Phenylpropiolic acid isolated in cryogenic nitrogen and xenon matrices: NIR and UV-induced study

Phenylpropiolic acid (C6H5C≡CCOOH, PPA) isolated in nitrogen and xenon cryogenic matrices was studied by infrared spectroscopy. The experimental studies were complemented by a series of quantum chemical calculations carried out at the density functional theory (B3LYP) and MP2 levels of theory (with different basis sets). The calculations predicted the existence of two planar PPA conformers, differing in the arrangement of the carboxylic group. The higher-energy trans-PPA conformer has a negligible population in the gas phase at room temperature and was prepared in situ in the N2 cryomatrix through vibrationally-induced rotamerization of the lower-energy cis-PPA conformer, achieved using selective narrowband infrared excitation of the OH stretching coordinate of the latter species. Broadband UV (λ > 235 nm) irradiation of matrix-isolated cis-PPA was also undertaken, leading to the observation of cis-PPA → trans-PPA isomerization. No other UV-induced photoreactions were observed. The in situ generated trans-PPA conformer was found to decay back to cis-PPA in the dark by tunneling, and its lifetimes under different experimental conditions were determined. The assignment of the infrared spectra of both conformers is presented, considerably extending the vibrational information available on this molecule.

Acute and chronic effects of the organophosphate malathion on the pancreatic α and β cell viability, cell structure, and voltage-gated K+ currents

Studies indicate that the pesticide malathion may have a role in diabetes. Herein, we determined the effects of different concentrations of malathion on survival, ultrastructure, and electrophysiologic islet cell parameters. Acutely, high concentrations of malathion (0.5 or 1 mM) increased cell death in rat islet cells, while low concentrations (0.1 mM) caused signs of cell damage in pancreatic α and β cells. Exposure of RINm5F cells to malathion for 24 or 48 h confirmed the reduction in β-cell viability at lower concentrations (0.001-100 µM). Chronic exposure of mouse pancreatic α and β cells to 3 nM of malathion led to increased voltage-gated K⁺ (K_v) currents in α-cells. Our findings show a time and concentration dependency for the malathion effect on the reduction of islet cell viability and indicate that pancreatic α cells are more sensitive to malathion effects on K_v currents and cell death.

Unintended intrapleural insertion of an epidural catheter in thoracic surgery: regional analgesia game over, or is there another way out?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia (EA) and paravertebral block (PVB) are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication. Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery (VATS). There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications. It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.

Exosomal glypican-1 discriminates pancreatic ductal adenocarcinoma from chronic pancreatitis

BACKGROUND AND AIMS

Pancreatic ductal adenocarcinoma (PDAC) diagnosis can be difficult in a chronic pancreatitis (CP) background, especially in its mass forming presentation. We aimed to assess the accuracy of glypican-1-positive circulating exosomes (GPC1+crExos) to distinguish PDAC from CP versus the state-of-the-art CA 19-9 biomarker.

METHODS

This was a unicentric prospective cohort. Endoscopic ultrasound with fine-needle aspiration or biopsy and blood tests (GPC1+crExos and serum CA 19-9) were performed.

RESULTS

The cohort comprised 60 PDAC and 29 CP (7 of which mass forming - MF) patients. Median levels of GPC1+crExos were significantly higher in PDAC (99.7%) versus CP (28.4%; p<0.0001) with an AUROC of 0.96 with 98.3% sensitivity and 86.2% specificity for a cut-off of 45.0% (p<0.0001); this outperforms CA 19-9 AUROC of 0.82 with 78.3% sensitivity and 65.5% specificity at a cut-off of 37 U/mL (p<0.0001). The superiority of% GPC1+crExos over CA 19-99 in differentiating PDAC from CP was observed in both early (stage I) and advanced tumors (stages II-IV).

CONCLUSION

Levels of GPC1+crExos coupled to beads enable differential diagnosis between PDAC and CP including its mass-forming presentation.

Healthcare system delay and utilization in tuberculosis patients in Portuguese high-incidence region

Background

In Portugal, the Tâmega e Sousa region (TeS) has a high incidence of tuberculosis (TB) [27.4 and 43.8 per 100.000 inhabitants in sub-regions Baixo Tâmega (BxT) and Vale do Sousa Sul (VSS), 2017]. Delay in TB diagnosis leads to increased transmission, which may lead to more people infected. This study aimed to describe healthcare system delay among TB patients and healthcare utilization from symptoms onset to diagnosis in TeS.

