Incidence of Bloodstream Infection in Patients with Pulmonary Hypertension under Intravenous Epoprostenol or Iloprost-A Multicentre, Retrospective Study.

Intravenous synthetic prostacyclin analogs (iPCAs), such as epoprostenol, treprostinil and iloprost have been widely used for the treatment of pulmonary arterial hypertension (PAH). Despite having good outcomes, continuous infusion of iPCAs has been associated with some adverse effects. Bloodstream infection (BSI) is one of the most severe complications, although poorly recognized, especially under iloprost administration, which few studies have addressed. This study aimed to compare the BSI incidence rates between intravenous iloprost and epoprostenol administration. Patients with pulmonary hypertension (PH) functional class III or IV receiving intravenous iloprost or epoprostenol through Hickman catheter, between 2004 and 2019, were retrospectively selected from two PH treatment centers. From a total of 36 patients (13 for iloprost and 23 for epoprostenol), 75% (n = 27) fulfilled the PAH criteria, mainly belonging to the idiopathic group. Overall BSI rate was 1.5/1000 days of treatment (3.38 and 0.09/1000 days for iloprost and epoprostenol, respectively). Patients receiving iloprost were at a higher risk of developing BSI than those receiving epoprostenol (HR: 12.5; 95% CI: 1.569-99.092). A higher mortality rate from BSI was also identified in the iloprost group (p = 0.04). Twenty-seven patients developed BSI, with 92% of them requiring hospitalization. A total of 29 agents were found, 10 Gram-positive (mainly Staphylococcus aureus; n = 5) and 19 Gram-negative (mainly Pseudomonas aeruginosa; n = 6) bacteria. Iloprost administration was linked to a significantly higher incidence of BSI, worse prognosis, and more BSI-related deaths than epoprostenol. BSI due to Gram-negative, commensal, low-virulence bacteria was also higher in the iloprost group. In short, physicians should be aware when prescribing iPCA to guarantee their patients' safety and best medical care.

1,8-Cineole ameliorates right ventricle dysfunction associated with pulmonary arterial hypertension by restoring connexin43 and mitochondrial homeostasis.

For the first time, the present study unravels a cardiospecific therapeutic approach for Pulmonary Arterial Hypertension (PAH), a disease with a very poor prognosis and high mortality rates due to right ventricle (RV) dysfunction. We first established a new in vitro model of high-pressure-induced hypertrophy that closely resembles heart defects associated with PAH and validated our in vitro findings on a preclinical in vivo model of monocrotaline (MCT)-induced PAH. Our results showed the in vitro antihypertrophic effect of 1,8-cineole, a monoterpene widely found in several essential oils. Also, a decrease in RV hypertrophy and fibrosis, and an improvement in heart function in vivo was observed, when 1,8-cineole was applied topically. Furthermore, 1,8-cineole restored gap junction protein connexin43 distribution at the intercalated disks and mitochondrial functionality, suggesting it may act by preserving cardiac cell-to-cell communication and bioenergetics. Overall, our results point out a promising therapeutic compound that can be easily applied topically, thus paving the way for the development of effective cardiac-specific therapies to greatly improve PAH outcomes.

A 45-year-old man with sudden cardiac death, cutaneous abnormalities and a rare desmoplakin mutation: a case report and literature review.

BACKGROUND: Arrhythmogenic cardiomyopathy (AC) is a rare, heritable myocardial disorder that is a leading cause of ventricular arrhythmia and sudden cardiac death (SCD) in young people. Desmoplakin (DSP) mutations account for 3-20% of AC cases. However, the number of patients with DSP mutations is extremely small in all published reports and genotype-phenotype correlations are scant and mostly non-gene-specific. CASE PRESENTATION: A 45-year-old man was admitted after an out-of-hospital cardiac arrest, with documented ventricular fibrillation. He had no previous history of heart disease or family history of SCD or cardiomyopathy. The cardiac magnetic resonance showed a mildly dilated left ventricle with an ejection fraction of 30% and a non-dilated right ventricle with mildly depressed systolic function, and extensive subepicardial late gadolinium enhancement. Genetic screening identified a heterozygote nonsense mutation in DSP (NM_004415.2: c.478 C > T; p.Arg160Ter). Cascade genetic screening of the relatives revealed a high prevalence of the genotype and cutaneous phenotype, but a very low penetrance of the cardiac phenotype. CONCLUSIONS: We report a case of SCD and an autosomal dominant mutation in DSP that causes arrhythmogenic dilated cardiomyopathy/AC. Like the recessive mutation in DSP known to cause Carvajal syndrome, Arg160Ter may be associated with cutaneous abnormalities.

