Filiation delusion: A rare presentation

Introduction

The filliation delusion was first described in 1950 by Ey as a false belief about belonging to a family group other than one’s own. Since then, 70 years have passed and litterature is still scarce on this type of presentation.

Objectives

Using a case report as a starting point, the aim of this article is to review data on the various frameworks of delusional development, while discussing in what capacity social cognition impairment, theory of mind and overall lack of insight, typical in schizophrenic patients, could be related to this type of delusion.

Methods

The authors present a case report of an episode of a filliation delusion in a patient with chronic schizophrenia. A search on PubMed and ClinicalKey was performed, from which the relevant publications were selected and reviewed.

Results

The case referes to a 64 year old woman previously diagnosed with schizophrenia who developed, over the period of two years, a filliation delusion. The patient believed having been born in Russia and being subsequently adopted by different families. There was history of irregular attendance to consultations and non-compliance to treatment.

Conclusions

There is still lack of proper investigation regarding the development of delusions in schizophrenic patients. Social cognition and insight are important predictors of functioning, and might behave as a marker of liability to psychosis. This should have strong implications in these patients’ treatment approaches. The lack of consensual measurement instruments make it difficult to draw solid conclusions, and this should be the main focus moving forward.

Psychiatric disorders during acute hospital treatment of COVID-19 - a case series

Introduction

Coronavirus disease (COVID-19) has been associated with the development mental and behavioural symptoms and psychiatric disorders. This association is stronger in severe cases of the disease and in those needing inpatient treatment, particularly in intensive care units (ICU).

Objectives

To determine the incidence of psychiatric disorders in a Portuguese hospital-based sample of patients with COVID-19. To describe relevant demographic and clinical data.

Methods

We reviewed all COVID-19 inpatients assessed by liaison psychiatry at our hospital between April and September 2020. Patients admitted due to a psychiatric disorder were excluded from the analysis. We reviewed medical records and retrieved relevant clinical data. ICD-10 was used to classify diagnoses.

Results

We identified 36 cases with a mean age of 62.64 years-old (SD 19.23). The most common disorder was delirium, which occurred in 41.7% of our sample (15 patients), followed by adjustment disorder (22.2%, n=8), and depressive episode (16.7%, n=8). Most patients had no personal (61.1%, n=22) nor family (75%, n=27) history of a psychiatric disorder. Mean length of admission was 36.89 days (SD 28.91). Seventeen cases (47.22%) had at least one risk factor for severe COVID-19 disease and 14 (38.89%) were admitted at some point to the ICU.

Conclusions

In our sample, delirium was the main cause for mental or behavioural symptoms in COVID-19 patients. However, we observed a wide array of presentations in our center. A larger sample would allow to better characterize this often-overlooked symptoms and identify risk factors to psychiatric syndromes.

Disclosure

No significant relationships.

Catatonia induced by abrupt discontinuation of clozapine - case report

Introduction

Catatonia is characterized by a bizarre and severe psychomotor change. According to DSM-5, the presence of three or more symptoms is necessary to affirm the diagnosis: stupor, catalepsy, brain flexibility, mutism, negativism, posturing, mannerisms, stereotypes, agitation not influenced by external stimuli, grimaces, echolalia or echopraxia. The association between first- and second-generation antipsychotics (AP) and the onset of catatonia is well established in the literature. In contrast, clozapine is one of the second-generation APs that is recognized for its effectiveness in treating catatonia, rather than inducing it. However, it has been documented that abrupt discontinuation of clozapine can induce rapid clinical deterioration with multiple presentations including: psychoses, cholinergic rebound states, serotonergic syndromes and catatonia.

Objectives

Review the literature on catatonia associated with abrupt interruption of clozapine. Describe a clinical case.

Methods

Observation of the patient and consultation the clinical file. Non-systematic literature review on catatonia, clozapine, side effects associated with rapid discontinuation and respective treatment.

