A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study

OBJECTIVES

To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications.

DESIGN

A retrospective before-after study.

SETTING

A tertiary-care academic hospital.

PARTICIPANTS

Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups.

INTERVENTION

The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035).

CONCLUSIONS

Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.

Pulmonary Mucormycosis: Beyond Classic COVID-19-Associated Fungal Infections

Coronavirus disease 2019 (COVID-19) is often linked to a broad range of opportunistic bacterial and fungal infections. The second wave of the COVID-19 pandemic has witnessed an unprecedented surge in mucormycosis cases, predominantly in India, while the disease remained relatively rare in Europe. The authors describe the case of a 62-year-old female patient admitted to the hospital for consolidation therapy with chemotherapy as a part of the treatment protocol for acute myeloid leukemia. During hospitalization, she was diagnosed with nosocomial COVID-19, which later progressed to respiratory deterioration. COVID-19 with bacterial superinfection was presumed, leading to the initiation of empirical antibiotic therapy. A bronchoscopy was performed several days later due to a lack of improvement, revealing an infection by the Rhizopus microsporus complex. Despite antifungal treatment, the patient experienced an unfavorable clinical course and ultimately died. Given the high index of suspicion required to diagnose pulmonary mucormycosis, which can lead to delays in appropriate treatment and increase the burden of disease, the authors are aiming to enhance its awareness.

Palliative medicine in the emergency department: symptom control and aggressive care

OBJECTIVES

Identifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care.

METHODS

We conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson's Index.

RESULTS

384 adults died at the ED (median age 82 (IQR 72-89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2-4) vs 3 (2-5)), p=0.082.

CONCLUSIONS

Nearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.

Mycobacterium szulgai Pulmonary Infection in an Immunocompromised Patient

Mycobacterium szulgai is a slow-growing nontuberculous mycobacterium (NTM). It was first described in 1972 and is responsible for less than 0.2% of all NTM infections. The most common presentation resembles pulmonary tuberculosis, but it may also present as an extrapulmonary disease. It primarily affects individuals with underlying lung disease or immunocompromising conditions. The increasing use of tumor necrosis factor-alpha inhibitors, such as adalimumab, is associated with an increased risk of serious infections. We report a case of Mycobacterium szulgai infection in a 23-year-old woman with a history of childhood pneumonia and Crohn's disease on adalimumab.

Revisiting Scrofula: An Entity Not to Forget in Migrants' Health

Tuberculous lymphadenitis (TBL) is one of the most common presentations of extrapulmonary tuberculosis (EPTB). The particularity of this presentation is the difficulty in establishing a definitive diagnosis, as clinical manifestations and imaging may be unspecific. We describe a case of tuberculous cervical lymphadenitis in a young male from Pakistan, a high-burden tuberculosis country. We intend to raise awareness of this entity, given the high index of suspicion required to diagnose it, which can lead to delays in appropriate treatment, potentially increasing the morbidity and mortality of affected patients. Increased awareness is especially important in immigrants, in whom tuberculosis cases continue to increase, exposing the need for easy and equitable access to healthcare. A brief review of the subject is also presented.

Novel Three-Dimensionally Printed Ultrasound Probe Simulator and Heart Model for Transthoracic Echocardiography Education

Simulation-based training is an essential component in the education of transthoracic echocardiography (TTE). Nevertheless, current TTE teaching methods may be subject to certain limitations. Hence, the authors in this study aimed to invent a novel TTE training system employing three-dimensional (3D) printing technology to teach the basic principles and psychomotor skills of TTE imaging more intuitively and understandably. This training system comprises a 3D-printed ultrasound probe simulator and a sliceable heart model. The probe simulator incorporates a linear laser generator to enable the visualization of the projection of the ultrasound scan plane in a 3D space. By using the probe simulator in conjunction with the sliceable heart model or other commercially available anatomic models, trainees can attain a more comprehensive understanding of probe motion and related scan planes in TTE. Notably, the 3D-printed models are portable and low-cost, suggesting their potential utility in various clinical scenarios, particularly for just-in-time training.

3% polidocanol foam sclerotherapy versus hemorrhoidal artery ligation with recto anal repair in hemorrhoidal disease grades II-III: a randomized, pilot trial

PURPOSE

Polidocanol foam sclerotherapy (SP) versus doppler-guided hemorrhoidal artery ligation with recto-anal repair (HAL-RAR) in the treatment of hemorrhoidal disease (HD) was analyzed.

