Can primary health care mitigate the effects of economic crises on child health in Latin America? An integrated multicountry evaluation and forecasting analysis

BACKGROUND

Latin American and Caribbean countries are dealing with the combined challenges of pandemic-induced socicoeconomic stress and increasing public debt, potentially leading to reductions in welfare and health-care services, including primary care. We aimed to evaluate the impact of primary health-care coverage on child mortality in Latin America over the past two decades and to forecast the potential effects of primary health-care mitigation during the current economic crisis.

METHODS

This multicountry study integrated retrospective impact evaluations in Brazil, Colombia, Ecuador, and Mexico from 2000 to 2019 with forecasting models covering up to 2030. We estimated the impact of coverage of primary health care on mortality rates in children younger than 5 years (hereafter referred to as under-5 mortality) across different age groups and causes of death, adjusting for all relevant demographic, socioeconomic, and health-care factors, with fixed-effects multivariable negative binomial models in 5647 municipalities with an adequate quality of vital statistics. We also performed several sensitivity and triangulation analyses. We integrated previous longitudinal datasets with validated dynamic microsimulation models and projected trends in under-5 mortality rates under alternative policy response scenarios until 2030.

FINDINGS

High primary health-care coverage was associated with substantial reductions in post-neonatal mortality rates (rate ratio [RR] 0·72, 95% CI 0·71-0·74), toddler (ie, aged between 1 year and <5 years) mortality rates (0·75, 0·73-0·76), and under-5 mortality rates (0·81, 0·80-0·82), preventing 305 890 (95% CI 251 826-360 517) deaths of children younger than 5 years over the period 2000-19. High primary health-care coverage was also associated with lower under-5 mortality rates from nutritional deficiencies (RR 0·55, 95% CI 0·52-0·58), anaemia (0·64, 0·57-0·72), vaccine-preventable and vaccine-sensitive conditions (0·70, 0·68-0·72), and infectious gastroenteritis (0·78, 0·73-0·84). Considering a scenario of moderate economic crisis, a mitigation response strategy implemented in the period 2020-30 that increases primary health-care coverage could reduce the under-5 mortality rate by up to 23% (RR 0·77, 95% CI 0·72-0·84) when compared with a fiscal austerity response, and this strategy would avoid 142 285 (95% CI 120 217-164 378) child deaths by 2030 in Brazil, Colombia, Ecuador, and Mexico.

INTERPRETATION

The improvement in primary health-care coverage in Brazil, Colombia, Ecuador, and Mexico over the past two decades has substantially contributed to improving child survival. Expansion of primary health-care coverage should be considered an effective strategy to mitigate the health effects of the current economic crisis and to achieve Sustainable Development Goals related to child health.

FUNDING

UK Medical Research Council.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Assessing the efficacy of the ovicidal fungus Mucor circinelloides in reducing coccidia parasitism in peacocks

The biological control of gastrointestinal (GI) parasites using predatory fungi has been recently proposed as an accurate and sustainable approach in birds. The current study aimed to assess for the first time the efficacy of using the native ovicidal fungus Mucor circinelloides (FMV-FR1) in reducing coccidia parasitism in peacocks. For this purpose, an in vivo trial was designed in the resident peacock collection (n = 58 birds) of the São Jorge Castle, at Lisbon, Portugal. These animals presented an initial severe infection by coccidia of the genus Eimeria (20106 ± 8034 oocysts per gram of feces, OPG), and thus received commercial feed enriched with a M. circinelloides suspension (1.01 × 108 spores/kg feed), thrice-weekly. Fresh feces were collected every 15 days to calculate the coccidia shedding, using the Mini-FLOTAC technique. The same bird flock served simultaneously as control (t0 days) and test groups (t15-t90 days). The average Eimeria sp. shedding in peacocks decreased up to 92% following fungal administrations, with significant reduction efficacies of 78% (p = 0.004) and 92% (p = 0.012) after 45 and 60 days, respectively. Results from this study suggest that the administration of M. circinelloides spores to birds is an accurate solution to reduce their coccidia parasitism.

Analyzing the safety of the parasiticide fungus Mucor circinelloides: first insights on its virulence profile and interactions with the avian gut microbial community

Parasiticide fungi are considered an accurate, sustainable, and safe solution for the biocontrol of animal gastrointestinal (GI) parasites. This research provides an initial characterization of the virulence of the native parasiticide fungus Mucor circinelloides (FMV-FR1) and an assessment of its impact on birds' gut microbes. The genome of this fungus was sequenced to identify the genes coding for virulence factors. Also, this fungus was checked for the phenotypic expression of proteinase, lecithinase, DNase, gelatinase, hemolysin, and biofilm production. Finally, an in vivo trial was developed based on feeding M. circinelloides spores to laying hens and peacocks three times a week. Bird feces were collected for 3 months, with total genomic DNA being extracted and subjected to long-read 16S and 25S-28S sequencing. Genes coding for an iron permease (FTR1), iron receptors (FOB1 and FOB2), ADP-ribosylation factors (ARFs) (ARF2 and ARF6), and a GTPase (CDC42) were identified in this M. circinelloides genome. Also, this fungus was positive only for lecithinase activity. The field trial revealed a fecal microbiome dominated by Firmicutes and Proteobacteria in laying hens, and Firmicutes and Bacteroidetes in peacocks, whereas the fecal mycobiome of both bird species was mainly composed of Ascomycetes and Basidiomycetes fungi. Bacterial and fungal alpha-diversities did not differ between sampling time points after M. circinelloides administrations (P = 0.62 and P = 0.15, respectively). Although findings from this research suggest the lack of virulence of this M. circinelloides parasiticide isolate, more complementary in vitro and in vivo research is needed to conclude about the safety of its administration to birds, aiming at controlling their GI parasites.IMPORTANCEA previous study revealed that the native Mucor circinelloides isolate (FMV-FR1) can develop parasiticide activity toward coccidia oocysts, one of the most pathogenic GI parasites in birds. However, ensuring its safety for birds is of utmost importance, namely by studying its virulence profile and potential effect on commensal gut microbes. This initial study revealed that although this M. circinelloides isolate had genes coding for four types of virulence factors-iron permease, iron receptors, ADP-ribosylation factors, and GTPase-and only expressed phenotypically the enzyme lecithinase, the administration of its spores to laying hens and peacocks did not interfere with the abundances and diversities of their gut commensal bacteria and fungi. Although overall results suggest the lack of virulence of this M. circinelloides isolate, more complementary research is needed to conclude about the safety of its administration to birds in the scope of parasite biocontrol programs.

Understanding the social determinants of child mortality in Latin America over the last two decades: a machine learning approach

The reduction of child mortality rates remains a significant global public health challenge, particularly in regions with high levels of inequality such as Latin America. We used machine learning (ML) algorithms to explore the relationship between social determinants and child under-5 mortality rates (U5MR) in Brazil, Ecuador, and Mexico over two decades. We created a municipal-level cohort from 2000 to 2019 and trained a random forest model (RF) to estimate the relative importance of social determinants in predicting U5MR. We conducted a sensitivity analysis training two more ML models and presenting the mean square error, root mean square error, and median absolute deviation. Our findings indicate that poverty, illiteracy, and the Gini index were the most important variables for predicting U5MR according to the RF. Furthermore, non-linear relationships were found mainly for Gini index and U5MR. Our study suggests that long-term public policies to reduce U5MR in Latin America should focus on reducing poverty, illiteracy, and socioeconomic inequalities. This research provides important insights into the relationships between social determinants and child mortality rates in Latin America. The use of ML algorithms, combined with large longitudinal data, allowed us to evaluate the effects of social determinants on health more carefully than traditional models.

