Population Characteristics Research Articles

Risk and management of acute kidney injury resulting from hemoglobinuria following pulsed-field ablation in atrial fibrillation

Abstract Background High-voltage pulses can cause hemolysis leading to hemoglobinuria. Purpose We evaluated the prevalence of hemoglobinuria after pulsed-field ablation (PFA) and its impact on renal function in patients with atrial fibrillation (AF). Methods A consecutive series of 128 AF patients undergoing PFA were included in this analysis. The initial patients that did not receive post-ablation hydration were classified as group 1 (n=28) and the rest of the study population that received planned fluid infusion of ≥2 L after the procedure, were categorized as group 2 (n=100). Patients with estimated glomerular filtration rate (eGFR) <45 were excluded. All underwent extensive ablation beyond pulmonary vein isolation. If urine tested positive for hemoglobin, blood samples were tested for Haptoglobin. Results Baseline characteristics of the study population are provided in Table 1. Number of overall PFA applications were comparable between groups (group 1: 52.07±23.99 vs group 2: 59.83±22.78, p=0.149). Four patients in group 1 received 94.63±3.20 PFA applications. In group 2, 4 patients received >90 applications (94±2.82) and 2 patients received >150 (158.5±4.95) PFA applications. Of the 28 in group 1, 21 (75%) developed hemoglobinuria during the 24-hour following catheter ablation. Mean post-ablation S-Cr was significantly higher than the baseline value in these 21 patients (1.46±0.28 vs 0.86±0.24, p <0.001). Of the 21, 4 (19%) patients that received a mean of 94.63±3.20 PFA applications had the S-Cr. >2.5 mg/dL (mean: 2.95±0.21). These 4 patients were also markedly oliguric (<400 ml/day) in the immediate post-ablation period. Group 2 patients received significantly higher amount of fluid infusion following catheter ablation compared to group 1 (2092.53±198.94 vs 487.48±72.74 ml, p<0.001). None of the 100 patients from group 2 developed detectable hemoglobinuria or elevation of S-Cr including the 4 patients with >90 and 2 patients with >150 PFA applications. Mean post-ablation Haptoglobin was 10.00± 8.40 (normal: 36–195 mg/dL). The accuracy of number of applications predicting Haptoglobin decline was excellent with the area-under the curve (AUC) 0.886 ± 0.068 with 95% CI of 0.754 – 1.000. (P-value = 0.002). In multivariable analysis, both hydration (R-square 0.34, p <0.01) and number of PFA applications (R-square 0.40, p <0.038) were independent predictors of post-procedure acute kidney injury. Conclusions Based on our findings, number of PFA applications was an independent predictor of renal insult in patients receiving extensive ablation that could be prevented using planned fluid infusion immediately after the procedure.

Ablation outcome in elderly women with atrial fibrillation undergoing pulsed-field ablation for electrical isolation of pulmonary veins and left atrial posterior wall

Abstract Background Documented evidences indicate higher prevalence of non-paroxysmal atrial fibrillation (AF) as well as in elderly women but also demonstrate the need to go beyond the pulmonary veins (PV) when treating these patients. Objective We compared the ablation outcome in elderly women (>70 years) with that in men in the same age group as well as in younger women (≤70 years) undergoing pulsed-field ablation (PFA) for persistent AF (PerAF). Methods This multicenter study included consecutive PerAF patients undergoing PFA as their first procedure. Patients were divided into 3 groups: Group 1: women >70 years, Group 2: men ≥70 years and Group 3: women ≤70 years. All received PV isolation (PVI) and isolation of left atrial posterior wall (LAPWI). Concentric overlapping lesions were placed in the LAPW. Number of applications were determined on a case-by-case basis. Isolation was confirmed by electrograms recorded on the multispline catheter. In all patients, ICE and fluoroscopy were used to optimize contact between the PFA catheter and the targeted tissue. Arrhythmia-monitoring was performed for 1-year with periodic clinic visits, event recorders and 7-day Holter monitoring. Results A total of 229 patients (group 1: 73; group 2: 47 and group 3: 109) were included in this analysis. Baseline characteristics of the study population is presented in table 1. At 1-year follow-up, 15 (20.5%), 3 (6.38%) and 10 (9.17%) from group 1, 2 and 3 respectively, experienced arrhythmia recurrence off-antiarrhythmic drugs. Recurrence rate in group 1 was significantly higher than that in group 2 (p=0.034) and group 3 (p=0.029). Conclusion In women aged ≤70 years and in elderly men (>70 years), PVI plus isolation of LAPW using ICE-guided PFA was associated with significantly lower recurrence rate compared to that in the elderly women. Given the higher recurrence rate following PVI+LAPWI in the elderly females, the operators should consider addressing all other AF-initiating extra-PV triggers for better ablation-outcome in this subset of the AF population.

