Integrative phylogenetic, phylogeographic and morphological characterisation of the Unio crassus species complex reveals cryptic diversity with important conservation implications

The global decline of freshwater mussels and their crucial ecological services highlight the need to understand their phylogeny, phylogeography and patterns of genetic diversity to guide conservation efforts. Such knowledge is urgently needed for Unio crassus, a highly imperilled species originally widespread throughout Europe and southwest Asia. Recent studies have resurrected several species from synonymy based on mitochondrial data, revealing U. crassus to be a complex of cryptic species. To address long-standing taxonomic uncertainties hindering effective conservation, we integrate morphometric, phylogenetic, and phylogeographic analyses to examine species diversity within the U. crassus complex across its entire range. Phylogenetic analyses were performed using cytochrome c oxidase subunit I (815 specimens from 182 populations) and, for selected specimens, whole mitogenome sequences and Anchored Hybrid Enrichment (AHE) data on ∼ 600 nuclear loci. Mito-nuclear discordance was detected, consistent with mitochondrial DNA gene flow between some species during the Pliocene and Pleistocene. Fossil-calibrated phylogenies based on AHE data support a Mediterranean origin for the U. crassus complex in the Early Miocene. The results of our integrative approach support 12 species in the group: the previously recognised Unio bruguierianus, Unio carneus, Unio crassus, Unio damascensis, Unio ionicus, Unio sesirmensis, and Unio tumidiformis, and the reinstatement of five nominal taxa: Unio desectusstat. rev., Unio gontieriistat. rev., Unio mardinensisstat. rev., Unio nanusstat. rev., and Unio vicariusstat. rev. Morphometric analyses of shell contours reveal important morphospace overlaps among these species, highlighting cryptic, but geographically structured, diversity. The distribution, taxonomy, phylogeography, and conservation of each species are succinctly described.

X-linked myotubular myopathy: a clinical report and a review of the mild phenotype

INTRODUCTION

X-linked myotubular myopathy is a rare centronuclear myopathy that affects approximately 1 in 50,000 male newborns caused by pathogenic variants in the myotubularin 1 gene (MTM1). The clinical severity varies, however the need for ventilatory support occurs almost invariably.

CASE REPORT

We report the case of a 4-year-old boy presenting mild muscle hypotonia at 12 months-old, expressive language disorder, global developmental delay, and a sensory processing disorder. Clinical exome sequencing identified the hemizygous variant c.722G>A p.(Arg241His) in exon 9 of the myotubularin 1 gene (NM_000252.2). The mother is a heterozygous carrier of the same variant. A diagnosis of a mild form of maternal inherited X-linked myotubular myopathy was established. The child presented significant improvement with speech, occupational, and physical therapies, with no respiratory intercurrences or ventilator dependency.

CONCLUSION

The presentation of a mild form of this myotubular myopathy, being less commonly reported, added challenge to the diagnosis. The combination of mild hypotonia, feeding difficulties and expressive language disorder should raise suspicion of a neuromuscular disease. There is a lack of verified motor or developmental scores specific to this myopathy to further determine prognosis and need of other therapies. While currently the severity myotubular myopathy is classified according to ventilator dependency, this may be insufficient and unapplicable to milder cases. There is an evident need for a grading system for mild and moderate cases assessing muscle weakness and fatigue, daily life limitations, motor developmental delay, early phenotypical scores, or recurrent respiratory infections.

ONLY IN DREAMS: a case report of sleep deprivation psychosis

Introduction

Sleep is essential for an adequate neurobiological functioning, being implicated in several cognitive functions. Even in healthy individuals, sleep deprivation can lead to a number of psychopathological changes, including perceptual distortions, hallucinations and delusions. Thus, the resulting clinical picture may be similar to a psychotic disorder.

Objectives

To present a clinical case of psychotic symptomatology induced by sleep deprivation.

Methods

Patient’s clinical file consultation and literature review using the search engine Pubmed® and the keywords: “sleep deprivation”, “sleep loss” and “psychosis”.

Results

We present the case of a 41-year-old woman with a history of an episode of mood changes with psychotic symptoms that was preceded by a period of total insomnia. No psychotropic drugs since then and no relapses. In May 2020, she was admitted in psychiatry department due to clinical picture composed by significant psychomotor slowing, drowsiness, slowed speech, verbal visual, tactile and auditory hallucinations accompanied by grandiose delusions. These symptoms were preceded by total insomnia with one week of duration. In the hospital was administered quetiapine 100mg and lorazepam 2.5mg to aid in the recovery of sleep deprivation and concomitantly aripiprazole 15mg was prescribed. The patient presented a rapid and significant clinical improvement. Currently, it is without any type of medication and without psychopathological changes.

Conclusions

The clinical picture present in this case report was triggered after a significant period of sleep deprivation. Thus, it illustrates the role that sleep has in the development of psychiatric symptomatology, sometimes difficult to differentiate from psychiatric disorders.

Disclosure

No significant relationships.

Catatonia and dementia: a case report

Introduction

Catatonia is a neuropsychiatric disorder characterized by motor, behavioral and autonomic changes. It is associated with several psychiatric disorders, including dementia. Catatonia is an underdiagnosed syndrome, so it is important to draw attention to it. Here, we review a case of a patient admitted to our psychiatric department with a clinical presentation compatible with catatonia. After proper treatment, further assessment revealed dementia.

Objectives

This work aims to describe a case of catatonia in a patient with dementia.

Methods

Bibliographic research using Pubmed®. Clinical file consultation and patient interviews.

Results

Catatonia is a disorder that was already been described as part of several types of dementia. We present a 69-year-old female patient, admitted to our psychiatric department with clinical presentation compatible with catatonia. To admission, she presented some typical complications resulting from long immobility such as pressure ulcers and nutritional deficiencies. During the hospitalization, she developed a urinary infection and there was the need to tube feeding. She was treated with benzodiazepines and improved. Further assessment revealed dementia.

