Primary thromboprophylaxis in cancer outpatients - real-world evidence

INTRODUCTION

Cancer-associated thrombosis (CAT) is a significant concern among patients with malignant diseases, leading to increased mortality. While current guidelines recommend primary thromboprophylaxis for venous thromboembolism (VTE) in medium-to-high-risk outpatients, this practice remains controversial. A better understanding of primary thromboprophylaxis is crucial, yet there is a lack of Real-World Evidence (RWE) in Portugal.

AIMS

This RWE study aimed to elucidate primary thromboprophylaxis practices among cancer outpatients in Portugal.

METHODS

A five-year observational multicentric study in eight Portuguese health institutions enrolled 124 adult cancer outpatients under primary thromboprophylaxis for VTE. The endpoints were CAT, bleeding, cancer progression and death.

RESULTS

High thrombotic risk tumours were prevalent, with 57% (71) of the patients presenting with pancreatic and gastric cancers. Regarding primary thromboprophylaxis, 55% (68) received Low-Molecular-Weight Heparin (LMWH). VTE was presented in 11% (14) of the patients and major bleeding in 2% (2). Vascular compression, elevated D-dimer and previous VTE were significantly associated with VTE occurrence under primary thromboprophylaxis. The Onkotev model was shown to be the best risk assessment model (RAM) in this population (p = 0.007). CAT patients exhibited a lower progression-free survival than non-CAT patients (p = 0.021), while thrombosis did not influence overall survival (p = 0.542).

CONCLUSION

Primary thromboprophylaxis in medium-to-high-risk cancer outpatients is a safe and effective practice in real-world settings. This study is the first Portuguese RWE on primary thromboprophylaxis, highlighting evidence for improving prophylactic strategies in this population.

It's You and Me: Infants' cross-modal communicative signals and mother-infant interactive behavior predict infant regulatory patterns in the still-face paradigm at 3 months

Infant regulatory behavior develops since birth and impacts their early social interactions. Infants differ in the relative coherence and incoherence of their cross-modal communicative signals during en-face infant-caregiver interactions. We expand this research by evaluating whether different infant regulatory patterns observed during the Face-to-Face Still-Face (FFSF) at 3 months are associated with the coherence or incoherence of infants' cross-modal communicative behaviors during en-face interactions or with multiple dimensions of mother-infant interactive behavior during free-play. Analyses were based on data collected from 100 mother-infant dyads from urban, working- and middle-class backgrounds in Portugal who were videotaped during the FFSF and free play at 3 months. Results confirm that infants' different regulatory behavior patterns in the FFSF at 3 months are associated with the coherence and incoherence of their cross-modal interactive behaviors and specific aspects of mother-infant interaction. Infants with a Social-Positive oriented regulatory pattern during the FFSF displayed more coherent and less incoherent communicative behaviors with their mothers and were more cooperative during free play. In turn, their mothers were more sensitive. Our findings support the perspective that infants' regulatory behavior strategies in the context of caregiver regulatory support and sensitivity are likely to increase dyadic correspondence and infant ability to engage with the world.

Sinonasal Adenocarcinoma: Clinicopathological Characterization and Prognostic Factors

Sinonasal (SN) malignancies are rare. Within SN adenocarcinomas, the most frequent are intestinal-type adenocarcinomas (ITACs). ITAC has been associated with wood and leather dust occupational exposure and TP53 mutations. Not much information is available regarding its characterization and treatment. The aim of this study is to characterize the clinicopathologic and prognostic factors of patients with sinonasal adenocarcinomas (SNACs) treated in our tertiary-level hospital. A retrospective, consecutive study including SNAC patients diagnosed between 2004-2023 was conducted. Clinicopathological data was collected, and p53 status was assessed in the tumor specimens. The association between p53 status and clinicopathological variables, as well as their impact on survival, was evaluated. In total, 35 were included, most of them having ITAC (91.4%) with papillary subtype (37.5%); the majority were subjected to occupational risk exposure (82.9%). Overexpression of p53 was identified in 48.6% of the tumors. Papillary and colonic subtypes were associated with higher median progression-free survival (mPFS) than mucinous and solid subtypes (mPFS 37 months, 95% CI, 20.0-54.0, vs. 9 months, 95% CI, 7.15-10.85, p=0.01); the former was also associated with higher median overall survival (mOS) (mOS 64 months, 95% CI, 37.18-90.81 vs. 14 months, 95% CI, 0-41.58, p=0.02). Histologic grade 1-2 and macroscopic complete resection were associated with higher PFS (PFS of five months of 90.9% vs. 33.3%, p=0.01; mPFS of 37 months, 95% CI, 4.93-69.07 vs. 10 months, 95% CI, 6.43-13.57, p=0.04, respectively). Disease recurrence with distant metastases was associated with lower OS (11 months, 95% CI, 6.1-15.9 vs. 53 months, 95% CI, 22.70-83.30, p=0.04). This study reinforces the importance of protective occupational measures. Future studies will be important to validate the best treatment strategy in the advanced stages of this disease and also to identify new prognostic and/or therapeutic target biomarkers in SNAC.

Effect of temperature on growth and yessotoxin production of Protoceratium reticulatum and Lingulodinium polyedra (Dinophyceae) isolates from the Portuguese coast (NE Atlantic)

The dinoflagellates Protoceratium reticulatum and Lingulodinium polyedra are potential yessotoxin (YTX) producers, which have been associated with blooms responsible for economic, social, and ecological impacts around the world. They occur in Iberian waters, but in this region, little is known of their ecophysiology and toxin profiles. This study investigated the growth and toxin production of two strains of each species, from the Portuguese coast, at 15 °C, 19 °C, and 23 °C. Growth curves showed higher growth rates at 19 °C, for both species. YTX and three analogs (homo YTX; 45-OH YTX; 45-OH homo YTX) were investigated by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS), and the presence of other analogs was investigated by Liquid Chromatography-High-Resolution Mass Spectrometry (LC-HRMS). No evidence of toxin production was found in L. polyedra. By contrast, YTX and 45,55-diOH-YTX were detected in both strains of P. reticulatum. These results confirm P. reticulatum as a source of yessotoxins along the Portuguese coast and add to the observed high intraspecific variability on YTX production of both species, at a global scale.

