Quadratus Lumborum block as primary anesthetic technique for colostomy procedure: a case report

An elderly patient was admitted to the hospital due to an enterovesical fistula and a terminal colostomy was proposed. The patient had a high anesthetic risk and thus a quadratus lumborum block was chosen as the sole anesthetic technique. This block has been described to provide both somatic and visceral analgesia to the abdomen. In fact, it yielded good anesthetic conditions to perform the procedure and allowed the patient to be hemodynamically stable and comfortable throughout the case. The postoperative period was uneventful.

Exploring the prevalence and antibiotic resistance profile of Klebsiella pneumoniae and Klebsiella oxytoca isolated from clinically ill companion animals from North of Portugal

Klebsiella spp. is an important pathogen in humans and animals and due to the indiscriminate use of antibiotics, its prevalence and antibiotic resistance has increased in companion animals. The main goal of this study was to investigate the prevalence and antibiotic resistance of Klebsiella spp. isolated from clinically ill cats and dogs admitted in veterinary clinics in the North of Portugal. A total of 255 clinical specimens were collected and, after isolation, the identification of Klebsiella strains was performed using the BBL Crystal™ identification system and confirmed by PCR-based sequencing with specific primers. Antibiotic resistance profile was determined through the disc diffusion method. Beta-lactam resistance genes were screened through a multiplex PCR assay. Fifty Klebsiella strains were isolated and, 39 were identified as Klebsiella pneumoniae and 11 as Klebsiella oxytoca. Thirty-one were recovered from dogs and 19 from cats. The Klebsiella isolates were recovered mainly from skin wounds, respiratory tract, and from urine. Fifty percent of K. oxytoca and K. pneumoniae isolates revealed to be Multidrug Resistant (MDR) strains, with most of them positive for the presence of blaTEM-like and blaSHV genes. This data shows that MDR Klebsiella are highly disseminated in companion animals and that extended-spectrum beta-lactamases can be easily found among these isolates. This highlights the potential role of dogs and cats as a reservoir of resistant Klebsiella spp. that have the potential to be transmitted to humans.

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism

The pulmonary thromboembolism may be a life-threatening condition. A hip fracture surgery patient aged >90 years old had a sudden post-operative episode of shock, de-saturation, and reverted cardiac arrest. A point-of-care transthoracic echocardiography (TTE) undertaken by an anesthesiologist revealed inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end-systole, indicating a high ejection fraction in the context of obstructive shock. As such, it revealed signs of pulmonary thromboembolism. Despite the absolute contraindication for thrombolysis and therapeutic hypocoagulation, the treatment was started immediately along with vasopressor support, which was life-saving in this patient. A summary TTE played a pivotal role in our patient's case, helping with the differential diagnosis of the cause of shock.

Should Non-Pharmacological and Non-Surgical Interventions be Used to Manage Neuropathic Pain in Adults With Spinal Cord Injury? - A Systematic Review

Spinal Cord Injury (SCI) results in a permanent or temporary alteration of the motor, sensory and/or autonomic functions, frequently leading to neuropathic pain. To deal with this comorbidity, several non-pharmacological and non-surgical (NP-NS) interventions have been developed. However, their efficacy is still uncertain. The aim of this study was to systematically synthetize the available evidence assessing the efficacy of NP-NS interventions for treating neuropathic pain in people with SCI. Thus, an electronic search was conducted in five databases (Pubmed, Scopus, Cochrane Central, Web of Science and EBSCO) and trials registry databases, in addition to a manual search strategy to retrieve additional records. The review included randomized controlled trials with adults with SCI, in any stage of the condition. Data on the efficacy of the interventions was narratively synthetized. Once the research was completed, of 4853 identified references, 24 were included with a total of 653 participants with SCI and neuropathic pain, mostly male and with paraplegia. These studies investigated the effect of 13 types of NP-NS interventions with different protocols and methodological limitations. Seven different assessment scales were analyzed, with neuropathic pain being the primary outcome in 21 studies. Such high heterogeneity impaired the conduction of meta-analysis for any of the interventions. Although promising results were found regarding analgesic effect of NP-NS on neuropathic pain in people with SCI, it is not yet possible to safely state that these interventions are in fact effective. Further studies with homogeneous protocols and methodological quality are still needed. PERSPECTIVE: This article presents a review of existing studies on the effectiveness of NP-NS interventions in neuropathic pain in SCI. This synthesis could potentially alert and motivate clinicians to develop studies on this topic, so that interventions can be objectively evaluated and recommendations for an evidence-based practice be created.

Acceptance and Commitment Therapy for Psychosis. What’s the evidence?

Introduction

Cognitive behavioural therapy for psychosis as an adjuvant to pharmacological treatment has been been shown to be one of the most effective interventions for schizophrenia with benefits noted in even treatment resistant schizophrenia. Benefits have been mostly registered in the positive symptoms domain of schizophrenia. Acceptance and commitment therapy is a third generation Cognitive-Behavioural Therapy, empirically supported for a range of symptoms and conditions, including psychosis, with quickly increasing data. It targets experiential avoidance, which seems to be closely related with psychopathology. Its ability to also target affective symptoms can be an important advantage in the adjuvant treatment of psychosis.

Objectives

To critically review the evidence of acceptance and commitment therapy in psychosis.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “schizophrenia”, “acceptance and commitment therapy”.

Results

Very few studies have been published on ACT and psychosis, with even less controlled trials and systematic reviews. So far there is convincing evidence for ACT reducing the frequency of hallucinations, increasing the outcomes of traumatic events associated with psychosis and having measurable effects on anxiety and help seeking behaviour.

Conclusions

As Acceptance and Commitment therapy evolves and more evidence arises a new kind of therapy with possible effects on both affective and positive symptoms in schizophrenia can emerge, allowing us to know what works for patients with psychosis and through what mechanisms and permitting the improvement of treatment strategies.

Disclosure

No significant relationships.

AB0067 INTERLEUKIN-1 RECEPTOR ANTAGONIST: RELATION TO CARDIOVASCULAR DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

The interleukin-1 receptor antagonist (IL1-Ra) belongs to the IL-1 family. IL1-Ra has an inhibitory function on the inflammatory reaction consisting of preventing the binding of IL-1α and β to their respective receptors. IL-1, in its different subtypes, has been implicated in the pathogenesis of both rheumatoid arthritis (RA) and cardiovascular disease (CV) in the general population.

Objectives

In the present work we aim to study the relation of IL1-Ra serum levels to RA’s features, and its CV comorbidity and subclinical carotid atheromatosis in a large RA cohort.

Methods

This was a cross-sectional study that included 430 RA patients. A complete panel of clinical and analytical information related to CV disease was collected: CV risk factors, full lipid profile, insulin and C-peptide serum levels, insulin resistance and β-cell function (%B) indexes by Homeostatic Model Assessment (HOMA2). A carotid ultrasound examination was performed to assess carotid intima-media thickness in the common carotid artery and to detect focal plaque in the extracranial carotid tree. Similarly, IL1Ra and IL-6 serum levels were assessed and disease activity indices, extra-articular manifestations and RA therapies were collected. A multivariable regression analysis was performed to determine how IL1Ra serum levels is associated with disease-related characteristics, CV comorbidity and subclinical atheromatosis in RA patients.

