Cycloid psychosis - from the past to the future: based on a case report

Introduction

The concept of cycloid psychosis has a long tradition in European psychiatry since it was introduced by Kleist in 1926. Nevertheless, this concept is not included explicitly in modern classifications, leading to a controversial discussion about its utility in current psychiatry.

Objectives

Starting from a case study, we intend to review the evolution of cycloid psychosis concept and analyze its role in modern psychiatry.

Methods

Non-systematic review of the literature and report of a case study.

Results

Following Kleist’s work, Leonhard described the three overlapping subtypes, and later Perris developed the first operational diagnostic criteria. Since then, this entity has shown a high diagnostic stability, validity and a good predictive diagnostic and prognostic value. We report a case of a 30-year-old woman, previous heathy, without regular medication, living with her parents and 5-year-old son, until she emigrated alone to Switzerland. After 10 days abroad, she was sent back to Portugal, and after organic disease and drug misuse exclusion, she was admitted in our inward with a clinical picture of perplexity, anxiety, thinking and behavioral disturbance with persecutory and poisoning delusions, auditory hallucinations, and total insomnia. Following rapid and full recovery, she was discharged 14 days later while being medicated with Paliperidone 3 mg/day and Lorazepam 4 mg/day, which was abandoned by her 2 months later, without relapse of the symptoms.

Conclusions

The current lack of a satisfactory system for categorizing acute, and remittent psychoses seems to be reason enough to remain awareness of this unique diagnostic entity, which is worthy of further investigation.

Disclosure

No significant relationships.

Long term left ventricular impairment after SARS-COV2 infection

Funding Acknowledgements

Type of funding sources: None.

Introduction

The impact of acute infection by SARS-COV2 on the cardiovascular system has been previously reported in the literature, with a higher propensity in patients with more serious pattern of disease and pro-inflammatory status. Nevertheless, the long-term burden and sequels of COVID-19 on the cardiovascular system is still unknown.

Purpose

To evaluate the long-term impact of COVID-19 on left ventricular function in patients with severe clinical presentation requiring intensive care hospitalization.

Methods

 

This was a single-center observational, prospective study which included patients requiring admission to the Intensive Care Unit (ICU) due to COVID-19 infection from January to November 2020. All discharged patients were contacted to perform a clinical, electrocardiographic and echocardiographic evaluation and those who accepted were included on the protocol. Baseline and clinical characteristics were collected from clinical reports. For the global longitudinal strain (GLS) analysis all patients with significant wall motion abnormalities and valvular cardiopathy were excluded. Statistical analysis was performed with Mann-Whitney and a safety cut-off was established with ROC curve analysis.

Results

 

A total of 43 patients were included (mean age 64 ± 12, 67.4% males). During SARS-COV2 infection 49% presented with severe ARDS and 51% with moderate, 35% required invasive mechanical ventilation, 14% noninvasive mechanical ventilation and 52% with high nasal flow cannula. On the follow-up analysis, fatigue was the most reported in symptom (52% patients) and the majority did not present other signs or symptoms suggestive of heart failure, with the mean NT-proBNP of 49 ± 389 pg/dL. The standard ECG and echocardiogram did not show significant changes with a mean LVEF of 58 ± 7.8 and mean TAPSE of 21 ± 4. The strain analysis showed low value of GLS (mean GLS of -17.14 ± 2.36) for a reference cut-off of -18%, suggesting subclinical left ventricular dysfunction in this subset of patients with preserved ejection fraction. Maximum CPR values during ICU did not correlate either with the extent of disease evolvement in CT (p= NS) or ARDS severity (p= NS). Nevertheless, maximum CPR correlated significantly with GLS reduction (R = 0.44, p = 0.019). A CPR value higher than iger30mg/dL had 100% specificity for GLS reduction and a cut-off of 14gm/dL reported a sensitivity of 65% and specificity pf 75% for reduction in GLS.

Conclusion

In our study, we reported subclinical impairment in left ventricular function detected with global longitudinal strain after serious infection with SARS-COV2. The detected myocardial dysfunction was related with higher inflammatory as expressed by CPR values. Long-term monitoring of these patients should be undertaken in order to timely detect late complications. Abstract Figure.

