Multifocal MRI-Directed Simultaneous Integrated Boost (SIB) in the Treatment of Prostate Cancer with Stereotactic Body Radiation Therapy (SBRT)

PURPOSE/OBJECTIVE(S)

Conventionally fractionated MRI-directed radiation boosts in the treatment of prostate cancer have been shown to improve oncologic outcomes in the FLAME trial. Moreover, recent data has demonstrated local recurrences following SBRT predominately occur at the site of the dominant intraprostatic lesion. Modern protocols including HYPO-Flame have demonstrated early safety profiles of a 5-fraction intraprostatic SBRT boost. This study aims to determine if multifocal SIB treatment is associated with additional acute toxicity relative to unifocal boosts.

MATERIALS/METHODS

In this single-center retrospective analysis, we identified all patients who underwent SBRT with a SIB using a robotic radiosurgical platform. Fiducial markers and hydrogel rectal spacers were placed prior to simulation. All patients underwent treatment planning MRI with documented PI-RADS 3-5 lesions targeted for SIB delineation. Patients were treated to a prescription dose of 3500 to 3625 cGy in 5 fractions, or 1800 to 2100 cGy in 3 fractions in concert with pelvic nodal irradiation. The SIB prescription dose ranged from 4000 to 4200 cGy and 2100 to 2300 cGy for the 5- and 3-fraction regimens, respectively. Acute toxicity was defined as that occurring within 60 days of treatment completion using the CTCAE v. 5.0.

RESULTS

A total of 35 patients with a median age of 70 underwent SBRT SIB from 5/2022 to 1/2023 with the following risk distribution: low (3%), intermediate (66%), high (28%), and regional (3%). Most patients received rectal spacers (77%) and neoadjuvant ADT (71%) prior to treatment. The majority of patients underwent 5-fraction SBRT (74%) with the remainder receiving SBRT as a boost. Approximately half (51%) of the cohort was treated with a multifocal SIB to multiple PI-RADS lesions. Mean SIB dose was 4105 and 2377 cGy in 5- and 3-fractions, respectively. With a median follow up of 33 days, we identified no grade 3+ acute toxicities. Crude rate of grade 2 GU and GI toxicity was 51% and 6%, respectively, on par with prior unifocal publications. There was no difference in median SIB volume between uni- and multifocal boosts (1.47 vs. 1.72 cc, p = 0.57), nor was SIB volume associated with an increased risk of grade 2 GU toxicity (p = 0.28). Dominant lesion location was not associated with increased grade 2 GU toxicity (p = 0.29). No grade 2 GI toxicities occurred in the multifocal group. Finally, univariate analysis did not identify multifocal boost as a risk of grade 2 GU toxicity (35%) relative to unifocal (67%) boost (p = 0.09).

CONCLUSION

In the first analysis of its kind in the literature, we demonstrate that multifocal MRI-directed intraprostatic SBRT SIB yields no acute high-grade toxicity and is not associated with a higher risk of low-grade GU and GI toxicity relative to unifocal boost. Longer follow is necessary to determine risk of late toxicity and oncologic efficacy.

Robotic SBRT in Prostate Cancer Patients Younger Than 50 Years Old-Updated Results

PURPOSE/OBJECTIVE(S)

Stereotactic Body Radiation Therapy (SBRT) is a standard therapeutic option for men with prostate adenocarcinoma. The median age of prostate cancer in the US is 66 but patients as young as 35 have been reported. Many younger patients will have surgery rather than SBRT for localized prostate cancer but some will be treated with SBRT. There is a paucity of data on the outcomes of this younger subset. This study reports updated outcomes on patients younger than 50 treated with SBRT at a single institution and compares outcomes to older patients.

MATERIALS/METHODS

Between April 2006 and December 2022, 6,130 patients with prostate cancer were treated with inhomogeneous-dosed SBRT using a robotic linear accelerator. Information was available for 4,143 patients. 3568 (86.12%) of patients were treated with a median dose of 3500cGY (3500-3625) delivered over 5 consecutive fractions prescribed to the 83-85% isodose line, and the remaining 575 (13.88%) other patients receiving a median dose of 4500cGY (4500-5400) to the pelvis in conventional fractionation followed by a 3 fraction SBRT boost of 2100 cGY (1950-2100) over 3 consecutive fractions. Androgen deprivation Therapy (ADT) was prescribed in 1,035 (24.98%) of these cases. The mean age was 67.4 years old. 48 patients were younger than 50 years old (mean age 46.6). 4,095 patients were 50 or older. Patients were divided into prognostic D'Amico risk groups with 43.75%, 50.00%, 6.25% of patients falling in the low, intermediate, and high-risk stratifications in the younger cohort and 23.88%, 57.05%, 19.07% in the older cohort respectively. Pretreatment PSA was 1.72 - 43.2 (median: 5.4) in the younger group and 0.3 - 661 (median: 6.5) in the older group. In the younger group, Gleason scores were 6 in 47.92%, 7 in 47.92%, and 8-10 in 4.16%. 44 younger patients were treated with SBRT alone. 4 patients also received supplemental external beam radiation (median dose 4500cGY) and 5 patients (10.42%) received Androgen Deprivation Therapy (ADT) as part of their treatment regimen. In the older group, Gleason scores were 6 in 29.84%, 7 in 54.14%, and 8-10 in 16.02%. 3522 were treated with SBRT alone. 573 patients also received supplemental external beam radiation (median dose 4500cGY) and 1030 patients (25.15%) received Androgen Deprivation Therapy (ADT) as part of their treatment.

