Dynamics of CO2, CH4, and N2O in Ria Formosa coastal lagoon (southwestern Iberia) and export to the Gulf of Cadiz

A first characterization of greenhouse gases had been carried out to study their role and impact in a productive transitional coastal system of the southern Portugal - Ria Formosa lagoon. To this purpose, the partial pressure of CO2 (pCO2) and the concentration of dissolved CH4 and N2O have been measured. Two surveys were carried out during 2020, at low tide under typical conditions of Spring (March) and end of Summer (October). The samplings sites were distributed along the costal lagoon covering: i) inner areas with strong human impact (influence of different flows of treated wastewater discharges); and ii) main channels in connection with the main inlets to study the exchanges with the ocean. In general, the highest values of the three greenhouse gases were found at the inner studied areas, especially affected by the disposal of treated effluents from wastewater treatment plans, in October. The mean water - atmosphere fluxes of the CO2, CH4 and N2O are positive, showing that the study area acts as a source of these gases to the atmosphere. On the other hand, it was calculated a rough estimation of the three gases globally exported from Ria Formosa to the ocean, through the main six inlets to evaluate the magnitude of the supply of these gases from Ria Formosa to the adjacent ocean. The mean CO2, CH4 and N2O horizontal water fluxes exported from all the inlets of Ria Formosa to the Gulf of Cadiz for both seasons, during low water, are 8.7 ± 3.9 mmol m-2 s-1, 8.0 ± 3.5 μmol m-2 s-1 and 3.2 ± 1.5 μmol m-2 s-1, which corresponds to a mass transport through the inlets section of 0.7 ± 0.7 kg s-1, 0.2 ± 0.2 g s-1 and 0.2 ± 0.3 g s-1 respectively. From these estimates, as expected, the higher mass transport was found at the larger and deeper inlets (Faro-Olhão and Armona).

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis recurrence temporally associated with allergen-specific immunotherapy in a female adolescent: a case report

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in pediatric patients. It is clinically characterized by fever flares lasting 3-7 days, reappearing every 2-8 weeks with a distinctive clockwork regularity. PFAPA generally begins before 5 years of age and usually ceases 3-5 years after onset. Recurrences may be observed in adolescence and adulthood in up to 20% of cases. The authors aim to describe a case of PFAPA recurrence in adolescence temporally associated with allergen-specific immunotherapy (ASIT). A 16-year-old female patient was referred to the rheumatology unit due to recurrent episodes of fever one month after initiating ASIT for allergic rhinitis. These episodes occurred every 4 weeks and lasted 3 days. During these episodes, she also presented with a sore throat, tonsillar exudates, and cervical lymphadenopathy. Abortive treatment with oral prednisolone was attempted in these episodes, with complete resolution of fever after a single dose. After reviewing her medical background, she had previously experienced febrile episodes accompanied by aphthous ulcers and tonsillar exudates occurring every 7-8 weeks from age 2-7. The etiopathogenesis of PFAPA remains uncertain. Environmental triggers, particularly those with immunomodulator effects, may interfere with the immune responses responsible for PFAPA occurrence, but the mechanisms are still unclear. The authors describe the first report of the reappearance of PFAPA flares, possibly due to ASIT. Further studies are needed to fully clarify if ASIT constitutes a true environmental trigger of PFAPA.

Impact of "early intervention" parent workshops on outcomes for caregivers of children with neurodisabilities: a mixed-methods study

PURPOSE

This study explored the feasibility, impact and parent experiences of ENVISAGE (ENabling VISions And Growing Expectations)-Families, a parent-researcher co-designed and co-led program for parents/caregivers raising children with early-onset neurodisabilities.

METHODS

Parents/caregivers of a child with a neurodisability aged ≤6 years, recruited in Australia and Canada, participated in five weekly online workshops with other parents. Self-report measures were collected at baseline, immediately after, and 3 months post-ENVISAGE-Families; interviews were done following program completion. Quantitative data were analyzed with generalized estimating equations and qualitative data using interpretive description methodology.

RESULTS

Sixty-five parents (86% mothers) were recruited and 60 (92%) completed the program. Strong evidence was found of effects on family empowerment and parent confidence (all p ≤ 0.05 after the program and maintained at 3-month follow-up). The ENVISAGE-Families program was relevant to parents' needs for: information, connection, support, wellbeing, and preparing for the future. Participants experienced opportunities to reflect on and/or validate their perspectives of disability and development, and how these perspectives related to themselves, their children and family, and their service providers.

CONCLUSIONS

ENVISAGE was feasible and acceptable for parent/caregivers. The program inspired parents to think, feel and do things differently with their child, family and the people who work with them.Implications for rehabilitationENVISAGE (ENabling VISions And Growing Expectations)-Families is a co-designed, validated parent/researcher "early intervention and orientation" program for caregivers raising a child with neurodevelopmental disabilities (NDDs).ENVISAGE-Families empowered parents' strengths-based approaches to their child, family, disability, and parenting.ENVISAGE-Families increased caregivers' confidence in parenting children with NDD's and provided them tools to support connection, collaboration, and wellbeing.Raising children with NDD can have a profound impact on caregivers, who can benefit from strengths-based, future focused supports early in their parenting experience.

Diet quality, asthma and airway inflammation in school-aged children

Summary

Background. Asthma is a major public health problem, with increasing prevalence in most countries, particularly among children. Poor dietary quality is also increasing in children, and evidence of the overall quality of children's food patterns effects on asthma is scarce. Methods. This cross-sectional analysis (660 children: 49.1% females, aged 7-12years) evaluated the association between diet quality and asthma (n = 56) and airway inflammation among school-aged children according to body mass index (BMI). Diet quality was assessed through the Healthy Eating Index (HEI)-2015, and categorized by tertiles. Higher scores represent a healthier diet. A questionnaire was used to enquire about self-reported medical diagnosis of asthma and asthma under medication. Lung function and airway reversibility were measured, and airway inflammation assessed measuring exhaled fractional nitric oxide (eNO). Two categories of BMI were considered: non-overweight/obese (p less than 85^th), (n = 491), and overweight/obese (p ≥ than 85^th), (n = 169). The associations between diet quality and asthma and airway inflammation were estimated using logistic regression models. Results. Non-overweight/obese children in 2^nd tertile of HEI-2015 score had decreased odds of having eNO ≥ 35ppb (OR 0.43, 95%CI 0.19-0.98), medical diagnosis of asthma (OR 0.18; 95%CI 0.04-0.84), and asthma treatment (OR 0.12; 95%CI 0.01-0.95), compared to children in the 1^st tertile. Conclusions. Our findings suggest that a higher diet quality associates with lower levels of airway inflammation and reduced prevalence of asthma among non-overweight/obese school-aged children.

Olaparib plus bevacizumab first-line maintenance in ovarian cancer: final overall survival results from the PAOLA-1/ENGOT-ov25 trial

BACKGROUND

In the PAOLA-1/ENGOT-ov25 primary analysis, maintenance olaparib plus bevacizumab demonstrated a significant progression-free survival (PFS) benefit in newly diagnosed advanced ovarian cancer patients in clinical response after first-line platinum-based chemotherapy plus bevacizumab, irrespective of surgical status. Prespecified, exploratory analyses by molecular biomarker status showed substantial benefit in patients with a BRCA1/BRCA2 mutation (BRCAm) or homologous recombination deficiency (HRD; BRCAm and/or genomic instability). We report the prespecified final overall survival (OS) analysis, including analyses by HRD status.

PATIENTS AND METHODS

Patients were randomized 2:1 to olaparib (300 mg bid; up to 24 months) plus bevacizumab (15 mg/kg q3w; 15 months total) or placebo plus bevacizumab. Analysis of OS, a key secondary endpoint in hierarchical testing, was planned for ∼60% maturity or 3 years after the primary analysis.

