Dementia and suicide: What relationship to establish and what risks to consider?

Introduction

Given the marked population aging in the world, the incidence of dementia has significantly increased, becoming a growing health care problem. Suicide is a considerable health issue throughout the life span, being prevalent in older adults, and in many countries the highest suicide rates are found in the elderly. Thus far, the relationship between dementia and suicide remains poorly understood and inconsistent.

Objectives

The aim of this study is to do a non-systematic review of the current literature regarding the association between suicide risk and dementia.

Methods

We conducted a research using the Medline database, through the Pubmed search engine, using the following key-words: “dementia”, “suicide” and “risk factors”.

Results

Overall, the risk of suicide in people with dementia appears to be the same as that of age-matched general population. However, studies point to the existence of a number of factors that can increase this risk, such as: early age of dementia diagnosis, recent diagnosis, disease awareness and depression, hopelessness, male gender, failure to respond to anti-dementia medication, history of inpatient psychiatric hospitalizations, concurrent medical comorbidities.

Conclusions

Studies have reported mixed results as to whether dementia itself is an independent risk factor for suicide. Despite these findings, understanding the risk factors for suicide among people with dementia is crucial and suicide prevention efforts should be carried out in this population.

What is the best approach for patients with prolonged duration of untreated psychosis (DUP) - about 2 clinical cases with dup longer than 10 years

Introduction

Studies have consistently found that many individuals with psychosis experience significant delays before receiving treatment. DUP refers to the period between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment.

Objectives

To review current knowledge on the best approach for patients with schizophrenia (SCZ) and prolonged DUP.

Methods

Non-systematic review of literature through search on PubMed database, following the terms “DUP and treatment” and “impact of longer DUP”. Two clinical cases are described.

Results

The clinical cases describe patients with SCZ with DUPs older than 10 years, in whom we could not achieve complete clinical remission after several therapeutic trials and whose prognosis was admitted as reserved. Longer DUP is an independent predictor of poorer outcome in SCZ, including the poor response to treatment and difficulty in achieving remission, predicting treatment resistance. Identifying treatment-resistant patients is crucial due to the importance of initiating clozapine as early as possible since the chances of responding are higher.

Conclusions

DUP is a key prognostic variable in psychosis, revealing the significance of early treatment. Patients with long DUP should be regarded as at high risk of poor recovery. The detection of these patients enables clinicians to avoid unnecessary exposure to ineffective treatments while effective interventions are delayed. However, in view of adverse side effects of clozapine, future studies need to examine relevant predictors to detect accurately non-responders. We also suggest further studies to understand if there is correspondence between DUP and different stages of the disease that justify these results.

A dual high-energy radiography platform with 15 μm resolution at the National Ignition Facility

To study matter at extreme densities and pressures, we need mega laser facilities such as the National Ignition Facility as well as creative methods to make observations during timescales of a billionth of a second. To facilitate this, we developed a platform and diagnostic to characterize a new point-projection radiography configuration using two micro-wires irradiated by a short pulse laser system that provides a large field of view with up to 3.6 ns separation between images. We used tungsten-carbide solid spheres as reference objects and inferred characteristics of the back-lighter source using a forward-fitting algorithm. The resolution of the system is inferred to be 15 μm (using 12.5 μm diameter wires). The bremsstrahlung temperature of the source is 70-300 keV, depending on laser energy and coupling efficiency. By adding the images recorded on multiple stacked image plates, the signal-to-noise of the system is nearly doubled. The imaging characterization technique described here can be adapted to most point-projection platforms where the resolution, spectral contrast, and signal-to-noise are important.

Automated HIV screening in the emergency department –earlier diagnosis, improved clinical outcomes

Background

HIV/AIDS is a public health problem worldwide because undiagnosed patients maintain onward transmission. To stop viral transmission an upscale in diagnostics is needed so that more patients start treatment; patients on treatment and with undetectable viral load do not transmit the virus to other persons (“Treatment as Prevention”).

Objectives

We aimed at identifying more HIV infections in the emergency Department (ED) and at doing so earlier in the course of disease.

Methods

we designed an automated and clinician independent HIV screening project in the ED. Electronic Medical Record (EMR) automatically generates a request for HIV antibody (HIV Ab) test when a patient: a) is 18-65 years of age and has a request for any blood test; b) is not identified in the EMR as being HIV infected; c) does not have an HIV Ab in the EMR in the previous year. Nursing staff receive a visual warning of patients' eligibility for screening and an extra tube label is printed out for HIV testing. The patient is informed of screening at the moment of blood drawing and an <<opt-out >> strategy is applied (optional verbal informed consent or <<opt-out >> of screening).