Face mask use during the COVID-19 pandemic: how risk perception, experience with COVID-19, and attitude towards government interact with country-wide policy stringency.

BACKGROUND: During the 2020 COVID-19 pandemic, governments imposed numerous regulations to protect public health, particularly the (mandatory) use of face masks. However, the appropriateness and effectiveness of face mask regulations have been widely discussed, as is apparent from the divergent measures taken across and within countries over time, including mandating, recommending, and discouraging their use. In this study, we analyse how country-level policy stringency and individual-level predictors associate with face mask use during the early stages of the global COVID-19 pandemic. METHOD: First, we study how (self and other-related) risk perception, (direct and indirect) experience with COVID-19, attitude towards government and policy stringency shape face mask use. Second, we study whether there is an interaction between policy stringency and the individual-level variables. We conduct multilevel analyses exploiting variation in face mask regulations across countries and using data from approximately 7000 students collected in the beginning of the pandemic (weeks 17 through 19, 2020). RESULTS: We show that policy stringency is strongly positively associated with face mask use. We find a positive association between self-related risk perception and mask use, but no relationship of mask use with experience with COVID-19 and attitudes towards government. However, in the interaction analyses, we find that government trust and perceived clarity of communication moderate the link between stringency and mask use, with positive government perceptions relating to higher use in countries with regulations and to lower use in countries without regulations. CONCLUSIONS: We highlight that those countries that aim for widespread use of face masks should set strict measures, stress self-related risks of COVID-19, and use clear communication.

The role of impulsivity and delay discounting in student compliance with COVID-19 protective measures.

During the 2020 COVID-19 pandemic, governments set recommendations and restrictions that have given rise to new situations that require residents to deliberate and respond nonautomatically. For highly impulsive individuals, dealing with these situations may be harder, as they tend to deliberate less about the consequences of their behaviors. In this study, we investigate the relationship between impulsivity and delay discounting on the one hand and compliance with COVID-19 restrictions on the other hand. We distinguish between compliance with social distancing measures and compliance with hygiene measures. Regression analyses of an international sample of 6759 students from seven European countries reveal that the self-reported personality construct of impulsivity is negatively related to both types of compliance behavior. However, and unexpectedly, we also find a weak positive association between the discount rate-as measured by a behavioral task-and compliance. Our study highlights the importance of individual differences in impulsivity in regard to compliance with public health measures during a pandemic.

A 10- and 15-year performance analysis of ESC/EAS and ACC/AHA cardiovascular risk scores in a Southern European cohort.

BACKGROUND: A key strategy for the primary prevention of cardiovascular disease (CVD) is the use of risk prediction algorithms. We aimed to investigate the predictive ability of SCORE (Systematic COronary Risk Estimation) and PCE (Pooled Cohort Equations) systems for atherosclerotic CVD (ASCVD) risk in Portugal, a low CVD risk country, at the 10-year landmark and at a longer, 15-year follow-up. METHODS: The SCORE and PCE 10-year risk estimates were calculated for 455 and 448 patients, respectively. Discrimination was assessed by Harrell's C-statistic. Calibration was analyzed by standardized incidence ratios (SIR). RESULTS: During the 10-year follow-up, 7 fatal ASCVD events (the SCORE outcome) and 32 any ASCVD events (the PCE outcome) occurred. The SCORE system showed good discrimination (C-statistic 0.83), while the PCE showed poor discrimination (C-statistic 0.62). Calibration was similar for both systems, according to SIR: SCORE, 0.3 (95% CI 0.1-0.7); PCE, 0.5 (95% CI 0.4-0.7). Globally, both 10-year fatal ASCVD risk and any ASCVD risk were overestimated in the overall population and men. However, the risk was underestimated by both systems in women. Despite an overestimation of 15-year fatal ASCVD by SCORE, the 15-year any ASCVD observed incidence was 1.8 times the 10-year incidence among men and 1.4 times among women. This acceleration of CVD risk was more relevant in the lowest classes of ASCVD risk. CONCLUSION: In this prospective, contemporary, Portuguese cohort, the SCORE had better discriminatory power and similar calibration compared to PCE. However, both risk scores underestimated 10-year ASCVD risk in women.

