Multivariate analysis applied to X-ray fluorescence to assess soil contamination pathways: case studies of mass magnetic susceptibility in soils near abandoned coal and W/Sn mines

Determining the origin and pathways of contaminants in the natural environment is key to informing any mitigation process. The mass magnetic susceptibility of soils allows a rapid method to measure the concentration of magnetic minerals, derived from anthropogenic activities such as mining or industrial processes, i.e., smelting metals (technogenic origin), or from the local bedrock (of geogenic origin). This is especially effective when combined with rapid geochemical analyses of soils. The use of multivariate analysis (MVA) elucidates complex multiple-component relationships between soil geochemistry and magnetic susceptibility. In the case of soil mining sites, X-ray fluorescence (XRF) spectroscopic data of soils contaminated by mine waste shows statistically significant relationships between magnetic susceptibility and some base metal species (e.g., Fe, Pb, Zn, etc.). Here, we show how qualitative and quantitative MVA methodologies can be used to assess soil contamination pathways using mass magnetic susceptibility and XRF spectra of soils near abandoned coal and W/Sn mines (NW Portugal). Principal component analysis (PCA) showed how the first two primary components (PC-1 + PC-2) explained 94% of the sample variability, grouped them according to their geochemistry and magnetic susceptibility in to geogenic and technogenic groups. Regression analyses showed a strong positive correlation (R2 > 0.95) between soil geochemistry and magnetic properties at the local scale. These parameters provided an insight into the multi-element variables that control magnetic susceptibility and indicated the possibility of efficient assessment of potentially contaminated sites through mass-specific soil magnetism.

A Survey on Environmental Sustainability Among Anesthesiologists: An Opportunity for Changing Behaviors

Introduction  Environmental sustainability (ES) is a current issue related to natural resource scarcity, pollution and climate change. Although operating rooms (ORs) comprise a small proportion of the entire hospital infrastructure, they significantly impact the environment. Anesthesiologists are ideally positioned to assume leadership, mitigating this negative impact regarding OR waste in the environment. We created a Green Team, comprising multidisciplinary professionals from different areas of a tertiary Portuguese medical center, and conducted a survey that was sent to all the institution's anesthesiologists to assess the current state of ES. Results  From the sample of 133 participants, 101 responses were obtained. Concerning knowledge and training on ES, a significant portion of the respondents (66.7%) seem to attribute "great importance" to the subject. As to the greatest barrier to waste separation in the OR, several respondents highlighted the issues of "inadequate information/education/training" (62.6%) and "lack of support from hospital/OR in-chief/administration" (26.3%). Finally, among seven methods to raise awareness of ES, "training during residency" was the top choice for these professionals, with 52.5% of the votes. Discussion  Most anesthesiologists who responded to the survey recognize the utmost importance of ES and have perceived the environmental impact of their anesthetic practices in the OR. Overall, this tendency is consistent with other international studies. Moreover, most of those surveyed separate waste at home and want to extend this practice -in a more structured approach- to their workplace, with an effective separation of anesthetic and general waste in the OR. Conclusion Professionals perceive barriers to performing green practices, whether the lack of environmental education and awareness, the absence of recycling containers or waste separation bags, or the lack of protocols and guidelines implementing these circuits. With the publication of this work, we aim to encourage other institutions to implement ES projects in their hospitals and ORs.

Airway Management of a Patient With a Giant Frontoethmoidal Encephalocele: A Pediatric Case Report

Meningoencephalocele is a rare congenital midline defect of cranial bone fusion characterized by herniation of the brain and meninges through the skull. In addition to the challenges of managing a major neurosurgical procedure in a pediatric patient, airway management in this group of patients requires advanced skills, and a difficult airway should be anticipated from the start. Since awake intubation is not an option in most pediatric cases with airway anatomy abnormalities and maintaining an adequate seal with a pediatric face mask is often impossible, airway management in patients with these lesions is highly challenging. We present the case of a 12-month-old girl with a postnatal diagnosis of frontoethmoidal meningoencephalocele who underwent craniotomy, followed by encephalocele resection, subsequent frontal cranioplasty, and reconstruction of the nasal bone defect. We discuss the timely adaptation of an adult face mask (size five) rotated 180º over the patient's entire face to perform adequate preoxygenation and spontaneous ventilation assistance with hand-bag ventilation after the inhalational induction of general anesthesia. After obtaining adequate depth of anesthesia, an initial video laryngoscopy with pediatric Medan® was performed. The epiglottis and vocal cords were identified, and rocuronium was administered. After complete muscle relaxation, another video laryngoscopy was performed and orotracheal intubation was successful on the first attempt. As an alternative airway, we planned orotracheal intubation using a pediatric fiberoptic bronchoscope with the aid of a laryngeal mask airway if required. As a rescue measure, we also ensured that an otolaryngologist was present in the operating room if a tracheostomy was deemed necessary. We aim to raise awareness of the importance of safe practices in anesthesia, reinforce preventive measures during careful airway examination, and plan approach strategies.

Disparities in Breast-Conserving Therapy vs. Mastectomy among Asian American and Pacific Islander Women

PURPOSE/OBJECTIVE(S)

Multiple randomized trials support the use of breast-conserving therapy (BCT), defined as lumpectomy followed by adjuvant radiotherapy, as an alternative to mastectomy for definitive treatment of early-stage (T1-2N0) breast cancer. However, data suggest that Asian American, Native Hawaiian, and Pacific Islander (AANHPI) may undergo mastectomy at higher rates than BCT and may experience barriers to receipt of BCT. The purpose of this study was to examine BCT utilization by disaggregated AANHPI groups to identify differences in receipt of mastectomy versus BCT.

MATERIALS/METHODS

The 2004-2017 National Cancer Database was queried to identify women age ≥18 years old diagnosed with cT1-2N0M0 breast cancer treated with either BCT or mastectomy without post-mastectomy radiation therapy. Women were classified based on self-reported race. Multivariable logistic regression defined adjusted odds ratios (OR) assessing the association between race and receipt of BCT versus mastectomy for all patients and separately by cT1-2 stage. All models were adjusted for relevant sociodemographic and clinical factors.

RESULTS

Of 794,403 women with cT1-2N0M0 breast cancer, 239,801 (30%) received mastectomy and 554,602 (70%) received BCT. After adjusting for clinical and sociodemographic factors, AANHPI women had greater odds of receiving mastectomy over BCT, compared to White women (OR [95% CI], 1.35 [1.30-1.39]; p<0.001). In contrast, Black women were less likely than White women to receive mastectomy (0.86 [0.84-0.87]; p<0.001). Upon disaggregation, Chinese, Japanese, Filipino, Korean, Vietnamese, and Asian Indian & Pakistani women were more likely to receive mastectomy over BCT compared to White women (p<0.001 for all). Treatment at academic (1.30 [1.27-1.32]), integrated (1.24 [1.21-1.27]), and comprehensive community cancer centers (1.15 [1.13-1.17]) were all associated with greater odds of mastectomy compared to treatment at community cancer programs (all p<0.001). Greater distance from treatment facility (≥50 mi. vs. 0 to <10 mi. [reference], OR 1.50 [1.47-1.53]) and cT2 disease (1.85 [1.82-1.87]) were also associated with greater odds of receiving mastectomy (all p<0.001).

CONCLUSION

In this evaluation of women with early-stage breast cancer, women from several AANHPI groups were more likely to receive mastectomy (as opposed to BCT) compared to White women. While sociocultural preferences, differences in access to and interest in reconstruction, as well as prevalent tumor-to-breast ratios may partially explain the disparities, collectively our data suggest an ongoing need for greater patient involvement in shared-decision making, particularly in vulnerable and understudied Asian populations.

Implementation Outcomes of Strategies to Promote Short-Course Radiation for Nonspine Bone Metastases in an Academic-Community Partnership: Survey Results from the ALIGNMENT Trial

PURPOSE/OBJECTIVE(S)

Local treatment of nonspine bone metastases has become increasingly complex, resulting in physician practice variability nationwide. The purpose of this study was to assess physician perceptions of 3 implementation strategies to promote adoption of short course radiotherapy (RT) for nonspine bone metastases.

MATERIALS/METHODS

ALIGNMENT ("Alliance Group for Bone Metastasis") was a multi-institutional stepped wedge cluster randomized implementation trial testing strategies to increase use of ≤5 fractions for nonspine bone metastases conducted across 3 clinical sites in an academic-community partnership. Strategies included a) multidisciplinary consensus guidelines, b) e-Consults, an email-based consultation platform, and c) personalized audit and feedback (A&F) reports with peer comparison. Using the Proctor et al. framework and validated questions from Weiner et al., physician surveys were used to assess each strategy's usefulness, acceptability (i.e., "I welcome [strategy]"), appropriateness (i.e., "[strategy] seems like a good match"), and feasibility (i.e., "[strategy] seems implementable" or "easy to use"). Survey responses were anonymized, so Fisher's Exact test was used to compare proportions with significance set at p<0.05.

