Influence of Deep Sedation in Intensive Care Medicine Memories of Critical COVID-19 Survivors

Introduction: Critical care survivors sustain a variety of sequelae after intensive care medicine (ICM) admission, and the Coronavirus Disease 2019 (COVID-19) pandemic has added further challenges. Specifically, ICM memories play a significant role, and delusional memories are associated with poor outcomes post-discharge including a delayed return to work and sleep problems. Deep sedation has been associated with a greater risk of perceiving delusional memories, bringing a move toward lighter sedation. However, there are limited reports on post-ICM memories in COVID-19, and influence of deep sedation has not been fully defined. Therefore, we aimed to evaluate ICM-memory recall in COVID-19 survivors and their relation with deep sedation. Materials/Methods: Adult COVID-19 ICM survivors admitted to a Portuguese University Hospital between October 2020 and April 2021 (second/third "waves") were evaluated 1 to 2 months post-discharge using "ICU Memory Tool," to assess real, emotional, and delusional memories. Results: The study included 132 patients (67% male; median age = 62 years, Acute Physiology and Chronic Health Evaluation [APACHE]-II = 15, Simplified Acute Physiology Score [SAPS]-II = 35, ICM stay = 9 days). Approximately 42% received deep sedation (median duration = 19 days). Most participants reported real (87%) and emotional (77%) recalls, with lesser delusional memories (36.4%). Deeply sedated patients reported significantly fewer real memories (78.6% vs 93.4%, P = .012) and increased delusional memories (60.7% vs 18.4%, P < .001), with no difference in emotional memories (75% vs 80.4%, P = .468). In multivariate analysis, deep sedation had a significant, independent association with delusional memories, increasing their likelihood by a factor of approximately 6 (OR = 6.274; 95% confidence interval = 1.165-33.773, P = .032), without influencing real (P = .545) or emotional (P = .133) memories. Conclusions: This study contributes to a better understanding of the potential adverse effects of deep sedation on ICM memories in critical COVID-19 survivors, indicating a significant, independent association with the incidence of delusional recalls. Although further studies are needed to support these findings, they suggest that strategies targeted to minimize sedation should be favored, aiming to improve long-term recovery.

Anxiety symptoms in critically ill COVID-19 survivors and its association with post-discharge health concerns

Introduction

Evidence suggest that critically ill COVID-19 patients are at higher risk of developing anxiety symptoms, which may be related to or exacerbated by patients concerns regarding their health status and recovery.

Objectives

To assess anxiety symptoms in critically ill COVID-19 survivors, 1-2 months after hospital discharge and to analyze its association with concerns reported by patients regarding their own health status and recovery.

Methods

In the framework of MAPA prospective research, this preliminary study included COVID-19 patients admitted in the Intensive Care Medicine Department (ICMD) of a University Hospital. Patients were excluded if they had an ICMD length of stay (LoS) ≤24h, terminal illness, major auditory impairment or inability to communicate at the evaluation time. Participants were assessed at a scheduled telephone follow-up appointment, with Generalized Anxiety Disorder Scale (GAD-7). Additional questions were asked to assess the survivors’ post-discharge concerns regarding discrimination against for COVID-19, infection of a family member, re-infection or sequelae related to COVID-19.

Results

Eighty-three patients were included (median age=63 years; 63% male) and 24% had anxiety symptoms. Anxiety scores were higher in survivors who reported being afraid of being discriminated against for COVID-19 (30% vs 10%; p=0.034), being re-infected (100% vs 79%; p=0.032) and having sequelae (94% vs 44%; p<0.001).

Conclusions

These findings revealed that anxiety is common in COVID-19 survivors and is associated with post-discharge patients concerns that may limit patient daily living. This study emphasizes the importance of psychological assessment and follow-up of the COVID-19 survivors, in order to support these patients recovery.

Disclosure

No significant relationships.

Development of posttraumatic stress disorder symptoms after intensive care - how to prevent it?

Introduction

Over the last decade, there has been identified that critical illness survivors have high rates of psychiatric disorders such as posttraumatic stress disorder (PTSD). The experience of admission to intensive care units (ICU) and illusory memories may cause short and long-term psychological disorders.

Objectives

To evaluate psychiatric disorders, such as PTSD, after ICU discharge, and determine the prevalence, risk factors, and prevention strategies for PTSD in these patients.

Methods

Non-systematic review through research in PubMed. Addicionally, a case report will be exposed, after the patient was diagnosed with SARS‑CoV‑2 and stayed in ICU for more than 30 days.

Results

The development of PTSD has been related to the number of adverse memories patients recall from their ICU experience. Some studies have shown that approximately 47% of patients remember real facts and 34% have illusory memories relative to their stays in the ICU. There were identified some risk factor associated to the increased risk of post-ICU PTSD, such as early post-ICU memories or psychotic experiences, pre-ICU psychopathology, benzodiazepine sedation during ICU and substantial acute stress symptoms occurring < 1 month after exposure to a traumatic stressor.

Conclusions

High levels of anxiety and the development by patients of PTSD are being recognized as significant problems occurring after a stay in an ICU. The results of this study highlight the need to recognise the risk factors and to establish a early follow-up after ICU stay. This way is possible to identify patients who are at risk of developing acute PTSD-related symptoms, and early intervention can be institued.

Disclosure

No significant relationships.

Depressive symptoms and health-related quality of life in critical COVID-19 survivors: Preliminary results of 1-year follow-up

Introduction

A higher risk of mental health consequences in critical COVID-19 patients is expected due to several reasons, including prolonged mechanical ventilation with exposure to high sedation. In this context, post-discharge depression has been reported in previous COVID-19 studies, with a profound impact on patients’ health-related quality of life (HRQoL).