Methods

We analysed pulmonary TB cases notified in BxT and VSS in 2014-7 in the national surveillance system (SVIG-TB). Concomitantly, we analysed healthcare utilisation from patients in a retrospective study (URBAN-TB) about TB delays in 2019-20. We characterised demographics of patients from each data source and comorbidities from SVIG-TB. We calculated median overall delay until diagnosis (days); and healthcare delay overall and by patient characteristics, for each sub-region. Delay was calculated only when relevant dates were recorded. Healthcare utilisation from symptoms onset to diagnosis was described using the frequency of each first contact provider and the average number of visits until diagnosis.

Results

Included 139 patients from BxT and 206 from VSS (83% male, 53% aged 40-59y, and 17% with silicosis). Global delays were 48 and 75 days (n = 57/132; BxT and VSS). Healthcare delays were 7 and 8 days (n = 76/180; BxT and VSS). In both ACES, healthcare delays were longer for patients aged 60-79y, with COPD and aged 0-19y. Healthcare utilisation analysis included 38 patients (89% male; 55% aged 40-59y; n = 17/21). Primary care (n = 15; 39%) and emergency department (ED) (n = 9; 24%) were frequent points of first contact. The average number of visits until diagnosis was higher for patients from ED (3.9) and lower for patients from TB specialised units (1.3).

Conclusions

Our results suggest that in TeS it is important to avoid ED as a point of first contact of TB patients and to facilitate the diagnosis in young, older and COPD patients.

Key messages

Emergency department is a relevant point of first contact and may be included in efforts to reduce tuberculosis delay. Policies to reduce tuberculosis delay may target younger, older and COPD patients.

Factors associated with avoidance of emergency department visits in Portugal during the pandemic

Background

Avoiding an emergency department (ED) visit risks irreversible negative consequences for patients' health. EDs are a frequent access point to the Portuguese health system. Previous studies have shown that patients may avoid visiting ED during the pandemic. This study aims to identify factors associated with avoidance of ED visits in Portugal during the COVID-19 pandemic.

Methods

We used data from a community-based survey, “COVID-19 Barometer: Social Opinion”, which includes healthcare utilisation, health status, and risk perception in Portugal from 11th April 2020 to 16th April 2021. We included respondents that reported having needed ED care. Data were collected on sociodemographics, health status (comorbidities, mental health), risk perception (COVID-19 and complications), level of trust in health services and self-assessment of the severity of the reason for ED visit. The outcome of interest was the decision to avoid ED care. We used logistic regression to identify factors associated with the decision to avoid ED.

Results

Preliminary data showed that 914 respondents reported needing ED care (74.8% female; mean age 43 years). From those, 224 (25%) decided to avoid ED care. ED visits avoidance was higher during lockdowns (28%). People reporting specific comorbidities (cardiac, autoimmune, respiratory) avoided ED more than those without them. Perception of no severe reason for ED visit, poor mental health, perception of higher risk of COVID-19 and complications, and low trust in health services response to the pandemic were associated with higher odds of ED visit avoidance.

Conclusions

People avoiding ED visits represented a considerable share. The decision to avoid ED visit was associated with clinical characteristics, but the perception of risk and assessment of the context and health system response also played a role in decision making.

Key messages

The effect of avoided ED visits on health should be a research and policy concern. People with certain comorbidities or perception of high risk of COVID-19 and complications may be closely monitored.

Resistant hypertension must be defined by ambulatory blood pressure and pulse pressure is best predictor of new cardiovascular events

Introduction

Resistant Hypertension (RH) defined by Ambulatory blood pressure monitoring (ABPM) isn't so common. Prognostic CV by ABPM of RH is uncertain.

Objective

RH Population defined by ABPM, followed 5.9±5.0 years and prognostic value of ABPM for new CV events (CVe).

Design and method

ABPM-collected 1999–2019. Identified RH patients by ABPM. Obtained anthropometric, clinic, laboratorial data from the patient and clinical records. CVe defined by: stroke (ST) (Ischemic (STisq), haemorrhagic (SThs)), Coronary Event (CD), Other CV events (OCV) (acute heart failure (HF), peripheral arterial disease (PAD). Follow-up finished with event, last evaluation of the patient or death.