RESULTS

Overall, 29 of 38 and 30 of 38 physicians participated in the pre- and post-implementation surveys, respectively, with 80% completing both. Pre-implementation, guidelines was most often ranked 1st in terms of usefulness (61%), followed by eConsults (38%) and A&F (3%). Post-implementation, guidelines and eConsults had the most and least favorable acceptability, appropriateness, and feasibility scores, respectively (Table), with 77% of physicians being likely to recommend the guidelines to other oncologists. In contrast, while 43% of physicians reported having at least 1 difficult clinical question regarding bone metastases during the study, only 33% of physicians preferred eConsults, while 50% preferred reaching out to a friend/colleague. Lastly, although A&F had the lowest perceived usefulness pre-implementation, A&F had the greatest increase in acceptability (72%→90%; p = 0.10), appropriateness (66%→90%; p = 0.03) feasibility ("implementable": 59%→93%, p = 0.002; "easy to use": 45%→93%, p<0.001).

CONCLUSION

In this multicenter trial, all strategies were acceptable, appropriate, and feasible, with guidelines and A&F showing the most favorable outcomes post-implementation. While guidelines were assessed as the most useful, A&F had significant increases in appropriateness and feasibility.

Disparities in Inpatient Care Including Receipt of Radiotherapy and Mortality in Unhoused Adults with Cancer in the United States

PURPOSE/OBJECTIVE(S)

Cancer is the second leading cause of death among unhoused individuals in the United States. This study aims to assess inpatient care and outcomes of unhoused vs. housed adults with cancer. We hypothesize that unhoused patients receive less intensive care than housed patients during hospitalization.

MATERIALS/METHODS

All hospitalized adults age ≥18 with a principal cancer diagnosis were identified in the 2016-2020 National Inpatient Sample (NIS). Logistic regression models tested for associations between housing status and primary outcomes: care management (i.e., receipt of invasive procedures, systemic therapy, or radiation therapy [RT]) and inpatient death. Adjusted analyses accounted for patient demographics, socioeconomic status, comorbidities, and potential interactions between housing status and length of stay (LOS).

RESULTS

A total of 9,030 unhoused and 2,758,693 housed hospitalized adults with cancer were included in this study. At baseline, there were significant (p<0.05) differences in age <65 years (77% unhoused vs. 41% housed), male sex (75% vs. 53%), race (Black, 25% vs. 13%; White, 58% vs. 71%), and insurance type (Private, 6% vs. 27%; Medicaid, 53% vs. 11%) between groups. There were also differences in the prevalence of certain cancer histologies, including lung (17% vs. 14%) and liver (8% vs. 3%) cancer. Additionally, while comorbidities such as congestive heart failure (18% vs. 15%) and HIV (10% vs. 1%) were more common among unhoused patients, other conditions such as autoimmune disease (21% vs. 26%) and diabetes mellitus (38% vs. 43%) were more common among housed patients. Compared to housed patients, unhoused patients had longer LOS (median 6 vs. 4 days), with 62% hospitalized for ≥5 days (vs. 46%). On adjusted analysis, unhoused patients were less likely to undergo invasive procedures (48% vs. 58%; aOR [95% CI], 0.34 [0.27-0.42]) or receive systemic therapy (6% vs. 8%; 0.41 [0.20-0.85]) while inpatient. There were no significant differences in odds of receipt of RT (2% vs. 1%; 0.85 [0.21-3.41]) or odds of inpatient death (4% vs. 6%; 0.78 [0.52-1.15]) between groups.

CONCLUSION

In this first nationally representative analysis of housing status among hospitalized adults with cancer, unhoused adults were significantly less likely to receive invasive procedures or systemic therapy while inpatient, despite a higher prevalence of certain aggressive cancers and serious comorbidities compared to housed adults. Although there were no significant differences in the receipt of RT or death, disparities in inpatient management among unhoused patients highlight missed opportunities to promote equitable cancer care in this vulnerable population.

Experience and Learning from the COVID-19 Pandemic in Portugal: Perceptions of Community Pharmacy Professionals

Background

During the COVID-19 pandemic, community pharmacy (CP) professionals were among those who experienced the greatest risk of contracting SARS-CoV-2, which forced major adaptations.

Objectives

The objectives of the study were to describe the changes implemented in CP professionals during the pandemic, understand the perception of professionals about their experience, and explore changes to remain.

Methods

An observational and cross-sectional study was conducted via an online questionnaire (June-September 2020). The target population was CP professionals working in Portugal for >2 years and serving the public during the pandemic.

Results

Of a total of 353 participants, 84% were female (mean age of 37.6 years), and 81% were pharmacists (mean professional experience of 12.9 years). In the management and organizational dimensions, the most mentioned changes were adaptation to legislative changes (90%), fluctuations in the treasury (82%), and reduction of working hours (46%). Only 2% resorted to simplified layoff. In the back office, there was a need to adapt stock management (93%) and purchase personal protective equipment (99%). In the front office, there was a change in service policies - wicket or conditional opening (92%), routes of the arrival of user requests (91%), and home delivery (82%). Physical changes occurred in 100% of pharmacies. The most frequently implemented procedures were the use of protection systems and PPE, articulation with hospital pharmacies for dispensing in proximity (75%), and training in this area (55%). Regarding interpersonal climate, improvements in the connection between team members are evident: increase in mutual help (57%), solidarity (54%), and group cohesion (50%); in the relationship with clients, the majority indicated the replacement of the usual user by third parties (71%), and changes in communication channels (increase in use of technological means 68%).

Conclusions

Results illustrate the profound impact of the pandemic on CP professionals, both professionally and personally. It also highlights the importance of their roles in proximity and community support.

Unexpected Myasthenic Crisis in Anesthesia for Magnetic Resonance Imaging - Diagnosis and Management

Myasthenic crisis (MC) is a rare and life-threatening manifestation of myasthenia gravis (MG) and is characterized by rapidly progressing weakness of respiratory and bulbar muscles leading to immobility, severe dyspnea, respiratory insufficiency, and possible aspiration. Early recognition and prompt treatment may prevent the development of further complications and the need for intubation, invasive mechanical ventilation, and ICU admission. Its diagnosis requires a high degree of clinical suspicion, and anesthesiologists, despite being prepared to deal with and provide anesthesia care to patients with MG, may not be immediately aware of the correct diagnosis and treatment of this medical emergency, and of the red flags that should prompt more invasive measures. Due to the very low incidence and possibly high morbidity of the condition, it is important to report cases of perioperative MC to raise awareness for early diagnosis and treatment. This case also emphasizes the importance of pre-anesthetic consultation and a multidisciplinary approach with appropriate communication and referral between medical specialties as the diagnosis of MG was not disclosed to the anesthetic team. The organizational, communication and safety gaps that occurred during the perioperative period could potentially have had a negative impact on patient outcomes. We report a case of MC in a patient who underwent general anesthesia for ambulatory magnetic resonance imaging and whose diagnosis of MG was not conveyed to the anesthesia care team.

At the outer edge of STEMI time: even after 12 hours, the clock keeps ticking

Introduction

Although primary percutaneous coronary intervention (pPCI) is not a class I recommendation in all patients (pts) presenting within 12 to 48h of symptom onset (late ST-segment Elevation Myocardial Infarction, STEMI), there is increasing evidence supporting its routine use in this population. Data on long-term clinical outcomes is sparse.

Objective

To evaluate long-term MACE in late-STEMI pts submitted to pPCI and compare with clinical outcomes of early reperfusion groups.

Methods

Retrospective analysis of consecutive pts submitted to pPCI due to STEMI between 2010 and 2015 in a pPCI centre. Included pts were stratified in 5 groups according to symptom-to-balloon time (SBT): &lt;3h; 3–6h; 6–12h; 12–24h; 24–48h. Of a total of 903 pts, 19 pts were excluded due to SBT &gt;48h. Long-term events were established as 5y mortality and 5y-MACE (a composite endpoint of death, re-infarction, heart failure hospital admission and ischemic stroke). The cumulative incidence of long-term outcomes was calculated by the Cox regression analysis and presented according to the Kaplan-Meier method.

Results

Of the 884 pts included in the study, stratification according to SBT was: pPCI&lt;3h (47.4%), pPCI 3–6h (24.9%), pPCI 6–12h (16.5%), pPCI 12–24h (8.0%), and pPCI 24–48h (3.2%). These groups showed no significant difference in terms of demographic characteristics (age, CV risk factors, previous coronary disease or heart failure), clinical severity (systolic arterial pressure, Killip-Kimball class, left ventricle ejection fraction) and angiography findings (multivessel disease, complete revascularization and PCI success). After a median follow-up of 76 (56; 98) months, 5-year mortality was 20.6% (182 pts) and 5-year MACE was 23.3% (206 pts). MACE was associated with increased median SBT: 5.0 (2.0; 9.0) hours vs 4.0 (2.0; 6.5) hours, p&lt;0.001. Of the MACE components, the only that showed a significant association with higher median SBT was mortality: 5.0 (2.0; 10.0) hours vs 4.0 (2.0; 6.0), p&lt;0.001. Differences in long-term outcomes were significant when considering SBT stratified by revascularization time (Figure 1).