Results

In 16 months, a total of 21.487 people were eligible for screening. 18.072 HIV Ab screening tests were done. The opt-out rate was 6.3% and there were 44 new HIV diagnostics (prevalence rate 0.24%). Late presenting patients (baseline CD4 counts <350) dropped from an average of 56% in the previous 6 years at our institution to 36.3%. Median CD4 count at diagnostics went up from 192 to 388 cells/mm³.

Conclusions

An automated and clinician independent HIV screening program in the ED proved to be successful at identifying more HIV patients and at tackling the problem of late presentation. Diagnosing early in the course of infection is beneficial for the individual patient, but also represents a gain in general public health because onward transmission is stopped by starting antiretroviral treatment.

Key messages

Early diagnosis through universal screening. Treatment as prevention.

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.

Mediterranean diet, sociodemographic factors and ultra-processed food consumption in Portugal

Background

Mediterranean diet has been shown to promote beneficial effects on health, while ultra-processed food (UPF) consumption has been associated with lower diet quality and higher risk for non-communicable diseases. Our aims were to explore the adherence to a Mediterranean dietary pattern (MDP) in Portugal and its association with sociodemographic factors and UPF consumption.

Methods

Participants were from the Portuguese National Food, Nutrition and Physical Activity Survey 2015-2016, aged 18-84y (n = 3,852). CAPI face-to-face interviews were used including 2 dietary 24-h recalls. UPF were identified using NOVA classification. Adherence to MDP was defined by the Mediterranean Diet Score (MDS), which may vary from 0 to 9. MDS≥6 was considered as high adherence. Weighted multivariate logistic regression analysis was used to explore associations of high adherence to MDP with sex, age, region, educational level, family income and dietary share of UPF groups.

Results

High adherence to MDP was observed for 19.6% of participants and was inversely associated with higher consumption of UPF, namely, sugar-sweetened beverages (OR = 0.924; 95%CI 0.883-0.966), confectionery (OR = 0.893; 95%CI 0.816-0.977), sweet snacks (OR = 0.953; 95%CI 0.923-0.985), cakes/desserts (OR = 0.956; 95%CI 0.934-0.978) and meat products (OR = 0.922; 95%CI 0.874-0.972). Being female (OR = 0.629; 95%CI 0.471-0.841) and not from the North or Alentejo regions were inversely associated with high adherence to MDP. There was no relation between income and adherence to MDP. The higher the level of education or age, the higher the odds of high adherence to MDP (OR = 2.573; 95%CI 1.741-3.803 and OR = 1.028; 95%CI 1.020-1.037, respectively).

Conclusions

Actions to improve adherence to MDP in Portugal should consider discouraging UPF consumption and be addressed to specific subgroups.

Funding

POCI-01-0145-FEDER-032090 (FCT/FEDER); FAPESP 2018/07391-9, 2019/05972-7 (MCR), 2016/14302-7 (FR).

Key messages

High adherence to a Mediterranean dietary pattern was observed for near 20% of Potuguese over 18 years old. The higher the level of education or age, the higher the odds of high adherence to MDP. High adherence to a Mediterranean dietary pattern was inversely associated with higher consumption of sugar-sweetened beverages, confectionery, sweet snacks, cakes/desserts and meat products.

The effect of climate change on domestic Rainwater Harvesting

One of the main strategies that are being applied to improve the efficiency of water consumption in buildings is the use of non-potable water for pavement washing, toilet flushing, irrigation, and others. According to several guidelines, the design and assessment of a Rainwater Harvesting System (RWHS) should be made using recent official records of precipitation. However, there is not an indication whether historical or future projections should be used, leaving space for the designer to choose. This article presents the study of RWHS in southern Europe, namely in Portugal, considering two case studies (a dwelling in Oporto and an apartment in Vila Real). The main goal was to explore the impacts that climate change will have on these systems and, for that purpose, a daily simulation using future rainfall data was performed for both cases considering two scenarios: RCP 4.5 which is more optimistic, and RCP 8.5 which is more pessimistic. The RWHS in Oporto showed a better performance in the future decades, comparing with simulations based on recent decades, for both scenarios. However, the savings will not have a significant variation (less than 5 €/year). In the future, this system will provide around 47 (±2.4) m³ of rainwater per year to the selected non-potable purposes, leading to savings of around 66 (±3.3) €/year. Vila Real case study also revealed a slight improvement of the system's efficiency in the future decades but the results for rainwater collected and used are so similar to the recent ones that it can be concluded that the performance will be sustained. This system will provide around 50 (±2.5) m³ of rainwater per year to the selected non-potable purposes, leading to savings of around 200 (±10.2) €/year. It can be concluded that there will be no significant changes in RWHS performance in the future, in the studied areas.

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.

