Challenges and opportunities in the development of mucosal mRNA vaccines

mRNA vaccines have played a critical role in controlling the SARS-CoV-2 pandemic, and are being actively studied for use in other diseases. There is a growing interest in applying mRNA vaccines at mucosal surfaces as it enables access to a unique immune reservoir in a less-invasive manner. However, mucosal surfaces present several barriers to mRNA uptake, including degrading enzymes, mucus, and clearance mechanisms. In this mini-review, we discuss our understanding of the immune response to mucosal mRNA vaccines as it compares to systemic mRNA vaccines. We also highlight physical and chemical methods for enhancing mRNA uptake across mucosal tissues. Mucosal mRNA vaccination is a nascent field of research, which will greatly benefit from fundamental investigations into the mechanisms of immune activation and the development of technologies for improved delivery.

Chronotype as a predictor of scholar performance in a full-time middle school

The performance of day-to-day tasks, whether satisfactory or unsatisfactory, varies due to several environmental synchronizers, including the 24-hour light-dark cycle. For instance, human performance on physical and/or cognitive demanding activities reaches its peak during the day when the body temperature is at its circadian peak. Individual differences in the circadian peaks in temperature along with individuals' timing of sleep is referred to as chronotype. Here, we aimed to answer if (a) chronotypes affect the performance of students in a Brazilian full-time school with an early start time and if (b) there are differences in performance based on chronotype. We expected to find (a) a positive effect of the morning chronotype on the students' performance, particularly in subjects that take place in early morning; (b) while a negative effect of the evening chronotype in that same period. To address the effect of the chronotype on the students' scholar performance we build a Generalized Linear Mixed Model (GLMM). Results support the hypothesis that the students' performance is partially attributed to their chronotype. In particular, our findings shows that evening-type students are expected to have an increase of 0.038 (p ≤0.05) log counts on their performance in Portuguese classes compared to other chronotypes. Here we add evidence for the effect that individual chronotypes have on the students' performance in a Brazilian full-time middle school. Distinctive features of the studied Brazilian full-time middle school related to chronotypes are discussed.

Acute physiological effects following Bacillus subtilis DE111 oral ingestion - a randomised, double blinded, placebo-controlled study

Previous studies using ileostomy samples from study participants demonstrated that the spore-forming probiotic Bacillus subtilis DE111® can germinate in the small intestine as early as 4 hours after ingestion. Metabolomics, proteomics and sequencing technologies, enabled further analysis of these samples for the presence of hypoglycaemic, hypolipidemic, antioxidant, anti-inflammatory and antihypertensive molecules. In the DE111 treatment group, the polyphenols trigonelline and 2,5-dihydroxybenzoic acid, orotic acid, the non-essential amino acid cystine and the lipokine 12,13-diHome were increased. DE111 also reduced acetylcholine levels in the ileostomy samples, and increased the expression of leucocyte recruiting proteins, antimicrobial peptides and intestinal alkaline phosphatases of the brush border in the small intestine. The combination of B. subtilis DE111 and the diet administered during the study increased the expression of the proteins phosphodiesterase ENPP7, ceramidase ASAH2 and the adipokine Zn-alpha-2-glycoprotein that are involved in fatty acid and lipid metabolism. Acute B. subtilis DE111 ingestion had limited detectable effect on the microbiome, with the main change being its increased presence. These findings support previous data suggesting a beneficial role of DE111 in digestion, metabolism, and immune health that appears to begin within hours of consumption.

Development of oil-based gels as versatile drug delivery systems for pediatric applications

Administering medicines to 0- to 5-year-old children in a resource-limited environment requires dosage forms that circumvent swallowing solids, avoid on-field reconstitution, and are thermostable, cheap, versatile, and taste masking. We present a strategy that stands to solve this multifaceted problem. As many drugs lack adequate water solubility, our formulations used oils, whose textures could be modified with gelling agents to form "oleogels." In a clinical study, we showed that the oleogels can be formulated to be as fluid as thickened beverages and as stiff as yogurt puddings. In swine, oleogels could deliver four drugs ranging three orders of magnitude in their water solubilities and two orders of magnitude in their partition coefficients. Oleogels could be stabilized at 40°C for prolonged durations and used without redispersion. Last, we developed a macrofluidic system enabling fixed and metered dosing. We anticipate that this platform could be adopted for pediatric dosing, palliative care, and gastrointestinal disease applications.

Burnout among Portuguese radiographers during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has had a global impact, including in health services, placing health professionals under enormous tension, pressure, and stress. Professionals involved in the care, diagnosis, and treatment of COVID-19-infected patients have been subject to emotional and physical distress that can potentially enhance the development of occupational diseases. The aim of this study was to assess the impact of the COVID-19 pandemic on the incidence of burnout among Portuguese radiographers.

METHODS

This was a cross-sectional, quantitative study. Burnout levels were estimated using the Maslach Burnout Inventory-Human Services Survey, composed of 22 questions. Specific questions were developed to characterize the socio-demographic situation and the impact of the pandemic on the radiographers. Data were descriptively analyzed and Mann-Whitney and Kruskal-Wallis tests were used for correlation analysis.