Job preferences of master public health candidates in Northeast China based on discrete choice experiments

BackgroundThe shortage of health workers in rural and remote areas is a key issue for global health systems, including China. Public health undertakings in Northeast China face the risk of a talent gap. In September 2023, the National Development and Reform Commission (NDRC) held a symposium on promoting the comprehensive revitalization of Northeast China in the New Era, proposing to support the comprehensive revitalization of Northeast China with high-quality population development, strengthen the development and utilization of human resources, and increase policy support for the revitalization of talent.MethodsThe questionnaire was designed by discrete choice experiments, and 1208 Public Health Master’s candidates from six universities in Northeast China were investigated online via the Powercx system network survey platform in April 2024. The mixed logit model was used to analyze the job preferences of Master Public Health candidates.ResultsAll 7 attributes included in the study had statistically significant effects on the job preferences of public health master’s degree candidates (P < 0.05). They tended to choose jobs with higher monthly income (12,000 CNY/month), located in cities with good working environments and with Bianzhi when seeking jobs. There is heterogeneity in job preference, and different preference characteristics are displayed in different subgroups.ConclusionThis study revealed that public health master’s degree candidates in Northeast China were more willing to choose jobs with higher monthly incomes, working places in cities and better working environments. The way to formulate a combination of policy packages is more attractive than improving a single aspect alone. Since the preferences of each subgroup are different, the preference characteristics of the target population should also be considered when formulating the policy package to meet the challenges of talent attraction and retention.

Echocardiographic left and right ventricular strain reference values and their associated characteristics in a healthy adult population from the ELSA-Brasil Study

Abstract Background/Introduction Impaired left ventricular (LV) systolic function is a well-known predictor of cardiovascular morbidity and mortality. Global longitudinal strain (GLS) analysis has been shown a robust measure to detect early systolic dysfunction and a prognostic parameter beyond traditional echocardiographic systolic parameters. Standard reference values for echocardiography measures have been established by echocardiography societies. However, these data may not accurately represent diverse world populations. Purpose We aimed to describe, from a Brazilian multiethnic population, age and sex-specific reference values for left (LV) and right ventricles (RV) GLS in a sample free of cardiovascular disease and risk factors, and to describe the impact of these risk factors according to GLS distribution. Methods ELSA-Brasil is a prospective cohort to investigate cardiovascular disease and diabetes including 15,105 participants aged 35 to 74 years. A predefined representative randomly selected sample with echocardiographic exam was included. We categorized the sample in tertiles according to severity of LV and RV systolic function measured by GLS, and applied trend tests across ordered groups to illustrate the association between GLS and demographic characteristics and echocardiographic measures of cardiac structure and function. Results In the study population (n=527), the mean age was 50.2 years and 59% were women. The overall mean value of LVGLS was -19.0 ± 2.4%, while the mean value of RVFWLS was -28.35 ± 3.06%. Women had higher absolute values of LV and RV GLS compared to men. Conclusion Our study provided the reference ranges for LV and RV GLS in a large middle-aged healthy Brazilian sample, with sex-differences reflected on these values.Central FigureTable 1:Tertiles of LVGLS and RVFWLS

Cultural Considerations in Intelligence Test Adaptations: a Critical Review of the WAIS-IV India and Its U.K. and U.S. Counterparts.

This study critically examined the adaptation and normative processes of the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV)India. WAIS-IV U.K. Edition Administration and Scoring Manual, WAIS-IVIndia Administration and Scoring Manual, and WAIS-IV Administration and Scoring Manual and Technical and Interpretive Manuals were used to extract test development and adaptation process data. The analyses were descriptive and qualitative. A review of the manuals showed that the normative sample were fluent English speakers with high education levels, which is not representative of India's multilingual and educational diversity. The study identified minimal cultural and linguistic adaptations in subtests, which raised concern about potential biases in the test adaptation process across cultures. The lack of clarity in item selection, demographic data, sample selection, and psychometric properties raised questions about the test's reliability and validity. Issues related to education, age, gender, and regional distribution are discussed, emphasizing the test's limitations in capturing the diverse characteristics of the heterogeneous Indian population. WAIS-IV India may not adequately represent India's population. More careful consideration of socioecological and psychometric factors when adapting intelligence (IQ) tests and use of advanced data harmonization methods can provide robust cross-national statistical harmonization in the future along with more ecologically valid local test development efforts. This can allow consideration of social determinants of health and other factors that can inform a more nuanced approach to IQ test development in non-western contexts.

Digital health literacy and associated socio-demographic characteristics in the French population

Abstract Background With the development of digital devices in the health field, digital health literacy has become an important issue in promoting and protecting people’s health. Digital health literacy was measured in a representative sample of the French adult population in order to assess its level and to identify the socio-demographic characteristics of individuals with the lowest literacy levels. Comparisons with works carried out in other European countries as well as implications for the implementation of digital interventions will be discussed. Methods Digital health literacy was assed using the HLS19-DIGI-HI Instrument. This 8-item scale measuring the skills related to dealing with digital health information was introduced in the 2023 Health Barometer survey, conducted by the French national public health agency. The survey included French-speaking individuals living in France, aged 18-85, selected through randomly generated phone numbers. 3007 persons were interviewed using a computer assisted telephone interview. A continuous score and categories were calculated to determine the level of Digital Health Literacy. Their associations with sociodemographic characteristics were studied using univariate and multivariate analysis. Results 1902 persons declared they used internet to search information or advice on health on internet in the last 12 months and completed the Digital health literacy questionnaire. 61 % of these individuals have a low level of digital health literacy (29 % “inadequate” and 32% “problematic”). Multiple sociodemographic characteristics were associated with lower levels of literacy in univariate and multivariate analysis. Conclusions These results are useful to better understand and assess the digital health literacy of the population according to their socio-demographic characteristics. They will provide a knowledge base to implement web-based interventions for promoting targeted digital health interventions, according to targeted audiences. Key messages • This study in large random sample of the French population showed frequent difficulties to deal with online health information. • Multiple sociodemographic characteristics were associated with digital health literacy and can help to support implementation of targeted digital health interventions.