Towards Fast Plume Source Estimation with a Mobile Robot.

The estimation of the parameters of an odour source is of high relevance for multiple applications, but it can be a slow and error prone process. This work proposes a fast particle filter-based method for source term estimation with a mobile robot. Two strategies are implemented in order to reduce the computational cost of the filter and increase its accuracy: firstly, the sampling process is adapted by the mobile robot in order to optimise the quality of the data provided to the estimation process; secondly, the filter is initialised only after collecting preliminary data that allow limiting the solution space and use a shorter number of particles than it would be normally necessary. The method assumes a Gaussian plume model for odour dispersion. This models average odour concentrations, but the particle filter was proved adequate to fit instantaneous concentration measurements to that model, while the environment was being sampled. The method was validated in an obstacle free controlled wind tunnel and the validation results show its ability to quickly converge to accurate estimates of the plume's parameters after a reduced number of plume crossings.

Going beyond classic echo in aortic stenosis: left atrial mechanics, a new marker of severity.

BACKGROUND: There is limited information regarding left atrial (LA) mechanics in aortic valve stenosis (AS). We assessed LA mechanics in AS through speckle-tracking echocardiography (STE) according to severity and prognosis. METHODS: We included 102 patients diagnosed with severe AS (sAS) and 80 patients with moderate AS (mAS), all with preserved ejection fraction and no coronary artery disease. LA mechanics and left ventricular global longitudinal strain (LV-GLS) were assessed by STE. The cohort was followed-up for a median of 30 (IQR 12.6-50) months, and outcomes were determined (combined outcome of HF, death, and aortic valve replacement). RESULTS: In our sample set, values of LV-GLS (- 18.5% vs - 17.1, p = 0.025), E/e' ratio (15.8 vs 18.4, p = 0.03), and global LA mechanics (LA ɛsys, 23% vs 13.8%, p < 0.001) were worse for sAS compared to those for mAS. However, LA ɛsys (AUC 0.85, 95% CI 0.78-0.90, p < 0.001), ɛe (AUC 0.83, 95% CI 0.75-0.88, p < 0.001), and ɛa (AUC 0.80, 95% CI 0.70-0.84, p < 0.001) were the best discriminators of sAS, with sensitivities higher than 85%. LA ɛsys showed a stronger correlation with both aortic valve area (r2 = 0.6, p < 0.001) and mean LV/aortic gradient (r2 = 0.55, p < 0.001) than LV-GLS (r2 = 0.3 and r2 = 0.25, p = 0.01). Either LV-GLS or LA ɛsys, but not the E/e' ratio, TAPSE, or RV/RA gradient, were a significant predictors of the combined outcome. CONCLUSIONS: LA global strain was the best discriminator of severity, surpassing E/e' ratio and LV-GLS, and a significant predictor of prognosis in AS.

Development of a theoretical-practical script for clinical simulation.