Results

Regarding CV risk factors, IL1-Ra serum levels were related with waist circumference (coefficient beta -β- 8 [95% confidence interval -CI- 5-11] pg/ml, p< 0.001) and obesity (body mass index >= 30 kg/m2) (β 169 [95% CI 78-260] pg/ml, p<0.001). After adjusting for confounders, IL1-Ra was related with higher levels of several lipid profile molecules, such as total cholesterol (β 12 [95%CI 2-22] mg/dl, p= 0.023), apolipoprotein A1 (β 13 [95% CI 0.5-25] mg/dl, p=0.042) and apolipoprotein C3 (β 3 [95% CI 2-5] mg/dl, p<0.001). Furthermore, higher IL1-Ra serum levels were associated with pancreatic beta cell dysfunction as measured by HOMA2-%B (β 22 [95%CI 2-42], p=0.031). Disease activity using different scores showed a positive relationship with IL1-Ra after multivariable adjustment: DAS28-ESR (β 60 [95% CI 28-92] pg/ml, p<0.001), DAS28-PCR (β 65 [95%CI 26-104] pg/ml, p=0.001) and CDAI (β 99 [95%CI 3-14] pg/ml, p=0.002). Likewise, ESR (β 2 [95% CI 0.07-5] pg/ml, p=0.044) and IL-6 plasma levels (β 3 [95% CI 1-6] pg/ml, p=0.003) were positively associated with IL1-Ra levels after adjusting for covariates. Hydroxychloroquine use, but not other therapies, was associated with lower IL1-Ra serum levels (β -131 [95% CI -260- -2] pg/ml, p=0.046), independently of confounding variables. No association was found between IL1-Ra and intima-media thickness or carotid plaque.

Conclusion

In RA patients, IL1-Ra serum levels are related to the clinical and biological disease activity, as well as with different CV comorbidities such as dyslipidemia, beta cell dysfunction and obesity. Our findings highlight the beneficial effect that blocking IL-1 activity can have both in the control of RA disease activity and in the management of the CV disease that accompanies the disease.

Acknowledgements

This work was supported by a grant to JC Q-A. from the Fundación Canaria Instituto de Investigación Sanitaria de Canarias, PI19/00012.

Disclosure of Interests

None declared

Electroconvulsive therapy in treatment resistant schizophrenia: Old beacon of hope when nothing else works

Introduction

Electroconvulsive therapy (ECT) is one of the oldest psychiatric treatments used to this day. It is particularly useful in cases of schizophrenia resistant to treatment with antipsychotics. 49% of patients with schizophrenia experience little or no response with one trial of antipsychotics, 71% do not achieve remission and up to 20% of patients are also resistant to clozapine.

Objectives

Description of a clinical case where ECT is used in the treatment of resistant schizophrenia and review of the literature.

Methods

Description of a clinical case. Non systematic review of the literature, searching the terms “treatment resistant”; “schizophrenia”; “ect” in the databases Pubmed, Medline, Cochrane and Uptodate.

Results

Male, 38-year-old patient, diagnosed with schizophrenia for 20 years, with history of multiple hospitalizations, institutionalized for 9 years. Treated with risperidone 50 mg intramuscular fortnightly, clozapine 750 mg daily, aripiprazol 30 mg daily and diazepam 10 mg daily. He presented with increased delusional intensity for a year. Hospitalized for treatment with ECT, submitted to 12 sessions with bitemporal stimuli, with effective convulsions. MoCA, PANSS and BPRS were applied before and after treatment, with an increase of 25% in MoCA and a decrease of 47.3% and 57.9% respectively, in the psychotic symptoms scales.

Conclusions

We present a case of schizophrenia resistant to treatment with multiple antipsychotics, including clozapine. ECT was used, with clinically demonstrated efficacy. In the future, it might be interesting to study in detail the mechanism of action of this treatment with the goal of deepening the knowledge of the neurobiology of schizophrenia.

Disclosure

No significant relationships.

Electroconvulsive therapy for Patients with Intellectual Disability. When and how?

Introduction

Intelectual disability is an illness with an important burden on patients and caregivers, especially when severe and when comorbidities such as other psychiatric disorders are present. There are case reports of treatment resistant self-aggression, agitation, epilepsy, catatonia and psychosis successfully treated with electroconvulsive therapy although controlled studies were not found.

Objectives

This work reviewed the current evidence for the use of electroconvulsive therapy in the management of patients with intellectual disability as well as its ethical and methodological implications.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 20 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “electroconvulsive therapy”, “intellectual disability”.

Results

Patients with intellectual disability can have incapacitating comorbilities that greatly impair quality of life, and may require withdrawl from the community Treatment often differs from the general population as psychotropic medication can worsen other comorbilities. Electroconvulsive therapy can be a relevant treatment option for comorbidities in this population due to its safety profile. Ethical considerations should be taken into account, especially with non-verbal patients or when adequate representatives have not been chosen or cannot be reached. Different legal challenges may be present on different countries.

Conclusions

Electroconvulsive therapy and intellectual disability share the burdens of heavy stigma and low investment. Intellectual disability and it’s commorbidites present both a diagnostic and treatment challenge. Electroconvulsive therapy is an important weapon capable of restoring patients to their families and diminishing the burdens of caregivers and healthcare systems

Disclosure

No significant relationships.

POS0003 DEVELOPMENT AND VALIDATION OF A DISEASE SPECIFIC PATIENT REPORTED OUTCOME FOR GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is caused by inflammation of the blood vessels of the head and neck; patients can present with cranial, ocular or large vessel vasculitis involvement. Treatment is with glucocorticoids, steroid sparing agents and biologics to control inflammation and protect sight.

Objectives

The aim of this study was to produce a validated disease specific PROM for patients with GCA, to capture the impact of GCA and its treatment on health-related quality of life.

Methods

Patients with clinician- confirmed GCA from the UK, either diagnosed in the last three years or with a flare in the last year, were included in the survey. A longlist of 40 candidate questionnaire items, each with a 5-point Likert scale, had previously been developed, based on a qualitative study with patients from the UK and Australia [1]. In this cross-sectional survey, patients completed the 40-item draft GCA-PROM alongside EQ5D-5L, CAT-PRO5 and self-report of GCA disease activity. Rasch and factor analysis were used in an iterative manner to determine the underlying construct validity of the new PROM. Items were fitted to the Rasch model to determine its construct validity, reliability, unidimensionality and statistical sufficiency of the total score from the scale. Factor analysis was used to establishing factor structure. Item reduction decisions were be based on clinical importance, lack of fit to the Rasch model, and redundancy detected during principal component analysis. External validity was tested by comparing the scores of the newly validated GCA-PROM (i) in participants who self-identify as having ‘active disease’ versus patients ‘in remission’ (known groups validity) (ii) with scores derived from EQ5D-5L and CAT-PRO5 (convergent validity).