RESULTS

The study sample comprised 386 radiographers, 68.7% of whom where female and 31.3% male. The mean sample age was 36.3 (±9.1) years. A total of 43.5% and 45.5% of subjects had a high level of emotional exhaustion and depersonalization, respectively, and 59.8% experienced low personal accomplishment. Altogether, 23.3% of study participants were at high risk of burnout in the three dimensions assessed and 77.2% in at least one.

CONCLUSION

Study results showed that radiographers were at high risk of developing burnout in the COVID-19 pandemic setting. Health institutions should actively monitor these professional's mental health and develop restorative strategies that enable their emotional wellbeing, preventing absenteeism and increasing patients' quality of care.

IMPLICATIONS FOR PRACTICE

Burnout of health professionals has a strong impact on health services organization, resulting in increased absenteeism and error probability, frequent work delays, low productivity and job satisfaction, inter- and intra-professional conflicts, high job turnover, high job quit, and decreased quality of care perceived by users.

Revisiting the “obsessional slowness” syndrome

Introduction

Obsessional slowness (OS) is a rare condition of disabling slow motor performance, first described in 1974, by Rachman, who documented 10 cases of “primary obsessional slowness”. Rachman argued that, although his patients with OS had Obsessive Compulsive Disorder (OCD), their motor symptoms were not related to the presence of motor-slowness-triggering obsessions/compulsions (e.g. checking and mental rituals). Whether OS truly is a distinct and “primary” entity is still a controversial issue, however.

Objectives

To present and discuss the phenomenology of OS.

Methods

Case reports of OS published in the literature, including Rachman’s descriptions.

Results

The literature on OS is extremely limited, with no published, large-scale descriptive studies or randomized controlled trials. Some authors doubt that OS is a “primary” condition, pointing out the clear overlap between OS and catatonia and emphasizing that the latter disorder also occurs in non-schizophrenic patients, for example, ones with OCD. Additionally, OCD and depression often co-occur. Thus, in severe cases, it may be challenging to disentangle the separate contribution of both disorders to psychomotor slowness. It is also crucial to exclude the possibility that a patience has juvenile parkinsonism or other causes of motor slowness before diagnosing him/her with OS, given that the diagnostic approaches and treatment strategies for OS and the aforementioned disorders differ.

Conclusions

OS seems to be a rare but often disabling motor manifestation of OCD, rather than a primary disease entity. However, some cases sit on the edge of current diagnostic criteria. Future research should help define OS more precisely.

Disclosure

No significant relationships.

Depersonalization and a severe form of agoraphobia: A case report and review

Introduction

Depersonalization during panic attacks may be a feature of a subgroup of Panic disorder. Several studies suggest that such subgroup corresponds to a more clinically severe form of Panic Disorder, with earlier onset and a higher rate of comorbidity with other psychiatric disorders, such as obsessive-compulsive disorder and generalized anxiety disorder. It is also hypothesized that depersonalization during panic attacks may lead Panic disorder to evolve into Agoraphobia.

Objectives

To present the case report of a patient with severe Agoraphobia, whose only symptom of Panic disorder was depersonalization.

Methods

Description of a case report.

Results

We describe the case of a 20-year-old woman who developed Agoraphobia after a single panic attack, during a physical education class, at the age of 13, with depersonalization symptoms only. After the attack, the patient stopped playing sports and engaging in any kind of activity in the absence of a trusted person. At the age of 20, the patient will only travel alone in the immediacies of her home, sometimes missing classes, because she cannot get a ride from trusted acquaintances. She justifies such avoidances with her fear of feeling depersonalized again. Over the course of her illness, she denied having experienced any other symptoms of a panic attack. She was treated with Paroxetine 40mg daily and cognitive behavioral therapy, having improved.

Conclusions

We believe this case provides good insight into depersonalization in panic attacks, supporting the view that Panic disorder with depersonalization may be a distinct and more severe subgroup of Panic Disorder.

TMOD-03. PAN-CANCER ANALYSIS OF ORTHOTOPIC PATIENT DERIVED XENOGRAFTS FROM BRAIN METASTASES

Brain metastases (BM) are a leading cause of cancer death and prognosis remains poor despite treatment advances at other sites. Models are central to therapeutic development, but few orthotopic patient-derived xenograft (PDX) models of BM exist. To represent diversity across BM types, we established a program to create orthotopic PDX at scale from all BM patients. To date BM were received from 100 patients and PDX attempted by direct brain injection (PDX, n=89) or injection of low passage patient-derived cell lines (PDCLX, n=11). We created 65 successful BM PDX from 13 cancers: 17 lung (55% take), 15 breast (68%), 6 melanoma (75%), 5 CNS lymphoma (83%), 3 gastrointestinal (75%), 2 esophageal (40%), 2 ovarian (67%), 1 sarcoma (100%), 1 laryngeal (100%), 1 prostate (100%), 1 pancreatic (100%), 1 uterine adenosarcoma (100%), and 1 yolk sac tumor (100%). Take rate was similar for models derived from patients with prior chemotherapy-only versus immune/targeted therapy-only (63 vs 58%). Fifteen patients had live tumor and matching PBMCs archived for modeling in vitro immunotherapy responses. Mean time to moribund among different cancer types ranged from 27 days (yolk sac tumor) to 177.5 days (ovarian). BM PDX had a favorable timeline for preclinical study (90% moribund at 180 days). All PDX retained high fidelity to the patient driver SNVs and copy aberrations, even at >P4. No significant differences noted by immunodeficient strain (SCID versus NSG) or injection site (orthotopic versus heterotopic). Explants from BM PDX were able to generate long-term cell lines (60%) or short-term cultures with qualitative concordance of model-to-patient responses to targeted therapy (Osimertinib, EGFRi) and immunotherapy (Pembrolizumab, PD1i). Genomic and clinical data were used to create the DFCI BM PDX cBioPortal for public release and models distribution will be available through the DFCI Center for Patient Derived Models.

