The Effects of Benralizumab on Lung Volumes and Airway Resistance in Severe Eosinophilic Asthma: A Real-World Study

INTRODUCTION

Add-on biological monoclonal antibodies such as benralizumab (anti-IL-5Ra) are recommended by international guidelines to reduce exacerbations in severe eosinophilic asthma (SEA). However, few studies have assessed the impact of these therapies on lung function-related outcomes. Our goal was to evaluate the effectiveness of benralizumab on lung function, including lung volumes and airway resistance, in SEA patients in Portugal.

METHODS

This was a real-world, observational, prospective, multicentric study including adult patients diagnosed with SEA (January-June 2023). Spirometry and plethysmography were performed at baseline (T0) and after six months of treatment (T6) with benralizumab to assess: total lung capacity (TLC), residual volume (RV), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), mean forced expiratory flow between 25% and 75% of FVC (mFEF-25/75), intrathoracic gas volume (ITGV), and respiratory airway resistance (Raw). Descriptive statistics (with categorical variables described as frequencies and continuous values as mean and standard deviation (SD)) and paired t-test and Cohen's d effect size were calculated (analyses performed in StataCorp v.15.1; StataCorp LLC, TX, USA).

RESULTS

Overall, 30 SEA patients were evaluated, mostly women (n=18, 60.0%), with atopy (n=22, 73.3%), a mean age of 58.4 years (SD 11.7), and assisted by pulmonology (n=19, 63.3%) or immunology-allergology (n=11, 36.7%) services. Mean eosinophilia at baseline was 1103.57 cells/mcL (SD 604.88; minimum-maximum 460-2400); after the use of benralizumab, the count dropped to zero. After six months of treatment, a significant increase (p<0.0001) in FVC (15.3%), FEV1 (22.6%), and mFEF-25/75 (17.7%) were observed from baseline (Cohen's d between 0.78 and 1.11). ITGV, RV, RV/TLC, and Raw significantly decreased (p<0.0001) during the study period (-17.3%, -29.7%, -8.9%, and -100.6%, respectively) (Cohen's d between -0.79 and -1.06). No differences in TLC were obtained (p=0.173). No differences between sexes were observed for any measure. Patients with more significant eosinophilia (>900 cells/mcL count; n=15) presented better responses in FEV1 (p=0.001) and mFEF-25/75 (p=0.007).

CONCLUSIONS

A notable eosinophil depletion with add-on benralizumab led to significant improvements in SEA patients' respiratory function (static lung volumes and airway resistance) in real-world settings after six months. The significant deflating effect of benralizumab on patients' hyperinflated lungs led to enhanced expiratory flow (increased FEV1 and mFEF-25/75) and air trapping (decreased RV/TLC), suggesting this antibody improves bronchial obstruction, lung hyperinflation, and airway resistance. Further studies in a larger population are required to confirm these findings.

Organic Medicinal and Aromatic Plants: Consumption Profile of a Portuguese Consumer Sample

The production and consumption of organic products have been increasing in Portugal, as well as in the European Union as a whole. The main objective of this work is to understand the consumption habits of organic medicinal and aromatic plants (OMAPs) among Portuguese adults. An online questionnaire was distributed using social networks, resulting in the collection and statistical analysis of 300 responses. Of the participants who reported consuming OMAPs, 44.3% showed a daily consumption pattern. The most frequently mentioned OMAPs for fresh consumption were parsley (Petrosselinum crispum L., 92%), garlic (Allium sativum L., 84.1%), and coriander (Coriandrum sativum L., 78.1%). The most commonly mentioned OMAP for consumption as dried plants were oregano (Origanum vulgare L., 74.6%), lemon balm (Melissa officinalis L., 49.2%), and lemon verbena (Aloysia citrodora L., 46.8%). The main reasons cited for using OMAPs were their benefits to health (58.7% of participants), benefits to the environment (33.2%), and reduced salt consumption (29.5%). Among these, the main health benefits mentioned included anti-inflammatory properties (45.0%), prevention of cardiovascular diseases (41.6%), and prevention of high cholesterol (39.9%). Furthermore, 82.5% of respondents considered themselves sufficiently, well, or excellently informed about the nutritional properties of OMAPs. This research initiates a discussion about whether profiling OMAP consumption habits can serve as a valuable tool for promoting organic farming in Portugal, increasing OMAP production and consumption, and strengthening the connection between these products and potential positive human health effects.

Wolfram Syndrome: A Curious Case of Repetitive Loss of Consciousness

Wolfram syndrome is a rare, multisystemic, progressive, and autosomal-recessive genetic disease, characterized by diabetes mellitus and diabetes insipidus, optic nerve atrophy, deafness, and other neurological signs. The diagnosis is usually based on history and clinical manifestations but genetic tests are necessary for confirmation. Currently, there are no treatments available to cure or delay disease progression. This report describes a case of a 23-year-old male diagnosed with Wolfram syndrome who presented to the emergency department with several episodes of loss of consciousness. This case reinforces the need for an early diagnosis of obstructive and central apneas, respiratory failure, and dysphagia, in order to prevent and treat the complications of this disease and to improve patients' quality of life.

Estimating the Glomerular Filtration Rate in Pediatric Patients With Neurogenic Bladder: A Comparison Between Creatinine- and Cystatin C-Equations

Background and objective Patients with neurogenic bladder (NB) are at a higher risk of developing chronic kidney disease (CKD). Due to their lower muscle mass, the estimated glomerular filtration rate (eGFR) based on creatinine (Cr) may be overestimated and delay the diagnosis of renal failure. This study compared eGFR calculated with different equations based on Cr and/or cystatin C (CysC) in children with NB, and the differences between patients with lower muscle mass (underdeveloped lower limbs) and those with independent gait (less muscle depletion). Methods We calculated the eGFR in pediatric patients with NB and CKD stages 1 and 2 by using the following equations: Chronic Kidney Disease in Children equation for serum creatinine (CKiD-Cr), CKiD-CysC, CKiD combined-Cr/CysC, Zappitelli-CysC, and Zappitelli combined-Cr/CysC. Results We evaluated a total of 47 patients, 74.5% with CKD stage 1, with a median age of 14.1 years. Of these participants, 59.6% had lipo/myelomeningocele. The CKiD-Cr and CysC-based equations led to significantly lower calculated eGFR ​​(p<0.05), specifically CKiD-CysC (p<0.001), Zappitelli-CysC (p<0.001), CKiD-Cr/CysC (p<0.001), and Zappitelli combined-Cr/CysC (p<0.05). When CKiD-CysC was used, 68% of the patients moved to a more advanced CKD stage. In patients without independent gait, with lower muscle mass (55.3%), the median eGFR calculated using the CKiD-Cr and CKiD combined-Cr/CysC equations was significantly higher (p<0.05). However, there were no differences between the two groups when using the other CysC-based equations. Conclusion In patients with NB and poor muscle mass, the CKiD-Cr equation may overestimate renal function. CysC-based equations seem more reliable in these patients, especially in those with greater muscular atrophy.