METHODS

A prospective, randomized study including patients with HD grades II and III was performed. Participants were randomly assigned (1:1) into SP or HAL-RAR, during a recruitment period between September 2019 and February 2020. Therapeutic success (Sodergren's and bleeding scores) was the primary outcome. Other outcomes evaluated included complications and implication in the professional life. Efficacy and safety outcomes were evaluated during the 8 weeks after surgery or the final SP session.

RESULTS

Forty-six patients were allocated either to SP (n=22) or HAL-RAR (n=24). Most patients achieved therapeutic success (SP 100% vs. HAL-RAR 90.9%, p=0.131). Complete success was higher in the SP group (91.7% vs. 68.2%, p=0.045) and SP patients had less complications (25% vs. 68.2%, p=0.003). HAL-RAR had a greater negative impact on work activity of the patient.

CONCLUSION

SP was more effective and safer than HAL-RAR. SP patients had less impact on their work activity. Clinical trials identifier NCT04675177.

Diagnosis of Asymptomatic Biliary Ascariasis by Abdominal Ultrasound in a Non-Endemic Area

Biliary ascariasis is rare in non-endemic areas. This infection is associated with severe complications of the biliary tract, which can become a medical emergency. Treatment with oral anthelmintics is often effective, but, in some cases, surgery is required.  We describe an unusual case of ultrasound diagnosis of biliary ascariasis in the gallbladder in a patient who, besides residing in a low-prevalence area of the infection, did not present with biliary tract manifestations. We intend to raise awareness of this clinical entity in non-endemic areas, where this diagnosis is not usually considered. A brief review of the subject is also presented.

V-013 ETEP - STEP BY STEP

Minimally invasive approaches are increasingly being used for the correction of abdominal wall hernias. Although laparoscopy presents as a greater technical challenge compared to classical techniques, once the learning curve is overcome, the advantages are multiple: less postoperative pain, shorter hospital stay, faster return to daily/professional activities and lower rate of surgical site infection.

The authors present the case of a 55yo women with a history of type 2 diabetes mellitus and peripheral venous insufficiency. No history of previous surgeries. The patient was referred to an appointment in the Ambulatory Surgery Centre for evaluation of a primary midline hernia. Symptoms were worsening in the last 6 months. No previous episodes of complications. Preoperative evaluation included an abdominopelvic computed tomography, which revealed a hernia sac containing only fatty tissue (no intestinal loops present) and a 19 mm hernial neck with a supra-umbilical median location. No other abdominal wall defects were evident.

The patient was proposed for a laparoscopic approach - extended totally extraperitoneal (eTEP) in ambulatory setting. The surgery and post-operative period (9 months) to date went without intercurrences.

The present video aims to demonstrate the main steps of the surgical technique applied in a tertiary centre with years of experience in laparoscopic abdominal wall surgery.

With this paper the authors pretend to demonstrate that laparoscopy may become the gold-standard in abdominal wall hernia correction as soon as the know-how and respective learning curve are aquired. Until then, these cases should continue to be referred to specialized tertiary centres.

Defining and Addressing Anesthesiology Needs in Simulation-based Medical Education

BACKGROUND

This study's primary aim was to determine how training programs use simulation-based medical education (SBME), because SBME is linked to superior clinical performance.

METHODS

An anonymous 10-question survey was distributed to anesthesiology residency program directors across the United States. The survey aimed to assess where and how SBME takes place, which resources are available, frequency of and barriers to its use, and perceived utility of a dedicated departmental education laboratory.

RESULTS

The survey response rate was 30.4% (45/148). SBME typically occurred at shared on-campus laboratories, with residents typically participating in SBME 1 to 4 times per year. Frequently practiced skills included airway management, trauma scenarios, nontechnical skills, and ultrasound techniques (all ≥ 77.8%). Frequently cited logistical barriers to simulation laboratory use included COVID-19 precautions (75.6%), scheduling (57.8%), and lack of trainers (48.9%). Several respondents also acknowledged financial barriers. Most respondents believed a dedicated departmental education laboratory would be a useful or very useful resource (77.8%).

CONCLUSION

SBME is a widely incorporated activity but may be impeded by barriers that our survey helped identify. Barriers can be addressed by departmental education laboratories. We discuss how such laboratories increase capabilities to support structured SBME events and how costs can be offset. Other academic departments may also benefit from establishing such laboratories.