Results

34-year-old man, with the diagnosis of Schizoaffective Disorder. Admitted due to an acute decompensation with psychotic symptoms resistant to treatment requiring the introduction of clozapine. In the absence of a clinical response, clozapine was suspended, with the consequent appearance of catatonia resistant to benzodiazepines in high doses.

Conclusions

Its already well established that the abrupt discontinuation of clozapine can trigger catatonia. This clinical case and literature review suits to emphasize the importance of educating psychiatrists on the adverse effects of psychiatric drugs and, in this case, the cautious discontinuation of clozapine in order to avoid its rebound effects.

Asymptomatic severe aortic stenosis: what is the current role of exercise stress test and NT-proBNP in patient risk stratification

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis (AS) is prevalent in the elderly population. When severe and the patient is symptomatic or left ventricular dysfunction arises, the prognosis deteriorates and valve replacement (AVR) is recommended. During the asymptomatic phase regular clinical evaluation is advised to detect early onset of symptoms and/or signs of myocardial maladaptation. Due to the inherent difficulties in the evaluation of symptoms, especially in the elderly, as well as the change in prognosis when symptoms appear (even if not perceived), it is crucial to evaluate the behavior of patients with effort and signs of myocardial injury.

Methods

An observational and retrospective study that included 74 patients followed at the Cardiology Service by severe AS (aortic valve area ≤ 1cm2 and/or aortic transvalvular mean gradient ≥40mmHg), who underwent exercise stress test (EST) and NT-proBNP evaluation for risk stratification. The outcome studied was hospitalization for heart failure (HF), or referral to SV, or death during the follow-up period. Independent predictors were obtained using multivariate Cox regression.

Results

Non-progression or decrease in systolic blood pressure (SBP) in EST is the only independent predictor of a short-term adverse event (p = 0.025). This parameter, NT-proBNP levels and interventricular septal thickness (IVS) were independent predictors of a medium (two (p = 0.025; p = 0.014; p = <0.001), three (p = 0.015; p = 0.007; p = 0.001) and four years (p = 0.007; p = 0.049; p = 0.005)) and a long term adverse event (p = 0.006; p = 0.028; p = 0.005).

Conclusion

In asymptomatic patients with severe AS, no progression or decrease in SBP in EST, increased NT-proBNP levels and thickness of IVS were independent predictors of hospitalization for HF, need for VS or death in short, medium and long term.

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients.

Aim

To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI.

Methods

From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year.

Results

The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029].

Conclusion

We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts.

Funding Acknowledgement

Type of funding source: None

What is the prognosis for patients who develop new-onset atrial fibrillation in the first 48 hours after an acute coronary syndrome?

 

Atrial fibrillation (AF) is a common complication in acute coronary syndrome (ACS). However, treating patients (pts) with new-onset AF (NOAF) after an ACS remains a challenge. Although it seems intuitive that pts who develop AF within the first 48h have increased morbidity and mortality, your prognosis is unclear because there are no robust studies in the literature to confirm this association.

Aim

To characterize the population of pts who developed NOAF in the first 48 hours after an ACS and to compare the prognosis between these pts and pts who didn't develop AF.

Methods

2916 ACS pts admitted consecutively in our coronary care unit during 6 years were analyzed retrospectively. Of these pts, 343 (11.7%) had AF within the first 48h, of which 99 (3.4%) had pre-existing AF and 243 (8.3%) presented NOAF. Pts were divided into two groups: group 1 -ACS pts who developed NOAF in the first 48h (n=243; 8.8%); group 2 – ACS pts who did not develop AF (n=2517; 91.2%). Pts with pre-existing AF were excluded (n=156; 5.4%). Primary endpoint were the occurrence of death at 6 months; follow-up was completed in 95.8% of pts.