Results

The survey included 428 patients; 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. 285 (67%) of participants were female with a mean age (SD) of 74.2 (7.2). 167 (39%) temporal artery biopsies and 177 (41.4%) temporal artery ultrasounds, and 51 (11.9%) Positron Emission Tomography and Computed Tomography (PET-CT)s were reported as positive. 108 (25%) received second-line immunosuppressants, and 34 (7.9%) anti-IL6 therapy. Active disease was reported in 197 (46%). Four factors (domains) were identified after deletion of 10 redundant items: Acute symptoms (8 items), Activities of daily living (7 items), Psychological (7 items) and Participation (8 items). The four domains were analysed as ‘super-items’ and shown to fit the Rasch model. The overall scale had an adequate fit to the Rasch model: X2 = 25.219, DF=24, p=0.394 including reliability PSI=0.828. The raw-to-linear transformation scale was calibrated to enable parametric analyses if desired. Each domain was shown to have known-groups validity (p<0.001 patients reporting active versus inactive disease) and correlation with EQ5D-5L and CAT-PRO5 (Rs) ranging between 0.4.42 and 0.778.

Conclusion

The GCA-PROM is a new patient reported outcome measure for patients with GCA which demonstrates good internal and external validity.

References

[1]Robson JC, Almeida C, Dawson J, Bromhead A, Dures E, Guly C, Hoon E, Mackie S, Ndosi M, Pauling J, Hill C. Patient perceptions of health-related quality of life in giant cell arteritis; international development of a disease-specific Patient-Reported Outcome Measure. Rheumatology (Oxford). 2021:keab076. http://dx.doi.org/10.1093/rheumatology/keab076

Disclosure of Interests

Joanna Robson Speakers bureau: Vifor Pharma EULAR 2021 Symposium, Consultant of: Vifor Pharma Advisory board 2021, Grant/research support from: Vifor Pharma Steroid PRO grant, Celia Almeida: None declared, Jill Dawson: None declared, Emma Dures: None declared, Rosemary Greenwood: None declared, Catherine Guly: None declared, Sarah Mackie Speakers bureau: Roche/Chugai Educational talk on GCA., Consultant of: Roche/Chugai

Sanofi

Abbvie (2021-)

AstraZeneca (2021-), Grant/research support from: Vifor Pharma Steroid PRO 2020

Vifor Pharma GTI Validation 2020

Roche GCA Tocilizumab Registry 2019

, Alison Bromhead: None declared, Steve Stern: None declared, Mwidimi Ndosi: None declared

Shame and psychopathology. Its role in the genesis and perpetuation of different disorders

Introduction

Shame is a profound negative emotion that can sometimes be cover up by guilt and remain undiagnosed. Shame and guilt have been described as self-conscious and moral emotions as they both involve self-evaluation and lay a role in facilitating moral conduct. They derive from the notion of responsibility, but some authors suggest that while guilt focuses only on the act at hand shame focuses on the one executing it. The self is the object.

Objectives

To review the literature on shame and its role in different disorders both as a causing agent and as a perpetuating agent

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 20 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “shame”, “psychopathology.

Results

Since shame globally decreases self-esteem and is an awareness of personal flaws it can lead to the feelings of helplessness and the development or worsening of mental disorders. As such it is no wonder to find shame being studied in many different forms, more and less structured with important connections being made with social anxiety, eating disorders, dysmorphic disorders, personality disorders and bereavement.

Conclusions

Shame’s role, independently from guilt can have an impact on both the genesis and perpetuation of mental disorders. Its study can uncover missing links between different types of experiences and the pathological reactions that may subsequently follow.

Disclosure

No significant relationships.

POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

Electroconvulsive therapy for Depression in Anorexia Nervosa. A review

Introduction

Anorexia nervosa has an important burden on both patients and families, with important comorbidities such as depression and obsessive symptoms. These are more resistant to pharmacological treatment than in non-anorexia patients, due to both biological and psychological mechanisms. Electroconvulsive therapy is the best available therapy for treatment resistant depression making it a treatment to consider in treatment resistant depression in anorexia though only case reports exist.

Objectives

To review the current evidence for electroconvulsive therapy of depression in patients with anorexia nervosa as well as it’s ethical challenges

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “electroconvulsive therapy”, “anorexia nervosa”.

Results

Electroconvulsive therapy in anorexia has no controlled trials with mostly case reports available on scientific databases. It presents important challenges due to patient age, medical status and ethical challenges. Even less evidence exist for electroconvulsive therapy in children and adolescents than for adults, anorexia can complicate medical status presenting an anesthetic and life-support challenge and it’s egosyntonicity can place a legal and ethical challenge when patient refuses treatment.

Conclusions

Anorexia has a dramatic burden on patients and families affected, with integrated evidence-based treatment being necessary both for treating the current episode and for remission prevention. Case-reports show that electroconvulsive therapy can play a role on treatment resistant depression in anorexia.

Disclosure

No significant relationships.

Single continuous erector spinae plane block for multiple rib, clavicle, and scapula fractures: A case report

The aim of this study is to describe the ability of a continuous erector spinae plane (ESP) block to provide analgesia in an extended territory (brachial plexus and thoracic nerves) with a single catheter. A continuous ESP block at T4 was performed in a 74-year-old man, two days after trauma involving clavicle, scapula, and multiple posterior rib fractures (first to ninth). The technique was maintained for 12 days and provided effective analgesia not only to the thoracic region but also the scapula and clavicle area (C5–T12 dermatomes). Concomitant respiratory insufficiency was ameliorated, which helped to avoid mechanical ventilation and intensive care unit admission. Moreover, this analgesia technique promoted patient's ambulation. ESP block, as an alternative to a thoracic epidural, is a more straightforward and safer procedure than paravertebral block (PVB). To obtain an extensive dermatome block using PVB, more than one paravertebral catheter would be necessary. Extensive cephalad–caudad spread of the PVB is primarily related to analgesia due to the concomitant epidural spread. PVB frequently causes bilateral block and may produce significant motor or sympathetic block. Additionally, proximal extension of the block under the erector spinae muscle fascia can provide a significant extension of the block to the cervical region, which allows brachial plexus block (cervical plexus block was not observed clinically). This is a unique feature of ESP block, as there is no communication between adjacent paravertebral levels in the cervical region that could allow the same pattern of analgesia using PVB.

Non-ST elevation myocardial infarction in patients with previous CABG: what is the best treatment option?

Background

Current European Society of Cardiology guidelines recommend an invasive strategy (IS) for the treatment of non-ST elevation myocardial infarction (NSTEMI) patients, but the clinical trials that support this recommendations included only a few patients with previous coronary artery bypass graft (CABG).

Purpose

To characterize NSTEMI patients with previous CABG who underwent medical and invasive management and to evaluate the prognostic impact of the type of strategy used.

Methods

Retrospective analysis of a cohort of patients from a multicenter national registry diagnosed with NSTEMI with a previous history of CABG between 2010 and 2021. Patient's baseline demographics, medical history and in-hospital management data was collected. Outcomes of in-hospital and six months follow-up all-cause mortality were accessed.

