Hosing of a Long Relativistic Particle Bunch in Plasma

Experimental results show that hosing of a long particle bunch in plasma can be induced by wakefields driven by a short, misaligned preceding bunch. Hosing develops in the plane of misalignment, self-modulation in the perpendicular plane, at frequencies close to the plasma electron frequency, and are reproducible. Development of hosing depends on misalignment direction, its growth on misalignment extent and on proton bunch charge. Results have the main characteristics of a theoretical model, are relevant to other plasma-based accelerators and represent the first characterization of hosing.

Unlocking the molecular realm: advanced approaches for identifying clinically and environmentally relevant bacteria

Rapid, effective, and specific identification of clinical and environmental bacterial pathogens is of major importance for their control. Traditionally, bacteria have been identified by phenotypic methods based on morphological, biochemical, and metabolic properties. While these methods are very useful in clinical practice, they have limitations including a poor ability to differentiate within and between species and time-consuming workflows. Newly developed molecular methods can greatly improve the accuracy of taxonomic characterization, identifying specific strains of medical or environmental importance. However, due to high costs and the need for trained professionals, these methods are not yet routine in diagnostic laboratories. Thus, disseminating knowledge on advances in molecular identification techniques is pivotal to make these methodologies accessible. The objective of this work was to review and discuss current molecular techniques for bacteria identification aiming to track and monitor microbial agents in clinical and environmental samples.

Sex-Specific Patterns of Cerebral Atrophy and Enlarged Perivascular Spaces in Patients with Cerebral Amyloid Angiopathy and Dementia

BACKGROUND AND PURPOSE

Cerebral amyloid angiopathy is characterized by amyloid β deposition in leptomeningeal and superficial cortical vessels. Cognitive impairment is common and may occur independent of concomitant Alzheimer disease neuropathology. It is still unknown which neuroimaging findings are associated with dementia in cerebral amyloid angiopathy and whether they are modulated by sex. This study compared MR imaging markers in patients with cerebral amyloid angiopathy with dementia or mild cognitive impairment or who are cognitively unimpaired and explored sex-specific differences.

MATERIALS AND METHODS

We studied 58 patients with cerebral amyloid angiopathy selected from the cerebrovascular and memory outpatient clinics. Clinical characteristics were collected from clinical records. Cerebral amyloid angiopathy was diagnosed on MR imaging on the basis of the Boston criteria. Visual rating scores for atrophy and other imaging features were independently assessed by 2 senior neuroradiologists.

RESULTS

Medial temporal lobe atrophy was higher for those with cerebral amyloid angiopathy with dementia versus those cognitively unimpaired (P = .015), but not for those with mild cognitive impairment. This effect was mainly driven by higher atrophy in men with dementia, compared with women with and without dementia (P = .034, P = .012; respectively) and with men without dementia (P = .012). Enlarged perivascular spaces in the centrum semiovale were more frequent in women with dementia versus men with and without dementia (P = .021, P = .011; respectively) and women without dementia (P = .011).

CONCLUSIONS

Medial temporal lobe atrophy was more prominent in men with dementia, whereas women showed a higher number of enlarged perivascular spaces in the centrum semiovale. Overall, this finding suggests differential pathophysiologic mechanisms with sex-specific neuroimaging patterns in cerebral amyloid angiopathy.

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

Microvascular dysfunction is associated with impaired myocardial work in obstructive and nonobstructive hypertrophic cardiomyopathy: a multimodality approach

Introduction

Myocardial work is a dynamic non-invasive method for assessing myocardial deformation. Microvascular dysfunction is a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between impaired myocardial work, evaluated by echocardiography, and left ventricular (LV) ischemia, detected by cardiac magnetic resonance (CMR).

Methods

Prospective assessment of HCM patients' (P) myocardial strain parameters with 2D speckle-tracking echocardiography. All P underwent CMR protocol (1.5-T) for the analysis of stress perfusion and late gadolinium enhancement (LGE). Perfusion defects were quantified as burden of ischemia (% of LV mass). Results were stratified according to obstructive (oHCM) and nonobstructive (nHCM) HCM as well as according to the presence of significant replacement fibrosis (LGE of ≥15% or <15% of LV mass). Multivariate regression analyses were used to explore the relation between myocardial work and the burden of ischemia.

Results

75 P with HCM (63% male, age 55±15 years), 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH and 28% exhibiting LV outflow tract obstruction (mean maximal LVOT gradient of 89±60 mmHg). Perfusion defects were found in 68 P (90.7%), with a mean of 22.5±16.9% of LV mass and 29 P (38.7%) had LGE ≥15% of LV mass.

A lower global work index (GWI) significantly correlated with higher burden of myocardial perfusion defects (r=−0.520, β-estimate −0.019, 95% CI −0.028 to −0.010, p<0.001). Likewise, impaired values of global work efficiency (GWE) were linked to higher percentage of hypoperfusion (r=−0.477, β-estimate −0.713, 95% CI −1.250 to −0.176, p<0.001). Moreover, impaired global constructive work (GCW) (r=−0.519, β-estimate −0.021, 95% CI −0.030 to −0.013, p<0.001) and a higher global wasted work (GWW) (r=0.280, p=0.017) were associated with a higher burden of perfusion defects (Figure 1).

GWI showed a higher correlation with perfusion defects in oHCM P (r=−0.518, p=0.019) vs. nHCM P (r=−0.492, p<0.001), and the same was also found with GWE (oHCM: r=−0.591, p=0.006 vs. nHCM: r=−0.317, p=0.022) (Figure 2A). Furthermore, GCW showed a slightly higher correlation with hypoperfusion in oHCM P (r=−0.564, p=0.010) vs. nHCM P (r=−0.520, p<0.001). There was no significant difference between oHCM and nHCM P regarding GWW.

In P with LGE ≥15%, GWI showed a better correlation with perfusion defects (r=−0.489, p=0.007) vs. P with LGE of <15% (r=−0.369, p=0.007). Moreover, GCW showed a higher correlation with hypoperfusion in P with LGE ≥15% (r=−0.455, p=0.013) comparing with P with LGE <15% LV mass (r=−0.359, p=0.019) (Figure 2B). No difference was found regarding GWE and GWW according to LGE burden.

Conclusion

In our cohort of P with HCM, impaired GWI, GWE and GCW and a higher GWW were significantly correlated with the presence of myocardial ischemia in CMR. This correlation was greater in P with oHCM and in P with LGE of ≥15% of LV mass.

Funding Acknowledgement

Type of funding sources: None.

Unusual presentation of idiopathic Bell’s palsy with involvement of the oculomotor nerve

Our patient presented with symptoms consistent with Bell’s palsy. The involved cranial nerves were the facial and oculomotor nerves. She had preceding upper respiratory tract infection symptoms. She had no risk factors or significant illnesses, and no other causes were found. Although there are reported cases of multiple cranial nerves affected in Bell’s palsy, our review of literature revealed no prior cases of involvement of the parasympathetic oculomotor fibres in Bell’s palsy.

Controlled Growth of the Self-Modulation of a Relativistic Proton Bunch in Plasma

A long, narrow, relativistic charged particle bunch propagating in plasma is subject to the self-modulation (SM) instability. We show that SM of a proton bunch can be seeded by the wakefields driven by a preceding electron bunch. SM timing reproducibility and control are at the level of a small fraction of the modulation period. With this seeding method, we independently control the amplitude of the seed wakefields with the charge of the electron bunch and the growth rate of SM with the charge of the proton bunch. Seeding leads to larger growth of the wakefields than in the instability case.

The difficult symbolic construction of physicians’ and nurses’ experiences working in COVID-19 intensive care units: A qualitative study on reports at a university public hospital in Southeastern Brazil

Introduction

Humanistic studies that explore symbolic aspects of the experience of working on the COVID-19 frontline are necessary. Do these professionals have psychic time to symbolize such acute experiences? We expect these preliminary findings of this research provide subsidies for discussing psychological management in groups with these professionals.

