The role of snow in scavenging aerosol particles: A physical-chemical characterization

The below cloud scavenging of aerosols by snow has been analysed in León (NW Spain). Six snow events were registered over the course of one year of study. Ultrafine and accumulation aerosol particles were measured using a scanning mobility particle sizer spectrometer, while hydrometeors were characterized using a disdrometer. Furthermore, the chemical composition of the melted snow-water samples (soluble and insoluble fractions) was analysed. The scavenging coefficient (λ) showed a great variability among events. An effective washing of particles was observed during the first 30 min of snowfall. The mean change in the scavenging efficiency (%ΔC) of particle number concentration (PNC) and λ coefficient during this time interval were: i) nucleation mode: 36.3 % and 3.02 · 10-4 s-1; ii) Aitken mode: 30.4 % and 2.37 · 10-4 s-1 and iii) accumulation mode: 22.4 % and 1.77 · 10-4 s-1. The range of particle sizes that is less efficiently scavenged by snowfall was observed between 400 and 600 nm. When analyzing the whole snow event, an increase of PNC was observed. Two possible explanations underlie this behaviour: it could be caused by changes in air masses or by the resuspension of aerosol particles scavenged by snowflakes upon reaching the ground. A clear relationship was observed between Ca2+, SO42- and NO3- concentrations of aerosol particles before the snow event and the concentrations registered in the melted snow-water. The largest and smallest changes in aerosol number concentrations were caused by snowflakes of 3 and 6 mm in diameter, respectively. The particle size distributions (PSD) were fitted to log-normal distributions and the parameters were compared before and after snowfall.

The evolution of universities of the third age around the world: A historical review

Universities of the Third Age (U3A), lifelong learning institutes, and "senior universities" are terms used to describe organizations that provide education for older adults, specifically for those who are retired or in the "third age" of life. The purpose of this article is to provide a comprehensive, historical overview of the evolution of these organizations across global settings. This article highlights the importance of older adult education while discussing U3A's structure and models. The article explores the origins and historical development of the U3A model and its influence on recent initiatives like the Age-Friendly Universities movement. It then focuses on the impact of French and British Models of U3A on providing older adult education. There is a general discussion of the expansion of these organizations in several countries and a comparison of each's curricular structure and approach. The article concludes with suggested future directions and potential areas of improvement (e.g. technology access, accessibility, and inclusion of older adult learners; diverse needs and interests) and ways these models can remain relevant to the ever-changing older adult learner population. Through this analysis, the article contributes to the understanding of U3A organizations and their role in promoting lifelong learning for older adults.

Clinical Case 01—Cardioembolic stroke with a twist: a case of left ventricular thrombus

Presentation and diagnosis

A 62-years old male was brought to the emergency department after being found unconscious, lying on his left side. He was last seen 1 week before. Past medical history revealed ischemic cardiomyopathy with reduced ejection fraction of 35% after ST-segment elevation myocardial infarction 3 months before, subject to coronary angioplasty of 2 vessels (left anterior descending artery with drug-eluting stent and circumflex artery with balloon angioplasty). He had poor therapeutic compliance with missing cardiology appointments. On examination, he was hypothermic and hemodynamically unstable with signs of hypoperfusion. He was admitted for septic shock with origin in a decubitus ulcer on his left-hand dorsum. Head CT-scan revealed sub-acute ischemic stroke in the right middle cerebral artery territory. He started fluid therapy, vasopressors and large spectrum antibiotics with favorable clinical evolution and no heart failure symptoms but remained febrile. Meanwhile, Proteus hauseri had grown in blood cultures. An echocardiography was performed excluding infectious endocarditis and revealing a large apical thrombus on the left ventricle.

Management

Therapeutic anticoagulation with enoxaparin was initiated and antibiotic was de-escalated according to the antibiogram. Later on, anticoagulation was switched to warfarin (target INR∼2.0–3.0). When clinically stable, was discharged home with anticoagulation and clopidogrel, with an echocardiography scheduled after 3 months.

Learning points

Left ventricular thrombus is a rare complication of ischemic cardiomyopathy with high risk of adverse outcomes, including ischemic stroke and death. Vitamin K antagonists are usually preferred to direct oral anticoagulants in the management of these patients, but further research is needed.

Health literacy in higher education students: findings from a Portuguese study

Background

Health literacy (HL) concerns the knowledge and competences of people to meet the complex demands of health in modern society. It is essential for health promotion, disease prevention and healthcare. Young adults can perform a very important role in taking a more active role in managing and protect their health, so this study aimed to identify the HL levels in the population of higher education students, according to the European Health Literacy Survey (HLS-EU-PT) and to evaluate its association with social and academic determinants.

Methods

A quantitative, observational, and cross-sectional study was carried out based on an online survey disseminated in Portuguese universities. Data were analysed using binary logistic regression, adjusted for age, income, parents’ education, gender, and chronic disease report.

Results

In total, 4801 students were surveyed, 76% female. Of those, 44% revealed a problematic or inadequate level of HL. Those students with higher income levels (OR (95% CI), OR = 4.5 (3.4; 5.9) and whose parents had higher education levels (OR = 1.3(1.1; 1.5) had higher odds of achieving sufficient or excellent levels of HL, even after adjusting for confounders. In what concerns academic determinants, data revealed that HL tends to be sufficient or excellent among those students from health-related courses (OR = 2.0 (1.6; 2.5). In the subgroup of students from non-health-related courses, it was found that HL levels do not differ in 1st year and last year's students. However, in students from health-related courses, data revealed that a last yeaŕs students had higher odds of having sufficient or excellent HL levels compared to a 1st-year student (OR = 1.7 (1.4; 2.2).

Conclusions

This study reveals low HL levels and addresses that socioeconomic and familiar context are determinants of HL in higher education students. Future intervention studies are needed, focused on these determinants so that adequate levels of HL are achieved in higher education students.

Key messages

AB0926 ENTHESITIS OF THE HAND IS A DOMINANT LESION IN PSORIATIC ARTHRITIS AND MAY HELP DISTINGUISH IT FROM RHEUMATOID ARTHRITIS: CASE-CONTROL, SINGLE-CENTRE, ULTRASOUND STUDY

Background

Enthesitis is the hallmark of psoriatic arthritis (PsA) and may assist in distinguishing PsA from other forms of arthritis (1,2). Its clinical evaluation is hampered by lack of specificity of physical examination (3). Ultrasound (US) may provide information about its presence and response to treatment. Although some previous works have shown that enthesitis of the hand is important in PsA (4), most US studies and scores focused on greater size entheses.