RESULTS

At 75 months the 6-year biochemical relapse free survival was 95.83% in younger patients compared to 98.41% in older patients using the Phoenix definition of biochemical failure. The 6-year median post treatment PSA was 0.3 in younger patients and 0.2 in the older patients. There were no significant differences in the risk stratification between the 2 groups.

CONCLUSION

This represents the largest series evaluating outcomes in very young patients treated with definitive SBRT for prostate cancer. With updated 6-year follow up, SBRT remains an effective treatment for this younger subset of patients. Continued follow up will be required to see if these results remain durable.

Predictors of immune-related adverse events and outcomes in patients with NSCLC treated with immune-checkpoint inhibitors

OBJECTIVE

To identify predictors of immune-related adverse events (IRAEs) in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). Assess associations between outcomes and the development of IRAEs.

METHODS

Retrospective analysis of patients with NSCLC treated with ICIs between 2016 and 2020 in the Pulmonology Department of our hospital. Patients with and without IRAEs were compared. A logistic regression analysis was performed to determine predictors of IRAEs. Progression-free survival (PFS) and overall survival (OS) curves were calculated using the Kaplan-Meier method, and the long-rank test was used to assess survival differences between groups. Univariate and multivariate Cox proportional-hazards regression models were used to identify factors associated with PFS and OS. The value considered statistically significant was p≤0.05.

RESULTS

A total of 184 patients (77.7% men, mean age 66.9±9.5 years) treated with ICIs were analyzed. During follow-up, 49 (26.6%) patients developed IRAEs and 149 (81.0%) died. According to the multivariate logistic regression analysis, treatment with statins (OR:3.15; p = 0.007), previous systemic corticosteroid therapy (OR:3.99; p = 0.001), disease controlled as response to ICI (OR:5.93; p < 0.001) and higher hemoglobin values (OR:1.28; p = 0.040) were independent predictors for the development of IRAEs. Patients who developed IRAEs had significantly longer medians of PFS (41.0 vs 9.0 weeks, p < 0.001) and OS (89.0 vs 28.0 weeks; p < 0.001).

CONCLUSIONS

Patients treated with statins, pre-ICI systemic corticosteroids, higher baseline hemoglobin value and controlled disease as initial response to ICI had a higher risk of developing IRAEs. The development of IRAEs was associated with better outcomes.

Training responsiveness of cardiorespiratory fitness and arterial stiffness following moderate-intensity continuous training and high-intensity interval training in adults with intellectual and developmental disabilities

BACKGROUND

Cardiorespiratory fitness (CRF) prompts antiatherogenic adaptations in vascular function and structure. However, there is an extraordinary interindividual variability in response to a standard dose of exercise, wherein a substantial number of adults with intellectual and developmental disabilities (IDD) do not improve CRF. We (1) evaluated the effects of 12-month of moderate-intensity continuous training (MICT) on CRF and arterial stiffness and (2) tested whether an additional 3-month of high-intensity interval training (HIIT) would add to improvements in CRF responsiveness and arterial stiffness.

METHODS

Fifteen adults with mild-to-moderate IDD (male adults = 9, 30.1 ± 7.5 years old) met 3 days per week for 30 min MICT for 12 months, after which the incidence of CRF responsiveness was calculated (≥5.0% change in absolute peak VO₂ ). Thereafter, responders and non-responders started HIIT for 3 months with identical daily training load/frequency. Peak VO₂ , local and regional indices of arterial stiffness were assessed prior to and after each period.

RESULTS

Sixty per cent of the participants were non-responders following MICT, but the incidence dropped to 20% following HIIT (P = 0.03). Absolute peak VO₂ values reached significant difference from pre-intervention (+0.38 ± 0.08 L min^-1 , P = 0.001) only when HIIT was added. Lower limb pulse wave velocity (PWV) decreased following MICT (-0.8 ± 1.1 m s^-1 , P = 0.049), whereas central PWV only decreased following HIIT (-0.8 ± 0.9 m s^-1 , P = 0.013).

CONCLUSIONS

Cardiorespiratory fitness responsiveness and reductions in PWV to a 12-month MICT period in adults with IDD improved following a period of HIIT programme inducing higher metabolic stress.

Suicidal ideation during the first wave of COVID-19 pandemic in a child and adolescent psychiatry emergency care sample

Introduction

The COVID-19 pandemic forced many countries to apply restrictive measures. During the first wave Portugal went through a lockdown, and all the child and adolescents had to stay home and could only contact with the one’s they lived with for several months.

Objectives

This study aimed to evaluate the impact of those restrictions on suicidal ideation in the pediatric population evaluated in a child and adolescent psychiatry emergency care of a tertiary referral hospital.

Methods

We conducted an exploratory retrospective study. All the data from discharge notes were collected between March 15^th and June 15^th of 2020 (n=59), and in the homologous period of the previous year (n=178). The referral after evaluation (primary care, child and adolescent psychiatry consultation, inpatient unit) was considered a measure of severity.

