Hypersensitivity to Non-Steroidal Anti-Inflammatory Drugs on a pediatric Portuguese cohort

Summary

Background. Non-steroidal anti-inflammatory drugs (NSAID)/analgesics (paracetamol) are among the most common causes of drug hypersensitivity reactions in children, with a reported prevalence of around 0.3% in the pediatric population. Paracetamol and ibuprofen are the most commonly reported culprits in the pediatric population. Our objective was to describe the allergy workup to NSAID/paracetamol of a pediatric population monitored in an allergy outpatient clinic. Methods. Retrospective observational study by consulting the medical records of patients evaluated in a pediatric outpatient clinic with history of NSAID/paracetamol, between January 2016 to August 2022. Results. A total of 43 patients have been evaluated for NSAID/paracetamol suspected allergy: 53.5% females, mean age of 9.8 ± 5.1 years, 47.7% atopic. The drugs reported as culprits were: ibuprofen (75.6%), paracetamol (17.8%), metamizole (4.4%) and naproxen (2.2%) and clinical manifestations were mainly urticaria/angioedema and maculopapular exanthema. Skin tests were performed in 7 patients: paracetamol (n = 5) and metamizole (n = 2), which were all negative. Fourty-six drug provocation tests were performed: 28 with the culprit drug and 18 with an alternative one; only 2 were positive (ibuprofen - culprit NSAID group): one immediate periorbital angioedema and one delayed lip edema with oropharyngeal tightness. Conclusions. The investigation of allergy to NSAID/paracetamol in children remains a challenge. In our population, ibuprofen was the most common NSAID reported. There were only 2 (4.3%) mild reactions on DPT. We could allow the use of the culprit NSAID/analgesic in 11 patients and an alternative one in 9 patients. This study highlights the importance of DPT in children for a correct diagnosis of NSAID hypersensitivity and selection of an alternative drug.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Comparing the long-term prognosis of myocardial infarction with non-obstructive coronary arteries to myocardial infarction with obstructive coronary artery disease

Background

The long-term survival rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients is lower than in the general population. Nevertheless, there are conflicting results regarding the prognosis of MINOCA patients in comparison to myocardial infarction with obstructive coronary artery disease (MI-CAD) patients.

Purpose

The aim of this study was to assess the long-term all-cause mortality of MINOCA patients and compare it to MI-CAD patients.

Methods

Retrospective analysis of 2443 consecutively admitted patients for acute myocardial infarction (AMI), in a single coronary intensive care unit. Only patients with 5 years of follow-up and those who died before the 5-year mark were considered. Patients were divided into two groups according to the presence or absence of obstructive coronary artery disease on angiography (≥50% stenosis). Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were compared using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Five-year all-cause mortality was the target endpoint. Five-year survival was modelled through the Cox proportional hazard regression model. The variable of interest (MINOCA vs MI-CAD) and possible confounders that displayed statistically significant differences in the initial demographic analysis were included in univariable Cox regressions, and those with statistically significant associations were included in a multivariable model. Those that displayed non-significant associations in the multivariable model were subsequently removed until we were left with significant associations only, giving us an adjusted hazard ratio.

Results

Comparison between groups is presented in table 1. MINOCA patients were younger and more often women. They were less likely to have smoking habits, diabetes, or a previous history of AMI. They had a lower Killip class, as well as lower troponin I, serum creatinine and low-density lipoprotein cholesterol at admission. On the other hand, they had higher left ventricular ejection fractions. They were also less likely to have beta-blockers or aspirin prescribed at discharge.

All-cause mortality at 5 years was 13.1% among MINOCA patients and 28.3% among MI-CAD patients, with an unadjusted hazard ratio (HR) of 0.421 (95% CI 0.322–0.550), p<0.001. Adjusting for known confounders, the HR was 0.461 (95% CI 0.261–0.816), p=0.008.

Conclusions

Compared with MI-CAD patients, those with MINOCA were slightly younger and had fewer comorbidities. In spite of having a worse long-term prognosis when compared to the general population, MINOCA patients have a significantly higher 5-year survival rate than MI-CAD patients, even after adjustment of confounding factors.

Funding Acknowledgement

Type of funding sources: None.

Maximum dose sacubitril/valsartan in heart failure with reduced ejection fraction: does atrial fibrillation compromise the benefits?

Background

In the PARADIGM-HF trial, sacubitril/valsartan (SV) was shown to be superior to enalapril in reducing hospitalizations for worsening heart failure (HF), cardiovascular mortality, and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). The 2021 ESC Guidelines recommends SV as a replacement for angiotensin-converting-enzyme inhibitors to reduce the risk of HF hospitalization and death. There is little information regarding the effects of SV according to atrial fibrillation (AF) status.

Purpose

The aim of this study was to compare the effects of maximum dose SV regarding symptomatic improvement, change in natriuretic peptides levels (NP) and left ventricular ejection fraction (LVEF) in patients with HFrEF with and without AF.

Methods

Retrospective analysis of 137 patients with HFrEF on maximum dose SV (97/103mg twice daily). Patients were divided into two groups according to AF status. Age, gender, relevant comorbidities, usual medication, baseline symptomatic status, NP levels and LVEF were assessed using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Variation in NYHA class, NP levels and LVEF between baseline and 6-month follow-up was evaluated and compared between groups.

Results

Comparison between groups is presented in Table 1. In our studied population, ischemic aetiology was more common in the sinus rhythm group (49.5% vs 30.4%; p 0.034). There were no significant differences between groups regarding age, gender, hypertension, diabetes, and beta-blocker and mineralocorticoid receptor antagonist usage. At baseline, the AF group had higher NT-proBNP levels [median 1421 mg/dL (IQR 743–3087) vs 467 mg/dL (IQR 140–797); p<0.001]. There were no significant differences regarding baseline NYHA class or LVEF. After 6 months of follow-up, reductions in NYHA class [−1 (IQR −2, −1) for AF; −1 (IQR −1, 0) for SR; p=0.437] and NT-proBNP levels [−358 mg/dL (IQR −2275, −47) for AF; −162 mg/dL (IQR −364, 27) for SR; p=0.156], as well as LVEF improvement [11% (IQR 3–15) for AF; 12% (IQR 7–21) for SR; p=0.201], displayed no statistically significant differences between the two groups.