Applicability of VICTORION-1 PREVENT Criteria to the US Population

Abstract Background VICTORION-1 PREVENT (V-1P) is an ongoing randomized clinical trial comparing inclisiran sodium 300mg every six months with placebo for primary prevention in patients with high cardiovascular (CV) risk. Purpose We evaluated the generalizability of V-1P trial enrollment criteria to the US population to understand the demographic and CV health characteristics of the trial target population. Methods We included data from the National Health and Nutrition Examination Survey (N=25,531, 2015-March 2020), a nationally representative sample of the US population. Enrollment criteria similar to V-1P were applied. Nonpregnant adults 40-79 years with low-density lipoprotein cholesterol (LDL-C) of 70-189 mg/dL were included. 10-year risk for CV disease was determined using the American Heart Association race-free 10-year PREVENT risk equations. Individuals with 10-year risk &amp;gt;20% or 7.5%-19.9% with two risk enhancing factors at baseline were included. Risk enhancing factors included elevated high sensitivity C-reactive protein (≥2 mg/L), inflammatory arthritis, estimated glomerular filtration rate &amp;lt;60 ml/min/1.73 m2, metabolic syndrome, or early family history of CV disease. Patients with history of atherosclerotic CV disease or liver disease were excluded. Estimates of demographics and health characteristics were nationally representative using survey weights. Results Among US adults, 21,576,506 (standard error [SE]: ±1,258,255) meet eligibility criteria for V-1P (weighted estimate). This represents 8.8% of all US adults or 15.1% of US adults 30-79 years. The V-1P eligible population had a mean age of 65.3 years (SE: ±0.5 years), and 55.0% (SE: ±2.5%) were female. Compared with the US adult population (≥18 years), V-1P eligible population had a higher mean body mass index (32.6 ± 0.3 kg/m2 vs 29.5 ± 0.2 kg/m2) and higher rates of obesity (61.0% ± 2.1% vs 40.0% ± 1.1%) (Table). V-1P eligible population also had higher mean systolic blood pressure (133.9 ± 1.0 mmHg vs 121.7 ± 0.3 mmHg), similar mean diastolic blood pressure (72.6 ± 0.8 mmHg vs 71.8 ± 0.2 mmHg), and higher rates of hypertension (85.8% ± 2.0% vs 45.9% ± 1.1%). Mean hemoglobin A1c percent (6.3 ± 0.1 vs 5.7 ± 0.02), fasting blood sugar (127.7 ± 1.9 mg/dL vs 109.2 ± 0.6 mg/dL), and diabetes rates (39.7% ± 2.6% vs 13.1% ± 0.7%) were higher in the V-1P eligible population. Mean low-density lipoprotein cholesterol (115.8 ± 1.5 mg/dL vs 110.2 ± 0.8 mg/dL) and fasting triglycerides (137.6 ± 5.0 mg/dL vs 110.4 ± 1.7 mg/dL) were higher, while mean high-density lipoprotein cholesterol was lower (49.9 ± 0.8 mg/dL vs 54.8 ± 0.4 mg/dL). The distribution of key CV risk factors is shown in the Figure. Conclusion V-1P enrollment criteria apply to many patients. These patients have significant cardiometabolic risk factor burden, and effective preventive therapies could have substantial health impact.

SNP Genotype Imputation in Forensics—A Performance Study

Background/Objectives: Emerging forensic genetic applications, such as forensic investigative genetic genealogy (FIGG), advanced DNA phenotyping, and distant kinship inference, increasingly require dense SNP genotype datasets. However, forensic-grade DNA often contains missing genotypes due to its quality and quantity limitations, potentially hindering these applications. Genotype imputation, a method that predicts missing genotypes, is widely used in population and medical genetics, but its utility in forensic genetics has not been thoroughly explored. This study aims to assess the performance of genotype imputation in forensic contexts and determine the conditions under which it can be effectively applied. Methods: We employed a simulation-based approach to generate realistic forensic SNP genotype datasets with varying numbers, densities, and qualities of observed genotypes. Genotype imputation was performed using Beagle software, and the performance was evaluated based on the call rate and imputation accuracy across different datasets and imputation settings. Results: The results demonstrate that genotype imputation can significantly increase the number of SNP genotypes. However, imputation accuracy was dependent on factors such as the quality of the original genotype data and the characteristics of the reference population. Higher SNP density and fewer genotype errors generally resulted in improved imputation accuracy. Conclusions: This study highlights the potential of genotype imputation to enhance forensic SNP datasets but underscores the importance of optimizing imputation parameters and understanding the limitations of the original data. These findings will inform the future application of imputation in forensic genetics, supporting its integration into forensic workflows.