Objectives

To explore the prevalence of enthesitis of the hand in PsA patients as evaluated by US, and compare it with other inflammatory arthritides, namely rheumatoid arthritis (RA).

Methods

Cross-sectional study in which consecutive patients with PsA and RA were recruited for an US protocol evaluating 4 entheses of the hand including: 1. measurement of the extensor digitorum tendon central slip at its insertion at the middle phalanx of the 2nd and 3rd finger bilaterally; 2. search for the presence of power-Doppler (PD) sign; 3. identification of structural lesions.

Linear regression models were built to test if diagnosis (PsA vs RA) explained part of the variance of the thickness of tendons insertion while controlling possible influences of age, type of work and body surface area. A ROC curve was built to find a mean thickness cut-off allowing distinction between PsA and RA. The prevalence of PD sign and structural lesions of the entheses was compared between groups.

Results

Fifty-eight patients were recruited (29 with PsA and 29 with RA) and a total of 232 entheses were evaluated.

Mean thickness of the interest entheses was superior in PsA patients compared to RA patients (2nd finger – 0.96 ± 0.16mm vs. 0.74 ± 0.09mm; 3rd finger – 0.96 ± 0.20mm vs. 0.76 ± 0.11mm).

Linear regression models including diagnosis and potential confounders significantly explained mean thickness of both entheses (2nd finger – R2=0.56, p<.001; 3rd finger – R2=0.41, p<.001), with the diagnosis group being the most important predictor (Table 1). ROC curve (AUC 0.897, p<.001) showed a cut-off value of 0.925mm for the mean of the 4 entheses had a specificity of 93.1% for the identification of PsA patients.

Table 1.

Multiple linear regression models explaining thickness of the entheses.

2nd finger (mean of both sides)3rd finger (mean of both sides)Linear regression modelR2=0.56p<.001***R2=0.39p<.001***Diagnosis (PsA vs RA)β=0.587; B=0.203mmp<.001***β=0.483; B = 0.182mmp<.001***

In our sample, 8 (3.5%) entheses had a measured thickness above mean + 2 SD, all belonging to PsA patients; 6 (75%) had signs of ongoing inflammatory process as proved by the presence of PD sign (Figure 1). Regarding structural lesions, enthesophytes or bone irregularities/erosions were found in 13.8% of PsA entheses, which compared to 1.7% of RA entheses.

Figure 1.

Enthesitis of the central slip of extensor digitorum of the 3rd finger in a patient with PsA: swelling of the 3rd proximal interphalangeal joint (A) due to inflammatory process originating in the enthesis, with no signs of synovitis, as evaluated by US (B).

Conclusion

This work reinforces enthesitis as a key lesion in PsA. It also shows enthesitis occurs significantly in small entheses, like the ones of the hand and that, in some instances, it may be the dominant lesion in a swollen joint. US may be valuable for establishing a diagnosis in the setting of inflammatory arthritis of unknown etiology.

References

[1]Mease P. Enthesitis in psoriatic arthritis (Part 3): clinical assessment and management. Rheumatology. 2020 Mar 1;59(Supplement_1):i21–8.

[2]Sapundzhieva T, Karalilova R, Batalov A. Hand ultrasound patterns in rheumatoid and psoriatic arthritis: the role of ultrasound in the differential diagnosis. Rheumatol Int. 2020 Jun;40(6):837–48.

[3]Kaeley GS. Enthesitis in psoriatic arthritis (Part 2): imaging. Rheumatology. 2020 Mar 1;59(Supplement_1):i15–20.

[4]Smerilli G, Di Matteo A, Cipolletta E, Grassi W, Filippucci E. Enthesitis in Psoriatic Arthritis, the Sonographic Perspective. Curr Rheumatol Rep. 2021 Sep;23(9):75.

Disclosure of Interests

None declared

POS1518-HPR BELIEFS ABOUT MEDICATION IN A POPULATION OF PATIENTS WITH INFLAMMATORY ARTHROPATHY

Background

The beliefs that patients have regarding their medication, namely about its need and concerns regarding possible adverse effects, are a determining factor for adherence and therapeutic success1.

Objectives

Determine which sociodemographic and clinical factors are associated with beliefs related to medication, either in terms of necessity or concerns about medication, in patients with Rheumatoid Arthritis (RA) or Psoriatic Arthritis (PsA).

Methods

Observational study, with a sample consisting of 58 patients (female 72,4%, male 27,6%; mean age = 51,0 ± 13,2 years; education < 9 years 39,7%, ≥ 9 years 60,3%). Of these, 33 had a diagnosis of RA and 25 of PsA (mean years of disease duration = 8,2 ± 7,3 years; mean disease activity by DAS28-PCR or DAS28-PCR 3 variables = 2,32 ± 0,95). Between March 2021 and June 2021, a brief questionnaire was applied with sociodemographic and clinical variables, such as the use of classic or biological DMARDs and their administration´s route. The Specific Beliefs About Medication Scale (BMQ) was anonymously applied, adapted from the Beliefs About Medicines Questionnaire, comprising 2 sections: section 1 – Specific Needs, patients beliefs about the need for medication; section 2 – Specific Concerns, beliefs related to the dangers of addiction and long-term toxicity or side effects. Higher scores (scale from 5 to 25 points), in sections 1 and 2, reflect the belief of greater need and greater concern regarding medication, respectively. The average scores in section 1 and in section 2 of the BMQ were 9 and 15,7 points, respectively. Statistics: descriptive, Student t-Test, Pearson Correlation and ANOVA, p<0,05.

Results

Patients with PsA and younger age had a higher mean score in section 2 of the BMQ (p= 0,049 e p<0,01, respectively). The variables male gender, education ≥ 9 years and shorter duration of the disease also showed a tendency to be associated with the higher score in section 2 of the BMQ, with p-values close to statistical significance (p=0,091, p=0,074 and p=0,094, respectively). In the multivariate analysis with the above variables, only the diagnosis of PsA showed a statistically significant association with the score in section 2 of the BMQ (B=4,269; p<0,001; CI 95%=[2,060-6,477]). There was also a statistically significant correlation (p=0,007) between the scores in section 1 and section 2 of the BMQ. Regarding analysis of the sample by diagnosis, there was an association between the subcutaneous route of drug administration in individuals with RA and greater concern with the adverse effects of the medication (p=0,007), and between low disease activity and greater belief in the specific need for medication for the disease (p=0,006).