Positioning Aeromonas Infection in Inflammatory Bowel Disease: A Retrospective Analysis

Background and Aim

Aeromonas are Gram-negative rods known to cause a spectrum of diseases. Inflammatory bowel disease (IBD) is an idiopathic complex condition resulting from interaction of multiple factors. Aeromonas infection in association with IBD is still largely unknown. We aim to look for the significance of Aeromonas infection and for significant differences between IBD and non-IBD patients.

Methods

A retrospective observational analysis was performed of all patients positive for Aeromonas in stool cultures, during a 10-year period, from a tertiary and university hospital.

Results

Fifty patients were included, 56% male with a mean age of 42.1 years. Thirty-eight (76%) were non-IBD and 12 (24%) IBD patients. IBD patients were more frequently under immunosuppressors. Two patients were asymptomatic and 44% developed mild, 44% moderate, and 16.7% severe infection. The main strains isolated were Aeromonas hydrophila/caviae. Bacterial co-isolation was found in 4 non-IBD and histological findings of cytomegalovirus in 2 IBD patients. Non-IBD patients presented more frequently with fever and IBD patients with bloody diarrhea and abdominal pain. There was higher tendency for severe infection rate in IBD patients with higher antimicrobial therapy use. Steroids were exclusively used in the IBD group. From IBD, 4 patients had the diagnosis of ulcerative colitis and 9 of Crohn's disease with colonic involvement. Of these patients, 5 received IBD diagnosis after the acute episode of Aeromonas infection.

Conclusions

Clinical presentation of Aeromonas infection differs between IBD and non-IBD patients. Non-IBD patients had milder severity of infection with less use of antibiotics. Aeromonas infection seems to greatly contribute to IBD manifestation.

Diagnostic confusion, clinical chaos - an acute and transient psychotic disorder case report and brief historical review

Introduction

Acute and Transient Psychotic Disorder (ATPD) is a group of rare psychotic disorders characterized by acute onset, symptom fluctuation and short duration typically followed by complete recovery. Throughout the time, there have been different attempts to classify these disorders (Bouffée Délirante, Cycloid Psychosis, etc.); nevertheless, in the current date, ATPD encompasses a broad spectrum of heterogenous clinical presentations with low diagnostic stability over time.

Objectives

To describe a case of ATPD, highlighting the variability of its’ psychopathological phenomena and establishing a comparison with historical descriptions of this nosological entity.

Methods

Clinical case report and brief review of literature.

Results

V, 20-year old male without psychiatric history, presents in the emergency room exhibiting fluctuant psychopathology over the preceding two weeks – initially with depressive mood, anhedonia, apathy, bizarre behaviors and soliloquies; afterwards, showing paranoid delusional ideation; total insomnia in the previous 2-3 days; finally, showing grandiose delusional ideation; and throughout the episode, revealing pseudohallucinatory verbal activity assuming multiple identities. Several stress factors were identified in close time-relation with the onset of these symptoms. V. started risperidone 2mg 2id and quetiapine 100mg id and was discharged 2 weeks later, fully recovering from these psychopathological phenomena. V. remains asymptomatic at 6 months of follow-up.

Conclusions

Historically, some classifications of this disorder focus on etiological factors, others on clinical evolution and course, and yet another group on separation from the Kraepelinian duality (schizophrenia and bipolar disorder). ATPD is a diagnosis with high clinical heterogeneity and low stability over time, which can have implications in follow-up and long-term outcome.

A Tool to Predict Readmission to the Intensive Care Unit in Surgical Critical Care Patients-The RISC Score

BACKGROUND

Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors.

METHODS

In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments.

RESULTS

Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation.

CONCLUSION

The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.

Academic entrepreneurship intentions: a systematic literature review

Purpose

The objective of this research is to have an up-to-date and comprehensive assessment of the current knowledge regarding the variables that encourage the individuals, within the academic community, to get involved in knowledge exploitation activities. It is influenced by the observation that there is a need for more systematic scrutiny of micro-level processes to deepen our understanding of academic entrepreneurship (Balven et al., 2018; Wright and Phan, 2018). The study proposes to answer to ‘What are the drivers of academic entrepreneurial intentions?’ and ‘What are the emerging topics for future research?’

Design/methodology/approach

The paper follows a Systematic Literature Review process (Tranfield et al., 2003) and adopts a four-step process format from previous literature reviews within the entrepreneurship context (Miller et al., 2018). From the results within Scopus and Web of Science databases, this research selected, evaluated, summarised and synthesised 66 relevant papers.