Results

A total of 890 patients were included in the analysis. Of these, 470 were medically managed (MM) – this group included 249 patients (53.1%) who underwent coronary angiography but did not perform any further revascularization. The remaining 420 underwent an invasive strategy (IS) and performed additional revascularization, mainly percutaneous (only 1 patient submitted to reCABG). Mean age was similar (MM 72±10 vs IS 71±10 years, p=0.147) and most patients were male (MM 81.5% vs IS 83.8%, p=0.362). MM patients had more chronic kidney disease (16.7% vs 9.9%, p=0.003), peripheral artery disease (20.5% vs 15.0%, p=0.003) and heart failure (20.5% vs 11.9%, p&lt;0.001). Main presenting symptom was chest pain in both groups, however it was more frequent in the IS group (89.4% vs 94.5%, p=0.006) and dyspnea in the MM patients (6.3% vs 3.1%). Mean left ventricle ejection fraction was similar between groups (MM 49±12% vs IS 50±11%, p=0.290). Although the GRACE risk score was available for only 124 patients, high risk patients (GRACE score &gt;140) were equally distributed among the two groups (55.9% vs 48.2%, p=0.395). An IS was associated with significant lower in-hospital mortality (4.5% vs 1.7%, OR 0.37, 95% CI 0.15–0.87, p=0.018). At six months follow-up an IS was also associated with lower mortality (6.6% vs 2.4%, HR 0.18, 95% CI 0.06–0.52, p=0.002), even after adjusting for the baseline differences (HR 0.41, 95% CI 0.20–0.85, p=0.016).

Conclusions

In this cohort of patients with NSTEMI and previous CABG, an IS was linked to better outcomes during hospitalization and during six months follow-up. Randomized clinical trials are needed to address this issue.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Early and long term prognostic accuracy of 4 acute pulmonary embolism mortality risk scores

Background

Acute pulmonary embolism (PE) is a frequent condition associated with significant morbidity and mortality. Multiple scores have been developed and validated to predict 30-day mortality risk, however accurate prognostic assessment remains a challenge in clinical practice.

Purpose

To compare the performance of PESI, simplified PESI, Hestia and Bova scores in predicting in-hospital, 30-day and 1-year mortality risk for acute PE.

Methods

We retrospectively assessed consecutive patients from a single center registry who were hospitalized with acute PE between January 2017 and October 2020. Discriminative power of each score was assessed by receiver operating characteristic curve analysis. Charlson comorbidity index (CCI) was also assessed for comparison.

Results

A total of 131 patients with a mean age of 67.6±15.3 years were included with a mean follow-up of 46.3±17.7 months. Thirty-six patients (27.5%) had a recent hospitalization or major surgery and 26 (19.8%) a medical history of cancer. Besides anticoagulation, 7 patients (5.3%) underwent fibrinolysis. Overall in-hospital mortality was 8.4%, 30-day mortality 12.2% and 1-year mortality 19.8%. All acute PE scores, except Bova score, were significantly higher in those patients who died during hospitalization and on 30-day and 1-year follow-up. CCI was also higher in those patients. Discriminative power for in-hospital mortality was higher for PESI (c-statistic 0.84, 95% CI 0.74–0.93, p=0.002), followed by sPESI (c-statistic 0.77, 95% CI 0.65–0.90, p=0.010) and Hestia (c-statistic 0.77, 95% CI 0.61–0.92, p=0.011). The Bova score showed a poor discriminative power for prediction of in-hospital mortality (c-statistic 0.61, 95% CI 0.43–0.78, p=0.325). For 30-day and 1-year mortality PESI score still maintained the best performance with acceptable discriminative power (c-statistic 0.73, 95% CI 0.61–0.85, p=0.007 for 30-day mortality; c-statistic 0.80, 95% CI 0.71–0.89, p&lt;0.0001 for 1-year mortality). However at longer follow-up CCI had a better performance to predict worse outcomes (c-statistic 0.79, 95% CI 0.65–0.92, p=0.001 for 30-day mortality; c-statistic 0.83, 95% CI 0.74–0.92, p&lt;0.0001 for 1-year mortality).

Conclusions

All scores, except Bova score, showed overall good performance in stratifying mortality for acute PE, however PESI score performed better in this population particularly at shorter follow-up. At longer follow-up, although PESI score maintained an acceptable performance, comorbidities seem to play a bigger role. The different performance of multiple scores highlights the complexity of this condition.

Funding Acknowledgement

Type of funding sources: None. ROC curves for mortality risk scores

P–042 Impact of semen parameters, sperm DNA fragmentation and sperm aneuploidy in male infertility

Study question

Should sperm aneuploidies and sperm DNA fragmentation (sDNAfrag) be included as valid tests in the routine investigation of male infertility?

Summary answer

Sperm DNA fragmentation was associated with male age, oligozoospermia (OZ), oligoteratozoospermia (OT), astenoteratozoospermia (AT) and oligoastenoteratozoospermia (OAT). Sperm aneuploidies were associated with OT and OAT.

What is known already

Semen parameters assist male infertility diagnosis and treatment, but sDNAfrag and aneuploidy analysis could add useful information, as abnormal values compromise fertility. To include these tests in the routine diagnosis it should be determined if behave as informative parameter and add information regarding the fertility status. For that, further studies comparing these tests to semen parameters are needed, since previous results are not consensual. Additionally, standardization of a sDNAfrag cut-off is needed, as different sample sizes and techniques originate distinct results. Also, until a standardization of the protocol is missing, a cut-off value should be defined for each laboratory.

Study design, size, duration

A retrospective and prospective investigation was performed, within a 12 years period (April 2007-December 2019). A total of 835 infertile males with a normal karyotype (46,XY) were included. Karyotyping and evaluation of sDNAfrag and sperm aneuploidies were made at a public Genetic unit. All normozoospermic (NZ) patients with a born child and patients whose infertility treatments were done due to female factors were selected from our database and used as controls (60 individuals).

Participants/materials, setting, methods

Semen analysis followed WHO–2010 guidelines. sDNAfrag was evaluated using the TUNEL assay. Sperm aneuploidies were detected using FISH (chromosomes 13, 18, 21, X, Y). Several tests were applied: correlations for linear associations between numerical variables, ANOVA for comparisons between means, Dunn-test for post-hoc comparisons. To determine the sDNAfrag cut-off value, the area under the ROC curve, sensitivity and specificity, were calculated, with the Youden-Index used to find a threshold that maximizes both sensitivity and specificity.

Main results and the role of chance

Regarding male age, it was observed a positive correlation with sperm concentration, a negative correlation with sperm vitality (VT) and hypoosmolality, and a positive correlation with sDNAfrag. Regarding sDNAfrag, it was observed negative correlation with sperm concentration, total progressive motility (TPM), morphology, VT and hypoosmolality. Regarding sperm aneuploidies, both total sperm aneuploidy and total sperm disomy exhibited a negative association with sperm concentration, TPM and morphology. It was also investigated whose groups of individuals could be indicated for sDNAfrag or sperm aneuploidy testing. The NZ group evidenced significant lower sDNAfrag, total sperm aneuploidy and total sperm disomy in relation to the non-NZ group. In the NZ group, sDNAfrag was significantly lower in relation to the OZ, OT, AT and OAT groups. The NZ group presented significant lower percentages of sperm aneuploidy in relation to the OT and OAT groups, and significant lower percentages of sperm disomy in relation to the OAT group. Additionally, sDNAfrag was positively correlated with total sperm aneuploidy and total sperm disomy. From the present large population, ROC curve analysis allowed estimating a cut-off value of 18.8% for the TUNEL-assay (sDNAfrag), with 0.658 of area under the curve, 53.9% sensitivity and 76.7% specificity.

