European Association Research Articles

Association and mediation pathways of maternal hyperglycaemia and liability to gestational diabetes with neonatal outcomes: A two-sample Mendelian randomization study.

Maternal hyperglycemia is linked to adverse neonatal outcomes. However, current evidence was insufficient for mechanistic pathways. We aim to use two-sample Mendelian randomization (MR) to obtain a comprehensive understanding of the causal association and mediation pathways. Genetic variants of fasting glucose (FG), insulin sensitivity index (ISI), glycated haemoglobin (HbA1c), gestational diabetes mellitus (GDM) and type 2 diabetes (T2D) were used as instruments (N = 50 404-898 130). The associations with offspring birthweight, gestational duration, spontaneous preterm and post-term birth were assessed by the inverse-variance weighted method, using summary statistics of European genome-wide association studies (N = 131 279-210 248). Sensitivity analyses, including multivariable MR removing pleiotropic effect from maternal body mass index (BMI), assessed the robustness. Mediation via placental weight and maternal hypertension were assessed via a two-step MR design. FG (0.46 SD per mmol/L, 95% confidence interval [95% CI]: 0.32, 0.61) and GDM liability (0.18 SD per log odds, 95% CI: 0.08, 0.18) were positively associated with birthweight, with consistent findings for HbA1c, T2D liability and ISI. These associations were mediated by placental weight (proportion mediated: 32.8% to 77.7%). Higher HbA1c, GDM and T2D liability were associated with preterm birth (odds ratios for GDM: 1.07, 95% CI: 1.01, 1.14) and shorter gestational duration, whilst the association for T2D attenuated after adjusted for maternal BMI and gestational hypertension. Maternal hyperglycemia is associated with higher birthweight (possibly indicating macrosomia), mediated via increased placental growth. GDM and T2D liability are related to preterm birth, whilst the association for T2D liability is driven by maternal adiposity.

Updated Guidelines for the Prevention and Management of Chronic Hepatitis B-World Health Organization 2024 Compared With China 2022 HBV Guidelines.

The year 2024 is the year of new clinical practice and management guidelines for chronic hepatitis B virus (HBV) infection. World Health Organization (WHO) published the updated HBV guidelines in March 2024. In contrast, two key international societies for liver diseases, including the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL), are currently in the process of updating their clinical practice guidelines for HBV. In 2022, China published their HBV guidelines, regarded as one of the most uncompromising ones as the threshold to start antiviral treatment is set at detectable HBV DNA above 10-20 IU/mL. In this chapter, the latest developments in the HBV guidelines with a specific focus on the Chinese & WHO guidelines are discussed. Specifically, the pros and cons of lowering treatment thresholds and the benefits of treating more people to avoid the complications of chronic hepatitis B, specifically HCC, are reviewed.

Imaging of peritoneal metastases of ovarian and colorectal cancer: joint recommendations of ESGAR, ESUR, PSOGI, and EANM.

Diagnostic imaging of peritoneal metastases in ovarian and colorectal cancer remains pivotal in selecting the most appropriate treatment and balancing clinical benefit with treatment-related morbidity and mortality. To address the challenges related to diagnostic imaging and detecting and reporting peritoneal metastatic spread, a joint guideline was created by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Society of Urogenital Radiology (ESUR), Peritoneal Surface Oncology Group International (PSOGI), and European Association of Nuclear Medicine (EANM). A targeted literature search was performed and consensus recommendations were proposed using Delphi questionnaires and a five-point Likert scale. A total of three Delphi rounds were performed. Consensus was reached on the position of diagnostic imaging for assessment of operability, treatment response monitoring, and follow-up of peritoneal metastases, optimal imaging modality and their technical imaging requirements depending on the indication and how to optimise communication of imaging results by the report and multidisciplinary board discussion. The complete list of recommendations is provided. These expert consensus statements aim to guide appropriate indications, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients. Question Staging peritoneal metastases (PM) helps toguide clinical decision-making for colorectal and ovarian cancer patients. How can we optimise the use of imaging techniques to assess PM? Findings Imaging plays a crucial role in the detection, operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in colorectal and ovarian cancer patients. Clinical relevance These expert consensus statements aim to guide appropriate indication, acquisition, interpretation, and reporting of imaging for operability assessment, treatment response monitoring, and follow-up of peritoneal metastases in ovarian and colorectal cancer patients.

Left ventricular diastolic dysfunction worsens prognosis in patients with heart failure due to dilated cardiomyopathy.

