventricular ejection fraction [LVEF]), LDL, HDL cholesterol, triglycerides, NTproBNP levels, and application of EuroQol-5D questionnaire (EQ5D), International Physical Activity Questionnaire – Short Form (IPAQ).

Statistical analysis was completed through software SPSS v28. p-values <0.05 were considered statistically significant.

Results

We analyzed 68 patients, 46 on group 1 and 22 on group 2. Variable analysis revealed similar group characteristics, except for age (p=0.011) and LVEF (p=0.005). There was an association between HCTR adherence and occupation (p=0.002; greater proportion of intellectual professionals on group 2). We observed a significant IPAQ (p=0.018) and EQ-5D index (p=0.034) improvement between T0 to T1 in both groups, but only in group 2 persisted till T2. In exercise stress testing, both groups revealed an increase in METs at T1 and decrease at T2, without significant differences between them. Regarding lipid profile, HbA1c, NTproBNP and BMI, both groups improved from T0 to T1 maintaining it till T2 with no differences between them, however in group 2 HDL cholesterol levels were greater and HbA1c levels were lower than group 1. In both groups, LVEF increased from T0 to T1 and from T1 to T2 in both groups, with faster and higher improvement in group 2.

Conclusions

HCTR outperformed CCRP improving physical activity, patient quality of life, HDL cholesterol and faster improvement of LVEF. These findings encourage the use of a mobile platform in CR.

Impact of severe mitral annular calcification on mitral regurgitation after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequent in patients with aortic stenosis, and its presence is associated with increased cardiovascular morbidity and mortality. Not infrequently, it is associated with significant morphologic and functional abnormalities of the mitral valve apparatus.

Purpose

 The aim of this work is to evaluate the relationship between severe MAC and the presence and development of significant mitral regurgitation after TAVI.

Methods

 We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019. Clinical, echocardiographic and procedure-related data were collected until a follow-up of 6 months. Statistical analysis was conducted on IBM SPSS® Statistics software. Descriptive statistics were calculated for all variables. Sample T-test, Chi-square and Wilcoxon sign test were used. A p-value < 0.05 was considered significant. The presence and severity of MAC was defined according to echocardiographic data. Severe MAC was defined by the presence of calcification of more than half of the mitral annular circumference.

Results

 A total of 343 patients were enrolled in the study. The mean age of the population was 80 ± 8 years, 45% were male. Mean functional area was 0.75 ± 0.18 cm2, mean transvalvular pressure gradient was 48 ± 15 mmHg and the mean left ventricular ejection fraction (LVEF) was 54 ± 14%.  MAC was detected in 231 (67%) patients. In 44 (19%) of these patients, MAC was graded as severe. Patients with severe MAC tended to have higher prevalence of moderate (27.3 vs 20.4%, p = 0.30) as well as severe (4.5 vs 1.8%, p = 0.24) mitral regurgitation at baseline. After TAVI, the prevalence of moderate mitral regurgitation at 6 months was similar between both groups (22.5 vs 20.4%, p = 0.76). Although not reaching statistical significance, patients with severe MAC had higher prevalence of severe mitral regurgitation at 6 months post-procedure (12.2 VS 5.0%, p = 0.07) as well as higher incidence of worsening of mitral regurgitation (34.2 vs 23.7%, p = 0.16). The proportion of patients that had improvement (13.2 vs 15.0%, p = 0.76) or no change (52.6 vs 61.3%, p = 0.31) in the degree of mitral regurgitation was similar in both groups. 

Conclusion

 The presence of severe MAC at baseline echocardiography in patients undergoing TAVI may be associated with worsening of mitral regurgitation after the procedure. These patients tend to have higher prevalence of severe mitral regurgitation post-TAVI. Further studies are needed in order to further elucidate this association.

Can aortic calcium score predict new conduction disturbances in pos-transcatheter aortic valve implantation?

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve implantation (TAVI) may be the first line treatment for severe aortic stenosis according to overall patient characteristics. Semi-quantitative Agatston score (AS), which quantifies aortic calcium by cardiac computed tomography (CCT), has knowledgeable practical and clinical implications, and is performed in TAVI diagnostic workup. Since conduction disturbances continue to be the most frequent complication, further refinements are required to predict high-risk patients.

Purpose

To access if aortic AS relates with new conduction disturbances and permanent pacemaker (PPM) implantation in patients undergoing TAVI.

Methods

We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019; patients with previous permanent pacemaker (PPM) or had no aortic AS were excluded. Clinical and electrocardiogram (ECG) data were collected at admission and after the procedure. All categorical variables are reported as numbers and percentages. Continuous variables were analyzed using the two-tailed unpaired Student’s t-test and are reported as mean values and the standard deviation. Statistical analysis was performed using the IBM SPSS.

Results

172 patients with a mean age 79 ± 9.1 years old were included (see table 1 for baseline characteristics). AS was on average 3008 ± 2262 (see table 2 for remaining diagnostic workup and procedure characteristics).

Comparing AS with new conduction disturbances, no statistically significant difference was found for new complete left branch block (LBBB) (no vs new LBBB, AS: 3179 ± 2555 vs 2637 ± 1388, p= 0,15) and with new complete atrioventricular block (AVB) (no vs new AVB, AS: 2834 ± 1520 vs 4485 ± 5285, p = 0.2). Considering PPM implantation after TAVI, there was a tendency for higher AS and PPM implantation (no vs PPM implantation, AS: 2756 ± 1451 vs 4242 ± 4310, p = 0.07).

In patients who had pre-ballooning, there was no difference relating to AS; however, in patients who had no pre-ballooning there was a trend to higher AS and PPM implantation (no vs PPM implantation, AS: 2417 ± 1301 vs 4616 ± 4969, p = 0.06). No statistically significant difference was found when comparing earlier (Portico, CoreValve Evolut R) vs newer valves (CoreValve Evolut Pro; Edward Sapiens 3; Accurate Neo).

