Biomonitoring of polycyclic aromatic hydrocarbons exposure and short-time health effects in wildland firefighters during real-life fire events

Human biomonitoring data retrieved from real-life wildland firefighting in Europe and, also, worldwide are scarce. Thus, in this study, 176 Portuguese firefighters were biomonitored pre- and post- unsimulated wildfire combating (average:12-13 h; maximum: 55 h) to evaluate the impact on the levels of urinary polycyclic aromatic hydrocarbons hydroxylated metabolites (OHPAH; quantified by high-performance liquid chromatography with fluorescence detection) and the associated short-term health effects (symptoms, and total and differentiated white blood cells). Correlations between these variables and data retrieved from the self-reported questionnaires were also investigated. Firefighters were organized into four groups according to their exposure to wildfire emissions and their smoking habits: non-smoking non-exposed (NSNExp), non-smoking exposed (NSExp), smoking non-exposed (SNExp), and smoking and exposed (SExp). The most abundant metabolites were 1-hydroxynaphthalene and 1-hydroxyacenaphthene (1OHNaph + 1OHAce) (98-99 %), followed by 2-hydroxyfluorene (2OHFlu) (0.2-1.1 %), 1-hydroxyphenanthrene (1OHPhen) (0.2-0.4 %), and 1-hydroxypyrene (1OHPy) (0.1-0.2 %); urinary 3-hydroxybenzo(a)pyrene was not detected. The exposure to wildfire emissions significantly elevated the median concentrations of each individual and total OHPAH compounds in all groups, but this effect was more pronounced in non-smoking (1.7-4.2 times; p ≤ 0.006) than in smoking firefighters (1.3-1.6 times; p ≤ 0.03). The greatest discriminant of exposure to wildfire emissions was 1OHNaph + 1OHAce (increase of 4.2 times), while for tobacco smoke it was 2OHFlu (increase of 10 times). Post-exposure, white blood cells count significantly increased ranging from 1.4 (smokers, p = 0.025) to 3.7-fold (non-smokers, p < 0.001), which was accompanied by stronger significant correlations (0.480 < r < 0.882; p < 0.04) between individual and total OHPAH and total white blood cells (and lymphocytes > monocytes > neutrophils in non-smokers), evidencing the impact of PAH released from wildfire on immune cells. This study identifies Portuguese firefighters with high levels of biomarkers of exposure to PAH and points out the importance of adopting biomonitoring schemes, that include multiple biomarkers of exposure and biomarkers of effect, and implementing mitigations strategies.

Enhancement of Acetate-Induced Apoptosis of Colorectal Cancer Cells by Cathepsin D Inhibition Depends on Oligomycin A-Sensitive Respiration

Colorectal cancer (CRC) is a leading cause of death worldwide. Conventional therapies are available with varying effectiveness. Acetate, a short-chain fatty acid produced by human intestinal bacteria, triggers mitochondria-mediated apoptosis preferentially in CRC but not in normal colonocytes, which has spurred an interest in its use for CRC prevention/therapy. We previously uncovered that acetate-induced mitochondrial-mediated apoptosis in CRC cells is significantly enhanced by the inhibition of the lysosomal protease cathepsin D (CatD), which indicates both mitochondria and the lysosome are involved in the regulation of acetate-induced apoptosis. Herein, we sought to determine whether mitochondrial function affects CatD apoptotic function. We found that enhancement of acetate-induced apoptosis by CatD inhibition depends on oligomycin A-sensitive respiration. Mechanistically, the potentiating effect is associated with an increase in cellular and mitochondrial superoxide anion accumulation and mitochondrial mass. Our results provide novel clues into the regulation of CatD function and the effect of tumor heterogeneity in the outcome of combined treatment using acetate and CatD inhibitors.

Baseline data and associations between urinary biomarkers of polycyclic aromatic hydrocarbons, blood pressure, hemogram, and lifestyle among wildland firefighters

Introduction

Available literature has found an association between firefighting and pathologic pathways leading to cardiorespiratory diseases, which have been linked with exposure to polycyclic aromatic hydrocarbons (PAHs). PAHs are highlighted as priority pollutants by the European Human Biomonitoring Initiative in occupational and non-occupational contexts.

Methods

This cross-sectional study is the first to simultaneously characterize six creatinine-adjusted PAHs metabolites (OHPAHs) in urine, blood pressure, cardiac frequency, and hemogram parameters among wildland firefighters without occupational exposure to fire emissions (> 7 days), while exploring several variables retrieved via questionnaires.

Results

Overall, baseline levels for total OHPAHs levels were 2 to 23-times superior to the general population, whereas individual metabolites remained below the general population median range (except for 1-hydroxynaphthalene+1-hydroxyacenaphtene). Exposure to gaseous pollutants and/or particulate matter during work-shift was associated with a 3.5-fold increase in total OHPAHs levels. Firefighters who smoke presented 3-times higher total concentration of OHPAHs than non-smokers (p < 0.001); non-smoker females presented 2-fold lower total OHPAHs (p = 0.049) than males. 1-hydroxypyrene was below the recommended occupational biological exposure value (2.5 μg/L), and the metabolite of carcinogenic PAH (benzo(a)pyrene) was not detected. Blood pressure was above 120/80 mmHg in 71% of subjects. Firefighters from the permanent intervention team presented significantly increased systolic pressure than those who performed other functions (p = 0.034). Tobacco consumption was significantly associated with higher basophils (p = 0.01-0.02) and hematocrit (p = 0.03). No association between OHPAHs and blood pressure was found. OHPAHs concentrations were positively correlated with monocyte, basophils, large immune cells, atypical lymphocytes, and mean corpuscular volume, which were stronger among smokers. Nevertheless, inverse associations were observed between fluorene and pyrene metabolites with neutrophils and eosinophils, respectively, in non-smokers. Hemogram was negatively affected by overworking and lower physical activity.

Conclusion

This study suggests possible associations between urinary PAHs metabolites and health parameters in firefighters, that should be further assessed in larger groups.

A combined experimental-molecular modeling study of crown ether europium complexes: Effects of the coordinated anion on structural and luminescence properties

It is reported the synthesis, characterization by elemental analysis, thermogravimetry; electronic absorption, infrared, excitation, and emission spectroscopies of the [Eu(12C4)(phen)2(X)n]X2 complexes, where 12C4 = 12-crown-4, phen = 1,10-phenanthroline, and X  = F-, Cl-, Br-, SCN-, ClO4-, and NO3-. It is verified that the polarizability of the anion X- exerts remarkable effects on the emission process. As a general trend, lower wavenumbers for the 7F0→5L6, 7F0→5D2 and 7F0→5D1 transitions are associated with the anions with higher volumes and, consequently, higher polarizability. The molecular modeling results performed with quantum methods (RHF and DFT) suggest some relationships between the calculated structures, electronic, and luminescence properties with the presence of the LMCT (ligand-to-metal charge transfer) states, which explains the differences in the emission spectra of these complexes due to the coordinated anion.

Forecasted Dementia Prevalence in Portugal (2020-2080)

Dementia is a global public health challenge, and its impact on Portugal is yet unclear. This study forecasts dementia prevalence in Portugal until 2080. Using the Gonçalves-Pereira et al (2021) method, we estimated dementia cases among older adults (≥65 years) in the community. Applying age-sex specific prevalence rates of the Gonçalves-Pereira study to population projections for Portugal between 2020-2080, based on the 10/66 Dementia Research Group criteria (10/66 DRG) and the Diagnostic and Statistical Manual of Mental Disorders IV criteria (DSM-IV), to Portugal's population projections (2020-2080) under various growth scenarios (low, medium, and high). We anticipate a more than 2-fold increase in dementia prevalence from 2020 to 2080, both for 10/66 DRG [2.1%-5.0%] and DSM-IV [.8%-2.0%]. By 2080, those aged ≥80 years are projected to constitute 75.0% (vs 59.0% in 2020) of all dementia cases, particularly affecting women. Addressing dementia growth in Portugal calls for a comprehensive global response, while country-level estimates facilitate informed public health planning, policy-making, and resource allocation.