Asbestos Exposure and Malignant Pleural Mesothelioma in Portugal: a scoping review

Introduction Asbestos, widely used for its important chemical and physical characteristics, are recognized in all their varieties as a human carcinogen by the International Agency for Research on Cancer (IARC) and as the leading cause of cancer associated with occupational exposure in industrialized countries. Despite being the most studied occupational hazard since 1965, it is the malignant pleural mesothelioma (MPM), the decisive aspect in the study of the exposure to asbestos.

Objectives Make a state of the art of the relationships between asbestos and MPM in Portugal.

Methodology A scoping review using the Joanna Briggs Institute (JBI) methodology was conducted using five information’s sources: Pubmed, Web of Science, The Cochrane Library, Scopus and Google Scholar and Open Access Scientific Repositories of Portugal and DART-Europe E-theses Portal to search also for gray literature. Data were collected between 1960-2019, with the keywords "Asbestos" and "Mesothelioma” and “Portugal”. Inclusion criteria were defined for types of participants, concept, context and types of studies.

Results Of the 1453 studies reviewed 9 were included. The oldest study is from 1986. Five studies are about incidence and survival, two are case reports, one about exposure and mortality and one about treatment. To analyse incidence and mortality, four authors used hospital data and two the data from the southern regional cancer registry (ROR). In these studies, it is also presented the description of the population in terms of mean age, type of exposure, latency time, histological type and stage.

Conclusion Portugal, such as other industrialized countries, used asbestos in a massive way, but despite this, few studies and data on the relationship between asbestos exposure and MPM are found. Dedicated studies are needed to objectively assess the true dimension of this potential problem in Portugal and characterise the different types of exposures related to MPM.

Asbestos Exposure and Malignant Pleural Mesothelioma in Portugal: a scoping review

Introduction Asbestos, widely used for its important chemical and physical characteristics, are recognized in all their varieties as a human carcinogen by the International Agency for Research on Cancer (IARC) and as the leading cause of cancer associated with occupational exposure in industrialized countries. Despite being the most studied occupational hazard since 1965, it is the malignant pleural mesothelioma (MPM), the decisive aspect in the study of the exposure to asbestos.

Objectives Make a state of the art of the relationships between asbestos and MPM in Portugal.

Methodology A scoping review using the Joanna Briggs Institute (JBI) methodology was conducted using five information’s sources: Pubmed, Web of Science, The Cochrane Library, Scopus and Google Scholar and Open Access Scientific Repositories of Portugal and DART-Europe E-theses Portal to search also for gray literature. Data were collected between 1960-2019, with the keywords "Asbestos" and "Mesothelioma” and “Portugal”. Inclusion criteria were defined for types of participants, concept, context and types of studies.

Results Of the 1453 studies reviewed 9 were included. The oldest study is from 1986. Five studies are about incidence and survival, two are case reports, one about exposure and mortality and one about treatment. To analyse incidence and mortality, four authors used hospital data and two the data from the southern regional cancer registry (ROR). In these studies, it is also presented the description of the population in terms of mean age, type of exposure, latency time, histological type and stage.

Conclusion Portugal, such as other industrialized countries, used asbestos in a massive way, but despite this, few studies and data on the relationship between asbestos exposure and MPM are found. Dedicated studies are needed to objectively assess the true dimension of this potential problem in Portugal and characterise the different types of exposures related to MPM.

Asbestos Exposure and Malignant Pleural Mesothelioma in Portugal: a scoping review

Introduction Asbestos, widely used for its important chemical and physical characteristics, are recognized in all their varieties as a human carcinogen by the International Agency for Research on Cancer (IARC) and as the leading cause of cancer associated with occupational exposure in industrialized countries. Despite being the most studied occupational hazard since 1965, it is the malignant pleural mesothelioma (MPM), the decisive aspect in the study of the exposure to asbestos.

Objectives Make a state of the art of the relationships between asbestos and MPM in Portugal.

Methodology A scoping review using the Joanna Briggs Institute (JBI) methodology was conducted using five information’s sources: Pubmed, Web of Science, The Cochrane Library, Scopus and Google Scholar and Open Access Scientific Repositories of Portugal and DART-Europe E-theses Portal to search also for gray literature. Data were collected between 1960-2019, with the keywords "Asbestos" and "Mesothelioma” and “Portugal”. Inclusion criteria were defined for types of participants, concept, context and types of studies.

Results Of the 1453 studies reviewed 9 were included. The oldest study is from 1986. Five studies are about incidence and survival, two are case reports, one about exposure and mortality and one about treatment. To analyse incidence and mortality, four authors used hospital data and two the data from the southern regional cancer registry (ROR). In these studies, it is also presented the description of the population in terms of mean age, type of exposure, latency time, histological type and stage.

Conclusion Portugal, such as other industrialized countries, used asbestos in a massive way, but despite this, few studies and data on the relationship between asbestos exposure and MPM are found. Dedicated studies are needed to objectively assess the true dimension of this potential problem in Portugal and characterise the different types of exposures related to MPM.

