Erythropoietin – a potential tool in the treatment of depressive disorders?

Introduction

Depression is one of the leading causes of psychiatric disability across the globe because of its high prevalence and chronic, treatment resistant and recurrent nature. Erythropoietin (EPO), well known for its effects on blood cells, has also a key role in neuroprotection and cognitive function.

Objectives

The authors aim to explore the potential of EPO to treat depressive disorders (DD) and related cognitive dysfunction.

Methods

A literature research was conducted on PubMed starting from the MeSH terms: “Erythropoietin” and “Depressive Disorders”. The results selected for our analysis corresponded to investigations using EPO based on an adult population with DD.

Results

The research provided 14 results, of which 9 met the defined criteria. Different types of studies with variable samples were considered, including randomized clinical trials (RCTs) and a systematic review. Overall, despite records of reduction in depression symptomatology and increased quality of life, evidence does not demonstrate statistically significant reductions in depression severity through the use of EPO in the treatment of DD. However, several RCTs examined its effect on cognitive performance, founding effective improvements in memory, verbal recall and recognition. The underlying potential mechanisms and the current limitations in the use of EPO, and of the available studies are analysed and discussed.

Conclusions

Although EPO does not appear to be effective treating depression, it may play a role in improvement of deficits in memory and executive function. Larger RCTs evaluating its potential use are needed, in order to move towards better clinical practice, quality of life and functional reintegration of these patients.

Disclosure

No significant relationships.

Imagery and perception: where is the phenomenological line?

Introduction

The overlap between imagery and perception has long fascinated philosophers and scientists. Many scientists considered how the mind is capable of constructing an internal world without intervention of the external environment. Descriptions of their core characteristics often draw attention to differential features, but other currents reveal that many of these are shared rather than unique and differential.

Objectives

The authors aim to analyse and discuss conceptualisation, similarities and differences of imagery and perception at the level of phenomenology, at the intersection with other psychopathological concepts, and thus reassemble them within a common framework.

Methods

A brief literature review was developed based on relevant works containing subject matter most relevant to the topic.

Results

Perception is conceived as a transformation of raw sensory stimuli into sensory information that is then decoded into meaningful at the cortical level. Imagery, in turn, corresponds to the internal mental representation of the world, actively drawn from memory. The differentiation between these concepts at a phenomenological level is analysed and discussed. Additionally, their individual role is evaluated in the pshycopathological expression of alterations of perception such as hallucinations, pseudohallucinations, pareidolic illusions, abnormal imagery, sensory deprivation and also of dreams, in an analytical perspective of integration and simultaneous conceptual differentiation.

Conclusions

Understanding imagery, its nature and formal characteristics is required for better recognising the nature of perceptions and related psychopathological alterations, as well as the mechanisms uniting these concepts. Further research is needed as these entities represent features of useful clinical and diagnostic significance.

Disclosure

No significant relationships.

Therapeutic use of ayahuasca: a review of the evidence of its use in approaching depressive disorders

Introduction

Ayahuasca (AYA) is a psychotropic plant from South America used for religious purposes by indigenous people of the Amazon. Increasing evidence indicates that AYA may have therapeutic potential in the treatment of mental health disorders like depression – a common life-disrupting, highly recurrent disorder – that is among the leading causes of disability worldwide.

Objectives

The aim of this exploratory study is to gather and assess scientific evidence about clinical effects of AYA in the treatment and symptomatological expression of patients with depression.

Methods

A literature research was conducted on PubMed, starting from the MeSH terms: “Banisteriopsis” and “Depression”. Results corresponding to investigations using AYA, and based on an adult population with depressive disorders, were selected for our analysis.

Results

The research provided 8 results, of which 6 met the defined criteria. Different types of studies with variable samples were considered, including retrospective and prospective observational studies, meta-analysis and a narrative review. Overall, evidence about the use of AYA in depressive disorders is associated to reductions in depression scales, to significant antidepressant effects and in mediating improvement of grief symptoms. AYA administration increased introspection and positive mood, self-acceptance, empathy, openness and potentiated improvements in emotional processing. The underlying potential mechanisms, adverse effects and the current limitations related to its study and use are analysed and discussed.

Conclusions

The use of AYA in depression shows promising results that should be further explored in controlled trials with larger sample sizes, in order to better evaluate its clinical effects, safety profile and related short and long-term effects.

Disclosure

No significant relationships.

Multimodal data fusion of cortical-subcortical morphology and functional network connectivity in psychotic spectrum disorder

•

Overlap has been noted disorders which fall on the psychotic spectrum.

•

Univariate studies may miss joint brain features across diagnostic categories.

•

mCCA with jICA is paired with features across the psychotic spectrum to produce joint components.

•

One joint component displayed a significant relationship with cognitive scores.

•

The replicate trends of cortical-subcortical irregularity in psychotic spectrum disorders.

