Study protocol for a randomized controlled trial testing the efficacy of Emotion Detectives In-Out: a blended version of the unified protocol for transdiagnostic treatment of emotional disorders in Portuguese children

BACKGROUND

Childhood emotional disorders (EDs; i.e., anxiety and depressive disorders) are currently a public health concern. Their high prevalence, long-term effects, and profound influence on the lives of children and families highlight the need to identify and treat these disorders as early and effectively as possible. This clinical trial will examine the efficacy of a blended version (i.e., combining face-to-face and online sessions into one treatment protocol) of the Unified Protocol for Children (the "Emotion Detectives In-Out" program). This program is a manualized cognitive-behavioral therapy for the transdiagnostic treatment of EDs in children aged 7 to 12 years that aims to reduce the intensity and frequency of strong and aversive emotional experiences by helping children learn how to confront those emotions and respond to them in more adaptive ways.

METHODS

This study is designed as a multicenter equivalence randomized controlled parallel-group two-arm trial comparing the Emotion Detectives In-Out program with an evidenced-based group intervention for children with anxiety disorders (the Coping Cat program). Participants will be children aged between 7 and 12 years with an anxiety disorder or with clinically significant anxiety symptoms as well as one of their parents or a legal representative. A minimum sample size of 138 children (69 per group) is needed to test whether the efficacy of the proposed intervention is equivalent to that of the well-established Coping Cat intervention.

DISCUSSION

We expect Emotion Detectives In-Out to be a feasible and efficacious alternative intervention for treating children's EDs by allowing for a greater increase in children's access to care. A blended format is expected to overcome common barriers to treatment (e.g., parents´ lack of time to attend regular sessions) and make the intervention more accessible to families.

TRIAL REGISTRATION

The clinical trial is registered at ClinicalTrials.gov (Identifier: NCT05747131, date assigned February 28, 2023).

Maternofetal outcomes in early-onset gestational diabetes: does weight gain matter?

AIM

Women with early-onset gestational diabetes mellitus (GDM) have overall lower gestational weight gain (GWG) compared to those with later-onset GDM, albeit with usually worse maternofetal outcomes. We intent to investigate the association between inadequate GWG and maternofetal outcomes in pregnant women with early-onset GDM.

METHODS

We performed a retrospective study of women with early-onset GDM based on the National Registry of GDM. Three study groups were defined according to the recommendations of the Institute of Medicine for GWG: excessive GWG (eGWG), adequate (aGWG) or insufficient (iGWG).

RESULTS

A total of 8040 pregnant women were included: 27% (n = 2170) eGWG, 31% (n = 2492) aGWG and 42% (n = 3378) iGWG. Preeclampsia (4.3 vs 3 vs 1.6%, p < 0.001), polyhydramnios (3.1 vs 2.3 vs 1.8%, p = 0.008) and cesarean section (37.4 vs 34.1 vs 29.5%, p < 0.001) were significantly more frequent among women with eGWG. Additionally, there was a higher frequency of macrosomia (8.1 vs 3.6 vs 2.4%, p < 0.001), large-for-gestational-age (8.2 vs 3.7 vs 2.6%, p < 0.001) and birth trauma (2.6 vs 1.5 vs 1.1%, p < 0.001) in this group. On the other hand, fetal death (0.2 vs 0.2 vs 0.5%, p = 0.04), small-for-gestational-age (9 vs 10.3 vs 14.9, p < 0.001) and preterm delivery (5.6 vs 7.1 vs 7.5%, p = 0.03) were more frequent in iGWG group.

CONCLUSIONS

Over two-thirds of pregnant women with early-onset GDM had inappropriate GWG, which was significantly associated with adverse maternofetal outcomes. Weight management must be a focus of special attention in women with early-onset GDM, beyond glycemic control, to achieve healthy pregnancy outcomes.

Poster No. 137 A very evident pulmonary thrombus

Clinical case

Female patient, 78 years-old, that complained of epigastric pain and intense fatigue for a week. While waiting in the urgency department, she became hypotensive, with refractory shock. Electrocardiogram showed sinus rhythm, 90 bpm, de novo right bundle block and infraST in the right precordial leads. The echocardiogram showed a dilated right ventricle (ratio RV/LV &gt; 1), with depressed function and major tricuspid regurgitation, RV/RA gradient of at least 55 mmHg. Left ventricle presented “D-shape”, preserved function and no segmental kinetic changes. The pulmonary artery was dilated and a serpentiform mass was visible, protruding through the pulmonary valve; similar masses were also visible in its branches. The diagnosis of pulmonary embolism (PE) was assumed and fibrinolysis was started, given there were no contra-indications.