Gynecologic Adnexal Tumors and Tumor-Like Lesions in Children and Adolescents: Experience at a Cancer Center

Introduction. Tumors and tumor-like lesions of the uterine adnexa in children and adolescents are uncommon but may carry devastating consequences. Methods. We conducted an observational retrospective cohort study, to describe patients aged 0 to 19 years diagnosed with tumors and tumor-like lesions of the uterine adnexa at our institution between 2000 and 2018. Results. Eighty-nine patients with 105 adnexal lesions were included. Thirty-seven (42%) patients presented with benign tumors, 13 (15%) with borderline tumors, 25 (28%) with malignant tumors and 14 (16%) with tumor-like lesions. Germ cell tumors (n = 45|43%) were the most frequent, followed by epithelial tumors (n = 30|29%). No significant differences were found in the age distribution of the lesions by malignant potential or histologic group. Most patients (n = 80|90%) were treated primarily with conservative surgery, including cystectomy (n = 25|28%) and unilateral oophorectomy/adnexectomy (n = 54|61%). Thirty-four (38%) underwent surgical staging (partial omentectomy and peritoneal biopsies). Twenty (23%) patients with borderline and malignant tumors were submitted to chemotherapy. Four (5%) patients with borderline or malignant tumors relapsed, one of whom died from disease. Conclusion. Gynecological lesions in children and adolescents encompass a wide range of rare histological tumor subtypes, requiring evaluation by experienced pathologists. Most tumors were diagnosed at early stages, with low relapse and mortality rates. Conservative management, with fertility sparing surgery and limited use of adjuvant chemotherapy, is of utmost importance.

Influence of the addition of nanohydroxyapatite to scaffolds on proliferation and differentiation of human mesenchymal stem cells: a systematic review of in vitro studies

One of the main challenges of tissue engineering in dentistry is to replace bone and dental tissues with strategies or techniques that simulate physiological tissue repair conditions. This systematic review of in vitro studies aimed to evaluate the influence of the addition of nanohydroxyapatite (NHap) to scaffolds on cell proliferation and osteogenic and odontogenic differentiation of human mesenchymal stem cells. In vitro studies on human stem cells that proliferated and differentiated into odontogenic and osteogenic cells in scaffolds containing NHap were included in this study. Searches in PubMed/MEDLINE, Scopus, Web of Science, OpenGrey, ProQuest, and Cochrane Library electronic databases were performed. The total of 333 articles was found across all databases. After reading and analyzing titles and abstracts, 8 articles were selected for full reading and extraction of qualitative data. Results showed that despite the large variability in scaffold composition, NHap-containing scaffolds promoted high rates of cell proliferation, increased alkaline phosphatase (ALP) activity during short culture periods, and induced differentiation, as evidenced by the high expression of genes involved in osteogenesis and odontogenesis. However, further studies with greater standardization regarding NHap concentration, type of scaffolds, and evaluation period are needed to observe possible interference of these criteria in the action of NHap on the proliferation and differentiation of human stem cells.

Willingness to institutionalize a relative with dementia: a web-platform assessment with the Portuguese adapted version of the Desire-to-Institutionalize Scale

Introduction

Older persons with dementia (PwD) are more likely to be institutionalized than their counterparts without dementia. The caregiver's desire to institutionalize has been suggested as the most important predictor of actual institutionalization. This cross-sectional study aimed to culturally adapt the Desire to Institutionalize Scale (DIS) to a country with a high prevalence of dementia (Portugal) and examine its psychometric properties.

Methods

The reliability, structural validity, and criterion validity of the DIS-PT were assessed by applying the scale using a remote measurement web platform. A sample of 105 dementia caregivers completed the DIS-PT and several psychosocial measures, including caregiver burden, anxiety, depression, quality of life, PwD functional independence, and neuropsychiatric symptoms.

Results

The DIS-PT demonstrated good structural validity, with one factor explaining 75% of the total variance. The internal consistency of the scale was high (α = 0.802). Most caregivers (65.7%) endorsed at least one item on the DIS-PT (Mdn 2). The caregiver's desire to institutionalize was significantly associated with the caregiver, care recipient, and contextual variables previously known to affect institutional placement. These included the caregivers' occupational status, perceived burden, anxiety (but not depression), physical and psychological quality of life, care recipient education, severity of neuropsychiatric symptoms, and cohabitation with the caregiver.

Discussion

This study offers preliminary support for the psychometric quality of the DIS-PT. The scale has practical applications in the early identification of caregivers considering nursing home placement, providing room for intervention in modifiable risk factors that may otherwise lead to the institutionalization of PwD. Remote measurement tools may hold value in assessing caregiving dyads non-intrusively and inexpensively.

Economic evaluation of biological treatments in patients with severe asthma: a systematic review

BACKGROUND

Asthma is a highly prevalent disease, one of the chronic diseases with the highest economic costs; thus, it imposes a high economic burden on society, the healthcare system, patients, and third-party payers. Contrary to this study, until now, systematic reviews of economic evaluations (EEs) of treatments for severe asthma have not been exclusively focused on biological treatments, and have included a small number of studies and only model-based EEs.

METHODS

This study systematically reviews EEs of biological therapies for severe asthma published until December 2022 using PRISMA guidelines. The review analyzes the cost-effectiveness of biologicals in comparison to SOC, or SOC plus OCS. The quality of the EEs is assessed using Consensus on Health Economics Checklist extended (CHEC-extended).

RESULTS

Thirty-nine studies were eligible: 15 based on a Markov model, and 19 trial-based; eight adopting societal and NHS perspectives, and seven the payer's perspective. The reviewed EEs addressed cost-effectiveness, cost-utility, and incremental costs and outcomes comparison. Their findings were mainly expressed through ICER-incremental cost-effectiveness ratio (24 studies: 13 concluded that biological were cost-effective) and cost comparison analysis (14 studies: 6 concluded that biological were cost-effective), and were sensitive to a wide variety of factors (e.g. medication cost, treatment response, time horizon, utility benefits, mortality, exacerbation rate, discount rate, etc.).

CONCLUSIONS

There has been some ambiguity concerning the EE of biological therapies due to variation in choice of study design and contradictory results. Nevertheless, it can be concluded that biological treatments improve health outcomes, in many contexts at a high cost.

Evaluation of a Dementia Training Course for Staff of a Center of Dementia Care

INTRODUCTION

Literature shows poor dementia training and competencies among health and social professionals. Due to the growing prevalence of people with dementia and all the related care demands, specialized training is increasingly needed but must be effective in terms of impact on knowledge, behaviors, and attitudes. We aimed to analyze the impact of a first-level dementia training course for staff of a new specialized center for people with dementia, considering the first three levels of Kirkpatrick's evaluation framework, namely, staff reaction (satisfaction), skills and learning (knowledge and dementia attitudes), and behavior changes.

METHODS

This is a single-center group pre-post design study of a 12-session online course. An online questionnaire was administered to measure satisfaction, expectations, knowledge/learning, attitudes (Dementia Attitude Scale), and new behaviors/practices. We compared perceived knowledge (Wilcoxon signed-rank test) and attitudes (paired t test). Thematic analysis explored new behaviors/practices.

RESULTS

Eighty-five professionals and 1 volunteer were included (median age 31, 92% female). Satisfaction with the training was high (median 4/5). Perceived knowledge improved (median 3-4; p < 0.001). The knowledge test median score was 70.8%. After training, participants showed better attitudes toward dementia (mean 116.5, SD 10.3, to mean 122.2, SD 11.5; p < 0.001). Most (93%) said their behavior/practice changed. Thematic analysis yielded four new behavior/practice dimensions: care provision/interaction, communication, family/caregivers, and self-confidence.

CONCLUSIONS

The course improved all dimensions evaluated, suggesting it effectively provides first-level dementia training. This may be transferable to similar settings.