Evaluation and Forecasting Analysis of the Association of Conditional Cash Transfer With Child Mortality in Latin America, 2000-2030

Importance

Latin America has implemented the world's largest and most consolidated conditional cash transfer (CCT) programs during the last 2 decades. As a consequence of the COVID-19 pandemic, poverty rates have markedly increased, and a large number of newly low-income individuals, especially children, have been left unprotected.

Objective

To evaluate the association of CCT programs with child health in Latin American countries during the last 2 decades and forecast child mortality trends up to 2030 according to CCT alternative implementation options.

Design, Setting, and Participants

This cohort study used a multicountry, longitudinal, ecological design with multivariable negative binomial regression models, which were adjusted for all relevant demographic, socioeconomic, and health care variables, integrating the retrospective impact evaluations from January 1, 2000, to December 31, 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. The study cohort included 4882 municipalities from Brazil, Ecuador, and Mexico with adequate quality of civil registration and vital statistics according to a validated multidimensional criterion. Data analysis was performed from September 2022 to February 2023.

Exposure

Conditional cash transfer coverage of the target (lowest-income) population categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%).

Main Outcomes and Measures

The main outcomes were mortality rates for those younger than 5 years and hospitalization rates (per 1000 live births), overall and by poverty-related causes (diarrheal, malnutrition, tuberculosis, malaria, lower respiratory tract infections, and HIV/AIDS), and the mortality rates for those younger than 5 years by age groups, namely, neonatal (0-28 days), postneonatal (28 days to 1 year), infant (<1 year), and toddler (1-4 years).

Results

The retrospective analysis included 4882 municipalities. During the study period of January 1, 2000, to December 31, 2019, mortality in Brazil, Ecuador, and Mexico decreased by 7.8% in children and 6.5% in infants, and an increase in coverage of CCT programs of 76.8% was observed in these Latin American countries. Conditional cash transfer programs were associated with significant reductions of mortality rates in those younger than 5 years (rate ratio [RR], 0.76; 95% CI, 0.75-0.76), having prevented 738 919 (95% CI, 695 641-782 104) child deaths during this period. The association of highest coverage of CCT programs was stronger with poverty-related diseases, such as malnutrition (RR, 0.33; 95% CI, 0.31-0.35), diarrhea (RR, 0.41; 95% CI, 0.40-0.43), lower respiratory tract infections (RR, 0.66, 95% CI, 0.65-0.68), malaria (RR, 0.76; 95% CI, 0.63-0.93), tuberculosis (RR, 0.62; 95% CI, 0.48-0.79), and HIV/AIDS (RR, 0.32; 95% CI, 0.28-0.37). Several sensitivity and triangulation analyses confirmed the robustness of the results. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of CCTs to protect those newly in poverty could reduce the mortality rate for those younger than 5 years by up to 17% (RR, 0.83; 95% CI, 0.80-0.85) and prevent 153 601 (95% CI, 127 441-180 600) child deaths by 2030 in Brazil, Ecuador, and Mexico.

Conclusions and Relevance

The results of this cohort study suggest that the expansion of CCT programs could strongly reduce childhood hospitalization and mortality in Latin America and should be considered an effective strategy to mitigate the health impact of the current global economic crisis in low- and middle-income countries.

Isolation of saprophytic filamentous fungi from avian fecal samples and assessment of its predatory activity on coccidian oocysts

Fungal strains used in the biocontrol of animal gastrointestinal parasites have been mainly isolated from pasture soil, decaying organic matter, and feces from herbivores and carnivores. However, their isolation from birds and assessment of predatory activity against avian GI parasites has been scarce thus far. This research aimed to isolate filamentous fungi from avian fecal samples and evaluate their predatory activity against coccidia. A pool of 58 fecal samples from chickens, laying hens, and peacocks, previously collected between July 2020-April 2021, were used for isolation of filamentous fungi and assessment of their in vitro predatory activity against coccidian oocysts, using Water-Agar medium and coprocultures. The Willis-flotation technique was also performed to obtain concentrated suspensions of oocysts. A total of seven Mucor isolates was obtained, being the only fungal taxa identified, and all presented lytic activity against coccidia. Isolates FR3, QP2 and SJ1 had significant coccidiostatic efficacies (inhibition of sporulation) higher than 70%, while isolates FR1, QP2 and QP1 had coccidicidal efficacies (destruction of the oocysts) of 22%, 14% and 8%, respectively, after 14 days of incubation, being a gradual and time-dependent process. To our knowledge, this is the first report regarding the isolation of native predatory fungi from avian feces and demonstration of their lytic activity against coccidia.

Exploring the prevalence and antibiotic resistance profile of Klebsiella pneumoniae and Klebsiella oxytoca isolated from clinically ill companion animals from North of Portugal

Klebsiella spp. is an important pathogen in humans and animals and due to the indiscriminate use of antibiotics, its prevalence and antibiotic resistance has increased in companion animals. The main goal of this study was to investigate the prevalence and antibiotic resistance of Klebsiella spp. isolated from clinically ill cats and dogs admitted in veterinary clinics in the North of Portugal. A total of 255 clinical specimens were collected and, after isolation, the identification of Klebsiella strains was performed using the BBL Crystal™ identification system and confirmed by PCR-based sequencing with specific primers. Antibiotic resistance profile was determined through the disc diffusion method. Beta-lactam resistance genes were screened through a multiplex PCR assay. Fifty Klebsiella strains were isolated and, 39 were identified as Klebsiella pneumoniae and 11 as Klebsiella oxytoca. Thirty-one were recovered from dogs and 19 from cats. The Klebsiella isolates were recovered mainly from skin wounds, respiratory tract, and from urine. Fifty percent of K. oxytoca and K. pneumoniae isolates revealed to be Multidrug Resistant (MDR) strains, with most of them positive for the presence of blaTEM-like and blaSHV genes. This data shows that MDR Klebsiella are highly disseminated in companion animals and that extended-spectrum beta-lactamases can be easily found among these isolates. This highlights the potential role of dogs and cats as a reservoir of resistant Klebsiella spp. that have the potential to be transmitted to humans.

Extracellular Vesicles as Potential Therapeutic Messengers in Cancer Management

A deeper understanding of the communication mechanisms of tumor cells in a tumor microenvironment can improve the development of new therapeutic solutions, leading to a more personalized approach. Recently, the field of extracellular vesicles (EVs) has drawn attention due to their key role in intercellular communication. EVs are nano-sized lipid bilayer vesicles that are secreted by all types of cells and can function as intermediators of intercellular communication with the ability to transfer different cargo (proteins, nucleic acids, sugar…) types among cells. This role of EVs is essential in a cancer context as it can affect tumor promotion and progression and contribute to the pre-metastatic niche establishment. Therefore, scientists from basic, translational, and clinical research areas are currently researching EVs with great expectations due to their potential to be used as clinical biomarkers, which are useful for disease diagnosis, prognosis, patient follow-up, or even as vehicles for drug delivery due to their natural carrier nature. The application of EVs presents numerous advantages as drug delivery vehicles, namely their capacity to overcome natural barriers, their inherent cell-targeting properties, and their stability in the circulation. In this review, we highlight the distinctive features of EVs, their application as efficient drug delivery systems, and their clinical applications.