Results

The demographic variables (sex, age) were homogeneous between the two groups (p ≥ 0,05). 17,4% (n=31) of the sample from 2019, and 16,9% (n=10) of the sample of 2020 had suicidal ideation, which was not statistically different between groups (p=1,000). The referral, after evaluation between groups were also not statistically different (p=0,186).

Conclusions

Even though the proportion of patients with suicidal ideation was homogenous during the two periods, the total number of patients evaluated in the emergency room were lower during the first wave of Covid-19 pandemic. We assume that the population had fear of seeking help in hospital facilities, but we also believe that the pause on school burdens and the reconnection between some families could have function as protective factors.

Disclosure

No significant relationships.

Not guilty by reason of insanity and dangerousness: A demographic, clinical and forensics description of the patients in the forensic inpatinent service of Coimbra

Introduction

Despite being essential for the service quality improvement, empirical research on the characteristics of people hospitalized in forensic psychiatry units and the psychopharmacological treatment instituted in this care context is scarce in Portugal.

Objectives

To describe the sociodemographic, clinical and criminological characteristics of the patients admitted to a forensic psychiatric unit in Portugal, as well as, the psychiatric drugs prescription pattern in this care context.

Methods

A retrospective observational study was carried out, through the data analysis of patients admitted to the Sobral Cid Forensic Psychiatry unit of the Coimbra Hospital and University over the past 12 years.

Results

The sample had 194 inpatients, 153(78.9%) male and 41(21.1%) females. The mean age was 43.3 years and 74.7% had no professional, school or occupational activity. The most frequent psychiatric diagnoses were psychotic disorders (56.7%) and neurodevelopmental disorders(33.5%). 24.2% had at least two psychiatric diagnoses and 38.7% had concomitant medical conditions. 77.8% had history of psychiatric hospitalizations and 21.6% had history of self-injurious behaviors. 37.1% of the sample had a criminal record. Crimes against people were the most frequent. The use of injectable antipsychotic formulations was frequent and 18.6% of the patients were medicated with Clozapine. The prescribed daily doses were above the defined daily dose. Psychotic disorders and addictive disorders were less frequent in women. Statistically significant differences were found in the frequency of homicide between females(41.5%) and males(22.2%).

Conclusions

Tailored solutions are crucial to accomplish the purpose of security measures, mostly by addressing the identified needs and rethinking the approach on this specific context.

Disclosure

No significant relationships.

Keyword

Forensic Psychiatry Units

Process modelling of organized screening programs – breast cancer

Breast cancer is the most frequent cancer among women and one of the principal causes of cancer related death in women worldwide, being a public health problem. Oncology screenings allow its early detection and reduce its mortality. Business process management (BPM) is a management field that leads an organization into continuously improvement with increase of efficiency. The processes of the healthcare system are complex what makes the application of BPM techniques harder, however their usage has been increasing in this sector.

The main objective of this study is the identification and modelling of BPM processes for the Portuguese breast cancer screening.

The current processes and the entities (actors, systems and documents) involved in the Breast Cancer Organized Screening performed by the Portuguese League Against Cancer were identified through interviews to the employees. With the information retrieved and using Bizagi the related As-Is diagrams were developed.

In this work 5 processes within the Breast Cancer Organized Screening were identified: Process “Patients' invitation”; Process “Screening”; Process “Reading of the exam”; Process “Check-up Consultation” and Process “Sending Results”. Through the analysis of the As-Is diagrams and of the available information, a critical analysis was made. As for example, in the process “Patients' invitation” an invitation letter is sent 15 days earlier to the patient but no telephone contact is done before the screening. An improvement could be sending a message in the day before the screening, remembering the appointment, avoiding forgetfulness absences.

With this work the mainly processes of the breast cancer organized screening were modelled as “As-Is” diagrams and, in a macroscopic way, some of the problems were identified and improvement suggestions were made in order to achieve the main objective of the process, the early detection of breast cancer, while optimizing the process.

Key messages

This work represents an important contribution to the Breast Cancer Organized Screening since, through the use of BPM, a set of actions is proposed with an impact on its effectiveness and efficiency. This work represents an example of what the BPM techniques can do to help in the optimization of all the processes of the healthcare sector, from screening to diagnosis and treatment.

Small for gestational age very preterm infants present a higher risk of developing bronchopulmonary dysplasia

INTRODUCTION

Several studies assessed the influence of a low birth weight on bronchopulmonary dysplasia (BPD), but not all could find a significant association. Our aim was to assess the association between low birth weight and BPD in preterm infants, prospectively recruited at 11 level III Portuguese neonatal centers.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 after a surveilled pregnancy, were analyzed. Neonates were considered small for gestational age (SGA) when their birthweight was below the 10th centile of Fenton's growth chats and BPD was defined as the dependency for oxygen therapy until 36 weeks of corrected age. Statistical analysis was performed using IBM SPSS® statistics 23 and a p-value <0.05 was considered statistically significant.