Conclusions

Our study shows that the beneficial effects of SV on symptomatic status, NP levels and LVEF were not compromised by the presence of AF at baseline.

Funding Acknowledgement

Type of funding sources: None.

Profiling cardiac fibroblasts in regenerative hearts after myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fundação para a Ciência e Tecnologia (FCT)

Introduction

Mouse neonates at postnatal day 1 (P1) are able to regenerate their hearts after myocardial infarction (MI) by reactivating cardiomyocyte proliferation and neovascularization, with little to no fibrosis. However, this process is transient and 7 day-old animals develop a reparative response as observed in adults [1]. After MI, these animals undergo permanent loss of myocardial tissue that is replaced by a rigid fibrotic scar to avoid organ rupture, having devastating consequences for heart function. Although the role of cardiac fibroblasts (CF) - the main orchestrators of fibrosis – in adults is well-documented, no study has unveiled the role of CF during neonatal regeneration. Recent work from our group showed that at least a subset of neonatal CF is able to provide pro-regenerative cues to cardiomyocytes, pointing to a beneficial role of CF in MI resolution.

Purpose

The ultimate goal of our research is to unravel CF-mediated mechanisms that confer regenerative potential to the neonate and re-activate these processes in the adult.

Methods

Mouse ventricles from E16, P1, P3 and P7 mice were subjected to targeted RNA-sequencing. To unveil non-myocyte cell dynamics in the first week after injury in regenerative (P1) hearts, myocardial infarction (MI) was induced by permanent ligation of the left descending coronary artery. To specifically assess the impact of CF in heart regeneration, a Tcf21iCre knock-in mouse line, carrying the diphtheria toxin receptor, was generated, rendering Tcf21+ CF - the majority of CF in the heart - susceptible to diphtheria toxin.

Results

Transcriptional profiling around birth highlighted severe extracellular matrix (ECM) changes from regenerative (P1) to reparative stages (P7). Coherently, from P1 to P7 CF were found to populate the myocardium and undergo a phenotypic shift that explained the transcriptional alterations observed for ECM-encoding genes, indicating a role of CF in the regeneration to repair transition. After MI at P1, CF were found to be readily and transiently recruited to the ischemic site, peaking at day 5 post-MI and returning to basal levels at day 7, a period in which cardiomyocyte proliferation and neovascularization were up-regulated. Of note, no evidence was found of fibrotic tissue or myofibroblasts from 7 days post-MI onwards. Contrarily, MI at P7 resulted permanent loss of cardiomyocytes, impaired neovascularization and formation of aberrant fibrosis as a result from exuberant and persistent fibroblast recruitment and activation. To evaluate the functional impact of fibroblast ablation during the regenerative response, ablation of Tcf21+ CF was performed after MI at P1. CF removal resulted impaired cardiac cell proliferation, indicating that CF recruited after MI are essential for effective neonatal regeneration.

Conclusion

After birth, CF undergo a switch from a regenerative to reparative phenotype that contributes to the loss of regenerative capacity after birth.

Specificities of the Use of Psychotropic Drugs in Bariatric Surgery

Introduction

Bariatric surgery is considered an effective treatment against obesity. Psychiatric illness is relatively common in patients who have undergone bariatric surgery. Over one-third of these patients are prescribed psychotropic drugs, particularly antidepressants. Unlike medications for diabetes, hypertension or hyperlipidemia, which are generally reduced and at times discontinued, postsurgery psychotropic use is only slightly reduced. The surgical intervention and the subsequent weight loss can affect several pharmacokinetic parameters, leading to a possible need of dosing adjustment.

Objectives

To review the influence of bariatric surgery on the use and pharmacokinetics of psychotropic drugs.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE for publications from 2011 to 2021, following the terms psychotropic and bariatric surgery. Textbooks were consulted.

Results

It is difficult to predict how psychotropics will be affected by bariatric surgery because of interindividual differences and limited data. Malabsorptive surgical procedures have a relatively greater potential to alter drug exposure. Medication disintegration, dissolution, absorption, metabolism and excretion have been found to be altered in postbariatric patients. Antidepressants are the best studied psychotropics in the bariatric population and their absorption is reduced. The risk of gastric bleeds with bariatric surgery will probably be increased by serotoninergic antidepressants. Antipsychotics and mood stabilisers are not well studied in these patients. Depot antipsychotics avoid the risk of reduced absorption after surgery. Lithium use requires particular close monitoring.

Conclusions

Close treatment monitoring and the ongoing monitoring of symptoms are needed after bariatric surgery. Many patients may not require significant changes to drug treatment after surgery.

Disclosure

No significant relationships.

Does my lifestyle explain my depression? The role of exercise, diet and smoking in the prevention of depression

Introduction

Depression as a public health concern highlights the importance of prevention. The nature of the disease is complex, linked to numerous biopsychosocial factors. However, it was found that healthiest lifestyle reduced 67% the risk of depressive symptoms.

Objectives

To review evidence on how exercise, diet, and smoking impact on the risk of depression.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE following the terms “Lifestyles”,“risk” and “depression”.

Results

Several studies have shown that exercise reduces the incidence of depressive symptoms and major depressive disorder regardless of intensity, geographic region, age, gender, or follow-up period. Smoking significantly increases the risk of depression, including the ones exposed to second-hand smoking and pregnant women in which prenatal smoking was associated with a three-fold increased risk of postpartum depression. The Mediterranean diet rich in complex carbohydrates, omega-3 fatty acids, B-group vitamins and several amino acids have shown a negative association with the incidence of depression. A high frequency of breakfast consumption, an increased intake of fruits, vegetables, and some specific nutrients (zinc, iron, magnesium, vitamins, and folate) was also inversely correlated with prevalence of depressive symptoms. On the other hand, western dietary patterns, with sweetened beverages, processed food, and foods rich in saturated fatty acids, have been linked to an increased risk. Skipping meals and snacking on unhealthy food also contributes to depressive symptoms.

Conclusions

Relatively modest changes in population diet, tobacco consumption and levels of exercise may have important public mental health benefits preventing a substantial number of new cases of depression.

Disclosure

No significant relationships.

Apathy - where do we find it and how to treat

Introduction

Although defined heterogeneously within the literature apathy is classified as a multidimensional deficit with emotional, behavioral, and cognitive domains in which there is a decrease in self-motivated/goal-directed activity. Recently conceptualized as a syndrome but lacking a universal screening tool.