Use of new antidiabetic drugs in patients with cardiovascular diseases - real life data

Abstract Introduction and aim Cardiovascular diseases (CVD) are among the most common and significant complications of type 2 diabetes mellitus (T2DM). Despite significant therapeutic progress in the prevention of CVD, T2DM remains a leading cause of major adverse cardiac events (MACE). Patients with T2DM and clinical manifestations of atherosclerotic CVD, or those at high risk of developing it, should receive cardioprotective and nephroprotective medications such as GLP-1 receptor agonists (GLP-1) and SGLT-2 inhibitors (SGLT2). This study aims to determine to what extent patients undergoing treatment at the general practitioner (GP) level comply with the recommendations. Methodology Retrospectively, in the period January 2022 to September 2023, records in the EHR were reviewed in the five GP offices. For all patients ( ≥18 years) with DMT2, all demografic as well as data on chronic therapy, stage of chronic kidney disease (CKD), presence of any cardiovascular (CV) risk factors and/or history of cardiovascular diseases (CVD), and the therapy applied were observed. Results A total of 6,941 patients' data were reviewed, out of which 483 (6.96%) had a diagnosis of DMT2. Table 1. shows the characteristics of the study population. Table 2. presents the values of HbA1c according to the criteria of good, acceptable, and poor DMT2 control, as well as the CKD stage by eGFR. Among the associated comorbidities, the most common was arterial hypertension, observed in 79.5% of the participants, followed by obesity in 28.2%. In terms of the applied therapy, the majority of participants were on metformin (76.8%). There were no significant differences in body mass index (BMI) and glycemic control between the group with and without CVD. However, compared to the group without CVD, patients with both DMT2 and CVD had a higher frequency of SGLT2 inhibitors (27% vs. 18.5%) [chi²=4.336, df=1, p=0.032] and GLP-1 receptor agonists (10.7% vs. 4.6%) [chi²=6.336, df=1, p=0.012] use, but a lower frequency of metformin (67.9% vs. 81.2%) [chi²=10.510, df=1, p=0.001]. Discussion According to current guidelines, all patients with CVD and CKD should have SGLT2 inhibitors and/or GLP-1 receptor agonists in their therapy. Comparing our study with the CAPTURE study, our patients were older and had slightly fewer associated CVD (38.7% vs. 32.9%). According to the CAPTURE study, less than 25% of patients with DMT2 in therapy have an antidiabetic medication with proven cardiovascular benefit, while in our sample, this was the case for 31.4% of the participants. This suggests that progress is being made, but it is still insufficient. Conclusion Over the past decade, there has been a rapid increase in knowledge regarding the appropriate treatment and management of risk factors in the population of individuals with DMT2. Although new insights are continuously incorporated into guidelines, our study shows that implementation in practice lags.

Clinical characteristics of patients with raised BNP referred from primary care to an outpatient heart failure with potential heart failure using NICE guidelines

Abstract Introduction UK NICE guidelines (1) mandate the referral of patients with potential heart failure (signs, symptoms and raised BNP) for specialist opinion including diagnostic echocardiography. We have analysed the demographic and clinical characteristics of 233 consecutive referrals over a nine month period of such patients from primary care to our outpatient cardiology service. Purpose To identify any differences between those who are subsequently identified as having reduced LV systolic function (HFrEF) and those with preserved LV systolic function. We have further explored any potential differences between those with moderately raised (&amp;gt;440 &amp;lt;2000ng/L) and those with grossly raised levels (&amp;gt;2000ng/L) of BNP as NICE guidance proposes a difference in urgency of assessment for these two patient cohorts. Methods All patients had diagnostic echocardiography following the British Society of Echocardiography guidelines (2) and were clinically assessed by a consultant cardiologist and specialist heart failure nurse. Results Of the 233 patients, 64 (27%) were identified as having HFrEF with the remaining 169 having preserved LV systolic function. In patients with HFrEF the majority had grossly raised BNP (62.5%) whereas with preserved LV systolic function the majority had moderately raised BNP (70.5%); Table 1. Within the referred population, demographics and clinical characteristics were broadly similar for patients with HFrEF and those with preserved LV systolic function for age and cardiovascular comorbidities (IHD, diabetes mellitus, hypertension) but were different for gender and heart rhythm. Patients with HFrEF and moderately raised BNP were twice as likely to be in sinus rhythm (75%) than those with grossly raised BNP (37.5%). In patients with moderately raised BNP those with preserved LV systolic function were more likely to be in AF than those with HFrEF (41% v. 25%). No gender difference was seen in patients with preserved LV systolic function whereas patients with HFrEF were twice as likely to be male; Table 2. Conclusions 1. The majority of patients with raised BNP and potential heart failure referred from primary care do not have HFrEF (72.5%) 2. Regardless of their LV systolic function those patients with the highest BNP levels are more likely to be in AF 3. Of patients with a raised BNP and HFrEF twice as many are male whereas no gender difference is seen in those with a raised BNP and preserved LV systolic 4. Whilst the mean age of both groups (preserved and reduced LV systolic function) is the same, in both groups those with grossly raised BNP are on average 5 years older than those with moderately raised BNP.

Association between wearable activity trackers usage and levels of physical activity among Athens Medical Society members