The Role of Benralizumab in Eosinophilic Immune Dysfunctions: A Case Report-Based Literature Review

In the past years, the knowledge of eosinophils playing a primary pathophysiologic role in several associated conditions has led to the development of biologics targeting therapies aiming at normalizing the immune response, reducing chronic inflammation, and preventing tissue damage. To better illustrate the potential relationship between different eosinophilic immune dysfunctions and the effects of biological therapies in this scenario, here, we present a case of a 63-year-old male first referred to our department in 2018 with a diagnosis of asthma, polyposis, and rhinosinusitis and presenting a suspicion of nonsteroidal anti-inflammatory drugs' allergy. He also had a past medical history of eosinophilic gastroenteritis/duodenitis (eosinophilia counts >50 cells/high-power field HPF). The use of multiple courses of corticosteroid therapy failed to completely control these conditions. In October 2019, after starting benralizumab (an antibody directed against the alpha chain of the IL-5 cytokine receptor) as add-on treatment for severe eosinophilic asthma, important clinical improvements were reported both on the respiratory (no asthma exacerbations) and gastrointestinal systems (eosinophilia count 0 cells/HPF). Patients' quality of life also increased. Since June 2020, systemic corticosteroid therapy was reduced without worsening of gastrointestinal symptoms or eosinophilic inflammation. This case warns of the importance of early recognition and appropriate individualized treatment of eosinophilic immune dysfunctions and suggests the conduction of further larger studies on the use of benralizumab in gastrointestinal syndromes aiming at better understanding its relying mechanisms of action in the intestinal mucosa.

Correction: Association of Tumor-Infiltrating Lymphocytes With Survival in Stages II and III Colorectal Cancer

[This corrects the article DOI: 10.7759/cureus.31144.].

Portuguese Family Physicians' Perceptions on Pain Management-A Qualitative Study Protocol

Pain is an important cause of disability and constitutes the main reason people seek medical care, especially in general practice. Nevertheless, nearly half of adult Europeans with chronic pain receive inadequate pain treatment. Limited knowledge about pain among physicians is recognized as a key barrier to treatment. This is due to the well-known insufficiency in pain education at both undergraduate and postgraduate levels. There is a scarcity of research exploring the perceptions of family medicine physicians on these issues. This study aims to evaluate the perceptions of these professionals concerning medical education, as well as their knowledge, skills, and preparedness to manage chronic pain and collect suggestions for improvement. A qualitative exploratory study will be performed using synchronous virtual focus groups and purposive sampling. Eligible participants will be 3rd- and 4th-year family medicine residents and family medicine specialists with at least five years of practice. Sample size and number of focus groups will depend on data saturation. A semi-structured guide will be used. A thematic categorical analysis will be conducted after verbatim transcription of the audiofiles. This protocol has been approved by the Health Ethics Committee.

Association of Tumor-Infiltrating Lymphocytes With Survival in Stages II and III Colorectal Cancer

The tumor microenvironment is crucial in tumourigenesis, response to therapy, and elimination of tumor cells. Tumor-infiltrating lymphocytes (TILs) promote the host immune response and are associated with a better prognosis in colorectal cancer (CRC). This multicentric retrospective study evaluated the relationship between the presence and intensity of TILs and survival outcomes. A total of 651 patients from four Portuguese oncological centers who underwent surgical resection for stages II or III colorectal adenocarcinoma between 2016 and 2019 were included in this study. The mean age of the study population was 70 years; 58.2% were males. The median overall survival was 58.03 ± 1.29 months (95% confidence interval (CI) 55.50 - 60.56), and the median disease-free survival (DFS) was 53.02 ± 1.39 months (95% CI 50.29 - 55.74). Patients with high infiltrate (including those with moderate, abundant, or Crohn-like infiltrate) had significantly longer DFS i.e., 58.48 ± 1.84 months (95% CI 54.87 - 62.09 months) vs 49.22 ± 1.75 months (95% CI 45.79 - 52.64 months) in the group with absent or minimal infiltrate; p = 0.003. Assessing the side of the tumor, high infiltrate was associated with higher DFS (59.86 ± 2.36 months (95% CI 55.23 - 64.50 months) vs 49.60 ± 2.40 months (95% CI 44.90 - 54.29 months), p = 0.011). This work reinforces the importance of research into possible prognostic and predictive factors in patients with CRC.

Possible etiologies of restless legs syndrome in pregnancy: a narrative review

Restless legs syndrome (RLS) is a sensorimotor disorder characterized by an urgent need to move the legs, due to the presence of a discomfort sensation in the lower limbs, especially at rest. Generally, it relieves with movement. There are several studies that argue the existence of an association between this syndrome and pregnancy. However, the pathophysiological mechanisms of this disorder in pregnancy are misunderstood. The objective of this narrative review is to identify and discuss some possible etiologies of RLS in pregnancy. A literature search was performed in the PubMed and ResearchGate databases by using the following search strategies: "restless legs syndrome", "restless legs syndrome in pregnancy", "pregnancy and vitamin D deficiency" and "pregnancy and zinc". The publications were initially sorted through their title. After the initial process, inclusion and exclusion criteria were applied. The included articles were sorted by authors, year, journal of publication, type of study, and organized by chronological order of publication. Among the main findings, hormonal changes, iron metabolism, vitamin D deficiency, genetic factors, zinc and magnesium fluctuations have been some of the hypotheses supporting the development or worsening of this disorder in pregnancy. Dopamine also appears to be correlated with hormonal changes, iron metabolism, ferritin, folic acid and vitamin D deficiency. In conclusion, there are several hypotheses trying to link restless legs syndrome with pregnancy. The most covered were hormonal fluctuations and iron metabolism. However, this thematic is still highly discussed, creating the need for additional and thorough research.

POS0423 CYCLIC CITRULLINATED PEPTIDE APTAMER TREATMENT ATTENUATES COLLAGEN INDUCED ARTHRITIS

Background

Anti-citrullinated peptide antibodies (ACPA) appear 10–15 years before the diagnosis of rheumatoid arthritis (RA) and are associated with a more severe disease course. In previous work, we rationally designed and screened ACPA-binding peptide aptamer sequences in silico and constructed a nanoparticle with chitosan and hyaluronic acid(1). A developmental stage version of this nanoparticle was able to reduce disease activity in the collagen-induced arthritis (CIA) and the serum transfer arthritis mouse models (2).

Objectives

Here, we investigated the effect and potential toxicity of three different versions of the aptamer nanoparticle (loading of 20%, 10% and 5% aptamer, respectively) in the CIA rat model.