Conclusion

In this study, patients with PsA were more concerned about the possible adverse effects of medication than patients with RA. RA patients who take subcutaneous drugs are more afraid of the drug’s toxic potential, and those with lower disease activity have a greater need to comply with the prescribed therapy, which can be explained by the previous effectiveness of the drug in disease control. It was also found that the greater the belief in the need for medication, the greater the concern with its possible long-term harmful effects.

References

[1]Smolen JS, Gladman D, McNeil HP, et al. Predicting adherence to therapy in rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis: A large cross-sectional study. RMD Open. 2019;5(1):1-13. doi:10.1136/rmdopen-2017-000585

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

Sexual expression involving people with dementia living in long-term care facilities: staff's reactions

This study aims to explore and compare the reaction of long-term care staff towards situations of sexual intercourse in which one or both partners have dementia. Participants were 538 staff members at 28 Portuguese long-term care facilities. Data were collected using a printed questionnaire with seven vignettes with situations related to the sexuality of LTCF residents. In this study, three of these vignettes were analysed with situations in which residents were having relationships in their bedrooms: (1) one male resident and one female resident; (2) two residents with dementia; (3) two residents, one of them with dementia. For each of the vignettes, participants are asked what they think their 'colleagues' would do in each vignette, i.e. 'What do you think most of your colleagues would do?' The results revealed that when sexual relationships involved both partners living with dementia, the most selected reaction was 'Comment on what happened with supervision or direction', which may suggest that the situation was perceived as difficult or problematic. The most restrictive reactions were most often chosen when only one partner had dementia. This study suggests the need to improve and provide training, so that staff have knowledge and strategies that allow people living with dementia to preserve their sexual rights in long-term care facilities.

AB0799 DO WE OVERDIAGNOSE SERONEGATIVE RHEUMATOID ARTHRITIS? – THE ROLE OF MUSCULOSKELETAL ULTRASOUND IN CLARIFYING SERONEGATIVE INFLAMMATORY ARTHRITIS

Background:

Several data indicate that seronegative rheumatoid arthritis (RA-) and seropositive RA (RA+) may have different mechanisms and prognosis, being well established that rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) have diagnostic and prognostic value. Several conditions, like peripheral spondyloarthritis (SpA), psoriatic arthritis or crystal-related arthropathies may mimic the presentation of RA. Mechanisms and treatment of each of these conditions differ significantly. The authors speculate that RA- may be overdiagnosed in the setting of seronegative chronic inflammatory arthritis and that musculoskeletal ultrasound (US) may help us to better classify these patients through the identification of characteristic lesions of the mentioned diseases.

Objectives:

To compare the frequency of US lesions found in joints and entheses between RA- and RA+ patients.

Methods:

Cross-sectional study: systematic US evaluation of ten joints, twelve entheses and both flexor and extensor tendons of four fingers (Table 1) in consecutive RA- patients. RA+ patients matched for sex and age were recruited. RA- patients included met every of the following criteria: history of chronic polyarthritis, RF and ACPA negativity, no extra-articular features of SpA or RA nor family history of SpA, no suspected crystal-related arthritis.

Results:

Twenty-one RA- patients were included and twenty RA+ patients were recruited as controls. No differences between groups were found in sex, age, body mass index, time of disease evolution or use of biological therapy.

RA- patients had a significantly higher number of entheseal structural and/or inflammatory lesions than RA+ patients (median 2.0 vs. 0.5, U 111.5, p=.008**), with triceps enthesitis being significantly more frequent in RA- patients (p=.036*). In total, 18.7% of RA- entheses had enthesitis lesions vs. only 8.3% of RA+ entheses. One RA- patient had ultrasonographic features of dactylitis which was not clinically evident.

As expected, considering the role of RF and ACPA in erosive RA, RA- patients had a significantly lower number of joints with erosions compared to RA+ patients (median 0.0 vs. 3.0, U 64.5, p<.001***), with significant differences in every considered joint. Erosions were found in 6.7% of RA- joints vs. 32.0% RA+ joints.

Additionally, two RA- patients had hyperechogenic foci in knee cartilage or carpal fibrocartilage suggestive of calcium pyrophosphate deposition.

Table 1.

Comparative frequency of ultrasound lesions found in joints and entheses of RA- and RA+ patients.

RA-(n=21)RA+(n=20)p-valueMdn number of ENTHESES with any lesion per patient ± IQR2.0 ± 3.00.5 ± 2.0.008**Triceps – n (%)8 (38.1%)2 (10.0%).036*Quadriceps – n (%)9 (42.9%)6 (30.0%).393Superior patellar – n (%)4 (19.0%)1 (5.0%).169Inferior patellar – n (%)---Achilles – n (%)9 (42.8%)4 (20.0%).116Plantar fascia – n (%)5 (23.8%)1 (5.0%).089DACTYLITIS – 2nd + 5th finger – n (%)1 (4.8%)--Mdn number of joints with EROSIONS per patient ± IQR0.0 ± 1.03.0 ± 3.0<.001***Ulnar styloid process – n (%)5 (23.8%)11 (55.0%).041*Metacarpophalangeal 2 – n (%)3 (14.3%)11 (55.0%).006**Metacarpophalangeal 5 – n (%)1 (4.8%)10 (50.0%).001**Metatarsophalangeal 1 – n (%)-3 (15.0%)-Metatarsophalangeal 5 – n (%)3 (14.3%)11 (55.0%).006**CHONDROCALCINOSIS – triangular fibrocartilage + knee – n (%)2 (9.5%)--DOUBLE CONTOUR – any joint – n (%)---

RA- – seronegative rheumatoid arthritis; RA+ – seropositive rheumatoid arthritis Mdn – median; IQR – interquartile range; n (%) – absolute number (percentage) of patients with the indicated lesion.