Limitations, reasons for caution

Although presenting a high number of cases and strict controls, the present study was unable to include as controls healthy men with proven fertility. Additionally, the present study did not take into account life-style factors and male associated pathologies besides infertility.

Wider implications of the findings: Semen parameters were shown to be negatively correlated with sDNAfrag and sperm aneuploidies. As sDNAfrag testing and sperm aneuploidy testing were associated with semen abnormalities and male age, it is suggested their inclusion in the routine evaluation of infertile men, thus adding important complementary information about the fertility status.

Trial registration number

Not Appliable

Bleuler’s a or autism spectrum disorder in adults?

Introduction

Nowadays we know that autism spectrum disorders (ASD) and Schizophrenic spectrum (SS) are different types of disorders in their etiology, symptoms and prognosis, but the clinical distinction is often difficult to make due to comorbidity and similar symptoms.

Objectives

With this project, the authors intend to explore the differential diagnosis between ASD and SS specially when we talk about critical ages of onset.

Methods

An analysis of articles searched on Pubmed (articles between 2010-2020) with the key words “adult autism”, “childhood onset schizophrenia”, “childhood psychosis”.

Results

Early-onset schizophrenia (EOS) is defined as occurring before age 18 years. The condition share key diagnostic symptoms with adult-onset schizophrenia (AOS) but his prognoses and comorbidities differ. Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterized by difficulties since early childhood across reciprocal social communication and restricted interests and behaviors. ASD is a lifelong neurodevelopmental disorder, however there is a lack of answers and research for adults with ASD. There are shared aspects of odd thinking, rigid behaviors and impaired socialization in schizophrenia and ASD and COS seems to have a strong relationship with ASD, being comorbid in up to 50% of cases.

Conclusions

Usually the evaluation of the developmental history of the person, prodrome and onset, its course and the presence of positive symptoms of schizophrenia is enough to help us find a diagnosis. Unfortunately, in some ages the conclusion is not so easy to find. However is essential to determine whether the clinical manifestations belong to the autistic spectrum, the schizophrenic or result from comorbidity.

SURG-08. SUPRASELLAR DERMOID CYST IN A PEDIATRIC PATIENT

BACKGROUND

Intracranial dermoid cysts (DC) are rare congenital non-neoplastic lesions that account for 0.04 – 0.6% of all intracranial tumors. They are formed by a fibrous capsule composed of epidermal and dermal derivatives (hair follicles, sebaceous and sweat glands), enclosing a viscous fluid. Intradural DC often arise in the midline and are more common in infratentorial locations. CASE REPORT: A 14-year-old male patient presented with headache, partial motor seizures and behavioral changes. Neurological examination and endocrine workup revealed no abnormalities. Brain magnetic resonance imaging showed a lesion that was 4.4cm x 2.2cm x 4.4cm in size, located at supraselar region, and extended superiorly to the left lateral ventricle and anterolaterally to the left orbitofrontal lobe, associated with hyperintense fat droplets in the right lateral ventricle. We performed a left transventricular microsurgical approach. The tumor capsule was coagulated and opened and a subtotal resection with peacemeal removal of the the lesion was obtained: it had gelatinous consistency, composed of droplets of fat and hair and keratinized scamous epihelium content. A total removal of the DC capsule was not possible due to its firm adherence to optic chiasm and to hypothalamus. Histological examination revealed dermoid cyst.

CONCLUSION

Surgery is the only effective treatment, and its goal should be the radical resection of the lesion to avoid recurrence. Whenever radical resection is not possible, because of the adhesions of the cyst capsule to surrounding tissues, a subtotal resection with piecemeal removal may be a satisfactory option in such cases to avoid high morbidity.

ATRT-10. ATYPICAL TERATOID/RHABDOID TUMOR OF THE PINEAL REGION IN A PEDIATRIC PATIENT

BACKGROUND

Atypical teratoid/rhabdoid tumor (ATRT) is a malignant neoplasm of the central nervous system and corresponds to 1.5% of all intracranial tumors. Mainly affects children under three years of age and shows aggressive behavior (most pediatric patients succumb to their disease within a year after the initial diagnosis, despite the treatment performed). Its place of occurrence in children is preferably in the posterior fossa, and it is rare to appear in other regions. There are only seven patients with ATRT reported on literature; all of them are adults. We present the case of a pediatric patient with a tumor in the pineal region diagnosed as ATRT. CASE REPORT: Three-year-old female patient admitted with occipital headache, vomiting, and seizure. Magnetic resonance imaging (MRI) showed obstructive hydrocephalus secondary to a solid-cystic lesion located at the pineal region that was 3.0 x 3.0 x 3.5 cm in size. Spine MRI did not reveal leptomeningeal spreading. We performed an occipital transtentorial approach to achieve the best safe resection possible, and a ventriculoperitoneal shunt. Histological examination revealed ATRT. The patient received adjuvant treatment with radiotherapy and chemotherapy according to the “Head Start” protocol. One year after the surgery, MRI did not identify any remaining lesion.

CONCLUSION

ATRT is an aggressive and rare neoplasm whose clinical picture depends on the location of the tumor; however, it must be considered in the differential diagnosis of tumors of the pineal region in the pediatric population.

SURG-06. AWAKE CRANIOTOMY FOR BRAIN TUMOR IN PEDIATRIC PATIENTS

BACKGROUND

The challenge of surgery in neurooncology is to achieve the maximum extent of resection while preserving eloquent functions. Intra-operative cortical mapping during resection of a brain tumor allows direct stimulation in eloquent areas with a reduction in postoperative deficits. This procedure has been performed in adults and children down to the age of 11 years. There are only two cases reported on the literature of an 8-year-old and 9-year-old child submitted to an awake craniotomy for brain tumor resection. Pediatric patients are prone to more risks than adults because they become easily agitated after pain sensation. Extensive preparation for the procedure is essential for pediatric patients in order to avoid a lack of cooperation. CASE PRESENTATION: Two patients, with 9-year-old presented with seizures due to a tumor in the left temporoparietal region. In order to identify language and motor–controlling areas during resection, we proposed an awake craniotomy. Because of their ages, they were prepared by a multidisciplinary team. The children’s cooperation during the mapping procedure and tumor resection were exceptional. Postoperative cranial MRI confirmed partial resection of the lesion, whose remnant was located in the left motor area. No seizures occurred during the postoperative period, and both were discharged without a neurological disability on the fifth day after the surgery. Histology revealed a dysembryoplastic neuroepithelial tumor (WHO grade I).

CONCLUSION

Brain mapping during resection of a tumor in an awake pediatric patient is feasible and can be safely performed even in patients under 11-year-old.