Findings

This study provides a factor-listed representation of the individual, organisational and institutional variables that should be considered in the strategies defined by the university. Moreover, the study concludes that the push factors behind the intentions are multiple, context-dependent, hierarchy-dependent, heterogeneous and, at the same time, dependent on each other and against each other. Lastly, the study contributes to academic entrepreneurship literature, especially entrepreneurial intention literature, which has recently received more researchers' attention.

Originality/value

The study corroborates that the individual factors, directly and indirectly via Theory of Planned Behaviour, strongly impact the academics' intentions. While the focus of the papers under review was an in-depth analysis of a selected group of factors, this SLR sought to compile the factors that were identified and provide a broader picture of all those factors to be considered by the university management. It contributes to the identification and clustering of the drivers that encourage academics to engage in knowledge valorisation activities, differentiating them by activity. For the practitioners, this list can be used by university managers, TTOs and department managers, and policymakers to guide questionnaires or interviews to analyse their academics' intentions and adequately support its academic engagement strategy. Lastly, this study also suggests worthwhile avenues for future research.

Lights4Violence: a quasi-experimental educational intervention in six European countries to promote positive relationships among adolescents

Background

Preventing intimate partner violence or dating violence (DV) among adolescents is a public health priority due to its magnitude and damaging short and long-term consequences for adolescent and adult health. In our study protocol, we complement prior experiences in DV prevention by promoting protective factors (or assets) against gender violence such as communication skills, empathy and problem-solving capability through “Cinema Voice”, a participatory educational intervention based on adolescents’ strengths to tackle DV.

Methods/design

A longitudinal quasi-experimental educational intervention addressed to boys and girls ages 13–17 years, enrolled in secondary education schools in Alicante (Spain), Rome (Italy), Cardiff (UK), Iasi (Romania), Poznan (Poland) and Matosinhos (Portugal). Both process and results evaluations will be carried out with 100–120 intervention and 120–150 control group students per city at three time periods: before, after and 6 months after the implementation of the following interventions: 1) Training seminar with teachers to promote knowledge and skills on the core issues of intervention; 2) Workshops with intervention groups, where participants produce their own digital content presenting their perspective on DV; and 3) Short film exhibitions with participants, their families, authorities and other stakeholders with the objective of share the results and engage the community. Outcome measures are self-perceived social support, machismo, sexism, tolerance towards gender violence, social problem-solving and assertiveness as well as involvement in bullying/cyberbullying. Other socio-demographic, attitudes and violence-related co-variables were also included.

Discussion

This study may provide relevant information about the effectiveness of educational interventions that combine a positive youth development framework with educational awareness about the importance of achieving gender equality and preventing and combating gender violence. To our knowledge, this is the first study that involves six European countries in an educational intervention to promote violence protective assets among enrolled adolescents in secondary schools. This study may provide the needed tools to replicate the experience in other contexts and other countries.

Trial registration

Clinicaltrials.gov: NCT03411564. Unique Protocol ID: 776905. Date registered: 18-01-2018.

Role of the impulse oscillometry in the evaluation of tracheal stenosis

INTRODUCTION AND OBJECTIVES

Tracheal stenosis is a rare and challenging disease. Bronchoscopy is the gold standard for diagnosis and assessment but brings inherent risks. Spirometry is commonly used to access obstructions but is not always feasible due to patient related factors. We therefore considered impulse oscillometry (IOS) as a non-invasive method to quantify airway obstruction and its potential use for diagnosis and follow-up of tracheal stenosis.

MATERIALS AND METHODS

Patients with confirmed tracheal stenosis were recruited between January 1st, 2015 and December 31st, 2016. Before bronchoscopy, all subjects underwent IOS and spirometry; for patients submitted to interventional bronchoscopy the same techniques were also performed after the procedure. We assessed the correlation between IOS measurements and airway narrowing as well as between IOS and spirometry values.

RESULTS

Twenty-one patients were included. Tracheal narrowing was inversely correlated with X5% (r -0.442, p 0.045) and positively correlated with FEV1/PEF (r 0.467, p 0.033). The stenosis length was inversely correlated with PEF and PEF% (r -0.729, p=0.001 and r -0.707, p=0.002, respectively). There was a strong correlation between spirometric and IOS values. We did not find any significant differences between pre- and post-intervention IOS values for patients assessed after interventional bronchoscopy.