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

Micromorphology and Chemical Studies on Anacardium occidentale L. Stem Bark as an Herbal Medicine

The red and white types of Anacardium occidentale L. stem barks (AoB) are used in the Community of Portuguese Language Countries, including Portugal, to make traditional herbal preparations for the treatment of diabetes. This work aims to obtain the macroscopic, micromorphological, chemical, and purity data necessary to use both types of AoBs as medicinal plants safely. Macroscopically, a brown inner (red AoB) or a dark-brown inner surface (white AoB) was observed. Light and scanning electron microscopy showed that sclereid cells with thin cell walls were significantly larger (p < 0.001) in red AoB than in white AoB, but calcium oxalate druses and starch grain areas were significantly larger (p < 0.001) in white AoB than in red AoB. The chromatographic profiles (thin-layer chromatography and high-performance liquid chromatography) of both types of AoBs were characterized by the presence of gallic and protocatechuic acids and other phenolic derivatives. The condensed tannins were the major secondary metabolites class (143.69 ± 4.67 mg and 73.79 ± 4.46 mg catechin equivalents/g AoB in red and white types, respectively). The loss on drying and the total ash were, respectively, 7.07 ± 0.16% and 2.31 ± 0.18% in red AoB and 6.58 ± 0.16% and 1.94 ± 0.14% in white AoB. The obtained data are helpful in ensuring the quality of AoB as raw material for the pharmaceutical market.

Occurrence of polycyclic aromatic hydrocarbons, microplastics and biofilms in Alqueva surface water at touristic spots

Freshwater pollution is a huge concern. A study aiming to evaluate physico-chemical characteristics, microbiota, occurrence of two groups of persistent environmental pollutants with similar chemical properties (polycyclic aromatic hydrocarbons- PAHs and microplastics - MPs) in Alqueva's surface water was performed during 2021. Water samples were collected at three spots related to touristic activities (two beaches and one marina) during the Winter, Spring, Summer and Autumn seasons. In addition, the presence of biofilms on plastic and natural materials (stone, wood/ vegetal materials) were assessed and compared. Water quality based on physicochemical parameters was acceptable with a low eutrophication level. PAHs concentration levels were lower than the standard limits established for surface waters by international organizations. However, carcinogenic compounds were detected in two sampling locations, which can pose a problem for aquatic ecosystems. PAHs profiles showed significant differences when comparing the dry seasons with the rainy seasons, with a higher number of different compounds detected in Spring. Low molecular weigh compounds, usually associated with the atmospheric deposition and petroleum contamination, were more prevalent. MPs were detected in all samples except one during the Winter season. The polymers detected were poly(methyl-2-methylpropenoate), polystyrene, polyethylene terephthalate, polyamide, polypropylene, styrene butadiene, polyvinyl chloride and low /high density polyethylene with the last being the most frequent. Biofilms were more often detected on plastics than on natural materials. In addition, biofilms detected on plastics were more complex with higher microbial diversity (e.g., bacteria, fungi/yeast and phytoplancton organisms) and richer in extrapolymeric material. Based on morphological analysis a good agreement between microbiota and microorganism present in the biofilms was found. Among microbiota were identified microorganisms previously linked to plastic and PAHs detoxification suggesting the need for further studies to evaluate the viability of using biofilms as part of a green bioremediation strategy to mitigate water pollution.

Acceptance and Commitment Therapy for Psychosis. What’s the evidence?

Introduction

Cognitive behavioural therapy for psychosis as an adjuvant to pharmacological treatment has been been shown to be one of the most effective interventions for schizophrenia with benefits noted in even treatment resistant schizophrenia. Benefits have been mostly registered in the positive symptoms domain of schizophrenia. Acceptance and commitment therapy is a third generation Cognitive-Behavioural Therapy, empirically supported for a range of symptoms and conditions, including psychosis, with quickly increasing data. It targets experiential avoidance, which seems to be closely related with psychopathology. Its ability to also target affective symptoms can be an important advantage in the adjuvant treatment of psychosis.

Objectives

To critically review the evidence of acceptance and commitment therapy in psychosis.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “schizophrenia”, “acceptance and commitment therapy”.

Results

Very few studies have been published on ACT and psychosis, with even less controlled trials and systematic reviews. So far there is convincing evidence for ACT reducing the frequency of hallucinations, increasing the outcomes of traumatic events associated with psychosis and having measurable effects on anxiety and help seeking behaviour.

Conclusions

As Acceptance and Commitment therapy evolves and more evidence arises a new kind of therapy with possible effects on both affective and positive symptoms in schizophrenia can emerge, allowing us to know what works for patients with psychosis and through what mechanisms and permitting the improvement of treatment strategies.

Disclosure

No significant relationships.

AB0067 INTERLEUKIN-1 RECEPTOR ANTAGONIST: RELATION TO CARDIOVASCULAR DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

The interleukin-1 receptor antagonist (IL1-Ra) belongs to the IL-1 family. IL1-Ra has an inhibitory function on the inflammatory reaction consisting of preventing the binding of IL-1α and β to their respective receptors. IL-1, in its different subtypes, has been implicated in the pathogenesis of both rheumatoid arthritis (RA) and cardiovascular disease (CV) in the general population.

Objectives

In the present work we aim to study the relation of IL1-Ra serum levels to RA’s features, and its CV comorbidity and subclinical carotid atheromatosis in a large RA cohort.

Methods

This was a cross-sectional study that included 430 RA patients. A complete panel of clinical and analytical information related to CV disease was collected: CV risk factors, full lipid profile, insulin and C-peptide serum levels, insulin resistance and β-cell function (%B) indexes by Homeostatic Model Assessment (HOMA2). A carotid ultrasound examination was performed to assess carotid intima-media thickness in the common carotid artery and to detect focal plaque in the extracranial carotid tree. Similarly, IL1Ra and IL-6 serum levels were assessed and disease activity indices, extra-articular manifestations and RA therapies were collected. A multivariable regression analysis was performed to determine how IL1Ra serum levels is associated with disease-related characteristics, CV comorbidity and subclinical atheromatosis in RA patients.

Results

Regarding CV risk factors, IL1-Ra serum levels were related with waist circumference (coefficient beta -β- 8 [95% confidence interval -CI- 5-11] pg/ml, p< 0.001) and obesity (body mass index >= 30 kg/m2) (β 169 [95% CI 78-260] pg/ml, p<0.001). After adjusting for confounders, IL1-Ra was related with higher levels of several lipid profile molecules, such as total cholesterol (β 12 [95%CI 2-22] mg/dl, p= 0.023), apolipoprotein A1 (β 13 [95% CI 0.5-25] mg/dl, p=0.042) and apolipoprotein C3 (β 3 [95% CI 2-5] mg/dl, p<0.001). Furthermore, higher IL1-Ra serum levels were associated with pancreatic beta cell dysfunction as measured by HOMA2-%B (β 22 [95%CI 2-42], p=0.031). Disease activity using different scores showed a positive relationship with IL1-Ra after multivariable adjustment: DAS28-ESR (β 60 [95% CI 28-92] pg/ml, p<0.001), DAS28-PCR (β 65 [95%CI 26-104] pg/ml, p=0.001) and CDAI (β 99 [95%CI 3-14] pg/ml, p=0.002). Likewise, ESR (β 2 [95% CI 0.07-5] pg/ml, p=0.044) and IL-6 plasma levels (β 3 [95% CI 1-6] pg/ml, p=0.003) were positively associated with IL1-Ra levels after adjusting for covariates. Hydroxychloroquine use, but not other therapies, was associated with lower IL1-Ra serum levels (β -131 [95% CI -260- -2] pg/ml, p=0.046), independently of confounding variables. No association was found between IL1-Ra and intima-media thickness or carotid plaque.

