Erector spinae plane block for surgery of esophageal atresia in a preterm neonate

Pain management during and after thoracotomy is challenging in premature neonates. Ultrasound-guided fascial plane block techniques, such as the erector spinae plane block are a relatively new regional anesthesia technique and have emerged as an alternative to thoracic epidural due to its clinical effectiveness, ease of administration and theoretically being safer to perform. The relative ease of identifying anatomical landmarks compared to the paravertebral block, as well as its safety profile compared to an epidural, may have contributed to the erector spinae plane Bs growing popularity. Currently, however, the published evidence for the efficacy of regional anesthesia techniques in low birth weight newborns undergoing this surgery is limited to few isolated case reports. Herein we describe the use of unilateral erector spinae plane block as part of anesthesia and postoperative analgesia management of surgical correction of esophageal atresia in a preterm neonate.

Body dysmorphic disorder treatment: about a clinical case

Introduction

Body dysmorphic disorder (BDD) is a relatively common disorder characterized by a preoccupation with non-existent or slight defects in appearance. It was first described in 1886 by Morselli as dysmorphophobia.

Objectives

This work reviews the current available data on BDD and its treatment options and describes a clinical case that reports an improvement in symptomatology after surgery.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “body dysmorphic disorder”, “dysmorphophobia”. Clinical file consultation.

Results

The usual treatment involves a combination of psychotherapy and pharmacotherapy. Antidepressant medication, mainly selective serotonin reuptake inhibitors (SSRIs) have been used. If the symptoms do not improve, a different SSRI can be considered or clomipramine, venlafaxine or second-generation antipsychotics can be useful.

Conclusions

The role of surgery remains controversial, several studies indicating that the symptoms typically worsen after an aesthetic procedure because the preoccupation shifts to a different body area. However a recent study reported 32 of the 41 patients that underwent surgery were highly satisfied with the outcome. In our clinical case, our patient, a 20-year-old female with non-delusional dysmorphic ideas about her nose initiated treatment with paroxetine with poor response and was, against medical opinion, submitted to a rhinoplasty. Three weeks after the surgery there was an improvement in preoccupation about her nose. More research should be made to clarify the role of surgery in this disorder that often lacks adequate therapeutical response.

Disclosure

No significant relationships.

Seizures and alcohol withdrawal: A literature review

Introduction

Seizures occur in about 3% cases of alcohol withdrawal. They usually appear within 48 hours after abrupt cessation, and are characterized by a reduction in seizure threshold secondary to adaptation to alcohol. More than 50% of individuals will experience a new seizure and in 5% of these cases, progression to a sustained epilepticus status can occur.

Objectives

The aim is to do a review of the literature on alcohol withdrawal and the onset of seizures in individuals with alcohol addiction.

Methods

A literature review was conducted using the PubMed search database.

Results

Alcohol is a central nervous system (CNS) depressant and chronic consumption causes neuroadaptation in order to maintain homeostasis. This adaptation involves the upregulation of excitatory neurotransmitters systems and the downregulation of inhibitory ones. When consumption is abruptly discontinued, the depressive contribution of alcohol to a previously established balance is disrupted, resulting in withdrawal symptoms associated to a generalized CNS’ hyperexcitability state.Critical episodes increase the risk of delirium tremens, a fatal condition in 20% of untreated cases. Thus, the treatment and prevention of seizure recurrences is essential: the clinical guidelines of the American Society of Addiction Medicine 2020, offer an action proposal. Pharmacological therapy after seizures is the preferential treatment: intravenous administration of fast-acting benzodiazepines (lorazepam and diazepam) is the first line treatment.

Conclusions

It is essential to monitor signs and symptoms that alert us to the appearance of seizures associated to alcohol withdrawal, effectively treat these cases, prevent recurrences, and provide a quality follow-up for these patients.

Disclosure

No significant relationships.

From Akute Primäre Verruckheit to Bouffée Delirante: The background of Acute Transient Psychosis

Introduction

Ever since the end of the 19th century that descriptions of acute and transient psychosis (ATP) have been found in the literature. Psychiatrists from different countries gave different names for these types of episodes, throughout the ages. Those early descriptions were an important part of the development of the concept of acute and transient psychotic disorders (F23: ICD-10).

Objectives

This review aims to provide historical background of the development of different concepts to describe ATP.

Methods

Non-systematic review of literature on acute and transient psychotic disorders, bouffee delirante, brief psychotic disorder, atypical psychosis.