Objectives

To interpret emotional meanings reported by physicians and nurses on their experiences of working at COVID-19 intensive care units.

Methods

Clinical-qualitative design. Data collection with semi-directed interviews with open-ended questions in-depth applied to a sample of six professionals, closed by theoretical information saturation, in a Brazilian university general hospital. Trigger question: “Talk about psychological meanings of your experience in face of management of patients with COVID-19 at ICU”. Data treatment by the Seven Steps of the Clinical-Qualitative Content Analysis. Theoretical framework of Medical Psychology using Balintian concepts.

Results

We raised 3 categories. (1) Psychic time and absence of symbolization in face of the pandemic; (2) Denial as a defense or psychosocial adaptation mechanisms; (3) Tensions and family support: triggers of ambivalent emotional experiences.

Conclusions

Raw experience of COVID-19 pandemic did not allow for realization of symbolization. Psychological defenses are manifested, either to maintain balance or to deny the existence of dangers related to mental health. Presence of families and health team confirm that the feeling of loneliness is avoided. Anxieties related to the fear of contamination are recurrent. There is dual relationship regarding the emotional experiences of health professionals, but the data point to importance of looking at how these individuals perceive and experience the pandemic.

Disclosure

No significant relationships.

“It’s not only the bad side” - Experiences reported by health professionals working with women victims of sexual violence in a Brazilian university specialized outpatient service: A qualitative study

Introduction

Health Psychology is a scientific branch that studies interpersonal relationships in the field of emotions and behavior in clinical settings. Violence against women is a gender-based action that alarmingly affects the population, with sexual violence (SV) being one of its main phenomena. The complexity of the care offered to SV patients by clinical professionals impacts themselves, affecting their personal lives and the quality of their work.

Objectives

To explore symbolic emotional meanings attributed by health professionals to care and follow-up of women victims of SV in state service of reference of the Unified Health System.

Methods

Clinical-Qualitative design was used to guide semi-directed interviews with open-ended questions in-depth. Clinical-Qualitative Content Analysis was employed to treat data. Five participants make up the multi-professional team at the Hospital of the Woman of the State University of Campinas. Theoretical framework chosen to interpret categories was Balintian Medical Psychology.

Results

Three categories were selected for this presentation: The human anguishes as the main challenge and handling of working with sexual violence; “To see things progressing”: to the patient and together with the team, a facilitator of the work; and “I try to leave it on the three’s leaves”: the difficult attempt to separate work from personal life.

Conclusions

Taking care of SV is a very emotionally demanding task. Working with the team and see expected outcomes help clinical professionals deal with negative feelings, avoiding, for example, compensatory traumas. New research about social-cultural impacts of working with SV is important to develop institutional approaches of coping for health teams.

Disclosure

No significant relationships.

Perceptions reported by residents in psychiatry on oral health problems in their patients with severe mental disorders: a qualitative study at a Brazilian university specialized psychiatric service

Introduction

There is a greater prevalence of oral problems in patients suffering from severe mental illness than in the general population. The psychiatrist use to be, naturally, a health professional with great clinical influence over these patients. Do young psychiatrists in training include oral evaluations on their patients? How does this doctor perceive oral health care in the context of follow-up of people with chronic mental disorders?

Objectives

To interpret the meanings of the practice or not, regarding oral health guidelines, as reported by residents in psychiatry working in care and follow-up services to patients with severe disorders at a public university.

Methods

Clinical-qualitative design. Semi-directed interviews with open-ended questions in-depth carried out with six participants. Sample closed by saturation information criterion. Residents see their patients at the General Hospital of the State University of Campinas. Interview material, audio-recorded and transcribed in full, was treated by Clinical-Qualitative Content Analysis, using concepts of theoretical framework from Medical Psychology. Interviewer was a female professor of dentistry.

Results

From the discussion, two categories of analysis were selected for this presentation. (1) medical practice obeys the natural logic of construction of paradigmatic areas: historically, dentistry has created a care model with independence from medicine; (2) dentist is not called to participate in “collusion of anonymity”. This is an expression construct by the psychoanalyst Balint to describe the taking of relevant clinical decisions, without no professional assume the responsibility for these.

Conclusions

These meanings may guide changes in professional conduct as well as in the curriculum of medical training programs.

Disclosure

No significant relationships.

Sex difference in lipid levels in first-diagnosed drug-naïve depression patients: A case-control and 12-weeks follow-up study

AIM

Patients with depression have a high prevalence of developing dyslipidemia. In this study, we aim to investigate the difference of serum lipids, including total cholesterol (TCH), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG), between the depressed patients and healthy controls. Sex differences in lipids and their psychological correlations were also included.

METHODS

The study included 56 healthy controls (males/females = 26/30) and 110 first-diagnosed drug-naïve outpatients (males/females = 35/75). A total of 42 patients (males/females = 14/28) were followed for 3 months.

RESULTS

A significant difference was found in TCH and LDL-C among healthy control and patients. Interestingly, female patients with first-diagnosed, drug-naïve depression had lower atherogenic indices than male patients. After 3 months of antidepressants therapy, female patients exhibited detrimental changes in serum lipids, namely increased TG and atherogenic index. Moreover, correlation analysis showed significant correlations between changes of depression inventory (HAMD and BDI) score and serum lipids (TCH, HDL-C) in depressed patients.

CONCLUSION

We found that dyslipidemia was more common in female patients with depression during therapy with antidepressants. Moreover, the altered serum lipids and atherogenic index might be a hallmark of female patients. Further investigation of sex differences in lipid metabolism of depression is warranted.

Three dimensional myocardial deformation parameters are associated with functional capacity in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P).

Methods

This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing.

Results

83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p < 0.001), global radial 3D strain (r = 0.336, p = 0.003) and global circumferential 3D strain (r=-0.353, p = 0.002) (Figure 1).

Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012).

Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p < 0.001), circulatory power (r=-0.272, p = 0.032) and (VE/VCO2 slope)/peak VO2 ratio (r = 0.391, p = 0.002). LV twist (r=-0.135, p = 0.284), torsion (r=-0.120, p = 0.341) and global area strain (r = 0.152, p = 0.235) impairment did not correlate with VE/VCO2 slope. Exercise capacity was not associated with LV mass index (r = 0.209, p = 0.095), LV end-diastolic volume (r = 0.058, p = 0.639), maximum wall thickness (r = 0.041, p = 0.744), LVEF (r=-0.092, p = 0.458), 2D global longitudinal strain (r=-0.024, p = 0.848) or peak LVOT gradient (r=-0.006, p = 0.964). In a subanalysis examining only the nonobstructive (nHCM) P, we found that peak VO2 had a superior correlation with global longitudinal 3D strain (r=-0.420, p = 0.004), global radial 3D strain (r = 0.356, p = 0.016) and global circumferential 3D strain (r=-0.357, p = 0.016) as well as LV twist (r = 0.300, p = 0.046) and torsion (r = 0.336, p = 0.024).

Conclusion

Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters  Abstract Figure. LV twist, torsion and global area strain

Assessment of myocardial work: a promising tool in obstructive and nonobstructive hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial work is a novel dynamic non-invasive method for assessing myocardial deformation providing incremental information to left ventricular ejection fraction (LVEF) and strain imaging. The aim of this study was to assess left ventricular myocardial work in hypertrophic cardiomyopathy (HCM) and compare patients with obstructive HCM (oHCM) and nonobstructive HCM (nHCM).

Methods

Prospective assessment of HCM patients’ myocardial strain parameters with 2D speckle-tracking echocardiography, stratified according to LV segments (basal, midcavity and apical regions). Results were compared between oHCM and nHCM patients.