Objectives

To identify depressive symptoms in COVID-19 survivors 1-year after hospital discharge and to analyse its association with HRQoL.

Methods

As part of the longitudinal MAPA project, this study enrolled critical COVID-19 patients admitted in the Intensive Care Medicine Department of a University Hospital (March-May 2020). Participants were assessed through telephone by an intensive care nurse and a psychologist, with the Patient Health Questionnaire (PHQ-9) (depressive symptoms), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and EQ-Visual Analogue Scale (EQ-VAS) (global health status patient record).

Results

A sample of 55 survivors (median age=66 years; 69% males) were included, with 20% showing depressive symptoms. Pain/discomfort (67%) and anxiety/depression (67%) were the most EQ-5D-5L domains reported. Survivors scoring for depression had more problems in all HRQoL areas (mobility:91%vs.48%, p=0.015; self-care:64%vs.27%, p=0.035; usual activities:91%vs.50%, p=0.017; pain/discomfort:100%vs.59%, p=0.010; anxiety/depression:100%vs.59%, p=0.010). Moreover, they had a lower EQ-VAS median, corresponding a worse self-perception of health status (50vs.80, p=0.010).

Conclusions

Even after 1-year, a significant proportion of survivors presented depressive symptoms with repercussions in all HRQoL dimensions and association with worse self-perception of global quality of life. Taking this in mind, early screening and treatment of depression in COVID-19 survivors will be crucial, minimizing its impact on quality of life.

Disclosure

No significant relationships.

Delirium and health-related quality of life in severe COVID-19 survivors

Introduction

Severe COVID-19 survivors experience long-term neuropsychiatric morbidity, particularly those who developed delirium, with a negative impact on health-related quality of life (HRQoL).

Objectives

To identify the cases of delirium in severe COVID-19 patients and to describe its association with post-hospital discharge HRQoL.

Methods

In the context of the longitudinal MAPA project, we included adult patients (≥ 18 years old) admitted with COVID-19 to the Intensive Care Medicine Department (ICMD) of a Portuguese University Hospital (October 2020-April 2021). Exclusion criteria were: ICMD length of stay ≤24h, terminal illness, major auditory loss, or inability to communicate at the time of assessment. Delirium during ICMD stay was ascertained based on patients’ clinical records. HRQoL was evaluated using the 5-Level EQ-5D questionnaire (EQ-5D-5L), at a scheduled telephone follow-up appointment on average 1-2 months after hospital discharge.

Results

Overall, 124 patients were included with a median age of 62 (range: 24-86) years, being mostly male (65%). About 19% had delirium, 42% were deeply sedated and 43% required invasive mechanical ventilation. Most survivors reported problems on the EQ-5D-5L domains: usual activities (85%), mobility (73%) and anxiety/depression (65%). Patients with delirium reported more pain/discomfort (75%vs46%; p=0.011) and considerably anxiety/depression (83%vs60%; p=0.032).

Conclusions

These findings pointed that COVID-19 patients who experienced delirium reported worse HRQoL, regarding pain/discomfort and anxiety/depression. This study highlights the importance of not only prevention but also early screening of delirium during hospital stay, as well as the crucial role of the timely interventions at discharge, in order to minimize delirium long-term impacts.

Disclosure

No significant relationships.

Depression and health-related quality of life in critical COVID-19 survivors

Introduction

Long-term neuropsychiatric consequences of critical illness are well known. Therefore, it is expected that critical COVID-19 patients might also present several psychiatric symptoms such as depression, with inevitable negative effect on health-related quality of life (HRQoL), commonly used as an indicator of illness and treatment impact.

Objectives

To identify depressive symptoms in critical COVID-19 survivors and to examine its association with HRQoL domains.

Methods

This preliminary study involved critical COVID-19 patients admitted into the Intensive Care Medicine Department (ICMD) of a University Hospital, between October and December of 2020. Patients with an ICMD length of stay (LoS)≤24h, terminal illness, major auditory loss, or inability to communicate at the follow-up time were excluded. From 1-2 months after discharge, all participants were evaluated by telephone at follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EuroQol 5-dimension 5-level EQ-5D-5L (HRQoL). This study is part of the longitudinal MAPA project.

Results

Eighty-three patients were included with a median age of 63 years (range: 31-86) and the majority were male (63%). The most reported problems on EQ-5D-5L domains were usual activities (82%) and mobility (76%). About 27% presented depressive symptoms, and with more problems of self-care (68%vs41%; p=0.029), pain/discomfort (86%vs49%; p=0.002), and anxiety/depression (96%vs54%; p<0.001).

Conclusions

These preliminary results are in line in previous studies in critical COVID-19 survivors, with depression being associated with worse HRQoL. Bearing this in mind, follow-up approaches with an early screening and treatment of these psychiatric symptoms will be fundamental to optimize the recovery of these patients.

Disclosure

No significant relationships.

Digital health literacy and online information queries in Portuguese university students

Background

Worldwide there is an overwhelming amount of information about COVID-19 circulating online, also named infodemic. Misinformation (the unintentional) and disinformation (the intentional) spreading of false information have proven to be very dangerous to public health. Hence, more than ever, people need skills for searching, evaluating and integrating information related to health in daily life, i.e., health literacy. Until now, little is known about the digital health literacy of university students and their information-seeking behaviour. Hence, this study aimed to analyse the associations between university students' digital health literacy and online information queries during the beginning of the COVID-19 pandemic (and infodemic) in Portugal.

Methods

A cross-sectional study of 3.084 Portuguese university students (75.7% females), with an average age of 24.2 (SD = 7.5), was conducted using an online survey. We used sociodemographic data (sex, age, subjective social status) and the digital health literacy questionnaire adapted to the specific COVID-19 context. Online information queries included the topics related to SARS-CoV-2 and COVID-19 searched by students. Logistic regression models were performed.