Abstract Introduction Wearable Activity Trackers (WAT) provide real-time feedback on activity levels and play a pivotal role in fostering an active lifestyle. Moreover, WAT can encourage doctors’ awareness to be more conscious of their daily physical activity whose exercise habits range between different medical specialties. Purpose The aim of this study is to evaluate the influence of WAT usage on physicians’ exercise habits according to the recommendations of ESC Guidelines. Methods This cross-sectional study comprised 742 physicians of the Athens Medical Society (AMS), Greece. The study instrument was a self-administered questionnaire mailed in October 2023 to evaluate physicians’ usage of WAT, baseline characteristics of population, specialty, and physical exercise habits. European Society of Cardiology (ESC) Guidelines recommend at least 150 min/week of moderate-intensity exercise in all healthy adults. Subjects were divided in two groups according to their usage of WAT or not in their everyday life: 1. Daily usage of WAT (Group A); 2. No regular or even on usage of WAT (Group B). Results A considerably high proportion of the total population use WAT daily (38%). Between Group A and Group B there was no difference in age (49±12 years vs. 51±13 years, p=0.07), male sex prevalence (55% vs. 49%, p=0.08) and BMI (25.7± 4.6 kg/m2 vs. 25.2± 4.1 kg/m2, p=0.11). Interestingly, there was statistically significant difference in mean exercise endurance training time between Group A and Group B (301±304 min. vs. 209±268 min., p&amp;lt;0.001) (Figure 1) and in the proportion of the doctors who follow the ESC Recommendations (63.5% vs. 47.2%, p&amp;lt;0.001). Furthermore, most of the physicians who use WAT have awareness for ESC Guidelines (59% vs. 47%, p&amp;lt;0.001), and most of them apply diet to lose weight (36% vs. 29%, p=0.04). Finally, WAT were mostly used by 4 main specialties: Cardiology (47%), Endocrinology (44%), Surgery (35%) and Internal Medicine (25%), with cardiologists reporting the higher use (p=0.045). Conclusion This study underscores the widespread adoption of WAT among physicians, highlighting their potential to positively influence exercise habits and adherence to ESC Guidelines. Physicians using WAT demonstrated increased exercise endurance training time, greater awareness of ESC Guidelines, and a higher propensity to implement weight loss diets compared to non-users. Additionally, variations in WAT usage and awareness of ESC Guidelines across medical specialties emphasize the need for targeted interventions to promote physical activity and enhance overall health among healthcare professionals.

Physical activity habits among members of the Athens Medical Society in Greece

Abstract Introduction Benefits of regular physical activity and exercise are well documented. Healthcare workers play a crucial role in counseling and appropriately referring their patients to adopt physical activity. However, doctors’ exercise habits range between different medical specialties and health service infrastructure. Purpose In this study, we assess physicians’ exercise performance according to the recommendations of 2020 ESC Guidelines. Methods The population of this cross-sectional study comprised 742 physicians of the Athens Medical Society (AMS), Greece. The study instrument was a self-administered questionnaire mailed in October 2023 to investigate physicians’ exercise habits, baseline characteristics of population, specialty, and health service infrastructure [Greek National Healthcare System (GNHS) or Private Practice (PP)]. European Society of Cardiology (ESC) Guidelines recommend at least 150 min/week of moderate-intensity exercise in all healthy adults. Subjects were divided in two groups according to their compliance to ESC Guidelines: 1. Moderate-intensity endurance exercise training per week ≥ 150 min (Group A); 2. Moderate-intensity endurance exercise training per week &amp;lt;150 min (Group B). Results The recommended exercise training per week goal is achieved by the majority of AMS members (53.4%) with an estimated mean exercise endurance training time of 240 ± 285 minutes. Between Group A and Group B there was no difference in age (50±12years vs. 50±13years, p=0.73), whereas there was significant difference in male sex prevalence (58% vs. 43%, p &amp;lt;0.001), in Body Mass Index (24.7 ± 3.8 kg/m2 vs. 26.2 ± 4.7 kg/m2, p &amp;lt;0.001), in Smoking habits (17.4% vs. 23.5%, p=0.04), in diabetes mellitus incidence (6.6% vs. 11.8%, p= 0.01) and in the use of activity monitoring wearables (45.2% vs. 29.8%, p&amp;lt;0.001). Interestingly, there was significant difference between GNHS and PP doctors representation in Group A and B with more doctors in the PP categorized in the Group A (p=0.008) (Figure 1). Importantly, logistic regression analysis revealed that even after adjustment for the aforementioned confounders there was significant under-representation of the GNHS in the Group A or otherwise doctors in the GNHS have 33% decrease odds of achieving the recommended exercise training per week (Odds Ratio: 0.676, 95%CI 0.484, 0.943, p=0.02) (Table 1). Conclusion A significant proportion of the AMS members follows the recommended ESC guidelines for minimum exercise training per week. Several factors affect their adherence to exercise time recommendation. Interestingly, AMS doctors working on the GNHS independently of other factors are less adherent to exercise recommendations. These findings emphasize the need to strengthen prevention strategies to AMS.

Productivity and consultation times in Portuguese primary care: trends and payment model variations

Abstract Background Portugal faces a shortage of primary care workforce resulting in an increase in patients without Family Physician (FP). While expanding the patient list per FP may help, it could also result in excessive workloads, compromising Consultation Times (CT) and quality of care. Furthermore, it is important to study the role of the primary healthcare (PHC) financing model in incentivizing their productivity. This study aims to analyse the productivity and CT in PHC units in Portugal, variation over time, and differences across PHC unit payment models. Methods 6,563 PHC units with different payment models (salary at UCSP, salary and group pay-for-performance at USF-A, and salary, capitation, and individual pay-for-performance at USF-B) from 2015 to 2022 were analysed, including the annual numbers of medical and nursing consultations and full-time equivalents (FTE) of physicians and nurses. Weekly productivity (WP) was calculated using the consultations per FTE physician and nurse. CT were determined by dividing each FTE’s weekly workload by WP. Multivariate analysis explored differences in CT between PHC units, temporal variations, and the influence of the patient population characteristics. Results FTE physicians had a mean WP of 117 consultations (SD 39) lasting 22.4 minutes (SD 7.0). FTE nurses had a mean WP of 56 consultations (SD 18) lasting 41.0 minutes (SD 14.3). Compared to UCSPs, USF-A and USF-B had shorter CT (p &amp;lt; 0.05) by 2.48 to 4.05 minutes for medical consultations and by 5.51 to 8.04 minutes for nursing consultations. CT increased over time, decreased with higher PHC age and favorable socio-demographic context, and increased with higher population density and elderly patients’ proportion (p &amp;lt; 0.05). Conclusions USF-B professionals showed higher productivity and shorter CT, suggesting that financial incentives are effective in enhancing productivity but that gains may be obtained with losses in visit duration. Key messages • Effective workforce management is crucial given the current primary care professionals shortages. • Physicians and nurses in PHC units pay-for-performance exhibit higher productivity and shorter consultation time.