Results

In 1876, K.Westphal introduced the term akute primäre Verruckheit, refering to a sudden paranoia associated with delusion ideas and hallucinations. In 1895, Magnan described Bouffée delirante, characterized by a recorrent, sudden psychosis with polymorphic symptoms. Later (1924), the term cycloid psychosis was introduced by K.Kleist: phasic psychosis with good prognosis. Different concepts appeared throughout history: psychogenic psychosis (Wimmer,1916); atypical psychosis (Mitsuda,1942), holodisfrenia (Barahona,1957). Nowadays, the classification systems include many of these concepts in the same categories: Schizophreniform disorder, Brief psychotic disorder (DSM-5), and ATP (F23 in ICD-10).

Conclusions

All throughout the History of Psychiatry, there was an evolution of concepts associated to ATP. They were strongly influenced by different time epochs. It is important to have context on the historical background of the concepts used in the contemporaneous Psychiatry. Diagnosis is challenging due to their heterogeneous presentation. There are not many studies available, because of ATP’s low diagnostic stability.

Disclosure

No significant relationships.

POS0496 CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS HAVE ALTERATIONS IN B AND T FOLLICULAR CELL SUBSETS IN PERIPHERAL BLOOD

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children1. Our group has recently demonstrated that extended oligoarticular (eoJIA) and polyarticular JIA (pJIA) mostly evolve to a rheumatoid arthritis (RA) like phenotype in adulthood2. Disturbances in B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cell immune responses are associated with the pathogenesis of RA3,4, but their exact role in JIA development is not entirely known.

Objectives

The main goal of this study was to characterize the frequency and phenotype of B, Tfh and Tfr cells in peripheral blood of children with eoJIA and pJIA when compared to healthy controls and children with persistent oligoarticular JIA (poJIA).

Methods

Blood samples were collected from children with eoJIA (n=5), pJIA (n=11) and poJIA (n=19) treated with disease modifying anti-rheumatic drugs. A group of age-matched healthy individuals (n=8) was used as control. Peripheral blood mononuclear cells were isolated and the frequency and phenotype of B, Tfh and Tfr cells were evaluated by flow cytometry.

Results

The frequency of B, Tfh and Tfr cells was similar between JIA patients and controls. Children with eoJIA and pJIA, but not poJIA, had higher levels of naïve B cells and lower frequencies of post-switch memory B cells and plasmablasts when compared to controls. Th17-like Tfh cells were significantly increased in all JIA patients when compared to controls. B cell phenotype was similar between JIA patients and controls, but a reduced activated phenotype of Tfh cells was observed in JIA patients in comparison to controls.

Conclusion

Changes in B and Tfh cell subpopulations, but not in Tfr cells, were found in peripheral blood of children with JIA when compared to controls. The increased frequencies of Th17-like Tfh cells detected in JIA when compared to controls suggests a potential role of these cells in JIA pathogenesis. A treatment effect on the activation state of B, Tfh and Tfr cells cannot be excluded.

References

[1]Ravelli, A. & Martini, A. Juvenile Idiopathic Arthritis. Lancet 369, 767–778 (2007).

[2]Oliveira-ramos, F. et al. Juvenile idiopathic arthritis in adulthood: fulfillment of classification criteria for adult rheumatic diseases, long-term outcomes and predictors of inactive disease, functional status and damage. 1–10 (2016)

[3]Moura, R. A., Graca, L. & Fonseca, J. E. To B or not to B the conductor of rheumatoid arthritis orchestra. Clin. Rev. Allergy Immunol. 43, 281–291 (2012).

[4]Deng, J., Wei, Y., Fonseca, V. R., Graca, L. & Yu, D. T follicular helper cells and T follicular regulatory cells in rheumatic diseases. Nat. Rev. Rheumatol. 15, 475–490 (2019).

Acknowledgements

C. Tomé was supported by a fellowship from Fundação para a Ciência e a Tecnologia (FCT) (PD/BD/135520/2018), Portugal. This work was supported by a grant from Sociedade Portuguesa de Reumatologia.

Disclosure of Interests

None declared.

Growing use of valproic acid in substance use disorders

Introduction

Valproic acid is an antiepileptic drug used in different fields of Psychiatry. It is known mostly for its use in managing patients with bipolar affective disorder. In psychiatry of addiction, there is still no approved indications for its usage, but it is widely prescribed in treating alcohol and cocaine abuse, due to the existence of studies in these addictions.

Objectives

This review aims to clarify the relation between valproic acid and dependences, particularly cocaine.

Methods

Non-systematic literature review using a PubMed search, using the following key words: “valproate”; “cocaine use”.

