Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Fosfomycin-Induced Liver Injury: A Case Report

Fosfomycin is an antibiotic frequently used to treat uncomplicated urinary tract infections. It is normally well-tolerated, but there are some reports of clinically relevant liver injury. We present the case of a 73-year-old female who presented with paucisymptomatic hepatocellular acute liver injury six days after taking fosfomycin. After ruling out viral, ischemic, and autoimmune hepatitis, as well as Wilson disease and biliary disorders, she was diagnosed with drug-induced liver injury (DILI) related to fosfomycin. The patient showed major improvement during the first week and the resolution of liver injury one month after onset. This case report aims to underscore the potential hepatotoxicity of fosfomycin.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

One Anastomosis Transit Bipartition (OATB): Rational and Mid-term Outcomes

BACKGROUND

The "One-anastomosis transit bipartition" (OATB) is a promising emerging technique in the metabolic syndrome treatment.

OBJECTIVE

To demonstrate the results achieved with OATB in the first 5 years after surgery.

METHOD

Cross-sectional, retrospective study, with individuals undergoing primary OATB. Individuals included in the study were: ≥ 18 years, BMI ≥ 35 kg/m2; and excluded smoking habits, drug dependence, inflammatory bowel diseases. The data analyzed demographic, anthropometric, surgical, clinical, and nutritional.

RESULTS

Sixty eight participants, 75% women, average age 45.5 years and BMI 41 kg/m2. Associated diseases: osteoarthritis (52.9%), hypertension (48.5%) and type 2 diabetes mellitus-T2DM (39.7%). All underwent laparoscopy, without conversions. Average operative time is 122.6 ± 31.7 min, and hospital stay is 2.2 ± 0.8 days. The common channel length 27 and 41 patients with 250 cm and 300 cm respectively. We registered no intraoperative complications, 2 (2.9%) early complications, and 14 (20.6%) late complications. In the first 6 months, 94.7% (250 cm) and 88.9% (300 cm) of the patients no longer used medication for T2DM, with no statistical difference between the two groups. The incidence of nutritional disorders at any time during follow-up: hypovitaminosis D (14.7%), folate hypovitaminosis (14.7%), elevated PTH (7.4%), hypoproteinemia (5.9%) and anemia (5.9%). We found no statistically significant difference between 250 and 300 cm common channel groups.

CONCLUSION

We conclude that OATB is a safe and effective technique, demonstrating good control of T2DM and metabolic syndrome. There is a requirement to treat previous nutritional deficits. We need more long-term evidence and comparison to other surgical techniques.

OAGB Bowel Function in Patients With up to 5 Years Follow-Up: Updated Outcomes

OBJECTIVE

One-anastomosis gastric bypass (OAGB) is considered an effective technique in weight reduction and remission of comorbidities. However, in common with many bariatric and metabolic/bariatric procedures, gastrointestinal side effects are frequently reported, but clinical experience varies. The objective of this study was to analyze the bowel function of patients who undergo OAGB looking at 5-year postoperative outcomes.

METHOD

This study is cross-sectional, descriptive and analytical, developed with individuals undergoing OAGB (n = 208) in yhe period between 2015 and 2020. The time periods evaluated were 1 to 6 months (T1), 6 to 12 months (T2), and 1 to 5 years (T3). Data analysis was performed using SPSS v.28.0, considering a significance level p ≤ 0.05.

RESULTS

114 participants (54.8%), 79.8% women, mean age 47.0 ± 12.6 years, and BMI 40.1 ± 5.6 kg/m2, 51.9% dyslipidemia, 43.6% arterial hypertension, and 19.1% diabetes mellitus. The T1 group had more severe symptoms/nausea than the T2 group. The T2 group had a significantly lower defecation frequency than the T1 and T3 groups. As for the occurrence of diarrhea, associations were not found in the considered groups. The T3 group had a greater severity of constipation associated with greater difficulty in consuming red meat, white meat, rice, vegetables, and salads.

CONCLUSIONS

Gastrointestinal symptoms are prevalent in the first postoperative months. However, diarrhea was not common. The patient selection policy and surgical technique were decisive in this result. Constipation was prevalent in patients between 1 and 5 postoperative years. It was also prevalent in those who had food intolerance, which from a nutritional point of view is an adverse factor for optimal bowel function.

