High glucose levels affect spermatogenesis: an in vitro approach.

Besides known factors that may cause male infertility, systemic diseases such as diabetes mellitus may further exacerbate a decline in male fertility. This metabolic disease, clinically characterised by a hyperglycaemic phenotype, has devastating consequences in terms of human health, with reproductive dysfunction being one of the associated clinical complications. Nonetheless, the mechanisms responsible for such alterations are still poorly understood due to the multiplicity of factors involved in the induced pathophysiological changes. With this in mind, we focused on the main mediator of diabetes-associated alterations and performed an in vitro approach to address the effects of high glucose conditions on spermatogenesis, avoiding other confounding in vivo factors. Mouse (5 days post partum) testis fragments were cultured on agar gel stands at a gas-liquid interface with either 5, 25 or 50mM D-glucose for 3 weeks. Stereological analysis revealed that high D-glucose levels increased Sertoli cell number (P<0.05) and decreased tubular luminal area (P<0.01), suggesting an impairment of this somatic cell type. Moreover, higher proliferative activity in a TM4 Sertoli cell line exposed to high D-glucose was found (P<0.05) without compromising cell viability (P>0.05), further suggesting altered Sertoli cell maturation. Overall, high D-glucose concentrations may lead to impairment of Sertoli cell function, which, given their significant role in spermatogenic control, may compromise male fertility.

Can cardiac computed tomography predict cardiovascular events in asymptomatic type-2 diabetics?: results of a long term follow-up.

BACKGROUND: Doubts remain about atherosclerotic disease and risk stratification of asymptomatic type-2 diabetic patients (T2DP). This study aims to evaluate the usefulness of calcium score (CS) and coronary computed tomography (CT) angiography (CTA) to predict fatal and non fatal cardiovascular events (CVEV) in T2DP. METHODS: Eighty-five consecutive T2DP undergoing CT (Phillips Brilliance, 16-slice) with CS and CTA were prospectively enrolled in a transversal case-control study. Patients were followed for 48 months (range 18 - 68) to assess CVEV: cardiovascular death, acute coronary syndrome, revascularisation and stroke. Potential predictors of CVEV were identified. Predictive models based on clinical features, CTA and CS were created and compared. RESULTS: Performing CT impacted T2DP treatment. Cardiovascular risk was lowered during follow-up but metabolic control remained suboptimal. CVEV occurred in 11.8% T2DP (3.1%/year). CS ≥86.6 was predictor of CVEV over time, with a high negative predictive value, an 80% sensitivity and 74.7% specificity. Although its prognostic value was not independent of the presence/absence of obstructive CAD, adding CS and CTA data to clinical parameters improved the prediction of CVEV: the combined model had the highest AUC (0.888, 95%CI 0.789-0.987, p < 0.001) for the prediction of the study endpoints. CONCLUSIONS: CS showed great value in T2DP risk stratification and its prognostic value was further enhanced by CTA data. Information provided by CT may help predict CVEV in T2DP and potentially improve their outcome.

Consequences and Management of Excessive Ostial Stent Protrusion: A Case Report.

Aorto-ostial lesions, especially in the right coronary artery, may be challenging due to their morphological and anatomical features, more so when there is a previous stent which may be protruding. Little is known about the long-term safety of protruding stents and results of re-intervention. Presented here is a case of restenosis of a markedly protruding stent at the right coronary ostium. This case was unusual in its 10-year longevity. Intravascular ultrasound-guided in-stent restenosis intervention using wire bumper technique was performed. Literature review and management are presented.

Artemisinin resistance-associated gene mutations in Plasmodium falciparum: A case study of severe malaria from Mozambique.