Attachment and mother-infant interactions in dyads with infants born full-term, moderate-to-late preterm, and very-to-extreme preterm

BACKGROUND

The impact of prematurity status on attachment quality remains indeterminate. Some studies found no differences between infants born preterm (PT) and infants born full-term (FT), while other investigations present opposite results.

AIMS

We aim to contribute to this body of research by studying mother-infant interactive behaviors and quality of attachment in 3 independent samples: Full-Term (FT), Moderate-to-Late Preterm (MLPT) and Very-to-Extreme Preterm (VEPT).

STUDY DESIGN

This is a longitudinal laboratory study conducted from 3 to 12 months of age (corrected-age in the case of infants born PT).

SUBJECTS

The participants are 213 Portuguese infants (FT = 105; MLPT = 52; VEPT = 56) and their mothers.

OUTCOME MEASURES

Mother-infant interactive behavior was observed in free-play at 3 and 9 months (corrected-age). Infant attachment was observed in Strange Situation at 12 months.

RESULTS

Secure attachment is more prevalent in infants born FT, and ambivalent attachment is more prevalent in infants born VEPT. Infants with a secure attachment have higher gestational age and weight at birth. Infant and maternal interactive behavior quality is associated with attachment patterns and varies according to infant prematurity status. Last, the results indicate changes in maternal sensitivity and infant difficult behavior from 3 to 9 months of infant's age.

CONCLUSIONS

Our findings indicate that prematurity status impacts attachment quality. Changes in maternal and infant behavior from 3 to 9 months suggest a period of rapid non-linear development, supporting a transactional multilayered approach to the study of mother-infant relationship.

Can Grapevine Leaf Water Potential Be Modelled from Physiological and Meteorological Variables? A Machine Learning Approach

Climate change is affecting global viticulture, increasing heatwaves and drought. Precision irrigation, supported by robust water status indicators (WSIs), is inevitable in most of the Mediterranean basin. One of the most reliable WSIs is the leaf water potential (Ψleaf), which is determined via an intrusive and time-consuming method. The aim of this work is to discern the most effective variables that are correlated with plants' water status and identify the variables that better predict Ψleaf. Five grapevine varieties grown in the Alentejo region (Portugal) were selected and subjected to three irrigation treatments, starting in 2018: full irrigation (FI), deficit irrigation (DI), and no irrigation (NI). Plant monitoring was performed in 2023. Measurements included stomatal conductance (gs), predawn water potential Ψpd, stem water potential (Ψstem), thermal imaging, and meteorological data. The WSIs, namely Ψpd and gs, responded differently according to the irrigation treatment. Ψstem measured at mid-morning (MM) and mid-day (MD) proved unable to discern between treatments. MM measurements presented the best correlations between WSIs. gs showed the best correlations between the other WSIs, and consequently the best predictive capability to estimate Ψpd. Machine learning regression models were trained on meteorological, thermal, and gs data to predict Ψpd, with ensemble models showing a great performance (ExtraTrees: R2=0.833, MAE=0.072; Gradient Boosting: R2=0.830; MAE=0.073).

Plant size, latitude, and phylogeny explain within-population variability in herbivory

Interactions between plants and herbivores are central in most ecosystems, but their strength is highly variable. The amount of variability within a system is thought to influence most aspects of plant-herbivore biology, from ecological stability to plant defense evolution. Our understanding of what influences variability, however, is limited by sparse data. We collected standardized surveys of herbivory for 503 plant species at 790 sites across 116° of latitude. With these data, we show that within-population variability in herbivory increases with latitude, decreases with plant size, and is phylogenetically structured. Differences in the magnitude of variability are thus central to how plant-herbivore biology varies across macroscale gradients. We argue that increased focus on interaction variability will advance understanding of patterns of life on Earth.

Communication preferences and perceptions of cancer patient during their first medical oncology appointment

BACKGROUND

The first medical oncology appointment serves as a platform for patients to comprehend their diagnosis and prognostic implications of cancer. This study aimed to determine patients' communication preferences during their first medical oncology appointment and to assess the disparities between patients' preferences and perceptions.

METHODS

A total of 169 cancer patients participated by completing the Communication in First Medical Oncology Appointment Questionnaire (C-FAQ), a two-section questionnaire designed to assess patients' preferences and perceptions regarding Content (information provided and its extent), Facilitation (timing and location of information delivery), and Support (emotional support) during their first medical oncology appointment. A comparative analysis was conducted to assess the variations between preferences and perceptions.

RESULTS

Content emerged as the most significant dimension compared to Facilitation and Support. The physician's knowledge, honesty, and ability to provide clear information were considered the most important attributes. Patients evaluated most of their preferences as "very important". Patients' perception of the communication dimensions present during their appointment was below preferences for 11 items, indicating significant discrepancies in clinical practice.

CONCLUSIONS

Patients highly valued their preferences concerning Content, Facilitation, and Support dimensions of communication. However, patient preferences were more prominently oriented towards the Content dimension. The discrepancies between preferences and perceptions should be viewed as an opportunity for enhancing communication skills through training.