Pre-exposure to seawater or chloride salts influences the avoidance-selection behavior of zebrafish larvae in a conductivity gradient

The risk assessment of freshwater salinization is constructed around standard assays and using sodium chloride (NaCl), neglecting that the stressor is most likely a complex mixture of ions and the possibility of prior contact with it, triggering acclimation mechanisms in the freshwater biota. To date, as far as we are aware of, no information has been generated integrating both acclimation and avoidance behavior in the context of salinization, that may allow these risk assessments upgrading. Accordingly, 6-days-old Danio rerio larvae were selected to perform 12-h avoidance assays in a non-confined 6-compartment linear system to simulate conductivity gradients using seawater (SW) and the chloride salts MgCl2, KCl, and CaCl2. Salinity gradients were established from conductivities known to cause 50% egg mortality in a 96-h exposure (LC50,96h,embryo). The triggering of acclimation processes, which could influence organisms' avoidance-selection under the conductivity gradients, was also studied using larvae pre-exposed to lethal levels of each salt or SW. Median avoidance conductivities after a 12-h of exposure (AC50,12h), and the Population Immediate Decline (PID) were computed. All non-pre-exposed larvae were able to detect and flee from conductivities corresponding to the LC50,96h,embryo, selecting compartments with lower conductivities, except for KCl. The AC50,12h and LC50,96h overlapped for MgCl2 and CaCl2, though the former is considered as more sensitive as it was obtained in 12 h of exposure. The AC50,12h for SW was 1.83-fold lower than the LC50,96h, thus, reinforcing the higher sensitivity of the parameter ACx and its adequacy for risk assessment frameworks. The PID, at low conductivities, was solely explained by the avoidance behavior of non-pre-exposed larvae. Larvae pre-exposed to lethal levels of salt or SW were found to select higher conductivities, except for MgCl2. Results indicated that avoidance-selection assays are ecologically relevant and sensitive tools to be used in risk assessment processes. Stressor pre-exposure influenced organisms' avoidance-selection behavior under conductivity gradients, suggesting that under salinization events organisms may acclimate, remaining in altered habitats.

Amendment of soils with metal-rich sludge: Potential water toxicity due to metal release via over-time slaking

Industrial metal-rich sludge can improve soil properties, but it is potentially toxic to soils and adjacent aquatic systems. The soil-sludge-water interactions influence metals bioavailability over time, a phenomenon mostly regulated by the still debatable "sludge physical protection" or "sludge delayed release" hypotheses. The present study aimed to investigate: (1) whether sludge increases soil aggregate stability against slaking, (2) which hypothesis mostly regulates metal release from soils to water and (3) the ecotoxicity of the metals released during soil slaking for aquatic organisms. Under a realistic field scale, soils amended with an industrial sludge or spiked with equivalent metal solutions (of Cr, Cu, Ni, Zn) were collected over three months to test soil aggregate stability, the ecotoxicity of the slaking water and metal contents in soil and water. The "sludge physical protection" was verified for all metals, though for Cu the "sludge delayed release" hypothesis appears plausible after three months. Soil amendment with sludge did not lead to effects on the growth of the microalga Raphidocelis subcapitata, contrarily to the observed for the metal-spiked soil. Criteria regulating soils sludge-amendment management should thus include doses not hazardous to biota, and not only metal threshold levels.

Spontaneous Pneumomediastinum: A Rare Cause of Chest Pain

Spontaneous pneumomediastinum is a rare medical condition characterized by the presence of free air in the mediastinum, not preceded by trauma, surgery, or another medical procedure. It predominantly affects young adult males and usually has a benign course, and in most cases, it is not possible to identify the precipitating factor. There are some conditions that predispose to its occurrence, namely those that lead to an increase in intrapleural pressure, such as coughing, vomiting, or vigorous exercise. We report a case of a 21-year-old male who presented with acute-onset shortness of breath after an episode of coughing and was found to have mediastinal and subcutaneous emphysema. Clinical, laboratory, and radiological studies did not demonstrate any predisposing factor, and the case was classified as spontaneous pneumomediastinum.

The platelet-to-lymphocyte ratio as an indirect outcome predictor in primary hypertension: a retrospective study

Background

Nondipper hypertensive patients have higher levels of platelet-to-lymphocyte ratio, a new studied inflammatory biomarker in primary hypertension. Furthermore, these patients have a higher risk of cardiovascular morbidity and mortality. This study aimed to assess the relationship between platelet-to-lymphocyte ratio and hypertensive pattern (dipper vs nondipper) and the association between the hypertensive pattern and major adverse cardiovascular events.

Methods

A retrospective analysis was performed. One hundred fifty-three patients were included and classified as dipper or nondipper according to 24-hour ambulatory blood pressure measurements. Platelet-to-lymphocyte ratio was calculated based on complete blood count data.

Results

The dipper group included 109 patients, and the nondipper group included 44 patients. Nondipper patients have 2.11 more risk of presenting a higher platelet-to-lymphocyte ratio than dipper individuals (odds ratio [OR] = 2.11; 95% CI, 1.220-3.664; P = .007). Nondipper patients also registered earlier cardiovascular events, such as acute myocardial infarction and stroke (P < .001).

Conclusions

Nondipper hypertensive individuals registered higher levels of platelet-to-lymphocyte ratio and earlier cardiovascular events than dipper patients. Therefore, platelet-to-lymphocyte ratio could be used as an indirect predictor of cardiovascular risk in primary hypertension and contribute to optimize preventive strategies.