Outcomes Management in a Real-World Evidence Context: The Case of Abiraterone and Enzalutamide in the Treatment of Metastatic Castration-Resistant Prostate Cancer

At present, for patients with metastatic and castration-resistant prostate cancer, European Society for Medical Oncology and National Comprehensive Cancer Network guidelines recommend enzalutamide (E) or abiraterone (A). There are still a few studies comparing both drugs in a real-world setting, thus, in this article, we discuss an outcomes management methodology, supporting the follow-up of patients. This involves measuring relevant baseline traits and outcomes, such as overall survival (OS), treatment duration, patient-reported outcomes, and adverse events. We include 38 men in the A group and 15 in the E group. When comparing the survival of both drugs, both present similar OS. Regarding the quality-of-life analysis (QoL) with EPIC26, reported Standard QoL score was 58.3% in our patients, which was in line with the European Organization for the Research and Treatment of Cancer reference. As a result, by showing that we can capture the distinctive clinical benefits of A and E, and that patient-reported outcomes can be systematically collected for more than 2 years per living patient, we can now incorporate these findings in clinical discussions, risk-sharing agreements, or policy-level arguments.

Therapeutic Drug Monitoring by Pharmacists: Does It Reduce Costs

Therapeutic drug monitoring (TDM) has as its main objective to ensure that the plasma drug concentration remains within the appropriate range. Regarding the economic dimension of TDM, it is known that there are gains in health outcomes; however, there is still little evidence for the benefit of this procedure performed by pharmacists within the hospital context. With this project, we aimed to create a matrix of cost avoidance associated with TDM performed by pharmacists and to quantify the total avoided costs in 1 year, by implementing a TDM process in a tertiary hospital. For the studied period, we collected 362 pharmaceutical interventions related to TDM of antibiotics performed in adults. As a result, considering these data, the total cost avoidance in 1 year was 371,018 ($416,584.58) at one medical center. We conclude that TDM is highly cost-avoidant and that the implementation costs by pharmaceutical services is clearly lower than the benefit achieved.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

P724 The mysteries of sinus of Valsalva

Sinus of Valsalva aneurysms are a rare pathology that can be clinically silent during years and/or become suddenly symptomatic. We described 3 cases with different clinical presentation, complications and surgical treatment.

A 26-year-old male, competitive cyclist was admitted with a 1.5 month history of fatigue, palpitations, and nocturnal cough and sweating. At physical examination he was apyretic, blood pressure 157/49mmHg and radial pulse 96 bpm; jugular vein engorgement and continuous heart murmur, were noticed. Blood samples only revealed a mild raised BNP. EKG showed sinus tachycardia and right intraventricular conduction delay and the transthoracic echocardiography (TTE) revealed high velocity systolic-diastolic shunt (image) between a non-dilated right coronary sinus (RCS) and the right atrium (RA); moderate left ventricle dilation, severe right atrium and mild right ventricle enlargement with mild pulmonary hypertension and normal biventricular systolic function. He was referred to angioCT that showed a large communication between a non-dilated RCS and RA with signs of right ventricular overload. He was submitted to surgery, where ruptured aneurysm sac was found. Fistula closure, aneurysm sac suture and tricuspid annuloplasty were performed.

A 45-year-old male asymptomatic, with no relevant medical background went to a Cardiology consultation after detection of a holossistolic murmur in the physical exam. EKG showed sinus rhythm arrhythmia with a nonspecific intraventricular conduction delay and the TTE revealed a communication between a dilated noncoronary sinus (NCS) and RA; the biventricular systolic function was normal. He was referred to angioCT which confirmed the diagnosis. He was submitted to surgery where an exeresis and closure of the fistula was performed.

A 38-year-old male with no relevant medical background was admitted to emergence room for an intermittent anterior thoracic pain radiating to the neck (2 days of evolution). The EKG showed sinus tachycardia, incomplete right bundle branch block and the high-sensitivity troponin assays were negative. The TTE revealed severe sinus of Valsalva aneurysm, particularly of the NCS with mild aortic regurgitation. The patient performed transesophageal echocardiography and angioCT which excluded an acute aortic syndrome. He was oriented to surgery where a contained rupture of the RCS and a non-visualization of the ostium right coronary artery were detected, suggesting an intimal dissection. The patient was submitted to Bentall procedure and a bypass with internal mammary artery to right coronary artery.

In spite of the unclear etiology, all the cases had a good clinical and echocardiographic evolution at follow-up. The difficulty in making a timely diagnosis is related to the variability of clinical presentation and the need of high clinical suspicion. Echocardiography and angioTC have demonstrated its value, in providing a prompt diagnosis and appropriate management guidance.

Abstract P724 Figure. Ruptured aneurysm sac and fistula