OBJECTIVE: To develop a theoretical-practical script based on the opinion of experts to be used in simulated clinical activities. METHOD: Qualitative study through analysis of content of interviews with experts on the theme in order to develop the proposed script. Of the 24 invited experts, 12 specialists from educational institutions in Brazil and abroad participated in the study in compliance with the ethical precepts. The experts responded to questions on the characterization of their study attributes and described the items required for the development of a simulated scenario. In view of the responses obtained, data content was analyzed and classified into units and subunits of significance. RESULTS: The items mentioned for the development of the script generated seven units of significance. The units and subunits of significance were gathered in three stages of the main components of the simulated scenario: prior, preparation, and finals. CONCLUSION: This study enables an innovative, stimulating teaching experience, making it easier for professors to use the simulation resource as a learning process in an effective and objective manner, as a guide to professors and researchers in the area of clinical simulation. OBJETIVO: Construir, com base na opinião de peritos, roteiro teórico-prático para uso em atividade clínica simulada. MÉTODO: Trata-se de um estudo qualitativo por meio de análise de conteúdo de entrevistas de peritos no assunto para construção do roteiro proposto. Seguido os preceitos éticos, entre os 24 peritos convidados pertencentes a instituições de ensino do Brasil e do exterior. Os peritos responderam a questões sobre a caracterização dos seus atributos de estudo e descreveram os itens imprescindíveis à construção de um cenário simulado. Diante das respostas obtidas, os dados foram analisados em relação ao seu conteúdo e organizados em unidades e subunidades de significância. RESULTADOS: Participaram 12 especialistas. Os itens mencionados para construção do roteiro originaram sete unidades de significância. As unidades e suas subunidades de significância foram ainda reunidas em três fases dos componentes principais do cenário simulado: prévios, preparo e finais. CONCLUSÃO: Este estudo permite um ensino inovador, estimulante e possibilita a facilidade ao professor, quanto à utilização do recurso de simulação, como processo de aprendizagem de maneira eficiente e objetiva, sendo um norteador aos docentes e pesquisadores na área de simulação clínica.

Usability Assessment of Moodle by Brazilian and Portuguese Nursing Students.

Distance education has turned into an important tool for nursing education. The virtual learning environments contribute toward an interactive and attractive educational process. In this study, we assess the usability of a virtual learning environment that was developed to teach nursing students how to care for patients with urinary retention. A multicenter and descriptive study was undertaken, which involved nursing students from the University of São Paulo at Ribeirão Preto College of Nursing, Brazil, and the Escola Superior de Enfermagem de Coimbra, Portugal. The participants were 79 students, mostly female, between 20 and 24 years of age. The virtual learning environment revealed good properties in terms of usability on most criteria. Future research will help to confirm the results.

Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score.

BACKGROUND: Fast and accurate chest pain risk stratification in the emergency department (ED) is critical. The HEART score predicts the short-term incidence of major adverse cardiac events (MACE) in this population, dividing it in three risk categories. We aimed to describe the population with chest pain, to characterize the subgroup of patients with acute coronary syndrome (ACS) and to assess the prognostic value of Manchester triage system and of HEART score. METHODS: Retrospective observational study including patients admitted to the ED of a tertiary hospital with chest pain as the presenting symptom. The primary outcome was a composite of all-cause mortality, myocardial infarction or unscheduled revascularization at 6 weeks. RESULTS: We enrolled 233 patients (age 58 ± 19; 55.4 % males). The most common final diagnosis was non-specific chest pain (n = 86, 36.9 %), followed by ACS (n = 22, 9.4 %). Male gender, smoking and chronic kidney disease were associated with higher risk of ACS. According to Manchester triage system, chest pain patients stratified with red or orange priority had a higher incidence of ACS (16.5 % vs. 3.8 %, p = 0.006). The application of HEART score showed that most patients were in low risk category (56.3 %). The six-week incidence of MACE in each category was 2 %, 15.6 % and 76.9 % (p < 0.001). HEART score accurately predicted the short-term incidence of MACE in chest pain patients (c-statistic 0.880; 95 % CI, 0.807-0.950, p < 0.001). CONCLUSIONS: Chest pain patients have very different levels of severity and the discriminatory power of Manchester triage system should be used in the assessment of this population. The HEART score seems to be an effective tool for risk stratification in the ED.

[Prehospital Care Times and Interventions for Victims of Major Trauma in the Central Region of Portugal: A Retrospective Study]. / Tempos de Resposta e Intervenções Extra-Hospitalar à Vítima de Trauma Major na Região Centro de Portugal: Um Estudo Retrospetivo.