Objectives

Review current knowledge on apathy and its best therapeutic approach.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE following the terms “apathy”and“psychiatry”.

Results

Apathy is amongst the most frequent symptoms of dementia and highly prevalent across different forms and stages of dementia, including mild cognitive impairment (MCI) as well as other neurodegenerative and psychiatric disorders such as Parkinson’s disease (PD), Schizophrenia, Depression and Brain Injury. Individuals with apathy have higher frequencies of cognitive impairment and are less likely to be compliant/respond to treatment for comorbid illnesses. Apathy reduces quality of life, increases mortality and leads to caregivers distress - often identified as the most burdensome symptom. Once treatment should favor dopaminergic neurotransmission, psychostimulants were considered. Methylphenidate showed encouraging results as well as dopamine agonists but both with limited evidence. Atypical antipsychotics(APs) seem beneficial compared to typical APs. Antidepressants did not improve symptoms and may even worsen them. Previously reported benefits of acetylcholinesterase inhibitors (AChEIs) were not replicated in recent studies except for rivastigmine in PD. Nonpharmacological interventions are also important.

Conclusions

Apathy occurs frequently in a broad range of neuropsychiatric conditions and considering its impact on patients´ quality of life more studies are needed to find an efficient treatment. A consensus regarding definition and screening tools would allow a better approach.

Disclosure

No significant relationships.

When Attention-Deficit/Hyperactivity Disorder reaches adulthood

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) was classically considered a childhood-onset neurodevelopmental condition. Over the past 40 years, it became evident that it can persist during adulthood.

Objectives

The purpose of the authors is to describe the characteristics of ADHD in adults and the specific comorbidities, proposing an approach to these patients.

Methods

A brief non-systematized review is presented, using the literature available on PubMed and Google Scholar.

Results

Only 40-50% of children and adolescents with ADHD will have symptoms that persist into adulthood (estimated adult prevalence of 2.8% across 20 countries; 25% in prisons). A more subtle presentation in adults and the difficulty to access past medical history, lead to diagnosis and treatment rates of lower than 20% (versus 50% in children). Well-characterized core symptoms in children evolve into a predominance of inattention symptoms. They became adults with marked disorganization, difficulties in completing tasks and managing time. Emotional dysregulation is a very prevalent symptom in this population. The comorbidities rate increase over time (reaching 75% of patients).

Conclusions

Adults (or even older subjects) with cognitive and/or behavioural complaints should be submitted to systematic screening for ADHD. Non-treated ADHD symptoms in adulthood are associated with severe impairment, therefore adjustments in the health care system to support the transition from child to adult services are needed.

Disclosure

No significant relationships.

Lost in Translation – What is Alexithymia

Introduction

Alexithymia is considered a personality trait characterized by difficulties in identifying and expressing emotions, impoverished fantasy life and tendency toward action-oriented or ‘operational’ Thinking. There are alterations in cognitive processing and regulation of emotions, and tendency to somatization.

Objectives

The authors examine literature regarding the concept of alexithymia, exploring the current definition and role in the clinic, research findings and proposed management.

Methods

A brief non-systematized review is presented, using the literature available on PubMed and Google Scholar.

Results

Alexithymia is not a discrete psychiatric diagnosis. It has been reported in 9-10% of the general population. It is related to numerous psychiatric disorders (substance use disorders, anxiety disorders, depression and eating disorders), but also to somatic illnesses (essential hypertension, functional gastrointestinal disorders, diabetes mellitus, psoriasis, fibromyalgia and cancer pain). Neuroimaging and neurobiological studies found evidence for morphological and functional brain alterations that integrate the classification introduced by Bermond. Affective type I is characterized by the absence of emotional experience and, consequently, by the absence of cognition accompanying the emotion (associated to right unilateral cortical lesions). Cognitive Type II is characterized by a selective deficit of emotional cognition with sparing of emotional experience (associated to a right-to-left unidirectional deficit in interhemispheric transfer).

Conclusions

There is little consensus on the subject. Clarification of the mechanisms underlying alexithymia can improve our management of these individuals. Identification of effective strategies could improve the patients’ capacities for adaptive emotional processing and enhance other aspects of functioning.

Disclosure

No significant relationships.

Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT): A Review

Introduction

Lithium has a narrow therapeutic window. Frequent monitoring of both serum levels and clinical signs of toxicity is warranted because toxicity may be present even when concentrations are within the therapeutic range. Persistent neurological signs and symptoms of lithium intoxication gained clinical attention in the 1980s and were named Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT).

Objectives

To review the long-term neurological sequelae of lithium intoxication (SILENT) to highlight their clinical presentation, assessment, management and preventive measures.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE for publications up to 2021, following the terms syndrome of irreversible lithium-effectuated neurotoxicity.

Results

Neurological manifestations of lithium poisoning may persist, even after effective removal of the drug – SILENT. The most frequent sequelae are cerebellum and brain stem dysfunction, extrapyramidal symptoms and dementia. They may last for weeks, months or years. Infection, dehydration, deteriorating renal function or the addition of other drugs may precipitate acute toxicity. Irreversible damage is difficult to treat. Some cases show spontaneous recovery that may be total, but in others, sequelae persist. Helpful measures include the avoidance of acute intoxications with lithium, long-term and continuous dose adjustment and serum level monitoring, stricter exclusion criteria for starting lithium, and aggressive treatment of acute neurotoxicity. Once the long-term neurologic sequelae have set in, the patient should be managed according to the impediment (physical rehabilitation, speech, cognitive training).

Conclusions

It is important to raise the awareness of SILENT so that clinicians are able to avoid it. There should be a low threshold for suspecting the existence of toxicity.

Disclosure

No significant relationships.

The development of a novel functional food: bioactive lipids in yogurts enriched with Aurantiochytrium sp. biomass

Western diets are poor in healthy n3 polyunsaturated fatty acids, such as docosahexaenoic acid. Since microalga Aurantiochytrium sp. is rich in docosahexaenoic acid, a functional food based on lean yogurt and this microalga was tested. This study entailed characterizing the lipid fraction and determining the fatty acid bioaccessibility. The tested yogurts (control and 2% w/w, Aurantiochytrium sp.) had differences. Docosahexaenoic acid was not detected in the control product, but it was the second most important fatty acid in Aurantiochytrium sp. and Aurantiochytrium yogurt, 29.7 ± 0.4% and 18.7 ± 2.0%, respectively. Based on the fatty acid profile only, an amount of 158.7 g of Aurantiochytrium yogurt in wet weight terms would be required to ensure an appropriate intake of healthy fatty acids. Generally, the fatty acid bioaccessibility was not high, remaining below 60-70% in almost all cases. Considering the docosahexaenoic acid bioaccessibility (44 ± 3%), an amount of 360.7 g of Aurantiochytrium yogurt would be advisable. A reasonable dietary prescription would be a daily consumption of 125 ml of Aurantiochytrium yogurt.

