A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

PURPOSE

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.

METHODS

An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.

RESULTS

A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.

CONCLUSION

Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.

AB1543-HPR WAITING ROOM PROJECT: IMPROVING HEALTHCARE OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Systemic lupus erythematosus (SLE) prognosis is determined by a wide range of factors, such as the severity of the disease manifestations, the psychosocial aspects of patients, the proper management of comorbidities, adoption of a healthy lifestyle and adherence to treatment. Studies on chronic diseases highlight the value of patient education to foster treatment adherence and improve prognosis.

Objectives

To promote health education to SLE patients and their families providing accessible and comprehensive scientific information, in order to improve adherence to treatment and the patient’s prognosis.

Methods

The Waiting Room Project is linked to the Extension Health Care Program for SLE patients and their families of Universidade Federal de Minas Gerais, Brazil, since 2011. A total of 700 patients under SLE treatment at the Rheumatology Unit of the University Hospital are involved. Medical students and rheumatology fellows, altogether, developed high-quality informative texts, with clear content and layman language appropriate for the patient, under the supervision of the rheumatology professors. The texts are illustrated by the team of the Communication Department of the Medical School and medical students, and are printed in a leaflet format. The material is handed out to the patients, while they wait for their medical appointment, by the students and the care team. The content of the leaflets is discussed, making sure that all the concerns and doubts are properly addressed

Results

The Waiting Room Project has produced 17 leaflets, addressing different aspects of SLE, comorbidities, and treatment. The texts approach the traditional cardiovascular risk factors (Smoking, Arterial Hypertension, Diabetes, Obesity, Physical Activity), and some medical conditions related to general health and SLE treatment (Sun Protection, Healthy Food, Oral Care, Vaccination, Pregnancy, Osteoporosis). In 2020 and 2021, two leaflets about Covid-19 were produced in order to clarify important aspects of this disease, its impact on lupus patients and to solve questions about SLE medications: one regarding the association between Lupus and Covid-19 and another about the treatment of lupus and Covid-19. Other four leaflets were produced concerning SLE treatment, including Adherence to Treatment, the use of Antimalarials, Corticosteroids, and Immunosuppressants. Information about the drugs, general importance on lupus treatment, recommendations and possible adverse events were described. Futhermore, additional content is currently in production with themes such as Intravenous Corticosteroid and Cyclophosphamide, Human Papillomavirus Infection, Malignant Neoplasm, and specific cancers frequently affecting women, such as Colorectal Cancer, Cervical Cancer, and Breast Cancer. The leaflets are also available online on the Medical School website in Portuguese and in English (medicina.ufmg.br/alo/material-didatico/), on the Minas Gerais Rheumatology Society website (reumatologia.org.br/orientacoes-ao-paciente/), and on the Instagram page @lupusufmg

Conclusion

The leaflets have been an important source of information and health education for SLE patients and their families, improving student/physician-patient communication. Despite the adversities caused by the coronavirus pandemic, the Waiting Room Project has kept its purpose to make each patient with SLE an agent of their healthcare. Improving the patients’ access to evidence-based information must be a goal of healthcare professionals that treat patients with SLE

References

[1]Koehn CL, Esdaile JM. Patient education and self-management of musculoskeletal diseases. Best Pract Res Clin Rheumatol. 2008; 22: 395-405.

[2]Navarra SV, Zamora LD, Collante MaTM. Lupus education for physicians and patients in a resource-limited setting. Clinical Rheumatol. 2019; 39:697–702.

[3]Zhang L, Luan W, Geng S, et al. Lack of patient education is risk factor of disease flare in patients with systemic lupus erythematosus in China. BMC Health Serv Res. 2019; 19: 378.

Disclosure of Interests

None declared

Bridging Learning in Medicine and Citizenship During the COVID-19 Pandemic: A Telehealth-Based Case Study

Background

COVID-19 presented great challenges for not only those in the field of health care but also those undergoing medical training. The burden on health care services worldwide has limited the educational opportunities available for medical students due to social distancing requirements.

Objective

In this paper, we describe a strategy that combines telehealth and medical training to mitigate the adverse effects of the COVID-19 pandemic.

Methods

A toll-free telescreening service, Telecoronavirus, began operations in March 2020. This service was operated remotely by supervised medical students and was offered across all 417 municipalities (14.8 million inhabitants) in the Brazilian state of Bahia. Students recorded clinical and sociodemographic data by using a web-based application that was simultaneously accessed by medical volunteers for supervision purposes, as well as by state health authorities who conducted epidemiological surveillance and health management efforts. In parallel, students received up-to-date scientific information about COVID-19 via short educational videos prepared by professors. A continuously updated triage algorithm was conceived to provide consistent service.