Results

Cocaine dependence can decrease GABA levels in humans. Valproic acid has multiple mechanisms that favour the synthesis of GABA, potentiating its release and postsynaptic GABAergic response. Because of this, valproic acid was found effective in promoting abstinence and in reducing the use of cocaine. There are studies that support the valproic acid’s use in alcohol and cocaine dependences. Valproic acid has been shown to be promising in relapse prevention. It has also showed efficacy in the management of impulsivity and irritability, what makes it useful in managing patients with borderline personality disorder – patients at higher risk for alcohol or substance use disorders.

Conclusions

Cocaine addiction involves different phenomena and may respond to distinct pharmacologic approaches. Although some studies need to be confirmed by larger clinical trials, valproic acid seems a promising agent as one of some potential treatments for cocaine dependence. Further studies are required in this field to come to more reliable conclusions.

Disclosure

No significant relationships.

The phenomenology of motivation

Introduction

The concept of motivation pervades our professional and personal lives. Motivation is almost impossible to be observed directly, it is a construct for the interpretation of a behaviour that “calls the attention”.

Objectives

This work reviews the current available data on the phenomenological description of motivation and the abnormalities of motivation.

Methods

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

Results

Abnormalities in motivation may involve diminution or exacerbation. Anhedonia is the absence of pleasure in relation to usually pleasurable activities, it occurs in depression and schizophrenia where the pleasurable intrinsic motivation that acts as incentive for behaviour may be lost. In mania it may be increased so that mundane activities become unduly fascinating and rewarding.

Conclusions

Countless theories have been proposed to explain human motivation but each sheds light on specific aspects of motivation, neglecting others. This diversity creates confusion because most theories have areas of conceptual overlap and disagreement. To facilitate the development of studies, an agreement should be achieved on an operational definition of motivation.

Disclosure

No significant relationships.

Cannabis use and cognitive impairment in schizophrenia

Introduction

Neurocognitive deficits amongst patients with schizophrenia are considered one of schizophrenia’s central features. These deficits appear to be present from the first episode of psychosis (FEP) and certain cognitive impairments could be components of a genetic vulnerability to schizophrenia. Regarding research on cannabis and cognition in schizophrenia, different studies have assessed neurocognitive functions: memory, attention/vigilance, processing speed, verbal learning, executive functions, and verbal fluency.

Objectives

The aim is to do a review of recent findings concerning the association of cannabis use with cognition in schizophrenia.

Methods

A literature review was conducted using the PubMed search database.

Results

Patients with schizophrenia and concomitant cannabis use are associated with worse performance in immediate verbal learning, and in some studies with worse working memory performance. There is an improvement of verbal memory when they cease the cannabis’ consumption. Regarding attention capacity and memory types assessed, the results are controversial. In FEP, heavy cannabis use during the previous year correlates with slower processing speed. Also, FEP-patients with cannabis use but no family history of psychosis perform worse in executive functions, while those with a family history of psychosis perform better.

Conclusions

The studies of psychosis, cannabis and cognition differ in relevant aspects, which might be connected to the result variability. Therefore, before solid conclusions can be reached, it is important to carry out longitudinal studies to understand the changes in the cognitive variables, which can depend on the pattern of cannabis’ use (concurrent or prior to the FEP). Possible confounding variables that might be present should be acknowledged.

Disclosure

No significant relationships.

Dermatitis artefacta and psychiatric illness: Brief review and case report

Introduction

Psychodermatologic disorders are conditions involving an interaction between the mind and the skin. Dermatitis artefacta (DA), also known as factitial dermatitis, is a frequently unrecognized psychocutaneous illness, in which the patient creates skin lesions to satisfy the unconscious need to presume a sick role. It is more common in women and in patients with a diagnosis of psychiatric illness. This is an exclusion diagnosis and organic causes should be ruled out. Treatment of DA can be challenging and it needs to involve a multidisciplinary approach consisting of dermatologists and mental health professionals.

Objectives

From a case report the authors intend to present a literature review of dermatitis artefacta.

Methods

Observation the patient and review the clinical file. Consultation published and referenced scientific articles on PubMed.

Results

60 year old man, diagnosed with Bipolar Disorder, was admitted for manic decompensation of his pathology. During physical examination he had sparse erythematous lesions, more exuberant in the neck, scalp, belly and upper limbs. The diagnosis of artifact dermatitis was made after excluding other possible causes.