A 15-Year Retrospective Review of Ciguatera in the Madeira Islands (North-East Atlantic, Portugal)

The first ciguatera fish poisoning (CFP) in Portugal dates from 2008 when 11 people reported CFP symptoms after consuming a 30 kg amberjack caught around the Selvagens Islands (Madeira Archipelago). Since then, 49 human poisonings have been reported. The emergence of a new threat challenged scientists and regulators, as methods for toxic microalgae analyses and ciguatoxin (CTX) detection were not implemented. To minimise the risk of ciguatera, the Madeira Archipelago authorities interdicted fisheries in Selvagens Islands and banned the capture of amberjacks weighing more than 10 kg in the entire region of Madeira Archipelago. The accurate identification and quantification of the benthic toxin-producing algae species spreading to new areas require efforts in terms of both microscopy and molecular techniques. Two ciguatera-causing dinoflagellates, Gambierdiscus excentricus and Gambierdiscus australes, were identified in the Madeira Island and Selvagens sub-archipelago, respectively. Regarding the CTX analysis (N2a cell-based assay and LC-MS) in fish, the results indicate that the Selvagens Islands are a ciguatera risk area and that fish vectoring CTX are not limited to top predator species. Nevertheless, advances and improvements in screening methods for the fast detection of toxicity in seafood along with certified reference material and sensitive and selective targeted analytical methods for the determination of CTX content are still pending. This study aims to revise the occurrence of ciguatera cases in the Madeira Archipelago since its first detection in 2008, to discuss the risk management strategy that was implemented, and to provide a summary of the available data on the bioaccumulation of CTX in marine fish throughout the marine food web, taking into consideration their ecological significance, ecosystem dynamics, and fisheries relevance.

Burnout in medical students: A longitudinal study in a Portuguese medical school

Background

Burnout is highly prevalent among medical students. This study aimed to assess burnout levels over the course of a semester and identify variables that might explain burnout's variance over time.

Method

This longitudinal study involved medical students from a Portuguese school. Participants completed the Maslach Burnout Inventory and Mental Health Inventory-5, along with questions related to social support, help-seeking behaviours, academic performance, mental health and lifestyle assessment at the beginning (first phase), middle (second phase) and end (third phase) of the first semester of 2018-2019 academic year.

Results

A total of 108 participants provided responses in all phases (paired sample). The prevalence of burnout in the first phase was 28.2%, which increased to 34% in the second and 39.5% in the third. To explore factors contributing to burnout levels, we used the 332 responses obtained in the third phase (non-paired sample). Higher burnout levels were associated with poor academic performance, mental health stigma, consumption of tranquillisers and living away from home. Conversely, they were negatively associated with social support and a healthy lifestyle.

Conclusions

The study reveals a high prevalence of burnout among medical students, with burnout levels increasing throughout the semester. These levels are influenced by modifiable variables.

Extra-Neural Metastases of Glioblastoma: A Case Series

Glioblastoma (GBM) is the most common brain tumor and has a median survival of less than two years. The current standard of care consists of surgery followed by concomitant radio and chemotherapy with temozolomide. Although it is an aggressive tumor, distant metastases are extremely rare. The dissemination mechanisms are not fully understood and currently there is no standard of care for its treatment. In this study, the authors present a comprehensive analysis of all the existing cases of extra-neural metastases of GBM in a tertiary care center over the last five years, along with the procedures carried out in each case.

Bronchiectasis

Bronchiectasis is a final common pathway of a wide variety of underlying conditions including infectious, autoimmune, allergic, genetic and inflammatory conditions. Patients experience a chronic disease with variable clinical symptoms and course, but most experience cough, sputum production and recurrent exacerbations. Symptoms of bronchiectasis lead to poor quality of life and exacerbations are the major driver of morbidity and mortality. Patients are often chronically infected with bacteria with the most common being Pseudomonas aeruginosa and Haemophilus influenzae. Treatment of bronchiectasis includes standardised testing to identify the underlying cause with targeted treatment if immune deficiency, allergic bronchopulmonary aspergillosis or non-tuberculous mycobacterial infection, for example, are identified. Airway clearance is the mainstay of therapy for patients with symptoms of cough and sputum production. Frequently exacerbating patients may benefit from long term antibiotic or mucoactive therapies. Bronchiectasis is a heterogeneous disease and increasingly precision medicine approaches are advocated to target treatments most appropriately and to limit the emergence of antimicrobial resistance.

Acanthosis Nigricans Manifesting as a Paraneoplastic Syndrome Associated With Cholangiocarcinoma

We present the case of a 64-year-old woman with type 2 diabetes who was diagnosed with early-stage intrahepatic cholangiocarcinoma and underwent partial hepatectomy followed by adjuvant chemotherapy. The patient simultaneously developed skin lesions compatible with acanthosis nigricans (AN). Thirty-seven months after completing chemotherapy, the patient had a recurrence of extensive skin and mucosal lesions compatible with AN. A thoracic-abdominal-pelvic (TAP) CT showed a relapse with hepatic hilar adenopathy. Currently, she is under evaluation to undergo radical treatment. Malignancy is a rare cause of AN and skin lesions can arise before, during, or after the diagnosis. As a paraneoplastic syndrome, it is usually related to gastric adenocarcinoma, with cholangiocarcinoma being a rare entity in this setting. Although an uncommon manifestation, the malignant etiology should be considered among other prevalent causes, such as metabolic disorders, and establishing an association can lead to an early diagnosis and initiation of curative treatment.