RESULTS

After median follow-up of 61.7 and 61.9 months in the olaparib and placebo arms, respectively, median OS was 56.5 versus 51.6 months in the ITT (hazard ratio [HR]=0.92, 95% CI 0.76-1.12; P=0.4118). Subsequent poly(ADP-ribose) polymerase (PARP) inhibitor therapy was received by 105 (19.6%) olaparib patients versus 123 (45.7%) placebo patients. In the HRD-positive population, OS was longer with olaparib plus bevacizumab (HR=0.62, 95% CI 0.45-0.85; 5-year OS rate, 65.5% versus 48.4%); at 5 years, updated PFS also showed a higher proportion of olaparib plus bevacizumab patients without relapse (HR=0.41, 95% CI 0.32-0.54; 5-year PFS rate, 46.1% versus 19.2%). Myelodysplastic syndrome, acute myeloid leukemia, aplastic anemia, and new primary malignancy incidence remained low and balanced between arms.

CONCLUSIONS

Olaparib plus bevacizumab provided clinically meaningful OS improvement for first-line patients with HRD-positive ovarian cancer. These prespecified exploratory analyses demonstrated improvement despite a high proportion of patients in the placebo arm receiving PARP inhibitors post-progression, confirming the combination as one of the standards of care in this setting with the potential to enhance cure.

A scoring tool to predict mortality and dependency after cerebral venous thrombosis

BACKGROUND

We developed a prognostic score to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials..

METHODS

We used data from the International CVT Consortium. We excluded patients with pre-existent functional dependency. We used logistic regression to predict poor outcome (modified Rankin Scale 3-6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunken using Ridge regression to adjust for optimism in internal validation.

RESULTS

Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, we derived the SI₂ NCAL₂ C score utilizing the following components: absence of female Sex-specific risk factor, Intracerebral hemorrhage, Infection of the central nervous system, Neurologic focal deficits, Coma, Age, lower Level of hemoglobin (g/L), higher Level of glucose (mmol/L) at admission, and Cancer. C-statistics were 0.80 (95%CI 0.75-0.84), 0.84 (95%CI 0.80-0.88) and 0.84 (95%CI 0.80-0.88) for the poor outcome, 30 days and 1 year mortality model, respectively. Calibration plots indicated good model fit between predicted and observed values. The SI₂ NCAL₂ C score calculator is freely available at www.cerebralvenousthrombosis.com.

CONCLUSIONS

The SI₂ NCAL₂ C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.

Uveitis in patients with oligoarticular juvenile idiopathic arthritis and juvenile spondyloarthritis/enthesitis related arthritis: is there any difference?

Juvenile idiopathic arthritis (JIA) is the most common systemic disease causing uveitis in childhood and adolescence.

Microvascular density and tumor budding in oral squamous cell carcinoma

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the most prevalent malignant head and neck tumor, excluding the nonmelanoma skin cancer. Despite recent advances in the diagnosis and treatment, the disease's mortality rate is nonetheless high. The presence of isolated neoplastic cells or small clusters of up to four cells at the tumor's invasive front, named tumor budding, is associated with a worse prognosis in OSCC. Angiogenesis has also been recognized as a determining factor in the progression of malignancies and in the development of metastases. Several studies have investigated the assessment of microvascular density (MVD) as a potential prognostic factor in OSCC. This study aimed to evaluate, in OSCC, differences in MVD between tumors with high-intensity tumor budding and tumors with low-intensity or no tumor budding. In samples with high-intensity tumor budding, differences in MVD between the budding area and the area outside the budding were also evaluated. Moreover, the study assessed differences in MVD concerning clinicopathological characteristics such as sex, age, tobacco smoking, tumor location and tumor size.

MATERIAL AND METHODS

One hundred and fifty [150] samples of OSCC were subjected to immunohistochemistry to assess the intensity of tumor budding (by immunostaining for multi-cytokeratin) and MVD (by immunostaining for CD34 and CD105, independently). The data were treated using descriptive and analytical statistics.

RESULTS

There were no differences in MVD, assessed by immunostaining for CD34 or CD105, concerning clinicopathological characteristics such as sex, age, tobacco smoking, tumor location and tumor size (p > 0.05). Tumors with high-intensity tumor budding did not show differences in MVD, assessed by immunostaining for CD34 or CD105, when compared to tumors with low-intensity or no tumor budding (p > 0.05). However, in samples with high-intensity tumor budding, the MVD assessed by immunostaining for CD34 was higher in the budding area than in the area outside the budding (p < 0.05). This difference was not observed when MVD was assessed by immunostaining for CD105 (p > 0.05).

CONCLUSIONS

The higher MVD in the budding area may be an additional indication that this is a peculiar region of the tumor, associated with biological phenomena related to tumor progression.

Drivers and implications of the extreme 2022 wildfire season in Southwest Europe

Wildfire is a common phenomenon in Mediterranean countries but the 2022 fire season has been extreme in southwest Europe (Portugal, Spain and France). Here we provide a preliminary but comprehensive analysis of 2022's wildfire season in southwest Europe. Burned area has exceeded the 2001-2021 median by a factor of 52 in some regions and large wildfires (>500 ha) started to occur in June-July, earlier than the traditional fire season. These anomalies were associated with record-breaking values of fuel dryness, atmospheric water demand and pyrometeorological conditions. Live fuel moisture content was below the historical minima for almost 50 % of the season in some regions. A few large wildfires were responsible for 82 % of the burned area and, in turn, 47 % of the area burned occurred in protected areas. Shrublands, transitional woodlands and conifer forests (but not eucalypt plantations) were the land cover types most affected by extreme fires. As climate change intensifies, we can expect such fire seasons to become the new normal in large parts of the continent, potentially leading to major negative impacts on rural economies. These results highlight the need for landscape level fuel management also in protected areas, to avoid fire-induced biodiversity losses and landscape scale degradation. Our results have important policy implications and indicate that fire prevention should be explicitly addressed within continental forest legislation and strategies.

Climate teleconnections modulate global burned area

Climate teleconnections (CT) remotely influence weather conditions in many regions on Earth, entailing changes in primary drivers of fire activity such as vegetation biomass accumulation and moisture. We reveal significant relationships between the main global CTs and burned area that vary across and within continents and biomes according to both synchronous and lagged signals, and marked regional patterns. Overall, CTs modulate 52.9% of global burned area, the Tropical North Atlantic mode being the most relevant CT. Here, we summarized the CT-fire relationships into a set of six global CT domains that are discussed by continent, considering the underlying mechanisms relating weather patterns and vegetation types with burned area across the different world's biomes. Our findings highlight the regional CT-fire relationships worldwide, aiming to further support fire management and policy-making.

Trajectories of wildfire behavior under climate change. Can forest management mitigate the increasing hazard?

Mediterranean forests and fire regimes are closely intertwined. Global change is likely to alter both forest dynamics and wildfire activity, ultimately threatening the provision of ecosystem services and posing greater risks to society. In this paper we evaluate future wildfire behavior by coupling climate projections with simulation models of forest dynamics and wildfire hazard. To do so, we explore different forest management scenarios reflecting different narratives related to EU forestry (promotion of carbon stocks, reduction of water vulnerability, biomass production and business-as-usual) under the RCP 4.5 and RCP 8.5 climate pathways in the period 2020-2100. We used as a study model pure submediterranean Pinus nigra forests of central Catalonia (NE Spain). Forest dynamics were simulated from the 3rd National Forest Inventory (143 stands) using SORTIE-nd software based on climate projections under RCPs 4.5 and 8.5. The climate products were also used to estimate fuel moisture conditions (both live and dead) and wind speed. Fuel parameters and fire behavior were then simulated, selecting crown fire initiation potential and rate of spread as key indicators. The results revealed consistent trade-offs between forest dynamics, climate and wildfire. Despite the clear influence exerted by climate, forest management modulates fire behavior, resulting in different trends depending on the climatic pathway. In general, the maintenance of current practices would result in the highest rates of crown fire activity, while management for water vulnerability reduction is postulated as the best alternative to surmount the increasingly hazardous conditions envisaged in RCP 8.5.