Conclusions

As expected, there is a clinical benefit of early reperfusion for long-term cardiovascular events. Within the late-STEMI group, there seems to be a clear distinction between pPCI&lt;24h and &gt;24h, although the clinical benefit of pPCI timing most probably acts a continuum.

Funding Acknowledgement

Type of funding sources: None.

Adenosine A2A receptors blockade attenuates dexamethasone-induced alterations in cultured astrocytes

Anxiety involves abnormal glucocorticoid signalling and altered glia-neuron communication in brain regions processing emotional responses. Adenosine A2A receptor (A2AR) blockade ameliorates mood and memory impairments by preventing synaptic dysfunction and astrogliosis. Since the glucocorticoid dexamethasone (DEX) can mimic early life-stress conditions, leading to anxiety-like behaviours, we now tested if A2AR blockade prevents alterations in the morphology and function of astrocytes exposed to DEX. Cultured astrocytes exposed to DEX exhibited an up-regulation of astrocytic markers (GFAP, connexin-43 and glutamine synthetase), as well as of A2AR. Moreover, DEX enhanced ATP and glutamate release and increased basal astrocytic Ca2+ levels. The selective A2AR antagonist SCH58261 prevented DEX-induced alterations in ATP release and basal Ca2+ levels but did not affect DEX-induced alteration of glutamate release and astrocytic markers. These findings suggest that alterations in astrocytes function, which might contribute to abnormal glucocorticoid brain signalling, are controlled by A2AR, and therefore, reinforce the relevance of A2AR as a potential therapeutic target to manage mood disorders.

Structural diversity, biosynthesis, and function of plant falcarin-type polyacetylenic lipids

The polyacetylenic lipids falcarinol, falcarindiol, and associated derivatives, termed falcarins, have a widespread taxonomical distribution in the plant kingdom and have received increasing interest for their demonstrated health-promoting properties as anti-cancer and anti-inflammatory agents. These fatty acid-derived compounds are also linked to plant pathogen resistance through their potent antimicrobial properties. Falcarin-type polyacetylenes, which contain two conjugated triple bonds, are derived from structural modifications of the common fatty acid oleic acid. In the past half century, much progress has been made in understanding the structural diversity of falcarins in the plant kingdom, whereas limited progress has been made on elucidating falcarin function in plant-pathogen interactions. More recently, an understanding of the biosynthetic machinery underlying falcarin biosynthesis has emerged. This review provides a concise summary of the current state of knowledge on falcarin structural diversity, biosynthesis, and plant defense properties. We also present major unanswered questions about falcarin biosynthesis and function.

Lipid Profile of Human Milk in Different Lactation Stages Submitted to Pasteurization, Lyophilization and Spray-Drying Processes

The objective of this study was to evaluate the effect of pasteurization, lyophilization and spray-drying on the lipid profile of donated human milk (DHM) at different lactation stages. Nine frozen samples of colostrum, transitional and raw mature human milk (HM) were collected from the Human Milk Bank (HMB) of the Hospital Universitário de Maringá (HUM). Samples were thawed and pooled according to lactation stage. Thereafter, it was submitted to pasteurization, lyophilization and spray-drying processes and later the fatty acid (FA) composition and the lipid profile analyses were performed. Gas chromatograph (GC) with flame ionization detector (FID) and electrospray ionization (ESI) mass spectrometer (MS) were used, respectively. In the FA composition analysis, it was observed that the same classes of saturated FA (SFA), monounsaturated FA (MUFA) and polyunsaturated FA (PUFA) were preserved throughout the process and in all lactation stages. The lipid profiles were also preserved after processing. Therefore, the lyophilization and spray-drying processes are promising techniques to preserve the DHM in the HMB, once the components evaluated were preserved, and both techniques facilitate the transport and storage, as the techniques reduce the sample volume.

Comparison of 2-years follow-up of optimal medical therapy versus balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

Introduction

Balloon pulmonary angioplasty (BPA) has emerged as a therapeutic option for chronic thromboembolic pulmonary hypertension (CTEPH) considered ineligible for pulmonary endarterectomy (PEA). The initial publications showed very good short-term outcomes for the technique, but there are limited data regarding medium-term outcomes and its comparison with optimal medical treatment (OMT).

Objectives

To evaluate and compare the medium-term outcomes of OMT versus (vs) BPA in inoperable CTEPH.

Methods

Retrospective study of consecutive patients (pts) with CTEPH followed in a referral centre for Pulmonary Hypertension. Selected those pts considered ineligible for PEA and with at least 2 years of follow-up. Comparison between two treatment strategies: OMT alone [maximum tolerated doses of pulmonary vasodilator drugs (PVD), as indicated] vs BPA (pts who completed the program with or without OMT). Endpoint was a composite of all-cause death and unplanned right heart failure admission at 2-year.

Results

From 62 pts, 19 pts were included (11 pts were excluded due to recent diagnosis; 32 were submitted to EAP): mean age 65.0±15.3 years, 89.5% female. At diagnosis, all pts had functional capacity limitation and elevated serum NTproBNP levels (median value 1255.0 pg/mL). Mean pulmonary arterial pressure (mPAP) was 46.2±9.3 mmHg and pulmonary vascular resistance (PVR) 15.3±8.3 Wood units (WU). Concerning treatment, 12 pts (63.2%) underwent OMT alone. These pts had higher NTproBNP levels (2670.0 vs 538.0 pg/mL, p&lt;0.01) and PVR values (19.7±7.6 vs 9.7±5.4 WU, p=0.01) and lower CI (1.6±0.3 vs 2.4±0.5 L/min/m2, p&lt;0.01), at baseline; the remaining basal features didn't differ among groups (Fig.A). At 2-year follow-up, pts submitted to BPA were under PVD in 71.4% of cases with a mean of 1±0.8 drugs per patient and no difference compared to OMT group (83.3%, 1.7±0.9 drugs per patient), although oxygen therapy was higher in medical group (50% vs 0%, p=0.04). A significant overall improvement was observed in BPA group (Table – A): all pts were in functional class I (p&lt;0.01), no one had right ventricular dysfunction (p&lt;0.01) and mPAP decreased to 25.1±6.7 mmHg (p=0.01) and RVP to 2.9±0.8 WU (p=0.01). Inversely, no change was observed in pts under OMT alone (p&gt;0.05 in all, Table – A). Endpoint rate was 31.6% with all adverse events occurring in the OMT group (50% vs 0%, p=0.04). After adjustment by Cox regression, no difference in baseline or follow-up features besides treatment influenced the outcome. Kaplan-Meier analysis (Graphic – B) confirmed significant benefit of BPA in 2-year outcome occurrence (long rank 4.6, p=0.03).

Conclusions

BPA strategy seems to improve medium-term functional capacity, right ventricular function and haemodynamics and decrease oxygen therapy dependence in inoperable CTEPH. Pts under OMT alone have a poor prognosis. These data encourage the development and implementation of the technique for inoperable CTEPH.

Funding Acknowledgement

Type of funding sources: None.

Cardiovascular disease in an intensive care unit: patterns of an often fatal omen

Background

Care for the critically ill patient with Cardiovascular Disease (CVD) requires a unique management approach, as the theoretical critical threshold for decompensation is lower and inherent adaptive mechanisms may be compromised. We aimed to characterize the prognostic impact of CVD in patients admitted to an Intensive Care Unit (ICU).

Methods

We performed a cohort study of consecutive patients admitted to an ICU from January to December 2019. Patients were stratified as follows: (1) established CVD – presence of either atrial fibrillation, heart failure, coronary artery disease and/or peripheral artery disease; (2) at higher risk of CVD – known arterial hypertension, dyslipidemia, diabetes mellitus and/or current smoking, in the absence of established CVD; and (3) at lower risk of CVD – i.e. none of the above. The co-primary endpoints were all-cause death in ICU and death during index hospitalization.

Results

During 2019, there were 334 admissions in ICU, comprising a total of 296 patients (mean age 67±15 years, 58.1% male). Overall, 69 (23.3%) and 108 (36.5%) died in ICU and during index hospitalization, respectively. Compared to patients at lower risk of CVD, those at higher CVD risk or with established CVD had markers of more severe disease, as noted by higher risk scores (e.g., SAPS-II 35.0±20.0 vs. 43.5±22.3 vs. 52.6±20.0; p&lt;0.001), higher rates of mechanical ventilation (41.5 vs. 57.3 vs. 63.9%; p=0.020), shock during ICU stay (34.0 vs. 52.7 vs. 66.9%; p&lt;0.001) and acute kidney injury (26.4 vs. 35.5 vs. 57.9%; p&lt;0.001), respectively, as well as higher death rates in ICU (5.7 vs. 21.8 vs. 31.6%; p=0.001) and index hospitalization (9.4 vs. 37.3 vs. 46.6%; p&lt;0.001). In multivariate analysis, adjusted for age and cause of admission, established CVD independently predicted the risk of all-cause death in ICU (HR: 2.084; 95% CI: 1.136–3.823; p=0.018) and during index hospitalization (HR 1.712; CI: 1.009–2.889; p=0.046). The analysis for the group of patients at higher risk of CVD yielded similar results to the abovementioned.