Six years of demography data for 11 reef coral species

Scleractinian corals are colonial animals with a range of life history strategies, making up diverse species assemblages that define coral reefs. We tagged and tracked approximately 30 colonies from each of 11 species during seven trips spanning six years (2009-2015) in order to measure their vital rates and competitive interactions on the reef crest at Trimodal Reef, Lizard Island, Australia. Pairs of species were chosen from five growth forms where one species of the pair was locally rare (R) and the other common (C). The sampled growth forms were massive [Goniastrea pectinata (R) and G. retiformis (C)], digitate [Acropora humilis (R) and A. cf. digitifera (C)], corymbose [A. millepora (R) and A. nasuta (C)], tabular [A. cytherea (R) and A. hyacinthus (C)] and arborescent [A. robusta (R) and A. intermedia (C)]. An extra corymbose species with intermediate abundance, A. spathulata was included when it became apparent that A. millepora was too rare on the reef crest, making the 11 species in total. The tagged colonies were visited each year in the weeks prior to spawning. During visits, two or more observers each took 2-3 photographs of each tagged colony from directly above and on the horizontal plane with a scale plate to track planar area. Dead or missing colonies were recorded and new colonies tagged in order to maintain approximately 30 colonies per species throughout the six years of the study. In addition to tracking tagged corals, 30 fragments were collected from neighboring untagged colonies of each species for counting numbers of eggs per polyp (fecundity); and fragments of untagged colonies were brought into the laboratory where spawned eggs were collected for biomass and energy measurements. We also conducted surveys at the study site to generate size structure data for each species in several of the years. Each tagged colony photograph was digitized by at least two people. Therefore, we could examine sources of error in planar area for both photographers and outliners. Competitive interactions were recorded for a subset of species by measuring the margins of tagged colony outlines interacting with neighboring corals. The study was abruptly ended by Tropical Cyclone Nathan (Category 4) that killed all but nine of the over 300 tagged colonies in early 2015. Nonetheless, these data will be of use to other researchers interested in coral demography and coexistence, functional ecology, and parametrizing population, community and ecosystem models. The data set is not copyright restricted, and users should cite this paper when using the data.

The role of intrasexual competition on the evolution of male-male courtship display: a systematic review

Background

Evidence of male-male courtship display is widespread across the animal kingdom. Yet, its function and evolutionary origin remain unclear. Here, we hypothesise that male-male courtship display evolved in response to selection pressure exerted by intrasexual competition during male-female courtship interactions. Intrasexual competition can be caused by bystander male pressure through eavesdropping and exploiting on displayer male's courtship interactions with females. This bystander pressure can lead to an audience effect by the displayer, who will change their courtship behaviour in the presence of bystanders and display directly towards them, even in the absence of females, as an intimidation strategy. In species where this selection pressure has taken place, we predict that the male courtship display will have a dual function: attract females and deter competitors. Therefore, we expected to find more evidence of bystander-related behaviours in species for which male-male courtship display is linked to intrasexual competition compared to species for which other explanatory hypotheses are more plausible (e.g., mistaken identity or courtship practice).

Methodology

We conducted two systematic reviews to test this hypothesis. First, we conducted a search for studies of species with courtship display between males and of the hypotheses provided to explain this behaviour. Our goal was to identify the species with male-male courtship display and evidence of intrasexual competition. Second, among the species with male-male courtship display, we searched for evidence of bystander-related behaviours, i.e., articles referring to eavesdropping, exploitation, and audience effect during male-female courtship interactions. Our goal was to test whether species with intrasexual competition are also more likely to show bystander-related behaviours.

Results

Although most studies reporting male courtship display towards other males do not suggest any explanatory hypothesis for this behaviour, the intrasexual competition hypothesis was largely mentioned and supported by some studies reviewed. Additionally, there is more evidence of eavesdropping and of all three bystander-related behaviours combined in species for which the intrasexual competition hypothesis was suggested.

Conclusions

Overall, our review supports the hypothesis that intrasexual competition can play a key role in male courtship display evolution, namely that male-male courtship display may have evolved as a secondary function of male-female courtship interactions via bystander male pressure. However, our review also shows that despite the increasing interest in same-sex sexual behaviours, and male-male courtship display in particular, most studies were found to be merely descriptive, and the hypotheses they suggested to explain courtship display between males mostly speculative. This highlights an important gap in the literature. To clarify both the evolution and the function of male-male courtship display, this behaviour needs to be empirically studied more often. Our review can help advancing this research area, as it makes the 20 species with male-male courtship display for which the intrasexual competition hypothesis was suggested excellent candidates for empirical research.

The Role of Cyclin-Dependent Kinase 4/6 Inhibitors Treatment in Oligometastatic Breast Cancer: A Case Report on a Possible Curative Intent Strategy

A small but important subset of patients with metastatic breast cancer has an oligometastatic disease. Some of these patients are highly responsive to systemic therapy and have the potential to achieve complete remission with treatment. However, it remains to be clarified the best locoregional and systemic treatment strategy for such patients and what features can determine whose patients are the best candidates. We also don't know what will be the role of cyclin-dependent kinase 4/6 inhibitors in those cases. We report the case of a 41-year-old woman with HR-positive/HER2-negative oligometastatic breast cancer who, after an excellent response to systemic treatment with palbociclib, anastrozole, and goserelin, underwent breast surgery and liver metastasectomy. After completing three years of systemic treatment, the CDK inhibitor was discontinued, maintaining the hormone therapy. The patient remained under regular follow-up with no evidence of disease after eight months.

Metastatic BRAF V600E-Mutated Thyroid Carcinoma: Molecular/Genetic Profiling Brings a New Therapeutic Option

We describe a case of a 46-year-old woman diagnosed with localized PTC 20 years ago, having already undergone several treatments with iodine-131 and then treatment with lenvatinib for metastatic disease, to which she developed intolerance. In 2020, in addition to pleural, thoracic, and abdominal lymph node metastasis, progression with symptomatic vertebral bone metastasis was detected, which led to the equation of new therapeutic options. In this context, a genetic/molecular test was carried out, which identified the BRAF V600E mutation and enabled the start of treatment with dabrafenib/trametinib since June 2020. This treatment allowed functional gain, symptomatic relief, and stabilization of the disease. It demonstrates how, in rare tumors, the personalized medicine approach can bring new treatment possibilities.