Involving families in psychiatric treatment and rehabilitation

Introduction

Psychiatric rehabilitation promotes recovery in individuals with mental disabilities. Its mission is to engage patients and families or caregivers in a collaborative treatment process. The vision of recovery is more likely to become a reality when patients and families are actively involved in treatment. Numerous factors have converged during the past decades to facilitate development and refinement of evidence-based approaches for strengthening families coping with mental disorders.

Objectives

To review current knowledge on the importance of involving families in psychiatric treatment and rehabilitation, addressing effectiveness of family interventions, role of family coping skills in neutralizing stress and vulnerability, and family burden of mental illness.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE database for publications up to 2020. Textbooks were consulted.

Results

Given the unpredictability of major mental disorders, families assume responsibility for extensive monitoring and supervision of a severely and chronically mentally ill relative. Clinical, social, family and economic benefits are achieved by adding psychosocial family interventions to a comprehensive array of services required by patients. Family interventions are not stand-alone modalities: they are coordinated with pharmacotherapy, illness management, crisis intervention, clinical case management, skills training and supportive services. Family interventions show benefits, such as fewer psychotic/affective episodes of exacerbation or relapse by the patient, reduced hospitalizations and improved family morale and less emotional burden.

Conclusions

The new and effective family interventions do not stigmatize families as being ‘sick’ or in need of therapy to ‘straighten them out’. Family interventions are viewed as conferring added therapeutic protection to the patient and relatives.

Disclosure

No significant relationships.

Hebephrenic schizophrenia as a variant of frontotemporal dementia – the true dementia praecox?

Introduction

Frontotemporal Demential (FTD) is a neurodegenerative disorder evolving the frontal or temporal brain lobes. They have been described six variants. Behaviour variant (BvFTD) is the most common, and is characterized by changes in social behaviour and conduct, with loss of social awareness and poor impulse control. Hebephrenic schizophrenia (HSz), or disorganized schizophrenia, was recognized as a schizophrenia subtype, characterized by desorganized behaviour and a cognitive deteriorization. Subtypes of schizophrenia are no longer recognized as separate conditions neither in the Diagnostic and Statistical Manual of Mental Disorders, nor in the new International Statistical Classification of Diseases.

Objectives

To review the literature about the concepts of hebephrenic schizophrenia and their similarities with the concept of frontotemporal dementia

Methods

Narrative review of the literature on PubMed/MEDLINE, using the keywords “hebephrenic szchizophrenia” AND “frontotemporal dementia”. Only articles in English were included.

Results

Some authors described dificulty in establish a diferential diagnosis between HSz and BvFTD. HSz has an earlier onset. However, BvFTD is an early age dementia. The fenomenology of both diseases is similar, and schizophrenia was historical conceptualized as praecox dementia. Frontotemporal abnormalities are common neuroimagiological findings in schizophrenia. Clinically, FTD shows a profound alteration in personality and social conduct, emotional blunting and loss of insight. Memory, intellectual functions, executive and attentional abilities may be disturbed in both.

Conclusions

A diferential diagnosis between HSz and BvFTD is dificult to establish (clinically and imagiologically). The response to treatment is weak in both. It should be investigated the possibility they could be the same syndrome, onseting in diferent ages.

Disclosure

No significant relationships.

Neuropsychiatric complications of traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality, giving rise to a variety of neuropsychiatric syndromes associated with great functional impairments, chronic disability and poor quality of life. Depending on diagnostic criteria, 20-90% of victims of TBI develop at least one neuropsychiatric manifestation in the first month, and about 40% present at least three symptoms during three months, with higher incidence in females. Survivors of TBI are at increased risk for development of severe, long-term psychiatric disorders. The aetiology of these disturbances remains unclear.

Objectives

To review current knowledge on the neuropsychiatric consequences associated with TBI.

Methods

Non-systematic review of literature through search on PubMed/MEDLINE database for publications up to 2020, following the terms “traumatic brain injury” and “neuropsychiatry”.

Results

Although the experience of neuropsychiatric symptoms may be temporary and may resolve in the acute period, many patients with TBI can experience psychopathology that is persistent or that develops in the post-acute period, regardless of injury severity. These symptoms can involve personality changes, psychosis, major depression, generalized anxiety disorder, post-traumatic stress disorder, maladaptive social behaviours, poor disability adjustment, reduced coping skills and cognitive impairment. Evidence remains insufficient to conclude the role of TBI-related neuropathological consequences in the development of post-TBI neuropsychiatric disorder. Non-organic factors are also implicated in its generation and maintenance.

Conclusions

Neuropsychiatric sequelae are common following TBI. Several of these syndromes are amenable to treatment. Further investigations are required to better understand the mechanistic aetiology of these conditions and the effectiveness of therapeutic modalities.

What is the best approach for patients with prolonged duration of untreated psychosis (DUP) - about 2 clinical cases with dup longer than 10 years

Introduction

Studies have consistently found that many individuals with psychosis experience significant delays before receiving treatment. DUP refers to the period between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment.

Objectives

To review current knowledge on the best approach for patients with schizophrenia (SCZ) and prolonged DUP.

Methods

Non-systematic review of literature through search on PubMed database, following the terms “DUP and treatment” and “impact of longer DUP”. Two clinical cases are described.

Results

The clinical cases describe patients with SCZ with DUPs older than 10 years, in whom we could not achieve complete clinical remission after several therapeutic trials and whose prognosis was admitted as reserved. Longer DUP is an independent predictor of poorer outcome in SCZ, including the poor response to treatment and difficulty in achieving remission, predicting treatment resistance. Identifying treatment-resistant patients is crucial due to the importance of initiating clozapine as early as possible since the chances of responding are higher.

