Access to cardiac rehabilitation programs in patients with acute coronary syndrome: can referral be a step towards improvement? Insights from a multicentre national registry

 

The burden of cardiovascular disease remains on top of society's health problems, and acute coronary syndromes are undoubtedly a major cause. Cardiac rehabilitation programs (CRP) have been demonstrated to be a cost-effective strategy in reducing morbimortality and improving quality of life after an acute event. Despite this evidence and clinical recommendations, CRP are still globally underused. The lack of referral patients to CRP has been appointed as an important impediment to patients' participation.

This study aimed to clarify the main features of referred patients to CRP vs non-referred patients after an acute coronary syndrome (ACS).

The authors performed a retrospective analysis of adult patients with information about CRP destination, included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and December 2021. Comparison tests for parametric and non-parametric variables were performed. Logistic regression was applied for multivariate analysis. A p-value less than 0.05 was considered statistically significant.

A total of 28809 patients admitted for ACS were analysed, 22896 (79.5%) not referred for CRP (group 1) and 5913 (20.5%) were referred or even had a planned CRP. Table 1 shows the most important baseline characteristics and differences between groups. Table 2 demonstrate the group differences regarding admission diagnosis, complementary study results and in-hospital complications. Multivariate analysis established the following variables as independent factors for non-referral for CRP: age greater than 75 years (OR 0.80, 95% CI [0.72, 0.89]), history of valvular disease (OR 0.76, 95% CI [0.59, 0.97]), history of kidney disease (OR 0.65, 95% CI [0.54, 0.79]), admission diagnosis of unstable angina (UA) (OR 0.37, 95% CI [0.27, 0.50]), multivessel disease (OR 0.73, 95% CI [0.67, 0.80]), left ventricular ejection fraction less than 50% (OR 0.76, 95% CI [0.68, 0.84]), mechanical complication of myocardial infarction (OR 0.26, 95% CI [0.10, 0.67]) and acute heart failure during hospitalization (OR 0.67, 95% CI [0.58, 0.77]).

In conclusion, contrary to international results, women and patients with non-ST-segment elevation myocardial infarction were not negative predictors for referral to CRP. However, we observed that in our country, older patients, those with UA as an admission diagnosis, comorbidities and/or reduced systolic function are less referred to CRP by physicians. Paradoxically, these patients often have greater disease management complexity and poor outcomes. Besides that, the beneficial effects of cardiac rehabilitation in these groups have been demonstrated. Thus, it is extremely important to understand the limitations of referral in our country and implement strategies to overcome them.

Funding Acknowledgement

Type of funding sources: None.

Phase III impact of telerehabilitation in patients with coronary heart disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) in coronary heart disease (CAD) has been shown to improve physical capability and health-related quality of life, reducing morbimortality. However, CR accessibility is still low and patient adherence remains poor. It has been hypothesized that using mobile applications to telemonitor exercise-based CR would increase patient adherence to CR, improving results. Hybrid cardiac telerehabilitation (HCTR) is a new concept that includes center and home interventions.

Objectives

Investigate the effects of HCTR program on improving physical activity, quality of life and reducing cardiovascular risk factors among patients with CAD 1 year after CR phase II.

Materials and methods

Longitudinal retrospective study with patients who attended phase 2 CR program (CRP) at a hospital center between august 2018-november 2020. They were divided in 2 groups: group 1 completed conventional CRP (CCRP), 12 weeks of monitored hospital physical exercise and educational sessions; group 2 participated on HCTR program (CCRP associated to a tele-monitorization platform consisting of a mobile application, MOVIDA.eros, with medical prescription of physical exercise and remote interaction). Group 2 maintained use of MOVIDA.eros on phase 3. Evaluations were performed on T0 – phase 2 onset, T1 – end of phase 2, T2 – 1 year after T1, with registration of age, gender, occupation, body mass index (BMI), exercise stress testing, echocardiogram (evaluation of left ventricular ejection fraction [LVEF]), LDL, HDL cholesterol, triglycerides, NTproBNP levels, and application of EuroQol-5D questionnaire (EQ5D), International Physical Activity Questionnaire – Short Form (IPAQ).

Statistical analysis was completed through software SPSS v28. p-values <0.05 were considered statistically significant.

Results

We analyzed 68 patients, 46 on group 1 and 22 on group 2. Variable analysis revealed similar group characteristics, except for age (p=0.011) and LVEF (p=0.005). There was an association between HCTR adherence and occupation (p=0.002; greater proportion of intellectual professionals on group 2). We observed a significant IPAQ (p=0.018) and EQ-5D index (p=0.034) improvement between T0 to T1 in both groups, but only in group 2 persisted till T2. In exercise stress testing, both groups revealed an increase in METs at T1 and decrease at T2, without significant differences between them. Regarding lipid profile, HbA1c, NTproBNP and BMI, both groups improved from T0 to T1 maintaining it till T2 with no differences between them, however in group 2 HDL cholesterol levels were greater and HbA1c levels were lower than group 1. In both groups, LVEF increased from T0 to T1 and from T1 to T2 in both groups, with faster and higher improvement in group 2.

Conclusions

HCTR outperformed CCRP improving physical activity, patient quality of life, HDL cholesterol and faster improvement of LVEF. These findings encourage the use of a mobile platform in CR.

Hybrid cardiac telerehabilitation program as a potential strengthening factor in the quality of life in patients with coronary heart disease: a retrospective single-centre analysis

 

Cardiac rehabilitation (CR) has well known beneficial effects on physical capacity, health-related quality of life, morbidity and mortality in patients with coronary artery disease (CAD). However, underuse of CR and not sustained improvements have been noted. It has been proposed that telemonitored exercise-based CR, by the use of mobile applications, can improve patient adherence to CR programs providing better outcomes.

The aim of this study was to investigate the effects of telemonitored cardiac rehabilitation on physical capacity, health-related quality of life and control of cardiovascular risk factors among patients with CAD on phase 2 of the Cardiac Rehabilitation Program (CRP).

A retrospective study was conducted and patients in CRP between 2017 and 2020 were included. Patient selection and information collection were obtained through medical records. Outcomes were Body Mass Index, Hospital Anxiety and Depression Scale (HADS), EuroQol-5D score (EQ-5D), International Physical Activity Questionnaire (IPAQ), estimated functional capacity in cardiac stress test, lipid panel and glycated hemoglobin. Patients were divided into two groups: group 1 followed the conventional strategy and group 2 followed a hybrid telemonitored CRP, with the use of MOVIDA mobile application. Variables were analysed in the beginning (T0) and in the end (T1) of the phase 2, around 3 months after. Group comparisons tests and multivariate logistic regression were performed. A p-value less than 0.05 is statistically significant. Statistical analysis was performed using SPSS software v25.0.

We analysed 107 patients, which 93 of these were assiduous and 69 concluded the phase 2 of CRP: 44 patients in group 1 and 25 patients in group 2. Two groups have similar baseline characteristics, except for age (p=0.02). It appears that participation in the PRC led to an improvement in physical capacity, mental well-being, and in lipid panel, regardless of the strategy. The improvement in quality of life, quantified by EQ-5D, was significant only in group 2 (p=0.03). There is also no correlation between age and the differences recorded in EQ-5D (p=0.86).