Exploring Clinical Trials to Manage Firefighters' Sleep Quality: A PRISMA Compliant Systematic Review

Sleep research has grown over the past decades and investigators are deeply involved in studying sleep and its impact on human health and body regulation. Despite the understanding that insufficient sleep is strongly linked to the development of several disorders, unsatisfactory sleep exposes health and safety to innumerous risks. The present study aims to review and analyze the main results of clinical trials, registered at ClinicalTrials.gov and ICTRT databases, and developed construct strategies to improve sleep quality on firefighters and enhance professionals' sleep and health conditions. The protocol was registered in PROSPERO under number CRD42022334719. Trials registered between first registry and 2022 were included. We retrieved 11 registered clinical trials; seven met eligibility criteria and were included in the review. A relation between sleep disorders, shift work, and occupational health problems was found, and retrieved trials showed that sleep education programs can improve sleep quality and sleep hygiene. Science has already recognized sleep's importance for metabolic functioning and survivorship. Nevertheless, it continues to play a major role in discovering methods to diminish the problems faced. Strategies contemplating sleep education, or intervention, should be presented to fire services to tackle this problem and promote healthier and safer environments.

Cells Responding to Closely Related Cholesterol-Dependent Cytolysins Release Extracellular Vesicles with a Common Proteomic Content Including Membrane Repair Proteins

The plasma membrane (PM) protects cells from extracellular threats and supports cellular homeostasis. Some pathogens produce pore-forming toxins (PFTs) that disrupt PM integrity by forming transmembrane pores. High PFT concentrations cause massive damage leading to cell death and facilitating infection. Sub-lytic PFT doses activate repair mechanisms to restore PM integrity, support cell survival and limit disease. Shedding of extracellular vesicles (EVs) has been proposed as a key mechanism to eliminate PFT pores and restore PM integrity. We show here that cholesterol-dependent cytolysins (CDCs), a specific family of PFTs, are at least partially eliminated through EVs release, and we hypothesize that proteins important for PM repair might be included in EVs shed by cells during repair. To identify new PM repair proteins, we collected EVs released by cells challenged with sub-lytic doses of two different bacterial CDCs, listeriolysin O and pneumolysin, and determined the EV proteomic repertoire by LC-MS/MS. Intoxicated cells release similar EVs irrespectively of the CDC used. Also, they release more and larger EVs than non-intoxicated cells. A cluster of 70 proteins including calcium-binding proteins, molecular chaperones, cytoskeletal, scaffold and membrane trafficking proteins, was detected enriched in EVs collected from intoxicated cells. While some of these proteins have well-characterized roles in repair, the involvement of others requires further study. As proof of concept, we show here that Copine-1 and Copine-3, proteins abundantly detected in EVs released by intoxicated cells, are required for efficient repair of CDC-induced PM damage. Additionally, we reveal here new proteins potentially involved in PM repair and give new insights into common mechanisms and machinery engaged by cells in response to PM damage.

Transition to bereavement: A prospective longitudinal study of health-related quality of life in informal caregivers of oldest-old individuals

INTRODUCTION

Experiencing bereavement may be challenging. Despite the oldest-old population increase, a subgroup at greater risk of death, few studies focus on the grieving process of informal caregivers (ICs). This study analyzed the transition to bereavement of ICs of oldest-old individuals (≥80 years) over 1-year and compares the evolution of the health-related quality of life (HrQoL) between those experiencing bereavement and those who continued care through the study period.

MATERIALS AND METHODS

A prospective longitudinal observational study was conducted enrolling 204 ICs of the Metropolitan Area of Porto (North Portugal), of which 36 experienced the death of care receiver (CR). ICs' health profile and burden were assessed. CRs' functional and cognitive status were also appraised.

RESULTS

Bereaving caregivers were mostly female, CRs' children, and had on average 60.4 years at baseline. Caregivers spent a mean of 10.1 h/day (SD = 7.7) caring, for 80.6 months (SD = 57.5). The time elapsed since CR's death was 6 months (SD = 3.5) from entering in the study. CRs who died had a mean age of 88.3 (SD = 5.4) years at baseline, and were very dependent. Over a 1-year follow-up, bereaving caregivers showed a significant decrease in mental health following CR's death; on the other hand, caregivers who continued caring improved mental health [F(1, 159) = 4.249, p = 0.041].

DISCUSSION

Ending the caregiver career was marked by a decline in mental health whereas to continue caring was marked by an improvement in this outcome. While it is highly expected that the CR's death will be perceived as a relief considering both the caregiver's characteristics (e.g., medicines) and the CR condition (e.g., high dependence levels), the results suggest an opposite direction. CRs' death seems to arise an emotional burden for IC, at least during the first year, possibly triggering feelings of loneliness and a life without purpose that seems to aggravate mental health issues.

CONCLUSION

The transition to bereavement among ICs seems to lead to a caregiver mental health decline while those who continued caring (and thereby, experiencing caregiving stressors) seems to improve in this outcome. Ceasing caregiving stressors does not seem to contribute better experiencing bereavement among ICs, suggesting the need for support throughout this phase.

Multidisciplinary management of idiopathic intracranial hypertension in pregnancy: case series and narrative review

Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by raised intracranial pressure of unknown etiology with normal cerebrospinal fluid (CSF) composition and no brain lesions. It occurs in pregnant patients at approximately the same frequency as in general population, but obstetric and anesthetic management of the pregnancy and labor remains controversial. In this article we provide a multidisciplinary review of the main aspects of IIH in pregnancy including treatment options, mode of delivery and anesthetic techniques. Additionally, we report three cases of pregnant women diagnosed with IIH between 2012 and 2019 in our institution.

Screening for Caregiver Burden in the Community: Validation of the European Portuguese Screening Version of the Zarit Burden Interview (ZBI-4)

Objectives: Brief screening instruments are useful in busy clinical practice to identify those requiring further assessment. This study aims to translate and validate a Portuguese version of the four-item Zarit Burden Interview (ZBI-4) to identify caregiver burden in a community-based sample in Northern Portugal.Methods: We collected data from 203 informal caregivers of community-dwellers aged ≥80 years. Internal consistency and factors were measured using Cronbach's alpha. Pearson's correlation was used to examine construct validity against negative and positive aspects of caregiving from the Caregiving Appraisal Scale. Discriminative ability was evaluated from the area under the receiver operating characteristic curve (AUC). Optimal cutoffs were calculated using Youden´s Index.Results: The internal consistency of the Portuguese version of the ZBI-4 was good (alpha = 0.71). Concurrent validity was acceptable, showing strong correlation with the negative (rho = 0.66) and medium correlation with positive (rho = -0.33) aspects of the Caregiving Appraisal Scale. Discriminative accuracy for caregiver burden was also good (AUC = 0.86). Youden's index produced an optimal cutoff of ≥7 points for burden.Conclusions: The Portuguese version of the ZBI-4 screen demonstrates good psychometric properties.Clinical implications: These results show the utility of the Portuguese version of ZBI-4 as a short screen for caregiver burden for use in the community to facilitate rapid screening for this important and complex stressor.

Abstract OT2-27-01: Solti-1718 NEREA Trial: Neratinib in hormone receptor (HR)-positive/HER2-negative HER2-enriched (HER2-E) advanced breast cancer (BC)

Background HR+/HER2-negative BC represents ∼70% of all newly diagnosed breast tumors. BC is a clinically and biologically heterogeneous disease where intrinsic subtypes play a role. Non-luminal subtypes within HR+/HER2-negative disease do not benefit to the same extent from the standard of care treatments as the luminal subtypes. Thus, other strategies are needed. HER2-E subtype represents approximately 6.6-11.0% of HR+/HER2-negative tumors and is enriched in twice as many cases in metastatic tumors. According to EGF30008 trial, HER2-E advanced BC patients despite presenting poor outcomes across treatments showed benefit from anti-HER2 therapy. SOLTI-1718 NEREA aims to evaluate whether EGFR/ERBB2 axis inhibition by neratinib improves efficacy in terms of progression-free survival (PFS) in patients with advanced HR+/HER2-negative disease resistant to endocrine treatment (ET). Methods SOLTI-1718 NEREA (NCT04460430) is an open-label, single-arm, multicenter, and multinational phase II clinical trial following a Simon’s 2-stage design with one interim and one final efficacy analysis. Locally advanced or metastatic HER2-E (determined at metastatic sample), HR+/HER2-negative BC patients who had recurrence or progression while receiving previous ET (with or without a CDK4/6 inhibitor) will be included. ≤ 1 prior line of chemotherapy will be allowed. The primary objective is to assess the efficacy of neratinib in combination with ET in HER2-E, HR+/HER2-negative patients in terms of PFS6 by local assessment by the investigator using RECIST v.1.1. Secondary endpoints include clinical benefit rate at 6 months, overall response rate, duration of response, time to response and incidence, duration, and severity of adverse events. The treatment schedule will consist of neratinib 240 mg daily in combination with ET, with either exemestane, fulvestrant, or tamoxifen (as per the investigator´s decision). All patients will take prophylactic loperamide with an established dosing scheme during the first cycle and on-demand in subsequent cycles. Tumor assessments will be performed at baseline and every 8 weeks during the first year, and every 12 weeks thereafter. An interim analysis will be performed after 33 patients are evaluable. If 15 to 27 patients achieve a PFS at 6 months (PFS6), the trial will continue to the second stage, otherwise, it will be stopped for futility (&lt;15) or efficacy (≥28). A total of 56 evaluable patients will be included in stages I and II. The Spanish regulatory national competent authority approved the study on April 8th 2020. Recruitment started in July 2020. As of June 2021. Seven patients have been enrolled in 15 sites in Spain and 3 sites in Portugal. Acknowledgments: We thank PUMA BIOTECHNOLOGY, INC for their provision of Neratinib and financial contribution to the study.