Has the time come to integrate genetic risk scores into clinical practice?

Background

The risk for Coronary Artery Disease (CAD) is determined by both genetic and environmental factors, as well as by the interaction between them. It is estimated that genetic factors could account for 40% to 55% of the existing variability among the population (inheritability). Therefore, some authors have advised that it is time we integrated genetic risk scores into clinical practice.

Aim

The aim of this study was to evaluate the magnitude of the association between an additive genetic risk score (aGRS) and CAD based on the cumulative number of risk alleles in these variants, and to estimate whether their use is valuable in clinical practice.

Methods

A case-control study was performed in a Portuguese population. We enrolled 3120 participants, of whom 1687 were CAD patients and 1433 were normal controls. Controls were paired to cases with respect to gender and age. 33 genetic variants known to be associated with CAD were selected, and an aGRS was calculated for each individual. The aGRS was further subdivided into deciles groups, in order to estimate the CAD risk in each decile, defined by the number of risk alleles. The magnitude of the risk (odds ratio) was calculated for each group by multiple logistic regression using the 5th decile as the reference group (median). In order to evaluate the ability of the aGRS to discriminate susceptibility to CAD, two genetic models were performed, the first with traditional risk factors (TRF) and second with TRF plus aGRS. The AUC of the two ROC curves was calculated.

Results

A higher prevalence of cases over controls became apparent from the 6th decile of the aGRS, reflecting the higher number of risk alleles present (see figure). The difference in CAD risk was only significant from the 6th decile, increasing gradually until the 10th decile. The odds ratio (OR) for the last decile related to 5th decile (median) was 1.87 (95% CI:1.36–2.56; p<0.0001). The first model yielded an AUC=0.738 (95% CI:0.720–0.755) and the second model was slightly more discriminative for CAD risk (AUC=0.748; 95% CI:0.730–0.765). The DeLong test was significant (p=0.0002).

Conclusion

Adding an aGRS to the non-genetic risk factors resulted in a modest improvement in the ability to discriminate the risk of CAD. Such improvement, even if statistically significant, does not appear to be of real value in clinical practice yet. We anticipate that with the development of further knowledge about different SNPs and their complex interactions, and with the inclusion of rare genetic variants, genetic risk scores will be better suited for use in a clinical setting.

Funding Acknowledgement

Type of funding source: None

P936Atrial remodeling in rat hearts after exposure to high-intensity infrasound

Background

Noise is an important environmental risk factor. Industrial environments are rich in high-intensity infrasound (hi-IFS), which we have found to induce myocardial and coronary perivascular fibrosis in rats. Recently, a significant association between noise exposure and the incidence of atrial fibrillation (AF) was found in large cohort studies but the pathophysiology is unclear. Atrial fibrosis remains the cornerstone of atrial pathology in AF. Purpose: We hypothesized that rats exposed to hi-IFS develop atrial remodeling involving fibrosis and connexin 43, which we sought to evaluate. Material and Methods: Seventy-two Wistar rats, half exposed to hi-IFS (120dB, <20Hz) during a maximum period of 12 weeks and half age-matched controls, were studied. Atrial fibrosis was analyzed by Chromotrope-aniline blue staining. The immunohistochemical evaluation of Cx43 was performed using the polyclonal antibody connexin-43m diluted 1:1000 at 4ºC overnight. Digitized images were obtained with an optical microscope using 400× magnifications. The measurements were performed using image J software. A two-way ANOVA model was used to compare the groups. Results: The mean values of the ratio "atrial fibrosis / cardiomyocytes" increased to a maximum of 0,1095 ± 0,04 and 0,5408 ± 0,01, and of the ratio "CX43 / cardiomyocytes" decreased to 0,0834 ± 0,03 and 0,0966 ± 0,03, respectively in IFS-exposed rats and controls. IFS-exposed rats exhibited a significantly higher ratio of fibrosis (p < 0,001) and lower ratio of Cx43 (p = 0,009). Conclusion: High-intensity infrasound exposure triggers atrial remodeling in rat hearts. Whether this finding correlates to arrhythmogenic substrate in noise induced-AF is not known and reinforces the need for further experimental studies.

