Anticuerpos naturales IgG e IgA frente a antígenos polisacarídicos de neumococo en adultos con neumonía adquirida en la comunidad en la era de la vacuna conjugada

Se determinaron los títulos de anticuerpos naturales IgG e IgA específicos frente a los polisacáridos capsulares de neumococo incluidos en la vacuna conjugada (PCV-7) y contra 4 serotipos emergentes en España (mediante un test de ELISA de tercera generación) durante la fase aguda de un episodio de neumonía adquirida en la comunidad neumocócica (NACN) en 40 pacientes adultos. Se obtuvieron muestras de 2 grupos control sanos (<65 años y ≥ 65 años), y también en 8 pacientes con NACN, en los que se conocía el serotipo responsable, durante la fase de convalecencia. Casi todos los pacientes con NACN mostraron títulos de IgG ≥ 1 mg/ml frente a todos los serotipos de PCV- 7, pero el porcentaje de pacientes con niveles de IgG <1 mg/mL frente a los serotipos emergentes 1, 3 y 7F fue de 47,5%, 55% y 45%, respectivamente. Los títulos de IgG en pacientes <65 años fueron más altos que los correspondientes controles sanos para la mayoria de serotipos (1, 4, 14, 19F, 23F, 6B y 18C) aunque en el grupo de personas de más edad estas diferencias tendieron a desaparecer. Los niveles de IgG específica en la fase de convalecencia, sólo aumentaron en la mitad de los pacientes después del episodio agudo. Sólo se observaron correlaciones anecdóticas entre las IgG e IgA específicas de cada serotipo. Se concluye que el porcentaje de pacientes con NACN que mostraron niveles de anticuerpos IgG específicos teóricamente protectores frente a los serotipos incluidos en la PCV-7 es elevado, pero es menor frente a algunos serotipos emergentes. Sin embargo, los niveles de anticuerpos naturales específicos, no son buenos predictores del riesgo de desarrollar NACN y las respuestas serológicas después de la NACN son variables.Natural serotype-specific IgG and IgA to the pneumococcal capsular polysaccharides included in the conjugate vaccine (PCV-7) and against 4 emerging serotypes in Spain were determined (a third-generation ELISA was used) during the acute phase of a community-acquired pneumococcal pneumonia (CAPP) episode among 40 adult patients. Another sample was obtained for 2 healthy control groups (<65 years and ≥65 years), and for 8 patients with CAPP, in whom the pathogenic serotype was known, during the convalescence phase. Almost all the patients with CAPP had IgG titers ≥1 μg/mL to all PCV-7 serotypes, but the percentages of patients with IgG levels <1 μg/mL for the emerging serotypes 1, 3 and 7F were 47.5%, 55% and 45% respectively. IgG titers in patients <65 years were higher than the corresponding healthy controls for many serotypes (1, 4, 14, 19F, 23F, 6B and 18C), although in elderly these differences tended to disappear. Serotype-specific IgG titers in the convalescence phase rose only in the half of patients after the acute episode. Only anecdotal correlations were observed between serotype-specific IgG and IgA. We conclude that the percentage of patients with CAPP that showed levels theoretically protective of natural serotype-specific IgG antibodies to the majority of PCV-7 serotypes is high, but it is lower against some emerging ones. However, natural serotype-specific antibody levels, are not good predictors of the risk to develop CAPP and serological responses after CAPP are variable

Electrophysiological effects of selective atrial coronary artery occlusion in humans

Background-The arrhythmogenesis of ventricular myocardial ischemia has been extensively studied, but models of atrial ischemia in humans are lacking. This study aimed at describing the electrophysiological alterations induced by acute atrial ischemia secondary to atrial coronary branch occlusion during elective coronary angioplasty.; Methods and Results-Clinical data, 12-lead ECG, 12-hour Holter recordings, coronary angiography, and serial plasma levels of high-sensitivity troponin T and midregional proatrial natriuretic peptide were prospectively analyzed in 109 patients undergoing elective angioplasty of right or circumflex coronary arteries. Atrial coronary branches were identified and after the procedure patients were allocated into two groups: atrial branch occlusion (ABO, n= 17) and atrial branch patency (non-ABO, n= 92). In comparison with the non-ABO, patients with ABO showed: (1) higher incidence of periprocedural myocardial infarction (20% versus 53%, P= 0.01); (2) more frequent intra-atrial conduction delay (19% versus 46%, P= 0.03); (3) more marked PR segment deviation in the Holter recordings; and (4) higher incidence of atrial tachycardia (15% versus 41%, P= 0.02) and atrial fibrillation (0% versus 12%, P= 0.03). After adjustment by a propensity score, ABO was an independent predictor of periprocedural infarction (odds ratio, 3.4; 95% confidence interval, 1.01-11.6, P< 0.05) and atrial arrhythmias (odds ratio, 5.1; 95% confidence interval, 1.2-20.5, P= 0.02).; Conclusions-Selective atrial coronary artery occlusion during elective percutaneous transluminal coronary angioplasty is associated with myocardial ischemic damage, atrial arrhythmias, and intra-atrial conduction delay. Our data suggest that atrial ischemic episodes might be considered as a potential cause of atrial fibrillation in patients with chronic coronary artery disease.Peer ReviewedPostprint (author's final draft