Citation Format: Eva Ciruelos, Cristina Saura, Xavier González-Farré, Javier Salvador Bofill, Maria Vidal, Isabel Blancas, Elena López-Miranda, Maria Iglesias, Miriam Arumi, Mireia Margelí, Catarina Pulido, Serafin Morales, Fernando Henao, Pilar Sánchez, Sara Alves, Diogo Branco, Joan Manel Gasent, Pedro Sánchez-Rovira, Ana Godoy, José L. Passos-Coelho, Santiago Escrivá-de-Romaní, Juan M Ferrero-Cafiero, Tomás Pascual, Aleix Prat. Solti-1718 NEREA Trial: Neratinib in hormone receptor (HR)-positive/HER2-negative HER2-enriched (HER2-E) advanced breast cancer (BC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT2-27-01.

Evaluation of Memantine in AAV-AD Rat: A Model of Late-Onset Alzheimer's Disease Predementia

BACKGROUND

Though our understanding of Alzheimer's disease (AD) remains elusive, it is well known that the disease starts long before the first signs of dementia. This is supported by the large number of symptomatic drug failures in clinical trials and the increased trend to enroll patients at predementia stages with either mild or no cognitive symptoms. However, the design of pre-clinical studies does not follow this attitude, in particular regarding the choice of animal models, often irrelevant to mimic predementia Late Onset Alzheimer's Disease (LOAD).

OBJECTIVES

We aimed to pharmacologically validate the AAV-AD rat model to evaluate preventive treatment of AD.

METHODS

We evaluated an N-methyl-D-aspartate receptor antagonist, named memantine, in AAV-AD rats, an age-dependent amyloid rat model which closely mimics Alzheimer's pathology including asymptomatic and prodromal stages. Memantine was used at a clinically relevant dose (20 mg daily oral administration) from 4 (asymptomatic phase) to 10 (mild cognitive impairment phase) months of age.

RESULTS

A 6-month treatment with memantine promoted a non-amyloidogenic cleavage of APP followed by a decrease in soluble Aβ42. Consequently, both long-term potentiation and cognitive impairments were prevented. By contrast, the levels of hyperphosphorylated endogenous tau remained unchanged, indicating that a long-term memantine treatment is ineffective to restrain the APP processing-induced tauopathy.

CONCLUSIONS

Together, our data confirm that relevant models to LOAD, such as the AAV-AD rat, can provide a framework for a better understanding of the disease and accurate assessment of preventive treatments.

Antimycobacterial compound of chitosan and ethambutol: ultrastructural biological evaluation in vitro against Mycobacterium tuberculosis

Chitosan (CS) is a promising biopolymer and has been tested as a complement to the action and compensation of toxicity presented by anti-tuberculosis drugs. The present work studied the adjuvant effect of CS with the drug ethambutol (EMB) as a compound (CS-EMB), to explore its antimicrobial and cytotoxic activity, using transmission electron microscopy (TEM), to examine ultracellular changes that represent possible antimycobacterial action of CS on Mycobacterium tuberculosis (Mtb). Antimycobacterial activities were tested against reference strains Mtb ATCC® H37Rv and multidrug resistant (MDR). In vitro cytotoxicity tests were performed on Raw 264.7. For the studied compounds, morphological, ultrastructural, and physical-chemical analyses were performed. Drug-polymer interactions that occur through the H bridges were confirmed by physical-chemical analyses. The CS-EMB compound is stable at pHs of 6.5-7.5, allowing its release at physiological pH. The antibacterial activity (minimum inhibitory concentration) of the CS-EMB compound was 50% greater than that of the EMB in the H37Rv and MDR strains and the ultrastructural changes in the bacilli observed by TEM proved that the CS-EMB compound has a bactericidal action, allowing it to break down the Mtb cell wall. The cytotoxicity of CS-EMB was higher than that of isolated EMB, IC50 279, and 176 μg/mL, respectively. It is concluded that CS-EMB forms a promising composite against strains Mtb H37Rv and multidrug resistant (MDR-TB).Key points• Our study will be the first to observe ultrastructurally the effects of the CS-EMB compound on Mtb cells.• CS-EMB antimicrobial activity in a multidrug-resistant clinical strain.• The CS-EMB compound has promising potential for the development of a new drug to fight tuberculosis.

Validation of the Portuguese Version of the Risk Instrument for Screening in the Community (RISC) Among Older Patients in Primary Care in Northern Portugal

Background: Aging is associated with an increase in adverse health outcomes for older people. Short screening instruments that easily and quickly identify those at highest risk can enable decision-makers to anticipate future needs, allocate scarce resources and act to minimize risk. The Risk Instrument for Screening in the Community (RISC) is a brief (2-5 min) Likert scale that scores one-year risk of institutionalization, hospitalization and death from low (1/5) to severe (5/5). Objectives: To externally validate the RISC, scored by general practitioners (GP's), in primary care in Northern Portugal. Methods: The RISC was translated and culturally adapted to Portuguese. A cohort of 457 older adults (aged ≥65) under active follow-up with their GP's were screened. Outcomes at one-year were recorded. Accuracy was determined from the area under the curve (AUC) of receiver operating curve analysis. Results: The mean age of participants was 75.2 years; 57% were female. The proportion identified as being at maximum risk (RISC scores of 3-5/5) of institutionalization, hospitalization and death, were 14.9, 52.4 and 38.4%, respectively. At follow-up 2% (10/431) were institutionalized, 18.6% (84/451) were hospitalized and 3% (14/456) died. Those who were institutionalized (p = 0.021), hospitalized (p = 0.012) or dead (p < 0.001) at one-year were significantly older. Those living alone were more likely to be institutionalized (p = 0.007). The RISC showed fair accuracy in predicting hospitalization (AUC of 0.62 [95% CI: 0.55-0.69]) and good accuracy for Institutionalization (AUC of 0.79 [95% CI: 0.62-0.96]) and death (AUC of 0.77 [95% CI: 0.65-0.88]). Conclusions: The Portuguese version of the RISC accurately predicted institutionalization and death at one-year but like most short screens was less able to predict hospitalization. Given its brevity, the RISC is useful for quickly identifying and stratifying those at increased risk in primary care.

Development of Dl1.72, a Novel Anti-DLL1 Antibody with Anti-Tumor Efficacy against Estrogen Receptor-Positive Breast Cancer

Simple Summary

Over 70% of breast cancers (BCs) are estrogen receptor-positive (ER⁺). The development of endocrine therapy has considerably improved patient outcomes. However, there is a clinical need for novel effective therapies against ER⁺ BCs, since many of these do not respond to standard therapy, and more than one-third of responders acquire resistance, experience relapse and metastasize. The Notch ligand Delta-like 1 (DLL1) is a key player in ER⁺ BC development and aggressiveness. Contrary to complete Notch pharmacological inhibitors, antibody-targeting of individual Notch components is expected to have superior therapeutic efficacy and be better tolerated. In this study, we developed and characterized a novel specific anti-DLL1 antibody with efficacy in inhibiting BC cell proliferation, mammosphere formation and angiogenesis, as well as anti-tumor and anti-metastatic efficacy in an ER⁺ BC mouse model without side effects. Thus, our data suggest that this anti-DLL1 antibody is a promising candidate for ER⁺ BC treatment.