Conclusion:

We found that some patients diagnosed with RA- had, in fact, ultrasonographic features of different diseases, namely enthesitis/dactylitis and crystal deposition. These data suggest that RA- may be overdiagnosed in clinical practice. Systematic US evaluation of joints and entheses may provide valuable diagnostic information in patients with chronic inflammatory seronegative arthritis and improve patient care.

Disclosure of Interests:

None declared

POS1438 EARLY FACTORS ASSOCIATED WITH THE INITIATION OF TREATMENT WITH BIOLOGICS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS – RESULTS FROM A SINGLE CENTRE RETROSPECTIVE COHORT STUDY

Background:

Axial Spondyloarthritis (axSpA) refers to a group of rheumatic diseases that mainly affect the axial skeleton. Treatment with Biological Disease Modifying Anti-Rheumatic Drug (bDMARDs) is indicated when low disease activity is not achieved with Non-Steroid Anti-inflammatory Drugs. Some studies reported that some clinical and socio-demographic were associated with biologics initiation1,2. However, early factors associated with the initiation of bDMARDs have not been extensively studied.

The authors speculate that certain features early in disease presentation may be associated with future need for treatment with bDMARDs in patients with axSpA.

Objectives:

To study a population of patients with axSpA and determine whether the presence of certain factors at diagnosis is associated with a later need for biological treatment.

Methods:

A single centre retrospective study was conducted comprising patients fulfilling the ASAS criteria for axSpA that attended the Rheumatology Outpatient Clinic from January to December 2019. Patients with psoriatic arthritis and enteropathic spondyloarthritis were excluded. All data, except regarding use of bDMARD, refers to the two initial appointments. Between group comparisons were performed through independent sample t-test or Chi-Square as applicable. Logistic Multivariate Regression was performed to understand which factors independently contributed to the use of bDMARDs.

Results:

One hundred and fifty patients were included, and 52 patients (34,7%) were under biological treatment. In comparison to the group that was not under treatment with bDMARDs, these were significantly more likely to be hard-workers (57,8% vs 29,7%; p =,003), to have had elevated C-Reactive Protein (81,6% vs 48,9%; p <,001), to have had a grade of sacroiliitis greater than 2 (67,4% vs 29,5%; p <,001) and to have history of enthesitis, (32,7% vs 13,3%; p =,006). No differences between groups were found in sex, age, HLA-B27 positivity, state of employment, diagnostic delay, smoking status, history of dactylitis and history of uveitis. In multivariate regression analysis, only the hard-worker type and the highest grade of sacroiliitis were found to be independently associated with the use of bDMARDs as presented in Table 1. Although not statistically significant, a trend to association was found between elevated CRP at diagnosis and use of bDMARDs.

Table 1.

Multivariate logistic regression of variables associated with initiation of bDMARDs.

BS.E.WaldOR95% CIpWorker typeaNon-hardref.Hard1,127,5094,8903.09 1.14 – 8.37.027*HLA-B27Negativeref.Positive1,153,6702,9623.17 0.85 – 11.77.085CRPaNormalref.Elevated1,003,5293,5912.730.97 – 7.69.058Grade of Sacroiliitisa≤2ref.>21,485,4899,2264.411.69 – 11.50.002*History of EnthesitisaNoref.Yes,299,574,2721.35 0.44 – 4.15.602

aAt the time of diagnosis; ref. - reference

S.E. – Standard Error; OR – Odds Ratio; CI – Confidence Interval

Conclusion:

In our study, the performance of work associated with greater biomechanical stress and the presence of greater structural damage at diagnosis were shown to be associated with the latter use of bDMARDs. The authors highlight the importance of recognizing these factors that seem to relate to more aggressive disease, with more structural damage, thus suggesting a need for a tighter control management strategy in these patients accordingly current guidelines. More studies still needed to better depict the influence of certain early clinical and patient related variables in management of axSpA patients.

References:

[1]Png WY, Kwan YH, Lee YX, et al. Factors Associated with Initiation of Biologics in Patients With Axial Spondyloarthritis in an Urban Asian City: A PRESPOND Study. J Clin Rheumatol. 2019 Mar;25(2):59-64.

[2]Inman R, Garrido-Cumbrera M, Chan J, et al SAT0629-HPR FACTORS ASSOCIATED WITH USE OF BIOLOGICAL THERAPIES FOR AXIAL SPONDYLOARTHRITIS IN CANADA. RESULTS FROM THE IMAS SURVEY. Annals of the Rheumatic Diseases 2020;79:1274-1275.

Disclosure of Interests:

None declared

The Role of Operative Vaginal Delivery in Postpartum Sexual Dysfunction: MOODS - A Prospective Study

BACKGROUND

Childbirth brings many changes to women's life and sexual health. The influence of operative vaginal delivery on sexual function has produced inconsistent results.

AIM

To evaluate the effects of mode of vaginal delivery (spontaneous or operative) in postpartum sexual function.

METHODS

Descriptive prospective study (MOODS- Maternal-neonatal Outcomes in Operative Vaginal Delivery) including 304 women who had a singleton term vaginal delivery (operative or spontaneous in a relation 2:1). Women were invited to answer a questionnaire at 3, 6 months and 1 year postpartum.

OUTCOMES MEASUREMENT

A validated questionnaire was applied, the Female Sexual Function Index (FSFI) Score, to evaluate effects of operative delivery on sexual health. Sexual dysfunction was defined by FSFI score <26.55.

RESULTS

211 women answered at least one questionnaire. Overall rate of sexual dysfunction was 62%, 43% and 48% at 3, 6 and 12 months respectively. At 3 months, total FSFI score was significantly lower in operative vaginal delivery group (mean±SD, 21.3±8.6 vs 24.9±7.9, P = 0.015). Arousal (P = 0.028), orgasm (P = 0.029), satisfaction (P = 0.015) and pain (P = 0.007) FSFI domains were also significantly inferior. At this time, 44% women in spontaneous delivery group and 70% in operative delivery group had sexual dysfunction (P = 0.0002). At 6 months, there were no differences in FSFI scores according the type of delivery. At 12 months, total FSFI score was similar in both groups, but pain domain was significantly lower in operative delivery (P = 0.004). Considering type of instrument (Thierry's Spatulas or Kiwi Vacuum), no differences were found regarding episiotomy, perineal trauma, obstetric anal sphincter injury or postpartum complications. FSFI scores did not differ between the two instruments at any time point. A logistic regression showed that, when controlled for perineal trauma, mode of delivery was independently associated with sexual dysfunction at 3 months (P = 0.02).