Results

258 patients, follow-up – 5.9±5.0 years,158 males, mean age – 60.4±11 years. Diabetes Mellitus (DM) 45.3%, Dyslipidaemia 74.4%, Obesity 45.3%, Chronic Kidney Disease 37.2%, previous CVe (PCVe) 34.5%. Observed 68 CVe: 26 ST (21 STisq, 5 SThs), 21 CD, 21 OCV (15 HF, 6 PAD). 18 death (8 unknown, 1 infection, 2 cancer, 1 sudden death, 2 STisq, 1 CD, 3 HF). When compared those with event vs no-event (fig. 1), in T student to independent samples, those with event had larger left atrium (42.6±5.7 vs 40.2±4.7, p&lt;0.05), lower creatinine clearance (mL/min/1.73m2) (63.6±34 vs 74.5±33). PCVe was significantly more prevalent on those with event (c 9.8, p&lt;0.01). In a multivariate Cox analysis for the risk of CVe (adjusted to age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive), Day Pulse Pressure with cut-off 60mmHg was statically significant (HR 2.46 (95% CI 1.26–4.83), p&lt;0.01). In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg of PP (24h, Day, night PP), mostly Day PP-60mmHg (log rank 9.27, p&lt;0.01) (fig. 2A). When analyzed for those who had Stroke, in the multivariate Cox analysis 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant on top of age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive. In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg PP, mostly Day PP 60mmHg (log rank 8.5 p&lt;0.01) (fig. 2B). For those who had CD in the multivariate Cox analysis, adjusted for other variables, 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05 HR1.03 (95% CI 1.00–1.06) were statically significant. In Kaplan-Meier survival curve free of events, night PP 60mmHg predicted CD events (log rank 4.42 p&lt;0.05) (fig. 2C). For OCV the multivariate Cox analysis, adjusted for other variables, 24h PP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07) and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant for new OCV. In Kaplan-Meier survival curve free of events, best predictor was mostly night PP 60mmHg (log rank 19, p&lt;0.001) (fig. 2D).

Conclusion

In our sample of RH the definition by ABPM is essential. PP is the key prognosis for future CVe, special if analysed by the cut of PP-60 mmHg.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier survival curves

Aerobic exercise training reduces blood pressure, angiotensin II and oxidative stress of patients with resistant hypertension: the EnRiCH trial

Introduction

Resistant hypertension is a major challenge of modern cardiovascular medicine, as it is a puzzling problem without a clear solution. Exercise training clearly reduces blood pressure (BP) and oxidative stress in patients with hypertension, however evidence is limited regarding resistant hypertension.

Purpose

To determine the effect of an aerobic exercise training program in BP, angiotensin II and oxidative stress in patients with resistant hypertension.

Methods

EnRicH is a prospective, two-center, single-blinded, randomized controlled trial with a parallel two-arm group. Sixty patients with resistant hypertension were randomly assigned in a 1:1 ratio to undergo a 12-week aerobic exercise training program (exercise) or usual care (control). The powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcome measures included daytime and nighttime ambulatory BP, office BP, cardiorespiratory fitness, and oxidative stress and inflammatory biomarkers: Interferon-gamma (IFN-y), Angiotensin II, vascular endothelial growth factor (VEGF), and superoxide dismutase (SOD).