Abstract

The Notch-signaling ligand DLL1 has emerged as an important player and promising therapeutic target in breast cancer (BC). DLL1-induced Notch activation promotes tumor cell proliferation, survival, migration, angiogenesis and BC stem cell maintenance. In BC, DLL1 overexpression is associated with poor prognosis, particularly in estrogen receptor-positive (ER⁺) subtypes. Directed therapy in early and advanced BC has dramatically changed the natural course of ER⁺ BC; however, relapse is a major clinical issue, and new therapeutic strategies are needed. Here, we report the development and characterization of a novel monoclonal antibody specific to DLL1. Using phage display technology, we selected an anti-DLL1 antibody fragment, which was converted into a full human IgG1 (Dl1.72). The Dl1.72 antibody exhibited DLL1 specificity and affinity in the low nanomolar range and significantly impaired DLL1-Notch signaling and expression of Notch target genes in ER⁺ BC cells. Functionally, in vitro treatment with Dl1.72 reduced MCF-7 cell proliferation, migration, mammosphere formation and endothelial tube formation. In vivo, Dl1.72 significantly inhibited tumor growth, reducing both tumor cell proliferation and liver metastases in a xenograft mouse model, without apparent toxicity. These findings suggest that anti-DLL1 Dl1.72 could be an attractive agent against ER⁺ BC, warranting further preclinical investigation.

Everolimus and exemestane in hormone receptor-positive advanced breast cancer: A comprehensive cancer center’s experience

e13017

Background: Activation of the mammalian target of rapamycin intracellular signaling pathway is one of the mechanisms of endocrine resistance in breast cancer. The addition of everolimus to exemestane improves progression-free survival (PFS) in patients with hormone receptor positive (HR+) advanced breast cancer (ABC) previously treated with nonsteroidal aromatase inhibitors (NSAIs). The aim of this study was to assess the effectiveness and safety of everolimus plus exemestane in patients with HR+ ABC. Methods: We retrospectively evaluated patients with HR+, HER2 negative ABC treated with everolimus/exemestane that recurred or progressed during/after treatment with NSAIs in a portuguese comprehensive cancer center. Study endpoints were PFS, overall survival (OS), overall response rate and adverse events. Results: Between April 2014 and September 2020, 63 female patients were treated with everolimus/exemestane. Median age was 59 years (36-79), and all had performance status ECOG ≤2. Seventeen (27.0%) patients had bone metastasis alone, 39 (61.9%) had bone and visceral metastasis, 25 (39.7%) had metastasis in 3 or more sites and 87.3% had previous hormone-sensitive disease. Before everolimus/exemestane, 61 (96.8%) patients were being treated with palliative endocrine therapy (alone or in combination with CDK4/6 inhibitors) or chemotherapy (ChT) and 2 (3.2%) patients were under adjuvant endocrine therapy. Median follow-up time was 12.8 months (1.4-74.6), with 39 patients alive. Overall response rate was 14.3% (1 complete response and 8 partial responses) and 45 patients had stable disease. Median PFS was 5.6 months (CI95% 2.4-8.8) and median OS was 25.4 months (CI95% 10.3-40.5). Subgroup analysis regarding PFS was statistically significant for previous treatment with CDK4/6 inhibitors (p = 0.026) and for site of metastasis (p = 0.025). In the subgroup of patients that previously underwent palliative ChT, median PFS was 4.0 months (CI95% 0.2-9.6) and median OS was 18.6 months (CI95% 8.2-29.0). For patients that did not receive previous palliative ChT, median PFS was 5.8 months (CI95% 3.8-7.8) and median OS was 43.5 months (CI95% 2.0-85.0). Grade 3 and 4 adverse events occurred in 21 (33.3%) patients, and were: nausea, anorexia, rash, headache, haematologic toxicity, hepatic cytolysis, hyperglycaemia, pneumonitis, oral mucositis and acute kidney failure with need for haemodialysis. Fifty-five (87.3%) patients suspended everolimus, 34 (54.0%) due to disease progression and 21 (33.3%) due to toxicity. Conclusions: Our results confirm the effectiveness and safety of everolimus/exemestane in real-world setting and support its use mainly before palliative ChT. Everolimus/exemestane in HR+ ABC is feasible in the clinic, with toxicity manageable under close surveillance.

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Introduction

Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim

To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods

Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results

A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion

Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement

Type of funding source: None

Unmet needs of informal carers of the oldest old in Portugal

Oldest-old individuals are a growing segment of the population that faces several challenges in terms of care demands. Informal caregivers experience more or less challenges, namely depending on the support they can access. The present study explores the unmet needs of a sample of informal caregivers of community-dwelling older adults aged 80+ and analyses the association of such needs with sociodemographic information, care-giving context (e.g., length of care),and health characteristics of the caregivers and care receivers (e.g., cognitive status and functionality). We recruited 175 care-giving dyads from the North of Portugal. Descriptive statistics summarised the sample's characteristics. Informal caregivers were mainly women with a mean age of 60.6 years (SD = 9.8). Care receivers' mean age was 88.7 years (SD = 5.6) and were functionally dependent (9.3 points [SD = 7.0] and 27.0 points [SD = 3.5] for Basic and Instrumental Activities of Daily Living, respectively). A thematic analysis of an open-ended question on unmet needs was performed, revealing the presence of unmet needs. The most relevant ones (financial support, caregiver support, primary care/medical specialities, and labour regulation) were further analysed, concerning the care-giving dyad's using Independent Student's t test or Mann-Whitney U Tests, and Chi-squared test or Fisher's Exact test depending on the variable. The most frequent unmet needs were associated with the caregiver's age, care receivers' kinship, number of care-giving hours, the caregiver's gender, professional status, the caregiver strain and medicines intake. Findings suggest the need for establishing policies that ensure adequate sustainability of the provision of informal care that takes into account the needs of care-giving dyads in the planning process.

A Path Toward Inclusive Social Cohesion: The Role of European and National Identity on Contesting vs. Accepting European Migration Policies in Portugal

The Western hemisphere has witnessed recent increased immigration flows generating social and political debate across Europe. In one view, migration flows represent an opportunity to construct a diverse social cohesion. In another view, migration flows are perceived as a threat to existent national cultures. This view is held by political nationalisms and right-wing populist forces installed in the majority of EU countries’ parliaments, accentuating discrimination against immigrants and residents in Europe. We theorize that European identity predicts positive attitudes toward immigrants (prosocial behavior and support for inclusive policies), whereas national identity’s predictions of attitudes toward immigrants’ inclusion depends on participants’ political tendency. Moreover, we test the mediation effect of positive (humanitarian concerns and economic benefit) and negative (jobs scarcity, cultural deterioration, and invasion) arguments used in political discourses regarding immigrants’ inclusion on the relation between national and European identities and attitudes toward immigrants’ inclusion. Results (Portuguese sample, N = 176) show that national identity predicts negative attitudes toward immigrants’ inclusion, but only among right-wing individuals. Among left-wing individuals, national identity predicts less contestation to immigrant’s inclusion sustained by humanitarian concerns. Interestingly, European identification weakened right-wing individuals’ adherence to discriminatory arguments and increased perceived economic contribution that immigrants bring to society, increasing agreement with prosocial behavior and immigrants’ inclusion. We discuss that European identity, sustained in humanitarian values and economic benefit, may stimulate a stronger multicultural social cohesion, intergroup trust, and social well-being based on democratic values, social justice, and equality, and on the respect for human dignity.

Trajectories of Informal Caregiving to the Oldest-old: A One-year Follow-up Study

This study aimed to analyze caregivers and care recipients' health characteristics and caregiving context changes during a one-year follow-up. A total of 204 informal caregivers and oldest-old care recipients ( ≥ 80 years) were assessed on two occasions, 12 months apart. Information was retrieved on the dyad's sociodemographic profile, caregiver's health/caregiving outcomes, care recipients' dependency level, and caregiving context. Descriptive analysis was performed for all variables and comparisons between the two moments using paired t tests or McNemar tests. Caregiving hours, caregiver burden, and negative aspects of caregiving got significantly worse over one year. The number of unmet needs, in-home services utilization, and self-perception of mental health improved. Care recipients declined in their functional and health status and on their cognitive performance. This study provides information about caregiving trajectory changes over one year and stresses a probable caregiver adaptation even when facing increasing caregiving demands.

