POS0468 EXTRACELLULAR VESICLES FROM SERUM OF MYOSITIS PATIENTS AS CIRCULATING BIOMARKERS AND DISEASE MEDIATORS

Background

Inflammatory myopathies (IM) are a heterogeneous group of disorders characterized by autoimmune inflammatory destruction of skeletal muscles. It is many times associated with lung, skin and joint involvement. Identifying biomarkers that can differentiate IM from other muscle disorders may elucidate the pathophysiology of IM, guide novel therapies, monitor disease activity/response to treatments and predict prognosis. Exosomes are membrane-bound nanovesicles with diameters of 30-150 nm that contain multiple proteins, nucleic acid, lipids and other molecules in a tissue- and cell-specific manner. Exosomes are secreted by a large variety of cells, play major roles in cell-cell interactions, and have recently emerged as circulating biomarkers in a variety of pathological conditions, including several autoimmune diseases.

Objectives

To characterize exosomes from serum of IM patients, analyze protein expression and study their potential mediators of disease pathologies.

Methods

Serum was collected from patients suffering from IM(n=5) and from patients suffering from Becker (BMD) and Duchenne (DMD) muscular dystrophies (n=6). Exosomes were isolated by Exoquick precipitation and analyzed for size distribution and by nanoparticle tracking analysis (NTA) and by Western blot for exosome markers. The effects of the isolated EVs on human satellite cell proliferation and differentiation and macrophage activation were examined.

Results

Exosomes from IM patients decreased human satellite cell proliferation (51%, P<0.01) and inhibited their myogenic differentiation as indicated by lower fusion index (24% inhibition, P<0.01) and expression of myosin heavy chain (72% inhibition, P<0.001). Similar results were obtained also with exosomes derived from DMD and BMD patients; however, their inhibitory effect were more pronounced on MyoG expression. Treatment of macrophages with exosomes from IM patients significantly increased the expression of IL-10 (3-fold, P<0.001), compared to exosomes of healthy controls and DMD patients. Another significant difference was in the expression of signaling molecules: Thus, exosomes from BMD patients increased the phosphorylation of Erk and p38, whereas a smaller effect was induced by IM exosomes.

Conclusion

Exosomes from IM patients decrease satellite cell proliferation and myogenic differentiation compared to healthy exosomes. In addition, these exosomes increased the expression of IL-10 in macrophages. These effects are unique to exosomes of IM patients compared to muscular dystrophies. These promising results suggest that serum exosomes should be further investigated as a novel biomarker with potential therapeutic implications.

Disclosure of Interests

Shaye Kivity Speakers bureau: BI, Abbvie, Lilly, Pfizer, Janssen, Neopharm, Grant/research support from: Sobi, Haya Kravitz: None declared, Coral Cohen: None declared, Darya Margoulis: None declared, Moshe Amar: None declared, Gila Kazimirsky: None declared, David Ozeri Speakers bureau: Neopharm, Consultant of: Abbvie, Amir Dori Grant/research support from: Biogen, Chaya Brodie Grant/research support from: Biogen.

Health in times of uncertainty in the eastern Mediterranean region, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background

The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.

Methods

GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.

Findings

The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.

Interpretation

Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.

Funding

Bill & Melinda Gates Foundation.

Mental distress and functional health in the United States

INTRODUCTION

Mental illness prevalence is increasing in USA. Understanding the relationship between functional status and mental health is crucial in optimizing psychiatric treatment.

METHODS

We used 2000-2014 BRFSS data to examine the relationship between functional health and frequent mental distress in 51 states.