CONCLUSIONS

Our study showed a weak correlation between X5% and tracheal narrowing making it unclear whether IOS can be used for physiological assessment of patients with tracheal stenosis. Stenosis length correlated with PEF making it a potential predictor of successful surgical approach. The correlation between IOS and spirometric values makes IOS a potential alternative in patients with suspected tracheal stenosis who are not able to perform spirometry. Larger scale studies should clarify the role of IOS in this pathology.

Transbronchial lung cryobiopsy: Associated complications

INTRODUCTION

Transbronchial lung cryobiopsy (TBC) has emerged as a diagnostic alternative to surgical lung biopsy in interstitial lung disease (ILD). Despite its less invasive nature, some associated complications have been described.

OBJECTIVE

To evaluate complications of TBC and associated factors.

METHODS

Prospective evaluation of all patients with ILD submitted to TBC in our centre. Clinicodemographic variables and factors associated to TBC complications were analyzed. The effect of the variables on the complication risk was evaluated by a logistic regression model.

RESULTS

Ninety patients were included (mean age 60±13 years; 58.9% male). Twenty-two patients presented pneumothorax, 18 (81.8%) of which were treated with chest tube drainage [median air leak time: 1 day (IQR=2)]. Grade 2 and 3 bleeding was observed in 13 (14.4%) cases. Presence of visceral pleura in the sample accounted for almost more than 10 times the odds of pneumothorax (OR=9.59, 95% CI 2.95-31.17, p<0.001). Increased body mass index (BMI) was associated with bleeding (16% additional odds for each BMI unit increase (OR=1.16, 95% CI 1.01-1.34, p=0.049).

CONCLUSION

The most frequent complication of TBC was pneumothorax, although rapidly reversible. There was a positive association between pneumothorax and the presence of pleura in the biopsy samples as well as between bleeding and increased BMI. More studies about TBC complications are needed to improve the selection of the candidates for this procedure.

Idiopathic pulmonary fibrosis in the era of antifibrotic therapy: Searching for new opportunities grounded in evidence

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease that up to now has been associated with a poor prognosis. However, the results of the INPULSIS and ASCEND trials and the approval of nintedanib and pirfenidone have marked the beginning of a new era for IPF patients. Questions remain, however. Should these drugs be used earlier? What effect will they have on more severe disease? Will their effects last beyond the trial period? This manuscript is the outcome of a multidisciplinary meeting between pulmonology, radiology, and pathology clinicians on the use of antifibrotic agents in IPF. In our opinion, the existing data show that pirfenidone and nintedanib slow functional decline in early stages of disease. These drugs also appear to result in therapeutic benefits when administered to patients with advanced disease at diagnosis and maintain effective over time. The data also suggest that continuing antifibrotic therapy after disease progression may confer benefits, but more evidence is needed. Early diagnosis and treatment are crucial for reducing functional decline, slowing disease progression, and improving quality of life.

Risk Factors of Increased Mortality During Hospitalization in Acutely-ill Elderly Patients with Altered State of Consciousness

Introduction

A significant proportion of acutely ill hospitalised elderly patients have impaired consciousness and this has been associated with increased mortality. It remains unclear which factors underlie this relation. Identification of mortality predictors in this population is important to improve care.

Objectives

Determine if advanced age, cognitive impairment, high burden of comorbidities and poor functional status are predictors of increased mortality during hospitalisation in acutely-ill medical hospitalised elderly patients with altered state of consciousness.

Methods

All male patients (> 65 years) admitted to a medical ward (> 48 h) between 01/03/2015 to 31/08/2015 with delirium or RASS lower than–2 were included in the study. Patients were excluded if unable to be assessed due to sensorial deficits, communication problems or medical condition precluding the evaluation. Baseline evaluation included socio-demographic variables, RASS, CAM, IQCODE-SF, DSM-IV-TR criteria for dementia, Charlson Comorbidity Index and Barthel Index. The variables were entered in a logistic regression model (significance level < 0.05).

Results

The final sample consisted of 75 male subjects with altered state of consciousness, 14 of them died during hospitalisation. Dementia and Barthel Index were significantly associated with mortality during hospitalisation (P = 0.01 and P < 0.01, respectively). On the other hand, age and Charlson Co-morbidity Index were not associated significantly with mortality during hospitalisation (P = 0.22 and P = 0.1, respectively).

Conclusions

Acutely ill elderly patients with altered state of consciousness at admission have higher risk of death during hospitalisation if they have prior dementia or poor functional status. Health care should be improved to provide better response to this type of patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in non-small cell lung carcinoma

INTRODUCTION

Lung cancer staging has recently evolved to include endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for nodal assessment.