Risk factors associated with the bovine subclinical mastitis in an Amazon micro-region

In this study, we evaluated the main risk factors for the occurrence of bovine mastitis, in the southeastern of Pará, in the Brazilian Amazon. We surveyed 91 dairy farmers to identify management practices and bovine breed characteristics. From each farm, 50 mL of milk sample was collected for microbiological analysis and somatic cell count (SCC). Depending on the management practices and breed, a logit model was used to determine the odds ratio of subclinical mastitis (SCM) occurrence. In irrigated pastures, an SCM-associated risk factor, the occurrence of SCM was 5.03 times higher than that in the non-irrigated pastures. Similarly, in Girolando breed herds, the occurrence of SCM increased by 5.8 times compared to the crossbred herds. Moreover, the occurrence of mastitis was 33 times higher in farms using common cloths for drying teats than in farms using paper towels. Therefore, adoption of better management practices can lead to SCC reduction, milk quality improvement and a guarantee to contain SCC within prescribed Brazilian limits for the Amazon region.

Poster No. 054 Genetic variation in the TCF21 gene is associated with the severity of coronary artery disease

Introduction

In vitro studies demonstrated that targeted deletion of the transcription factor encoding gene TCF21, was associated with vascular smooth muscle cell disruption. Recent research showed that TCF21 expression contribute to fibrous cap formation, preventing heart attacks.

Purpose

Analyse the TCF21 rs12190287 gene and evaluate its association with atherosclerosis severity measured according to the coronary angiogram patients´ data. Methods: Prospective study with 1,639 coronary artery disease (CAD) patients (mean age 53.4 ± 7.8 years). Two age groups (&lt; 55 and &gt; 55 years) were stratified and analyzed. TCF21 rs12190287 G &gt; C was genotyped in all patients. The severity of CAD was graded according to the number of obstructed coronary arteries with at least 70% narrowed lumen. Chi-squared tests and multivariate logistic regression models were analysed.

Results

The CC genotype was associated with &gt; 70% obstructive lesions (vascular disease rate, 48.1%). Contrariwise, the GG wild genotype was associated with less severe obstructive disease (19.5%) (P = 0.003). When we stratified the TCF21 genotypes per age group (55 years), the CC genotype in the younger group had more obstructed disease (47.4%) when compared with GG (18.8%) (P = 0.012), but this effect was not significant in the older group. Multivariate analysis (logistic regression) showed that the CC genotype had a high risk of multivessel coronary disease (OR = 2.88; P = 0.001) than GG.

Conclusion

This work shows that the TCF21 wild genotype protects against CAD severity. In contrast, the CC genotype is associated with an increased risk of CAD severity.

Prognostic impact of adding Coronary Calcium Score to European SCORE2 in an asymptomatic Portuguese population

Introduction

The new European SCORE2 estimates the combined risk of fatal and non-fatal cardiovascular (CV) events, in contrast with SCORE's use for CV mortality only. Although controversial, several studies point out that Coronary Artery Calcification (CAC) scoring could improve CV risk stratification in primary prevention.

Purpose

Assess the impact of including CAC score to the new SCORE2 in MACE prediction and CV risk stratification in an asymptomatic Portuguese population.

Methods

The new SCORE2 was calculated in a population-based cohort of 1,014 individuals (mean age 58.6±8.5 years) without known CV disease and diabetes. Population was stratified into three SCORE2 risk categories (low-, moderate- and high-risk). According to the Hoff's nomogram, CAC score was categorized into: low CAC (0≤CAC&lt;100 or P&lt;50); moderate CAC (100≤CAC&lt;400 or P50–75) and high or severe CAC (CAC≥400 or P&gt;75). Kaplan-Meier survival curves were estimated and a multivariate regression analysis predicted the MACE risk for both scores. C-statistic methodology evaluated the ability of CAC when added to the SCORE2 model in MACE prediction.

Results

Kaplan-Meier curves showed that the highest categories of both scores presented a worst survival. Cox regression analysis showed that the highest categories of both CAC and SCORE2 remained in the equation with an increased MACE risk (HR) of 3.69 (p=0.008) and 9.87 (p=0.005), respectively, when compared with the lowest categories. C-statistic demonstrated that the predictive value for MACE increased from 0.668 (SCORE2 model) to 0.787 when CAC was included (p=0.012), showing a better predictive and discriminative capacity for MACE.

Conclusions

Our results highlight the importance of adding CAC score to SCORE2 in primary prevention to improve cardiovascular risk stratification and MACE risk prediction. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Lipoprotein(a) and cardiovascular outcomes in patients with coronary artery disease and impaired glucose metabolism

Introduction

Lipoprotein(a) [Lp(a)] is an LDL-like molecule composed of a part of apolipoprotein(a) bounding covalently to apolipoprotein B-100. High plasma Lp(a) levels were associated with MACE in stable CAD patients. Recent research shows contradictory results in stable CAD patients with high Lp(a) plasmatic levels and impaired glucose metabolism in MACE occurrence.

Purpose

Investigate whether high Lp(a) levels were associated with MACE in CAD patients with impaired glucose metabolism, at an extended follow-up.

Methods

A prospective cohort of 1,127 CAD patients with impaired glucose metabolism (pre-diabetes and diabetes) was observed during 4.9±3.4 years. Pre-diabetes was considered when fasting plasma glucose ranged from 5.6 to 6.9 mmol/L, or hemoglobin A1c levels ranging from 5.7 to 6.4%. Lp(a) levels ≥30 mg/dL were considered high. Bivariate and multivariate Cox regression analysis evaluated the risk of Lp(a) ≥30 mg/dL for MACE occurrence. Kaplan-Meier curves estimated the survival probability for high and low Lp(a) levels.

Results

Of the patients with Lp(a) levels ≥30, 44.4% presented MACE and 32.0% had no MACE (p&lt;0.0001). Cox regression analysis with smoking, hypertension, dyslipidemia, physical inactivity and kidney failure (creatinine clearance &lt;60 mL/min) showed that high Lp(a) remained in the equation as an independent risk factor for MACE (HR=1.24; p=0.031). The Kaplan-Meier showed, at 10-year' follow-up, a better survival in the group with lower Lp(a) levels (p=0.023).

Conclusion

Our study demonstrated that high Lp(a) levels were an independent predictor of MACE and cardiovascular mortality in a CAD population with impaired glucose metabolism. Lp(a) measurement may help further risk stratification for diabetes and pre-diabetes patients suffering CAD. With the recent development of drugs that selectively lower Lp(a) levels, this marker can become a clinical target for reducing CVD risk.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Genetic information or coronary artery calcium score? What is more helpful in today's clinical practice?

Introduction

Coronary artery calcium (CAC) score has emerged as the most predictive cardiovascular risk marker in asymptomatic individuals, capable of adding prognostic information beyond the traditional risk factors (TRF). Genetic risk score (GRS) significantly improves cardiovascular genetic risk assessment at the individual level providing a more personalized measure of disease risk.

Purpose

We intend to evaluate which tool, added to TRF, is more valuable in predicting and discriminating cardiovascular events and death (MACE) - GRS or CAC score?

Methods

We performed a prospective study with 1153 participants without CAD history at baseline (74.2% male, age 51.7±8.3 years) during a mean follow-up of 5.4±3.4 years. We selected 14 SNPs previously associated with CAD presenting a risk (HR) for cardiovascular events ≥1. A weighted GRS was calculated, as the sum of these 14 risk alleles weighted by the corresponding effect size in prognostic (HR), and subsequently, subdivided into tertiles. CAC (Agatson) score was calculated in all participants and categorized into: low CAC (0≤CAC&lt;100 or P&lt;50); moderate CAC (100≤CAC&lt;400 or P50–75) and high or severe CAC (CAC≥400 or P&gt;75). Two models were created with TRF baseline (hypertension, smoking, body mass index, dyslipidemia, diabetes, chronic kidney disease, physical inactivity): 1) plus wGRS and 2) plus CAC score categories. Cox Regression Analyses and C-statistic assessed the predictive and discriminative capacity of both models.