Results

83 patients with HCM, 60% male, 33% oHCM (with a LVOT gradient of 89 ± 60 mmHg). There was no significant difference between groups in mean age (56 ± 13 years vs. 55 ± 15 years, p = 0.719), LV mass index (186 ± 75 g/m2 vs. 158 ± 65 g/m2, p = 0.103), maximum wall thickness (21 ± 4 mm vs. 19 ± 5 mm, p = 0.425) or left ventricular ejection fraction (LVEF) (68 ± 8% vs. 67 ± 11%, p = 0.584).

Regarding global work index (GWI) there was no significant difference between oHCM and nHCM (1206 ± 431 mmHg% vs. 1384 ± 437 mmHg%, p = 0.090), although oHCM patients had a significantly inferior GWI in the basal (921 ± 383 mmHg% vs. 1364 ± 419 mmHg%, p < 0.001) and midcavity (1049 ± 456 mmHg% vs. 1288 ± 492 mmHg%, p = 0.038) segments (Figure 1). No significant difference was noted in the apical segments (1680 ± 653 mmHg% vs. 1519 ± 770 mmHg%, p = 0.335). Myocardial work index in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.242, p = 0.032) and maximum provoked LVOT gradient (r=-0.291, p = 0.010). Furthermore, patients with septal hypertrophy pattern showed significantly impaired basal myocardial work index compared with apical hypertrophy patients (1090 ± 428 mmHg% vs 1537 ± 389 mmHg%, p < 0.001).

Global constructive work (GCW) (1443 ± 449 mmHg% vs. 1604 ± 426 mmHg%, p = 0.123) and global wasted work (GWW) (197 ± 140 mmHg% vs. 154 ± 107 mmHg%, p = 0.137) were not significantly different between groups.

Global work efficiency (GWE) was significantly reduced in oHCM patients vs. nHCM (84.1 ± 7% vs. 88.3 ± 7.3%, p = 0.017), particularly in the basal (80.2 ± 11.2% vs. 88.3±.7.2%, p = 0.033) and midcavity segments (85.4 ± 9.2% vs. 90.0 ± 8.5%, p = 0.044) (Figure 2). No significant difference was noted in the apical segments (88.2 ± 9.9% vs. 87.0 ± 12%, p = 0.679). Myocardial work efficiency in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.389, p = 0.002) and maximum provoked LVOT gradient (r=-0.446, p < 0.001). Moreover, patients with septal hypertrophy pattern showed significantly reduced basal myocardial work efficiency versus apical hypertrophy patients (83 ± 9% vs 92 ± 3%, p < 0.001).

Conclusion

Myocardial work is a promising tool to evaluate myocardial function in patients with oHCM and nHCM. oHCM patients had a significantly inferior GWI and GWE particularly in the basal and midcavity segments versus nHCM patients. Abstract Figure 1: Myocardial Work Index  Abstract Figure 2: Myocardial Work Efficiency

Analysis of sexual and reproductive health indicators according sexual orientation young Brazilians’

Background

Sexual and reproductive health indicators and behaviors may occur differently between sex and according to sexual orientation. In addition, there is a lack of studies that consider sexual orientation and approach young adults in Brazil.

Objective

To analyze sexual and reproductive health indicators of young Brazilian adults and their differences according to sex and sexual orientation.

Methods

Cross-sectional study with 2,063 young adults, undergraduate students from a public university who responded to the online survey. We estimated the prevalence of sexual and reproductive health indicators, desire or not to have children, report of pregnancy and feeling about the pregnancy state), according to sex (male and female) and sexual orientation (heterosexual, bisexual, homosexual). Differences between prevalence were assessed using Pearson's chi-square test.

Results

Among heterosexuals, condoms were the contraceptive method most used by men (90.6%) and women (75.5%). Women used double protection (53.5%) and had a fixed sexual partner (67.8%) in a greater proportion. Men, on the other hand, maintain the practice of casual relationships more frequently (70.5%) and 43.2% have already had unprotected casual relationships. Among bisexuals, condoms were the method most used by men (97.7%) and women (85.4%). In this group, 51% of women use double protection and have a steady partner (62.2%). Among homosexuals, 99.1% of gays and 46.1% of lesbians used condoms at the last sexual intercourse and 46.1% of lesbians used hormonal methods. Also, 28.8% of gays have already had an STI, a higher rate than among heterosexuals.

Conclusions

There are important differences in sexual and reproductive behaviors between genders and according to the sexual orientation of young people, such as greater vulnerability to STIs among gays and lesbians, and medicalization around the female body, highlighted by the permanence of questionable practices among lesbians.

Key messages

Gender issues could also explain the differences found between men and women. Differences between the sexes are also present when evaluating the use of protection against STIs or unplanned pregnancies.

P–452 The challenge of ovarian tissue culture: 2D versus 3D

Study question

Does an alginate matrix scaffold improve ovarian tissue culture?

Summary answer

Ovarian tissue culture within an alginate scaffold has no advantage over conventional culture, being more time consuming and less reproductible

What is known already

Cryopreservation of ovarian tissue is a powerful technique for preserving female fertility, as it can restore fertility and endocrine function. Several studies have been carried out aiming to increase the longevity of the transplant and decrease the risk of reimplantation of neoplastic cells. For in vitro follicle culture, recent research has shifted from two dimensional (2D) toward the use of three-dimensional (3D) structures. The use of a matrix maintains the architecture and mimics in vivo conditions, with a variable access to oxygen and nutrients. This bridges the gap between conventional cell culture and animal models.

Study design, size, duration

Ovarian tissue fragments were divided into 2 groups: conventional culture (2D culture) and culture using an alginate matrix scaffold (3D culture). Tissue was evaluated at four time-points: immediately after thawing and after 24, 48 and 72 hours of culture.

Participants/materials, setting, methods

Rat ovarian tissue was cryopreserved and thawed with validated protocols. Follicular analysis was conducted after haematoxylin and eosin staining, regarding density, classification and degeneration. Tissue viability was assessed using lactate dehydrogenase (LDH) levels in supernatants and histological score. Three parameters were considered, namely, interstitial oedema, follicular cell degeneration and percentage of tissue in necrosis. Apoptosis was assessed by caspase 3 immunostaining. Proliferating cells were identified using Ki67 immunohistochemical labelling.

Main results and the role of chance

Follicular density, cell proliferation and apoptosis both in follicles and stroma was similar in both culture conditions. Stromal cells proliferation was stable in conventional culture but decreased in 3D culture (p = 0.001), which can be explained by the rigidity of alginate matrix. At 24 hours of culture, cytotoxicity was lower in the 3D model (p = 0.006), due to low levels of LDH in the supernatant, that may be related to retention within the matrix. As culture time increased cytotoxicity seemed to be similar. Degradation of the tissue was suggested by the histological score analysis of tissue during 72 hours of culture. Tissue injury was greater (p = 0.01) in 3D culture due to higher interstitial oedema (p = 0.017) and tissue necrosis (p = 0.035). In the interior of the alginate scaffold, the bioavailability of oxygen and nutrients may be limited, affecting cell survival over time and conditioning higher level of necrosis and release of intracellular content.

Limitations, reasons for caution

There are two major limitations that should be addressed in future research, namely the study of the tissue-matrix interactions and culture medium supplementation to decrease follicular atresia.

Wider implications of the findings: There is no advantage in the use of an alginate matrix scaffold for ovarian tissue culture, as it is more time consuming, difficult to perform and less reproductible.

Trial registration number

Not applicable

Gynaecological cytology in women under the age of 30—the impact of P16/KI67 dual-staining cytology

Background

The HPV detection test is not recommended as a primary screening of cervical lesions, before the age of 30, because the high rate of HPV infections with a high rate of spontaneous resolution in this age group. This study aims to evaluate the performance of p16/Ki67 dual staining in detecting high-grade squamous cervical lesions in these women.

Methods

Cervical-vaginal samples from 67 women HPV positives under the age of 30 and cervical biopsies of 41 of these women. Results of p16/Ki67 dual staining, cytology and histology were analysed. In 53 of the women, 159 results of p16/Ki67 dual staining, HPV test and cytology, obtained in 3 follow-up medical visit, were compared.