Results

Fifty-three patients (exercise n=26, control n=27) completed the study. Patients were mainly women (54.7%), with an office BP of 140.7±15.9/84.2±9.4 mm Hg and taking an average of 4.6 antihypertensive medications (median, 5; range, 3 to 7). At baseline, no differences were found between groups for the study outcomes and patient characteristics. Ambulatory systolic BP was reduced −7.1 mm Hg (95% CI, −12.8 to −1.4; P=0.015) in the exercise group (127.4±12.2 to 121.2±12.2, p=0.007) compared to control group (126.1±17.2 to 126.9±15.2, p=514) over 24-hour. In addition, 24-hour ambulatory diastolic BP (−5.1 mm Hg, −7.9 to −2.3, P=0.001), daytime ambulatory systolic (−8.4 mm Hg, −14.3 to −2.5, P=0.006), and diastolic BP (−5.7 mm Hg, −9.0 to −2.4, P=0.001) were also reduced in the exercise group compared to the control group. There were no differences in the change of nighttime ambulatory BP between groups. Cardiorespiratory fitness improved in the exercise group by 14% (4.7 ml.kg-1.min-1, P&lt;0.001), while it remained unchanged in the control group (−0.37 ml.kg-1.min-1, P=0.442). A significant between-group difference in favor of exercise group was found for IFN-y (−4.3 pg/mL, 95% CI: −7.1 to −1.5; P=0.003), Angiotensin II (−157.0 pg/mL, 95% CI: −288.1 to −25.9; P=0.020), VEGF (10.53 pg/mL, 95% CI: 0.60 to 22.54; P=0.035), and SOD (0.35 pg/mL, 95% CI: 0.10 to 0.58; P=0.009).

Conclusions

A 12-week moderate intensity aerobic exercise program reduced ambulatory BP, angiotensin II and oxidative stress in patients with resistant hypertension. The antihypertensive effects of exercise in patients with resistant hypertension may be mediated by positive changes in oxidative stress and inflammatory biomarkers.

Funding Acknowledgement

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

May the brief physical activity assessment tool accurately measure physical activity in patients with resistant hypertension?

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FEDER Funds through the Operational Competitiveness Factors Program—COMPETE National Funds through the Portuguese Foundation for Science and Technology (FCT) “PTDC/DTP-DES/1725/2014”. SL is a PhD fellow supported by the FCT (Grant Ref: SFRH/BD/129454/2017).

Introduction

Resistant hypertension is a major health problem due to the increased risk of cardiovascular events and mortality. Physical activity and exercise reduces blood pressure in resistant hypertension and is associated with lower cardiovascular risk and mortality. It is presently recommended that physical activity assessment should be a priority in all visits to health settings

Purpose

This study aims to determine if the Brief Physical Activity Assessment Tool (BPAAT), a 2-question tool to assess physical activity, is a valid instrument to detect inactive patients with resistant hypertension. 

Methods

Sixty patients with a diagnosis of resistant hypertension were recruited. Outcome measures included clinical data, blood pressure and daily physical activity. Physical activity was objectively measured over a 7-day period with an accelerometer and subjectively assessed (self-assessment) by the BPAAT. The association between the BPAAT and accelerometry, according to the BPAAT scoring categories, was assessed bythe percentage of agreement, Cohen’s Kappa and sensitivity and specificity.

Results

Patients (33 were male) had a mean age of 59.4 ± 9.1years, were on average overweight (BMI 29.5 ± 4.5 kg/m2) and on an average of 4.5 ± 0.7 antihypertensive medications. Forty-two patients (70%) were classified as insufficiently active by the BPAAT compared to the 38 (63.3%) insufficiently active patients identified by the accelerometry data. Regarding the questionnaire’s specificity and sensitivity, the BPAAT correctly identified 32 [84.2 (73.1 – 95.3) %] of the 38 ‘insufficiently active’ patients and 12 [54.5 (34.3 – 74.7) %] of the 22 ‘sufficiently active’ patients identified by accelerometry. The agreement between BPAAT and accelerometry to identify sufficiently/insufficiently active patients, according to the BPAAT’s cut-off values was fair to moderate (Kappa = 0.403 (0.162 – 0.674), with a percentage of agreement of 73.3%.

Conclusion

The BPAAT, a 2-question tool to assess physical activity, seems to be a valid and fast solution to identify insufficiently active adults with resistant hypertension during routine clinical visits.

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

Funding Acknowledgements

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Risk assessment of wildlife-watching tourism in an important endangered loggerhead turtle rookery