The prognostic significance of left ventricular (LV) diastolic dysfunction (LVDD) severity in patients with dilated cardiomyopathy (DCM) remains uncertain. This study aimed to evaluate the association of LVDD severity and elevated left atrial pressure (eLAP) with patient outcomes in stable, non-acutely decompensated patients with DCM. This single-centre, retrospective, observational study involved 740 DCM patients (either inpatients or outpatients) managed at our tertiary cardiac centre between 2010 and 2021. Due to incomplete data, 96 patients were excluded. LVDD and eLAP were assessed using echocardiography according to the 2016 guidelines of the European Association of Cardiovascular Imaging (EACVI). The primary outcomes were all-cause mortality and heart failure (HF)-related mortality. The final cohort comprised of 644 DCM patients [mean age: 52±12years, LV ejection fraction (LVEF): 26±10%]. Over a median follow-up period of 41 (18.5-66.7) months, 105 (16.3%) patients died: 8 (5.3%) patients in the normal left atrial pressure (nLAP) group and 97 (19.6%) patients in the eLAP group. eLAP was identified as an independent prognostic factor for both all-cause mortality [hazard ratio (HR) 2.0; 95% confidence interval (CI) 1.1-3.7; P=0.01] and HF-related mortality (HR 2.5; 95% CI 1.01-6.5; P=0.04), even after adjusting for LVEF and atrial fibrillation (AF) presence. Additionally, HF-related mortality rates were significantly higher in patients with moderate to severe LVDD compared with those with mild LVDD [5 (3.3%) vs. 67 (13.6%), P<0.05]. This study's findings highlight the importance of assessing the severity of LVDD in patients with DCM, which provides incremental prognostic information over LVEF.

Comprehensive Review of Pharmacological Therapies and Clinical Guidelines for Diabetes Mellitus: A Depth Study

Diabetes mellitus (DM) is a colossal burden in global health, its prevalence increases steadily throughout the world. This systematic review explores the pathophysiology and epidemiology of diabetes, which describes the interactions that implicate that is the result of the play between genetic, environmental, and lifestyle factors in the development and progression of the disease. The review also describes a plethora of pharmacological treatments available to manage diabetes, with the oral agent, insulin regimens, and new approaches to therapy. Integrating the wisdom of the best clinical guidelines, those are from American diabetes association (ADA), European association for the study of diabetes (EASD), and International Diabetes Federation (IDF). Since these reviews are consistent with normative standards for evidence-based recommendations of optimal care of diabetes. The review goes further to cover technological advances in the management of diabetes. They include Continuous Glucose Monitoring, advanced insulin delivery systems, and Artificial Pancreas Systems. Such technologies hold more promising routes to better glucose control and patient quality of life. All this comes along with challenges that their deployment and maintenance that run through economic, adherence issues, and unequal access to healthcare. The future research and innovation in the battle against DM will include the application of personalized medicine and the development of advanced digital health solutions. This article will become a treasure for health professionals, researchers, and policymakers who have dedicated themselves to battling the adversities of diabetes mellitus.

Drug therapy and catheter ablation for management of arrhythmias in continuous flow left ventricular assist device's patients. A Clinical Consensus Statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC.

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common with a prevalence of 20-50% at one year after LVAD implantation. Arrhythmias predispose these patients to additional risk and are associated with considerable morbidity from recurrent implantable cardioverter-defibrillator (ICD) shocks, progressive failure of the unsupported right ventricle, and herald an increased risk of mortality. Management of patients with arrhythmias and LVAD differs in many aspects from the general population heart failure patients. These include ruling out the reversible causes of arrhythmias that in LVAD patients may include mechanical irritation from the inflow cannula and suction events. For patients with symptomatic arrhythmias refractory to medical treatment, catheter ablation might be relevant. There are specific technical and procedural challenges perceived to be unique to LVAD-related ventricular tachycardia ablation such as vascular and LV access, signal filtering, catheter manoeuvrability within decompressed chambers, and electroanatomic mapping system interference. In some patients, the arrhythmogenic substrate might not be readily accessible by catheter ablation after LVAD implantation. In this regard, the peri-implantation period offers a unique opportunity to surgically address arrhythmogenic substrate and suppress future ventricular tachycardia recurrences. This document aims to address specific aspects of the management of arrhythmias in LVAD patients focusing on anti-arrhythmic drug therapy and ablations.

Topical steroid use for suppression of hypergranulation in burns: Trends across the Atlantic.

Hypergranulated wounds from thermal injury remain a complex and debilitating problem for burn patients. Currently, there is no standard therapy to prevent or treat hypergranulation following burn injury. Many centers use topical corticosteroids; however, their use seems to be geographically dependent and controversial. The primary aim of this study was to quantify the current use of topical corticosteroids for post-burn hypergranulation in North America (NA) and Europe, while secondarily assessing for perceptions of safety and efficacy. We designed a survey that was distributed to the members of the European and American Burn Associations. Data was extracted and analyzed using SPSS software. A total of 165 respondents completed the survey (90 and 75 for the European and NA members, respectively). Seventy-one of the 90 (78.9%) European respondents reported they routinely use topical steroids for suppression of hypergranulation tissue in burns, versus 25 of the 75 (33.3%) NA respondents (p<0.001). European respondents, compared to NA respondents, were significantly more likely to consider topical steroid use safe (100% vs. 74.4%, p <0.001) and effective (98.6% vs. 66.7%, p < 0.001) for treatment of hypergranulated burn wounds. There was no significant difference in reported systemic effects seen after topical steroid use when comparing NA respondents and European respondents (6.5% vs. 6.9%, p > 0.10). The results of this study suggest that the use of steroids for hypergranulation tissue in burn care is more prevalent in Europe than NA, which may be due to discordant views on safety and efficacy despite minimal reported adverse effects.