Results

Online information queries (e.g., individual measures to protect against infection, current spread of the virus, current situation assessments and recommendations) were associated with an increased odds of achieving sufficient digital health literacy.

Conclusions

Online information queries related to epidemiological and public health topics are significantly associated with digital health literacy in times of COVID-19. Further studies are needed, including programs that improve digital health literacy among university students and increase the availability of high-quality content information.

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.

The magnitude of depression in heart failure patients and its association with NYHA class

Introduction

Depression is commonly present among HF patients and is associated with adverse clinical outcomes. However, research regarding its association with New York Heart Association (NYHA) class is still scarce.

Objectives

To evaluate the presence of depression symptoms in HF outpatients and analyze its association with NYHA class.

Methods

This study is part of a larger research project (Deus Ex-Machina/NORTE-01-0145-FEDER-00026). HF patients were recruited from an outpatient clinic at a University Hospital. Exclusion criteria were: unable to communicate, severe visual acuity deficit or NYHA class IV. Sociodemographic data and NYHA class were registered. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression, with a score ≥10 indicating clinically relevant depression.

Results

A sample of 136 HF patients was included, with a median age of 59 (range: 24-81) years old, where 66% were men. Almost half of the patients (49%) were in NYHA class II, followed by class I (36%) and class III (15%). The median score of PHQ-9 was 4(range:0-18), with 26% showing clinically relevant depression. PHQ-9 total score was associated with NYHA class (p=0.001), with higher median scores in worse NYHA classes [class I: 3 (IQR: 5.5), class II: 4 (IQR: 8) and class III: 8.5 (IQR:9.3)].

Conclusions

In this study, depression was present in 26% of HF outpatients and was associated with more severe HF symptoms. Consequently, preventing, monitoring, and treating depression in the management of these patients is recommended. Further research is needed for a deeper analysis of this association.

Visual hallucinations in parkinson’s disease: Experience from a portuguese level 3 hospital

Introduction

Parkinson’s disease is a neurodegenerative pathology characterized by motor and non-motor symptoms. Hallucinations, especially visual ones, are frequent in this context, with an estimated prevalence of 16 to 40% and associated with a less favorable prognosis. These hallucinations can range from coarse formations to well-defined structures.

Objectives

To assess the prevalence of visual hallucionations in a sample of patients diagnosed with Parkinson’s Disease.

Methods

A cross-sectional descriptive study conducted in a Neurology Department of a Level III portuguese hospital. The sample included patients with Parkinson’s Disease observed in an outpatient Neurology appointment between October 1 and December 9, 2019.

Results

In the period considered, 100 patients with Parkinson’s disease were observed, 65% male, with an average age of 69 years. In 11% of the patients visual hallucinations were reported, of which about half were well defined. All of them had no previous history of visual hallucinations and were under dopaminergic medication.

Conclusions

The results show an inferior prevalence when comparing to the literature, albeit still frequent. Therapeutic adequacy has a well recognised impact at a functional level and prognosis. Therefore we stress the importance of a regular follow-up of these patients, recommending a rigorous and comprehensive clinical review.

Post-discharge depressive symptoms and health-related quality of life of critical COVID-19 survivors

Introduction

Survivors of critical illness stay frequently experience long-term mental health morbidity, suggesting that many critically ill patients with COVID-19 may also show a high prevalence of psychiatric conditions.

Objectives

To describe depression in COVID-19 survivors 4-months post-hospital discharge and to examine its association with health-related quality of life (HRQoL).

Methods

This pilot study involved COVID-19 adult patients admitted in Intensive Care Medicine Service (ICMS) of a University Hospital. Exclusion criteria were: ICMS length of stay (LoS)≤24h, terminal illness, major sensory loss and inability to communicate at the time of assessment. All participants were evaluated at ICMS scheduled telephone follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EQ-5D-5L (HRQoL). Critical-illness severity was assessed with APACHE-II and SAPS-II.

Results

Twenty patients were included with a median age of 62(range: 24-77) y.o., the majority male (75%) and married (70%). Median (range) APACHE-II and SAPS-II was 17 (5-34) and 32.5 (7-77), respectively, and LoS was 18 (4-58) days. Overall, 25% patients presented depression symptoms and most reported problems on EQ-5D-5L domains of pain/discomfort (65%), anxiety/depression (55%) and mobility (50%). Depression scores were higher in patients with problems in EQ-5D-5L domains of usual activities (median 4 vs 1.5; p=0.046), pain/discomfort (median 0 vs 4; p=0.004) and anxiety/depression (median 4 vs 0;p<0.001).

Conclusions

These preliminary findings show that depression is frequent in COVID-19 survivors and it is associated with worse HRQoL. This pilot study highlights the importance of psychological assessment and treatment of COVID-19 survivors, in order to minimize its negative impact on HRQoL, optimizing their recovery.

First episode psychosis and the use of psychostimulants - a case report

Introduction

Stimulants are considered the mainstay of treatment for attention-deficit/hyperactivity disorder (ADHD), and most patients are put on a long-term regimen with these psychostimulants. However some children treated with psychostimulants have reported psychosis as an adverse effect.

Objectives

Understand the capacity of psychostimulant medications to induce psychotic symptoms and determine the frequency of such reactions in adolescents and young adults.

Methods

Non-systematic review of the literature in English, through research in PubMed. Additionally, a clinical case is exposed, which was treated at the psychiatric inpatient unit of the Tamega e Sousa hospital center.