Conclusions

Catatonia in dementia is not uncommon, although it is an underdiagnosed syndrome, and when treated early and properly it has a good prognosis.

Disclosure

No significant relationships.

Role of migration in the development of a first episode of psychosis

Introduction

Currently, there is scientific evidence supporting the relationship between socio-environmental factors and the onset of a first episode of psychosis (FEP). In this context, the phenomenon of migration, seen as a negative life experience, may become an important risk factor in developing a psychotic disorder (PD). In Europe, the impact of this phenomenon is growing and, therefore, it’s necessary to provide a proper answer to these individual’s mental health problems.

Objectives

Identify which phases of this migration process are most important in the development of a FEP and what are the more significant socio-environmental factors in each phase.

Methods

Bibliographic research in Pubmed database using the terms “Migration” and “First Episode Psychosis”.

Results

Research confirms that migrants have a 2 to 3-fold increased risk of developing a PD. This risk will be even higher in the refugee population. Pre- and post-migration factors demonstrated to be more important than factors related with the migration process itself. In the pre-migration phase highlight factors like the lower parental social class and a previous trauma. In the post-migration phase highlight factors like discrimination, social disadvantage and a mismatch between expectations and reality.

Conclusions

Literature is unanimous in considering migrant status as an independent risk factor for the development of FEP, possibly due to the outsider’s role in society. Thus, despite the growing interest in Biological Psychiatry, this work demonstrates that socio-environmental factors are very preponderant in the development of these disorders and because of that further investigation is still necessary.

Disclosure

No significant relationships.

“Walking with myself by my side” - non-medical use of Ketamine

Introduction

Ketamine, synthesized in 1962 as phencyclidine derivate, is denominated a “dissociative anesthetic” because of its side-effects, such as dissociative episodes and psychotic-like symptoms, which have limited its applicability on clinical practice. Otherwise, in the last decades the non-medical use of ketamine has been growing and today is one of the most popular illicit substances consumed between adolescents and young adults.

Objectives

Increasing the knowledge and understanding of the factors related to crescent use of ketamine and the experiences and consequences associated to its consumption.

Methods

Clinical interview with patients diagnosed with ketamine use disorder and bibliographic research in Pubmed database using the terms “Ketamine use” and “Ketamine addiction”.

Results

Pat et al. (2002) describes a clinical case of a young male, diagnosed with substance use disorders, specifically alcohol and cocaine use disorders, that started a treatment with ketamine. After the treatment, pleasant depersonalization experiences contributed to the development of patient’s ketamine dependence. Other patient’s reports confirm the association of ketamine use with psychedelic effects and dissociative episodes and pointed these effects as main reason for its consumption.

Conclusions

The adverse effects that limited the medical use of ketamine are the same that promote its utilization with recreational purposes by adolescents and young adults in parties and nightclubs. About the ketamine dependence, the literature is scarce and doesn´t clearly identify a physical withdrawal syndrome, pointing only to a serious psychological dependence. Thus, with the crescent non-medical use of ketamine, it’s urgent to develop an intervention plan directed to this problem.

Disclosure

No significant relationships.

Dissociation and emotional dysregulation in pathological personalities related to the fear of SARS-COV-2: a case report

Introduction

The COVID-19 pandemic represented a serious strain on the mental health resilience worldwide. Implementation of restrictive rules implied the disruption of social networks, eliciting emotional exhaustion and intense response to fear. This was amplified by media spread of panic and fake news, representing risk factors for post traumatic stress disorder (PTSD). Fear can be dangerous, especially accounting premorbid psychopathological vulnerability, such as pathological personality traits. Emotional dysregulation increases fear levels, mediated by the relationship between emotional dysregulation and lack of tolerance.

Objectives

Clinical case presentation of patient who developed dissociative and behavioral symptoms following COVID-19 infection. Bibliographic research.

Methods

Bibliographic research using Pubmed®. Clinical file consultation and patient interviews.

Results

Heightened psychophysiological reactivity can result from the persistent fear experienced during a traumatic event and repeated memories related to it, leading to a sensitization of the response to fear. We present 57 year-old female patient, admitted to the COVID ward after trying to escape from home isolation due to positivity to COVID-19. In the hospital setting she developed dissociative symptoms, trying to escape from the ward and infect other people.

Conclusions

Intense fear responses to COVID-19 are likely explained by poor emotion regulation capacities as well as dissociative mechanisms. Studies have shown that this pandemic was experienced as a real traumatic event and some studies have found that it may lead to the development of PTSD. Pathological personality is positively related to PTSD symptoms, attributable to higher levels of mood instability, cognitive/perceptual disorders, interpersonal dysfunctions and negative affection.

Disclosure

No significant relationships.

Relationship between personality, adherence to (mental) health behaviours and psychological distress during the COVID-19 pandemic

Introduction

Public health authorities around the world have been disseminating messages to support mental health and psychosocial well-being during the COVID-19 pandemic. Based on the Portuguese guidelines, we have developed the Adherence Scale to the Recommendations for Mental Health during the COVID-19 Pandemic (ASR-MH-COVID19) to better understand this health behaviour.

Objectives

To analyse the relationship between sociodemographics, personality traits, Adherence (to the Recommendations for Mental Health during the COVID-19 Pandemic) and psychological distress.

Methods

413 individuals (69.2% female; mean age=31.02±14,272) completed an on-line survey, in September-December 2020, including sociodemographic questions, ASR-MH-COVID19, NEO-FFI-20 and Depression Anxiety Stress Scale (DASS-21) and Health Perception Scale.

