Early Diagnosis of 46,XX Testicular Difference of Sexual Development: Unusual Presentation with Increased Nuchal Translucency

INTRODUCTION

46,XX testicular disorder of sexual development (DSD) may present prenatally as a mismatch between phenotype and karyotype. Enlarged nuchal translucency is an abnormal sign of many disorders. We present a first trimester fetus with increased nuchal translucency that was later determined to be a 46,XX testicular DSD.

CASE PRESENTATION

A first-trimester pregnancy ultrasound revealed enlarged nuchal translucency. Chorionic villous sampling documented a 46,XX karyotype. Subsequent ultrasounds identified male external genitalia. FISH analysis documented a SRY gene translocation. At birth, the infant had normal male internal and external genitalia.

CONCLUSIONS

46,XX testicular DSD may present in the first trimester with an enlarged nuchal translucency.

Leg dystrophic calcification as a consequence of chronic diabetic foot infection: a case report

Foot ulceration and infection is associated with a substantial increase in morbidity and mortality in patients with diabetes. We present a clinical case of recurrent diabetic foot infection with an atypical clinical evolution. A 58-year-old male patient with type 1 diabetes and a history of bilateral Charcot foot neuroarthropathy was followed at our Diabetic Foot Clinic for an unhealed plantar foot ulcer for >1.5 years with recurrent episodes of infection. He was admitted to hospital due to foot ulcer reinfection with sepsis and ipsilateral lower limb cellulitis. The foot infection was found to be associated with an underlying abscess in the anterior compartment of the leg, with a cutaneous fistulous course with extensive alterations of an inflammatory nature. Exudate from the lesion was drained and tissue biopsied, revealing Serratia marcescens and Klebsiella oxytoca with dystrophic calcification (DC). Surgical excision of dystrophic tissue with debridement of the fistulous tracts was performed. The excised material corroborated the presence of fibroadipose connective tissue with marked DC, as well as areas of mixed inflammation compatible with a chronic infectious aetiology. Targeted long-term antibiotic therapy was implemented, for a total of six weeks, with a favourable clinical evolution and complete closure of the lesion at the final follow-up. DC results from calcium deposition in degenerated tissues without evidence of systemic mineral imbalance and is a potential cause of non-healing ulcers. Few cases of DC have been reported in diabetic foot patients and its treatment remains challenging and controversial. A longer follow-up period is necessary to verify the effectiveness of our approach.

Shedding Light on Multiple Symmetric Lipomatosis: An Overlooked Syndrome in the Evaluation of Obesity

BACKGROUND Multiple symmetric lipomatosis (MSL), also known as Launois-Bensaude syndrome, is a rare syndrome that is frequently misinterpreted as simple obesity. It has seldom been reported. Both conditions can coexist; however, unlike common obesity, in which total body fat is well distributed, patients affected by MSL present with symmetrical, painless fat masses that predominantly appear in the face, neck, occipital region and supraclavicular fossa. Launois-Bensaude syndrome's etiology is still poorly understood but an association with alcohol use has been documented. CASE REPORT A 49-year-old woman was referred to our department due to class II obesity (body mass index of 39.8 kg/m²). She had a history of arterial hypertension and daily wine consumption (2 glasses on average). She complained of weight gain after menopause and she reported having tried multiple times to lose weight by herself without success. On physical examination, the patient had an unusual pattern of fat distribution: exuberant symmetrical fat masses that were localized in her arms and thighs and spared her face, neck, forearms, and lower legs. She claimed that these masses had a rapid onset and then stabilized. The clinical history and the patient's phenotype were compatible with a non-classic type of Launois-Bensaude syndrome. CONCLUSIONS We concluded that our patient's condition encompasses more than just simple obesity; it involved a distinct form of adiposopathy that led to a completely different clinical approach. A detailed physical examination seems to be key for clinical suspicion of this rare syndrome, which can be a true pitfall in obesity evaluation.

Inappropriate gestational weight gain impact on maternofetal outcomes in gestational diabetes

OBJECTIVE

To evaluate the association between the dimension of deviation from appropriate gestational weight gain (GWG) and adverse maternofetal outcomes in women with gestational diabetes mellitus (GDM).

METHODS

We performed a multicentric retrospective study based on the Portuguese GDM Database. Women were classified as within GWG, insufficient (IGWG) or excessive (EGWG) than the Institute of Medicine recommendations. EGWG and IGWG were calculated for each prepregnancy BMI category. Large-for-gestational-age (LGA) and macrosomia were defined as a birthweight more than the 90th percentile for the gestational age and newborn weight greater than 4000 g, respectively. Logistic regression models (adjusted odds ratio [aOR] plus 95% confidence interval [95%CI]) were derived to evaluate the association between EGWG or IGWG and adverse maternofetal outcomes.