Wildlife-watching tourism is a non-exploitative activity that can contribute to sustainable economic development of coastal communities. However, it is important to assess the potential impact and implement best practices to mitigate any negative effects of such tourism. We studied this issue on Boa Vista (Cabo Verde), which supports around 60% of nesting activity of one of the most endangered loggerhead turtle rookeries globally. Between 2013 and 2016, authorized turtle watching involved 4942 tourists, generating a mean annual direct income of >USD 289000 and the direct creation of >250 jobs. On João Barrosa beach, which supports around 20% of nests and 48% of turtle-watching activity on the island, we tested the influence of turtle watching on nesting behavior, reproduction and nest-site fidelity. Nesting females observed by tourists spent significantly less time on nest-camouflaging behavior, although all other phases of nesting were unaffected. There were no statistically significant differences between the re-nesting frequency of females watched (n = 187) and non-watched (n = 972) by tourists. We found no evidence that the current turtle-watching intensity has an effect on turtle reproduction. Turtle poaching remains a severe threat on beaches with no turtle watching, although it has strongly decreased on beaches with tourist visits. We suggest tour guides follow best practice guidelines to minimize disturbance, specifically retreating from the immediate vicinity of a female during nest camouflaging to mitigate the observed impact.

Structural, spectroscopic, and photochemical study of ethyl propiolate isolated in cryogenic argon and nitrogen matrices

Ethyl propiolate (HC ≡ CCOOCH₂CH₃, EP) was studied experimentally by infrared spectroscopy in argon and nitrogen cryomatrices (15 K) and by quantum chemical calculations (at the DFT(B3LYP) and MP2 levels of theory). Calculations predict the existence of four conformers: two low-energy conformers (I and II) possessing the carboxylic moiety in the cis configuration (O=C-O-C dihedral equal to ~0°) and two higher-energy trans forms (O=C-O-C dihedral equal to ~180°; III and IV). The conformation of the ethyl ester group within each pair of conformers is either anti (C-O-C-C equal to 180°; in conformers I and III) or gauche (C-O-C-C equal to ±86.6° in II, and ± 92.5° in IV). The two low-energy cis conformers (I and II) were predicted to differ in energy by less than 2.5 kJ mol^-1 and were shown to be present in the studied cryogenic matrices. Characteristic bands for each one of these conformers were identified in the infrared spectra of the matrix-isolated compound and assigned taking into account the results of normal coordinate analysis, which used the geometries and harmonic force constants obtained in the DFT calculations. The two trans conformers (III and IV) were estimated to be 17.5 kJ mol^-1 higher in energy than the conformational ground state (form I) and were not observed experimentally. The unimolecular photochemistry of matrix-isolated EP (in N₂ matrix) was also investigated. In situ irradiation with UV light (λ > 235 nm) leads mainly to decarbonylation of the compound, with generation of ethoxyethyne, which in a subsequent photoreaction generates ketene (plus ethene).

Frequency and patient attributes associated with ED visits within 30 days after discharge

Background

About 20%-25% of patients return to the emergency department (ED) within 30 days after inpatient discharge. This outcome is relevant since it may signal failures in inpatient care and care transitions. However, literature on the topic is still scarce. Our study aims to describe frequency and patient attributes associated with ED visits within 30 days (30d) of inpatient discharge in one public Portuguese hospital.

Methods

The study included adult patients discharged in 2016. Admissions of deceased or transferred patients were excluded. The rate of 30d ED visits after discharge was computed for selected patient (gender and age) and admission attributes [urgent, Major Diagnostic Category (MDC)]. Number of days from discharge to ED visit was determined. Logistic regression was used to compute crude and age-gender adjusted odds-ratios (cOR, aOR) for each selected admission attribute.

Results

From the 21744 admissions included (median age: 58y; 40% male), for 5058 there was at least one ED visit within 30d after discharge (23%). The majority of ED visits were triaged urgent (n = 2286; 45%) or very urgent (n = 1499; 30%). Time to first ED visit was, on average, 11 days. The risk of ED visit was increased among men (cOR = 1.180; 95% confidence interval - 95%CI: 1.103-1.262) and patients aged 75 or older (cOR = 1.704; 95%CI: 1.557-1.866). After controlling for gender and age differences, admissions with mental diseases (aOR = 1.807; 95%CI: 1.452-2.247), respiratory diseases (aOR = 1.786; 95%CI: 1.535-2.078), endocrine diseases (aOR = 1.758; 95%CI: 1.374-2.250) showed increased risk of visiting ED after discharge.

Conclusions

ED visits after inpatient discharge are frequent and mostly due to urgent and very urgent needs. Older age, mental, respiratory and endocrine conditions are relevant patient risk factors for returning hospital for ED care shortly after discharge.

Key messages

Improved quality of inpatient care and care transitions that reduce ED visits after discharge may benefit a significant part of patients. Future initiatives to reduce adverse events after discharge may target patients with older age or with mental conditions.