We hypothesise that, when compared to conventional CRP, cardiac telemonitored exercise using modern communication methods and on-demand coaching will result in an improved behavioural change, which translates to higher quality of life. Further studies including more patients and the phase 3 of CRP are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None.

Is there a real difference in approach between women and men with non-ST-segment elevation myocardial infarction? Insights from a multicentre national registry

 

In patients with non-ST-elevation myocardial infarction (NSTEMI), the early invasive strategy has shown benefit in morbidity and mortality, especially in intermediate-to-high risk patients. However, women still seem to have a lower revascularization rate, regardless of the risk.

The aim of this study is to describe our clinical practice reality about the performance of the invasive strategy between genders among NSTEMI patients, in Portugal.

The authors performed a retrospective analysis of patients admitted with NSTEMI included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and February 2021. A propensity score matching included baseline characteristics and previous history was applied. Comparison tests and log-rank test were performed. A p-value less than 0.05 was considered statistically significant.

A total of 11858 patients with NSTEMI were included, of which 71.3% (n=8450) were men. After the propensity score performing, 4458 patients were analysed, 50.0% (n=2229) men. Table 1 shows the most important baseline characteristics.

The authors found a significant delay in hospital admission after the onset of symptoms in women (median of 6 hours and 48 minutes) compared to men (median of 5 hours) (p<0.01). Grace score was higher in males (mean 153 points) than in females (mean 145 points) (p<0.01).

The cardiac catheterization was performed in 82.9% (n=3695) of the patients, with no difference between genders (p-value=0.19), as shown in table 2. Among those who underwent cardiac catheterisation, the presence of significant stenosis and coronary occlusion was greater in males, for almost all localizations. The absence of obstructive coronary lesions was more common in females (p-value<0.01).

During hospitalization, sustained ventricular tachycardia was more prevalent in males (p-value =0.01), with no significant difference for other complications or in-hospital mortality.

A 1-year follow-up of 2351 patients (1184 men and 1163 women) was analysed, with survival of 91.2% (n=1080) in men and 91.0% (n=1056) in women, with no significant difference (p-value=0.80).

In conclusion, we observed that women are admitted to the hospital later than men and have a lower Grace score at admission. However, the standardized analysis of the groups allows us to infer that the invasive strategy does not seem to be less frequent or late in women, as observed in other populations. A more recent analysis, including risk groups, would be interesting to clarify the results.

Funding Acknowledgement

Type of funding sources: None.

Hybrid cardiac rehabilitation program as a potential enhancer of adherence to cardiac rehabilitation in smoking patients with coronary heart disease - a retrospective single-centre analysis

Funding Acknowledgements

Type of funding sources: None.

Cardiac rehabilitation (CR) has well known beneficial effects on physical capacity, health-related quality of life, morbidity and mortality following an acute cardiac event. It is also known that smoking status is a powerful predictor of recurrent cardiovascular disease events. However, it has been noted that smoker patients may be less likely to access or complete CR.

The aim of this study was to determine the levels of anxiety and depression and its improvement, depending on the smoking status of patients with coronary artery disease (CAD) on phase 2 of the Cardiac Rehabilitation Program (CRP). Additionally, we intend to investigate the mental health impact on smoker patients" group in conventional CR versus telemonitored CR.

A retrospective study was conducted and patients in CRP between 2017 and 2020 were included. Patient selection and information collection were obtained through medical records. The outcomes of anxiety and depression were evaluated through the Hospital Anxiety and Depression Scale (HADS). Patients were divided into two groups: group 1 for non-smokers or ex-smokers and group 2 for smokers. For group 2 patients, a sub-analysis was performed for patients following the conventional CR versus the telemonitored CR, with the use of MOVIDA mobile application. Variables were analysed in the beginning (T0) and in the end (T1) of phase 2, around 3 months after. Group comparisons tests and statistical analysis were performed using SPSS software v25.0. A p-value less than 0.05 is statistically significant. 

We analysed 107 patients, which 93 of these were assiduous and 69 concluded the phase 2 of CRP: 39 patients in group 1 and 30 patients in group 2. Two groups have similar baseline characteristics, except for the higher presence of diabetes (p = 0.02) in group 1. It was noted an improvement in both anxiety and depression items for group 1 (p < 0.01 for both), but only for anxiety item for group 2 (p = 0.03). In subgroup analysis, we observed no improvement for smoking patients following the conventional CR for both anxiety and depression items (p = 0.60 and p = 0.71, respectably) versus a significant difference in telemonitored CR patients (p = 0.02 and p = 0.04).

We hypothesise that, when compared to conventional CR, cardiac telemonitored exercise using modern communication methods may result in an improved mental health state among smoking patients, which can lead to a better adherence for CRP. Further studies including more patients and phase 3 of CRP are needed to confirm these results.

An outbreak of infective endocarditis during the COVID-19 pandemic? - an observational retrospective single centre study

Funding Acknowledgements

Type of funding sources: None.

Infective endocarditis (IE) is described as an uncommon and challenging infective disease, due to its presentation variability. Its mortality remains high besides the better disease knowledge and therapeutic progress.

The aim of this study was to describe the clinical features and the incidence of IE. Furthermore, we try to identify the risk factors associated with early mortality.

A retrospective study was conducted and all patients diagnosed with definite or possible IE between January 2015 and June 2020, according to the modified Duke criteria, were included. Patient selection and information collection were obtained through medical records. Outcomes were in-hospital and 3 months after discharge mortality.

Group comparisons and multivariate logistic regression analysis were performed. A p-value less than 0.05 is statistically significant.

We analysed 51 patients, which 41 were admitted between 2015 and 2019 with a mean incidence of 8.2 cases per year. In 2020, 10 cases were diagnosed, corresponding to a percentual increase of 143.9%.

Of the 51 patients, 70.6% were male. The mean age was 65 years. Fever was the main presentation feature at admission. We counted 33.3% prosthetic valve endocarditis (PVE) and 5.9% IE device-related. The most common pathogens were Streptococcus gallolyticus (13.7%) and Streptococcus oralis (13.7%). 35 patients (68.6%) had local complications and 26 patients (51%) had systemic complications. One-third of the patients was referenced to surgical treatment. Overall in-hospital mortality was 19.6% and early mortality at 3 months was 27.5%.

In the univariate analysis, early mortality was higher in diabetes mellitus (DM) patients (p < 0.01) and in those who developed sepsis during hospitalization (p = 0.04). In multivariate logistic regression, only DM (OR = 15.8, 95% CI [3.2, 79.0]) was shown to be an independent factor of mortality.

The incidence of IE increased during the first semester of 2020, possibly due to the increased attention given to patients with fever. Diabetes mellitus was found to be the only independent predictor of mortality. More national multicentre studies are needed.