OTHR-14. DIENCEPHALIC SYNDROME SECONDARY TO PITUITARY STALK THICKENING

BACKGROUND

Diencephalic syndrome (DS) is a rare condition associated with neoplastic lesions of the sellar-suprasellar region, whose pathophysiological mechanisms are still unclear. DS occurs in <10% of hypothalamic gliomas and has also been described in suprasellar germinomas, craniopharyngiomas, epidermoid cysts, rarely with non-suprasellar lesions such as brainstem gliomas. DS has not been associated with isolated pituitary stalk thickening. Isolated pituitary stalk thickening (IPST) presents a diagnostic challenge, ranging from benign (craniopharyngioma) to malignant lesions (germinoma, metastasis, histiocytoses of the Langerhans group). The coexistence of diabetes insipidus (DI) with anterior pituitary dysfunction and IPST implies more risk to harbor neoplasia. CASE REPORT: A 6-year old girl presented with DI and inadequate weight gain (despite regular caloric intake) and preservation of linear growth. Neurological examination showed no abnormalities. However, physical examination revealed a malnourished patient (both weight-for-age value and body-mass-index below the third percentile). Blood tests and negative IgA anti-endomysial antibodies excluded malabsorption as a cause of her malnutrition; endocrine work-up excluded thyroid dysfunction, growth hormone deficiency, and adrenal insufficiency. Magnetic resonance imaging (MRI) showed thickening of the pituitary stalk with a transverse diameter of 7 mm. The patient underwent a biopsy through a supraorbital eyebrow approach. Histopathological examination revealed lymphocytic hypophysitis, with tissue markers all negative for germinoma. The girl is currently under follow up with serial MRI every three months.

CONCLUSION

DS should be considered as a differential diagnosis in any child with failure to thrive, and imaging studies should be performed even if there are no additional neurological symptoms.

SURG-22. CERVICAL SPINE ANEURYSMAL BONE CYST OF A PEDIATRIC PATIENT

BACKGROUND

Aneurysmal bone cysts (ABCs) are benign, expanding lesions that represent 15% of all primary spine tumors, and only 2% have been found at the cervical level. There are different therapeutic options; the most successful is complete surgical resection. Although not always possible, due to high blood loss that occurs during the procedure, a combination of surgery with other treatment modalities was used in 40% of the cases reported so far. We describe a pediatric patient that we managed with embolization plus surgery. CASE REPORT: A 5-year-old girl presented with painful torticollis associated with a left posterior cervical mass, without neurological impairment. Magnetic resonance imaging of the cervical spine showed a multiseptated bony lesion with multiple fluid levels, involving the posterior elements of C2, associated with diffuse soft tissue enhancement of the left paravertebral muscles. We proposed a multi-staged treatment with pre-operative arterial embolization followed by the posterior surgical approach. Super selective embolization of the left ascending cervical artery was performed. The right ascending cervical artery also contributed to the tumor blush, but due to its connection to the right vertebral artery and, therefore, associated with a high risk of neurological injury, we prefer not to embolize it. Two days later, we performed a posterior surgical approach, with a gross total resection of the tumor. Histological examination revealed an ABC.

CONCLUSION

An aneurysmal bone cyst is a rare cervical spine lesion that demands a multidisciplinary approach due to its locally aggressive behavior and the excessive blood loss related to surgery.

SURG-09. REACTIVATION OF HERPES SIMPLEX VIRUS AFTER NEUROLOGIC SURGERY

BACKGROUND

Herpes simplex virus encephalitis (HSVE) is a rare complication after neurosurgery, and its clinical picture mimics features of other most frequent infectious complications of bacterial origin. Probable triggering factors are manipulation and surgical stress, since most cases occur due to reactivation rather than primary infection. The main symptoms include fever and altered consciousness. DNA identification of HSV by PCR has accuracy. Even with adequate treatment, HSVE is associated with a mortality of 30%, and potential neurologic sequelae such as cognitive and motor. CASE REPORT: An 18-year-old male patient presented with loss of vision due to cystic craniopharyngioma. We inserted an Omaya catheter and drained the cyst. On the third day, he presented with fever, seizures, and decreased consciousness. Magnetic resonance imaging (MRI) showed high signal intensity on T2-weighted and FLAIR images in the left frontal and temporal lobe, cingulate gyrus, and corpus callosum, with mass effect. He was submitted to decompressive craniectomy and empirical antibiotic therapy. CSF and blood cultures were negative. Due to inexpressive clinical improvement after 48 hours, CSF was collected for polymerase chain reaction (PCR), and we performed a brain biopsy and started intravenous acyclovir. Histology and PCR confirmed HSVE type 1 and 2. He received antiviral for two weeks and was discharged after CSF PCR negative.

CONCLUSION

Clinical suspicion, CSF PCR, and imaging are of paramount importance for early diagnosis of HSVE, which should be considered in the differential diagnosis of recent postoperative neurologic surgery in cases of unexplained postoperative fever with altered consciousness.

QOL-27. SWALLOWING ASSESSMENT IN PEDIATRIC PATIENTS WITH BRAIN TUMOR

BACKGROUND

Neurosurgical intervention is the initial modality of treatment for the vast majority of pediatric brain tumors. However, studies on the swallowing process in pediatric patients with brain tumors are scarce, especially comparing changes that can be identified before and after surgery. In clinical practice, it is possible to observe that these patients may present modifications in the swallowing phases both before and after surgery. Therefore, we conducted a longitudinal study with a cohort of 20 patients ranging in age from 0 to 17 years, in order to characterize the swallowing disorders.

RESULTS

30% of the patients presented some change in orofacial motricity in the organs related to initiation, coordination, and maintenance of swallowing at the time of hospital admission, and 65% of the patients exhibited these changes after surgery. Due to worsening in swallowing after surgery, 40% of the patients required modification of the consistence of oral diet or required the use of an alternative route of feeding.

CONCLUSIONS

There is a high prevalence of swallowing disorders in pediatric patients with brain tumors, mainly regarding the proper functioning of organs related to initiation, coordination, and maintenance of swallowing even before the surgical intervention, and these changes increase after surgery - especially in patients with posterior fossa tumors. The role of the speech/language pathologist is of paramount importance, given their role in the assessment and adequacy of the feeding route, identifying patients at risk of pulmonary aspirations, minimizing swallowing complications, and also facilitating communication with patients and their families.

Recommendation of Workplaces in a Coworking Building: A Cyber-Physical Approach Supported by a Context-Aware Multi-Agent System

Recommender systems are able to suggest the most suitable items to a given user, taking into account the user’s and item`s data. Currently, these systems are offered almost everywhere in the online world, such as in e-commerce websites, newsletters, or video platforms. To improve recommendations, the user’s context should be considered to provide more accurate algorithms able to achieve higher payoffs. In this paper, we propose a pre-filtering recommendation system that considers the context of a coworking building and suggests the best workplaces to a user. A cyber-physical context-aware multi-agent system is used to monitor the building and feed the pre-filtering process using fuzzy logic. Recommendations are made by a multi-armed bandit algorithm, using ϵ-greedy and upper confidence bound methods. The paper presents the main results of simulations for one, two, three, and five years to illustrate the use of the proposed system.

SAT0076 VERY ELDERLY ONSET RHEUMATOID ARTHRITIS (VEORA): CLINICAL CHARACTERISTICS AND THERAPEUTIC IMPLICATIONS

Background:

There are differences in the characteristics of patients with Rheumatoid Arthritis (RA) depending on their age at onset with two traditional groups: YORA (young onset RA) and EORA (elderly onset RA). These aspects have not been studied in cases of very late onset (≥ 80 years)

Objectives:

To describe the clinical characteristics, treatments and evolution at one year in “very elderly onset RA” (VEORA). Compare these characteristics with YORA (40-50 years) and EORA (60-70 years).