Priapismo Secundário a Heparinas de Baixo-Peso-Molecular: Um Caso Clínico

Priapism may be a side effect of low-molecular-weight heparins, and its mechanism remains unknown. The authors present a clinical case of a 51-year-old male patient with oligodendroglioma. The patient presented ischemic priapism on the third month after starting tinzaparin, without other recent changes to his medication and he denied the use of other new medicines. The patient went through surgery and the erection was resolved but presented fibrosis of the cavernous body which left him with erectile dysfunction. Since this event, the patient is no longer receiving Heparin and has had no other episodes of priapism. The prompt recognition of this side effect may decrease its morbidity and consequent impact on the quality of life. More studies are needed to better understand its pathophysiology.

Living on the edge: a review on potential risk factors for suicide in adult attention-deficit/hyperactivity disorder

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms including inattention, hyperactivity and/or impulsivity that commonly persists into adulthood. Suicide is a major cause of death in adult ADHD (aADHD) patients. Suicidality is higher in these patients, in possible relationship to various clinical and socio-demographic factors.

Objectives

To review the current literature concerning potential risk factors for suicide in aADHD patients.

Methods

A research was made using the Medline database through the Pubmed search engine, with the following keywords: “adhd”, “suicide”, “risk factors”.

Results

Comorbid psychiatric disorders (major depressive disorder, sleep disturbances, behavior disorders and addictive disorders) are powerful predictors of suicidal behavior in aADHD. Depression is the most frequent diagnosis among aADHD patients with previous suicide attempts. Subtype (mostly the combined type) and severity of ADHD were also associated with a higher number of prior suicide attempts. Impulsiveness, poor emotional self-regulation, recklessness, persistent hyperactivity, inability to relax, engagement in risk behavior (often found in ADHD), common personality traits in aADHD like low frustration tolerance, maladaptive coping and poor problem-solving, as well as interpersonal relationship problems, were associated with higher suicidality. Financial distress caused by unemployment is associated with higher suicidal behaviors. The suicidality is higher in females, mostly associated to self-concept, whereas in males is typically related to impulsivity.

Conclusions

Clinicians should be aware of the potential risk factors for suicide in aADHD patients because the early detection of these factors is fundamental to improve the patients’ quality of life and could contribute to the design of more effective treatments.

Disclosure

No significant relationships.

The cognitive effects of esketamine: what do we know so far?

Introduction

Esketamine is an S-enantiomer of ketamine approved by the EMA for treatment-resistant depression (TRD). As an NMDA receptor antagonist, its administration results in increase of glutamate release and AMPA receptor activation, supporting both rapid-onset and long-term antidepressant effects. Short-term tolerability seems acceptable but major concerns remain regarding long-term safety, specifically regarding potential neurocognitive toxicity.

Objectives

To clarify the potential short and long-term cognitive beneficial-effects and side-effects of esketamine.

Methods

Research was made using the Medline database, through the Pubmed search engine, using the keywords: “esketamine”, “cognition”. Only randomized-controlled trials were considered.

Results

One study focused on the effects of intranasal esketamine (INE) on cognitive functioning in 24 healthy individuals, who were evaluated pre- and postdose (40 min, 2h, 4h and 6h). The results showed a decline in cognitive performance at 40 min postdose, returning to comparable levels as placebo by 2h postdose. Another study, with a follow-up of 1 year, involving 802 TRD patients, accessed the long-term safety of INE. In patients aged <65 years-old, performance on all cognitive tests remained stable or slightly improved from baseline during long-term treatment. In patients ≥ 65 years-old, the mean performance on all tests improved or remained stable, while the simple and choice reaction time began slowing at week 20.

Conclusions

Esketamine has proven to be a promising new option for the treatment of TRD and available studies have shown promising results regarding patients’ cognitive function. Larger clinical trials are needed to further evaluate its short-term and long-term cognitive effects.

Disclosure

No significant relationships.

Adult attention-deficit/hyperactivity disorder and bipolar disorder: diagnostic and management challenges

Introduction

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) are neurodevelopmental disorders that commonly persist into adulthood. ADHD in adults can resemble, and often co-occurs with, bipolar disorder (BD), which might lead to diagnostic errors, ineffective treatment and potentially serious adverse consequences.

Objectives

To review on the overlaps and differences in the psychopathology of the two entities and particularities of the management when they occur comorbidely.

Methods

The Medline database through the Pubmed search engine was used with the following keywords: “adhd” and “bipolar disorder”.

Results

ADHD has an estimated prevalence of 10-30% in adults with BD. Despite the symptomatic similarities, there are some important differences. In the ADHD/BD comorbidity, symptoms like attention-deficit, distractibility, irritability, impulsiveness and hyperactivity that may present in (hypo)manic and/or depressive episodes, tend to persist after clinical stabilization. While adult patients with ADHD typically experience ceaseless mental activity and wandering mind, BD patients may have racing thoughts and perceive them as making sense. ADHD patients may have poor socio-occupational achievement that may lead to low self-esteem, low self-confidence and depressed mood. Features like course of illness, psychiatric family history and treatment response may help differentiate the two entities. The treatment must start with mood stabilization and then proceed to the treatment of ADHD symptoms.

Conclusions

A complete clinical history, with particular focus in the neurodevelopmental history, is important but sometimes is not enough for an accurate diagnosis of this comorbidity. As so, clinicians should be aware of the high comorbidity rates to prevent misdiagnosis and provide the best care for both disorders.

Disclosure

No significant relationships.

