Chronic pain after breast surgery: incidence, risk factors and impact on quality of life

INTRODUCTION AND OBJECTIVES

Breast cancer is the most frequently diagnosed malignancy, and chronic pain after breast surgery (CPBS) is an increasingly recognized therapy-related problem. We evaluated CPBS incidence, characteristics, associated factors, and impact on patient quality of life (QoL).

MATERIALS AND METHODS

Six-month observational prospective study conducted in patients undergoing breast surgery in a tertiary university hospital. Data were collected using several questionnaires: Pain Catastrophizing Scale, Brief Pain Inventory-Short Form, Douleur Neuropathique 4 Questionnaire, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and its Breast Cancer Module.

RESULTS

A total of 112 patients completed the study. Approximately, one third (34.8%) developed CPBS, and almost all with potentially neuropathic pain. CPBS interfered with patients' daily life and reduced their QoL. Diabetes (p = 0.028), catastrophizing (p = 0.042), and acute postoperative pain severity (p < 0.001) were associated with CPBS.

CONCLUSIONS

This study broadens our understanding of CPBS and shows the impact of this syndrome. Healthcare workers need to be aware of CPBS and take steps to prevent and treat it, and provide patients with adequate information.

Study of the ketohexokinase inhibitor PF-06835919 as a clinical cytochrome P450 3A inducer: Integrated use of oral midazolam and liquid biopsy

PF-06835919, a ketohexokinase inhibitor, presented as an inducer of cytochrome P450 3A4 (CYP3A4) in vitro (human primary hepatocytes), and static mechanistic modeling exercises predicted significant induction in vivo (oral midazolam area under the plasma concentration-time curve [AUC] ratio [AUCR] = 0.23-0.79). Therefore, a drug-drug interaction study was conducted to evaluate the effect of multiple doses of PF-06835919 (300 mg once daily × 10 days; N = 10 healthy participants) on the pharmacokinetics of a single oral midazolam 7.5 mg dose. The adjusted geometric means for midazolam AUC and its maximal plasma concentration were similar following co-administration with PF-06835919 (vs. midazolam administration alone), with ratios of the adjusted geometric means (90% confidence interval [CI]) of 97.6% (90% CI: 79.9%-119%) and 98.9% (90% CI: 76.4%-128%), respectively, suggesting there was minimal effect of PF-06835919 on midazolam pharmacokinetics. Lack of CYP3A4 induction was confirmed after the preparation of subject plasma-derived small extracellular vesicles (sEVs) and conducting proteomic and activity (midazolam 1'-hydroxylase) analysis. Consistent with the midazolam AUCR observed, the CYP3A4 protein expression fold-induction (geometric mean, 90% CI) was low in liver (0.9, 90% CI: 0.7-1.2) and non-liver (0.9, 90% CI: 0.7-1.2) sEVs (predicted AUCR = 1.0, 90% CI: 0.9-1.2). Likewise, minimal induction of CYP3A4 activity (geometric mean, 90% CI) in both liver (1.1, 90% CI: 0.9-1.3) and non-liver (0.9, 90% CI: 0.5-1.5) sEVs was evident (predicted AUCR = 0.9, 90% CI: 0.6-1.4). The results showcase the integrated use of an oral CYP3A probe (midazolam) and plasma-derived sEVs to assess a drug candidate as inducer.

Concurrent Radiation and Deep Hyperthermia Therapy for the Treatment of Recurrent Prostate Cancer

PURPOSE/OBJECTIVE(S)

Robustpreclinical and clinical data have established hyperthermia as an effective radiosensitizer which can be used in the setting of recurrent disease to enhance the therapeutic window. We present a single institution experience examining outcomes in recurrent prostate cancer (RPCA) patients treated with concurrent deep hyperthermia (DHT) and radiation (RT). We hypothesized that concurrent DHT and RT would be well tolerated and would provide durable local control without unexpected toxicity.

MATERIALS/METHODS

Consecutive RPCA patients treated with concurrent DHT and pelvic RT were retrospectively analyzed. Patients received twice weekly DHT treatments in addition to daily or twice daily (BID) RT. DHT was delivered using a concentric ring radiofrequency phased array system to a target temperature of 40-43°C. Acute and late treatment associated toxicities, graded per Common Terminology Criteria for Adverse Events (CTCAE) v5.0, were evaluated. Survival and control outcomes were evaluated using the Kaplan-Meier method.