RESULTS

A total of 18961 pregnant women were included: 39.7% with IGWG and 27.8% with EGWG. An EGWG over 3 kg was associated with a higher risk of LGA infants (aOR 1.95, 95%CI 1.17-3.26) and macrosomia (aOR 2.01, 95%CI 1.23-3.27) in prepregnancy normal weight women. An EGWG greater than 4 kg was associated with a higher risk of LGA infants (aOR 1.67, 95%CI 1.23-2.23) and macrosomia (aOR 1.90, 95%CI 1.38-2.61) in obese women. In overweight women, an EGWG above 3.5 kg was associated with a higher risk of LGA infants (aOR 1.65, 95%CI 1.16-2.34), macrosomia (aOR 1.85, 95%CI 1.30-2.64), preeclampsia (aOR 2.40, 95%CI 1.45-3.98) and pregnancy-induced hypertension (aOR 2.21, 95%CI 1.52-3.21). An IGWG below -3.1 kg or -3kg was associated with a higher risk of small-for-gestational-age [SGA] infants in women with normal (OR 1.40, 95%CI 1.03-1.90) and underweight (OR 2.29, 95%CI 1.09-4.80), respectively.

CONCLUSIONS

Inappropriate gestational weight gain seems to be associated with an increased risk for adverse maternofetal outcomes, regardless of prepregnancy BMI. Beyond glycemic control, weight management in women with GDM must be a focus of special attention to prevent adverse pregnancy outcomes.KEY MESSAGESThe dimension of deviation from appropriate gestational weight gain was associated with an increased risk for adverse maternofetal outcomes among women with gestational diabetes.Weight management must be a focus of special attention in women with gestational diabetes to prevent adverse pregnancy outcomes.

Gender-Affirming Hormone Therapy: Physical and Sociopsychological Effects, Impact and Satisfaction

Background Gender dysphoria treatment includes gender-affirming hormone therapy (GAHT). Studies are still lacking on how to characterize its effects and impact on transgender people's lives more effectively. Aim To study the physical and psychological effects of GAHT on transgender individuals, assess its impact on their lives, and rate their overall satisfaction. Methods Participants (n = 114; ages 18-62 years; median age 24.0 (21.0 - 33.0) years) included transgender adults residing in Portugal who were undergoing or had undergone hormonal therapy for at least one uninterrupted year. Participants completed an original questionnaire. For most items, an ordinal Likert-style scale ranging from 0 (worst result) to 6 (best result) was used. Descriptive statistics and non-parametric tests, including Pearson's chi-squared test, Wilcoxon signed-rank test, and Mann-Whitney U test were used to analyze categorical and continuous variables, with a significance level set at 0.05. Outcomes The outcomes included desired physical changes rating (perception and satisfaction with changes); side effects of GAHT; the sociopsychological impact of GAHT (on self-esteem, body image, psychological wellbeing, social and family relations); overall satisfaction (with treatment results and medical follow-up). Results The changes classified as the most perceptible in those undergoing masculinizing treatment (Group M) were amenorrhea (6 (5.0-6.0) points) and clitoris enlargement (6 (5.0-6.0) points). These were also the ones rated as the most satisfactory (6 (6.0-6.0) points for amenorrhea and 6 (4.0-6.0) points for clitoris enlargement). On those undergoing feminizing therapy (Group F), the alteration voted as the most perceptible was sperm production decrease (6 (2.0-6.0) points), and the ones classified as the most satisfactory were sperm production decrease (6 (4.0-6.0) points) and spontaneous erections decrease (6 (5.0-6.0) points). Side effects were reported by 89.7% of Group M (mood swings were the most common) and 96.3% of Group F (decreased libido was the most frequent). The sociopsychological impact of hormonal treatment was significantly positive in all analyzed variables (p<0.001). Overall satisfaction with treatment results and medical follow-up were rated with 5 points and 4.5 points, respectively. Clinical implications This study provides clinicians with more evidence that GAHT may improve the physical, psychological and social health of transgender people seeking medical transition. Strengths and limitations The strengths of the current study include a high participant count relative to the target population, the acquisition of data on previously unexplored variables, and the significance of being one of the few investigations of its kind conducted in Portugal. However, the study has limitations, including differences in participant characteristics, a small sample size for some variables, potential bias due to the retrospective nature of the study, individualized treatment regimens, and the inclusion of participants from different countries, which limit the generalization of the results. Conclusions This study provides further evidence that GAHT is effective, and that its physical effects are satisfactory while resulting in mostly non-severe nor life-threatening side effects. GAHT is an important therapy in gender dysphoria and has consistent results in improving numerous sociopsychological variables.

Maternofetal outcomes in early-onset gestational diabetes: does weight gain matter?

AIM

Women with early-onset gestational diabetes mellitus (GDM) have overall lower gestational weight gain (GWG) compared to those with later-onset GDM, albeit with usually worse maternofetal outcomes. We intent to investigate the association between inadequate GWG and maternofetal outcomes in pregnant women with early-onset GDM.

METHODS

We performed a retrospective study of women with early-onset GDM based on the National Registry of GDM. Three study groups were defined according to the recommendations of the Institute of Medicine for GWG: excessive GWG (eGWG), adequate (aGWG) or insufficient (iGWG).

RESULTS

A total of 8040 pregnant women were included: 27% (n = 2170) eGWG, 31% (n = 2492) aGWG and 42% (n = 3378) iGWG. Preeclampsia (4.3 vs 3 vs 1.6%, p < 0.001), polyhydramnios (3.1 vs 2.3 vs 1.8%, p = 0.008) and cesarean section (37.4 vs 34.1 vs 29.5%, p < 0.001) were significantly more frequent among women with eGWG. Additionally, there was a higher frequency of macrosomia (8.1 vs 3.6 vs 2.4%, p < 0.001), large-for-gestational-age (8.2 vs 3.7 vs 2.6%, p < 0.001) and birth trauma (2.6 vs 1.5 vs 1.1%, p < 0.001) in this group. On the other hand, fetal death (0.2 vs 0.2 vs 0.5%, p = 0.04), small-for-gestational-age (9 vs 10.3 vs 14.9, p < 0.001) and preterm delivery (5.6 vs 7.1 vs 7.5%, p = 0.03) were more frequent in iGWG group.