BACKGROUND: The effectiveness of artemisinin-based combination therapies (ACT) in treating Plasmodium falciparum, is vital for global malaria control efforts, particularly in sub-Saharan Africa. The examination of imported cases from endemic areas holds implications for malaria chemotherapy on a global scale. METHOD: A 45-year-old male presented with high fever, dry cough, diarrhoea and generalized muscle pain, following a two-week trip to Mozambique. P. falciparum infection with hiperparasitemia was confirmed and the patient was treated initially with quinine and doxycycline, then intravenous artesunate. To assess drug susceptibility, ex vivo half-maximal inhibitory concentration assays were conducted, and the isolated P. falciparum genome was deep sequenced. RESULTS: The clinical isolate exhibited elevated ex vivo half-maximal inhibitory concentration values to dihydroartemisinin, lumefantrine, mefloquine and piperaquine. Genomic analysis identified a I416V mutation in the P. falciparum Kelch13 (PF3D7_1343700) gene, and several mutations at the Kelch13 interaction candidate genes, pfkics (PF3D7_0813000, PF3D7_1138700, PF3D7_1246300), including the ubiquitin carboxyl-terminal hydrolase 1, pfubp1 (PF3D7_0104300). Mutations at the drug transporters and genes linked to next-generation antimalarial drug resistance were also present. CONCLUSIONS: This case highlights the emergence of P. falciparum strains carrying mutations in artemisinin resistance-associated genes in Mozambique, couple with a reduction in ex vivo susceptibility to ACT drugs. Continuous surveillance of mutations linked to drug resistance and regular monitoring of drug susceptibility are imperative to anticipate the spread of potential resistant strains emerging in Mozambique and to maintain effective malaria control strategies.

Seroprevalence of Protective Antibodies Against Influenza and the Reduction of the Influenza Incidence Rate: An Annual Repeated Cross-Sectional Study From 2014 to 2019.

BACKGROUND: Seroepidemiological studies provide estimates of population-level immunity, prevalence/incidence of infections, and evaluation of vaccination programs. We assessed the seroprevalence of protective antibodies against influenza and evaluated the correlation of seroprevalence with the cumulative annual influenza incidence rate. METHODS: We conducted an annual repeated cross-sectional seroepidemiological survey, during June-August, from 2014 to 2019, in Portugal. A total of 4326 sera from all age groups, sex, and regions was tested by hemagglutination inhibition assay. Seroprevalence and geometric mean titers (GMT) of protective antibodies against influenza were assessed by age group, sex, and vaccine status (65+ years old). The association between summer annual seroprevalence and the difference of influenza incidence rates between one season and the previous one was measured by Pearson correlation coefficient (r). RESULTS: Significant differences in seroprevalence of protective antibodies against influenza were observed in the population. Higher seroprevalence and GMT for A(H1N1)pdm09 and A(H3N2) were observed in children (5-14); influenza B seroprevalence in adults 65+ was 1.6-4.4 times than in children (0-4). Vaccinated participants (65+) showed significant higher seroprevalence/GMT for influenza. A strong negative and significant correlation was found between seroprevalence and ILI incidence rate for A(H1N1)pdm09 in children between 5 and 14 (r = -0.84; 95% CI, -0.98 to -0.07); a weak negative correlation was observed for A(H3N2) and B/Yamagata (r ≤ -0.1). CONCLUSIONS: The study provides new insight into the anti-influenza antibodies seroprevalence measured in summer on the ILI incidence rate in the next season and the need for adjusted preventive health care measures to prevent influenza infection and transmission.

Payment for Environmental Services: A critical review of schemes, concepts, and practice in Brazil.

The Payment for Environmental Services (PES) is often conceived through complex schemes without a clear definition of all concepts involved. This study presents the results of a systematic literature review on PES schemes in Brazil, accompanied by a critical assessment of their efficacy for potential environmental gains. The PES approaches were grouped into six categories based on the research focus, and those that were focused on PES policies were identified as the most studied. A particular emphasis has been given to the Amazon and Atlantic Forest biomes, where the ecosystem services studied were mostly centered on issues related to carbon and water, respectively. Approximately one-third of all schemes provided no clear definition of which ecosystem services are proposed for payment. In addition, the review showed no consensus among studies on the definition of services in similar schemes. Most schemes presented no payment system conditioned on the provision of environmental services. Furthermore, the review showed that the absence of clarity in the application of concepts may hinder the development of public policies to properly implement PES in Brazil. The conclusion is that standardizing terms used in the literature and in PES schemes is critical; therefore, the use of the Common International Classification of Ecosystem Services (CICES) as a reference is recommended to ensure clarity, objectivity and, more importantly, the expected environmental efficacy.

Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters.