Ecological risk assessment of the Paraíba River estuary (Brazil): Plan for a tier 1 screening phase for the ecotoxicological line of evidence

The knowledge produced in temperate regions is still used today to evaluate environmental problems in the tropics, without taking into consideration environmental differences, such as local conditions, the sensitivity and ecology of species, and exposure routes of contaminants, essential for understanding and determining the fate and toxicity of chemicals. Considering that Environmental Risk Assessment (ERA) studies for tropical systems are scarce and need to be adjusted, the present study aims at contributing to the awareness and development of tropical ecotoxicology. The estuary of the Paraíba River in Northeast Brazil was selected as a model study-case, as it is a large estuary, subjected to a heavy human pressure due to the numerous social, economic and industrial activities. The present study describes the framework for the problem formulation phase of the ERA process; it first includes a detailed integration of the scientific information available on the study area, to then derive the conceptual model, and finally present the analysis plan for the tier 1 screening phase. The latter is designed to be fundamentally supported by the ecotoxicological line of evidence, to ascertain, without delay, where and why there are environmental problems (i.e., adverse biological effects); ecotoxicological tools developed in temperate climates will be optimized to assess water quality in a tropical system. In addition to its intrinsic value for protecting the study area, the results of the present study are expected to provide an important baseline for conducting ERA in similar tropical aquatic systems across the globe.

Gastrointestinal reported outcomes following One Anastomosis Gastric Bypass based on a multicenter study

OBJECTIVES

To describe gastrointestinal-related side-effects reported following One Anastomosis Gastric Bypass (OAGB).

METHODS

A multicenter study among OAGB patients across Israel (n=277) and Portugal (n=111) who were recruited to the study based on time elapsed since surgery was performed. An online survey with information on demographics, anthropometrics, medical conditions, and gastrointestinal outcomes was administered in both countries simultaneously.

RESULTS

Respondents from Israel (pre-surgery age of 41.6±11.0 years, 75.8% females) and Portugal (pre-surgery age of 45.6±12.3 years, 79.3% females) presented mean excess weight loss of 51.0±19.9 and 62.4±26.5%, 89.0±22.0 and 86.2±21.4%, and 89.9±23.6 and 98.2±20.9% (P<0.001 for both countries), at 1-6 months, 6-12 months, and 1-5 years post-surgery, respectively. Median Gastrointestinal Symptom Rating Scale score was similar between time elapsed since surgery groups among respondents from Israel and Portugal (≤1.97 and ≤2.12). A notable proportion of respondents from Israel and Portugal at all time points reported 1-3 bowel movements per day (≤62.8 and ≤87.6%), Bristol stool scale categories which represent diarrhea-like stools (≤51.9 and ≤56.3%), having discomfort due to flatulence (≤79.4 and ≤90.2%), and mild to severe dyspepsia symptoms (≤50.5 and ≤73.0%).

CONCLUSIONS

A notable proportion of OAGB patients might experience certain gastrointestinal symptoms postoperatively, including flatulence, dyspepsia, and diarrhea-like stools.

Nutritional and Lifestyle Behaviors Reported Following One Anastomosis Gastric Bypass Based on a Multicenter Study

This study aimed to describe nutritional and lifestyle parameters following one-anastomosis gastric bypass (OAGB). A multicenter study among OAGB patients across Israel (n = 277) and Portugal (n = 111) was performed. Patients were approached according to the time elapsed since surgery. An online survey with information regarding demographics, anthropometrics, and nutritional and lifestyle aspects was administered in both countries simultaneously. Respondents from Israel (pre-surgery age of 41.6 ± 11.0 years, 75.8% females) and Portugal (pre-surgery age of 45.6 ± 12.3 years, 79.3% females) reported changes in their appetite (≤94.0% and ≤94.6%), changes in their taste (≤51.0 and ≤51.4%), and intolerance to specific foods (i.e., red meat, pasta, bread, and rice). Bariatric surgery-related eating recommendations were generally followed well, but a trend toward lower adherence was evident in groups with longer time elapsed since surgery in both countries. Most respondents from Israel and Portugal reported participation in follow-up meetings with a surgeon (≤94.0% and 100%) and a dietitian (≤92.6% and ≤100%), while far fewer reported participation in any follow-up meeting with a psychologist/social worker (≤37.9% and ≤56.1%). Patients following OAGB might experience changes in appetite, taste, and intolerance to specific foods. Adherence to bariatric surgery-related eating recommendations is not always satisfying, especially in the longer term post-surgery.

Conversion of Roux-en-Y gastric bypass to single anastomosis duodenal ileal bypass with sleeve gastrectomy with gastrogastric jejunal bridge

Surgical conversion of Roux-en-Y gastric bypass (RYGB) to one anastomosis duodenal switch with sleeve gastrectomy (SADI-S), can be effective, when there is obesity recidivism, but surgically challenging. This case report video aims to detail the technical modifications that simplifies this conversion, in one stage. This video article demonstrates the conversion of RYGB to SADI-S using a jejunal bridge to facilitating the gastro-gastric reconnection. Surgical conversion was done laparoscopically, firstly removing the fundus, gastric body and the proximal part of the antrum. The gastrojejunal (GJ) anastomosis from the previous RYGB was preserved and the jejunal alimentary limb that follows was transected, 8cm distal to the GJ anastomosis, and anastomosed, at this level, with the antrum. The remaining alimentary limb was removed, until the jejuno-jejuno anastomosis, from the previous RYGB. The interposition of a segment of jejunal alimentary limb between the gastric bypass pouch and the antrum, has shown to be safe and feasible in RYGB conversion to SADI-S, without complications. Not reconnecting the remnant jejunal alimentary limb to the intestinal transit, but removing it, makes the procedure shorter and safer.