Metastatic Castration-Resistant Prostate Cancer with BRCA2 Mutation: The Challenge Incorporating PARP Inhibitors and Platinum in Treatment Sequencing

Prostate cancer is the second most frequent malignancy in men worldwide. Despite the improvement in survival achieved by increasingly early diagnosis and advances in treatment, it is still associated with high mortality. Because of its molecular heterogeneity, there is a need to identify genetic alterations in order to apply targeted therapies. Increasing evidence suggests that the PARP inhibitor olaparib could have a significant synthetic lethal effect in prostate cancer with homologous recombination defects, such as BRCA1/2 mutations. It is not yet known if, under these circumstances, platinum-based chemotherapy induces higher response rates in prostate cancer. We present the case of a patient with BRCA2-mutated metastatic castration-resistant prostate cancer whose treatment sequence included carboplatin and olaparib.

Use of Cognitive Enhancers by Portuguese Medical Students: Do Academic Challenges Matter?

INTRODUCTION

Nonmedical use of prescription drugs and other substances for cognitive enhancement in the academic environment has been documented in several studies. However, the prevalence among Portuguese university students is unknown. We aimed to assess the prevalence and academic contexts of the use of cognitive enhancers of a sample of Portuguese medical students.

MATERIAL AND METHODS

An online questionnaire about the use of cognitive enhancers was completed by 1156 participants, who were either medical students (group 1) or newly qualified physicians applying for the Portuguese medical licensing exam (group 2).

RESULTS

Coffee was the most frequently used substance for cognitive enhancement purposes in both groups, whereas nonmedical use of prescription drugs for cognitive enhancement was lower in undergraduate students (5%) and higher in licensing exam applicants (14%). Methylphenidate (35%) and modafinil (10%) were the most consumed prescription substances and they were mainly used to enhance attention (83%) and memory (44%). Use of prescription drugs for cognitive enhancement was mainly associated with studying for medical school exams and the medical licensing exam. Most prescription drugs for cognitive enhancement were obtained through medical prescription (54%).

DISCUSSION

These results show a low consumption of prescription drugs for cognitive enhancement by Portuguese medical students. Licensing exam applicants show a higher consumption of almost every substance included in this study, which might be explained by the crucial role of the exam in defining their future career path and desire by students to improve the cognitive skills that determine exam success.

CONCLUSION

Studying drugtaking behaviors in medical students and young doctors is relevant for public health and medical education, since they will soon be in charge of drugs prescription. Therefore, ethical and medical concerns raised by off label consumption of prescription drugs for cognitive enhancement purposes must be openly addressed.

Communication skills in psychiatry for undergraduate students: A scoping review

Communication skills are paramount in all areas of medicine but particularly in psychiatry due to the challenges posed by mental health patients and the essential role of communication from diagnosis to treatment. Despite the prevalence of psychiatric disorders in different medical specialties, particularly in primary care settings, communication skills in psychiatry and their training are not well studied and are often not included in the undergraduate medical curriculum. Our paper explores the relevance of teaching communication competencies in psychiatry for undergraduate medical students. Our work focused on reviewing the methods for teaching communication skills to undergraduate students in Psychiatry. Eleven studies were selected to be included in this review. We found considerable heterogeneity among methods for teaching communication skills but also some common elements such as the use of simulated patients and providing feedback. This review has identified two models: the Calgary-Cambridge interview model and the Kolb cycle-based model. However, most studies still lack a theoretical background model. We believe that the inclusion of communication skills training in medical curricula is fundamental to teaching medical students general communication skills but also specific training on establishing adequate communication with psychiatric patients. However, more research is needed to determine the best method for training but also regarding its translation to patient care and cost-effectiveness.

Intervertebral disc decellularisation: progress and challenges

Intervertebral disc (IVD) degeneration and the consequent low-back pain (LBP) affect over 80 % of people in western societies, constituting a tremendous socio-economic burden worldwide and largely impairing patients' life quality. Extracellular matrix (ECM)-based scaffolds, derived from decellularised tissues, are being increasingly explored in regenerative medicine for tissue repair. Decellularisation plays an essential role for host cells and antigen removal, while maintaining native microenvironmental signals, including ECM structure, composition and mechanical properties, which are essential for driving tissue regeneration. With the lack of clinical solutions for IVD repair/regeneration, implantation of decellularised IVD tissues has been explored to halt and/or revert the degenerative cascade and the associated LBP symptoms. Over the last few years, several researchers have focused on the optimisation of IVD decellularisation methods, combining physical, chemical and enzymatic treatments, in order to successfully develop a cell-free matrix. Recellularisation of IVD-based scaffolds with different cell types has been attempted and numerous methods have been explored to address proper IVD regeneration. Herein, the advances in IVD decellularisation methods, sterilisation procedures, repopulation and biocompatibility tests are reviewed. Additionally, the importance of the donor profile for therapeutic success is also addressed. Finally, the perspectives and major hurdles for clinical use of the decellularised ECM-based biomaterials for IVD are discussed. The studies reviewed support the notion that tissue-engineering-based strategies resorting to decellularised IVD may represent a major advancement in the treatment of disc degeneration and consequent LBP.

A self-comfort oriented pattern of regulatory behavior and avoidant attachment are more likely among infants born moderate-to-late preterm

Infants born preterm (<37 gestational weeks, GW) are at increased risk for regulatory difficulties and insecure attachment. However, the association between infants' regulatory behavior patterns and their later attachment organization is understudied in the preterm population. We addressed this gap by utilizing a Portuguese sample of 202 mother-infant dyads. Specifically, we compared the regulatory behavior patterns of 74 infants born moderate-to-late preterm (MLPT, 32-36 GW) to those of 128 infants born full-term (FT, 37-42 GW) and evaluated the associations of these regulatory patterns with later attachment. Infants' regulatory behavior patterns (Social-Positive Oriented, Distressed-Inconsolable, or Self-Comfort Oriented) were evaluated in the Face-to-Face-Still-Face paradigm at 3 months, and their attachment organization (secure, insecure-avoidant, or insecure-ambivalent) was evaluated in the Strange Situation at 12 months corrected age. In both samples, the Social-Positive-Oriented regulatory pattern was associated with secure attachment; the Distressed-Inconsolable pattern with insecure-ambivalent attachment; and the Self-Comfort-Oriented pattern with insecure-avoidant attachment. However, compared to FT infants, infants born MLPT were more likely to exhibit a Self-Comfort-Oriented pattern and avoidant attachment. Most perinatal and demographic variables were not related to infant outcomes. However, infants with a higher 1-min Apgar were more likely to exhibit the Social-Positive-Oriented regulatory pattern and secure attachment.