Methods

Wistar rats (males and females) were given a single intravenous dose (100 mg/kilo) of type II collagen in PBS in the tail vein. The dosing was repeated three times with one day interval, followed by blood sample collection at day 7 after the initial collagen injection. To evaluate route of administration and dosing, we injected a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen, and plasma concentration−time profiles were followed for 2 days after dosing with weekly blood sampling. To evaluate organ uptake, rats were given a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen. The procedure was repeated after 24 hours. Blood and urine samples were taken once a week. A group of 10 animals was sacrificed every week over a three-week period, and the organs were processed. To examine efficacy, rats were given a single subcutaneous dose (2.5 mg/kilo) of aptamer-nanoparticles and nanoparticle controls without aptamer or PBS alone in the abdomen. The procedure was repeated once a week over a course of three weeks. Weight, joint measurement, blood, and urine samples were taken once a week. Paw swelling was measured on a weekly basis. In the plasma samples we measured CPEP2 and anti-collagen II by enzyme linked immunosorbent assay (ELISA).

Results

Using a rather high dose of collagen (100 mg/kilo) via an intravenous administration route, ACPA was measurable in all CIA rats with rapid development of RA in 82% of the included animals. Intravenous administration resulted in an immediate high plasma concentration post injection, which decreased rapidly to low levels. The s.c. administration route gave a steady, long-term aptamer release with a maximum availability 8 hours post-injection. After three aptamer-nanoparticle doses (2.5 mg/kg; either 20%, 10% or 5% aptamer), we observed a dose-dependent reduction in swollen joint count for the aptamer-nanoparticle treated groups (10 rats in each group) compared with the healthy control group (10 rats) (P-value = 2,1E-6). We observed decreased ACPA IgG levels in the rats treated with aptamer-nanoparticle. The decrease in ACPA levels correlated with the aptamer-nanoparticle having higher loading. Anti-collagen II IgG levels slightly increased towards the end of the study.

Conclusion

We developed and tested a novel peptide aptamer-based drug candidate for seropositive rheumatoid arthritis in CIA rats. Over a 3-week course of treatment with subcutaneous administration of aptamer-nanoparticles, joint swelling was decreased during treatment, and completely reversed at the end of the observation period. The reduction of joint swelling was associated with decreased levels of ACPA in the blood.

References

[1]Khatri S, Hansen J, Mendes AC, et al. Citrullinated Peptide Epitope Targets Therapeutic Nanoparticles to Human Neutrophils. Bioconjug Chem. 2019;30(10):2584-2593. doi:10.1021/acs.bioconjchem.9b00518

[2]Khatri S, Hansen J, Clausen MH, et al. LB0002 A FIRST IN CLASS THERAPEUTIC NANOPARTICLE FOR SPECIFIC TARGETING OF ANTI-CITRULLINATED PROTEIN ANTIBODY AMELIORATES SERUM TRANSFER AND COLLAGEN INDUCED ARTHRITIS. Annals of the Rheumatic Diseases 2020;79:212.

Disclosure of Interests

Sangita Khatri: None declared, Jonas Hansen: None declared, Nadia Pedersen: None declared, Sanne Gram-Nielsen: None declared, Ana Mendes: None declared, Ioannis Chronakis: None declared, Ulrik Keiding: None declared, Bence Réthi: None declared, Mads Hartvig Clausen Shareholder of: affiliated with IBIO TECH ApS, Tue Wenzel Kragstrup Shareholder of: affiliated with IBIO TECH ApS, Speakers bureau: TWK received speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, UCB, and Abbvie., Consultant of: Consultancy fees from Bristol-Myers Squibb and Gilead, Grant/research support from: Received research grant from Gilead, Kira Astakhova Shareholder of: KA is affiliated with iBio tech.

PLATOX: Integrated In Vitro/In Vivo Approach for Screening of Adverse Lung Effects of Graphene-Related 2D Nanomaterials

Graphene-related two-dimensional nanomaterials possess very technically promising characteristics, but gaps exist regarding their potential adverse health effects. Based on their nano-thickness and lateral micron dimensions, nanoplates exhibit particular aerodynamic properties, including respirability. To develop a lung-focused, in vitro/in vivo screening approach for toxicological hazard assessment, various graphene-related nanoplates, i.e., single-layer graphene (SLG), graphene nanoplatelets (GNP), carboxyl graphene, graphene oxide, graphite oxide and Printex 90® (particle reference) were used. Material characterization preceded in vitro (geno)toxicity screening (membrane integrity, metabolic activity, proliferation, DNA damage) with primary rat alveolar macrophages (AM), MRC-5 lung fibroblasts, NR8383 and RAW 264.7 cells. Submerse cell exposure and material-adapted methods indicated material-, cell type-, concentration-, and time-specific effects. SLG and GNP were finally chosen as in vitro biologically active or more inert graphene showed eosinophils in lavage fluid for SLG but not GNP. The subsequent 28-day inhalation study (OECD 412) confirmed a toxic, genotoxic and pro-inflammatory potential for SLG at 3.2 mg/m3 with an in vivo-ranking of lung toxicity: SLG > GNP > Printex 90®. The in vivo ranking finally pointed to AM (lactate dehydrogenase release, DNA damage) as the most predictive in vitro model for the (geno)toxicity screening of graphene nanoplates.

Monitoring Adherence to Asthma Inhalers Using the InspirerMundi App: Analysis of Real-World, Medium-Term Feasibility Studies

Background: Poor medication adherence is a major challenge in asthma and objective assessment of inhaler adherence is needed. InspirerMundi app aims to monitor inhaler adherence while turning it into a positive experience through gamification and social support.

Objective: We assessed the medium-term feasibility of the InspirerMundi app to monitor inhaler adherence in real-world patients with persistent asthma (treated with daily inhaled medication). In addition, we attempted to identify the characteristics of the patients related to higher app use.

Methods: Two real-world multicenter observational studies, with one initial face-to-face visit and a 4-month telephone interview, were conducted in 29 secondary care centers from Portugal. During an initial face-to-face visit, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients took a photo of the medication (inhaler, blister, or others) using the image-based medication detection tool. Medication adherence was calculated as the number of doses taken as a percentage of the number scheduled. Interacting with the app ≥30 days was used as the cut-off for higher app use.

Results: A total of 114 patients {median 20 [percentile 25 to percentile 75 (P25–P75) 16–36] years, 62% adults} were invited, 107 (94%) installed the app and 83 (73%) completed the 4-month interview. Patients interacted with the app for a median of 18 [3–45] days, translated on a median use rate of 15 [3–38]%. Median inhaler adherence assessed through the app was 34 [4–73]% when considering all scheduled inhalations for the study period. Inhaler adherence assessed was not significantly correlated with self-reported estimates. Median adherence for oral and other medication was 41 [6–83]% and 43 [3–73]%, respectively. Patients with higher app use were slightly older (p = 0.012), more frequently taking medication for other health conditions (p = 0.040), and more frequently prescribed long-acting muscarinic antagonists (LAMA, p = 0.024). After 4 months, Control of Allergic Rhinitis and Asthma Test (CARAT) scores improved (p < 0.001), but no differences between patients interacting with the app for 30 days or less were seen.