Clinical and Prognostic Value of the Electrocardiogram in Patients With Acute Occlusion of the Left Circumflex Coronary Artery

The utility of the electrocardiogram (ECG) in patients with acute left circumflex (LC) coronary occlusion is not established. This study aimed at determining the clinical, angiographic, and prognostic characteristics associated with the different patterns of ST-segment changes in patients with LC occlusion. A cohort of 314 patients with LC occlusion was categorized according to the admission ECG: (1) ST-segment elevation (ST-E, n=208), (2) isolated ST-segment depression in precordial leads (ST-D, n=62), and (3) negligible ST-segment changes (No-ST, n=44). Clinical variables, coronary angiography, and 30-day major adverse cardiac event (MACE) (in-hospital ventricular fibrillation, 1-month mortality, or heart failure) were compared among the three groups. As compared with No-ST, patients with ST-E or ST-D presented more advanced Killip class, higher troponin peak, lower LV ejection fraction, and were independently associated with MACE (odds ratio 5.43, 95% confidence interval 1.09 to 27.20 and odds ratio 3.39, 95% confidence interval 0.66 to 17.50, respectively). Patients with ST-D were tardily reperfused, had more often mitral regurgitation (23.1% vs 9.3% in ST-E and 3.3% in No-ST, p=0.03), and presented ST-segment elevation in leads V7 to V9 in 12 of 16 cases with available recordings. Culprit proximal LC predominated in ST-D (41.9%), distal LC in ST-E (42.8%), and obtuse marginal in No-ST (59.1%) (all p<0.01). The No-ST had smaller coronary vessels and more collaterals. In conclusion, the three ST-segment patterns of LC occlusion identify patients with different clinical, angiographic, and prognostic characteristics. Patients with ST-depression pattern require a prompt reperfusion therapy and could be better recognized by recording leads V7 to V9

Response by Álvarez-García et al. to Letters Regarding article, “Electrophysiological effects of selective atrial coronary artery occlusion in humans”

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Evolution, Clinical and Microbiological Characteristics of Invasive Pneumococcal Disease since the Introduction of the Pneumococcal Conjugate Vaccine 13-Valent in Adults over 18 Years Old

Invasive pneumococcal disease (IPD) presents high mortality in the population at risk. The aim of this work is to know the evolution, clinical and microbiological characteristics of IPD in the adult population of Majorca, since the introduction of a public funded program for pneumococcal conjugate vaccine (PCV-13) in the pediatric population in the Balearic Islands in 2016. For this purpose, a retrospective multicenter study was carried out in which all episodes of IPD in adult patients from the four hospitals of the public health system of Majorca were included, comparing the periods between 2012 and 2015 and between 2016 and 2019. Clinical variables, serotypes and antibiotic sensitivity were collected. There were 498 cases of IPD; 56.8% were male with a mean age of 67 (standard deviation: 16). Most infections were bacterial pneumonias (73.7%). Of the total cases, 264 (53%) presented complications. Of the 498 cases, 351 strains were obtained, of which 145 (41.3%) belong to vaccinal serotypes (included in the PCV-13 vaccine) and 206 (58.7%) to non-vaccinal serotypes (not included in the PCV-13 vaccine). The percentage of IPD caused by vaccinal serotypes was lower in the second period (47.8% vs. 34.5%; p = 0.012)

Response by Álvarez-García et al. to Letters Regarding article, “Electrophysiological effects of selective atrial coronary artery occlusion in humans”

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Comparison of long-term clinical outcomes in multivessel coronary artery disease patients treated either with bioresoarbable polymer sirolimus-eluting stent or permanent polymer everolimus-eluting stent: 5-year results of the CENTURY II randomized clinical trial

To assess the long-term safety and efficacy of a sirolimus-eluting stent with bioresorbable polymer (BP-SES; Ultimaster), in comparison to a benchmark everolimus-eluting, permanent polymer stent (PP-EES; Xience), in a prespecified subgroup of patients with multivessel coronary artery disease (MVD) enrolled in the CENTURY II trial. The use of coronary stenting in high-risk subgroups, like MVD patients, is rising. The clinical evidence, including long-term comparative analysis of the efficacy and safety benefits of different new-generation drug eluting stents, however, remains insufficient. Among 1,119 patients (intention-to-treat) enrolled in the CENTURY II prospective, randomized, single-blind, multicenter trial, a prespecified subgroup of 456 MVD patients were allocated by stratified randomization to treatment with BP-SES (n = 225) or PP-EES (n = 231). The previously reported primary endpoint of this study was freedom from target lesion failure (TLF: a composite of cardiac death, target vessel-related myocardial infarction [MI] and clinically-indicated target lesion revascularization) at 9 months. In this MVD substudy, baseline patient, lesion and procedure characteristics were similar between the treatment arms. At 1 and 5 years, both BP-SES and PP-EES displayed low and comparable rates of TLF (5.3 vs. 7.8%; p = .29 and 10.2 vs. 13.4%; p = .29), and definite or probable stent thrombosis (0.4 vs. 1.3%; p = .33 and 0.9 vs. 1.7%; p = .43), respectively. Composite endpoint of cardiac death and MI, and patient-oriented composite endpoint of any death, MI, and coronary revascularizations were also similar. These results confirm good long-term safety and efficacy of the studied bioresorbable polymer stent in this high-risk patient population