RESULTS

Eighteen patients were included for analysis. Median patient age was 69 yrs (64-82 yrs). Fifteen (83%) patients had received prior RT and 12 (67%) patients had undergone radical prostatectomy. At time of treatment, two patients had RPCA which had dedifferentiated to a small cell phenotype. Eight (44%) patients had extra-pelvic disease at time of treatment. Seventeen (94%) patients received proton RT, while 1 (6%) received photon RT. Median RT dose was 49 Gy (range 30-73.8 Gy). Five (28%) patients received BID RT. Fifteen (83%) patients also received sequential or concurrent systemic therapy including androgen deprivation therapy or chemotherapy. A total of 142 DHT treatments were administered (median of 7.5 treatments). Fourteen (78%) patients completed ≥ 75% of planned DHT treatments. Reasons for inability to complete treatment included discomfort and abnormal vital signs during DHT. Only one patient reported Grade 2 pain and pruritus attributed to concurrent RT and DHT. One acute Grade 3 RT toxicity (diarrhea) was reported. No late Grade 3+ toxicities occurred. Of ten patients (56%) treated with curative intent, 8 (44%) had no reported failures at 2-year follow up while two had distant failure and biochemical failure respectively. Three (17%) patients were treated with palliative intent for disease related pain; two reported partial relief and one reported complete pain relief. With a median follow-up of 27 months (1-46 months), 2-year failure free survival was 41.4% (95% CI: 27.8-55%), local control was 76.5% (95% CI 66.2-86.8%) and overall survival was 70.9% (95% CI 58.4-83.3%).

CONCLUSION

Our results suggest that concurrent RT and DHT is well tolerated and allows for safe escalation of local therapy for RPCA, providing patients with durable local control and palliation with an acceptable toxicity profile. Prospective validation is warranted.

A282 RISK FACTORS ASSOCIATED WITH UNSUCCESSFUL HIGH-RESOLUTION MANOMETRY: FAILURE IS COMMON BUT WHAT CAN WE CHANGE

Background

High-resolution manometry (HRM) is a diagnostic tool used to evaluate esophageal motor function and diagnose motility disorders. A standardized protocol is used to make an accurate diagnosis based on the Chicago Classification. Some existing literature suggests that incomplete or imperfect manometry tests are common, however; there remains a paucity of data to evaluate risk factors for failure to help clinicians determine when a study may be difficult to perform.

Purpose

Our goal was to quantify how often failed tests occurred and determine specific factors that may be associated with failed HRM.

Method

We retrospectively evaluated records for HRM tests performed over 1 year at our academic centre. Based on clinical experience, we identified several factors that may be associated with the success of HRM testing including the following: indications and symptoms leading to testing, patient’s age and biological sex, previous esophageal manometry history, previous esophageal/gastric surgery, previous septal repair/deviated septum, history of significant nausea/vomiting, history of anxiety/depression, history of irritable bowel syndrome, and medication use (opioids, proton pump inhibitors, calcium channel blockers, nitrates). We then compared patients with successful HRM vs. unsuccessful HRM with regard to our pre-specified risk factors.

Result(s)

29 HRM tests were unsuccessful from a total of 152 that were performed (19% failure rate). Reasons for failure included the inability to pass the probe through LES (55%) and the inability to tolerate the manometry probe for a minimum of 10 saline swallows (45%). After separating the failed cases from successful tests, both groups had a similar distribution of age and sex. Specific symptoms and indications did not have a significant association with unsuccessful tests. A previous history of failed manometry was associated with unsuccessful HRM (OR: 15, 95% CI 1.88 to 183.8, p=0.0156). Conversely, PPI usage was associated with fewer failed HRM tests (OR: 0.37, 95% CI 0.16 to 0.90, p=0.0343). Other medical history or medication use was not found to be associated with testing failure in our study.

Conclusion(s)

HRM is useful for diagnosing esophageal motility disorders, but incomplete tests are common. Although this study did not identify any factors in a patient’s medical history that could be used to predict failure in patients who have never had testing, further investigations may identify if PPI therapy can make HRM testing more tolerable. Additionally, the association between previous failed HRM and repeat failures suggests that endoscopic probe placement techniques should be considered instead of retrying conventional probe placement.

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Disclosure of Interest

None Declared

Evaluation of the Impact of Ritlecitinib on Organic Cation Transporters Using Sumatriptan and Biomarkers as Probes

Ritlecitinib, an inhibitor of Janus kinase (JAK)3 and hepatocellular carcinoma family kinases, is in development as potential treatment for several inflammatory diseases. In vitro studies presented ritlecitinib as an inhibitor of hepatic organic cation transporter (OCT)1, renal transporters OCT2 and multidrug and toxin extrusion (MATE) proteins 1/2K using multiple substrates, and ritlecitinib's major inactive metabolite M2, as an inhibitor of OCT1. A clinical interaction study with an OCT1 drug probe (sumatriptan) and relevant probe biomarkers for OCT/MATE was conducted to assess the effect of ritlecitinib on these transporters in healthy adult participants. The selectivity of sumatriptan for OCT1 was confirmed through a series of in vitro uptake assays. A simple static model was used to help contextualize the observed changes in sumatriptan area under the plasma concentration-time curve (AUC). Co-administration of a single 400 mg dose of ritlecitinib increased sumatriptan AUC from time 0 to infinity (AUC_inf ) by ∼30% relative to a single 25 mg sumatriptan administration alone. When administered 8 hours post ritlecitinib dose, sumatriptan AUC_inf increased by ∼50% relative to sumatriptan given alone. Consistent with OCT1 inhibition, the AUC from time 0 to 24 hours of isobutyryl-L-carnitine (IBC) decreased by ∼15% post ritlecitinib. Based on the evaluation of the renal clearance of N¹ -methylnicotinamide (NMN), ritlecitinib does not exert clinically meaningful inhibition on renal OCT2 or MATE1/2K. This study confirmed ritlecitinib and M2 are inhibitors of OCT1 but not OCT2 or MATE1/2K in healthy adults. This article is protected by copyright. All rights reserved.