RESULTS

East-South-Central US (14.88%) had the highest prevalence of frequent mental distress and West-North-Central (9.42%) the lowest. Tennessee (15.7%) had the highest prevalence of frequent mental distress and North Dakota (7.4%) the lowest. East-South-Central had the highest prevalence on all functional limitation items. West Virginia had the highest prevalence of functional limitation (29.1%), use of special equipment (14.0%), blindness (8.6%), walking difficulty (23.0%), and difficulty running errands (12%). Females were more likely to report frequent mental distress in all states and more likely to report functional limitations in 32 states. Those who were divorced, smoker, unemployed, and of African American/American Indian/Alaskan native/other race were more likely to have a functional limitation. The prevalence of frequent mental distress increased steadily from 2000 for males and females but showed a decline from 2013 to 2014. The rate of increase was higher between 2008 and 2013 compared to previous years.

CONCLUSIONS

Our study showed a high prevalence of mental distress and poor functional health in the US with a large variation between states and socio-demographic groups. Moreover, our findings showed a strong association between poor mental health and functional limitations. Our findings call for integrating mental and physical health research and clinical care to reduce the burden of mental health in the US.

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Young people's health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people's health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors.

METHODS

The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories.

FINDINGS

The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs.

INTERPRETATION

Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people's health risk factors and their determinants in health information systems.

FUNDING

Bill & Melinda Gates Foundation.

Use of dental clinics and oral hygiene practices in the Kingdom of Saudi Arabia, 2013

Objectives: We conducted a large household survey in 2013 to determine the current status of oral health practices and use of oral health services in the Kingdom of Saudi Arabia (KSA). Methods: The Saudi Health Information Survey is a national multistage survey of individuals ≥ 15 years of age. We used a backward elimination multivariate logistic regression model to measure the association between having been to a dental clinic during the last year, and sex, age, marital status, education, time since last routine medical examination, history of diagnosis with a cardiovascular chronic condition, brushing or flossing teeth and use of Miswak (a chewing stick). Results: Between April and June 2013, 10,735 participants completed the survey (89.4% of the households contacted). An estimated 1.5 million (11.5%) and 6.3 million (48.6%) Saudi Arabian people, ≥ 15 years of age, had visited a dental clinic for a routine check-up and for a complaint during the last year, respectively. In total, 16.3%, 85.0% and 52% of Saudi Arabian people never brush their teeth, never floss their teeth or never use Miswak, respectively. The probability of visiting a dental clinic increased with education, among individuals who brushed or flossed their teeth and who used Miswak. Conclusions: Oral hygiene practices are not common among Saudi Arabian people, and use of health care for prevention of oral disease is limited. Hence, the need for oral health promotion is pressing. The KSA Ministry of Health should develop and implement programmes, through its primary health clinics, to increase the awareness of the importance of good oral health.

Prevalence of asthma in Saudi adults: findings from a national household survey, 2013

BACKGROUND

There are not enough data on the epidemiology of asthma in the Kingdom of Saudi Arabia (KSA). We analyzed data from a national household survey conducted in KSA in 2013 to estimate prevalence, associated risk factors and control measurements of asthma.

METHODS

The Saudi Health Interview Survey was a cross-sectional national multistage survey of 10,735 individuals aged 15 years or older. The survey included a detailed household questionnaire and a physical exam. We used self-reported clinical diagnosis of asthma to assess prevalence of asthma.

RESULTS

The prevalence of asthma in KSA was 4.05 % (95 % confidence interval [CI]: 3.54-4.62 %). Asthma was less frequent in individuals with higher education but higher in former smokers and obese individuals. Around 76.7 % of asthma patients (95 % CI: 70.6-82.0 %) experienced an asthmatic attack, and 61.6 % (95 % CI: 54.4-68.4 %) visited a hospital/emergency room because of asthma during the past year. Asthma attack was less frequent in older patients (odds ratio [OR] = 0.78, 95 %CI: 0.59-0.96 for each decade of life). Current use of medication for asthma was highly associated with asthma attacks (OR = 9.14, 95 % CI: 3.29-25.38). Asthma attack was also more frequent in individuals who were exposed to secondhand smoking (OR = 2.17, 95 %CI: 1.05-4.45) and those who were obese (OR = 3.01, 95 %CI: 1.34-6.78).