Results

The p16/ki67 dual staining was positive in 23.9% and negative in 76.1% of all 67 women. All women with high squamous intraepithelial lesion cytology, 39.1% with low squamous intraepithelial lesion cytology, 17.4% with negative for intraepithelial lesion cytology and 10% with atypical squamous cells cytology, were p16/Ki-67 dual staining positives. In the 41 women with histological diagnosis, p16/ki67 dual staining showed a sensitivity of 87.5% and a specificity of 96% to detect HSIL. When comparing, the tests differ significantly (P < 0.001), p16/ki67 dual staining was positive in 24% of positive cytology and in 19.5% of positive HPV tests.

Conclusions

Our results demonstrate that p16/Ki67 dual stain has good sensitivity and specificity to detect HSIL and can be useful on women under the age of 30, avoiding excessive diagnosis and reducing colposcopy referrals. Further studies are required in a large number of women.

Early Cerebrovascular Ultrasonography as a Predictor of Hemorrhagic Transformation After Thrombectomy

OBJECTIVES

To determine the predictive value of early transcranial color-coded sonography (TCCS) for intracranial hemorrhage (ICH) in patients with large artery occlusion (LAO) stroke of carotid circulation, who were submitted to endovascular therapy (EVT) with successful reperfusion.

MATERIALS AND METHODS

Retrospective study evaluating a cohort of consecutive stroke patients with LAO of the carotid circulation that were recanalyzed with EVT. We measured angle-corrected peak systolic velocities, end-diastolic velocities and mean flow velocities (PSV, EDV and MFV) of the symptomatic and asymptomatic middle cerebral artery (MCA). The ratio between MFV of the symptomatic MCA and MFV of the asymptomatic MCA (MCA-Ra) was calculated. Parenchymal hematoma in the 24 hours control CT was considered as ICH. Univariate associations and multivariate analyses were used to identify early independent predictors for ICH among TCCS findings.

RESULTS

We included 234 patients, mean age 72.5 (SD 12.6) years, 52.1% male. The mean time between recanalization and TCCS was 12.3 hours (range 3-22). Patients who developed postinterventional ICH showed a higher MCA-Ra (1.02 ± 0.26 vs 1.16 ± 0,21, p = 0.036). In multivariate analysis, only higher MCA-Ra remained independently associated with postinterventional ICH (OR: 6.778, 95%CI: 1.152-39.892, p = 0.034). A value of MCA-Ra ≥ 1,05 was associated with ICH, showing a sensitivity of 81.3% and a specificity of 65.9%; the AUC based of the ROC analysis was 0.688 (95% CI 0.570-0.806).

CONCLUSION

TCCS performed within the first 24 hours after stroke onset can help to predict hemorrhagic transformation in patients with LAO.

Cerebral glucose metabolism in bipolar disorder: A voxel-based meta-analysis of positron emission tomography studies

BACKGROUND

Previous positron emission tomography studies have reported the changes of cerebral glucose metabolism in bipolar disorder. However, the findings across studies remain controversial, containing differing results.

METHODS

A systematic literature search of the PubMed, Embase, Cochrane Library, and Web of Science databases was conducted. We conducted a voxel-wide meta-analysis of cerebral glucose metabolism studies, using the seed-based mapping approach, in patients with bipolar disorder (BD).

RESULTS

We identified 7 studies suitable for inclusion, which included a total of 126 individuals with BD and 160 healthy controls. The most consistent and robust findings were an increase in cerebral glucose metabolism in the right precentral gyrus and a decrease in the left superior temporal gyrus, left middle temporal gyrus, and cerebellum. Additionally, the sex distribution and illness duration had significant moderating effects on cerebral glucose metabolism alterations.

CONCLUSIONS

Cerebral glucose metabolism alterations in these brain regions are likely to reflect the disease-related functional abnormalities such as emotion and cognition. These findings contribute to a better understanding of the neurobiological underpinnings of bipolar disorder.

LIMITATIONS

This study was done at a study level and cannot be addressed at the patient level. Subgroup analysis of BD I and BD II is not possible due to limited literature data.

Association between microvascular dysfunction and impaired myocardial deformation in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Objective

To analyze the relationship between coronary microvascular dysfunction (MCD) and left ventricular (LV) myocardial deformation in hypertrophic cardiomyopathy (HCM). 

Methods

Prospectively inclusion of HCM patients (P). MCD was assessed by CMR, during regadenoson-induced hyperemia. For perfusion assessment, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer). Ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Epicardial coronary artery disease was excluded by computed tomography or invasive coronary angiography.

LV myocardial deformation was evaluated by 2D and 3D speckle-tracking echocardiography (STE), including global longitudinal strain (GLS), peak systolic dispersion (PDS), global circumferential strain (GCS), global radial strain (GRS), area strain, twist and torsion.

Results

31 P enrolled (51%male,age57.8 ± 15.5years). Asymmetric septal hypertrophy was seen in 55%, apical in 29%, concentric in 16%,maximal wall thickness (MWT) of 20.5 ± 4.9mm; 26% with LVOT obstruction; LV ejection fraction 67.9 ± 7.9%.

In 2DSTE analysis, P with more ischemia (>20%of LV) presented more severe impaired GLS and greater PDS, comparing with patients with ≤20% of ischemia.

Similarly, 3DSTE imaging showed worse LV performance in P with greater ischemic burden, expressed by significant difference in GLS, GRS and area strain. GCS also trended to be worse in the presence of >20% of ischemia.

The stronger correlation was found between 2D GLS and ischemic burden (Pearson correlation factor 0.545; p = 0.002).

Conclusion

In HCM, the severity of ischemia secondary to MCD was associated with impairment in LV myocardial deformation evaluated by 2D and 3D STE.

Table 1. Echocardiography Ischemic burden (% of LV) 2D parameters ≤ 20% (n = 15) > 20% (n = 16) p-value GLS (%) -15.6 ± 2.7 -12.1 ± 4.7 0.016 PSD (ms) 73.2 ± 25.6 102.1 ± 57.6 0.150 3D parameters GLS (%) -10.3 ± 4.5 -7.3 ± 3.0 0.010 GCS (%) -12.6 ± 3.0 -10.1 ± 4.5 0.079 GRS (%) 30.8 ± 8.5 22.8 ± 11.4 0.035 Area strain(%) -20.8 ± 4.9 -15.8 ± 6.3 0.020 Twist (deg) 6.0 ± 4.8 4.1 ± 4.0 0.175 Torsion (deg/cm) 1.2 ± 0.9 0.8 ± 0.7 0.232

Adiponectin restrains ILC2 activation by AMPK-mediated feedback inhibition of IL-33 signaling

ILC2s are present in adipose tissue and play a critical role in regulating adipose thermogenesis. However, the mechanisms underlying the activation of adipose-resident ILC2s remain poorly defined. Here, we show that IL-33, a potent ILC2 activator, stimulates phosphorylation of AMPK at Thr172 via TAK1 in primary ILC2s, which provides a feedback mechanism to inhibit IL-33-induced NF-κB activation and IL-13 production. Treating ILC2s with adiponectin or an adiponectin receptor agonist (AdipoRon) activated AMPK and decreased IL-33-NF-κB signaling. AdipoRon also suppressed cold-induced thermogenic gene expression and energy expenditure in vivo. In contrast, adiponectin deficiency increased the ILC2 fraction and activation, leading to up-regulated thermogenic gene expression in adipose tissue of cold-exposed mice. ILC2 deficiency or blocking ILC2 function by neutralization of the IL-33 receptor with anti-ST2 diminished the suppressive effect of adiponectin on cold-induced adipose thermogenesis and energy expenditure. Taken together, our study reveals that adiponectin is a negative regulator of ILC2 function in adipose tissue via AMPK-mediated negative regulation of IL-33 signaling.