Table 1 Time of exposure (weeks) Group IFS (n = 36) Group CTL (n = 36) P value Ratio of atrial fibrosis / cardiomyocytesMean ± SD 1 0,0896 ± 0,04 0,0460 ± 0,03 0,007 6 0,0936 ± 0,03 0,0491 ± 0,01 0,001 12 0,1095 ± 0,04 0,0541 ± 0,01 0,001 Ratio of atrial CX43 / cardiomyocytesMean ± SD 1 0,1100 ± 0,03 0,1371 ± 0,03 0,047 6 0,0829 ± 0,04 0,1036 ± 0,03 0,170 12 0,0834 ± 0,03 0,0966 ± 0,03 0,259 Mean ± SD of the two measured outcomes in the two groups. IFS – Infrasound; CTL – Control; SD – standard deviation; Cx43 – Connexin 43

Abstract Figure. Atrial fibrosis and Cx43 /cardiomyocytes

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Experimental evidence supporting a global melt layer at the base of the Earth's upper mantle

The low-velocity layer (LVL) atop the 410-km discontinuity has been widely attributed to dehydration melting. In this study, we experimentally reproduced the wadsleyite-to-olivine phase transformation in the upwelling mantle across the 410-km discontinuity and investigated in situ the sound wave velocity during partial melting of hydrous peridotite. Our seismic velocity model indicates that the globally observed negative Vs anomaly (−4%) can be explained by a 0.7% melt fraction in peridotite at the base of the upper mantle. The produced melt is richer in FeO (~33 wt.%) and H₂O (~16.5 wt.%) and its density is determined to be 3.56–3.74 g cm⁻³. The water content of this gravitationally stable melt in the LVL corresponds to a total water content in the mantle transition zone of 0.22 ± 0.02 wt.%. Such values agree with estimations based on magneto-telluric observations.

A 56–60 km thick low velocity layer exists at the base of the Earth’s upper mantle. Here, the authors experimentally reproduced the wadsleyite-to-olivine transition in the upwelling mantle and show that the low velocity anomaly can be explained by melting of hydrous peridotite.

Physical fitness percentile charts for children aged 6-10 from Portugal

AIM

The present study aims (1) to provide reference percentile charts for the following measures of Physical Fitness (PF): the sit-and-reach, handgrip, standing long jump, 50 yards' dash, 4x10m shuttle run and 1-mile run/walk tests in children aged 6 to 10 years, and (2) to compare the performance of the Portuguese children with their age- and sex peers.

METHODS

A total of 3804 Portuguese children (1985 boys and 1819 girls) aged 6-10 years old participated in this study. The sample was stratified from 20 public elementary schools and children were randomly selected in each school. Charts were separately built for each sex using the LMS method.

RESULTS

Boys showed better results than girls in handgrip, standing long jump, 50 yards' dash, 4x10 m shuttle run and 1-mile run/walk, while girls are better performers than boys in sit-and-reach.

CONCLUSION

Age- and gender- percentiles for a set of physical fitness tests for 6-10 year old (primary school) Portuguese children have been established. Boys showed greater overall PF than girls, except in the flexibility test, in which girls performed better. The reported normative values provide ample opportunities to accurately detect individual changes during childhood. These reference values are especially important in healthcare and educational settings, and can be added to the worldwide literature on physical fitness values in children.

Perceived Stress in Obsessive-Compulsive Disorder is Related with Obsessive but Not Compulsive Symptoms

Obsessive-compulsive disorder (OCD) is achronic psychiatric disorder characterized by recurrent intrusive thoughts and/or repetitive compulsory behaviors. This psychiatric disorder is known to be stress responsive, as symptoms increase during periods of stress but also because stressful events may precede the onset of OCD. However, only a few and inconsistent reports have been published about the stress perception and the stress-response in these patients. Herein, we have characterized the correlations of OCD symptoms with basal serum cortisol levels and scores in a stress perceived questionnaire (PSS-10). The present data reveals that cortisol levels and the stress scores in the PSS-10 were significantly higher in OCD patients that in controls. Moreover, stress levels self-reported by patients using the PSS-10 correlated positively with OCD severity in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Interestingly, PSS-10 scores correlated with the obsessive component, but not with the compulsive component, of Y-BOCS. These results confirm that stress is relevant in the context of OCD, particularly for the obsessive symptomatology.

One year of Lamivudine therapy for portuguese patients with chronic hepatitis B

OBJECTIVE

To assess the efficacy of lamivudine treatment on hepatitis B e antigen (HBeAg) and/or hepatitis B surface antigen (HBsAg) seroconversion, on other virological and serological markers of response including hepatitis B virus (HBV) DNA and serum aminotransferases, and the safety of lamivudine treatment in hepatitis B patients.

PATIENTS

This phase III open-label study evaluated the virological and biochemical response to lamivudine in 70 Portuguese patients with HBeAg positive chronic hepatitis B. Patients were treated with lamivudine 100mg once daily for 12 months.

METHODS

Antiviral activity was assessed by measuring alanine aminotransferase (ALT)/aspartate aminotransferase (AST) levels at all protocol visits, and hepatitis B serology and HBV DNA were performed at baseline and at month 12 visits. Evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses.

RESULTS

The primary endpoint was virological response at month 12, defined as loss of detectable HBeAg from serum with a reduction of HBV DNA to undetectable levels, and this was observed in 19/69 (27.5%) of patients. Almost half of the patients were HBV DNA negative by this time. Mean ALT values decreased steadily during treatment and by 12 months 61% of patients had values within the normal range. HBeAg seroconversion (HBeAg negative, HBeAb positive) was achieved in 27.9% of patients by 12 months, although all patients remained HBsAg positive.