The causal role of gastroesophageal reflux disease in endometriosis: a bidirectional Mendelian randomization study

Observational studies have reported an association between gastroesophageal reflux disease (GERD) and endometriosis. We conducted a two-sample and bidirectional Mendelian randomization analysis to determine whether those associations are causal. Two-sample and bidirectional MR analyses were performed using summary statistics from the European Individual Genome-Wide Association Study (GWAS). The inverse variance weighting (IVW) method is used as the main analysis method to evaluate causality. Sensitivity analyses were performed to assess heterogeneity, horizontal versatility, and stability. The results showed no significant causal association between GERD in women with endometriosis in the UK Bank database [ratio (OR) ≈ 0, 95% adjusted interval (CI) 1.0007∼1.0044, P = 0.006] and Finn databases [ratio (OR) = 1.29, 95% adjusted interval (CI) 0.99∼1.67, P = 0.06]. However, when studying the Finn database only for endometriosis, which is confined to the uterus, a significant increase in GERD was limited to the risk of endometriosis in the uterus [ratio (OR) = 1.47, 95% adjusted interval (CI) 1.00∼2.17, P = 0.05]. Sensitivity analysis showed that the results were robust and did not detect multi efficacy or heterogeneity. Meanwhile, reverse MR analysis showed that endometriosis did not increase the risk of GERD. This MR study supports a causal relationship between GERD and an increased risk of endometriosis confined to the uterus. Therefore, patients with gastric esophageal reflux should be treated with gynecological examination to avoid and prevent the development of endometriosis.

Liver and Let Die? A Retrospective Analysis of Secretarybird Mortality in European Zoos.

The secretarybird (Sagittarius serpentarius) is a threatened African raptor species, and as such requires conservation attention. While the species is managed under a European Association of Zoos and Aquaria (EAZA) Ex-situ Programme (EEP), no studies of mortality are currently available. A retrospective mortality project was therefore conducted to identify the most common causes of death in captive secretarybirds, with a view to informing management decisions. Data were collected by requesting the postmortem reports from zoos where secretarybirds had died and combining this with the existing data recorded in the Zoological Information Management System. Overall, 167 birds were recorded as having died within the EEP population, of which post-mortem information was available for 51 (30.54%) individuals. Trauma was the most common cause of death identified (22 birds, 13.17%), with infection appearing as the second most prevalent cause (15 birds, 8.98%). One incidental finding at postmortem was that many (9) birds showed evidence of liver damage, with reports of bacterial hepatitis, staphylococcal infection, lesions, and dark coloration. Further research into liver complications and diet composition for secretarybirds may therefore have value in reducing mortality. Similarly, investigating strategies to reduce trauma caused by other enclosure occupants or conspecifics may have value in lengthening lifespans for this endangered species.

Cohort Profile: VZNKUL–NMIBC Quality Indicators Program: A Flemish Prospective Cohort to Evaluate the Quality Indicators in the Treatment of Non-Muscle-Invasive Bladder Cancer