Conclusion

Aortic calcium measured by Agatston score did not show a correlation with new LBBB or new AVB after TAVI. Nevertheless, it seems to be a trend for higher AS and PPM implantation; this was more noticeable when pre-ballooning was not performed. Further studies are needed in order to further elucidate this association. Abstract Figure. Patients baseline characteristics  Abstract Figure. TAVI diagnostic workup and procedure

Catheter ablation supported by extracorporeal membrane oxygenation -last resort treatment of arrhythmic storm?

Introduction

Arrhythmic storm (AS) is associated with high mortality, even with best medical care and hemodynamic support. If medical therapeutic failure, electrophysiological mapping and ablation are potential lifesaving therapies. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and can be used as a salvage intervention in patients with cardiogenic shock. Considering the seriousness of AS and the technical complexity involved, catheter ablation supported by VA-ECMO is infrequently performed. We sought to assess the safety and effectiveness of emergent catheter ablation procedures performed in patients on VA-ECMO at our hospital.

Methods

Retrospective study of all ventricular tachycardia (VT) catheter ablation procedures performed with VA-ECMO support at a tertiary centre between 2016 and 2020. Follow-up data was obtained from review of electronical records.

Results

Five patients underwent 6 emergent VT ablation procedures due to AS. The median age was 62 years (range, 52) and 4 patients were men. Three patients had VT at admission, while 2 were admitted with an acute coronary syndrome and developed VT during the hospitalization. Four patients had ischemic heart disease, though only 1 had previous history of VT; the remaining patient presented no structural heart disease. Median left ventricle ejection fraction was 11% (range 30).

All patients had incomplete response to amiodarone, lidocaine or overdrive pacing, before being proposed to catheter ablation. Four patients were on ECMO support before ablation, while 1 was cannulated during the procedure due to hemodynamic instability. Ablation was performed using a retrograde approach in 3 patients, and combined retrograde and transeptal access in 2; one patient had epicardial ablation after unsuccessful endovascular approach. Three patients had left ventricle substrate ablation and the remaining 2 of the right ventricle. No major complications were seen directly related to the procedures.

The median length of stay in intensive care unit was 22 days (range 41 days). Weaning of VA-ECMO was accomplished in all patients. Two patient died during the same hospitalization (one due to uncontrolled arrhythmic events). At a median 23 months (range 31) of follow-up of the surviving patients, two had recurrence of VT but no one had return of AS.

Conclusion

In our sample VT ablation on VA-ECMO support was a safe procedure, with no immediate complications. However, as reported in the literature, a high mortality rate was observed both in-hospital and during follow-up, mostly related to advanced structural heart disease. Also, considerable VT recurrence rates were seen, but with no re-hospitalization. Our experience shows that catheter ablation is a life-saving procedure in otherwise uncontrollable AS and allowed absolute success in weaning VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Coronary calcification by computed tomography in patients with paroxysmal and persistent atrial fibrillation undergoing catheter ablation

Introduction

Cardiac computed tomography (CCT) is routinely performed for pulmonary vein isolation (PVI) planning in patients with paroxysmal or persistent atrial fibrillation (AF). This imaging method can also identify coronary artery calcium (CAC).

Purpose

To evaluate the prevalence of CAC in patients with paroxysmal and persistent AF undergoing catheter ablation.

Methods

Cross-sectional study including patients with AF/atrial flutter (AFL) undergoing CCT for ablation procedure planning from 2017 to 2019. Baseline clinical and demographic data were collected and CAC score was assessed using the Agatston method. Patients with paroxysmal and persistent AF/AFL (defined according to 2020 European Society of Cardiology guidelines for the diagnosis and management of AF) were compared.

Results

A total of 474 patients were included (441 with AF and 33 with AFL), with a mean age of 57±12 years, of which 295 (62%) were males. CHA2DS2-VASc score was ≥1 (male) or ≥2 (female) in 278 (64%) patients and most patients had a low to moderate cardiovascular risk (259, 80%). CAC was identified in 254 (54%) patients. AF/AFL was paroxysmal in 348 (75%) patients and persistent in 116 (25%). Baseline characteristics and cardiovascular risk factors were similar between groups except for diabetes mellitus (33 [10%] vs 22 [20%], p=0.012) and valvular heart disease (13 [4%] vs 18 [16%], p<0.001) that were more prevalent in patients with persistent AF/AFL. Patients with persistent AF/AFL had higher left atrial volume and left ventricle mass (36±8 vs 43±12 ml/m2, p<0.001 and 90±22 vs 96±22 g/m2, p=0.041). CAC was more frequently present in patients with persistent AF/AFL (175 [50%] vs 72 [62%], p=0.028), especially CAC score >100 (58 [17%] vs 35 [30%], p=0.002). After multivariate analysis, CAC score>100 remained an independent predictor of persistent AF/AFL (OR 2.12, 95% CI 1.18–3.82, p=0.013) along with higher left atrial volume (OR 1.06, 95% CI 1.03–1.08, p<0.001).

Conclusion

In this study, coronary artery calcium was present in more than half of AF/FLA patients undergoing catheter ablation. Patients with persistent AF/AFL showed higher calcium scores and this could derive from chronic, more advanced disease. Especially in those patients, opportunistic CV risk screening and CAC-guided clinical management might be clinically useful.

Funding Acknowledgement

Type of funding sources: None.

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Introduction

Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes.

Methods

In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)].

Results

Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68).

Conclusion

A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery calcium in patients with atrial fibrillation undergoing catheter ablation – an opportunity to personalize cardiovascular and thromboembolic risk management

Introduction

There is a well-established association between atrial fibrillation (AF) and coronary artery disease (CAD). Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular risk stratification and guide strategies of cardiovascular (CV) primary prevention.

Purpose

To evaluate the prevalence and clinical implications of CACS in terms of CV and thromboembolic risk stratification and preventive therapies, in patients with AF and atrial flutter (AFL) undergoing catheter ablation.