INTRODUCTION: The quality and promptness of prehospital care for major trauma patients are vital in order to lower their high mortality rate. However, the effectiveness of this response in Portugal is unknown. The objective of this study was to analyze response times and interventions for major trauma patients in the central region of Portugal. METHODS: This was a retrospective, descriptive study, using the 2022 clinical records of the National Institute of Medical Emergency's differentiated resources. Cases of death prior to arrival at the hospital and other non-transport situations were excluded. Five-time intervals were determined, among which are the response time (T1, between activation and arrival at the scene), on-scene time (T2), and transportation time (T5; between the decision to transport and arrival at the emergency service). For each ambulance type, averages and dispersion times were calculated, as well as the proportion of cases in which the nationally and internationally recommended times were met. The frequency of recording six key interventions was also assessed. RESULTS: Of the 3366 records, 602 were eliminated (384 due to death), resulting in 2764 cases: nurse-technician ambulance (SIV) = 36.0%, physician- nurse ambulance (VMER) = 62.2% and physician-nurse helicopter = 1.8%. In a very large number of records, it was not possible to determine prehospital care times: for example, transport time (T5) could be determined in only 29%, 13% and 8% of cases, respectively for SIV, VMER and helicopter. The recommended time for stabilization (T2 ≤ 20 min) was met in 19.8% (SIV), 36.5% (VMER) and 18.2% (helicopter). Time to hospital (T5 ≤ 45 min) was achieved in 80.0% (SIV), 93.1% (VMER) and 75.0% (helicopter) of the records. The administration of analgesia (42% in SIV) and measures to prevent hypothermia (23.5% in SIV) were the most recorded interventions. CONCLUSION: There was substantial missing data on statuses and a lack of information in the records, especially in the VMER and helicopter. According to the records, the time taken to stabilize the victim on-scene often exceeded the recommendations, while the time taken to transport them to the hospital tended to be within the recommendations.

Introdução: A qualidade e rapidez do socorro pré-hospitalar à pessoa vítima de trauma major é vital para diminuir a sua elevada mortalidade. Contudo, desconhece-se a efetividade desta resposta em Portugal. O objetivo deste estudo foi analisar os tempos de resposta e as intervenções realizadas às vítimas de trauma major na região centro de Portugal. Métodos: Estudo retrospetivo, descritivo, utilizando os registos clínicos de 2022 dos meios diferenciados do Instituto Nacional de Emergência Médica. Casos de óbito pré-chegada ao hospital e outras situações de não transporte foram excluídos. Determinaram-se cinco tempos, entre os quais o tempo de resposta (T1, decorrente entre acionamento e chegada ao local), o tempo no local (T2) e o tempo de transporte (T5, intervalo entre a decisão de transporte e a chegada ao serviço de urgência). Foram calculadas médias e medidas de dispersão para cada meio, bem como a proporção de casos em que foram cumpridos os tempos recomendados nacional e internacionalmente. Avaliou-se também a frequência de registo de seis intervenções chave. Resultados: Dos 3366 registos, eliminaram-se 602 (384 por óbito), resultando em 2764 casos [suporte imediato de vida (SIV) = 36,0%, viaturas médicas de emergência e reanimação (VMER) = 62,2%, helicóptero de emergência médica (HEM) = 1,8%]. Num elevado número de registos não foi possível determinar tempos de socorro: por exemplo, o tempo de transporte (T5) foi determinável em apenas 29%, 13%, e 8% dos casos, respetivamente para SIV, VMER e HEM. O tempo recomendado para a estabilização (T2 ≤ 20 min), foi cumprido em 19,8% (SIV), 36,5% (VMER), e 18,2% (HEM) dos regis- tos. Já o tempo de transporte (T5 ≤ 45 min) foi cumprido em 80,0% (SIV), 93,1% (VMER) e 75,0% (HEM) dos registos (avaliáveis). A administração de analgesia (42% na SIV) e as medidas de prevenção de hipotermia (23,5% na SIV) foram as intervenções mais registadas. Conclusão: Observaram-se muitos status omissos e falta de informação nos registos, sobretudo na VMER e HEM. De acordo com os registos, o tempo no local superou frequentemente as recomendações, enquanto o tempo de transporte tende a estar dentro das normas.

Unstable Angina: Risk Stratification for Significant Coronary Artery Disease in The Era of High-Sensitivity Cardiac Troponin.