Results

Some patients, including some with no identifiable risk factors, can develop drugrelated signs or symptoms of psychosis or mania, such as hallucinations, at usual doses of frequently used ADHD drugs. Age of onset of psychosis can be significantly earlier in individuals with a history of stimulant use. In our clinical case, a young man of 18 years, previously diagnosed with ADHD, was medicated with atomoxetine two months prior being admitted to our psychiatric unit. There was no reported history of a similar psychiatric condition, and no risk factors were identified. At admission, he had bizarre behavior, with allucinatory activity and delusions of persecution. Atomoxetine was suspended and started oral antipsychotic, with improvement of symptoms and stabilization of the clinical condition.

Conclusions

In adolescents and young adults with ADHD undergoing stimulant therapy, any psychotic symptoms or mood changes need to be carefully assessed at regular intervals by the physicians and the caregivers, in order to observe change in the symptoms.

Disclosure

No significant relationships.

Cocaine bugs: A brief case report of cocaine-induced delusion of parasitosis

Introduction

Delusional parasitosis (DP), also know as Ekbom syndrome and in some cases as Morgellons, was first described in the late 17th century in France. It is an obsessive phobic state in which the patient believes that the is infested by parasites. In the hallucinatory state, they frequently remove parts of the skin, identifying them as parasites. The cause of DP is unknown. Evidence supporting the dopamine theory defend that the inhibition of dopamine reuptake (for example cocaine and amphetamines) induce symptoms such as formication.

Objectives

Through the description of the following clinical case, we emphasize its clinical features and complexities.

Methods

Review of DP in light of a clinical case

Results

A 48-year-old woman was brought to the psychiatric emergency due to psychotic symptoms following cocaine use. She had a history of drug abuse. She was apparently asymptomatic until October 2019, when, in the background of vague sensation of something crawling under his skin, she developed a sudden onset belief that she had been infested by insects that crawled under his skin. Previous medical observation found no reason for a skin infection or infestation. Skin examination revealed itch marks and skin excoriations in the abdomen. Mental status examination revealed anxious and depressive affect, delusion of parasitosis, tactile hallucination and impaired insight. Routine hemogram and urinalysis was unremarkable, except for the detection of cocaine.

Conclusions

Delusional parasitosis often presents to nonpsychiatric medical professionals. An awareness of such ilness, with an early recognition and timely referral are management cornerstones in order to successfully diagnose and treat patients.

Disclosure

No significant relationships.

Electroconvulsive therapy after conservative treatment of vertebral fractures

Introduction

Electroconvulsive therapy (ECT) remains a valuable treatment for major depression with psychotic symptoms. However, it is necessary to pay special attention when there is a history of fractures.

Objectives

Through the description of the following clinical case, we will emphasize the importance of screening for vertebral fractures within ECT and the different procedures that must be taken if that occurs.

Methods

We undertook a narrative literature review by performing a search on PubMed for English-written articles. The query used was “Electroconvulsive Therapy” AND “Vertebral Fractures”.

Results

A 71-year-old woman was admitted with an episode of psychotic depression. Basic tests were performed and were all normal. After not responding to pharmacologic treatment, she was referred for ECT. The patient had a full recovery after 4 weeks of biweekly sessions. She was discharged and proposed for maintenance ECT. However, she started complaining of back pain after falling and did an X-ray and CT scan which revealed fractured L1 and L2. It was suggested conservative treatment with a Jewett orthosis. Within this period, the ECT was suspended and after a 4-week treatment, the fracture was consolidated. As there was no risk of neurological compression, the treatment was restarted with the same dosage of succinylcholine, and it was achieved complete muscular relaxation. The patient fully recovered without any orthopedic sequel.

Conclusions

Electroconvulsive therapy can be safely performed after conservative treatment of vertebral fractures, if special attention is provided to complete muscular relaxation. For this effect, the dosage of succinylcholine can be adjusted.

Disclosure

No significant relationships.

Anxiety in heart failure patients and its association with NYHA class

Introduction

Heart failure (HF) is a worldwide public health problem and the main cause of morbidity and mortality in older people. Previous studies have demonstrated that psychological symptoms are associated with worse cardiovascular outcomes. Nevertheless, the research regarding the association between anxiety and HF is still scarce.

Objectives

To analyse the levels of anxiety in HF patients and its association with New York Heart Association (NYHA) class in HF patients.

Methods

This study takes part of a wider project named Deus Ex-Machina project (NORTE-01-0145-FEDER-00026). HF patients were recruited from an outpatient clinic at a University Hospital. Patient with inability to communicate, with severe visual impairment or with NYHA class IV were excluded. Sociodemographic data and NYHA class were recorded. Anxiety was assessed using the Generalized Anxiety Disorder-7 (GAD-7).

Results

Overall, 136 patients were included, with a mean age of 57(±13) years old. Most of them were men (66%) and married (76%), with mean education of 8 years (±4). Regarding NYHA class, 36%, 49% and 15% were at class I, II and III, respectively. The mean GAD-7 total score was 6.4 (±5.2) and 32% of patients showed moderate to severe anxiety symptoms. No association between the NYHA functional class and anxiety was found (p=0.106).

Conclusions

The results reveal that anxiety is frequent among HF patients. However, as found in previous studies, it was not associated with more severe HF symptoms. The coexistence of HF and anxiety deserves further studies, in order to build a better understanding of this association.

In utero opioid exposure and birth outcomes: a systematic review and meta-analysis

Background

The nonmedical use of opioids during pregnancy, either those prescribed or obtained illegally, is a worldwide public health issue. Opioids pass through the placental barrier, which can expose the fetus to maternal opioid use; opioid-exposed babies may experience Neonatal Abstinence Syndrome (or Neonatal Opioid Withdrawal). We conducted a systematic review and meta-analysis to investigate how maternal opioid use during pregnancy may impact infants' birth outcomes.