Nicotinamide Mononucleotide Prevents Free Fatty Acid-Induced Reduction in Glucose Tolerance by Decreasing Insulin Clearance

The NAD-dependent deacetylase SIRT1 improves β cell function. Accordingly, nicotinamide mononucleotide (NMN), the product of the rate-limiting step in NAD synthesis, prevents β cell dysfunction and glucose intolerance in mice fed a high-fat diet. The current study was performed to assess the effects of NMN on β cell dysfunction and glucose intolerance that are caused specifically by increased circulating free fatty acids (FFAs). NMN was intravenously infused, with or without oleate, in C57BL/6J mice over a 48-h-period to elevate intracellular NAD levels and consequently increase SIRT1 activity. Administration of NMN in the context of elevated plasma FFA levels considerably improved glucose tolerance. This was due not only to partial protection from FFA-induced β cell dysfunction but also, unexpectedly, to a significant decrease in insulin clearance. However, in conditions of normal FFA levels, NMN impaired glucose tolerance due to decreased β cell function. The presence of this dual action of NMN suggests caution in its proposed therapeutic use in humans.

Deletion of pancreas-specific miR-216a reduces beta-cell mass and inhibits pancreatic cancer progression in mice

miRNAs have crucial functions in many biological processes and are candidate biomarkers of disease. Here, we show that miR-216a is a conserved, pancreas-specific miRNA with important roles in pancreatic islet and acinar cells. Deletion of miR-216a in mice leads to a reduction in islet size, β-cell mass, and insulin levels. Single-cell RNA sequencing reveals a subpopulation of β-cells with upregulated acinar cell markers under a high-fat diet. miR-216a is induced by TGF-β signaling, and inhibition of miR-216a increases apoptosis and decreases cell proliferation in pancreatic cells. Deletion of miR-216a in the pancreatic cancer-prone mouse line KrasG12D;Ptf1aCreER reduces the propensity of pancreatic cancer precursor lesions. Notably, circulating miR-216a levels are elevated in both mice and humans with pancreatic cancer. Collectively, our study gives insights into how β-cell mass and acinar cell growth are modulated by a pancreas-specific miRNA and also suggests miR-216a as a potential biomarker for diagnosis of pancreatic diseases.

Multidimensional characterization of a new antifouling xanthone: Structure-activity relationship, environmental compatibility, and immobilization in marine coatings

The accumulation of marine biofouling on ship hulls causes material damage, the spread of invasive species, and, indirectly, an increase in full consumption and subsequent pollutant gas emissions. Most efficient antifouling (AF) strategies rely on the conventional release of persistent, bioaccumulative, and toxic biocides incorporated in marine coatings. A simple oxygenated xanthone, 3,4-dihydroxyxanthone (1), was previously reported as a promising AF agent toward the settlement of Mytilus galloprovincialis larvae, with a therapeutic ratio higher than the commercial biocide Econea®. In this work, a structure-AF activity relationship study, an evaluation of environmental fate, and an AF efficiency in marine coatings were performed with compound 1. Hydroxy or methoxy groups at 3 and 4 positions in compound 1 favored AF activity, and groups with higher steric hindrances were detrimental. Compound 1 demonstrated low water-solubility and a short half-life in natural seawater, contrary to Econea®. In silico environmental fate predictions showed that compound 1 does not bioaccumulate in organism tissues, in contrast to other current emerging biocides, has a moderate affinity for sediments and slow migrates to ground water. No toxicity was observed against Vibrio fischeri and Phaeodactylum tricornutum. Polyurethane-based marine coatings containing compound 1 prepared through an innovative non-release-strategy were as efficient as those containing Econea® with low releases to water after 45 days. This proof-of-concept helped to establish compound 1 as a promising eco-friendly AF agent.

Prevalence of cognitive impairment before treatments for prostate cancer

Background/Objective

Up to 30% of patients with cancer may present cognitive impairment (CI) before treatment but data are scarce regarding prostate cancer (PCa). We aim to estimate the prevalence of CI in patients with PCa, before cancer treatment.