One year before, she had an intermediate-risk PE in the context of COVID-19, with a similar echocardiographic presentation. She recovered RV function in the following months and stopped anticoagulation 3 months after that episode.

Discussion

PE can present with varying degrees of severity. Bedside echocardiography can be of major help in its diagnosis, especially in critical patients. The visualization of a thrombus in the pulmonary artery is rare, particularly in transthoracic echocardiogram. Echocardiogram is also useful for risk stratification and prognostic evaluation. This patient developed obstructive shock due to massive PE and the fibrinolytic treatment was paramount for her survival. A good echocardiogram helped in the differential diagnosis and enabled the Cardiologist to assist the patient in the best way.

Multimodality imaging for the assessment of left ventricular dynsfunction in cardio-oncology

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVD) is a key concern in the context of cardio-oncology (CO). Usually, referral for suspected Cancer therapy-related cardiac dysfunction (CTRCD) is the main challenge, but heart failure with other more common causes, such as ischemic cardiomyopathy can also decompensate during cancer treatment or be diagnosed incidentally during cardiotoxicity echocardiographic (echo) surveillance. Multimodality imaging is essential in these patients in order to better establish aetiology and assure the most appropriate clinical management.

Purpose

evaluate clinical impact of multimodality imaging in the clinical management of CO patients.

Methods

retrospective study of a population followed in CO consultation. Statistical analysis of demographic, clinical, transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) data was made.

Results

we included 115 pts, mean age 66.3 ± 10.2 years, 67,8% female, with mean follow-up of 16.1 ± 12.8 months. About half (56.5%) had breast cancer, followed by gastrointestinal tract (16.5%) and haematological (8,7%) malignancies, with a significant proportion (32,2%) with advanced disease. Prevalence of cardiovascular risk factors was high (hypertension in 74.8%, dyslipidaemia in 47%, type 2 diabetes mellitus in 17.4%), but also coronary artery disease (18,3%) and atrial fibrillation (18.3%). All of them were treated with different types of chemotherapy and 53,9% of pts with radiotherapy.  At baseline, 13% of pts had a left ventricular ejection fraction (LVEF) under 50% (LVD) assessed by TTE, which increased to 26,9% (n = 31) after oncological treatment initiation. Of these (n = 31), an ischemic aetiology was found in 32,3% and non-ischemic in 54,8%, which was significantly more frequent in patients with CTRCD (OR 2,7, p = 0,001). CMR was performed in 45,2%, mostly in CTRCD cases (p = 0,012, OR 8,4), which, apart from LVD, did not show any tissue changes in most patients (p = 0,026, OR 35). Only one patient with CTRCD (under treatment with trastuzumab and anthracyclines) had subepicardial late gadolinium enhancement, with wall motion abnormalities, suggesting a myocarditis-like mechanism for cardiotoxicity.

Conclusion

LVD has a major impact in patients" prognosis, particularly in CO context, where effective oncological treatments can be compromised due heart failure decompensation. Therefore, a thorough clinical evaluation should encompass etiological study in order to provide the most appropriate treatment strategies. Moreover, CTRCD can develop through different physiopathological mechanisms. Thus, multimodality imaging, particularly including CMR evaluation, can have a major role ensuring a good clinical outcome for these patients.

Never Too Old for Congenital Heart Disease: A Case of Cor Triatriatum Sinistrum and Mitral Valve Prolapse

Cor triatriatum is a congenital atrial abnormality, which comprises a membrane that divides the atrium into two chambers. Symptoms can arise either due to the obstructive nature of this membrane or related to other associated anomalies, such as atrial septal defects or abnormal pulmonary venous return.

The authors report the case of an adult male, in whom an incidental finding of cor triatriatum sinistrum was documented in association with mitral valve prolapse. However, both the late diagnosis and the association with mitral valve disease are uncommon.

Multimodality imaging evaluation can prove very helpful in these cases to better define the anatomy of the left atrium and appropriately plan for intervention when indicated.