Methods

We searched PubMed, Embase, PsycInfo, and the Web of Science, and identified 90 articles that met our inclusion criteria. Cohort, case-control and cross-sectional studies comparing birth outcomes of any opioid-exposed group (prescribed or obtained illegally) and a non-exposed comparison group were eligible for our systematic review. An adapted version of the Newcastle-Ottawa-Scale was used for quality assessment of the studies. Due to high heterogeneity between studies, we used random effects models to estimate pooled effects.

Results

In meta-analyses, opioid-exposed infants had lower birthweight (mean difference (MD):-405.9 grams, 95%CI: -472.26,-339.54, N = 37 studies), smaller head circumference (MD:-1.19 cm, 95%CI:-1.41, -0.96,N=22 studies), shorter gestational age (MD:-0.93 weeks, 95%CI: -1.20, -0.66,N= 34 studies), and shorter birth length (MD:-0.97 cm, 95%CI: -1.20, -0.74, N = 15 studies). The pooled relative risk of fatal outcomes was higher among the exposed infants: (RR:2.64, 95%CI: 1.06,6.59). Almost half of the studies were rated as poor, based on the Newcastle Ottawa Scale.

Conclusions

Our meta-analysis provides evidence of a link between opioid use during pregnancy and multiple adverse infant birth outcomes. Efforts should focus on increasing awareness about risks associated with opioid use and provide access to harm reduction measures for people who use opioids preconceptionally and in pregnancy.

Key messages

This meta-analysis provides insight into the magnitude of effects of in-utero opioid exposure on birth outcomes among the included studies. The findings highlight the importance of access to harm reduction measures in the periconceptional period and during pregnancy for people who use opioids.

Occupational Contamination with Cyclophosphamide in Manipulators

Introduction Cyclophosphamide is a cytotoxic widely used in the treatment of various cancers. It has been observed, for many years, that those responsible for its handling and administration are exposed and levels of contamination have been detected in biological samples collected from these professionals, in surfaces and in the air.

Objectives To review the literature on occupational contamination by cyclophosphamide.

Methodology The following inclusion criteria were selected: articles published until the present year, articles in English, scientific papers on cyclophosphamide contamination in hospital health professionals, scientific articles on contamination detection methods and articles on the effects that can outcome from cyclophosphamide contamination.

Results The cyclophosphamide levels have been decreasing with the implementation of preparation and cleaning guidelines as well as with the emergence of new techniques of manipulation and technological innovations. However, the dermal route remains the main route of contamination and those responsible for cytotoxic manipulation are not the only ones exposed. It was verified that hospital professionals, who in their profession would not be in contact with cyclophosphamide, also presented levels of contamination in the collected urine samples.

Conclusion

It is necessary to continue to alert hospital professionals to the importance of always complying with the handling and cleaning protocols, since one of the main causes of contamination is precisely the performance of incorrect procedures during both tasks. This is a topic that should be further studied in order to minimize the exposure and consequently the associated risks.

Sleep duration and suicidal behavior: A systematic review

Introduction

Suicide is a serious public health problem, being the second leading cause of death among 15–29-year-olds. Many risk factors have been associated with suicidal behavior, such as psychiatric disorders, family history of suicide, loss of a close friend/relative, physical/sexual abuse, lack of support network, or sleep disturbances where nightmares and insomnia have been consistently reported to increase the risk of suicidal behaviors.

Objective

To conduct a systematic review to examine the association between short sleep duration and suicidal behaviour (suicide ideation/attempt/suicide).

Methods

This is a systematic review of published research articles in the electronic database PubMed in the last 10 years. The query “sleep” or “sleep disorders” and “suicide” was used. Studies that assessed the relation between sleep duration and suicidal behaviour, with a well-defined index for sleep disorders and with an outcome measure of suicidal behavior were included.

Results

Of the 522 references founded, 33 articles met the inclusion criteria (1 review, 1 qualitative and 31 quantitative studies). An association between short sleep duration and suicidal behaviour was found in most of the studies with children/adolescents and adult samples. However, this relation was not verified in the research into the elderly.

Conclusion

The results point to a significant association between short sleep time and the presence of suicidal behaviours, for both adults and children/adolescents. The effect of short sleep duration seems to be more consistent with suicidal ideation, but not for attempts, needing further studies to highlight the importance of this link between sleep duration and suicide.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