Introduction: High-sensitivity troponin (hsTn) has a very high diagnostic accuracy for myocardial infarction (MI), and patients who were formerly diagnosed with unstable angina (UA) are being reclassified as having NSTEMI in the era of hsTn. This paradigm shift has changed the clinical features of UA, which remain poorly characterized, specifically the occurrence of obstructive coronary artery disease (CAD) and the need for myocardial revascularization. The main purpose of this study was to clinically characterize contemporary UA patients, assess predictors of obstructive CAD, and develop a risk model to predict significant CAD in this population. Methods: We conducted a retrospective cohort study of 742 patients admitted to the hospital with UA. All patients underwent coronary angiography. The endpoint of the study was the presence of obstructive CAD on angiography. The cohort was divided into two groups: patients with significant coronary artery disease (CAD+) and those without CAD (CAD-). We developed a score (UA CAD Risk) based on the multivariate model and compared it with the GRACE, ESC, and TIMI risk scores using ROC analysis. Results: Obstructive CAD was observed on angiography in 53% of the patients. Age, dyslipidemia, troponin level, male sex, ST-segment depression, and wall motion abnormalities on echocardiography were independent predictors of obstructive CAD. hsTn levels (undetectable vs. nonsignificant detection) had a negative predictive value of 81% to exclude obstructive CAD. We developed a prediction model with obstructive CAD as the outcome (AUC: 0.60). Conclusions: In a contemporary UA cohort, approximately 50% of the patients did not have obstructive CAD on angiography. Commonly available cardiac tests at hospital admission show limited discrimination power in identifying patients at risk of obstructive CAD. A revised diagnostic and etiology algorithm for patients with UA is warranted.

Cognitive maturity of Portuguese nursing students to intervene in disasters: initial training contribution.

OBJECTIVE: To understand whether, from the perspective of coordinators/directors of nursing courses and nurses with skills in the field of disasters, nursing students have the necessary cognitive maturity to articulate the various dimensions inherent to the area of disasters, allowing efficient performance. METHOD: A study with a qualitative methodological approach, based on inductive reasoning and rigorous phenomenon description, based on exploratory research. RESULTS: Given the specificity and complexity of these phenomena, the inclusion of the disaster domain in the teaching-learning process, supporting valid knowledge construction and allowing the development and maturity of nursing students' cognitive processes, is crucial. CONCLUSION: Currently, reduced technical-scientific training in the field of disasters in Portugal constitutes a barrier in the development of nursing students' cognitive maturity, impeding their ability to respond when faced with phenomena of this complexity.

Heart failure management with ß-blockers: can we do better?

Heart failure (HF) is associated with disabling symptoms, poor quality of life, and a poor prognosis with substantial excess mortality in the years following diagnosis. Overactivation of the sympathetic nervous system is a key feature of the pathophysiology of HF and is an important driver of the process of adverse remodelling of the left ventricular wall that contributes to cardiac failure. Drugs which suppress the activity of the renin-angiotensin-aldosterone system, including ß-blockers, are foundation therapies for the management of heart failure with reduced ejection fraction (HFrEF) and despite a lack of specific outcomes trials, are also widely used by cardiologist in patients with HF with preserved ejection fraction (HFpEF). Today, expert opinion has moved away from recommending that treatment for HF should be guided solely by the LVEF and interventions should rather address signs and symptoms of HF (e.g. oedema and tachycardia), the severity of HF, and concomitant conditions. ß-blockers improve HF symptoms and functional status in HF and these agents have demonstrated improved survival, as well as a reduced risk of other important clinical outcomes such as hospitalisation for heart failure, in randomised, placebo-controlled outcomes trials. In HFpEF, ß-blockers are anti-ischemic and lower blood pressure and heart rate. Moreover, ß-blockers also reduce mortality in the setting of HF occurring alongside common comorbid conditions, such as diabetes, CKD (of any severity), and COPD. Higher doses of ß-blockers are associated with better clinical outcomes in populations with HF, so that ensuring adequate titration of therapy to their maximal (or maximally tolerated) doses is important for ensuring optimal outcomes for people with HF. In principle, a patient with HF could have combined treatment with a ß-blocker, renin-angiotensin-aldosterone system inhibitor/neprilysin inhibitor, mineralocorticoid receptor antagonist, and a SGLT2 inhibitor, according to tolerability.