Conclusions

Treatment of DA can be challenging and it needs to involve a multidisciplinary approach. Dermatitis artefacta is a long-term disorder, and patients need regular follow up with a dermatologist and a psychiatrist because relapses are common. These doctors must be aware of this possible pathology in order to make a correct diagnosis and treatment of psychiatric disorders that sometimes coexist with skin lesions. The prognosis for most patients is poor leading to self-injury, scarring and poor cosmesis.

Disclosure

No significant relationships.

Persistant genital arousal disorder and venlafaxine: A case report

Introduction

In this presentation we describe the case of a woman referred to the Sexology Department after having developed symptoms of Persistent Genital Arousal (PGAD) for the last 5 years, during treatment for Depression with Venlafaxine. PGAD is a clinical entity first described in 2001 by Leiblum and Nathan. Despite having received more attention in the last few years, its etiology remains unclear, with numerous causal factors of different natures being suggested.

Objectives

We aim to describe this clinical case of PGAD and to discuss the possible etiological factors involved as well as to make a brief revision of the literature on this topic.

Methods

We conducted a detailed interview, focused on the nature of the complaints, psychological history, medications, diet and neurologic disorders and performed a thorough clinical examination. We also searched for relevant articles in medical databases such as PubMed and Google Scholar.

Results

A 52 year-old woman previously treated for Depression with Venlafaxine complains of involuntary sensations of genital arousal, with perceived vasocongestion, tingling and pulsatlity during her journey to work in public transportations. The symptoms subsided only after getting home 8-10 hours later and reaching orgasm by masturbating. She stopped Venlafaxine in 2015, but these symptoms persisted. Some authors suggest a link between SSRIs/SNRIs and PGAD.

Conclusions

PGAD is a relatively recent addition to our diagnostic catalog with increasingly more cases being reported in the last few years. It is likely that the condition, however, has no discrete etiology and that a customized approach will be necessary to successfully treat most patients.

The digital era and the psychiatric follow up during COVID-19 pandemic– are we ready?

Introduction

The pandemic caused by the SARS CoV-2 virus (COVID-19) has a profound effect in the health care system (HCS). The therapeutic effect of communication skills is well known. Psychiatric patients are a vulnerable population and remote care via telephone was one of the first implemented measures during the lockdown.

Objectives

The aim is to highlight the potential benefits and risks of remote follow up, according to the scientific evidence currently available.

Methods

Non-systematic review of the literature with the selection of scientific articles published in the last year. The search was performed in Pubmed database with the following Mesh terms: “COVID-19”, “psychiatry”, and “health communication”. Complementary references were also included.

Results

For those with a stable psychiatric condition, remote appointments may guarantee the adequate follow up in a safe way throughout the COVID-19 pandemic. However, telephonic appointments are associated with a limited ability to perform psychopathological examination. A better assessment can be achieved if video call is used. Also, data protection and the ability of giving informed consent by psychiatric patients should be addressed. Additional training should be considered. A subgroup of patients with severe mental illness may require face-to-face visits.

Conclusions

COVID-19 pandemic is an unprecedented crisis and telemedicine is now emerging as an alternative. Remote consultation has advantages and, in some situations, it may replace or complement the in-person visits. Since social isolation is one of the most effective measures, digital means constitute a window of opportunity for the HCS.

The importance of mental and sexual health in addressing people with hiv - the double stigma

Introduction

Having a mental disorder is associated with increased vulnerability to the transmission of the Human Immunodeficiency Virus (HIV) and the prevalence of HIV is higher in people with a severe mental disorder. People with psychiatric comorbidities such as bipolar affective disorder and depressive disorder, post-traumatic stress disorder (physical or sexual abuse) and/or psychoactive substance use have a higher risk of HIV infection.

Objectives

This work is intended to expose the importance of integrating mental health care with the care of HIV patients.

Methods

The authors conducted a non-systematic review of the literature, conducting research through Pubmed and Medscape using the keywords ‘Preexposure prophylaxis’, ‘HIV’, ‘Mental health problems’.

Results

Several factors may contribute to the high comorbidity between HIV and Mental Disorders, including socio-demographic factors, weak social and environmental structures, as well as internalized stigma, social and experienced discrimination. Mental health problems may interfere with the care needed for prevention, including regular HIV testing and/or adherence to Preexposure Prophylaxis (PrEP); and influence access to and adherence to antiretroviral treatment.

Conclusions

This compelling evidence makes the necessary contribution of integrating mental health into an assessment and continuous treatment of the HIV patient, on the other hand, the assessment and treatment of mental disorders should address sexual health.