Patterns of regulatory behavior in the still-face paradigm at 3 months: A comparison of Brazilian and Portuguese infants

Three infant regulatory behavior patterns have been identified during the Face-to-Face Still-Face paradigm (FFSF) in prior research samples: a Social-Positive Oriented pattern (i.e., infants exhibit predominantly positive social engagement), a Distressed-Inconsolable pattern (i.e., infants display conspicuous negative affect that persists or increases across FFSF episodes), and a Self-Comfort Oriented pattern (e.g., infants primarily engage in self-comforting behaviors such as thumb-sucking). However, few studies have examined these patterns outside US and European countries or evaluated potential cross-country differences in these patterns. In this study, we compared the regulatory behavior patterns of 74 Brazilian and 124 Portuguese infants in the FFSF at 3 months of age, and evaluated their links to demographic and birth variables. The prevalence of the three regulatory patterns varied by country. The most frequent pattern in the Portuguese sample was the Social-Positive Oriented, followed by the Distressed-Inconsolable and the Self-Comfort Oriented. However, in the Brazilian sample, the Distressed-Inconsolable pattern was the most prevalent, followed by the Social-Positive Oriented and the Self-Comfort Oriented. Moreover, in the Brazilian sample, familial SES was higher among infants with a Social-Positive pattern whereas 1^st-minute Apgar scores were lower among Portuguese infants with a Distressed-Inconsolable Oriented pattern of regulatory behavior. In each sample, Social Positive pattern of regulatory behavior was associated with maternal sensitivity, Self-Comfort Oriented pattern of regulatory behavior with maternal control, and Distressed-Inconsolable pattern with maternal unresponsivity.

Treating addiction with psychedelics - are we waking up?

Introduction

Classic psychedelics have been administered in sacramental contexts since ancient times. They were of prominent interest within psychiatry and neuroscience in the 1950s to 1960s, but the association between classic psychedelics and the emerging counterculture put an end to their research. Modern research with classic psychedelics has reinitiated interest in the treatment of both cancer-related distress and addiction, with really promising results.

Objectives

We aim to provide a review about history and new insights regarding research with psychedelics specially as treatment of addictive disorders.

Methods

A framing analysis of articles, searched on Pubmed (articles between 2010-2020) with the key words: “ psychedelics”, “psilocybin”, “substance use disorder”, “addiction”.

Results

Classic psychedelics are 5HT2AR agonists such as LSD, mescaline, and psilocybin. They were shown to occasion mystical experiences, which are experiences reported throughout different cultures and religions involving a strong sense of unity. These experiences are scientifically important because they appear to cause abrupt and sustained changes in behavior and perception, that can be very useful in the substance use disorder field. From this analysis is possible to understand that the use of psychadelics in the treatment of some addictions is currently at an early stage of research. However, they show interesting results with no clinically significant adverse events when risk individuals are excluded.

Conclusions

In comparison to psychedelic research about cancer-related psychological distress, studies with addictions are less developed, but if they continue to suggest safety and efficacy, may be the use of psilocybin for the treatment of specific addiction can happen in a close future.

MAternal Mental Health in the WORKplace (MAMH@WORK): A Protocol for Promoting Perinatal Maternal Mental Health and Wellbeing

Women are exposed to increased burden of mental disorders during the perinatal period: 13–19% experience postpartum depression. Perinatal psychological suffering affects early mother-child relationship, impacting child’s emotional and cognitive development. Return-to-work brings additional vulnerability given the required balance between parenting and job demands. The MAternal Mental Health in the WORKplace (MAMH@WORK) project aims to develop and evaluate the effectiveness of a brief and sustainable intervention, promoting (a) maternal mental health throughout pregnancy and first 12 months after delivery, and (b) quality of mother–child interactions, child emotional self-regulation, and cognitive self-control, while (c) reducing perinatal absenteeism and presenteeism. MAMH@WORK is a three-arm randomized controlled trial. A short-term cognitive-behavioral therapy-based (CBT-based) psychoeducation plus biofeedback intervention will be implemented by psychiatrists and psychologists, following a standardized procedure manual developed after consensus (Delphi method). Participants (n = 225, primiparous, singleton pregnant women at 28–30 weeks gestational age, aged 18–40 years, employed) will be randomly allocated to arms: CBT-based psychoeducation intervention (including mindfulness); psychoeducation plus biofeedback intervention; and control. Assessments will take place before and after delivery. Main outcomes (and main tools): mental health literacy (MHLS), psychological wellbeing (HADS, EPDS, KBS, CD-RISC, BRIEF COPE), quality of mother–child interaction, child–mother attachment, child emotional self-regulation and cognitive self-control (including PBQ, Strange Situation Procedure, QDIBRB, SGS-II, CARE-Index), job engagement (UWES), and presenteeism. Intention-to-treat and per-protocol analyses will be conducted; Cohen’s d coefficient, Cramer’s V and odds ratio will be used to assess the effect size of the intervention. MAMH@WORK is expected to contribute to mental health promotion during the perinatal period and beyond. Its results have the potential to inform health policies regarding work–life balance and maternal mental health and wellbeing promotion in the workplace.

