V-013 ETEP - STEP BY STEP

Minimally invasive approaches are increasingly being used for the correction of abdominal wall hernias. Although laparoscopy presents as a greater technical challenge compared to classical techniques, once the learning curve is overcome, the advantages are multiple: less postoperative pain, shorter hospital stay, faster return to daily/professional activities and lower rate of surgical site infection.

The authors present the case of a 55yo women with a history of type 2 diabetes mellitus and peripheral venous insufficiency. No history of previous surgeries. The patient was referred to an appointment in the Ambulatory Surgery Centre for evaluation of a primary midline hernia. Symptoms were worsening in the last 6 months. No previous episodes of complications. Preoperative evaluation included an abdominopelvic computed tomography, which revealed a hernia sac containing only fatty tissue (no intestinal loops present) and a 19 mm hernial neck with a supra-umbilical median location. No other abdominal wall defects were evident.

The patient was proposed for a laparoscopic approach - extended totally extraperitoneal (eTEP) in ambulatory setting. The surgery and post-operative period (9 months) to date went without intercurrences.

The present video aims to demonstrate the main steps of the surgical technique applied in a tertiary centre with years of experience in laparoscopic abdominal wall surgery.

With this paper the authors pretend to demonstrate that laparoscopy may become the gold-standard in abdominal wall hernia correction as soon as the know-how and respective learning curve are aquired. Until then, these cases should continue to be referred to specialized tertiary centres.

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

A new ratio with PaO2/FiO2 and pulmonary arterial systolic pressure in the prognosis of intermediate high risk pulmonary embolism

Background

Intermediate high (IH) risk pulmonary embolism (PE) defines a category of patients (P) at increased risk of haemodynamic decompensation. Therefore, it is important to develop tools to identify P who will have an unfavourable outcome. The ratio between arterial oxygen partial pressure (PaO2) to fractional inspired oxygen (FiO2) – P/F ratio - is associated with in-hospital mortality (IHM) in PE. Pulmonary arterial systolic pressure (PASP) is another prognostic factor, related with right ventricular (RV) pressure overload. This study evaluates the usefulness of a new ratio with P/F divided by PASP (P/F:PASP), reflecting both severity of respiratory failure and pressure overload, in the prognosis of P with IH risk PE.

Methods

All P admitted for IH risk PE in an Intensive Cardiac Care Unit (ICCU) for 10 years were included. P/F ratio was calculated with admission blood gas analysis and PASP was obtained with echocardiography at admission in ICCU. P/F:PASP ratio was considered low if inferior to its median. Need for fibrinolysis and IHM were assessed. Follow-up (FU) of 2 years for all-cause mortality was done. Statistical analysis used chi-square and Mann-Whitney U tests, binary logistic regressions and Kaplan-Meier curves.

Results

101 P were studied (mean age 63±17 years; 35.6% male). Mean P/F, PASP and P/F:PSAP were 264±68, 45±15 mmHg and 6.7±3.3, respectively. P/F:PASP was considered low if inferior to 5.9.

There was no difference in age, gender, comorbidities or Pulmonary Embolism Severity Index (PESI) between P with low or high P/F:PASP. However, low P/F:PASP ratio was associated with tachypnea at admission (p=0.034), higher BNP level (p=0.011), right precordial leads T-wave inversion (p=0.029), presence of echocardiographic right ventricle dilation (p=0.002) and lower TAPSE (p=0.002).

Among P who underwent fibrinolysis, 60.4% had low P/F:PASP and 39.6% had high P/F:PASP ratio (χ2=3.32, p=0.05). P/F:PASP ratio was a predictor of fibrinolysis (OR 0.83, 95% CI 0.72–0.96, p=0.011), with lower ratio increasing the probability of fibrinolysis. This result was independent from PESI (OR 0.84, 95% CI 0.72–0.97, p=0.015). P/F:PASP ratio was also a predictor of IHM (OR 0.62, 95% CI 0.38–1, p=0.05).

During FU, there was no difference in mortality between P with low or high P/F:PASP ratio (8.5% vs. 10.4%, respectively; Kaplan-Meier χ2=0.095; p=0.758).