Systemic inflammation and risk of death in patients with atherosclerotic cardiovascular disease and chronic kidney disease

Abstract Background Atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease stage 3 - 4 (CKD) affects 7% and 10% of the Danish population, respectively. Systemic inflammation (SI) contributes to destabilisation of atherosclerotic plaques and is characterized by elevated levels of C-reactive protein (CRP) in the blood. CKD is associated with SI and is independently associated with an increased risk of ASCVD. CRP levels ≥2 mg/L have been identified as a risk factor for mortality and major adverse cardiovascular events (MACE). Purpose To provide real-world evidence on the clinical burden of SI in patients diagnosed with ASCVD and CKD, using national health registers. Method Data from the Danish National Patient Registry from 1994-2022 was used to identify ASCVD patients by ICD-10 codes. CKD was identified by eGFR test results in the range [15 -59mL/min/1.73m2], in the Register of Laboratory Results for Research (RLRR). The latter diagnosis of ASCVD and CKD was set as index date. CRP-test results were extracted from RLRR and only individuals with at least two CRP tests were included. If two CRP-test results ≥2mg/L to &amp;lt; 20mg/L were observed less than six month apart, and within two years of index date, the individual was classified to have SI. The eGFR data from RLRR was available from 2011 onwards, with some regional differences in reporting. Individuals observed with CKD or ASCVD in the first year of eGFR availability were excluded to ensure a study of incident individuals. Individuals using select medications or diagnosed with selected chronic conditions thought to influence CRP levels were excluded. Additional population characteristics were extracted from corresponding national health and administrative registers. Hazard of all-cause mortality and MACE was analysed in a Cox proportional risk regression. Results From 2012 to 2022, a total of 19,162 individuals were eligible for the study population (SI: 13,039, No SI: 6,123). Median follow-up time was 4.1 and 8.2 years for individuals with or without SI, respectively. Median CRP two years before and after index date in the two groups was 7mg/L and 1mg/L. No clinically significant differences were found for demographic or socioeconomic characteristics. Patients with SI had more frequent history of hypertension, atrial fibrillation, COPD, heart failure and Type 2 diabetes before index, and higher risk of hypertension, atrial fibrillation, stroke, heart failure and type 2 diabetes after index. SI population had significantly increased hazard of mortality in a crude model (HR: 2.35, 95% CI: [2.22 – 2.50]), and in adjusted analysis HR: 2.06 ([1.92 - 2.21]). The corresponding hazard ratios for MACE were 1.9 ([1.81 – 2.01]) and 1.66 ([1.57 – 1.77]). The results were consistent across different model specifications and subgroups. Conclusion SI is associated with a significantly higher clinical burden of disease and a higher risk of all-cause mortality.Flowchart of inclusion/exclusionHazard ratio, overall and by subgroup

Biomass prediction of sea lamprey population based on dynamic feature matrix composite differential equation system

This article presents a mathematical model to predict sea lamprey biomass, addressing the species' impact on the Great Lakes fishery. The model, comprising a Dynamic Age Pyramid and a Multi-species Lotka-Volterra system, captures the complex life stages and behaviors of sea lampreys. It simulates their diet, habits, and growth parameters across different ages, considering their adaptive sex ratio variation. Key findings include the model's ability to dynamically update sea lamprey population characteristics annually in response to environmental changes. Simulations show that populations with dynamic sex ratios reach equilibrium faster, with an increasing female proportion over time in resource-rich environments. However, these populations exhibit less resilience to rapid environmental shifts compared to those with stable sex ratios. The study concludes that the model offers a valuable tool for understanding complex organism-environment interactions and enhances traditional ecological models by providing a dynamic, biologically meaningful population feature matrix. This innovation aids in managing invasive species like sea lampreys without harming native ecosystems.