Conclusion

Roughly 4 in every 5 patients admitted in ICU were at risk of or had established CVD. The presence of either of the above independently predicted a two- to three-fold higher risk of death during hospitalization. Our findings emphasize the considerable burden of CVD in ICU and underscore the importance of comprehensive management of the complex critically ill patient.

Funding Acknowledgement

Type of funding sources: None.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Contrast-induced nephropathy after staged balloon pulmonary angioplasty: lower risk compared with left-sided cardiac procedures

Introduction

The risk of contrast-induced nephropathy (CIN) after left-sided cardiac procedures is reported as 10–15%. When the ratio of total contrast volume in ml to glomerular filtration rate (GFR) in mL/min (ratio V/GFR) exceeds 3.7, the risk increases significantly. However, there are few reports regarding the risk of CIN in patients (pts) with right-sided cardiac interventions such as balloon pulmonary angioplasty (BPA) and ratio V/GFR is not validated for use in this procedures.

Purpose

To assess the prevalence of CIN in pts with chronic thromboembolic pulmonary disease with or without hypertension (CTEPH/CTED) undergoing BPA.

Methods

Prospective single-centre study that included all BPA sessions performed from 2017 to 2020. Serum creatinine concentration (SC) was measured and the GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) before and 48 hours after each BPA procedure and 6 months after BPA treatment completion. CIN was defined as an increase of ≥25% and/or ≥0.5 mg/dL in SC from the baseline value within 48h of contrast administration.

Results

76 consecutive BPA sessions were performed in 15 CTEPH/CTED pts: mean age 63.2±14.0 years, 60% female, 86.7% CTEPH, mean of 5.3±1.9 sessions per patient with 4.3±1.9 vessels dilated per session. Mean value of GFR before BPA program was 73.5±26.3 mL/min. All the procedures were performed using low-osmolality contrast agent with a 1:1 dilution ratio with normal saline solution. Pts received 273.0±73.0 mL of contrast per session with a ratio V/GFR 3.7±1.7 mL. SC and GFR did not change significantly within 48h after BPA (+3.1%, p=0.07 and −3.0%, p=0.13, respectively). Ratio V/GFR &gt;3.7 occurred in 44.3% of cases (n=31), but CIN occurred in only 5.3% (n=4) with an increase in SC &lt;0.5 mg/dL but ≥25% in 3 cases (+33% in mean) and ≥0.5 mg/dL in 1 case. None of the pts required renal replacement therapy. Higher SC and lower GFR 48h after BPA were significantly correlated with greater rato V/GFR during procedure (r=0.75, p&lt;0.01 and r=−0.74, p&lt;0.01, respectively) – see figure. But neither higher values of ratio V/GFR (OR 1.43; CI95% 0.84–2.41; p=0.19) nor V/GFR &gt;3.7 (OR 1.28; CI95% 0.17–9.6; p=0.81) were predictors of CIN. GFR before procedure did not influence the contrast volume administered (p=0.901), number of vessels (p=0.63) and segments treated by session (p=0.45). At 6 months follow-up, there was a trend for SC (1.3±0.2 mg/dL vs 1.1±0.2 mg/dL, −15%, p=0.43) and GFR (44.5±8.3 mg/dL vs 53.0±12.6 mg/dL, +16%, p=0.34) improvement in pts with impaired renal function at baseline (GFR&lt;60 mL/min).

Conclusions

These findings suggested that the occurrence of CIN after BPA was low, raising the hypothesis that the influence of contrast agent on renal function could differ in right-sided cardiac interventions. Although the ratio V/GFR may be correlated with the risk of nephropathy, it is necessary to find a new cut-off to predict CIN in BPA pts.

Funding Acknowledgement

Type of funding sources: None.

One-year follow-up of continuous aspiration mechanical thrombectomy for the management of intermediate-high and high-risk pulmonary embolism: what is the line between utility and futility?

Introduction

Percutaneous catheter-directed treatments have emerged at the last decade for the management of acute high- or intermediate-high-risk pulmonary embolism (PE). Good short-term efficacy and safety have been published, but there are limited data regarding medium- to long-term outcomes.

Purpose

This study aimed to evaluate 1-year all-cause mortality of acute high- and intermediate-high-risk PE patients (pts) treated with continuous aspiration mechanical thrombectomy.

Methods

Twenty-nine consecutive pts with acute central PE (mean age 67.2±14.4 years; 72.4% female; 24.1% active cancer; Charlson comorbidity index 4.5±2.1; 82.8% in class&gt;III of original PESI score; 44.8% high-risk PE) were treated with the Indigo Mechanical Thrombectomy System (Penumbra, Inc) between 03/2018 and 03/2020. Clinical success was defined as improvement in hemodynamic and/or oxygenation parameters or pulmonary hypertension or right heart strain at 48 hours after intervention plus survival to hospital discharge. Data regarding severe adverse events potentially related to the procedure, in-hospital and 1-year all-cause mortality were collected.

Results

Clinical success was 75.9%, with a significant improvement in mean paO2/fiO2 ratio (+77.1±103.2; p&lt;0.01), shock index (−0.4±0.4, p&lt;0.01), need for aminergic support (−75.0%, p&lt;0.01), right ventricular function (66.6%, p&lt;0.01) and systolic pulmonary arterial pressure (−10.2±11.5mmHg, p&lt;0.01) at 48 hours after procedure. In-hospital survival rate was 82.8% but severe adverse events potentially related to the procedure occurred in 3 pts (10.3%). One-year follow-up was completed in 93.1% of cases and all-cause mortality rate was 34.5% (n=10 of which half occurred during the index hospital stay). Higher scores of Charlson comorbidity index (5.8±1.9 vs 3.7±1.9, p=0.01) and de novo atrial fibrillation at admission (40% vs 0%, p&lt;0.01) were associated with higher 1-year all-cause mortality occurrence and were identified as 2 independent risk predictors by multivariate Cox regression. Kaplan-Meier curves confirmed its significant influence in 1-year survival free of adverse event (Figure). Time among diagnosis and percutaneous treatment (p=0.99), PESI score (p=0.24) and other clinical, haemodynamic and echocardiographic features did not influence mortality and suggest similarity of the PE severity at baseline. Technical characteristics were also not associated with mortality.

Conclusions

Aspiration thrombectomy for acute high- and intermediate-high-risk PE was feasible with a high clinical success rate. One-year all-cause mortality rate was elevated and predicted by high comorbidity index and de novo atrial fibrillation at admission. This data support the national expansion of this new PE treatment, but probably and as similar to other invasive techniques, we need to take into account comorbidities and avoid futility in multimorbidity pts.

Funding Acknowledgement

Type of funding sources: None.

Complications of balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease according to the classification proposed by the 6th world symposium on pulmonary hypertension

Introduction

Balloon pulmonary angioplasty (BPA) is a complex procedure and not risk free. In an attempt to standardize reports of BPA complications in the several centers, a classification of complications was proposed by the task force on chronic thromboembolic hypertension (CTEPH) in the 6th World Symposium on Pulmonary Hypertension (WSPH).

Purpose

To determine the prevalence of BPA complications according to the classification of 6th WSPH and to identify its predictors.

Methods

Detailed procedural and technical aspects were collected for consecutive patients (pts) with inoperable, residual/recurrent chronic thromboembolic disease, undergoing BPA at a single institution from December/2017 to December/2020. Per procedure logistic regression analysis was used to evaluate the predictive variables for complications.

Results

A total of 76 BPA sessions in 15 pts were performed (mean age 63.2±14.0 years; 60.0% women; 86.7% CTEPH). Mean pulmonary artery pressure and pulmonary vascular resistance before the first BPA session were 33.1±13.3 mmHg and 4.8±3.2 woods unit, respectively (73.3% of pts under vasodilator therapy). Femoral access was used for all pts. Mean vessels treated per procedure were 4.3±1.9 (324 vessels in total). Webs, subtotal occlusions, ring-like stenosis and total occlusions were noted in 215 (66.4%), 58 (17.9%), 31 (9.6%) and 20 (6.2%) treated vessels, respectively. We performed 21 pressure-wire-guided sessions (27.6%). Intravascular imaging was used in 6 procedures (7.9%). Average time of fluoroscopy was 60.3±14.0 minutes and volume of contrast 273.0±73.0 mL per session. Procedure-related adverse events occurred in 25.0% of the interventions (27.6% in the first two years vs 16.7% in the last two). Pulmonary artery vascular injuries were noted in 6 BPA vessels (7.9% per procedure and 1.9% per treated vessel): haemoptysis in all, but perforation was only detected angiographically in 3 of them (balloon inflation was performed for 2 distal perforations, and 1 perforation sealed without any intervention). Vascular dissection in distal lesions occurred in 4 cases (5.3%) with no need of transcatheter or surgical procedures. We had 3 lung injuries, all grade 2. None of the pts required oral intubation or mechanical ventilation. Extra-pulmonary complications were illustrated in table. Importantly, there was no peri-procedural death. The occurrence of vascular or lung injuries was 0% in pressure-wire-guided BPA versus 14.5% in non-guided (p=0.098). Multivariate analysis revealed that age (OR 1.05; CI 1.01–1.10; p=0.030) was the only independent predictor of complications.