Results

For model 1, Cox regression presented an HR of 4.292 for TRF (p=0.007) and 2.713 for 3rd tertile of wGRS (0.036). A modest but statistically significant improvement in MACE discriminative capacity was verified by adding wGRS to TRF, increasing the C-statistic from 0.617 to 0.687 (ΔC=0.070; p=0.013). On the other hand, model 2 better discriminated MACE when the CAC score (C-statistic = 0.765) was added to TRF (ΔC=0.148; p=0.001). Cox regression displayed an HR of 4.42 for TRF (p=0.015) and an HR of 4.55 for high-risk CAC score (p=0.001).

Conclusion

Our results suggest that adding a polygenic risk score to conventional risk factors provides a modest improvement in the discrimination of first-onset MACE. However, the CAC score added to the traditional model allows better discrimination of MACE compared to wGRS. CAC score could be helpful for MACE prediction, at least in individuals belonging to the higher genetic risk group. However, further investigation is required before clinical implementation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Prognostic role of adding a genetic risk score to the new European SCORE2 in a cardiovascular events prediction, in a moderate-risk region

Introduction

The new SCORE2 provides risk estimates for the combined outcome of fatal and non-fatal cardiovascular disease (CVD) events, in contrast with SCORE's use for CVD mortality only. Genetic predisposition to CVD is not considered in SCORE2 for prevention and treatment.

Purpose

Evaluate the impact of adding a Genetic Risk Score (GRS) to the new European SCORE2 in MACE prediction and estimate the additional value in cardiovascular risk stratification in an asymptomatic Portuguese population.

Methods

A prospective study was performed in a population-based cohort of 1,100 individuals without known CVD and diabetes (mean age 53.3±6.9 years). For all included participants, SCORE2 was calculated and three risk categories were considered: low-, moderate- and high-risk. A 33-SNP GRS was constructed and two groups were analyzed: lower and higher than the GRS median. Kaplan-Meier survival curves were created and a Cox regression model was performed with the two scores to assess MACE risk. C-statistic methodology compared the model between SCORE2 solely and SCORE2 plus GRS.

Results

After Kaplan-Meier analysis for MACE occurrence, the high categories of SCORE 2 and GRS showed worst survival when compared to the lower categories (p&lt;0.0001). Cox regression presented an HR of 8.528 (p=0.001) for high-risk SCORE2 and an HR of 4.520 (p&lt;0.0001) for GRS higher than the median. C-statistic demonstrated that the SCORE2 predictive value was 0.678, increasing to 0.792 when GRS was included (p=0.0005).

Conclusions

In this work, combining SCORE2 with multiple genetic loci gathered into a GRS, improved the identification of patients with the worst prognosis. This new tool may be of great utility in risk stratification in primary prevention. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Transcription factor 21 and prognosis in a coronary population

Introduction

TCF21 is a member of the basic helix-loop-helix (bHLH) transcriptor factor family, being critical for embryogenesis of the heart. It regulates epicardium-derived cells differentiation into smooth muscle (SMC) and fibroblast lineages. The biological roles of TCF21 in epicardial fate determination and the progression of atherosclerosis remains a controversial issue.

Purpose

Investigate the impact of the TCF21 rs12190287 G&gt;C variant on the prognosis of a coronary artery disease (CAD) cohort.

Methods

A prospective study was performed with 1,713 CAD patients (mean age 53.3±7.8; 78.7% male) surveyed in terms of MACE occurrence in an extended follow-up of 5.0±4.3. TCF21 rs12190287 was genotyped and analysed using the dominant model (GC+CC) and, subsequently, compared with the wild-type GG to evaluate the survival probability by Kaplan-Meier. A Cox regression analysis with all the risk factors and genetic models was performed to assess the independent variables associated with the prognosis of CAD patients.

Results

GG wild genotype was present in 9.5% of the population, GC in 43.2% and the risk genotype CC accounted for 47.3% of the CAD patients. The dominant model GC+CC showed a worse survival throughout the follow-up period. After multivariate Cox regression analysis, this model remained in the equation as an independent risk factor for MACE occurrence with an HR of 1.41 (p=0.033) together with multivessel disease, physical inactivity, chronic kidney disease (CKD) and diabetes.

Conclusion

TCF21 rs12190287 is a risk factor for prognosis in our population. The role of this gene may influence fundamental SMC processes in response to vascular stress, accelerating atherosclerosis progression and may represent a target for future therapies.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

ZNF259 rs964184 variant is associated with dyslipidemia and coronary artery disease in the young population

Introduction

Coronary artery disease (CAD) is a dynamic inflammatory disease caused by atherosclerosis. GWAS showed that ZNF259 rs964184 encoding zinc finger protein (ZPR1) was associated with dyslipidemia and CAD. Recent research found that ZPR1 transcription is up-regulated in the brain of mice fed a high-fat diet, influencing the cell cycle, apoptosis, and RNA metabolism in neurons. This process at the heart vessels may increase oxidative stress and CAD.

Purpose

Study the association between the ZNF259 rs964184 C&gt;G polymorphism with dyslipidemia and CAD susceptibility in a Portuguese population.

Methods

A case-control study was performed with 3,160 individuals, namely 1,723 CAD patients (mean age 53.3±7.9; 78.7% male) and 1,437 controls (mean age 52.8±7.8; 76.3% male). Participants were stratified into two age groups (&lt;45 and &gt;55 years). ZNF259 rs964184 C&gt;G was genotyped and analysed using the dominant model (CG+GG vs CC). Multivariate logistic regression was performed in both age groups to investigate whether rs964184 polymorphism was associated with dyslipidemia and CAD susceptibility.

Results

The dominant model of ZNF259 was associated with dyslipidemia (OR=1.85; 95% CI: 1.22–2.79; p=0.003) and CAD (OR=1.46; 95% CI: 1.02–2.09; p=0.036) in the younger population under 45 years. In the &gt;55 years group, this model was associated with dyslipidemia (OR 1.46; 95% CI: 1.06–2.01; p=0.020) but not with CAD. After multivariate logistic regression, the CG+GG remained an independent risk factor for CAD susceptibility only in the population &lt;45 years (OR=1.60; 95% CI: 1.03–2.50; p=0.037).

Conclusion

ZNF259 rs964184 is a risk factor for dyslipidemia in the whole population. Dyslipidemia may up-regulate ZPR1 transcription, enhancing the vulnerability of coronary endothelial cells to both oxidative stress and inflammatory response, increasing CAD susceptibility. This mechanism seems more relevant at the cellular level in young patients representing a possible prophylactic and therapeutic target, especially in this age group.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

A Genetic Risk Score englobing variants associated with coronary artery disease is a good marker for prognosis in an asymptomatic population

 

Genome-wide association studies have identified several loci linked to coronary artery disease, and coronary atherosclerosis progression. However, the impact of the genetic contribution to MACE occurrence in sub-clinical atherosclerosis is unknown.

Purpose

This study intended to assess the relationship between a set of single nucleotide popymorphism (SNP) associated with CAD by GWAS and the MACE occurrence in an asymptomatic population. After that evaluate whether a wGRS englobing these variants is useful to estimate the prognostic.

Methods

Prospective study performed in an asymptomatic cohort from GENEMACOR population-based sample of 1114 subjects aged 51.7±8.3, 74.2 male, without prior coronary artery disease. Coronary Artery Calcium (CAC) score was assessed by coronary computed tomography (Agatston method), and two categories were considered 1–99 and &gt;100. 33 SNP were evaluate to assess the significantly associated with prognostic. A weighted (wGRS) was constructed as the sum of the risk alleles weighted by the corresponding effect size (HR). Cox regression analysis adjusted for the main risk factors, calcium score (CAC) and wGRS to assess the risk of MACE during follow-up. Kaplan Meier assessed the survival.