Results

Adherence scores did not significantly differ by gender, age and years of education. Women presented higher DASS and Neuroticism scores (p<.01). Adherence were negatively correlated with Neuroticism (r=-.247) and with Depression/Anxiety/Stress (all r».-200), positively with Openness to Experience (r=.174), Conscientiousness (r=.194) and Perceived Health (Physical, r=.173 and Psychological, r=.215) (all p<.01). Mediation analysis (Hays’ Macro Process - Model 4) revealed that Adherence is a partial mediator between Openness and DASS and Conscientiousness and DASS; when considering Neuroticism, only the direct effect was significant. The effect of Perceived Health (both Physical and Psychological) on DASS was also mediated by Adherence.

Conclusions

The Health Behaviour Model proposes a pathway linking personality and health that applies to these results about adherence and psychological distress during the COVID-19 pandemic. Personality and perceived health (also a trait) influence both adherence to mental health behaviours and psychological distress. Understanding personality is vital for health care providers.

Disclosure

No significant relationships.

A Case Report of Anorexia Nervosa - the “perfect“ woman

Introduction

Anorexia nervosa (AN) is an eating behavior disorder characterized by intense fear of gaining weight or persistent behavior that interferes with weight gain, with caloric intake restriction and secondary loss of body weight. It can affect up to 4% of women during their lifetime and is responsible for one of the highest mortality rates from psychiatric disorders.

Objectives

Review of the literature and exposure of a case report of AN in a woman with high level of stress at work.

Methods

Case report and nonsystematic review using databases such as PubMed and UpToDate.

Results

Caucasian woman, 31-year-old, PhD in biology, who works in a multinational company. No personal or family history of psychiatric disorder. She was observed in the psychiatry emergency department, due to low weight, caloric restriction and intense physical exercise, maladaptive personality traits related to perfectionism and control were found. She began follow-up with a multidisciplinary team, but there was a need for hospitalization due to clinical deterioration with BMI of 11. After 6 months, she continued to follow up at the consultations and, despite refusing psychotropic drugs, she maintains psychotherapy and presents clinical improvement (BMI - 17).

Conclusions

Eating behavior disorders are chronic and difficult to treat diseases that are more frequent among people subject to high levels of stress. This case represents a restrictive AN in a woman with multiple risk factors: athlete, perfectionist, with stressful work and life events and restricted interpersonal and affective relationships.

Disclosure

No significant relationships.

Anorexia Nervosa and Gender Dysphoria: A Clinical Case

Introduction

Eating disorders (ED) and gender dysphoria (GD) are associated with a change in body perception. Therefore, body dissatisfaction plays a common and central role in these disorders. In GD, body image concerns are related to the features of the biological sex. In ED, body dissatisfaction comes from a distorted perception of weight and body shape and plays an important role in the development and maintenance of the psychopathology.

Objectives

To present and discuss the clinical case of a patient with a previous diagnosis of GD who presented with a clinical condition suggesting a restrictive anorexia nervosa (AN).

Methods

Patient´s clinical files consultation and literature review using Pubmed and the keywords: eating disorders and gender dysphoria.

Results

We present the case of a 25-year-old patient who was living in a shelter for victims of domestic violence and was admitted for severe restrictive AN. The patient was discharged after 40 days and medicated with sertraline, diazepam and olanzapine, as well as her previous medication (hormonal therapy): cyproterone, finasteride, estradiol, oxybutynin.

Conclusions

Although studies on this subject are still scarce, there has been some progress and the literature recognizes the coexistence of these conditions. However ED symptoms in patients with GD could have a different meaning: they may represent a dysfunctional coping strategy adopted to block features of the biological sex. Therefore health professionals may take a more holistic approach to body image. Additional studies will be necessary, allowing the establishment of cause-consequence interactions between weight loss and psychopathology related to GD.

Disclosure

No significant relationships.

Adherence Scale to the Recommendations for Mental Health during the COVID-19 pandemic from the Portuguese General Directorate of Health (ASR-MH-COVID19) - Development and validation

Introduction

The COVID-19 crisis has generated an increasing stress throughout the population.

Objectives

To develop and validate the Adherence Scale to the Recommendations for Mental Health during the COVID-19 pandemic from the Portuguese General Directorate of Health (GDH) (ASR-MH-COVID19).

Methods

The items content was based on the GDH guides for the prevention of mental health and psychosocial well-being of the general population during the COVID-19 outbreak. After content and facial validity analysis, the preliminary version of the ASR-MH-COVID19 (8 items to be answered on a Likert scale) was completed by 413 individuals (69.2% female; mean age=31.02±14,272), in September-December 2020 (Sample1) and then by 967 (70.9% female; mean age=34.02±14,272), in February-May 2021 (Sample2). Sample1 was randomly divided in two sub-samples. Sample1A was used for exploratory factor analysis/EFA and Sample1B for confirmatory factor analysis/CFA; CFA was then replicated with Sample2. The online surveys also included the Adherence Scale to the Recommendations of Portuguese GDH to minimize the impact of COVID-19 (ASR-COVID-19; Pereira et al. 2020).

Results

CFAs were informed by EFA and showed that the unidimensional model presented acceptable-good fit indexes (Sample1B: χ²/df=2.747; RMSEA=.0980, p<.001; CFI=.973; TLI=.918, GFI=.972; Sample2: χ²/df=3.327; RMSEA=.0490, p<.001; CFI=.993; TLI=.983, GFI=.990). Cronbach’s alfas were α<.850. Pearson correlations between ASR-MH-COVID19 and ASR-COVID19 were significant (p<.01) and moderate-high for the total (r=.753) and dimensional scores (Distance and respiratory hygiene, r=.739; House and personal hygiene, r=.584; Use of remote services and isolation r=.425).

Conclusions

The new ASR-MH-COVID19 has shown validity and reliability, allowing the investigation of this (mental) health behaviour.

Disclosure

No significant relationships.