Etiology of avascular necrosis of the hip and shoulder. Screening for Gaucher disease

INTRODUCTION

Avascular necrosis (AON) of the hip and shoulder is a little studied disease and the predisposing risk factors for its development are not well known. A high percentage of patients are diagnosed with idiopathic osteonecrosis. This study aims to investigate the prevalence of potential etiological factors for AON and to screen for Gaucher disease among patients with idiopathic AON.

MATERIAL AND METHODS

This retrospective, single-center, observational study was conducted on patients who had at least one episode of AON of the hip or shoulder at the Hospital de Poniente (Almería, Spain) from January 2010 to December 2019. Clinical and analytical data were collected. Patients whose medical record described no etiological factors for this disease were screened for Gaucher disease.

RESULTS

The study sample consisted of 81 patients, of whom 58 were male. The mean age at presentation of AON was 45.9 years. They presented with unilateral hip necrosis (n=43), bilateral hip necrosis (n=34), bilateral hip and unilateral shoulder necrosis (n=3), and unilateral shoulder necrosis (n=1). The most frequent potential etiological factors were smoking (46.9%) and obesity (17.3%). Screening for Gaucher disease was performed in ten patients, all of whom tested negative.

CONCLUSIONS

In our study population, the main potential etiological factors the onset of AON of the shoulder or hip were smoking and obesity. A high percentage of patients were diagnosed with idiopathic AON. We believe that a more exhaustive study of less frequent risk factors should be carried out in these cases.

Genotypic and Phenotypic Characterization of Pathogenic Escherichia coli, Salmonella spp., and Campylobacter spp., in Free-Living Birds in Mainland Portugal

Birds are potential carriers of pathogens affecting humans and agriculture. Aiming to evaluate the occurrence of the top three most important foodborne pathogens in free-living birds in Portugal, we investigated 108 individual fecal samples from free-living birds and one pooled sample of gull feces (n = 50) for the presence of Escherichia coli (pathogenic and non-pathogenic), Salmonella spp. and Campylobacter spp. Virulence- and antimicrobial resistance- (AMR) associated genes were detected by PCR and Whole-Genome Sequencing (WGS), and phenotypic (serotyping and AMR profiles) characterization was performed. Overall, 8.9% of samples tested positive for pathogenic E. coli, 2.8% for Salmonella spp., and 9.9% for Campylobacter spp. AMR was performed on all pathogenic isolates and in a fraction of non-pathogenic E. coli, being detected in 25.9% of them. Ten of the tested E. coli isolates were multidrug-resistant (MDR), and seven of them were Extended-spectrum β-lactamase (ESBL) producers. Among Salmonella (n = 3) and Campylobacter (n = 9), only one strain of C. jejuni was identified as MDR. Most of the identified serotypes/sequence types had already been found to be associated with human disease. These results show that free-living birds in Portugal may act as carriers of foodborne pathogens linked to human disease, some of them resistant to critically important antimicrobials.

A131 ESOPHAGEAL MUCOSAL BIOPSIES FOR THE DIAGNOSIS OF NON-EROSIVE REFLUX DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Non-erosive reflux disease (NERD) accounts for over half of all cases of gastroesophageal reflux disease (GERD). It is characterized by symptoms of GERD with pathologic acid exposure on ambulatory pH monitoring and no evidence of erosive esophagitis on upper endoscopy. Symptoms and negative endoscopy alone are insufficient to diagnose NERD. Ambulatory pH monitoring is limited due to availability and patient tolerance. Conventional histologic analysis of mucosal esophageal biopsies has been studied in this context but there is no clear guidance as to its utility in diagnosing NERD.

Aims

The purpose of this study was to conduct a systematic review and meta-analysis to determine the sensitivity and specificity of esophageal biopsy histology in diagnosing NERD.

Methods

Data were obtained from Embase (1947- April 2021) and Ovid MEDLINE (1946 – April 2021). We included all studies where esophageal mucosal biopsies were taken and light microscopy was used to analyze histopathology in symptomatic adult NERD patients (i.e., no evidence of erosive esophagitis and ambulatory pH testing confirmed the presence of pathologic acid exposure). Papers were sorted in duplicate. Relevant data was extracted from papers meeting inclusion criteria, including histologic abnormalities and the location of the biopsy. Sensitivities and specificities were calculated from raw data and pooled using RevMan 5.4 software, using asymptomatic patients with no significant esophageal acid exposure and/or patients with functional heartburn (i.e., symptoms but no elevated acid exposure on ambulatory pH testing) as controls.