Conclusions

In our experience, BPA can be safely performed in inoperable, residual or recurrent CTEPH or CTED pts, with 25% minor procedural-related complications but no major adverse event. Age was the strongest factor related to the occurrence of complications.

Funding Acknowledgement

Type of funding sources: None.

Chronic heart failure in intensive care unit: can we accurately predict the risk?

Background

Severity of disease scoring systems, namely the Simplified Acute Physiology Score (SAPS) and Acute Physiology and Chronic Health Evaluation (APACHE), are widely used to predict mortality in Intensive Care Units (ICU). Yet, neither score includes chronic HF in their model. We aimed to evaluate whether these scores perform well in risk prediction of death of patients previously diagnosed with heart failure (HF).

Methodology

This is a single-center retrospective cohort of patients admitted to an ICU in 2019. Those whose admission lasted &lt;24 hours were excluded from analysis. The SAPS II and APACHE II scores were calculated using data from the first 24 hours of ICU admission, imputing the worst variable obtained within this timeframe. HF was defined according to the ESC recommendations. In order to assess the performance of the scores, Receiver Operating Characteristic (ROC) Curves were used to predict the risk of death in ICU in HF compared to the non-HF population.

Results

A total of 267 patients were hospitalized in ICU for a period over 24 hours in 2019 (mean age 67±16 years; 58.8% males; 21.7% with chronic HF; 33.7% admitted for sepsis). Compared to patients without HF, those with chronic HF were older (74±13 vs. 65±16 years; p&lt;0.001) and had higher risk scores (mean SAPS II: 43.2±21.7 vs. 56.5±20.7; p&lt;0.001; mean APACHE II: 19.8±10.0 vs. 25.1±10.0; p&lt;0.001). Moreover, these patients were at higher risk of meaningful events during hospitalization (e.g. acute kidney injury: 38.0 vs. 66.1%; p&lt;0.001; shock at any time: 52.4 vs. 67.8%; p=0.036). Furthermore, patients with HF had a trend towards higher mortality rates in ICU (17.3 vs. 28.8%; p=0.051) and a significantly higher death in overall hospitalization (30.8 vs. 45.8%; p=0.032). ROC curves performed well in predicting the risk of ICU death regardless of HF (SAPS II – AUC 0.78 vs. 0.81; p=0.36; APACHE II – AUC 0.75 vs. 0.78; p=0.37).

Conclusion

Approximately 1 in every 4 patients admitted to the ICU had chronic HF. Traditional risk scoring systems (SAPS II and APACHE II) performed well regardless of HF. While these results are reassuring as far as risk stratification accuracy is concerned, HF patients remained at a higher risk for worse outcomes. Therefore, prognostic tools with a therapeutic clinical applicability are urgently needed to improve the outcome of this population.

Funding Acknowledgement

Type of funding sources: None.

Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators

AIMS

This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators.

METHODS

We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium.

RESULTS

The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%.

CONCLUSIONS

This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.

Can shear wave imaging distinguish between diffuse interstitial and replacement myocardial fibrosis?

Funding Acknowledgements

Type of funding sources: None.

Background

  Diffuse interstitial or myocardial replacement fibrosis are common features of a large variety of cardiomyopathies. These alterations contribute to functional changes, particularly to an increased myocardial stiffness (MS). Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsy which is invasive and not without risks. Cardiac magnetic resonance (CMR) can characterize the extent of both diffuse and replacement fibrosis and may have prognostic value in various cardiomyopathies. Echocardiographic shear wave (SW) elastography is an emerging approach for measuring MS in vivo. SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure (MVC), and their propagation velocity is directly related to MS, thus providing an opportunity to assess stiffness at end-diastole.

Purpose

The aim was to investigate if velocities of natural SW can distinguish between interstitial and replacement fibrosis. 

Methods

We prospectively enrolled 47 patients (22 patients after heart transplant [54.2 ± 15.8 years, 82.6% male] and 25 patients with established hypertrophic cardiomyopathy [54.0 ± 13.5 years, 80.0% male]) undergoing CMR during their check-up. We performed SW elastography in parasternal long axis views of the LV using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2-5AC) at 1100 ± 250 frames per second. Tissue acceleration maps were extracted from an anatomical M-mode line along the midline of the LV septum. The SW propagation velocity at MVC was measured as the slope in the M-mode image. All patients underwent T1 mapping as well as late gadolinium enhancement (LGE) cardiac magnetic resonance at 1.5 T to assess the presence of diffuse or replacement fibrosis (Figure A). Therefore, patients were divided in three groups: no fibrosis, diffuse fibrosis and replacement fibrosis.

Results

Mechanical SW’s were observed in 46 subjects starting immediately after MVC and propagating from the LV base to the apex. SW propagation velocity at MVC correlated well with native myocardial T1 values (r = 0.65, p &lt; 0.0001) and differed significantly among groups (p &lt; 0.0001), with a significant post-test between any pair of groups (Figure B). SW velocities below a cut-off of 6.01 m/s showed the highest accuracy to identify patients without any type of fibrosis (sensitivity 88 %, specificity 89%, area under the curve = 0.93) (Figure C). A cut-off of 8.11 m/s could distinguish replacement fibrosis from diffuse fibrosis with a sensitivity and specificity of 59% and 92 %, respectively (area under the curve = 0.80) (Figure D).

Conclusions

  Shear wave velocities after mitral valve closure can distinguish between normal and pathological myocardium and can detect differences between diffuse and replacement fibrosis.

Abstract Figure.

Relationship between myocardial properties and myocardial stiffness in hearts with thick walls: a shear wave imaging study using ultra-high frame rate echocardiography

Funding Acknowledgements

Type of funding sources: None.

Background

Shear wave (SW) imaging, based on high frame rate (HFR) echocardiography, is a new non-invasive approach for assessing myocardial stiffness. Operating myocardial stiffness increases with increasing wall stress, therefore measured myocardial stiffness does not necessarily reflect intrinsic myocardial properties only, but can be influenced by cavity pressure and chamber geometry.

Purpose

 To explore the relationship between local myocardial geometry, cavity pressure and pathological substrate with SW velocity and to determine to which extent the above mentioned factors influence SW velocity.

Methods

We included 26 healthy controls (55 ± 14 years, 77 % male) and 61 patients with thick heart (24 patients with cardiac amyloidosis (AML) [70 ± 9 years, 52 % male], 37 patients with hypertrophic cardiomyopathy (HCM) [54 ± 14 years, 78 % male]). Left ventricular (LV) parasternal long axis views were acquired with an experimental HFR scanner at 1142 ± 282 frames per seconds. Propagation velocity of the SW occurring after mitral valve closure in the interventricular septum (IVS) served as measure of myocardial stiffness (Figure A). While conventional echocardiographic measurements were used to evaluate local myocardial geometry (LV end-diastolic diameter [EDD], IVS thickness) and LV cavity pressure (LV diastolic pressure-estimated by E/e` and LV systolic pressure-estimated by systolic blood pressure and potential LV outflow gradient in HCM).

Results

 LV cavity pressure and local geometry differed significantly between controls and patients (p &lt; 0.05, for all, Figure B). SW velocity correlated with cavity pressure (E/e`: r = 0.375, p &lt; 0.001, LV systolic pressure: r = 0.264, p = 0.020) and local geometry (IVS thickness: r = 0.700, p &lt; 0.001; EDD: r=-0.307, p = 0.007) and differed significantly among groups (Figure C). Multivariate analysis revealed that SW velocity was independently related only with the pathological substrate and IVS thickness (p = 0.006 and p &lt; 0.001, respectively). In a regression model, the pathological substrate, cavity pressure and local geometry accounted for 56% of variation in SW velocity (p &lt; 0.001), while the pathological substrate alone accounted for nearly half of the variance (R2 = 0.44, p &lt; 0.001) (Figure D).

Conclusions

 Our study demonstrated that SW velocity is related to both pathological substrate and local geometry and LV pressures. Additionally, our results suggest that variations in myocardial tissue properties had the most influence on SW velocity, while LV pressure and local geometry played a minor role. Therefore, the changes in SW velocity reflect predominantly tissue properties that are altered by underlining disease rather than cavity pressure and morphological abnormalities. Thus, SW elastography could provide useful novel diagnostic information in the evaluation of cardiomyopathies.