Conclusions

In IH risk PE, low P/F:PASP ratio was associated with analytical, electrocardiographic and echocardiographic risk features. In this study, P/F:PASP ratio was a predictor of short term prognosis, allowing identification of P at higher risk of fibrinolysis and IHM, but it was not useful for long term prognosis, as 2-year mortality was similar between the groups. Therefore, this ratio, as a measure of both respiratory failure and pressure overload, might allow refinement in risk stratification of P with IH risk PE.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of relative wall thickness in heart failure with preserved ejection fraction: what is the best method for its calculation?

Background

The HFA-PEFF diagnostic algorithm is a recently published tool to help in the diagnosis of heart failure with preserved ejection fraction (HFpEF). One of the echocardiographic diagnostic criteria is left ventricular (LV) relative wall thickness (RWT), an index of LV concentricity. LV wall thickness can be measured by echocardiography at the posterior wall (PW) and/or the interventricular septum (IVS) in parasternal long axis view. There are three methods of RWT calculation: RWTPW= 2xPW/LV dimension at end diastole (LVDd) – the most used method, RWTIVS = 2 x IVS / LVDd and RWTPW + IVS = (PW + IVS) / LVDd. This study compares the prognostic value of these 3 methods of calculation in patients with acute HFpEF.

Methods

All patients admitted with acute HFpEF in a Cardiology Department during 7 years were included. RWT was considered elevated if superior to its median and was calculated with the 3 formulas. In-hospital mortality (IHM) was evaluated. The primary endpoint (EP) was a composite of all-cause mortality or hospitalization for HF during follow-up of 24 months. Statistical analysis used chi-square and Mann-Whitney U tests, binary logistic regressions, and Kaplan-Meier curves.

Results

478 patients were studied (61.3% female, mean age 79.4±8.3 years). Mean RWTPW, RWTIVS and RWTPW+IVS were 0.46±0.16, 0.50±0.17 and 0.48±0.16, respectively. IHM was 3.4% and primary EP occurred in 57.8%.

High RWTPW was associated with higher LV ejection fraction (LVEF) (p<0.001). Patients with high RWTIVS were older (p=0.044). High RWTPW+IVS was associated with higher left atrial area (p=0.037) and higher LVEF (p=0.002).

There was no statistically significant difference between patients with high and low RWT, calculated using the 3 formulas, in other indices that are commonly used to assess diastolic function, namely in e' and E/e'.

None of the 3 methods of RWT calculation was a predictor of IHM.

Survival analysis showed that patients with high RWTPW had higher incidence of the primary EP (43.2% vs. 16.8%, Kaplan-Meier χ2=5.99; p=0.014), but not patients with high RWTIVS (Kaplan-Meier χ2=0.23; p=0.631) or RWTPW+IVS (Kaplan-Meier χ2=1.92; p=0.166).

RWTPW was a predictor of primary EP (OR 1.81; 95% CI 1.15–2.85; p=0.011) and this result was independent from e' and E/e' (OR 2.96; 95% CI 1.08–8.10; p=0.035).

Conclusion

In this study comparing 3 formulas for calculation of RWT, RWTPW had better risk prediction during follow-up than RWTIVS or RWTPW+IVS. RWTPW was a predictor of all-cause mortality and hospitalization for HF, and was independent from e' and E/e', indexes that are also recommended in HFA-PEFF diagnostic algorithm. Therefore, the formula incorporating PW should be preferred in the evaluation of patients with suspected or diagnosed HFpEF.

Funding Acknowledgement

Type of funding sources: None.

The health of immigrant children: a cohort study in the Metropolitan area of Lisbon - Portugal

Background

Studies in Europe show immigrant children to be more vulnerable to health problems. Portugal has a gap in knowledge about the health of immigrant children. The objective of this paper is to present results on a cohort study for health trajectories of immigrant children in the Amadora Municipality which has one of the highest numbers of immigrants in Portugal. We will analyse health profile characteristics of immigrant and native children and their utilisation of health services.

Methods

Prospective cohort study in Amadora health units (questionnaires and patient registers data). Participants: 420 native and immigrant children born in 2015 registered in Amadora Primary Health Care Centers (PHCC); recruitment from June 2019 to March 2020. Main outcomes: psychomotor development (Mary Sheridan); emotional and behavioural problems (SDQ); BMI; vaccination;

Results

From the 420 children recruited, 48,3% were immigrant mostly from Brazil and Portuguese speaking African countries, 41 children were born outside the EU (1st generation).