Purpose: Bladder cancer (BC) is a heterogeneous disease with varying outcomes, influenced by disease heterogeneity and variability in treatment and follow-up. Risk groups have been established for non–muscle-invasive BC (NMIBC) to standardize therapy, and several quality control indicators (QCIs) monitor adherence to these risk group-based guidelines. However, controversial results had been obtained regarding the oncological benefits of these QCIs until recent high-quality studies from large registries showed their usefulness. To improve adherence to the European Association of Urology (EAU) Guidelines and benchmark current care in Flemish hospitals within Vlaams Ziekenhuisnetwerk–KU Leuven (VZNKUL), a QCI program for NMIBC was initiated in 2013. This study aims to describe the demographic, clinical, and treatment data of patients enrolled in this program. Participants: The VZNKUL–NMIBC Quality Indicators Program Registry is a prospective cohort including patients treated and followed up with at seven academic and non-academic Flemish hospitals since June 2013. Data collection includes patient characteristics, tumor data, treatment, and oncological outcomes. Findings to date: From June 2013 to December 2020, 4744 transurethral resections of bladder tumors (TURBTs) from 2237 unique patients were analyzed. Most patients (80%) were men with a median age of 73. The median time from diagnosis to TURBT was 19 days. A single tumor was detected in 37% of TURBTs. Tumors larger than 3 cm were found in 20.8% of cases. In 46% of TURBTs, a reTURBT was scheduled according to guidelines. The complication rates were 7.5% and 2.4% for bladder perforation and bleeding, respectively. Postoperative single intravesical instillation of chemotherapy (SIVIC) was administered to 56.9% of 1533 indicated patients with a median time to administration of 4.7 h. Among the cohort, 60.4% had NMIBC, and 9.3% had muscle-invasive BC. Of 972 high-risk patients, 60.7% received adequate BCG induction, while 39.4% received adequate maintenance. After BCG induction ± maintenance, 39.7% were tumor-free, with 17.7% recurrence and 4% progression to muscle-invasive BC. BCG treatment was terminated early for 17% of patients due to intolerance. Early cystectomy was performed for 2.4% of the BCG-naïve patients, and 27.7% of patients with BCG failure underwent a BCG rechallenge. For intermediate-risk patients, 2.1% received adequate BCG, and 23% received intravesical chemotherapy. The median follow-up was 57 months. Five-year recurrence-free, progression-free, cancer-free, overall, and cancer-specific survival rates were 53%, 91.6%, 89%, 70.6%, and 95.6%, respectively, for the NMIBC patients. Of 400 non-metastatic MIBC patients, 217 (54.3%) underwent radical cystectomy (RC), of whom 46% received neoadjuvant chemotherapy, while 18 (4.5%) refused RC, and 74 (18.5%) were considered unfit for the surgery. Future plans: The VZNKUL–NMIBC Quality Indicators Program Registry will continue collecting data to evaluate QCIs and monitor treatment quality, enabling hospitals to benchmark their performance and improve patient care. Additionally, the registry’s real-world data can support research and international collaboration. Trial registration: The study was registered on ClinicalTrials.gov (NCT04167332).

Cognitive behavioral therapy for symptomatic paroxysmal atrial fibrillation: effects on physical activity, sleep and heart rate variability

Abstract Background We have devised a novel psychological intervention, cognitive behavioral therapy for paroxysmal atrial fibrillation (AF-CBT), that targets symptom preoccupation and avoidance behaviour. AF-CBT significantly improved cardiac anxiety and quality of life (QoL) in a randomized trial. To what extent this may be attributed to changes in physiological parameters is yet to be determined. Purpose A) to assess changes in objective and subjective measures of physical activity and sleep. B) to evaluate potential treatment effects on heart rate variability (HRV). Methods Patients with paroxysmal AF on optimal medical therapy (65.4±8.3 years, 58% women) and European Heart Rhythm Association Symptom Score ≥2b were randomized to a 10-week therapist-led online AF-CBT (n=65) or a control group (n=62), with the primary outcome of Atrial Fibrillation Effect on Quality-of-life (AFEQT). A Patch-Holter with an integrated accelerometer was applied for five days at baseline, post-treatment, and at three months follow-up. Each recording was divided into day and night (sleep time) based on posture, heart rate, and activity. HRV was analysed in both time and frequency domains, excluding AF episodes and aberrant beats. Results AFEQT increased from 62.4±14.3 to 83.7± 13.8 points in the AF-CBT group at the 3-month follow-up with a relative difference of 15.0 points. At baseline, the participants walked 8040±2600 steps/day and slept 8.0 ± 1.1 hours. AF-CBT did not increase physical activity, and there were no significant changes in objective sleep duration. The Insomnia Severity Score went from subclinical (12.2±6.7) to near normal values (8.1±5.6), which was significant as compared to controls (p=0.032). AF burden increased from 5.3% to 7.3% in the AF-CBT group and 5.0% to 9.2% in the control group, with no difference between the groups (p=0.59). We did not observe any change in heart rate or HRV indices at rest during the day or at night. Conclusion AF-CBT did not mediate its effects on QoL by improving objective physiological variables. Thus, our findings underline the importance of subjective, psychological, and behavioural aspects and indicate that AF-CBT might fill a void beyond medical and lifestyle interventions in comprehensive AF care.