Regional analysis of pediatric admissions with complex chronic conditions in mainland Portugal

Background

The expected rise in the number of children living longer with complex chronic conditions (CCC) and the social relevance of this group prompt the study of the patterns of their inpatient care utilization. We aimed to compare the utilization of inpatient care by children with CCC between regions of mainland Portugal.

Methods

Observational longitudinal retrospective study using anonymized administrative data for mainland Portuguese public hospitals. We selected admissions within the pediatric age limit (&lt;18yo), 2011-15. The variable of interest was the patient region of residence [Alentejo, Algarve, Centre, Lisbon Metropolitan Area (Lisbon MA), or North]. Variables related to condition (number and categories of CCC) and to care utilization [admission type, hospital type (I- community, II- regional, III- tertiary & university, IV- specialized), inpatient days, expenses] were described by region.

Results

A total of 64,918 pediatric admissions with CCC were included (ranging from 2,839 to 23,194 by region). The percentage of admissions with 2 or more CCC ranged from 16% to 22%. Haematologic & Immunologic and Metabolic categories were the ones with the highest range between regions (8%-19%; 5%-10%); the smallest range was seen in Cardiovascular (15%-18%). Urgent admissions ranged from 48% to 70%. Hospital type varied considerably, especially for type II (8%-69%). Median length of stay was 4-5 days, and median expense ranged from €1,256 to €1,467.

Conclusions

The utilization of inpatient care by children with CCC in mainland Portugal varied by region, mainly on type of admission, type of hospital, and distribution of CCC categories. Possible explanatory factors may include differences in CCC prevalence, patterns of care, and available care in each region.

Key messages

Differences in the percentage of urgent admissions require further analysis, aiming at reducing the disruption that healthcare needs may cause in the life of children with CCC and their families. There are considerable differences in the type of hospital where children with CCC in each region receive care. Healthcare system must ensure appropriate resources are available where needed.

Effect of a therapeutic exercise program (FisioPausa) on the quality of life of employees from CESPU

Introduction In the context of work, labouring time is mainly spent in the sitting position and in a continuous way. This reality contributes for the increase of a sedentary lifestyle of workers, leading to health-related diseases and consequently decreasing they quality of life (QoL).

Objectives Verify the effect of a therapeutic exercise program in quality of life, and evaluate the association between different components of QoL, with back pain, physical activity and Body Mass Index (BMI).

Methodology A pré-post interventional study was realized in workers from the Cooperativa de Ensino Superior Politécnico Universitário. Fourteen participants were included and submitted to evaluations with a preliminary survey, the SF-36v2 (before and after 8 weeks of intervention) to assess the effects of the program in QoL. All the participants were submitted to a specific therapeutic exercise program of 20 minutes, twice a week, and during 8 weeks.

Results There was a general improvement in Health-Related Physical and Mental Quality of Life. These improvements were especially observed in the functional capacity with a higher median of 5.00 (p = 0,015). Although it was less evident, Vitality was the domain with higher improvements amongst all the four Mental domains (increase of 10.00 points across time, p = 0.341). Associations were observed between pain and functional capacity (p = 0,027) BMI and Mental Health (p = 0,027) and finally between Age and Mental Health (p = 0,028).

Conclusion Our therapeutic exercise program seems to have positive effect on quality of life, especially regarding functional capacity of workers. Participants with the highest pain were associated with decreased functional capacity and older people or those with higher BMI showed weaker mental health.

Low Golimumab Trough Levels at Week 6 Are Associated With Poor Clinical, Endoscopic and Histological Outcomes in Ulcerative Colitis Patients: Pharmacokinetic and Pharmacodynamic Sub-analysis of the Evolution Study

BACKGROUND AND AIMS

Golimumab has an established exposure-response relationship in patients with ulcerative colitis [UC]. However, the association of serum golimumab trough levels [TL] with objective markers of disease activity, such as endoscopic and histological activity scores and concentrations of biomarkers, remains less understood. This report describes the relationship of serum golimumab TL at the end of the induction period [Week 6] with clinical, endoscopic, histological, and biomarker parameters.