RESULTS

Out of 614, a total of 494 preterm infants delivered from 410 women were enrolled in the study; 40 (8.0%) infants with SGA criteria. SGA were more often associated with a single pregnancy, had greater use of antenatal corticosteroids, increased prevalence of gestational hypertensive disorders, C-section, rupture of membranes below 18 hours, rate of intubation in the delivery room, use of surfactant treatment, oxygen therapy, mechanical ventilation need, BPD, cystic periventricular leukomalacia, nosocomial sepsis and pneumonia; had lower prevalence of chorioamnionitis, and lower Apgar scores. The multivariate analysis by logistic regression, adjusted for BPD risk factors revealed a significant association between SGA and BPD: OR = 5.2 [CI: 1.46-18.58]; p = 0.01.

CONCLUSION

The results of this study increase the scientific evidence that SGA is an independent risk factor for BPD.

Hard routes of mental health in Portugal: what can we offer to an adolescent with serious mental illness and multiple social risk factors?

Worldwide, millions of children and adolescents are suffering due to a lack of efficient mental healthcare. Although some progress has been made to address the mental health problems in this age group, currently, even developed countries fail in providing psychiatric patients with the best practice care. We present a case of a Portuguese adolescent with a first episode of psychosis in whom multiple social and environmental risk factors were identified as triggers to his clinical presentation, as well as fundamental determinants of prognosis in the short and long term. In this case, we demonstrate how social determinants, including poverty, family dysfunction and difficulties in accessing appropriate mental healthcare, strongly influence the development, maintenance and prognosis in early psychosis during adolescence. Furthermore, we consider the implications of an absence of community-based mental healthcare and rehabilitation services and reasons for why this may complicate the management and limit opportunities to this patient population.

Mitochondria, endoplasmic reticulum and innate immune dysfunction in mood disorders: Do Mitochondria-Associated Membranes (MAMs) play a role?

Mood disorders like major depression and bipolar disorder (BD) are among the most prevalent forms of mental illness. Current knowledge of the neurobiology and pathophysiology of these disorders is still modest and clear biological markers are still missing. Thus, a better understanding of the underlying pathophysiological mechanisms to identify potential therapeutic targets is a prerequisite for the design of new drugs as well as to develop biomarkers that help in a more accurate and earlier diagnosis. Multiple pieces of evidence including genetic and neuro-imaging studies suggest that mood disorders are associated with abnormalities in endoplasmic-reticulum (ER)-related stress responses, mitochondrial function and calcium signalling. Furthermore, deregulation of the innate immune response has been described in patients diagnosed with mood disorders, including depression and BD. These disease-related events are associated with functions localized to a subdomain of the ER, known as Mitochondria-Associated Membranes (MAMs), which are lipid rafts-like domains that connect mitochondria and ER, both physically and biochemically. This review will outline the current understanding of the role of mitochondria and ER dysfunction under pathological brain conditions, particularly in major depressive disorder (MDD) and BD, that support the hypothesis that MAMs can act in these mood disorders as the link connecting ER-related stress response and mitochondrial impairment, as well as a mechanisms behind sterile inflammation arising from deregulation of innate immune responses. The role of MAMs in the pathophysiology of these pathologies and its potential relevance as a potential therapeutic target will be discussed.

Intravaginal administration of gelatine capsules containing freeze-dried autochthonous lactobacilli: a double-blind, randomised clinical trial of safety

Vaginal lactobacilli (LAB) in probiotic formulas constitute a promising alternative for microbiome reconstitution and for the prevention and treatment of urogenital infections. A double-blind, randomised clinical trial was conducted to assess the safety of LAB-gelatine capsules vaginally administered to healthy sexually active women. Participants were randomised into three groups: intervention A: Lactobacillus reuteri CRL1324, Lactobacillus gasseri CRL1263 and CRL1307; intervention B: Lactobacillus rhamnosus CRL1332, L. gasseri CRL1256 and CRL1320; and intervention C: placebo. In a survey and clinical evaluation, participants received a blister with 7 capsules to be administered 1 per day. A second sampling and a new survey were conducted 3-10 days after completing application. Colposcopy was performed to assess adverse effects on vaginal-cervical mucosa. Vaginal swabs were taken for Gram staining to determine the Nugent score, and obtainment of viable-cell cultures to quantify cultivable lactic acid bacteria and pathogens. The main outcomes evaluated were overall satisfaction and secondary effects, including discomfort, urogenital infection, inflammatory response or other symptoms. No significant differences were found in Nugent score or in leukocyte numbers in vaginal samples either before or after the three interventions. However, a tendency to decrease in both the Nugent score and in leukocyte numbers was observed after interventions A and B, though not after C. A significant increase in cultivable lactobacilli was determined after LAB interventions. No severe adverse events were detected. LAB-containing capsules were well tolerated by subjects, so they could be proposed as an adequate alternative to restore vaginal lactobacilli in sexually active women.

Skin tears: prevention and management

Skin tears commonly occur at the extremes of age and are associated with skin changes in ageing skin. They are considered to be acute wounds caused by mechanical forces, such as blunt trauma. While the true prevalence and incidence of skin tears is unknown, the available evidence suggests that these wounds occur in all healthcare settings. Importantly, skin tears are preventable with the implementation of a risk-reduction programme, which includes twice-daily skin moisturisation. Where these injuries do occur, it is important to categorise the extent of damage as well as to choose the most appropriate dressing to avoid adding any risks for further trauma.

