Integrative phylogenetic, phylogeographic and morphological characterisation of the Unio crassus species complex reveals cryptic diversity with important conservation implications

The global decline of freshwater mussels and their crucial ecological services highlight the need to understand their phylogeny, phylogeography and patterns of genetic diversity to guide conservation efforts. Such knowledge is urgently needed for Unio crassus, a highly imperilled species originally widespread throughout Europe and southwest Asia. Recent studies have resurrected several species from synonymy based on mitochondrial data, revealing U. crassus to be a complex of cryptic species. To address long-standing taxonomic uncertainties hindering effective conservation, we integrate morphometric, phylogenetic, and phylogeographic analyses to examine species diversity within the U. crassus complex across its entire range. Phylogenetic analyses were performed using cytochrome c oxidase subunit I (815 specimens from 182 populations) and, for selected specimens, whole mitogenome sequences and Anchored Hybrid Enrichment (AHE) data on ∼ 600 nuclear loci. Mito-nuclear discordance was detected, consistent with mitochondrial DNA gene flow between some species during the Pliocene and Pleistocene. Fossil-calibrated phylogenies based on AHE data support a Mediterranean origin for the U. crassus complex in the Early Miocene. The results of our integrative approach support 12 species in the group: the previously recognised Unio bruguierianus, Unio carneus, Unio crassus, Unio damascensis, Unio ionicus, Unio sesirmensis, and Unio tumidiformis, and the reinstatement of five nominal taxa: Unio desectusstat. rev., Unio gontieriistat. rev., Unio mardinensisstat. rev., Unio nanusstat. rev., and Unio vicariusstat. rev. Morphometric analyses of shell contours reveal important morphospace overlaps among these species, highlighting cryptic, but geographically structured, diversity. The distribution, taxonomy, phylogeography, and conservation of each species are succinctly described.

Wide-Awake Local Anesthesia No Tourniquet for Rhizarthrosis Surgery: Technique and Experience for 16 Consecutive Cases

Since it was described, wide-awake local anaesthesia no tourniquet (WALANT) has gained popularity. Our department has started using WALANT for hand surgery with increasing complexity. We present our results with WALANT rhizarthrosis surgery, including prosthetic replacement, trapeziectomy with suture button suspensionplasty and revision surgery. A retrospective review of all rhizarthrosis procedures under WALANT was performed from April 2021 to July 2022. We included patients who fulfilled inclusion criteria and had adequate imaging and clinical follow-up. A satisfaction survey was performed by telephone. Surgical time, complications, conversion to conventional anesthesia, pain, anxiety and global satisfaction were recorded. Tumescent anesthesia is performed 20-25 minutes before surgery, and is performed in four or five strategic locations that allow adequate anesthesia and vasoconstriction for the procedure to be comfortably carried out. We observed a series of 16 sequential surgeries involving 14 patients. All were female with a mean age of 65 years. Fourteen cases were performed due to primary rhizarthrosis, eight trapeziectomies with suture button suspensionplasty, six prosthetic replacements, and two revision surgeries. One patient needed to be converted to conventional anaesthesia due to anxiety during the procedure. Mean procedure time was 73 minutes. There were no WALANT-related complications. Mean patient-reported satisfaction with the anesthetic technique was a 9 (on a scale from 1 to 10) and 100% of patients would choose to undergo surgery with WALANT anesthesia for a future procedure. We find it useful to actively engage the patients during surgery to keep them comfortable and also help the surgeons assess stability and functional results. After wound closure, the hand is shown to the patient and he performs various tasks. There is somewhat of a learning curve for rhizarthrosis surgery under WALANT; patient comfort can be achieved through an adequate anesthetic technique and reassurance before and during surgery. We recommend that the first few cases be done in the presence of an anesthesiologist and a fasting patient in case there is a need to convert to conventional anesthesia. Wide awake rhizarthrosis surgery, even revision surgery, is safe and pain-free. Patient-reported satisfaction is also high. The authors find that including patient participation in their own surgery might be promising for post-op rehabilitation. There are limitations in this study such as the absence of a control conventional anesthesia group, the satisfaction questionnaire was not done immediately post-operatively, as such, a memory bias cannot be excluded, and it is not yet validated for the Portuguese population.

Interval between two-stage exchanges: what is optimal and how do you know?

BACKGROUND

Two-stage exchange arthroplasty remains the most popular option for the treatment of chronic periprosthetic joint infection (PJI). Determining infection eradication and optimal timing of reimplantation can be challenging. Information to allow for a truly informed evidence-based decision is scarce.

METHODS

We conducted a critical review of available evidence on the presently available tests to help determine timing of reimplantation.

RESULTS

Serology is traditionally used to follow up patients after the first stage. Despite tradition mandates waiting for normal inflammatory markers, there is actually no evidence that they correlate with persistent infection. The role of synovial fluid investigation between stages is also explored. Cultures lack sensitivity and neither differential leukocyte counts nor alternative biomarkers have proven to be accurate in identifying persistent infection with a spacer in situ. We also examined the evidence regarding the optimal time interval between resection and reimplantation and whether there is evidence to support the implementation of a two week "antibiotic holiday" prior to proceeding with reimplantation. Finally, wound healing and other important factors in this setting will be discussed.

CONCLUSION

Currently there are no accurate metrics to aid in the decision on the optimal timing for reimplantation. Decision must therefore rely on the resolution of clinical signs and down trending serological and synovial markers.

[Inflammation of BCG Inoculation Site Scar after the First Dose of an Anti-SARS-CoV-2 mRNA Vaccine]

Inflammatory reactions in the Bacillus Calmette-Guérin (BCG) inoculation scar site have been previously described, in association with viral infections. The inflammation of the scar in association with other vaccines has been described with the flu vaccine and, more recently, after the second dose of mRNA anti-SARS-CoV-2 vaccines (mRNA-1273 e BNT162b2), in two healthcare workers. We present the case of a 27-year-old female, without a relevant past medical history, including no previous SARS-CoV-2 infection, and with inflammation of the BCG scar eight days after the first dose of the mRNA anti-SARS-CoV-2 vaccine. Pharmacovigilance and the notification of adverse events should be encouraged, as a way of warding off hesitation in this process.

Making the diagnosis in prosthetic joint infection: a European view

Prosthetic joint infections (PJI) can be difficult to diagnose. Studies have shown that we are missing many infections, possibly due to poor diagnostic workup and the presence of culture-negative infection. PJI diagnosis requires a methodical approach and a standardised set of criteria. Multiple PJI definitions have been published with improved accuracy in recent years. The new European Bone and Joint Infection Society definition offers some advantages in clinical practice. It identifies more clinically important infections and accurately defines those with the highest risk of treatment failure. It reduces the number of patients with uncertain diagnoses. Classification of PJIs may offer a better understanding of treatment outcomes and risk factors for failure.

X-linked myotubular myopathy: a clinical report and a review of the mild phenotype

INTRODUCTION

X-linked myotubular myopathy is a rare centronuclear myopathy that affects approximately 1 in 50,000 male newborns caused by pathogenic variants in the myotubularin 1 gene (MTM1). The clinical severity varies, however the need for ventilatory support occurs almost invariably.