METHODS

This was an open-label, uncontrolled, prospective and interventional study. Moderate to severely active UC patients naïve to biologic therapy were treated with golimumab. Serum golimumab TL and faecal calprotectin levels were measured at baseline [Week 0 of induction] and Week 6.

RESULTS

A total of 34 patients completed the induction phase [Week 6] and were included in this analysis. Overall, 47.1% and 14.7% of patients achieved clinical response and remission with significantly higher serum golimumab TL in patients with early response or remission [3.7 μg/mL vs 1.3 μg/mL, p = 0.0013; and 3.1 μg/mL vs 1.7 μg/mL, p = 0.0164, respectively]. In addition, golimumab TL were significantly higher in patients achieving histological remission [4.2 μg/mL vs 1.7 μg/mL, p = 0.0049]. Week 6 golimumab TL were inversely correlated with the total Mayo score [rs = -0.546; p = 0.0008], the Mayo endoscopic subscore [rs = -0.381; p = 0.0262], the Geboes histological activity score [rs = -0.464; p = 0.0057], and faecal calprotectin levels [rs = -0.497; p = 0.0044].

CONCLUSIONS

A higher early exposure to golimumab is associated with a better objective response in active UC patients and appears to drive the outcome at Week 6.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The performance of Remicade®-optimized quantification assays in the assessment of Flixabi® levels

BACKGROUND

The advent of Remicade® biosimilars, Remsima®, Inflectra® and, more recently, Flixabi®, has brought along the potential to decrease the costs associated with this therapy, therefore increasing its access to a larger group of patients. However, and in order to assure a soft transition, one must make sure the assays and algorithms previously developed and optimized for Remicade perform equally well with its biosimilars. This study aimed to: (a) validate the utilization of Remicade-optimized therapeutic drug monitoring assays for the quantification of Flixabi; and (b) determine the existence of Remicade, Remsima and Flixabi cross-immunogenicity.

METHODS

Healthy donors' sera spiked with Remicade, Remsima and Flixabi were quantified using three different Remicade-quantification assays, and the reactivity of anti-Remicade and anti-Remsima sera to Remicade and to its biosimilars was assessed.

RESULTS

The results show that all tested Remicade-infliximab-optimized assays measure Flixabi as accurately as they measure Remicade and Remsima: the intraclass correlation coefficients between theoretical and measured concentrations varied from 0.920 to 0.990. Moreover, the interassay agreement values for the same compounds were high (intraclass correlation coefficients varied from 0.936 to 0.995). Finally, the anti-Remicade and anti-Remsima sera reacted to the different drugs in a similar fashion.

CONCLUSIONS

The tested assays can be used to monitor Flixabi levels. Moreover, Remicade, Remsima and Flixabi were shown to have a high cross-immunogenicity, which supports their high similarity but prevents their switching in nonresponders with antidrug antibodies.

Paget disease of the male breast

Paget disease of the breast is an uncommon tumor of the nipple-areola complex that usually presents as an erythematous and erosive lesion. We report the case of a 61-year-old man that presented with a three-year history of an erythematous lesion of the right areola, first treated with topical corticosteroids without benefit. He was then referred to our dermatology department and the clinical suspicion of Paget disease was considered. The diagnosis was later confirmed by biopsy. This case report highlights the importance of clinical recognition of this entity along with other diseases that mimic these skin changes in order to allow earlier diagnosis and proper follow-up.

Outcome and risk factors assessment for adverse events in advanced esophageal cancer patients after self-expanding metal stents placement

Self-expanding metal stents (SEMS) are the treatment of choice for advanced esophageal cancers. Literature is scarce on risk factors predictors for adverse events after SEMS placement. Assess risk factors for adverse events after SEMS placement in advanced esophageal cancer and evaluate survival after SEMS placement. Cross-sectional study of patients with advanced esophageal cancer referred for SEMS placement, during a period of 3 years. Ninety-seven patients with advanced esophageal cancer placed SEMS. Adverse events were more common when tumors were located at the level of the distal esophagus/cardia (47% vs 23%, P = 0.011, OR 3.1), with statistical significance being kept in the multivariate analysis (OR 3.1, P = 0.018). Time until adverse events was lower in the tumors located at the level of the distal esophagus/cardia (P = 0.036). Survival was higher in patients who placed SEMS with curative intent (327 days [126-528] vs. 119 days [91-147], P = 0.002) and in patients submitted subsequently to surgery compared with those who did just chemo/radiotherapy or who did not do further treatment (563 days [378-748] vs. 154 days [133-175] vs. 46 days [20-72], P < 0.001). Subsequent treatment kept statistical significance in the multivariate analysis (HR 3.4, P < 0.001). SEMS allow palliation of dysphagia in advanced esophageal cancer and are associated with an increased out-of-hospital survival, as long as there are conditions for further treatments. Tumors located at the level of the distal esophagus/cardia are associated with a greater number of adverse events, which also occur earlier.