Methods

Cross-sectional study including patients with AF/AFL undergoing multidetector computed tomography (MDCT) for ablation procedure planning from 2017 to 2019. Baseline clinical and demographical data were collected. CV and thromboembolic risks were evaluated based on the SCORE (Systematic Coronary Risk Evaluation) system and CHA2DS2-VASc score. CACS was assessed in patients without history of coronary artery disease using the Agatston method.

Results

A total of 474 patients were included (441 with AF and 33 with AFL, mean age of 58±10 years, 62% male). Excluding those over 70 years of age (n=50, 11%), most patients had low (n=69, 22%) or moderate (n=188, 60%) CV risk and 277 (64%) patients had a CHA2DS2-VASc score ≥1 (male) or ≥2 (female). Overall, 265 patients (65%) were under chronic anticoagulation and 157 (39%) were under statin therapy. CAC was present in 254 (54%) patients and showed a multivessel distribution in 62% of the cases. The left main stem was affected in 81 (17%) patients and the left anterior descending artery in 211 (45%). Incorporating CACS>100 as a variable in CHA2DS2-VASc score (vascular disease parameter in patients without history of vascular disease) would have resulted in a significant score reclassification (n=87, 20%) and identification of new potential candidates for anticoagulation (n=12, 3%). Additional, anticoagulation would be indicated as a class IA recommendation in more 26 (6%) patients. Twenty three percent of patients with zero calcium were taking statins, and only 7% of patients with a CACS >300 were on high-intensity statin therapy. According to the recommendations and based on their CACS and current therapy, 103 (25%) patients would be candidates for statin therapy and 69 (17%) patients would be candidates for changes in the current statin therapy intensity (Table 1).

Conclusion

In our study, more than half of the patients undergoing MDCT before AF/AFL catheter ablation had coronary calcium above zero. Our findings suggest that an opportunistic evaluation of CACS can be clinically valuable in thromboembolic risk stratification and management of preventive pharmacological strategies such as anticoagulation and statins.

Funding Acknowledgement

Type of funding sources: None.

Is there a real difference in approach between women and men with non-ST-segment elevation myocardial infarction? Insights from a multicentre national registry

 

In patients with non-ST-elevation myocardial infarction (NSTEMI), the early invasive strategy has shown benefit in morbidity and mortality, especially in intermediate-to-high risk patients. However, women still seem to have a lower revascularization rate, regardless of the risk.

The aim of this study is to describe our clinical practice reality about the performance of the invasive strategy between genders among NSTEMI patients, in Portugal.

The authors performed a retrospective analysis of patients admitted with NSTEMI included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and February 2021. A propensity score matching included baseline characteristics and previous history was applied. Comparison tests and log-rank test were performed. A p-value less than 0.05 was considered statistically significant.

A total of 11858 patients with NSTEMI were included, of which 71.3% (n=8450) were men. After the propensity score performing, 4458 patients were analysed, 50.0% (n=2229) men. Table 1 shows the most important baseline characteristics.

The authors found a significant delay in hospital admission after the onset of symptoms in women (median of 6 hours and 48 minutes) compared to men (median of 5 hours) (p<0.01). Grace score was higher in males (mean 153 points) than in females (mean 145 points) (p<0.01).

The cardiac catheterization was performed in 82.9% (n=3695) of the patients, with no difference between genders (p-value=0.19), as shown in table 2. Among those who underwent cardiac catheterisation, the presence of significant stenosis and coronary occlusion was greater in males, for almost all localizations. The absence of obstructive coronary lesions was more common in females (p-value<0.01).

During hospitalization, sustained ventricular tachycardia was more prevalent in males (p-value =0.01), with no significant difference for other complications or in-hospital mortality.

A 1-year follow-up of 2351 patients (1184 men and 1163 women) was analysed, with survival of 91.2% (n=1080) in men and 91.0% (n=1056) in women, with no significant difference (p-value=0.80).

In conclusion, we observed that women are admitted to the hospital later than men and have a lower Grace score at admission. However, the standardized analysis of the groups allows us to infer that the invasive strategy does not seem to be less frequent or late in women, as observed in other populations. A more recent analysis, including risk groups, would be interesting to clarify the results.

Funding Acknowledgement

Type of funding sources: None.

What am I doing here? Enablers and barriers to community-based cardiac rehabilitation attendance: a qualitative study utilising a behavioural science approach

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Community Engaged Scholars Programme (CES-P), PPI Ignite, National University of Ireland, Galway

Background

Despite the well-established benefits of cardiovascular prevention and rehabilitation, programme uptake rates remain suboptimal. Delivering cardiac rehabilitation (CR) in the community offers an alternative model of care that may help address the challenges that exist around uptake and accessibility of CR. Yet in comparison to traditional hospital based CR programmes less is known about the enablers and barriers that may be unique to attending community based CR programmes.

Purpose

This study aimed to identify enablers and barriers to attending and completing a community-based CR programme from the patient perspective.

Methods

Individuals who were referred to a 12 week, interdisciplinary, multi-component community-based CR programme were invited to take part in semi-structured interviews. Reasons for attending or not attending the programme and for completing or not completing the full programme were discussed. Purposeful sampling was used to obtain variation in age, gender, and level of engagement with the programme. Interviews were transcribed verbatim and analysed using framework analysis guided by the Capability Opportunity Motivation (COM B) Model and the Theoretical Domains Framework, to explore initial attendance and programme completion.

Results

Data saturation was achieved with sixteen participants. The majority of the identified barriers and enablers were common to both initial programme attendance and completion of programme. Having the social opportunity to receive support from peers, family members and staff was seen as an important enabler. While ease of access to a programme based in the community enabled attendance and completion, for some, distance to the cardiac rehabilitation centre was a barrier. Further barriers related to capability issues regarding poor physical health, time, work commitments and travel. Key motivational enablers included, beliefs around consequences, improved health status, knowledge, goals, intentions and personality. Identity was an important determinant of attendance as participants discussed their understanding of "what am I doing here?" Some participants identified themselves as the type of person who would benefit from the programme and others did not. For example, some felt the programme would suit those who needed motivation to enhance their health and some felt the programme was more or less suited to people of different ages and fitness levels.