Avaliação da aprendizagem de enfermeiros em um curso online sobre úlcera venosa

Objetivo: Avaliar o grau de conhecimento de enfermeiros sobre úlcera venosa (UV) e terapia compressiva (TC); comparar o grau de conhecimento sobre a temática entre enfermeiros com e sem formação especializada em estomaterapia, após a realização de curso online; e analisar as variáveis demográficas e educacionais associadas à aprendizagem. Métodos: Estudo quase experimental e comparativo em que se testou uma intervenção didática em dois grupos distintos de enfermeiros, por meio da aplicação de questionário para avaliação da aprendizagem antes e após o curso. Os dados foram analisados por testes McNemar, qui-quadrado, F da ANOVA, t de Student e equações de estimação generalizada. Resultados: Os enfermeiros especialistas obtiveram notas médias 7,79 e 9,07 e os generalistas 6,39 e 8,49, respectivamente, nos pré- e pós-curso. A idade igual ou superior a 30 anos influenciou para o maior grau de conhecimento após o curso. Conclusão: O curso permitiu a aprendizagem sobre a temática em ambos os grupos. Enfermeiros especializandos tinham maior conhecimento sobre o tema quando comparados aos enfermeiros generalistas.

Evaluation of nurses’ learning in an online course about venous leg ulcer

Objective: To evaluate the degree of knowledge of nurses about venous leg ulcer (VLU) and compressive therapy (CT); comparing the degree of knowledge on the subject between nurses with and without specialized training in stomatherapy, after the online course; and analyze the demographic and educational variables associated with learning. Methods: A quasi-experimental and comparative study in which a didactic intervention was tested in two different groups of nurses, through the application of a questionnaire to evaluate learning before and after the course. Data were analyzed by McNemar, chi-square, F of ANOVA tests, Student t and generalized estimation equations. Results: The specialist nurses obtained average scores of 7.79 and 9.07 and the generalists of 6.39 and 8.49, respectively, in the pre and post-course. Age equal or higher to 30 years influenced to the highest degree of knowledge after the course. Conclusion: The course allowed learning about the theme in both groups. Specialist nurses had greater knowledge on the subject when compared to generalist nurses.

Adaptação cultural e validade de conteúdo do ISTAP Skin Tear Classification para o português no Brasil

Objetivo: Adaptar culturalmente o ISTAP Skin Tear Classification para a língua portuguesa no Brasil e testar a validade de conteúdo da versão adaptada. Métodos: Três fases compuseram a adaptação cultural: tradução, avaliação por comitê de juízes composto de cinco estomaterapeutas (gerando a validação de conteúdo do instrumento) e retrotradução. O projeto foi aprovado por comitê de ética em pesquisa. Resultados: Duas versões em português do instrumento foram obtidas após tradução e analisadas pelo comitê de juízes, ocorrendo discordâncias apenas em termos específicos utilizados na área, seguidas por sugestões para melhor adequação do vocabulário em saúde. Isso gerou valores baixos do índice de validade de conteúdo. No entanto, a validade de conteúdo foi confirmada após discussão das discrepâncias entre as autoras e alguns membros do comitê de juízes, bem como com uma das autoras do instrumento original, Dra. Kimberly LeBlanc, que também a atestou quando aprovou as retrotraduções dessa versão. Conclusão: Considera-se obtida a versão adaptada culturalmente do ISTAP Skin Tear Classification, com sua validade de conteúdo também atestada. Neste momento, os testes para confiabilidade inter e intraobservadores e validade concorrente estão em fase de finalização, após o que se disponibilizará o instrumento adaptado e validado para o Brasil.

Cultural adaptation and content validity of ISTAP Skin Tear Classification for Portuguese in Brazil

Objective: To translate and culturally adapt the International Skin Tear Advisory Panel (ISTAP) Skin Tear Classification into the Portuguese language in Brazil and test the content validity of the adapted version. Methods: The cultural adaption comprised three phases: translation, evaluation by committee of judges composed of five stomatherapists (confirming the instrument content validity) and back-translation. Results: Two Brazilian Portuguese versions of the instrument were obtained after translation and analyzed by the committee, disagreements arose over several health related terms. This generated low values of the content validity index. However, the content validity was confirmed after discussion of discrepancies between the authors and some members of the judges’ committee, as well as with one of the authors of the original instrument, Dr. Kimberly LeBlanc, who also testified that validity when approving the back-translations of the adapted version to Brazilian Portuguese. Conclusion: The culturally adapted version of the ISTAP Skin Tear Classification is considered to have been obtained, with its content validity also attested. At that moment, the tests for inter and intraobserver reliability and concurrent validity are in the finalization phase, after which the instrument adapted and validated for Brazil will be made available.

Correction: Preeclampsia predicts higher incidence of bronchopulmonary dysplasia

Text for Correction.