Results

The search yielded 2871 studies after the removal of duplicates, of which 158 were eligible for full text review. In total, 12 papers met our stringent inclusion criteria and contained raw data that allowed for sensitivity calculations. Histological abnormalities that were commonly reported included gross morphological scores, papillary elongation, basal cell hyperplasia and dilated intraepithelial spaces. Biopsies were taken at &lt;3cm in 5 studies, ≥3cm in 5 studies, and at multiple sites in 2 studies, and all were reviewed by a blinded pathologist. When assessing for the presence of any abnormality in the histological analysis, biopsies taken at &lt;3cm had a pooled sensitivity of 0.70 (95% CI 0.64 – 0.75) and specificity of 0.72 (95% CI 0.63 – 0.77). Biopsies taken at ≥3cm revealed a pooled sensitivity of 0.39 (95% CI 0.32 – 0.47) and specificity of 0.63 (95% CI 0.51 – 0.74).

Conclusions

Esophageal mucosal biopsies have poor sensitivity and specificity at diagnosing non-erosive gastroesophageal reflux disease. Biopsies taken below 3cm appear to have a higher sensitivity and specificity than those taken more proximally.

Funding Agencies

None

A135 DO VISCOUS SWALLOWS IMPROVE THE DIAGNOSTIC YIELD OF HIGH-RESOLUTION MANOMETRY?

Background

Esophageal motility disorders are diagnosed using high-resolution esophageal manometry (HR-EMS) using the Chicago Classification (CC V4.0) which is based on a series of 10 normal saline swallows (LS). Viscous swallows (VS; thickened liquid/applesauce) are often performed during esophageal manometry; however, they were not included within the framework of CC V4.0. Previous literature has suggested inconsistency between LS and VS in up to 25% of studies, yet it remains unclear whether routine use of VS offers any benefit to LS alone in diagnosing manometric abnormalities according to the CC V4.0.

Aims

To determine if the routine use of VS improves the diagnostic yield in HR-EMS

Methods

A retrospective analysis of all HR-EMS studies performed between December 2020 and July 2021 at Kingston Health Sciences Centre was completed. Demographic information including age, sex, indication for HR-EMS, surgical history, and chronic narcotic use was documented. Each study (consisting of 10 LS and 10 VS) was reviewed independently by a Gastroenterology Fellow and Neurogastroenterologist. A manometric diagnosis using CC V4.0 was made for both LS and VS. Descriptive statistics were performed.

Results

A total of 101 HR-EMS studies were reviewed (33 male, 68 female, age range 26 to 90 years). The most common indication for HR-EMS was dysphagia (87/101) with 23/101 having 2 indications, 30/101 having 3 indications, and 43/101 patients having >3 indications. Prior upper GI tract surgery and chronic narcotic use was recorded in 9/101 and 8/101 patients, respectively. Two HR-EMS studies were excluded due to incomplete protocol. In total, 38.4% (38/99) had normal HR-EMS for both LS and VS. LS and VS that resulted in a CC V4.0 diagnosis were concordant in 37.4%(37/99) and discordant in 24.2% (24/99). Of the 24 discordant studies, 6 had a CC V4.0 diagnosis for LS (4 esophagogastric outflow obstruction (EGJOO), 1 ineffective esophageal motility (IEM), 1 diffuse esophageal spasm) and normal VS. Ten studies had normal LS and a CC V4.0 diagnosis for VS (9 IEM, 1 EGJOO). Eight had differing CC V4.0 diagnoses for LS and VS.

Conclusions

LS and VS resulted in concordant diagnoses in the majority of cases. However, there were discordant results in approximately 25% of cases. In nearly half of these studies, the LS was within normal limits whereas VS yielded a diagnosis of an esophageal motility disorder which may be of clinical significance to the patient’s management. The addition of VS to HR-EMS protocol may increase diagnostic yield in symptomatic patients.

Funding Agencies

None

A102 INDICATION FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATION WITH HEMORRHAGE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Hemorrhage is a complication associated with up to 2% of cases of Endoscopic Retrograde Cholangiopancreatography (ERCP), most commonly following sphincterotomy. Studies investigating risk factors associated with hemorrhage, such as ERCP indication, have been conflicting.

Aims

We performed a systematic review and meta-analysis to determine the association between the indication for ERCP and ERCP-associated hemorrhage.

Methods

A systematic search of MEDLINE, EMBASE, and CENTRAL was done from inception until September 2021 for studies reporting on factors associated with ERCP-associated hemorrhage (both immediate and delayed) in adults. Exclusion criteria included: pediatric patients, no outcome of interest, did not investigate hemorrhage risk factors, inappropriate study design (basic science, reviews, and case reports/series), or if no English text was available. A DerSimonian and Laird random-effects meta-analysis was performed to generate pooled Odds Ratios (OR) with 95% Confidence Intervals (CIs) for each procedural indication in relation to hemorrhage.

Results

952 records were identified of which 17 were included in our quantitative analysis. Common indications included acute cholangitis, choledocholithiasis, Sphincter of Oddi dysfunction (SOD), acute pancreatitis, chronic pancreatitis, and malignancy-associated duct obstruction. Rates of hemorrhage varied in the included studies (median 2.2%; IQR 1.7–6.9). Sphincterotomy rates also differed in the included studies (median 100%; IQR 71.1–100). Five studies did not report on antiplatelet or anticoagulant use with the remaining reporting varying rates of antiplatelet (median 8.3%; IQR 0–26.5) and anticoagulant (median 0.8%; IQR 0–2.25) use. Hemorrhage was significantly associated with acute cholangitis (OR 2.48; 95% CI 1.62–3.78) and choledocholithiasis (OR 1.76; 95% CI 1.06–2.94) but not SOD (OR 1.38; 95% CI 0.74–2.58), malignancy (OR 0.68; 95% CI 0.29–1.59), acute pancreatitis (OR 1.08; 95% CI 0.30–3.82), or chronic pancreatitis (OR 0.56; 95% CI 0.16–1.99).