Conclusion

In RA patients, IL1-Ra serum levels are related to the clinical and biological disease activity, as well as with different CV comorbidities such as dyslipidemia, beta cell dysfunction and obesity. Our findings highlight the beneficial effect that blocking IL-1 activity can have both in the control of RA disease activity and in the management of the CV disease that accompanies the disease.

Acknowledgements

This work was supported by a grant to JC Q-A. from the Fundación Canaria Instituto de Investigación Sanitaria de Canarias, PI19/00012.

Disclosure of Interests

None declared

Electroconvulsive therapy in treatment resistant schizophrenia: Old beacon of hope when nothing else works

Introduction

Electroconvulsive therapy (ECT) is one of the oldest psychiatric treatments used to this day. It is particularly useful in cases of schizophrenia resistant to treatment with antipsychotics. 49% of patients with schizophrenia experience little or no response with one trial of antipsychotics, 71% do not achieve remission and up to 20% of patients are also resistant to clozapine.

Objectives

Description of a clinical case where ECT is used in the treatment of resistant schizophrenia and review of the literature.

Methods

Description of a clinical case. Non systematic review of the literature, searching the terms “treatment resistant”; “schizophrenia”; “ect” in the databases Pubmed, Medline, Cochrane and Uptodate.

Results

Male, 38-year-old patient, diagnosed with schizophrenia for 20 years, with history of multiple hospitalizations, institutionalized for 9 years. Treated with risperidone 50 mg intramuscular fortnightly, clozapine 750 mg daily, aripiprazol 30 mg daily and diazepam 10 mg daily. He presented with increased delusional intensity for a year. Hospitalized for treatment with ECT, submitted to 12 sessions with bitemporal stimuli, with effective convulsions. MoCA, PANSS and BPRS were applied before and after treatment, with an increase of 25% in MoCA and a decrease of 47.3% and 57.9% respectively, in the psychotic symptoms scales.

Conclusions

We present a case of schizophrenia resistant to treatment with multiple antipsychotics, including clozapine. ECT was used, with clinically demonstrated efficacy. In the future, it might be interesting to study in detail the mechanism of action of this treatment with the goal of deepening the knowledge of the neurobiology of schizophrenia.

Disclosure

No significant relationships.

Electroconvulsive therapy for Patients with Intellectual Disability. When and how?

Introduction

Intelectual disability is an illness with an important burden on patients and caregivers, especially when severe and when comorbidities such as other psychiatric disorders are present. There are case reports of treatment resistant self-aggression, agitation, epilepsy, catatonia and psychosis successfully treated with electroconvulsive therapy although controlled studies were not found.

Objectives

This work reviewed the current evidence for the use of electroconvulsive therapy in the management of patients with intellectual disability as well as its ethical and methodological implications.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 20 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “electroconvulsive therapy”, “intellectual disability”.

Results

Patients with intellectual disability can have incapacitating comorbilities that greatly impair quality of life, and may require withdrawl from the community Treatment often differs from the general population as psychotropic medication can worsen other comorbilities. Electroconvulsive therapy can be a relevant treatment option for comorbidities in this population due to its safety profile. Ethical considerations should be taken into account, especially with non-verbal patients or when adequate representatives have not been chosen or cannot be reached. Different legal challenges may be present on different countries.

Conclusions

Electroconvulsive therapy and intellectual disability share the burdens of heavy stigma and low investment. Intellectual disability and it’s commorbidites present both a diagnostic and treatment challenge. Electroconvulsive therapy is an important weapon capable of restoring patients to their families and diminishing the burdens of caregivers and healthcare systems

Disclosure

No significant relationships.

POS0003 DEVELOPMENT AND VALIDATION OF A DISEASE SPECIFIC PATIENT REPORTED OUTCOME FOR GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is caused by inflammation of the blood vessels of the head and neck; patients can present with cranial, ocular or large vessel vasculitis involvement. Treatment is with glucocorticoids, steroid sparing agents and biologics to control inflammation and protect sight.

Objectives

The aim of this study was to produce a validated disease specific PROM for patients with GCA, to capture the impact of GCA and its treatment on health-related quality of life.

Methods

Patients with clinician- confirmed GCA from the UK, either diagnosed in the last three years or with a flare in the last year, were included in the survey. A longlist of 40 candidate questionnaire items, each with a 5-point Likert scale, had previously been developed, based on a qualitative study with patients from the UK and Australia [1]. In this cross-sectional survey, patients completed the 40-item draft GCA-PROM alongside EQ5D-5L, CAT-PRO5 and self-report of GCA disease activity. Rasch and factor analysis were used in an iterative manner to determine the underlying construct validity of the new PROM. Items were fitted to the Rasch model to determine its construct validity, reliability, unidimensionality and statistical sufficiency of the total score from the scale. Factor analysis was used to establishing factor structure. Item reduction decisions were be based on clinical importance, lack of fit to the Rasch model, and redundancy detected during principal component analysis. External validity was tested by comparing the scores of the newly validated GCA-PROM (i) in participants who self-identify as having ‘active disease’ versus patients ‘in remission’ (known groups validity) (ii) with scores derived from EQ5D-5L and CAT-PRO5 (convergent validity).

Results

The survey included 428 patients; 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. 285 (67%) of participants were female with a mean age (SD) of 74.2 (7.2). 167 (39%) temporal artery biopsies and 177 (41.4%) temporal artery ultrasounds, and 51 (11.9%) Positron Emission Tomography and Computed Tomography (PET-CT)s were reported as positive. 108 (25%) received second-line immunosuppressants, and 34 (7.9%) anti-IL6 therapy. Active disease was reported in 197 (46%). Four factors (domains) were identified after deletion of 10 redundant items: Acute symptoms (8 items), Activities of daily living (7 items), Psychological (7 items) and Participation (8 items). The four domains were analysed as ‘super-items’ and shown to fit the Rasch model. The overall scale had an adequate fit to the Rasch model: X2 = 25.219, DF=24, p=0.394 including reliability PSI=0.828. The raw-to-linear transformation scale was calibrated to enable parametric analyses if desired. Each domain was shown to have known-groups validity (p<0.001 patients reporting active versus inactive disease) and correlation with EQ5D-5L and CAT-PRO5 (Rs) ranging between 0.4.42 and 0.778.

Conclusion

The GCA-PROM is a new patient reported outcome measure for patients with GCA which demonstrates good internal and external validity.

References

[1]Robson JC, Almeida C, Dawson J, Bromhead A, Dures E, Guly C, Hoon E, Mackie S, Ndosi M, Pauling J, Hill C. Patient perceptions of health-related quality of life in giant cell arteritis; international development of a disease-specific Patient-Reported Outcome Measure. Rheumatology (Oxford). 2021:keab076. http://dx.doi.org/10.1093/rheumatology/keab076

Disclosure of Interests

Joanna Robson Speakers bureau: Vifor Pharma EULAR 2021 Symposium, Consultant of: Vifor Pharma Advisory board 2021, Grant/research support from: Vifor Pharma Steroid PRO grant, Celia Almeida: None declared, Jill Dawson: None declared, Emma Dures: None declared, Rosemary Greenwood: None declared, Catherine Guly: None declared, Sarah Mackie Speakers bureau: Roche/Chugai Educational talk on GCA., Consultant of: Roche/Chugai

Sanofi

Abbvie (2021-)

AstraZeneca (2021-), Grant/research support from: Vifor Pharma Steroid PRO 2020

Vifor Pharma GTI Validation 2020

Roche GCA Tocilizumab Registry 2019

, Alison Bromhead: None declared, Steve Stern: None declared, Mwidimi Ndosi: None declared

Shame and psychopathology. Its role in the genesis and perpetuation of different disorders

Introduction

Shame is a profound negative emotion that can sometimes be cover up by guilt and remain undiagnosed. Shame and guilt have been described as self-conscious and moral emotions as they both involve self-evaluation and lay a role in facilitating moral conduct. They derive from the notion of responsibility, but some authors suggest that while guilt focuses only on the act at hand shame focuses on the one executing it. The self is the object.