218 Urine samples as a noninvasive source of induced pluripotent cells in the swine model

Noninvasive collection of cells used for generation of induced pluripotent stem cells (iPSC) generation would simplify its use for regenerative and reproductive purposes in veterinary medicine, although it is still unpublished in species other than humans. This study aimed to derive urine progenitor cells (UPCs) invitro from urine samples collected from swine, and then to reprogram them into iPSCs. For that, urine samples were collected from three females, and cells were isolated and cultured from each following the human UPCs protocol (Steichen et al. 2017 Curr. Protoc. Hum. Genet. 21, 7.1-21.7.22; https://doi.org/10.1002/cphg.26). Approximately 200mL of urine samples were collected in sterile flasks and centrifuged at 300×g; the pellet was washed in Dulbecco's PBS, resuspended, and cultured in 45% Dulbecco's modified Eagle's medium (DMEM)-high glucose, 5% fetal bovine serum (FBS), 50% Renal Epithelial Cell Growth basal medium (REBM) supplemented with 1% glutamine, 1% nonessential amino acids (NEAA), penicillin/streptomycin (P/S), and REGM supplements hEGF, insulin, hydrocortisone, GA-1000, FBS, transferrin, triiodothyronine, epinephrine (Lonza), and 10ngmL−1 basic fibroblast growth factor (bFGF). The UPCs first colonies were observed approximately 1 week after and resembled epithelial-like cells. At passage 2, one cell line was transduced with murine OCT4, SOX2, KLF4, and C-MYC cDNAs (OSKM) using a lentiviral vector. After 5 days, cells were plated onto mouse embryonic fibroblasts and cultured in knockout DMEM/F12, 20% knockout serum replacement, NEAA, L-glutamine, 2-mercaptoethanol, and P/S supplemented with 10ngmL−1 bFGF. Efficiency of reprogramming was 8.45%, measured by analysing the number of typical iPSC colonies relative to the transduced cells plated, after ~12 days. Three clonal lines (C1, C4, and C6) were maintained invitro and characterised regarding pluripotency markers for at least 30 passages. All three lines were positive for alkaline phosphatase activity in passages 15 and also 22. Immunocytochemistry analysis revealed that C6 (passage 22) was positive for the pluripotency genes OCT4 (1:100, SC), SOX2 (1:500, AB), SSEA1 (1:50, SC), TRA1- 81 (1:50, Millipore), and NANOG (1:100, AB), whereas C1 and C4 (passages 23 and 22, respectively) were positive only for OCT4, SOX2, and SSEA1. The expression of exogenous and endogenous pluripotency factors (OCT4, SOX2, and NANOG) was evaluated by qRT-PCR, comparing the three clonal lines at passages 16/17 and 21/22 and comparing different passages (10, 11, 14, 17, and 22) on C1 line. No statistical difference was observed between cell lines when compared in different passages, perhaps because of the great variation between lines. However, analysis of C1 line over time showed that pluripotency genes increased and exogenous vector expression decreased during early passages (±10 passages); however, after passage 17, OCT4 and NANOG decreased whereas SOX2 and exogenous vector expression increased. In conclusion, it was possible to reprogram UPCs into iPSCs and maintain them in culture for at least 30 passages; however, iPSCS were dependent on exogenous factors. These results represent the partial reprogramming of UPCs to iPSCs in animals for the first time, enabling the generation of invitro disease models using a noninvasive method. Financial support for this study was received from FAPESP (2019/02811-2, 2015/26818-5), CNPq (433133/2018-0), and CAPES.

54 Altrenogest supplementation during early pregnancy improves swine embryonic development

Progesterone (P4) is of paramount importance in the establishment and maintenance of pregnancy for mammals. Progesterone stimulates the endometrial secretion of several molecules involved in conceptus growth and development during the peri-implantation period. Indeed, several studies involving ruminants have reported that exogenous P4 supplementation is related to increased early embryo development, higher levels of interferon tau, and improved pregnancy rate. However, there is a lack of information about P4 supplementation during early pregnancy regarding swine embryonic development. Additionally, some of the few studies involving pigs have shown an impaired pregnancy rate when supplementation was performed before Day 6 of pregnancy. Thus, the objective of this study was to evaluate the effects of progesterone/progestin supplementation from Day 6 of pregnancy on total number of embryos (TE), pregnancy rate (PR), embryo development, and maternal serum 17β-oestradiol concentration (17β-E). A total of 31 crossbred, 2 to 6 parity sows were used. All sows were inseminated every 24h through the first oestrus following a 21-day lactation, and ovulation was detected by transrectal real-time ultrasound to determine Day 0 of pregnancy. On Day 6 of pregnancy, animals were randomly allocated to one of the following groups: CON (n=11), non-supplemented sows; RU (n=11), sows supplemented daily with 20mg of Altrenogest-Regumate® from Day 6 to 12 of pregnancy; and PG (n=9), sows supplemented with 2.15 mg/kg of long-acting P4 IM on Day 6 of pregnancy. Sows were treated with altrenogest p.o. as a top dressing over a small portion of feed. Blood samples were collected from 12 sows (4 per group) on Day 12 of pregnancy to measure the level of plasma 17β-E by radioimmunoassay. Sows were slaughtered on Day 28 of pregnancy. The uterus from each sow was collected and embryos were counted to determine TE. Embryos were individually separated from their placentas, weighed, and crown-to-rump length was determined. Data were analysed by the SAS program. All variables were analysed by PROC-MIXED t-test. Statistical difference was considered when P&lt;0.05. The PR did not differ among groups (91, 90, and 88%, for CON, RU, and PG, respectively; P&gt;0.05). No difference was observed among groups for TE and 17β-E level (P&gt;0.05). However, embryonic weight and crown-to-rump length differed among the 3 groups (P&lt;0.001). The RU-treated sows had heavier and bigger embryos when compared with the other groups. In contrast, PG-treated sows had the lowest averages for the same variables (weight: 1.39±0.01, 1.46±0.02, and 1.22±0.01; crown-to-rump: 21.07±0.08, 21.61±0.11, and 20.66±0.11; for CON, RU, and PG, respectively). In conclusion, altrenogest supplementation from Day 6 to 12 of pregnancy increases size and weight of porcine embryos, whereas 2.15mg kg−1 of long-acting P4 on Day 6 of pregnancy decreased these variables when compared with non-supplemented sows. Research was supported by FAPESP Grant 2017/00290-0.

Gaining insight into the photophysical properties of a coumarin STP ester with potential for bioconjugation

The photophysical properties of a coumarin 392 4-sulfotetrafluorophenyl ester, C392STP (sodium (E/Z)-4-(4-(2-(6,7-dimethoxycoumarin-3-yl)vinyl)-benzoyl)-2,3,5,6-tetrafluoro-benzenesulfonate), an amine reactive coumarine with potential for bioconjungation, have been studied in different solvents.