AIM: Some transoesophageal echocardiogram (TEE) findings are associated with an increased risk of stroke in patients with atrial fibrillation (AF). This study was designed to evaluate and compare the accuracy of CHADS(2) and CHA(2)DS(2)-VASc in the prediction of these findings and test the additive value of transthoracic echocardiogram (TTE)-derived parameters as a possible refinement for these classifications. METHODS AND RESULTS: Cross-sectional study of 405 consecutive patients who underwent TTE and TEE evaluation during AF. Stroke risk assessment was performed using the CHADS(2) and CHA(2)DS(2)-VASc scores, alone and alongside with the addition of two TTE-derived parameters (left atrium area and left ventricle global systolic function). Comparisons regarding the presence of left atrial appendage thrombi (LAA T), dense spontaneous echo contrast (SEC), and left atrial appendage (LAA) low flow velocities (LFV) were performed using receiver operating characteristic curves. In low-risk patients, as assessed through the CHA(2)DS(2)-VASc score and CHADS(2) and CHA(2)DS(2)-VASc scores plus echo parameters, no high-risk features were found on TEE. In subjects classified as low risk using CHADS(2), this figure rose to 10%. No significant differences were found between CHADS(2) and CHA(2)DS(2)-VASc in the prediction of LAA T, dense SEC, and LAA LFV. The addition of TTE-derived parameters to the previous clinical-risk scores resulted in improved prediction of the TEE endpoints. CONCLUSION: These findings suggest that the use of TTE-derived parameters may be a valuable way of refining the available clinical risk schemes for the detection of surrogate markers of stroke. Follow-up studies using clinical endpoints will be necessary to confirm this hypothesis.

[Rotational atherectomy in the drug-eluting stent era: a recent single-center experience]. / O ressurgimento da aterectomia rotacional na era dos stents farmacoativos - A experiência de um centro.

INTRODUCTION: Percutaneous coronary intervention (PCI) of heavily calcified lesions is a challenge for the interventional cardiologist and is associated with a high rate of restenosis and target lesion revascularization (TLR). Adequate lesion preparation by rotational atherectomy followed by drug-eluting stent implantation has shown favorable results. OBJECTIVE: To report the recent experience of our center with rotational atherectomy (RA) of complex and heavily calcified coronary lesions. METHODS: We retrospectively analyzed consecutive patients who underwent PCI with RA in our center between January 2009 and December 2010. A total of 42 patients were included, 65% of whom had been previously refused for coronary artery bypass grafting due to unfavorable coronary anatomy or high surgical risk. RA was performed using the standard Boston Scientific Rotablator(®) system. The procedure was performed ad-hoc in 50% of patients and transradial access was used in 35%. Data were collected on immediate post-procedural events and major cardiac events during follow-up - cardiovascular death, myocardial infarction, TLR and recurrent angina. RESULTS: Of 1650 PCIs performed in a 23-month period from January 2009, 42 (2.5%) involved RA, a total of 42 patients (mean age 70.3±10.1 years, 67% male, 55% diabetic), three of whom had left main disease, six had three-vessel disease, 18 had two-vessel disease and the other 15 had single-vessel disease. Of the lesions treated, 71% were >20 mm long and classified in 69% of cases as type C according to the ACC/AHA lesion classification, 4% being chronic total occlusions. The left anterior descending artery was treated in 56% of the procedures. The mean number of burrs used per lesion was 1.3 and a total of 69 stents were implanted, 81% of which were drug-eluting. During follow-up three patients had recurrent angina, one required TLR and two died due to a cardiovascular event. There was significant clinical improvement in 83% of patients. CONCLUSIONS: This study demonstrates that rotational atherectomy followed by stenting in heavily calcified lesions can nowadays be performed with high success rates and few complications, extending the possibility of coronary revascularization to a greater number of patients.

[Intracardiac echocardiography imaging for device closure of atrial septal defects--a single-center experience]. / Encerramento percutâneo de defeitos do septo interauricular guiado por ecocardiograma intracardíaco--a experiência de um centro.