PURA syndrome in a child with severe developmental delay: a challenging diagnosis

INTRODUCTION

PURA syndrome is a rare autosomal dominant condition caused by de novo pathogenic variants in PURA gene and characterized by a multisystemic phenotype that includes global neurodevelopmental delay, early hypotonia, absence of speech, feeding difficulties, hypersomnolence, epilepsy and movement disorders.

CASE REPORT

We report a 9-year-old girl with hypotonia and feeding difficulties with failure to thrive since the neonatal period. At the age of 3 years motor and intellectual delay were evident, she had a wide-based gait, no speech and an exaggerated acoustic startle response. She developed hand-mouthing stereotypies and epilepsy at 6 years old. The 24 hours continuous electroencephalogram monitoring revealed global slow activity and frequent epileptiform activity in left temporal and centrotemporal areas. The brain MRI revealed delayed myelination. At 6 years old the clinical exome sequencing identified a heterozygous pathogenic variant in the PURA gene, c.153delA p.(Leu54CysfsTer24).

CONCLUSION

PURA syndrome has clinical features similar to other neurological disorders but the association with some clinical features, not as common in other neurological entities, like never being able to speak but being able to follow simple orders and exaggerated acoustic startle response, should raise the suspicion of PURA syndrome and genetic analysis must be performed to confirm the diagnosis and provide early multidisciplinary intervention.

Relationship between fear of COVID-19 and individual factors – a preliminary study

Introduction

Fear associated to infectious diseases is directly related with their transmission rate, morbidity and mortality. High levels of fear associated with COVID-19 can affect people’s ability to act and think rationally. In a time of pandemics, it is essential to understand individual factors that might be associated to higher vulnerability to stress and fear.

Objectives

To analyse: a)correlations between Fear of Covid-19 and clinical and sociodemographic characteristics; b)the mediator role of repetitive negative thinking on the relationship between personality traits and Fear of Covid-19.

Methods

234 adults (75.6% women; mean age=29.53±12.51) completed an on-line survey with the Portuguese version of the Fear of Covid-19 Scale (FCV-19S) and other questionnaires to evaluate clinical and sociodemographic characteristics (years of education, perceived physical and mental health and infection by Covid-19), Personality (NEO-FFI-20) and Repetitive negative thinking (PTQ-15). SPSS and Process Macro (Hays, 2020) were used.

Results

FCV-19 mean scores were significantly higher in women and significantly correlated with years of education (r=-.14) (p<.05). History of previous/current Covid-19 infection did not significantly distinguish FCV-19 scores and they did not correlate with perceived health. FCV-19 correlated significantly with neuroticism and PTQ total and dimensional scores (r>.20, p<.01). Both Repetitive thinking and Cognitive interference were mediators of the relationship between neuroticism and fear of COVID, even after controlling for gender and education.

Conclusions

This study provides preliminary evidence on individual factors that might be associated to the emotional response to the Covid-19 pandemics, aiming to facilitate public health initiatives to ease people’s fears in a near future.

Relationship between COVID-19 perceived risk and perfectionism – a preliminary study

Introduction

Research following the Covid-19 pandemics has shown that psychological reactions to the pandemic and its constraints can vary significantly depending on personality. One of the traits that has not been studied yet, but can play a harmful role in the COVID-19 psychological impact is perfectionism. This trait, characterized by setting excessively high standards of performance and striving for flawlessness, has increased in recent years and is considered a transdiagnostic process involved in several (mental) health problems (Curran & Hill 2019).

Objectives

To analyze the role of Perfectionism in the levels of fear of COVID19 and of perception of infection risk by COVID-19.

Methods

234 adults (75.6% women; mean age=29.53±12.51) completed an on-line survey with the Portuguese validated versions of Covid-19 Perceived Risk Scale (C19PRS; Pereira et al. 2020), Fear of COVID-19 Scale (FC19S; Cabaços et al. 2020) and Big Three Perfectionism Scale (BTPS; Garrido et al. 2020). SPSS was used to perform correlation and regression analysis.

Results

Perceived Risk and Fear of COVID-19 were significantly correlated with perfectionism (.243, .228, respectively) (both, p<.01). Perfectionism explains 5.5% (Adjusted R2) of the FC19S variance (Beta=.243, p<.001) and 4.8% of the C19PRS variance (Beta=.228, p=.01).

Conclusions

This study provides preliminary, but completely innovative evidence that perfectionism contribute to the psychological impact of Covid-19 pandemics. In the near future we will test the hypothesis that the nature of unpredictability and the limitations imposed by the global crisis may be exacerbating the already high levels of psychological distress that affect negative perfectionists.

Portuguese version of the fear of COVID-19 scale – psychometric study

Introduction

More than in other conditions, fear is associated with infectious diseases, and is directly associated with its transmission rate, morbidity and mortality. High levels of fear can affect the individual’s ability to think clearly, react proportionately and make rational decisions in the context of COVID-19. Recently, Mertens et al. (2020) developed the Fear of Covid-19 Scale (FCV-19S) to measure this construct.

Objectives

To analyse the psychometric properties of the FCV-19S Portuguese version, namely construct validity, internal consistency and convergent validity.

Methods

A community sample of 234 adults (75.6% women; mean age= 29.53±12.51; range:16-71) completed an on-line survey with the Portuguese versions of the FCV-19S, the Covid-19 Perceived Risk Scale (CPRS) and the Depression Anxiety Stress Scale (DASS-21).The total sample was randomly divided in two sub-samples: sample A (n=117) was used to perform an exploratory factor analysis/EFA; sample B (n=117) to make a confirmatory factor analysis/CFA.