Results

The program operated for approximately 4 months, engaging 1396 medical students and 133 physicians. In total, 111,965 individuals residing in 343 municipalities used this service. Almost 70,000 individuals were advised to stay at home, and they received guidance to avoid disease transmission, potentially contributing to localized reductions in the spread of COVID-19. Additionally, the program promoted citizenship education for medical students, who were engaged in a real-life opportunity to fight the pandemic within their own communities. The objectives of the education, organization, and assistance domains of the Telecoronavirus program were successfully achieved according to the results of a web-based post-project survey that assessed physicians’ and students’ perceptions.

Conclusions

In a prolonged pandemic scenario, a combination of remote tools and medical supervision via telehealth services may constitute a useful strategy for maintaining social distancing measures while preserving some practical aspects of medical education. A low-cost tool such as the Telecoronavirus program could be especially valuable in resource-limited health care scenarios, in addition to offering support for epidemiological surveillance actions.

164 Gonadotrophin-releasing hormone injection and colour flow Doppler ultrasound of the preovulatory follicle as a tool to increase pregnancy outcome after timed AI in beef cows

The aims of this study were to determine (1) the association between Doppler vascularisation scores (DVS) of the preovulatory follicle (POF) and fertility of beef cows submitted to timed AI (TAI) and (2) whether cows with low DVS benefit from a gonadotrophin-releasing hormone (GnRH) treatment at TAI. Multiparous lactating Nelore cows (Bos indicus; n=69) from a commercial beef farm in the state of Rondônia, Brazil, were enrolled in this study. Cows received 2mg of oestradiol benzoate intramuscularly (Bioestrogen, Biogénesis Bagó) and an intravaginal progesterone-releasing device (1.9g of progesterone; controlled internal drug release, CIDR) to synchronise follicular wave emergence on Day 0. The CIDR device was removed and cows were treated with 150μg of D-cloprostenol intramuscularly (prostaglandin F2α analogue; Croniben), 1mg of oestradiol cypionate intramuscularly, and 300IU of equine chorionic gonadotrophin (Novormon) intramuscularly on Day 8. Cows were then painted with a tail chalk marker to identify those displaying oestrus. All cows were submitted to TAI 48h after CIDR removal. At TAI, occurrence of oestrus was recorded and all cows were examined using transrectal ultrasonography. Blood flow of the POF was evaluated using colour Doppler imaging. Colour Doppler signals present on the follicular wall were subjectively scored using a 1-to-4 scale (1=absence or very low blood flow, and 4=intense blood flow detected on most of the follicular wall surface) adapted from Ginther (2007Ultrasonic Imaging and Animal Reproduction: Color-Doppler Ultrasonography, pages 87-114). Then, cows were divided into three groups according their DVS of the POF: (1) high DVS (DVS ≥3; n=36), (2) low DVS (DVS &lt;3; n=16), and (3) low DVS (DVS &lt;3; n=17) plus a GnRH treatment at TAI. The diameter of the POF was analysed using analysis of variance (PROC GLIMMIX of SAS; SAS Institute Inc.), and the means were compared among groups using Tukey's test. The proportion of cows that displayed oestrus and pregnancy rates was analysed using chi-square test. Cows in the high-DVS group had a larger POF than cows in the low-DVS and low-DVS-GnRH groups (13.2±0.2, 11.7±0.5, and 12.2±0.4, respectively; P&lt;0.05). The proportion of cows that displayed oestrus was greater (P&lt;0.05) in the high-DVS group (72%, 26/36) than in the low-DVS (37.5%, 6/16) or low-DVS-GnRH (53%, 9/17) groups. Finally, greater (P&lt;0.05) pregnancy rates were observed in cows from the high-DVS (47.2%; 17/36) and low-DVS-GnRH (52.9%; 9/17) groups than in cows from the low-DVS group (18.7%; 3/16). The preliminary results from this study demonstrated that diameter of POF is positively associated with DVS. Moreover, cows that presented POF with higher DVS are more likely to become pregnant, and the administration of GnRH to females with low DVS can increase the fertility of beef cows submitted to TAI protocols. This study received funding support from Embrapa (MP1/PC3 project no. 01.03.14.011.00.00) and from CNPq (universal project no. 407307/2016-8).

Massive gastrointestinal bleeding after chemotherapy for gastric lymphoma

INTRODUCTION

Gastrosplenic fistula (GSF) is a rare condition almost always associated with lymphoma, with gastric and splenic involvement.