Conclusions

DUP is a key prognostic variable in psychosis, revealing the significance of early treatment. Patients with long DUP should be regarded as at high risk of poor recovery. The detection of these patients enables clinicians to avoid unnecessary exposure to ineffective treatments while effective interventions are delayed. However, in view of adverse side effects of clozapine, future studies need to examine relevant predictors to detect accurately non-responders. We also suggest further studies to understand if there is correspondence between DUP and different stages of the disease that justify these results.

The prolactine hypothesis for peripartum cardiomyopathy: has it found its feet for good?

Background

Peripartum cardiomyopathy (PPCM) is a rare but serious condition that affects childbearing women. Dopamine agonists (DAs) may represent a specific therapy, potentially facilitating left ventricular recovery, through inhibition of prolactin secretion. However, their therapeutic value in this setting has not been fully demonstrated.

Purpose

To perform a meta-analysis aimed at evaluating the extent to which DAs are able to interfere with the natural history of PPCM.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library, Google Scholar, Scopus and DARE for both randomized controlled trials (RCTs) and observational studies addressing the impact of DAs on main outcomes of PPCM patients, published up until February 1, 2020. Endpoints were those of mortality, recovery from heart failure and, likewise, the degree to which left ventricular ejection fraction (LVEF) was restored. All analyses were conducted under a DA plus optimized medical therapy (OMT) vs. OMT alone design, while results were pooled using traditional meta-analytic techniques, under a random-effects model. Odds ratios (ORs) were computed for the first two outcomes, whereas mean difference (MD) was calculated to quantify LVEF restoration.

Results

2 RCTs, 2 prospective cohort, 1 prospective case-control and 2 retrospective cohort studies, encompassing 452 patients, were regarded as eligible for quantitative evaluation. 180 patients were allocated to the DA arm, which was mostly represented by bromocriptine; in fact, only 1 study, including 24 patients, specified cabergolin utilization. Overall, 5 papers including 295 patients reported 42 deaths, whereas 5 papers comprising 305 patients detailed 220 heart failure recoveries, thus unveiling that LVEF restoration was the norm. The addition of a DA to OMT provided no signal of a survival benefit (OR 0.71, 95% CI 0.27–1.87, p=0.49, i2=27%). On the other hand, the incorporation of a DA into the therapeutic regimen narrowly missed significance for the heart failure recovery endpoint (OR 2.68, 95% CI 0.98–7.31, p=0.05, i2=56%). Furthermore, DAs were demonstrated to incrementally improve LVEF by 15% (MD 15.00, 95% CI 10.24–19.76, p<0.00001, i2=77%). Adverse events, including thromboembolic ones, were rare, though adjunct anticoagulation was broadly reported.

Conclusion

In PPCM patients, the addition of a DA to OMT seems to be both effective at incrementally improving LVEF and safe, even though not reaching survival benefit status. These findings appear to corroborate the so-called prolactin hypothesis for PPCM pathophysiology.

Funding Acknowledgement

Type of funding source: None

Statins for venous thromboembolism prevention: old dog, new tricks

Background

Statins are highly effective in preventing major acute cardiovascular events in the setting of atherosclerotic arterial disease. On the other hand, given their antithrombotic and anti-inflammatory properties, statins may also attenuate patients' odds of developing venous thromboembolism (VTE). However, clinical studies have yielded variable estimates of this effect.

Purpose

To perform a meta-analysis designed to evaluate the extent to which statin use influences the rate of subsequent VTE events.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for both randomized controlled trials (RCTs) and observational studies addressing the association between statins and VTE risk, published up until December 1, 2019. Manually reviewed references and key investigators interaction via e-mail correspondence were also data sources. RCTs comparing the effects of statin therapy with those of a placebo or no treatment were included, while interventional studies appraising different lipid-lowering pharmacological strategies were not. Observational studies encompassed both cohort and case-control designs. The primary endpoints were general VTE, deep vein thrombosis or pulmonary embolism. Patients with cancer, heart failure and chronic kidney disease (CKD) were further investigated separately. Study-specific relative risks (RRs) were pooled using generic inverse variance outcome meta-analytic technique with a random-effects model.

Results

23 RCTs comprising 118.464 participants, 12 cohort studies encompassing 2.881.184 patients and 9 case-control studies including 354.367 patients were regarded as eligible for quantitative evaluation. Specifically, 5 observational studies comprising 9.656 cancer patients, 3 studies encompassing 9.693 heart failure patients and 4 studies including 4.353 CKD patients were gathered. In RCTs, statin therapy was proven slightly superior to placebo or no treatment in lowering VTE incidence (RR 0.85, 95% CI 0.73–0.99, p=0.04, i2=14%). Observational studies were found to corroborate this effect, with statin treatment resulting in VTE risk reduction overall (RR 0.72, 95% CI 0.64–0.81, p<0.001, i2=84%) and in both cohort (RR 0.86, 95% CI 0.83–0.90, p<0.001, i2=85%) and case-control (RR 0.68, 95% CI 0.57–0.82, p<0.001, i2=80%) designs. This positive effect held true in cancer patients (RR 0.56, 95% CI 0.33–0.95, p=0.03, i2=78%), but not in those with heart failure (RR 0.7, 95% CI 0.42–1.16, p=0.17, i2=2%) and CKD (RR 1.04, 95% CI 0.67–1.60, p=0.87, i2=0%).

Conclusion

Currently available evidence suggests that statins significantly reduce patients' odds of developing VTE. Given their favorable safety profile and low cost, statin treatment should now be considered in high-risk individuals, particularly in those with cancer.

Funding Acknowledgement

Type of funding source: None

Provisional versus 2-stent strategies for coronary bifurcations: is a bird in the hand worth two in the bush?

Background

Among all subsets of coronary artery lesions, bifurcations stand out due to high incidence, demanding percutaneous interventions (PCIs) and poor outcomes. Amid the different PCI strategies, the provisional (PS) approach is generally recommended over 2-stent (TS) techniques, but this paradigm has been challenged.

Purpose

To compare PS with TS for PCI of coronary bifurcation lesions, concerning procedural aspects and both immediate and long-term patient outcomes.

Methods

Retrospective study encompassing patients consecutively referred to a tertiary interventional cardiology unit for coronary angiography, who were found to have at least 1 native bifurcation lesion. According to operator experience and angiographic features, patients were managed with PS or/(and) TS. Procedural aspects regarding radiological variables, angiographic success and immediate complications were reviewed, as were in-hospital outcomes. Besides, clinical follow-up, by clinic appointment or telephone calling, was performed targeting stent failure, target vessel revascularization (TVR), acute coronary syndromes (ACS), heart failure and mortality.