Risk and limits in dental practice: a Portuguese approach to medical-legal evaluation and professional liability

Patient safety and quality of healthcare delivery systems are an objective of WHO. This study aims to present and analyse Portuguese clinical data on risk and malpractice in dental practice. Data from the Forensic Dentistry Laboratory (Faculty of Medicine, University of Coimbra) was analysed, between the years of 2013 to 2018. One hundred and seven technical reports were selected, and seventy nine files were included in the iatrogenic sequelae group. Data included the analysis of the performance of dental professionals. Sequelae were divided in descending order of occurrence:1) mandibular dysfunction (53,2%)[(42)79]; 2) neurological deficit (39,2%)[(31)79]; 3) tooth loss (6,3%)[(5)79]; and 4) opening deficit (1,3%)[(1)79].Three major areas with significant expression in the field of expert evaluations were analysed: 1) orthodontic treatment (51,9%), implant rehabilitation (29,1%), and oral surgery. Given the prevalence of malpractice, the need to assess its causes and recognise standards for its prevention is necessary.

Can psychosocial work factors influence psychologists' positive mental health?

BACKGROUND

Working in healthcare can entail intense emotional demands that increases susceptibility to occupational risk factors. Psychosocial risk assessment can contribute to promoting awareness of the effects of work on positive mental health.

AIMS

To explore and analyse the influence of psychosocial work factors on positive mental health among psychologists.

METHODS

A cross-sectional study of 339 psychologists was conducted. Two instruments were used for data collection: the Mental Health Continuum-Short Form (MHC-SF) to assess well-being and the Health and Work Survey (INSAT) to assess psychosocial work factors.

RESULTS

This study identified psychosocial work factors that affect psychologists' positive mental health, namely, emotional well-being was affected by 'Need help from colleagues' (β = -1.091), 'Have no one I can trust' (β = -1.253) and 'Complex work' (β = 0.751); psychological well-being was affected by 'Intense work pace' (β = 1.151), 'Not able to participate in decisions' (β = -3.695) and 'Complex work' (β = 1.520); and social well-being was affected by 'Always changing roles and tasks' (β = -1.810) and 'Not able to participate in decisions' (β = -2.470).

CONCLUSIONS

Psychosocial work factors such as work organization, work relationships and emotional demands influence psychologists' positive mental health. Social support at the workplace and having challenging and autonomous work can promote mental health. It is important to develop better organizational practices to promote mental health and well-being among these professionals.

Functional and Physiological Methods of Evaluating Median Nerve Regeneration in the Rat

The main goal of this investigation is to show how to create and repair different types of median nerve (MN) lesions in the rat. Moreover, different methods of simulating postoperative physiotherapy are presented. Multiple standardized strategies are used to assess motor and sensory recovery using an MN model of peripheral nerve lesion and repair, thus permitting easy comparison of the results. Several options are included for providing a postoperative physiotherapy-like environment to rats that have undergone MN injuries. Finally, the paper provides a method to evaluate the recovery of the MN using several noninvasive tests (i.e., grasping test, pin prick test, ladder rung walking test, rope climbing test, and walking track analysis), and physiological measurements (infrared thermography, electroneuromyography, flexion strength evaluation, and flexor carpi radialis muscle weight determination). Hence, this model seems particularly appropriate to replicate a clinical scenario, facilitating extrapolation of results to the human species. Although the sciatic nerve is the most studied nerve in peripheral nerve research, analysis of the rat MN presents various advantages. For example, there is a reduced incidence of joint contractures and automutilation of the affected limb in MN lesion studies. Furthermore, the MN is not covered by muscle masses, making its dissection easier than that of the sciatic nerve. In addition, MN recovery is observed sooner, because the MN is shorter than the sciatic nerve. Also, the MN has a parallel path to the ulnar nerve in the arm. Hence, the ulnar nerve can be easily used as the nerve graft for repairing MN injuries. Finally, the MN in rats is located in the forelimb, akin to the human upper limb; in humans, the upper limb is the site of most peripheral nerve lesions.

[A Potentially Fatal Aphrodisiac: Cantharidin Poisoning]

Cantharidin is a toxin extracted from coleoptera beetles, commonly known as 'Spanish fly'. Traditionally it was used as an aphrodisiac, a vesicant or as an abortifacient. Intoxication by this substance has been widely reported, generally associated with gastrointestinal complications, such as digestive hemorrhage, and genitourinary disorders, such as hematuria and acute kidney injury. The authors describe the case of a 51-year old male patient who developed severe cantharidin poisoning after ingesting a preparation ('tea formulation') containing the substance. The patient reported a burning sensation in his oral cavity, diarrhea and hematuria, having sustained acute kidney injury and atypical neurological symptoms. Due to the lack of an antidote, the available treatment options are reduced to supportive measures. This case strengthens the need for a thorough medical history to ascertain the use of 'natural' products and medicinal herbs (i.e. of unregulated origin), and the importance of educating the community to their potential toxicity.

Examining Frailty Phenotype Dimensions in the Oldest Old

INTRODUCTION

Frailty has been studied among the old population due to its association with negative outcomes. Presently there is no gold standard for measuring frailty, but several studies have used the frailty phenotype of Fried consisting of five components (weakness, slowness, unintentional weight loss, exhaustion, and low physical activity) that classify individuals as robust, pre-frail, or frail, depending on the number of components affected, respectively, zero, one or two, and three or more. This study aims to explore the specific contribution of each of these components to the frailty phenotype in a sample of oldest old community-dwelling individuals.

MATERIALS AND METHODS

Individuals aged 80+ years old living in the community (N = 142) participated in this study. Sociodemographic data (age, sex, educational level, and marital status) and Fried's frailty phenotype were collected. Descriptive analysis summarized sociodemographic information and the frailty components. Multiple correspondence analysis (MCA) was performed to detect and explore relationships between frailty's five components.

RESULTS

Participants had a mean age of 88.07 years (SD = 5.30 years) and were mainly women (73.9%). The majority of the sample were considered frail (71.8%) and pre-frail (24.7%), and the most recurrent component for both groups was slowness. From the MCA analysis, a two-dimension solution was considered the most adequate, with 53.47% of variance explained. Dimension 1 (32.21% of variance explained) showed weakness as the most discriminant component; dimension 2 (21.26% of variance explained) showed unintentional weight loss as the most discriminant component.

DISCUSSION

Results revealed a high number of pre-frail and frail participants. MCA proved to add an important understanding in examining the frailty phenotype; it revealed weakness as the most discriminant component for dimension 1, suggesting a high association with the frailty phenotype. MCA also identified two main features of frailty: one related with physical features (motor behavioral and grip strength) including weakness, low physical activity, and slowness; and the second related with intrinsic conditions (unintentional weight loss and exhaustion).

CONCLUSION

This study corroborates the need of a differentiated approach to the frailty phenotype among very old individuals, bringing for consideration the specific influence of its components.

Psychiatric symptoms in Huntington's disease the importance of reliable information – A case report

Introduction

Huntington's Disease is an autosomal dominant neurodegenerative disease characterized by motor, psychiatric and cognitive symptoms. Irritability, affective disorders, apathy and psychosis are among the most frequent psychiatric symptoms and can predate the pre-clinical period.

Objective

The authors’ goal is to understand the complexity of Huntington's disease clinical presentation. Additionally, we present an illustrative clinical case.

Aims

To convey the importance of collecting reliable information in order to make a proper diagnosis.

Methods

A PubMed database review was performed using “Psychiatry”, “Psychiatric”, “Symptoms” and “Huntington's Disease” as keywords; retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

Results

The authors report a case of a 39-year-old woman, who was referred in 2014, to a psychiatrist because of depressive mood and suicidal ideation with two suicidal attempts in the past 5 years. However, she did not disclose her family history of Huntington's disease neither to her GP nor her psychiatrist. She never complied with the treatment plan and was admitted, in November, into a psychiatric unit because of subtle motor changes and apathy, which had resulted in personal neglect. The diagnosis could only be made after a family interview was held and the family medical history was revealed.