Adverse in-hospital prognosis in patients with non-ST-segment elevation myocardial infarction with right bundle branch block – red flag ECG and sicker patients

Introduction

Recent recommendations regarding myocardial infarction (MI) underline the adverse prognosis associated with right bundle branch block (RBBB), suggesting that, in some cases of non-ST-segment elevation MI (NSTEMI) with RBBB a primary percutaneous coronary intervention (PCI) strategy should be considered. However, it is unclear if this is due to a more difficult and late diagnosis or to the clinical severity inherent to these patients (pts).

Purposes

To characterize the NSTEMI with RBBB population and find predictors of worse prognosis.

Methods

Retrospective analysis of pts included in the Portuguese Registry of Acute Coronary Syndromes with NSTEMI, comparing pts with RBBB (group A) vs without RBBB (group B), regarding clinical and demographic variables, diagnostic and therapeutic approaches. Primary endpoint was heart failure, electrical and mechanical complications and death in the in-hospital period.

Results

We included 9375 pts, 686 in group A and 8689 in group B. Pts in group A were more likely to be male (p&lt;0.001) and over 75 years old (p&lt;0.001). Also, they were more prone to have cardiovascular risk factors (hypertension - p&lt;0.001, diabetes – p&lt;0.001) and history of coronary artery disease (stable angina p=0.007, previous MI p=0.002 and revascularization, either PCI – p=0.016 or surgery – p&lt;0.001), stroke (p&lt;0.001), chronic kidney disease (p&lt;0.001) and cancer (p=0.025), comparing to pts in group B. There were no differences between time from onset of symptoms and first medical contact or hospital admission between groups. Upon admission, these pts presented more frequently with hypotension (p=0.026), Killip class&gt;II (p&lt;0.001) and atrial fibrillation (p&lt;0.001) than pts in group B. There were statiscally significant differences between groups, regarding the use of inotropes (p&lt;0.001), non-invasive (p=0.008) and invasive ventilation (p=0.018) and temporary pacing (p=0.001), all of them higher in group A.

Pts with RBBB were less likely to undergo coronary angiography (CA) (p&lt;0.001). However, among those who did, there were no differences in CA timing (p=0.091), but pts from group A had more frequently multivessel disease (p=0.044) and no revascularization was undertaken (p=0.012).

About 16.64% of all pts reached the endpoint, but unfavourable in-hospital outcome was significantly more common in group A (p&lt;0.001). RBBB remained an independent predictor of the endpoint (p=0.032) in a multivariate regression analysis, controlled for other variables (namely gender, age, cardiovascular risk factors, previous evidence of cardiovascular disease, and clinical and coronary anatomy data) – AUC of 0.833.

Conclusion

Although pts with NSTEMI and RBBB have a poorer in-hospital prognosis, partly due to their bigger clinical complexity (older age, multiple comorbidities and complex coronary anatomy), RBBB itself still remains an independent predictor of worse outcome.

Funding Acknowledgement

Type of funding sources: None.

Mild periconceptional hyperglycemia: predictor of adverse fetomaternal outcomes in gestational diabetes?

AIM

To clarify whether mild first trimester hyperglycaemia (characteristic of early-onset GDM) is associated with higher incidence of congenital malformations and other adverse fetomaternal outcomes compared to women with second trimester hyperglycaemia (later-onset GDM).

DESIGN AND METHODS

We analyzed the Portuguese National GDM database, containing data collected between 2011 and 2017. Two study groups were defined: Group 1-Women with GDM diagnosed during the first trimester (with fasting glycemia ≥ 92 and < 126 mg/dL); Group 2-Women with GDM diagnosed after the first 12 weeks of gestation, with either fasting glycemia or oral glucose tolerance test, according to the International Association of Pregnancy and Diabetes Study Group criteria. The fetomaternal characteristics of each group were compared.

RESULTS

A total of 18.518 pregnant women diagnosed with GDM were included which 34.4% of them belonged to Group 1. Pregnant women from this group were significantly younger and had a higher median BMI than the women from the other group. Overall, there was no significant differences in maternal morbidity parameters between groups. Non-evolutive pregnancies were significantly more frequent along the present gestation in the group 1 (1.1% vs. 0.1%, p < 0.001), as was fetal death (0.6% vs. 0.2%, p < 0.001). Congenital malformations did not differ significantly between groups (3.2% vs. 2.8%, p = 0.155).