INTRODUCTION: Device closure of interatrial communications has become a well-established technique to treat left-to-right shunt associated with atrial septal defect (ASD) and to prevent paradoxical embolism in patients with patent foramen ovate (PFO). Guidance by transesophageal echocardiography (TEE) is the standard practice but intracardiac echocardiography (ICE) is a feasible and safe alternative for monitoring these procedures. OBJECTIVES: To report our experience in the percutaneous closure of ASD and PFO guided by ICE. METHODS: We retrospectively reviewed all patients with ASD or PFO who underwent percutaneous closure guided exclusively by ICE between January 2008 and December 2010. All patients were followed clinically with regular echocardiographic evaluation (at discharge, one month, three, six and twelve months) to exclude residual shunt and device malposition. RESULTS: A total of 127 patients (mean age 46.6 +/- 12.2 years; 71% female) underwent transcatheter device closure of ASD or PFO during the study period. Device deployment with ICE monitoring was 100% successful, with a low rate of complications and eliminating the need for additional imaging techniques. CONCLUSIONS: ICE provides anatomical detail of ASD/PFO and cardiac structures, facilitating congenital cardiac interventional procedures. It eliminates the major drawbacks associated with TEE and enables the interventional cardiologist to control all aspects of the procedure without relying on additional echocardiographic support.

Clostridium difficile Severity and Outcome at a North of Portugal Healthcare Facility.

INTRODUCTION: Clostridium difficile infection has been increasingly reported, with a significant healthcare burden and important morbimortality. This study aimed to characterize and describe the severity and outcomes of this event at a Portuguese hospital. MATERIAL AND METHODS: We conducted a retrospective analysis, by clinical record review, of all confirmed cases diagnosed in a hospital in the North of Portugal, between January 2013 and December 2018. We included those who were non-pregnant and at least 18 years old. RESULTS: Fifty-seven cases occurred, mostly in females and aged patients; 33.3% were healthcare facility-outset, while 31.6% were community-associated. Regarding severity, 43.9% had non-severe, while 29.8% severe and 21.0% fulminant presentations, the latter with the need of admission. Exposure to antibiotics occurred in 68.4%, while to proton-pump inhibitors in 57.9%. Risk factors for severe disease were female gender, chronic renal disease, and high neutrophil-lymphocyte ratio. Moreover, renal disease and a higher ratio were associated with fulminant disease. Thirty-day all-cause mortality was found in 15.8% while 90-day in 28.1%. Risk factors for 30-day mortality were renal disease, higher Charlson score, and higher neutrophil-lymphocyte ratio. Risk factors for 90-day mortality were advanced age, previous antibiotic exposure, higher Charlson score, and higher neutrophil-lymphocyte ratio. CONCLUSION: Data concerning Clostridium difficile infection severity and prognosis in Portugal is scarce, and future studies should focus on this important topic.

Introdução: A infeção por Clostridium difficile tem aumentado, com importante morbimortalidade e impacto nos sistemas de saúde. Este estudo procurou caracterizar e descrever a severidade e prognóstico desta infeção, na nossa instituição. Material e Métodos: Realizou-se uma análise retrospetiva dos casos confirmados ocorridos entre janeiro de 2013 e dezembro de 2018, num hospital do Norte de Portugal. Recorreu-se à análise de processo clínico e foram incluídos doentes sem gravidez em curso e com pelo menos 18 anos. Resultados: Verificaram-se 57 casos, a maioria em mulheres e idosos, sendo que 33,3% tiveram origem em instituições de saúde e 31,6% na comunidade. Nesta amostra, 43,9% tiveram doença não severa, 29,8% severa e 21,0% fulminante, estes com necessidade de internamento. A toma prévia de antibióticos ocorreu em 68,4%, e de inibidores da bomba de protões em 57,9%. O sexo feminino relacionou-se com doença severa, enquanto que a doença renal crónica e um elevado rácio neutrófilos-linfócitos se relacionaram com doença severa e fulminante. A mortalidade aos 30 dias verificou-se em 15,8% e associou-se a doença renal e elevação do score de Charlson e do rácio neutrófilos-linfócitos. A mortalidade aos 90 dias ocorreu em 28,1%, associada a idade avançada, toma de antibióticos e elevação do score e do rácio. Conclusão: Em Portugal, são escassos os dados sobre a severidade e prognóstico desta infeção, pelo que são necessários mais estudos nacionais.

Prevalence of metal levels above the reference values in a municipality affected by the collapse of a mining tailings dam: Brumadinho Health Project.