CONCLUSION

Saudi Arabia has a relatively low prevalence of diagnosed asthma; however, many of the patients with known asthma do not have it under good control. Our study calls for programs to inform patients about the importance and proper means of controlling their condition. Implementing and monitoring of clinical guidelines can also help to improve asthma control among patients as well as identify undiagnosed cases.

Access and barriers to healthcare in the Kingdom of Saudi Arabia, 2013: findings from a national multistage survey

OBJECTIVES

We analysed data from a large household survey to identify barriers to healthcare in the Kingdom of Saudi Arabia.

METHODS

The Saudi Health Interview Survey (SHIS) is a national multistage survey of individuals aged 15 years or older. The survey combined a household questionnaire and a laboratory blood analysis. We used a backward elimination multivariate logistic regression model to measure association between (1) diagnosis, (2) treatment, and (3) control of hypertension or diabetes and sociodemographic factors, history of diagnosis with chronic conditions, and type of, and distance travelled to, the clinic last visited.

RESULTS

Between April and June 2013, a total of 10,735 participants completed SHIS and were invited to the local health clinics. Among hypertensive individuals, women, older individuals, and those previously diagnosed with diabetes and hypercholesterolaemia were more likely to have been diagnosed with hypertension than their counterparts. Among participants diagnosed with hypertension, the likelihood of being treated increased with age and education. The likelihood of having uncontrolled blood pressure despite treatment increased with education and a history of diagnosis with hypercholesterolaemia. Type of clinic visited and distance travelled to last clinic visit were not associated with diagnosis or treatment of hypertension or control of blood pressure. Similar factors were associated with the likelihood of diagnosis and treatment among individuals with diabetes. Having uncontrolled glycated haemoglobin levels, despite treatment, was less common among those who visited governmental clinics other than those of the Ministry of Health, compared with those who visited Ministry clinics.

CONCLUSIONS

Our findings highlight the importance of individual characteristics in healthcare-seeking practices rather than system-based potential barriers. Saudis seem to mostly seek healthcare when sick. Hence, the Saudi Ministry of Health needs to implement a comprehensive plan including health education and investigations, to understand the barriers and bottlenecks to healthcare-seeking behaviour.

The effectiveness of sweeping membranes at term: a randomized trial

OBJECTIVE

To determine whether sweeping or stripping membranes at 38-40 weeks' gestation leads to spontaneous labor within 7 days.

METHODS

One hundred fifty antenatal low-risk patients at 38-40 weeks' gestation were assigned randomly to sweeping or control (ie, Bishop score only) groups and stratified based on the ability to pass a finger through the internal os. The primary outcome was the rate of spontaneous labor within 7 days. Major secondary outcomes included the spontaneous labor rate before 41 weeks and the overall spontaneous labor rate. Other outcomes included maternal and neonatal morbidity. The sample size was calculated based on doubling of the spontaneous labor rate within 7 days from 28% to 56% (alpha = 0.05, beta = 0.10).

RESULTS

The subjects were demographically similar between the groups. There were no differences between the groups in the primary outcome of spontaneous labor within 7 days (33% sweeping, 38% control; P = .39) or in the secondary outcomes of spontaneous labor before 41 weeks (P = .66) or the overall spontaneous labor rate (P = .09). The Bishop score predicted spontaneous labor within 7 days (P = .003), and gestational age at enrollment predicted spontaneous labor before 41 weeks (P = .008) and the overall spontaneous labor rate (P = .008), using logistic regression to control for potential confounders.

CONCLUSIONS

Sweeping membranes once at 38-40 weeks' gestation does not significantly increase the proportion of women who begin spontaneous labor within 7 days.