Results

EFA resulted in one component. CFA revealed that the unifactorial model presented acceptable fit indexes (X2/df=3.291; CFI=.977; GFI=.932; TLI=.919; p[RMSEA≤.01]=.091). Cronbach alpha was α=.855. The total score significantly correlated with Covid-19 Perceived Risk (r=.529, p<.01) and with anxiety from DASS-21 (r=.132, p<.05).

Conclusions

This study provides preliminary evidence for the validity and reliability of the Portuguese version of FCV-19S, which will be used in an ongoing research project on the relationship between fear of Covid-19, personality, cognitive processes and adherence to public health measures to contain the pandemic.

Portuguese version of the COVID-19 perceived risk scale – psychometric study

Introduction

Risk perception of COVID-19 is potentially a significant determinant of the pandemic evolution and the public’s response to it. Acceptable levels of risk perception can be considered good for people to effectively fight the pandemic and adopt preventive health behaviors while high levels of risk perception may be damaging. Recently, Yıldırım&Güler (2020) developed the Covid-19 Perceived Risk Scale (C19PRS) to measure this construct.

Objectives

To analyze the psychometric properties of the C19PRS Portuguese version, namely construct validity, internal consistency and convergent validity.

Methods

A community sample of 234 adults (75.6% women; mean age= 29.53±12.51; range:16-71) completed an on-line survey with the Portuguese versions of the CPRS and the Fear of Covid-19 Scale (FCV-19S; Cabaços et al. 2020). The total sample was randomly divided in two sub-samples: sample A (n=117) was used to perform an exploratory factor analysis/EFA; sample B (n=117) to make a confirmatory factor analysis/CFA.

Results

EFA resulted in three components. CFA revealed that the second-order model with three factors presented good fit indexes (X2/df=1.471; CFI=.959; GFI=.948; TLI=.932; p[RMSEA≤.01]=.065). CPRS Cronbach alphas was α=.687; for F1 Worry, F2 Susceptibility to Covid-19 and F3 Susceptibility to Overall Morbimortality were α=.747, α=.813 and α=.543, respectively. The total and dimensional scores significantly correlated with FCV-19S (r>.30, p<.01).

Conclusions

This study provides evidence for the validity and reliability of the Portuguese version of CPRS, which will be used in an ongoing research project on the relationship between Covid-19 perceived risk, perfectionism, cognitive processes and adherence to public health measures to contain the pandemic.

RHOBTB2 p.Arg511Trp Mutation in Early Infantile Epileptic Encephalopathy-64: Review and Case Report

Early infantile epileptic encephalopathy-64 (EIEE 64), also called RHOBTB2-related developmental and epileptic encephalopathy (DEE), is caused by heterozygous pathogenic variants (EIEE 64; MIM#618004) in the Rho-related BTB domain-containing protein 2 (RHOBTB2) gene. To date, only 13 cases with RHOBTB2-related DEE have been reported. We add to the literature the 14th case of EIEE 64, identified by whole exome sequencing, caused by a heterozygous pathogenic variant in RHOBTB2 (c.1531C > T), p.Arg511Trp. This additional case supports the main features of RHOBTB2-related DEE: infantile-onset seizures, severe intellectual disability, impaired motor functions, postnatal microcephaly, recurrent status epilepticus, and hemiparesis after seizures.

An electron holography study of perpendicular magnetic tunnel junctions nanostructured by deposition on pre-patterned conducting pillars

The fabrication of multi-gigabit magnetic random access memory (MRAM) chips requires the patterning of magnetic tunnel junctions at very small dimensions (sub-30 nm) and a very dense pitch. This remains a challenge due to the difficulty in etching magnetic tunnel junction stacks. We previously proposed a strategy to circumvent this problem by depositing the magnetic tunnel junction material on prepatterned metallic pillars, resulting in the junction being naturally shaped during deposition. Upon electrical contact, the deposit on top of the pillars constitutes the magnetic storage element of the memory cell. However, in this process, the magnetic material is also deposited in the trenches between the pillars that might affect the memory cell behaviour. Here we study the magnetic interactions between the deposit on top of the pillars and in the trenches by electron holography, at room temperature and up to 325 °C. Supported by models, we show that the additional material in the trenches is not perturbing the working principle of the memory chip and can even play the role of a flux absorber which reduces the crosstalk between neighboring dots. Besides, in the studied sample, the magnetization of the 1.4 nm thick storage layer of the dots is found to switch from out-of-plane to an in-plane configuration above 125 °C, but gradually decreases with temperature. Electron holography is shown to constitute a very efficient tool for characterizing the micromagnetic configuration of the storage layer in MRAM cells.

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.

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 &lt; 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.

Island effect in the shell phenotypic plasticity of an intertidal gastropod

The pattern of shell shape variation in populations of the top shell, Phorcus sauciatus from Madeira Island (NE Atlantic) was analysed as a function of substrate type and wave exposure, using geometric morphometrics. We hypothesized that P. sauciatus shows morphological variations to inhabit contrasting environments. Highly significant differences in shell shape were found depending on both substrate type and coastal exposure. The most marked differences were found between exposed and sheltered environments. Rounded shells in exposed environments may be explained by physiological reasons, since larger muscles are needed to ensure attachment to substrate in areas subject to harsh conditions. On the other side, conically-shaped shells may accommodate a larger body but with a smaller foot, an adaptation to sheltered environments. Slight shape variations were also observed among substrates, mostly in the degree of differentiation of some whorls. Differences could be related to a particular use of habitat and/or to the degree of exposure to water current. These results suggest that P. sauciatus is locally adapted to varying coastal hydrodynamics and may be considered as a good model in studies on adaptations of fauna to certain climate change effects.