Conclusions

Acute cholangitis and choledocholithiasis were associated with increased hemorrhage, whereas SOD, malignancy, acute pancreatitis, and chronic pancreatitis were not. Providers should consider procedural indication when counselling patients on hemorrhage risk in ERCP.

Funding Agencies

None

A80 CANADIAN NEUROGASTROENTEROLOGY NETWORK (CNN) SURVEY ON PH/MOTILITY TESTING IN CANADA

Background

Anecdotal reports suggest that access to pH/motility testing is problematic in Canada, but to date there is little data documenting this.

Aims

To assess the volume and accessibility of motility lab testing in Canada.

Methods

The CNN developed a questionnaire directed at the scope, volume and accessibility of pH/motility testing in Canadian labs. Fifty-three labs were identified using lists provided by companies that supply pH/motility recording equipment in Canada. Of these, 12 labs were excluded (10 had incorrect or absent contact information, 1 had recently closed and 1 had just opened). Questionnaires were sent in early 2020 to the remaining 41 labs, and respondents were asked to use data from their last fiscal year pre-pandemic.

Results

26 completed questionnaires were returned (i.e., 63% response rate, but representing ~ 51% of active labs): 23 adult units (7 community, 15 academic and 1 private) and 3 academic pediatric units. Of the adult units, 6 performed studies in children <12 yrs old. All 3 pediatric units provided both esophageal and anorectal high-resolution manometry (HRM) and pH/Impedance recording, with wait times of < 3 months. All 23 adult labs provided esophageal HRM, but just 50% performed anorectal manometry and only 3 anorectal manometry with biofeedback. Ambulatory pH/Impedance was performed in all but 1 adult unit. 15 of 23 adult centres reported access to colon transit studies and only one performed colonic manometry. No units performed antroduodenal manometry. Five units offered Bravo wireless pH recording and 4 performed ENDOFLIP. In adult units, the median number of procedures per year were as follows: esophageal HRMs - 278 (range: 50–1140); pH/impedance - 225 (range: 40–634); anorectal manometry - 90 (range: 10–450). Corresponding median wait times in months were as follows: esophageal HRM - 4 (range: 0.5–14); pH/Impedance - 4.5 (range: 0.5–14); anorectal manometry - 4.6 (range: 2–9). Only 6 of the 23 adult units met recommended wait time targets of <2 months. Testing was performed by a nurse in ~ 80% of centres, while testing was done by technicians in 2 units and physicians in 3 units. 8 units accepted referrals from primary care physicians, whereas the remainder only accepted specialist referrals. 50% screened referrals for appropriateness and restricted access accordingly.

Conclusions

The scope of motility and pH testing across Canada is variable, with lower GI testing lacking in many regions. Wait times vary significantly across labs and the majority of centres exceed recommended limits of 2 months. The reasons underlying the identified limitations to pH/motility testing access warrant further study.

Funding Agencies

None

OSA patients not treated with PAP - Evolution over 5 years according to the Baveno classification and cardiovascular outcomes

INTRODUCTION

The evolution of patients with obstructive sleep apnea (OSA) non-eligible for PAP-therapy at diagnosis is unknown. Currently, the severity of OSA is based on the apnea-hypopnea index (AHI), but its prognostic relevance has raised concerns. The Baveno classification may allow a better stratification of severity and therapeutic guidance in OSA.

METHODS

Patients with AHI≥5/h in 2015, classified into Baveno groups A and B and non-eligible for PAP therapy at diagnosis and over 5 years, were analyzed. Patients were reclassified into Baveno groups (A-D) and changes in groups over 5 years were explored. Patients in Baveno groups C and D, who developed major cardiovascular comorbidities (CVC) or end-organ damage (EOD group), were compared with patients in Baveno groups A and B (non-EOD group). To identify predictors of the development of major CVC or EOD, a logistic regression analysis was performed.

RESULTS

There were 76 patients, 58% male, mean age 51.9 ± 10.1 years, mean body mass index (BMI) of 30.3 ± 5.0 kg/m2 and median AHI of 8.9 (5.9-12.0) events/h. At diagnosis, 46% and 54% of patients were classified into Baveno group A and group B, respectively. In total, 21% of patients developed major CVC or EOD (Baveno group C or D); higher age (p = 0.011) and BMI (p = 0.004) and a higher percentage of central apneas (p = 0.012) at diagnosis significantly predicted it, while sex, sleepiness, insomnia, AHI, ODI and T90 were not.

CONCLUSIONS

A significant percentage of patients non-eligible for PAP-therapy at diagnosis of OSA developed CVC or EOD; higher age and BMI and a higher percentage of central apneas were significant predictors.