Methods

Between February 2018 and April 2021, the NEON-PC cohort included 609 patients with a recent PCa diagnosis to be treated at Instituto Português de Oncologia do Porto. Previous history of chemotherapy, radiotherapy, androgen deprivation therapy, and neurologic or psychyatric conditions impairing cognitive performance were exclusion criteria. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive performance before any treatment for PCa. Participants with a MoCA at least 1.5 SD below age- and education-specific norms were considered to have probable cognitive impairment (PCI) and were proposed for a comprehensive neuropsychological (NP) assessment. Participants scoring <2.0 SD age-corrected norms in at least one cognitive test, or < 1.5 SD age-corrected norms in ≥ 2 cognitive tests were classified as having CI. Data from the population-based cohort EPIPorto (n = 351 men, evaluated in 2013-2015) were used for comparison.

Results/Discussion

Prevalence of PCI was 17.4% in the EPIPorto and 15.1% in the NEON-PC cohort (age- and education-adjusted OR = 1.02,95% confidence interval: 0.70,1.50). NP assessment was performed in 65 patients with PCa: 38.5% had normal cognitive function; 7.7% had a light deficit (<1.0 SD of age-corrected norms in ≥ 1 cognitive tasks); and 53.9% had CI.

Conclusions

PCI was as frequent in patients recently diagnosed with PCa as in the general population. Prevalence of CI was lower than in previous reports, which may be explained by differences in the assessment and definition of CI and of the type of cancer.

Funding

POCI-01-0145FEDER-032358;PTDC/SAU-EPI/32358/2017;UIDB/4750/2020; SFRH/BD/119390/2016

Key messages

Patients with prostate cancer and the general population had similar odds of having a score below normative values in the MoCA. Differences in the prevalence of CI between this study and others suggest that the type of cancer may affect patients’ cognitive performance differently, which deserves further confirmation.

Androgen deprivation therapy and cognitive decline in the NEON-PC study

Background/Objective

Androgen deprivation therapy (ADT) has been associated with cognitive decline, but results have been heterogenous. We describe changes in cognitive performance in patients with prostate cancer (PCa), according to treatment with ADT, during the 1st year after PCa diagnosis.

Methods

Between February 2018 and March 2021, 348 patients with PCa treated at the Instituto Português de Oncologia do Porto were evaluated with the Montreal Cognitive Assessment (MoCA), before treatment and after one year (1y). ADT was used in 183 participants, and 165 were treated without ADT (total prostatectomy, radiotherapy, brachytherapy, active surveillance). Cognitive decline was defined as the decrease in MoCA from baseline to the 1y-evaluation below 1.5SD of the distribution of the MoCA variation in the whole cohort. Participants scoring below age- and education-based normative reference values in MoCA were considered to have probable cognitive impairment (PCI). Multivariate logistic regression was used to estimate age- and education-adjusted OR (aOR) of the association between ADT and cognitive decline/incident PCI.

Results/Discussion

PCI was observed in 12.4% of the patients at baseline. Mean MoCA scores increased from baseline to the 1y-evaluation (22.4 vs. 22.9, p = 0.001), and 51.2% of PCI cases at baseline had normal MoCA scores at 1y. Cognitive decline was most frequent in the ADT group (9.3% vs. 3.6%, p = 0.034), although the aOR was 2.44 (95%CI:0.89-6.71). The 1yr cumulative incidence of PCI was 10.4% (95%CI:6.2%-16.2%) in the ADT-group and 2.8% (95%CI:0.8-%-7.1%) in the non-ADT group [aOR=3.15 (95%CI:0.97-10.25)].

Conclusions

ADT was associated with a decrease in the cognitive performance of PCa patients during the 1st year after diagnosis. The completion of the 1y-evaluation in the whole cohort (n = 600) is needed to confirm these preliminary results.

Funding

POCI-01-0145FEDER-032358;PTDC/SAU-EPI/32358/2017; UIDB/4750/2020;SFRH/BD/119390/2016

Key messages

Half of the cases with cognitive impairment at baseline improved at one-year. Patients treated with ADT seem to be affected by cognitive decline more frequently.

New foundational therapy in heart failure with reduced ejection fraction: should we keep following the 2016 European Society of Cardiology Heart Failure Guideline in 2021?