OBJECTIVE: To describe the prevalence of levels of arsenic, cadmium, mercury, lead and manganese above the reference values (RV) in the population of Brumadinho, after the rupture of the mining tailings dam and to verify the factors associated with these levels. METHODS: Baseline study of a prospective cohort, in a representative sample of 3,080 residents (aged 12 and over) in Brumadinho, Minas Gerais. Exploratory variables (age, sex, skin color, household income, smoking and place of residence) were collected using a questionnaire and the levels of As, Cd and Hg in urine and Pb and Mn in blood were evaluated using the technique of inductively coupled plasma mass spectrometry. The distribution of prevalence of levels above the reference for metals was made, according to the exploratory variables. Multiple logistic regression analyzes were used to investigate the association between altered levels of metals and characteristics evaluated. RESULTS: Concentrations above RV were found in 38.08% of the population for Mn, 33.37% for As, 5.04% for Pb, 0.76% for Hg and 0.17% for Cd. There was a significant association between age group and levels of Mn and Pb; and between place of residence and As level. CONCLUSION: The results show a high prevalence of levels above the reference for Mn, As and Pb, with small differences in relation to the other variables, suggesting that it is an exposure distributed throughout the municipality.

Importance of Manchester Triage in acute myocardial infarction: impact on prognosis.

BACKGROUND: Fast and effective diagnosis of patients with acute myocardial infarction (AMI) in the Emergency Department (ED) is needed. Manchester Triage (MT) is based on identification of the patient's main complaint, establishing, through decision flowcharts, a target-time for first observation. This study aimed to evaluate the impact of MT on short-term mortality in AMI and detect potential improvements, and to analyse high-risk groups: diabetic patients, women and older patients. METHODS: 332 consecutive patients (69.0+13.6 years mean age; 34.9% women) with final diagnosis of AMI were assessed in the ED using MT. Data were analysed according to demographics and risk groups, as well as several AMI parameters, admission duration and intrahospital mortality (IHM). Independent predictors of mortality were determined. RESULTS: 82.8% of patients met the ideal goal of ≤10 min target-time for a first observation (ITTFO). This was higher (95%) in typical presentations ('chest pain'), versus 52% in other flowcharts; p<0.01. Patients ≥70 years old were less frequently screened with ITTFO ≤10 min (76.2% vs 90.0% in those under 70; p=0.001) or the 'chest pain' flowchart (66.9% vs 77.5%; p=0.031). IHM was 13.3%. Triage with ≤10 min ITTFO and the 'chest pain' algorithm seems to predict a lower mortality (0.33 OR; 95% CI 0.17 to 0.63; p=0.0005 and 0.49 OR; 95% CI 0.24 to 1.03; p=0.056). CONCLUSION: MT proved to be an effective system. Patients with typical AMI presentation, ST elevation myocardial infarction and less than 70 years old are protected by MT, with lower ITTFO and better short-term survival.

Screening for warning signs of sudden cardiac death in the young: the SCD-SOS questionnaire.

INTRODUCTION: Sudden cardiac death (SCD) is one of the most common causes of death in the young. It may be preceded by "red flags", but screening for these warning signs is not routinely performed. OBJECTIVE: To test a new questionnaire for fast clinical assessment of possible warning signs of serious heart disease in a young population. METHODS: We studied a population of 1472 university students and hospital employees (mean age 22.3 +/- 5.9 years; maximum age 40 years; 56.5% women), using a rapid-response questionnaire, evaluating major cardiac symptoms, past pathological and family history and medication: the Sudden Cardiac Death-Screening of Risk Factors (SCD-SOS) questionnaire. Descriptive statistical analysis and comparison of quantitative and nominal variables were performed using SPSS version 16.0. RESULTS: Of the questionnaires, 0.3% were blank and 3.5% had 1 to 3 missing answers (of a total of 8); 42.5% had no previous cardiac complaints, 27.8% had previous syncope and 24.5% chest pain; palpitations were reported by 23.5%, cardiac murmur by 5.9%, epilepsy or antiepileptic drugs by 1.6%, cardiovascular medication by 1.4% and family history of cardiac disease by 3.3%. A history of sudden unexplained or cardiovascular death in first- or second-degree family members was reported by 2.0%. Full analysis of the questionnaires identified 69 participants (4.7%) with at least one warning sign indicating need for cardiological evaluation, among whom 17 had two warning signs and three had three. CONCLUSIONS: SCD-SOS detected some cases requiring careful examination by a cardiologist. It could, however, be improved in some respects (characterization of chest pain, palpitations and family history of heart disease), in order to clearly identify possible high-risk patients. Applying this questionnaire together with an ECG may be a better way of risk stratifying this population.