Objectives

To review the literature on shame and its role in different disorders both as a causing agent and as a perpetuating agent

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 20 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “shame”, “psychopathology.

Results

Since shame globally decreases self-esteem and is an awareness of personal flaws it can lead to the feelings of helplessness and the development or worsening of mental disorders. As such it is no wonder to find shame being studied in many different forms, more and less structured with important connections being made with social anxiety, eating disorders, dysmorphic disorders, personality disorders and bereavement.

Conclusions

Shame’s role, independently from guilt can have an impact on both the genesis and perpetuation of mental disorders. Its study can uncover missing links between different types of experiences and the pathological reactions that may subsequently follow.

Disclosure

No significant relationships.

POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

Electroconvulsive therapy for Depression in Anorexia Nervosa. A review

Introduction

Anorexia nervosa has an important burden on both patients and families, with important comorbidities such as depression and obsessive symptoms. These are more resistant to pharmacological treatment than in non-anorexia patients, due to both biological and psychological mechanisms. Electroconvulsive therapy is the best available therapy for treatment resistant depression making it a treatment to consider in treatment resistant depression in anorexia though only case reports exist.

Objectives

To review the current evidence for electroconvulsive therapy of depression in patients with anorexia nervosa as well as it’s ethical challenges

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “electroconvulsive therapy”, “anorexia nervosa”.

Results

Electroconvulsive therapy in anorexia has no controlled trials with mostly case reports available on scientific databases. It presents important challenges due to patient age, medical status and ethical challenges. Even less evidence exist for electroconvulsive therapy in children and adolescents than for adults, anorexia can complicate medical status presenting an anesthetic and life-support challenge and it’s egosyntonicity can place a legal and ethical challenge when patient refuses treatment.

Conclusions

Anorexia has a dramatic burden on patients and families affected, with integrated evidence-based treatment being necessary both for treating the current episode and for remission prevention. Case-reports show that electroconvulsive therapy can play a role on treatment resistant depression in anorexia.

Disclosure

No significant relationships.

Extracellular Vesicles Derived-LAT1 mRNA as a Powerful Inducer of Colorectal Cancer Aggressive Phenotype

Colorectal cancer (CRC) is the third most common cancer in the world and represents the third most deadly tumor worldwide. About 15–25% of patients present metastasis in the moment of diagnosis, the liver being the most common site of metastization. Therefore, the development of new therapeutic agents is needed, to improve the patients’ prognosis. Amino acids transporters, LAT1 and ASCT2, are described as upregulated in CRC, being associated with a poor prognosis. Extracellular vesicles have emerged as key players in cell-to-cell communication due to their ability to transfer biomolecules between cells, with a phenotypic impact on the recipient cells. Thus, this study analyzes the presence of LAT1 and ASCT2 mRNAs in CRC-EVs and evaluates their role in phenotype modulation in a panel of four recipient cell lines (HCA-7, HEPG-2, SK-HEP-1, HKC-8). We found that HCT 116-EVs carry LAT1, ASCT2 and other oncogenic mRNAs being taken up by recipient cells. Moreover, the HCT 116-EVs’ internalization was associated with the increase of LAT1 mRNA in SK-HEP-1 cells. We also observed that HCT 116-EVs induce a higher cell migration capacity and proliferation of SK-HEP-1 and HKC-8 cells. The present study supports the LAT1-EVs’ mRNA involvement in cell phenotype modulation, conferring advantages in cell migration and proliferation.

SCORE2 Assessment in the Calculation of Cardiovascular Risk in Patients with Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) are at increased risk for cardiovascular disease (CVD). Risk chart algorithms, such as the Systematic Coronary Risk Assessment (SCORE), often underestimate the risk of CVD in patients with RA. In this sense, the use of noninvasive tools, such as the carotid ultrasound, has made it possible to identify RA patients at high risk of CVD who had subclinical atherosclerosis disease and who had been included in the low or moderate CVD risk categories when the SCORE risk tables were applied. The 2003 SCORE calculator was recently updated to a new prediction model: SCORE2. This new algorithm improves the identification of individuals from the general population at high risk of developing CVD in Europe. Our objective was to compare the predictive capacity between the original SCORE and the new SCORE2 to identify RA patients with subclinical atherosclerosis and, consequently, high risk of CVD. 1168 non-diabetic patients with RA and age > 40 years were recruited. Subclinical atherosclerosis was searched for by carotid ultrasound. The presence of carotid plaque and the carotid intima media wall thickness (cIMT) were evaluated. SCORE and SCORE2 were also calculated. The relationships of SCORE and SCORE2 to each other and to the presence of subclinical carotid atherosclerosis were studied. The correlation between SCORE and SCORE2 was found to be high in patients with RA (Spearman’s Rho = 0.961, p < 0.001). Both SCORE (Spearman’s Rho = 0.524) and SCORE2 (Spearman’s Rho = 0.521) were similarly correlated with cIMT (p = 0.92). Likewise, both calculators showed significant and comparable discriminations for the presence of carotid plaque: SCORE AUC 0.781 (95%CI 0.755–0.807) and SCORE2 AUC 0.774 (95%CI 0.748–0.801). Using SCORE, 80% and 20% of the patients were in the low or moderate and high or very high CVD risk categories, respectively. However, when the same categories were evaluated using SCORE2, the percentages were different (58% and 42%, respectively). Consequently, the number of RA patients included in the high or very high CVD risk categories was significantly higher with SCORE2 compared to the original SCORE. (p < 0.001). In conclusion, although predictive capacity for the presence of carotid plaque is equivalent between SCORE and SCORE2, SCORE2 identifies a significantly higher proportion of patients with RA who are at high or very high risk of CVD.

Non-ST elevation myocardial infarction in patients with previous CABG: what is the best treatment option?

Background

Current European Society of Cardiology guidelines recommend an invasive strategy (IS) for the treatment of non-ST elevation myocardial infarction (NSTEMI) patients, but the clinical trials that support this recommendations included only a few patients with previous coronary artery bypass graft (CABG).

Purpose

To characterize NSTEMI patients with previous CABG who underwent medical and invasive management and to evaluate the prognostic impact of the type of strategy used.

Methods

Retrospective analysis of a cohort of patients from a multicenter national registry diagnosed with NSTEMI with a previous history of CABG between 2010 and 2021. Patient's baseline demographics, medical history and in-hospital management data was collected. Outcomes of in-hospital and six months follow-up all-cause mortality were accessed.