Usefulness of the society for cardiovascular angiography and intervention classification for predicting in-hospital mortality in patients with acute decompensated heart failure

Introduction

Recently a multidisciplinary group of the Society for Cardiovascular Angiography and Interventions (SCAI) derived a new classification schema for cardiogenic shock (CS), simple, clinically based and suitable for rapid assessment at the bedside but also arbitrary. Validation in different clinical datasets, specifically in patients with acute decompensated heart failure (ADHF), is necessary to establish the utility of this proposed classification schema.

Purpose

We aimed to evaluate the ability of a new SCAI CS staging classification to predict in-hospital mortality in patients with ADHF.

Methods

We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data of consecutive patients admitted with ADHF as a primary diagnosis between January 2015 and January 2019. We excluded patients who were hospitalized for an acute coronary syndrome. Patients were assigned to the modified SCAI Classification for CS: Stage A is “at risk” for CS, stage B is “beginning” shock, stage C is “classic”, stage D is “deteriorating”, and E is “extremis”, and in-hospital mortality was evaluated for each group. All-cause mortality was compared across SCAI stages using Kaplan-Meier analysis and log-rank test. Cox proportional hazards models were used to determine the association between SCAI stages and in-hospital mortality after adjusting for age, gender, left ventricular ejection fraction, use of vasoactive medication, mechanical circulatory assist devices, mechanical ventilation, percutaneous coronary intervention and cardiac surgery.

Results

Among 668 patients with a mean age of 74.9±12 years, 63.9% were male. In-hospital mortality was 11.2%. According to SCAI classification, the proportion of patients in stages A through E was 51.7%, 26.7%, 14.4%, 4.6% and 2.5%. The unadjusted mortality in each stages was: A 0.6%, B 4.5%, C 32.3%, D 61.3%, and E 88.2% (Log Rank P&lt;0.0001). After multivariable adjustment, each SCAI shock stage remained associated with increased in-hospital mortality (all P&lt;0.001 compared to stage A). Compared with SCAI shock stage A, adjusted hazard ratio (HR) values in SCAI shock stages B through E were 5.2, 31, 107, and 185, respectively (Figure).

Conclusion

In this large clinical cohort of patients with ADHF exclusively, the new SCAI CS staging classification was associated with in-hospital mortality. This finding supports the rationale of the classification in this setting, further prospective trials are needed to validate these findings.

Adjusted in-hospital Mortality as a Func

Funding Acknowledgement

Type of funding source: None

Intraventricular conduction defects in patients with st-segment elevation myocardial infarction – the paradox of right bundle branch block

 

Intraventricular conduction defects (IVCD) in patients with acute myocardial infarct (AMI) are predictors of a worse prognosis. When acquired they can be the result of an extensive myocardial damage.

Purpose

To assess the impact of IVCD, regardless of being previously known or presumed new, on in-hospital outcomes of patients with AMI with ST segment elevation (STEMI) or undetermined location.

Methods

From a series of patients included in the National Registry of Acute Coronary Syndrome between 10/1/2010 and 9/1/2019, were selected patients with STEMI or undetermined AMI, undergoing coronary angiography.

Results

7805 patients were included: 461 (5.9%) presenting left bundle branch block (LBBB), 374 (4.8%) with right bundle branch block (RBBB) and 6970 (89.3%) with no IVCD. Clinical characteristics as well as in-hospital outcomes are described in the table 1. An unexpected worse prognosis in patients with RBBB has motivated a multivariate analysis. RBBB remained an independent predictor of in-hospital mortality (OR 1.91, 95% CI 1.04–3.50, p=0.038), along with female gender (OR 1.73, 95% CI 1.11–2.68, p=0.015), Killip Class&gt;1 (OR 2.26, 95% CI 1.45–3.53, p&lt;0.001), left ventricular ejection fraction &lt;50% (OR 3.93, 95% CI 2.19–7.05, p&lt;0.001) and left anterior descending artery as the culprit lesion (OR 1.85, 95% CI 1.16–2.91, p=0.009).

Conclusion

In spite of an apparent better clinical profile, in the current large series of unselected STEMI patients, the presence of RBBB is associated with the worst in-hospital outcome. RBBB doubles the risk of death, being an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Dual Behavior of Long-Chain Fatty Acids and Their Cyclooxygenase/Lipoxygenase Metabolites on Human Intestinal Caco-2 Cell Growth

Etiology of colorectal cancer (CRC) is related, at least in part, with nutritional profile and epidemiological data indicating a key role of dietary fat on CRC pathogenesis. Moreover, inflammation and eicosanoids produced from arachidonic acid might have a pivotal role in CRC development. However, the effect of specific fatty acids (FAs) on intestinal epithelial cell growth is not completely studied now. By this reason, the aim of this work is to unravel the effect of different saturated and unsaturated long-chain fatty acids (LCFA) and some LCFA metabolites on CRC cell line growth and their possible mechanisms of action. Our results demonstrated that oleic acid is a potent mitogenic factor to Caco-2 cells, at least in part, through 10-hydroxy-8-octadecenoic synthesized by lipoxigenase pathway, whereas polyunsaturated FAs such as eicosapentaenoic (EPA) acid has a dual behavior effect depending on its concentration. A high concentration, EPA induced apoptosis through intrinsic pathway, whereas at low concentration induced cell proliferation that could be related to the synthesis of eicosanoids such as prostaglandin E₃ and 12-hydroxyeicosapentaenoic acid and the subsequent induction of mitogenic cell signaling pathways (ERK 1/2, CREB, p38α). Thus, this study contributes to understand the complicated relationship between fat ingest and CRC.

The Public Health Workforce in Portugal in 2019

While the slogan of a fit for purpose workforce pushes us to consider qualitative aspects, there are still quantitative aspects that need further consideration. In some planning and forecast processes, greater quantitative detail should be considered. We use an example from Portugal to explore this matter in the Public Health workforce (PHW). In 2019, for the first time, all Public Health Units (PHU) were supposed to fill in a plan of action on a public online platform. This included some self-reported data on their PHW.

We have used this data to explore which and how many professionals were available in each of the PHU, also having in mind their percentage of work hours dedicated to the PHU and their gender. For this analysis, we have used Microsoft Office Excel 365, R 3.6.1, RStudio 1.2.5033, and ArcMap 10.7.1.

Of the 55 PHU in Portugal, 12 (21,8%) did not publish their Plan, 2 (3,6%) were released without being correctly filled, and 3 (5,4%) with substantial data regarding their human resources being incomplete. In total, the plans identified 220 public health medical specialists, 130 medical residents, 184 nurses, 136 secretaries, and 314 other professionals. From the reported data, there was an average of the percentage of week hours dedicated to the PHU of 82,8% for medical specialists, 71,8% for nurses, 89,8% for secretaries, and 92,1% for other professionals. In what concerns gender distribution, women represented 60,9% of medical specialists, but only 52,6% of PHU coordinators, 55,5% of medical residents, 86,4% of nurses, 83,7% of secretaries, and 77,7% of the remaining professionals. There were considerable differences between PHU in these results.