Testicular mitochondrial alterations in untreated streptozotocin-induced diabetic rats.

Diabetes-induced complications are associated with mitochondrial dysfunction and increasing evidence suggests that diabetes has an adverse effect on male reproductive function. The STZ-induced diabetic rat was used as an animal model for the type 1 form of the disease with the aim of determining its effects in spermatogenesis and testicular mitochondrial function. Several aspects of mitochondrial function were measured, including respiratory and electric potential function, as well as mitochondrial calcium loading capacity. Additionally oxidative stress production, antioxidant levels and possible apoptotic alterations were also evaluated. We observed that diabetic animals present alterations in spermatogenesis in both the testis and epidydimus. However, and surprisingly, the overall results in mitochondrial parameters failed to reveal severe testicular mitochondrial dysfunction in diabetic animals, with the exception of a decrease in calcium load. Taken together, results suggest that in animal models that mimic untreated type 1 diabetes the severe effects of the condition on spermatogenesis are not directly mitochondrial-mediated.

Mitochondrial bioenergetics of testicular cells from the domestic cat (Felis catus)-a model for endangered species.

Efficient spermatogenesis relies on the balance between energy production and expenditure, and thus depends on mitochondrial function. Our goal was to characterize testis mitochondria isolated from the domestic cat for their future use as a model for endangered felids. Respiration parameters were monitored with a Clark-type oxygen electrode, and the mitochondrial transmembrane potential (DeltaPsi) was estimated with a TPP(+) electrode. Testis mitochondria are shown to require low oxygen consumption to generate approximately the same maximum DeltaPsi as other tissues. We also found differences between young and adult cats suggesting a less efficient phosphorylation system in the first group. Furthermore, an interpolation equation of the relation between maximum DeltaPsi and age allowed the prediction of the expected DeltaPsi at each age, as well as possible deviations. The results generate a novel model from a carnivore to further test drugs or environmental contaminants (such as pesticides and herbicides), many of which act on mitochondria and may interfere with the reproduction of wild animals.

Host defence mechanisms against bacterial aggression in periodontal disease: Basic mechanisms.

Periodontal diseases are complex bacteria-induced infections characterised by an inflammatory host response to plaque microbiota and their by-products. Most of these microorganisms have virulence factors capable of causing massive tissue destruction both directly, through tissue invasion and the production of harmful substances, or indirectly, by activation of host defense mechanisms, creating an inflammatory infiltrate of potent catabolic activity that can interfere with normal host defense mechanisms. In response to the aggression, host defense mechanisms activate innate and adaptive immune responses. Our aim is to offer a general overview of the main mechanisms involved in the host response to bacterial aggression in periodontitis, such as lipopolysaccharide receptor CD14, complement system, polymorphonuclear neutrophils, antibodies and immunoglobulins.

Myocardial infarction with anomalous coronary anatomy.

Congenital coronary anomalies are rare but present a diagnostic challenge as detailed study of the coronary anatomy is required for their detection and accurate characterization. The authors present the case of a 71-year-old man with a previous history of angina, who had undergone cardiac catheterization several years ago, which was described as normal. He was admitted to our center with an acute myocardial infarction, three years after symptom onset; cardiac catheterization was repeated and revealed a subocclusive lesion located in a circumflex artery with an anomalous origin. We highlight the diagnostic difficulties encountered in this particular case, as the culprit artery was not identified in the first coronary angiography. Closer analysis of the images and the patient's clinical course helped identify the missing vessel, a dominant circumflex artery with an anomalous origin, and the atherosclerotic lesion responsible for the events.

Natural history of aortic arch aneurysm: the need for new therapeutic approaches.

Aortic arch aneurysms are a therapeutic challenge, as they are usually associated with a high surgical risk and their natural history is poorly understood. The authors present a case report of a 74-year-old man, with widespread atherosclerotic disease and an inoperable aortic arch aneurysm. Despite the severity of his condition, the patient survived for four years. Through regular follow-up, it was possible to document th growth mechanism of the aneurysm and the associated complications. We highlight the lack of information in the literature regarding the evolution and natural history of aneurysms of the aortic arch and the urgent need for new therapeutic strategies, especially a percutaneous approach, which could provide better treatment and outcome for high-risk surgical patients.

Comparing the delay with different anticoagulants before elective electrical cardioversion for atrial fibrillation/flutter.