Alzheimer's disease-related amyloid-β1-42 peptide induces the loss of human sperm function

Characteristically identified as the main component of senile plaques present in patients suffering from Alzheimer's disease, Aβ has been detected in human testis and reproductive fluids, but its effect on spermatozoa has not been addressed. The present study evaluated whether the most toxic and aggregant amyloid precursor protein (APP)-proteolytic product, amyloid-β_1-42 (Aβ_1-42), was capable of affecting sperm functionality. Normozoospermic samples were either exposed to different Aβ_1-42 doses or to the untreated and scrambled controls for a maximum of 48 h at 37 °C and 5%CO₂, and motility, viability and mitochondrial status were evaluated. Additionally, tyrosine phosphorylation was analyzed by immunocytochemistry and acrosomal integrity through PSA-FITC. A shorter treatment period was used to monitor prompt Ca²⁺ responses. Aβ_1-42 peptide decreased motility before inducing mitochondrial impairment (p < 0.05; n = 6). Both outcomes became more pronounced with time, reaching their maximal decrease at 48 h, where even 1 μM produced undesirable effects (p < 0.05; n = 6). Aβ_1-42 peptide also decreased cell survival (p < 0.05; n = 6). Furthermore, although no effects on tyrosine phosphorylation were observed (p > 0.05; n = 6), reduced acrosomal integrity was detected (p < 0.05; n = 7), which was not correlated with viability loss (p > 0.05). In parallel, all Aβ_1-42 concentrations elicited a [Ca²⁺]_i rise but a significant difference was only observed at 20 μM (p < 0.05; n = 7) and a tendency was obtained with 10 μM (p = 0.053; n = 7). In conclusion, Aβ_1-42 peptide oligomers impair sperm function in vitro, although further studies are required to determine the clinical relevance of these findings.

Tuberculosis in children from diagnosis to decision to treat

SETTING

Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

OBJECTIVE

Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

DESIGN

A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

RESULTS

We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

CONCLUSION

TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

Review of Association Between Delirium and Dementia in Elderly People

Delirium is a neuropsychiatric syndrome, characterized by an acute change in mental status with a fluctuating course of symptoms, that affects almost 50% of people aged 65 years or older, admitted to hospital. Delirium is associated with negative outcomes, including increased risk of mortality, cognitive and functional decline. In 50% of the cases, the cause of delirium is multifactorial, resulting from a complex inter-relationship between several predisposing factors (e.g. advanced age, dementia) in highly vulnerable patients that are exposed to precipitating factors (e.g. infections). In this context, cognitive impairment and dementia are important risk factors for delirium, increasing its risk by two to five times, associated with worse outcomes. The underlying brain vulnerability of these patients with dementia may predispose to the development of delirium, as a consequence of insults related to the acute medical disease, medication or environmental factors. On the other hand, delirium may cause permanent neuronal damage, which may lead to the development or worsening of a pre-existing dementia. As a result, delirium and dementia frequently coexist and overlap, challenging differential diagnosis.

The identification of risk factors for delirium, specifically pre-existing cognitive impairment or dementia, in elderly people admitted to hospital is essential to the implementation of preventive strategies that may contribute to the decrease of delirium rates. The present literature review aims to highlight the association between delirium and dementia in elderly people, focusing on diagnosis, pathophysiology, prevention, and management.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychotropic Use in Elderly with Cognitive Impairment Living in Nursing Homes

Introduction

Elderly patients in nursing homes (NH) are often prescribed medications for many physical and mental health problems, with polypharmacy. There is a considerable number of studies documenting this extensive prescription of psychotropic medication, despite the raised concerns about their overuse/misuse, due to serious adverse effects, including increased rate of cognitive decline associated with antipsychotics.

Aims

To characterize the prescription of psychotropics in elderly sample with cognitive impairment living in NH.

Methods

Elderly living in three Portuguese NH were included in this cross-sectional study. All residents were eligible, unless they were unwilling or unresponsive. Participants’ medication was obtained from medical records. Guidelines of ATC were used to categorize the drugs. Participants were assessed with MMSE and GDS.

Results

The sample included 172 elderly, mostly women (90%), with average of 81(sd = 10) years and median lengths of stay of 3 years. Overall, 79.1% used ≥ 1 nervous system-acting drugs. Anxiolytics (54.7%), antidepressants (29.1%) and antipsychotics (23.3%) were the most frequent. The majority (58%) presented cognitive impairment (MMSE). Among those, 46.2% presented depression (GDS) and 79.6% took at least one drug for the CNS and 41.9% ≥ 3. Antipsychotics were received by 26.5%, while 57.1% used anxiolytics, 31.6% antidepressants and 16.3% anti-dementia drugs. No significant relation between GDS and antidepressants was found.

Conclusion

This study confirms the high usage of CNS drugs in patients with cognitive impairment in NH. These rates were comparable with previous studies. Antidepressants appear to be under-used, which can be related to the under-recognition of depression. Also, potential harmful psychotropic drugs such as anxiolytics and antipsychotics are overused.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Behavioral and Psychological Symptoms: A Contribution for their Understanding Based on the Unmet Needs Model

Introduction

Behavioural and psychological symptoms (BPSD) are frequent in dementia and their contribution to poor health outcomes is well recognized. Four major frameworks attempt an explanation their aetiology: biological, behavioural, environmental vulnerability and unmet needs models. The latter states that BPSD are symptoms of needs that are not being met due to patients’ decreased ability to communicate/fulfil them. This model also implies that if needs were met, BPSD would improve.

Aims

To explore the relation between needs and BPSD, and describe which unmet needs were contributing to BPSD in an elderly sample.

Methods

A cross-sectional study was conducted in three Portuguese nursing homes. All residents were considered eligible. However, those unwilling or unable to participate were excluded. For each elderly patient, needs were assessed with camberwell assessment of need for the elderly/cane and BPSD with European Portuguese neuropsychiatric inventory/NPI.

Results

The final sample included 166 elderly with an average of 80.9(sd = 10.2) years. Significant correlations between NPI and unmet and global needs were found (rs = 0.181,P = 0.020; rs = 0.254,P = 0.001, respectively). Additionally, the unmet needs of daytime activities (P = 0.019), company (P = 0.028) and behaviour (P = 0.001), presented significant correlations with NPI.