Multiple authors have noted overlapping symptoms and alterations across clinical, anatomical, and functional brain features in schizophrenia (SZ), schizoaffective disorder (SZA), and bipolar disorder (BPI). However, regarding brain features, few studies have approached this line of inquiry using analytical techniques optimally designed to extract the shared features across anatomical and functional information in a simultaneous manner. Univariate studies of anatomical or functional alterations across these disorders can be limited and run the risk of omitting small but potentially crucial overlapping or joint neuroanatomical (e.g., structural images) and functional features (e.g., fMRI-based features) which may serve as informative clinical indicators of across multiple diagnostic categories. To address this limitation, we paired an unsupervised multimodal canonical correlation analysis (mCCA) together with joint independent component analysis (jICA) to identify linked spatial gray matter (GM), resting-state functional network connectivity (FNC), and white matter fractional anisotropy (FA) features across these diagnostic categories. We then calculated associations between the identified linked features and trans-diagnostic behavioral measures (MATRICs Consensus Cognitive Battery, MCCB).

Component number 4 of the 13 identified displayed a statistically significant relationship with overall MCCB scores across GM, resting-state FNC, and FA. These linked modalities of component 4 consisted primarily of positive correlations within subcortical structures including the caudate and putamen in the GM maps with overall MCCB, sparse negative correlations within subcortical and cortical connection tracts (e.g., corticospinal tract, superior longitudinal fasciculus) in the FA maps with overall MCCB, and negative relationships with MCCB values and loading parameters with FNC matrices displaying increased FNC in subcortical-cortical regions with auditory, somatomotor, and visual regions.

Developing and validating high-value patient digital follow-up services: a pilot study in cardiac surgery

Background

The existing digital healthcare solutions demand a service development approach that assesses needs, experience, and outcomes, to develop high-value digital healthcare services. The objective of this study was to develop a digital transformation of the patients’ follow-up service after cardiac surgery, based on a remote patient monitoring service that would respond to the real context challenges.

Methods

The study followed the Design Science Research methodology framework and incorporated concepts from the Lean startup method to start designing a minimal viable product (MVP) from the available resources. The service was implemented in a pilot study with 29 patients in 4 iterative develop-test-learn cycles, with the engagement of developers, researchers, clinical teams, and patients.

Results

Patients reported outcomes daily for 30 days after surgery through Internet-of-Things (IoT) devices and a mobile app. The service’s evaluation considered experience, feasibility, and effectiveness. It generated high satisfaction and high adherence among users, fewer readmissions, with an average of 7 ± 4.5 clinical actions per patient, primarily due to abnormal systolic blood pressure or wound-related issues.

Conclusions

We propose a 6-step methodology to design and validate a high-value digital health care service based on collaborative learning, real-time development, iterative testing, and value assessment.

Pressure-induced phase transition in Glycinium maleate crystal

The multicomponent glycinium maleate single crystal was grown by the slow evaporation method. The crystal was submitted to pressures ranging from 1 atm to 5.6 GPa and Raman spectroscopy was used as a spectroscopic probe. The modifications of relative intensity bands related to the lattice modes at 0.3 GPa were associated with rearrangements of hydrogen bonds. Moreover, between 1.7 and 4.8 GPa the Raman results indicate that the crystal experience a long structural phase transition, which was confirmed by PCA analysis. DFT calculations gave us more precision in the assignments of modes. The behavior of the internal modes under pressure showed that the maleic acid molecule undergoes greater modifications than glycine amino acid. All observed modifications were reversible when the pressure was released.

On- vs off-hours primary percutaneous coronary intervention: a single-centre experience

Introduction

In ST-segment elevation myocardial infarction (STEMI) patients, emergency medical system delays importantly affect outcomes. The effect of admission time in STEMI patients is dubious when percutaneous coronary intervention (PCI) is the preferred reperfusion strategy.

Aims

The authors aimed to retrospectively describe the association between admission time and STEMI patient's care standards and outcomes.

Methods

Characteristics and outcomes of 1222 consecutive STEMI patients treated in a PCI-centre were collected. On-hours were defined as admission on non-national-holidays from Monday to Friday from 8 AM to 6 PM. Time delays, in-hospital and one-year all-cause mortality were assessed.

Results

A total of 439 patients (36%) were admitted on-hours and 783 patients (64%) were admitted off-hours. Baseline characteristics were well-balanced between groups, including the percentage of patients admitted in cardiogenic shock (on-hours: 4.6% vs off-hours 4%; p=0.62).

Median emergency system dependent time to reperfusion (i.e. first-medical contact to reperfusion) did not differ between the two groups (on-hours: 120 min vs. off-hours 123 min, p=0.54). The authors observed no association between admission time and in-hospital mortality (on-hours: 5% vs. off-hours 4.9%, p=0.90) or 1-year mortality (on-hours: 10% vs. off-hours 10%, p=0.97).

