Brain activation by a VR-based motor imagery and observation task: An fMRI study

Training motor imagery (MI) and motor observation (MO) tasks is being intensively exploited to promote brain plasticity in the context of post-stroke rehabilitation strategies. This may benefit from the use of closed-loop neurofeedback, embedded in brain-computer interfaces (BCI's) to provide an alternative non-muscular channel, which may be further augmented through embodied feedback delivered through virtual reality (VR). Here, we used functional magnetic resonance imaging (fMRI) in a group of healthy adults to map brain activation elicited by an ecologically-valid task based on a VR-BCI paradigm called NeuRow, whereby participants perform MI of rowing with the left or right arm (i.e., MI), while observing the corresponding movement of the virtual arm of an avatar (i.e., MO), on the same side, in a first-person perspective. We found that this MI-MO task elicited stronger brain activation when compared with a conventional MI-only task based on the Graz BCI paradigm, as well as to an overt motor execution task. It recruited large portions of the parietal and occipital cortices in addition to the somatomotor and premotor cortices, including the mirror neuron system (MNS), associated with action observation, as well as visual areas related with visual attention and motion processing. Overall, our findings suggest that the virtual representation of the arms in an ecologically-valid MI-MO task engage the brain beyond conventional MI tasks, which we propose could be explored for more effective neurorehabilitation protocols.

Factors influencing kidney transplantation rates: a study from the ERA Registry

BACKGROUND

Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade.

METHODS

KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010.

RESULTS

Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system.

CONCLUSIONS

In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.

Electrocardiography: an usefull tool for prediction of the diagnosis and severity of pulmonary embolism

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary embolism (PE) is associated with morbidity and mortality. Immediate recognition of this condition is critical to commencement of early and appropriate therapy which could be lifesaving. Particularly in patients with suspected PE in which computed tomography pulmonary angiography (CTPA) is not promptly available or is contra-indicated, an electrocardiographic (ECG) score could serve as a ubiquitously available test to raise suspicion of PE. This study aimed to evaluate the diagnostic value of an ECG score for PE diagnosis.

Methods

Retrospective study of consecutive patients who performed CTPA in Emergency Department due to PE suspicion. All ECG were scored according to the previous published Daniel’s ECG score, by an investigator blinded for the CTPA result.

Results

The most common ECG findings in patients with PE were incomplete right-brand bock (48%), T wave inversion in DIII (48%), sinus tachycardia (41%) and Q wave in DII (31%). The S1Q3T3 sign was documented in 20% of patients.

The ECG score was significantly higher in patients with PE compared to those without PE (5.06 vs 3.70, p=0.005). ECG score showed moderate accuracy to detect PE (AUC: 0.60; 95%CI: 0.53-0.67; p=0.004), but it is of a particular value because of very high specificity: an ECG score > 12 identified PE with a specificity of 96% (95% CI 91.93 – 98.38).

The ECG score significantly increased the diagnostic accuracy of the diagnostic algorithm based on pretest clinical probability evaluated by Wells score combined with D-Dimer measurement (Wells & DD). In comparison to patients in which clinical pretest probability combined with D-dimer measurement considers PE excluded (Wells & ECG -), PE was 6.3 times more frequent in patients with Wells & DD +/ECG- (95% 2.7- 14.5) and 14.6 times more prevalent in the ones with Wells & DD +/ECG+ (95%CI: 4.1-51.3; p<0.001) – Figure 1.

Conclusion

In patients with clininal suspition of PE, na ECG score (Daniel’s score) >12 predicts PE with 96% specificity and could be used to increase the suspicion and define therapeutic strategy in patients in whom CTPA could not be immediately performed or is contra-indicated.

Modified CHA2DS2-VASc can predict mortality in COVID-19 patients admitted to the emergency department

Introduction

CHA2DS2-VASc score is used to determine the thromboembolic risk, but its prognostic value has been demonstrated in several cardiovascular (CV) diseases. Except for female gender, many CV risk factors comprising this score are recognized as risk factors for mortality in COVID-19. Cetinak G. et al demonstrated the ability of modified CHA2DS2-VASc (M-CHA2DS2-VASc) to predict mortality in COVID-19, which is based on changing gender criteria from female to male.