Challenges in schizoaffetive disorder therapeutic – a case report of a patient with hiperprolactinemia

Introduction

The only FDA approval therapeutic for schizoaffective disorder is paliperidone. Hiperprolactinemia is one of the most frequent side effects induced by first generation antipsychotics (FGA) or by second generation antipsychotic (SGA), such as risperidone and paliperidone. Prolactin related symptoms (PRS) include amenorrhea, galactorrhea, gynecomastia and fluctuations in psychotic symptoms.

Objectives

To report the case of a patient with schizoaffective disorder difficult to manage due to symptom resistance and PRS, that improved symptomatology when prolactin serum levels were reduced.

Methods

Clinical-demographic data collected by clinical interview and clinical process consultation. Non-systematic literature review, searching “psychosis”; “prolactin”; “antipsychotic”; “schizoaffective disorder” on Pubmed database.

Results

We report the case of 33 years-old female, admitted to our psychiatry inpatient unit for persecutory delusions, loosening of association, auditory hallucinations, and irritability with functional impairment. Symptoms began 13 years before. She was medicated with paliperidone 100mg IM monthly, lithium 800mg daily and clozapine 225mg daily. When admitted she wasn’t adhering to oral medication. On physical examination presented some PRS. The serum presented hyperprolactinemia and lithium in non-therapeutic levels. Initially was re-introduced the previous therapeutic without improval. It was made a therapeutic switch to associate aripiprazole 400mg IM monthly and clozapine 225mg daily, and lithium 800mg daily resulting in prolactine normalization and subsequent improval of psychotic symptoms previously presented.

Conclusions

This case reports challenges in management of patients diagnosed with Schizoaffetive Disorder due to therapeutic refractoriness and side effects. PRS can be ruling, therefore impacting therapeutic choices. We propose a possible role of combination of clozapine and aripiprazole in this scenario.

Disclosure

No significant relationships.

Mental health in pandemic times - a review

Introduction

Any outbreak of pandemic dimension will most likely produce a serious amount of distress and prejudice to anyone, in particular when it comes to mental health. The pandemic impact in primary care and in the psychiatric emergency department are some of the topics discussed in this review.

Objectives

It aims to review, evaluate and reflect over the impact of a deadly coronavirus pandemic on mental health, as well as presenting possible long-term challenges and potential ways to approach it.

Methods

A non-systematic literary review was performed on the Pubmed, PsycInfo and Cochrane databases using the key words “covid-19”, “psychiatry”, “self-isolation” and “telepsychiatry”.

Results

Globally and, as expected, there has been a general increase in need for psychiatric assessment and treatment due to the COVID-19 pandemic.

Conclusions

The role of psychiatry has faced quite some challenges in such a short period of time: the rise of telepsychiatry; the management of patients with both a psychiatric disorder and an infection with the new coronavirus and the need to provide an adequate psychiatric assistance in the emergency room has become the new normal.

Hopelessness in patients with schizophrenia

Introduction

Individuals with schizophrenia have a shortened average life expectancy, with a lifetime risk of suicide around 5%.

Objectives

Here we present a case of a patient diagnosed with schizophrenia who developed depressive symptoms with suicidal ideation, reactive to psychotic symptoms. Considering this specific case, the factors that contribute to the increased risk of suicide in these patients are reviewed.

Methods

Relevant clinical information was extracted from the patient’s clinical process. In addition, we searched Pubmed^R database with the terms “Schizophrenia”, “Hopelessness” and “Suicide”.

Results

A 40-year-old male patient, single and unemployed presents a progressive psychotic condition, with 20 years of evolution, with an impact on social and work behaviour. As a background he has a history of depressive episodes with suicidal ideation at the age of 36, following psychotic symptoms. This is a patient with preserved cognitive functioning combined with a high level of education, who understands the impact of his reality on his functioning. In this context, he develops feelings of hopelessness, that are the risk factor for suicide, most consistently reported in patients with schizophrenia.

Conclusions

This case assesses a patient with schizophrenia who has several factors, that contribute to an increased risk of suicide, focusing on hopelessness. In the future, it may be interesting to study in more detail the individual weight of each factor, so that it is possible to accurately predict the individual risk of each patient and, consequently, it is possible to implement preventive strategies.

Diagnostic challenges presented by women with anorexia nervosa and elevated rates of autistic traits

Introduction

The link between autism spectrum disorder (ASD) and anorexia nervosa (AN) firstly emerged in the 80’s. Given the overlap in behavioural and cognitive features between these two seemingly different disorders, AN has been hypothesized to be a female phenotype of ASD.

Objectives

This report aims to describe a clinical case of an anorexic female patient diagnosed later in life with ASD, while presenting a bibliographic review on the subject.

Methods

After gaining consent, detailed information about the case history was collected and medical records were analysed and reviewed. A non-systematic literary review was performed on the Pubmed and Cochrane databases using the key words “anorexia nervosa”, “females”, “comorbidity” and “autism spectrum disorder”.

Results

The current case report is of a 28-year-old female, whose extremely low body weight and complete food refusal for three days prompted her first hospitalization in a psychiatric unit with the admission diagnosis of anorexia nervosa. However, long-term impairments in social interaction and flexibility, emotional difficulties and sensory processing overload were acknowledged and the primary diagnosis of ASD was then considered.