Conclusion

The results suggest that interventions to enhance attendance at community-based CR need to address multiple factors related to capability, opportunity and motivation. While there is no one model of cardiovascular prevention and rehabilitation that will meet the needs of all patients, patients should be offered community based programmes as part of a choice of options that fit their needs and personal preferences.

The effect of denudation and injection timing in the reproductive outcomes of ICSI cycles: new insights into the risk of in vitro oocyte ageing

STUDY QUESTION

Does the time elapsed between oocyte pick-up (OPU) and denudation or injection affect the probability of achieving a live birth (LB) in ICSI cycles?

SUMMARY ANSWER

Prolonged oocyte culture before denudation (>4 h) was associated with an increase in clinical pregnancy (CP), LB and cumulative LB (CLB) rates when compared with earlier denudation timings.

WHAT IS KNOWN ALREADY

Oocyte maturation is a complex and dynamic process involving structural and biochemical modifications in the cell necessary to support fertilization and early embryo development. While meiotic competence is easily identifiable by the presence of an extruded first polar body, cytoplasmic maturation cannot be assessed microscopically. Culturing oocytes with their surrounding cumulus cells (CCs) prior to ICSI can enhance the completion of in vitro cytoplasmic maturation; conversely, prolonged culture may induce cell degeneration. The optimal culture intervals prior to oocyte denudation and/or injection have not yet been established and may prove relevant for the improvement of ICSI reproductive outcomes.

STUDY DESIGN, SIZE, DURATION

This is a single-centre retrospective cohort analysis of 1378 ICSI cycles performed between January 2005 and October 2018. Data were categorized according to: (i) the time interval between OPU and denudation (<3 h, 3-4 h and ≥4 h), (ii) the time interval between denudation and ICSI (<1.5 h, 1.5-2 h, ≥2 h) and (iii) the time interval between OPU and ICSI (<5 h, 5-6 h and ≥6 h). The effect of these timings on fertilization, CP, LB and CLB rates were compared. The culture intervals between different procedures were dependent exclusively on laboratory workload.

PARTICIPANTS/MATERIALS, SETTING, METHODS

ICSI cycles performed in women younger than 40 years old using autologous gametes with at least one metaphase II injected oocyte were included. The effect of oocyte culture duration prior to denudation and injection of the oocytes was compared using multivariable regression accounting for potential confounding variables.

MAIN RESULTS AND THE ROLE OF CHANCE

Fertilization and oocyte damage rate after ICSI was found to be independent of the time interval to denudation (<3 h, 3-4 h and ≥4 h) and/or injection (<5 h, 5-6 h and ≥6 h). Extending oocyte culture before denudation significantly improved CP (29.5%, 42.7% and 50.6%, respectively), LB (25.1%, 34.4% and 40.7%, respectively) and CLB rates (26.0%, 36.1% and 42.2%, respectively), particularly if the time interval was at least 4 h. Additionally, LB (31.7%, 35.8% and 27.4%, respectively) and CLB rates (34.2%, 36.6% and 27.7%, respectively) were also dependent on the time from OPU to injection.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by its retrospective nature and potential unmeasured confounding cannot be excluded. Furthermore, the effect of even shorter or longer periods of culture before denudation and/or injection were not evaluated and should not be extrapolated from these results.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings propose new evidence of a previously unrecognized protective effect of the CCs-oocyte interactions in human ART, raising the question of a possible downstream effect in embryogenesis which significantly affects LB rates. Additionally, this is the first study to suggest a negative effect of further extending culture before ICSI on LB and CLB rates, thus potentially allowing for the narrowing of an optimal ICSI time interval. Simple strategies such as the establishment of more effective time frames to perform these procedures and adjusting laboratory practice may prove beneficial, ultimately improving ICSI reproductive outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Fetal cerebellar growth and Sylvian fissure maturation: international standards from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To construct international ultrasound-based standards for fetal cerebellar growth and Sylvian fissure maturation.

METHODS

Healthy, well nourished pregnant women, enrolled at < 14 weeks' gestation in the Fetal Growth Longitudinal Study (FGLS) of INTERGROWTH-21^st , an international multicenter, population-based project, underwent serial three-dimensional (3D) fetal ultrasound scans every 5 ± 1 weeks until delivery in study sites located in Brazil, India, Italy, Kenya and the UK. In the present analysis, only those fetuses that underwent developmental assessment at 2 years of age were included. We measured the transcerebellar diameter and assessed Sylvian fissure maturation using two-dimensional ultrasound images extracted from available 3D fetal head volumes. The appropriateness of pooling data from the five sites was assessed using variance component analysis and standardized site differences. For each Sylvian fissure maturation score (left or right side), mean gestational age and 95% CI were calculated. Transcerebellar diameter was modeled using fractional polynomial regression, and goodness of fit was assessed.

RESULTS

Of those children in the original FGLS cohort who had developmental assessment at 2 years of age, 1130 also had an available 3D ultrasound fetal head volume. The sociodemographic characteristics and pregnancy/perinatal outcomes of the study sample confirmed the health and low-risk status of the population studied. In addition, the fetuses had low morbidity and adequate growth and development at 2 years of age. In total, 3016 and 2359 individual volumes were available for transcerebellar-diameter and Sylvian-fissure analysis, respectively. Variance component analysis and standardized site differences showed that the five study populations were sufficiently similar on the basis of predefined criteria for the data to be pooled to produce international standards. A second-degree fractional polynomial provided the best fit for modeling transcerebellar diameter; we then estimated gestational-age-specific 3^rd , 50^th and 97^th smoothed centiles. Goodness-of-fit analysis comparing empirical centiles with smoothed centile curves showed good agreement. The Sylvian fissure increased in maturation with advancing gestation, with complete overlap of the mean gestational age and 95% CIs between the sexes for each development score. No differences in Sylvian fissure maturation between the right and left hemispheres were observed.