Conclusions

Corroborative history from caregivers is of extreme importance in psychiatry. Early detection of symptoms can help mitigate the disease social impact. In our patient's case, by the time of proper diagnosis, she was estranged from her family and had endured distressing psychiatric symptoms without adequate treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P2516Cardiac rehabilitation program - experience and outcomes in a tertiary center

Introduction

Cardiac rehabilitation (CR) programs are effective in improving functional capacity and reducing mortality. The level of adherence to them seems to be less than the ideal, and some factors can predict non-compliance with impact on outcomes.

Purpose

The aim was to characterize the population of the cardiac rehabilitation (CR) appointment, determine factors predictive of compliance with the standard CR exercise program and evaluate the benefits of the program.

Methods

Retrospective analysis of patients in a CR appointment at a single center between 2014 and 2017. Patients (P) were divided into two groups: compliance >80% of the program (GI) and non-compliance (GII). We assessed clinical, laboratory, and echocardiographic characteristics and determined predictors for compliance and compared the follow-up to date.

Results

270P (83% men) were included, with a mean age of 57 years. The P had a median follow up of 35 months, with an interquartil interval of 28 months. The majority (92.5%) had at least one cardiovascular risk factor (25.1% diabetes, 57.1% hypertension, 72.8% dyslipidemia, 75.8% obesity or weight excess, with mean body mass index (BMI) 27.3±3.46, 16.7% family history, 19.8% acute myocardial infarction (AMI), 48.2% smoking). 99% of the patients were medicated (93.7% acetylsalicylic acid, 67.3% clopidogrel, 24.1% ticagrelor, 95.6% beta-blocker, 93.7% ACEI/ARB, 95.5% statin). 144P (53.3%) were not from Lisbon. Most patients (77%) were referred after AMI, 8.9% with heart failure (HF), 8.5% with stable or unstable coronary disease and 1.9% with valvulopathy. 69P (25.6%) attended >80% of the CR program. Death occurred in 4.4% of the P (71.4% cardiovascular causes) and 27% had at least 1 hospitalization. Age, sex, economic insufficiency and residence local (Lisbon or non-Lisbo) were not predictors of non-compliance (p=0.859, p=0.656, p=0.914 and p=0.515 respectively). Predictors of non-compliance were higher IMC (CC=-0.141, p=0.014), higher cholesterol (CC=-0.140, p=0.016), higher C reactive protein (CC=-0.120, p=0.043), higher HbA1c (CC=-0.170, p=0.008) and CR for heart failure (HF) (OR = 0.715, IC [0.659–0.775], p=0.002). Of these, higher HbA1C (p=0.018) and CR for HF (p=0.034) were independent predictors. Compliance with>80% of the program was associated with lower overall mortality (OR = 0.732, IC [0.679–0.788], p=0.037), but not as an independent factor (p=0.378). The only independent predictor of mortality were BNP (p<0.0001).

Conclusion

Of the patients referred to the CR consultation one fourth concludes the program. Several factors can predict non-compliance, with higher HbA1c and CR for HF being independent predictors. Compliance with the CR program is associated with lower overall mortality.

P2510Cardiorespiratory optimal point as a predictor of outcomes in patients enrolled in a cardiac rehabilitation program

Introduction

The cardiopulmonary exercise test (CEPT) allows the evaluation of peak and sub-maximal tolerance to the effort, giving us relevant information for clinical decisions. Evidence has emerged that Cardiorespiratory Optimal Point (COP)>30, calculated as the minimum ratio between ventilation and oxygen (VE/VO2) may be a good predictor of events.

Purpose

The aim was to characterize the population of the cardiac rehabilitation (CR) appointment that performed CEPT, evaluate COP as a predictor of events and determine the best cut off for our population.

Methods

Retrospective analysis of CR appointment patients who performed CEPT between 2014 and 2017 in a single center. We compared the mortality and hospitalizations according to COP and COP>30. We established the appropriate Cut Off for our population and compared the same with the occurrence of events.

Results

207Patients (P) (83.6% men) were included, with a mean age of 57 years. The mean COP was 23.6±5.8 (IC [24.06–25.66]). 15.9% P had COP >30 and 33.8% had COP<22. The majority (96.6%) had a cardiovascular disease or risk factors and 99% were medicated. The majority (87.9%) was referred for CR with isquemic cardiopathy (AMI or stable or unstable coronary disease), 9.2% with heart failure (HF) and 9.2% with valvulopathy. 6.9% P died from any cause, 33.8% had an hospitalization (78.6% from a cardiovascular reason). Higher COP values correlated with higher number of all causes hospitalizations (H) (CC = 0.123, p=0.032), cardiovascular H (CC = 0.123, p=0.032), heart failure H (CC = 0.189, p=0.001) and device placement H (CC = 0.173, p=0.003). COP did not correlate with mortality (p=0.453). The cut off of 30 only correlated with HF hospitalization in this population (OR = 5, IC [1.429–17.494] p=0.006). In our population, COP was a good predictor for all cause H and heart failure H (AUC = 0.8 in both). A cut off of 25 had a sensitivity (S) of 78% with a specificity (E) of 70% for all cause hospitalization and S 73% and E 68% for heart failure H. Values above this cut off correlate with more all cause H (OR = 1,928, IC [1.06–3.507], p=0.031) and heart failure H (OR = 5.63, IC [1,44–21.94]), p=0.006). COP was an independent predictor of all-cause H (p=0.018) and heart failure H (p<0.0001). Other independent predictors of HF hospitalization are BNP (p=0.0011) and ejection fraction (p<0.0001).

Conclusion

COP was a good independent predictor of all-cause hospitalizations and HF hospitalization. In our population the cut off 25 for COP had the greatest S and E for predicting events. In our population this factor was not a good predictor of mortality.

BD-2 and BD-3 increase skin flap survival in a model of ischemia and Pseudomonas aeruginosa infection

The main aim of this work was to study the usefulness of human β-defensins 2 (BD-2) and 3 (BD-3), which are part of the innate immune system, in the treatment of infected ischemic skin flaps. We investigated the effect of transducing rat ischemic skin flaps with lentiviral vectors encoding human BD-2, BD-3, or both BD-2 and BD-3, to increase flap survival in the context of a P. aeruginosa infection associated with a foreign body. The secondary endpoints assessed were: bacterial counts, and biofilm formation on the surface of the foreign body. A local ischemic environment was created by producing arterialized venous flaps in the left epigastric region of rats. Flaps were intentionally infected by placing underneath them two catheters with 10⁵ CFU of P. aeruginosa before the surgical wounds were hermetically closed. Flap biopsies were performed 3 and 7 days post-operatively, and the specimens submitted to immunohistochemical analysis for BD-2 and BD-3, as well as to bacterial quantification. Subsequently, the catheter segments were analyzed with scanning electron microscopy (SEM). Flaps transduced with BD-2 and BD-3 showed expression of these defensins and presented increased flap survival. Rats transduced with BD-3 presented a net reduction in the number of P. aeruginosa on the surface of the foreign body and lesser biofilm formation.

Bright thermal (blackbody) emission of visible light from LnO2 (Ln = Pr, Tb), photoinduced by a NIR 980 nm laser

The light-induced blackbody emission from lanthanide dioxide can improve the solar cell performance by converting NIR photons into bright visible light.

Development of a bioreactor system for cytotoxic evaluation of pharmacological compounds in living cells using NMR spectroscopy

INTRODUCTION

The evaluation of drug's cytotoxicity is a crucial step in the development of new pharmacological compounds. ³¹P NMR can be a tool for toxicological screening, as it enables the study of drugs' cytotoxicity and their effect on cell energy metabolism in a real-time, in a non- invasive and non-destructive way. This paper details a step-by-step protocol to implement a bioreactor system able to maintain cell viability during NMR acquisitions, at high cell densities and for several hours, enabling toxicological evaluation of pharmacological compounds in living cells.