CONCLUSIONS

The mild near conceptional hyperglycaemic state characteristic of an early-onset GDM seems to be associated with an increased prevalence of non-evolutive pregnancies and foetal deaths when compared to later-onset GDM.

Recurrent myocarditis in the context of Behçet's disease: a case report

Background

Behçet’s syndrome is a multisystemic vasculitis of unknown aetiology. Cardiac involvement is rare, with described prevalence between 1% and 46%, with pericarditis, valvular insufficiency, intracardiac thrombosis, and eventually sinus of Valsalva aneurysms being the most common findings. Although previously reported, myocarditis is a very rare complication of Behçet’s syndrome.

Case summary

A 26-year-old man, smoker but otherwise healthy, was admitted to the emergency department with atypical chest pain, with no radiation, relation to efforts, position or deep inspiration, and dyspnoea, since the day before. His physical examination was unremarkable, including no fever, tachycardia, or pericardial friction rub. Electrocardiogram (ECG) revealed an early repolarization pattern, with no changes noted in subsequent exams. He had elevation of inflammatory parameters and an increased high-sensitivity troponin level of 3300 ng/L. Transthoracic echocardiography (TTE) was unremarkable. Coronary angiography showed no coronary stenosis. A presumed diagnosis of non-complicated viral myocarditis was established. The patient’s condition improved with acetylsalicylic acid as needed and colchicine and he was discharged after 3 days. Cardiac magnetic resonance was performed, showing late epicardial enhancement in the apical segment of the lateral wall, supporting the diagnosis of myocarditis. Four months later, the patient returned with recurrence of chest pain. Additionally, he also complained of fever, odynophagia, and otalgia since the previous week. Oropharyngeal examination revealed tonsillar pillars aphthosis. The ECG was similar to the previous and TTE was normal. Bloodwork revealed once again elevation of inflammatory parameters and elevation of troponin. Recurrent myocarditis was diagnosed. Treatment with ibuprofen, colchicine, and antibiotic therapy was started with no significant improvement. After a more thorough physical examination, an ulcerated scrotal lesion, a left buttock folliculitis, and an axillary hidradenitis were found, which, according to the patient, were recurrent in the last year. Accordingly, the diagnosis of Behçet’s syndrome with mucocutaneous and cardiac involvement was established. The patient was kept on colchicine and was also started on immunosuppressive therapy with corticosteroids and azathioprine, with resolution of the symptoms in the following day. A positron emission tomography (PET) was performed 2 days after discharge and showed a higher myocardial uptake in the left ventricular basal segments and both papillary muscles. Prednisolone tapering was started after 2 months, while maintaining azathioprine. At 1-year follow-up, the patient remained asymptomatic. A re-evaluation PET was performed, showing no images suggestive of metabolically active disease in the myocardium.

Discussion

This case highlights the importance of awareness of this rare but potentially serious entity and reinforces the significance of aetiology investigation in cases of recurrent myocarditis. It also shows the success of immunosuppressive therapy in a context where the optimal management is still considerably uncertain.

Impact of pre-treatment with acetylsalicylic acid on the severity of a first myocardial infarction in diabetic patients

Introduction

Diabetes Mellitus (DM) is one of the main risk factors for cardiovascular disease (CVD). Guidelines on the use of acetylsalicylic acid (ASA) for primary prevention of CVD in this population are conflicting. A potential reduction in the severity of a first episode of Acute Myocardial Infarction (AMI) could be seen has an additional argument for the use of ASA in primary prevention. Aim: To evaluate the impact of prior intake of ASA on the presentation, severity and short-term prognosis of AMI in diabetic patients without history of CVD.

Methods

Retrospective analysis of diabetic patients without previous evidence of CVD diagnosed with type 1 AMI between January 2002 and December 2018, inserted in a multicentric registry of acute coronary syndromes. Patients were dichotomized according to whether or not they were taking ASA prior to the index event. Groups were compared according to clinical, analytical and imaging endpoints.