CONCLUSION

Lamivudine was well tolerated and the incidence of adverse events was similar to those reported in previous studies. Lamivudine treatment resulted in virological and biochemical improvements in HBeAg positive chronic hepatitis B patients, with HBeAg seroconversion in one-third of patients.

Clinical and radiological results following radial osteotomy in patients with Kienböck’s disease

Radial osteotomy is currently advocated for patients with Lichtman’s stages II and IIIA of Kienböck’s disease; its place in the treatment of patients with stage IIIB disease remains controversial. The purpose of this study was to evaluate the medium-term results of this procedure and to compare the outcome in patients with stage IIIB disease and those with earlier stages (II and IIIA). A total of 18 patients (18 osteotomies) were evaluated both clinically and radiologically at a mean follow-up of 10.3 years (4 to 18). Range of movement, grip strength and pain improved significantly in all patients; the functional score (Nakamura Scoring System (NSSK)) was high and self-reported disability (Disabilities of Arm, Shoulder and Hand questionnaire) was low at the final follow-up in all patients evaluated. Patients with stage IIIB disease, however, had a significantly lower grip strength, lower NSSK scores and higher disability than those in less advanced stages. Radiological progression of the disease was not noted in either group, despite the stage. Radial osteotomy seems effective in halting the progression of disease and improving symptoms in stages II, IIIA and IIIB. Patients with less advanced disease should be expected to have better clinical results.

Olfactory reference syndrome - A case report

Introduction

Olfactory reference syndrome (ORS), first described by Pryse-Phillips in 1971, is a rare psychiatric condition whose defining characteristic is a preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others. Although the existence of ORS is now widely accepted, current classifications do not explicitly mention ORS as an independent category, but consider it as a delusional disorder, somatic type. Nonetheless, given this syndrome's consistent description along time and cultures, and the associated substancial distress and disability, many authors debate the possibility of a new classification in order to establish its nosological status.

Objectives/aims

The aim of this paper is to show and discuss some troublesome and complex issues of diagnosis and management of patients with ORS.

Methods

Herein we report a case of a 38-year-old woman who presented with ORS.

Results/conclusions

Improvement in ORS can take place, in some extent, with a variety of different modalities of treatment, with the disorder responding to antidepressants and psychotherapy more frequently than to neuroleptics. Data on ORS are still limited and more research in this field is needed. Awareness of this particular diagnosis allows appropriate treatment to be administered.

Screening for twin-twin transfusion syndrome at 11-14 weeks of pregnancy: the key role of ductus venosus blood flow assessment

OBJECTIVES

A discrepancy in crown-rump length (CRL) and/or nuchal translucency thickness (NT) between monochorionic twins has been found to be associated with an increased risk of twin-twin transfusion syndrome (TTTS). As one of the most plausible mechanisms for increased NT is hemodynamic imbalance and cardiac dysfunction, indirectly manifested by abnormal blood flow in the ductus venosus (DV), we aimed to clarify the role of DV blood flow assessment in identifying those monochorionic twins more prone to develop TTTS.

METHODS

We present 99 cases of monochorionic diamniotic twin pregnancies in which CRL, NT and DV blood flow were evaluated at 11-14 weeks' gestation.

RESULTS

Discrepant values of CRL were not predictive of TTTS development. Intertwin NT discrepancy >or= 0.6 mm had a sensitivity of 50.0% and a specificity of 92.0%. The presence of at least one abnormal blood flow waveform in the DV was associated with a relative risk for developing TTTS of 11.86 (95% CI, 3.05-57.45), with a sensitivity of 75.0% and a specificity of 92.0%. The combination of abnormal DV blood flow with NT discrepancy >or= 0.6 mm yielded a relative risk for the development of TTTS of 21 (95% CI, 5.47-98.33).

CONCLUSIONS

Both intertwin discrepancy in NT and abnormal flow in the DV in monochorionic twins may represent early manifestations of hemodynamic imbalance between donor and recipient. In these pregnancies, in addition to NT measurement at 11-14 weeks, the Doppler assessment of DV blood flow significantly increases the performance of screening for those at risk of developing TTTS.

Skeletal maturity and socio-economic status in Portuguese children and youths: the Madeira growth study

BACKGROUND

Skeletal maturity is used to evaluate biological maturity status. Information about the association between socio-economic status (SES) and skeletal maturity is limited in Portugal.

AIMS

The aim of this study is to document the skeletal maturity of youths in Madeira and to evaluate variation in maturity associated with SES.

SUBJECTS AND METHODS

The study involved 507 subjects (256 boys and 251 girls) from the Madeira Growth Study, a mixed-longitudinal study of five cohorts (8, 10, 12, 14 and 16 years of age) followed at yearly intervals over 3 years (1996-1998). A total of 1493 observations were made. Skeletal age was estimated from radiographs of the hand and wrist using the Tanner-Whitehouse 2 method (TW2). Social class rankings were based on method. Five social rankings were subsequently grouped into three SES categories: high, average and low.