CASE REPORT

We report the case of a 4-year-old boy presenting mild muscle hypotonia at 12 months-old, expressive language disorder, global developmental delay, and a sensory processing disorder. Clinical exome sequencing identified the hemizygous variant c.722G>A p.(Arg241His) in exon 9 of the myotubularin 1 gene (NM_000252.2). The mother is a heterozygous carrier of the same variant. A diagnosis of a mild form of maternal inherited X-linked myotubular myopathy was established. The child presented significant improvement with speech, occupational, and physical therapies, with no respiratory intercurrences or ventilator dependency.

CONCLUSION

The presentation of a mild form of this myotubular myopathy, being less commonly reported, added challenge to the diagnosis. The combination of mild hypotonia, feeding difficulties and expressive language disorder should raise suspicion of a neuromuscular disease. There is a lack of verified motor or developmental scores specific to this myopathy to further determine prognosis and need of other therapies. While currently the severity myotubular myopathy is classified according to ventilator dependency, this may be insufficient and unapplicable to milder cases. There is an evident need for a grading system for mild and moderate cases assessing muscle weakness and fatigue, daily life limitations, motor developmental delay, early phenotypical scores, or recurrent respiratory infections.

Simple and inexpensive synovial fluid biomarkers for the diagnosis of prosthetic joint infection according to the new EBJIS definition

Introduction: diagnosis of periprosthetic joint infection (PJI) is challenging, as no single test has absolute accuracy. The purpose of this study was to assess the utility of different simple synovial biomarkers in the diagnosis of PJI as defined by the European Bone and Joint Infection Society (EBJIS). Methods: we retrospectively identified all patients undergoing revision hip or knee arthroplasty from 2013 to 2019 on our prospectively maintained database. Only patients with minimum required infection diagnostic workup were included in the study. Patients with comorbidities that may influence the accuracy of synovial biomarkers were excluded. Receiver operator characteristic (ROC) curves were utilised to assess the diagnostic utility of synovial fluid white blood cell (WBC) count, polymorphonuclear leukocyte percentage (PMN %), C-reactive protein (CRP), adenosine deaminase (ADA), and alpha-2-microglobulin (A2M). Results: in total, 102 patients met the inclusion criteria. Of these, 58 were classified as infection unlikely, 8 as infection likely, and 36 as infection confirmed. Synovial WBC count (area under the curve (AUC) 0.94) demonstrated the best utility for the diagnosis of PJI, followed by PMN % (AUC 0.91), synovial CRP (AUC 0.90), ADA (AUC 0.82), and A2M (AUC 0.76). We found added value in the combined interpretation of different biomarkers. We calculated high sensitivity and negative predictive value if at least two of them are negative and high specificity and positive predictive value if at least two are elevated. Conclusion: current results show that synovial fluid investigation is a useful tool for the diagnosis of PJI, and the combined interpretation of simple and inexpensive biomarkers demonstrated improved diagnostic accuracy.

ONLY IN DREAMS: a case report of sleep deprivation psychosis

Introduction

Sleep is essential for an adequate neurobiological functioning, being implicated in several cognitive functions. Even in healthy individuals, sleep deprivation can lead to a number of psychopathological changes, including perceptual distortions, hallucinations and delusions. Thus, the resulting clinical picture may be similar to a psychotic disorder.

Objectives

To present a clinical case of psychotic symptomatology induced by sleep deprivation.

Methods

Patient’s clinical file consultation and literature review using the search engine Pubmed® and the keywords: “sleep deprivation”, “sleep loss” and “psychosis”.

Results

We present the case of a 41-year-old woman with a history of an episode of mood changes with psychotic symptoms that was preceded by a period of total insomnia. No psychotropic drugs since then and no relapses. In May 2020, she was admitted in psychiatry department due to clinical picture composed by significant psychomotor slowing, drowsiness, slowed speech, verbal visual, tactile and auditory hallucinations accompanied by grandiose delusions. These symptoms were preceded by total insomnia with one week of duration. In the hospital was administered quetiapine 100mg and lorazepam 2.5mg to aid in the recovery of sleep deprivation and concomitantly aripiprazole 15mg was prescribed. The patient presented a rapid and significant clinical improvement. Currently, it is without any type of medication and without psychopathological changes.

Conclusions

The clinical picture present in this case report was triggered after a significant period of sleep deprivation. Thus, it illustrates the role that sleep has in the development of psychiatric symptomatology, sometimes difficult to differentiate from psychiatric disorders.

Disclosure

No significant relationships.

Catatonia and dementia: a case report

Introduction

Catatonia is a neuropsychiatric disorder characterized by motor, behavioral and autonomic changes. It is associated with several psychiatric disorders, including dementia. Catatonia is an underdiagnosed syndrome, so it is important to draw attention to it. Here, we review a case of a patient admitted to our psychiatric department with a clinical presentation compatible with catatonia. After proper treatment, further assessment revealed dementia.

Objectives

This work aims to describe a case of catatonia in a patient with dementia.

Methods

Bibliographic research using Pubmed®. Clinical file consultation and patient interviews.

Results

Catatonia is a disorder that was already been described as part of several types of dementia. We present a 69-year-old female patient, admitted to our psychiatric department with clinical presentation compatible with catatonia. To admission, she presented some typical complications resulting from long immobility such as pressure ulcers and nutritional deficiencies. During the hospitalization, she developed a urinary infection and there was the need to tube feeding. She was treated with benzodiazepines and improved. Further assessment revealed dementia.

Conclusions

Catatonia in dementia is not uncommon, although it is an underdiagnosed syndrome, and when treated early and properly it has a good prognosis.

Disclosure

No significant relationships.

Role of migration in the development of a first episode of psychosis

Introduction

Currently, there is scientific evidence supporting the relationship between socio-environmental factors and the onset of a first episode of psychosis (FEP). In this context, the phenomenon of migration, seen as a negative life experience, may become an important risk factor in developing a psychotic disorder (PD). In Europe, the impact of this phenomenon is growing and, therefore, it’s necessary to provide a proper answer to these individual’s mental health problems.

Objectives

Identify which phases of this migration process are most important in the development of a FEP and what are the more significant socio-environmental factors in each phase.

Methods

Bibliographic research in Pubmed database using the terms “Migration” and “First Episode Psychosis”.

Results

Research confirms that migrants have a 2 to 3-fold increased risk of developing a PD. This risk will be even higher in the refugee population. Pre- and post-migration factors demonstrated to be more important than factors related with the migration process itself. In the pre-migration phase highlight factors like the lower parental social class and a previous trauma. In the post-migration phase highlight factors like discrimination, social disadvantage and a mismatch between expectations and reality.

Conclusions

Literature is unanimous in considering migrant status as an independent risk factor for the development of FEP, possibly due to the outsider’s role in society. Thus, despite the growing interest in Biological Psychiatry, this work demonstrates that socio-environmental factors are very preponderant in the development of these disorders and because of that further investigation is still necessary.