Cross-national characteristics and differences in type 2 diabetes: Malta versus Luxembourg

Abstract Introduction Type 2 diabetes mellitus (T2DM) is a significant global health concern, requiring a thorough understanding of its population-level features and impact. This study aims to compare the characteristics of T2DM in Malta and Luxembourg, two European nations with distinctive healthcare systems and societal attributes. Methods Data from national health surveys conducted in Malta and Luxembourg, encompassing various factors such as socio-demographics, medical history, biochemical metrics, and anthropometric measurements, were analysed to investigate the features of T2DM. Comparative analyses were conducted utilizing chi-square tests, independent t-tests, and multivariable binary regression. Results Malta (8.23%) and Luxembourg (7.82%) shared similar T2DM prevalence, with a predominance of men having T2DM. Malta exhibited a higher prevalence of obesity among the individuals having T2DM. Multivariable analysis showed no significant association between living in Malta or Luxembourg and diabetes. However, being male (OR: 1.49, CI 95%: 1.07–2.08, p = 0.02), an occasional smoker (OR: 2.49, CI 95%: 1.54–4.03, p &amp;lt; 0.01), increasing age (OR: 1.05, CI 95%: 1.03–1.67), and larger waist circumference (OR: 1.02, CI 95%: 1.01–1.04, p = 0.01) were positively associated with diabetes. Conclusions Understanding similarities and differences in T2DM between Malta and Luxembourg is crucial for identifying common challenges to formulate effective prevention and management strategies. Despite similar T2DM prevalence rates, notable differences in obesity rates and socioeconomic factors may contribute to disparities in disease burden. The complex interplay of numerous population characteristics underscores the importance of tailored public health interventions. This study accentuates the need for interventions and evidence-based policies to address modifiable risk factors, and advocate for cross-national cooperation to reduce the T2DM epidemic, especially in the context of post-COVID public health planning and resource allocation. Key messages • Malta and Luxembourg share similar T2DM prevalence despite differences in other factors, hypothesised to be attributed to differences in risk factor profiles and health care infrastructure. • This study underscores the necessity for tailored interventions and cross-national cooperation to address common challenges in T2DM management in the two small countries.

HIV and cardiovascular risk: should we use other targets for cholesterol control? Brazilian data compared to major studies

Abstract In daily clinical practice, cardiologists are confronted with patients with HIV/AIDS and this population needs special attention due to their higher cardiovascular risk. Studies show an increase in cardiovascular disease (CVD) among people with HIV/AIDS and one of the main causes of death in this group. HIV is associated with dyslipidaemia and endothelial damage, which have been proposed as a cause of the increased risk of events, and HIV replication is a determining factor in endothelial dysfunction. With antiretroviral therapy (ART) there has been a reduction in morbidity and mortality from HIV/AIDS, however, several studies have shown an increase risk factors for CVD in this population, both in individuals on ART and those not on it. Two high-impact studies related to cardiovascular risk in the HIV population are Start and Smart. Studies are important for understanding this occurrence and its relationship with the presence of the virus and the use of antiretroviral therapy in this population. In view of the higher cardiovascular risk of these patients and the question of whether they deserve a different cholesterol target from other populations. Methods A retrospective, observational study was carried out on a sample of HIV patients from the Brazilian STD/AIDS Reference Centre (CRT), selected by lottery using their registration number, from 1 January 2011 to February 2023, aged over 18. 148 medical records were assessed and the following were collected population characteristics. Discussion: the CRT data were compared with the Start and Smart studies. The Reprieve study showed benefits earlier than expected with patients receiving a statin. An interim analysis revealed a 35 per cent reduction in serious adverse cardiovascular events in the statin group, leading to the placebo group stopping earlier. The viral load varied between the studies, with CRT having an average of 500,000 copies/ml, Start 12,759 copies/ml and Smart less than 400 copies/ml. Studies have associated HIV infection and higher viral loads with impaired endothelial function and vasodilation. Despite the data in the literature, all the patients with heart disease had undetected viral loads and CD4+ cell counts above 500 cells/mm³. Those with a high viral load in the study were not the ones with CVD. Conclusions In CRT, the percentage of primary events attributable to serious conditions unrelated to AIDS was 1.3 per cent. Analysing biomarkers could elucidate the effects of antiretroviral therapy on arterial disease. Another fact that probably justifies the low occurrence of cardiovascular and cerebral events in CRT is the multidisciplinary care given to patients, providing intensive primary and secondary prevention through counselling and follow-up. We suggest better control of cardiovascular risk factors with multi-professional intervention and more aggressive targets for the control of comorbidities.Characteristics and Cardiovascular risk

Regadenoson stress echocardiography: a road ahead

Abstract Introduction Drugs used in stress echocardiography (SE) have important limitations due to side effects and contraindications. Since its approval in 2008, Regadenoson has seen a significant increase in usage. This is largely attributed to its good safety profile and diagnostic accuracy, making it the preferred drug for stress tests in many European centers. However, despite its expanding use and major advantages, current guidelines don't place it as the first choice for SE, probably because the reported experience with this drug remains limited. The aim of the present study was to assess the safety and short-medium term prognosis of patients who underwent Regadenoson SE. Methods Retrospective observational study. Patients who underwent Regadenoson SE between 2017 and 2023 were included. Safety was assessed by monitoring immediate adverse effects following Regadenoson infusion and the need for using an antidote (Aminophylline). A positive test result was defined by the occurrence of any of the following: wall motion abnormalities, left ventricle dilatation, electrocardiographic changes or symptoms of ischemia. During the follow up, we registered the incidence of ischaemic events (admission for unstable angina, acute myocardial infarction (AMI) or cardiovascular (CV) death) and other CV events such as admission for heart failure (HF) and stroke. Additionally, we evaluated patients in both groups who underwent coronary angiography (by computerized tomography or coronary catheterization) during the follow up period. The groups with negative SE (NSE) and positive SE (PSE) were compared. Results The total number of patients was 344, with a median follow up of 29 months. Basal population characteristics and events by group (NSE and PSE) are shown in Figure 1. We needed to use the antidote in only one case, because of ventricular bigeminism, with no other major adverse effects reported. SE was positive in 37 (11%) patients. In this group, patients were more likely to present ischaemic events (16% vs. 3%, p&amp;lt;0.01) and admissions for HF (24% vs. 5%, p &amp;lt;0.01), compared to the NSE one. In those who underwent coronary angiography, revascularization was needed in 14 patients of the PSE group, and only in 7 of the NSE group (38% vs 2%, p &amp;lt; 0.05). The indications for these last cases were persistent angina in 5 patients (2 of them with history of coronary artery disease) and revascularization following an AMI in 2 patients. (Figure 2). Conclusions The probability of an ischaemic event after a negative Regadenoson SE remains very low, unlike positive studies. Regadenoson SE showed to be both safe in assessing ischemic cardiomyopathy and very useful for its prognostic value. These findings encourage its expanding use in the stress echo lab.