Purpose

To evaluate the prognostic value of a M-CHA2DS2-VASc score to predict pulmonary embolism (PE) and mortality in pts with COVID-19 admitted at the emergency department (ED).

Methods

Retrospective study of pts admitted to the ED between June 2020-January 2021, who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. Pts were stratified into 3 M-CHA2DS2-VASc risk groups: lower (0–1), intermediate (2–3) and high risk (≥4). Kruskal-Wallis and X-square test were used to compare score risk groups. Logistic regression was used to determine predictors of PE and mortality. ROC curve was performed to evaluate the discriminative power of the score.

Results

We included 300 pts: median age 71 years, 59% male. Hypertension (59%) chronic kidney disease (CKD, 33%), dyslipidemia (32%) and diabetes (28%) were the most common comorbidities. PE was diagnosed in 46 pts (15%). We found no difference in PE incidence according to M-CHA2DS2-VASc groups (p=0.531) and it showed no predictive value for PE (OR: 1.050, p=0.596). The AUC of M-CHA2DS2-VASc was 0.52, suggesting no discriminative power to predict PE.

Regarding mortality, M-CHA2DS2-VASc score was higher in non-survivors COVID-19 pts than in survivors [4 (IQR 3–5) vs 2 (1–4), respectively, p<0.001]. A multivariate logistic regression analysis was performed for mortality based on M-CHA2DS2-VASC, troponin, CKD and smoking history, and only M-CHA2DS2-VASc was identified as an independent predictor of mortality (OR: 1.406, p=0.007). Kaplan-Meier showed that M-CHA2DS2-VASc score was associated with mortality: the survival rate was 92%, 80% and 63% in the lower, intermediate and higher M-CHA2DS2VASc score risk group (logrank test p<0.001; Fig. A).

Most of the pts in the cohort were hospitalized (83%), but 21 pts (17%) discharged from the ED. Among these pts, 33% (n=17) had low risk, 37% (n=19) intermediate risk and 29% (n=15) high risk for mortality according to the M-CHA2DS2VASc score. The Kaplan-Meier individual survival analysis for hospitalized patients (Fig. B) and for those discharged from the ED (Fig. C) showed that M-CHA2DS2-VASc score had a good discriminative ability to predict short-term mortality for both groups (logrank test p<0.001 and p=0.007, respectively).

Conclusion

Considering the lack of validated scores to predict mortality in COVID-19 pts, the M-CHA2DS2-VASc might be a simple tool to predict short-term mortality in these pts, irrespectively of the need for hospitalization or not.

Funding Acknowledgement

Type of funding sources: None.

P–787 Impact of delaying ART to promote weight loss: a large multicentre study accounting for the combined effect of female/male age and body mass index (BMI)

Study question

Is postponing the start of ART (to promote a reduction in female BMI) beneficial for cumulative live birth rates (CLBR) when accounting for the female/male ageing this delay will cause?

Summary answer

Postponing ART treatment in one year to promote female weight loss could be detrimental in women of advanced maternal age (AMA, &gt;35 years-old).

What is known already

Overweight/obese couples are frequently encouraged to lose weight prior to infertility treatment to enhance ART outcomes. However, a meaningful weight loss is often difficult to achieve for these couples, frequently taking at least one year to accomplish. Given that both female and male ageing are also important for ART success, we were interested in understanding the combined impact on CLBR of BMI reduction and ageing following a one-year delay.

Study design, size, duration

A retrospective study including patients performing their first ART cycle using autologous gametes between 2013–2018 in one of 39 participating ART centres. Only GnRH antagonist cycles were included (n = 14260). CLBR was the primary outcome. Secondary outcomes included time-to-pregnancy, birthweight and gestational age.

Participants/materials, setting, methods

Patients were subdivided according to female BMI (Kg/m2) in either underweight (&lt;18.5), normal-weight (18.5–24.9), overweight (BMI 25.0–29.9 kg/m2) and obese (≥30 kg/m2). Meaningful and extreme weight loss were defined as a reduction from obesity to either overweight or normal-weight, respectively. We performed multivariable regression analysis to account for potential confounding.