Disclosure

No significant relationships.

“Walking with myself by my side” - non-medical use of Ketamine

Introduction

Ketamine, synthesized in 1962 as phencyclidine derivate, is denominated a “dissociative anesthetic” because of its side-effects, such as dissociative episodes and psychotic-like symptoms, which have limited its applicability on clinical practice. Otherwise, in the last decades the non-medical use of ketamine has been growing and today is one of the most popular illicit substances consumed between adolescents and young adults.

Objectives

Increasing the knowledge and understanding of the factors related to crescent use of ketamine and the experiences and consequences associated to its consumption.

Methods

Clinical interview with patients diagnosed with ketamine use disorder and bibliographic research in Pubmed database using the terms “Ketamine use” and “Ketamine addiction”.

Results

Pat et al. (2002) describes a clinical case of a young male, diagnosed with substance use disorders, specifically alcohol and cocaine use disorders, that started a treatment with ketamine. After the treatment, pleasant depersonalization experiences contributed to the development of patient’s ketamine dependence. Other patient’s reports confirm the association of ketamine use with psychedelic effects and dissociative episodes and pointed these effects as main reason for its consumption.

Conclusions

The adverse effects that limited the medical use of ketamine are the same that promote its utilization with recreational purposes by adolescents and young adults in parties and nightclubs. About the ketamine dependence, the literature is scarce and doesn´t clearly identify a physical withdrawal syndrome, pointing only to a serious psychological dependence. Thus, with the crescent non-medical use of ketamine, it’s urgent to develop an intervention plan directed to this problem.

Disclosure

No significant relationships.

Dissociation and emotional dysregulation in pathological personalities related to the fear of SARS-COV-2: a case report

Introduction

The COVID-19 pandemic represented a serious strain on the mental health resilience worldwide. Implementation of restrictive rules implied the disruption of social networks, eliciting emotional exhaustion and intense response to fear. This was amplified by media spread of panic and fake news, representing risk factors for post traumatic stress disorder (PTSD). Fear can be dangerous, especially accounting premorbid psychopathological vulnerability, such as pathological personality traits. Emotional dysregulation increases fear levels, mediated by the relationship between emotional dysregulation and lack of tolerance.

Objectives

Clinical case presentation of patient who developed dissociative and behavioral symptoms following COVID-19 infection. Bibliographic research.

Methods

Bibliographic research using Pubmed®. Clinical file consultation and patient interviews.

Results

Heightened psychophysiological reactivity can result from the persistent fear experienced during a traumatic event and repeated memories related to it, leading to a sensitization of the response to fear. We present 57 year-old female patient, admitted to the COVID ward after trying to escape from home isolation due to positivity to COVID-19. In the hospital setting she developed dissociative symptoms, trying to escape from the ward and infect other people.

Conclusions

Intense fear responses to COVID-19 are likely explained by poor emotion regulation capacities as well as dissociative mechanisms. Studies have shown that this pandemic was experienced as a real traumatic event and some studies have found that it may lead to the development of PTSD. Pathological personality is positively related to PTSD symptoms, attributable to higher levels of mood instability, cognitive/perceptual disorders, interpersonal dysfunctions and negative affection.

Disclosure

No significant relationships.

Relationship between personality, adherence to (mental) health behaviours and psychological distress during the COVID-19 pandemic

Introduction

Public health authorities around the world have been disseminating messages to support mental health and psychosocial well-being during the COVID-19 pandemic. Based on the Portuguese guidelines, we have developed the Adherence Scale to the Recommendations for Mental Health during the COVID-19 Pandemic (ASR-MH-COVID19) to better understand this health behaviour.

Objectives

To analyse the relationship between sociodemographics, personality traits, Adherence (to the Recommendations for Mental Health during the COVID-19 Pandemic) and psychological distress.

Methods

413 individuals (69.2% female; mean age=31.02±14,272) completed an on-line survey, in September-December 2020, including sociodemographic questions, ASR-MH-COVID19, NEO-FFI-20 and Depression Anxiety Stress Scale (DASS-21) and Health Perception Scale.

Results

Adherence scores did not significantly differ by gender, age and years of education. Women presented higher DASS and Neuroticism scores (p<.01). Adherence were negatively correlated with Neuroticism (r=-.247) and with Depression/Anxiety/Stress (all r».-200), positively with Openness to Experience (r=.174), Conscientiousness (r=.194) and Perceived Health (Physical, r=.173 and Psychological, r=.215) (all p<.01). Mediation analysis (Hays’ Macro Process - Model 4) revealed that Adherence is a partial mediator between Openness and DASS and Conscientiousness and DASS; when considering Neuroticism, only the direct effect was significant. The effect of Perceived Health (both Physical and Psychological) on DASS was also mediated by Adherence.

Conclusions

The Health Behaviour Model proposes a pathway linking personality and health that applies to these results about adherence and psychological distress during the COVID-19 pandemic. Personality and perceived health (also a trait) influence both adherence to mental health behaviours and psychological distress. Understanding personality is vital for health care providers.

Disclosure

No significant relationships.

A Case Report of Anorexia Nervosa - the “perfect“ woman

Introduction

Anorexia nervosa (AN) is an eating behavior disorder characterized by intense fear of gaining weight or persistent behavior that interferes with weight gain, with caloric intake restriction and secondary loss of body weight. It can affect up to 4% of women during their lifetime and is responsible for one of the highest mortality rates from psychiatric disorders.

Objectives

Review of the literature and exposure of a case report of AN in a woman with high level of stress at work.

Methods

Case report and nonsystematic review using databases such as PubMed and UpToDate.

Results

Caucasian woman, 31-year-old, PhD in biology, who works in a multinational company. No personal or family history of psychiatric disorder. She was observed in the psychiatry emergency department, due to low weight, caloric restriction and intense physical exercise, maladaptive personality traits related to perfectionism and control were found. She began follow-up with a multidisciplinary team, but there was a need for hospitalization due to clinical deterioration with BMI of 11. After 6 months, she continued to follow up at the consultations and, despite refusing psychotropic drugs, she maintains psychotherapy and presents clinical improvement (BMI - 17).

Conclusions

Eating behavior disorders are chronic and difficult to treat diseases that are more frequent among people subject to high levels of stress. This case represents a restrictive AN in a woman with multiple risk factors: athlete, perfectionist, with stressful work and life events and restricted interpersonal and affective relationships.

Disclosure

No significant relationships.

Anorexia Nervosa and Gender Dysphoria: A Clinical Case

Introduction

Eating disorders (ED) and gender dysphoria (GD) are associated with a change in body perception. Therefore, body dissatisfaction plays a common and central role in these disorders. In GD, body image concerns are related to the features of the biological sex. In ED, body dissatisfaction comes from a distorted perception of weight and body shape and plays an important role in the development and maintenance of the psychopathology.

Objectives

To present and discuss the clinical case of a patient with a previous diagnosis of GD who presented with a clinical condition suggesting a restrictive anorexia nervosa (AN).

Methods

Patient´s clinical files consultation and literature review using Pubmed and the keywords: eating disorders and gender dysphoria.