These results might differ from formal administrative data. However, due to being reported from the PHU themselves might portrait a more realistic picture of the local public health workforce. These results underline the importance of the hours dedicated to the PHU in the planning and forecasting of the PHW.

Key messages

The % of time PH professionals dedicate to their Unit should be included in Workforce planning. Greater adherence to the Portuguese public platform for action plans is needed.

FRI0462 PREDICTIVE FACTORS OF RELAPSE AFTER METHOTREXATE DISCONTINUATION IN JIA PATIENTS WITH INACTIVE DISEASE

Background:

Methotrexate (MTX) is the most widely used conventional synthetic disease-modifying antirheumatic drug (csDMARD) in the treatment of juvenile idiopathic arthritis (JIA).1,2When remission is achieved, questions remain about discontinuing MTX. There is some evidence that a longer period of inactive disease before MTX withdrawal is associated with lower likelihood of relapse, while both rheumatoid factor (RF) positive polyarthritis and extended oligoarthritis categories are associated with higher probability of disease relapse.2,3

Objectives:

To identify predictive factors of relapse after discontinuation of MTX in JIA patients with inactive disease.

Methods:

Prospective multicentre cohort study in patients diagnosed with JIA, according to the ILAR classification, using real world data from the Portuguese national register database, Reuma.pt (Fig 1).4We evaluated patients who have reached JADAS27 inactive disease (≤1 and no active extra-articular manifestations) and discontinued MTX before the age of 18 years-old.5Relapse was defined as recurrence (>1 or extra-articular manifestations) or restarting a DMARD.5To identify differences of relapse risk, univariate analyses were performed. Persistence in remission was estimated using the Kaplan-Meier method. Subsequently, Cox regression analyses were performed to identify predictors of relapse.

Results:

119 JIA patients discontinued MTX due to inactive disease (Fig 1). 69.7% were females and 60.6% had oligoarticular JIA. Sociodemographic and clinical characteristics are shown in Table 1. Relapse has occurred in 32.8%. Table 2 shows the disease characteristics at MTX initiation and discontinuation and at relapse or last visit.

In univariate analysis, relapse was associated with the use of NSAIDs at the time of MTX discontinuation (p=.027) and with a period of less than two years in inactive disease before MTX suspension (p=.040). We found no association with gender, race, immunology (RF, antinuclear and cyclic citrullinated peptide antibodies), MTX dose, discontinuation modality (tapering and spacing the doses or just tapering the dose), extra-articular manifestations, previous corticotherapy, family history, body mass index, JADAS, CHAQ index, inflammatory parameters, tender and swollen joint counts at MTX initiation or discontinuation nor with age at remission or at MTX suspension. Median persistence in inactive disease was significantly higher in patients with more than two years in remission before MTX discontinuation (p=.034) and in those who did not use NSAIDs at time of MTX discontinuation (p=.026) (Fig 2).

After adjustment for age at diagnosis, MTX tapering and JIA category, use of NSAIDs at the time of discontinuation (HR, 1.98 95%CI 1.03-3.82) and less than two years in remission (HR, 3.12 95%CI 1.35-7.13) remained associated with relapse.

Conclusion:

In this large cohort we found that the use of NSAIDs at the time of MTX discontinuation was associated with two times the likelihood of relapse. Like in other studies we also showed that the time in remission before MTX discontinuation is the main predictor of relapse. We found no association between the JIA category and the risk of relapse.

References:

[1]Hügle B 2016

[2]Klotsche J 2018

[3]Guzman J 2014

[4]Canhão H 2011

[6]Consolaro A 2014

Disclosure of Interests:

Soraia Azevedo: None declared, José Tavares-Costa: None declared, Ana Teresa Melo: None declared, Raquel Freitas: None declared, Marta Cabral: None declared, Marta Conde: None declared, Francisca Aguiar: None declared, Agna Neto: None declared, Ana Filipa Mourão: None declared, Filipa Oliveira-Ramos: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Daniela Peixoto: None declared

Local Tuberculosis Georeference: a tool to define BCG vaccination in high-incidence area in Portugal

Issue

Tuberculosis (TB) incidence in Portugal is &lt; 20/100000 people, with high-incidence municipalities in urban areas such as Amadora. In 2016, the national vaccination programme moved the BCG vaccine from universal to restricted risk groups. Amadora, due to the higher-incidence area, maintained a universal vaccination policy. Recently, it was hypothesized that vaccination could be applied to specific parishes even in high incidence counties.

Description

We aimed to identify specific geographic areas with higher risk of TB to help redefine the local BCG vaccination policy. We proposed to georeference active TB cases between 2015 and 2017, in Amadora, to then assess the incidence per parish and statistical section. We also aimed at identifying geo-clusters and density of cases.

Methods

(1) notified TB cases from 1 January of 2015 to 31 December 2017 were extracted from TB surveillance system; (2) cases of latent TB infection (LTBI), cases out of Amadora’s bounds and without national ID were excluded; (3) ArcGis®Online and associated maps were used to provide populational estimates; (4) cumulative incidence was calculated per year and averaged for the 3-year period; (5) Clusters were determined using distance and simple density of cases was calculated using Kernel algorithm.

Results

Considering the 6 parishes of Amadora, the 3-year cumulative incidence varied from 19.58 to 38.3 per 100000 hab. The highest incidence was found on the parish with the best socio-economic profile. 14 geo-clusters were mapped; 3 matched known deprived neighborhoods. Overall density was higher in these neighborhoods.

Lessons

With this approach we found that deprived neighborhoods had higher levels of case density, but 3-year cumulative incidence was higher on the parish considered to have low occurrence of TB. As such, and due to the intense population flows in Amadora, the local public health unit recommended the persistence of BCG vaccination to all residents of the municipality.

Key messages

Georeferecing supported our recommendation to mantain a universal BCG vaccination policy. Georeferencing associated to surveillance systems is highly useful to ensure evidence based public health practices, even at the local level.

Leadership and chronic diseases: a bibliometric review

Background

Leadership and chronic diseases are two frequent topics in current public health discussions. We performed a bibliometric analysis to study what interactions exist between these two themes. This study allows an insight on what is being published and also identifies potential gaps that need to be addressed.

Methods

We have reviewed all the titles and abstracts of articles available at PUBMED with the MESH terms ’Leadership’ and ’Chronic Disease’. We collected information about the authors, year, journal and type of publication and country where the study was done. We have also done a qualitative analysis on the themes addressed.

Results

We have found 171 entries, of witch 85 (49,7%) referred to apparent peer reviewed studies in English. All other publications referred to editorials, commentaries or the PUBMED entry did not allow for greater clarification. From 1998 the publication of articles became regular, with a peak of 14 articles published in 2014. The average of authors per publication was 3,19. The most frequent country involved was the USA (62), follow by the UK (14), Canada (11) and Australia (10). 128 publications were identified, of which BMC Health Serv Res was the one with the highest number of articles included (5). There was some form of a call for greater leadership from nurses in 22 articles. We also highlight 5 articles that called for a greater role of pastors and religious communities in this field.