Acute kidney injury stage 2/3 during acute heart failure admission - clinical contributors and outcomes

Abstract Introduction Acute Heart failure (AHF) may be complicated by acute kidney injury (AKI) as a result of cardiorenal syndrome.(1) However other factors may contribute to AKI. AKI stage 2 or 3 predicts negative inpatient outcomes in the general population.(2) We have reported data in a contemporary cohort on AKI in AHF. This study looks at a larger cohort in 5 previous years to test whether those findings were consistent. Better understanding of this clinical scenario may lead to improvements in care. Aim To assess the clinical factors associated with AKI 2/3 in AHF inpatients. Methods This study used retrospective data from a single teaching hospital collected for inclusion in the UK National Heart Failure National Audit. All AHF admissions over a 5-year period, from April 2017 – April 2022 inclusive, were analysed. Renal function on admission and discharge/death were assessed. AKI stage was defined according to KDIGO guidelines based on serum creatinine levels. Electronic patient records were reviewed and the clinical course leading up to and following AKI 2/3 was reviewed. Reported mode of death was also collected. Results 3219 AHF admissions (2360 unique patients) were assessed. 257 patients died during admission (8% admission mortality, 10.9% patients). 157 (4.9%) admissions had AKI 2/3 on admission/discharge. 85 (54.1%) AKI 2/3 died during their hospital admission vs 6.1% mortality in admissions without AKI 2/3. Baseline population characteristics are summarised in Table 1. Admissions with AKI 2/3 who died were older (77.6±11.5 vs 71.5 ±15.8) and had higher rates of atrial fibrillation (48.2% vs 39.9%), diabetes (40% vs 36%), ischaemic cardiomyopathy (56.5% vs 41.7%) and LVEF &amp;lt;35% (38.8% vs 27.7%). The most frequent contributors to AKI 2/3 were sepsis (55, 64.7%) and congestive cardiac failure/cardiorenal syndrome (48, 56.6%). Hypotension (25, 29.4%), over-diuresis (17, 20%), radioiodine contrast (10, 11.8%) and aminoglycosides (8, 9.4%) were less common factors in development of AKI 2/3. ≥2 contributors were present in 49, 57.6%. The dominant contributor for AKI 2/3 was adjudicated to be sepsis in 33 (38.8%) of admissions, followed by cardiorenal syndrome (congestive heart failure with AKI) in 29 (34.1%), and cardiogenic shock in 7 (8.2%). AKI 2/3 contributors are summarised in Table 2. In AKI 2/3 cases who died, 35 (41.2%) involved renal specialist input; 60 (70%) involved heart failure specialist review. Conclusion AKI in AHF is associated with high inpatient mortality. Despite this, specialist renal input was uncommon. AKI 2/3 was usually multifactorial. Cardiorenal syndrome accounted for one third of cases and may not be preventable. In keeping with our findings from a smaller contemporary cohort, sepsis was the most common dominant cause of severe AKI. Prevention, early identification, and treatment of infection could reduce this risk. Awareness of the high mortality of AKI in AHF and specialist review may improve outcomes in AHF.

Development and validation of the four-item Concise Aging adults Smell Test to screen for olfactory dysfunction in older adults.

Olfactory dysfunction (OD) in the elderly is common and associated with numerous comorbidities, yet often underrecognized. This study sought to develop an instrument for widespread screening of this condition. Demographic factors, comorbidities, and olfactory-related questions were examined in a focus group (N=20) and development cohort (N=190). The 4-item Concise Aging adults Smell Test (4-CAST) screening instrument was then developed to predict OD on Sniffin Sticks testing. An independent validation cohort (N=147) was then examined to confirm ability of the 4-CAST to predict OD on Smell Identification Test 40 (SIT40). The most important variables for predicting olfactory loss in older subjects were age, type II diabetes status, Visual Analog Scale (VAS) of overall rating of smell, and VAS of impact of smell upon safety. In the development cohort, the 4-CAST model yielded predictive probability (area under the curve) of 0.805 (p<0.001) for predicting the bottom 25th percentile on Sniffin Sticks. Results were similar in the validation cohort, as the 4-CAST accurately classified 83.8% subjects (area under the curve [AUC] 0.789, p<0.001) in the bottom 25th percentile of SIT40 testing. The 4-CAST was able to accurately classify 89.4% of subjects with anosmia. The 4-CAST is a quick screening instrument for predicting OD in older adults and has similar performance characteristics in independent populations using the two most common validated olfactory tests. Given the high prevalence of unrecognized olfactory loss in this population, this can be a useful tool for practitioners to determine which subjects may benefit from more extensive olfactory testing.