The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Choice of Bariatric Surgery in Patients with Obesity and Type 1 Diabetes Mellitus? an Up-to-Date Systematic Review

BACKGROUND

The prevalence of obesity in patients with type 1 diabetes mellitus (T1DM) has been increasing. Metabolic bariatric surgery (MBS) has proven to be effective in treating patients with T2DM. However, evidence for the benefit of the procedure for patients with T1DM is still limited, particularly in terms of glycemic control, demonstrating the need for a systematic review investigating this.

METHOD

A systematic review was performed in accordance with the PRISMA guidelines. Outcome measures such as weight loss, remission of comorbidities, pre- and post-intervention insulin requirements, and HbA1c levels were extracted.

RESULTS

Thirty studies were included with a total of 706 patients (F = 524, M = 74, N/A = 60). The mean age was 40.01 years. The mean weight and body mass index (BMI) were 112.76 kg and 40.88 kg/m² (24-58.9) respectively. The common procedure performed was RYGB (n = 497 (70.4%)), followed by SG (n = 131 (18.6%)). The mean decrease of insulin requirements was 92.3 IU/day (36.2-174) preoperatively to a mean of 35.8 IU/day (5-75) post-operatively. No significant trend was found for changes in HbA1c levels. The main side effects were episodes of hypoglycemia and diabetic ketoacidosis (DKA); there was no mortality. The mean %EWL was 74.57% (60-90.5%) at ≥ 6 follow-up months. Reductions in comorbidities such as hypertension and cardiovascular disease (CVD) were recorded in multiple studies.

CONCLUSION

Patients with obesity and T1DM can expect significant weight loss, potential resolution of comorbidities, and reduction of insulin requirements, but it does not usually result in improved glycemic control. Based on current review, best choice of bariatric surgery in such patients cannot yet be established.

Humane acute testing with tadpoles for risk assessment of chemicals: Avoidance instead of lethality

In spite of the sensitivity of amphibians to contamination, data from fish have been commonly used to predict the effects of chemicals on aquatic life stages. However, recent studies have highlighted that toxicity data derived from fish species may not protect all the aquatic life stages of amphibians. For pesticide toxicity assessment (PTA), EFSA has highlighted that more information on lethal toxicity for the aquatic life stages of amphibians is still needed to reduce uncertainties. The current review aims to propose a test with amphibians based on spatial avoidance, as a more humane alternative method to the lethality tests for chemicals. A review of lethal toxicity tests carried out with amphibians in the period between 2018 and 2021 is presented, then we discuss the suitability of using fish toxicity data as a surrogate to predict the effects on more sensitive amphibian groups. The possible differences in sensitivity to chemicals may justify the need to develop further tests with amphibian embryos and larvae in order to reduce uncertainties. A new test is proposed focused on the avoidance behaviour of organisms fleeing from contamination to replace lethal tests. As avoidance indicates the threshold at which organisms will flee from contamination, a reduction in the population density, or its disappearance, at the local scale due to emigration is expected, with ecological consequences analogous to mortality. Avoidance tests provide an ethical advantage over lethal tests as they respect the concepts of the 3 Rs (mainly Refinement), reducing the suffering of the organisms.

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus

PURPOSE

One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus.

METHODS

A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus.

RESULTS

Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m² as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m² (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%).

CONCLUSION

Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m²) with associated metabolic problems, and patients with BMIs more than 50 kg/m² as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

In vivo cyclic induction of the FOXM1 transcription factor delays natural and progeroid aging phenotypes and extends healthspan

The FOXM1 transcription factor exhibits pleiotropic C-terminal transcriptional and N-terminal non-transcriptional functions in various biological processes critical for cellular homeostasis. We previously found that FOXM1 repression during cellular aging underlies the senescence phenotypes, which were vastly restored by overexpressing transcriptionally active FOXM1. Yet, it remains unknown whether increased expression of FOXM1 can delay organismal aging. Here, we show that in vivo cyclic induction of an N-terminal truncated FOXM1 transgene on progeroid and naturally aged mice offsets aging-associated repression of full-length endogenous Foxm1, reinstating both transcriptional and non-transcriptional functions. This translated into mitigation of several cellular aging hallmarks, as well as molecular and histopathological progeroid features of the short-lived Hutchison-Gilford progeria mouse model, significantly extending its lifespan. FOXM1 transgene induction also reinstated endogenous Foxm1 levels in naturally aged mice, delaying aging phenotypes while extending their lifespan. Thus, we disclose that FOXM1 genetic rewiring can delay senescence-associated progeroid and natural aging pathologies.