Insights from microRNAs into the pathophysiology of coronary and multiterritorial atherosclerosis

Introduction

The mechanisms underlying the different phenotypic presentations of atherosclerosis are still poorly understood. MicroRNAs regulate genetic expression at the post-transcriptional level and each has specific biological functions. MicroRNAs could therefore be useful for understanding the epigenetic drivers for development of isolated coronary atherosclerosis and more extensive disease (coronary and extra-coronary). We evaluated if the expression profile of circulating microRNAs was associated with coronary and multiterritorial atherosclerosis.

Methods

We prospectively recruited three groups of age- and sex-matched participants, with: 1) no coronary atherosclerosis (calcium score=0, no soft plaques in coronary angioCT scan), neither carotid or inferior limbs atherosclerosis (controls); 2) isolated obstructive coronary artery disease (CAD) (≥50% for the left main, ≥70% for other epicardial vessels) (isolated CAD group); 3) obstructive disease of the coronary, inferior limbs and carotid arterial beds (multi-territorial disease group). Obstructive atherosclerosis of carotid and inferior limbs arteries (≥50% stenosis by Doppler or angioCT imaging) was assessed in all participants. Acute atherosclerotic events or coronary revascularization within 12 months, heart failure, infections, malignancy and severe renal dysfunction were exclusion criteria. Six microRNAs with diverse mechanisms of action were selected (mir-21, miR-27b, miR-29a, miR-126, miR-146, miR-218) and measurements of their circulating levels were performed in a blinded fashion, using RT-PCR SYBR Green.

Results

Twenty four patients were included, including 8 patients in each group. Mean age was 61±9 years, and 83% were male. In patients with atherosclerosis, classical cardiovascular risk factors were globally more prevalent. The expression of miR-146 and miR-218, both of which regulate endothelial function, was significantly decreased in the isolated CAD group compared to controls (Figure; data are expressed as median [IQR]). There was a further decrease in the expression of both microRNAs in patients with multiterritorial atherosclerosis compared to patients with isolated CAD. The expression of other microRNAs did not differ. Smoking was associated with the presence of isolated CAD and multiterritorial atherosclerosis (14% vs 30% vs 56% of smokers across groups, p=0.002), and with a decreased expression of miR-218 (1.6 [0.02–83] fold vs 0.1 [0.001–0.7] fold, p=0.023).

Conclusions

The expression of the endothelial regulators miR-146 and miR-218 was decreased in patients with isolated CAD compared to controls, and even more hampered in patients with multiterritorial atherosclerosis. Higher degrees of endothelial dysfunction may therefore contribute to a more diffuse atherosclerotic presentation through miR-146 and miR-218. Atherogenesis related to smoking may be partially mediated by miR-218.

Funding Acknowledgement

Type of funding source: None

Innate immunity is linked to the severity of stable coronary artery disease through sCD40L pathway

Introduction

Soluble CD40 ligand (sCD40L) activates different cell types involved in innate immunity, including macrophages and platelets. The influence of innate immunity, particularly of sCD40L pathway, on stable coronary artery disease (SCAD) expression is not fully understood. We evaluated if sCD40L expression is related to the presence of SCAD and to its clinical and anatomical severity.

Methods

We prospectively recruited two groups of age- and sex-matched participants: 1) without coronary artery disease (CAD) (calcium score=0, no soft plaques on coronary angioCT scan) (controls); and 2) with stable obstructive CAD (≥50% for the left main, ≥70% for other epicardial vessels, on invasive coronary angiography). Acute atherosclerotic events or coronary artery bypass grafting (CABG) within 12 months, previous percutaneous coronary intervention, heart failure, infection, malignancy and severe renal dysfunction were exclusion criteria. Clinical, laboratorial and anatomical data were prospectively collected. Serum was stored at −80°C and measurements were performed in a blinded fashion, by ELISA (sCD40L Human Quantikine).

Results

Sixty-three participants were included: 14 controls and 49 patients with SCAD. In SCAD patients, classical cardiovascular risk factors were globally more prevalent and the serum levels of sCD40L (5553±3356 vs 3099±644 ng/mL, p<0.001), leucocytes counts (7.6±1.8 vs 6.4±1.7x109/L, p=0.010), neutrophils counts (4.4±1.5 vs 3.5±1.5x109/L, p=0.010) and neutrophils/lymphocytes ratio (2.4±1.1 vs 1.9±0.7, p=0.019) were significantly higher, while c-reactive protein (CRP) levels did not differ, compared to controls. sCD40L levels were positively correlated with leucocytes (r=0.36) and neutrophils (r=0.28) counts (all p<0.05), but not with CRP. Clinically, sCD40L levels were associated (ANOVA p<0.001) and positively correlated (Pearson r=0.54, p<0.001) with angina severity (Fig. 1A). Anatomically, patients with a higher number of significant coronary artery lesions presented higher sCD40L levels (Fig. 1B); sCD40L levels were positively correlated with the number of: diseased vessels (r=0.33), significant coronary artery lesions (r=0.31), and all coronary artery lesions (r=0.33) (all p<0.05), without correlation with the Gensini score. Linear regression analysis considering clinical and laboratorial data revealed that sCD40L was an independent predictor of CAD severity, as assessed by the number of significant lesions (model: sCD40L β 0.28, 95% CI 0.03–0.34; hypertension β 1.1, 95% CI 0.97–3.64). Among SCAD patients, those with previous CABG (n=15) had lower sCD40L levels than patients waiting for revascularization (n=34) (3317±1680 vs 6793±3631 ng/mL, p<0.001).

Conclusions

Increased expression of sCD40L was associated with the presence of SCAD, with angina severity and with CAD severity, while previous revascularization was associated with decreased sCD40L levels.

Funding Acknowledgement

Type of funding source: None

Negative impact on the reproductive potential of blue jack mackerel Trachurus picturatus by Kudoa infection of the ovary

Reproduction of Trachurus picturatus off the western Portuguese coast was studied over 1 yr. During histological analyses, the presence of Kudoa sp. was detected in advanced vitellogenic oocytes. Kudoa infections are known to cause economic loss through the induction of post-mortem liquefaction of fish muscles, but ovarian infection as reported in this study will seriously affect the reproductive potential of the species and thus impact fisheries productivity. Only females showed gonad infection which led to total degradation of advanced vitellogenic oocytes. No macroscopic, somatic or condition indices revealed differences between infected and uninfected females, rendering this infection event a concealed suppression of reproduction.

Analysis of hospitalization trends for ambulatory care sensitive conditions in Piauí/Brazil, 2009-18

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are hospitalizations that can be potentially preventable through care at the first level of contact for health care. In fact, the actions offered in a timely and effective manner can reduce the risk of unnecessary hospitalizations by preventing diseases, controlling acute episodes and managing chronic diseases.

Aim

Analyze the trends in hospitalizations for ACSC in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH) of the public health system (SUS), which comprised all hospitalizations of residents of Piauí, Brazil, in the period from 2009 to 2018. The explanatory variables were the hospitalizations for ACSC groups. For temporal trend analysis, the Prais-Winsten linear regression model was used in the Stata version 14 program.

Results

567,577 were recorded as ACSC, representing 35.3% of the total hospitalizations (1,608,263). Most hospitalizations for ACSC were caused by infectious gastroenteritis (33.5%). The risk of hospitalization for ACSC decreased 36.8%, showing a significant reduction in the trend of the hospitalization rate (Annual Percent Change - APC: -4.6%; 95%CI: -6.4; -2.8). There was a greater decrease in the risk of hospitalization for asthma (70.3%), hypertension (66.4%) and infectious gastroenteritis (61.8%). However, a significant increase was identified for skin infection (6.1 times) and diseases related to prenatal care and childbirth (3.2 times).