AIM

Evaluate the performance and safety of EBUS-TBNA as a key component of a staging algorithm for non-small cell lung carcinoma (NSCLC) and as a single investigation technique for diagnosis and staging of NSCLC.

METHODS

Patients undergoing EBUS-TBNA for NSCLC staging at our institution between April 1, 2010 and December 31, 2014 were consecutively included with prospective data collection. EBUS-TBNA was performed under general anesthesia through a rigid scope.

RESULTS

A total of 122 patients, 84.4% males, mean age 64.2 years. Histological type: 78 (63.9%) adenocarcinoma, 33 (27.0%) squamous cell carcinoma, 11 (8.9%) undifferentiated/other NSCLC. A total of 435 lymph node stations were punctured. Median number of nodes per patient was 4. EBUS-TBNA nodal staging: 63 (51.6%) N0; 8 (6.5%) N1; 34 (27.9%) N2, and 17 (13.9%) N3. EBUS-TBNA was the primary diagnostic procedure in 27 (22.1%) patients. EBUS-TBNA NSCLC staging had a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate of 83.3, 100, 100, 86.1, and 91.8%, respectively. No complications were attributable to the procedure.

CONCLUSION

A comprehensive lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective. Our EBUS-TBNA performance and safety in this particular setting was in line with previously published reports. Additionally, our study showed that, in selected patients, lung cancer diagnosis and staging are achievable with a single endoscopic technique.

Discrimination of fast click-series produced by tagged Risso's dolphins (Grampus griseus) for echolocation or communication

Early studies that categorized odontocete pulsed sounds had few means of discriminating signals used for biosonar-based foraging from those used for communication. This capability to identify the function of sounds is important for understanding and interpreting behavior; it is also essential for monitoring and mitigating potential disturbance from human activities. Archival tags were placed on free-ranging Grampus griseus to quantify and discriminate between pulsed sounds used for echolocation-based foraging and those used for communication. Two types of rapid click-series pulsed sounds, buzzes and burst pulses, were identified as produced by the tagged dolphins and classified using a Gaussian mixture model based on their duration, association with jerk (i.e. rapid change of acceleration) and temporal association with click trains. Buzzes followed regular echolocation clicks and coincided with a strong jerk signal from accelerometers on the tag. They consisted of series averaging 359±210 clicks (mean±s.d.) with an increasing repetition rate and relatively low amplitude. Burst pulses consisted of relatively short click series averaging 45±54 clicks with decreasing repetition rate and longer inter-click interval that were less likely to be associated with regular echolocation and the jerk signal. These results suggest that the longer, relatively lower amplitude, jerk-associated buzzes are used in this species to capture prey, mostly during the bottom phase of foraging dives, as seen in other odontocetes. In contrast, the shorter, isolated burst pulses that are generally emitted by the dolphins while at or near the surface are used outside of a direct, known foraging context.

Patients With Anorexia Nervosa: Outcome Inpatient Care

Introduction

Anorexia nervosa (AN) is characterized by self-induced starvation coupled with fear of gaining weight and a distorted body image. Its treatment is complex and challenging, and sometimes hospitalization is needed.

Santa Maria Hospital's Eating Disorders Unit (SMH-EDU) is a multidisciplinary team, formed in 1989, that provides both outpatient and inpatient treatment.

Objective

To present and discuss SMH-EDU's AN treatment and its results.

Methods

Revision and statistical analysis of all hospitalized AN’ patients’ clinical files, from 1 January 2014 to 31 December 2014. Treatment outcome was assessed by BMI variation.

Results

A total of 45 admissions (41 patients) were analysed: 75.65% had AN restricting type and 24.45% had AN purging type. All patient were females, with median age of 27 years old (range 12–57 years). Average admission BMI was 14.51 kg/m2 (ranging from 11.19 to 17.77 kg/m2). The mean lengths of stay were 39 days. Thirty-six percent of the patients had at least one previous hospitalization. Only 2 patients were readmitted at SMH-EDU: triple readmissions. The mean time between the beginning of the disorder and the admission was 111 months (ranging 2 to 408 months). Average discharged BMI was 16.32 kg/m2 (ranging from 13.24 to 19.11 kg/m2).