Aspergilose sistêmica em um cavalo - relato de caso

RESUMO O presente trabalho relata o caso de aspergilose sistêmica em um cavalo da raça Quarto de Milha. O animal apresentava quadro de emagrecimento progressivo e alopecia. Os parâmetros avaliados durante o exame clínico encontravam-se de acordo com os valores normais para a espécie. No hemograma verificou-se leucocitose por neutrofilia, sem desvio à esquerda, proteínas plasmáticas totais elevadas e aumento do fibrinogênio, indicando um processo inflamatório acompanhado de desidratação. Os exames bioquímicos séricos demonstraram aumento no valor da ureia. Apesar dos exames realizados e da terapia instituída com antibióticos de amplo espectro e suporte nutricional, após 51 dias de internamento o quadro clínico evoluiu para caquexia e decúbito permanente do paciente, o qual foi submetido à eutanásia seguida de necropsia. Com base nos achados nos exames necroscópico e histopatológico, diagnosticou-se infecção sistêmica por Aspergillus sp., acometendo pulmões, fígado, rins, peritônio parietal e encéfalo. Dentre os fatores predisponentes à relatada infecção fúngica sistêmica, destaca-se o status imunológico debilitado do paciente, possivelmente proporcionado por tratamentos prolongados com antibióticos e anti-inflamatórios esteroidais. O presente trabalho relata o primeiro caso descrito de arpergilose sistêmica no Brasil. O diagnóstico definitivo só foi possível após necropsia e histopatologia, visto que os sinais clínicos inespecíficos não foram determinantes para o diagnóstico em vida.

Decay and persistence of empty bivalve shells in a temperate riverine system

Bivalve shells can persist over a geological time, acting as important physical resources to the associated fauna. However, few studies have investigated their relevance as persistent long-term ecological attributes to the ecosystem. As such, it is relevant to investigate the shell decays in riverine systems subjected to different environmental conditions. Towards this end, shells of four bivalve species (Anodonta anatina, Corbicula fluminea, Potomida littoralis and Unio delphinus) were made available individually and in clusters of different sizes. The effects of river flow and seasonality were assessed by recording the decay rates of shells in lentic and lotic habitats throughout the year. Our results evidenced that the decays varied among species and depend on shell size, water flow and season. Thin shelled species (A. anatina and U. delphinus) showed the highest mean percentage of decay per month, 3.17% (lotic) and 2.77% (lotic), respectively, and thick shelled species (C. fluminea and P. littoralis) the lowest, 2.02% (lotic) and 1.83% (lotic), respectively. Size was a relevant variable explaining decays, with the smallest shells presenting the highest values, 1.2-2.0 times higher compared to the other size classes. Also, robustness showed to be the most relevant feature explaining the decays in thick shelled species. River flow was also a relevant descriptor of the decays, with higher decays observed in the lotic compared to the lentic habitats. Furthermore, lower decays were observed mainly during summer (lentic site), and autumn (lotic site) associated to the burial effect of leaves. In summary, shells of the native species A. anatina and U. delphinus are expected to persist and contribute less as habitat engineering species, than shells of the native P. littoralis and invasive C. fluminea species. This is especially valid to lotic habitats where the decays were up to 2.13 times higher than in lentic habitats.

Avaliação de anti-inflamatórios não esteroidais no tratamento da dor de ovinos submetidos à implantação de cânula ruminal e orquiectomia

RESUMO O presente trabalho objetivou comparar o efeito do flunixin meglumine, cetoprofeno e meloxicam no tratamento da dor pós-operatória de ovinos submetidos à implantação de cânula ruminal e orquiectomia. Foram utilizados 32 ovinos, machos, pesando em média 35,5±3,5kg, distribuídos em três grupos: GFlu (flunixin meglumine 1,1mg/kg i.v.), GCet (cetoprofeno 3,0mg/kg i.v.) e GMel (meloxicam 0,5mg/kg i.v.). Exame clínico e coletas de sangue foram realizados no M0 (pré-avaliação), M1 (10 minutos após a pré-avaliação), M2 (início da sutura para fixação da cânula ruminal), M3 (logo após o término da cirurgia) e em duas, 12, 23, 25, 48 e 72 horas após a cirurgia (M2h, M12h, M23h, M25h, M48h e M72h), quando foram avaliados cortisol, glicose, proteína total, albumina, γ-glutamiltransferase (GGT), aspartato aminotransferase (AST), creatina quinase (CK), ureia, creatinina e hemograma. Nos M2h, M12h, M23h, M25h e M48h, foi realizada avaliação comportamental. O GFlu apresentou maior concentração de cortisol no M12h e no M48h e maior escore de dor na fístula e no testículo no M12h, quando comparado ao GMel. Os animais do GCet apresentaram menor interação com outros membros da baia no M23h. A ação analgésica do meloxicam foi maior em animais submetidos à implantação de cânula ruminal e orquiectomia, quando comparado ao flunixin meglumine e ao cetoprofeno.

Efeito do uso de minerais traços (cobre, zinco, selênio e manganês) e vitaminas (A e E) injetáveis sobre o estresse oxidativo e função de neutrófilos de fêmeas da raça Holandesa no período de transição

RESUMO O objetivo deste estudo foi avaliar o efeito metafilático de minerais traços e vitaminas A e E injetáveis, em parâmetros do estresse oxidativo e na função de neutrófilos em fêmeas da raça Holandesa no período de transição. Sessenta animais foram divididos em dois grupos: animais que receberam minerais traços e vitaminas A e E injetáveis (GMTV) (n= 30) e grupo controle (GC) (n= 30). Não houve diferença significativa entre os grupos nos parâmetros avaliados, porém observou-se diferença significativa entre tratamento e dia para os valores da SOD, com maior atividade dessa enzima em fêmeas GMTV, nas semanas próximas ao parto. Observou-se diferença de dia e para interação tratamento e dia para o TBARS, em que fêmeas GMTV mostraram menores valores de TBARS em todos os momentos, exceto sete dias após o parto. Houve efeito significativo de dia para leucócitos, interação tratamento e dia para neutrófilos e interação tratamento e dia para fagocitose de neutrófilos, em que as fêmeas GMTV apresentaram valores menores de leucócitos e neutrófilos próximo ao parto, além de maior fagocitose de neutrófilos. Pode-se observar que houve melhora no sistema oxidativo e imune de fêmeas GMTV, resposta que provavelmente está relacionada com a administração dos minerais traços e vitaminas A e E.