Results

From January 2010 to June 2017, 404 patients with 433 bifurcation lesions were included. Median age was 70 (62–77) years and 25.3% were female. Median follow-up was 2 (1–3) years. Chronic angina was the dominant PCI context (61.3%) with 9.7% presenting with ST-segment elevation myocardial infarction (MI). Medina class 1,1,1 was documented in 54.1% and 64.9% of lesions were hailed as true bifurcations. 303 patients underwent PS, whereas 67 were managed with TS, with TAP (43.3%) and mini-crush (34.3%) as the leading techniques. True bifurcations were more frequently approached with TS (p<0.001), whereas PCI context did not influence procedure selection. Fluoroscopy time (p<0.001), radiation dose (p=0.003) and contrast volume (p=0.009) were higher in the TS subgroup. OCT guidance (p=0.039) was also more common with TS. Angiographic success was uniformly high (95.1% for PS and 97% for TS), while procedural complications, including iatrogenic coronary dissections (7.4%, mostly minor) and slow-reflow (3.5%), were homogenously low. Acute kidney injury and type 4a MI occurred in 14.5% and 32.3%, respectively, also with no difference between groups. As for long-term outcomes, stent failure, encompassing both stent thrombosis (1 event) and restenosis (4.2%), occurred more often with TS (p=0.046), with ACS events (9.5%) following the same trend (p=0.08). In turn, rates of TVR (12.5%), heart failure hospitalization (6.2%) and mortality, regardless of its cardiovascular nature, were similar.

Conclusion

PS outperforms TS during follow-up, particularly due to lower stent failure odds. Thus, this study further supports the concept of PS as the standard approach for coronary bifurcation lesions.

Funding Acknowledgement

Type of funding source: None

Moment of truth for aspirin use in variant angina: a meta-analysis

Background

Aspirin has been a mainstay of antiplatelet therapy for coronary artery disease (CAD). However, in the context of variant angina (VA), high-dose aspirin was reported to exacerbate coronary spasms. Consequently, the value of traditional low-dose aspirin in VA, especially if not associated with atherosclerotic CAD, may be disputed.

Purpose

To perform a meta-analysis aimed at evaluating the extent to which low-dose aspirin therapy influences cardiovascular (CV) prognosis in VA.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for studies addressing the long-term impact of low-dose aspirin on main CV outcomes of VA patients, published up until February 1, 2020. The primary endpoint was all-cause mortality, whereas secondary endpoints included CV mortality, acute coronary syndrome (ACS) events, revascularization procedures and hospital admissions for angina. The subgroup of patients with no significant epicardial CAD was further investigated separately, underneath similar outcomes. Study-specific odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random-effects model.

Results

One prospective multicenter and two retrospective single-center studies, encompassing 1652 and 1164 patients, respectively, were regarded as eligible for quantitative evaluation. Median follow-up ranged between 12 and 52.1 months. 1284 patients were allocated to the aspirin arm and 2770 had no epicardial CAD. Absolute number of events for each endpoint may be reported as follows: all-cause mortality, 33; CV mortality, 11; ACS, 57; revascularization, 14; hospital admission for angina, 218. Aspirin was not found to reduce neither all-cause mortality (OR 0.78, 95% CI 0.38–1.58, p=0.49, i2=0%), nor CV mortality (OR 0.98, 95% CI 0.30–3.25, p=0.98, i2=0%), nor ACS events (OR 1.44, 95% CI 0.51–4.10, p=0.49, i2=47%), nor revascularization procedures (OR 2.06, 95% CI 0.63–6.75, p=0.23, i2=0%), nor hospital admissions for angina (OR 1.60, 95% CI 0.67–3.80, p=0.29, i2=86%). Likewise, this comprehensively neutral effect held true in those with VA and no significant atherosclerotic CAD (OR 1.04, 95% CI 0.28–3.92, p=0.95, i2=0%, for CV mortality; OR 1.29, 95% CI 0.19–8.94, p=0.79, i2=33%, for revascularization; OR 1.73, 95% CI 0.81–3.73, p=0.16, i2=75%, for hospital admission for angina).

Conclusion

Even though scarce, currently available evidence suggests that low-dose aspirin is not effective in shrinking major adverse cardiovascular events in VA patients, particularly in those with no epicardial CAD. On the other hand, lower doses of aspirin may avoid the menace of clinically significant coronary spasms.

Funding Acknowledgement

Type of funding source: None

Ranolazine as you have never seen it before: an antiarrhythmic for atrial fibrillation

Background

Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias.

Purpose

To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF.

Methods

We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model.

Results

A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p<0.001, i2=58%). This effect held true, with an even larger effect size, in the context of post-cardiac surgery (OR 0.34, 95% CI: 0.16–0.72, p=0.005, i2=64%). Ranolazine increased the chances of successful AF cardioversion when added to amiodarone over amiodarone alone (OR 6.67, 95% CI: 1.49–29.89, p=0.01, i2=76%), while significantly reducing time-to-cardioversion [SMD 9.54h, 95% CI: −13.3–5.75, p<0.001, i2=99%]. Interestingly, cardioversion was faster with ≤1000mg of ranolazine (SMD −13.16h, 95% CI: −15.07–11.25, p<0.001, i2=95%) than with 1500mg (SMD −3.57h, 95% CI: −5.06–2.08, p<0.001, i2=23%). In paroxysmal AF, ranolazine was also proved to significantly reduce both AF burden and episodes. There were no safety signals regarding mortality odds, QTc interval prolongation (mostly clinically insignificant) and hypotension (mostly transitory).

Conclusion

Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed.

Funding Acknowledgement

Type of funding source: None

P1092Syncope in the emergency department: can 24-hour holter monitoring be of any help?

Background 

Syncope is a very common reason for presenting to the emergency department (ED). The existence of a telemetry unit is crucial but it is not the reality in some hospitals. In order to avoid unnecessary ward admission, 24-hour Holter (24HH) monitoring could be useful to help with the diagnosis (when the arrhythmic etiology is suspected and the symptoms are frequent enough) and also be important to safely discharge a patient. 