Symptoms and atrial fibrillation burden measured by an insertable cardiac monitor in endurance athletes

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia in athletes, but knowledge regarding AF burden, symptoms and quality of life (QoL) in endurance athletes with AF is limited. Purpose To study AF burden by continuous monitoring using insertable cardiac monitor (ICM), AF symptoms and QoL in endurance athletes with paroxysmal AF. Methods In endurance athletes diagnosed with paroxysmal AF who reported ≥2 episodes of AF, of which ≥1 during the past six months, we continuously monitored AF using ICM. Episodes recognized as AF by ICM were validated by a cardiologist. We defined AF burden as the cumulative duration of AF episodes lasting ≥30 secs divided by the total duration of monitoring. AF symptoms were assessed using the 21-item Atrial Fibrillation Effect on QualiTy-of-Life Questionnaire (AFEQT). AFEQT produces a summary score and three subscale scores (symptoms, daily activities, treatment concerns), ranging from 0 (complete AF-related disability) to 100 (no AF-related disability). We defined any score &amp;lt;80 as clinically relevant AF symptoms. We classified athletes according to the modified European Heart Rhythm Association (mEHRA) classification. Sport participation was obtained by questionnaires. Height and weight were measured and physical fitness was examined during cardiopulmonary exercise testing. Results A total of 38 athletes (3 female, 8%) were included. Table 1 shows their characteristics. Eight of the athletes (21%) had recurrent AF after previous AF ablation therapy. ICM recordings were available in 30 athletes who were monitored for an average of 53±21 days (mean±SD). Eighteen athletes (60%) had ≥1 AF episode, the median number of AF episodes was 2 (interquartile range 8.75), and the mean AF burden was 1.4±2.5%. The mean AFEQT summary score was 84±12 and 11 athletes (29%) had an AFEQT summary score &amp;lt;80. The mean AFEQT symptom subscale score was 78±18). While 21 athletes (55%) had a symptom subscale score &amp;lt;80, indicating clinically relevant symptomatic AF, 9 (24%) scored &amp;lt;60, indicating more severely symptomatic AF. Figure 1 shows ICM-detected AF burden across categories of mEHRA classes and categories of the AFEQT summary score. The AF burden corresponded to both AFEQT scores and mEHRA categories, with a higher AF burden associated with more symptomatic AF (Figure 1). AF burden was numerically lower in athletes with recurrent AF after previous AF ablation therapy, compared to athletes previously not treated with AF ablation (0.6% vs. 1.7%, p= 0.66), but previously ablated athletes were more symptomatic (AFEQT symptom subscale score 68 vs. 80, p= 0.04). Conclusions Despite a relatively low AF burden during continuous monitoring with ICM, a majority of the athletes had clinically relevant symptomatic AF. Athletes with recurrent AF after previous ablation therapy had a numerically lower AF burden, but were more symptomatic compared to athletes with paroxysmal AF not previously treated with AF ablation.

Improving the functional detection of sarcopenic obesity: prevalence and handgrip scoring in the OBESAR cohort.

The study objectives were: 1) to detect early signs of low muscle function and assess sarcopenic obesity (SO) prevalence in patients with obesity; and 2) to introduce a new online diagnostic tool for scoring handgrip strength (HGS), adjusted for age and sex. Patients from the OBESAR cohort (184 men and 499 women) were tested for body composition and functional testing (chair stand test or HGS based on the cutoffs from the European Society for Clinical Nutrition and Metabolism [ESPEN]/European Association for the Study of Obesity [EASO] or adjusted HGS [adHGS] based on reference values), and SO prevalence was calculated accordingly. Among the 683 patients (mean [SD], age 42.6 [12.8]years; BMI 44.4 [6.3] kg/m2), HGS averaged 25.6 (6.8) kg for women and 43.2 (10.4) kg for men. A total of 25.2% of patients had adHGS lower than the 10th percentile, but this was true for only 5.6% using ESPEN/EASO cutoffs of HGS. SO prevalence rates were different according to functional tests: 5.4%, 24.5%, and 3.2% for HGS, adHGS, and the chair stand test, respectively. Using adHGS through a scoring process considering age and sex may help to detect early signs of SO in a primary care setting in order to better prevent SO through a personalized approach in adults with obesity. A free online application, "GRip And Sarcopenia Prediction" (GRASP), is proposed to diagnose probable SO.

9.C. Round table: The Global Oral Health Action Plan – Integrating Oral Health into the global health agenda