Methods:

Retrospective and longitudinal study of RA patients from 2 spanish hospitals. From their databases, VEORA patients were identified and their clinical characteristics were analyzed at onset, treatments at diagnosis and in the first 12 months, as well as DAS28-ESR activity after 1 year. These variables were compared between cases belonging to one of the hospitals and 2 control groups of YORA and EORA patients of the same center, matched by sex, diagnosis date ± 2 years, RF and / or ACPA status and presence of erosions in baseline Rx.

Results:

A total of 2790 records of RA patients were analyzed, identifying 59 cases of onset in “very elderly” (2% of the total). Table 1 shows its clinical, analytical characteristics and treatments at diagnosis.

Table 1.

Demographic and clinical data of the 59 VEORA patients

n=59Female, n(%)43 (73)Age at onset, years83 ± 3ComorbidityHypertension, n(%)54 (92)Diabetes, n(%)19 (32)CV disease20 (34)Clinical and analytical data at diagnosisAcute onset, n(%)26 (44)Polyarticular onset, n(%)37 (63)Specific forms, n(%)21 (36)Polymyalgia Rheumatica, n16RS3PE, n5Rheumatoid factor, n(%)40 (68)ACPA, n(%)24 (41)DAS28-ESR5 (4,4-5,7)high activity, n(%)32 (54)First visit treatmentNSAIDs, n(%)5 (9)Steroids, n(%)55 (93)starting dose, mg/day*10 (7,5-15)DMARD, n(%)52 (88)Hidroxychloroquine14 (24)Methotrexate36 (61)starting dose, mg/week10 (7,5-10)Combined therapy5 (8)

DAS28-ESR and the number of patients in remission or low activity at one year showed no differences between EORA and VEORA, or between these groups and that of younger patients.

Elderly patients (EORA and VEORA), compared with YORA, presented with higher frequency hypertension and CV disease, higher elevation in acute phase reactants at the onset and disease activity at diagnosis. VEORA patients, compared to EORA, showed a higher frequency of dyslipidemia (p = 0.04). There were also no significant differences between VEORA and EORA in the distribution and type of joints affected, time to diagnosis, acute phase reactants or disease activity at the onset. A higher frequency of special forms (such as PMR or RS3PE) was close to statistical significance in the VEORA group (p = 0.054).

Regarding initial treatment, both EORA and VEORA received steroidal treatment more frequently and a lower dose of Methotrexate during the first year. Biological treatments was also significantly higher in YORA (p=0,000). When comparing VEORA and EORA, differences related to the use of NSAIDs were found, lower in VEORA (p = 0.000), as well as in the maximum dose of Methotrexate reached in the next 12 months, higher in the EORA group (p = 0.01). No differences in adverse events with DMARDs were observed.

Conclusion:

There have been few differences in the comorbidity profile and clinical characteristics at the onset between VEORA and EORA patients. Despite the differences observed in its management (more conservative in EORA and VEORA vs YORA, and in VEORA vs EORA), we have not observed differences in DAS28-ESR activity after one year.

Disclosure of Interests:

Alicia García Dorta: None declared, Cristina Almeida: None declared, Hernández Díaz Marta: None declared, Laur Cáceres Martín: None declared, Elisa Trujillo: None declared, Carlos Rodríguez-Lozano: None declared, Iván Ferraz-Amaro Grant/research support from: Pfizer, Abbvie, Speakers bureau: Pfizer, Abbvie, MSD., Juan Carlos Quevedo-Abeledo Speakers bureau: Abbvie

THU0136 VERY ELDERLY ONSET RHEUMATOID ARTHRITIS (VEORA): CLINICAL AND THERAPEUTIC IMPLICATIONS AFTER 80 YEARS

Background:

There are differences in the characteristics of patients with Rheumatoid Arthritis (RA) depending on their age at onset with two traditional groups: YORA (young onset RA) and EORA (elderly onset RA). These aspects have not been studied in cases of very late onset (≥ 80 years)

Objectives:

To describe the clinical characteristics, treatments and evolution at one year in “very elderly onset RA” (VEORA). Compare these characteristics with YORA (40-50 years) and EORA (60-70 years).

Methods:

Retrospective and longitudinal study of RA patients from 2 spanish hospitals. From their databases, VEORA patients were identified and their clinical characteristics were analyzed at onset, treatments at diagnosis and in the first 12 months, as well as DAS28-ESR activity after 1 year. These variables were compared between cases belonging to one of the hospitals and 2 control groups of YORA and EORA patients of the same center, matched by sex, diagnosis date ± 2 years, RF and / or ACPA status and presence of erosions in baseline Rx.

Results:

A total of 2790 records of RA patients were analyzed, identifying 59 cases of onset in “very elderly” (2% of the total). Table 1 shows its clinical, analytical characteristics and treatments at diagnosis.

Table 1.

Demographic and clinical data of the 59 VEORA patients

n=59Female, n(%)43 (73)Age at onset, years83 ± 3ComorbidityHypertension, n(%)54 (92)Diabetes, n(%)19 (32)CV disease20 (34)Clinical and analytical data at diagnosisAcute onset, n(%)26 (44)Polyarticular onset, n(%)37 (63)Specific forms, n(%)21 (36)Polymyalgia Rheumatica, n16RS3PE, n5Rheumatoid factor, n(%)40 (68)ACPA, n(%)24 (41)DAS28-ESR5 (4,4-5,7)high activity, n(%)32 (54)First visit treatmentNSAIDs, n(%)5 (9)Steroids, n(%)55 (93)starting dose, mg/day*10 (7,5-15)DMARD, n(%)52 (88)Hidroxychloroquine14 (24)Methotrexate36 (61)starting dose, mg/week10 (7,5-10)Combined therapy5 (8)

Elderly patients (EORA and VEORA), compared with YORA, presented with higher frequency hypertension and CV disease, higher elevation in acute phase reactants at the onset and disease activity at diagnosis. VEORA patients, compared to EORA, showed a higher frequency of dyslipidemia (p = 0.04). There were also no significant differences between VEORA and EORA in the distribution and type of joints affected, time to diagnosis, acute phase reactants or disease activity at the onset. A higher frequency of special forms (such as PMR or RS3PE) was close to statistical significance in the VEORA group (p = 0.054).

Regarding initial treatment, both EORA and VEORA received steroidal treatment more frequently and a lower dose of Methotrexate during the first year. Biological treatments was also significantly higher in YORA (p=0,000). When comparing VEORA and EORA, differences related to the use of NSAIDs were found, lower in VEORA (p = 0.000), as well as in the maximum dose of Methotrexate reached in the next 12 months, higher in the EORA group (p = 0.01). No differences in adverse events with DMARDs were observed.

DAS28-ESR and the number of patients in remission or low activity at one year showed no differences between EORA and VEORA, or between these groups and that of younger patients.