CLINICAL IMPLICATIONS

Clinicians should assess women's sexual health during pregnancy and postpartum period in order to enhance their wellbeing.

STRENGTHS/LIMITATIONS

Strengths include its prospective design, standardized questionnaire and the new perspectives about a different obstetrical instrument (Thierry's spatulas). Limitations include the absence of pre-pregnancy sexual function data and considerable drop-out rate.

CONCLUSION

Sexual dysfunction affects a great proportion of newly mothers and in postpartum period mode of delivery and perineal trauma seem to play an important role. Although there was a progressive reduction over time, prevalence of sexual dysfunction at 6 months and 1 year postpartum was still considerable. The type of obstetrical instrument does not seem to influence short or long-term sexual function. de Sousa NQ, Borges AC, Sarabando R, et al. The Role of Operative Vaginal Delivery in Postpartum Sexual Dysfunction: MOODS - A Prospective Study. J Sex Med 2021;18:1075-1082.

Test-Retest Reliability of Pain Measures in Institutionalized Older Adults: Number of Painful Body Sites, Pain Intensity, and Pain Extent

OBJECTIVE

The reliability of pain assessment in frail and older adults has seldom been assessed. This study aims to assess the test-retest reliability of (1) the number of painful body sites, (2) pain intensity, and (3) pain extent in institutionalized older adults.

METHODS

Seventy-four older adults who were institutionalized were assessed in 2 separate sessions, 2 days to 1 week apart, for pain intensity, number of painful body sites, and pain extent (in pixels) using a vertical pain numeric scale (0 to 10), a body chart divided into 50 body regions, and ImageJ, respectively. Intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and minimal detectable differences (MDDs) were calculated.

RESULTS

In session 1, the mean values (± standard deviation) were 5.54 ± 2.12 points for pain intensity, 4.47 ± 3.27 for number of painful body sites, and 2,726.00 ± 2,322.09 for pain extent. ICCs were 0.82 (95% confidence interval [CI] = 0.72 to 0.89) for pain intensity, 0.89 (95% CI = 0.83 to 0.93) for number of painful body sites, and 0.74 (95% CI = -0.07 to 0.91) for pain area. The MDDs were 2.46 for pain intensity, 3.14 for number of painful body sites, and 4,997.60 for pain extent.

CONCLUSIONS

The vertical pain rating scale and the body chart seem reliable to assess pain intensity and number of pain sites, respectively. The wide CI for the ICC found for pain area and the high measurement error compromise its potential clinical relevance.

Hyperbaric oxygen for radiation-induced cystitis: A long-term follow-up

INTRODUCTION AND OBJECTIVES

Bladder complications may be seen in up to 12% of patients treated with pelvic irradiation. Hyperbaric oxygen therapy (HBOT) is an option for the management of radiation-induced hemorrhagic cystitis (RIHC). The aim of this study was to evaluate the efficacy of HBOT in radiation cystitis and to identify the predictive factors for a successful outcome.

MATERIAL AND METHODS

We retrospectively reviewed 105 patients diagnosed with RIHC which were treated with HBOT between 2007 and 2016 in our institution. Patients received 100% oxygen in a multiplace hyperbaric chamber at 2.4atm for 80minutes. All patients fulfilled a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period.

RESULTS

After a median of 40 HBOT sessions, there was success rate of 92,4% in the control of hematuria. During our follow-up period (median of 63 months) 24,7% patients presented with recurrence of hematuria. The mean score of the questionnaire-assessed variables: dysuria, urinary frequency and hematuria, was significantly lower after the follow-up period (P<.05). Our data shows that the sooner HBOT is delivered after the first episode of hematuria, better response rates are achieved and lower recurrences concerning hematuria were registered (P<.05). No serious complications were observed.

CONCLUSIONS

Our results support the safety and long-term benefits of HBOT on RIHC and other distressful bladder symptoms, which represents an expected improvement of quality of life in our patients.

Chemical composition of rainwater under two events of aerosol transport: A Saharan dust outbreak and wildfires

A one-year campaign of joint sampling of aerosols and precipitation, carried out in León, Spain, allowed to study the impact of two special events that affected the air quality in the north of the country, on rainfall in the city: a period with wildfires and a Saharan dust intrusion. The wildfires that occurred in northern Portugal and northwestern Spain in August 2016 affected the chemistry of rainfall on 15 August 2016, causing an increase in concentrations of NH₄⁺, Na⁺, Cl^-, K⁺, Mg²⁺, Ca²⁺, SO₄^2- and NO₃^- and in the concentrations of organic acids, which was reflected in the levels of soluble and insoluble organic carbon. This led to acidification of rainwater (pH = 4.8). The second precipitation event was registered between 11 and 14 February 2017, during which the rainwater was collected in four daily fractions (P₁, P₂, P₃ and P₄). The rain sample of 12 February (P₂) coincided with a Saharan dust intrusion that reached northern Iberia that day. The chemical composition of P₂ showed an increase in the Ca²⁺ (>800%), Mg²⁺ (71%), Cl^- (62%), and SO₄^2- (33%) concentrations, with respect to P₁. The input of crustal elements to the atmosphere helped to neutralize the P₂ rainwater, causing pH values higher than 6.5. Once the dust intrusion left the north of the Peninsula, the composition of rainwater P₃ and P₄ revealed a mixture of marine contribution with local anthropogenic emissions, as well as a decrease in ion concentrations and conductivity, and an increase in pH values.

FRI0388 ARE WE OVERLOOKING OSTEOARTHRITIS? – A COMPARATIVE STUDY OF PAIN, FUNCTION AND QUALIFY OF LIFE IN PATIENTS WITH HAND OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing (1). On the other hand, it is well established that rheumatoid arthritis (RA) is a pathological condition requiring prompt and efficacious treatment and in which remarkable progresses have been achieved in the last decades. Pain and physical limitations are hallmarks of both conditions. Some previous studies suggest that OA and RA may have a similar burden (2,3).

Objectives:

To compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA: active disease (aRA) or in remission (rRA).