Results

We present the case of a 25-year-old patient who was living in a shelter for victims of domestic violence and was admitted for severe restrictive AN. The patient was discharged after 40 days and medicated with sertraline, diazepam and olanzapine, as well as her previous medication (hormonal therapy): cyproterone, finasteride, estradiol, oxybutynin.

Conclusions

Although studies on this subject are still scarce, there has been some progress and the literature recognizes the coexistence of these conditions. However ED symptoms in patients with GD could have a different meaning: they may represent a dysfunctional coping strategy adopted to block features of the biological sex. Therefore health professionals may take a more holistic approach to body image. Additional studies will be necessary, allowing the establishment of cause-consequence interactions between weight loss and psychopathology related to GD.

Disclosure

No significant relationships.

Adherence Scale to the Recommendations for Mental Health during the COVID-19 pandemic from the Portuguese General Directorate of Health (ASR-MH-COVID19) - Development and validation

Introduction

The COVID-19 crisis has generated an increasing stress throughout the population.

Objectives

To develop and validate the Adherence Scale to the Recommendations for Mental Health during the COVID-19 pandemic from the Portuguese General Directorate of Health (GDH) (ASR-MH-COVID19).

Methods

The items content was based on the GDH guides for the prevention of mental health and psychosocial well-being of the general population during the COVID-19 outbreak. After content and facial validity analysis, the preliminary version of the ASR-MH-COVID19 (8 items to be answered on a Likert scale) was completed by 413 individuals (69.2% female; mean age=31.02±14,272), in September-December 2020 (Sample1) and then by 967 (70.9% female; mean age=34.02±14,272), in February-May 2021 (Sample2). Sample1 was randomly divided in two sub-samples. Sample1A was used for exploratory factor analysis/EFA and Sample1B for confirmatory factor analysis/CFA; CFA was then replicated with Sample2. The online surveys also included the Adherence Scale to the Recommendations of Portuguese GDH to minimize the impact of COVID-19 (ASR-COVID-19; Pereira et al. 2020).

Results

CFAs were informed by EFA and showed that the unidimensional model presented acceptable-good fit indexes (Sample1B: χ²/df=2.747; RMSEA=.0980, p<.001; CFI=.973; TLI=.918, GFI=.972; Sample2: χ²/df=3.327; RMSEA=.0490, p<.001; CFI=.993; TLI=.983, GFI=.990). Cronbach’s alfas were α<.850. Pearson correlations between ASR-MH-COVID19 and ASR-COVID19 were significant (p<.01) and moderate-high for the total (r=.753) and dimensional scores (Distance and respiratory hygiene, r=.739; House and personal hygiene, r=.584; Use of remote services and isolation r=.425).

Conclusions

The new ASR-MH-COVID19 has shown validity and reliability, allowing the investigation of this (mental) health behaviour.

Disclosure

No significant relationships.

PURA syndrome in a child with severe developmental delay: a challenging diagnosis

INTRODUCTION

PURA syndrome is a rare autosomal dominant condition caused by de novo pathogenic variants in PURA gene and characterized by a multisystemic phenotype that includes global neurodevelopmental delay, early hypotonia, absence of speech, feeding difficulties, hypersomnolence, epilepsy and movement disorders.

CASE REPORT

We report a 9-year-old girl with hypotonia and feeding difficulties with failure to thrive since the neonatal period. At the age of 3 years motor and intellectual delay were evident, she had a wide-based gait, no speech and an exaggerated acoustic startle response. She developed hand-mouthing stereotypies and epilepsy at 6 years old. The 24 hours continuous electroencephalogram monitoring revealed global slow activity and frequent epileptiform activity in left temporal and centrotemporal areas. The brain MRI revealed delayed myelination. At 6 years old the clinical exome sequencing identified a heterozygous pathogenic variant in the PURA gene, c.153delA p.(Leu54CysfsTer24).

CONCLUSION

PURA syndrome has clinical features similar to other neurological disorders but the association with some clinical features, not as common in other neurological entities, like never being able to speak but being able to follow simple orders and exaggerated acoustic startle response, should raise the suspicion of PURA syndrome and genetic analysis must be performed to confirm the diagnosis and provide early multidisciplinary intervention.

Observation of Magnetic Helicoidal Dichroism with Extreme Ultraviolet Light Vortices

We report on the experimental evidence of magnetic helicoidal dichroism, observed in the interaction of an extreme ultraviolet vortex beam carrying orbital angular momentum with a magnetic vortex. Numerical simulations based on classical electromagnetic theory show that this dichroism is based on the interference of light modes with different orbital angular momenta, which are populated after the interaction between light and the magnetic topology. This observation gives insight into the interplay between orbital angular momentum and magnetism and sets the framework for the development of new analytical tools to investigate ultrafast magnetization dynamics.

Adult Native Joint Septic Arthritis: A Nine-Year Retrospective Analysis in a Portuguese University Hospital

INTRODUCTION

Septic arthritis of a native joint represents a medical emergency. Drainage and effective antibiotic treatment are critical to avoid joint destruction and long-term impairment. The aim of this study was to evaluate epidemiological and clinical characteristics of patients with the diagnosis of septic arthritis to help establish local guidelines for empirical antibiotic treatment.

MATERIAL AND METHODS

Retrospective analysis of adult patients admitted at Centro Hospitalar Universitário do Porto from 2009 to 2017 with suspected native joint septic arthritis. Relevant demographics, microbiology findings and respective antibiotic susceptibilities were analysed.

RESULTS

Ninety-seven patients, predominantly males (59.8%) with a median age of 61 years old were included. The most commonly reported comorbidity associated with septic arthritis was diabetes mellitus (20.6%). The knee was the most commonly affected joint (71.1%). Arthrocentesis was performed in all patients, but only 50.5% had positive microbial growth in the synovial fluid. Staphylococcus aureus was the most frequently identified microorganism, 86% of which were methicillin susceptible. Gram-negative bacteria were the causative agent in 15% of cases. A wide range of empirical antibiotic regimens were prescribed with a combination of vancomycin/carbapenem being the most common (30.9%). Analysis of antibiotic susceptibility profiles revealed that amoxicillin/clavulanate would have been appropriate as the initial regimen in 89% of cases.

DISCUSSION

The main causative pathogen was Staphylococcus aureus, with methicillin resistant Staphylococcus aureus remaining rare. The proportion of Gram-negative bacteria implies that these agents should be covered by empirical treatment, although no case of Pseudomonas infection has been identified. Therefore, antipseudomonal coverage is not necessary in empirical regimens.

CONCLUSION

Routine coverage of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa is not warranted but must be considered when specific risk factors are found. Amoxicillin/clavulanate can provide adequate antibiotic coverage as an empirical treatment for adult native joint septic arthritis. Its use may allow a reduction in use of broader spectrum antibiotics.