Results

A total of 2596 patients were included, predominantly men (66.4%), with a mean age of 68±12 years old. Patients on ASA (19.7%) were significantly older (71±10 vs. 67±12, p&lt;0.001) and had a higher prevalence of hypertension (89.2% vs 77.9%, p&lt;0.001), dyslipidaemia (69.8% vs. 61.1%, p&lt;0.001) and chronic kidney disease (10.6% vs. 4.9%, p&lt;0.001). Overall, there was a lower prevalence of AMI with ST-segment elevation (36.5% vs. 50.8%, p&lt;0.001) in patients on ASA. However, the same group of patients had a significantly higher probability of evolution in Killip class &gt; I (25.4% vs. 17.0%, p&lt;0.001), a higher median BNP elevation (315 [126–623] vs. 166 [64–431], p&lt;0.001); and a lower average ejection fraction upon discharge (49.0±12 vs. 51±12, p=0.011). Patients on prior regular intake of ASA also had a higher prevalence of multivessel disease (38.4% vs. 28.9%, p&lt;0.001) and multiple significant stenosis (70.2% vs. 61.7%, p&lt;0.001). There was no significant difference regarding the percentage of electrical complications (2.3% vs. 1.2%, p=0.06), use of intra-aortic balloon pump (1.0 vs. 0.9%, p=0.74) and in-hospital death (3.0% vs. 2.4%, p=0.46). In a logistic regression model adjusted for age, sex, comorbidities and previous medication as variates, prior ASA intake was an independent predictor of a lower rate of AMI with ST-segment elevation (ExpB −0.34; 95% CI: 0.57–0.89; p=0.003). On the contrary, when adjusted to these variables, prior ASA intake was not an independent predictor of higher BNP (p=0.13) or higher probability of multivessel disease (p=0.22) or presence of ≥1 significant stenosis (p=0.31).

Conclusions

In this population of diabetic patients with a first episode of ACS, prior use of ASA in the context of primary prevention was associated with a significant lower rate of ST-segment elevation myocardial infarction.

Funding Acknowledgement

Type of funding source: None

Genomic Regions 10q22.2, 17q21.31, and 2p23.1 Can Contribute to a Lower Lung Function in African Descent Populations

Accumulated evidence supports the contribution of genetic factors in modulating airway function, especially ancestry. We investigated whether genetic polymorphisms can affect lung function in a mixed Brazilian child population using the admixture mapping strategy through RFMix software version 1.5.4 (Stanford University, Stanford, CA, USA), followed by fine mapping, to identify regions whereby local African or European ancestry is associated with lung function measured by the forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) ratio, an indicator of airway obstruction. The research cohort included 958 individuals aged 4 to 11 years enrolled in the SCAALA (Social Change, Asthma, Allergy in Latin America) Program. We identified that African ancestry at 17q21.31, 10q22.2, and 2p23.1 regions was associated with lower lung function measured by FEV1/FVC p < 1.9 × 10-4. In contrast, European ancestry at 17q21.31 showed an opposite effect. Fine mapping pointed out 5 single nucleotide polymorphisms (SNPs) also associated in our replication cohort (rs10999948, rs373831475, rs8068257, rs6744555, and rs1520322). Our results suggest that genomic regions associated with ancestry may contribute to differences in lung function measurements in African American children in Brazil replicated in a cohort of Brazilian adults. The analysis strategy used in this work is especially important for phenotypes, such as lung function, which has considerable disparities in terms of measurements across different populations.

P887 Two sides of the same mass

Echocardiography (echo) remains the first-line imaging modality for the evaluation of cardiac masses. Three-dimensional (3D) echo, either transthoracic or transesophageal (TTE and TEE respectively), has allowed for better definition imaging, providing more information about the size, mobility, attachment and relation of these lesions with cardiac structures. Nevertheless, due to its superior tissue characterization capability, other imaging techniques, such as cardiac magnetic resonance (CMR), are very helpful in the differential diagnosis, making multimodality imaging the most attractive option for the study of intracardiac masses.