In patients admitted directly in the PCI-centre, median time from first-medical contact to reperfusion (on-hours: 87 min vs off-hours: 88 min, p=0.54), in-hospital mortality (on-hours: 4% vs off-hours: 7%, p=0.30) and 1 year mortality (on-hours: 9% vs off-hours: 13%, p=0.27) did not differ between the two groups.

Survival analysis showed no survival benefit of on-hours PCI over off-hours PCI (HR 1.01; 95% CI [0.77–1.46], p=0.95).

Conclusion

In a contemporary well-organized emergency network, STEMI patients admission time in the PCI-centre was not associated with reperfusion delays or increased mortality.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve

The Predictive role of speckle-tracking and left ventricular ejection fraction estimation using 2D and 3D echocardiography in the detection of chemotherapy related cardiotoxicity

Background

2D left ventricular ejection fraction (LVEF) estimation through echocardiography has been the classic parameter for cancer therapy–related cardiac dysfunction (CTrCD) detection. However, it is hypothesized that other parameters can be used in order to detect early stages of subclinical cardiotoxicity when LVEF is still preserved. Therefore, 3D LVEF and 2D and 3D strain parameters assessments have been evaluated in patients submitted to anthracyclines treatment.

Objectives

To compare 2D and 3D LVEF and strain parameters estimation using echocardiography regarding its ability to predict and detect subclinical and clinical cardiotoxicity during and after anthracyclines treatment.

Search methods and criteria

A systematic review was done and search was performed on PubMed and EMBASE from January 1st of 2000 to October 31th of 2020. Observational studies comparing 2D and 3D echocardiographic exams performed in adult patients submitted to anthracyclines were analyzed. Studies that evaluated survivors of pediatric cancer were excluded. 11 studies were included (n=844 patients).

Main results

2D and 3D LVEF decreased throughout the echocardiographic assessments of 7 studies, but 2D LVEF drops were not statistically significant in 4 studies and 3 studies showed that 3D LVEF detected a superior number of patients with abnormal LVEF. Compared to 3D LVEF,

2D GLS decreased at an earlier point of treatment and detected a superior number of patients with subclinical LV dysfunction. Despite 2D and 3D GLS decreased throughout treatment, 3D GLS measurements were consistently lower and had higher relative variation. All 3D strain parameters decreased during and after the treatment and have higher relative variations than 2D GLS, with the exception of 1 study. 3D GLS reference values are not yet recognized by guidelines, so subclinical LV dysfunction was not evaluated.

Conclusions

LVEF estimation through 3D proved to be a better parameter for CTrCD detection vs 2D imaging. GLS is superior to 3D LVEF in detecting earlier LV changes, even if calculated using 2D echocardiography. Moreover, GLS reduction can be a predictor of subsequent LVEF decrease. 3DE is a growing potential technique and may be superior to 2DE in detecting and predicting subclinical LVEF dysfunction and CTrCD, respectively. Though 3D strain parameters presented promising results, more studies are needed to prove its incremental value over 2D strain echocardiography

Funding Acknowledgement

Type of funding sources: None.

Managing bifurcations: are two stents better than one?

Introduction

Bifurcation percutaneous coronary intervention (PCI) is associated with a higher degree of complexity when compared with non-bifurcation procedures. Although 1-stent PCI remains the standard approach for most bifurcation lesions, data is constantly being published on 2-stent PCI.

Aim

To evaluate and compare the characteristics and outcomes of patients that underwent bifurcation PCI with one or two stents.

Methods

Single center, retrospective observational study including all patients who underwent bifurcation PCI between January 2015-December 2018. We defined two groups: 1-stent PCI group (1s-PCI) and 2-stent PCI group (2s-PCI). The 2s-PCI group included PCI patients with all the different techniques used in our center: provisional stenting with 2 stents, Cullote, crushing stent and DK Crush.

Results

1s-PCI group included 376 individuals and 2s-PCI group included 26. Overall baseline clinical characteristics were balanced between groups. There was no statistically significant difference in age (mean 64 vs 66; p=0.388), gender (79% vs 85% males; p=0.622) and comorbidities (hypertension, diabetes mellitus, hypercholesterolemia, chronic kidney disease, smoking and previous history of coronary artery disease). Also, there was no difference in clinical status (NSTEMI 36% vs 38%; stable disease 32% vs 42%; STEMI 28% vs 19%; unstable angina 5% vs 0%; p=0.419). Coronary angiography and lesion distribution were similar in both groups (p=0.367). However, radiation dose (median 90.5 [IQR=79] vs 156 [IQR=84] mGy cm2; p<0,001) and contrast volume (median 150 [IQR=100] vs 156 [IQR=83] ml; p<0,001) were significantly higher in 2s-PCI group. At 12-month follow-up, mortality rate was higher in 1s-PCI group, but without statistical significance (8% vs 4%; p=0.71); the same is true for acute myocardial infarction at 12 months (3% vs 0%; p=0.368). Target-lesion failure was only reported in 4 patients in the 1s-PCI group. Survival tests showed no significant difference between groups (χ2(1,n=402)=0.634; p=0.426).