Use of spray nozzles to recover dissolved methane from an Upflow Anaerobic Sludge Blanket (UASB) reactor effluent

Methane is a powerful greenhouse gas and a source of energy. Recovering this gas means lower greenhouse gas emission and potential reduction of energetic costs. The lack of full-scale results, the use of different methodologies to detect dissolved methane (d-CH₄) and the fact that no process to remove d-CH₄ from anaerobic effluents is energetically or economically viable at full-scale urged a different approach to the problem. To avoid methodological interference and facilitate comparison of results the Standard Test Method number D8028-17 published by ASTM International can be used to determine d-CH₄. The use of real anaerobic reactor effluent also helps results to be compared. In this study, 80 samples from a full-scale anaerobic reactor showed an average concentration of dissolved methane of 14.9 mg·L^-1, meaning an emission of 229 kg of CO₂ eq·h^-1 and an average of 113.5 kW wasted. Using spray nozzles, an alternative to the methods being researched, the average methane recovery was 11.5 mg·L^-1 of CH₄, an efficiency of 81.6%, meaning 177 kg of CO₂ eq·h^-1 emissions avoided and 87.9 kW of recoverable energy.

Influence of salinity on the toxicity of copper and cadmium to Zebrafish embryos

Salinization has become a serious worldwide environmental perturbation in freshwater ecosystems. Concomitantly, many of such ecosystems are already impacted by other toxicants, which together with increased salinity may result in synergistic, antagonistic or additive toxic effects to biota. This work intended to assess the influence of increasing salinity (by using NaCl) on the lethal and sublethal toxicity of two metallic elements (copper and cadmium) in embryos of the fish species Danio rerio. This goal was achieved by exposing zebrafish embryos to seven concentrations of NaCl, individually or combined with each metal, using a full factorial design. The following endpoints were monitored in the test organisms: mortality, hatching, malformations and the enzymatic activity of glutathione S-transferase (GST) and cholinesterase (ChE). Overall, moderate salinity levels alleviated the lethal toxicity of both copper and cadmium although this effect was stronger in the copper assay. This effect was also influenced, as expected, by the concentrations of the metals indicating that the protective effect of salt only reaches some levels, after what is overwhelmed by the high metal toxicity, especially with the non-essential metal cadmium. At sub-lethal concentrations, the interactive effect resulting from NaCl and metals was not consistent and varied with the endpoint analyzed and the metal tested. Overall, the interactions between the salt and metals seem complex and with more drastic effects (positive or negative) on lethal endpoints than sub-lethal.

Seawater intrusion: an appraisal of taxa at most risk and safe salinity levels

Seawater intrusion into low-lying coastal ecosystems carries environmental risks. Salinity levels at these coastal ecosystems may vary substantially, causing ecological effects from mortality to several sublethal endpoints, such as depression of rates of feeding, somatic growth, or reproduction. This review attempts to establish safe salinity levels for both terrestrial and freshwater temperate ecosystems by integrating data available in the literature. We have four specific objectives: (i) to identify the most sensitive ecological taxa to seawater intrusion; (ii) to establish maximum acceptable concentrations-environmental quality standards (MAC-EQSs) for sea water (SW) from species sensitivity distributions (SSDs); (iii) to compile from the literature examples of saline intrusion [to be used as predicted environmental concentrations (PECs)] and to compute risk quotients for the temperate zone; and (iv) to assess whether sodium chloride (NaCl) is an appropriate surrogate for SW in ecological risk assessments by comparing SSD-derived values for NaCl and SW and by comparing these with field data. Zooplankton, early life stages of amphibians and freshwater mussels were the most sensitive ecological receptors for the freshwater compartment, while soil invertebrates were the most sensitive ecological receptors for the terrestrial compartment. Hazard concentration 5% (HC₅ ) values, defined as the concentration (herein measured as conductivity) that affects (causes lethal or sublethal effects) 5% of the species in a distribution, computed for SW were over 22 and 40 times lower than the conductivity of natural SW (≈ 52 mS/cm) for the freshwater and soil compartment, respectively. This sensitivity of both compartments means that small increments in salinity levels or small SW intrusions might represent severe risks for low-lying coastal ecosystems. Furthermore, the proximity between HC₅ values for the soil and freshwater compartments suggests that salinized soils might represent an additional risk for nearby freshwater systems. This sensitivity was corroborated by the derivation of risk quotients using real saline intrusion examples (PECs) collected from the literature: risk was >1 in 34 out of 37 examples. By contrast, comparisons of HC₅ values obtained from SSDs in field surveys or mesocosm studies suggest that natural communities are more resilient to salinization than expected. Finally, NaCl was found to be slightly more toxic than SW, at both lethal and sublethal levels, and, thus, is suggested to be an acceptable surrogate for use in risk assessment.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Is resveratrol a prospective therapeutic strategy in the co-association of glucose metabolism disorders and neurodegenerative diseases?