Conclusions

The reduction in hospitalizations due to ACSC is a result of the strengthening of Primary Health Care as the Brazilian health system organizer and the implementation of the Mais Médicos Program, which enabled the presence of doctors in family health teams, especially in places that had not previously been attended. It is also necessary to develop new studies to expand the discussions and debates on these findings.

Key messages

Hospitalizations reflect the living conditions of individuals, with social changes being perceived by changes in hospitalization patterns over time. The strengthening of primary care policies in Brazil was able to reduce hospitalizations for ACSC and it is necessary to further strengthen these practices to improve people's health care.

Nurses' production of meaning about National Program for Access and Quality Improvement Primary Care

Introduction

The Brazil's Family Health Strategy (ESF) is one of the initiatives for the strengthening of primary health care (PHC) in Brazil. The ESF is composed of a team of professionals, with the nurse usually adding care and administrative functions. In regard to the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), the nurses have played a prominent role, especially in the external evaluation phase.

Aim

Analyze the meanings produced by nurses about the PMAQ-AB in a state in the northeastern of Brazil.

Methods

A qualitative research was carried out with twenty-five nurses from the health macro-regions of the State of Piauí. Data were collected from four focus groups, with one group in each macro-region, containing at least six and at most seven participants. The meetings were held from September to October 2018, in which semi-structured interview script was used. For the analysis of information, the maps of association of ideas proposed by Spink and Gimenes (1994) were used.

Conclusions

Despite the difficulties and conflicts felt by nurses with the implementation of PMAQ-AB, the program was understood as an agent for transforming in the work process of family health teams. In addition, the realization of this study allowed another space for reflection to the nurses about the program, qualification and financing of PHC, which can contribute to the institutionalization of the culture of monitoring and evaluation and also the consequent strengthening of these services.

Key messages

Based on the expected impacts, we seek collaborate with reflection on the experience and generate consistent and useful information to contribute to the decision-making processes of health policies. The PMAQ-AB was considered a program that was able to induce substantial changes in work processes because it was a way to finance the workforce.

Sustained activation of autophagy suppresses adipocyte maturation via a lipolysis-dependent mechanism

Dysregulation of macroautophagy/autophagy is implicated in obesity and insulin resistance. However, it remains poorly defined how autophagy regulates adipocyte development. Using adipose-specific rptor/raptor knockout (KO), atg7 KO and atg7 rptor double-KO mice, we show that inhibiting MTORC1 by RPTOR deficiency led to autophagic sequestration of lipid droplets, formation of LD-containing lysosomes, and elevation of basal and isoproterenol-induced lipolysis in vivo and in primary adipocytes. Despite normal differentiation at an early phase, progressive degradation and shrinkage of cellular LDs and downregulation of adipogenic markers PPARG and PLIN1 occurred in terminal differentiation of rptor KO adipocytes, which was rescued by inhibiting lipolysis or lysosome. In contrast, inactivating autophagy by depletion of ATG7 protected adipocytes against RPTOR deficiency-induced formation of LD-containing lysosomes, LD degradation, and downregulation of adipogenic markers in vitro. Ultimately, atg7 rptor double-KO mice displayed decreased lipolysis, restored adipose tissue development, and upregulated thermogenic gene expression in brown and inguinal adipose tissue compared to RPTOR-deficient mice in vivo. Collectively, our study demonstrates that autophagy plays an important role in regulating adipocyte maturation via a lipophagy and lipolysis-dependent mechanism.

ABBREVIATIONS

ATG7: autophagy related 7; BAT: brown adipose tissue; CEBPB/C/EBPβ: CCAAT enhancer binding protein beta; DGAT1: diacylglycerol O-acyltransferase 1; eWAT: epididymal white adipose tissue; iWAT: inguinal white adipose tissue; KO: knockout; LD: lipid droplet; MAP1LC3/LC3: microtubule-associated protein 1 light chain 3; MTOR: mechanistic target of rapamycin kinase; MTORC1: mechanistic target of rapamycin kinase complex 1; PLIN1: perepilin 1; PNPLA2/ATGL: patatin-like phospholipase domain containing 2; PPARG/PPARγ: peroxisome proliferator activated receptor gamma; RPTOR: regulatory associated protein of MTOR complex1; TG: triglyceride; ULK1: unc-51 like kinase 1; UCP1: uncoupling protein 1; WAT: white adipose tissue.

Expenditure trends in ambulatory care sensitive conditions in Piauí, Brazil, 2009 a 2018

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are an indicator that assesses the effectiveness of Primary Health Care. Such hospitalizations burden the public health budget and use the resources that could subsidize other health actions.

Aim

Analyze expenditure trends in hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH). For temporal trend analysis, a linear regression model was built using the Stata version 14 program.

Results

US$ 119,559,009.56 (Average = US$ 6,292,579.45/year) was spent on ACSC, representing 17.3% of the total hospitalizations (US$ 690,714,037.24). 2010 was the period with the highest cost (14.8%). In contrast, 2018 was the year with the lowest expenditure (5.8%). 23.7% of the costs went to hospitalizations for gastroenteritis. There was a significant decrease in total expenses with ACSC (β = -1.27; 95%CI: -1.65; -0.89; p < 0.001). There was also a reduction in expenses per individual hospitalized, while in 2009, the average expenditure was US$ 230.97/hospitalization, in 2018 it was US$ 157.30/ hospitalization, representing a significant reduction of 31.9%, (β = -12.4; 95%CI: -18.2; -6.6; p = 0.001). The “asthma” and “hypertension” groups showed the greatest cost reductions, 84.8% and 80.7%, respectively. However, an increase in spending on diseases related to prenatal and childbirth (4.1 times) and skin infection (3.9 times) was identified.

Conclusions

Part of the cost reduction is explained by the reduction of hospitalizations for ACSC. The reduced spending averages are compatible with lower hospitalizations by most expensive groups. Linked to these findings, it is observed that Brazil has faced a period of recession since 2015. To this end, additional research must be carried out to relate the expansion of health coverage with the results presented.

Key messages

The costs of hospitalizations for PHC-sensitive conditions reflect the policy of inducing health system coverage, being lower for greater coverage. The evaluation of the cost of specific groups allows the induction of PHC policies focusing on the specific care for each group with a higher cost so as not to burden the health system.

Single-shot d-scan technique for ultrashort laser pulse characterization using transverse second-harmonic generation in random nonlinear crystals

We demonstrate a novel dispersion-scan (d-scan) scheme for single-shot temporal characterization of ultrashort laser pulses. The novelty of this method relies on the use of a highly dispersive crystal featuring antiparallel nonlinear domains with a random distribution and size. This crystal, capable of generating a transverse second-harmonic signal, acts simultaneously as the dispersive element and the nonlinear medium of the d-scan device. The resulting in-line architecture makes the technique very simple and robust, allowing the acquisition of single-shot d-scan traces in real time. The retrieved pulses are in very good agreement with independent frequency-resolved optical grating measurements. We also apply the new single-shot d-scan to a terawatt-class laser equipped with a programmable pulse shaper, obtaining an excellent agreement between the applied and the d-scan retrieved dispersions.

THU0559 IMPLEMENTATION OF A TRIAGE SYSTEM IN A HOSPITAL WITH HIGH DEMAND FOR CARE

Background:

Our hospital has 4 Rheumatologists and is in charge of 425.000 inhabitants (1 rheumatologist per 106.250 inhabitants). In November 2017, there were 503 referrals from primary care waiting for a first visit with the rheumatologist. Given the impossibility of covering this number of waiting patients through normal operation, it was decided to implement a rapid access polyclinic that started in December of 2017.

Objectives:

To evaluate the effectiveness of a triage system in a center with high demand for care.