Purpose 

The purpose of this study is to evaluate the diagnostic performance of 24HH monitoring, during a syncope episode in the ER, and to compare the readmission rates between patients with normal and abnormal not diagnostic 24HH monitoring. 

Methods 

A cohort study of consecutive patients (P) who were monitored with 24HH in one hospital in the ED, between January 2015 and December 2017, were included. All the 24HH results were seen by a senior cardiologist and divided in three groups: A - normal, B - abnormal Holter study unlikely to explain syncope and C- Holter study considered to be diagnostic. 

Groups A and B were compared using chi-square independence test to evaluate association between the result of the 24HH and readmission rates at 30 days and 1 year, as well as mortality and device implantation at 1 year. Multivariate logistic regression was used to look for other confounders. 

Results 

A total of 111 P were included in this study. Mean age was 75 ± 14 years old, with 55.6% male patients. 

A previous emergency episode with syncope was present in 56.9% of P. The mortality at one-year follow-up was 11.9%. The 24HH was considered diagnostic in 25.2% of P (28 P), with 18.9% of all the P with necessity of pacemaker (PM) implantation. In the patients with a non-diagnostic 24HH, 6,4% implanted a loop recorder before discharge. 

Group B patients had a higher 30-day readmission rate to the ED when compared with group A (OR = 4.050 CI 95 [1.13 – 14.497], p = 0.033), but no difference in one-year readmission rate (p= 0.065). There was no difference in one-year mortality between the two groups (p= 0.731) or in one-year implantation of pacemaker (p= 0.431). 

Conclusion 

The use of 24HH in the ED could be a valuable tool in the diagnosis of rhythm disorders that cause syncope.  An abnormal non diagnostic result can still be a predictor of 30-day readmission to the ED with similar complaints.

P235 A happy ending for a dancing thrombus on the right atrium

Discussion

Large right atrial thrombus in the setting of PTE is a clinical situation in which there is no consensus regarding clinical management. In most cases, management is dictated by haemodynamic status of the patient. In the setting of a hemodynamically stable patient, systemic anticoagulation can be an option. Surgery, fibrinolysis and percutaneous aspiration have also been advocated. Successful treatment of right heart thrombus with anticoagulation alone has been reported, but there are also reports of unsuccess with that strategy. This is a case of a successful treatment with anticoagulation alone and so, we currently consider that the choice of treatment strategy based on hemodynamic status continues to be the wisest strategy to adopt.

Abstract P235 Figure. Thrombus before and after

2210Symptomatic severe aortic stenosis: predictor factors and outcomes

Introduction

The natural history in aortic stenosis (AS) is a slowly progressive process which begins as aortic sclerosis and subsequently progresses to severe opening restriction, conditioning symptoms development. At this time, surgical aortic valve replacement is strongly recommended due to its poor prognosis.

Purpose

Evaluation of predictor factors of symptomatic severe AS and its prognostic impact.

Methods

Single center retrospective analysis of patients' data accompanied in cardiology consultation due to severe AS diagnosed between 2015–2016. Data was collected regarding clinical and echocardiographic parameters to determine predictor factors of stablished endpoints.

Results

150 patients were reviewed, mean age 76.6±9.0 years, 72% males. 68.7% had hypertension, 42% dyslipidaemia and 32.7% diabetes. 64.7% of the patients had symptoms attributable to severe AS: 48% dyspnoea, 12% angina and 4.7% syncope. 7.3% of the patients were hospitalized due to acute heart failure in this context. Comparing echocardiographic parameters between symptomatic versus non-symptomatic patients with severe AS, symptomatic patients had higher values of aortic maximum velocity (4.5±0.5 vs 4.3±0.4 m/sec, p<0.001) and mean gradient (50.1±12.7 vs 43.2±7.7 mmHg, p<0.001). There were no significant differences regarding mean aortic valvular area neither left ventricle ejection fraction. At univariate analysis, predictor factors of symptoms attributable to severe AS development were: hypertension (odds ratio (OR) 2.044, confidence interval (CI) 1.004–4.161, p 0.049), anaemia (OR 0.420, CI 0.207–0.851, p 0.016), aortic maximum velocity (OR 5.497, CI 2.014–15.000, p 0.001) and mean gradient (OR 1.073, CI 1.029–1.118, p 0.001). At multivariate analysis, only aortic maximum velocity showed to be independent predictor factor of symptomatic severe AS (p 0.012). Hospitalization and all-cause mortality rates (respectively: 9.3 vs 9.4%, p 0.975; and 25.8 vs 34%, p 0.305) did not differ between groups.

Conclusion

In patients with severe AS, aortic maximum velocity showed to be the only independent predictor factor of symptoms development, however it was not associated with an increased hospitalization or mortality rates.

Acetylation as a major determinant to microtubule-dependent autophagy: Relevance to Alzheimer's and Parkinson disease pathology

Protein post-translational modifications (PTMs) that potentiate protein aggregation have been implicated in several neurological disorders, including Alzheimer's (AD) and Parkinson's disease (PD). In fact, Tau and alpha-synuclein (ASYN) undergo several PTMs potentiating their aggregation and neurotoxicity. Recent data posits a role for acetylation in Tau and ASYN aggregation. Herein we aimed to clarify the role of Sirtuin-2 (SIRT2) and HDAC6 tubulin deacetylases as well as p300 acetyltransferase in AD and PD neurodegeneration. We used transmitochondrial cybrids that recapitulate pathogenic alterations observed in sporadic PD and AD patient brains and ASYN and Tau cellular models. We confirmed that Tau protein and ASYN are microtubules (MTs)-associated proteins (MAPs). Moreover, our results suggest that α-tubulin acetylation induced by SIRT2 inhibition is functionally associated with the improvement of MT dynamic determined by decreased Tau phosphorylation and by increased Tau/tubulin and ASYN/tubulin binding. Our data provide a strong evidence for a functional role of tubulin and MAPs acetylation on autophagic vesicular traffic and cargo clearance. Additionally, we showed that an accumulation of ASYN oligomers imbalance mitochondrial dynamics, which further compromise autophagy. We also demonstrated that an increase in Tau acetylation is associated with Tau phosphorylation. We found that p300, HDAC6 and SIRT2 influences Tau phosphorylation and autophagic flux in AD. In addition, we demonstrated that p300 and HDAC6 modulate Tau and Tubulin acetylation. Overall, our data disclose the role of Tau and ASYN modifications through acetylation in AD and PD pathology, respectively. Moreover, this study indicates that MTs can be a promising therapeutic target in the field of neurodegenerative disorders in which intracellular transport is altered.