Conclusion

Individuals that underwent 1s-PCI were overall similar to those who underwent 2s-PCI. Predictably, deploying more than 1 stent required more contrast volume and implied a higher radiation dose. We should note that our studied is greatly limited by the 2s-PCI group size, which may justify the lack of difference in the evaluated outcomes.

Funding Acknowledgement

Type of funding sources: None.

Impact of a cardio-oncology rehabilitation program in patients with breast cancer undergoing cardiotoxic treatment

Background

Cancer treatment–related cardiotoxicity (CTrCD) is commonly associated with anthracyclines and anti-HER2 agents which are widely used for the treatment of breast cancer. In order to mitgate CTrCD, exercise-based cardio-oncology rehabilitation (COR) involving a structured exercise program has been proposed.

Objectives

To evaluate the impact of a cardiac-rehabilitation program in breast cancer patients submitted to chemotherapy with known cardiotoxicity.

Methods

A systematic review was performed. Two databases were searched, PubMed and SCOPUS. All randomized or controlled trials and other prospective studies published between 2000 and March 2020 which evaluate the impact of an aerobic exercise program on cardiorespiratory fitness (CRF), health-related quality of life (QOL), vascular/endothelial function as well as cardiac assessment namely through the evaluation of left ventricular function and cardiac biomarkers in patients undergoing anthracycline and/or anti-HER2 treatments were included.

Main results

Fourteen studies were included enrolling 578 breast cancer patients with a mean age of 48.80 years. Regarding the impact of exercise in CRF, 5 studies (n=176) reported a significant improvement of VO2 max. and 4 studies of VO2max./kg (n=137). The peak power output was also improved in 4 studies (n=95) in the exercise-group. Considering the assessment of QOL, 3 studies (n=180) revealed significant differences favoring the exercise-group. The results regarding the evaluation of the LVEF were not clear: 2 studies (n=48) reported a significant decrease on LVEF when compared to baseline at the end of the intervention in both groups, despite the exercise program. However, 2 studies (n=97) showed a significant increase on LVEF in the exercise-group. Three studies (n=82) did not found significant differences in global longitudinal strain between groups. Limited evidence was found in vascular and endothelial functon. In 2 studies (n=50), endothelial function measured by brachial artery flow-mediated dilatation significantly improved in the exercise-group. Two studies (n=98) reported no significant impact of exercise on atenuating the increase of cTnI and BNP levels in the course of chemotherapy. On the other hand, when considering NT-proBNP, an increase in its levels was attenuated in the exercise-group.

Conclusions

This study confirms that exercise-based COR seems to be an effective approach to improve several cardiovascular outcomes and quality of life in breast cancer patients.

Funding Acknowledgement

Type of funding sources: None.

Quality by design (QbD) optimization of diazepam-loaded nanostructured lipid carriers (NLC) for nose-to-brain delivery: Toxicological effect of surface charge on human neuronal cells

Diazepam is commonly used in the management of epileptic seizures, although it has limitations that can be overcome by using formulations that are easier to administer and capable of directing the drug to the brain. In this field, it has been reported that the use of nanostructured lipid carriers (NLC) via intranasal (or via nose-to-brain) promotes the targeting of drugs to the brain, improving the effectiveness of therapy. The aim of this work was to optimize two diazepam-loaded NLC formulations for nose-to-brain delivery, one with positive surface charge and one with negative surface charge. The quality by design (QbD) approach was used to design the experiments, where the quality target product profile (QTPP), the risk assessment and the critical quality attributes (CQAs) were defined to ensure safety, efficacy and quality of the final formulations. The experiments started with the optimization of critical material attributes (CMAs), related to the ratios of lipids and emulsifiers, followed by the selection of critical process parameters (CPPs), related to the production methods of the diazepam-loaded NLC formulation (ultrasound technique and high-pressure homogenization - HPH). Afterwards, the positive surface charge of the diazepam-loaded NLC was optimized. Finally, the biocompatibility with human neuronal cells of the formulation with a negative surface charge and of the formulation with a positive surface charge was evaluated. The results of the optimization of the CMAs showed that the ratios of lipids and emulsifiers more adequate were 6.7:2.9 and 4.2:0.3 (% w,w), respectively. Regarding the CPPs, HPH was considered the most suitable production method, resulting in an optimized diazepam-loaded NLC formulation (F1C15) with negative surface charge, showing particle size of 69.59 ± 0.22 nm, polydispersity index (PDI) of 0.19 ± 0.00, zeta potential (ZP) of -23.50 ± 0.24 mV and encapsulation efficiency (EE) of 96.60 ± 0.03 %. The optimized diazepam-loaded NLC formulation (F2A8) with positive surface charge had particle size of 124.40 ± 0.84 nm, PDI of 0.17 ± 0.01, ZP of 32.60 ± 1.13 mV and EE of 95.76 ± 0.24 %. In addition, the incorporation of diazepam in NLC resulted in a sustained release of the drug. No significant changes in particle size, PDI, ZP and EE were observed for the formulation F1C15, after 3 months of storage, whereas for formulation F2A8, particle size increased significantly. Biocompatibility studies showed that the formulation F2A8 was more cytotoxic than the formulation F1C15. Thereby, we conclude that the formulation F1C15 is more suitable for targeting the brain, when compared with the formulation F2A8. From the results of these studies, it can be confirmed that the QbD approach is an adequate and central tool to optimize NLC formulations.