We present the case of a 85 year-old male, with paroxysmal atrial fibrillation (under effective anticoagulation), type 2 diabetes mellitus, hypertension, referred for the study of an asymptomatic cardiac mass found in a routine TTE. There were no relevant findings on physical examination. The TTE showed a bilobar spheroid mass, in the right atrium, attached to the interatrial septum, with 33x23mm and regular edges. A 3D TEE was performed confirming the previous findings, but also showing extension of this mass through the fossa ovalis membrane, reaching the left atrium; this aspect raised the doubt about either protrusion or invasion of the left atrium and, respectively, a benign (like a myxoma) versus malignant behaviour (such as a sarcoma). To better characterize this lesion, a CMR was ordered, which revealed a bilobar heterogeneous mass, attached to the right side of the interatrial septum, at the fossa ovalis membrane, without signs of adjacent tissue invasion, namely unequivocal invasion of the left atrium; it presented with intermediate T1 signal, hyperintense T2 signal and heterogeneous pattern of gadolinium enhancement, features mostly in favour of a right atrial myxoma. The complimentary study found no other relevant changes, namely no findings suggestive of endocarditis (negative blood cultures), autoimmune disease or malignancy. The patient refused undergoing heart surgery and, therefore, kept follow-up with clinical and echocardiographic stability.

Although histological examination remains the only tool for definitive diagnosis, multimodality imaging allows a quite comprehensive evaluation of intracardiac masses, enlightening the differential diagnosis. Here the imaging findings helped to establish a benign origin as the most likely, very important in this case of a probable right atrial myxoma, due to its peculiar protrusion to the left atrium through the fossa ovalis membrane.

Abstract P887 Figure. atrial myxoma

1098 Atrial thickening: a surprisingly "gouty" heart

Case Presentation

A 49 year-old male presented to the emergency department with fever and lower limb myalgia for 5 days. His past history was notable for acute episodes of microcrystalline pyrophosphate oligoarthritis for which he was receiving allopurinol 100mg, colchicine 1mg and prednisolone 5mg. Physical examination was unrevealing. Laboratory workup showed normocytic normochromic anemia (Hb 12.8g/dL), leukocytosis (22 490 /mm3), neutrophilia (86.8%), increased C-reactive protein (CRP

26mg/dL), low procalcitonin (0.82ng/mL) and mildly elevated creatinine-kinase (83 UI/L). The patient was admitted with fever of unknown origin and started on ceftriaxone after blood and urine cultures.

He remained febrile with persistently heightened inflammation. Cultures, infectious and auto-immune tests, bone marrow biopsy, myelogram and abdominopelvic CT scan were negative. Three weeks later, syncope due to complete atrioventricular (AV) block led to temporary pacemaker implantation. Transoesophageal echocardiography (TOE) revealed a left atrial (LA) wall thickening,

evident on MRI as an 8-10mm T2-hyperintensity sign, with right atrial (RA) and ventricular sparing. PET/CT scan showed an 18F FDG uptake exclusively in the LA. As a neoplasia was highly suspected, a transspeptal biopsy was attempted, yet the sample was scarce for analysis. Thus, a biopsy via sternotomy was performed, now sampling both the LA and RA. Indeed, repeated TOE showed de novo RA involvement with a prominent nodular finding (19x24mm) in the lateral wall.

Myocyte inflammation and necrosis accompanied with granulocyte infiltration (mostly neutrophils but also eosinophils) was observed in all samples. There were no findings suggestive of neoplasia. The patient was still on allopurinol, which has been reported to involve the myocardium in a late (type IV) hypersensitivity reaction (the so-called DRESS syndrome), even in the absence of systemic inflammation. Thus, allopurinol was stopped and 1mg/Kg prednisolone was started. The patient

significantly improved and was discharged home with negative CRP the following two weeks. After 1 month, MRI was repeated and no atrial inflammation was found. After 4 months follow-up, he is doing well on 2.5mg of prednisolone and febuxostat 80mg.

P5242Gender equality in acute coronary syndrome: modern times, old habits?

Introduction

Historically, women with acute coronary syndrome (ACS) have worse outcomes compared with men. Differences in clinical, demographic characteristics and treatment may explain this result. In recent times with new diagnostic capabilities and revascularization therapies this panorama may be changing.

Methods

Single-center retrospective study comparing gender differences in ACS patients from 2012 to 2017. Two groups were formed comparing women and men: Group A: years 2012 to 2014 and group B: years 2015 to 2017.