Covid 2019 and suicide - a global pandemic: How to prevent?

Introduction

The mental health effects of Coronavirus2019(COVID-19) outbreak might be profound, including higher suicide rates.This phenomena is likely to become a more pressing concern as the pandemic spreads.While remarkable social distancing interventions have been implemented to reduce the rate of new infections,the potential for adverse outcomes on suicide risk is high, especially among vulnerable populations.

Objectives

The aim is to do a review of the literature of suicide prevention during the COVID-19 outbreak.

Methods

Non-systematic review of the literature with selection of scientific articles published in the last 7 months; by searching the Pubmed databases, the following MeSH terms were used: Suicide prevention; COVID-19

Results

In order to prevent suicide, urgent consideration must be extend beyond general mental health approaches. A wide-ranging interdisciplinary response that recognises how the pandemic might heighten risk is needed. The application of knowledge about effective suicide prevention is the key. Mental health services should develop clear remote assessment and care pathways, and staff training to support new ways of dealing with. Publications on mental health and psychological effects of COVID-19 outbreak provide important information and recommendations for all three levels of suicide prevention: primary, secondary, and tertiary.

Conclusions

The challenge of the COVID-19 outbreak might bring with it an opportunity to advance the field of suicide prevention and, thus, to save lives, which also represent a public health priority. The mental health community, backed by active vigilance and international collaboration, should be prepared and can use this challenging period to advance suicide prevention.

Washing COVID-19 away: COVID-19 and obsessive compulsive disorder

Introduction

We are facing a crisis caused by an extremely infectious disease, Covid-19. The mechanisms of infection and transmission of this coronavirus are largely unknown but some of the clearer recommendations are washing hands and surfaces. Obsessive-Compulsive Disorder has a lifetime prevalence of 2-3%, among the multiple symptoms, fear of dirt or being contaminated, and excessive washing are the most common affecting about 50% of patients.

Objectives

We reviewed the available information to understand if there are changes in OCD symptoms during the pandemic.

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 6 months; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: Covid-19; SARS-Cov2; pandemic; obsessive compulsive disorder; OCD.

Results

From a theoretical point of view, the increased frequency of hand washing and the importance of following hand-washing steps can add to a ritualistic pattern, also cleaning hands every time a person comes from outside or contacts with others can be justified as a preventive action rather than considered a problem and it can be “normalized” by others as a pandemic response.

Conclusions

In conclusion, there is evidence that during quarantine an overall increase in obsession and compulsion severity emerged with contamination symptoms associated with worse outcomes. There is data on an increase in relapses with patients not asking for help in a timely manner. The current situation is unpredictable and rapidly changing. It is likely that more information about this topic will arise in the next months.

The coronavirus pandemic impact on involuntary hospitalization

Introduction

Compulsory admission is the last line of intervention in individuals who suffer from severe mental disorders, based on the principles of therapeutic need and social protection. In Portugal, the law configures this measure as a hospitalization by court order. The SARS-CoV-2 coronavirus is a global public health emergency, with multifaceted consequences for people’s lives and health. Several studies are showing a great impact of the pandemic on the overall mental health.

Objectives

The aim is to assess the impact of the pandemic on the number of involuntary hospitalizations, their socio-demographic and clinical characteristics, and study the differences between 2019 and 2020.

Methods

Consultation of all patient’s clinical files that were involuntarily admitted in Hospital Magalhães Lemos during 2019 and 2020. Statistical analysis of data.

Results

The authors claim to investigate the impact of the pandemic on involuntary hospitalizations, the factors of admission and decompensation and other clinical characteristics, by comparing the involuntary hospitalizations during 2019 and 2020. The authors believe that the number of compulsory admissions increased significantly with the pandemic. They also believe that factors such as increased or relapsed consumption of alcohol and drugs, suicide attempts, missed appointments and long-term injectable medication are at the root of this increase in 2020.

Conclusions

This study helps to analyze the impact of the new coronavirus on compulsory hospitalizations and allows to understand the main factors that aggravate the underlying pathologies. Thus, understanding the targets of greater attention from psychiatrists to avoid the decompensation of patients in times of pandemic in which we currently live.

Disclosure

No significant relationships.

COVID-19 pandemic: Regarding alcohol consumption

Introduction

On March, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic. Social isolation, unemployment and financial difficulties can have an impact on mental health and trigger the use of alcohol as a form of coping. Since the beginning of this pandemic, the WHO had warned the general public of the potential risks of increased alcohol consumption, which might result in a higher incidence of alcohol use disorders (AUD) in future.