Abstract Figure A, B, C, D

Evaluation of the Adulteration of Edible and Cosmetic Sunflower Oils by GC-FID and ESI-MS

Sunflower oil has several properties that are valuable to the human skin and health; however, they are target of adulterations. In this study, in order to evaluate the authenticity of edible and cosmetics based on sunflower oils, the triacylglycerol (TAG) profiles using direct infusion electrospray ionization mass spectrometry (ESI-MS), the fatty acid (FA) composition by gas chromatography with flame ionization detection (GC-FID) and principal component analysis, of seven commercial samples were determined and the results obtained were compared with the pure sunflower and soybean oils. Of the seven brands analyzed, just one sample presented only sunflower oil in its composition; two stated in the label soybean addition; and four did not present the real composition of the product in the label. Therefore, GC-FID and ESI-MS analysis in conjunction with principal component analysis (PCA) demonstrated that they are complementary techniques and could be applied in food industries to assess the quality of vegetable oils, since results showed the need for stricter quality control for this product.

More Rule than Exception: Parallel Evidence of Ancient Migrations in Grammars and Genomes of Finno-Ugric Speakers

To reconstruct aspects of human demographic history, linguistics and genetics complement each other, reciprocally suggesting testable hypotheses on population relationships and interactions. Relying on a linguistic comparative method based on syntactic data, here we focus on the non-straightforward relation of genes and languages among Finno-Ugric (FU) speakers, in comparison to their Indo-European (IE) and Altaic (AL) neighbors. Syntactic analysis, in agreement with the indications of more traditional linguistic levels, supports at least three distinct clusters, corresponding to these three Eurasian families; yet, the outliers of the FU group show linguistic convergence with their geographical neighbors. By analyzing genome-wide data in both ancient and contemporary populations, we uncovered remarkably matching patterns, with north-western FU speakers linguistically and genetically closer in parallel degrees to their IE-speaking neighbors, and eastern FU speakers to AL speakers. Therefore, our analysis indicates that plausible cross-family linguistic interference effects were accompanied, and possibly caused, by recognizable demographic processes. In particular, based on the comparison of modern and ancient genomes, our study identified the Pontic-Caspian steppes as the possible origin of the demographic processes that led to the expansion of FU languages into Europe.

Shear wave elastography by high frame rate echocardiography can detect diffuse myocardial fibrosis after heart transplantation

Background

Myocardial fibrosis is fundamental in the development of cardiac failure, regardless of ethiology. In both animal models and humans it has been shown that diffuse myocardial fibrosis (DMF) contributes to functional impairment, especially to increased passive myocardial stiffness, which is an important pathophysiological determinant of left ventricular diastolic dysfunction. Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsies which are invasive and not without risk. Echocardiographic shear wave (SW) elastography, based on high frame rate imaging, is an emerging approach for measuring myocardial stiffness in vivo. Natural SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure (MVC) and their propagation velocity is directly related to myocardial stiffness, thus providing an opportunity to assess myocardial stiffness at end-diastole.

Purpose

The aim was to investigate if propagation velocities of natural SWs can be used to detect diffuse myocardial fibrosis in a cohort of heart transplant recipients.

Methods

We prospectively enrolled 22 patients (10.3±6.3 years after HTx) that underwent CMR during their annual check-up. We performed SW elastography in parasternal long axis views of the left ventricle using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2–5AC) at 1100±250 frames per second. The SW propagation velocities at MVC were measured in the basal LV septum. Native T1 and extracellular volume (ECV) were measured at the same segment to evaluate DMF. A cut-off value for native T1 of 1040 ms and for ECV of 29% was used to define DMF in our cohort.

Results

We found good correlations between SW velocities and both myocardial T1 (r=0.80, p&lt;0.0001, Figure A) and ECV (r=0.64, p=0.003, Figure B) measured with CMR. Further, we derived reference thresholds of natural SW velocities to identify DMF in HTx patients. The optimal cut-off value of SW velocity to identify patients with nativT1&gt;1040 ms was 4.84 m/s (AUC 0.81, sensitivity 82%, specificity 82%, Figure C). To identify patients with ECV&gt;0.29 the cut-off value of SW velocity was 4.74 m/s (AUC 0.74, sensitivity 73%, specificity 78%, Figure D).

Conclusions

End-diastolic shear wave propagation velocities, as measure of myocardial stiffness, showed a good correlation with CMR defined diffuse myocardial injury. Values higher than 4.74 m/s could identify diffuse myocardial injury in HTX patients with a good sensitivity and good specificity. These findings thus suggest that shear wave elastography has the potential to become a valuable non-invasive method for the detection of diffuse myocardial fibrosis.

Funding Acknowledgement

Type of funding source: None

Differentiation of hypertensive heart disease and hypertrophic cardiomyopathy with myocardial stiffness measurements: a shear wave imaging study using ultra-high frame rate echocardiography

Background

Recently, cardiac shear wave (SW) elastography, based on high frame rate (HFR) echocardiography, has been proposed as new non-invasive technique for assessing myocardial stiffness. As myocardial stiffness increases with increasing wall stress, differences in measured operating myocardial stiffness do not necessarily reflect differences in intrinsic myocardial properties, but can also be caused by mere changes in loading or chamber geometry. This complicates myocardial stiffness interpretation for different types of pathologic hypertrophy.

Purpose

To explore the relationship between myocardial stiffness and underlying pathological substrates for cardiac hypertrophy.

Methods

We included 20 patients with hypertension (HT) and myocardial remodelling (59±14 years, 75% male), 20 patients with hypertrophic cardiomyopathy (HCM) (59±16 years, 60% male) and 20 healthy controls (56±14 years, 75% male). Left ventricular (LV) parasternal long axis views were acquired with an experimental HFR scanner at 1293±362 frames per seconds. Propagation velocity of SW occurring after mitral valve closure in the interventricular septum (IVS) served as measure of operating myocardial stiffness (Figure A). To compare myocardial stiffness among hearts with differing loading conditions and chamber geometry, SW velocities were normalized to end-diastolic wall stress, estimated at IVS from regional wall thickness, longitudinal and circumferential regional radii of curvature, and non-invasively estimated LV end-diastolic pressure (EDP).

Results

SW velocities differed significantly between groups (p&lt;0.001). The controls had the lowest SW velocities (4.02±0.97 m/s), whereas values between HT and HCM group were comparable (6.46±0.99 m/s vs. 7.00±2.10 m/s; p=0.738). Considering end-diastolic wall stress, HCM patients had the same SW velocity at lower wall stress compared to HT (Figure B), indicating higher myocardial stiffness in the HCM group. SW velocities normalized for wall stress indicated significantly different myocardial stiffness among all groups (p&lt;0.001) (Figure C). In a multiple linear regression model, the underlying pathological substrate independently influenced SW velocity (beta 1.37, 95% CI (0.78–1.96); p&lt;0.001), while wall stress did not significantly affect its value (p=0.479).

Conclusions

Our study demonstrated that SW elastography can detect differences in myocardial stiffness in hypertensive heart and hypertrophic cardiomyopathy. Additionally, our results suggest that SW velocity is dominated by underlying myocardial tissue properties. We hypothesize that differential changes in cardiomyocytes and/or the extracellular matrix contribute to the differential myocardial stiffening in different pathologic entities of LV hypertrophy. Thus, SW elastography could provide useful novel diagnostic information in the evaluation of LV hypertrophy.

Figure A, B, C

Funding Acknowledgement

Type of funding source: None

Commercial green tea from Portugal: Comprehensive microbiologic analyses

In recent times green tea (GT) consumption has increased, due to the numerous studies that indicate a wide variety of health benefits following its regular consumption. The aim of this study was to assess the bioburden (bacteria and fungi) of bulk and bags of GT marketed in Lisbon and to obtain a more refined fungal burden characterization, including azole resistance profile. The bacteriota in tea bags before boiling ranged from lower than the detection limit to 1770 CFU.g^-1, whereas in brew samples ranged from lower than the detection limit to 54.55 CFU.mL^-1. In bulk samples before boiling ranged from lower than the detection limit to 2636 CFU.g^-1, while after boiling ranged from lower than the detection limit to 72.73 CFU.mL^-1. Fungal contamination on tea bags before boiling ranged from lower than the detection limit to 66.67 CFU.g^-1 and after boiling, all samples presented results lower than the detection limit. Concerning bulk samples before boiling ranged from lower than the detection limit to 96.97 CFU.g^-1, whereas after boiling ranged from lower the detection limit to 30.3 CFU.mL^-1. Before boiling, the most common fungal species in the bagged tea (90.91 CFU.g^-1; 45.45%) and bulk samples (66.67 CFU.g^-1; 91.67%) was Aspergillus section Nigri. Fungal diversity was higher on bulk samples than in tea bags. Aspergillus section Nigri and Rhizopus sp. growth was observed mostly on itraconazole-supplemented Sabouraud dextrose agar media, which require further investigation. Aspergillus sections Fumigati and Nidulantes were detected by using real time PCR, but not in the GT samples in which they were identified through culture-based methods. A significantly reduction of bacterial contamination after boiling was observed, however fungal contamination with toxigenic potential was observed before and after boiling. Future research work needs to characterize in detail the mycotoxins contamination to allow a risk-benefit assessment to estimate the human health benefits and risks following tea consumption and to support policy-actions, if and when needed. The results also suggest that the conditions how tea is packed can influence the fungal diversity and this variable should be further investigated.