Cardiac microcalcification burden is associated with cardiac fat variables in high cardiovascular risk patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Calcification plays a major role in coronary atherogenesis. Positron emission tomography (PET) imaging with fluorine-18 sodium fluoride (Na[18F]F) is able to detect microcalcification and is associated with cardiovascular (CV) risk factors. Thoracic fat volume (TFV) and epicardial adipose tissue (EAT) are associated with atherosclerosis, pro-inflammatory state, and CV events.

Purpose

We aimed to evaluate the association between Na[18F]F uptake and cardiac fat variables.

Methods

Cardiac Na[18F]F uptake was assessed as global molecular calcification score (GMCS): the sum of the product of the mean standardized uptake value times the area of the cardiac regions of interest times the slice thickness for all cardiac transaxial slices, divided by the total number of slices. TFV was assessed in computed tomography (CT) using automated software to sum the voxels consisting of fat (threshold of -190 to -30 Hounsfield units) between the bifurcation of pulmonary artery and the end of pericardial sac. EAT was segmented manually tracing the counter of the pericardium with 3DSlicer and the final volume calculated using the dedicated software. Coronary artery calcium score (CAC) was measured with dedicated software for calcium scoring (GE Healthcare Advantage Workstation 4.2).

Results

Thirty-four high CV risk individuals without previous CV events (50% with ≥5 CV risk factors) were retrospectively scanned with Na[18F]F PET-CT. Mean age is 63.5 ± 7.8 years and 62% male. Median values are: GMCS 320.9 (240.8-402.8), TFV 167.8 (131.4-211.3) mL, EAT 81.3 (60.7-107.2) cm3, and CAC 0.0 (2.5-20.0). There is a positive correlation between GMCS and abdominal perimeter (rs = 0.74), weight (rs = 0.61), TFV (rs = 0.47), and EAT (rs = 0.41), all with p ≤ 0.01. Thoracic and epicardial fat volumes are strongly correlated (rs = 0.80, p < 0.01). Both TFV and EAT are correlated with abdominal perimeter (rs = 0.60, p < 0.01 and rs = 0.46, p < 0.01, respectively) and weight (rs = 0.47, p < 0.01 and rs = 0.42, p = 0.01, respectively). GMCS [356.7 (321.0-409.6) vs. 261.1 (225.6-342.1), p = 0.01] and thoracic fat volume [184.3 (153.2-303.7) vs. 142.1 (90.0-173.1) mL, p = 0.01] are higher in patients with ≥5 CV risk factors, but not EAT [92.5 (62.0-145.7) vs. 76.7 (56.2-86.8) cm3, p = 0.14]. Neither GMCS (rs=-0.06, p = 0.77), TFV (rs = 0.20, p < 0.32) nor EAT (rs = 0.06, p < 0.76) are correlated with CAC score.

Conclusions

In this exploratory analysis with high CV risk patients, the global cardiac microcalcification burden assessed by GMCS is associated with TFV and EAT, but there was no correlation between these variables and CAC. We hypothesize that both GMCS and cardiac fat variables might help to identify higher-risk patients in earlier phases than traditional CT.

The prevalence of cardiac sarcoidosis is underestimated: [18F]FDG-PET is the answer

Funding Acknowledgements

Type of funding sources: None.

Background

Overt cardiac involvement is reported in 5% of patients with sarcoidosis, although autopsy and imaging studies suggest higher prevalence, worldwide variation. The role of 18F-fluorodeoxyglucose positron emission tomography ([18F]FDG-PET) in non-invasive diagnosis and follow-up has increased in the last decade.

Purpose

Our goal is to describe the prevalence, clinical manifestations and outcomes of cardiac sarcoidosis (CS), diagnosed through [18F]FDG-PET, in a southern European population.

Methods

We included all patients with histological diagnosis of extracardiac sarcoidosis screened with [18F]FDG-PET between 2009 and 2020. We collected data on clinical manifestations, cardiac magnetic resonance (CMR) results, and mortality outcomes and compared those with and without cardiac involvement. We applied the criteria for the diagnosis of CS from Heart Rhythm Society.