Abstract Oral diseases (OD) are a global public health problem affecting 3.5 billion people, with a global prevalence of 45%, higher than the prevalence of any other non-communicable disease (NCD). Recognizing the global public health importance, the 76th World Health Assembly (WHA) (May 2023) adopted the WHO’s Global Oral Health Action Plan (GOHAP) 2023-2030; a crucial step to bring momentum and mobilise all actors to address the burden of OD and common risk factors for all NCDs, while integrating oral health (OH) as part of general health and promoting cross-sectoral cooperation on good OH worldwide to reach UHC. Drawing insights from other successful global health action plans, this roundtable (RT) will explore key lessons learned in implementing effective strategies to improve OH outcomes at European and global levels, ensuring access to quality care for all. The objectives of the RT are: 1.To present the GOHAP 2023-2030, incl. challenges and opportunities; 2. To draw insights from other global health action plans; 3. To present good examples of civil society organization (CSO) actions supporting the GOHAP’s implementation - The Manifesto of the Platform for Better Oral Health, calling for policy actions by EU policymakers; 4. To present findings from the EU DELIVER (DELiberative ImproVEment of oRal care quality) and PRUDENT projects, funded by the European Commission, aiming to provide and implement a blueprint model for ensuring access to quality OH care for all; 5. To inform follow-up actions and collaboration across EUPHA sections, its strategy, as well as that of European Member States (MS), CSOs and other institutional partners, and to raise awareness across the European public and global health communities. The structure of the RT will include brief interactive presentations with real-time polling to maximize participant engagement and to consolidate key messages to present at the end of the session, incl. to inform follow-up actions across EUPHA. The first brief presentation on GOHAP will highlight the aims and evidence-informed actions, followed by: 1. Insights from other global health action plans, exploring lessons learned in implementing effective strategies, examining the approaches, opportunities, challenges and outcomes; 2. Good examples of actions taken by CSOs; 3. Preliminary findings from the EU DELIVER and EU PRUDENT will be presented, incl. key co-creation tools of deliberative dialogues and the development of a set of quality indicators for applicability on the practice, community and policy levels. Guided discussion will focus on opportunities and challenges in GOHAP implementation, with the targeted questions to panellists on: What can countries learn from other global health action plans? What should be the priorities of EU MS? What is the role the public health community can play? What are key steps needed to eliminate common NCD risk factors to drastically reduce the prevalence and burden of ODs? Key messages • There is an urgent need in the global and public health communities to better understand the processes involved in implementing the GOHAP, incl. challenges and opportunities. • Interdisciplinary and cross-sectoral collaboration is key to address the common risk factors of NCDs, to inform concerted action and evidence-informed policymaking to improve oral health care. Speakers/Panelists Pauline Vassallo European Association of Dental Public Health, Valletta, Malta Benoit Varenne Dental Officer, Prevention of Non Communicable Disease Department, WHO, Geneva, Switzerland Dympna Kavanagh Chief Dental Officer, Platform for Better Oral Health in Europe, Dublin, Ireland Neville Calleja Department of Health Information and Research, G’Mangia, Malta

Can examining shear wave elastography predict elevated filling pressures? - A comparative evaluation against the current guideline algorithm

Abstract Background The clinical assessment of left ventricular diastolic function is complex, as there is no single non-invasive parameter that provides a direct measurement of myocardial relaxation, myocardial compliance, or–as a surrogate-LV filling pressure. The estimation of diastolic function involves therefore a combination of various parameters. Shear wave (SW) elastography (SWE) is a novel method based on high frame rate echocardiography. SWs are generated following mechanical excitation of the myocardium, such as after mitral valve closure (MVC), and their propagation velocity is directly linked to myocardial stiffness (MS) and is therefore a potential marker of diastolic function. Purpose The aim of this study was to investigate if the propagation velocities of natural shear waves are related to invasively measured mid-(LVMDP) and end-diastolic LV filling pressures (LVEDP) and, thus, could be used as echocardiographic estimate of left ventricular diastolic function. Methods We prospectively enrolled 95 patients with a wide range of diastolic function, scheduled for heart catheterization so that LVMDP and LVEDP could be invasively measured. Patients with myocardial pathology or dysfunction of the anteroseptal wall, as well as severe aortic stenosis, and a more than moderate mitral regurgitation were excluded. Echocardiography was performed immediately after catheterization. SW elastography in parasternal long axis views of the left ventricle (LV) was performed using an experimental scanner (HD-PULSE) at 1040±200 frames per second. An anatomical M-mode was extracted from the midline of the LV septum and color coded for tissue acceleration. The SW propagation velocity at MVC was measured as slope on the M-mode (A). Standard echocardiographic parameters were obtained with a high-end ultrasound machine (Vivid 95, GE Vingmed Ultrasound). The algorithm for evaluating diastolic dysfunction as recommended by the European Association of Cardiovascular Imaging expert consensus 2021 was applied to categorize LV filling pressure as normal or elevated. Results SW velocities correlated significantly with both, LVMDP (r=0.47; p&amp;lt;0,001) and LVEDP (r=0.71, p&amp;lt;0.001). They could excellently detect elevated LVEDP (AUC=0.95, Sensitivity=0.92, Specificity=0.94) and detected elevated LVMDP with AUC=0.79, Sensitivity=0.87, Specificity= 0.65, similar to the guideline approach (AUC=0.78, Sensitivity=0.62, Specificity=0.94). Conclusions SW velocities, measured by high frame rate echocardiography, show a strong correlation with the end-diastolic and a good correlation with mid-diastolic filling pressures. The method could excellently distinguish normal and elevated LVEDP and could–through a single measurement-differentiate normal and elevated LVMDP as good as the current guideline algorithm with its combination of four parameters in a decision tree. Our data suggest a potential clinical value of the new method for the non-invasive assessment of diastolic function.