CASE REPORT

We report a 52 year old male with gastric lymphoma admitted to the emergency department with hematemesis. The first chemotherapy cycle had been completed four weeks before. Oesophagoduodenoscopy showed a pulsatile ulcerated lesion. Surgical hemostasis was performed. Four days after surgery, the patient initiated sudden and massive upper gastrointestinal bleeding with hemodynamic compromise. A gastrosplenic fistula was recognized during emergency laparotomy and an en bloc total gastrectomy and splenopancreatectomy resection was performed, with massive blood transfusion. Patient was discharged 13 days after the second surgery.

DISCUSSION

Gastrosplenic fistula is a rare condition, previously described associated with gastric lymphoma at presentation or after treatment. A prompt recognition of the underlying pathology could avoid a second surgery.

CONCLUSION

A systematic and interdisciplinary approach is the key for success in rare challenging emergencies. Infrequent etiologies must always be considered as they need specific therapeutic approaches that defy paradigms.

A Case of Acute Generalized Pustular Psoriasis of von Zumbusch Triggered by Hypocalcemia

Psoriasis is an autoimmune disease triggered by different conditions in genetically susceptible people. It is characterized by variable cutaneous manifestations including localized or disseminated pustules. Generalized pustular psoriasis (GPP) has two main clinical forms: von Zumbusch psoriasis, characterized by severe erythrodermia and scaling skin after the resolution of pustules, and the annular form. GPP may also present severe extracutaneous manifestations including pneumonitis, heart failure and hepatitis. Old reports showed a relationship between hypoparathyroidism and hypocalcemia as triggers for GPP highlighting the importance of adequate workup of the patient and possible therapeutic changes in acute situations. Here, we present a case of severe von Zumbusch psoriasis with life-threatening complications triggered by severe hypocalcemia secondary to hypoparathyroidism successfully treated with aggressive calcium reposition.

New insights into cystinuria: 40 new mutations, genotype-phenotype correlation, and digenic inheritance causing partial phenotype

OBJECTIVE

To clarify the genotype-phenotype correlation and elucidate the role of digenic inheritance in cystinuria.

METHODS

164 probands from the International Cystinuria Consortium were screened for mutations in SLC3A1 (type A) and SLC7A9 (type B) and classified on the basis of urine excretion of cystine and dibasic amino acids by obligate heterozygotes into 37 type I (silent heterozygotes), 46 type non-I (hyperexcretor heterozygotes), 14 mixed, and 67 untyped probands.

RESULTS

Mutations were identified in 97% of the probands, representing 282 alleles (86.8%). Forty new mutations were identified: 24 in SLC3A1 and 16 in SLC7A9. Type A heterozygotes showed phenotype I, but mutation DupE5-E9 showed phenotype non-I in some heterozygotes. Type B heterozygotes showed phenotype non-I, with the exception of 10 type B mutations which showed phenotype I in some heterozygotes. Thus most type I probands carried type A mutations and all type non-I probands carried type B mutations. Types B and A mutations contributed to mixed type, BB being the most representative genotype. Two mixed cystinuria families transmitted mutations in both genes: double compound heterozygotes (type AB) had greater aminoaciduria than single heterozygotes in their family.

CONCLUSIONS

Digenic inheritance is an exception (two of 164 families), with a limited contribution to the aminoaciduria values (partial phenotype) in cystinuria. Further mutational analysis could focus on one of the two genes (SLC3A1 preferentially for type I and SLC7A9 for type non-I probands), while for mixed probands analysis of both genes might be required, with priority given to SLC7A9.

Study of the WFS1 gene and mitochondrial DNA in Spanish Wolfram syndrome families

Wolfram syndrome (WS) is an autosomal recessive neurodegenerative disorder characterized by early onset diabetes mellitus and progressive optic atrophy. Patients with WS frequently develop deafness, diabetes insipidus, renal tract abnormalities, and diverse psychiatric illnesses, among others. A gene responsible for WS was identified on 4p16.1 (WFS1). It encodes a putative 890 amino acid transmembrane protein present in a wide spectrum of tissues. A new locus for WS has been located on 4q22-24, providing evidence for the genetic heterogeneity of this syndrome. Six Spanish families with a total of seven WS patients were screened for mutations in the WFS1-coding region by direct sequencing. We found three previously undescribed mutations c.873C > A, c.1949_50delAT, and c.2206G > C, as well as the duplication c.409_424dup16, formerly published as 425ins16. Several groups had detected deletions in the mitochondrial DNA (mtDNA) of WS patients. For this reason, we also studied the presence of mtDNA rearrangements as well as Leber's hereditary optic neuropathy, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes, and A1555G point mutations in the WS families. No mtDNA abnormalities were detected.