Objectives: The mechanism behind the progression of Mild Cognitive Impairment (MCI) to Alzheimer's disease (AD) remains poorly understood. However some evidence pointed out that the co-occurrence of metabolic conditions affecting glucose homeostasis, as type 2 diabetes mellitus (T2DM), may be an important catalyst in this context. Notably, candidate drugs which modulate common pathways in the development of MCI-to-AD mediated by T2DM may offer likely therapy for AD. Nonetheless, limited pharmacological alternatives that modulate common pathways in T2DM, MCI, and AD are available. In the recent decades, studies have shown that resveratrol may act as a neuroprotective compound, but little is known about its potential in improving cognitive and metabolic aspects associated with AD progression mediated by the co-association between TDM2-MCI.Methods: In this review, we discuss possible protective mechanisms of resveratrol on shared pathways associated with AD progression mediated by T2DM-MCI co-occurrence.Results: Some studies indicated that insulin resistance and hyperglycemia may be also a T2DM risk factor for the progression of MCI-to-AD, promoting alterations in metabolic pathways associated with neuronal plasticity, and increasing pro-inflammatory environment. Interestingly, basic research and clinical trials indicate that resveratrol may modulate those pathways, showing a potential neuroprotective effect of this polyphenol.Conclusion: Therefore, there is not enough clinical data supporting the translational therapeutic use of resveratrol in this scenario.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Using hypothesis testing on the mass-transfer effect with sulfate removal as an application

Sulfate and chemical oxygen demand removal by an anaerobic batch reactor treating of acid mine drainage is modelled. Available models are abundant but excessively complex, with large numbers of free parameters. Here, maximum likelihood and chi-squared hypothesis tests are applied to three simple models, with Malthus-Monod and Fick description, in increasing order of complexity: (i) planktonic single population (of sulfate-reducing bacteria); (ii) planktonic double-competing populations (adding fermentative bacteria); (iii) granule bound double-competing populations. The data set consists of 6 time profiles, sampled from 120 days of operation after stabilization of the reactor in pH 4. Single population is refuted by all profiles, in which the sulfate reduction is 72% larger than fermentatives. The planktonic double-competing population description is refuted at 119 days, with inner granule diffusion rate as low as 10% of the previous period. The results showed that, after an operation time, the influence of mass transfer became more evident and the incorporation of Fick's law in the model was fundamental to the description of this trend. All tests and inferences are performed at the 90% confidence interval due to large systematic uncertainties in the data.

Effects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

Survival recovery rates by six clonal lineages of Daphnia longispina after intermittent exposures to copper

Natural populations are commonly exposed to sequential pulses of contaminants. Accordingly, this study aimed at testing the existence of an association between the tolerance to lethal levels of copper (Cu) and the survival recovery ability from pulsed partially lethal copper exposures in six clonal lineages of Daphnia longispina. It was hypothesized that the most tolerant genotypes would be the ones exhibiting a faster survival recovery from a pulsed contaminant exposure. For each clonal lineage, the intensity of pulses corresponded to the respective concentration of Cu causing 30% of mortality after 24h of exposure (LC_30,24h). The initial hypothesis was not corroborated: obtained results showed no association between survival recovery and lethal tolerance to Cu. Nevertheless, some patterns could be detected. Firstly, the most sensitive lineages to lethal levels of copper revealed a faster survival recovery from a first Cu pulse comparatively to the most tolerant ones, though they were the most sensitive to a second pulse exposure. Secondly, the most tolerant lineages, though being more tolerant to a second exposure, exhibited the lowest survival recovery capacity after exposure to a first pulse of Cu. However, differences in the survival recovery capacity of the six clonal lineages after the exposure to the two pulses of Cu were not observed. Increasing the duration of the recovery period from 24h to 72h did not significantly alter mortality rates, except for the most sensitive and most tolerant clonal lineages. The results here obtained suggests that standard lethality assays may sub-estimate the toxicity of chemicals under realistic exposure scenarios, since sequential pulses are not infrequent in natural conditions.

Easiness, usefulness and intention to use a MOOC in nursing

BACKGROUND

The growing ageing population and the increasing prevalence of non-communicable diseases call for innovation and healthcare mastered professional skills. Emerging digital learning contents envisioning to complement education, lifelong learning and in-service training. The use of digital platforms allows nurses to access contents in several formats, enabling the required pedagogical autonomy and personal time management. This allows nurses to enrol in education wherever accessible, reducing personal and professional costs and ensuring high-quality standards.

OBJECTIVES

To assess students and nurses' easiness, usefulness and intention to use a Massive Open Online Course (MOOC) as an educational resource to enhance self-management intervention skills in COPD patients.

METHODS

An exploratory, descriptive and transversal study was conducted. Participants were nursing students, registered nurses and rehabilitation nurses. A questionnaire supported by Davis Technology Acceptance Model and on the determinants of the ease-of-use perception of Venkatesh was applied. An EFA was performed and two dimensions were obtained (perceived easiness and global quality of the course and perceived usefulness and intention to use the MOOC) and groups were compared in these dimensions.