Conclusions

Despite the perception of being common topics, there is still a low rate of publication of studies in the field of leadership and chronic diseases. There is a predominance of articles from the USA. There was not a predominant publication in this field. Despite doctors being typically seen as the leaders within the health field, the articles included seem to point to a trend in calling for a bigger leadership role of other actors, such as nurses.

Key messages

There is a need for more research in the field of leadership in chronic diseases. There seems to be a trend calling for greater leadership in the field from non-physician actors.

Benefits from a tabletop exercise in a Heat-Health Action Plan in Amadora, Portugal

Issue

National guidelines for Heat-Health Action Plans (HHAP) in Portugal exist since 2004. These guidelines are further developed and implemented at Local Public Health Units (LPHU) together with local partners. Tabletop exercises are a useful tool to improve preparedness. Despite the long experience with HHAP there has not been any tabletop exercise in Amadora.

Description

Amadora’s LPHU organized a tabletop exercise with local partners to improve HHAP preparedness (12th July 2018). It included: LPHU, city hall, civil protection services, local social services, primary healthcare services, local public hospital, and firefighters. The exercise hypothesized a scenario of an unprecedented increase of temperature for an extended period of time, activating the highest level of warning (red) and action in the HHAP.

Results

During the exercise several issues were identified. Some partners were not clear about the pathway established for red warnings and partners were not aware of relevant HHAP activities. Also, from the 8 sites listed as climate shelters, only 2 were deemed as adequate for using in this scenario, even though they have been listed for several HHAP. Due to the exercise, it was possible to conduct an inspection of said shelters, which hadn’t took place yet due to the lack of resources. It was possible to find out that only one shelter was fit for purpose. Additional private facilities were identified as desirable shelter locations during the exercise. A few weeks later, a red warning was issued and clarification arising from the tabletop exercise was useful to properly implement measures.

Lessons

Despite the perceived frequent and good communication among partners of the HHAP, several issues - mainly regarding the adequacy of shelters - were identified with a tabletop exercise. It also improved preparedness for the following HHAP warning. As such, tabletop exercises should be promoted within HHAP.

Key messages

Despite developing heat-health action plans for several years, with the involvement of community partners, unidentified constraints existed in Amadora, Portugal. Tabletop exercises should be used more frequently, as we were able to identify and solve constraints within our heat-health action plan using one.

Evaluating implementation of an Heat-health action plan during 2018 heatwave in Amadora, Portugal

Issue

Heatwave-health effects are preventable. Heat-health action plans (HHAPs) include preventive measures aimed at protecting population. In Portugal, HHAPs exist since 2004 and have been operationalized at local level. Heatwaves occur infrequently, thus experience with HHAPs is relevant to countries implementing their own HHAPs.

Description

In the summer of 2018, Amadora (Lisbon, Portugal) issued a warning from the 2nd-6th August (highest level:4th-6th). Before/during the warning we implemented: 1.climatized shelter opened available upon request;2.text messages with recommendations and information on the walk-in clinic services available;3.information to nursing homes regarding available services (walk-in services/shelter);4.contact with individuals receiving home support and identified as vulnerable. Nationwide media publicity of individual protection measures was also ongoing. We aimed at evaluating these HHAP measures. We compared demand of walk-in clinic (primary care) and emergency department with existing capacity, updated during the heatwave. Mortality was analysed using an observed-expected ratio (O/E) of week 32 (following the heatwave) and 95% confidence interval (95%CI) under a Poisson distribution. Expected deaths were the average deaths in week 32 of the previous 4 years (2014-17).

Results

In the primary care walk-in clinic the demand was ½ of capacity; hospital emergency services demand did not increase. We had no requests for the shelter unit. Regarding mortality, O/E was 1.57 (95%CI:1.12-2.14). These results are preliminary; we are producing more detailed analyses of mortality data.

Lessons

We have no counterfactual to assess the effect of our HHAP but our results indicate the possibility to reduce heatwaves-mortality further and thus the need for additional measures. We did not observed the expected surge in service demand; the adequacy of supply-based measures is currently under debate. More detailed mortality analysis will provide further insights.

Key messages

We implemented several measures during a heatwave in Amadora, Portugal with no increased demand in available health services in the area. We detected an increased mortality following the heatwave, suggesting the need to implement further measures.

P4674Implementation of the new chronic thromboembolic pulmonary hypertension treatment algorithm: an ongoing effort from a portuguese referral centre

Background

To date, the first-line treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), although a significant number of patients will have inoperable disease or residual pulmonary hypertension (PH). Balloon pulmonary angioplasty (BPA) has provided a new therapeutic option for these patients. In addition, medical therapy (MT) also plays an important role.

Purpose

Characterization of a population of patients with CTEPH or chronic thromboembolic disease (CTED) and comparison of the different treatment strategies according to the updated treatment algorithm.

Methods

Retrospective analysis of patients with CTEPH/CTED followed in a referral centre for the treatment of PH submitted to different treatment strategies: PEA plus MT and BPA in patients with residual PH (group 1), MT plus BPA (group 2), and MT only (group 3). Cox regression was used to identify predictors of all-cause mortality.

Results

58 patients were included (median age 63.5 years, 74% female); 17% had CTED, and the remaining had CTEPH 50% (n=29) were submitted to PEA (group 1), of which 58% had residual PH (21% underwent BPA, n=3). Among the remaining patients, 31% (n=9) underwent MT plus BPA (group 2), and 69% (n=20) were treated with MT only (group 3). Overall, 55% were under pulmonary vasodilator therapy, including 38% with riociguat. Most of the patients (67%) were in functional class III or IV, the distance in the 6MWT was 328±147 meters, the median NT-proBNP was 538pg/ml, 40% had RV systolic dysfunction, the mean mPAP was 42±13 mmHg, and the mean PVR was 11±6 WU. Comparing the different treatment strategies, during follow-up (median 945 days) the following differences were found (comparison between group 1 vs group 2 vs group 3): improvement in functional class (class III-IV: 0% vs 0% vs 58%); distance in 6MWT (438±83 vs 390±79 vs 281±105 meters); evolution of NT-proBNP (−984±1736 vs −198±205 vs +1177±2342); normalization of RV dimensions (89% vs 50% vs 20%); resolution of pericardial effusion (100% vs 100% vs 0%); normalization of mPAP (73% vs 71% vs 0%); PVR (median 3.4 vs 2.7 vs 10.6 WU); all-cause mortality (7% vs 0% vs 35%) (p<0.02 in all).

In the overall population, the most relevant predictors of all-cause mortality were the absence of functional class improvement, baseline and follow-up NT-proBNP, baseline and follow-up SPAP by echocardiogram, and maintenance of treatment with prostanoids (p<0.05 in all).

Conclusion

Our results confirm that, in patients with CTEPH/CTED, PEA is associated with functional, and hemodynamic improvement and increased survival, although BPA is an alternative in patients with inoperable disease or residual PH, with similar results on short-term follow-up. Patients who are not submitted to surgical or percutaneous intervention have a poor prognosis, both in terms of morbidity and mortality.