Methods:

Patients referred by the general practitioner were evaluated by a senior rheumatologist in a 10-minute consultation using a predefined interrogation, expanded case-by-case based on the criteria of each rheumatologist. According to the results of the interview, the situation of the patient was categorized into: urgent, normal rheumatology control or control in primary care. For urgent consultations, an early control polyclinic was created to evaluate these patients within the following 15 days. The usual consultations entered into the usual scheduling system. The pathologies that were considered to require control in primary care were assigned to a coordination polyclinic where the patients were evaluated by an internist, in charge of confirming the diagnosis, educating the patient, and, if applicable, refer to primary care. No patient was discharged immediately after the triage. We report the data of the first 136 patients.

Results:

The waiting time was reduced from a median of 275 days (IQR 66-591) to 46.5 (23-140). Refer to table 1 for full results. In 52.2% of referred patients the suspicion of a chronic autoimmune or inflammatory disease was described in the referral note. In these patients, when comparing with patients whose referral notes did not refer to an inflammatory or autoimmune disease, the waiting time for triage was significantly shorter, the percentage of patients who were discharged from rheumatology was significantly lower, and the percentage of patients in whom a chronic autoimmune or inflammatory disease was confirmed in the first control was significantly higher.

Table 1All patientsOnly those with suspected autoimmune or chronic inflammatory disease in referral notePatients referred for other reasons (fibromyalgia, arthralgia, myalgia, osteoporosis, etc.)pNumber (%)136 (100)71 (52.2)65 (47.8)NAAge,mean years (SD)51.8 (16.3)50.7 (16.4)53.1 (16.2)NSMen, n (%)24 (17.6)15 (21.1)9 (13.8)NSTime between referral and triage, median days (IQR)46.5 (23-140)34 (15.5-124.5)54 (28-441)0,017Triage resolutionUrgent control, n (%)92 (67.6)55 (77.5)37 (56.9)0,011Normal Control, n (%)25 (18.4)12 (16.9)13 (20)NSPrimary care coordination, n (%)19 (14)4 (5.6)15 (23.1)0,003Time between triage and first control, median days (IQR)21 (14-42)21 (12.5-41)26 (21-42)NSFirst control resolution, n (%)96 (70.6)54 (76.1)42 (64.6)NSDiagnosis confirmation, n (%)37 (38.5)26 (48.1)11 (16.9)0,028Continue control, n (%)41 (42.7)26 (48.1)15 (23.1)NSDischarge to primary care, n (%)18 (18.8)2 (3.7)16 (24.6)<0,001

SD: standard deviation; n: number; IQR: Interquartile range

Conclusion:

We consider this strategy as successful in reducing care times and identifying patients who require an early start of treatment and close control. Referral notes from primary care were generally adequate to identify patients who required to continue rheumatologist control.

References:

None.

Disclosure of Interests:

Sebastian Ibáñez Consultant of: Novartis, Paid instructor for: Bristol Myers, Speakers bureau: Abbvie, Francisca Valenzuela: None declared, Oriela Martinez: None declared, Omar Valenzuela Consultant of: Bristol Myers, Paid instructor for: Bristol Myers, Speakers bureau: Bristol Myers, Abbvie, Francisco Silva Consultant of: Roche, Speakers bureau: Roche, María José Villar: None declared, María Paz Poblete: None declared, Claudia Mardones: None declared

[Efficacy and safety of transcranial magnetic stimulation in patients with non-fluent aphasia, following an ischaemic stroke. A controlled, randomised and double-blind clinical trial]

INTRODUCTION

Non-fluent aphasia is a frequent complication in post-ischemic stroke patients, with repetitive transcranial magnetic stimulation (rTMS) being one of the possible treatment alternatives.

AIM

To assess the efficacy and safety of rTMS in patients with non-fluent after-ischemic stroke aphasia.

PATIENTS AND METHODS

Double blind, randomized controlled clinical trial in post-stroke patients who were assigned to receive 10 sessions (one daily) of active treatment or placebo of rTMS, without the addition of language therapy. The baseline characteristics were compared initially and the efficacy between the active group versus the placebo group at day 30 was evaluated through a Mann-Whitney U test.

RESULTS

82 patients were included: active group (n = 41) and placebo group (n = 41). At baseline, statistically significant differences were found between the groups in favor of the placebo in the domains of the Boston test of auditory compression (p = 0.024), denomination (p = 0.014) and praxis (p = 0.026), and also occurred on the 30th day in the naming domains (p = 0.037) and reading (p = 0.001). There were 39 adverse reactions: 23 (26.83%) in the active group vs 16 (21.96%) in the placebo group (p = 0.290); the majority corresponded to episodes of mild headache.

CONCLUSION

rTMS is a safe therapy, however, given the conditions of this study, we could not demonstrate the efficacy of rTMS versus placebo in patients with non-fluent aphasia with involvement of Broca's area after an ischemic stroke.

The Evolution of Cognitive Behavioural Therapy – The Third Generation and Its Effectiveness

Introduction.

First wave cognitive behavioural therapy (CBT) focuses essentially on classical conditioning and operant learning and second wave on information processing. They are based on the premise that certain cognitions, emotions and physiological states lead to dysfunctional behaviour and so, by eliminating the first ones, changes in behaviour will take place. Third wave CBT appeared in an attempt to increase the effectiveness of first and second wave by emphasizing contextual and experiential change strategies.

Objectives/Aims.

To make a review on the actual state of the art of third wave CBT, focusing on MBSR (Mindfulness-Based Stress Reduction), MCBT (Mindfulness-based Cognitive Behavioural Therapy), DBT (Dialectical Behaviour Therapy), ACT (Acceptance and Commitment Therapy) and CFT (Compassion Focused Therapy).

Methods.

Research on PubMed using the terms “third wave cognitive behavioural therapy”.

Results.

Methods and targets differ between MBSR, MCBT, DBT, ACT and CFT. Depression, anxiety and borderline personality disorders are some of those targets. However, a transdiagnostic approach is the hallmark of all third wave therapies: mental processes or emotions transversal to many psychiatric disorders such as shame, self-criticism, experiential avoidance or cognitive fusion are the main focus, emphasizing the context and human experience over any categorical diagnosis.

Conclusions.

Third wave cognitive behavioural therapy is an emerging approach born from the need to improve and complement first and second waves. Although very promising, it is still a recent approach and data to support its superiority over the conventional therapies is missing.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P1594 Relationship between left ventricular morphology and systolic performance and coronary microcirculatory dysfunction in hypertrophic cardiomyopathy

Background

Myocardial ischemia constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy (HCM). Chronic and recurrent myocardial ischemia leads to fibrosis, which may culminate in myocardial dysfunction.

Objective

To analyse the relationship between left ventricular (LV) morphology and systolic performance and coronary microcirculatory dysfunction in HCM.

Methods

The present study prospectively included HCM patients (P) who underwent transthoracic echocardiography. Left ventricular (LV) function was evaluated by ejection fraction (LVEF), global longitudinal strain (GLS) and tissue Doppler septal and lateral s’. The evaluation of coronary flow velocity reserve (CFVR) was performed in apical three chambers view for the left anterior descending (LAD) artery and in an apical three chambers view for the posterior descending (PD) artery. Diastolic coronary flow velocity was measured in basal conditions and in hyperemia, induced by adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). Absolute CFVR was calculated as the ratio of hyperemic to basal peak diastolic flow velocities; relative CFVR was calculated as the ratio between CFVR LAD and CFVR PD.

Results

23 P were enrolled (57% male, mean age 57.9 ± 13.7 years). Asymmetric septal hypertrophy was verified in 70% of P, with maximal wall thickness of 21.6 ± 4.3mm. Obstructive HCM was documented in 35% of patients.

CFV was successfully measured in the LAD in all patients, but only in 70% of patients in the PD due to technical issues related to poor acoustic window and anatomical constraints. 78% of P (n = 18) presented CFVR &lt;2, denoting microcirculatory dysfunction. Relative CFVR (LAD CFVR/ PD CFVR) was ≥1 in 43% of P.