CONCLUSIONS

Over two-thirds of pregnant women with early-onset GDM had inappropriate GWG, which was significantly associated with adverse maternofetal outcomes. Weight management must be a focus of special attention in women with early-onset GDM, beyond glycemic control, to achieve healthy pregnancy outcomes.

A Retrospective Cohort Study on Diabetic Foot Disease: Ascertainment of Ulcer Locations by Age Group

Background and aims

Diabetic foot ulcer location is a known independent predictor for cure with a better healing gradient proximal to distal. Although advanced age is one of the main factors associated with greater diabetic foot ulcer severity, there are no studies evaluating diabetic foot ulcer location specifically in the elderly population in an outpatient setting. This study evaluated diabetic foot ulcer location and age-group interactions in diabetic foot presentation.

Methods

A retrospective cohort study including adult patients with diabetic foot ulcers observed on their first visit to our center's Diabetic Foot Unit in 2018, divided into younger adults (YA) (18 to 64 years) and older adults (OA) (≥65 years).

Results

A total of 435 patients were included in the study with 159 (36.6%) in the YA, and 276 (63.4%) in the OA group.

Neuro-ischemic diabetic foot ulcers were more frequent in the OA group (71.4% vs 43.4%, p<0.001). The number of patients with a history of diabetic foot ulcers was lower in the OA group (18.1% vs 25.2%, p=0.03). A smaller proportion of forefoot diabetic foot ulcers (74.9% vs 86.2%, p=0.007) and plantar location diabetic foot ulcers (9.4% vs 24.5%, p<0.001) occurred in the OA group.

By univariate logistic regression analysis, we found two associations with older age: proximal (odds ratio (OR) 2.09 (1.23-3.53), p=0.006), and non-plantar (OR 3.13 (1.82-5.37), p<0.001) diabetic foot ulcer location. After adjusting for potential confounders in a multivariate analysis, older age lost the association to more proximal (OR 1.72 (0.94-3.15), p=0.081) and non-plantar (OR 1.78 (0.83-3.77), p=0.133) diabetic foot ulcer location.

Conclusions

There are essential age differences in diabetic foot ulcer presentation. The OA group more frequently presents neuro-ischemic diabetic foot ulcers with more proximal and non-plantar locations.

Gestational diabetes in twin pregnancy: A predictor of adverse fetomaternal outcomes?

AIM

To compare fetomaternal outcomes between GDM pregnant women with twin versus singleton pregnancies and then between women with GDM versus non-GDM twin pregnancies.

METHODS

We performed a retrospective study including GDM pregnant women with both twin and singleton pregnancies followed in our tertiary center between 2011 and 2018. The fetomaternal characteristics of each group were compared. We then compared women with GDM twin pregnancy followed at our institution between 2011 and 2018 to non-GDM twin pregnant women giving childbirth in 2018.

RESULTS

A total of 1127 GDM pregnant women were evaluated: 42 with twin pregnancy and 1085 with singleton pregnancy. Preeclampsia (14.3% vs. 3.3%, p < 0.001) and cesarean delivery (76.2% vs. 36.9%, p < 0.001) were more frequent among women with twin pregnancy. Neonatal morbidity was also more common among neonates delivered from twin pregnant women, including preterm labor (73.8% vs. 7.8%, p < 0.001), hypoglycemia (6% vs. 4.8%, p = 0.043), hyperbilirubinemia (33.3% vs. 9.0%, p < 0.001), RDS (28.6% vs. 2.7%, p < 0.001), admission in NICU (32.1% vs. 4.5%, p < 0.001) and SGA (19.0% vs. 11.0%, p = 0.001). Overall there were no significant differences in fetomaternal morbidity parameters between GDM (n = 42) versus non-GDM (n = 83) twin pregnancies, although SGA infants were more frequent in the latter group (33.9% vs. 19.0%, p = 0.014).

CONCLUSIONS

In GDM pregnant women, twin pregnancy seems to be associated with an increased prevalence of neonatal morbidity when compared to singleton pregnancy. On the other hand, in twin pregnancy, diagnosis of GDM does not seem to be associated with poorer fetomaternal outcomes. GDM seems to be protective for the occurrence of SGA neonates in twin pregnancies.

Impact of intermittently scanned continuous glucose monitoring on quality of life and glycaemic control in persons with type 1 diabetes: A 12-month follow-up study in real life

BACKGROUND AND AIM

We sought to prospectively assess the impact of intermittently scanned continuous glucose monitoring (isCGM) initiation in the glycaemic control and quality of life (QoL) in type 1 diabetes mellitus (T1DM) patients followed in real-live conditions.

METHODS

Prospective, observational, cohort, single-centre and single-arm study conducted between September 2018 and March 2020, enrolling adults with T1DM with at least one year of diagnosis, interested in using isCGM. After training at isCGM initiation, CGM metrics and QoL were assessed at baseline and 12 months.