Diastolic dysfunction and survival in patients with preserved or mildly reduced left ventricular ejection fraction

Abstract Background Left ventricular ejection fraction (LVEF) is relatively indiscriminate for prognosis in patients with preserved or mildly reduced LVEF (&amp;gt;40%) following myocardial infarction (MI). Aims This study sought to determine the value of guideline-based assessment of diastolic dysfunction (DD) in predicting all-cause and cardiac mortality in patients with a first-ever MI and LVEF&amp;gt;40%. Methods A retrospective single centre study involving 2234 patients with a first-ever MI (STEMI or NSTEMI) with LVEF&amp;gt;40% was performed. Clinical, angiographic, and echocardiographic data were obtained from prospectively maintained institutional databases. Outcomes data were obtained from the state-wide registry. Echocardiography was performed early post-admission for all patients. Significant diastolic dysfunction (DD) was defined as grade 2+3 diastolic dysfunction according to current American Society of Echocardiography/ European Association of Cardiovascular Imaging guidelines. Results The mean age of patients was 61.4±12.3 years, 70.7% were males, and 12.1% had 3-vessel disease. The mean LVEF was 55.8±7.2% and 9.1% had significant DD. At a median follow up of 4.5 years, there were 219 deaths (46 cardiac deaths). On Cox proportional hazards multivariable analyses incorporating significant clinical, angiographic, and echocardiographic variables, significant DD was an independent predictor of both all-cause (HR 2.01,95%CI 1.37-2.94, p&amp;lt;0.001) and cardiac (HR 3.97,95%CI 1.98-7.99, p&amp;lt;0.001) mortality. Conclusions Significant DD is an independent predictor of all-cause and cardiac mortality following MI in patients with preserved or mildly reduced LVEF and thus effectively re-stratifies prognosis in a subgroup where the LVEF is relatively indiscriminate for survival. The benefit of further investigation and/or treatment in this subgroup needs further study.

HFpEF and glycemic variability: GHIDD Trial

Abstract Background Recently the guidelines of European Association of Preventive Cardiology reported that the prevalence of diabetes mellitus in patients with diastolic heart failure (HFpEF) is around 31%. Glunovo® is a transdermal device capable of detecting and storing the concentration of glucose in the abdominal interstitial fluid 480 times a day for up to 14 consecutive days. Purpose In our study we evaluated the non diabetic patients with HFpEF with Glunovo to evaluate the glycaemic variability in this population Methods 100 patients with HFpEF admitted to cardiology units of 4 Italian centres on the major islands were enrolled consecutively. Glunovo® was applied to each enrolled patient for 7 days. At the end of the glycaemic monitoring were calculated for each patient the glycaemic variability and the incidence of hyperglycaemia and hypoglycaemia. Glycaemic variability refers to a blood glucose value of ≥ 200 mg / dL or ≤ 59 mg / dL detected more than 3 times in a day for at least 4 days. The inclusion criterion was the presence of diastolic heart failure while the only exclusion criterion was the presence of diabetes diagnosis. Overall, 43 males and 57 females were enrolled with a mean age of 69.3 years (39-87 years). All patients underwent a timely glucose measurement at admission which excluded the presence of hyperglycaemia. No potentially hyperglycaemic drugs were added to the treatment during the hospital stay. Continuous glucose monitoring was performed as an integral part of the hospitalization diagnostic routine. Results In 94 of the 100 patients enrolled it was possible to conclude the analysis, detecting the glycaemic variability, the point glycaemia values and the estimated glycated haemoglobin value. A glycaemia ≥200 mg/dL was found in 53 patients (56%) while a high glycaemic variability was found in 51 patients (54%). A blood glucose value &amp;lt;59 mg / dl was found in 48 patients (51%). Only 5 times the estimated glycated Hb values were&amp;gt; 7%. 32 of the patients who had at least 3 punctual glucose values ≥200 mg/dL were prescribed an oral glucose load curve, which in 100% of cases confirmed the diagnosis of diabetes.No statistically significant differences were found based on age group or sex. In the control group, consisting of 10 patients without DHF undergoing continuous glucose monitoring at one of the participating cardiology units, an unknown hyperglycaemia was found in only 1 patient (10%) and a glycaemic variability in only 1 patient (10%). Conclusions Our experience suggests an incidence of hyperglycaemia and glycaemic variability more then 65% in patients affected by HFpEF. If our data were reproducible on a large scale, a so high prevalence of diabetes in patients with HFpEF cold explain the efficacy of SGLT-2 inhibitor and GLP-1 Agonist in this class of patients.

Upper tract urothelial carcinoma: epidemiology, presentation, and high-risk endemic populations.