Conclusions: The InspirerMundi app was feasible to monitor inhaler adherence in patients with persistent asthma. The persistent use of this mHealth technology varies widely. A better understanding of characteristics related to higher app use is still needed before effectiveness studies are undertaken.

Monitoring non-small cell lung cancer progression and treatment response through hyaluronic acid in sputum

We evaluated whether hyaluronan (HA) levels in the sputum could be used as a noninvasive tool to predict progressive disease and treatment response, as detected in a computed tomography scan in non-small cell lung cancer (NSCLC) patients. Sputum samples were collected from 84 patients with histological confirmation of NSCLC, 33 of which were in early-stage and 51 in advanced-stage disease. Patients received systemic chemotherapy (CT) after surgery (n=36), combined CT and immunotherapy (IO) (n=15), or targeted therapy for driver mutation and disease relapse (N=4). The primary end-point was to compare sputum HA levels in two different concentrations of hypertonic saline solution with overall survival (OS) and the secondary and exploratory end-points were radiologic responses to treatment and patient outcome. Higher concentrations of HA in the sputum were significantly associated to factors related to tumor stage, phenotype, response to treatment, and outcome. In the early stage, patients with lower sputum HA levels before treatment achieved a complete tumor response after systemic CT with better progression-free survival (PFS) than those with high HA levels. We also examined the importance of the sputum HA concentration and tumor response in the 51 patients who developed metastatic disease and received CT+IO. Patients with low levels of sputum HA showed a complete tumor response in the computed tomography scan and stable disease after CT+IO treatment, as well as a better PFS than those receiving CT alone. HA levels in sputum of NSCLC patients may serve as a candidate biomarker to detect progressive disease and monitor treatment response in computed tomography scans.

Patient-level costs in intensive care: a case report of a standardized and scalable approach

Background

Intensive care units (ICU) costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs (Value-Based Healthcare).

Methods

Case report of a costing methodology implementation, in a 15-bed ICU, in a public, teaching hospital at Teresina/Piauí-Brazil (as part of a broader initiative, with 10 hospitals from all Brazilian regions). All costs incurred during ICU stay were measured from the hospital perspective, applying absorption costing method, by using a standardized approach and a specific central IT system. The study was carried out from Oct/19-Sep/20, including 613 patients, and a team of 10 researchers working with 4 teams of the local hospital (costs, IT, ICU and managers).

Results

ICU fixed costs (personnel, overheads, energy/water, depreciation, non-tracked drugs/medical materials), were divided by service capacity (total bed-hours) for calculation of the costs/minute. Costs were then allocated in the patient level multiplying costs/minute by the ICU length of stay. Variable costs (lab/image tests, transfusions, hemodialysis, and traceable medical materials/drugs) were directly allocated, multiplying the unit cost by the volume consumed per patient. A mini-survey applied 1-year after showed that both cost researchers and hospital staff agreed on the main challenges in measuring patient-level costs (fragmented process; fixed costs available only at the hospital level; lack of control on cost-drivers; indirect costs not considered; any reference for lab/image costs) and that the approach was sufficient to overcome them. The local team also reported increased awareness about the importance of patient-level costs after the experience.

Conclusions

The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Key messages

ICU costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs. The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Determinants of the Use of Health and Fitness Mobile Apps by Patients With Asthma: Secondary Analysis of Observational Studies

Background

Health and fitness apps have potential benefits to improve self-management and disease control among patients with asthma. However, inconsistent use rates have been reported across studies, regions, and health systems. A better understanding of the characteristics of users and nonusers is critical to design solutions that are effectively integrated in patients’ daily lives, and to ensure that these equitably reach out to different groups of patients, thus improving rather than entrenching health inequities.

Objective

This study aimed to evaluate the use of general health and fitness apps by patients with asthma and to identify determinants of usage.

Methods

A secondary analysis of the INSPIRERS observational studies was conducted using data from face-to-face visits. Patients with a diagnosis of asthma were included between November 2017 and August 2020. Individual-level data were collected, including age, gender, marital status, educational level, health status, presence of anxiety and depression, postcode, socioeconomic level, digital literacy, use of health services, and use of health and fitness apps. Multivariate logistic regression was used to model the probability of being a health and fitness app user. Statistical analysis was performed in R.

Results

A total of 526 patients attended a face-to-face visit in the 49 recruiting centers and 514 had complete data. Most participants were ≤40 years old (66.4%), had at least 10 years of education (57.4%), and were in the 3 higher quintiles of the socioeconomic deprivation index (70.1%). The majority reported an overall good health status (visual analogue scale [VAS] score>70 in 93.1%) and the prevalence of anxiety and depression was 34.3% and 11.9%, respectively. The proportion of participants who reported using health and fitness mobile apps was 41.1% (n=211). Multivariate models revealed that single individuals and those with more than 10 years of education are more likely to use health and fitness mobile apps (adjusted odds ratio [aOR] 2.22, 95%CI 1.05-4.75 and aOR 1.95, 95%CI 1.12-3.45, respectively). Higher digital literacy scores were also associated with higher odds of being a user of health and fitness apps, with participants in the second, third, and fourth quartiles reporting aORs of 6.74 (95%CI 2.90-17.40), 10.30 (95%CI 4.28-27.56), and 11.52 (95%CI 4.78-30.87), respectively. Participants with depression symptoms had lower odds of using health and fitness apps (aOR 0.32, 95%CI 0.12-0.83).

Conclusions

A better understanding of the barriers and enhancers of app use among patients with lower education, lower digital literacy, or depressive symptoms is key to design tailored interventions to ensure a sustained and equitable use of these technologies. Future studies should also assess users’ general health-seeking behavior and their interest and concerns specifically about digital tools. These factors may impact both initial engagement and sustained use.

Cryptococcus bacillisporus causing cryptococcoma of the beak of an African grey parrot (Psittacus erithacus), Portugal

We report a severe case of rhinothecal cryptococcoma in a 13-year-old female African Grey Parrot (Psittacus erithacus). The bird was born and bred in captivity in Portugal. The beak was deformed and showed several round soft masses, and microscopic examination revealed the presence of cells suggestive for Cryptococcus. Phenotypic and molecular analyses identified the obtained yeast culture as C. bacillisporus (AFLP5/VGIII). By phylogenetic analysis the parrot strain clustered with clinical C. bacillisporus strains from Mexico.

Feasibility and Acceptability of an Asthma App to Monitor Medication Adherence: Mixed Methods Study

BACKGROUND

Poor medication adherence is a major challenge in asthma, and objective assessment of inhaler adherence is needed. The InspirerMundi app aims to monitor adherence while providing a positive experience through gamification and social support.

OBJECTIVE

This study aimed to evaluate the feasibility and acceptability of the InspirerMundi app to monitor medication adherence in adolescents and adults with persistent asthma (treated with daily inhaled medication).