Pleistocene expansion, anthropogenic pressure and ocean currents: Disentangling the past and ongoing evolutionary history of Patella aspera Röding, 1798 in the archipelago of Madeira

AIMS

Rising sea-level following the Last Glacial Maximum lead to fragmentation of coastal limpet populations between islands of the Archipelago of Madeira. This fragmentation is reinforced by recent heavy exploitation reducing effective population size on Madeira Island. We use the limpet P. aspera to understand how the role of processes at different time scales (i.e. changes in the sea level and overexploitation) can influence the genetic composition of an extant species, relating these processes to reproductive phenology and seasonal shifts in ocean currents.

LOCATION

Madeira Island, Porto Santo and Desertas (Archipelago of Madeira, NE Atlantic Ocean).

TAXON

The limpet Patella aspera.

METHODS

Twelve microsatellite genetic markers were used. A power analysis was used to evaluate the power of the microsatellite markers to detect a signal of population differentiation. Long-term past migrations were assessed using a Bayesian Markov Montecarlo approach in the software MIGRATE-n to estimate mutation-scaled migration rates (M = m/μ; m, probability of a lineage immigrating per generation; μ, mutation rate). Two scenarios were evaluated using an Approximate Bayesian Computation (ABC) in the software DIYABC 2.1 (i) Scenario 1: considered a population scenario from a reduced Ne at time t₃ to a higher Ne at time t₂; and (ii) Scenario 2 considering a reduction of Ne from a time t₃ to a time t₂.

RESULTS

Colonization of the archipelago by Portuguese settlers six centuries ago probably led to an important decrease in the genetic diversity of the species (N_e). Contemporary gene flow strongly support a pattern of high asymmetric connectivity explained by the reproductive phenology of the species and spatio-temporal seasonal changes in the ocean currents. Spatio-temporal reconstructions using Bayesian methods, including coalescent and Approximate Bayesian Computation (ABC) approaches, suggest changes in the migration patterns from highly symmetric to highly asymmetric connectivity with subtle population differentiation as consequence of post-glacial maximum sea level rise during the Holocene.

MAIN CONCLUSIONS

Our results suggest that anthropogenic activity could have had serious effects on the genetic diversity of heavily exploited littoral species since the end of the Pleistocene, probably accelerating in recent years.

Risk Factors for Acute Surgical Site Infection after Spinal Instrumentation Procedures: A Case-Control Study

BACKGROUND

Surgical site infection (SSI) prevalence in spinal instrumentation varies, depending on patient and surgery factors. This study aims to identify patient- and procedure-related factors associated with SSI after spinal instrumentation in 3 patient-specific groups: those undergoing surgery for degenerative, trauma-related, and pediatric deformity conditions.

METHODS

A case-control (1:2 ratio) analysis of SSI after spinal instrumentation, from 2009 to 2017, in a University Hospital and Spinal Trauma Centre was performed.

RESULTS

From a total of 2582 surgeries, 33 cases (1.3%) were identified with SSI according to study inclusion criteria: 14 (out of 1326) in the degenerative group, 11 (out of 207) in the trauma group, and 8 (out of 850) in the pediatric deformity group. Cases were matched with controls (n = 66) of the same group. Univariate analysis identified procedure and anesthesia duration in the degenerative group (P = .032 and .038, respectively), age (P = .014) and need for intraoperative and postoperative blood transfusions (both P = .039) in the trauma group and American Society of Anesthesiologists score (P = .022) and neuromuscular scoliosis (P = .002) in the pediatric deformity group as associated with SSI. After multivariate analysis, procedure duration was independently associated with SSI in degenerative surgery (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.03-4.82) and procedure duration (OR, 3.79; 95% CI, 1.27-11.32) and number of levels instrumented (OR, 11.77; 95% CI, 1.55-89.40) in the trauma group.

CONCLUSIONS

This study identified procedure duration as a risk factor for SSI after spinal instrumentation in degenerative and trauma spine surgery and the number of levels instrumented in trauma spine surgery. Awareness of these factors will help develop strategies to improve patient and health system overall outcomes.

Combined antibiotic therapy spacers either commercial or handmade are superior to monotherapy - a microbiological analysis at the second stage of revision

Background: Antibiotic-loaded spacers are often used during two-stage exchange for periprosthetic joint infections (PJIs) both for its mechanical properties and as a means of local antibiotic delivery. Purpose: The main goal of this study is to compare the efficacy of different options of antibiotic(s) in spacers concerning the rate of positive cultures at the second stage. Patients and Methods: We retrospectively evaluated two-stage exchange procedures for infected hip or knee arthroplasty performed between 2012 and 2018 in which adequate (at least four deep tissue samples) culture results in both stages were available. The type of spacer and antibiotics used, in addition to several other patient, infection and treatment-related variables, were registered and correlated to microbiological findings in the second stage. Results: Fifty-eight cases were included with a 19.0 % (11/58) overall rate of positive cultures during reimplantation. With a mean follow-up of 46 months, failure rate was significantly higher at 63.6 % (7/11) in cases with positive cultures at reimplantation compared to 4.3 % (2/47) for those with negative cultures during reimplantation ( p <  0.001). The need for additional surgeries was also significantly higher (odds ratio (OR) 122.67, confidence interval (CI) 95 % 11.30-1331.32, p <  0.001). Multivariable analysis revealed antibiotics in the spacers were the main independent prognostic risk factor associated with positive cultures at the second stage with an advantage for combined antibiotics. Monotherapy is associated with failure with an OR of 16.99. Longer time between surgeries did not have statistical significance ( p =  0.05), and previous surgical treatment for PJI, presence of difficult-to-treat microorganism(s), duration of systemic antibiotic therapy or even treatment within a dedicated septic team were not shown to be independent risk factors. Among combined antibiotic spacers, there were no significant differences between the rate of positive cultures during the second stage, comparing commercially available vancomycin/gentamicin spacers to hand-mixed vancomycin/meropenem manufactured spacers (8.3 % [2/24] vs. 15.0 % [3/20], p =  0.68). Conclusions: Results show that combined antibiotic therapy spacers are advantageous when compared to gentamicin monotherapy as they produce significantly lower rates of subsequent positive cultures during the second stage. Hand-mixed high-dose vancomycin/meropenem spacers seem to perform just as well as prefabricated commercially available vancomycin/gentamicin options. Level of Evidence: Therapeutic level III.

Extensive skin necrosis after periprosthetic knee infection: a case that highlights the possibility of complications induced by low-molecular-weight heparin

We describe a case of a patient with atrial fibrillation, anticoagulated with dabigatran, that developed severe knee skin necrosis in the setting of an acute periprosthetic knee infection, after initiating low-molecular-weight heparin. A wide range of etiology hypotheses was discussed within a multidisciplinary team. The complex approach consisted of treating the underlying infection, multiple types of soft-tissue management, and stopping enoxaparin.

Optimal microbiological sampling for the diagnosis of osteoarticular infection

Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.

If, when, and how to use rifampin in acute staphylococcal periprosthetic joint infections, a multicentre observational study

Background

Rifampin is generally advised in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampin remains a matter of debate. We evaluated the outcome of patients treated with and without rifampin, and analyzed the influence of timing, dose and co-antibiotic.

Methods

Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death or the need for suppressive antimicrobial treatment.