Risk assessment of exotic disease incursion and spread

This Technical Report describes the activities developed in the scope of the EU‐FORA Fellowship, within the work programme of risk assessment (RA) of exotic disease incursion and spread, developed at Wageningen Bioveterinary Research (WBVR). The programme focused on the work carried out in the Generic risk assessment for introduction of animal diseases (G‐RAID) project, which brings together a number of different generic RA tools from multiple European partners. The aim of the fellowship was to gain understanding of veterinary import risk assessment by using different RA tools and to learn how different algorithms can be used to calculate disease incursion risks. G‐RAID's tools cover a wide range of RA methodologies; from purely qualitative, to semi‐quantitative and fully stochastic quantitative methods, which allowed the fellow to understand a variety of algorithms used to produce the final risk estimate. The fellowship programme provided the fellow with the chance to learn in detail about how generic RAs are performed across Europe, understanding how to deal with the uncertainty and variability involved in RAs and the potential problems of data availability and reliability. The fellow made an inventory of publicly available databases on disease occurrence and international trade that could be used for import RA and assessed their quality and usefulness for the different generic RA tools. The programme also provided the fellow the opportunity to perform several import risk assessments using the RA tools of G‐RAID. She completed a RA on African swine fever using the MINTRISK model developed by WBVR. Furthermore, she assessed the risk of foot and mouth disease introduction using the Rapid Risk Assessment Tool (RRAT) model developed by WBVR and the COMPARE model developed by the Animal and Plant Health Agency (APHA). To this end, the fellow completed a short‐term visit to APHA, enabling her to have additional training in quantitative RA and to expand her professional network in this area.

Longitudinal association of adiposity and high-sensitivity C-reactive protein from adolescence into early adulthood

BACKGROUND AND AIMS

Longitudinal studies relating adiposity with low-grade inflammation are scarce. We aimed to examine the longitudinal association between the cumulative exposure to adiposity and low-grade inflammation from adolescence into early adulthood.

METHODS AND RESULTS

Data from a population-based cohort (EPITeen) (n = 1147) was analyzed. Body mass index (BMI), body fat percentage (BF%), waist circumference (WC), and waist-to-height ratio (WHtR) and high-sensitivity C-reactive protein (hsCRP) were ascertained at 13, 17 and 21 years of age and standardized for each wave. Generalized least squares models with a compound symmetry correlation structure were fitted to estimate the longitudinal effect of adiposity on hsCRP and results were presented as linear regression coefficients and 95% confidence intervals [β (95%CI)].The final model estimated the association between the difference in adiposity between two consecutive evaluations (13-17 and 17 to 21-years-old), adjusted for previous adiposity and hsCRP levels, sex, parental education, leisure-time physical activity and fruits and vegetables intake. A positive association between the cumulative exposure to adiposity and final hsCRP was observed, in which the difference between adiposity indicators of two consecutive study waves was independently associated with hsCRP: 0.382 (0.299; 0.465) for BMI, 0.234 (0.164; 0.304) for WC, 0.395 (0.314; 0.477) for BF% and 0.195 (0.133; 0.258) for WHtR.

CONCLUSION

A significant longitudinal effect of the accumulation of adiposity on low-grade inflammation was observed. The change in adiposity from consecutive study waves was shown to have a stronger effect on final hsCRP concentrations than both previous adiposity and hsCRP levels.

Individual exposure level following indoor and outdoor air pollution exposure in Dakar (Senegal)

The consequences of indoor and outdoor air pollution on human health are of great concern nowadays. In this study, we firstly evaluated indoor and outdoor air pollution levels (CO, CO₂, NO, NO₂, PM₁₀) at an urban site in Dakar city center and at a rural site. Then, the individual exposure levels to selected pollutants and the variations in the levels of biomarkers of exposure were investigated in different groups of persons (bus drivers, traders working along the main roads and housemaids). Benzene exposure levels were higher for housemaids than for bus drivers and traders. High indoor exposure to benzene is probably due to cooking habits (cooking with charcoal), local practices (burning of incense), the use of cleaning products or solvent products which are important emitters of this compound. These results are confirmed by the values of S-PMA, which were higher in housemaids group compared to the others. Urinary 1-HOP levels were significantly higher for urban site housemaids compared to semirural district ones. Moreover, urinary levels of DNA oxidative stress damage (8-OHdG) and inflammatory (interleukin-6 and -8) biomarkers were higher in urban subjects in comparison to rural ones. The air quality measurement campaign showed that the bus interior was more polluted with PM₁₀, CO, CO₂ and NO than the market and urban or rural households. However, the interior of households showed higher concentration of VOCs than outdoor sites confirming previous observations of higher indoor individual exposure level to specific classes of pollutants.

Percutaneous electrical stimulation for overactive bladder in children: a pilot study

PURPOSE

The purpose of this was to evaluate the efficacy (tolerance and safety) of once-a-week parasacral percutaneous electrical nerve stimulation (PENS) to treat overactive bladder (OAB) in children.

MATERIALS AND METHODS

This is a prospective case series of children aged 4-14 years who underwent PENS for OAB. Acupuncture needles were used bilaterally and symmetrically at S3 for sacral nerve stimulation (Figure). Eighteen children with pure OAB underwent PENS weekly for 20 weeks. Frequency was 10 Hz. Intensity varied up to a maximum of 10 mA, as tolerated by the participant, but without reaching the motor threshold. Pulse width was 600 μs Patients' voiding history was assessed before treatment using a structured questionnaire. The dysfunctional voiding scoring system (DVSS) was used before and after treatment to quantify symptoms of lower urinary tract dysfunction. A visual analog scale (VAS) was used to evaluate treatment outcome.

RESULTS

Seven boys and eleven girls (mean age, 7.82 ± 2.45 years) were included. According to the VAS, symptoms were resolved in 66% of patients. Urinary urgency, present in all children at baseline, was resolved in 84% (P = 0.001). The proportion of patients with involuntary loss of urine without urgency decreased from 77% before treatment to 27% (P = 0.04). Urge incontinence resolved in 13 of 16 patients after treatment (P = 0.001). Only one of the 12 children with frequent urination at baseline reported this complaint after treatment (P = 0.04). All cases of recurrent urinary tract infection were resolved (P = 0.001). Regarding nocturnal enuresis, treatment was successful in 9 of 14 children (P = 0.004).

DISCUSSION

The theory behind this new method is that when skin impedance is overcome through the use of acupuncture needles and greater proximity is attained between the tip of the electrode and the sacral nerves, a more effective stimulus is achieved, with enough energy to provide the same benefits as parasacral transcutaneous electrical nerve stimulation with the advantage that treatment can be given only once a week.

CONCLUSIONS

Percutaneous electrical nerve stimulation seems to be an effective and safe treatment for OAB over the short term. Furthers studies with a control group are needed.