METHODS

A 1-month mixed method multicenter observational study was conducted in 26 secondary care centers from Portugal and Spain. During an initial face-to-face visit, physicians reported patients' asthma therapeutic plan in a structured questionnaire. During the visits, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients registered the intake (inhaler, blister, or other drug formulation) by using the image-based medication detection tool. At 1 month, patients were interviewed by phone, and app satisfaction was assessed on a 1 (low) to 5 (high) scale. Patients were also asked to point out the most and least preferred app features and make suggestions for future app improvements.

RESULTS

A total of 107 patients (median 27 [P25-P75 14-40] years) were invited, 92.5% (99/107) installed the app, and 73.8% (79/107) completed the 1-month interview. Patients interacted with the app a median of 9 (P25-P75 1-24) days. At least one medication was registered in the app by 78% (77/99) of patients. A total of 53% (52/99) of participants registered all prescribed inhalers, and 34% (34/99) registered the complete asthma therapeutic plan. Median medication adherence was 75% (P25-P75 25%-90%) for inhalers and 82% (P25-P75 50%-94%) for other drug formulations. Patients were globally satisfied with the app, with 75% (59/79) scoring ≥4,; adherence monitoring, symptom monitoring, and gamification features being the most highly scored components; and the medication detection tool among the lowest scored. A total of 53% (42/79) of the patients stated that the app had motivated them to improve adherence to inhaled medication and 77% (61/79) would recommend the app to other patients. Patient feedback was reflected in 4 major themes: medication-related features (67/79, 85%), gamification and social network (33/79, 42%), symptom monitoring and physician communication (21/79, 27%), and other aspects (16/79, 20%).

CONCLUSIONS

The InspirerMundi app was feasible and acceptable to monitor medication adherence in patients with asthma. Based on patient feedback and to increase the registering of medications, the therapeutic plan registration and medication detection tool were redesigned. Our results highlight the importance of patient participation to produce a patient-centered and engaging mHealth asthma app.

Decidual NK cell-derived conditioned medium from miscarriages affects endometrial stromal cell decidualisation: endocannabinoid anandamide and tumour necrosis factor-α crosstalk

STUDY QUESTION

What are the effects of endocannabinoid anandamide (AEA) in uterine natural killer (unK) cells from miscarriage decidua, regarding their cytokine profile and endometrial stromal cell (ESC) crosstalk?

SUMMARY ANSWER

uNK-conditioned media from miscarriage samples present high TNF-α levels which inhibit ESC decidualisation.

WHAT IS KNOWN ALREADY

AEA plasma levels are higher in women who have suffered a miscarriage. Moreover, AEA inhibits ESC proliferation and differentiation, although the levels and impact on the uNK cell cytokine profile at the feto-maternal interface remain elusive.

STUDY DESIGN, SIZE, DURATION

This laboratory-based study used human primary uNK cells which were isolated from first-trimester decidua (gestational age, 5-12 weeks) derived from 8 women with elective pregnancy termination and 18 women who suffered a miscarriage.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The first-trimester placental tissues were assayed for AEA levels by UPLC-MS/MS and respective enzymatic profile by western blot. The uNK cells were isolated and maintained in culture. The expression of angiogenic markers in uNK cells was examined by quantitative PCR (qPCR). The uNK-conditioned medium was analysed for IFN-γ, TNF-α and IL-10 production by enzyme-linked immunosorbent assay, and the impact on ESC differentiation was assessed by measuring decidual markers Prl, Igfbp-1 and Fox01 mRNA expression using qPCR.

MAIN RESULTS AND THE ROLE OF CHANCE

AEA levels were higher in miscarriage decidua compared with decidua from elective terminations. The uNK cell-conditioned medium from the miscarriage samples exhibited high TNF-α levels and interfered with the decidualisation of ESCs. Exacerbated inflammation and elevated TNF-α levels at the feto-maternal interface may trigger AEA signalling pathways that, in turn, may impact decidualisation and the angiogenic ability of uNK cells.

LARGE-SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Primary uNK cell responses are based on a simple in vitro model. Thus, in complex microenvironments, such as the feto-maternal interface, the mechanisms may not be exactly the same. Also, the inflammatory events of miscarriage that, in this study, have happened prior to processing of the samples may cause different responses to that observed. In addition, the magnitude of the inflammatory response, required to trigger the AEA pathways that impact decidualisation and the uNK angiogenic ability in vivo, is still unclear.

WIDER IMPLICATIONS OF THE FINDINGS

The endocannabinoid AEA is a modulator of reproductive competence. AEA not only may contribute to neuroendocrine homeostasis but also can take part in uterine changes occurring during early pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

The work was supported by UID/MULTI/04378/2019 with funding from Fundação para a Ciência e a Tecnologia (FCT)/MCTES through national funds and PORTUGAL 2020 Partnership Agreement, NORTE-01-0145-FEDER-000024. S.C. Cunha acknowledges FCT for the IF/01616/2015 contract. There are no conflicts of interest.

The Biological Assessment and Rehabilitation of the World's Rivers: An Overview

The biological assessment of rivers i.e., their assessment through use of aquatic assemblages, integrates the effects of multiple-stressors on these systems over time and is essential to evaluate ecosystem condition and establish recovery measures. It has been undertaken in many countries since the 1990s, but not globally. And where national or multi-national monitoring networks have gathered large amounts of data, the poor water body classifications have not necessarily resulted in the rehabilitation of rivers. Thus, here we aimed to identify major gaps in the biological assessment and rehabilitation of rivers worldwide by focusing on the best examples in Asia, Europe, Oceania, and North, Central, and South America. Our study showed that it is not possible so far to draw a world map of the ecological quality of rivers. Biological assessment of rivers and streams is only implemented officially nation-wide and regularly in the European Union, Japan, Republic of Korea, South Africa, and the USA. In Australia, Canada, China, New Zealand, and Singapore it has been implemented officially at the state/province level (in some cases using common protocols) or in major catchments or even only once at the national level to define reference conditions (Australia). In other cases, biological monitoring is driven by a specific problem, impact assessments, water licenses, or the need to rehabilitate a river or a river section (as in Brazil, South Korea, China, Canada, Japan, Australia). In some countries monitoring programs have only been explored by research teams mostly at the catchment or local level (e.g., Brazil, Mexico, Chile, China, India, Malaysia, Thailand, Vietnam) or implemented by citizen science groups (e.g., Southern Africa, Gambia, East Africa, Australia, Brazil, Canada). The existing large-extent assessments show a striking loss of biodiversity in the last 2-3 decades in Japanese and New Zealand rivers (e.g., 42% and 70% of fish species threatened or endangered, respectively). A poor condition (below Good condition) exists in 25% of South Korean rivers, half of the European water bodies, and 44% of USA rivers, while in Australia 30% of the reaches sampled were significantly impaired in 2006. Regarding river rehabilitation, the greatest implementation has occurred in North America, Australia, Northern Europe, Japan, Singapore, and the Republic of Korea. Most rehabilitation measures have been related to improving water quality and river connectivity for fish or the improvement of riparian vegetation. The limited extent of most rehabilitation measures (i.e., not considering the entire catchment) often constrains the improvement of biological condition. Yet, many rehabilitation projects also lack pre-and/or post-monitoring of ecological condition, which prevents assessing the success and shortcomings of the recovery measures. Economic constraints are the most cited limitation for implementing monitoring programs and rehabilitation actions, followed by technical limitations, limited knowledge of the fauna and flora and their life-history traits (especially in Africa, South America and Mexico), and poor awareness by decision-makers. On the other hand, citizen involvement is recognized as key to the success and sustainability of rehabilitation projects. Thus, establishing rehabilitation needs, defining clear goals, tracking progress towards achieving them, and involving local populations and stakeholders are key recommendations for rehabilitation projects (Table 1). Large-extent and long-term monitoring programs are also essential to provide a realistic overview of the condition of rivers worldwide. Soon, the use of DNA biological samples and eDNA to investigate aquatic diversity could contribute to reducing costs and thus increase monitoring efforts and a more complete assessment of biodiversity. Finally, we propose developing transcontinental teams to elaborate and improve technical guidelines for implementing biological monitoring programs and river rehabilitation and establishing common financial and technical frameworks for managing international catchments. We also recommend providing such expert teams through the United Nations Environment Program to aid the extension of biomonitoring, bioassessment, and river rehabilitation knowledge globally.