Conclusions

As illustrated in this case, the diagnosis of ASD should always be considered in females with eating disorders, in particular AN, regardless of age. As this neurodevelopmental condition appears to present differently in females, they also seem more likely to go underdiagnosed. Also, due to poorer treatment outcomes in females with both ASD and AN, the importance of developing a specialized approach and prompt referral of these patients is highlighted.

Disclosure

No significant relationships.

A131 POINT OF CARE ULTRASOUND CHANGES THE NEEDLE INSERTION LOCATION FROM AN ANATOMICALLY LANDMARKED SITE DURING BEDSIDE PARACENTESIS

Background

Paracentesis is a bedside procedure to obtain ascitic fluid from the peritoneum. It is traditionally performed using anatomic landmarking and percussion to ascertain a safe drainage site. The serious complication rate has been reported as less than 2%. Point-of-care ultrasound (POCUS) has been adopted into education and clinical use and has been shown to improve the safety of certain procedures such as central line insertion and thoracentesis. However, the evidence supporting its use is limited.

Aims

We aimed to assess if POCUS would yield a user-preferred site for needle insertion compared to conventional landmarking, defined as a &gt;5cm change in location.

Methods

Adult patients under the care of gastroenterology or general internal medicine at Kingston Health Sciences Centre undergoing paracentesis were consecutively enrolled between January and September of 2020. Physicians performing the procedure were enrolled based on availability. An anatomic site was selected 4cm superiorly and 2-4cm medially to the anterior superior ileac spine and confirmed with dullness to percussion. POCUS was then employed to determine if there was an alternative user-preferred site. Patient and operator demographic data and procedure-related information were collected.

Results

A total of 30 individual patients and 24 operators were enrolled, comprising 45 unique procedure combinations. Operators were primarily in their PGY 1 and 2 years of training (33% and 31% respectively). Per procedure, patients mean age was 61, and most of the ascites was due to cirrhosis (84%) predominantly due to EtOH (47%) and NAFLD (34%). As per indication, 29% of procedures were for diagnostic purposes alone. In total, users primarily preferred the POCUS site which resulted in a change in needle insertion site &gt;5cm from the anatomic site in 69% of cases. The average depth of fluid was greater at the POCUS site vs. the anatomic site (5.4cm+/-2.8 vs 3.0cm+/-2.5, p&lt;0.005). On average, POCUS deflected the needle insertion site superiorly and laterally to the anatomic site. Operators listed that per procedure the POCUS site was chosen to avoid adjacent organs (38%), optimize fluid pocket (61%) and due to abdominal wall issues (primarily issues with pannus; 11.5%). Importantly 6 cases were aborted due to a lack of an appropriate fluid pocket, despite clinical and/or prior radiographic evidence of ascites.

Conclusions

Overall, POCUS changes the needle insertion site from the conventional anatomic site for most procedures, due to user-perceived safety concerns. POCUS also prevented an attempt at paracentesis in 6 cases that were deemed unsafe. Therefore, POCUS plays an important role in bedside paracentesis. This research supports the use of POCUS in paracentesis and argues for continued training with POCUS throughout medical school and residency.

Funding Agencies

None

Do smartphone applications and activity trackers increase physical activity in adults? Systematic review, meta-analysis and metaregression

OBJECTIVE

To determine the effectiveness of physical activity interventions involving mobile applications (apps) or trackers with automated and continuous self-monitoring and feedback.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed and seven additional databases, from 2007 to 2020.

STUDY SELECTION

Randomised controlled trials in adults (18-65 years old) without chronic illness, testing a mobile app or an activity tracker, with any comparison, where the main outcome was a physical activity measure. Independent screening was conducted.

DATA EXTRACTION AND SYNTHESIS

We conducted random effects meta-analysis and all effect sizes were transformed into standardised difference in means (SDM). We conducted exploratory metaregression with continuous and discrete moderators identified as statistically significant in subgroup analyses.

MAIN OUTCOME MEASURES

Physical activity: daily step counts, min/week of moderate-to-vigorous physical activity, weekly days exercised, min/week of total physical activity, metabolic equivalents.

RESULTS

Thirty-five studies met inclusion criteria and 28 were included in the meta-analysis (n=7454 participants, 28% women). The meta-analysis showed a small-to-moderate positive effect on physical activity measures (SDM 0.350, 95% CI 0.236 to 0.465, I²=69%, T ²=0.051) corresponding to 1850 steps per day (95% CI 1247 to 2457). Interventions including text-messaging and personalisation features were significantly more effective in subgroup analyses and metaregression.

CONCLUSION

Interventions using apps or trackers seem to be effective in promoting physical activity. Longer studies are needed to assess the impact of different intervention components on long-term engagement and effectiveness.