Results

Of the 400 patients screened with [18F]FDG-PET, 128 had a histological diagnosis of extracardiac sarcoidosis (54.7% females, mean age 51.0 ± 14.2 years). None underwent endomyocardial biopsy. Ten patients had a pattern of [18F]FDG uptake consistent with CS defined as diffuse (n = 5), focal (n = 3), and focal on diffuse (n = 2). Of the 128 patients, 14 also underwent CMR, which identified 2 subjects with positive findings in both modalities and 3 additional patients: focal (n = 1), multifocal mid-wall (n = 2), focal mid-wall (n = 2), and multifocal subepicardial (n = 1) delayed gadolinium enhancement. Overall, 13 patients (10.2%) fulfilled the criteria for probable CS (53.8% female, mean age 56.2 ± 12.6 years), all with multiorgan involvement, mostly lung and lymph nodes (each 92%), followed by skin and central nervous system (each 15%). Median left ventricle ejection fraction was 62% [55-65] and there were cardiac manifestations of CS in 6 patients (46%): sick sinus syndrome (n = 2), complete heart block (n = 1), frequent premature ventricular complexes (n = 1), ventricular tachycardia plus heart failure (n = 1), and bifascicular block plus heart failure (n = 1). Eleven patients (85%) with probable CS were medicated with immunosuppressant drugs: corticosteroids (n = 9), methotrexate (n = 4), and azathioprine (n = 2). Four patients with previous [18F]FDG screening were revaluated after treatment, each showing no cardiac uptake.  After a mean follow-up of 4.0 ± 1.0 years, mortality was three-fold higher in patients with cardiac involvement, despite the absence of statistical significance (15% vs. 5%, P = 0.151).

Conclusions

In a southern European population with histological extracardiac sarcoidosis, the prevalence of cardiac involvement was 10.2%, most asymptomatic. [18F]FDG-PET improves the diagnostic yield and plays an important role in monitoring response to therapy. The higher mortality trend in those with CS needs to be ascertained in longer follow-up.

Temporal characterization of ventricular function and deformation after Takotsubo syndrome using cardiovascular magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

The time course of ventricular recovery in Takotsubo Syndrome (TS) patients(pts) is still not well characterized. Quantification of myocardial deformation using Cardiovascular Magnetic Resonance Feature-Tracking (CMR-FT) may be a useful method to better characterize ventricular recovery during TS.

AIM

To assess the time course of ventricular function using CMR-FT myocardial strain in patients (pts) with an episode of TS.

METHODS

We performed a single-center, retrospective cohort study including 130 pts admitted with TS over a 10-year period. From this cohort, 39 (30%) pts were selected and age and sex-matched with 16 healthy controls for a comparative analysis of myocardial strain using CMR-FT. TS pts were divided in 3 homogeneous subgroups according to the time from index-event and the CMR acquisition: Group 1(G1): <8 days; Group 2(G2): 8 to 30 days; Group 3 (G3): >30 days.

One operator blinded for the study group performed the analysis. Left ventricle (LV) radial strain (RS), longitudinal strain (LS) and right ventricle (RV) LS were quantified.

RESULTS

The mean age of TS group was 66 years and 90% were female. The median ejection fraction (EF) at admission was 38%; 82% displayed an apical ballooning (AB) pattern. Around 19% had at least 1 in-hospital complication and 1.5% died during hospitalization. A significant increase use of CMR was observed over the years (p = 0.001).

Myocardial deformation analysis showed a significant group interaction for LV LS and RS. Specifically, the global values of G1 LV LS and RS were significantly decreased when compared with G3 (LS:-15vs-20%;p = 0.002; RS:40vs61%; p < 0.001) and controls (LS:-15vs-22%;p < 0.001; RS: 40vs70; p < 0.001). There were no significant differences in the RV LS across groups.

The CMR-quantified EF was significantly decreased in G1 when compared with G3 (52vs64%; p < 0.003) and controls (52vs64%; p < 0.001). Differences between G1 and G2 were found in LV RS (LS:40vs57%; p < 0.001) and EF (52vs62%; p < 0.001). No differences were observed for any parameters between G3 and controls.

This study showed that global LV LS (r=-0.6, p < 0.001) and RS (r = 0.7, p < 0.001) had a significant correlation with the CMR-quantified EF.

A comparison between the different patterns of TS was also performed (Figure 1). Pts with AB pattern in G1 displayed lower global RS (P = 0.014), although there were no differences regarding global LS. As expected, in the AB group the reduction in myocardial strain was limited to the apical segments.

Despite not being significantly different across groups RV LS was the only CMR-derived predictor of complications during follow-up (OR = 1.17; p = 0.026).

CONCLUSION

This study revealed that after an episode of TS myocardial function quantified either by EF or CMR-FT strain fully recovers between the 8th and 30th day of the event. RV strain was a predictor of complications during follow-up.

Impact of Atrial Fibrillation type in Acute Coronary Syndrome and the antithrombotic strategy

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Atrial fibrillation (AF) is an adverse prognostic factor during acute coronary syndrome (ACS). Current evidence recommends dual antithrombotic therapy (DAT), 1 antiplatelet drug and 1 anticoagulant drug, as the default strategy after nonST elevation ACS.