Main results and the role of chance

Overweight (36.8%) and obese (33.0%) women had significantly lower CLBR when compared to the underweight (42.6%) and normal-weight (41.4%). When assessing the confounder-adjusted net-effect of male/female age and BMI, the predicted benefit of promoting a meaningful BMI reduction was lower than the estimated hindrance due to male/female ageing as soon as women reached AMA (n = 8365, 58.6%). This absence of benefit was especially important in women &gt;38 years-old, in which even extreme weight-loss did not compensate for the age-related reduction in CLBR caused by the one-year delay. Moreover, male weight-loss failed to provide any additional benefit when accounted for in the regression models. Finally, obesity was also associated with a modest but statistically significant one-month delay in time-to-pregnancy and a 96.1 g (95% confidence interval: 39.9–152.4) increase in birth weight. The diagram of predicted outcomes presented in this study may serve as a useful tool to counsel patients before treatment, namely when recommending treatment postponement to promote short-term (i.e. 3–6 months) or long-term (i.e. 1 year) weight loss.

Limitations, reasons for caution

Caution is recommended when extrapolating these results into everyday practice owing to the retrospective nature of the study and the fact that only GnRH antagonist cycles were included.

Wider implications of the findings: Patients are frequently confronted with the dilemma to either postpone treatment (and promote weight loss) or start treatment immediately (to avoid further ageing). Our results seem to show that women in AMA may have hindered CLBR if recommended to delay treatment even if the desired weight loss is ultimately achieved.

Trial registration number

Not applicable

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.

A pig slurry feast/famine feeding regime strategy to improve mesophilic anaerobic digestion efficiency and digestate hygienisation

The increasing concentration of livestock farms results in large amounts of waste production and the need for their management. The study of anaerobic digestion (AD) technology, under mesophilic conditions, applied to pig slurry is of the upmost importance for biogas recovery and sanitised digestate, contributing to a circular economy. The assessment of the effects of a feast/famine regime on biogas and biomethane (bio-CH₄) yield with different feeding frequencies was performed. The evaluation was made in regards to three scenarios: the first is based on daily feeding (FR1); in the second, the feeding occurs once every two days (FR2); and in the third, the feeding happens once every three days (FR3). The results demonstrate that the biogas and methane yield increased by 34% and 37% between FR1 and FR3. The stability inside the reactor was maintained since specific loading energetic rate values did not exceed the recommended limit (0.4 d^-1). It was also possible to conclude that the AD technology was efficient to sanitise the pig slurry, with the count of Escherichia coli going from 1 × 10⁵ colony-forming units (CFU) g^-1 to less than 100 CFU g^-1, meeting the legal requirements for agricultural valorisation. The total anaerobic mesophile plate counts were significantly (p < 0.1) reduced from feeding to digestate, and the plate counts of Clostridia were significantly (p < 0.05) increased, reflecting the changes in the composition of the microbiota. The increasing yield in bio-CH₄ in accordance with Clostridium counts suggests this genus as a positive microbiological key indicator of the AD performance.

The use of game modes to promote engagement and social involvement in multi-user serious games: a within-person randomized trial with stroke survivors

Background

Serious games are promising for stroke rehabilitation, with studies showing a positive impact on reducing motor and cognitive deficits. However, most of the evidence is in the context of single-user rehabilitation, and little is known concerning the impact in multi-user settings. This study evaluates the impact that different game modes can have on engagement and social involvement during a two-user game. Specifically, we want to understand the benefits of game modalities based on competition, co-activation, and collaboration and analyze the influence of different motor and cognitive deficits and personality traits.

Methods

We developed a two-player setup—using tangible objects and a large screen interactive table—for upper limb rehabilitation purposes. We implemented a game that, while keeping the same basic mechanics, can be played in the three different modes (Competitive, Co-active, and Collaborative). We ran a within-person randomized study with 21 stroke survivors that were paired and played the game in its three versions. We used the Game Experience Questionnaire—Core Module to assess engagement and the Social Presence Module to assess Social Involvement. For personality, motor, and cognitive function, users answered the International Personality Item Pool (short version), Fugl-Meyer Assessment—Upper Extremity, Modified Ashworth Scale, and Montreal Cognitive Assessment, respectively.