Results

Group 1 pts were older (72±12 vs 62±13, p<0.001), with higher proportion of women (30,9% vs 20,9%, p<0.001), hypertensive (78,5% vs 60,7%, p<0.001), smokers (17,4% vs 32,6%, p<0.001), previous CABG (7,9% vs 3,8%, p=0.06) and stroke (10,7% vs 6,8%, p=0.035). Group 1 had a higher proportion of STEMI pts (58,5% vs 46,5%, p<0.001) and, during hospitalization, had more often respiratory infection (p<0.001), malignant arrhythmias (p<0.001), heart failure (p<0.001), stroke (p=0.001), higher values of NT-proBNP (p<0.001) increased C-reactive protein levels (p<0.001), leukocytes (p=0.020), peak of TropI (p=0.029) and creatinine (p<0.001). On echocardiography, group1 had greater LA diameter (45±6 VS 41±5mm, p<0.001), more frequent significant mitral regurgitation (13,9% vs 2,9%, p<0.001), worst LVEF (41±10% vs 46±10%, p<0.001) and a higher value of pulmonary artery pressure (39±12 vs 24±10, p<0.001). Group 1 were less likely to have undergone coronary revascularization (84% vs 74%, p=0.005). In multivariate analysis, age ≥75 (OR 1.05, p<0.001), LVEF ≤40% (OR 2.50, p<0.001), LA diameter (OR 1.59, p=0.027), more significant mitral regurgitation (OR 2.49, p=0.001) and Killip class >1 (OR 1.51, p=0.015) remained independent predictors of NOAF. In multivariate analysis and after adjusting for different baseline characteristics, pts with NOAF have the same risk of 6-months mortality compared to those who didn't develop AF [OR 1.03, p=0.91].

Conclusion

The incidence of NOAF was 8.8% in our population, which is similar to the literature. Age, LVEF, LA diameter, a significant mitral regurgitation and Killip class >1 were independent predictors of NOAF after ACS. Pts with NOAF in the first 48h after an ACS had worse clinical manifestations during hospitalization but no higher 6-months mortality risk.

Funding Acknowledgement

Type of funding source: None

Level of literacy and clinical outcomes in patients with Chagas disease: SaMi-Trop project

Background

Chagas disease (CD) is a neglected tropical disease that affects mainly vulnerable population, whose majority has low ability to understand health information. This study aimed to assess the prevalence of health literacy (HL) and its association with sociodemographic, quality of life, health care aspects and worse clinical outcomes.

Methods

This is a cross-sectional study developed inside a cohort study (SaMi-Trop) including 1959 patients. It has been conducted in an endemic region to CD in Brazil. The eligible criteria for HL evaluation was the ability to read. The HL was assessed with SALPHA-18 scale and literacy was categorized in inadequate HL; adequate HL and; illiterate. Multiple models were adjusted using binary logistic regression, multinomial and beta regression models using the gamlss framework.

Results

Of the patients included, 1136 (74.1%) are illiterate. For HL assessment, only 397 managed to complete the HL evaluation. The prevalence of inadequate HL was 85.1% (338), only 59 patients (14.9%) had adequate HL. Our results are as following: 1) being illiterate increases the chance of using more drugs when compared to individuals with adequate HL - 1 or 2 drugs (OR: 1.96; CI: 1.06-3.62) and 3 to 4 medications (OR: 3.06; CI:1.44-6.52), to have hypertension (OR: 2.24; CI: 1.29-3.90), report an average self-perceived health (OR: 2.97; IC: 1.63-5.42) and report poor self-perceived health (OR: 3.67; CI: 1.71-7.89); 2) inadequate literacy increases the chance of using 3 to 4 medications (OR: 2.26; CI: 1.04-4.93) and report an average self-perceived health (OR: 2.48; CI: 1.34-4.62); 3) Illiterate patients present worst quality of life scores in Physical (OR: 0,730; CI: 0,583-0,914), Psychological (OR: 0,671; CI: 0,544-0,828) and Environmental (OR: 0,727; CI: 0,601-0,880) domains.

Conclusions

We found a high prevalence of inadequate HL; it was associated with worse clinical outcomes and poor self-perceived health.