Profiling Persistent Asthma Phenotypes in Adolescents: A Longitudinal Diagnostic Evaluation from the INSPIRERS Studies

We aimed to identify persistent asthma phenotypes among adolescents and to evaluate longitudinally asthma-related outcomes across phenotypes. Adolescents (13–17 years) from the prospective, observational, and multicenter INSPIRERS studies, conducted in Portugal and Spain, were included (n = 162). Latent class analysis was applied to demographic, environmental, and clinical variables, collected at a baseline medical visit. Longitudinal differences in clinical variables were assessed at a 4-month follow-up telephone contact (n = 128). Three classes/phenotypes of persistent asthma were identified. Adolescents in class 1 (n = 87) were highly symptomatic at baseline and presented the highest number of unscheduled healthcare visits per month and exacerbations per month, both at baseline and follow-up. Class 2 (n = 32) was characterized by female predominance, more frequent obesity, and uncontrolled upper/lower airways symptoms at baseline. At follow-up, there was a significant increase in the proportion of controlled lower airway symptoms (p < 0.001). Class 3 (n = 43) included mostly males with controlled lower airways symptoms; at follow-up, while keeping symptom control, there was a significant increase in exacerbations/month (p = 0.015). We have identified distinct phenotypes of persistent asthma in adolescents with different patterns in longitudinal asthma-related outcomes, supporting the importance of profiling asthma phenotypes in predicting disease outcomes that might inform targeted interventions and reduce future risk.

Acute abdomen as atypical manifestation of chikungunya

INTRODUCTION: Chikungunya fever is an arbovirus caused by the chikungunya virus (CHIKV). It is one of the main differential diagnoses of dengue, due to characteristic fever and arthralgia. CASE REPORT: An 8-year-old Black male patient had a history of abdominal pain associated with daily fever, odynophagia and asthenia. It evolved over the days with myalgia and polyarthralgia. He was then admitted for investigation. Maintained clinical worsening with persistent fever and increased abdominal pain. After 8 days of hospitalization showed signs of intestinal perforation and septic shock. After surgery and stabilization, he underwent serology and confirmed CHIKV infection by Elisa. DISCUSSION: Most individuals infected with the chikungunya virus develop symptomatic infection (70%). High values compared to other arboviruses. The signs and symptoms are clinically similar to those of dengue fever - acute onset fever, arthralgia and myalgia, headache, nausea, fatigue and rash. Some cases may develop atypically, characterized by the appearance of signs of severity or by presenting less frequent clinical manifestations, such as those in this case. The frequency of severe frames is 0.3%. CONCLUSION: Less common manifestations may occur, and pediatricians should be alert and consider CHIKV infection as a differential diagnosis.

Data integration for infrastructure asset management in small to medium-sized water utilities

Water utilities collect, store and manage vast data sets using many information systems (IS). For infrastructure asset management (IAM) planning those data need to be processed and transformed into information. However, information management efficiency often falls short of desired results. This happens particularly in municipalities where management is structured according to local government models. Along with the existing IS at the utilities' disposal, engineers and managers take their decisions based on information that is often incomplete, inaccurate or out-of-date. One of the main challenges faced by asset managers is integrating the several, often conflicting, sources of information available on the infrastructure, its condition and performance, and the various predictive analyses that can assist in prioritizing projects or interventions. This paper presents an overview of the IS used by Portuguese water utilities and discusses how data from different IS can be integrated in order to support IAM.

The arrival of a red invasive seaweed to a nutrient over-enriched estuary increases the spatial extent of macroalgal blooms

The red seaweed Agarophyton vermiculophyllum is an invasive species native to the north-west Pacific, which has proliferated in temperate estuaries of Europe, North America and Africa. Combining molecular identification tools, historical satellite imagery and one-year seasonal monitoring of biomass and environmental conditions, the presence of A. vermiculophyllum was confirmed, and the invasion was assessed and reconstructed. The analysis of satellite imagery identified the first bloom in 2014 and revealed that A. vermiculophyllum is capable of thriving in areas, where native bloom-forming species cannot, increasing the size of blooms (ca. 10%). The high biomass found during the peak bloom (>2 kg m^-2) and the observation of anoxic events indicated deleterious effects. The monitoring of environmental conditions and biomass variability suggests an essential role of light, temperature and phosphorous in bloom development. The introduction of this species could be considered a threat for local biodiversity and ecosystem functioning in a global change context.

AB0983 LIPID METABOLISM AND DISEASE ACTIVITY IN JSLE PATIENTS

Background:

Systemic lupus erythematosus (SLE) is an autoimmune systemic disease associated with premature atherosclerosis. Risk factors include dyslipoproteinemia, inflammation, oxidized low-density lipoprotein (LDL), hyperhomocysteinemia and antiphospholipid antibodies. Hyperlipidemic condition is being reported to promote the production of proinflammatory cytokines such as IL-1β, IL-6, and IL-27 and lowering blood lipid levels improves the disease. Oxidative stress is elevated, mainly due to mitochondrial dysfunction, further disrupting lipid metabolism. Some drugs also have an impact on lipid profile, such as chronic steroid use, which worsens LDL, HDL, and TG levels.

Objectives:

To assess the relationship between lipid profile and disease activity in juvenile SLE (jSLE) patients.