Upper tract urothelial carcinoma (UTUC) only accounts for 5-10% of all urothelial cancers but these patients present with high stage disease and 2 out of 3 patients have evidence of muscle-invasion at time of diagnosis. Furthermore, 10% of UTUC patients have associated Lynch syndrome and therefore diagnosis of UTUC should prompt timely evaluation and familial counseling. The purpose of this review is to outline the current evidence on the epidemiology, presentation, and high-risk endemic populations of UTUC through review of contemporary publications occurring over the preceding 18 months. Both the American Urological Association (AUA) and European Association of Urology (EAU) have published updated guidelines within the last 18 months for the management of UTUC. Of note, the updated guidelines give special consideration to identifying patients with risk factors for Lynch syndrome and recommend universal histologic testing for those with high probability of having Lynch syndrome cancers as well as referral for genetic counseling and germline testing. UTUC is an overall rare malignancy but tends to present with advanced stage and muscle-invasion. A proper understanding of the epidemiology, presentation, and high-risk endemic populations is necessary to develop preventive and interventional strategies.

Preoperative Briganti Nomogram Score and Risk of Prostate Cancer Progression After Robotic Surgery Beyond EAU Risk Categories

Background and Objectives: We sought to investigate whether the 2012 Briganti nomogram may represent a potential prognostic factor of prostate cancer (PCa) progression after surgical treatment beyond European Association of Urology (EAU) risk categories. Materials and Methods: From January 2013 to December 2021, data on PCa patients treated with robot-assisted radical prostatectomy at a single tertiary referral center were extracted. The 2012 version of the Briganti nomogram assessing the risk of pelvic lymph node invasion was used. Here, the nomogram score was evaluated both as a continuous and a categorical variable. The association between variables and disease progression after surgery was evaluated through Cox regression models. Results: Overall, 1047 patients were identified. According to the EAU classification system, 297 (28.4%) patients were low-risk, 527 (50.3%) intermediate-risk, and 223 (21.3%) high-risk. The median (interquartile range) 2012 Briganti nomogram score within the investigated population was 3% (2–8%). Median (95% Confidence Interval [CI]) follow-up was 95 (91.9–112.4) months. Disease progression occurred in 237 (22.6%) patients, who were more likely to have an increasing 2012 Briganti nomogram score (Hazard Ratio [HR]: 1.03; 95%CI: 1.01–1.81; p = 0.015), independently of unfavorable issues at clinical presentation. Moreover, the nomogram score stratified according to tertiles (&lt;3% vs. 3–8% vs. ≥8%) hold significance beyond EAU risk categories: accordingly, the risk of disease progression increased as the score increased from the first (reference) to the second (HR: 1.50; 95%CI: 1.67–3.72; p &lt; 0.001) up to the third (HR: 3.26; 95%CI: 2.26–4.72; p &lt; 0.001) tertile. Conclusions: Beyond EAU risk categories, the 2012 Briganti nomogram represented an independent predictor of PCa progression after surgery. Likewise, as the nomogram score increased so patients were more likely to experience disease progression. Accordingly, it may allow further stratification of patients within each risk category to modulate appropriate treatment paradigms.

CURRENT LEVEL OF KNOWLEDGE AND AWARENESS OF HEALTHCARE PERSONNEL IN BASIC AND ADVANCED LIFE SUPPORT IN ARREST CASES WITH AND WITHOUT COVID-19 INFECTION

Objective: The knowledge of healthcare professionals about life support is crucial for saving lives. It was aimed to evaluate the knowledge and awareness level of healthcare professionals about advanced life support. Materials and methods: Our study was conducted between 15.02.2021 and 15.03.2021 with healthcare personnel working in our hospital. Data were collected by the questionnaire method. The researcher prepared the survey questions according to the European Resuscitation Council COVID-19 guidelines and American Heart Association Advanced Cardiac Life Support algorithms updated in 2020. 265 healthcare personnel (physicians, physician assistants, family physicians, nurses, health officers, and anesthesia technicians) participated in the study. Demographic characteristics of the participants (gender, age, duration of service, duties, duty stations), training and practice status, and level of knowledge were evaluated. Results: 67.2% of the participants were female, and 32.8% were male. The majority of the participants were nurses working in the inpatient clinics. 49.9% had a tenure of 1-5 years. 52.0% had received advanced cardiac life support training, and 19.6% had obtained and used automatic external defibrillators. 63.8% had performed advanced cardiac life support on a patient. In our study, the general level of advanced cardiac life support knowledge of the participants was found to be low. There was no significant difference in advanced cardiac life support scores in terms of gender, age, occupation, workplace, and tenure (p=0.604; p=0.986; p=0.927; p=0.982; p=0.295, respectively). Conclusion: Providing in-service resuscitation training to healthcare workers in line with current guidelines and supporting them with practical applications can provide quality knowledge and skills and increase their awareness of their responsibilities.