Measuring health expectancy in the European Union

Background

Healthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).

Methods

We performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman's r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.

Results

Correlation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.

Conclusions

We showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Acknowledgements: This presentation was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

Key messages

• Different methods for evaluating health expectancy lead to significantly different results.

• There is a systematic tendency with countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Higher levels of physical activity is associated with lower arterial stiffness in patients with resistant hypertension

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Portuguese Foundation for Science and Technology (FCT) European Regional Development Fund – Operational Competitiveness Factors Program (COMPETE)

Background

 Physical activity has been associated with reduced arterial stiffness in patients with hypertension. However, in resistant hypertension, a specific population with an increased risk for target organ damage, cardiovascular morbidity, and mortality, the evidence is sparse. 

Purpose

 The present study aimed to determine the association between daily physical activity and arterial stiffness in patients with resistant hypertension.

Methods

 Fifty-seven patients with resistant hypertension were recruited. Physical activity was objectively assessed during 7 consecutive days with accelerometers. Arterial stiffness was evaluated using carotid-femoral pulse wave velocity (cf-PWV) . 

Results

 Participants (50.9% men), aged 58.8 ± 9.4 years, were mainly overweight and were taking in average 4.5 antihypertensive medications. The cf-PWV showed an inverse correlation with light-intensity physical activity (r = -0.290, p = 0.029) and total daily physical activity (r = -0.287, p = 0.030). Additionally, cf-PWV tended to be inversely associated with the number of steps per day (r = -0.242, p = 0.069). Patients with higher risk of cardiovascular events (cf-PWV ≥ 10 m/s) tended to spend less time in light-intensity physical activity (324.0 ± 129.4 vs. 380.5 ± 103.1 min/day, p = 0.090) and to perform less total daily physical activity (351.5 ± 141.7 vs. 411.7 ± 109.1 min/day, p = 0.091) than participants with cf-PWV below the risk threshold value.

Conclusions

 Higher levels of total physical activity and daily levels of light-intensity were associated to lower arterial stiffness. These results emphasize the importance of physical activity as a nonpharmacological tool for patients with resistant hypertension.

Primary care organizational model mix and avoidable hospitalization: an ecological study in Portugal

Background

In Portugal, there are different organizational models in primary health care (PHC), mainly regarding the payment scheme. USF-B is the only type with financial incentives to the professional (pay-for-performance). Our goal was to assess the relationship between groups of primary healthcare centres (ACES) with higher proportion of patients within USF-B model and the rate of avoidable hospitalizations, as proxy of primary care quality.

Methods

We conducted a cross-sectional study considering the 55 ACES from mainland Portugal, in 2017. We used data from public hospitalizations to calculate the prevention quality indicator (avoidable hospitalizations) adjusted for age and sex, using direct standardization. The main independent variable was the proportion of patients in one ACES registered in the USF-B model. Unemployment rate, proportion of patients with family doctor and presence of Local Health Unit (different organization model) within ACES were also considered. The association was assessed by means of a linear regression model.

Results

Age-sex adjusted PQI value varied between 490 and 1715 hospitalizations per 100,000 inhabitants across ACES. We observed a significant effect of the proportion of patients within USF-B in the crude PQI rate (p = 0.001). However, using the age-sex adjusted PQI, there was not a statistical significant association (p = 0.504). This last model was also adjusted for confounding variables and the association remains non-significant (p = 0.865).

Conclusions

Our findings suggest that, when adjusting for age and sex, there is no evidence that ACES with more patients enrolled in a pay-for-performance model is associated with higher quality of PHC (using avoidable hospitalizations as proxy). Further studies addressing individual data should be performed.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Adjusting PQI to sex and age seems to influence its value more than the type of organizational model of primary health care. Groups of primary healthcare centres with more units under the pay-for-performance scheme was not associated with different rate of avoidable hospitalizations.