RESULTS

Median for the radius, ulna and short finger bones (RUS scores) in the total sample of boys and girls increased curvilinearly across age whereas median for the 7 (without pisiform) carpal bones (Carpal scores) increased almost linearly. The 20-bone maturity scores demonstrated distinctive trends by gender: the medians for boys increased almost linearly while the medians for girls increased curvilinearly. SES differences were minimal. Only among children aged 10-11 years were high SES boys and girls advanced in skeletal maturity. Madeira adolescents were advanced in skeletal maturity compared with Belgian reference values.

CONCLUSION

The data suggests population variation in TW2 estimates of skeletal maturation. Skeletal maturity was not related to SES in youths from Madeira.

Analysis of resilience scores in a cohort of solid tumors ambulatory cancer patients in chemotherapy treatment

e20736

Background: Resillience is the ability to successfully cope with change or misfortune, allowing a person or a group to regain balance and keep going despite adversity and also to find meaning amidst confusion and tumult. It is a positive personality characteristic that enhances individual and group adaptation. Very scanty data exists regarding its quantification and distribution in cancer patients. The objective of this study is to evaluate and describe resilience scores in a population of ambulatory solid tumors cancer patients receiving chemotherapy treatment. Methods: Individual Resillience scores were measured by the Wagnild and Young Scale, validated for portuguese language from Brazil. It is composed by 25-item questions, scored on a 7-point scale from 1 = disagree, to 7 = agree, with all items worded positively. Possible scores range from 25 to 175 with higher scores reflecting higher resilience. During the year 2008, this scale was applied to 48 ambulatory solid tumor cancer patients in chemotherapy treatment at Oncosinos / Hospital Regina in Novo Hamburgo, Brazil. The study was approved by the Ethics comitte and all patiens signed the informed consent form. Results: The mean age of patients was 52 years (19–76) and 34 (70%) were women. The most common cancer types were: breast (48%), colo-rectal (21%) and prostate (8%). Most patients (47%) had stage IV disease and were in palliative chemotherapy treatment. Stage III cancer was present in 40% and stages I and II in 13% of patients. The mean score of resilience was 141+ 12 (101–174). The scores demosntrated a normal statistical distribution. No statistical differences in the mean resillience scores were detected between groups of patients as defined by: sex (P=0.11), age > or < 50 years (P=0.9), cancer type (P= 0.78), disease staging (P= 0.9), or the chemotherapy treatment intention, if palliative or curative (P=0.91). Conclusions: The resilience scores in this cohort of patients display a statistically normal distribution. Our results suggest that the total resillience score is an intrinsic individual characteristic that is independent of cancer stage, cancer type, age and sex of the patients. Further research is necessary to clarify the implications of these findings.

No significant financial relationships to disclose.

"Downhill" varices. A rare cause of esophageal hemorrhage

"Downhill" varices or upper esophageal varices are a rare cause of proximal digestive tract hemorrhage with only 16 cases described in the literature. In our series, hemorrhage due to "downhill" varices represents 0.1% of all acute esophageal variceal bleeding. Their etiology differs from that of the usual "uphill" varices secondary to portal hypertension, and the clinical management should be directed to vascular obstruction if present. We report a case of an 89-year-old male with hemorrhagic "downhill" varices not associated, as usually, with superior vena cava obstruction or compression, but with severe pulmonary hypertension and drug-related hemorrhagic risk factors, whose removal proved sufficient to prevent rebleeding.

Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?

BACKGROUND/AIMS

Variceal bleeding is still associated with high mortality and balloon tamponade may be a lifesaving measure when endoscopic therapy is not available or feasible. The risk of esophageal perforation with balloon tamponade after endoscopic therapy is still uncertain. The aims of the study were to investigate balloon tamponade effectiveness and safety after endoscopic therapy.

METHODOLOGY

Retrospective analysis of 100 consecutive episodes of acute variceal bleeding treated with the Sengstaken-Blakemore tube.

RESULTS

Balloon tamponade had an overall effectiveness of 61%. The Child-Pugh score was significantly higher in patients who failed balloon tamponade. In 48 cases balloon tamponade was preceded by failure of endoscopic therapy. Balloon tamponade was more effective if a previous attempt to perform endoscopic therapy happened (75% vs. 48%; p = 0.006). Aspiration was the most frequent complication. No cases of esophageal perforation were registered.

CONCLUSIONS

Currently balloon tamponade is only used as a temporary bridge to other strategies, when other forms of hemostatic therapies do not succeed. Balloon tamponade was more effective in patients with less severe hepatic dysfunction. Previous attempts to perform endoscopic therapy may augment tamponade effectiveness without increasing the risk of esophageal perforation.

Sildenafil improves quality of life in men with heart failure and erectile dysfunction

Patients with congestive heart failure (CHF) have specific factors that enhance the risk for erectile dysfunction (ED), such as low cardiac output and the use of drugs with vasodilator effect. ED can negatively affect interpersonal relationships and self-esteem, with significant impact on the quality of life. We hypothesized that the improvement of the sexual dysfunction would enhance the quality of life of individuals with systolic heart failure. This is a prospective study of 12 male CHF patients using a fixed dose of sildenafil during 1 month. Patients were included if they had left ventricular ejection fraction lower than 40% documented by echocardiography and International Index of Erectile Function (IIEF) score lower than 21. The effect of sildenafil in quality of life was evaluated by the Minnesota questionnaire. Improvement in ED was assessed using the IIEF. The mean IIEF5 score was 9.6 (+/-3.8) before the use of sildenafil and 19.3 (+/-4.3) after sildenafil (P = 0.0001). The mean Minnesota score was 28.75 (+/-21) before treatment and 12.75 (+/-10.1) after the intervention (P = 0.012). In conclusion, the sexual function improvement provided by sildenafil enhances quality of life in individuals with systolic heart failure.