Conclusion:

There have been few differences in the comorbidity profile and clinical characteristics at the onset between VEORA and EORA patients. Despite the differences observed in its management (more conservative in EORA and VEORA vs YORA, and in VEORA vs EORA), we have not observed differences in DAS28-ESR activity after one year.

Disclosure of Interests:

Alicia García Dorta: None declared, Cristina Almeida: None declared, Hernández Díaz Marta: None declared, Laur Cáceres Martín: None declared, Elisa Trujillo: None declared, Iván Ferraz-Amaro Grant/research support from: Pfizer, Abbvie, Speakers bureau: Pfizer, Abbvie, MSD., Juan Carlos Quevedo-Abeledo: None declared

Impact of adverse effects to oral antidiabetics on adherence and quality of life in patients with type 2 diabetes

Introduction Diabetes is a metabolic disorder with many comorbidities, microvascular and macrovascular complications. In Portugal the prevalence was 13,3% which corresponds to 1 million Portuguese diagnosed, but the forecasts are for a big increase. The various therapeutic options currently available have been shown to be effective in controlling glycaemia and HbA1 levels. Adherence with this therapeutic is essential for optimization and control of chronic conditions. However, they present side effects that may compromise adherence to therapy and the quality of life of the patients.

Objectives The objective of this study is to evaluate the impact of the adverse effects of oral antidiabetic medicines on patient’s quality of life and adherence to therapy.

Methodology We developed a cross-sectional study in a sample of 65 patients with type 2 diabetes recruited in several Portuguese pharmacies. Data collected through a questionnaire previously validated with MAT Scale and EQ-5D-3L questionnaire.

Results In total, 36 men (55,4%) and 29 women (44,6%) participated in the study, the mean age was 65 years. 73,8 % take oral medication and 92,30% of people have high adherence. The adverse events with more impact in the patients’ perception are "Discomfort in the genital area", "Dry mouth" and gastrointestinal events such as "Abdominal distention", "Flatulence" and "Constipation". The number of adverse events have a negative impact on patients’ quality of life (rs=-0,479; p≤0,01). The satisfaction with the therapeutic regime is significantly associated with adherence (rs = 0,348; p≤0,01)and their quality of life (rs = 0,316; p=0,01).

Conclusion We concluded that the adverse events have a negative impact on adherence and quality of life. The presence of adverse events, the type of medication and the therapeutic regimen are factors that negatively influence the patients’ quality of life, especially in the polymedicated elderly people.

Ocular Syphilis mimicking Acute Zonal Occult Outer Retinopathy (AZOOR)

Ocular syphilis can simulate various ophthalmic pathologies with multiple possible ophthalmic findings. Timely treatment of these patients can minimize visual damage, but its diagnosis is often a challenge for the ophthalmologist. We review a case report of a 45-year-old man with a rare and atypical clinical presentation of ocular syphilis, its clinical and imaging characteristics, its diagnosis, treatment and evolution. The patient presented with bilateral painless loss of vision, photopsia and peripheral scotomas with about 1 week evolution. There were no signs of ocular inflammation. The complementary ophthalmic study revealed an acute zonal occult outer retinopathy-like ("AZOOR-like") presentation. Ocular syphilis does not always present with ocular inflammation and its presentation as "AZOOR-like" is very rare. So, we should always maintain a high index of suspicion for this condition, as early diagnosis and treatment are essential for a better prognosis.

Complementary feeding: what do we know?

INTRODUCTION: Complementary feeding (CF) is defined as the set of foods that are offered to the infant, from the 6th month of life, in addition to breastfeeding or infant formulas. One of the roles of the pediatrician is to guide the introduction of CF. METHODOS: Descriptive cross-sectional study through self-administered questionnaire with pediatricians and pediatrics residents on demographic information, knowledge of feeding practices, nutrition and supplementation in the first two years of life. There were analyzed associations between time since medical degree and degree of formation with the variables supplementation of iron and vitamin D. RESULTS: The final sample consisted of 109 questionnaires; 63% of the participants considered the presence of topics on infant feeding insufficient. A total of 66,9% and 38.53% of the participants follow the current recommendations regarding the age of supplementation of iron and vitamin D, respectively. DISCUSSION: We observed divergent practices of current scientific evidence by pediatricians and pediatric residents. There was a relationship between training time and a higher proportion of inadequate practice regarding iron supplementation. CONCLUSION: A more emphatic approach to the topic of infant feeding should be considered both in pediatric training and in the context of professional update.

Sweet cognition: The differential effects of glucose consumption on attentional food bias in individuals of lean and obese status

In general, glucose consumption improves cognitive performance; however, it is unknown whether glucose specifically alters attentional food bias, and how this process may vary by BMI status. We hypothesized that glucose consumption would increase attentional food bias among individuals of obese BMI status more so than among individuals of lean BMI status. Participants (N = 35) completed the n-back, a working memory task modified to assess attentional food bias (ATT-Food), under fasting and glucose challenge conditions. We computed pre-post changes in ATT-Food, blood glucose and insulin (∆BG & ∆BI), and perceived task-stress (∆stress). After the second cognitive test and blood draw, participants ate lunch and completed a "taste test" of highly palatable foods, and we recorded food consumption. Pre-post changes in ATT-Food were greater among participants of obese (relative to lean) BMI status (F(1,33) = 5.108, p = .031). Greater ∆ATT-Food was significantly associated with greater ∆BG (r = .462, p = .007) and reduced ∆stress (r =-.422, p = .011), and marginally associated with greater taste-test eating (r =.325, p = .057), but was not associated with ∆BI. Our findings suggest that individuals of obese BMI status may exhibit "sweet cognition," as indexed by greater attentional food bias following glucose ingestion, relative to individuals of lean BMI status. Among individuals of obese BMI status, sweet cognition may arise from difficulty broadening attention toward non-food cues after consuming a high glucose load, thereby potentially perpetuating sugar consumption. If confirmed by further research, measures of sweet cognition may help identify individuals with a phenotype of risk for obesity and greater sugar consumption, who may benefit from tailored interventions.

Data Dissemination: Shortening the Long Tail of Traumatic Brain Injury Dark Data

Translation of traumatic brain injury (TBI) research findings from bench to bedside involves aligning multi-species data across diverse data types including imaging and molecular biomarkers, histopathology, behavior, and functional outcomes. In this review we argue that TBI translation should be acknowledged for what it is: a problem of big data that can be addressed using modern data science approaches. We review the history of the term big data, tracing its origins in Internet technology as data that are "big" according to the "4Vs" of volume, velocity, variety, veracity and discuss how the term has transitioned into the mainstream of biomedical research. We argue that the problem of TBI translation fundamentally centers around data variety and that solutions to this problem can be found in modern machine learning and other cutting-edge analytical approaches. Throughout our discussion we highlight the need to pull data from diverse sources including unpublished data ("dark data") and "long-tail data" (small, specialty TBI datasets undergirding the published literature). We review a few early examples of published articles in both the pre-clinical and clinical TBI research literature to demonstrate how data reuse can drive new discoveries leading into translational therapies. Making TBI data resources more Findable, Accessible, Interoperable, and Reusable (FAIR) through better data stewardship has great potential to accelerate discovery and translation for the silent epidemic of TBI.