156 Shear wave propagation velocity after aortic valve closure could be a novel parameter for myocardial contractility

Funding Acknowledgements

Research Foundation (FWO) Flanders grant

Background

Shear wave imaging is a novel ultrasound technique based on the detection of transverse waves travelling through the myocardium by using high frame rate (HFR) echocardiography. These waves can be induced by an external or internal stimulus, such as aortic valve closure (AVC). The propagation velocity of shear waves is directly dependent on myocardial stiffness. It has been previously suggested in animals that the shear wave propagation velocity at AVC might be related to myocardial contractility.

Aim

The aim of this study was to validate if the shear wave propagation velocity after AVC (end-systole) is related to myocardial contractility.

Methods

Firstly, 11 healthy volunteers (age: 25 ± 4 years; male: n = 11) performed a supine bicycle exercise test. Images were taken at rest and during 25%, 50% and 66% of maximal workload, as determined by previous upright bicycle exercise testing. Secondly, 9 patients (age: 63 ± 10 years; male: n = 7) underwent a dobutamine stress echocardiography. The stress echo was negative in all patients. Images were taken at rest and after a dobutamine administration of 10µg/kg/min and 40µg/kg/min. Left ventricular (LV) parasternal long axis views were acquired with an experimental HFR ultrasound scanner (HD-PULSE) (average frame rate: 1217 ± 233fps). Apical 4-chamber views were acquired with a conventional ultrasound machine. Non-invasive single beat end-systolic elastance (Ees) was used as a measure of contractility. Acceleration maps were created from HFR-datasets by drawing a M-mode line along the midline of the interventricular septum. Shear wave propagation speed at AVC (end-systole) was calculated by measuring the slope of the wave front on the acceleration maps (Figure A).

Results

During the bicycle exercise, heart rate (61 ± 11bpm vs. 146 ± 13bpm; p &lt; 0.001), systolic blood pressure (125 ± 12mmHg vs. 173 ± 15mmHg; p &lt; 0.001), LV ejection fraction (55 ± 3% vs. 70 ± 5%; p &lt; 0.001), Ees (1.8 ± 0.3mmHg/ml vs. 3.6 ± 1.0mmHg/ml; p &lt; 0.001) and propagation velocity of the shear waves (3.3 ± 0.5m/s vs. 6.2 ± 1.7m/s; p &lt; 0.01) (Figure B) increased significantly from rest to exercise. Likewise, dobutamine administration significantly increased the heart rate (68 ± 10bpm vs. 131 ± 14bpm; p &lt; 0.001), LV ejection fraction (57 ± 5% vs. 74 ± 7%; p &lt; 0.001), as well as the shear wave velocity after AVC (4.4 ± 0.6m/s vs. 7.2 ± 1.7m/s; p &lt; 0.01) (Figure C) and Ees (2.1 ± 0.4mmHg/ml vs. 3.3 ± 0.8mmHg/ml; p &lt; 0.001). Independent from the stressor, shear wave propagation velocity had a good and significant correlation with Ees (Figure D).

Conclusion

Shear wave propagation velocity after AVC increases with increasing level of exercise or dobutamine dose. Shear wave velocities at AVC show a good correlation with Ees. Our data indicate that end-systolic shear wave velocity is related to myocardial contractility and might therefore be a potential novel parameter for the non-invasive assessment of myocardial function.

Abstract 156 Figure.

556 Shear wave imaging using ultra-high frame rate echocardiography for the assessment of structural changes in cardiac transplant recipients

Background

Cardiac allografts undergo characteristic alterations of the extracellular matrix, including myocardial fibrosis, that contribute to functional changes, particularly diastolic dysfunction due to increased myocardial stiffness(MS). Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsies which are invasive and not without risk. Increased native T1 and extracellular volume(ECV) using CMR T1 mapping have shown good correlation with biopsy evidence of myocardial interstitial fibrosis in heart transplant(HTx) recipients. Echocardiographic shear wave(SW) elastography is an emerging approach for measuring MS in vivo. SWs occur after mechanical excitation of the myocardium, e.g. after mitral(MVC) and aortic valve closure(AVC), and their propagation velocity is directly related to MS, thus providing an opportunity to assess stiffness at end-diastole(ED) and end-systole(ES).

Purpose

The aim was to investigate if natural shear wave velocities increase with the degree of diffuse myocardial fibrosis in HTx recipients.

Methods

We prospectively enrolled 22 HTx patients (8.8 ± 5.9 years post-HTx) that underwent CMR during their annual check-up. We performed SW elastography in parasternal long axis views of the left ventricle(LV) using an experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2-5AC) at 1100 ± 250 frames per second. Tissue acceleration maps were extracted from an anatomical M-mode line along the midline of the LV septum. The SW propagation velocity at MVC and AVC was measured as the slope on the M-mode acceleration map(FigureA). All patients underwent right heart catheterization on the same day for the measurement of pulmonary capillary wedge pressure(PCWP), as surrogate for LV filling pressure. The CMR protocol consisted of standard sequences including native and post-contrast T1 mapping. To evaluate diffuse myocardial fibrosis, native T1 and ECV were measured in the anteroseptal wall over all available short-axis slices.

Results

We found good correlations between SW velocities at ED and both myocardial T1 (r = 0.8,p &lt; 0.001,FigureB) and ECV (r = 0.6,p &lt; 0.05,FigureC) measured with CMR. Similarly, we found significant correlations between SW velocities at ES and T1 (r = 0.7,p &lt; 0.005) and ECV (r = 0.5,p &lt; 0.05), respectively. Furthermore, we observed a significant correlation between SW velocities at ED and PCWP (r = 0.6,p &lt; 0.05).

Conclusions

Both end-diastolic and end-systolic shear wave velocities showed a good correlation with CMR defined myocardial fibrosis in cardiac transplant patients. Shear wave velocities at end-diastole correlated with invasively-determined left ventricular filling pressure, reflecting the impact of the fibrous changes on the left ventricular diastolic function. These results suggest the potential of cardiac shear wave elastography for the assessment of structural changes in cardiac transplant recipients.

Abstract 556 Figure.

417 Can myocardial stiffness measurements distinguish the underlying pathology in hearts with thick walls? A shear wave imaging study using ultra-high frame rate echocardiography

Background

Different pathophysiologic pathways in the development of left ventricular (LV) hypertrophy may alter passive myocardial stiffness differently. Recently, cardiac shear wave (SW) elastography has been proposed as new non-invasive technique for assessing myocardial stiffness.

Purpose

To explore the relationship between myocardial stiffness and the underlying pathological substrates for cardiac hypertrophy.

Methods

We included 17 patients with cardiac amyloidosis (AML) (69 ± 10 years, 41% male), 17 patients with hypertrophic cardiomyopathy (HCM) (59 ± 16 years, 65% male) matched for interventricular septum (IVS) thickness and 17 hypertensive patients (HT) with prominent myocardial remodelling (56 ± 15 years, 71% male). LV parasternal long axis views were acquired with an experimental ultrasound scanner at 1255 ± 354 frames per seconds. Myocardial acceleration maps were created from the HFR-datasets and an anatomical M-mode line was drawn along the midline of the IVS (Figure A). The propagation velocity of natural SWs occurring at mitral valve closure (MVC) was measured on these M-modes in order to assess operating myocardial stiffness. To compare myocardial stiffness among hearts with differing loading conditions and chamber geometry, SW velocities were normalized to operating end-diastolic wall stress. The end-diastolic wall stress was estimated at the IVS from regional wall thickness, longitudinal and circumferential regional radii of curvature, and noninvasively estimated left ventricular end-diastolic pressure (EDP).

Results

IVS thickness was significant different among groups (AML: 1.63 ± 0.33 cm, HCM: 1.69 ± 0.21 cm, HT: 1.48 ± 0.14 cm; p = 0.037). HT patients had significant higher septal radius of curvature compared to other two groups (p &lt; 0.05), while the AML patients had the highest estimated EDP (p &lt; 0.05). All groups had comparable, elevated SW velocities at MVC (AML: 6.49 ± 1.00 m/s, HCM: 6.46 ± 1.45 m/s, HT: 6.22 ± 0.96 m/s; p = 0.752). Considering end-diastolic wall stress, HT patients had the same SW velocity at higher wall stress compared to AML and HCM (Figure B), indicating lower myocardial stiffness in the HT group. SW velocities normalized for wall stress indicated significantly different myocardial stiffness among groups (p = 0.003) (Figure C). The HT group had the lowest normalized myocardial stiffness, whereas values of the AML group overlapped with the HCM group (p = 1.00).