Conclusion

Inpatient treatment for AN at SMH-EDU is considered only for those patients whose disorder has not improved with appropriate outpatient treatment. Therefore, most inpatients at SMH-EDU have disorders of high severity, as demonstrated in our results.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A New Look at Personality Disorders Treatments

Introduction

Mental illness develops and is inseparable from the sociocultural context. The Disturbances may exhibit different symptoms in different cultures. In personality disorders, there is a pathological expansion of normal traits that often demonstrate a sociocultural change. The quality of life of these patients can improve with certain treatments, which appears to be relevant to be achieved.

Method

Search on Pubmed and Medline for original research or review articles published in English or Portuguese in the last 10 years. It used a combination of terms: “personality”, “treatment”, “personality disorder”, “borderline”, “antissocial”, “pharmacotherapy”, and other named personality disorders.

Objectives/Aim

Search the evidence base and the new perspectives for the effective treatment of personality disorders.

Results

The same personality traits may be adaptive or non-adaptive in different contexts. So, without changing these characteristics, patients can learn to use them more effectively. In other words, although the therapy did not change the personality traits, it can be modified in the way they affect the behavioral expression.

Conclusions

Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Diffuse vascular hamartoma with malignant behavior

Pulmonary hamartomas are benign lesions, usually asymptomatic and incidentally discovered on a routine chest radiograph; occasionally, however, this benign lesion may cause life threatening symptoms due to it's location and diffuse vascular involvement. We report the case of a 27 year-old male, non-smoker, who presented with dyspnea, cough, hemoptysis and weight loss. He was found to have a mass in the right hilar region which also involved the right main bronchus, pulmonary artery and esophagus. Surgical biopsy of the lesion led to the diagnosis of diffuse vascular hamartoma. Although it was a benign lesion, due to the size and location, surgical removal was not possible and patient died 10 years after being diagnosed with the condition.

Diagnosis of sarcoidosis in the endobronchial ultrasound-guided transbronchial needle aspiration era

BACKGROUND

Sarcoidosis is a multisystemic disorder of unknown etiology. Its diagnosis is based on compatible clinical and radiological features and supported by histological demonstration of epithelioid cell noncaseating granulomas with exclusion of other causes. Endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA) has been proposed as a valuable tool in obtaining suitable tissue sample. The aim of this study was to evaluate the contribution of EBUS-TBNA to the diagnosis of stages I and II thoracic sarcoidosis in a community-based hospital.

METHODS

A prospective study was conducted in patients with suspected stages I and II pulmonary sarcoidosis, based on clinical and radiological data, who were being followed in our Interstitial Lung Disorders Outpatient Clinic or sent from other hospitals to our Respiratory Endoscopy Unit for diagnostic procedures. All suitable and fit patients underwent EBUS-TBNA between March 2010 and June 2013. We assessed demographic characteristics, radiological stages, cytological/histological examination and diagnostic techniques performed.

RESULTS

In the period considered 39 patients underwent EBUS-TBNA for suspected stages I and II thoracic sarcoidosis and adequate samples were obtained in 38 (97.4%). Within this population, 33 (84.6%) patients had a definite diagnosis of sarcoidosis, of which 31 patients (93.9%) were confirmed to have epithelioid noncaseating granulomas by EBUS-TBNA. Four patients were submitted to surgical procedures (three to mediastinoscopy and one to open surgical lung biopsy). Data analysis allowed to calculate a sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of 93.9%, 100%, 100%, 75.0% and 94.8%, respectively. No complications were observed.

CONCLUSIONS

EBUS-TBNA is a valuable tool in the diagnostic workup of patients with suspected stages I and II thoracic sarcoidosis providing a substantial number of pathological confirmations and with few complications. Its high diagnostic accuracy precludes the need for more invasive procedures such as surgical biopsy.

Epidermal growth factor receptor mutation study for 5 years, in a population of patients with non-small cell lung cancer

INTRODUCTION

In 2006, the Vila Nova de Gaia/Espinho Hospital Centre Pulmonary Oncology Unit started performing EGFR (Epidermal Growth Factor Receptor) mutation sequencing in selected patients with NSCLC and systematically in all patients since 2010, regardless of histology, smoking habits, age or sex. The aim of this study was to characterize the group of patients that carried out the sequencing between 2006-2010, to determine EGFR mutation frequency, to evaluate the overall survival and the survival after the use of tyrosine kinase inhibitors (TKI), in patients who performed this therapy in second and third line, knowing the EGFR mutation status.