Introduction

The 2016 European Society of Cardiology Heart Failure Guidelines (2016 HF GL) suggest sequential therapy initiation with angiotensinogen converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), beta-blocker (BB) and mineralocorticoid receptor antagonist (MRA) for patients with heart failure with reduced ejection fraction (HFrEF). Since their publication, major trials established the benefit of sacubitril/valsartan (ARNi) and SGLT2 in HFrEF, and ARNi are suggested to replace ACEi/ARB as first line therapy. So, with HFrEF foundational therapy evolvement, the 2016 HF GL sequential therapy initiation algorithm has been raised into question.

Purpose

To compare in the real-world practice, the effect on all-cause mortality of the simultaneous use of every pharmacological class currently included in the HFrEF foundational therapy with conventional sequential therapy.

Methods

A population of consecutive patients (pts) included in a post-discharge structured follow-up programin in a tertiary center was analyzed. Two groups were defined: 1) patients medicated with all pharmacological classes considered the HFrEF foundational therapy (ARNi, BB, MRA and SGLT2 inhibitor), independently of the dosages – “FT group”; 2) patients medicated with ACEi/ARB, BB and MRA on maximal tolerated doses – “2016 HF GL group”. Pts under other therapeutical combinations were excluded. The study groups were compared with Chi-square and Mann-Whitney tests. Impact on all-cause mortality was established with Kaplan-Meier survival analysis and multivariate Cox regression after adjustment for age, sex and baseline creatinine, NYHA functional class and LVEF.

Results

From 2016 to February 2021, a total of 101 pts with HFrEF were included and followed for 25±16 months. 54 pts were included in the FT group and 47 in the 2016 HF GL. The study population (69.3% males, 64.6±11.4 years) were mainly in NYHA functional class II (48%) and III (48%). The most common HF aethiologies were ischemic heart disease (49.5%) and dilated cardiomyopathy (30.7%), median LVEF was 26% and 22% were under CRT. Baseline characteristics were similar between groups, except for diabetes (more common in FT group, 70 vs 22%, p<0.001). All-cause mortality rate during follow-up was significantly different between two groups: 1.9% in FT group and 17% in the HF GL group (p: 0.047) – Figure 1. The implementation of all foundational therapy classes was an independent protective factor for all-cause mortality (HR 0.41; IQR 0.004–0.468; P: 0.010) in multivariate Cox regression.

Conclusion

This real-world study suggests that conventional sequential therapy suggested by the 2016 HF GL may be less effective on reducing all-cause mortality in HFrEF than simultaneous use of all pharmacological classes that nowadays compose the foundation therapy. These results support the hypothesis of promoting early introduction of all therapy classes followed by a tailored uptitration may be beneficial.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Tree–Crop Ecological and Physiological Interactions Within Climate Change Contexts: A Mini-Review

The effects of climate change are increasingly noticed worldwide, and crops are likely to be impacted in direct and indirect ways. Thus, it is urgent to adopt pliable strategies to reduce and/or mitigate possible adverse effects to meet the growing demand for sustainable and resilient food production. Monoculture cropping is globally the most common production system. However, adaptation to ongoing climate change, namely, to more extreme environmental conditions, has renewed the interest in other practices such as agroforestry, agroecology, and permaculture. This article provides an overview of ecological and physiological interactions between trees and crops in Mediterranean agroforestry systems and compares them with those from monocultures. The advantages and disadvantages of both systems are explored. The added value of modeling in understanding the complexity of interactions within agroforestry systems, supporting decision-making under current and future weather conditions, is also pinpointed. Several interactions between trees and crops might occur in agroforestry systems, leading to mutual positive and/or negative effects on growth, physiology, and yield. In this sense, selecting the most suitable combination of tree/crop species in mixtures may be best be indicated by complementary traits, which are crucial to maximizing trade-offs, improving productivity, ecosystem services, and environmental sustainability.