To be or not to be hospitalised with tuberculosis in Portugal

SETTING: In Portugal, as in other countries, tuberculosis (TB) is considered a disease that should be managed on an ambulatory basis. However, hospitalisation remains important to manage some at-risk groups and complications.OBJECTIVE: To identify the possible risk factors associated with hospitalisations in TB patients in Portugal.DESIGN: Data extraction through two national databases (one for registration of TB cases and the other with hospitalisation information in public health facilities) between 2007 and 2013. Univariate and multivariate analysis of demographic and clinical variables was performed.RESULTS: We identified 4421 hospitalisations. Chronic diseases, cancer, substance abuse, a higher social/economic risk, extra-pulmonary TB, lung cavitary disease and previous uncompleted treatment were more frequent among hospitalised patients. Human immunodeficiency virus coinfection, cancer, alcohol abuse, extra-pulmonary TB and uncompleted previous TB treatment were the most important predictors of hospitalisation with TB. The hospitalisation rate among TB patients in Portugal was lower when compared with other countries with lower and higher incidences.CONCLUSION: Immune dysfunctions and progression of chronic diseases are associated with more severe forms of TB and frequent adverse effects which can be sufficiently severe to necessitate hospital admission. Despite having an intermediate TB incidence, the hospitalisation rate in Portugal is not higher than that of other countries.

174 Use of mesenchymal stem cell treatment to improve oocyte yield and invitro embryo production in cattle

Cumulative tissue damage and chronic inflammation associated with frequent ovum pickup (OPU) may lead to a progressive reduction in the number and quality of the oocytes recovered, particularly in donors with a high antral follicle count. The aim of this study was to evaluate the effect of an intraovarian treatment with mesenchymal stem cells (MSC) on oocyte yield, quality, and development potential during invitro embryo production (IVEP) in cattle donors undergoing repeated OPU. Mesenchymal stem cells were previously isolated from adipose tissue, cultured in Dulbecco's modified Eagle medium until reaching 80% confluence, isolated with trypsin, and frozen in liquid N2 until use. Characterisation of MSC was carried out according to the guidelines of the International Society for Cellular Therapy. Nelore (Bos indicus) cows (n=5) were used in this study, with the ovaries as replicates. The cows underwent eight OPU sessions at 15-day intervals, and the oocytes recovered were graded and used for IVEP with the semen of a single sire and batch under similar invitro culture conditions. To ensure a high inflammatory response, immediately after the fourth OPU session all ovaries received 30 additional punctures, performed with a 16-gauge Jelco needle. Six hours later, the left ovary of each cow was injected with 500µL of Dulbecco's modified phosphate buffered saline (control ovary) and the right ovary received 500µL of Dulbecco's modified phosphate buffered saline with 2.5×106 allogenic MSC (treated ovary). Oocyte yield and embryo production before and after treatment were recorded for each ovary and donor. Grade I blastocysts produced from control and treated ovaries were used for gene expression evaluation. Data was analysed using the repeated-measures procedure of SAS (SAS Institute Inc.) to account for the effects of treatment, time, and interactions. There was no difference (P>0.05) in any endpoint before treatment (sessions 1-4) between the right and left ovaries. Thus, differences between ovaries observed in OPU sessions 5-8 were assumed to be due to the treatment. After the injection of MSC, more total and viable oocytes were collected from the right ovaries compared with the left ovaries (15.3±2.2 vs. 8.7±1.2 (P<0.02) and 13.6±2.1 vs. 7.1±1.0 (P<0.01), respectively), resulting in more embryos produced invitro (7.6±1.2 vs. 3.6±0.6, respectively; P<0.01) as well as more initial and expanded blastocysts (1.4±0.3 vs. 0.4±0.1 and 4.4±0.9 vs. 2.1±0.4, respectively; P<0.04). The proportion of viable oocytes recovered from the right ovary after treatment was greater than that from the left ovary (89.1% vs. 81.5%; P<0.05). However, blastocyst rates did not differ between ovaries before or after treatment (50.4% vs. 55.5%: P>0.05). In the blastocysts produced from treated ovaries, SLC2A3 was overexpressed (P<0.04), whereas there was no difference for the expression of KRT8, PLAC8, SLC2A1, CASP3, PRDX3, or SOD2 (P>0.05), suggesting potential differences in glucose uptake and metabolism. In conclusion, intraovarian treatment with MSC improved oocyte yield and quality and may be an alternative to increase IVEP from donors under intensive OPU schedules. This research was supported by CNPq, CAPES, and Fazenda Grupo Esplanada.