METHODS

Descriptive statistical analysis of patients who did EGFR sequencing in 2006-2010 and of overall survival in patients treated with TKI as 2nd and 3rd line therapy. Record of the material available for analysis and average delay of exam results, according to the material submitted.

RESULTS

The sequencing was performed in 374 patients, 71,1% males, 67,1% non/ex-smokers, 32,9% smokers, 57,8% adenocarcinoma and 23,5% squamous cell carcinoma (SCC). The mutation was detected in 49 patients (13,1%). In all studied patients, the mutation rate was 9% in males and 23% in females. Median overall survival after erlotinib use of was 14 months for patients with positive EGFR mutation versus 6 months in not mutated patients (p = 0.003).

CONCLUSION

Our group had an overall mutation rate of 13.1% with female, non-smokers, adenocarcinoma histology predominance. In selected patients (2006/2009), the mutation rate was 16%, in not selected patients (2010) the mutation rate was 10.4%. This study has permitted a better understanding of the EGFR mutation rate in the Portuguese population as welll as an evaluation of the patients survival after the use of of tyrosine kinase inhibitors, in second and third line therapy with previous knowledge of the EGFR mutational status. Statistical significant differences in survival were found in the two patient groups (EGFR mutated and non mutated). The EGFR mutation research should be performed in all patients with NSCLC, giving the possibility to a considerable number of patients to perform a first line treatment with TKI (EGFR mutated patients) and the advantage of performing other chemotherapy schemes, when progression occurs.

Granulomatosis with polyangiitis initially misdiagnosed as lung cancer

Granulomatosis with Polyangiitis (GPA), which was formerly named Wegener's Granulomatosis (WG) is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract, as well as kidneys. Diagnosing GPA on the basis of transthoracic fine needle aspiration (TFNA) may be problematic, as it can be misdiagnosed as cancer. We describe a patient with a probable GPA which was originally diagnosed as malignancy, but who responded to lung cancer chemotherapy.

Bronchoscopic hemostatic tamponade with oxidized regenerated cellulose for major hemoptysis control: two case reports

Hemoptysis is a common and alarming clinical problem. Acute massive hemoptysis is a life threatening condition. Different therapeutic strategies such as surgery, endovascular treatment and/or bronchoscopy have been applied. We report two cases of patients with severe hemoptysis who were treated by bronchoscopy guided topical hemostatic tamponade therapy with oxidized regenerated cellulose.

Cellular and molecular events associated with the antitumor response induced by the cytosine deaminase/5-fluorocytosine suicide gene therapy system in a rat liver metastasis model

The bacterial cytosine deaminase (CD) gene converts the non-toxic prodrug 5-fluorocytosine (5-FC) into 5-fluorouracil. We have previously shown, in a rat liver metastasis model from colon carcinoma, that intratumoral injection of a CD-expressing plasmid into the animals followed by 5-FC treatment results in the regression of the treated tumor as well as distant uninjected tumors. The aim of this study was to further analyze the mechanisms associated with tumor regression induced upon application of suicide CD/5-FC strategy. Tumor regression was associated with an increased apoptosis, the recruitment of natural killer cells, CD4- and CD8 T lymphocytes within the tumors and an increased expression of several cytokines/chemokines mRNAs. These data indicate that the CD/5-FC suicide strategy is associated with the triggering of cellular and molecular events leading to an efficient antitumor immune response involving both innate and acquired immunity.

Cationic liposomes for gene delivery: from biophysics to biological applications

The use of an efficient carrier for nucleic acid-based medicines is considered to be a determinant factor for the successful application of gene therapy. The drawbacks associated with the use of viral vectors, namely those related with safety problems, have prompted investigators to develop alternative methods for gene delivery, cationic lipid-based systems being the most representative. Despite extensive research in the last decade on the use of cationic liposomes as gene transfer vectors and the development of elegant strategies to enhance their biological activity, these systems are still far from being viable alternatives to the use of viral vectors in gene therapy. In this review considerations are made regarding the structure-activity relationships of cationic liposome/DNA complexes and the key formulation parameters influencing the features of lipoplexes are presented and discussed in terms of their effect on biological activity. Particular emphasis is given to the interaction of the lipoplexes with serum components as well as to novel strategies developed to circumvent difficulties that may emerge upon iv administration of the complexes. Finally, since the ability of the lipoplexes to be stored while preserving their transfection activity is a crucial issue for the repeated use of such carriers, approaches reported on the improvement of their physical stability are also reviewed.