RESULTS

Thirty-six individuals (55.6% male) were included; median age at inclusion was 49.0 (43.5-62.5)years and the mean(±SD) duration of T1DM was 25.5 ± 12.0 years. Median (interquartile range) HbA1c decreased from 7.6(7.0-8.7)% to 7.4(6.8-7.7)% at 12 months (p = 0.02), driven by the subgroup of individuals with baseline HbA1c ≥ 7.5%. The number of scans per day increased from 7.0(5.5-10.0) to 10.0(7.0-14.0) but no correlation was found between the number of daily scans and CGM metrics. Total daily insulin dose remained unchanged, however the proportion of basal insulin decreased, and the proportion of bolus insulin increased over time. Multiple QoL subscales scores improved significantly, including disease-burden subscale for which TIR proved to be a significant predictive factor.

CONCLUSION

isCGM improved both glycaemic control, namely time in range, time below range and glycaemic variability, as well as QoL scores in the long term. The increase of the bolus insulin proportion suggests a behavioural change. However, the appraisal of our results must consider our substantial rate of drop-out limiting the external validity of our findings.

Multimodality imaging for the assessment of left ventricular dynsfunction in cardio-oncology

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVD) is a key concern in the context of cardio-oncology (CO). Usually, referral for suspected Cancer therapy-related cardiac dysfunction (CTRCD) is the main challenge, but heart failure with other more common causes, such as ischemic cardiomyopathy can also decompensate during cancer treatment or be diagnosed incidentally during cardiotoxicity echocardiographic (echo) surveillance. Multimodality imaging is essential in these patients in order to better establish aetiology and assure the most appropriate clinical management.

Purpose

evaluate clinical impact of multimodality imaging in the clinical management of CO patients.

Methods

retrospective study of a population followed in CO consultation. Statistical analysis of demographic, clinical, transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) data was made.

Results

we included 115 pts, mean age 66.3 ± 10.2 years, 67,8% female, with mean follow-up of 16.1 ± 12.8 months. About half (56.5%) had breast cancer, followed by gastrointestinal tract (16.5%) and haematological (8,7%) malignancies, with a significant proportion (32,2%) with advanced disease. Prevalence of cardiovascular risk factors was high (hypertension in 74.8%, dyslipidaemia in 47%, type 2 diabetes mellitus in 17.4%), but also coronary artery disease (18,3%) and atrial fibrillation (18.3%). All of them were treated with different types of chemotherapy and 53,9% of pts with radiotherapy.  At baseline, 13% of pts had a left ventricular ejection fraction (LVEF) under 50% (LVD) assessed by TTE, which increased to 26,9% (n = 31) after oncological treatment initiation. Of these (n = 31), an ischemic aetiology was found in 32,3% and non-ischemic in 54,8%, which was significantly more frequent in patients with CTRCD (OR 2,7, p = 0,001). CMR was performed in 45,2%, mostly in CTRCD cases (p = 0,012, OR 8,4), which, apart from LVD, did not show any tissue changes in most patients (p = 0,026, OR 35). Only one patient with CTRCD (under treatment with trastuzumab and anthracyclines) had subepicardial late gadolinium enhancement, with wall motion abnormalities, suggesting a myocarditis-like mechanism for cardiotoxicity.

Conclusion

LVD has a major impact in patients" prognosis, particularly in CO context, where effective oncological treatments can be compromised due heart failure decompensation. Therefore, a thorough clinical evaluation should encompass etiological study in order to provide the most appropriate treatment strategies. Moreover, CTRCD can develop through different physiopathological mechanisms. Thus, multimodality imaging, particularly including CMR evaluation, can have a major role ensuring a good clinical outcome for these patients.

Third trimester HbA1c and the association with large-for-gestational-age neonates in women with gestational diabetes

Objective

To evaluate the association between HbA1c levels measured in the third trimester and the risk for large for gestational age (LGA) in neonates of mothers affected by gestational diabetes mellitus (GDM). Secondarily, we aimed to identify an ideal cut-off for increased risk of LGA amongst pregnant women with GDM.

Methods

Observational retrospective review of singleton pregnant women with GDM evaluated in a diabetes and pregnancy clinic of a tertiary and academic hospital. From January/2011 to December/2017, 1,085 pregnant women underwent evaluation due to GDM, of which 665 had an HbA1c test in the third trimester. A logistic regression model was performed to evaluate predictors of LGA. A receiver-operating-characteristic (ROC) curve was used to evaluate the predictive ability of third trimester HbA1c for LGA identification.

Results

A total of 1,085 singleton pregnant women were evaluated during the study period, with a mean age of 32.9 ± 5.3 years. In the multivariate analysis, OGTT at 0 minutes (OR: 1.040; CI 95% 1.006-1.076, p = 0.022) and third trimester HbA1c (OR: 4.680; CI 95% 1.210-18.107, p = 0.025) were associated with LGA newborns. Using a ROC curve to evaluate the predictive ability of third trimester HbA1c for LGA identification, the optimal HbA1c cut-off point was 5.4% where the sensitivity was 77.4% and the specificity was 71.7% (AUC 0.782; p < 0.001).