Objectives

The aim is to do a review of the literature of alcohol consumption during the COVID-19 pandemic.

Methods

Non-systematic review of the literature with selection of scientific articles published in the last 7 months; by searching the Pubmed databases, the following MeSH terms were used: COVID-19; alcohol consumption.

Results

A recent article in The Lancet suggested that mental health and alcohol use during the pandemic, a major public health concern, are worthy of attention. Market research showed that alcohol sales increased in several countries compared to the same time last year. However, with the closure of several drinking places, sales are not in themselves reliable enough estimates of alcohol consumption. On the other hand, economic crises can lead to a reduction in alcohol consumption, due to financial problems or the risk of unemployment.

Conclusions

The present global circumstance is unique, and there is a need for further research on the relationship between alcohol consumption and COVID-19 to understand its long-term effects and develop specific prevention programs for this population.

Stigmatization as a barrier in opioid substitution therapy patients

Introduction

Goffman defined stigma as an “attribute that is deeply discrediting” and in the last two decades research on this subject grew substantially.Opioids were ranked as the second most common form of illicit drug used worldwide and there is consensus in the literature that opioid substitution therapy (OST), methadone or buprenorphine, are the most effective treatments, although remain underutilized. People with an history of substance use disorders (SUD) are widely stigmatized, a significant barrier to detection and treatment efforts. Care workers were cited as the second most common source of stigma.

Objectives

The aim is to do a review of the literature of stigma as a significant barrier to OST and present several potential strategies to reduce stigma.

Methods

Non-systematic review of the literature with selection of scientific articles published in the last 5 years; by searching the Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: Opioid Use Disorder; Stigma; Opioid Substitution Therapy

Results

OST providers should actively bring up the topic of stigma in clinic appointments to determine whether the patient is experiencing stigma, and if so, whether it is adversely affecting their ability to continue in the treatment. More active measures need to be taken to help reducing the stigma through public awareness campaigns at local levels, continuing education of health care providers regarding substance OST, and greater incorporation of family members into the program.

Conclusions

In conclusion, further research is required to understand and address this issue.

Disclosure

No significant relationships.

Catatonia induced by abrupt discontinuation of clozapine - case report

Introduction

Catatonia is characterized by a bizarre and severe psychomotor change. According to DSM-5, the presence of three or more symptoms is necessary to affirm the diagnosis: stupor, catalepsy, brain flexibility, mutism, negativism, posturing, mannerisms, stereotypes, agitation not influenced by external stimuli, grimaces, echolalia or echopraxia. The association between first- and second-generation antipsychotics (AP) and the onset of catatonia is well established in the literature. In contrast, clozapine is one of the second-generation APs that is recognized for its effectiveness in treating catatonia, rather than inducing it. However, it has been documented that abrupt discontinuation of clozapine can induce rapid clinical deterioration with multiple presentations including: psychoses, cholinergic rebound states, serotonergic syndromes and catatonia.

Objectives

Review the literature on catatonia associated with abrupt interruption of clozapine. Describe a clinical case.

Methods

Observation of the patient and consultation the clinical file. Non-systematic literature review on catatonia, clozapine, side effects associated with rapid discontinuation and respective treatment.

Results

34-year-old man, with the diagnosis of Schizoaffective Disorder. Admitted due to an acute decompensation with psychotic symptoms resistant to treatment requiring the introduction of clozapine. In the absence of a clinical response, clozapine was suspended, with the consequent appearance of catatonia resistant to benzodiazepines in high doses.

Conclusions

Its already well established that the abrupt discontinuation of clozapine can trigger catatonia. This clinical case and literature review suits to emphasize the importance of educating psychiatrists on the adverse effects of psychiatric drugs and, in this case, the cautious discontinuation of clozapine in order to avoid its rebound effects.

Burnout among Portuguese oncology healthcare providers – Differences between pediatric an adult teams

Introduction

Burnout is characterized by emotional exhaustion, depersonalization and reduced personal accomplishment, resulting from the inability to cope with chronic job stress. The literature suggests that staffs working in adult oncology are at risk of burnout. At the same time, research found that pediatric staff experiences a different set of stressors when compared with colleagues working in adult oncology. However, no studies were identified which directly compared prevalence and sources of Burn-out on pediatric and adult oncology staff.

Objectives

To compare the differences on prevalence and sources of burnout between pediatric and adult oncology multidisciplinary teams.

Methods

Pediatric and adult oncology professionals, including medical and nursing from a Portuguese oncology center completed the Portuguese version of the Copenhagen Burnout Inventory. Data was analyzed using SPSS.