Homebound aged: the dilemma of psychiatric intervention

This study reports the 12 month experience of a hospital-based, multidisciplinary psychogeriatric community team. The patients evaluated were unable to come to the hospital clinics because of a psychiatric and/or physical disability. The group included some patients rarely seen in psychiatric office practice and outpatient facilities, but who posed problems for their families and the community. Some required referral to a clinic, crisis management or emergency hospitalization. Others however, required only minimal intervention. A total of 151 patients (119 females and 32 males) whose average age was 78.2, were seen. Seventy percent were widowed, single, divorced or separated; 43% lived alone. The patients were grouped according to the method of intervention used: psychiatric and social intervention--55%; social and nursing intervention--28%; no follow-up--11% and; emergency hospitalization--6%. Seventeen patients were left "untreated". These patients usually had more adequate family or community support than was initially apparent. They were referred for a crisis which was resolved quickly. An attempt is made to explain our approach, and several case examples are given.

Report: conference on key issues in post-graduate psychiatric education in Canada

At a national conference in 1985, the Royal College guidelines for post-graduate training in psychiatry in Canada were reviewed. The topics considered included geriatrics, consultation-liaison, chronic care, out-patient, and psychotherapy training, as well as pre-licensure requirements and examinations. The recommendations will be used by the Royal College in reformulating its requirements for psychiatric residency programs.

Clinical studies on the phenylethylamine hypothesis of affective disorder: urine and blood phenylacetic acid and phenylalanine dietary supplements

To test the hypothesis that 2-phenylethylamine (PEA) modulates affect, plasma levels and urinary excretion of its main metabolite, phenylacetic acid (PAA), were studied in depressed and manic subjects, and the mood-elevating effects of its precursor, L-phenylalanine, were studied in depressed subjects. Mean total plasma PAA concentrations were 491.83 +/- 232.84 ng/ml in 12 healthy volunteers and 300.33 +/- 197.44 ng/ml in 23 drug-free patients with major depression. The 24-hour urinary PAA excretion was also measured in 48 healthy volunteers (141.1 +/- 10.2 mg PAA/24 hr) and in 144 patients with major depression (78.2 +/- 41.0 mg PAA/24 hr). The results suggest that low plasma and urinary PAA may be state markers for depression and are compatible with the PEA hypothesis. In further support, phenylalanine elevated mood in 31 of 40 depressives.

Sleep position training as treatment for sleep apnea syndrome: a preliminary study

Ten male patients selected as having sleep apnea predominantly of the obstructive type associated with the supine sleep position on their evaluation night were trained for 1 additional night to avoid the back sleep position by wearing a gravity-activated position monitor/alarm on the chest. This device emitted an auditory signal if the patient remained supine for more than 15 s. The number of apneic events was significantly reduced, as were the number of episodes of significant O2 desaturation. While wearing the alarm, the apnea index of seven patients remained within or near normal limits. On a follow-up night, with only instructions to maintain the lateral decubitus posture, five patients remained significantly improved. Sleep position training may be appropriate as a single or interim treatment for a significant number of sleep apnea patients who have position-related obstruction.

Tactual exploration by normal infants

The age of onset for tactual exploration of the fingers, body (torso), knee, foot and penis by the fingers was determined in 100 normal infants. Exploration of the mouth, face, head, ears, nose and eyes was also studied by daily observations in the first three days of life in a second sample of 12 normal newborns, and the age of onset was recorded. The data show that the ability of the normal infant to explore by touch the various parts of his body appears to have a definite age of onset and a definite sequence.

Lightning injury: management of a case with ten-day survival

A boy, injured by lightning, had cardiopulmonary arrest. Following resuscitation and during the course of hospitalization, he developed further cardiac arrhythmia, cerebral edema, generalized seizures, and upper gastrointestinal bleeding. Despite efforts to combat these complications, the patient's condition deteriorated, and he died on the tenth day of hospitalization. The pathologic findings are described and the treatment discussed.

Inpatients in love: conjoint therapy of two adolescents

This paper describes two disturbed adolescent inpatients who fell in love and whose management included a series of conjoint therapy sessions. Their dynamics were explored and revealed themes of symbiosis, sadomasochism and identity-diffusion. This exploration led to the rupture of the relationship but it also stirred up multiple conflicts in the ward milieu. Some advantages and disadvantages of this technique are discussed.

Management of adolescents in general hospital setting

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