Conclusion

Few studies in the Mediterranean population have evaluated the role of HbA1c in predicting neonatal complications in women with GDM. A third trimester HbA1c > 5.4% was found to have good sensitivity and specificity for identifying the risk of LGA.

Adverse in-hospital prognosis in patients with non-ST-segment elevation myocardial infarction with right bundle branch block – red flag ECG and sicker patients

Introduction

Recent recommendations regarding myocardial infarction (MI) underline the adverse prognosis associated with right bundle branch block (RBBB), suggesting that, in some cases of non-ST-segment elevation MI (NSTEMI) with RBBB a primary percutaneous coronary intervention (PCI) strategy should be considered. However, it is unclear if this is due to a more difficult and late diagnosis or to the clinical severity inherent to these patients (pts).

Purposes

To characterize the NSTEMI with RBBB population and find predictors of worse prognosis.

Methods

Retrospective analysis of pts included in the Portuguese Registry of Acute Coronary Syndromes with NSTEMI, comparing pts with RBBB (group A) vs without RBBB (group B), regarding clinical and demographic variables, diagnostic and therapeutic approaches. Primary endpoint was heart failure, electrical and mechanical complications and death in the in-hospital period.

Results

We included 9375 pts, 686 in group A and 8689 in group B. Pts in group A were more likely to be male (p&lt;0.001) and over 75 years old (p&lt;0.001). Also, they were more prone to have cardiovascular risk factors (hypertension - p&lt;0.001, diabetes – p&lt;0.001) and history of coronary artery disease (stable angina p=0.007, previous MI p=0.002 and revascularization, either PCI – p=0.016 or surgery – p&lt;0.001), stroke (p&lt;0.001), chronic kidney disease (p&lt;0.001) and cancer (p=0.025), comparing to pts in group B. There were no differences between time from onset of symptoms and first medical contact or hospital admission between groups. Upon admission, these pts presented more frequently with hypotension (p=0.026), Killip class&gt;II (p&lt;0.001) and atrial fibrillation (p&lt;0.001) than pts in group B. There were statiscally significant differences between groups, regarding the use of inotropes (p&lt;0.001), non-invasive (p=0.008) and invasive ventilation (p=0.018) and temporary pacing (p=0.001), all of them higher in group A.

Pts with RBBB were less likely to undergo coronary angiography (CA) (p&lt;0.001). However, among those who did, there were no differences in CA timing (p=0.091), but pts from group A had more frequently multivessel disease (p=0.044) and no revascularization was undertaken (p=0.012).

About 16.64% of all pts reached the endpoint, but unfavourable in-hospital outcome was significantly more common in group A (p&lt;0.001). RBBB remained an independent predictor of the endpoint (p=0.032) in a multivariate regression analysis, controlled for other variables (namely gender, age, cardiovascular risk factors, previous evidence of cardiovascular disease, and clinical and coronary anatomy data) – AUC of 0.833.

Conclusion

Although pts with NSTEMI and RBBB have a poorer in-hospital prognosis, partly due to their bigger clinical complexity (older age, multiple comorbidities and complex coronary anatomy), RBBB itself still remains an independent predictor of worse outcome.

Funding Acknowledgement

Type of funding sources: None.

Mild periconceptional hyperglycemia: predictor of adverse fetomaternal outcomes in gestational diabetes?

AIM

To clarify whether mild first trimester hyperglycaemia (characteristic of early-onset GDM) is associated with higher incidence of congenital malformations and other adverse fetomaternal outcomes compared to women with second trimester hyperglycaemia (later-onset GDM).

DESIGN AND METHODS

We analyzed the Portuguese National GDM database, containing data collected between 2011 and 2017. Two study groups were defined: Group 1-Women with GDM diagnosed during the first trimester (with fasting glycemia ≥ 92 and < 126 mg/dL); Group 2-Women with GDM diagnosed after the first 12 weeks of gestation, with either fasting glycemia or oral glucose tolerance test, according to the International Association of Pregnancy and Diabetes Study Group criteria. The fetomaternal characteristics of each group were compared.

RESULTS

A total of 18.518 pregnant women diagnosed with GDM were included which 34.4% of them belonged to Group 1. Pregnant women from this group were significantly younger and had a higher median BMI than the women from the other group. Overall, there was no significant differences in maternal morbidity parameters between groups. Non-evolutive pregnancies were significantly more frequent along the present gestation in the group 1 (1.1% vs. 0.1%, p < 0.001), as was fetal death (0.6% vs. 0.2%, p < 0.001). Congenital malformations did not differ significantly between groups (3.2% vs. 2.8%, p = 0.155).

CONCLUSIONS

The mild near conceptional hyperglycaemic state characteristic of an early-onset GDM seems to be associated with an increased prevalence of non-evolutive pregnancies and foetal deaths when compared to later-onset GDM.