Results

From 2012 to 2017 we identified 1091 patients with ACS. Of them 356 (32,6%) were women and NSTEMI (60%) was the most frequent type of ACS in this group. Women with ACS were older than men (73 vs 66 years) had more arterial hypertension (83,4% vs 68,3% p<0,001), diabetes mellitus (46,3% vs 30,9% p<0,001) and were less frequently smokers (6,5% vs 25,3% p<0,01). Dyspnea as the predominant symptom was more frequent in women (10,4% vs 5,2% p=0,002) who were less submitted to invasive strategy (63,2% vs 74,7% p<0,001) where non obstructive disease was more prevalent compared to men (9,8% vs 3,3% p<0,001). In-hospital mortality was greater in the women group (7,9% vs 3,7% p=0.005). There were no differences between groups in hospitalization or cardiovascular mortality over 1-year follow-up. When comparing Group A with Group B there were differences in hospitalization at 1 year (Group A 15,4% vs 9,3% p=0,029, Group B 11% vs 12,4% p=0,766), in-hospital women mortality (Group A 9,5% vs 3,6 p=0,005, Group B 5,8 vs 3,8% p=0,346) and coronary invasive angiography (Group A 61,2% vs 80,2% p<0,001 vs Group B 65,8 vs 68,5%, p=0,606).

Conclusion

Different demographic and clinical presentation as well as in-hospital and 1-year outcomes were present in our study population: while in Group A threre were significant gender differences regarding hospitalization and in-hospital mortality, those differences faded away in Group B. Efforts should be made to lessen gender differences in treatment and assistance knowing the different demographical and clinical patient profile.

Predictors and outcomes of disseminated tuberculosis in an intermediate burden setting

SETTING

University-affiliated hospital located in Porto, North Portugal, an area with a low to intermediate incidence of tuberculosis (TB).

OBJECTIVE

To identify predictors and outcomes of disseminated TB (dTB).

DESIGN

A cohort of patients diagnosed with TB between 2007 and 2013 was retrospectively analysed. Patients with dTB criteria were characterized and compared to single organ TB cases. Factors independently associated with dTB were determined by multivariate logistic regression analysis.

RESULTS

A total of 744 patients were analysed, including 145 with dTB. Independent risk factors for dTB were pharmacological immunosuppression (OR 5.6, 95% CI 2.8-11.3), HIV infection (OR 5.1, 95% CI 3.1-8.3), chronic liver failure or cirrhosis (OR 2.3, 95% CI 1.4-4.1) and duration of symptoms (OR 2.3, 95% CI 1.4-3.8). Compared to single organ TB, the clinical presentation of dTB patients differed by the absence of haemoptysis (OR 3.2, 95% CI 1.3-8.4) and of dyspnoea (OR 1.9, 95% CI 1.2-3.1), presence of weight loss (OR 1.8, 95% CI 1.1-2.9), night sweats (OR 1.7, 95% CI 1.1-2.7) and bilateral lung involvement (OR 4.4, 95% CI 2.8-7.1). Mortality and time until culture conversion were higher for dTB patients, although not reaching statistical significance.

CONCLUSION

Immunosuppressive conditions and chronic liver failure or cirrhosis were associated with increased risk of dTB. The haematogenous spread may be dependent on longer symptomatic disease and usually progresses with bilateral lung involvement.

Light chain cardiac amyloidosis - a rare cause of heart failure in a young adult

Cardiac amyloidosis is an infiltrative cardiomyopathy, resulting from amyloid deposition within the myocardium. In primary systemic (AL-type) amyloidosis, the amyloid protein is composed of light chains resulting from plasma-cell dyscrasia, and cardiac involvement occurs in up to 50% of the patients We present a case of a 43-year-old man, with complaints of periodical swollen tongue and xerostomia, bleeding gums and haematuria for two months. His blood results showed normocytic anaemia, thrombocytopenia and a high spontaneous INR, therefore he was referred to the Internal Medicine clinic. In the first visit, he showed signs and symptoms of overt congestive heart failure and was referred to the emergency department. The electrocardiogram showed sinus tachycardia and low voltage criteria. Echocardiography showed biventricular hypertrophy with preserved ejection fraction, restrictive physiology with elevated filling pressures, thickened interatrial septum and atrioventricular valves, small pericardial effusion and relative "apical sparing" on 2D longitudinal strain. Cardiac MRI showed diffuse subendocardial late enhancement. Serum protein electrophoresis was inconclusive, however urine analysis revealed nephrotic range proteinuria, positive Bence Jones protein and an immunofixation test with a monoclonal lambda protein band. Abdominal fat biopsy was negative for Congo red stain, nevertheless a bone marrow biopsy was performed, revealing lambda protein monoclonal plasmocytosis, confirming the diagnosis of primary systemic amyloidosis. This case represents a rare cause of heart failure in a young adult. Low-voltage QRS complexes and typical echocardiography features should raise the suspicion for cardiac amyloidosis. Prognosis is dictated by the level of cardiac involvement; therefore, early diagnosis and treatment are crucial.