Morfometria dos meniscos lateral e medial na articulação femorotibial de equinos

RESUMO As lesões dos meniscos são uma das principais causas de dor e claudicação em equinos. O objetivo do presente estudo foi avaliar a morfometria dos meniscos da articulação femorotibial de equinos. Foram utilizados 48 meniscos de 12 animais de ambos os sexos, com idade entre cinco e 15 anos e com peso entre 400kg e 500kg. A medida da extensão periférica compreendeu desde a parte mais cranial à mais caudal e denominou-se circunferência externa (CE). A margem interna, com o mesmo tratamento, foi chamada de circunferência interna (CI). Os meniscos foram divididos em terços craniais, médios e caudais. A espessura foi obtida nos pontos médios de cada terço. Foi calculada a área dos meniscos em contato com os côndilos femorais. O menisco medial apresentou maior CE com média de 126,38mm, enquanto o menisco lateral apresentou média de 115,32mm. O menisco lateral mostrou maior espessura nos terços médio e caudal, com valores médios de 16,00mm e 19,85mm, respectivamente, contra 13,75mm e 14,99mm dos meniscos mediais. Os resultados deste estudo mostraram relação importante entre os dados morfométricos e os achados clínicos na tentativa de explicar a maior incidência de lesões envolvendo o menisco medial.

Resposta inflamatória peritoneal de asininos (Equus asinus) submetidos à ovariectomia por laparotomia e laparoscopia

RESUMO Objetivou-se avaliar resposta inflamatória e concentrações de proteínas em líquido peritonealde asininas submetidas à ovariectomia por laparotomia e laparoscopia. Foram utilizadas 18 fêmeas adultas, pesando em média 100kg, as quais foram divididas em dois grupos, de nove animais cada: o grupo I, em que foram ovariectomizadas por laparotomia, e o grupo II por laparoscopia. Após as cirurgias, em ambos os grupos foram avaliadas as seguintes variáveis no líquido peritoneal: pH, densidade, número de hemácias, leucócitos e proteínas de fase aguda (fibrinogênio, haptoglobina, albumina, antitripsina, alfa-1 glicoproteína ácida, ceruloplasmina, transferrina, imunoglobulinas A e G). Todas as variáveis foram analisadas antes das cirurgias, 12, 24, 48, 72 horas, oito e 16 dias após os procedimentos cirúrgicos. O número de hemácias e leucócitos aumentou 24 horas depois das cirurgias nos dois grupos. Haptoglobina, alfa-1 glicoproteína ácida,albumina, transferrina, gamaglobulinas A, G e proteínas totais aumentaram nos dois grupos. As concentrações de ceruloplasmina não variaram enquanto a antitripsina não foi detectada no líquido peritoneal de asininos.Foi identificada uma proteína com23.000kD, que não tem denominação nem descrição no líquido peritoneal de asininos.

Abundance and population structure of Plesionika narval (Fabricius, 1787) in the Northeastern Atlantic

Analysis of abundance and population structure of Plesionika narval was performed on data concerning 5,255 specimens obtained from 62 fishing sets carried out off the Madeira archipelago (Northeastern Atlantic) between 2004 and 2008 in a depth range from 101 to 350 m. Abundance ranged from 0.01 to 19.74 specimens-per-trap and significant differences were found between seasons, probably as a result of an increment of population in the spring during the recruitment season. The analysis of size distribution revealed that the carapace length (CL) ranged from 2.45 to 28.61 mm and that mean female size consistently exceeded that of males. Differences in mean CL were statistically significant between depth strata and seasons. Of the specimens sampled, 57.00% were males, 41.88% females and 1.42% undetermined. Sex ratio also differed significantly between seasons according to depth strata, consolidating the hypothesis of the existence of seasonal migrations related with the reproductive cycle of this species. Ovigerous females showed larger sizes and occurred all year around and remain in shallow waters in winter, summer and autumn and move to deeper waters in spring. The highest frequency of ovigerous females was recorded in summer, between 151 and 200 m deep supporting the hypothesis that spawning of this species occurs in shallow waters, especially in late summer.

Weight-length relationships of six shrimp species caught off the Madeira Archipelago, Northeastern Atlantic

Length and weight relationships and descriptive statistics are reported for six shrimp species caught off the Madeira archipelago between 1983 and 2014 using bottom and floating traps from depths ranging from 50 to 1,300 m. The parameter b ranged between 2.36 for Plesionika ensis and 2.97 for Plesionika williamsi. All species showed a pattern of negative allometric growth. To the authors' knowledge all weight-length relationships presented herein are recorded for the first time from the Madeira area, and in the cases of Ligur ensiferus and Plesionika ensis are the first references worldwide.