Results

Since the study is currently ongoing the authors will only be able to provide final results and conclusions by the time of submission of our work presentation, in March 2016. However, according to the literature available, we are expecting to found symptoms of Burnout in the superior limit of normality, with differences in the major sources of stress between adult and pediatric professionals.

Conclusion

The differences in the challenges experienced by adult and pediatric teams highlight the importance of adequate prevention strategies to specific needs of each unit. Further investigation of stress across a wider range of professional disciplines is required in order to explore this gap.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Highly porous multiwalled carbon nanotube buckypaper using electrospun polyacrylonitrile nanofiber as a sacrificial material

Polyacrylonitrile (PAN) was solubilized in N,N-dimethyl formamide (DMF) and the electrospinning process has been employed to obtain PAN nanofibers (PF). Multiwalled carbon nanotubes (MWCNT) were dispersed with the aid of Triton X-100 surfactant and subsequently centrifugated. Buckypapers (BP/PF) were prepared by vacuum filtration procedure of MWCNT suspension supernatant stacking four PF layers over a nylon membrane. The PF removal was carried out by immersing the BP/PF system in DMF and removal periods of 10 and 30 min were evaluated. Scanning electron microscopy (SEM) has not shown any PAN residue in the MWCNT network resulting in highly porous BP. However, by Fourier transform infrared spectroscopy (FT-IR) a PAN band was found around of 2243 cm-1 corresponding to nitrile group (C≡N). Besides, PAN leftover was evidenced by thermogravimetric analysis (TGA), high-resolution transmission electron microscopy (HR-TEM), electrical characterization through four-point probe, nitrogen adsorption at 77 K, and X-ray diffraction (XRD).

Radiation therapy facility risk analysis in Brazil with SEVRRA software

Risk assessment deals with processes, accident-initiating events, barriers and risk ratings to unveil the fragility and weakness of some processes; within this study, specifically related to radiation therapy facilities. Barriers are technical or organizational safety measures put in place to avoid, prevent, detect, control, reduce or mitigate the consequences of an accident once an initiating event has occurred. In this work, radiological risk analysis was performed for a set of 20 Brazilian radiotherapy facilities making use of the freeware sevrra risk-management software. The objective of this study was to define parameters that could be useful in creating an overall risk profile. This profile would be helpful for establishing priorities for decision making and support a risk-informed regulatory process. The most relevant missing barriers in facilities were identified according to three parameters: the 'importance index', 'impacted facilities index' and the 'barrier-effectiveness index'. Barriers such as 'in vivo dosimetry in the first treatment session', 'weekly in vivo dosimetry to detect errors in the dose delivering process', 'annual external audit for the control of reference dose rate' and 'independent verification of calibration by various medical physicists with a different dosimetry equipment' were found to be the most effective in reducing the risk level of the facilities. The present investigation reinforces the need to strengthen the mechanisms that guarantee the effectiveness of such barriers in radiation therapy procedures.

Upper bound dose values for meson radiation in heavy-ion therapy

Radiation treatment of cancer has evolved to include massive particle beams, instead of traditional irradiation procedures. Thus, patient doses and worker radiological protection have become issues of constant concern in the use of these new technologies, especially for proton- and heavy-ion-therapy. In the beam energies of interest of heavy-ion-therapy, secondary particle radiation comes from proton, neutron, and neutral and charged pions produced in the nuclear collisions of the beam with human tissue atoms. This work, for the first time, offers the upper bound of meson radiation dose in organic tissues due to secondary meson radiation in heavy-ion therapy. A model based on intranuclear collision has been used to follow in time the nuclear reaction and to determine the secondary radiation due to the meson yield produced in the beam interaction with nuclei in the tissue-equivalent media and water. The multiplicity, energy spectrum, and angular distribution of these pions, as well as their decay products, have been calculated in different scenarios for the nuclear reaction mechanism. The results of the produced secondary meson particles has been used to estimate the energy deposited in tissue using a cylindrical phantom by a transport Monte Carlo simulation and we have concluded that these mesons contribute at most 0.1% of the total prescribed dose.