RESULTS

From the total participants (n = 93), 65.6% were nursing students, 15.1% were Portuguese nurses and 19.4% were Portuguese rehabilitation nurses. The perceived easiness and global quality score of the course were 4.70 (SD = 0.314) and the perceived usefulness and intention to use the MOOC was 4.73 (SD = 0.346). Rehabilitation nurses, who are older, scored higher than nurses and students (χ²(2, n = 93) = 8.43, p = .015, ε² = 0.092). The dropout rate was 25%.

CONCLUSIONS

The MOOC showed usefulness and nurses' intention to use this educational resource in future education and yielded high average rates of perceived easiness and global quality. These massive courses unlock new opportunities for nursing education and to lifelong learning in nursing, enhancing safety and quality of the healthcare services in supporting patients to achieve a better quality of life.

Gyroxin, a toxin from Crotalus durissus terrificus snake venom, induces a calcium dependent increase in glutamate release in mice brain cortical synaptosomes

Gyroxin is a thrombin-like toxin obtained from the venom of the South American rattlesnake, Crotalus durissus terrificus. Literature has reported "gyroxin syndrome" characterized, in mice, as series of aberrant motor behavior, known as barrel rotation, mainly after intraperitoneal administration. Despites several studies, a physiological mechanism of "gyroxin syndrome" are still not completely understood. In this context, alterations on the central nervous system (CNS), especially causing neurotoxic events, are pointed out as likely candidates. Then, we decided to investigate whether gyroxin induces alterations in glutamate release, one of the most important neurotransmitter involved in neurotoxicity. For that, we performed all experiments, in vitro, using a model of mice brain cortical synaptosomes. Notably, our results indicate that the administration of gyroxin on purified presynaptic brain cortical terminals resulted in an extracellular Ca²⁺- dependent raise in glutamate release. Indeed, our results also showed that gyroxin increases intrasynaptosomal calcium (Ca²⁺) levels through acting on voltage gated calcium channels (VGCC), specifically N and P/Q subtypes. Moreover, our data show that gyroxin increases exocytosis rate. Interestingly, these data suggest that gyroxin might induce neurotoxicity by increasing glutamate levels. However, future investigations are needed in order to elucidate the nature of the following events.

Hybrid MM/CG Webserver: Automatic Set Up of Molecular Mechanics/Coarse-Grained Simulations for Human G Protein-Coupled Receptor/Ligand Complexes

Hybrid Molecular Mechanics/Coarse-Grained (MM/CG) simulations help predict ligand poses in human G protein-coupled receptors (hGPCRs), the most important protein superfamily for pharmacological applications. This approach allows the description of the ligand, the binding cavity, and the surrounding water molecules at atomistic resolution, while coarse-graining the rest of the receptor. Here, we present the Hybrid MM/CG Webserver (mmcg.grs.kfa-juelich.de) that automatizes and speeds up the MM/CG simulation setup of hGPCR/ligand complexes. Initial structures for such complexes can be easily and efficiently generated with other webservers. The Hybrid MM/CG server also allows for equilibration of the systems, either fully automatically or interactively. The results are visualized online (using both interactive 3D visualizations and analysis plots), helping the user identify possible issues and modify the setup parameters accordingly. Furthermore, the prepared system can be downloaded and the simulation continued locally.

Primary health care attributes of family health teams with and without family physician

Background

The four essential attributes of primary health care (PHC): access, longitudinality, comprehensiveness and coordination, guide the professional practices of service management and also the professionals of the family health strategy teams. Family medicine residence (FMR) is the speciality that trains medical practitioners capable of acting properly in PHC. It develops a person-centred approach, oriented towards the individual, his family and community, which dialogues with the PHC precepts of comprehensive patient care from a social point of view. Thus, the objective of this study was to verify whether there are differences in the PHC attributes perceived by patients treated by teams with FMR doctors and by the others.

Methods

This was an observed cross-sectional study conducted during 2019, which used the Adult Primary Care Assessment Tool (PCATool) to evaluate preliminarily 28 PHC teams working at the city of São Paulo, Brazil. The teams were compared based on 337 patient answers using domains medians and Mann-Whitney tests. The study was approved by the ethics committee.

Results

Eight teams (28.6%) had doctors trained in FMR. The attributes of longitudinality and access were very similar between the two groups. The teams with FMR doctors showed better evaluations in the components: information systems, median 7.78, versus 6.67 (p = 0.391); services available, median 6.52, versus 6.06 (p = 0.086); and services received, median 4.85, versus 3.85 (p = 0.180) of the coordination and comprehensiveness attributes.

Conclusions

We didn't find statistically significant results indicating better PHC attributes of teams with FMR doctors, based on user perception. A continuous study is recommended to follow the evolution of this speciality in the PHC context.

Key messages

FMR is a fundamental key to PHC and must be evaluated continuously. It is necessary to strengthen their insertion in the Brazilian health system and discuss the ways to do so.