AIM

To identify the clinical differences and prognosis of AF type-new onset (nAF) or pre-existing (pFA)- during ACS, to evaluate antithrombotic strategy at hospital discharge (HD) and its impact on haemorrhagic and ischemic events.

METHODS

We performed a retrospective observational cohort study including 3241 patients (pts) with ACS (mean age 64 years, 77.5% male) admitted to a single center over a 6-year period, with 12-months follow-up.

RESULTS

AF rhythm was identified in 11.2% pts, of whom 63.2% presented nAF and 36.8% pAF.

When AF types where compared, pts with pAF had a higher prevalence of cardiovascular (Cv) comorbidities, including hypertension (p < 0.001), previous ACS (p = 0.03), valvular disease (p = 0.01) or stroke (p = 0.05), had greater left atrial diameter (p < 0.001) and were less likely to have significant coronary lesions (p = 0.05). Pts with nAF more frequently presented with STelevation ACS (p < 0.001) and had a lower Hemoglobin nadir (p < 0.001). The independent predictors of nAF in ACS were age (OR 1.1, p< =0.001), LVEF ≤ 40% (OR 2.2, p = 0.001), STelevation ACS (OR 2.6, p< =0.001) and previous valvular disease (OR 3.5, p< =0.01). Compared with the population without AF, nAF was a predictor of in-hospital death (OR 2.9, p = 0.027) and in-hospital composite endpoint (death, stroke, reinfarction and cardiogenic shock) (OR 2.5, p = 0.001) in multivariate analysis, but pAF wasn’t. During 12-months follow-up of pts with ACS and AF, there was no difference regarding death or follow-up composite endpoint (death, stroke and ACS) between the AF types.Regarding antithrombotic therapy, nAF pts were less often anticoagulated (p < 0.001) and pAF pts where more often treated with triple antithrombotic therapy (TAT) at HD (<0.001). Most of the pts with TAT stopped the second antiplatelet at agent 6-months (43.8%) or 12 months (25.5%) after HD. During 12-months follow-up, pts discharged with TAT had trend towards more haemorrhagic events (TAT 6.2% vs DAT2.7%,p = 0.69) and both groups had similar ischaemic events (death, ACS, stroke) (TAT 20.9% vs DAT23.7%,p = 0.714). In multivariate analysis the choice of TAT or DAT wasn’t a predictor of ischaemic events.

CONCLUSIONS

In ACS, pts with nAF had worst in-hospital outcomes than pts with pAF. Regarding antithrombotic strategy at HD pts with nFA were less often anticoagulated and less often treated with TAT. In our study the choice between DAT or TAT had no statistical impact on follow-up outcomes.

Syncope: call for the missed diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas.

Purpose

To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope.

Methods

Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation.

Results

In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications.

Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department.

Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance).

Conclusions

Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Association of whole mtDNA, an NADPH G11914A variant, and haplogroups with high physical performance in an elite military troop

Physical performance is a multifactorial and complex trait influenced by environmental and hereditary factors. Environmental factors alone have been insufficient to characterize all outstanding phenotypes. Recent advances in genomic technologies have enabled the investigation of whole nuclear and mitochondrial genome sequences, increasing our ability to understand interindividual variability in physical performance. Our objective was to evaluate the association of mitochondrial polymorphic loci with physical performance in Brazilian elite military personnel. Eighty-eight male military personnel who participated in the Command Actions Course of the Army were selected. Total DNA was obtained from blood samples and a complete mitochondrial genome (mtDNA) was sequenced using Illumina MiSeq platform. Twenty-nine subjects completed the training program (FINISHED, 'F'), and fifty-nine failed to complete (NOT_FINISHED, 'NF'). The mtDNA from NF was slightly more similar to genomes from African countries frequently related to endurance level. Twenty-two distinct mtDNA haplogroups were identified corroborating the intense genetic admixture of the Brazilian population, but their distribution was similar between the two groups (FST=0.0009). Of 745 polymorphisms detected in the mtDNA, the position G11914A within the NADPH gene component of the electron transport chain, was statistically different between F and NF groups (P=0.011; OR: 4.286; 95%CI: 1.198-16.719), with a higher frequency of the G allele in group F individuals). The high performance of military personnel may be mediated by performance-related genomic traits. Thus, mitochondrial genetic markers such as the ND4 gene may play an important role on physical performance variability.

Early intervention program for psychosis in a portuguese hospital: The first results of the open program

Introduction

OPEN is a structured intervention program for patients who present with untreated psychosis at an early stage, under the guidance of a case manager and a periodic evaluation performed by a multidisciplinary team.

Objectives

The aim of the OPEN program is to create an individual care plan, promoting recovery, functionality, quality of life and prevent relapses. One year after implementation of the program, we present the first results.