Role of myeloid cell leptin signaling in the regulation of glucose metabolism

Although innate immunity is linked to metabolic health, the effect of leptin signaling in cells from the innate immune system on glucose homeostasis has not been thoroughly investigated. We generated two mouse models using Cre-lox methodology to determine the effect of myeloid cell-specific leptin receptor (Lepr) reconstitution and Lepr knockdown on in vivo glucose metabolism. Male mice with myeloid cell-specific Lepr reconstitution (Lyz2Cre⁺Lepr^loxTB/loxTB) had better glycemic control as they aged compared to male mice with whole-body transcriptional blockade of Lepr (Lyz2Cre⁻Lepr^loxTB/loxTB). In contrast, Lyz2Cre⁺Lepr^loxTB/loxTB females only had a trend for diminished hyperglycemia after a prolonged fast. During glucose tolerance tests, Lyz2Cre⁺Lepr^loxTB/loxTB males had a mildly improved plasma glucose profile compared to Cre⁻ controls while Lyz2Cre⁺Lepr^loxTB/loxTB females had a similar glucose excursion to their Cre⁻ controls. Myeloid cell-specific Lepr knockdown (Lyz2Cre⁺Lepr^flox/flox) did not significantly alter body weight, blood glucose, insulin sensitivity, or glucose tolerance in males or females. Expression of the cytokine interleukin 10 (anti-inflammatory) tended to be higher in adipose tissue of male Lyz2Cre⁺Lepr^loxTB/loxTB mice (p = 0.0774) while interleukin 6 (pro-inflammatory) was lower in male Lyz2Cre⁺Lepr^flox/flox mice (p < 0.05) vs. their respective controls. In conclusion, reconstitution of Lepr in cells of myeloid lineage has beneficial effects on glucose metabolism in male mice.

4-Phenylbutyric acid improves free fatty acid-induced hepatic insulin resistance in vivo

Plasma free fatty acids (FFAs) are elevated in obesity and can induce insulin resistance via endoplasmic reticulum (ER) stress. However, it is unknown whether hepatic insulin resistance caused by the elevation of plasma FFAs is alleviated by chemical chaperones. Rats received one of the following i.v. treatments for 48 h: saline, intralipid plus heparin (IH), IH plus the chemical chaperone 4-phenylbutyric acid (PBA), or PBA alone and a hyperinsulinemic-euglycemic clamp was performed during the last 2 h. PBA co-infusion normalized IH-induced peripheral insulin resistance, similar to our previous findings with an antioxidant and an IκBα kinase β (IKKβ) inhibitor. Different from our previous results with the antioxidant and IKKβ inhibitor, PBA also improved IH-induced hepatic insulin resistance in parallel with activation of Akt. Unexpectedly, IH did not induce markers of ER stress in the liver, but PBA prevented IH-induced elevation of phosphorylated eukaryotic initiation factor-2α protein in adipose tissue. PBA tended to decrease circulating fetuin-A and significantly increased circulating fibroblast growth factor 21 (FGF21) without affecting markers of activation of hepatic protein kinase C-δ or p38 mitogen-activated protein kinase that we have previously involved in hepatic insulin resistance in this model. In conclusion: (i) PBA prevented hepatic insulin resistance caused by prolonged plasma FFA elevation without affecting hepatic ER stress markers; (ii) the PBA effect is likely due to increased FGF21 and/or decreased fetuin-A, which directly signal to upregulate Akt activation.

Wells and Geneva decision rules to predict pulmonary embolism: can we use them in Covid-19 patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA. 

Purpose

 To evaluate the accuracy of the Wells and Geneva scores to predict PE in patients with SARS-COV2 infection.

Methods

 Retrospective study of consecutive outpatients with SARS-COV2 infection proved by positive PCR who underwent CTPA due to suspected PE. The Wells and Geneva scores were calculated and the area under the curve (AUC) of the receiver operating characteristic curve was measured.

Results

 We enrolled 235 patients (61% males, mean age 69.10 ± 16.69 years) and the incidence of pulmonary embolism was 15% (35 patients). In patients with PE, emboli were located mainly in segmental arteries (60%) and bilaterally (46%). Patients with PE were older (mean age 75.06 ± 2.23 vs. 68.06 ± 1.21 years, p = 0.022), and did not differ in sex or risk factors for thromboembolic diseases from the non-PE group. Patients with PE had higher D-dimer levels (median 15.41 mg/dl, IQR 1.17 – 20.00) compared to patients without PE (median 5.99 mg/dl, IQR 0.47 – 2.82, p &lt; 0.001).

 There was no statically significant difference between the average Wells score in patients with PE and without PE (1.04 and 0.89 respectively, p = 0.733) and the AUC demonstrated that the Wells score had no discriminatory power (AUC = 0.52). Within patients with PE, 19 patients had a Wells score of zero. Regarding the Geneva score, there was also no difference between the average score in patients with and without PE (4.20 vs 3.93 respectively, p = 0.420). AUC for Geneva score was 0.54.