Results

A total of 669 patients were analyzed. Treatment failure was 32.2% (131/407) in patients treated with rifampin and 54.2% (142/262) in whom rifampin was withheld (P < .001). The most prominent effect of rifampin was observed in knees (treatment failure 28.6% versus 63.9%, respectively, P < .001). The use of rifampin was an independent predictor of treatment success in the multi-variate analysis (OR 0.30, 95% CI 0.20 – 0.45). In the rifampin group, the use of a co-antibiotic other than a fluoroquinolone or clindamycin (OR 10.1, 95% CI 5.65 – 18.2) and the start of rifampin within 5 days after surgical debridement (OR 1.96, 95% CI 1.08 – 3.65) were predictors of treatment failure. The dosing of rifampin had no effect on outcome.

Conclusions

Our data supports the use of rifampin in acute staphylococcal PJIs treated with surgical debridement, particularly in knees. Immediate start of rifampin after surgical debridement should probably be discouraged, but requires further investigation.

Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty

BACKGROUND

The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty.

METHODS

We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics.

RESULTS

We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals.

CONCLUSIONS

DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.

Relationship between fear of COVID-19 and individual factors – a preliminary study

Introduction

Fear associated to infectious diseases is directly related with their transmission rate, morbidity and mortality. High levels of fear associated with COVID-19 can affect people’s ability to act and think rationally. In a time of pandemics, it is essential to understand individual factors that might be associated to higher vulnerability to stress and fear.

Objectives

To analyse: a)correlations between Fear of Covid-19 and clinical and sociodemographic characteristics; b)the mediator role of repetitive negative thinking on the relationship between personality traits and Fear of Covid-19.

Methods

234 adults (75.6% women; mean age=29.53±12.51) completed an on-line survey with the Portuguese version of the Fear of Covid-19 Scale (FCV-19S) and other questionnaires to evaluate clinical and sociodemographic characteristics (years of education, perceived physical and mental health and infection by Covid-19), Personality (NEO-FFI-20) and Repetitive negative thinking (PTQ-15). SPSS and Process Macro (Hays, 2020) were used.

Results

FCV-19 mean scores were significantly higher in women and significantly correlated with years of education (r=-.14) (p<.05). History of previous/current Covid-19 infection did not significantly distinguish FCV-19 scores and they did not correlate with perceived health. FCV-19 correlated significantly with neuroticism and PTQ total and dimensional scores (r>.20, p<.01). Both Repetitive thinking and Cognitive interference were mediators of the relationship between neuroticism and fear of COVID, even after controlling for gender and education.

Conclusions

This study provides preliminary evidence on individual factors that might be associated to the emotional response to the Covid-19 pandemics, aiming to facilitate public health initiatives to ease people’s fears in a near future.

Relationship between COVID-19 perceived risk and perfectionism – a preliminary study

Introduction

Research following the Covid-19 pandemics has shown that psychological reactions to the pandemic and its constraints can vary significantly depending on personality. One of the traits that has not been studied yet, but can play a harmful role in the COVID-19 psychological impact is perfectionism. This trait, characterized by setting excessively high standards of performance and striving for flawlessness, has increased in recent years and is considered a transdiagnostic process involved in several (mental) health problems (Curran & Hill 2019).

Objectives

To analyze the role of Perfectionism in the levels of fear of COVID19 and of perception of infection risk by COVID-19.

Methods

234 adults (75.6% women; mean age=29.53±12.51) completed an on-line survey with the Portuguese validated versions of Covid-19 Perceived Risk Scale (C19PRS; Pereira et al. 2020), Fear of COVID-19 Scale (FC19S; Cabaços et al. 2020) and Big Three Perfectionism Scale (BTPS; Garrido et al. 2020). SPSS was used to perform correlation and regression analysis.

Results

Perceived Risk and Fear of COVID-19 were significantly correlated with perfectionism (.243, .228, respectively) (both, p<.01). Perfectionism explains 5.5% (Adjusted R2) of the FC19S variance (Beta=.243, p<.001) and 4.8% of the C19PRS variance (Beta=.228, p=.01).

Conclusions

This study provides preliminary, but completely innovative evidence that perfectionism contribute to the psychological impact of Covid-19 pandemics. In the near future we will test the hypothesis that the nature of unpredictability and the limitations imposed by the global crisis may be exacerbating the already high levels of psychological distress that affect negative perfectionists.

Portuguese version of the fear of COVID-19 scale – psychometric study

Introduction

More than in other conditions, fear is associated with infectious diseases, and is directly associated with its transmission rate, morbidity and mortality. High levels of fear can affect the individual’s ability to think clearly, react proportionately and make rational decisions in the context of COVID-19. Recently, Mertens et al. (2020) developed the Fear of Covid-19 Scale (FCV-19S) to measure this construct.

Objectives

To analyse the psychometric properties of the FCV-19S Portuguese version, namely construct validity, internal consistency and convergent validity.

Methods

A community sample of 234 adults (75.6% women; mean age= 29.53±12.51; range:16-71) completed an on-line survey with the Portuguese versions of the FCV-19S, the Covid-19 Perceived Risk Scale (CPRS) and the Depression Anxiety Stress Scale (DASS-21).The total sample was randomly divided in two sub-samples: sample A (n=117) was used to perform an exploratory factor analysis/EFA; sample B (n=117) to make a confirmatory factor analysis/CFA.

Results

EFA resulted in one component. CFA revealed that the unifactorial model presented acceptable fit indexes (X2/df=3.291; CFI=.977; GFI=.932; TLI=.919; p[RMSEA≤.01]=.091). Cronbach alpha was α=.855. The total score significantly correlated with Covid-19 Perceived Risk (r=.529, p<.01) and with anxiety from DASS-21 (r=.132, p<.05).

Conclusions

This study provides preliminary evidence for the validity and reliability of the Portuguese version of FCV-19S, which will be used in an ongoing research project on the relationship between fear of Covid-19, personality, cognitive processes and adherence to public health measures to contain the pandemic.

Portuguese version of the COVID-19 perceived risk scale – psychometric study

Introduction

Risk perception of COVID-19 is potentially a significant determinant of the pandemic evolution and the public’s response to it. Acceptable levels of risk perception can be considered good for people to effectively fight the pandemic and adopt preventive health behaviors while high levels of risk perception may be damaging. Recently, Yıldırım&Güler (2020) developed the Covid-19 Perceived Risk Scale (C19PRS) to measure this construct.

Objectives

To analyze the psychometric properties of the C19PRS Portuguese version, namely construct validity, internal consistency and convergent validity.

Methods

A community sample of 234 adults (75.6% women; mean age= 29.53±12.51; range:16-71) completed an on-line survey with the Portuguese versions of the CPRS and the Fear of Covid-19 Scale (FCV-19S; Cabaços et al. 2020). The total sample was randomly divided in two sub-samples: sample A (n=117) was used to perform an exploratory factor analysis/EFA; sample B (n=117) to make a confirmatory factor analysis/CFA.