Results

Of the studied 33 SNPs previously associated with CAD (GWAS), only 4 presented the significant association with MACE occurrence: CDKN2B-AS1 rs4977574, HNF4A rs1884613,

APOE rs7412/rs429358A and GJA4A rs 618675. After Cox regression analysis the wGRS remained in the equation (HR=2.834); p=0.012, together with CAC score (HR 3.35); p=0.012; diabetes (HR=2.398); p=0.032 and age (HR=1.056; p=0.049. WGRS above the median presented a worst survival rate (p=0.006).

Conclusion

The wGRS englobing: CDKN2B-AS1 rs4977574, HNF4A rs1884613, APOE rs7412/rs429358A and GJA4A rs 618675 is independently associated with cardiovascular events in an asymptomatic population. CDKN2B-AS1 rs4977574 gene expression modulates the progression and severity of vascular calcification in vascular smooth muscle cells (VSMCs), HNF1α-AS1 is an important regulatory molecule in cancer biology and cardiovascular disease (its expression may regulate VSMCs, and high expression promotes atheroprotection). More research is crucial for understand prognosis in asymptomatic population.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPE

Socio-Economic Development and Mental Health: Case Study of the Spanish Region of Aragon (2010-20)

Introduction

Considering health as a cross-cutting element of all public policies leads to rethinking its interactions with the environment in which people live. The collection of large volumes of data by public administrations offers the opportunity to monitor and analyze the possible associations between health and territory. The increase in the incidence and prevalence of mental health diseases, particularly depression, justifies the need to develop studies that seek to identify links with the socioeconomic and environmental setting.

Objective

The objective of this study is to explain the behavior of the depression in a mediterranean region of Northeastern Spain from an ecological and diachronic perspective.

Methods

We conducted a correlation and multivariate logistic regression analysis to identify explanatory factors of the prevalence of depression in 2010 and 2020 and in the variation rate. Potential explanatory factors are related to the socioeconomic status and to the territorial development level.

Results

The regression models retained both socioeconomic and territorial development variables as predictors of the prevalence in both years and in the variation rate. Rural areas seem to play a protective role against the prevalence.

Conclusion

It is under the territorial prism that epidemiological studies could offer useful guidelines for proactive decision-making. The integration of data on diseases and territory must be considered when developing policies for the creation of healthier environments and for directing health services with more specific resources to where they may be needed.

AB0696 Prevalence and clinical associations of different autoantibodies in the Reuma.pt systemic sclerosis cohort: is it all really set in stone?

Background

Different autoantibodies (Ab) have been associated with distinct systemic sclerosis (SSc) phenotypes. Most of these associations have not been confirmed in Portuguese patients.

Objectives

To evaluate SSc immuno-clinical associations in the Rheumatic Diseases Portuguese Register (Reuma.pt) cohort.

Methods

Multicentre open cohort study including adult SSc patients registered in Reuma.pt up to February 2021. The associations between Ab expression and clinical data were established using Chi-Square, Fischer’s Exact or Mann-Whitney U tests. The Bonferroni correction for multiple comparisons was applied to get α≤0.05. Definite associations were defined by p≤0.002, and likely associations by p≤0.05.

Results

1080 patients were included, with a mean age and disease duration of 60.2±14.6 and 12.4±10.0 years, respectively. Most were females (87.5%) and had white European ancestry (WEA, 93.2%). The most common disease subtypes were limited cutaneous (lcSSc, 57.4%), diffuse cutaneous (dcSSc, 17.7%), and very early diagnosis of SSc (VEDOSS, 12.3%). Most patients expressed antinuclear Ab (ANA, 93.4%), and the most frequent were anti-centromere (ACA, 54.6%), anti-topoisomerase I (Scl70, 21.8%), and anti-Pm/Scl Ab (PmScl, 4.7%).

ACA had definite positive associations with female sex, older age at diagnosis, lcSSc, lower modified Rodnan skin score (mRSS, median 0 vs 4), and isolated sclerodactyly, and likely associations with a higher diagnosis delay, WEA and VEDOSS. ACA had definite inverse associations with flexion contractures (FC), myositis, digital ulcers (DU), and interstitial lung disease (ILD), and likely inverse associations with pitting scars (PS) and oesophageal involvement (OI).

Scl70 had definite positive associations with male sex, dcSSc, higher mRSS, FC, DU, PS, ILD, and OI, and likely associations with younger age at diagnosis, tendon friction rubs, active scleroderma pattern in capillaroscopy, and heart involvement.

PmScl had a definite association with myositis and likely associations with male sex, calcinosis, joints involvement, and ILD. Anti-U1RNP Ab had definite associations with younger age at diagnosis, MCTD and myositis, and likely associations with a lower diagnosis delay, African ancestry and joint involvement. Anti-RNA polymerase III Ab (RP3) had likely associations with higher mRSS and renal involvement. Anti-U3RNP Ab had a definite association with dcSSc and likely associations with calcinosis and renal involvement. Anti-Th/To Ab had likely associations with male sex and myositis. Anti-Ku Ab had likely associations with systemic lupus erythematosus and mixed connective tissue disease (MCTD) overlap syndromes.

Conclusion

There was a higher prevalence of ACA and PmScl compared to other cohorts, most likely due to the high proportion of WEA patients. Most immuno-clinical associations described in the literature apply, including ACA with lcSSc and Scl70 with dcSSc, DU, PS and ILD. However, Scl70+ patients did not have an increased risk of renal involvement, and ACA+ patients did not have an increased risk for calcinosis, PAH or OI, contrary to what was described in the literature. New findings included the association of PmScl with ILD and Scl70 with an active pattern in capillaroscopy. Also, anti-U3RNP+ and Th/To+ patients did not have an increased risk of ILD or PAH, contrarily to what was previously reported. These nuances may be specific to the Portuguese SSc population or signal previously reported associations as geographically specific.

Disclosure of Interests

None declared

POS0891 REUMA.pt/MYOSITIS – THE PORTUGUESE REGISTRY OF INFLAMMATORY MYOPATHIES

Background

The idiopathic inflammatory myopathies (IMM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) is a tool used to systematically evaluate IIM patients.

Objectives

To clinically characterise the Reuma.pt/Myositis cohort.

Methods

Multicentre open cohort study, including IIM patients registered in Reuma.pt up to January 2022. Data collected included demographic, clinical, and treatment data and patient-reported outcomes. Data were presented as frequencies and median (interquartile range) for categorical and continuous variables, respectively.

Results

280 patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years, respectively. Patients were classified as having definite (N=57/118, 48.3%; N=35/224, 15.6%), likely (N=23/118, 19.5%; N=50/224, 22.3%), or possible (N=2/118, 1.7%; N=46/224, 20.5%) IIM by 2017 EULAR/ACR and Bohan-Peter criteria, respectively. Disease subtypes included dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), myositis in overlap syndromes (N=41/280, 14.6%), clinically amyopathic DM (N=17/280, 6.1%), nonspecific myositis (N=13/280, 4.6%), mixed connective tissue disease (N=12/280, 4.3%), immune-mediated necrotizing myositis (N=9/280, 3.2%), and inclusion bodies myopathy (N=7/280, 2.5%). Over the course of the disease, the most common symptoms were proximal muscle weakness (N=180/215, 83.7%), arthralgia (N=127/249, 52.9%), erythema (N=63/166, 38.0%), fatigue (N=47/127, 37.0%), Raynaud’s phenomenon (N=76/234, 32.5%), and dysphagia (N=33/121, 27.3%), and the most common clinical signs were Gottron’s sign (N=75/184, 40.8%), heliotrope rash (N=101/252, 40.1%), Gottron’s papules (N=93/237, 39.2%), and arthritis (N=38/98, 38.8%). Organ involvement included lung (N=78/230, 33.9%), oesophageal (N=40/221, 18.1%), and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) and/or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent antibodies were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%) at diagnosis, with median highest CK levels of 1308 (518-3172) and aldolase of 42 (12-121) mg/dL. Neoplasia was found in 11/127 patients (8.7%), most commonly breast (N=3/11, 27.3%), non-melanoma skin (N=2/11, 18.2%), and colorectal (N=2/11, 18.2%) cancer (Table 1). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs over the course of disease were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), mycophenolate mofetil (N=56/280, 20.0%), intravenous immunoglobulin (N=55/280, 19.6%), and rituximab (N=45/280, 16.1%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

Table 1.