Results

A total of 890 patients were included in the analysis. Of these, 470 were medically managed (MM) – this group included 249 patients (53.1%) who underwent coronary angiography but did not perform any further revascularization. The remaining 420 underwent an invasive strategy (IS) and performed additional revascularization, mainly percutaneous (only 1 patient submitted to reCABG). Mean age was similar (MM 72±10 vs IS 71±10 years, p=0.147) and most patients were male (MM 81.5% vs IS 83.8%, p=0.362). MM patients had more chronic kidney disease (16.7% vs 9.9%, p=0.003), peripheral artery disease (20.5% vs 15.0%, p=0.003) and heart failure (20.5% vs 11.9%, p&lt;0.001). Main presenting symptom was chest pain in both groups, however it was more frequent in the IS group (89.4% vs 94.5%, p=0.006) and dyspnea in the MM patients (6.3% vs 3.1%). Mean left ventricle ejection fraction was similar between groups (MM 49±12% vs IS 50±11%, p=0.290). Although the GRACE risk score was available for only 124 patients, high risk patients (GRACE score &gt;140) were equally distributed among the two groups (55.9% vs 48.2%, p=0.395). An IS was associated with significant lower in-hospital mortality (4.5% vs 1.7%, OR 0.37, 95% CI 0.15–0.87, p=0.018). At six months follow-up an IS was also associated with lower mortality (6.6% vs 2.4%, HR 0.18, 95% CI 0.06–0.52, p=0.002), even after adjusting for the baseline differences (HR 0.41, 95% CI 0.20–0.85, p=0.016).

Conclusions

In this cohort of patients with NSTEMI and previous CABG, an IS was linked to better outcomes during hospitalization and during six months follow-up. Randomized clinical trials are needed to address this issue.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Early and long term prognostic accuracy of 4 acute pulmonary embolism mortality risk scores

Background

Acute pulmonary embolism (PE) is a frequent condition associated with significant morbidity and mortality. Multiple scores have been developed and validated to predict 30-day mortality risk, however accurate prognostic assessment remains a challenge in clinical practice.

Purpose

To compare the performance of PESI, simplified PESI, Hestia and Bova scores in predicting in-hospital, 30-day and 1-year mortality risk for acute PE.

Methods

We retrospectively assessed consecutive patients from a single center registry who were hospitalized with acute PE between January 2017 and October 2020. Discriminative power of each score was assessed by receiver operating characteristic curve analysis. Charlson comorbidity index (CCI) was also assessed for comparison.

Results

A total of 131 patients with a mean age of 67.6±15.3 years were included with a mean follow-up of 46.3±17.7 months. Thirty-six patients (27.5%) had a recent hospitalization or major surgery and 26 (19.8%) a medical history of cancer. Besides anticoagulation, 7 patients (5.3%) underwent fibrinolysis. Overall in-hospital mortality was 8.4%, 30-day mortality 12.2% and 1-year mortality 19.8%. All acute PE scores, except Bova score, were significantly higher in those patients who died during hospitalization and on 30-day and 1-year follow-up. CCI was also higher in those patients. Discriminative power for in-hospital mortality was higher for PESI (c-statistic 0.84, 95% CI 0.74–0.93, p=0.002), followed by sPESI (c-statistic 0.77, 95% CI 0.65–0.90, p=0.010) and Hestia (c-statistic 0.77, 95% CI 0.61–0.92, p=0.011). The Bova score showed a poor discriminative power for prediction of in-hospital mortality (c-statistic 0.61, 95% CI 0.43–0.78, p=0.325). For 30-day and 1-year mortality PESI score still maintained the best performance with acceptable discriminative power (c-statistic 0.73, 95% CI 0.61–0.85, p=0.007 for 30-day mortality; c-statistic 0.80, 95% CI 0.71–0.89, p&lt;0.0001 for 1-year mortality). However at longer follow-up CCI had a better performance to predict worse outcomes (c-statistic 0.79, 95% CI 0.65–0.92, p=0.001 for 30-day mortality; c-statistic 0.83, 95% CI 0.74–0.92, p&lt;0.0001 for 1-year mortality).

Conclusions

All scores, except Bova score, showed overall good performance in stratifying mortality for acute PE, however PESI score performed better in this population particularly at shorter follow-up. At longer follow-up, although PESI score maintained an acceptable performance, comorbidities seem to play a bigger role. The different performance of multiple scores highlights the complexity of this condition.

Funding Acknowledgement

Type of funding sources: None. ROC curves for mortality risk scores

P–042 Impact of semen parameters, sperm DNA fragmentation and sperm aneuploidy in male infertility

Study question

Should sperm aneuploidies and sperm DNA fragmentation (sDNAfrag) be included as valid tests in the routine investigation of male infertility?

Summary answer

Sperm DNA fragmentation was associated with male age, oligozoospermia (OZ), oligoteratozoospermia (OT), astenoteratozoospermia (AT) and oligoastenoteratozoospermia (OAT). Sperm aneuploidies were associated with OT and OAT.

What is known already

Semen parameters assist male infertility diagnosis and treatment, but sDNAfrag and aneuploidy analysis could add useful information, as abnormal values compromise fertility. To include these tests in the routine diagnosis it should be determined if behave as informative parameter and add information regarding the fertility status. For that, further studies comparing these tests to semen parameters are needed, since previous results are not consensual. Additionally, standardization of a sDNAfrag cut-off is needed, as different sample sizes and techniques originate distinct results. Also, until a standardization of the protocol is missing, a cut-off value should be defined for each laboratory.

Study design, size, duration

A retrospective and prospective investigation was performed, within a 12 years period (April 2007-December 2019). A total of 835 infertile males with a normal karyotype (46,XY) were included. Karyotyping and evaluation of sDNAfrag and sperm aneuploidies were made at a public Genetic unit. All normozoospermic (NZ) patients with a born child and patients whose infertility treatments were done due to female factors were selected from our database and used as controls (60 individuals).

Participants/materials, setting, methods

Semen analysis followed WHO–2010 guidelines. sDNAfrag was evaluated using the TUNEL assay. Sperm aneuploidies were detected using FISH (chromosomes 13, 18, 21, X, Y). Several tests were applied: correlations for linear associations between numerical variables, ANOVA for comparisons between means, Dunn-test for post-hoc comparisons. To determine the sDNAfrag cut-off value, the area under the ROC curve, sensitivity and specificity, were calculated, with the Youden-Index used to find a threshold that maximizes both sensitivity and specificity.

Main results and the role of chance

Regarding male age, it was observed a positive correlation with sperm concentration, a negative correlation with sperm vitality (VT) and hypoosmolality, and a positive correlation with sDNAfrag. Regarding sDNAfrag, it was observed negative correlation with sperm concentration, total progressive motility (TPM), morphology, VT and hypoosmolality. Regarding sperm aneuploidies, both total sperm aneuploidy and total sperm disomy exhibited a negative association with sperm concentration, TPM and morphology. It was also investigated whose groups of individuals could be indicated for sDNAfrag or sperm aneuploidy testing. The NZ group evidenced significant lower sDNAfrag, total sperm aneuploidy and total sperm disomy in relation to the non-NZ group. In the NZ group, sDNAfrag was significantly lower in relation to the OZ, OT, AT and OAT groups. The NZ group presented significant lower percentages of sperm aneuploidy in relation to the OT and OAT groups, and significant lower percentages of sperm disomy in relation to the OAT group. Additionally, sDNAfrag was positively correlated with total sperm aneuploidy and total sperm disomy. From the present large population, ROC curve analysis allowed estimating a cut-off value of 18.8% for the TUNEL-assay (sDNAfrag), with 0.658 of area under the curve, 53.9% sensitivity and 76.7% specificity.

Limitations, reasons for caution

Although presenting a high number of cases and strict controls, the present study was unable to include as controls healthy men with proven fertility. Additionally, the present study did not take into account life-style factors and male associated pathologies besides infertility.

Wider implications of the findings: Semen parameters were shown to be negatively correlated with sDNAfrag and sperm aneuploidies. As sDNAfrag testing and sperm aneuploidy testing were associated with semen abnormalities and male age, it is suggested their inclusion in the routine evaluation of infertile men, thus adding important complementary information about the fertility status.

Trial registration number

Not Appliable

Bleuler’s a or autism spectrum disorder in adults?