Methods

We performed a retrospective review of the patients’ clinical profiles included in the OPEN program.

Results

Nine patients were included in the program. The most frequent diagnosis was schizophrenia (n=5). By the time of inclusion in the program, 5 patients used cannabis frequently; one patient kept substance use. At the 6^th month assessment, 4 in 5 patients showed an improvement in social functioning (Personal and Social Performance Scale; ± 16 points), and a decrease in symptom severity in all (Brief Psychiatric Rating Scale; ± 11 points). Due to COVID-19 pandemics, group interventions were suspended, and some visits were performed by teleconsultation. No patients lost follow-up.

Conclusions

We observed an overall positive result of the first months of this program, regarding both functionality and clinical outcomes. The main obstacle so far is the impossibility of performing group interventions since the start of the contingency measures regarding COVID-19 pandemics. We expect further results of the OPEN program with the inclusion of more patients.

“I am the coronavirus”: A case report and review

Introduction

As disorders of thought, delusions are modified by patients’ background, and so their content varies widely according to location and throughout the ages. The COVID-19 pandemic has shown its global impact on society and mental health of the population, thus becoming a new delusional topic.

Objectives

We report a case where the COVID-19 pandemic has been integrated into a patient’s delusion in an attempt to raise professional awareness for this new psychotic presentation.

Methods

Review of clinical notes and literature review.

Results

A 38-year-old female patient with no prior psychiatric history presented with psychotic symptoms characterized by self-referential ideas, feelings of guilt and delusions of ruin, with a sudden onset of less than 24 hours prior to observation. The patient claimed that she was the coronavirus and, as such, she was a common topic of conversation in both television and social media, and the reported deaths caused by COVID-19 were her own doing. As a result of this, the patient was asking doctors to kill her in order to save everyone else affected by the virus. After evaluation, a diagnosis of Acute and Transient Psychotic Disorder was considered. The patient was initially treated with paliperidone, but due to hyperprolactinemia and menstrual changes this was switched to aripiprazole. Symptoms remitted fully after 21 days of treatment, and six months later no recurrences have been described.

Conclusions

This case illustrates the potential of the coronavirus pandemic outbreak as a new delusional topic. Possible side effects of treatment are also discussed.

“How many likes?”: The use of social media, body image insatisfaction and disordered eating

Introduction

Social media use has grown exponentially over the past few years, having a key role in communication among our youngsters. The impact of social media in mental health is still unclear. While some studies advocate that it increases social support and general satisfaction, others associate social media with the development of mental health issues. Social media can also perform some pressure regarding body image and eating behavior, caused by the idealistic appearance shown there in a very visual way.

Objectives

This review intends to identify the existing evidence regarding social media use, its impact on body image and eating behavior.

Methods

Search performed on May 11, 2020, including articles published since January 1st, 2006, written in Portuguese, English, Spanish and French. We used the MeSH terms ‘Body dissatisfaction’, ‘Body image’, ‘Feeding and eating disorders’, ‘Eating behaviors’ and ‘Social media’. The quality and strength of recommendation of the articles were evaluated using the Strength of Recommendation Taxonomy (SORT) scale from the American Academy of Family Physicians.

Results

716 articles were initially found. Eight were selected: two systematic reviews, three cohort studies, two cross-sectional studies and one observational study.

Conclusions

This review presents studies that establish a correlation between social media use, body image dissatisfaction and disordered eating. However, methodological and population heterogeneity can compromise the conclusions observed. With the current evidence, we can conclude that there is a relationship between the use of social media and changes in body image and/or eating behaviors in adolescents and young adults (SORT B).

Disclosure

No significant relationships.

From hysteria to conversion: A case of stuttering

Introduction

Conversion Disorder is a condition defined by the sudden appearance of neurologic symptoms without an identifiable organic cause, often thought to be associated with psychological triggers. This disorder can lead to severe distress and loss of functionality which, without appropriate treatment, can be made permanent.

Objectives

To raise awareness for this unexplained and often misunderstood disorder using a clinical case as background.

Methods

Clinical history, organic evaluation, psychological evaluation and literature review.

Results

28-year-old female, single, with two children, working from home as a call-centre operator. Previously followed and medicated for depression. Presents to the ER due to sudden loss of consciousness while working, after which her speech became hindered by stuttering. Neurologic evaluation was unremarkable and she was referred for Psychiatric assessment, resulting in a diagnosis of Conversion Disorder. Speech was at first understandable but in the following weeks became progressively worse and eventually led to aphonia, while written communication remained normal and was the patient’s method of choice.

Conclusions

Once a favourite of Psychiatrists, little is yet known about the underlying mechanisms behind this disorder. Experts disagree on whether to classify it as a dissociative disorder, a somatoform disorder, or its own category. Patients presenting with this condition are often mistaken for malingering and thus subject to unhelpful or outright discriminatory practices. Broadened awareness is required to ensure patients get early access to the best possible care and thus improve their quality of life.