ENVIRONMENTAL MONITORING WITH PASSIVE DETECTORS AT CTN IN PORTUGAL

The aim of this work is to present the methods in use for environmental dose assessment with passive detectors at Campus Tecnológico e Nuclear (CTN) of Instituto Superior Técnico, in Portugal. The methods are based on LiF:Mg,Ti (TLD-100) detectors inserted in Harshaw holders placed at four locations and exchanged on a quarterly basis. An initial group of measurements allowed the estimation of the time interval necessary to attain a stable value, the determination of a fading factor, as well as the calculation method for the assessment of the ambient dose equivalent rate.

FADING EFFECT OF LiF:Mg,Ti AND LiF:Mg,Cu,P Ext-Rad AND WHOLE-BODY DETECTORS

Thermoluminescence dosemeters are widely used in individual and environmental monitoring. The aim of this work was to compare the thermal stability of dosemeters of the Ext-Rad and whole-body card types with LiF:Mg,Ti and LiF:Mg,Cu,P detectors stored at different temperatures and periods. The dosemeters were stored at 0°C, room temperature and 40°C for periods that lasted 8, 30, 45, 90 and 120 d. In general, TLD-100H detectors present higher TL signal stability than TLD-100 detectors. The intensity of the signal remained constant for both materials for storage periods at 0°C. At RT the same results was observed for TLD-100H. For TLD-100 detectors, a maximum variation of 22 % was registered for the longest period. At 40°C the TL signal decreased with storage time for both detectors. The TL signal of TLD-100H detectors presented maximum variations of 12 % whereas for TLD-100 detectors, larger variations of 25 % were observed.

Cushing's syndrome due to ectopic ACTH production by a nasal paraganglioma

Ectopic secretion of ACTH is an infrequent cause of Cushing's syndrome. We report a case of ectopic ACTH syndrome caused by a nasal paraganglioma, a 68-year-old female with clinical features of Cushing's syndrome, serious hypokalaemia and a right paranasal sinus' lesion. Cranial magnetic resonance image showed a 46-mm mass on the right paranasal sinuses. Endocrinological investigation confirmed the diagnosis of ectopic ACTH production. Resection of the tumour normalised ACTH and cortisol secretion. The tumour was found to be a paraganglioma through microscopic analysis. On follow-up 3 months later, the patient showed nearly complete clinical recovery. Ectopic ACTH syndrome due to nasal paraganglioma is extremely uncommon, as only two other cases have been discussed in the literature.

CrmE, a novel soluble tumor necrosis factor receptor encoded by poxviruses

Cytokines and chemokines play a critical role in both the innate and acquired immune responses and constitute prime targets for pathogen sabotage. Molecular mimicry of cytokines and cytokine receptors is a mechanism encoded by large DNA viruses to modulate the host immune response. Three tumor necrosis factor receptors (TNFRs) have been identified in the poxvirus cowpox virus. Here we report the identification and characterization of a fourth distinct soluble TNFR, named cytokine response modifier E (CrmE), encoded by cowpox virus. The crmE gene has been sequenced in strains of the orthopoxviruses cowpox virus, ectromelia virus, and camelpox virus, and was found to be active in cowpox virus. crmE is expressed as a secreted 18-kDa protein with TNF binding activity. CrmE was produced in the baculovirus and vaccinia virus expression systems and was shown to bind human, mouse, and rat TNF, but not human lymphotoxin alpha, conjugates of lymphotoxins alpha and beta, or seven other ligands of the TNF superfamily. However, CrmE protects cells only from the cytolytic activity of human TNF. CrmE is a new member of the TNFR superfamily which is expressed as a soluble molecule that blocks the binding of TNF to high-affinity TNFRs on the cell surface. The remarkable finding of a fourth poxvirus-encoded TNFR suggests that modulation of TNF activity is complex and represents a novel viral immune evasion mechanism.