CONCLUSION

We present, for the first time, international standards for fetal cerebellar growth and Sylvian fissure maturation throughout pregnancy based on a healthy fetal population that exhibited adequate growth and development at 2 years of age. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Is coronary computed tomography angiography a good choice for elders and high probability cases?

Introduction

Coronary computed tomography angiography (cCTA) is widely considered the optimal non-invasive test to rule out coronary artery disease (CAD) and the gatekeeper for invasive coronary angiography (ICA). However, its diagnostic utility in elderly patients (pts) and in cases of high pre-test probability (PTP) is still questioned.

Aim

To determine whether older age and high PTP are correlated with non-diagnostic cCTA scans in pts with suspected chronic coronary syndrome (CCS).

Methods

Single-centre retrospective study of 302 pts with suspected CAD assigned to two groups: (A) 207 pts aged ≥70 years (y); (B) 95 aged &lt;70y. Younger pts were randomly selected from our database. We excluded pts with known history of CAD and suspected acute coronary syndrome. A 192x2 dual-source CT equipment was used. Baseline demographic and clinical characteristics were collected as well as scan features and findings. We defined high PTP according to clinical Morise score. Our endpoint was the obtention of diagnostic scan (all segments evaluable). Multivariate analysis was performed to assess the determinants of non-diagnostic scans. We used SPSS Statistics 22 for statistical analysis.

Results

Overall, mean age was 68±9y and 53% were male. Elderly pts presented more co-morbidities (hypertension: 78.3 vs 54.7%, p&lt;0.01; hyperlipidaemia: 69.1 vs 52.6%, p&lt;0.01; pulmonary disease: 13.0 vs 4.2%, p=0.02) and high PTP more frequently (16.9 vs 6.3%, p&lt;0.01). Total coronary calcium score (CaS) was higher in elderly pts (382.7±658.7 vs 243.5±490.8, p=0.04); per-vessel, both left anterior descending (156.7±254.2 vs 92.2±187.8, p=0.01) and left circumflex (LCX) arteries (65.5±131.3 vs 26.8±67.6, p&lt;0.01) showed higher CaS in the elderly. Multiple calcified plaques (≥5) were also more common in this group (60.4 vs 45.3%, p=0.01). However, the proportion of pts with CaS considered prohibitive for angiography (13.5 vs 7.4%; p=0.12) and calcium blooming artefacts impairing interpretation (14.5 vs 12.5%; p=0.65) did not differ. A diagnostic study was more frequently obtained in younger pts but without reaching statistical significance (69.1 vs 76.8%; p=0.17). Obstructive CAD was equally identified (30.3 vs 30.4%; p=0.92) with a respective per-patient accuracy of 68.4% (13/19) and 57.1% (8/14) comparing with ICA when performed. Multivariate analysis showed that LCX CaS ≥75th percentile and multiple calcified plaques (≥5) were associated with non-diagnostic cCTA scan (Figure 1). High PTP (p=0.83) and age ≥70y (p=0.61) were not associated with the endpoint.

Conclusion

In this comparison study of elderly and young pts undergoing cCTA for suspected CCS, age ≥70y and high PTP were not associated with non-diagnostic tests while multiple calcified lesions and severe LCX calcification predicted inconclusive studies. Our results cast hope on the applicability of cCTA to elderly pts and cases with high PTP, although larger studies are required.

Funding Acknowledgement

Type of funding source: None

Blood biomarkers associated with inflammation predict poor prognosis in cerebral venous thrombosis:: a multicenter prospective observational study

BACKGROUND AND PURPOSE

Experimental studies suggest inflammation can contribute to blood barrier disruption and brain injury in cerebral venous thrombosis (CVT). We aimed to determine whether blood biomarkers of inflammation were associated with the evolution of brain lesions, persistent venous occlusion or functional outcome in patients with CVT.

METHODS

Pathophysiology of Venous Infarction-Prediction of Infarction and Recanalization in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Evaluation of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) concentrations in peripheral blood samples was performed at admission in 62 patients. Additional quantification of interleukin (IL)-6 was performed at day 1, 3 and 8 in 35 patients and 22 healthy controls. Standardized magnetic resonance imaging was performed at day 1, 8 and 90. Primary outcomes were early evolution of brain lesion, early recanalization and functional outcome at 90 days.

RESULTS

Interleukin-6 levels were increased in patients with CVT with a peak at baseline. IL-6, NLR and CRP levels were not related with brain lesion outcomes or early recanalization but had a significant association with unfavourable functional outcome at 90 days (IL-6: OR = 1.28, 95% CI: 1.05-1.56, P = 0.046; NLR: OR = 1.39, 95% CI: 1.4-1.87, P = 0.014; CRP: OR = 1.756, 95% CI: 1.010-3.051, P = 0.029). Baseline IL-6 had the best discriminative capacity, with an area under the receiver operating characteristic curve to predict unfavourable functional outcome of 0.74 (P = 0.031).

CONCLUSIONS

Increased baseline levels of NLR, CRP and IL-6 may serve as new predictive markers of worse functional prognosis at 90 days in patients with CVT. No association was found between inflammatory markers and early evolution of brain lesion or venous recanalization.

International standards for fetal brain structures based on serial ultrasound measurements from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To create prescriptive growth standards for five fetal brain structures, measured using ultrasound, in healthy, well-nourished women at low risk of impaired fetal growth and poor perinatal outcome, taking part in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21^st Project.

METHODS

This was a complementary analysis of a large, population-based, multicenter, longitudinal study. The sample analyzed was selected randomly from the overall FGLS population, ensuring an equal distribution among the eight diverse participating sites and of three-dimensional (3D) ultrasound volumes across pregnancy (range: 15-36 weeks' gestation). We measured, in planes reconstructed from 3D ultrasound volumes of the fetal head at different timepoints in pregnancy, the size of the parieto-occipital fissure (POF), Sylvian fissure (SF), anterior horn of the lateral ventricle, atrium of the posterior horn of the lateral ventricle (PV) and cisterna magna (CM). Fractional polynomials were used to construct the standards. Growth and development of the infants were assessed at 1 and 2 years of age to confirm their adequacy for constructing international standards.