Riddling: Chimera's dilemma

We investigate the basin of attraction properties and its boundaries for chimera states in a circulant network of Hénon maps. It is known that coexisting basins of attraction lead to a hysteretic behaviour in the diagrams of the density of states as a function of a varying parameter. Chimera states, for which coherent and incoherent domains occur simultaneously, emerge as a consequence of the coexistence of basin of attractions for each state. Consequently, the distribution of chimera states can remain invariant by a parameter change, and it can also suffer subtle changes when one of the basins ceases to exist. A similar phenomenon is observed when perturbations are applied in the initial conditions. By means of the uncertainty exponent, we characterise the basin boundaries between the coherent and chimera states, and between the incoherent and chimera states. This way, we show that the density of chimera states can be not only moderately sensitive but also highly sensitive to initial conditions. This chimera's dilemma is a consequence of the fractal and riddled nature of the basin boundaries.

Allergic rhinitis severity can be assessed using a visual analogue scale in mild, moderate and severe

BACKGROUND

Allergic rhinitis is a global healthcare problem due to its high prevalence, impact on individuals and socioeconomic burden for the nations. Allergic rhinitis severity evaluation is the key to a correct treatment, prevention of comorbidities and improving the quality of life of patients. This evaluation should be made with a simple, easy, fast but accurate and reliable methodology, both in a primary care and specialist setting. The visual analogue scale (VAS) meets all requirements to be the ideal tool to assess allergic rhinitis severity and has already been validated by using a single cut-off point, but this classification in two degrees of severity suffer from not allocating the patients uniformly and from giving a blind interval to classify the patients when the score is between 5 to 6 cm.

METHODOLOGY

The main objective of our study is to describe the optimal cut-off points by using a VAS to discriminate between three degrees of allergic rhinitis severity (mild, moderate, and severe) following the ARIA modified severity criteria that has been previously validated. Sensitivity, specificity, positive and negative predictive values just like receiver operating characteristic curves were used to select the best cut-off values.

RESULTS

In a cross-sectional multicentre study with 3,572 patients included we have found that VAS has a significant correlation with nasal symptom score and quality of life and that the best cut-off points to differentiate between mild, moderate an severe allergic rhinitis are a VAS score of 4 and 7, respectively.

CONCLUSIONS

Allergic rhinitis severity could be assessed in three degrees by using VAS in a simple, easy, and accurate method.

Relationship Between Self-reported and Clinician-rated Psychopathology in Youth Psychiatric Outpatients

Introduction

Psychopathology rating scales have been widely used. Studies evaluating the congruence between self and observer-reported ratings show inconsistent results.

Objectives or aims

Determine whether there was consistency between psychopathology as assessed by patients and clinicians’ assessment in outpatients observed in the Young Adult Unit of our Psychiatry Department (Coimbra Hospital and University Centre-Portugal).

Methods

Socio-demographic characterization was undertaken with young adult outpatients observed during nineteen months (1st January 2015–31st July 2016). Brief Symptom Inventory–53 items (BSI-53) and Brief Psychiatric Rating Scale (BPRS) were applied at the first clinical evaluation. Spearman correlation coefficient between General Severity Index (GSI) of BSI-53 and BPRS total score was calculated.

Results

During the mentioned interval 255 outpatients were observed: 64.3% females and 35.7% males; aged between 17 and 39 years old (average: 20.56; median: 20). Fifty percent were diagnosed with neurotic, stress-related and somatoform disorders (ICD-10 F40-48) and 14.1% with mood disorders (ICD-10 F30-39). BPRS and BSI-53 rating scales were administered to 55 patients: 72.5% females and 27.5% males; average age 21.2. A statistical significant correlation was found between BPRS total and GSI score.

Conclusions

Several factors can determine the accuracy of psychopathology self-assessment, including diagnosis and severity of illness. In fact, studies show strong correlation between self and observer assessment of depressive and anxious psychopathology, but no correlation in psychotic psychopathological dimensions. Therefore, the correlation found in this population can be explained by the fact that the majority of patients were diagnosed with neurotic, stress-related and somatoform and mood disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Socio-demographic and clinic characterization in youth psychiatric outpatients: An observational study

Introduction

Most mental disorders begin during adolescence and early adulthood (18–24-years-old), highlighting the importance of understanding the onset and progression of mental disorders among youths. Although progress has been made, namely by creating youth mental health transition services, gaps continue to exist. Locally, our recently constituted young adults unit aimed to minimize discontinuities in care.

Objectives/aims

To characterize a population of young adult psychiatric outpatients, regarding socio-demographic and clinic variables.

Methods

Socio-demographic and clinic characterization of young adult psychiatric outpatients observed during 1st January 2015–30th July 2016.

Results

Two hundred and fifty-five outpatients were observed: 64.3% females and 35.7% males, average age 20.56-years-old (median 20). Most lived in urban areas (59.4%), with their parents (27.8%), were students (80.4%), attending secondary school (36.1%). A total of, 27.5% were referenced by an emergency department, and adjustment disorders (ICD-10 F43.2) were the most frequent diagnosis (21.6%). Regarding suicidal behaviours and self-harm, 9.8% did self-cutting. A vast majority did not have previous psychiatric hospitalizations–only 5.9% outpatients had at least one. In total, 39.8% were medicated with antidepressants (1/3 of which in association with other drugs), and about 38.8% received cognitive-behavioural interventions. About 2/3 of patients (66.3%) remained in care and only about 1/6 (15.7%) were discharged.