Key messages

Our findings reinforce the importance of improving health communication in CD patients seeking to avoid unfavorable outcomes. A high prevalence of inadequate health literacy was observed in our study, which can impact the self-care ability of patients with CD.

Govern of conducts, risk and homeless care in Brazil: Reflections

In this study, inspired by governmental studies on Foucault, Nikolas Rose, Deborah Lupton and Mitchell Dean, we develop considerations about the ways through which the concept of risk has been operating within the homeless health care that live in some metropolitan areas of Brazil. In this paper, we discuss risk us as a moral and political technology that produces patterns to experience and to analyze reality.: Risk as a technology that has an important role in governing conducts and production of subjectivity. We argue that whilst health policy determines healthy ways of life, its effect can contribute to active surveillance (by the health care experts and by the homeless persons) that stigmatizes and divide society around the concept o 'normality' informed, between others, by epidemiological 'evidence'. Albeit the risks associated with risk-based technologies to build up a surveillance net and standardization that reinforces submissive ways of life, we find out on our ethnographic study within the services - named 'Street Surgery'- that offers transdisciplinary healthcare for people living in the streets of Campinas, Brazil, that those technologies strikes itself continuously with practices of counter-conducts by the homeless that resist the normalization of their lives and point out to other ways of producing life and care. Others ways that, is important to say, have been very influential to change the medical and other professional experts practices of the 'Street Surgery' of Campinas and had been very important to academic researchers that have been questioning hegemonic discourses, arrangements and practices of care on the Primary Health System.

Key messages

Risk-based approach to health can lead to the reinforcement of submissive ways of life, incompatible with a broader concept of health. For the development of a compromised and humanized care, it's important to take into consideration the.

Determinantes individuais e organizacionais na percepção de indisciplina em sala de aula. Um estudo transcultural

A indisciplina nas escolas e os comportamentos desafiadores dos alunos constituem uma das principais preocupações dos professores, administradores e pais. Esta investigação visa comparar as percepções de indisciplina em salas de aula do ensino primário e secundário em estabelecimentos de ensino públicos e privados de Angola e Portugal. Participaram no estudo 1600 professores: 800 professores angolanos (493 homens e 307 mulheres) e 800 professores portugueses (181 homens e 619 mulheres). Os professores angolanos reportaram alguns tipos de comportamentos com maior frequência, como intervir fora de vez, agressão verbal, desrespeito ao professor, enquanto que os professores portugueses indicaram o comportamento de desatenção como o mais frequente. As percepções de indisciplina diferem também em função do tipo de escola, do género e experiência profissional. Considerando que Angola saiu recentemente de décadas de guerra, enfrenta problemas cujo impacto na disciplina nas salas de aula não é suficientemente conhecido. Pretende-se que este estudo seja inovador em Angola, e que possa assumir uma dimensão transcultural, nomeadamente através da comparação de algumas variáveis e tipos de indisciplina com países como Portugal.

Cross-cultural adaptation and validation of the VISA-A questionnaire for Portuguese-speaking (Portugal) patients with Achilles tendinopathy

Introduction Achilles tendinopathy is considered one of the most frequent injuries in individuals who practice regular physical activity, thus the existence of an instrument that allows the evaluation of the degree of severity of the lesion is important. The VISA-A was developed for English-speaking population to evaluate patients with this condition, and there is a need to adapt this tool to Portuguese (Portugal).

Objectives To cross-cultural adapt and validate the VISA-A questionnaire for Portuguese-speaking (Portugal) Achilles tendinopathy patients.

Methodology The VISA-A questionnaire was translated and cross-culturally adapted into Portuguese (VISA-A-Por) according to specific guidelines, using six steps: Translation, synthesis, back translation, expert committee review, pretesting (n = 10), and appraisal of the adaptation process. The resulting VISA-A-Por was then subjected to an analysis of the psychometric properties (construct validity, reproducibility [agreement and reliability], internal consistency and floor and ceiling effects) in 57 Achilles tendinopathy patients and 58 asymptomatic people. Participants completed the questionnaire at baseline and after a minimum interval of 48 hours.