RESULTS

From the entire FGLS cohort of 4321 women, 451 (10.4%) were selected at random. After exclusions, 3D ultrasound volumes from 442 fetuses born without a congenital malformation were used to create the charts. The fetal brain structures of interest were identified in 90% of cases. All structures, except the PV, showed increasing size with gestational age, and the size of the POF, SF, PV and CM showed increasing variability. The 3^rd , 5^th , 50^th , 95^th and 97^th smoothed centiles are presented. The 5^th centiles for the POF and SF were 3.1 mm and 4.7 mm at 22 weeks' gestation and 4.6 mm and 9.9 mm at 32 weeks, respectively. The 95^th centiles for the PV and CM were 8.5 mm and 7.5 mm at 22 weeks and 8.6 mm and 9.5 mm at 32 weeks, respectively.

CONCLUSIONS

We have produced prescriptive size standards for fetal brain structures based on prospectively enrolled pregnancies at low risk of abnormal outcome. We recommend these as international standards for the assessment of measurements obtained using ultrasound from fetal brain structures. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Experience report on the training of Brazilian dental managers using active methodologies

This is an account on the training of dental managers in a Social Welfare, not-for-profit, non-governmental institution present in all Brazilian states. Given the continental dimension of Brazil, its regional inequalities and the need for uniformity in the management conduct, as well as in the planning and evaluation of services, it is understood that developing managers' skills and competences is fundamental. Bearing in mind that the model adopted by the company is based on collective health, and its structure is organized in Primary Care, this proposal can be applied by other organizations that offer services of a similar nature. The aim of this study is to describe the training of oral health managers (n = 54) on the themes of sustainability, practices based on evidence/health economics and social determinants - themes that were requested by the managers themselves. Using problem-based learning, active and distance-learning methodologies, three working groups were set up among the managers to go through the contents of the training program, which aimed at training mentors and identifying successful service experiences for sharing. This process peaked at a face-to-face session with all participants where a specialist and their respective mentors presented each topic. The products obtained were: (1) three scientific-economic studies for decision making on the incorporation of hard technologies; (2) a guide to sustainable practices in dentistry and (3) a set of criteria for prioritizing access based on social determinants. In the evaluation of the training, 89% of managers were very satisfied, 8.98% were satisfied and 1.79% were dissatisfied. It is concluded that the methodology used in this process significantly contributed to the development of the company's regional service managers and such improvement stemmed from the empowerment, engagement and alignment of these managers, to which action plans were directed, with measures for monitoring and evaluation.

Key messages

Active methodologies in training contributes to the empowerment, engagement and alignment of dental managers before epidemiological, economic and social challenges faced in the management of services. Trainings where the participants are protagonists in all stages of the educational processes, are those that produce the best results and the highest degree of satisfaction among employees.

The interplay between autophagy and apoptosis mediates toxicity triggered by synthetic cathinones in human kidney cells

Synthetic cathinones abuse remains a serious public health problem. Kidney injury has been reported in intoxications associated with synthetic cathinones, but the molecular mechanisms involved have not been explored yet. In this study, the potential in vitro nephrotoxic effects of four commonly abused cathinone derivatives, namely pentedrone, 3,4-dimethylmethcatinone (3,4-DMMC), methylone and 3,4-methylenedioxypyrovalerone (MDPV), were assessed in the human kidney HK-2 cell line. All four derivatives elicited cell death in a concentration- and time-dependent manner, in the following order of potency: 3,4-DMMC >> MDPV > methylone ≈ pentedrone. 3,4-DMMC and methylone were selected to further elucidate the mechanisms behind synthetic cathinones-induced cell death. Both drugs elicited apoptotic cell death and prompted the formation of acidic vesicular organelles and autophagosomes in HK-2 cells. Moreover, the autophagy inhibitor 3-methyladenine significantly potentiated cell death, indicating that autophagy may serve as a cell survival mechanism that protects renal cells against synthetic cathinones toxicity. Both drugs triggered a rise in reactive oxygen and nitrogen species formation, which was completely prevented by antioxidant treatment with N‑acetyl‑L‑cysteine or ascorbic acid. Importantly, these antioxidant agents significantly aggravated renal cell death induced by cathinone derivatives, most likely due to their autophagy-blocking properties. Taken together, our results support an intricate control of cell survival/death modulated by oxidative stress, apoptosis and autophagy in synthetic cathinones-induced renal injury.

Image-scoring system for umbilical and uterine artery pulsed-wave Doppler ultrasound measurement

OBJECTIVES

To develop an objective image-scoring system for pulsed-wave Doppler measurement of maternal uterine and fetal umbilical arteries, and evaluate how this compares with subjective assessment.

METHODS

As an extension to the INTERGROWTH-21^st Project, we developed a scoring system based on six predefined criteria for uterine and umbilical artery pulsed-wave Doppler measurements. Objective evaluation using the scoring system was compared with subjective assessment which consisted of classifying an image as simply acceptable or unacceptable. Based on sample size estimation, a total of 120 umbilical and uterine artery Doppler images were selected randomly from the INTERGROWTH-21^st image database. Two independent reviewers evaluated all images in a blinded fashion, both subjectively and using the six-point scoring system. Percentage agreement and kappa statistic were compared between the two methods.

RESULTS

The overall agreement between reviewers was higher for objective assessment using the scoring system (agreement, 85%; adjusted kappa, 0.70) than for subjective assessment (agreement, 70%; adjusted kappa, 0.47). For the six components of the scoring system, the level of agreement (adjusted kappa) was 0.97 for anatomical site, 0.88 for sweep speed, 0.77 for magnification, 0.68 for velocity scale, 0.68 for image clarity and 0.65 for angle of insonation.