ATB(0)/SLC1A5 gene. Fine localisation and exclusion of association with the intestinal phenotype of cystic fibrosis

The Na+-dependent amino acid transporter named ATB(0) was previously found to be located in 19q13.3 by fluorescence in situ hybridisation. Genetic heterogeneity in the 19q13.2-13.4 region, syntenic to the Cystic Fibrosis Modulator Locus 1 (CFM1) in mouse, seemed to be associated to the intestinal phenotypic variation of cystic fibrosis (CF). We performed fine chromosomal mapping of ATB(0) on radiation hybrid (RH) panels G3 and TNG. Based on the most accurate location results from TNG-RH panel, mapping analysis evidenced that ATB(0) is localised between STS SHGC-13875 (D19S995) and STS SHGC-6138 in 19q13.3, that corresponds with the immediately telomeric/distal segment of the strongest linkage region within the human CFM1 (hCFM1) syntenic region. Regarding to the genomic structure and exon organisation, our results show that the ATB(0) gene is organised into eight exons. The knowledge of the genomic structure allowed us to perform an exhaustive mutational analysis of the gene. Evaluation of the possible implication of ATB(0) in the intestinal phenotype of CF was performed on the basis of the functional characteristics of the encoded protein, its apparent relevance to meconium ileus (MI) and position in relation to the hCFM1 syntenic region. We have analysed this gene in samples from CF patients with and without MI. Several sequence variations in the ATB(0) gene were identified, although none of them seemed to be related to the intestinal phenotype of CF. Even though no particular allele or haplotype in ATB(0) appears to be associated to CF-MI disease, new SNPs identified should be useful in segregation and linkage disequilibrium analyses in families affected by other disorders caused by the impairment of neutral amino acid transport.

[Cystinuria and cystine kidney lithiasis. Diagnosis and therapeutic approach]

OBJECTIVE

Cystine renal stone is the only clinical consequence of cystinuria, an autosomal recessive hereditary disease that affects an average of 1 out of 7,000 newborns, and whose geographical distribution varies significantly. The diagnosis and treatment of this condition is reviewed in the light of the advances in genetics and molecular biology.

METHODS

The evolution of current knowledge about this disease is reviewed.

RESULTS/CONCLUSIONS

The advances over the last 8 years have led to the characterization, at the present time, of two genes responsible for this disease, which demonstrates its polygenic origin. By phenotype, cystinuria can be classified into two types: type 1 and non-type 1. Both types show genetic and biochemical, but not clinical differences. From the therapeutic viewpoint, the main objective is to eliminate existing calculi and, above all, prevent recurrence by acting on the pathophysiologic mechanisms of renal cystine. Experience shows that despite the correct use of our current therapeutic armamentarium and the application of the general guidelines discussed in this paper, some cystinuric patients still maintain an important stone-forming activity. Patient clinical evaluation and a genetic study of both patient and family will be decisive for phenotyping.

Markedly elevated lipid transfer inhibitor protein in hypercholesterolemic subjects is mitigated by plasma triglyceride levels

Lipid transfer inhibitor protein (LTIP, apolipoprotein F) regulates the interaction of cholesteryl ester transfer protein (CETP) with lipoproteins and is postulated to enhance the ability of CETP to stimulate reverse cholesterol transport. The factors that regulate LTIP levels and control its biosynthesis are unknown. Here, we demonstrate that plasma LTIP is dramatically increased (3-fold) in hypercholesterolemic subjects with normal to mildly elevated plasma triglyceride (TG) levels compared with control subjects. LTIP in these subjects is not correlated with the extent of hypercholesterolemia or with low density lipoprotein (LDL), high density lipoprotein, or CETP levels. However, unlike CETP, LTIP levels correlate negatively with plasma TG levels. This association does not appear to reflect decreased LTIP synthesis, inasmuch as conditions that stimulate TG synthesis and secretion (200 micromol/L oleate) do not reduce LTIP secretion by SW872 or Caco-2 cells. In contrast, native or acetyl LDL stimulates LTIP secretion 2-fold. Importantly, although plasma LTIP typically resides on LDL, up to 25% of LTIP is bound to very low density lipoprotein when this lipoprotein is enriched in cholesteryl esters, as occurs in hypercholesterolemia. In summary, LTIP levels are markedly elevated by hypercholesterolemia; however, plasma TG levels attenuate this response. We hypothesize that this arises from an increased association of LTIP with very low density lipoprotein, leading to a more rapid clearance of the inhibitor from circulation.