Results

The Collaborative mode promoted significantly more Behavioral Involvement. The Competitive mode promoted more Flow and Challenge than the Co-active mode with participants with better cognitive performance, with low extraversion, or with higher motor skills. Participants with higher cognitive deficits reported more Competence with the Co-active mode.

Conclusions

Our results indicate that, for multi-user motor rehabilitation settings, the collaborative mode is the more appropriate gaming approach to promote social involvement, showing a high potential for increasing adherence and effectiveness of therapy. Additionally, we show that a player's motor and cognitive ability and personality should be considered when designing personalized tasks for multiplayer settings.

Best approach in d-dimer algorithm to exclude pulmonary thromboembolism: a comparative study

Funding Acknowledgements

Type of funding sources: None.

Background

 Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal.

Purpose

 To compare sensitivity, specificity, and reduction in CTPA requests of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD.

Methods

 Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. 

In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if Ddimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers &gt;500µg/L or low probability and Ddimer &gt;1000 µg/L are selected for CTPA.

Results

We enrolled 409 patients and PE was confirmed by CTPA in 125 patients. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increased of specificity (p &lt; 0.001), correctly avoiding 29 CTPAs, without losing sensitivity. YEARS resulted in a marked increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity(p = 0.002). PEGeD had the worst sensitivity, associated with 11 more false negatives (FN) than the fixed cutoff. Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, YEARS had a significantly higher specificity (p &lt; 0.001) and allowed to correctly avoid a higher number of CTPA(55 vs 63), compared to the fixed cutoff. Results are summarized in table 1.

Conclusion

 Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA.

Sens(%) Spec(%) Correctly avoid CTPAs(n) FN(n) Fixed cutoff 95 29 85 6 Age-adjusted 93 40 114 9 YEARS 87 52 148 16 PEGeD 86 49 140 17

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Introduction

Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy.

Objective

To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting.

Methods

Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression.

Results

100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (&lt;40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures.

The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall.

In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046).

While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF &lt;40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI.

Conclusion

In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Oviposition behaviour of mated or unmated Cleruchoides noackae (Hymenoptera: Mymaridae)

Cleruchoides noackae (Hymenoptera: Mymaridae), native to Australia, is the most promising biological control agent for Thaumastocoris peregrinus (Hemiptera: Thaumastocoridae), an exotic Eucalyptus spp. pest in Brazil. The aim of this study was to determine the courtship behaviour, mating and oviposition of unmated or mated C. noackae females parasitizing T. peregrinus eggs utilizing the same rearing system used in biological control programmes in Brazil. The mating behaviour of eleven C. noackae unmated couples was observed and the time taken for males and females to find each other in polystyrene vials and the duration and number of copulations were recorded. Ten unmated or mated females were placed individually in vials with 10 T. peregrinus eggs each, and oviposition behaviour, percentage of eggs inserted and parasitized, viability and sex ratio of emerged C. noackae were recorded. This species lacked defined courtship behaviour and mated in less than an hour after adults' emergence. The time spent finding the first host, evaluating and inserting the ovipositor was similar for mated and unmated C. noackae females, as well as the frequency of inserted and parasitized eggs and their viability. Mated females took less time to find other host eggs and the sex ratio is female-biased. Occurrence of arrhenotokous parthenogenesis was confirmed. The ability of C. noackae to mate and lay eggs in less than one hour and parasitism of T. peregrinus eggs by females can improve the parasitoid mass rearing and biological control of T. peregrinus.

Acridomorpha (Orthoptera) species associated with the protected wetlands of Santa Luc&iacute;a, Montevideo, Uruguay

The diversity of Acridomorpha in protected areas of Uruguay has been little studied to date. In the protected wetlands of Humedales de Santa Luc&iacute;a in the Montevideo Department, we made monthly surveys from December 2012 to March 2013. Sampling was conducted with entomological nets and by hand. We collected 1216 individuals of 26 different species belonging to seven subfamilies. Gomphocerinae and Melanoplinae were the most abundant, accounting for 71% and 16% of the individuals respectively. The Shannon index showed a medium diversity, but the Berger-Parker dominance index and Pielou equitativity index indicate a slight dominance of the acridomorph community studied. This is probably because five species accounted for 87% of the individuals collected. Although our results are similar to previous studies of acridomorph communities in grasslands of the region, our study, the first of this kind for this ecosystem in Uruguay, will be important for the conservation of this protected area.