Autoantibodies in cancer-associated myositis

CancerIIMAutoantibodiesBreastDM (3)Mi2, SRP (+ SSA/SSB), Pm/SclSkin (non-melanoma)Clinically amyopathic DM, PMJo1, SAE1 (+SSA/SSB)ColorectalDM (2)Mi2 (2)KidneyDM-LungDM-LymphomaInclusion bodies myopathy-UnknownDM-

Conclusion

Reuma.pt/Myositis adequately captures the main features of inflammatory myopathies’ patients, depicting in this first report a heterogeneous population, with frequent muscle, joint, skin and lung involvements. Of interest, most patients reached low disease activity at the last follow-up appointment.

Disclosure of Interests

None declared

POS0861 ANTI-Ku ANTIBODY SYNDROME: IS IT A DISTINCT CLINICAL ENTITY? A CLUSTER ANALYSIS OF 75 PATIENTS

Background

Anti-Ku antibodies are rare among patients with Connective Tissue Diseases (CTD) (1). Their potential role as a disease biomarker is not well established.

Objectives

To identify subgroups of anti-Ku positive patients according to their spectrum of anti-nuclear antibody (ANA) specificities and analyze their clinical and analytical features.

Methods

Multicenter, cross-sectional study of anti-Ku positive patients, irrespective of their diagnosis, followed at eight Rheumatology outpatient clinics. Patients were spontaneously identified according to the local work-out for suspected autoimmune diseases. Anti-Ku and other ANA specificities were determined at each hospital’s Immunology lab according to the local methodology and strategy to decide on which auto-antibodies to check when faced with a positive ANA immunofluorescence. Clinical, analytical and treatment cumulative features were identified following a dedicated structured questionnaire. Hierarchical cluster analysis (method: between-groups linkage, squared Euclidian distance) for ANA specificity variables was performed to identify subgroups.

Results

Seventy-five anti-Ku positive patients were included (female: 73.3%, mean age at diagnosis: 50.5±17.9 years, mean disease duration: 4.7±5.4 years). Their clinical diagnosis were undifferentiated connective tissue disease (UCTD) (21.3%), systemic lupus erythematosus (17.3%), Sjögren’s syndrome (16.0%), inflammatory myositis (14.7%), systemic sclerosis (10.7%), overlap CTD syndrome (8.0%), other connective tissue diseases (17.3%), healthy anti-Ku carrier (17.3%).

Six autoantibody clusters were identified and included most patients (Figure 1): Cluster 1 - anti-Ku without any other ANA specificities (36.0%); cluster 2 - Anti-nor90 and anti-fibrillarin (8.0%); cluster 3 - anti-Jo1, PL-7, PL-12, and PM-Scl100 (9.3%); cluster 4 - anti-Scl70 (4.0%); cluster 5 - anti-Sm, anti-ribosome, and anti-dsDNA (13.3%); cluster 6 - anti-centromere, Th/To, PM-Scl75 (8.0%). The remaining patients were outliers (21.3%) not fitting in any cluster.

Figure 1.

Hierarchical cluster analysis of ANA specificities in anti-Ku+ patients

Detailed clinical analysis of patients in cluster 1, the most numerous, presenting anti-Ku antibodies without any other ANA specificities, the most frequent clinical manifestations were: Raynaud’s phenomenon (40.7%), arthritis (25.9%), sicca syndrome (25.9%), myositis (14.8%), and interstitial lung disease (ILD) (14.8%); 25.9% were healthy anti-Ku carriers. Patients from cluster 1 were most frequently treated with low dose glucocorticoids (51.9%), hydroxychloroquine (37.0%), or methotrexate (18.5%).

Among the whole study population (n=75), major organ involvement was present in 18.7%, with ILD in 10.7% and renal involvement in 8.0%. None of the patients in cluster 1 presented nephritis.

Conclusion

Anti-Ku positive patients without any other ANA specificities is the largest subset and may represent a distinct entity among the differentiated CTD (2). Patients with this anti-Ku syndrome may develop ILD. In addition, anti-Ku antibodies can be found in patients with a diversity of other ANA specificities and heterogeneous CTD diagnosis.

References

[1]Lakota K, et al. International cohort study of 73 anti-Ku-positive patients: association of p70/p80 anti-Ku antibodies with joint/bone features and differentiation of disease populations by using principal-components analysis. Arthritis Res Ther. 2012 Jan 6;14(1):R2. doi: 10.1186/ar3550. PMID: 22226402; PMCID: PMC3392788.

[2]Spielmann L, et al. Anti-Ku syndrome with elevated CK and anti-Ku syndrome with anti-dsDNA are two distinct entities with different outcomes. Ann Rheum Dis. 2019 Aug;78(8):1101-1106. doi: 10.1136/annrheumdis-2018-214439. Epub 2019 May 24. PMID: 31126956.

Disclosure of Interests

None declared

POS1282 PEDIATRIC INFLAMMATORY MULTISYSTEM SYNDROME TEMPORALLY-ASSOCIATED WITH SARS-CoV-2 – A PORTUGUESE SINGLE CENTRE CASE SERIES

Background

Across the globe, coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 appears to affect paediatric population in a milder and nonthreatening way, when compared to adults. However, since April 2020 case reports of previously healthy children presenting with unremitting fever, biologic inflammatory syndrome and cardiac dysfunction have been emerging. This syndrome, which has been termed Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 infection (PIMS-TS), represents a rare complication of COVID-19 in children1.

Objectives

To describe the clinical, laboratory and imaging characteristics, course, management and outcomes of hospitalized children diagnosed with PIMS-TS in a Portuguese tertiary care hospital.

Methods

A retrospective study including children (< 18 years) that attended our hospital from April 2020 to December 2021 was performed. All the children included fulfilled the case definition of PIMS-TS published by the Centre for Disease Control and Prevention. Sociodemographic and clinical data, laboratory markers and imaging findings were collected.

Results

A total of 19 children met the criteria for PIMS-TS, 68% male with a mean age at diagnosis of 8 years old (IQR 5.8-15). They were all caucasian, except for a mixed-race patient, and all previously healthy, except one patient who was obese. Twelve had recent infection by SARS-CoV-2 detected by reverse transcriptase (RT) PCR and 18 had positive IgG serology.

All had fever at diagnosis, with a median duration of 6 days (IQR 5-6) and 89.5% had mucocutaneous, gastrointestinal and hematological attainment, respectively. Other affected systems were respiratory (73.7%), cardiovascular (63%), lymphoid organs (52.6%), musculoskeletal (47%), genito-urinary (31.6%) and neurological (26.3%). Laboratory findings can be found in Table 1.

Thirty-six percent were admitted in intensive care unit for a median duration of 8 days (IQR 4-9). 42.1% needed respiratory support, 87.5% with supplemental oxygen therapy, 62.5% with mechanical ventilation and 12.5% with non-invasive ventilation. All patients received intravenous (IV) immunoglobulin, 52.6% IV corticosteroid (CS) pulses and 78.9% IV and oral CS. Other treatments included acetylsalicylic acid (n=18), heparin (n=8) and antibiotic therapy (n=19) - Table 3. Seventeen fully recovered and 2 had sequalae: one of them with coronary artery aneurysms and other exertional dyspnea.