METHOD

HeLa cells were immobilized in agarose gel threads and continuously perfused with oxygenated medium inside a 5 mm NMR tube. Signals corresponding to intracellular high-energy phosphorous compounds were continuously monitored by ³¹P NMR to assess cell energy levels, intracellular pH and intracellular free Mg²⁺ concentrations ([Mg²⁺]_f) under control and in the presence of two different cytotoxic drugs, calix-NH₂ or 5-fluorouracil (5-FU).

RESULTS

The bioreactor system was effective in maintaining cell energy levels as well as intracellular pH and [Mg²⁺]_f along time, with a good ³¹P NMR signal to noise ratio. Calix-NH₂ and 5-FU decreased cell energy levels by 35% and 39%, respectively, with a negligible increase in intracellular [Mg²⁺]_f, and without affecting intracellular pH.

DISCUSSION

The immobilization and perfusion system here detailed, along with ³¹P NMR, is useful in toxicological evaluation of new pharmacological compounds, enabling the continuous assessment of drugs' effect on energy levels, intracellular pH and [Mg²⁺]_f in intact cells, for several hours without compromising cell viability.

Pharmacogenomics in epithelial ovarian cancer first-line treatment outcome: validation of GWAS-associated NRG3 rs1649942 and BRE rs7572644 variants in an independent cohort

The identification of predictive biomarkers for the first-line treatment of epithelial ovarian cancer (EOC) remains a challenge. Although genome-wide association studies (GWAS) have identified several genetic polymorphisms as predictors of EOC clinical outcome, the subsequent validation has not yet been performed. This study aims to validate the influence of Neuregulin 3 (NRG3) rs1649942 and Brain and reproductive organ-expressed (TNFRSF1A modulator) (BRE) rs7572644 GWAS-identified variants in an independent cohort of EOC patients from the North region of Portugal (n = 339) submitted to first-line treatment. Polymorphism genotypes were determined by real-time PCR using validated assays. Patients carrying the NRG3 rs1649942 A allele presented a significantly longer overall survival (OS) when compared to GG-genotype patients (log-rank test, P = 0.011) in the FIGO IV stage subgroup. No impact was observed for early-stage patients or considering disease-free survival (DFS) as an outcome. For FIGO I/II stage patients, BRE rs7572644 C allele carriers exhibit a decreased OS (P = 0.014) and DFS (P = 0.032) when compared to TT-homozygous patients. Furthermore, a Multivariate Cox regression analysis revealed a three-fold increase in the risk of death (HR, 3.09; P = 0.015) and recurrence (HR, 3.33; P = 0.009) for FIGO I/II C allele carriers. No significant impact was observed for late-stage patients. The BRE rs7572644 and NRG3 rs1649942 genetic variants were validated in an independent cohort of EOC Portuguese patients, particularly in specific subgroups considering FIGO staging. Further functional post-GWAS analyses are indispensable to understand the biological mechanisms underlying the observed results.

Impact of ovarian metastases on survival in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy originating from appendiceal and colorectal cancer

AIM

Ovarian metastases from gastrointestinal tract malignancies have been considered an ominous finding with poor prognosis. The aim of this project was to determine the impact on survival, and potential cure, when cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are combined to treat peritoneal malignancy in women with Krukenberg tumours.

METHOD

A retrospective analysis of prospectively collected data between January 2010 and July 2015. Female patients undergoing complete CRS (macroscopic tumour removal) and HIPEC for pseudomyxoma peritonei (PMP) of appendiceal origin, or colorectal peritoneal metastases (CPM) were included. Survival was estimated using the Kaplan-Meier method and survival rates compared using the log-rank test.

RESULTS

In total, 889 patients underwent surgery for peritoneal malignancy, of whom 551 were female. Of these, 504/551 (91%) underwent complete CRS and HIPEC. Overall, 405/504 (80%) had at least one involved ovary removed either during CRS and HIPEC or at their index prereferral operation. Three hundred and fifty-two patients (87%) had an appendiceal tumour and 53 (13%) had CPM. At a median follow up of 40 months, overall survival (OS) did not differ significantly between patients with or without ovarian involvement in women with a primary low-grade appendiceal tumour or CPM. In women with high-grade primary appendiceal pathology, OS was significantly lower in patients with ovarian metastases compared with those without ovarian involvement.

CONCLUSION

Women with ovarian metastases from low-grade appendiceal tumours or colorectal cancer treated with CRS and HIPEC have similar survival rates to patients without ovarian metastases. Long-term survival and cure is feasible in patients amenable to complete tumour removal.

Reconstruction of a 10-mm-long median nerve gap in an ischemic environment using autologous conduits with different patterns of blood supply: A comparative study in the rat

The aim of this study was to evaluate in the Wistar rat the efficacy of various autologous nerve conduits with various forms of blood supply in reconstructing a 10-mm-long gap in the median nerve (MN) under conditions of local ischemia. A 10-mm-long median nerve defect was created in the right arm. A loose silicone tube was placed around the nerve gap zone, in order to simulate a local ischemic environment. Rats were divided in the following experimental groups (each with 20 rats): the nerve Graft (NG) group, in which the excised MN segment was reattached; the conventional nerve flap (CNF) and the arterialized neurovenous flap (ANVF) groups in which the gap was bridged with homonymous median nerve flaps; the prefabricated nerve flap (PNF) group in which the gap was reconstructed with a fabricated flap created by leaving an arteriovenous fistula in contact with the sciatic nerve for 5 weeks; and the two control groups, Sham and Excision groups. In the latter group, the proximal stump of the MN nerve was ligated and no repair was performed. The rats were followed for 100 days. During this time, they did physiotherapy. Functional, electroneuromyographic and histological studies were performed. The CNF and ANVF groups presented better results than the NG group in the following assessments: grasping test, nociception, motor stimulation threshold, muscle weight, and histomorphometric evaluation. Radial deviation of the operated forepaw was more common in rats that presented worse results in the other outcome variables. Overall, CNFs and ANVFs produced a faster and more complete recovery than NGs in the reconstruction of a 10-mm-long median nerve gap in an ischemic environment in the Wistar rat. Although, results obtained with CNFs were in most cases were better than ANVFs, these differences were not statistically significant for most of the outcome variables.

Spectrum of CFTR gene sequence variants in a northern Portugal population

In Portugal, the spectrum of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene variants is not known. The main objective of this work was to determine the type and frequency of CFTR variants in a sample from northern Portugal by the complete analysis of the CFTR coding sequencing performed in 512 Portuguese children. A total of 30 different CFTR sequence variants, already reported as cystic fibrosis (CF) or CFTR related disorders variants, were detected. Ninety-two children (18.0%; 95%CI: 14.7-21.6) were found to be carriers of one sequence variant and 8 (1.6%; 95%CI: 0.7-3.1) had two sequence variants. Taking into consideration only variants that may cause CF when combined with a pathogenic CF variant, the CF pathogenic variant carrier frequency was 3.3% (95%CI: 1.9-5.3). One (0.2%; 95%CI: 0.01-0.7) child presented two CF pathogenic variants.

CONCLUSIONS

The majority of CFTR variants detected have been associated with a less severe CF phenotype. A wide spectrum of CFTR variants was identified, confirming the highest CFTR allelic heterogeneity previously reported in Mediterranean country. Additionally, better knowledge about the CFTR sequence variation spectrum may contribute to more efficient genetic testing in the Portuguese population.

Screening of Dementia in Portuguese Primary Care: Methodology, Assessment Tools, and Main Results

The objectives of this article are as follows: (1) to describe the assessment protocol used to outline people with probable dementia in Primary Health Care; (2) to show the methodological design and procedure to obtain a representative sample of patients with probable dementia; and (3) to report the main characteristics of the sample collected in the context of the study "Characteristics and needs of people with probable dementia." The study protocol was based on the "Community Assessment of Risk and Treatment Strategies (CARTS) Program" and is composed by a set of instruments that allow the assessment of older adults with probable dementia in several areas (health, psychological, functionality, and other). Descriptive analysis was used to characterize the final sample (n = 436). The study protocol as well as the methodological procedure to obtain the referral of research participants and data collection on the condition of people with probable dementia in Primary Health Care proved to be a valuable tool to obtain a sample of patients distributed by the full range of probable dementia in a large geographical area. Results may allocate the design of care pathways for old people with cognitive disorders to prevent, delay impairment, and/or optimize quality of life of patients.