Continuous Teriparatide Treatment in Chronic Hypoparathyroidism: A Case Report

Patient: Female, 29-year-old

Final Diagnosis: Chronic hypoparathyroidism

Symptoms: Muscle cramps • numbness • tingling in fingers

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and Metabolic

Mapping health vulnerabilities: exploring territorial profiles to support health policies

Vulnerability processes and effects, albeit of great importance to cohesion and territorial policies, are nonetheless still underexplored and narrowly operationalized in scientific research. In particular, most assessments rely on economic indicators and a limited territorial scale, which do not have the same analytic potential of a broader view at a national level with regional/municipal similarities, specificities, and inter-connections. This gap also applies to health-related vulnerabilities, which, stemming from a lack of socioeconomic and environmental resources, has increased during and after the economic crisis of the past decade. This paper aims to analyze the health vulnerability phenomena in Portugal from a spatial perspective. Following a Multiple Correspondence Analysis, different territorial profiles of social vulnerability associated with the population health condition and access to and use of "health services" are identified. We conclude by outlining the importance of adding the spatial context to health policies addressing vulnerabilities and suggest avenues for future research.

Impact of pre-treatment with acetylsalicylic acid on the severity of a first myocardial infarction in diabetic patients

Introduction

Diabetes Mellitus (DM) is one of the main risk factors for cardiovascular disease (CVD). Guidelines on the use of acetylsalicylic acid (ASA) for primary prevention of CVD in this population are conflicting. A potential reduction in the severity of a first episode of Acute Myocardial Infarction (AMI) could be seen has an additional argument for the use of ASA in primary prevention. Aim: To evaluate the impact of prior intake of ASA on the presentation, severity and short-term prognosis of AMI in diabetic patients without history of CVD.

Methods

Retrospective analysis of diabetic patients without previous evidence of CVD diagnosed with type 1 AMI between January 2002 and December 2018, inserted in a multicentric registry of acute coronary syndromes. Patients were dichotomized according to whether or not they were taking ASA prior to the index event. Groups were compared according to clinical, analytical and imaging endpoints.

Results

A total of 2596 patients were included, predominantly men (66.4%), with a mean age of 68±12 years old. Patients on ASA (19.7%) were significantly older (71±10 vs. 67±12, p&lt;0.001) and had a higher prevalence of hypertension (89.2% vs 77.9%, p&lt;0.001), dyslipidaemia (69.8% vs. 61.1%, p&lt;0.001) and chronic kidney disease (10.6% vs. 4.9%, p&lt;0.001). Overall, there was a lower prevalence of AMI with ST-segment elevation (36.5% vs. 50.8%, p&lt;0.001) in patients on ASA. However, the same group of patients had a significantly higher probability of evolution in Killip class &gt; I (25.4% vs. 17.0%, p&lt;0.001), a higher median BNP elevation (315 [126–623] vs. 166 [64–431], p&lt;0.001); and a lower average ejection fraction upon discharge (49.0±12 vs. 51±12, p=0.011). Patients on prior regular intake of ASA also had a higher prevalence of multivessel disease (38.4% vs. 28.9%, p&lt;0.001) and multiple significant stenosis (70.2% vs. 61.7%, p&lt;0.001). There was no significant difference regarding the percentage of electrical complications (2.3% vs. 1.2%, p=0.06), use of intra-aortic balloon pump (1.0 vs. 0.9%, p=0.74) and in-hospital death (3.0% vs. 2.4%, p=0.46). In a logistic regression model adjusted for age, sex, comorbidities and previous medication as variates, prior ASA intake was an independent predictor of a lower rate of AMI with ST-segment elevation (ExpB −0.34; 95% CI: 0.57–0.89; p=0.003). On the contrary, when adjusted to these variables, prior ASA intake was not an independent predictor of higher BNP (p=0.13) or higher probability of multivessel disease (p=0.22) or presence of ≥1 significant stenosis (p=0.31).

Conclusions

In this population of diabetic patients with a first episode of ACS, prior use of ASA in the context of primary prevention was associated with a significant lower rate of ST-segment elevation myocardial infarction.

Funding Acknowledgement

Type of funding source: None

P887 Two sides of the same mass

Echocardiography (echo) remains the first-line imaging modality for the evaluation of cardiac masses. Three-dimensional (3D) echo, either transthoracic or transesophageal (TTE and TEE respectively), has allowed for better definition imaging, providing more information about the size, mobility, attachment and relation of these lesions with cardiac structures. Nevertheless, due to its superior tissue characterization capability, other imaging techniques, such as cardiac magnetic resonance (CMR), are very helpful in the differential diagnosis, making multimodality imaging the most attractive option for the study of intracardiac masses.

We present the case of a 85 year-old male, with paroxysmal atrial fibrillation (under effective anticoagulation), type 2 diabetes mellitus, hypertension, referred for the study of an asymptomatic cardiac mass found in a routine TTE. There were no relevant findings on physical examination. The TTE showed a bilobar spheroid mass, in the right atrium, attached to the interatrial septum, with 33x23mm and regular edges. A 3D TEE was performed confirming the previous findings, but also showing extension of this mass through the fossa ovalis membrane, reaching the left atrium; this aspect raised the doubt about either protrusion or invasion of the left atrium and, respectively, a benign (like a myxoma) versus malignant behaviour (such as a sarcoma). To better characterize this lesion, a CMR was ordered, which revealed a bilobar heterogeneous mass, attached to the right side of the interatrial septum, at the fossa ovalis membrane, without signs of adjacent tissue invasion, namely unequivocal invasion of the left atrium; it presented with intermediate T1 signal, hyperintense T2 signal and heterogeneous pattern of gadolinium enhancement, features mostly in favour of a right atrial myxoma. The complimentary study found no other relevant changes, namely no findings suggestive of endocarditis (negative blood cultures), autoimmune disease or malignancy. The patient refused undergoing heart surgery and, therefore, kept follow-up with clinical and echocardiographic stability.