Anthropogenic noise influences on marine soundscape variability across coastal areas

Acoustic data was collected across 15 sites distributed through the coastal area of Rio de Janeiro, Brazil, encompassing regions of different natural characteristics. Noise levels and the acoustic complexity index were calculated. Quantity and composition of anthropogenic sound sources varied across recording sites, with at least one type of sound source being registered in each location. A cluster analysis using third-octave levels from eight frequency bands divided recording sites into two groups, one considered as impacted by anthropogenic noise and the other as less-impacted. The noisiest recording locations were those with higher numbers of anthropogenic sound sources, specifically large ships. It was evidenced that anthropogenic noise affects not only noise levels, but also low-frequency acoustic complexity, which decreased in the presence of vessel traffic. The constant noise input of human activities tended to mask natural variability in the soundscape at lower frequencies.

Health regulation in Brazilian municipalities

The regulatory structures can become determinants in the organizational process of health management, as it has the possibility of giving more effective responses to the user who seeks the Brazilian health system. The objective of the study is to analyze the regulation of health services in Brazilian municipalities, considering the regulation centers, recommended by the legislation of the Unified Health System (SUS). This is a descriptive exploratory study with a qualitative focus, developed in municipal regulatory centers in Brazilian states, through semi-structured interviews. The sample consisted of eighteen managers and seventy regulation professionals, from September / 2017 to January 2018. As limiting factors in regulation, the following stand out: great demand for people; unavailability of beds; systemic difficulties in relation to the agreed services; procedures that are difficult to schedule and execute; problems in information flows between primary care and regulation. The main potentialities are: increased financial resources for health; reorganization of internal regulatory procedures; meeting users' needs; health training for regulatory professionals; and strengthening primary health care. The study showed that it is difficult to concentrate higher education professionals to perform the tasks of regulators of medium and high complexity procedures; there are obstacles to operationalize the regulatory process, since the regulatory structures created coexist with insufficient resources, agreements that are inconsistent with the country's reality; there is recognition of the need for a strong regulatory component in guaranteeing qualified access to health, and one of the greatest challenges is to understand the multiplicity of scenarios, subjects and interests, and to implement user-centered strategies.

Key messages

Health regulation in Brazilian municipalities.

Emerging patterns of infant regulatory behavior in the Still-Face paradigm at 3 and 9 months predict mother-infant attachment at 12 months

Prior research described three stable patterns of organized behavior employed by infants to manage stressful interactive situations with their mothers in the Face-to-Face Still-Face paradigm (FFSF) at 3 and 9 months postpartum.  The current longitudinal study expands this research by examining the extent to which these patterns predict infants' later attachment quality. For that purpose, 108 full-term infants and their mothers participated in the FFSF at 3 and 9 months, and in the Strange Situation at 12 months. Cross-tabulation analyses indicated a significant association between (1) the Social-positive oriented pattern and secure attachment, (2) the Distressed-inconsolable pattern and insecure-ambivalent attachment, and (3) the Self-comfort oriented pattern and insecure-avoidant attachment. Our results contribute to a growing body of studies suggesting that patterns of infants' regulatory behavior assessed during the FFSF during the first year, may be early developmental precursors of attachment patterns at 12 months.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

P724 The mysteries of sinus of Valsalva

Sinus of Valsalva aneurysms are a rare pathology that can be clinically silent during years and/or become suddenly symptomatic. We described 3 cases with different clinical presentation, complications and surgical treatment.

A 26-year-old male, competitive cyclist was admitted with a 1.5 month history of fatigue, palpitations, and nocturnal cough and sweating. At physical examination he was apyretic, blood pressure 157/49mmHg and radial pulse 96 bpm; jugular vein engorgement and continuous heart murmur, were noticed. Blood samples only revealed a mild raised BNP. EKG showed sinus tachycardia and right intraventricular conduction delay and the transthoracic echocardiography (TTE) revealed high velocity systolic-diastolic shunt (image) between a non-dilated right coronary sinus (RCS) and the right atrium (RA); moderate left ventricle dilation, severe right atrium and mild right ventricle enlargement with mild pulmonary hypertension and normal biventricular systolic function. He was referred to angioCT that showed a large communication between a non-dilated RCS and RA with signs of right ventricular overload. He was submitted to surgery, where ruptured aneurysm sac was found. Fistula closure, aneurysm sac suture and tricuspid annuloplasty were performed.

A 45-year-old male asymptomatic, with no relevant medical background went to a Cardiology consultation after detection of a holossistolic murmur in the physical exam. EKG showed sinus rhythm arrhythmia with a nonspecific intraventricular conduction delay and the TTE revealed a communication between a dilated noncoronary sinus (NCS) and RA; the biventricular systolic function was normal. He was referred to angioCT which confirmed the diagnosis. He was submitted to surgery where an exeresis and closure of the fistula was performed.

A 38-year-old male with no relevant medical background was admitted to emergence room for an intermittent anterior thoracic pain radiating to the neck (2 days of evolution). The EKG showed sinus tachycardia, incomplete right bundle branch block and the high-sensitivity troponin assays were negative. The TTE revealed severe sinus of Valsalva aneurysm, particularly of the NCS with mild aortic regurgitation. The patient performed transesophageal echocardiography and angioCT which excluded an acute aortic syndrome. He was oriented to surgery where a contained rupture of the RCS and a non-visualization of the ostium right coronary artery were detected, suggesting an intimal dissection. The patient was submitted to Bentall procedure and a bypass with internal mammary artery to right coronary artery.

In spite of the unclear etiology, all the cases had a good clinical and echocardiographic evolution at follow-up. The difficulty in making a timely diagnosis is related to the variability of clinical presentation and the need of high clinical suspicion. Echocardiography and angioTC have demonstrated its value, in providing a prompt diagnosis and appropriate management guidance.

Abstract P724 Figure. Ruptured aneurysm sac and fistula