Food intake and high-sensitivity C-reactive protein levels in adolescents

BACKGROUND AND AIMS

Diet comprises factors with anti and pro-inflammatory potential that can contribute to modulate obesity-induced inflammation. We aimed to assess the association between food intake and high-sensitivity C-reactive protein (hsCRP) levels in adolescents.

METHODS AND RESULTS

A cross-sectional analysis of 991 adolescents aged 13 years old was conducted as part of the EPITeen cohort, Porto, Portugal. Food intake was assessed by a food frequency questionnaire and thirteen food groups were defined. Anthropometric assessment was performed and serum hsCRP was measured in a fasting blood sample. hsCRP concentrations above the 75th percentile were considered high. Logistic regression was fitted to estimate the association between the intake frequency of the food groups and hsCRP, stratified by BMI and adjusted for sex, parental education and total energy intake. Median (25-75th percentiles) hsCRP concentrations increased with increasing values of BMI [normal weight: 0.20 (0.10-0.50); overweight: 0.40 (0.20-0.80); obese: 1.10 (0.40-2.15) mg/l, p < 0.001]. After adjustment for sex, parental education and total energy intake, no statistically significant associations were found amongst normal weight and overweight participants. However, among obese individuals, having as reference the first frequency category (<1 per day), a higher frequency of vegetables/legumes intake showed a decreased odds of high hsCRP levels (OR: 0.10, 95%CI 0.03-0.38, 1-3 per day; and OR: 0.14, 95%CI 0.04-0.52, >3 per day).

CONCLUSION

Among participants with obesity-induced higher hsCRP levels, a higher frequency of vegetable/legume intake was inversely related to hsCRP.

Sensory attributes and volatile composition of a dry white wine under different packing configurations

The aim of this work was to study the effect of different configurations of packaging on the volatile composition and sensory properties of a white wine. Certain oenological parameters were also evaluated. Bag-in-box (BIB) and glass bottles sealed with two different cork stoppers, natural and Neutrocork (technical), were used in the experiments. Analysis were carried out before packaging and after 3, 6 and 12 months of storage. Results showed that wines packaged in BIB presented higher levels of brown color than wines in bottles sealed with corks. In all packaging configurations, the content of free SO₂ decreased with storage time; however, BIB wines showed a lower content of free SO₂ than bottle wines during 12 months. Moreover, wines under BIB presented a significant lower amount of 2-phenylethanol, 2-phenylethyl acetate, isoamyl acetate, ethyl butanoate, ethyl hexanoate, ethyl octanoate, linalool and β-damascenone than bottled wines.

Prevention of isoniazid toxicity by NAT2 genotyping in Senegalese tuberculosis patients

Isoniazid (INH), recommended by WHO (World Health Organization) in the treatment of tuberculosis (TB), is metabolized primarily by the genetically polymorphic N-acetyltransferase 2 (NAT2) enzyme. The human population is divided into three different phenotypic groups according to acetylation rate: slow, intermediate, and fast acetylators. The objective of this study was to explore the relationship between NAT2 genotypes and the serum concentrations of INH. Blood samples from 96 patients with TB were taken for the analysis. NAT2 polymorphisms on coding region were examined by polymerase chain reaction (PCR) direct sequencing; the acetylation status was obtained by measuring isoniazid (INH) and its metabolite, acetylisoniazid (AcINH) in plasma was obtained by using the liquid chromatography coupled to mass spectrometry. TB patients were distributed into two groups of fast and slow acetylators according to the acetylation index calculated based on the plasma concentration of INH in the 3rd hour (T3) after an oral dose. Our PCR analysis identified several alleles, where NAT2*4, NAT2*5A, NAT2*6A, and NAT2*13A were the most important. The concentrations of INH varied between 1.10 mg/L and 13.10 mg/L at the 3rd hour and between 0.1 and 9.5 mg/L at the 6th hour. The use of the acetylating index I₃ allowed the classification of tested patients into two phenotypic groups: slow acetylators (44.3% of TB patients), and rapid acetylators (55.7%). Patient’s acetylation profile provides valuable information on their therapeutic, pharmacological, and toxicological responses.

2016 update of the Portuguese recommendations for the use of biological therapies in children and adolescents with Juvenile Idiopathic Arthritis

OBJECTIVE

To provide evidence-based guidance for the rational and safe prescription of biological therapies in children and adolescents with juvenile idiopathic arthritis (JIAs) considering the latest available evidence and the new licensed biologics.

METHODS

Rheumatologists and Pediatricians with expertise in Pediatric Rheumatology updated the recommendations endorsed by the Portuguese Society of Rheumatology and the Portuguese Society of Pediatrics based on published evidence and expert opinion. The level of agreement with final propositions was voted using an online survey.

RESULTS

In total, 20 recommendations to guide the use of biological therapy in children and adolescents with JIAs are issued, comprising 4 general principles and 16 specific recommendations. A consensus was achieved regarding the eligibility and response criteria, maintenance of biological therapy, and procedures in case of non-response, for each JIA category. Specific recommendations concerning safety procedures were also updated.

CONCLUSIONS

These recommendations take into account the specificities of each JIA category and are intended to continuously improve the management of JIA patients.

Leukotriene D4-induced Caco-2 cell proliferation is mediated by prostaglandin E2 synthesis

Leukotriene D₄ (LTD₄) is a pro-inflammatory mediator formed from arachidonic acid through the action of 5-lipoxygenase (5-LOX). Its biological effects are mediated by at least two G-coupled plasmatic cysteinyl LT receptors (CysLT_1-2R). It has been reported an upregulation of the 5-LOX pathway in tumor tissue unlike in normal colon mucosa. Colon tumors generally have an increased expression of CysLT₁R and colon cancer patients with high expression levels of CysLT₁R have poor prognosis. We previously observed that the cyclooxygenase pathway is involved in the control of intestinal epithelial cancer cell growth through PGE₂ production. The aim of this study was therefore to assess the effect of LTD₄ binding with CysLT₁R on Caco-2 cell growth. We note a number of key findings from this research. We observed that at a concentration similar to that found under inflammatory conditions, LTD₄ was able to induce Caco-2 cell proliferation and DNA synthesis. Moreover, with the use of a specific receptor antagonist this study has demonstrated that the effect of LTD₄ is a result of its interaction with CystLT₁R. We also note the possible participation of the PLC-IP₃-Ca²⁺/DAG-PKC signaling pathways in cytosolic PLA₂ and [³H]AA release induced by LTD₄-CystLT₁R interaction. Finally, we found that the resulting activation of the AA cascade and the production of PGE₂ eicosanoid could be related to the activation of cell signaling pathways such as ERK and CREB. These findings will help facilitate our understanding of how inflammatory mediators can affect the survival and dissemination of intestinal carcinoma cells.