Time trends of primary care quality across Portuguese regions: using prevention quality indicators

Background

Primary care quality is one of the main dimensions of primary care performance and can be evaluated by several methods, e.g. studying hospitalizations for conditions that could be treated, or less severe, if appropriately managed in primary care. Accordingly, the Agency for Healthcare Research and Quality (AHRQ) developed prevention quality indicators (PQIs). In this study, we aimed to compare PQIs and their time trends across Portuguese regions.

Methods

We performed a retrospective study, using all adult public hospital discharges in mainland Portugal, between 2011 and 2015. PQI rates for the overall (PQI 90) and composite indicators (i.e. 91 - acute, 92 - chronic, 93 - diabetes) were computed using AHRQ specifications. These rates were compared between the 5 Portuguese NUTS 2 regions of residence.

Results

From the total of 407,792 hospital discharges in mainland Portugal (2011-2015) 11.9% comprised the selected PQIs, the majority related the acute composite PQI, followed by the chronic composite PQI. The hospitalization rate of the overall PQI increased from 999.5 hospitalizations (2011) to 1231,0 hospitalizations/100,000 inhabitants (2015), with an increase in all NUTS 2 regions. In 2015, while Algarve and North had the lowest PQI rates, Centro and Alentejo showed the highest ones.

Conclusions

Between 2011 and 2015, there was an increasing trend of overall and composite PQI rates. Also, important differences between Portuguese regions were found that must be further studied.

The authors thank the support given by the Project ’POCI-01-0145-FEDER-030766’ (1st.IndiQare - Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool), funded by Fundação para a Ciência e a Tecnologia (FCT) and co-funded by Fundo de Desenvolvimento Regional (FEDER) through Operacional Competitividade e Internacionalização (COMPETE 2020).

Key messages

Between 2011 and 2015, overall prevention quality indicator rate increased in Portugal. There are great differences between Portuguese NUTS 2 regions regarding prevention quality indicators.

Effects of Acute Aerobic Exercise on Rats Serum Extracellular Vesicles Diameter, Concentration and Small RNAs Content

Physical exercise stimulates organs, mainly the skeletal muscle, to release a broad range of molecules, recently dubbed exerkines. Among them, RNAs, such as miRNAs, piRNAs, and tRNAs loaded in extracellular vesicles (EVs) have the potential to play a significant role in the way muscle and other organs communicate to translate exercise into health. Low, moderate and high intensity treadmill protocols were applied to rat groups, aiming to investigate the impact of exercise on serum EVs and their associated small RNA molecules. Transmission electron microscopy, resistive pulse sensing, and western blotting were used to investigate EVs morphology, size distribution, concentration and EVs marker proteins. Small RNA libraries from EVs RNA were sequenced. Exercise did not change EVs size, while increased EVs concentration. Twelve miRNAs were found differentially expressed after exercise: rno-miR-128-3p, 103-3p, 330-5p, 148a-3p, 191a-5p, 10b-5p, 93-5p, 25-3p, 142-5p, 3068-3p, 142-3p, and 410-3p. No piRNA was found differentially expressed, and one tRNA, trna8336, was found down-regulated after exercise. The differentially expressed miRNAs were predicted to target genes involved in the MAPK pathway. A single bout of exercise impacts EVs and their small RNA load, reinforcing the need for a more detailed investigation into EVs and their load as mediators of health-promoting exercise.