Conclusion

In this case series, there was a broad spectrum of clinical symptoms and disease severity, ranging from fever and systemic inflammation to critical care admission with myocardial injury, shock, and development of coronary artery aneurysms.

Despite short-term morbidity, there were no mortality cases, with most of them recovering without sequelae. All physicians providing clinical care to children should consider this rare but severe delayed syndrome in paediatric population.

References

[1]Ramcharan T, Nolan O, Lai CY et al. Paediatric Inflammatory Multisystem Syndrome: Temporally Associated with SARS-CoV-2 (PIMS-TS): Cardiac Features, Management and Short-Term Outcomes at a UK Tertiary Paediatric Hospital. Pediatr Cardiol. 2020 Oct;41(7):1391-1401.

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Disclosure of Interests

None declared

Convergence in critical fuel moisture and fire weather thresholds associated with fire activity in the pyroregions of Mediterranean Europe

Wildfires are becoming an increasing threat to many communities worldwide. There has been substantial progress towards understanding the proximal causes of increased fire activity in recent years at regional and national scales. However, subcontinental scale examinations of the commonalities and differences in the drivers of fire activity across different regions are rare in the Mediterranean zone of the European Union (EUMed). Here, we first develop a new classification of EUMed pyroregions, based on grouping different ecoregions with similar seasonal patterns of burned area. We then examine the thresholds associated with fire activity in response to different drivers related to fuel moisture, surface meteorology and atmospheric stability. We document an overarching role for variation in dead fuel moisture content (FM_d), or its atmospheric proxy of vapor pressure deficit (VPD), as the major driver of fire activity. A proxy for live fuel moisture content (EVI), wind speed (WS) and the Continuous Haines Index (CH) played secondary, albeit important, roles. There were minor differences in the actual threshold values of FM_d (10-12%), EVI (0.29-0.36) and CH (4.9-5.5) associated with the onset of fire activity across pyroregions with peak fire seasons in summer and fall, despite very marked differences in mean annual burned area and fire size range. The average size of fire events increased with the number of drivers exceeding critical thresholds and reaching increasingly extreme values of a driver led to disproportionate increases in the likelihood of a fire becoming a large fire. For instance, the percentage of fires >500 ha increased from 2% to 25% as FM_d changed from the wettest to the driest quantile. Our study is among the first to jointly address the roles of fuel moisture, surface meteorology and atmospheric stability on fire activity in EUMed and provides novel insights on the interactions across fire activity triggers.

The Map of Need: identifying and predicting the spatial distribution of financial hardship in Scotland's veteran community

INTRODUCTION

During military service, many household costs for both married and single service personnel are subsidised, and transition can leave veterans unprepared for the financial demands of civilian life. Armed Forces organisations such as Sailor, Soldier, Air Force Association (SSAFA) play a central role in understanding the financial challenges that UK veterans face and provide an insight into the financial hardship experienced by veterans. The aim of this study was to use SSAFA beneficiary data as a proxy to identify the nature of financial benefit, the spatial distribution of financial hardship in the Scottish SSAFA beneficiary community and explore factors that might predict where those recipients are located.

METHODS

Using an anonymised data set of Scottish SSAFA financial beneficiaries between 2014 and 2019, this study used a geographical methodology to identify the geospatial distribution of SSAFA benefit recipients and exploratory regression analysis to explore factors to explain where SSAFA beneficiaries are located.

RESULTS

Over half of benefit applicants (n=10 735) were concentrated in only 50 postcode districts, showing evidence of a clustered pattern, and modelling demonstrates association with area-level deprivation. The findings highlight strong association between older injured veterans and need for SSAFA beneficiary assistance.

CONCLUSION

The findings demonstrate that beneficiaries were statistically clustered into areas of high deprivation, experiencing similar challenges to that of the wider population in these areas. Military service injury or disability was strongly associated with areas of high SSAFA benefit use and in those areas high unemployment was also a significant factor to consider.

Hydrothermally-altered feldspar reduces metal toxicity and promotes plant growth in highly metal-contaminated soils

Novel green technologies for soil remediation have been focusing on altering soil properties and improving soil health. Hydrothermally-altered feldspar (HYP, HydroPotash), recently developed, is being related as both an efficient amendment to immobilize heavy metals in soils and a plant nutrients source, consisting in a promising technology for revegetation of contaminated sites. In order to evaluate the effectiveness of using HYP for phytostabilization programs, two different soils (Technosol and Oxisol) collected from a smelting site were amended with increasing doses of HYPs (HYP-1 and HYP-2): 15, 30, 60, and 120 Mg ha^-1. For comparison, a control (soil without amendment) and a soil amended with zeolite (clinoptilolite) were also included as treatments. After 90 days of incubation, HYPs decreased up to 83.8 % of Cd availability and reduced exchangeable Al up to 100 %. HydroPotash increased pH, cation exchange capacity, and contents of potassium, calcium, and phosphorus, as well as microbial biomass carbon, and fluorescein diacetate hydrolysis of soils. Andropogon gayanus, Eucalyptus grandis, and Heterocondylus vitalbae started growing from the dose of 15 Mg ha^-1 HYPs in the Oxisol and 60 Mg ha^-1 HYPs in the Technosol. Principal component analysis indicates that plant shoot dry weight was negatively correlated with extractable Cd and Zn and positively with pH, CEC, and Ca content. Besides promoting plant growth, HYPs reduced heavy metals (Cd and Zn) absorption by plants, indicating that HYP has potential use as an amendment in phytostabilization programs.

Patient-level costs in intensive care: a case report of a standardized and scalable approach

Background

Intensive care units (ICU) costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs (Value-Based Healthcare).

Methods

Case report of a costing methodology implementation, in a 15-bed ICU, in a public, teaching hospital at Teresina/Piauí-Brazil (as part of a broader initiative, with 10 hospitals from all Brazilian regions). All costs incurred during ICU stay were measured from the hospital perspective, applying absorption costing method, by using a standardized approach and a specific central IT system. The study was carried out from Oct/19-Sep/20, including 613 patients, and a team of 10 researchers working with 4 teams of the local hospital (costs, IT, ICU and managers).

Results

ICU fixed costs (personnel, overheads, energy/water, depreciation, non-tracked drugs/medical materials), were divided by service capacity (total bed-hours) for calculation of the costs/minute. Costs were then allocated in the patient level multiplying costs/minute by the ICU length of stay. Variable costs (lab/image tests, transfusions, hemodialysis, and traceable medical materials/drugs) were directly allocated, multiplying the unit cost by the volume consumed per patient. A mini-survey applied 1-year after showed that both cost researchers and hospital staff agreed on the main challenges in measuring patient-level costs (fragmented process; fixed costs available only at the hospital level; lack of control on cost-drivers; indirect costs not considered; any reference for lab/image costs) and that the approach was sufficient to overcome them. The local team also reported increased awareness about the importance of patient-level costs after the experience.

Conclusions

The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Key messages

ICU costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs. The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Is there a different impact of traditional risk factors on calcium score, in an asymptomatic population?

Background

The coronary calcium score has been increasingly used to stratify and predict cardiovascular risk, particularly in low and intermediate-risk persons. Understanding which determinants have more impact on coronary calcium score level, could lead to the development of new stricter preventive measures for reducing coronary artery calcification (CAC) and, consequently, cardiovascular risk.

Purpose

Our study aimed to investigate the impact of the traditional risk factors (TRFs) on the CAC score level and if there is a different association between this TRFs and CAC score degrees, in an asymptomatic population.