Ion chambers compliance results of Brazilian radiation therapy facilities

The Brazilian Nuclear Energy Commission (cnen) has been making a constant effort to keep up to date with international standards and national needs to strengthen the status of radiological protection of the country. The guidelines related to radiation therapy facilities have been revised in the last five years in order to take into consideration the most relevant aspects of the growing technology as well as to mitigate the accidents or incidents observed in practice. Hence, clinical dosimeters have gained special importance in this matter. In the present work, we discuss the effectiveness of regulation and inspections to the enforcement of instrument calibration accuracy for the improvement of patient dosimetry and quality control. As a result, we observed that the number of calibrated instruments, mainly well chambers, is increasing each year. The same behavior is observed for instruments employed in technologically advanced radiation treatments such as intensity modulated radiotherapy, volumetric therapy and stereotatic radiosurgery. We ascribe this behavior to the new regulation.

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update

BACKGROUND

Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007.

METHODS

SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey.

RESULTS

The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Ect Combined with Clomipramine and rTMS in an OCD Patient with Secondary Severe Depression

Introduction

Obsessive-compulsive disorder (OCD) has high rates of comorbidity with mood disorders, mainly major depressive disorder (MDD). Symptoms of depression are usually secondary to severe and disabling OCD. Electroconvulsive therapy (ECT) has been an effective and well tolerated therapeutic alternative in the management of refractory MDD. Other neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), have well known efficacy in MDD and also have shown positive results, in clinical trials, treating other psychiatric disorders such as OCD.

Objectives/aims

To determine the efficacy of combining rTMS, ECT and clomipramine in the treatment of severe OCD with comorbid severe MDD.

Methods

The authors report a case of a 54-year-old male patient diagnosed with severe OCD for 23 years. He has been submitted to several drug treatments and intensive cognitive-behavioural therapy (CBT) always with poor response. The patient was admitted in the beginning of 2016 in our inpatient unit. Besides continuing drug treatment (clomipramine IV) and CBT, he was submitted to 12 ECT sessions during one month (3 sessions per week) and to daily sessions of rTMS during the following month.

Outcome measures were obtained using Y-BOCS for OCD and HAM-D for depression.

Results

Our patient responded to ECT with mood improvement after session 4 to full euthymic state at the final session. He also responded well to rTMS with Y-BOCS score reduction.

Conclusion

Combined ECT and rTMS treatment with clomipramine IV and CBT was effective in our patient with a severe form of both disorders (OCD and MDD).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Gender Difference among Psychiatric Patient's Profile in Emergency Department

Introduction

Over the past 40 years, services for psychiatric patients have become increasingly deinstitutionalized, shifting away from inpatient facilities. as a result, patients seek other avenues for treatment, including outpatient facilities and community resources. Unfortunately, those resources have also become increasingly constrained by widespread budget cuts, leaving patients with the health care system's last remaining safety net—the emergency department (ED).

Because EDs are seeing increasing numbers of patients, hospital administrators have recognized the importance of improving throughput and the quality of care delivered in EDs.

The aim of this report is to investigate the gender difference among patient's profile in psychiatric emergency room, assessing the socio-demographic and clinical characteristics, reasons for attendance and practices.

Methods

Retrospective and observational study, conducted at Centro Hospitalar e Universitário de Coimbra, during a three month period. Statistical analysis of data with “SPSS 21”.

Results

During the three months period, a total of 2309 patients were admitted in Psychiatric ED, 1485 female and 824 male.

Regarding clinical data, the authors are expecting to find different psychopathology among male and female, as well as psychiatric comorbidities, diagnoses after discharge, treatment conducts, social support and different rates of psychiatric comorbidities.

Conclusions

Factors such as patient's vulnerability, defined by socio-demographic elements, characteristic as the type and severity of their mental illness, social support, treatment adherence, with significant implications of prognosis, costs and care. The conducted study enabled us to outline a profile of male and female psychiatric patients in ED.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Leaching behaviour and ecotoxicity evaluation of chars from the pyrolysis of forestry biomass and polymeric materials

The main objective of this study was to assess the environmental risk of chars derived from the pyrolysis of mixtures of pine, plastics, and scrap tires, by studying their leaching potential and ecotoxicity. Relationships between chemical composition and ecotoxicity were established to identify contaminants responsible for toxicity. Since metallic contaminants were the focus of the present study, an EDTA washing step was applied to the chars to selectively remove metals that can be responsible for the observed toxicity. The results indicated that the introduction of biomass to the pyrolysis feedstock enhanced the acidity of chars and promote the mobilisation of inorganic compounds. Chars resulting from the pyrolysis of blends of pine and plastics did not produce ecotoxic eluates. A relationship between zinc concentrations in eluates and their ecotoxicity was found for chars obtained from mixtures with tires. A significant reduction in ecotoxicity was found when the chars were treated with EDTA, which was due to a significant reduction in zinc in chars after EDTA washing.