Conclusions

Our typical youth psychiatric outpatient was of female gender, student, living with its parents. Adjustment disorders were the most frequent diagnosis, and antidepressants were the main psychopharmacologic option, often combined with other psychotropic drugs. In the future, psychotherapy interventions should be more widely available, namely group psychotherapy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Patients with schizophrenia assessing psychiatrists’ communication skills

The doctor-patient relationship constitutes the matrix of the entire medical practice. One way in which doctors develop a positive rapport with their patients is through appropriate communication. Evidence suggests that doctors do not communicate with their patients as they should. Important gaps are observed in doctors’ communication with patients with schizophrenia.

Aim

Examine psychiatrists’ communication skills as assessed by their patients with schizophrenia and through external observation, considering patients’ socio-demographic and clinical variables and analyse the importance that aspects of communication have for patients.

Methodology

This cross-sectional study involved a sample of 30 patients and 11 doctors. An adapted and culturally validated version of the Communication Assessment Tool was used for data collection. Data were analysed in IBM SPSS Statistics®, version 24.

Results

Male patients constituted 86.7% of the sample and mean age was 46.7 ± 13.3. The overall mean percentage of items rated as excellent by patients was 57.4%. On the other hand, external observer percentage of excellent scores was much lower when compared with patients’ scores. Single, divorced or widower/widow patients, patients with higher educational level and patients with shorter number of years in medical treatment gave significantly higher scores to psychiatrists’ communication. Patients’ sex, age, occupation residence and family type did not yield statistically significant effects on patients’ ratings.

Conclusions

Communication is at the heart of psychiatrists’ daily practice. Many communication styles might be needed, depending on the nature of clinical encounters and patient expectations. Specific training is required to optimise psychiatrists’ communication skills on everyday practice.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Gender Difference Among Admitted Patients with Bipolar Disorder in a Psychiatric Service During a Three-year Period

Introduction

Gender differences in bipolar disorder are becoming apparent, but have been less studied compared with major depression. The presentation, clinical features, course and evolution of bipolar disorder differ between men and women. Research data on these differences will help determine whether gender is important in influencing illness variables.

Objectives

Determine whether men and women with bipolar disorder have statistical significant differences in socio-demographic and clinical data.

Methods

Charts of all patients with a diagnosis of bipolar disorder admitted in the Coimbra Hospital and Universitary Center over a three-year period (between 2013 and 2015) were reviewed to gather data on socio-demographic, clinical and psychopathological variables to assess differences across genders. Statistical analysis of data with “SPSS21”.

Results

During a three-year period, 189 patients were admitted with bipolar disorder, the majority were female patients, with ages between 21 and 84 years old. The authors will analyse if there is any statistical significant difference between gender in the rate of bipolar I or II diagnoses, age at onset, symptom presentation, delay in diagnoses, number of depressive, or manic episodes, hospitalisations, involuntarily admissions, number of suicide attempts, co-morbidity rates, negative life events, family history and treatment options. Sociodemograpic characteristics will also be analysed.

Conclusion

Gender differences in bipolar disorder is a controversial issue in the literature. The importance of gender on the course and outcome in bipolar disorder has been widely acknowledged. The limited data suggest that the prevalence is similar between sexes but that the course of illness may be different.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Substance use among youth psychiatric outpatients

Introduction

Portuguese young adults (15–34 years old) were more frequent engaged in substance abuse (1.2%) than the general population, according to the Portuguese substance use annual report (2014). Alcohol was the most frequent substance use on youth adults. Cannabis was the most frequent illicit substance used (23.9% of users were considered dependent), with higher prevalence than previously reported. LSD (0.4%) use was also higher among young adults than in previous studies. Cocaine (0.4%), heroine/opiates (0.4%), ecstasy (0.3%), and hallucinogenic mushrooms (1.1%) had their consumption lowered among young adults.

Objectives/aims

To characterize a population of young adult psychiatric outpatients, regarding substance use and associated risk.

Methods

Socio-demographic characterization of our young adult unit outpatient users between 1st January 2015–31st July 2016. Substance use was assessed with the Portuguese version of Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

Results

A total of 255 outpatients were observed during the timeframe; 58 outpatients were assessed with ASSIST: 44 females (75.9%) and 14 males (24.1%), aged between 16–33 years old (average: 20.95; median: 19.50). For tobacco, 3.5% had high risk, 37.9% moderate risk and 58.6% low risk; 22.4% had moderate risk of alcohol, 13.8% moderate risk of cannabis, and 20.7% moderate risk of tranquilizers. For others substances (cocaine, stimulants, inhalants, hallucinogens, and opiates) the risk was low.

Conclusions

In our sample, alcohol and cannabis use had the highest risk, as reported in the National Annual Report; however, we observed a moderate risk for tranquilizers use. In future care planning, youth mental health should address tobacco and alcohol abstinence, and preventive measures regarding anxiolytics should be undertaken, such as banning sale without medical prescription.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Cystic fibrosis - Comparison between patients in paediatric and adult age

Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians. Although most cases are diagnosed in childhood, diagnosis in adults is apparently increasing.

OBJECTIVE

Evaluate the adult population with CF, comparing patients who were diagnosed before and after 18 years of age.