Methods:

Retrospective study of jSLE patients, fulfilling both 2012 and 2019 EULAR/ACR classification criteria for SLE. Juvenile-onset was defined as age at diagnosis <18 years. Demographics and clinical characteristics were collected. To evaluate the activity of jSLE, the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used. Statistical analysis was performed with SPSS®. Spearman’s rank non-parametric test or Pearson’s parametric test were used to assess the bivariate correlation for inflammatory and metabolic variables. P value <0.05 was considered significant for all the statistical tests.

Results:

35 patients were included, with current median (min-max) age of 22 (16-35) years, mean (SD) age of diagnosis of 15.8 (2.4) years; 91.4%female. Median ESR was 19 (2-75) mm/h, CRP 1.65 (0.1-9.6) mg/L, albumin 41.6 (16.7-46.3) g/L, proteinuria 0.2 (0-3) g/dL, leukocyturia 0 (0-1362.7)/uL, erythrocyturia 0 (0-501.9)/uL and anti-double stranded DNA 89.3 (10-800) U/mL. Mean C3 was 102.1 (21.6), C4 17.1 (7.4) mg/dL and creatinine 0.63 (0.1) mg/dL. Median SLEDAI was 2 (0-12). All were ANA positive, 40 % positive for antinucleossome antibodies, 25.7% anti-ribossomal P protein antibody, 11.4% anti-Sm, 8.6% autoantibodies againstβ2-glycoproteinI, 8.6% anti-cardiolipin, 14.3% lupus anticoagulant, 37.1% anti-SSA and 8.6% anti-SSB. Articular manifestations were present in 48.6%, mucocutaneous in 77.1%, haematological in 45.7%, lupus nephritis in 42.9%, serositis in 8.6% and pulmonary interstitial disease in 2.9%. Mean (SD) total cholesterol values (TC) was 165.5 (44.7) mg/dL and LDL 94.5 (29.9) mg/dL. Median high-density lipoprotein was 52 (28-92) and triglycerides (TG) 81.5 (41-253) mg/dL. Median daily prednisolone dose was 5 (0-40) mg. 88.6% were treated with hydroxychloroquine, 31.4% with mychophenolate mophetil and 14.3% with azathioprine. TC was negatively correlated with serum albumin (p=0.043, rho=-378) and positively with SLEDAI (p=0.032; rho= 0.392), proteinuria (p=0.009; rho= 0.469) and leukocyturia (p=0.031; rho= 0.394). A positive correlation was found between LDL and proteinuria (p=0.043; rho= 0.385) and between TG and CRP (p=0.001; rho= 0.575). TG were also positively correlated with prednisolone daily dose (p=0.035; rho= 0.394). Mean LDL was higher in anti-Sm positive patients (p=0.022). No differences were found regarding anti-phospholipids antibodies. Nephritic lupus patients had worse lipid metabolism, but this did not reach statistical significance.

Conclusion:

In out cohort, increased expression of TC, LDL and TGs is associated with disease activity in SLE. As expected, higher doses of prednisolone also correlated with lipid metabolism.

References:

[1]Machado D et al. Lipid profile among girls with systemic lupus erythematosus. Rheumatol Int. 2017 Jan;37(1):43-48

Disclosure of Interests:

None declared

Assessment of indoor air exposure at residential homes: Inhalation dose and lung deposition of PM10, PM2.5 and ultrafine particles among newborn children and their mothers

Accurate assessment of particulate matter (PM) dose and respiratory deposition is essential to better understand the risks of exposure to PM and, consequently, to develop the respective risk-control strategies. In homes, this is especially relevant in regards to ultrafine particles (UFP; <0.1 μm) which origin in these environments is mostly due to indoor sources. Thus, this study aimed to estimate inhalation doses for different PM mass/number size fractions (i.e., PM₁₀, PM_2.5 and UFP) in indoor air of residential homes and to quantify the deposition (total, regional and lobar) in human respiratory tract for both newborn children and mothers. Indoor real-time measurements of PM₁₀, PM_2.5 and UFP were conducted in 65 residential homes situated in Oporto metropolitan area (Portugal). Inhalation doses were estimated based on the physical characteristics of individual subjects and their activity patterns. The multi-path particle dosimetry model was used to quantify age-specific depositions in human respiratory tract. The results showed that 3-month old infants exhibited 4-fold higher inhalation doses than their mothers. PM₁₀ were primarily deposited in the head region (87%), while PM_2.5 and UFP depositions mainly occurred in the pulmonary area (39% and 43%, respectively). Subject age affected the pulmonary region and the total lung deposition; higher deposition being observed among the newborns. Similarly, lower lobes (left lobe: 37% and right lobe: 30%) received higher PM deposition than upper and middle lobes; right lobes lung are prone to be more susceptible to respiratory problems, since asymmetric deposition was observed. Considering that PM-related diseases occur at specific sites of respiratory system, quantification of site-specific particle deposition should be predicted in order to better evidence the respective health outcomes resulting from inhaled PM.

Brucellosis: A rapid risk assessment by a regional outbreak team and its coordinated response with the Directorate-General for Food and Veterinary, North region of Portugal, 2019

We report a Brucella outbreak with seven cases in the Northern Region of Portugal in 2018-2019, associated with the consumption of fresh cheese. This outbreak has implications for risk assessment in Portuguese migrants related to this area, and it is an example of cooperation between public institutions, in a One Health based approach.

Sleep apnea: before and after heart transplant

Sleep disorder breathing is a highly prevalent public health problem and is common among patients with cardio and cerebrovascular diseases. Respiratory events are associated with numerous consequences, such as the hyperadrenergic state, known as a predictor of premature mortality in patients with heart failure. On the other hand, reduced stroke volume is associated with fluid retention in patients with heart failure, leading to changes in the upper airflow dynamics. Whether and how to treat sleep disorder breathing enables chronic cardiovascular consequences to be reversed is not fully established. Few cases are known where sleep disordered breathing diagnosis was made several years before heart transplantation. To better understand how does sleep apnea evolve and to ponder about what is the best treatment approach in this context, is the objective with this case presentation.

Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

OBJECTIVE

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

DESIGN

Baseline data from two prospective multicentre observational studies.

SETTING

29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

PARTICIPANTS

395 patients (≥13 years old) with persistent asthma.

MEASURES

Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV₁) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

RESULTS

High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (r_s=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV₁ ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R²=44%).

CONCLUSION

Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

Sleep disturbances in Parkinson's disease are associated with central parkinsonian pain

Introduction

Sleep disturbances and pain are common non-motor symptoms in Parkinson’s disease (PD). This study aimed to explore the association between these two symptoms in a cohort of patients with PD.