Methods:

Observational cross-sectional study including patients of two clinical centres with hOA and RA, either in remission or with active disease (at least two swollen and/or tender hand joints). Matching for sex and age was performed. Patients were asked to complete a survey consisting of visual analogic scale (VAS) for pain, Health Assessment Questionnaire (HAQ) and Short Form 36 (SF36). Mean values for each domain were compared between the three groups using one-way ANOVA test with significance accepted for p<.05.

Results:

Thirty patients with hOA and 93 with RA (33 with aRA and 60 with rRA) were included. All patients were caucasian females with no significant differences in age between groups. Patients with hOA reported higher levels of pain in comparison with aRA patients (mean VAS 57.3vs49.3mm, respectively, p=.265) and with rRA patients (57.3vs28.6mm, respectively, p<.001) [F(2.120)=25.907, p<.001]. Regarding physical function, patients with hOA reported levels of disability similar to rRA patients, but significantly lower disability than patients with aRA [F(2.120)=6.962, p=.001]. Patients with hOA evaluated their quality of life significantly better than patients with aRA and in similar levels to patients with rRA, as measured by mental health and general health status domains of SF36.

Conclusion:

Our results show that hOA may have similar or even higher burden of pain than RA; this is in line with previous studies, although most of them did not consider the level of inflammatory activity of RA. On the other hand, patients with hOA seem to preserve function and have better health-related quality of life despite the higher levels of pain. These results highlight OA as a cause of severe pain, which should lead us to try an optimal symptom control for these patients. These findings should also encourage rheumatologists to endeavor efforts to perform more studies in the field of OA, to better understand its pathogenesis and to eventually find disease modifying drugs.

References:

[1]Gignac MAM, Davis AM, Hawker G, Wright JG, Mahomed N, Fortin PR, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006 Dec 15;55(6):905–12.

[2]El-Haddad C, Castrejon I, Gibson KA, Yazici Y, Bergman MJ, Pincus T. MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites. RMD Open. 2017 Jul;3(1):e000391.

[3]Slatkowsky-Christensen B, Mowinckel P, Kvien T. Health status and perception of pain: a comparative study between female patients with hand osteoarthritis and rheumatoid arthritis. Scand J Rheumatol. 2009 Jan;38(5):342–8.

Disclosure of Interests:

None declared

FRI0533 SMOKING AS A PREDICTIVE FACTOR FOR SPONDYLOARTHRITIS RELATED UVEITIS: RESULTS FROM A SINGLE CENTRE CROSS-SECTIONAL STUDY

Background:

Although spondyloarthritis (SpA) is primarily a musculoskeletal condition, ocular involvement is an important clinical feature and contributes to the burden of disease. Acute anterior uveitis (AAU) is classically described as the most frequent extra-articular manifestation of SpA and in some cases the first clinical presentation. The prevalence of AAU varies according to the subtype of SpA. In a systematic literature review, the mean prevalence of AAU was 32.7% and a positive association between HLA-B27 positivity, axial SpA, male sex and uveitis has been reported (1). More recently, some cross-sectional studies have described lower odds of spondyloarthritis-related uveitis (SpA-U) in smokers than in patients who are ex smokers or never smokers (2). Predictors of SpA-U are poorly defined in literature and the influence of smoking status remains controversial.

Objectives:

To analyse the factors associated with uveitis in SpA patients in a Tertiary Rheumatology Center.

Methods:

An observational cross-sectional study was performed including patients fulfilling the ASAS criteria for axial SpA with a follow-up visit between January and June 2019. Clinical patients’ charts were reviewed and the following variables were considered: age, gender, history of uveitis (confirmed by ophthalmologist observation), number of AAU episodes, smoking status (never smoker or ever smoker), HLA-B27, disease duration, disease involvement (exclusively axial or axial and peripheral), history of enthesitis and syndesmophytes. History of AAU and associated variables were determined in this subset of patients.

Statistical analysis was performed with logistic regression model. P value <.05 was defined as statistically significant.

Results:

The study included 164 patients (62.3% men) with median age of 44.0 years (IQR 37 to 54) and a median disease duration of 14.6 years (IQR 9.28 to 20.32). SpA diagnosis was ankylosing spondylitis in 70.7% cases and the remaining were non-radiographic axial SpA. HLA-B27 was positive in 84.8%, 31.1% of patients were ever smokers and 21% had both axial and peripheral joint involvement. Twenty four percent of patients had at least one AAU episode. Recurrence of uveitis occurred in 70% of patients. Ever smoking (OR=2.256; 95%CI [1.077-4.276]; p<.05) and syndesmophytes (OR=2.125; 95%CI [1.009-4.475]; p<.05) showed a statistically significant association with uveitis in univariated logistic regression. Althougth not statistically significant, a trend to association was found between smoking and recurrence of AAU (OR=2.235; 95%ICI [.973-5.135], p=.058). In multivariated logistic regression only ever smoking was independently associated with uveitis (OR=2.542; 95%CI [1.007-6.420]; p<.05). We did not find association between presence of uveitis and gender, age, disease duration, disease involvement, HLA-B27 positivity and enthesitis.

Conclusion:

Contrary to few cross-sectional studies showing a possible protective effect of smoking in SpA-U, and in line with new data from Zhaoet al(3), we report a statistically significant independent association between history of smoking and uveitis. Nevertheless, we emphasize the need of more studies to confirm these findings.

References:

[1] Zeboulon N, et al. Prevalence and characteristics of uveitis in the spondyloarthropathies: a systematic literature review. Annals of Rheumatic Diseases 2008;67:955.

[2] Zhao S, et al. Associations between smoking and extra-axial manifestations and disease severity in axial spondyloarthritis: results from the BSR Biologics Register for Ankylosing Spondylitis (BSRBR-AS). Rheumatology 2018;69.

[3] Zhao S, et al. Smoking does not protect patients with axial spondyloarthritis from attacks of uveitis. Annals of Rheumatic Diseases 2019;78(9).

Disclosure of Interests:

None declared

A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure.

