Depression in medical students during the COVID-19 lockdown in Greece

The COVID-19 pandemic has caused a mental health crisis. The purpose of this study was to estimate the prevalence of depression in medical students in Greece during a nationwide lockdown. The secondary aims were to assess the association of depression with socio-demographic factors and students' attitudes regarding the quality of their studies. The data was gathered anonymously through a self-administered online questionnaire between January 11 and 27, 2021. The CES-D scale was used to measure depression rates. Multiple logistic regression was used to identify factors independently associated with depression. Analyses were conducted using Stata version 16.0 and the IBM® SPSS® software. In total, 978 sixth- and fifth-year medical students participated; their mean age was 23.2 years and 65.6% were females. The prevalence of clinical depression was 21.3% (95% CI: 18.7%, 24.0%), whereas 17.9% (95% CI: 15.5%, 20.4%) experienced severe distress. Depression was more prevalent in females (25.4% vs 13.1% in males, p<0.001). Approximately half (53.4%) of the participants reported a change in plans regarding their medical career due to the pandemic and 16.9% expressed a decreased willingness to practice medicine. Factors independently associated with depression were female gender, living alone or with housemates at high risk for COVID-19, being anxious about becoming infected with SARS-CoV-2, studying in one of the three largest medical schools, negatively evaluating the adjustment of the teaching personnel to online teaching and the university's response to the pandemic. The findings of this study report depression in one out of five medical students during the COVID-19 pandemic, highlighting the need to protect the most vulnerable medical students during a pandemic. Medical students must be able to seek professional mental health services, even in the era of a pandemic. Universities should increase accessibility to support services and provide a student-centered approach in their strategies, as the pandemic has placed a spotlight on an existing phenomenon.

Sex differences in ambulatory blood pressure levels, control and phenotypes of hypertension in hemodialysis patients

BACKGROUND AND AIMS

Ambulatory blood pressure (BP) control is worse in men than women with chronic kidney disease or kidney transplantation. So far, no study investigated possible sex differences in the prevalence, control, and phenotypes of BP according to predialysis and 48-h ambulatory blood pressure monitoring (ABPM) in hemodialysis patients. Further, no study has evaluated the diagnostic accuracy of predialysis BP in male and female hemodialysis patients.

METHOD

One hundred and twenty-nine male and 91 female hemodialysis patients that underwent 48-h ABPM were included in this analysis. Hypertension was defined as: (1) predialysis SBP ≥140 or DBP ≥90 mmHg or use of antihypertensive agents, (2) 48-h SBP ≥130 or DBP ≥80 mmHg or use of antihypertensive agents.

RESULTS

Predialysis SBP did not differ between groups, while DBP was marginally higher in men. 48-h SBP (137.2 ± 17.4 vs. 132.2 ± 19.2 mmHg, P  = 0.045), DBP (81.9 ± 12.1 vs. 75.9 ± 11.7 mmHg, P  < 0.001) and daytime SBP/DBP were higher in men. The prevalence of hypertension was not different between groups with the use of predialysis BP or 48-h ABPM (92.2% vs. 89%, P  = 0.411). However, concordant lack of control was more frequent in men than women (65.3% vs. 49.4%, P  = 0.023). The prevalence of white-coat and masked hypertension did not differ between groups; the misclassification rate with the use of predialysis BP was marginally higher in women. In both sexes, predialysis BP showed low accuracy and poor agreement with ABPM for diagnosing ambulatory hypertension [area-under-the-curve in receiver-operating-curve analyses (SBP/DBP): men, 0.681/0.802, women: 0.586/0.707].

CONCLUSION

Ambulatory BP levels are higher in male than female hemodialysis patients. Although hypertension prevalence is similar between sexes, men have worse rates of control. The diagnostic accuracy of predialysis BP was equally poor in men and women.

Effect of patient gender on short-term blood pressure variability in hemodialysis patients

Increased blood pressure variability (BPV) is strongly associated with cardiovascular events in end-stage kidney disease patients. Male hemodialysis patients present higher cardiovascular risk compared with females. The aim of this study is to investigate sex differences in short-term BPV in hemodialysis patients. 129 male and 91 female hemodialysis patients that underwent 48-h ABPM were included in this analysis. Standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV) of SBP and DBP were calculated with validated formulas. Age, dialysis vintage and history of major comorbidities did not differ between men and women. 48-h SBP/DBP (137.2 ± 17.4/81.9 ± 12.1 mmHg vs 132.2 ± 19.2/75.9 ± 11.7 mmHg, p = 0.045/<0.001) was significantly higher in men than women. During the 48-h period, all systolic BPV indices were similar between men and women (48-h SBP-ARV: 12.0 ± 2.9 vs 12.1 ± 3.2 mmHg, p = 0.683); 48-h DBP-SD, DBP-wSD and DBP-ARV (9.1 ± 1.6 vs 8.4 ± 1.8 mmHg, p = 0.005) were higher in men. In conclusion, short-term diastolic BPV indices are higher in male than female hemodialysis patients. Increased BPV may impact on the higher incidence of cardiovascular events observed in male hemodialysis patients.