Introduction

Nowadays we know that autism spectrum disorders (ASD) and Schizophrenic spectrum (SS) are different types of disorders in their etiology, symptoms and prognosis, but the clinical distinction is often difficult to make due to comorbidity and similar symptoms.

Objectives

With this project, the authors intend to explore the differential diagnosis between ASD and SS specially when we talk about critical ages of onset.

Methods

An analysis of articles searched on Pubmed (articles between 2010-2020) with the key words “adult autism”, “childhood onset schizophrenia”, “childhood psychosis”.

Results

Early-onset schizophrenia (EOS) is defined as occurring before age 18 years. The condition share key diagnostic symptoms with adult-onset schizophrenia (AOS) but his prognoses and comorbidities differ. Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterized by difficulties since early childhood across reciprocal social communication and restricted interests and behaviors. ASD is a lifelong neurodevelopmental disorder, however there is a lack of answers and research for adults with ASD. There are shared aspects of odd thinking, rigid behaviors and impaired socialization in schizophrenia and ASD and COS seems to have a strong relationship with ASD, being comorbid in up to 50% of cases.

Conclusions

Usually the evaluation of the developmental history of the person, prodrome and onset, its course and the presence of positive symptoms of schizophrenia is enough to help us find a diagnosis. Unfortunately, in some ages the conclusion is not so easy to find. However is essential to determine whether the clinical manifestations belong to the autistic spectrum, the schizophrenic or result from comorbidity.

LAT1 and ASCT2 Related microRNAs as Potential New Therapeutic Agents against Colorectal Cancer Progression

The development and progression of colorectal cancer (CRC) have been associated with genetic and epigenetic alterations and more recently with changes in cell metabolism. Amino acid transporters are key players in tumor development, and it is described that tumor cells upregulate some AA transporters in order to support the increased amino acid (AA) intake to sustain the tumor additional needs for tumor growth and proliferation through the activation of several signaling pathways. LAT1 and ASCT2 are two AA transporters involved in the regulation of the mTOR pathway that has been reported as upregulated in CRC. Some attempts have been made in order to develop therapeutic approaches to target these AA transporters, however none have reached the clinical setting so far. MiRNA-based therapies have been gaining increasing attention from pharmaceutical companies and now several miRNA-based drugs are currently in clinical trials with promising results. In this review we combine a bioinformatic approach with a literature review in order to identify a miRNA profile with the potential to target both LAT1 and ASCT2 with potential to be used as a therapeutic approach against CRC.

SAT0076 VERY ELDERLY ONSET RHEUMATOID ARTHRITIS (VEORA): CLINICAL CHARACTERISTICS AND THERAPEUTIC IMPLICATIONS

Background:

There are differences in the characteristics of patients with Rheumatoid Arthritis (RA) depending on their age at onset with two traditional groups: YORA (young onset RA) and EORA (elderly onset RA). These aspects have not been studied in cases of very late onset (≥ 80 years)

Objectives:

To describe the clinical characteristics, treatments and evolution at one year in “very elderly onset RA” (VEORA). Compare these characteristics with YORA (40-50 years) and EORA (60-70 years).

Methods:

Retrospective and longitudinal study of RA patients from 2 spanish hospitals. From their databases, VEORA patients were identified and their clinical characteristics were analyzed at onset, treatments at diagnosis and in the first 12 months, as well as DAS28-ESR activity after 1 year. These variables were compared between cases belonging to one of the hospitals and 2 control groups of YORA and EORA patients of the same center, matched by sex, diagnosis date ± 2 years, RF and / or ACPA status and presence of erosions in baseline Rx.

Results:

A total of 2790 records of RA patients were analyzed, identifying 59 cases of onset in “very elderly” (2% of the total). Table 1 shows its clinical, analytical characteristics and treatments at diagnosis.

Table 1.

Demographic and clinical data of the 59 VEORA patients

n=59Female, n(%)43 (73)Age at onset, years83 ± 3ComorbidityHypertension, n(%)54 (92)Diabetes, n(%)19 (32)CV disease20 (34)Clinical and analytical data at diagnosisAcute onset, n(%)26 (44)Polyarticular onset, n(%)37 (63)Specific forms, n(%)21 (36)Polymyalgia Rheumatica, n16RS3PE, n5Rheumatoid factor, n(%)40 (68)ACPA, n(%)24 (41)DAS28-ESR5 (4,4-5,7)high activity, n(%)32 (54)First visit treatmentNSAIDs, n(%)5 (9)Steroids, n(%)55 (93)starting dose, mg/day*10 (7,5-15)DMARD, n(%)52 (88)Hidroxychloroquine14 (24)Methotrexate36 (61)starting dose, mg/week10 (7,5-10)Combined therapy5 (8)

DAS28-ESR and the number of patients in remission or low activity at one year showed no differences between EORA and VEORA, or between these groups and that of younger patients.

Elderly patients (EORA and VEORA), compared with YORA, presented with higher frequency hypertension and CV disease, higher elevation in acute phase reactants at the onset and disease activity at diagnosis. VEORA patients, compared to EORA, showed a higher frequency of dyslipidemia (p = 0.04). There were also no significant differences between VEORA and EORA in the distribution and type of joints affected, time to diagnosis, acute phase reactants or disease activity at the onset. A higher frequency of special forms (such as PMR or RS3PE) was close to statistical significance in the VEORA group (p = 0.054).

Regarding initial treatment, both EORA and VEORA received steroidal treatment more frequently and a lower dose of Methotrexate during the first year. Biological treatments was also significantly higher in YORA (p=0,000). When comparing VEORA and EORA, differences related to the use of NSAIDs were found, lower in VEORA (p = 0.000), as well as in the maximum dose of Methotrexate reached in the next 12 months, higher in the EORA group (p = 0.01). No differences in adverse events with DMARDs were observed.

Conclusion:

There have been few differences in the comorbidity profile and clinical characteristics at the onset between VEORA and EORA patients. Despite the differences observed in its management (more conservative in EORA and VEORA vs YORA, and in VEORA vs EORA), we have not observed differences in DAS28-ESR activity after one year.

Disclosure of Interests:

Alicia García Dorta: None declared, Cristina Almeida: None declared, Hernández Díaz Marta: None declared, Laur Cáceres Martín: None declared, Elisa Trujillo: None declared, Carlos Rodríguez-Lozano: None declared, Iván Ferraz-Amaro Grant/research support from: Pfizer, Abbvie, Speakers bureau: Pfizer, Abbvie, MSD., Juan Carlos Quevedo-Abeledo Speakers bureau: Abbvie

THU0136 VERY ELDERLY ONSET RHEUMATOID ARTHRITIS (VEORA): CLINICAL AND THERAPEUTIC IMPLICATIONS AFTER 80 YEARS

Background:

There are differences in the characteristics of patients with Rheumatoid Arthritis (RA) depending on their age at onset with two traditional groups: YORA (young onset RA) and EORA (elderly onset RA). These aspects have not been studied in cases of very late onset (≥ 80 years)

Objectives:

To describe the clinical characteristics, treatments and evolution at one year in “very elderly onset RA” (VEORA). Compare these characteristics with YORA (40-50 years) and EORA (60-70 years).

Methods:

Retrospective and longitudinal study of RA patients from 2 spanish hospitals. From their databases, VEORA patients were identified and their clinical characteristics were analyzed at onset, treatments at diagnosis and in the first 12 months, as well as DAS28-ESR activity after 1 year. These variables were compared between cases belonging to one of the hospitals and 2 control groups of YORA and EORA patients of the same center, matched by sex, diagnosis date ± 2 years, RF and / or ACPA status and presence of erosions in baseline Rx.