Cognitive appraisal in fish: stressor predictability modulates the physiological and neurobehavioural stress response in sea bass

The role of cognitive factors in triggering the stress response is well established in humans and mammals (aka cognitive appraisal theory) but very seldom studied in other vertebrate taxa. Predictability is a key factor of the cognitive evaluation of stimuli. In this study, we tested the effects of stressor predictability on behavioral, physiological and neuromolecular responses in the European sea bass (Dicentrarchus labrax). Groups of four fish were exposed to a predictable (signalled) or unpredictable (unsignalled) stressor. Stressor predictability elicited a lower behavioural response and reduced cortisol levels. Using the expression of immediate early genes (c-fos, egr-1, bdnf and npas4) as markers of neuronal activity, we monitored the activity of three sea bass brain regions known to be implicated in stressor appraisal: the dorsomedian telencephalon, Dm (putative homologue of the pallial amygdala); and the dorsal (Dld) and ventral (Dlv) subareas of the dorsolateral telencephalon (putative homologue of the hippocampus). The activity of both the Dm and Dlv significantly responded to stressor predictability, suggesting an evolutionarily conserved role of these two brain regions in information processing related to stressor appraisal. These results indicate that stressor predictability plays a key role in the activation of the stress response in a teleost fish, hence highlighting the role of cognitive processes in fish stress.

Mobile Health to Support Ageing in Place

The study reported in this article aimed to identify: i) the most relevant application domains of mHealth to support older adults in their domiciles; ii) the most relevant chronic conditions of older adults, whose management is being supported by mHealth; iii) the characteristics, outcomes and impacts of mHealth tools that might support older adults in their domiciles. The method of a systematic review of reviews and meta-analyses was performed based on a search of the literature. The result of a total of 66 reviews and meta-analyses across several chronic diseases were retrieved. These studies compare mHealth interventions with usual care. The conclusion is that mHealth interventions have positive effects on various health related outcomes, but further research is required to allow their incorporation in the clinical practice.

Living Too Long? Exploring Attitudes Toward Reaching 100 Years Old

Objective

This study analyses the relationship between pro- and anti-longevity attitudes, attitudes toward centenarians, and the wish to reach 100 years of age in a sample of community dwelling older adults.

Methods

Participants ( N = 137) completed a questionnaire on attitudes toward life-extension and an aging semantic differential using centenarians as an attitudinal target. Sociodemographic information, perceived health status, and information on knowing a centenarian were also obtained. A cluster analysis was used to identify subgroups (leaning anti-longevity group vs. leaning prolongevity group), and their associations with personal attributes were tested using logistic regression models.

Results

Most respondents said they would wish to reach 100 years old (54.7%) and presented a leaning positive attitude toward centenarians (52.6%). Holding a negative attitude toward centenarians rather than any other attribute increases the odds of having more negative attitudes toward life extension.

Conclusion

Results stress the importance of social views on extreme longevity in shaping life extension attitudes.

Effect of Comedication With Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Retention of Tumor Necrosis Factor Inhibitors in Patients With Spondyloarthritis: A Prospective Cohort Study

OBJECTIVE

To evaluate whether use of comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) influences the retention of tumor necrosis factor inhibitors (TNFi) in patients with spondyloarthritis (SpA).

METHODS

Patients with SpA from the Rheumatic Diseases Portuguese Register who started treatment with their first TNFi between 2001 and 2014 were included in this study. Cox regression analysis was used to estimate the effect of comedication with csDMARDs on TNFi retention in 2 types of models: a model in which baseline (time-fixed) variables were included, and a second model incorporating time-varying variables, including sociodemographic features, measures of disease activity, measures of physical function, and cotreatment with other drugs (nonsteroidal antiinflammatory drugs and oral steroids). To control for possible confounding by indication, the effect of csDMARD comedication on TNFi retention was also tested after adjustment for the treatment propensity score.

RESULTS

In total, 954 patients were included in the study, of whom 289 (30.3%) discontinued treatment with their first TNFi after a median follow-up time of 2.5 years (range 0.08-13 years). Inefficacy was the most common reason for TNFi discontinuation (55.7% of patients). In the multivariable analyses, comedication with csDMARDs had no measurable effect on TNFi retention, neither in the baseline model (hazard ratio [HR] 0.83, 95% confidence interval [95% CI] 0.59-1.16) nor during follow-up in the model adjusted for time-varying covariates (HR 1.07, 95% CI 0.68-1.68). The effect of csDMARD comedication remained nonsignificant after propensity score adjustment.

CONCLUSION

Comedication with csDMARDs does not prolong TNFi retention in patients with SpA in clinical practice, suggesting that there is no benefit conferred by the concomitant use of these drugs.

Validation of European Portuguese Version of the Kwazo Instrument

Kwazo instrument was designed to assess the customer's satisfaction with prescription and attribution services of assistive technology. This paper presents the cross-cultural translation and validation of the European Portuguese version of the Kwazo, whose psychometric proprieties were assessed by customers of rehabilitation facilities of North and Centre of Portugal.

Remote Care Technology: A Systematic Overview

The present study was based on a systematic review of reviews and meta-analyses and aimed to identify technologies being used to provide home monitoring to support older adults with chronic diseases and to promote their empowerment, as well as to identify how these technologies impact health related outcomes.

Clinical features and long-term outcomes of systemic lupus erythematosus: comparative data of childhood, adult and late-onset disease in a national register

Systemic lupus erythematosus (SLE) affects predominantly women at reproductive age but may present at any age. Age at disease onset has a modulating effect on presentation and course of disease, but controversies persist regarding its impact on long-term outcome. Our aims were to characterize clinical features, co-morbidities and cumulative damage in childhood-onset, adult-onset and late-onset SLE. Patients with childhood-onset SLE fulfilling ACR 1997 criteria were identified in a nationwide register-Reuma.pt/SLE (N = 89) and compared with adult-onset and late-onset counterparts matched 1:1:1 for disease duration. 267 SLE patients with mean disease duration of 11.9 ± 9.3 years were analyzed. Skin (62 %), kidney (58 %), neurological (11 %) and hematologic involvement (76 %) were significantly more common in childhood-onset SLE and disease activity was higher in this subset than in adult- and late-onset disease (SLEDAI-2K 3.4 ± 3.8 vs. 2.2 ± 2.7 vs. 1.6 ± 2.8, respectively; p = 0.004). Also, more childhood-onset patients received cyclophosphamide (10 %) and mycophenolate mofetil (34 %). A greater proportion of women (96 %), prevalence of arthritis (89 %) and anti-SSA antibodies (34 %) were noted in the adult-onset group. There was a significant delay in the diagnosis of SLE in older ages. Co-morbidities such as hypertension, diabetes and thyroid disease were significantly more frequent in late-onset SLE, as well as the presence of irreversible damage evaluated by the SLICC/ACR damage index (20 vs. 26 vs. 40 %; p < 0.001). Greater organ involvement as well as the frequent need for immunosuppressants supports the concept of childhood-onset being a more severe disease. In contrast, disease onset is more indolent but co-morbidity burden and irreversible damage are greater in late-onset SLE, which may have implications for patients' management.