Conclusions

Our study demonstrated that shear wave elastography can detect differences in myocardial stiffness in hearts with thick walls. Considering the effect of wall stress, our results suggest that factors other than chamber geometry and loading condition mediate myocardial stiffness in hearts with thick walls. We hypothesize that differential changes in cardiomyocytes and/or the extracellular matrix contribute to the differential myocardial stiffening in different pathologic entities of LV hypertrophy.

Abstract 417 Figure.

Does wild rabbit population size affect connectivity?

<p>Wild rabbit is a relevant species in the Iberian Peninsula due to its ecological  and economic roles. Conservationists and game managers therefore have a shared interest in assuring the existence of resilient and sustainable populations. Although management principles and guidelines are  mostly known and understood, often the results are not as good as expected. Local abundance can vary significantly even in short periods, while the colonisation of adjacent territories is uncommon, probably due to the territorial behaviour of the species. Aware that the foundation of nuclei requires interaction among individuals, we hypothesised that rabbit abundance plays a significant part in population connectivity. In order to find out whether the population size affects nuclei connectivity, we conducted a graph theory-based connectivity analysis. The results confirm that connectivity grows with rabbit abundance, but only to a certain degree, and there is a spatial separation of the nuclei regardless of the population size. These outcomes suggest that a comprehensive wild rabbit population increment plan should address both the abundance and spatial distribution, but should not aim at achieving a continuous distribution of wild rabbit with constant or similar abundance. Regarding specific management actions, we argue that in restocking operations new nuclei should be located within dispersal range from the existing ones to promote inter-nuclei connectivity, but not too close, as the nuclei segregation tendency is likely to persist due to the species’ territoriality.</p>

Factors affecting space use by wild boars (Sus scrofa) in high-elevation tropical forests

The wild boar (Sus scrofa Linnaeus, 1758) is considered one of the 100 worst invasive species in the world and is present in the high-elevation forests in Brazil. Our objective was to understand how landscape and atmospheric conditions affect space use by wild boars. We hypothesized that wild boars would be more frequent at lower elevations, warmer and wetter forested areas, and away from human disturbances. After three years of data collection (2013–2016) using 16 camera traps, 881 independent records were obtained with a mean of 4.44 ± 9.25 pigs per record. Wild boar frequency of occurrence was higher at lower elevations, in more humid and warmer areas, and farther away human disturbance factors, corroborating our initial hypothesis. Understanding space-use patterns of wild boars is necessary for the design of management strategies that target areas of more intense usage, as well as for defining more effective population-control techniques.

P975Safety and clinical outcomes of rotational atherectomy: an eleven-year centre experience

Introduction

Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality.

Objectives

To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure.

Methods

Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year.

Results

246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach.

Conclusions

RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

Serum lactate levels are associated with glioma malignancy grade

OBJECTIVE

Recent studies have suggested that high grade gliomas are associated with elevated serum lactate concentrations. The aim of the present study is to assess these findings in a sample of patients.

PATIENTS AND METHODS

We reviewed the anesthetic charts of patients with low-grade and high-grade glioma who underwent resection surgery and collected serum lactate concentration before tumor resection, as well as other demographic and tumor-related data (age, gender, WHO grade, and size of the tumor). A statistical comparison between patients with normal (<2 mmol/L) and elevated (≥ 2 mmol/L) serum lactate was performed.

RESULTS

We included a total of 152 patients (mean age 49.07 years). 62.5% of patients (n = 95) had a high-grade glioma and 37.5% (n = 67) a low-grade glioma. The multivariate regression showed that high grade gliomas had significantly higher lactate concentration (p < 0.01). The OR for elevated pre-resection serum lactate increased from 4.94 to 14.33 after adjusting for age and pre-surgical corticosteroid use, and the AUC for the final regression model was 0.98.

CONCLUSION

This study reinforces the role of serum lactate as a potential biomarker of brain tumors malignancy, and its results encourage further research on this subject, in order to improve the understanding of this phenomenon and to assess its potential as prognostic and therapeutic monitoring tool.

P1501Can we measure the stiffening of hypertensive hearts non-invasively? A shear wave imaging study using ultra-high frame rate echocardiography

Background

Cardiac shear wave (SW) elastography is a novel technique based on high-frame-rate (HFR) echocardiography which has been shown to be related to myocardial stiffness. In this study we explore the relation between myocardial SW velocity and myocardial remodelling in remodelled hearts of patients with arterial hypertension (AH).

Methods

We prospectively included 33 treated AH patients with hypertrophic left ventricular (LV) remodelling (59±14 years, 55% male) and 26 aged matched healthy controls (55±15 years, 77% male). AH patients were further divided according to their LV geometric pattern into a concentric remodelling (CR) group (13 patients) and a concentric hypertrophy (CH) group (20 patients). LV parasternal long axis views were acquired with an experimental HFR ultrasound scanner (HD-PULSE) at 1266±317 frames per seconds. Myocardial acceleration maps were created from the HFR-datasets and an anatomical M-mode line was drawn along the midline of the interventricular septum (IVS). The propagation velocity of natural SWs occurring at mitral valve closure (MVC) was measured on these M-modes (Figure A) in order to assess passive myocardial stiffness. Standard echocardiography using a commercial scanner was performed to evaluate LV remodelling.

Results

SW velocities at MVC differed significantly between AH patients and controls (5.83±1.20 m/s vs. 4.04±0.96 m/s; p<0.001). Within the patient group, patients with CH had highest SW velocities at MVC (p<0.001), whereas values between controls and patients with CR were comparable (p=0.075) (Figure B). In AH patients, significant positive correlations were found between SW velocity at MVC and parameters of LV remodelling (IVS thickness: r=0.728, p<0.001; LV mass index: r=0.780, p<0.001, LV end-diastolic volume: r=0.604, p=0.008) (Figure C) and also parameters of diastolic function (E/e': r=0.495, p=0.005, left atrium diameter: r=0.866, p<0.001, left atrium volume index: r=0.661, p<0.001).

Figure A, B, C

Conclusions

SW velocity – and therefore myocardial stiffness – is higher in AH patients compared to healthy controls and increases with increasing severity of hypertensive heart disease. Patients with concentric remodelling have still close-to-normal passive myocardial properties while patients with concentric hypertrophy show significant stiffening. Echocardiographic shear wave elastography is a promising new technique for the non-invasive assessment of myocardial stiffness and might provide valuable new insights into myocardial function and the pathophysiology of myocardial disease.

Effect of obesity on labor duration among nulliparous women with epidural analgesia

Objective: The aim of this study was to describe the effect of obesity on the duration of labor, specifically latent and active phases of labor, and on mode of delivery, among nulliparous women with epidural analgesia.Study design: We conducted a retrospective cohort study, comparing a sample of nulliparous obese women (body mass index ≥30 kg/m², n = 121) with a random sample of normal weight nulliparous (18.5 kg/m² ≤body mass index ≤25 kg/m², n = 161). Analysis included all obese women delivered at the Department of Obstetrics and Gynecology of Centro Hospitalar, São João, Porto, Portugal between 1 January and 31 December, 2016. Only women submitted to epidural analgesia were included. Information on maternal age, obstetric history, current pregnancy and labor characteristics (gestational age, birthweight, mode of delivery, total duration of labor, latent and active phases duration) was retrieved from electronic obstetrical databases and labor charts.Results: In our department, the prevalence of maternal obesity was 12.0%. Obese women had a significantly higher rate of cesarean delivery (47.1 versus 27.3%), fewer normal vaginal deliveries (28.9 versus 32.9%) and fewer instrumental vaginal deliveries (24.0 versus 39.8%). Labor induction was significantly more frequent among obese women (51.2 versus 29.2%; p = 0.001). The median (interquartile range) for length of latent phase when labor was induced with prostaglandins in the obese group was 23.3 hours (20.9). This was significantly longer than in normal weight women -15.6 hours (13.15) (p = 0.001). However, there was no significant difference in latent phase duration when labor was induced with oxytocin (12.4 versus 9.4 hours; p = 0.150). The medians (interquartile range) for length of latent phase in spontaneous delivery -6.5 hours (6.8) versus 6.6 hours (6.5) did not differ (p = 0.992). The duration of active phase was not significantly different between obese and normal weight (5.1 versus 5.1 hours; p = 0.784). For spontaneous labor, there was no difference between the two groups in the total duration of labor (11.9 versus 11.3 hours; p = 0.573). But for induced labor, the total duration was significantly higher among obese women (31.1 versus 21.4 hours; p = 0.001).Conclusion: Latent phase was longer in obese than normal weight women undergoing labor induction with prostaglandins. Obesity had no effect on duration of active phase. Obese women undergoing labor induction had a longer total duration of labor, compared to normal weight women mainly due to prolonged latent phase.