Imunidade celular em vacas Holandesas soropositivas para o Vírus da Leucose Bovina (BLV) durante o período de transição

RESUMO Esta pesquisa avaliou a dinâmica dos leucócitos e das subpopulações de linfócitos em vacas Holandesas soropositivas para o BLV no período de transição. Amostras de sangue (n=72) provenientes de 12 vacas foram coletadas entre as semanas -2 e +3 para a realização do leucograma, imunofenotipagem, dosagem de cortisol e haptoglobina (Hp). O perfil leucocitário foi caracterizado por leucocitose, neutrofilia, monocitose e eosinopenia próximo ao parto. Linfocitose e elevada proporção de linfócitos B CD21+ foram achados constantes entre as semanas -2 e +3; assim, as vacas foram testadas e confirmadas soropositivas para o BLV. Os valores das subpopulações de linfócitos T apresentaram-se baixos durante o período de transição, observando-se dois picos máximos que coincidiram com as elevações nas concentrações de cortisol no parto (2,11µg/dL) e semana +3 (1,97µg/dL). Hp apresentou aumento crescente de -2 (166µg/mL) a +3 (576µg/mL), provavelmente associada à elevada taxa de infecções uterinas observadas nas semanas +2 e +3. As vacas soropositivas para o BLV apresentaram leucograma de estresse próximo ao parto, exceto para linfócitos. A linfocitose e as elevadas proporções de células B CD21+, associadas com as baixas proporções de células T, podem ser indicativo de imunossupressão e predisposição aos processos inflamatórios no período pós-parto.

Eslicarbazepine acetate as adjunctive therapy in clinical practice: ESLADOBA study

OBJECTIVE

To assess seizure control and tolerability of eslicarbazepine acetate (ESL) as adjunctive therapy to one baseline antiepileptic drug (AED), in adults with partial-onset seizures (POS) with or without secondary generalization.

METHODS

Multicenter, non-interventional, prospective cohort study conducted between March 2012 and September 2014 at 12 neurology departments in Portugal. Adults with POS not controlled with one AED who had initiated ESL as adjunctive treatment were enrolled. Retention rate was defined at the final visit (Vfinal) 6-9 months of follow-up. Proportion of responders, seizure-free, changes in seizure frequency were evaluated using patients' diaries. Clinical Global Impression of Change (CGI-C) and Clinical Global Impression of Severity (CGI-S) were assessed by the neurologist.

RESULTS

Fifty-two patients (48.1% male) were included with mean age 41.5±13.3 years. Mean epilepsy duration was 18.5±14.8 years; mean seizure frequency in the four previous weeks to baseline was 7.5±12.7. At Vfinal, retention rate was 73.0%; responder rate and seizure-free rates were 71.1% and 39.5%, respectively. The median relative reduction in seizure frequency between baseline and Vfinal was 82.2%. A reduction in epilepsy severity (CGI-S) was observed in 42.1%. According to CGI-C, 73.6% patients had their epilepsy "much improved" or "very much improved". Twelve patients (23.1%) had at least one adverse event (AE), two (3.9%) had one serious AE, and five (9.6%) discontinued due to AE.

CONCLUSIONS

Eslicarbazepine acetate showed good retention rates, elicited a significant reduction in seizure frequency, and was well tolerated when used in the clinical practice.

Remote cerebellar haemorrhage after placement of an external ventricular drainage for acute hydrocephalus: A case report

INTRODUCTION

Remote cerebellar haemorrhage (RCH) is a rare complication following a craniotomy. This generally benign phenomenon is an identifiable complication of supratentorial craniotomies and should not be mistaken with other pathologies. The most common presenting symptom is a decrease in the level of consciousness but in some cases the RCH may be asymptomatic and accidentally discovered in follow-up CT scans.

CASE REPORT

A 70-year-old man was admitted to our emergency department with sudden mental status deterioration. A head CT scan was carried out and an acute hydrocephalus was diagnosed. The patient was transferred to the operating room for external ventricular drainage (EVD) placement via a frontal burr-hole. At 24hours, the patient made a complete neurological recovery. On third postoperative day, a follow-up CT scan showed an asymptomatic right remote cerebellar haemorrhage. The MRI assessment confirmed the diagnosis. The EVD was removed on the 6th postoperative day and the patient was discharged after one week with no further symptoms.

DISCUSSION

This case report is the first documented case, to our knowledge, of a remote cerebellar haemorrhage after placement of external ventricular drainage via a frontal burr-hole. The precise aetiology of remote cerebellar haemorrhage remains unclear. One of the most accepted theories is the "cerebellar sag" explanation, which defends hypothesis that peri-operative over drainage of cerebrospinal fluid (CSF) is the main mechanism involved. Further investigation is required to understand the pathogenesis and risk factors for the occurrence of this phenomenon.

Improving the accuracy of synovial fluid analysis in the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers

Aims

The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin.

Patients and Methods

Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis. The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker.

Results

There were 23 PJIs and 32 patients with aseptic loosening. The levels of total leucocyte count, proportion of polymorphonuclear leucocytes (PMNs), CRP, ADA and α2M in the synovial fluid were all significantly higher in those with a PJI than in those with aseptic loosening. The levels of procalcitonin were comparable in the two groups. Cutoff values for the optimal performance in the diagnosis of infection were: total leucocyte count > 1463 cells/μL (sensitivity (Sens) 100%, specificity (Spec) 71.9%, positive predictive value (PPV) 71.9%, negative predictive value (NPV) 100%); proportion of PMNs > 81% (Sens 78.3%, Spec 75.0%, PPV 69.2%, NPV 82.8%); CRP > 6.7mg/L (Sens 78.3%, Spec 93.8%, PPV 90.0%, NPV 85.7%); ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%) and α2M > 958 mg/L (Sens 47.8%, Spec 96.9%, PPV 91.7%, NPV 72.1%). The addition of a raised level of CRP or ADA to the total leukocyte count increased the specificity: total leukocyte count > 1463 cells/μL and CRP > 6.7mg/L (Sens 78.3%, Spec 100%, PPV 100%, NPV 86.5%) or with ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%).

Conclusion

The total leucocyte count in the synovial fluid offers great negative predictive value in the diagnosis of PJI and the addition of more specific markers such as CRP and ADA improves the positive predictive value. Thus the addition of simple and inexpensive markers to the measurement of the leucocyte count in the synovial fluid may reduce the number of equivocal results which demand more expensive investigation. Cite this article: Bone Joint J 2017;99-B:351–7.