MO685: Brain Oxygenation Assessed by Near-Infrared Spectroscopy During a Mental Task and a Mild Physical Stress in Hemodialysis and Peritoneal Dialysis

BACKGROUND AND AIMS

Cognitive impairment is highly prevalent in end-stage kidney disease (ESKD) individuals. Brain oxygenation is a parameter that plays major role in cognitive function. This study aimed to examine for the first time changes in brain oxygenation during a mental and a mild physical task in hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHOD

A total of 63 ESKD patients (≥18 years old) were enrolled in this cross-sectional study. Patients were allocated in two groups according to dialysis modality (n = 29 HD and n = 34 PD). All participants underwent a mental (countdown from 100 to 0 by 7, performed twice) and a mild physical task (a 3-min intermittent handgrip exercise at 35% of maximal handgrip strength). Changes in brain oxygenation [oxy—(O2Hb), deoxy—(HHb) and total—(tHb) hemoglobin] during the two tasks were continuously recorded via near-infrared spectroscopy (NIRS, Artinis).

RESULTS

Age, sex and dialysis vintage did not differ between the two groups. The average response in brain oxygenation during the mental task (O2Hb change from rest: 1.51 ± 1.68 versus 1.60 ± 1.82 μmol, in HD and PD, respectively, P = 0.841), as well as the duration needed for task completion (191.53 ± 124.27 versus 200.19 ± 118.84 s, P = 0.781) were similar between groups. Furthermore, the average response in brain oxygenation during the handgrip exercise also did not differ between the groups (O2Hb change 1.20 ± 1.03 versus 1.49 ± 0.95 μmol, respectively, P = 0.262). In the total cohort, the average response in brain oxygenation during handgrip exercise was inversely correlated with dialysis vintage (P &lt; 0.05).

CONCLUSION

Dialysis modality does not appear to have an impact on brain oxygenation, as HD and PD patients presented similar responses during a mental and a mild physical task. Dialysis vintage may negatively affect brain oxygenation in ESKD individuals.

FC085: Cerebral Oxygenation During Exercise Across Different Stages of Chronic Kidney Disease

BACKGROUND AND AIMS

Cognitive impairment and reduced exercise tolerance are common in patients with chronic kidney disease (CKD), in part due to reduced brain function. Proper brain function relies on sufficient blood flow and oxygen supply by the cerebral vasculature. A reduction in cerebral oxygenation of more than 10% may deteriorate brain function and influence the decision to continue exercise. This study aims to examine the cerebral oxygenation and blood volume during a mild physical stress as an index of brain activation in patients at different stages of CKD and controls without CKD.

METHOD

This is a preliminary analysis of an observational study enrolling patients with CKD stage 2–4 (matched for age and sex within the different stages) and controls without CKD. All participants underwent a 3-min intermittent handgrip exercise (HG) at 35% of their maximal voluntary contraction. Changes in prefrontal oxygenation (oxyhaemoglobin—O2Hb) and deoxyhaemoglobin—HHb) and total blood volume (total hemoglobin—tHb) were continuously recorded during HG-exercise by near-infrared spectroscopy (NIRS).

RESULTS

A total of 59 participants are included in this preliminary analyses (n = 11 controls, n = 15 stage 2 CKD, n = 18 stage 3 CKD and n = 15 stage 4 CKD patients). During HG-exercise, O2Hb significantly increased (P &lt; 0.001) and HHb remained relatively unchanged in all groups compared to pre-exercise values. However, this O2Hb increase was progressively lower with advancing CKD Stages (controls: 2.58 ± 1.43;  stage 2: 1.51 ± 1.31;  stage 3: 1.29 ± 0.97;  stage 4: 0.95 ± 0.92;  P = 0.006) (Figure). During HG, tHb (an index of microvascular blood volume) increased significantly in controls, stage 2 and stage 3 CKD patients (P &lt; 0.05) but not in stage 4 CKD patients (P = 0.100). As before this tHb increase was progressively lower with advancing CKD stages (P = 0.030). Controlling for age differences between groups did not alter the above observations.

CONCLUSION

Brain activation/response during a mild physical task appears to decrease with advancing CKD as suggested by the smaller rise in cerebral oxygenation and blood volume. This may contribute both impaired cognitive function and reduced exercise tolerance with advancing CKD.