Enhanced Recovery After Surgery (ERAS) protocol in bariatric and metabolic surgery (BMS)-analysis of practices in nutritional aspects from five continents

This study aims to understand the prevalent practices on the nutritional aspects of the enhanced recovery after surgery (ERAS) protocol based on the knowledge and practice of surgeons, nutritionists, and anesthesiologists who work in the bariatric and metabolic surgery (BMS) units worldwide. This cross-sectional study enrolled BMS unit professionals from five continents-Africa, America, Asia, Europe, and Oceania. An electronic questionnaire developed by the researchers was provided to evaluate practices about the three nutritional aspects of ERAS protocol in BMS (Thorel et al. 2016): preoperative fasting, carbohydrate loading, and early postoperative nutrition. Only surgeons, nutritionists, and anesthesiologists were invited to participate. One hundred twenty-five professionals answered the questionnaires: 50.4% from America and 39.2% from Europe. The profile of participating professionals was bariatric surgeons 70.2%, nutritionists 26.4%, and anesthesiologists 3.3%. Approximately 47.9% of professionals work in private services, for about 11 to 20 years (48.7%). In all continents, a large majority were aware of the protocol. Professionals from the African continent reported having implemented the ERAS bariatric protocol 4.0 ± 0 years ago. It is worth mentioning that professionals from the five continents implemented the ERAS protocol based on the published literature (p = 0.012). About preoperative fasting abbreviation protocol, a significant difference was found between continents and consequently between services (p = 0.000). There is no uniformity in the conduct of shortening of fasting in the preoperative period and the immediate postoperative period. Early postoperative (PO) period protein supplementation is not performed in a standard fashion in all units globally. ERAS principles and practices are partial and insufficiently implemented on the five continents despite the prevalent knowledge of professionals based on evidence. Moreover, there is no uniformity in fasting, immediate postoperative diet, and early protein supplementation practices globally.

Letter to the Editor Regarding the Article: "Quality of Sleep among Portuguese Anaesthesiologists: A Cross-Sectional Study"

N/a.

Active emigration from climate change-caused seawater intrusion into freshwater habitats

Ecological risk assessment associated with seawater intrusions has been supported on the determination of lethal/sublethal effects following standard protocols that force exposure neglecting the ability of mobile organisms to spatially avoid salinized environments. Thus, this work aimed at assessing active emigration from climate change-caused seawater intrusion into freshwater habitats. To specific objectives were delineated: first, to compute median 12-h avoidance conductivities (AC_50,12h) for freshwater species, and second, to compare it with literature data (LC_{50,48 or 96h}, EC_{50,6 or 21d}) to assess the relevance of the inclusion of stressor-driven emigration into risk assessment frameworks. Four standard test species, representing a broad range of ecological niches - Daphnia magna, Heterocypris incongruens, Danio rerio and Xenopus laevis - were selected. The salt NaCl was used as a surrogate of natural seawater to create the saline gradient, which was established in a 7-compartment system. At each specific LC_{50, 48 or 96h}, the proportion of avoiders were well above 50%, ranging from 71 to 94%. At each LC₅₀, considering also avoiders, populations would decline by 85-97%. Furthermore, for D. magna and X. laevis it was noticed that at the lowest conductivities eliciting mortality, the avoidance already exceeded 50%. The results showed that the emigration from salinity-disturbed habitats exists and that can even be more sensitive than standard endpoints. Looking solely to standard endpoints involving forced exposure may greatly underestimate the risk of local population extinction, because habitat function can be severely disrupted, with subsequent stressor-driven emigration, before any adverse physiological effects at the organism level. Thus, the present study highlights the need to include non-forced exposure testing into ecological risk assessment, namely of salinity-menaced costal freshwaters.

Connective tissue disease-associated interstitial lung disease

BACKGROUND

Connective tissue diseases (CTD) are frequently associated with interstitial lung disease (ILD), significantly impacting their morbidity and mortality.

AIM

Analyze the experience of an autoimmune specialized unit on treating CTD-ILD and characterize the population based on most frequent diseases, imaging patterns, lung function tests results, serology and treatment. Assess mortality and mortality predictors in these patients.

METHODS

Retrospective, descriptive and statistical analysis of the CTD-ILD patients followed up at an autoimmune diseases unit during a 6-year period.

RESULTS

Over the study period, 75 patients with CTD-ILD were treated with a mean follow-up of 49 ± 31 months. The most frequent CTD were systemic sclerosis and rheumatoid arthritis. ILD was diagnosed prior to CTD in 8% of patients and concomitantly in 35%. Nonspecific interstitial pneumonia was the CT pattern in 60% and 35% had an isolated diminished DLCO on lung function tests. Pulmonary hypertension was present in 12% and it was the single most important mortality predictor (OR 14.41, p = 0.006). Corticosteroids are the mainstay of treatment but biologics were prescribed in 39% of the patients (mostly tocilizumab and rituximab). Two scleroderma patients were recently treated with nintedanib.

CONCLUSIONS

ILD is a potential complication of every CTD and can impose a dramatic burden on these patients. The clinical relevance of ILD together with their early expression in the course of the disease underlines the importance of the presence of chest physicians in these units.