Results The Visa-A-Por semantic and content validity was considered good by the expert committee and has construct validity shown by the differences between groups (p < 0,001). The questionnaire presented good internal consistency, with a Cronbach α of 0,88. Concerning reproducibility, agreement levels were considered optimal which can be verified in the Bland Altman graph, the standard error measurement (6,49) and the minimally important change (17,99 points), as well as the excellent ICC value (0,88). No ceiling-floor effect was found.

Conclusion The VISA-A-Por questionnaire has been shown to be equivalent to the original questionnaire, which indicates that it is a valid and reliable measure for the evaluation of the severity and functional impact of patellar tendinopathy in Portuguese-speaking (Portugal) patients.

Plectorhinchus macrolepis (Actinopterygii: Haemulidae) in the western Atlantic Ocean

Morphometric measurements, meristic counts and DNA barcoding identified the presence of a biglip grunt Plectorhinchus macrolepis in the western Atlantic Ocean. As the species is endemic to the tropical eastern Atlantic Ocean and has not previously been reported in the western Atlantic Ocean, we discuss the possible means by which it might have dispersed to the western Atlantic Ocean. Even though this species is not considered established in Paranaguá Bay, we advocate monitoring of possible new individuals and other exotic fish species.

Prevalência de estomias de eliminação em uma microrregião do norte de Minas Gerais

Objetivos: Estimar a prevalência de pessoas com estomia de eliminação e caracterizá-las quanto aos aspectos sociodemográficos e clínicos. Método: Estudo transversal descritivo com amostra de 27 pacientes com estomias de eliminação, residentes em uma microrregião do norte de Minas Gerais, que atenderam aos critérios de inclusão. Os dados coletados foram registrados em instrumento utilizado em estudos anteriores e analisados por meio de estatística descritiva. Estudo aprovado pelo Comitê de Ética. Resultados: A prevalência de pessoas com estomia foi de 2,16/10.000, a amostra continha 55,6% de homens, 40,7% eram casados, com média de idade de 59,1 anos, 59,2,% eram alfabetizados e 74,0% tinham baixa renda; 59,3% das estomias decorreram de câncer, sendo mais frequentes os de cólon e reto, 70,4% das estomias eram definitivas e 74,0% eram colostomias. Dermatite foi a principal complicação e 68,2% dos pacientes apresentavam efluente de consistência pastosa e realizavam autocuidado. Conclusão: A prevalência de pessoas com estomia foi semelhante à de outros municípios de Minas Gerais e abaixo do esperado pelas Associações Nacional e Internacional de Ostomizados. A caracterização das pessoas, das estomias e do manejo destas contribuirá para que profissionais de saúde e gestores revisem os protocolos de assistência utilizados na microrregião estudada.

Prevalence of elimination stomas in a microregion in the north of Minas Gerais

Objectives: To estimate the prevalence of people with elimination stoma and to characterize them for sociodemographic and clinical aspects. Method: A descriptive cross-sectional study with a sample of 27 patients with elimination stomas residing in a microregion in the north of Minas Gerais, who met the inclusion criteria. The data collected were recorded in an instrument used in previous studies and analyzed using descriptive statistics. Study approved by the Ethics Committee. Results: The prevalence of people with stoma was 2.16/10.000, the sample contained 55.6% of men, 40.7% were married, mean age 59.1 years, 59.2% were literate and 74.0% had low income; 59.3% of the stomas were cancerous, more frequent colon and rectum tumours, 70.4% of the stomas were definitive, and 74.0% were colostomies. Dermatitis was the main complication and 68.2% of the patients presented effluent of pasty consistency and performed self-care. Conclusion: The prevalence of people with stoma was like that of other municipalities in Minas Gerais and below that expected by the National and International Ostomized Associations. The characterization of the people, of the stomas and the management of these, will contribute for health professionals and managers to review the assistance protocols used in the studied microregion.