CONCLUSION

In quality assessment of umbilical and uterine artery pulsed-wave Doppler measurements, our proposed objective six-point image-scoring system is associated with greater reproducibility than is subjective assessment. We recommend this as the preferred method for quality control, auditing and teaching. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Papilar topografy and morphology of the tongue in the E. sexcinctus

Introduction: The Six-banded armadillo (Euphractussexcintus) belongs to Cigunlata order, has diverse feeding habits and masticatory apparatus developed. The tongue, one of the major components of this equipment, has the mucosa papillae, taste buds and tongue glands. Materials and Methods: Six-banded armadillo were submitted to an anesthetic protocol with Tiletamine and zolazepan (Telazol®, Fortdotge, Brazil) and Sodium Thiopental (Thiopentax®, Cristália, Brazil), we proceeded to euthanasia using Potassium Chloride 19.1%, to then fix them in a 10% formaldehyde solution. The tongues were dissected and identified structures. For microscopic processing, segments from different parts of the tongue were subjected to histological routine and stained with hematoxylin-eosin and Masson. Results: The tongue of the six-banded armadillo presents three types of papillae: filiform, fungiform and vallate, with no conical buds and foliate. Still in the tongue mucosa, was observed mucous glands and various taste corpuscles. Some data differ from those same found in other wild animals that have been studied, but are similar to those of the same phylogenetic. Conclusion: The morphological characteristics of the six-banded armadillo's tongue are adapted to the difficulties faced by him during chewing, requiring the tongue, structures that provide you mobility, strength and sensitivity.

Quality control of ultrasound for fetal biometry: results from the INTERGROWTH-21st Project

OBJECTIVE

To assess a comprehensive package of ultrasound quality control in the Fetal Growth Longitudinal Study of the INTERGROWTH-21^st Project, a large multicenter study of fetal growth.

METHODS

Quality control (QC) measures were performed for 20 313 ultrasound scan images obtained prospectively from 4321 fetuses at 14-41 weeks' gestation in eight geographical locations. At the time of each ultrasound examination, three fetal biometric variables (head circumference (HC), abdominal circumference (AC) and femur length (FL)) were measured in triplicate on separately generated images. All measurements were taken in a blinded fashion. QC had two elements: (1) qualitative QC: visual assessment by sonographers at each study site of their images based on specific criteria, with 10% of images being re-assessed at the Oxford-based Ultrasound Quality Unit (compared using an adjusted kappa statistic); and (2) quantitative QC: assessment of measurement data by comparing the first, second and third measurements (intraobserver variability), remeasurement of caliper replacement in 10% (interobserver variability), both by Bland-Altman plots and plotting frequency histograms of the SD of triplicate measurements and assessing how many were above or below 2 SD of the expected distribution. The system allowed the sonographers' performances to be monitored regularly.

RESULTS

A high level of agreement between self- and external scoring was demonstrated for all measurements (κ = 0.99 (95% CI, 0.98-0.99) for HC, 0.98 (95% CI, 0.97-0.99) for AC and 0.96 (95% CI, 0.95-0.98) for FL). Intraobserver 95% limits of agreement (LoA) of ultrasound measures for HC, AC and FL were ± 3.3%, ± 5.6% and ± 6.2%, respectively; the corresponding values for interobserver LoA were ± 4.4%, ± 6.0% and ± 5.6%. The SD distribution of triplicate measurements for all biometric variables showed excessive variability for three of 31 sonographers, allowing prompt identification and retraining.

CONCLUSIONS

Qualitative and quantitative QC monitoring was feasible and highly reproducible in a large multicenter research study, which facilitated the production of high-quality ultrasound images. We recommend that the QC system we developed is implemented in future research studies and clinical practice. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Plasma level of club-cell (CC-16) predicts outcome in amyotrophic lateral sclerosis

OBJECTIVES

The club cell protein (CC-16) is a biomarker associated with respiratory distress and pulmonary inflammation. We evaluated CC-16 as a candidate biomarker for respiratory failure in amyotrophic lateral sclerosis (ALS).

MATERIALS AND METHODS

We studied 81 ALS patients and 30 matched controls. We used an ALS-related measure of functional capacity, and tested forced vital capacity (FVC) and the amplitude of the diaphragmatic response by phrenic nerve stimulation (PhrenAmpl). Plasma CC-16 levels were measured in venous blood. Kaplan-Meier survival curves were plotted to evaluate risk to non-invasive ventilation and death in patients with abnormal CC-16 levels.

RESULTS

CC-16 levels were significantly raised in ALS patients (10.56 ng/mL ± 6.84 vs 8.34 ng/mL ± 3.10, P = .02), and in 17% of them, CC-16 level was above the upper cutoff value (mean + 2.5SD). CC-16 levels did not correlate with age, onset region, disease duration, functional status, FVC, and PhrenAmpl. In patients with increased CC-16 level, the risk of non-invasive was greater in the following 6 months (P = .01) and tended to have higher mortality in the following 30 months (P = .07).

CONCLUSIONS

We propose that increased CC-16 levels is a marker of lung inflammatory response that associated with ventilatory insufficiency are related to impending respiratory failure, not fully predicted by conventional respiratory tests. The latter are limited by the moment of testing.

Eslicarbazepine acetate as adjunctive therapy in clinical practice: ESLADOBA study

OBJECTIVE

To assess seizure control and tolerability of eslicarbazepine acetate (ESL) as adjunctive therapy to one baseline antiepileptic drug (AED), in adults with partial-onset seizures (POS) with or without secondary generalization.

METHODS

Multicenter, non-interventional, prospective cohort study conducted between March 2012 and September 2014 at 12 neurology departments in Portugal. Adults with POS not controlled with one AED who had initiated ESL as adjunctive treatment were enrolled. Retention rate was defined at the final visit (Vfinal) 6-9 months of follow-up. Proportion of responders, seizure-free, changes in seizure frequency were evaluated using patients' diaries. Clinical Global Impression of Change (CGI-C) and Clinical Global Impression of Severity (CGI-S) were assessed by the neurologist.