Results

EFA resulted in three components. CFA revealed that the second-order model with three factors presented good fit indexes (X2/df=1.471; CFI=.959; GFI=.948; TLI=.932; p[RMSEA≤.01]=.065). CPRS Cronbach alphas was α=.687; for F1 Worry, F2 Susceptibility to Covid-19 and F3 Susceptibility to Overall Morbimortality were α=.747, α=.813 and α=.543, respectively. The total and dimensional scores significantly correlated with FCV-19S (r>.30, p<.01).

Conclusions

This study provides evidence for the validity and reliability of the Portuguese version of CPRS, which will be used in an ongoing research project on the relationship between Covid-19 perceived risk, perfectionism, cognitive processes and adherence to public health measures to contain the pandemic.

The importance of appropriate diagnostics in prosthetic joint infection: letter to the editor of BMC musculoskeletal disorders

Assessment of a new diagnostic test must be performed against an acceptable and validated standard to allow comparison with other studies. We are concerned that the adoption of lower diagnostic criteria in this paper has contributed to an over-diagnosis of prosthetic joint infection and makes interpretation of the results difficult.

RHOBTB2 p.Arg511Trp Mutation in Early Infantile Epileptic Encephalopathy-64: Review and Case Report

Early infantile epileptic encephalopathy-64 (EIEE 64), also called RHOBTB2-related developmental and epileptic encephalopathy (DEE), is caused by heterozygous pathogenic variants (EIEE 64; MIM#618004) in the Rho-related BTB domain-containing protein 2 (RHOBTB2) gene. To date, only 13 cases with RHOBTB2-related DEE have been reported. We add to the literature the 14th case of EIEE 64, identified by whole exome sequencing, caused by a heterozygous pathogenic variant in RHOBTB2 (c.1531C > T), p.Arg511Trp. This additional case supports the main features of RHOBTB2-related DEE: infantile-onset seizures, severe intellectual disability, impaired motor functions, postnatal microcephaly, recurrent status epilepticus, and hemiparesis after seizures.

The EBJIS definition of periprosthetic joint infection

Aims

The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.

Methods

This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.

Results

This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI.

Conclusion

The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice.

Cite this article: Bone Joint J 2021;103-B(1):18–25.

An electron holography study of perpendicular magnetic tunnel junctions nanostructured by deposition on pre-patterned conducting pillars

The fabrication of multi-gigabit magnetic random access memory (MRAM) chips requires the patterning of magnetic tunnel junctions at very small dimensions (sub-30 nm) and a very dense pitch. This remains a challenge due to the difficulty in etching magnetic tunnel junction stacks. We previously proposed a strategy to circumvent this problem by depositing the magnetic tunnel junction material on prepatterned metallic pillars, resulting in the junction being naturally shaped during deposition. Upon electrical contact, the deposit on top of the pillars constitutes the magnetic storage element of the memory cell. However, in this process, the magnetic material is also deposited in the trenches between the pillars that might affect the memory cell behaviour. Here we study the magnetic interactions between the deposit on top of the pillars and in the trenches by electron holography, at room temperature and up to 325 °C. Supported by models, we show that the additional material in the trenches is not perturbing the working principle of the memory chip and can even play the role of a flux absorber which reduces the crosstalk between neighboring dots. Besides, in the studied sample, the magnetization of the 1.4 nm thick storage layer of the dots is found to switch from out-of-plane to an in-plane configuration above 125 °C, but gradually decreases with temperature. Electron holography is shown to constitute a very efficient tool for characterizing the micromagnetic configuration of the storage layer in MRAM cells.

Analysis of hospitalization trends for ambulatory care sensitive conditions in Piauí/Brazil, 2009-18

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are hospitalizations that can be potentially preventable through care at the first level of contact for health care. In fact, the actions offered in a timely and effective manner can reduce the risk of unnecessary hospitalizations by preventing diseases, controlling acute episodes and managing chronic diseases.

Aim

Analyze the trends in hospitalizations for ACSC in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH) of the public health system (SUS), which comprised all hospitalizations of residents of Piauí, Brazil, in the period from 2009 to 2018. The explanatory variables were the hospitalizations for ACSC groups. For temporal trend analysis, the Prais-Winsten linear regression model was used in the Stata version 14 program.

Results

567,577 were recorded as ACSC, representing 35.3% of the total hospitalizations (1,608,263). Most hospitalizations for ACSC were caused by infectious gastroenteritis (33.5%). The risk of hospitalization for ACSC decreased 36.8%, showing a significant reduction in the trend of the hospitalization rate (Annual Percent Change - APC: -4.6%; 95%CI: -6.4; -2.8). There was a greater decrease in the risk of hospitalization for asthma (70.3%), hypertension (66.4%) and infectious gastroenteritis (61.8%). However, a significant increase was identified for skin infection (6.1 times) and diseases related to prenatal care and childbirth (3.2 times).

Conclusions

The reduction in hospitalizations due to ACSC is a result of the strengthening of Primary Health Care as the Brazilian health system organizer and the implementation of the Mais Médicos Program, which enabled the presence of doctors in family health teams, especially in places that had not previously been attended. It is also necessary to develop new studies to expand the discussions and debates on these findings.

Key messages

Hospitalizations reflect the living conditions of individuals, with social changes being perceived by changes in hospitalization patterns over time. The strengthening of primary care policies in Brazil was able to reduce hospitalizations for ACSC and it is necessary to further strengthen these practices to improve people's health care.

Nurses' production of meaning about National Program for Access and Quality Improvement Primary Care

Introduction

The Brazil's Family Health Strategy (ESF) is one of the initiatives for the strengthening of primary health care (PHC) in Brazil. The ESF is composed of a team of professionals, with the nurse usually adding care and administrative functions. In regard to the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), the nurses have played a prominent role, especially in the external evaluation phase.

Aim

Analyze the meanings produced by nurses about the PMAQ-AB in a state in the northeastern of Brazil.

Methods

A qualitative research was carried out with twenty-five nurses from the health macro-regions of the State of Piauí. Data were collected from four focus groups, with one group in each macro-region, containing at least six and at most seven participants. The meetings were held from September to October 2018, in which semi-structured interview script was used. For the analysis of information, the maps of association of ideas proposed by Spink and Gimenes (1994) were used.

Conclusions

Despite the difficulties and conflicts felt by nurses with the implementation of PMAQ-AB, the program was understood as an agent for transforming in the work process of family health teams. In addition, the realization of this study allowed another space for reflection to the nurses about the program, qualification and financing of PHC, which can contribute to the institutionalization of the culture of monitoring and evaluation and also the consequent strengthening of these services.

Key messages

Based on the expected impacts, we seek collaborate with reflection on the experience and generate consistent and useful information to contribute to the decision-making processes of health policies. The PMAQ-AB was considered a program that was able to induce substantial changes in work processes because it was a way to finance the workforce.

Expenditure trends in ambulatory care sensitive conditions in Piauí, Brazil, 2009 a 2018

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are an indicator that assesses the effectiveness of Primary Health Care. Such hospitalizations burden the public health budget and use the resources that could subsidize other health actions.