METHODS

Retrospective analysis of patients followed in three main medical centres in Portugal in 2012. Comparison of two groups: G1 - patients diagnosed at <18 years and G2 - patients diagnosed at ≥18 years.

RESULTS

89 adults were identified: 61.8% in G1, 38.2% in G2. Gender distribution was similar in both groups. Average age in G2 was higher (38.3±8.4 vs. 26.8±6.1 years, p<0.001). Respiratory symptoms most frequently led to CF diagnosis in all patients, mainly in adulthood. There was a greater percentage of patients homozygous for the mutation delF508 in G1 (43.6 vs. 8.8%, p=0.02). Respiratory and pancreatic function, and body mass index (BMI) showed a higher severity in G1 (G1 vs. G2: FEV1: 54.6±27.3 vs. 29.9±64.6%, p=0.177; pancreatic insufficiency 72.7 vs. 26.5%, p<0.001; BMI 20.2±3.4 vs. 22.2±4.8, p=0.018). Pseudomonas aeruginosa and methicillin-sensitive Staphylococcus aureus were the most frequently isolated microorganisms. Lung transplantation rate was higher in G2 (20.6 vs. 10.9%, p=0.231) while mortality rate was higher in G1 (0 vs. 3.6%, p=0.261). Hospital admission rate was higher in G1 as well as mortality rate.

CONCLUSION

The results suggest that patients with CF diagnosed in childhood have characteristics that distinguish them from those diagnosed in adulthood, and these differences may have implications for diagnosis, prognosis and life expectancy.

Control of attention in bipolar disorder: Effects of perceptual load in processing task-irrelevant facial expressions

Bipolar disorder (BD), along with schizophrenia, is one of the most severe psychiatric conditions and is correlated with attentional deficits and emotion dysregulation. Bipolar patients appear to be highly sensitive to the presence of emotional distractors. Yet, no study has investigated whether perceptual load modulates the interference of emotionally distracting information. Our main goal was to test whether bipolar patients are more sensitive to task-irrelevant emotional stimulus, even when the task demands a high amount of attentional resources.

Fourteen participants with BD I or BD II and 14 controls, age- and gender-matched, performed a target-letter discrimination task with emotional task-irrelevant stimulus (angry, happy and neutral facial expressions). Target-letters were presented among five distractor-letters, which could be the same (low perceptual load) or different (high perceptual load). Participants should discriminate the target-letter and ignore the facial expression. Response time and accuracy rate were analyzed.

Results

showed a greater interference of facial stimuli at high load than low load, confirming the effectiveness of perceptual load manipulation. More importantly, patients tarried significantly longer at high load. This is consistent with deficits in control of attention, showing that bipolar patients are more prone to distraction by task-irrelevant stimulus only when the task is more demanding. Moreover, for bipolar patients neutral and angry faces resulted in a higher interference with the task (longer response time), compared to controls, suggesting an attentional bias for neutral and threating social cues. Nevertheless, a more detailed investigation regarding the attentional impairments in social context in BD is needed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

PTSD And Quality of Life Among Firefighters and Municipal Police Forces

Research has shown that PTSD is prevalent among firefighters and police forces and that Quality of Life (QoL) is seriously compromised in individuals suffering from PTSD. However, QoL studies with these professionals are scarce. This study results from a screening program held by the Portuguese Red Cross (PRC) aiming to analyze predictors of QoL. Participants were 95 firefighters and municipal police officers. They answered the Posttraumatic Stress Disorder Checklist (PCL-5) in order to evaluate the prevalence of PTSD symptoms, as well as measures of social support (3-Item Oslo Social Support Scale) and QoL (EUROHIS-QOL-8). From the results, there were no group differences regarding total PTSD, social support or QoL and 10% of participants reported enough symptoms to PTSD diagnostic. Social Support and PTSD explained 25% of QoL variance, PTSD symptoms explaining 10% (negative beta) and, in the second step, social support explained 15%. The results suggest that it would be important to include QoL as an outcome measure in clinical and research work in these populations, with special attention to PTSD and social support.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Role of Isotretinoin Therapy for Cushing's Disease: Results of a Prospective Study

Objective. This prospective open trial aimed to evaluate the efficacy and safety of isotretinoin (13-cis-retinoic acid) in patients with Cushing's disease (CD). Methods. Sixteen patients with CD and persistent or recurrent hypercortisolism after transsphenoidal surgery were given isotretinoin orally for 6-12 months. The drug was started on 20 mg daily and the dosage was increased up to 80 mg daily if needed and tolerated. Clinical, biochemical, and hormonal parameters were evaluated at baseline and monthly for 6-12 months. Results. Of the 16 subjects, 4% (25%) persisted with normal urinary free cortisol (UFC) levels at the end of the study. UFC reductions of up to 52.1% were found in the rest. Only patients with UFC levels below 2.5-fold of the upper limit of normal achieved sustained UFC normalization. Improvements of clinical and biochemical parameters were also noted mostly in responsive patients. Typical isotretinoin side-effects were experienced by 7 patients (43.7%), though they were mild and mostly transient. We also observed that the combination of isotretinoin with cabergoline, in relatively low doses, may occasionally be more effective than either drug alone. Conclusions. Isotretinoin may be an effective and safe therapy for some CD patients, particularly those with mild hypercortisolism.