Circulating tumor necrosis factor-α levels in non-alcoholic fatty liver disease: A systematic review and a meta-analysis

BACKGROUND AND AIM

To synthesize data on circulating tumor necrosis factor (TNF)-α levels between patients with histologically confirmed non-alcoholic fatty liver disease (NAFLD) (simple steatosis or non-alcoholic fatty liver [NAFL] and/or non-alcoholic steatohepatitis [NASH]) and controls.

METHODS

We performed a systematic search in PubMed, Scopus, and Cochrane Library. Fifty-six studies, published between 2003 and 2019, were finally included, reporting data from 5848 individuals (1634 controls and 4214 NAFLD patients).

RESULTS

Higher circulating TNF-α levels were observed in NAFLD patients than controls (standardized mean difference [SMD] 0.84; 95% confidence interval [95% CI] 0.59-1.09), NAFL patients than controls (SMD 0.56; 95% CI 0.27-0.85), NASH patients than controls (SMD 0.93; 95% CI 0.64-1.22), and NASH than NAFL patients (SMD 0.31; 95% CI 0.16-0.46). There were only minimal changes in the comparisons between groups after excluding studies with morbidly obese populations (n = 11), or pediatric/adolescent populations (n = 6), or other than enzyme-linked immunosorbent assay method of TNF-α measurement (n = 8). There was high heterogeneity among studies in all comparisons, which was not essentially affected after sensitivity analyses. The meta-regression analysis revealed that the male ratio was positively associated with TNF-α SMD in the comparison between patients with NASH and NAFL (beta = 0.809; 95% CI 0.052-1.566) and accounted for 36% (P = 0.037) of the heterogeneity in this pair of comparison. TNF-α SMD was not associated with age, body mass index, and alanine aminotransferase in any pair of comparisons.

CONCLUSIONS

Circulating TNF-α levels were higher in patients with NAFLD compared with controls. Higher levels of circulating TNF-α were also associated with the severity of NAFLD.

Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus

Orthorexia nervosa (ON) is an unspecified feeding or eating disorder (USFED) characterized by an exaggerated, unhealthy obsession with healthy eating. Τypical eating disorders (EDs) and USFEDs are common among patients with diabetes mellitus (DM), which complicates metabolic control and disease outcomes. The present systematic review summarizes the evidence on the prevalence of ON symptomatology among patients with DM. PubMed, Web of Science, Scopus, and grey literature were searched, and relevant observational studies were screened using the Rayyan software. The quality of the studies was assessed using the appraisal tool for cross-sectional studies (AXIS) and the Newcastle–Ottawa scale (NOS). Out of 4642 studies, 6 fulfilled the predefined criteria and were included in the qualitative synthesis. Most studies relied on the ORTO-15 or its adaptations to identify ON among patients with DM. No apparent sex or age differences exist regarding the prevalence of ON symptoms. None of the studies compared the prevalence of ON in patients with type 1 and type 2 DM. Most of the research was of average to good methodological quality. In conclusion, patients with DM often exhibit ON tendencies, although research is still limited regarding the etiology or mechanistic drivers behind ON and the characteristics of patients with a dual ON–DM diagnosis.

Prognostic significance of RACGAP1 mRNA expression in high-risk early breast cancer: a study in primary tumors of breast cancer patients participating in a randomized Hellenic Cooperative Oncology Group trial

PURPOSE

RACGAP1 is a Rac GTPase-activating protein involved in cell growth regulation, cell transformation and metastasis. The aim of the present study was to explore the prognostic and/or predictive significance of RACGAP1 mRNA expression on disease-free survival (DFS) and overall survival (OS) in high-risk early breast cancer patients and compare it to that of Ki67 protein expression and to the Nottingham prognostic index (NPI).

METHODS

A total of 595 high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative dose-dense sequential chemotherapy with epirubicin followed by CMF with or without paclitaxel. RNA was extracted from 314 formalin-fixed paraffin-embedded primary tumor tissue samples followed by one-step quantitative RT-PCR for assessing RACGAP1 mRNA expression.

RESULTS

High RACGAP1 mRNA expression (above the median) was associated with poor DFS (log-rank, p = 0.002) and OS (p < 0.001). High histological grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of RACGAP1. Results of the Cox multivariate regression analysis revealed that high RACGAP1 mRNA expression independently predicted poor overall survival (Wald's p = 0.008). High Ki67 protein expression was also an adverse prognostic factor for death (p = 0.016), while high NPI score values were not.

CONCLUSIONS

High RACGAP1 mRNA expression, as assessed by qRT-PCR, was found to be of adverse prognostic significance in high-risk early breast cancer patients treated with dose-dense sequential chemotherapy. The utility of RACGAP1 mRNA expression in patient selection for treatment with aggressive chemotherapy regimens should be further explored and validated in larger cohorts.