Erectile dysfunction and HTLV-I infection: a silent problem

The human T-lymphotropic virus type I (HTLV-I) is a retrovirus associated with a chronic myelopathy known as HTLV-I-Associated Myelopathy or Tropical Spastic Paraparesis (HAM/TSP). The main objective was to assess the frequency of erectile dysfunction (ED) in HTLV-I-infected individuals from Salvador and other cities from Bahia, Brazil, as well as to verify if sexual dysfunction correlates with urinary symptoms and overall neurological impairment. From January 2001 to April 2004, 218 HTLV-I carriers (111 male and 107 female subjects) had complete clinical, neurological, and urological evaluation. They were assessed using standardized questionnaires to determine urinary complaints (Urinary Distress Inventory) and ED (Brief Male Sexual Function Inventory). Neurological impairment was established by Expanded Disability Status Scale (EDSS) from 0 to 10. HAM/TSP was considered as EDSS> or =2. A total of 17 males had clinically defined HAM/TSP (group 1). From the 94 HTLV-I-infected males, 62 were selected (group 2) and paired by age with patients in group 1. A total of 79 individuals were selected for this study. The age ranged from 35 to 81 y (mean=47.9+/-9.65). The percentage of ED in the studied population was 40.5%. In the HAM/TSP group, ED frequency was 88.2%. The associations among sexual dissatisfaction, erectile dysfunction, urinary symptoms (frequency, nocturia, and urgency) and EDSS> or =2 were statistically significant. In HAM/TSP, there is a slow and progressive degeneration of the lateral funiculus of the spinal cord. HTLV-I-infected individuals present a high frequency of ED and it is closely associated to urinary symptoms and the overall neurological picture. The HTLV-I carriers already had prominent compromise of the sexual activity.

An experimental model of mycobacterial infection under corneal flaps

In order to develop a new experimental animal model of infection with Mycobacterium chelonae in keratomileusis, we conducted a double-blind prospective study on 24 adult male New Zealand rabbits. One eye of each rabbit was submitted to automatic lamellar keratotomy with the automatic corneal shaper under general anesthesia. Eyes were immunosuppressed by a single local injection of methyl prednisolone. Twelve animals were inoculated into the keratomileusis interface with 1 microl of 10(6) heat-inactivated bacteria (heat-inactivated inoculum controls) and 12 with 1 microl of 10(6) live bacteria. Trimethoprim drops (0.1%, w/v) were used as prophylaxis for the surgical procedure every 4 h (50 microl, qid). Animals were examined by 2 observers under a slit lamp on the 1st, 3rd, 5th, 7th, 11th, 16th, and 23rd postoperative days. Slit lamp photographs were taken to document clinical signs. Animals were sacrificed when corneal disease was detected and corneal samples were taken for microbiological analysis. Eleven of 12 experimental rabbits developed corneal disease, and M. chelonae could be isolated from nine rabbits. Eleven of the 12 controls receiving a heat-inactivated inoculum did not develop corneal disease. M. chelonae was not isolated from any of the control rabbits receiving a heat-inactivated inoculum, or from the healthy cornea of control rabbits. Corneal infection by M. chelonae was successfully induced in rabbits submitted to keratomileusis. To our knowledge, this is the first animal model of M. chelonae infection following corneal flaps for refractive surgery to be described in the literature and can be used for the analysis of therapeutic responses.

Dieulafoy's lesion: management and long-term outcome

BACKGROUND AND STUDY AIMS

Dieulafoy's lesion is usually considered to be a rare cause of gastrointestinal bleeding and little information is available about the long-term follow-up of this condition. We studied the clinical pattern and long-term outcome in patients with Dieulafoy's lesion who were managed in a gastrointestinal intensive care unit.

PATIENTS AND METHODS

We reviewed the data on the diagnosis, treatment, and outcome of 70 patients admitted to our unit for acute upper gastrointestinal bleeding due to Dieulafoy's lesion. Endoscopic hemostasis was performed in 69 cases. Patients underwent surgery if endoscopic therapy failed. A phone interview was carried out to assess the long-term clinical outcome.

RESULTS

Dieulafoy's lesion accounted for 4 % of cases of upper gastrointestinal bleeding in patients admitted during the period studied. The mean number +/- SD of endoscopies required to establish the diagnosis was 1.4 +/- 0.75. Endoscopic hemostasis was initially successful in 91.3 % of patients, while nearly 16 % of patients required surgery because endoscopic therapy failed. The overall mortality rate was 8.6 %. None of the 52 patients who were followed up by phone reported recurrent bleeding after discharge from hospital, in a mean follow-up period of 69 months.