Proactive therapeutic drug monitoring of infliximab: a comparative study of a new point-of-care quantitative test with two established ELISA assays

BACKGROUND

Therapeutic drug monitoring is a powerful strategy known to improve the clinical outcomes and to optimise the healthcare resources in the treatment of autoimmune diseases. Currently, most of the methods commercially available for the quantification of infliximab (IFX) are ELISA-based, with a turnaround time of approximately 8 h, and delaying the target dosage adjustment to the following infusion.

AIM

To validate the first point-of-care IFX quantification device available in the market - the Quantum Blue Infliximab assay (Buhlmann, Schonenbuch, Switzerland) - by comparing it with two well-established methods.

METHODS

The three methods were used to assay the IFX concentration of spiked samples and of the serum of 299 inflammatory bowel diseases (IBD) patients undergoing IFX therapy.

RESULTS

The point-of-care assay had an average IFX recovery of 92%, being the most precise among the tested methods. The Intraclass Correlation Coefficients of the point-of-care IFX assay vs. the two ELISA-based established methods were 0.889 and 0.939. Moreover, the accuracy of the point-of-care IFX compared with each of the two reference methods was 77% and 83%, and the kappa statistics revealed a substantial agreement (0.648 and 0.738).

CONCLUSIONS

The Quantum Blue IFX assay can successfully replace the commonly used ELISA-based IFX quantification kits. This point-of-care IFX assay is able to deliver the results within 15 min makes it ideal for an immediate target concentration adjusted dosing. Moreover, it is a user-friendly desktop device that does not require specific laboratory facilities or highly specialised personnel.

Recommendations for aetiological diagnosis of bronchiectasis

The number of bronchiectasis diagnoses has increased in the last two decades due to several factors. Research carried out over the last years showed that an aetiological diagnosis could change the approach and treatment of a relevant percentage of patients and consequently the prognosis. Currently, systematic investigation into aetiology, particularly of those disorders that can be subject to specific treatment, is recommended. Given the complexity of the aetiological diagnosis, the Pulmonology Portuguese Society Bronchiectasis Study Group assembled a working group which prepared a document to guide and standardize the aetiologic investigation based on available literature and its own expertise. The goal is to facilitate the investigation, rationalize resources and improve the delivery of care, quality of life and prognosis of patients with bronchiectasis.

[Home based and group based exercise programs in patients with ankylosing spondylitis: systematic review]

<p>

INTRODUCTION

Ankylosing Spondylitis (AS) is a chronic inflammatory rheumatic disease characterized by inflammation of the joints of the spine and sacroiliac and to a lesser percentage of the peripheral joints. It is a debilitating condition which reduces quality of life in patients with AS. The practice of physical therapy is recommended as non-pharmacological treatment as well as the treatment and prevention of associated deformities.

OBJECTIVE

To collect and summarize the available evidence in scientific databases to realize the effectiveness of home based and group based programs in patients with AS.

METHODS

Systematic review, where articles for the study were collected from scientific database PubMed. We have found 65 articles with publication date between January 1, 2004 and January 31, 2014. Inclusion and exclusion criteria were established to make the selection of articles to include in the study. All investigators provided their agreement in presencial meeting for a final selection, and at a later stage, the articles were read in full by the three investigators.

RESULTS

The present systematic review includes eight randomized controlled trials. All articles show functional benefits in patients with AS subject to exercise programs in group based and / or home based. From the eight articles, 4 addressed programs conducted in home based context and 4 addressed in group based context programs.

CONCLUSION

There appears to be evidence that the programs carried out based on group are more effective than those home based conducted in patients with AS. It was concluded also be advantageous to carry out home based exercise programs than the absence of any exercise program.</p>.