From the 126 children who had no routine medical examination at the age of 4, 59% were immigrant. Almost all immigrant children had vaccinations up to date (90%). Around 70% of native and 60% of immigrant children achieved all parameters in Mary Sheridan's test (p = 0.09). Overweight was found in 28% of native and 22% of immigrant children (p = 0.2). Median SDQ score for externalizing behaviours is different for 1st generation immigrants suggesting higher behaviour problems for this group of children (p = 0,003).

Conclusions

Most differences in overall outcomes occur between 1st generation immigrant and other children; immigrants showed significantly higher emotional and behaviour problems. Early identification of above difficulties and higher utilisation of routine health examinations should be a priority.

Key messages

1st generation immigrant children appear more at risk for emotional and behaviour difficulties. Early identification of above difficulties and higher utilisation of routine health examinations should be a priority.

A women’s right with limitations - global and European perspective on abortion decriminalization

Background

The decriminalization of abortion is a controversial subject whose policies widely vary across the world. In some countries it is available upon request, at least up to the 24-week limit, while in others it is totally prohibited. This practice also raises ethical issues, since some defend access to abortion as a human right, while others condemn it, highlighting the embryo's right to life. This study aims to compare abortion decriminalization laws and the maximum gestational age limit for induced abortion in each country of the six WHO member states.

Methods

Data on abortion decriminalization laws and the maximum gestational age limit for induced abortion were collected from the Global Abortion Policies Database on the WHO website. Descriptive analysis of data considered absolute and relative frequencies. Comparison between regions considered the number of countries, including a deeper analysis for European context.

Results

Approximately 30% of reviewed countries have specific laws for abortion decriminalization, while in 48% it is still a prohibited practice. Among the 48 European countries, 29 have decriminalized abortion laws, a practice that is only considered in 5 of the 54 African countries. Considering abortion by women's request, accepted practices are valid between 8 and 24 weeks gestation, depending on each country. However, 12 weeks of gestation is the most frequent limit for abortion, and it is the threshold of increased bleeding risk for pregnant women.

Conclusions

No legal abortion practices are performed after fetal viability period, usually up to 24 weeks of gestation. There are relevant differences between six regions. While most high-income countries have decriminalized abortion, this practice is still prohibited in most South American and African countries, raising multiple public health issues. Cultural, sociological and healthcare context is expected to have a strong influence in decriminalization of abortion.

Key messages

Abortion is considered a human right but there are many countries that do not allow it, particularly in Africa and South America. Most European countries have abortion decriminalization laws.

Serum IGF-I, IGFBP-3 and ALS concentrations and physical performance in young swimmers during a training season

INTRODUCTION

The GH/IGF-I axis is a system of growth mediators, receptors, and binding proteins that regulate somatic and tissue growth; and it has been shown that exercise programs are related to the anabolic function of this axis.

OBJECTIVE

The aim of this study was to analyse the changes of serum IGF-I concentration and that of its binding proteins IGFBP-3 and ALS in adolescent swimmers at different stages of a training season, and compare them with physical performance parameters and body composition of the athletes.

MATERIAL AND METHODS

Nine male athletes, aged 16 to 19years and who trained regularly throughout the season, were included in this study. Serum IGF-I, IGFBP-3, and ALS concentrations were recorded before and after (pre×post) standardized training sessions during the different stages of a training season (extensive×intensive×tapering). Endurance in freestyle, anaerobic fitness in tied swimming (Peak Force and Average Force), body mass, fat percentage, and lean body mass were also analysed at the different stages of training in order to compare the changes of the IGF-I/IGFBP/ALS system with the physical performance and body composition of the athletes. Variations in the IGF-I/IGFBP-3-ALS system before and after a standardized training session, and at the different stages of training were analysed by the Wilcoxon and Friedman non-parametric tests, respectively. Significance was considered at 5%.