CONCLUSIONS

Dieulafoy's lesion is a not uncommon cause of severe recurrent gastrointestinal bleeding. Endoscopic therapy is safe and effective in achieving permanent hemostasis. The long-term prognosis for Dieulafoy's lesion is excellent, even when patients are treated using endoscopic methods alone.

Aerobic Bacterial Conjunctival Flora in Diabetic Patients

OBJECTIVE

To study the aerobic conjunctival flora of diabetic patients and its relation to the presence and level of diabetic retinopathy and the duration of the disease.

METHODS

One hundred three patients from the diabetic retinopathy screening program of the Federal University of São Paulo with no evidence of ocular surface disease were included. The diabetic patient cohort was compared with 60 nondiabetic subjects. All patients underwent slit-lamp evaluation, conjunctival scrapings, and indirect ophthalmoscopy.

RESULTS

The frequency of positive conjunctival cultures was significantly higher in the diabetic group (94.18%) than in the nondiabetic group (73.33%). Among diabetic patients, a significantly higher frequency of positive cultures was detected in those with diabetic retinopathy than in those without retinopathy. Neither the duration of the diabetes nor the hypoglycemic therapy correlated with the culture results. Coagulase-negative Staphylococcus was the most common microorganism isolated, and its identification was more frequent in patients with retinopathy than in those without diabetic retinopathy.

CONCLUSION

Diabetic patients have a significantly higher number of positive conjunctival cultures. The presence of diabetic retinopathy was correlated with an increase in positive cultures and a higher proportion of coagulase-negative Staphylococcus.

Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility

BACKGROUND AND STUDY AIMS

The risk of variceal bleeding cannot be accurately predicted using endoscopy alone. Although variceal pressure has been demonstrated to be a major determinant for the rupture of esophageal varices, direct determination by needle puncture is unsuitable for routine clinical use. Due to their operator-dependency, current noninvasive endoscopic methods for determination of variceal pressure have not gained wide acceptance. We have developed a new method of measuring variceal pressure, using endoscopic power Doppler imaging to monitor the manometry of esophageal varices. The aims of this study were to test in vitro the accuracy of Doppler-guided manometry and to assess the clinical feasibility of this method.

MATERIALS AND METHODS

Experimental validation of this technique was performed using an in vitro model of artificial varices of different sizes. A linear-array endosonography (EUS) probe with power Doppler capability was used to assess flow in the varices and a balloon for manometry of esophageal varices was attached to the tip of the probe. Pressure readings were made at the time of disappearance of the Doppler signal during variceal compression by the balloon. Linear regression analysis was used to compare the results of Doppler-guided and direct intraluminal pressure measurement in the artificial varices. Variceal pressure was then measured with this technique in 28 patients with portal hypertension and esophageal varices without previous bleeding, and the results were compared with portal pressure assessed according to the hepatic vein pressure gradient (HVPG).

RESULTS

In vitro studies demonstrated a good correlation between the pressure measured with Doppler monitoring and the actual intravariceal pressure (r > or = 0.922; P < 0.001). The determination of variceal pressure with this method was technically successful in 26/28 patients (93 %). The intraoperator variance was 9.3 +/- 8.6 %. Overall, the mean variceal pressure was significantly lower than the mean HVPG (21.2 +/- 5.3 mmHg vs. 24.3 +/- 7.8 mmHg; P < 0.01). Variceal pressure and portal pressure (as assessed by the HVPG) correlated significantly (r = 0.64; P < 0.001).

CONCLUSIONS

Our preliminary results indicate that EUS Doppler-guided manometry of esophageal varices is feasible and accurate. This technique may become a more reliable method for noninvasive measurement of variceal pressure and warrants further investigation.

Epidemiological study of 134 subjects with allergic conjunctivitis

At times it is difficult to distinguish among the subtypes of chronic allergic conjunctivitis. A prospective study with 134 patients was carried out. Patients were diagnosed with vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC) or perennial allergic conjunctivitis (PAC). Demographic information was also collected including, age at symptom onset, sex, history of non-ocular allergy, and history of family allergy. Forty-six percent were diagnosed with VKC, 40% with AKC, 8% with PAC, and 6% were not specifically diagnosed. This distribution information as well as the demographic information collected demonstrates that there are patterns within each subgroup of chronic ocular allergy sufferers. These findings will be helpful in the diagnosing and proper classification of ocular allergic conditions.

Fosinopril-induced prolonged cholestatic jaundice and pruritus: first case report

We report a case of fosinopril-induced prolonged cholestatic jaundice and pruritus in a 61-year-old man, with no previous hepatobiliary disease, who presented with asthenia, jaundice and itching 3 weeks after starting fosinopril therapy. Other drugs taken by the patient were not considered probable causes. The diagnostic evaluation showed no biliary obstruction and other possible causes of intra-hepatic cholestasis were excluded. Liver biopsy showed cholestasis without bile duct damage. The disease ran a severe course during the 2 months of hospitalization, with prolonged itching for 6 months, eventually controlled with oral naltrexone. Jaundice subsided after 4 months, with anicteric cholestasis persisting for more than 18 months. Similar occurrences have been reported with other inhibitors of angiotensin-converting enzyme (mostly captopril), but this is the first case of an important adverse reaction to fosinopril.