Clinical probability combined with D-dimer measurement had a 100% sensitivity for both Wells and Geneva scores, but a specificity of 10% and 11%, respectively. 

Conclusion

 PE diagnosis may be challenging in patients with SARS-COV2 infection since both conditions may have similar signs and symptoms and may be associated with increased D-dimers. According to our results, traditional clinical prediction scores have little discriminatory power in these patients and a higher D-dimer cut-off should be considered to better select patients for CTPA to minimize radiation exposure and contrast-related complications in COVID-19 patients.

[Radiological and functional results in high-energy tibial plate fractures]

INTRODUCTION

The tibial plateau fractures due to high-energy mechanisms are serious injuries that occur on a load bearing joint. These are difficult to approach because, also affect the bone structure of the leg, they usually have associated soft tissue injuries.

OBJECTIVE

To evaluate the radiological and functional results of high-energy tibial plateau fractures with a minimum follow-up of one year.

MATERIAL AND METHODS

Retrospective, observational and multicenter study. Analysis of radiological and functional outcomes in the treatment of high-energy tibial plateau fractures, treated by open reduction and internal fixation (ORIF) between 2014 and 2019.

RESULTS

54 fractures treated by ORIF. Follow-up one year. 98.1% consolidation in 13 weeks on average. 83.4% without alterations of the axis in the coronal plane. 74% without postoperative joint widening. Functional scores: Lysholm 82.1 average points and Oxford Knee Score (OKS) 39.5 average points.

CONCLUSION

The joint range of motion was reduced after a high-energy tibial plateau fracture, but with good functional results. The less off axis and less post-operative radiographic widening, the better results are obtained.

Anesthetic considerations in a laboring woman with systemic mastocytosis

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Early discharge after cryoablation procedure: is it safe?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To access the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive pts admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four pts were included, with a mean age of 61 ± 10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 (IQ 178 – 729) days. Most of the pts had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two pts (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p = NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of pts with early discharge and in 8.7% of pts in overnight stay, without statistical significance between the two groups (p = 0.61). The most frequent complications were local hematoma (5 pts, 2 in early discharged group), pericardial effusion (3 pts, all in overnight stay), femoral pseudo-aneurism (2 pts, 1 in each group) and arteriovenous fistula (1 pt in overnight stay group). The type of complications did not differ between the two groups (p = 0.51). Two pts died during the follow up, unrelated with the procedure.

In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups. (p = NS)

Conclusion

Our study suggests that is safe to early discharge pts submitted to AF ablation, reducing the hospital stay length in selected pts. Larger studies are needed to confirm this data before routine implementation of this strategy.

Direct and indirect control of hepatic glucose production by insulin

There is general agreement that the acute suppression of hepatic glucose production by insulin is mediated by both a direct and an indirect effect on the liver. There is, however, no consensus regarding the relative magnitude of these effects under physiological conditions. Extensive research over the past three decades in humans and animal models has provided discordant results between these two modes of insulin action. Here, we review the field to make the case that physiologically direct hepatic insulin action dominates acute suppression of glucose production, but that there is also a delayed, second order regulation of this process via extrahepatic effects. We further provide our views regarding the timing, dominance, and physiological relevance of these effects and discuss novel concepts regarding insulin regulation of adipose tissue fatty acid metabolism and central nervous system (CNS) signaling to the liver, as regulators of insulin's extrahepatic effects on glucose production.

“This is not a doctors thing, it is witchcraft” - A case report of acute psychosis concomitant to primary hyperparathyroidism

Introduction

Primary hyperparathyroidism (PHPT), usually caused by a parathyroid adenoma, is characterized by a pathologically high secretion of parathyroid hormone and consequent hypercalcemia. PHPT has a high prevalence among elderly patients and might be responsible for neuropsychiatric symptoms.

Objectives

We aim to report the rare manifestation of acute psychosis accompanying a PHPT diagnosis, and to discuss the neurobiological relationship between hyperparathyroidism, hypercalcaemia and neuropsychiatric symptoms.