Conclusion

In this sample, a high number of unmet needs were found. The absence of daytime activities, company and behaviour contributed to the identified BPSD, which is in line with other studies also highlighting the importance of these needs in nursing homes. This not only provides a framework for understanding BPSD, but also points to the identification of unmet needs as pivotal in prevention and treatment of these symptoms.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Delirium related distress in family: A non-systematic review

Introduction

Delirium is a common neuropsychiatric syndrome, particularly in elderly hospitalized patients, and is associated with an increase in morbidity and mortality. Although these negative consequences are well documented, only a few studies describe the experience of delirium from the families’ perspective.

Aims

To analyze studies regarding the experience and distress caused by delirium in the families/caregivers of adult/elderly hospitalized patients.

Methods

A non-systematic review of published articles until October 2015 in the database PubMed was carried out. The keyword “Delirium” was combined with: “experience”, “distress”, “anxiety” and “family”, “carer” and “relatives”. Inclusion criteria were: standardized diagnosis of delirium, systematic/prospective assessment of distress level. Clinical cases were excluded.

Results

Sixteen studies met the inclusion criteria for analysis. In most of them, family members (mostly younger) showed high levels of distress, even higher than health care professionals and patients. Several predictors of family distress were found, including poor functional status, psychomotor agitation, delusions, emotional lability, incoherent speech, inattention and disorientation. Higher distress was associated with long-term consequences (e.g. generalized anxiety). In the qualitative research, family members interpreted delirium as a sign of approaching death, result of pain/discomfort or an effect of medication. In addition, distress was associated with rapid and unexpected changes or unable to recognize the loved ones.

Conclusions

Delirium in patients was associated with significant distress in family members. These findings underline the importance of providing information and the development of appropriate supportive and psychoeducational interventions in order to help families throughout this process and reduce the associated distress. This work is supported by FCT (SFRH/BPD/103306/2014).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Dementia severity among institutionalized elderly: Are there more unmet needs?

Introduction

The ageing population and the resulting increase in chronic diseases, including dementia, make the evaluation of their emergent needs a crucial step in psychogeriatric care. Unmet needs are found to be important clinical targets that should be followed by active management in order to improve health status and survival.

Objectives

To analyze the relation between unmet needs and cognition, and explore the nature of these needs across dementia severity stages.

Methods

A cross-sectional study was conducted in three nursing homes. Residents were excluded if they were terminally ill, unresponsive or presented delirium. All participants were assessed by Mini-Mental State Examination/MMSE (cognition) and Camberwell Assessment of Need for the Elderly/CANE (needs). Additionally, cognitive decline was staged as: absent (MMSE = 30), questionable (26–29), mild (21–25), moderate (11–20) and severe (≤ 10).

Results

The study included 175 elderly with a mean age of 80.6 (SD = 10.1) years, of which 58.7% presented cognitive decline. For these, the mean number of unmet needs was greater than for those without (4 vs 3, P < 0.001), and they differed significantly in the domains of daytime activities (P < 0.001), memory (P < 0.001) and psychotic symptoms (P = 0.005). A significant negative correlation was found between MMSE and number of unmet needs (rs = −0.369, P < 0.001). Considering the severity stages, unmet needs also differed: more needs in early stages in daytime activities (73.3%), and in advanced ones in memory (63.9%) and psychotic symptoms (23%).

Conclusions

Greater cognitive decline was related with more unmet needs, which agree with previous studies. The different nature of needs across severity stages also suggests that interventions should be tailored comprising this specificity and complexity, when effective care is planned.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Cross-sectional and prospective associations between moderate to vigorous physical activity and sedentary time with adiposity in children

BACKGROUND

Physical activity (PA) and sedentary time (SED) have both been suggested as potential risk factors for adiposity in children. However, there is paucity of data examining the temporal associations between these variables.

OBJECTIVE

This study aimed to analyze the cross-sectional and prospective associations between PA, SED and body composition in children.

METHODS

A total of 510 children (age at baseline 10.1±0.8, age at follow-up 11.8±0.9) from six Portuguese schools from the Oeiras Municipality participated in this study. PA and SED were measured by accelerometry and trunk fat mass (TFM) and body fat mass (BFM) were measured by dual energy X-ray absorptiometry. Fat mass index (FMI) was calculated as BFM divided by height squared. Several regression models adjusted for age, sex, maturity status, follow-up duration, baseline levels of the outcome variable and SED or moderate to vigorous PA (MVPA) were performed.

RESULTS

MVPA (min per day) was cross-sectionally inversely associated with adiposity indexes (FMI, TFM and BFM). Adiposity indexes were inversely associated with time in MVPA. In prospective analyses, MVPA was associated with a lower levels of FMI (β=-0.37, 95% confidence interval (CI): -0.49 to -0.26, P<0.001), TFM (β=-0.20, 95% CI: -0.29 to -0.10, P<0.001) and BFM (β=-0.37, 95% CI: -0.49 to -0.26, P<0.001). When the model was adjusted for age, sex, maturity status and for baseline levels of the outcome variables MVPA remained a significant predictor of lower adiposity indexes (FMI: β=-0.09, 95% CI: -0.16 to -0.01, P<0.05; TFM: β=-0.08, 95% CI: -0.15 to -0.01, P<0.05; BFM: β=-0.07, 95% CI: -0.15 to 0.00, P<0.05). Adiposity was not associated with MVPA when modeled as the exposure in prospective analyses. SED was not related with adiposity indexes, except for the relationship with FMI.

CONCLUSIONS

In cross-sectional and prospective analyses, MVPA is associated with lower adiposity independent of covariates and SED. Results suggest that promoting MVPA is important for preventing gain in adiposity in healthy children.