Materials and methods

The Parkinson’s Disease Sleep Scale (PDSS-2) was used to identify sleep disturbances in a series of 229 PD patients. The identification and characterization of pain was performed by a semi-structured interview and by the application of the Ford classification and the Brief Pain Inventory (BPI). The Unified Parkinson’s Disease Rating Scale-III, Hoehn & Yahr (H&Y), and Schwab and England Independence Scale were used to assess motor symptoms and functional independence in off and on conditions. The Hospital Anxiety and Depression Scale (HADS) and SF-36 were applied to screen for anxiety and depression and to evaluate the quality of life. Non-parametric tests were used for group comparisons and logistic regressions were applied to explore predictors of sleep disturbances.

Results

Seventy-five (33%) patients had clinically relevant sleep disturbances (PDSS-2≥18) and 162 patients (71%) reported pain. Of those with pain, 38 (24%) had central parkinsonian pain. PD patients with sleep disturbances experienced more pain and had more severe motor symptoms, lower functional independence, more anxiety and depression symptoms, and worst quality of life. Among patients with pain, central parkinsonian pain was the subtype of pain with the highest odds of sleep disturbances, even when taking into account motor symptoms (H&Y off), motor fluctuations, intensity of pain (BPI), and symptoms of anxiety and depression (HADS).

Conclusions

The association between pain and sleep disturbances in PD appears to be dependent on subtype of pain. The close relationship between central parkinsonian pain and sleep disturbances in PD raises the possibility of common pathophysiological mechanisms. A better understanding of the relationship between sleep disturbances and central parkinsonian pain may contribute to the development of new care strategies in PD patients.

The impact of indoor air quality on respiratory health of older people living in nursing homes: spirometric and exhaled breath condensate assessments

In the Portuguese Geriatric Study of the Health Effects of Indoor Air Quality in Senior Nursing Homes, we aimed to evaluate the impact of indoor air contaminants on the respiratory symptoms and biomarkers in a sample of elderly living in nursing homes. A total of 269 elderly answered a health questionnaire, performed a spirometry and 150 out of these collected an exhaled breath condensate sample for pH and nitrites analysis. The study included the evaluation of indoor chemical and microbiological contaminants. The median age of the participants was 84 (78-87) years and 70.6% were women. The spirometric data indicated the presence of airway obstruction in 14.5% of the sample. Median concentrations of air pollutants did not exceed the existing standards, although increased peak values were observed. In the multivariable analysis, each increment of 100 µg/m³ of total volatile organic compounds was associated with the odds of respiratory infection in the previous three months ( OR̂ =1.05; 95% CI: 1.00-1.09). PM_2.5 concentrations were inversely associated with pH values ( β̂ = -0.04, 95%: -0.06 to -0.01, for each increment of 10 µg/m³). Additionally, a direct and an inverse association were found between total bacteria and FEV₁/FVC and FVC, respectively.

Air pollution: A public health approach for Portugal

At the global level, several epidemiological studies have conclusively pointed out the associations between short-term exposure to air pollution and acute health effects, and long-term exposure with adverse health effects such as premature mortality from severe respiratory and cardiovascular diseases. This study intended to characterize exposures and their adverse health effects. Three independent sets of vectors were analyzed on a nationwide level and annual basis: air pollutant emissions, ambient air concentrations and health indicators of the period 2009 to 2015. The emissions analysis, for the studied pollutants, pointed out the main findings: (i) Lisbon Metropolitan Area presents the most problematic region with regard to the emissions of all the pollutants under study; (ii) the regions of the Alentejo and Algarve showed reduced emissions of the studied pollutants compared to other parts of the country; (iii) Northern regions PM10 concentrations decreased during the two years in analysis. Regarding the analysis of air quality, it was concluded that: (i) regarding ozone, concentration shown a decreasing trend throughout the country; (ii) nitrogen dioxide and particulate matter, concentrations demonstrated an increasing trend in most of the northern part of the country; (iii) the regions of Alentejo and Lisbon Metropolitan Area showed increasing trends for sulfur dioxide and fine particles for the evaluated period. Decreasing trends in mortality associated with cardiovascular and respiratory causes are found mainly in the Alentejo and Algarve regions. In comparison, the North, Central regions, as well as, Lisbon Metropolitan Area exhibited higher mortality values related to this health indicators.

The Portuguese Severe Asthma Registry: Development, Features, and Data Sharing Policies

The Portuguese Severe Asthma Registry (Registo de Asma Grave Portugal, RAG) was developed by an open collaborative network of asthma specialists. RAG collects data from adults and pediatric severe asthma patients that despite treatment optimization and adequate management of comorbidities require step 4/5 treatment according to GINA recommendations. In this paper, we describe the development and implementation of RAG, its features, and data sharing policies. The contents and structure of RAG were defined in a multistep consensus process. A pilot version was pretested and iteratively improved. The selection of data elements for RAG considered other severe asthma registries, aiming at characterizing the patient's clinical status whilst avoiding overloading the standard workflow of the clinical appointment. Features of RAG include automatic assessment of eligibility, easy data input, and exportable data in natural language that can be pasted directly in patients' electronic health record and security features to enable data sharing (among researchers and with other international databases) without compromising patients' confidentiality. RAG is a national web-based disease registry of severe asthma patients, available at asmagrave.pt. It allows prospective clinical data collection, promotes standardized care and collaborative clinical research, and may contribute to inform evidence-based healthcare policies for severe asthma.

The effect of psychosis associated CACNA1C, and its epistasis with ZNF804A, on brain function

CACNA1C-rs1006737 and ZNF804A-rs1344706 polymorphisms are among the most robustly associated with schizophrenia (SCZ) and bipolar disorder (BD), and recently with brain phenotypes. As these patients show abnormal verbal fluency (VF) and related brain activation, we asked whether the latter was affected by these polymorphisms (alone and in interaction)-to better understand how they might induce risk. We recently reported effects on functional VF-related (for ZNF804A-rs1344706) and structural (for both) connectivity. We genotyped and fMRI-scanned 54 SCZ, 40 BD and 80 controls during VF. With SPM, we assessed the main effect of CACNA1C-rs1006737, and its interaction with ZNF804A-rs1344706, and their interaction with diagnosis, on regional brain activation and functional connectivity (psychophysiological interactions-PPI). Using public data, we reported effects of CACNA1C-rs1006737 and diagnosis on brain expression. The CACNA1C-rs1006737 risk allele was associated with increased activation, particularly in the bilateral prefronto-temporal cortex and thalamus; decreased PPI, especially in the left temporal cortex; and gene expression in white matter and the cerebellum. We also found unprecedented evidence for epistasis (interaction between genetic polymorphisms) in the caudate nucleus, thalamus, and cingulate and temporal cortical activation; and CACNA1C up-regulation in SCZ and BD parietal cortices. Some effects were dependent on BD/SCZ diagnosis. All imaging results were whole-brain, voxel-wise, and familywise-error corrected. Our results support evidence implicating CACNA1C and ZNF804A in BD and SCZ, adding novel imaging evidence in clinical populations, and of epistasis-which needs further replication. Further scrutiny of the inherent neurobiological mechanisms may disclose their potential as putative drug targets.