Effectiveness and safety of local anesthetic, semi-flexible pleuroscopy - experience from a peripheral hospital

If the seemingly less invasive semi-flexible pleuroscopes are combined with strategies of conscious sedation and local anesthesia the pleuroscopy has the potential to reach an increasing number of hospital settings. Local experiences can provide valuable information pertaining to the reproducibility of this technique in different scenarios. We performed a retrospective analysis of the clinical records of all patients that had undergone local anesthetic semi-flexible pleuroscopy in our unit between February 2015 and July 2017. Data on demographics, previous biochemical, cytological and histopathological analysis, procedure details, diagnostic and therapeutic results, complications and mortality were collected from all patients. Statistical analysis was performed using SPSS v23. A total of 30 patients were included. They were mainly male (66.7%), with a median age of 72 years (minimum 19 years, maximum 87 years). All presented with exudative pleural effusions and the exam was performed for diagnostic reasons. Pleural tissue was obtained in all patients and the overall diagnostic accuracy was 93.3%. Malignancy was the chief group of diagnosis (66.7%), followed by pleural tuberculosis (13.3%). The procedure was well tolerated and self-limited subcutaneous emphysema was the only complication registered (13.3%). No deaths were associated with the procedure. Our results globally overlap those of wider series and reinforce the perception that local anesthetic semi-flexible pleuroscopy is a well-tolerated, safe and highly accurate diagnostic and therapeutic tool which has proved to be both feasible and effective in our experience.

Sub-millisecond electron density profile measurement at the JET tokamak with the fast lithium beam emission spectroscopy system

Diagnostic alkali atom (e.g., lithium) beams are routinely used to diagnose magnetically confined plasmas, namely, to measure the plasma electron density profile in the edge and the scrape off layer region. A light splitting optics system was installed into the observation system of the lithium beam emission spectroscopy diagnostic at the Joint European Torus (JET) tokamak, which allows simultaneous measurement of the beam light emission with a spectrometer and a fast avalanche photodiode (APD) camera. The spectrometer measurement allows density profile reconstruction with ∼10 ms time resolution, absolute position calculation from the Doppler shift, spectral background subtraction as well as relative intensity calibration of the channels for each discharge. The APD system is capable of measuring light intensities on the microsecond time scale. However ∼100 μs integration is needed to have an acceptable signal to noise ratio due to moderate light levels. Fast modulation of the beam up to 30 kHz is implemented which allows background subtraction on the 100 μs time scale. The measurement covers the 0.9 < ρ_pol < 1.1 range with 6-10 mm optical resolution at the measurement location which translates to 3-5 mm radial resolution at the midplane due to flux expansion. An automated routine has been developed which performs the background subtraction, the relative calibration, and the comprehensive error calculation, runs a Bayesian density reconstruction code, and loads results to the JET database. The paper demonstrates the capability of the APD system by analyzing fast phenomena like pellet injection and edge localized modes.

Ecotoxicological effect of zinc pyrithione in the freshwater fish Gambusia holbrooki

Currently diverse biocidal agents can be used for distinct applications, such as personal hygiene, disinfection, antiparasitic activity, and antifouling effects. Zinc pyrithione is an organometallic biocide, with bactericidal, algicidal and fungicidal activities. It has been recently incorporated in antifouling formulas, such as paints, which prevent the establishment of a biofilm on surfaces exposed to the aquatic environment. It has also been used in cosmetics, such as anti-dandruff shampoos and soaps. Previously reported data has shown the presence of this substance in the aquatic compartment, a factor contributing to the potential exertion of toxic effects, and there is also evidence that photodegradation products of zinc pyrithione were involved in neurotoxic effects, namely by inhibiting cholinesterases in fish species. Additional evidence points to the involvement of zinc pyrithione in alterations of metal homeostasis and oxidative stress, in both aquatic organisms and human cell models. The present work assesses the potential ecotoxicity elicited by zinc pyrithione in the freshwater fish Gambusia holbrooki after an acute (96 h) exposure. The oxidative stress was assessed by the quantification of the activities of specific enzymes from the antioxidant defense system, such as catalase, and glutathione-S-transferases; and the extent of peroxidative damage was quantified by measuring the thiobarbituric acid reactive substances levels. Neurotoxicity was assessed through measurement of acetylcholinesterase activity; and a standardized method for the description and assessment of histological changes in liver and gills of was also used. Zinc pyrithione caused non-specific and reversible tissue alterations, both in liver and gills of exposed organisms. However, histopathological indices were not significantly different from the control group. In terms of oxidative stress biomarkers, none of the tested biomarkers indicated the occurrence of pro-oxidative effects, suggesting that the oxidative pathway is not the major toxicological outcome of exposure to zinc pyrithione.

Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

BACKGROUND

Bronchial artery embolisation (BAE) becomes a mainstay in the treatment of hemoptysis.

OBJECTIVE

To characterise patients with hemoptysis undergoing bronchial artery angiography (BAA) for embolisation, evaluating outcomes.

METHODS

We retrospectively evaluated patients with acute severe or chronic recurrent hemoptysis admitted to the Pulmonology department and submitted to BAA for purpose of embolisation.

RESULTS

A total of 88 patients were submitted to BAA, 47 (53.4%) were male, with a mean age of 61.4 ± 15.8 years. In 64 (72.7%) patients, hemoptysis presented as chronic recurrent episodes. Hemoptysis was considered severe in 40 (45.5%) patients. Bronchiectasis (other than cystic fibrosis) (n=35; 38.0%) and tuberculosis sequelae (n=31; 35.2) were the major aetiology for hemoptysis. The main angiographic abnormality was hypertrophy and tortuosity (n=68; 77.3%). BAE was performed in 67 (76.1%) of the 88 patients submitted to BAA. Immediate success was achieved in 66 (98.5%) patients. Recurrence of hemoptysis occurred in 25 (37.3%) patients, and was related to presence of shunting (p=0.049). The procedure-related complications were self-limited.

CONCLUSION

Our results suggest that BAE is a safe and effective treatment for acute severe and chronic recurrent hemoptysis, supporting the current literature. Besides this, bleeding recurrence was relatively high, and correlated with presence of systemic pulmonary shunting.