Level of understanding of Alzheimer disease among caregivers and the general population

INTRODUCTION

Understanding of Alzheimer disease (AD) is fundamental for early diagnosis and to reduce caregiver burden. The objective of this study is to evaluate the degree of understanding of AD among informal caregivers and different segments of the general population through the Alzheimer's Disease Knowledge Scale (ADKS).

PATIENTS AND METHODS

We assessed the knowledge of caregivers in different follow-up periods (less than one year, between 1 and 5 years, and over 5 years since diagnosis) and individuals from the general population. ADKS scores were grouped into different items: life impact, risk factors, symptoms, diagnosis, treatment, disease progression, and caregiving.

RESULTS

A total of 419 people (215 caregivers and 204 individuals from the general population) were included in the study. No significant differences were found between groups for overall ADKS score (19.1 vs 18.8, P = .9). There is a scarce knowledge of disease risk factors (49.3%) or the care needed (51.2%), while symptoms (78.6%) and course of the disease (77.2%) were the best understood aspects. Older caregiver age was correlated with worse ADKS scores overall and for life impact, symptoms, treatment, and disease progression (P < .05). Time since diagnosis improved caregivers' knowledge of AD symptoms (P = .00) and diagnosis (P = .05).

CONCLUSION

Assessing the degree of understanding of AD is essential to the development of health education strategies both in the general population and among caregivers.

Efficacy and Brain Imaging Correlates of an Immersive Motor Imagery BCI-Driven VR System for Upper Limb Motor Rehabilitation: A Clinical Case Report

To maximize brain plasticity after stroke, a plethora of rehabilitation strategies have been explored. These include the use of intensive motor training, motor-imagery (MI), and action-observation (AO). Growing evidence of the positive impact of virtual reality (VR) techniques on recovery following stroke has been shown. However, most VR tools are designed to exploit active movement, and hence patients with low level of motor control cannot fully benefit from them. Consequently, the idea of directly training the central nervous system has been promoted by utilizing MI with electroencephalography (EEG)-based brain-computer interfaces (BCIs). To date, detailed information on which VR strategies lead to successful functional recovery is still largely missing and very little is known on how to optimally integrate EEG-based BCIs and VR paradigms for stroke rehabilitation. The purpose of this study was to examine the efficacy of an EEG-based BCI-VR system using a MI paradigm for post-stroke upper limb rehabilitation on functional assessments, and related changes in MI ability and brain imaging. To achieve this, a 60 years old male chronic stroke patient was recruited. The patient underwent a 3-week intervention in a clinical environment, resulting in 10 BCI-VR training sessions. The patient was assessed before and after intervention, as well as on a one-month follow-up, in terms of clinical scales and brain imaging using functional MRI (fMRI). Consistent with prior research, we found important improvements in upper extremity scores (Fugl-Meyer) and identified increases in brain activation measured by fMRI that suggest neuroplastic changes in brain motor networks. This study expands on the current body of evidence, as more data are needed on the effect of this type of interventions not only on functional improvement but also on the effect of the intervention on plasticity through brain imaging.

Hepatitis C Virus Eradication in Kidney Transplant Recipients: A Single-Center Experience in Portugal

INTRODUCTION

Hepatitis C (HCV) is a major cause of liver impairment post-kidney transplantation (KT). Anti-HCV direct-acting antivirals (DAA) made viral eradication possible.

METHODS

We performed a retrospective review of KT patients (n = 23) who received DAA at our hospital. Sustained viral response (SVR) was defined as absence of viral detection 12 weeks after cessation of therapy.