Differential cell growth/apoptosis behavior of 13-hydroxyoctadecadienoic acid enantiomers in a colorectal cancer cell line

Cyclooxygenases (COXs) and lipoxygenases (LOXs) are important enzymes that metabolize arachidonic and linoleic acids. Various metabolites generated by the arachidonic acid cascade regulate cell proliferation, apoptosis, differentiation, and senescence. Hydroxyoctadecadienoic acids (HODEs) are synthesized from linoleic acid, giving two enantiomeric forms for each metabolite. The aim was to investigate the effect of 13-HODE enantiomers on nondifferentiated Caco-2 cell growth/apoptosis. Our results indicate that 13(S)-HODE decreases cell growth and DNA synthesis of nondifferentiated Caco-2 cells cultured with 10% fetal bovine serum (FBS). Moreover, 13(S)-HODE showed an apoptotic effect that was reduced in the presence of a specific peroxisome proliferator-activated receptor-γ (PPARγ) antagonist. In addition, we observed that 13(S)-HODE but not 13(R)-HODE is a ligand to PPARγ, confirming the implication of this nuclear receptor in 13(S)-HODE actions. In contrast, 13(R)-HODE increases cell growth and DNA synthesis in the absence of FBS. 13(R)-HODE interaction with BLT receptors activates ERK and CREB signaling pathways, as well as PGE2 synthesis. These results suggest that the proliferative effect of 13(R)-HODE could be due, at least in part, to COX pathway activation. Thus both enantiomers use different receptors and have contrary effects. We also found these differential effects of 9-HODE enantiomers on cell growth/apoptosis. Therefore, the balance between (R)-HODEs and (S)-HODEs in the intestinal epithelium could be important to its cell growth/apoptosis homeostasis.

Life cycle assessment of a packaging waste recycling system in Portugal

Life Cycle Assessment (LCA) has been used to assess the environmental impacts associated with an activity or product life cycle. It has also been applied to assess the environmental performance related to waste management activities. This study analyses the packaging waste management system of a local public authority in Portugal. The operations of selective and refuse collection, sorting, recycling, landfilling and incineration of packaging waste were considered. The packaging waste management system in operation in 2010, which we called "Baseline" scenario, was compared with two hypothetical scenarios where all the packaging waste that was selectively collected in 2010 would undergo the refuse collection system and would be sent directly to incineration (called "Incineration" scenario) or to landfill ("Landfill" scenario). Overall, the results show that the "Baseline" scenario is more environmentally sound than the hypothetical scenarios.

Role of arachidonic acid metabolites on the control of non-differentiated intestinal epithelial cell growth

Increasingly evidence indicates that enzymes, receptors and metabolites of the arachidonic acid (AA) cascade play a role in intestinal epithelial cell proliferation and colorectal tumorigenesis. However, the information available does not provide a complete picture and contains a number of discrepancies. For this reason it might be appropriate a thorough study into the impacts of the AA cascade on intestinal epithelial cell growth. Our data show that non-differentiated Caco-2 cells cultured with 10% fetal bovine serum (FBS) synthesize appreciable amounts of prostaglandin E2 (PGE2), leukotriene B4 (LTB4) and 5-, 12 and 15-hydroxyeicosatetraenoic acid (HETE) but not LTD4, 20-HETE and epoxyeicosatrienoic acids. We also found that inhibitors of PGE2, LTB4 and 5-, 12-, 15-HETE synthesis as well as receptor antagonists of PGE2 and LTB4 blocked Caco-2 cell growth and DNA synthesis induced by 10% FBS without cytotoxic or apoptotic activity. Interestingly, PGE2, LTB4 and 5-, 12- and 15-HETE at concentrations reached in 10% FBS Caco-2 cultures (1-10nM) were able to induce Caco-2 cell growth and DNA synthesis. This was due to the interaction of PGE2 with EP1 and EP4 receptors and LTB4 and HETEs with BLT1 and BLT2 receptors. Moreover, we provide evidence that PGE2 stimulates several cell signaling pathways such as ERK, P38α, CREB and GSKβ/β-catenin involved in the regulation of Caco-2 growth. Finally, we provide evidence that the mitogenic effects of LTB4 and HETEs can be dependent, at least in part, on PGE2 synthesis.

Low-level environmental exposure to lead and renal adverse effects: a cross-sectional study in the population of children bordering the Mbeubeuss landfill near Dakar, Senegal

This study deals with the health effects within a child population, neighbouring a landfill. After detecting metals in soil and air samples collected in the surroundings of the landfill and in a control site, we have studied: (i) levels of lead (Pb) and exposure biomarkers in blood and urine, (ii) oxidative stress biomarkers and (iii) renal injury by applying a set of early effect biomarkers. Levels of Pb were higher in the exposed site (i.e. 1129 mg/kg and 640 ng/m(3) in soil and air samples, respectively) versus those in the control site (i.e. 14.3 mg/kg and 9.3 ng/m(3) in soil and air samples, respectively). Pb impregnation and levels of delta-aminolevulinic acid in urine were influenced by the living site that shows the prevailingly alarming situation in the Mbeubeuss landfill. Malondialdehyde changes indicated Pb-induced excessive production of reactive oxygen species. Lactate dehydrogenase activities and proteinuria were found to be higher in the children living in the exposed site. These evidences may reveal the usefulness of these two effect biomarkers to monitor the kidney injury entailed by relatively low-environmental exposure to Pb. Overall, these results show that the Mbeubeuss landfill constitutes a real source of environmental and health risk, be it living or working on site, of the surrounding population, predominantly for children.

[Protracted Febrile Myalgia Syndrome with Henoch-Schönlein Purpura: an atypical presentation of Familial Mediterranean Fever]

Familial Mediterranean Fever (FMF) is an hereditary autosomal recessive disease characterized by recurrent attacks of fever, arthritis and serositis: peritonitis, pleurisy and/or pericarditis. Its main complication is systemic AA amyloidosis. The authors present a case of a 8-years-old female child with african ancestry, who was admitted three times since 5 years-old with abdominal pain, fever and high acute phase reactants. At the first admission appendectomy was made and at the third hospital admission the clinical picture was accompanied by myalgia, purpuric lesions and non nephrotic proteinuria. A renal biopsy was performed and was compatible with Henoch-Schönlein nephritis. Serum Amyloid A protein had high levels - 92 mg/L (> 6.8) and a diagnosis of Familial Mediterranean Fever was confirmed by genetic test (homozygote for M694V in MEFV gene). She started colchicine and is doing well, without any further complaints. FMF must be considered in the differential diagnosis of recurrent attacks of fever and abdominal pain in children, even with an atypical presentation (p.e. Protracted Febrile Myalgia Syndrome). Genetic study allows the confirmation of the diagnosis and has prognostic implications.

Sorption behaviour of bifenthrin on cork

Biphentrin, a known pyrethroid, was studied, aiming its removal from aqueous solutions by granulated cork sorption. Batch experiments, either for equilibrium or for kinetics, with two granulated cork sizes were performed and results were compared with those obtained with of activated carbon sorption. Langmuir and Freundlich adsorption isotherms were obtained both showing high linear correlations. Bifenthrin desorption was evaluated for cork and results varied with the granule size of sorbent. The results obtained in this work indicate that cork wastes may be used as a cheap natural sorbent for bifenthrin or similar compounds removal from wastewaters.