P with maximal wall thickness (MWT)&gt;20mm presented higher CFV PD at baseline (46.5 ± 17.4 vs 32.5 ± 12.6 cm/s; p = 0.072), lower CFVR PD (1.3 ± 0.3 vs 2.5 ± 0.8; p = 0.003) and greater regional difference of microcirculation (relative CFVR 1.4 ± 0.6 vs 0.8 ± 0.3; p = 0.048).

At baseline conditions, CFV LAD was higher in obstructive HCM (44.0 ± 4.8 vs 35.3 ± 10.6 cm/s; p = 0.040).

P with impairment in global longitudinal strain (GLS&gt;-18%) had higher basal CFV LAD (40.1 ± 8.6 vs 30.0 ± 12.2 cm/s; p = 0.059) and PD (44.5 ± 15.2 vs 20.0 ± 5.0 cm/s; p = 0.015) but lower CFVR PD (1.5 ± 0.5 vs 2.8 ± 1.1; p = 0.039). The reduction in CFVR PD was also noted in P with time to peak longitudinal strain dispersion &gt;90mseg (CFVR PD 1.2 ± 0.2vs1.9 ± 0.9;p = 0.012).

Conclusion

Higher CFV at baseline was noted in P with greater MWT, obstructive HCM and worse GLS. Coronary microcirculatory dysfunction was associated with the degree of LV hypertrophy and impairment in LV systolic performance.

Adipose mTORC1 Suppresses Prostaglandin Signaling and Beige Adipogenesis via the CRTC2-COX-2 Pathway

Beige adipocytes are present in white adipose tissue (WAT) and have thermogenic capacity to orchestrate substantial energy metabolism and counteract obesity. However, adipocyte-derived signals that act on progenitor cells to control beige adipogenesis remain poorly defined. Here, we show that adipose-specific depletion of Raptor, a key component of mTORC1, promoted beige adipogenesis through prostaglandins (PGs) synthesized by cyclooxygenase-2 (COX-2). Moreover, Raptor-deficient mice were resistant to diet-induced obesity and COX-2 downregulation. Mechanistically, mTORC1 suppressed COX-2 by phosphorylation of CREB-regulated transcription coactivator 2 (CRTC2) and subsequent dissociation of CREB to cox-2 promoter in adipocytes. PG treatment stimulated PKA and promoted differentiation of progenitor cells to beige adipocytes in culture. Ultimately, we show that pharmacological inhibition or suppression of COX-2 attenuated mTORC1 inhibition-induced thermogenic gene expression in inguinal WAT in vivo and in vitro. Our study identifies adipocyte-derived PGs as key regulators of white adipocyte browning, which occurs through mTORC1 and CRTC2.

Determination of Minerals and Trace Elements in Milk, Milk Products, Infant Formula, and Adult Nutrition: Collaborative Study 2011.14 Method Modification

Official Method SM 2011.14/ISO 15151:2018/IDF 229:2018 uses microwave digestion of samples and inductively coupled plasma–atomic emission spectrometry for determination of nine elements, including Ca, Cu, Fe, K, Mg, Mn, Na, P, and Zn. The method was evaluated in a collaborative study of 25 products, including 13 fortified nutritional products (powders, ready-to-feed liquids, and liquid concentrates), five product placebos, six dairy products (liquids, powders, butter, and processed cheese), and the National Institute for Standards and Technology (NIST) Standard Reference Material (SRM) 1849a, in compliance with AOAC INTERNATIONAL Standard Method Performance Requirement (SMPR®) 2014.004. This study significantly expanded the applicability of Official Method 2011.14 beyond the original scope of chocolate milk powder, dietetic milk powder, infant cereal, peanut butter, and wheat gluten. The study included 14 collaborators from 11 countries, and results were compared to SMPR 2014.004. Accuracy of the method was demonstrated using NIST SRM 1849a, yielding recoveries across all laboratories of 98–101% for the nine elements. Precision for the 13 fortified nutritional product samples was 2.2–3.9% for repeatability (relative SD of repeatability) and 6.0–12.2% for reproducibility (RSDR). Excluding Mn, which was present at a wide range of concentrations, the reproducibility was 6.0–9.5%, meeting the performance requirements of SMPR 2014.004. Placebo samples (not fortified with Cu, Fe, Mn, or Zn) yielded acceptable repeatability of 1.8–2.9% for Ca, K, Mg, Na, and P (minerals) but 5.4–29.4% for the low levels of Cu, Fe, Mn, and Zn (trace elements). Reproducibility for the placebos showed the same pattern, with acceptable reproducibility (5.4–10.3%) for minerals but not for the low levels of the trace elements (13.2–82.8%). In the six dairy product samples, repeatability ranged from 1.6 to 3.6% for the minerals, Zn, and the low range of Mn but from 9.4 to 24.6% for Cu, Fe, and the high range of Mn, where concentrations were low as for the nutritional placebos. Reproducibility in the dairy samples was 5.3–8.8% for the minerals but 11.4–55.0% for the trace elements. The mean concentrations of Cu, Fe, and Zn in the dairy products were similar with those in the placebo products, while Zn was present at levels more similar with the fortified nutritional products. Thus, the method met the SMPR criteria except where the trace minerals were present at very low levels. Based on these results, the AOAC Stakeholder Panel for Infant Formula and Adult Nutritionals recommended Final Action status of the expanded applicability of the method. The method was adopted as Final Action by the AOAC Official Methods Board.

Role of the health sector in EIA

EIA is an obligation for many projects in many countries. Consideration of human health within EIA is also an obligation. This results in an invaluable opportunity for early consideration of a variety of environmental health determinants, leading to minimization of noxious exposures and promotion of the salutogenic factors involved in plans and projects in many sectors. In other words, EIA can be an extremely powerful vehicle to scaling up primary prevention - by far the most effective strategy in public health. This opportunity is further enriched by the recent revision of the EU Directive on EIA, which makes better provision for human health considerations in EIA, in particular referring to the need to address “significant” health effects of plans and projects - without elaborating further.

The health sector can play a key role in EIA by: recognizing the opportunity and its potential, so far under-exploited; engage in dialogue with other sectors, on specific applications; make institutional arrangements so as to secure manpower and competences to contribute to EIA; advocate for a high level of human health consideration in EIAs on the ground.

This process requires careful consideration of needs and constraints of EIA, including a need to establish a common language with other sectors, the identification of realistic, achievable goals, as well as long-term objectives, the consolidation of available methods and tools and a need to engage in possibly unfamiliar conversations. A pragmatic, operational decision on what constitutes significant health effects in the context of EIA may be a good starting point to measure the readiness of the health sector to undertake this journey.

The amended EIA directive creates opportunities for public health

Environmental Impact Assessment (EIA) is conducted by the developer as part of the process of seeking consent to proceed with the project. The developer may be a public authority or a private company. The Directive for Environmental Impact Assessment (EIA) (2011/92/EU) was amended in 2014 (2014/52/EU). The changes are now transposed into national regulations across European Union Member States. These changes have an influence beyond EU borders, for example, through the policies of the European Investment Bank and the European Bank of Reconstruction and Development. The amendments to the Directive create both opportunities and challenges for public health. The opportunities stem from the changes that have been made to the Directive. Population and human health are now on the list of core topics that must be considered in an EIA. The other core topics to be assessed are each ‘determinants of health’, for example: biodiversity; land, soil, water, air and climate; and material assets, cultural heritage and the landscape. The Directive now requires the interaction between these factors to be considered. The amended Directive includes other issues that are relevant to human health, for example, climate change and vulnerability (exposure and resilience) to major accidents and/or disasters. The developer’s assessment must be prepared by Competent Experts. The changes also pose challenges. These are technical. For example, human health needs to be assessed within the framework of EIA. The changes also pose challenges to the public health workforce. There is a need to ensure there is capacity to participate in EIA. The EIA is typically prepared by the developer and reviewed by the competent authority. There is a role for public health expertise in these complementary activities. This presentation will focus on the opportunities created by the changes to the Directive and the opportunities this creates. It will also touch on the challenges.