RESULTS

From 1985 to September 2017, 1440 patients underwent transplantation at Hospital Santa Cruz. From a total of 32 HCV RNA+ KT recipients on follow-up, we describe the first 23 patients treated with DAA. They were 56.7 ± 9.1 years old; 22 were white, 52.2% were males, they underwent transplantation 18.8 ± 9.0 years ago, and 13 had genotype 1B, 21 were naïve, and 9 had stages F3/F4. All but 2 patients, treated with grazoprevir/elbasvir, received sofosbuvir (18 with ledispasvir, 2 with daclastavir, and 4 with simultaneous ribavirin). Pretreatment, intra-treatment, and post-treatment creatinine clearances were 61.4, 60.6, and 60.7 mL/min/1.73 m², respectively (not significant [NS]). Cyclosporine A was the basis of immunosuppression in the majority [(n = 14); pretreatment and intra-treatment levels were 79.5 ± 23.0 and 91.8 ± 26.0 ng/mL, respectively (P = .08)]; tacrolimus (n = 8) and mammalian target of rapamycin (mTOR) levels (n = 5) were also similar. One patient interrupted ribavirin after 7 weeks due to anemia; all other patients completed the treatment course without major side effects. Only 3 patients presented positive viral RNA at the fourth week of treatment and SVR was achieved in 100% of the patients 12 weeks after treatment.

CONCLUSIONS

DAA therapy was well tolerated and effective in 100% of our treated patients, without significant impact on the renal function or on the immunosuppression.

Intravenous Immunoglobulin and Rituximab in HLA Highly Sensitized Kidney Transplant Recipients

INTRODUCTION

HLA-sensitized patients are penalized both in the access to kidney transplantation (KT) and, once transplanted, in the incidence of rejections and long-term allograft survival despite aggressive induction and maintenance therapy.

METHODS

This study retrospectively evaluates the impact of combining T- and B-cell-depleting agents and intravenous immunoglobulin for induction therapy in 45 highly sensitized KT patients (anti-panel reactive antibodies >60%, positive flow cytometry crossmatch or donor specific antibodies at the time of transplantation). The outcome data included the occurrence of biopsy-proven acute rejection, new-onset proteinuria, development of leukopenia, incidence of poliomavirus infection (BK or JC virus), fungal or bacterial infection after KT, de novo neoplasia, graft function, graft loss, or death with functioning KT.

RESULTS

The average panel reactive antibody was 62.5%; 41 patients (91.1%) had ≥3 HLA mismatches with the donor and 91.1% of patients had class I or II anti-HLA antibodies. Fourteen patients (31.1%) presented pre-KT donor-specific antibodies and 6 patients (13.3%) had a positive flow cytometry cross-match at the time of transplantation. The incidence of acute rejection in the first 6 months was 24.4% and the cumulative incidence was 37.8%. Two patients were diagnosed with leukopenia in the first 6 months after KT. Two patients (4.5%) had cytomegalovirus disease, 17 patients (37.8%) were diagnosed with bacterial infections. Cutaneous neoplasms were identified in 5 patients (11.1%) and solid tumors in 4 (8.9%). The death-censored graft survival was 100% in the first 6 months and 93.5% at the last evaluation. Patient survival in the same periods was 97.8% and 93.3%, respectively.

CONCLUSIONS

Induction immunosuppressive therapy with intravenous immunoglobulin and rituximab is effective; outcomes demonstrate an excellent patient and allograft survival and allograft function over the follow-up period.

On the taxonomy of Latonigena auricomis (Araneae, Gnaphosidae), with notes of geographical distribution and natural history

The male of Latonigena auricomis Simon, 1893 is described for the first time and the female is redescribed. New records are provided for Argentina, Brazil and Uruguay. Notes on the natural history and a potential distribution model of the species are presented in the Neotropical Region.

Habitat, redescription and distribution of Latrodectus geometricus in Uruguay (Araneae: Theridiidae)

This study provides the first accurate records of Latrodectus geometricus C. L. Koch, 1841 for Uruguay and extends the known distribution of this species to the Southeastern region of South America. Data and figures of the genitalic morphology for the recognition of the species and natural history in this country are indicated. In Uruguay L. geometricus was mainly restricted to urban areas at the west of this country and it is associated with locations with high human activity.

A simple and safe technique for closure of trocar wounds using a new instrument

An easy and safe method for closing trocar wounds with a new hook-type instrument is presented. The procedure is performed quickly without the need for pneumoperitoneum or a video camera and is done under direct vision.