RESULTS

The results from this study demonstrate that IGF-I is sensitive to the acute and chronic effects of training, exhibiting biphasic behaviour throughout the season. The catabolic phase was characterized by a reduction in serum IGF-I concentrations during the intensive stage (∆_IGF-I: - 43.33±47.32ng/ml; P<0.05) while the anabolic phase was marked by similar basal concentrations at the different stages of training and an increase in post-training serum IGF-I concentrations during the tapering stage (320±40; 298±36 and 359±94ng/ml; P<0.05). IGFBP-3 was only sensitive to the chronic effects of training, with a reduction in post-training serum concentrations during the intensive stage and an increase during the tapering stage (4.7±0.7, 4.6±0.4 and 5.0±0.7mg/l; P<0.05). No significant difference (P>0.05) was observed in pre- or post-training IGFBP-3 concentrations (∆_IGFBP-3) at the different stages. ALS concentrations remained unchanged throughout the season, demonstrating that in adolescent athletes they are unaffected by the acute or chronic effects of swimming. Peak Force (25.0±6.3, 24.2±5.7 and 28.5±6.5N; P<0.05) and Average Force (10.3±3.6, 8.8±1.8 and 14.7±1.8N; P<0.05) followed IGF-I and IGFBP-3 variations, with a decrease during the intensive stage and a significant (P<0.05) increase during the tapering stage. The body composition and cardiorespiratory condition of the swimmers did not vary significantly throughout the season, exhibiting behaviour independent of IGF-I or IGFBP-3.

CONCLUSION

Serum IGF-I and IGFPB-3 concentrations have proven to be sensitive markers of training status and, thus, may be used as guides for coaches and athletes in the challenging task of modulating training intensity in young athletes.

[Prognostic implications of folliculo-stellate cells in pituitary adenomas: relationship with tumoral behavior]

INTRODUCTION

Despite progress in understanding its pathogenesis, there has not yet been found any independent predictive marker of aggressive behavior of pituitary adenomas, to facilitate the treatment and monitoring of patients.

AIM

To analyze the expression of folliculo-stellate cells by immunostaining with S-100 protein, in a series of patients with pituitary adenomas followed for at least seven years.

PATIENTS AND METHODS

A retrospective study of 51 patients diagnosed with a pituitary adenoma between 2006 and 2008 was performed, according to current criteria established by the World Health Organization. The S-100 expression in folliculo-stellate cells was immunohistochemically evaluated, correlating it with clinico-radiological and histopathological tumor parameters and post-operative progression/recurrence.

RESULTS

Of 51 tumors, 40 were classified as typical and 11 as atypical pituitary adenomas. Most typical pituitary adenomas showed positive folliculo-stellate cells for S-100 (mean: 3.93%); atypical had little/no cell S-100 positive (mean: 0.83%). There were no significant differences in the expression of S-100 with respect to age or sex of the patient, size, invasiveness or post-operative tumor recurrence.

CONCLUSIONS

In our study group, with the exception of non-functioning adenomas immunopositive for prolactin, with the lowest and highest average of all subtypes in both groups (typical 0.25% vs atypical 9.24%; p = 0.0028), the predictive factor of tumor aggressiveness for pituitary adenomas, is not represented by a low value of S-100 in folliculo-stellate cells, not allowing select patients for intensive post-operative treatment.

Hemangiossarcoma ocular em um equino: relato de caso

O hemangiossarcoma ocular na espécie equina é um tumor maligno, raro e agressivo, de origem vascular endotelial. No presente trabalho, descreve-se um caso de hemangiossarcoma ocular em uma égua de 10 anos que apresentava secreção serossanguinolenta advinda de uma massa, acometendo a conjuntiva bulbar e a terceira pálpebra do olho direito. O diagnóstico foi realizado com base na avaliação histopatológica e na imuno-histoquímica. Foi realizada a enucleação, assim como a completa excisão cirúrgica do tecido acometido, não sendo observada, após seis meses da terapia, a recidiva ou a metástase da lesão.

Atopy patch test with Aleuroglyphus ovatus antigen in patients with atopic dermatitis

BACKGROUND

Epicutaneous test made with dust mite antigens.

OBJECTIVE

Evaluation of the response of the epicutaneous test with Aleuroglyphus ovatus antigen in atopic patients.

METHODS

We patch tested 119 individuals, 48 with atopic dermatitis, 50 with respiratory allergy and 21 healthy controls. We compare the positive response frequency to a closed patch test using Aleuroglyphus ovatus antigen in different concentrations and 48 and 96h reading times among those individuals.

RESULTS

Six patients with atopic dermatitis (12.5%) and 4 with respiratory atopy (8.0%) had positive reactions. None of the non-atopic controls had a positive response. As the antigen concentration raised, the number of positive reactions to epicutaneous test raised as well.

CONCLUSION

Our data suggest a positive relation between Atopy Patch Test positive responses and Aleuroglyphus ovatus antigen concentration, no matter the kind of the atopic clinical expression.