Severe psychosocial deprivation in early childhood is associated with increased DNA methylation across a region spanning the transcription start site of CYP2E1

Exposure to adverse rearing environments including institutional deprivation and severe childhood abuse is associated with an increased risk for mental and physical health problems across the lifespan. Although the mechanisms mediating these effects are not known, recent work in rodent models suggests that epigenetic processes may be involved. We studied the impact of severe early-life adversity on epigenetic variation in a sample of adolescents adopted from the severely depriving orphanages of the Romanian communist era in the 1980s. We quantified buccal cell DNA methylation at ~400 000 sites across the genome in Romanian adoptees exposed to either extended (6-43 months; n=16) or limited duration (<6 months; n=17) of severe early-life deprivation, in addition to a matched sample of UK adoptees (n=16) not exposed to severe deprivation. Although no probe-wise differences remained significant after controlling for the number of probes tested, we identified an exposure-associated differentially methylated region (DMR) spanning nine sequential CpG sites in the promoter-regulatory region of the cytochrome P450 2E1 gene (CYP2E1) on chromosome 10 (corrected P=2.98 × 10(-5)). Elevated DNA methylation across this region was also associated with deprivation-related clinical markers of impaired social cognition. Our data suggest that environmental insults of sufficient biological impact during early development are associated with long-lasting epigenetic changes, potentially reflecting a biological mechanism linking the effects of early-life adversity to cognitive and neurobiological phenotypes.

Bisphenol A causes reproductive toxicity, decreases dnmt1 transcription, and reduces global DNA methylation in breeding zebrafish (Danio rerio)

Bisphenol A (BPA) is a commercially important high production chemical widely used in epoxy resins and polycarbonate plastics, and is ubiquitous in the environment. Previous studies demonstrated that BPA activates estrogenic signaling pathways associated with adverse effects on reproduction in vertebrates and that exposure can induce epigenetic changes. We aimed to investigate the reproductive effects of BPA in a fish model and to document its mechanisms of toxicity. We exposed breeding groups of zebrafish (Danio rerio) to 0.01, 0.1, and 1 mg/L BPA for 15 d. We observed a significant increase in egg production, together with a reduced rate of fertilization in fish exposed to 1 mg/L BPA, associated with significant alterations in the transcription of genes involved in reproductive function and epigenetic processes in both liver and gonad tissue at concentrations representing hotspots of environmental contamination (0.1 mg/L) and above. Of note, we observed reduced expression of DNA methyltransferase 1 (dnmt1) at environmentally relevant concentrations of BPA, along with a significant reduction in global DNA methylation, in testes and ovaries following exposure to 1 mg/L BPA. Our findings demonstrate that BPA disrupts reproductive processes in zebrafish, likely via estrogenic mechanisms, and that environmentally relevant concentrations of BPA are associated with altered transcription of key enzymes involved in DNA methylation maintenance. These findings provide evidence of the mechanisms of action of BPA in a model vertebrate and advocate for its reduction in the environment.

The allograft valve in heart transplantation and valve replacement. Genetic assessment of the origin of the cells by means of deoxyribonucleic acid profiles

Assessment of the cellular origin of allograft valves is essential in comprehending their biologic behavior and in improving preparation methods. In this study we retrospectively analyzed 10 allografts obtained from patients who underwent valve replacement or heart transplantation. Histologic evaluation and deoxyribonucleic acid amplification by polymerase chain reaction technology with fluorescence labeled primers was performed on different parts of the valve leaflets. Automated analyses of the obtained amplimers showed in the heart transplantation group the presence of receptor cells interspersed with native donor cells in three cases. Preliminary results for the valve replacement group are inconclusive as yet.

Acute non-lymphoblast leukaemia presenting as a Guillain-Barré syndrome

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