AIMS: To assess the impact of the introduction of direct oral anticoagulants upon the outcomes from elective electrical cardioversion for atrial fibrillation. METHODS: This is a retrospective comparison of delay to elective cardioversion with different anticoagulants. The data was gathered from a large regional hospital from January 2013 to September 2017. There were 3 measured outcomes: 1) the time in weeks from referral to the date of attempted electrical cardioversion; 2) the proportion of patients who were successfully cardioverted; and 3) the proportion of patients who remained in sinus rhythm by the 12 week follow-up. Time-to-cardioversion was non-parametrically distributed so was analysed with Kruskal-Wallis testing and Mann-Whitney-U testing. Maintenance of sinus rhythm was analysed using z-testing. RESULTS: 1,374 patients were submitted to cardioversion. The referrals for cardioversion were either from primary care or from cardiologists. At the time of cardioversion, 789 cases were anticoagulated on warfarin (W), 215 on apixaban (A) and 370 on rivaroxaban (R). All 3 cohorts were initially compared independently using Kruskal-Wallis testing. This demonstrated a significant difference in the delay (measured in weeks) between the A and W group (A = 7, W = 9, P<0.00001); the R and W group (R = 7, W = 9, P<0.00001) and no difference between R and A (A = 7, R = 7, P = 0.92). As there was no difference between the A and R groups, they were combined to form the AR group. The AR group was compared to the W group using Mann-Whitney-U testing which demonstrated a significant delay between the groups (AR = 7, W = 9, P<0.00001). Excluding patients with prior or unknown attempts of cardioversion (n = 791), the W patients (n = 152) were less successful in achieving sinus rhythm at cardioversion than the AR (n = 431) group (W = 95% vs AR = 99% P = 0.04). However at 12 weeks, incidence of sinus rhythm was significantly different (W = 40% vs AR = 49% P = 0.049). These groups were compared by z testing. At 12 weeks' follow-up there was no statistical difference in rate of adverse consequences between the AR group and the W group, but the rate of adverse consequences was too low to draw further conclusions. CONCLUSION: DOACs appear to significantly shorten the latency between the decision to cardiovert and the cardioversion procedure by at least 2 weeks compared to warfarin in a real-world setting. In this study, patients who had not previously been cardioverted who were anticoagulated with warfarin had a significantly lower probability of conversion to sinus rhythm and a significantly lower probability to remain in sinus rhythm at the 12 week follow-up compared to the combined apixaban and rivaroxaban group.

Epidemiology and genetic variability of respiratory syncytial virus in Portugal, 2014-2018.

INTRODUCTION: Respiratory syncytial virus (RSV) is associated with substantial morbidity and mortality since it is a predominant viral agent causing respiratory tract infections in infants, young children and the elderly. Considering the availability of the RSV vaccines in the coming years, molecular understanding in RSV is necessary. OBJECTIVE: The objective of the present study was to describe RSV epidemiology and genotype variability in Portugal during the 2014/15-2017/18 period. MATERIAL AND METHODS: Epidemiological data and RSV-positive samples from patients with a respiratory infection were collected through the non-sentinel and sentinel influenza surveillance system (ISS). RSV detection, subtyping in A and B, and sequencing of the second hypervariable region (HVR2) of G gene were performed by molecular methods. Phylogenetic trees were generated using the Neighbor-Joining method and p-distance model on MEGA 7.0. RESULTS: RSV prevalence varied between the sentinel (2.5%, 97/3891) and the non-sentinel ISS (20.7%, 3138/16779), being higher (P < 0.0001) among children aged <5 years. Bronchiolitis (62.9%, 183/291) and influenza-like illness (24.6%, 14/57) were associated (P < 0.0001) with RSV laboratory confirmation among children aged <6 months and adults ≥65 years, respectively. The HVR2 was sequenced for 562 samples. RSV-A (46.4%, 261/562) and RSV-B (53.6%, 301/562) strains clustered mainly to ON1 (89.2%, 233/261) and BA9 (92%, 277/301) genotypes, respectively, although NA1 and BA10 were also present until 2015/2016. CONCLUSION: The sequence and phylogenetic analysis reflected the relatively high diversity of Portuguese RSV strains. BA9 and ON1 genotypes, which have been circulating in Portugal since 2010/2011 and 2011/2012 respectively, predominated during the whole study period.