Methods

We present a clinical case based on patient’s history and clinical data, along with a literature review on PHPT neuropsychiatric symptons.

Results

We present the case of a 68-year-old man diagnosed with PHPT in November 2019. He was brought up to psychiatric evaluation for the first time in May 2020 upon behavioral changes (aggressiveness and bizarre rituals). The patient described the sensation of burns scattered throughout the body since January 2020, felling anxious and frightened, sleeping poorly and progressive social isolation. He presented delusional ideas of mystical and paranoid content. No significant cognitive impairments were found. The patient’s psychosis was partially responsive to atypical antipsychotics. He’s waiting for surgery. Hypercalcaemia might manifest as mood disorders, cognitive changes and rarely as acute psychosis. Although there is not yet a clear mechanism to explain it, high calcium levels seem to cause neurotoxicity and neurotransmission dysfunction. Restoration of normal calcium levels tend to resolve neuropsychiatric symptoms, but in PHPT parathyroidectomy is usually recommended.

Conclusions

Neuropsychiatric symptoms are responsible for great disability, and demand an organic in-depth investigation. A multidisciplinary team approach must always be considered in the management of such conditions.

Clinical case of animal hoarding – characterization and management of a new disorder

Introduction

Animal hoarding is characterized by hoarding of a large number of animals without providing minimum conditions of nutrition and sanitation, accompanied by lack of insight for the behavior and by social isolation. Despite studies detecting an increasing incidence, the behavior is still poorly understood.

Objectives

To review clinical evidence on animal hoarding and to report a clinical case.

Methods

We report a clinical case based on patient’s history and clinical data, along with a review of the literature on animal hoarding. The terms “Noah syndrome” and “animal hoarding disorder” were searched on PubMed® database.

Results

We present the case of a 51-years-old woman, living alone, with higher education. His first contact with psychiatry was in August 2019 upon aggravated self-neglect and behavioral disorganization. She was living with around 40 cats, her home was extremely deteriorated. In December 2019 she was admitted to a psychiatric unit. A schizophrenia diagnosis was established and pharmacological treatment was initiated. She was discharged to a chronic psychiatric institution. Studies found out that animal hoarders are typically middle age/older women living alone in squalid conditions. Animal hoarding is characterized by a chronic course and intense emotional attachment to animals. It seems to be associated with traumatic situations, as well as mental disorders such as schizophrenia or dementia. Published data on intervention and treatment is still limited.

Conclusions

Animal hoarding phenomenon requires further investigation, regarding developmental risk factors and co-morbid mental disorders. Comprehensive approaches to clinical intervention and management strategies in animal hoarding are necessary.

Prolonged length of stay in acute psychiatric wards: A descriptive study

Introduction

The psychiatric care paradigm has shifted towards community-centered models. Yet, prolonged hospitalizations are still a reality, with debated impact at healthcare systems and patients.

Objectives

This work aims to describe prolonged hospitalizations in acute psychiatric wards through patients’ sociodemographic and clinical data.

Methods

We analyzed a national hospitalization database that contained all hospitalization episodes registered in Portuguese public hospitals from 2008 to 2015. All episodes with a primary diagnosis of mental disorder defined as ICD-9-CM codes 290.x-319.x were included. Prolonged hospitalizations were defined as having a LoS ≥ P97.5; LOS ≥180 days or LOS ≥1 year. Age, sex, lengh of stay, in-hospital mortality were analysed.

Results

The LoS ≥ P97.5(≥62 days) group comprised 3911 hospitalizations (2.3% of all psychiatric hospitalizations) and 1755 patients. The median LOS was 81 days and the mean age was 51 years. Sex was equally distributed, though a higher frequency of male patients was found on the ≥180 days (n=364) and ≥ 1 year (n=121) groups. Psychotic disorders were the main diagnosis at discharge (n= 1769, 45.2%), followed by mood disorders (n=1057, 27.0%) and dementia (n=451, 11.5%). In-hospital mortality increased in the higher LoS groups (1.1%; 4.4%; 9.1%, respectively).

Conclusions

Overall, middle aged patients with psychotic disorders represent most of the prolonged hospitalizations occurring in acute psychiatric wards. Community-based programs require further development to meet the existing needs.

Disclosure

No significant relationships.