Aim

Analyze expenditure trends in hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH). For temporal trend analysis, a linear regression model was built using the Stata version 14 program.

Results

US$ 119,559,009.56 (Average = US$ 6,292,579.45/year) was spent on ACSC, representing 17.3% of the total hospitalizations (US$ 690,714,037.24). 2010 was the period with the highest cost (14.8%). In contrast, 2018 was the year with the lowest expenditure (5.8%). 23.7% of the costs went to hospitalizations for gastroenteritis. There was a significant decrease in total expenses with ACSC (β = -1.27; 95%CI: -1.65; -0.89; p &lt; 0.001). There was also a reduction in expenses per individual hospitalized, while in 2009, the average expenditure was US$ 230.97/hospitalization, in 2018 it was US$ 157.30/ hospitalization, representing a significant reduction of 31.9%, (β = -12.4; 95%CI: -18.2; -6.6; p = 0.001). The “asthma” and “hypertension” groups showed the greatest cost reductions, 84.8% and 80.7%, respectively. However, an increase in spending on diseases related to prenatal and childbirth (4.1 times) and skin infection (3.9 times) was identified.

Conclusions

Part of the cost reduction is explained by the reduction of hospitalizations for ACSC. The reduced spending averages are compatible with lower hospitalizations by most expensive groups. Linked to these findings, it is observed that Brazil has faced a period of recession since 2015. To this end, additional research must be carried out to relate the expansion of health coverage with the results presented.

Key messages

The costs of hospitalizations for PHC-sensitive conditions reflect the policy of inducing health system coverage, being lower for greater coverage. The evaluation of the cost of specific groups allows the induction of PHC policies focusing on the specific care for each group with a higher cost so as not to burden the health system.

Severe shifts of Zostera marina epifauna: Comparative study between 1997 and 2018 on the Swedish Skagerrak coast

The interaction between bottom-up and top-down processes in coastal ecosystems has been scarcely studied so far. Temporal changes in trophic interactions of Zostera marina along the Swedish west coast are relatively well studied, with the exception of epifaunal communities. Epifauna was used as a model study to explore resource (bottom-up) or predator (top-down) regulated in a vegetated ecosystem. We conducted a 21-year comparative study (1997 and 2018) using epifauna of 19 Zostera marina meadows along the Swedish Skagerrak coast. Large changes were observed in the composition of small (0.2-1 mm) and large (>1 mm) epifauna. In the small-sized epifauna, the nematode Southernia zosterae and harpacticoids showed an increase of 90% and a decrease of 50% of their abundances, respectively. In the large-sized epifauna, the polychaete Platynereis dumerilii and chironomid larvae were absent in 1997 but thrived in 2018 (>2000 ind. m^-2). Mesoherbivores (Idoteids and gammarids) were locally very abundant in 1997 but disappeared in 2018. An 83% decline of mytilids settling in Zostera marina leaves was observed. Our results showed that epifauna is predominantly top-down regulated. An integrative framework of the study area is outlined to shed light on the causes and consequences of the environmental shifts reported in Zostera meadows from the northern Skagerrak area throughout the last three decades.

The cement-in-cement technique is a reliable option in hip arthroplasty revision surgery: a systematic review

INTRODUCTION

The cement-in-cement technique for revision hip arthroplasty has many potential advantages and has recently gained widespread interest but still lacks evidence to support it. Our aim was to examine the surgical and patient-reported outcomes after cement-in-cement revision hip arthroplasty.

MATERIALS AND METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE databases were searched up to February 2019 for original studies reporting the outcomes of revision hip arthroplasty surgeries using the cement-in-cement technique. The methodological quality was assessed using the methodological index for non-randomized studies scale.

RESULTS

Sixteen non-comparative studies met the eligibility criteria, comprising 1899 hips in 1856 patients (72.2 mean age, 37% male), with a mean follow-up of 7.2 years. Most studies reported only primary revisions and focused on the stem component. Intraoperative complications such as femoral or acetabular fractures (5.3%) were low and easily manageable with no relevant sequelae, as were dislocation rates (2.8% of uncomplicated events and 1.6% of cases requiring re-revision). Failure (considered if there was aseptic loosening of the cement-in-cement revised component, 2%), re-revision (9.3%), implant survival and late complication rates were favourable. Functional patient-reported outcomes showed an overall improvement above the minimal clinically important difference at final follow-up.

CONCLUSION

The cement-in-cement technique is a viable option for hip arthroplasty revision surgery with low intraoperative and late complication rates, dislocations and immediate post-operative morbidity, resulting in good functional patient-reported outcomes and favourable medium-term implant survival.

2020 Frank Stinchfield Award: Identifying who will fail following irrigation and debridement for prosthetic joint infection

AIMS

Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors.

METHODS

This was an international, multicentre retrospective study of 1,174 revision total hip (THA) and knee arthroplasties (TKA) undergoing I&D for PJI between January 2005 and December 2017. PJI was defined using the Musculoskeletal Infection Society (MSIS) criteria. A total of 52 variables including demographics, comorbidities, and clinical and laboratory findings were evaluated using random forest machine learning analysis. The algorithm was then verified through cross-validation.

RESULTS

Of the 1,174 patients that were included in the study, 405 patients (34.5%) failed treatment. Using random forest analysis, an algorithm that provides the probability for failure for each specific patient was created. By order of importance, the ten most important variables associated with failure of I&D were serum CRP levels, positive blood cultures, indication for index arthroplasty other than osteoarthritis, not exchanging the modular components, use of immunosuppressive medication, late acute (haematogenous) infections, methicillin-resistant Staphylococcus aureus infection, overlying skin infection, polymicrobial infection, and older age. The algorithm had good discriminatory capability (area under the curve = 0.74). Cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model.

CONCLUSION

This is the first study in the orthopaedic literature to use machine learning as a tool for predicting outcomes following I&D surgery. The developed algorithm provides the medical profession with a tool that can be employed in clinical decision-making and improve patient care. Future studies should aid in further validating this tool on additional cohorts. Cite this article: Bone Joint J 2020;102-B(7 Supple B):11-19.

Island effect in the shell phenotypic plasticity of an intertidal gastropod

The pattern of shell shape variation in populations of the top shell, Phorcus sauciatus from Madeira Island (NE Atlantic) was analysed as a function of substrate type and wave exposure, using geometric morphometrics. We hypothesized that P. sauciatus shows morphological variations to inhabit contrasting environments. Highly significant differences in shell shape were found depending on both substrate type and coastal exposure. The most marked differences were found between exposed and sheltered environments. Rounded shells in exposed environments may be explained by physiological reasons, since larger muscles are needed to ensure attachment to substrate in areas subject to harsh conditions. On the other side, conically-shaped shells may accommodate a larger body but with a smaller foot, an adaptation to sheltered environments. Slight shape variations were also observed among substrates, mostly in the degree of differentiation of some whorls. Differences could be related to a particular use of habitat and/or to the degree of exposure to water current. These results suggest that P. sauciatus is locally adapted to varying coastal hydrodynamics and may be considered as a good model in studies on adaptations of fauna to certain climate change effects.