Results:

A total of 2790 records of RA patients were analyzed, identifying 59 cases of onset in “very elderly” (2% of the total). Table 1 shows its clinical, analytical characteristics and treatments at diagnosis.

Table 1.

Demographic and clinical data of the 59 VEORA patients

n=59Female, n(%)43 (73)Age at onset, years83 ± 3ComorbidityHypertension, n(%)54 (92)Diabetes, n(%)19 (32)CV disease20 (34)Clinical and analytical data at diagnosisAcute onset, n(%)26 (44)Polyarticular onset, n(%)37 (63)Specific forms, n(%)21 (36)Polymyalgia Rheumatica, n16RS3PE, n5Rheumatoid factor, n(%)40 (68)ACPA, n(%)24 (41)DAS28-ESR5 (4,4-5,7)high activity, n(%)32 (54)First visit treatmentNSAIDs, n(%)5 (9)Steroids, n(%)55 (93)starting dose, mg/day*10 (7,5-15)DMARD, n(%)52 (88)Hidroxychloroquine14 (24)Methotrexate36 (61)starting dose, mg/week10 (7,5-10)Combined therapy5 (8)

Elderly patients (EORA and VEORA), compared with YORA, presented with higher frequency hypertension and CV disease, higher elevation in acute phase reactants at the onset and disease activity at diagnosis. VEORA patients, compared to EORA, showed a higher frequency of dyslipidemia (p = 0.04). There were also no significant differences between VEORA and EORA in the distribution and type of joints affected, time to diagnosis, acute phase reactants or disease activity at the onset. A higher frequency of special forms (such as PMR or RS3PE) was close to statistical significance in the VEORA group (p = 0.054).

Regarding initial treatment, both EORA and VEORA received steroidal treatment more frequently and a lower dose of Methotrexate during the first year. Biological treatments was also significantly higher in YORA (p=0,000). When comparing VEORA and EORA, differences related to the use of NSAIDs were found, lower in VEORA (p = 0.000), as well as in the maximum dose of Methotrexate reached in the next 12 months, higher in the EORA group (p = 0.01). No differences in adverse events with DMARDs were observed.

DAS28-ESR and the number of patients in remission or low activity at one year showed no differences between EORA and VEORA, or between these groups and that of younger patients.

Conclusion:

There have been few differences in the comorbidity profile and clinical characteristics at the onset between VEORA and EORA patients. Despite the differences observed in its management (more conservative in EORA and VEORA vs YORA, and in VEORA vs EORA), we have not observed differences in DAS28-ESR activity after one year.

Disclosure of Interests:

Alicia García Dorta: None declared, Cristina Almeida: None declared, Hernández Díaz Marta: None declared, Laur Cáceres Martín: None declared, Elisa Trujillo: None declared, Iván Ferraz-Amaro Grant/research support from: Pfizer, Abbvie, Speakers bureau: Pfizer, Abbvie, MSD., Juan Carlos Quevedo-Abeledo: None declared

Impact of adverse effects to oral antidiabetics on adherence and quality of life in patients with type 2 diabetes

Introduction Diabetes is a metabolic disorder with many comorbidities, microvascular and macrovascular complications. In Portugal the prevalence was 13,3% which corresponds to 1 million Portuguese diagnosed, but the forecasts are for a big increase. The various therapeutic options currently available have been shown to be effective in controlling glycaemia and HbA1 levels. Adherence with this therapeutic is essential for optimization and control of chronic conditions. However, they present side effects that may compromise adherence to therapy and the quality of life of the patients.

Objectives The objective of this study is to evaluate the impact of the adverse effects of oral antidiabetic medicines on patient’s quality of life and adherence to therapy.

Methodology We developed a cross-sectional study in a sample of 65 patients with type 2 diabetes recruited in several Portuguese pharmacies. Data collected through a questionnaire previously validated with MAT Scale and EQ-5D-3L questionnaire.

Results In total, 36 men (55,4%) and 29 women (44,6%) participated in the study, the mean age was 65 years. 73,8 % take oral medication and 92,30% of people have high adherence. The adverse events with more impact in the patients’ perception are "Discomfort in the genital area", "Dry mouth" and gastrointestinal events such as "Abdominal distention", "Flatulence" and "Constipation". The number of adverse events have a negative impact on patients’ quality of life (rs=-0,479; p≤0,01). The satisfaction with the therapeutic regime is significantly associated with adherence (rs = 0,348; p≤0,01)and their quality of life (rs = 0,316; p=0,01).

Conclusion We concluded that the adverse events have a negative impact on adherence and quality of life. The presence of adverse events, the type of medication and the therapeutic regimen are factors that negatively influence the patients’ quality of life, especially in the polymedicated elderly people.

Ocular Syphilis mimicking Acute Zonal Occult Outer Retinopathy (AZOOR)

Ocular syphilis can simulate various ophthalmic pathologies with multiple possible ophthalmic findings. Timely treatment of these patients can minimize visual damage, but its diagnosis is often a challenge for the ophthalmologist. We review a case report of a 45-year-old man with a rare and atypical clinical presentation of ocular syphilis, its clinical and imaging characteristics, its diagnosis, treatment and evolution. The patient presented with bilateral painless loss of vision, photopsia and peripheral scotomas with about 1 week evolution. There were no signs of ocular inflammation. The complementary ophthalmic study revealed an acute zonal occult outer retinopathy-like ("AZOOR-like") presentation. Ocular syphilis does not always present with ocular inflammation and its presentation as "AZOOR-like" is very rare. So, we should always maintain a high index of suspicion for this condition, as early diagnosis and treatment are essential for a better prognosis.

Study of lamina cribrosa depth and optic nerve in patients with spontaneous intracranial hypotension

PURPOSE

The aim of this study is to analyze the lamina cribrosa depth and to study the optic nerve in patients with spontaneous intracranial hypotension.

METHODS

A total of 10 eyes of the patients with spontaneous intracranial hypotension with unknown etiology (study group) and 10 eyes of healthy patients without any ophthalmological or neurological pathologies (control group) were included. The subjects were submitted to ophthalmological examination with the evaluation of visual acuity, spherical equivalent, applanation tonometry, pachymetry, axial length, retinography, computerized static perimetry (Humphrey 30-2 SITA-Standard), and OCT Spectralis with enhanced depth image, to calculate the depth of the anterior surface of the lamina cribrosa and to measure the nerve fiber layer thickness of the optic nerve. All of these parameters were compared between the two groups.

RESULTS

Mean anterior surface of the lamina cribrosa depth was 447.96 ± 118.51 (313.30-632.0) μm for the spontaneous intracranial hypotension group and 292.56 ± 40.71 (247-387) μm for the control group, with a statistically significant difference between them (p = 0.001). The thickness of the nerve fiber layer did not differ significantly in the temporal (p = 0.94), nasal (p = 0.173), superior (p = 0.41), central (p = 0.36) or inferior (p = 0.5) sectors. Four eyes of patients with spontaneous intracranial hypotension showed a marked reduction in the temporal nerve fiber layer. Pachymetry (p = 0.16), axial length (p = 0.71), and intraocular pressure (p = 0.6) did not differ significantly between groups, whereas spherical equivalent (p = 0.03) was significantly different. Visual fields were normal in both groups.

CONCLUSION

The translaminar gradient is determinant in the structure of the lamina cribrosa. Low intracranial pressure associated with a high translaminar gradient leads to an increased lamina cribrosa depth similar to that observed in glaucoma patients.