RESULTS

Fifty-two patients (48.1% male) were included with mean age 41.5±13.3 years. Mean epilepsy duration was 18.5±14.8 years; mean seizure frequency in the four previous weeks to baseline was 7.5±12.7. At Vfinal, retention rate was 73.0%; responder rate and seizure-free rates were 71.1% and 39.5%, respectively. The median relative reduction in seizure frequency between baseline and Vfinal was 82.2%. A reduction in epilepsy severity (CGI-S) was observed in 42.1%. According to CGI-C, 73.6% patients had their epilepsy "much improved" or "very much improved". Twelve patients (23.1%) had at least one adverse event (AE), two (3.9%) had one serious AE, and five (9.6%) discontinued due to AE.

CONCLUSIONS

Eslicarbazepine acetate showed good retention rates, elicited a significant reduction in seizure frequency, and was well tolerated when used in the clinical practice.

International estimated fetal weight standards of the INTERGROWTH-21st Project

OBJECTIVE

Estimated fetal weight (EFW) and fetal biometry are complementary measures used to screen for fetal growth disturbances. Our aim was to provide international EFW standards to complement the INTERGROWTH-21^st Fetal Growth Standards that are available for use worldwide.

METHODS

Women with an accurate gestational-age assessment, who were enrolled in the prospective, international, multicenter, population-based Fetal Growth Longitudinal Study (FGLS) and INTERBIO-21^st Fetal Study (FS), two components of the INTERGROWTH-21^st Project, had ultrasound scans every 5 weeks from 9-14 weeks' until 40 weeks' gestation. At each visit, measurements of fetal head circumference (HC), biparietal diameter, occipitofrontal diameter, abdominal circumference (AC) and femur length (FL) were obtained blindly by dedicated research sonographers using standardized methods and identical ultrasound machines. Birth weight was measured within 12 h of delivery by dedicated research anthropometrists using standardized methods and identical electronic scales. Live babies without any congenital abnormality, who were born within 14 days of the last ultrasound scan, were selected for inclusion. As most births occurred at around 40 weeks' gestation, we constructed a bootstrap model selection and estimation procedure based on resampling of the complete dataset under an approximately uniform distribution of birth weight, thus enriching the sample size at extremes of fetal sizes, to achieve consistent estimates across the full range of fetal weight. We constructed reference centiles using second-degree fractional polynomial models.

RESULTS

Of the overall population, 2404 babies were born within 14 days of the last ultrasound scan. Mean time between the last scan and birth was 7.7 (range, 0-14) days and was uniformly distributed. Birth weight was best estimated as a function of AC and HC (without FL) as log(EFW) = 5.084820 - 54.06633 × (AC/100)³  - 95.80076 × (AC/100)³  × log(AC/100) + 3.136370 × (HC/100), where EFW is in g and AC and HC are in cm. All other measures, gestational age, symphysis-fundus height, amniotic fluid indices and interactions between biometric measures and gestational age, were not retained in the selection process because they did not improve the prediction of EFW. Applying the formula to FGLS biometric data (n = 4231) enabled gestational age-specific EFW tables to be constructed. At term, the EFW centiles matched those of the INTERGROWTH-21^st Newborn Size Standards but, at < 37 weeks' gestation, the EFW centiles were, as expected, higher than those of babies born preterm. Comparing EFW cross-sectional values with the INTERGROWTH-21^st Preterm Postnatal Growth Standards confirmed that preterm postnatal growth is a different biological process from intrauterine growth.

CONCLUSIONS

We provide an assessment of EFW, as an adjunct to routine ultrasound biometry, from 22 to 40 weeks' gestation. However, we strongly encourage clinicians to evaluate fetal growth using separate biometric measures such as HC and AC, as well as EFW, to avoid the minimalist approach of focusing on a single value. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Frailty Syndrome: Visceral Adipose Tissue and Frailty in Patients with Symptomatic Severe Aortic Stenosis

BACKGROUND/OBJECTIVES

In patients with severe aortic stenosis (AS), frailty is a clinically relevant measure of increased vulnerability that should be included in the preoperative risk assessment. Bioelectrical impedance analysis (BIA) derived phase angle (PA) reflects cell membrane integrity and function. Few studies are available on the relative contribution of adiposity distribution on frailty, and about the influences of frailty and visceral obesity in PA value. Therefore, we aimed to evaluate associations among frailty, visceral fat depots and PA in patients with symptomatic severe AS.

METHODS

In a cohort of patients with symptomatic severe AS and preserved ejection fraction, we examined the associations between frailty, visceral fat depots and bioelectrical impedance analysis (BIA) derived phase angle (PA); and between visceral fat and PA. Frailty was defined according the Fried et al. scale criteria and the body fat distribution was determined by multidetector computed tomography and by BIA.

RESULTS

Of the fifty-five included patients, 26 were frail (47%). Adjusting for age and gender, frailty was associated with indexed epicardial adipose tissue volume (EATVi) (the odds of frailty increased 4.1-fold per additional 100 cm3/m2 of EAT [95% confidence interval (CI) of 1.03 to 16.40, p=0.04] and with PA (OR of 0.50, 95% CI, 0.26 to 0.97, p=0.04), but not with body mass index (BMI), waist circumference (WC), indexed total, visceral and subcutaneous abdominal fat areas (TAFAi, VAFAi and SAFAi) nor with indexed mediastinal adipose tissue volume (MATVi). In an age and gender adjusted linear model, PA was inversely correlated with EATVi (β=-0.008, 95% CI, -0.016 to -0.001, p=0.03), but not with BMI, WC, nor with MATVi, VAFAi, SAFAi and TAFAi.

CONCLUSIONS

In patients with symptomatic severe AS, EATVi is associated with frailty, independently of age and gender, but not with MAFVi or VAFAi. Moreover, frailty and EATVi are associated with impaired cell membrane integrity and function assessed by PA.