O Desafio Diagnóstico do Novo Coronavírus: A Propósito de um Caso Clínico

COVID-19 é o nome atribuído, pela Organização Mundial da Saúde, à doença provocada pelo novo coronavírus SARS-Cov-2, que pode causar infeção respiratória grave como a pneumonia, tendo sido declarada como pandemia a 11 de março de 2020. O conhecimento acerca dos seus testes diagnósticos ainda está em clara evolução, bem como a sua correta interpretação. Apresentamos o caso clínico de um homem, de 67 anos, com história prévia de hipertensão arterial e glaucoma. Evidência de quadro clínico arrastado de febre, astenia e mialgias. Tomografia computorizada do tórax com infiltrados periféricos sugestivos de pneumonia atípica. Iniciou terapêutica protocolada com hidroxicloroquina e azitromicina, por elevada suspeição para COVID-19, apesar de só a terceira pesquisa de SARS-CoV-2 no exsudado faríngeo, ter sido positiva.

Romantic Jealousy: A Test of Social Cognitive and Evolutionary Models in A Population-Representative Sample of Adults

Whereas sexually dimorphic evolutionary models argue for clear sex differences in responses to jealousy-evoking scenarios, social cognitive models emphasize the importance of other factors. This paper explores variables associated with responses to a commonly-used jealousy-evoking scenario in a population-representative sample. Data from 8,386 Australian men and women aged 16-69 were weighted to match the population. The results provided some support for evolutionary models among heterosexual respondents, but findings contrary to evolutionary models were found among non-heterosexual respondents. Support for social cognitive models was provided by the identification of six variables that had significant independent multivariate associations with jealousy: sex, age, education, lifetime number of partners, relationship status, and attitudes toward infidelity. The results suggest that although men and women may tend to respond differently to sexual or emotional infidelity scenarios, the anticipated experience of jealousy in each context is strongly influenced by biographical and cultural factors.

National Programme for Promotion of Physical Activity: the situation in Portugal

Primary health care, due to its proximity and easy access, knowledge of the family and their community, and through preventive measures and continuity of care, has an important and decisive role to play in counselling and promotion of physical activity throughout the various stages of life. Portugal has the lowest levels of physical activity in Europe and high levels of sedentary lifestyle, which led the Directorate General of Health to establish Physical Activity as a priority health programme, and develop the National Strategy for Promotion of Physical Activity. This article aims to describe initiatives that have been implemented that promote physical activity. More family physicians have become interested in promoting physical activity in their clinical practice. Specific training has become more widely available, computer based tools have been developed as clinical practice aids (for evaluation of levels of physical activity and counselling) and local initiatives involving health professionals have increased, as well as more investment in terms of investigation and monitoring of all of the above. At the same time change is happening among urban spaces and local policies that favour physical activity.

A132 SMOOTH MUSCLE BIOPSIES FROM POEM PROCEDURES FOR ACHALASIA SHOW LACK OF FUNCTIONAL INNERVATION

Background

Idiopathic achalasia is a disease of the esophagus causing impaired peristalsis and absent lower esophageal sphincter relaxation. The etiopathogenesis of the disease is unclear but most histopathologic studies from surgical resections show an absence of nitric oxide-producing neurons in the myenteric plexus. The peroral endoscopic myotomy (POEM) procedure has evolved in the last decade to treat achalasia and has provided a unique way to sample diseased tissue from an otherwise inaccessible tissue compartment.

Aims

To study the effects of achalasia on innervation of smooth muscle and smooth muscle phenotype.

Methods

Patients with a diagnosis of achalasia based on high resolution manometry undergoing a POEM at Kingston general hospital were approached for enrollment between June 2017 to September 2018. Demographic information including age, symptom duration, previous treatments, and Eckhardt score was collected. Intraoperatively, biopsies of the circular smooth muscle (CSM) layer were taken at the proximal and distal extents of the myotomy and placed in formalin. Tissue was embedded in wax, sectioned and stained using immunocytochemistry (ICC) for neuronal, axonal and smooth muscle cell markers. This was compared to control tissue from patients undergoing gastroesophagectomy for adjacent malignancy.

Results

Control tissue from 3 separate esophagectomies were obtained. Samples were obtained from a total of 25 patients (13 males), with a median age of 50 (IQR 38–67). Most patients had Type 2 achalasia (19 [76%]) followed by Type 1 and 3 (2, [8%] respectively). Two cases had conflicting manometric findings. The median duration of symptoms was 3 years (IQR 1.5–10.5) and the median Eckhardt score was 6.5 (IQR 5–9). In sample tissues, no neuronal cell bodies were detected in the CSM layer. ICC for the axonal marker PGP9.5 showed that CSM of achalasia samples were almost completely devoid of axon structure, independent of the subtype of achalasia, compared to abundant axon presence in control tissues. In parallel, ICC showed that cholinergic (ChAT) or nitrergic (nNOS) axonal subtypes were absent in biopsy CSM while abundant in controls. CSM cells displayed hypertrophy with no detection of proliferation by ICC (KI67) or alterations in the phenotypic marker SM-22.

Conclusions

Preliminary results from advanced immunohistochemical techniques show the absence of functional innervation of the CSM layer of all patients with achalasia. This is characterized by a depleted excitatory and inhibitory axon population. Further studies are focused on defining differences in smooth muscle phenotype and the presence or absence of inflammatory cells within the CSM.

Funding Agencies

None