Rheumatoid arthritis and associated large granular lymphocytic leukemia--successful treatment with rituximab

Large granular lymphocytic (LGL) leukemia is an uncommon, usually indolent, lymphoproliferative disorder strongly associated with various autoimmune diseases. The authors report a case of a 67-year-old woman with a long-standing rheumatoid arthritis, who developed neutropenia and associated recurrent infections, diagnosed with LGL leukemia. We describe the treatment approach and the response to an anti-TNF and the rituximab.

Characterization of damage in Portuguese lupus patients: analysis of a national lupus registry

Background: Although the survival rate has considerably improved, many patients with systemic lupus erythematosus (SLE) develop irreversible organ damage. Objectives: The objectives of this paper are to characterize cumulative damage in SLE patients and identify variables associated with its presence and severity. Methods: A cross-sectional analysis of SLE patients from the Portuguese Lupus register Reuma.pt/SLE in whom damage assessment using the SLICC/ACR-Disability Index (SDI) was available was performed. Predictor factors for damage, defined as SDI ≥ 1, were determined by logistic regression analyses. A sub-analysis of patients with severe damage (SDI ≥ 3) was also performed. Results: In total, 976 patients were included. SDI was ≥1 in 365 patients, of whom 89 had severe damage. Musculoskeletal (24.4%), neuropsychiatric (24.1%) and ocular (17.2%) domains were the most commonly affected. Older age, longer disease duration, renal involvement, presence of antiphospholipid antibodies and current therapy with steroids were independently associated with SDI ≥ 1. The subpopulation with severe damage had, in addition, a greater interval between the first manifestation attributable to SLE and the clinical diagnosis as well as and more frequently early retirement due to SLE. Conclusions: This large lupus cohort confirmed that demographic and clinical characteristics as well as medication are independently associated with damage. Additionally, premature retirement occurs more often in patients with SDI ≥ 3. Diagnosis delay might contribute to damage accrual.

An investigation of the potential application of chitosan/aloe-based membranes for regenerative medicine

A significant number of therapeutics derived from natural polymers and plants have been developed to replace or to be used in conjunction with existing dressing products. The use of the therapeutic properties of aloe vera could be very useful in the creation of active wound dressing materials. The present work was undertaken to examine issues concerning structural features, topography, enzymatic degradation behavior, antibacterial activity and cellular response of chitosan/aloe vera-based membranes. The chitosan/aloe vera-based membranes that were developed displayed satisfactory degradation, roughness, wettability and mechanical properties. A higher antibacterial potency was displayed by the blended membranes. Moreover, in vitro assays demonstrated that these blended membranes have good cell compatibility with primary human dermal fibroblasts. The chitosan/aloe vera-based membranes might be promising wound dressing materials.

Results from a large multinational clinical trial (guardian™1) using prophylactic treatment with turoctocog alfa in adolescent and adult patients with severe haemophilia A: safety and efficacy

Recombinant factor VIII (rFVIII) products provide a safe and efficacious replacement therapy for prophylaxis and treatment of bleeding episodes in patients with severe haemophilia A. This multinational, open-label, non-controlled trial investigated the safety and efficacy of turoctocog alfa, a new rFVIII product. The primary objective was to evaluate safety. A total of 150 patients (24 adolescents and 126 adults) with severe haemophilia A (FVIII activity ≤ 1%), with at least 150 exposure days (EDs) to any FVIII product and no history of inhibitors were enrolled, and 146 patients (97%) completed the trial. All patients received prophylaxis with turoctocog alfa for approximately 6 months and had a mean of 85 EDs during the trial. None of the patients developed FVIII inhibitors, there were no indications of early FVIII inhibitor development and no safety concerns were identified. A total of 225 adverse events were reported in 100 (67%) patients, with the most common being events associated with dosing procedures, headaches, and nasopharyngitis. A total of 499 bleeding episodes were reported during the trial, the majority (89%) were controlled with 1-2 infusions of turoctocog alfa. Based on patient reports, the success rate (defined as 'excellent' or 'good' haemostatic response) for treatment of bleeding episodes was 81%. The overall median annualized bleeding rate was 3.7 (interquartile range: 8.7) bleeds/patient/year. In conclusion, turoctocog alfa provides a new, safe and effective alternative for prophylaxis and treatment of bleeding episodes in patients with haemophilia A.

Indoor air quality in elementary schools of Lisbon in spring

Analysis of indoor air quality (IAQ) in schools usually reveals higher levels of pollutants than in outdoor environments. The aims of this study are to measure indoor and outdoor concentrations of NO(2), speciated volatile organic compounds (VOCs) and carbonyls at 14 elementary schools in Lisbon, Portugal. The investigation was carried out in May-June 2009. Three of the schools were selected to also measure comfort parameters, such as temperature and relative humidity, carbon dioxide (CO(2)), carbon monoxide (CO), total VOCs, and bacterial and fungal colony-forming units per cubic metre. Indoor concentrations of CO(2) in the three main schools indicated inadequate classroom air exchange rates. The indoor/outdoor (I/O) NO(2) ratio ranged between 0.36 and 0.95. At the three main schools, the total bacterial and fungal colony-forming units (CFU) in both indoor and outdoor air were above the advised maximum value of 500 CFU/m(3) defined by Portuguese legislation. The aromatic compounds benzene, toluene, ethylbenzene and xylenes, followed by ethers, alcohols and terpenes, were usually the most abundant classes of VOCs. In general, the indoor total VOC concentrations were markedly higher than those observed outdoors. At all locations, indoor aldehyde levels were higher than those observed outdoors, particularly for formaldehyde. The inadequate ventilation observed likely favours accumulation of pollutants with additional indoor sources.