Although histological examination remains the only tool for definitive diagnosis, multimodality imaging allows a quite comprehensive evaluation of intracardiac masses, enlightening the differential diagnosis. Here the imaging findings helped to establish a benign origin as the most likely, very important in this case of a probable right atrial myxoma, due to its peculiar protrusion to the left atrium through the fossa ovalis membrane.

Abstract P887 Figure. atrial myxoma

1098 Atrial thickening: a surprisingly "gouty" heart

Case Presentation

A 49 year-old male presented to the emergency department with fever and lower limb myalgia for 5 days. His past history was notable for acute episodes of microcrystalline pyrophosphate oligoarthritis for which he was receiving allopurinol 100mg, colchicine 1mg and prednisolone 5mg. Physical examination was unrevealing. Laboratory workup showed normocytic normochromic anemia (Hb 12.8g/dL), leukocytosis (22 490 /mm3), neutrophilia (86.8%), increased C-reactive protein (CRP

26mg/dL), low procalcitonin (0.82ng/mL) and mildly elevated creatinine-kinase (83 UI/L). The patient was admitted with fever of unknown origin and started on ceftriaxone after blood and urine cultures.

He remained febrile with persistently heightened inflammation. Cultures, infectious and auto-immune tests, bone marrow biopsy, myelogram and abdominopelvic CT scan were negative. Three weeks later, syncope due to complete atrioventricular (AV) block led to temporary pacemaker implantation. Transoesophageal echocardiography (TOE) revealed a left atrial (LA) wall thickening,

evident on MRI as an 8-10mm T2-hyperintensity sign, with right atrial (RA) and ventricular sparing. PET/CT scan showed an 18F FDG uptake exclusively in the LA. As a neoplasia was highly suspected, a transspeptal biopsy was attempted, yet the sample was scarce for analysis. Thus, a biopsy via sternotomy was performed, now sampling both the LA and RA. Indeed, repeated TOE showed de novo RA involvement with a prominent nodular finding (19x24mm) in the lateral wall.

Myocyte inflammation and necrosis accompanied with granulocyte infiltration (mostly neutrophils but also eosinophils) was observed in all samples. There were no findings suggestive of neoplasia. The patient was still on allopurinol, which has been reported to involve the myocardium in a late (type IV) hypersensitivity reaction (the so-called DRESS syndrome), even in the absence of systemic inflammation. Thus, allopurinol was stopped and 1mg/Kg prednisolone was started. The patient

significantly improved and was discharged home with negative CRP the following two weeks. After 1 month, MRI was repeated and no atrial inflammation was found. After 4 months follow-up, he is doing well on 2.5mg of prednisolone and febuxostat 80mg.

P5242Gender equality in acute coronary syndrome: modern times, old habits?

Introduction

Historically, women with acute coronary syndrome (ACS) have worse outcomes compared with men. Differences in clinical, demographic characteristics and treatment may explain this result. In recent times with new diagnostic capabilities and revascularization therapies this panorama may be changing.

Methods

Single-center retrospective study comparing gender differences in ACS patients from 2012 to 2017. Two groups were formed comparing women and men: Group A: years 2012 to 2014 and group B: years 2015 to 2017.

Results

From 2012 to 2017 we identified 1091 patients with ACS. Of them 356 (32,6%) were women and NSTEMI (60%) was the most frequent type of ACS in this group. Women with ACS were older than men (73 vs 66 years) had more arterial hypertension (83,4% vs 68,3% p<0,001), diabetes mellitus (46,3% vs 30,9% p<0,001) and were less frequently smokers (6,5% vs 25,3% p<0,01). Dyspnea as the predominant symptom was more frequent in women (10,4% vs 5,2% p=0,002) who were less submitted to invasive strategy (63,2% vs 74,7% p<0,001) where non obstructive disease was more prevalent compared to men (9,8% vs 3,3% p<0,001). In-hospital mortality was greater in the women group (7,9% vs 3,7% p=0.005). There were no differences between groups in hospitalization or cardiovascular mortality over 1-year follow-up. When comparing Group A with Group B there were differences in hospitalization at 1 year (Group A 15,4% vs 9,3% p=0,029, Group B 11% vs 12,4% p=0,766), in-hospital women mortality (Group A 9,5% vs 3,6 p=0,005, Group B 5,8 vs 3,8% p=0,346) and coronary invasive angiography (Group A 61,2% vs 80,2% p<0,001 vs Group B 65,8 vs 68,5%, p=0,606).

Conclusion

Different demographic and clinical presentation as well as in-hospital and 1-year outcomes were present in our study population: while in Group A threre were significant gender differences regarding hospitalization and in-hospital mortality, those differences faded away in Group B. Efforts should be made to lessen gender differences in treatment and assistance knowing the different demographical and clinical patient profile.

Predictors and outcomes of disseminated tuberculosis in an intermediate burden setting

SETTING

University-affiliated hospital located in Porto, North Portugal, an area with a low to intermediate incidence of tuberculosis (TB).

OBJECTIVE

To identify predictors and outcomes of disseminated TB (dTB).