Methods

The study cohort comprised 1,122 consecutive asymptomatic individuals without known coronary artery disease (CAD) belonging to the healthy controls of GENEMACOR study and referred for computed tomography for CAC scoring assessment. The traditional risk factors considered were (1) current cigarette smoking, (2) dyslipidemia, (3) diabetes mellitus, (4) hypertension and (5) family history of coronary artery disease. According to the Hoff's nomogram, 3 categories were created: low CAC (0≤CAC&lt;100 and P&lt;50); moderate CAC (100≤CAC&lt;400 or P50–75) and high or severe CAC (CAC≥400 or P&gt;75). We evaluated the association of the different TRFs with these levels of CAC score (Chi-square test). Finally, we performed a logistic regression model adjusted for all significant TRFs selected in the bivariate analyses.

Results

Smoking was significantly associated with high levels of CAC score, 28.4% vs 21.7%; p=0.038 as well as hypertension, 58.8% vs 45.6%; p=0.001, type 2 diabetes 21.1% vs 9.6%; p&lt;0.0001, dyslipidemia, 73.0% vs 66.1%; p=0.057. Family history did not show a significant association with CAC (p=0.717). Then, we constructed a logistic regression model adjusted the significant risk factors in previous analysis. The final multivariate analysis, selected as independent predictors of high CAC: Type 2 diabetes; OR=2.309; 95% CI 1.533–3.479; p&lt;0.0001, hypertension; OR=1.627; 95% CI 1.185–2.233; p=0.003, and smoking, OR=1.565; 95% CI 1.102–2.222; p=0.012.

Conclusions

In this study, well-known and modifiable cardiovascular risk factors are associated with high calcium score levels. However, hypertension and diabetes seem to be preferentially associated with higher CAC scores, while tobacco, although it has a significant association, seems to be not so strong as diabetes and hypertension. This concept may mean that smoking has its primary role in plaque instability and not so much in the growing and calcification of plaques.

Funding Acknowledgement

Type of funding sources: None.

Is HNF4A gene, a risk factor or protection against coronary artery disease?

Background

Hepatocyte nuclear factor4 A (HNF4A) gene was considered by GWAS associated with atherosclerosis and CAD susceptibility. Loss-of-function mutations in human hepatocyte nuclear factor 4α (HNF4α), a transcriptor factor encoded by the HNF4A gene, are associated with maturity-onset diabetes of the young and lipid disorders. However, the mechanisms underlying the lipid disorders are poorly understood.

Aim

We propose identifying the genetic predisposition to atherosclerosis progression and events occurrence or regression and better prognosis, through a cohort study from GENEMACOR population.

Methods

We investigated a cohort of 1,712 patients who underwent coronary angiography with more than 70% stenosis of at least one main coronary vessel. 33 SNPs associated with the risk of CAD in previous GWAS were genotyped by TaqMan assays methodology. We evaluated the best genetic model associated with CAD prognosis (events) with a 95% CI in bivariate analysis. The hazard function was performed by a Cox survival regression model adjusted for age, sex, type 2 diabetes, hypertension, and hypercholesterolemia, to evaluate their relationship with the event's incidence. Finally, we constructed Kaplan–Meier cumulative-event curves for the significant genetic variants.

Results

Our evaluation revealed a SNP paradoxically associated with protection from atherosclerosis progression and events occurrence: rs1884613 C&gt;G in the HNF4A gene on chromosome 20 dominant model [OR=0.653; 95% CI (0.522–0.817); p=0.0002]. Cox survival regression model showed a CAD protective effect of HNF4A with a Hazard ratio (HR) of 0.771; p=0.007. The Kaplan-Meier cumulative event analysis disclosed that the CG+GG vs CC genotype of rs1884613 HNF4α was associated with a better prognosis (Breslow test, p=0.004) at the end of the follow-up.

Conclusion

We identified, in this study, one SNPs paradoxically associated with a better CAD prognosis rs1884613 in HNF4A. The HNF4A gene variants could induce loss of HNF4α function, modifying and modulating hepatic lipase and lipid metabolism conferring a beneficial effect on atherosclerosis progression and events occurrence.

Funding Acknowledgement

Type of funding sources: None.

Epicardial adipose tissue volume improves cardiovascular risk reclassification: the Framingham Risk Score example

Introduction

Epicardial adipose tissue (EAT) volume can be noninvasively detected by CT and has been suggested to predict major adverse cardiovascular events (MACE). Framingham Risk Score is one of a number of scoring systems used to determine an individual's chances of developing cardiovascular disease, hence identifying who is most likely to benefit from prevention.

Objectives

The purpose of this study was to determine net reclassification improvement (NRI) and improved risk prediction based on EAT volume, in comparison to a traditionally known cardiovascular risk score, such as the Framingham.

Methods

895 asymptomatic volunteers were prospectively enrolled in a single Portuguese center (mean age 51.9±7.7, 78.5% male) and underwent a median follow-up time of 3.7 years (IQR 5.0). EAT volume was measured by Cardiac Computed Tomography (CCT) using a modified simplified method. For NRI assessment, EAT volume as a continuous variable was added to the Framingham Risk Score.

Results

After 3.7 median years of follow-up, 27 patients developed a MACE. Using NRI, the net proportion of events (netNRIe) that assigned a higher risk was 33.3% (better reclassified), and the net ratio of non-events (netNRIne) was 24.7%, resulting in a net reclassification index (netNRI) of 58.0%. When the new marker was included in the model, 58.0% of patients were better reclassified. In our work, a total of 33.3% of patients who suffered events (n=27) were correctly reclassified and assigned a higher risk.

Conclusion

EAT volume results in a high reclassification rate in an asymptomatic, low-risk population, demonstrating the benefit of this marker beyond traditional risk assessment models. Our study supports its application, especially in carefully selected individuals.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The significant role of coronary artery calcification score in asymptomatic patients with metabolic syndrome

Background

Metabolic syndrome (MetS) is a clinical condition composed of metabolic and cardiovascular risk factors, such as abdominal obesity, hyperglycemia, dyslipidemia and hypertension. Many patients with MetS suffer major adverse cardiovascular events (MACE) that are not adequately identified by traditional risk assessment, suggesting the need for early detection of subclinical coronary heart disease to identify those at high-risk. Coronary artery calcification (CAC) screening has added utility in categorizing patients with low, intermediate and high cardiovascular risk.

Purpose

Evaluate the prognostic role of CAC score in asymptomatic population patients with metabolic syndrome in cardiovascular events risk prediction.

Methods

A total of 1,122 asymptomatic individuals without known coronary heart disease, enrolled from GENEMACOR study, were followed for a mean of 5.3±3.4 years for the primary endpoint of all-cause of cardiovascular events. All were referred for computed tomography for the CAC scoring assessment. According to the Hoff's nomogram, 3 categories were created: low CAC (0≤CAC&lt;100 or P&lt;50); moderate CAC (100≤CAC&lt;400 or P50–75) and high or severe CAC (CAC≥400 or P&gt;75). In a subgroup of 507 individuals with MetS and 615 controls, CAC values were compared by T-student and association of CAC severity with events occurrence was evaluated. Finally, a logistic regression model adjusted for CAC severity was performed in patients with MetS.

Results

Among our population, the extent of CAC differs significantly between men and women in the same age group. Patients with Mets (23.2%, n=115) had higher CAC scores than controls (219.0±486.0 vs 115.8±370.8, p&lt;0.0001). In this cohort, with higher CAC scores, 46.7% vs 22.5% had MACEs (p=0.049) during the follow-up. The logistic regression analysis revealed that CAC≥400 is a MACE predictor (OR=4.326, CI 95% 1.241–15.080, p=0.021) in patients with MetS.

Conclusion

Our results point to the importance of the inclusion of CAC screening in patients with MetS to further stratify those patients that, despite tight control of cardiovascular risk factors, may benefit from more intensive therapies. This tool is a useful and straightforward method that could have a significant impact on the prognosis of future cardiovascular disease in patients with MetS.

Funding Acknowledgement

Type of funding sources: None.