DESIGN

A cohort of patients diagnosed with TB between 2007 and 2013 was retrospectively analysed. Patients with dTB criteria were characterized and compared to single organ TB cases. Factors independently associated with dTB were determined by multivariate logistic regression analysis.

RESULTS

A total of 744 patients were analysed, including 145 with dTB. Independent risk factors for dTB were pharmacological immunosuppression (OR 5.6, 95% CI 2.8-11.3), HIV infection (OR 5.1, 95% CI 3.1-8.3), chronic liver failure or cirrhosis (OR 2.3, 95% CI 1.4-4.1) and duration of symptoms (OR 2.3, 95% CI 1.4-3.8). Compared to single organ TB, the clinical presentation of dTB patients differed by the absence of haemoptysis (OR 3.2, 95% CI 1.3-8.4) and of dyspnoea (OR 1.9, 95% CI 1.2-3.1), presence of weight loss (OR 1.8, 95% CI 1.1-2.9), night sweats (OR 1.7, 95% CI 1.1-2.7) and bilateral lung involvement (OR 4.4, 95% CI 2.8-7.1). Mortality and time until culture conversion were higher for dTB patients, although not reaching statistical significance.

CONCLUSION

Immunosuppressive conditions and chronic liver failure or cirrhosis were associated with increased risk of dTB. The haematogenous spread may be dependent on longer symptomatic disease and usually progresses with bilateral lung involvement.

ENVIRONMENTAL MONITORING WITH PASSIVE DETECTORS AT CTN IN PORTUGAL

The aim of this work is to present the methods in use for environmental dose assessment with passive detectors at Campus Tecnológico e Nuclear (CTN) of Instituto Superior Técnico, in Portugal. The methods are based on LiF:Mg,Ti (TLD-100) detectors inserted in Harshaw holders placed at four locations and exchanged on a quarterly basis. An initial group of measurements allowed the estimation of the time interval necessary to attain a stable value, the determination of a fading factor, as well as the calculation method for the assessment of the ambient dose equivalent rate.

FADING EFFECT OF LiF:Mg,Ti AND LiF:Mg,Cu,P Ext-Rad AND WHOLE-BODY DETECTORS

Thermoluminescence dosemeters are widely used in individual and environmental monitoring. The aim of this work was to compare the thermal stability of dosemeters of the Ext-Rad and whole-body card types with LiF:Mg,Ti and LiF:Mg,Cu,P detectors stored at different temperatures and periods. The dosemeters were stored at 0°C, room temperature and 40°C for periods that lasted 8, 30, 45, 90 and 120 d. In general, TLD-100H detectors present higher TL signal stability than TLD-100 detectors. The intensity of the signal remained constant for both materials for storage periods at 0°C. At RT the same results was observed for TLD-100H. For TLD-100 detectors, a maximum variation of 22 % was registered for the longest period. At 40°C the TL signal decreased with storage time for both detectors. The TL signal of TLD-100H detectors presented maximum variations of 12 % whereas for TLD-100 detectors, larger variations of 25 % were observed.

Cushing's syndrome due to ectopic ACTH production by a nasal paraganglioma

Ectopic secretion of ACTH is an infrequent cause of Cushing's syndrome. We report a case of ectopic ACTH syndrome caused by a nasal paraganglioma, a 68-year-old female with clinical features of Cushing's syndrome, serious hypokalaemia and a right paranasal sinus' lesion. Cranial magnetic resonance image showed a 46-mm mass on the right paranasal sinuses. Endocrinological investigation confirmed the diagnosis of ectopic ACTH production. Resection of the tumour normalised ACTH and cortisol secretion. The tumour was found to be a paraganglioma through microscopic analysis. On follow-up 3 months later, the patient showed nearly complete clinical recovery. Ectopic ACTH syndrome due to nasal paraganglioma is extremely uncommon, as only two other cases have been discussed in the literature.

CrmE, a novel soluble tumor necrosis factor receptor encoded by poxviruses

Cytokines and chemokines play a critical role in both the innate and acquired immune responses and constitute prime targets for pathogen sabotage. Molecular mimicry of cytokines and cytokine receptors is a mechanism encoded by large DNA viruses to modulate the host immune response. Three tumor necrosis factor receptors (TNFRs) have been identified in the poxvirus cowpox virus. Here we report the identification and characterization of a fourth distinct soluble TNFR, named cytokine response modifier E (CrmE), encoded by cowpox virus. The crmE gene has been sequenced in strains of the orthopoxviruses cowpox virus, ectromelia virus, and camelpox virus, and was found to be active in cowpox virus. crmE is expressed as a secreted 18-kDa protein with TNF binding activity. CrmE was produced in the baculovirus and vaccinia virus expression systems and was shown to bind human, mouse, and rat TNF, but not human lymphotoxin alpha, conjugates of lymphotoxins alpha and beta, or seven other ligands of the TNF superfamily. However, CrmE protects cells only from the cytolytic activity of human TNF. CrmE is a new member of the TNFR superfamily which is expressed as a soluble molecule that blocks the binding of TNF to high-affinity TNFRs on the cell surface. The remarkable finding of a fourth poxvirus-encoded TNFR suggests that modulation of TNF activity is complex and represents a novel viral immune evasion mechanism.