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Thyroid disorders are highly prevalent, occurring most frequently in aging women. Thyroid-associated symptoms are very similar to symptoms of the aging process; thus, improved methods for diagnosing overt and subclinical hypothyroidism in elderly people are crucial. Thyrotropin measurement is considered to be the main test for detecting hypothyroidism. Combined evaluations of thyroid stimulating hormone (TSH) and free-thyroxine can detect overt hypothyroidism (high TSH with low free-thyroxine levels) and subclinical hypothyroidism (high TSH with normal free-thyroxine levels). It is difficult to confirm the diagnosis of thyroid diseases based only on symptoms, but presence of symptoms could be an indicator of who should be evaluated for thyroid function. The most important reasons to treat overt hypothyroidism are to relieve symptoms and avoid progression to myxedema. Overt hypothyroidism is classically treated using L-thyroxine; elderly patients require a low initial dose that is increased every 4 to 6 weeks until normalization of TSH levels. After stabilization, TSH levels are monitored yearly. There is no doubt about the indication for treatment of overt hypothyroidism, but indications for treatment of subclinical disease are controversial. Although treatment of subclinical hypothyroidism may result in lipid profile improvement, there is no evidence that this improvement is associated with decreased cardiovascular or all-cause mortality in elderly patients. In patients with a high risk of progression from subclinical to overt disease, close monitoring of thyroid function could be the best option.

Atrial fibrillation (AF) is a major risk factor for stroke. To enable improvements to AF diagnosis and follow-up care, understanding current patient pathways and barriers to optimal care are essential. We investigated the patient care pathways and their drivers, and the impact of the COVID-19 pandemic on patient pathways in a middle-income country setting, Brazil. This mixed-methods study in São Paulo, included adults ([greater than or equal to]18y) with AF from 13 primary/secondary healthcare facilities. Surveys using baseline, follow-up (administered [greater than or equal to]two months after baseline) and COVID-19 questionnaires (quantitative), and three focus group discussions (FGDs) were conducted. Minimum sample size for the quantitative component was 236 and we aimed to reach saturation with at least three FGDs for the qualitative component. Descriptive statistics were used for quantitative data and a content analysis was used for qualitative data to identify themes related to AF diagnosis and follow-up care. 267 participants completed the baseline questionnaire: 25% were diagnosed in primary care, 65% in an emergency or inpatient department. At follow-up (n = 259), 31% visited more than one facility for AF care, and 7% had no follow-up. Intervals between international normalised ratio (INR) tests were increased during the pandemic, and the number of healthcare visits and availability of medication were reduced. Seventeen patients participated in three FGDs and revealed that AF diagnosis often occurred following a medical emergency and patients often delay care-seeking due to misconceptions about AF symptoms. Long waiting times, doctor/patient interactions and health system factors, such as doctor availability and the referral system, influence where participants visited for follow-up care. Lack of public awareness and underdeveloped primary healthcare lead to delayed diagnosis, which impacts clinical outcomes and excess patient and healthcare system costs. Health system, care-provider, and pandemic factors disrupt timely and effective continuity of care.

ObjectiveTo provide insight into how people cope with living with atrial fibrillation (AF) and taking oral anticoagulants (OACs), informing how services and healthcare delivery could be improved to offer the appropriate support patients require, thereby optimising their quality of life and well-being.DesignA qualitative study employing focus group discussions (FGDs).Setting11 primary care units in a socioeconomically deprived area of the Butantan district in São Paulo, Brazil.ParticipantsAdults (≥18 years) with AF purposively recruited based on sex, age and socioeconomic status.ResultsSaturation was met with three FGDs comprising seven, five and five participants, respectively. Theme one focused on self-management, where many participants discussed their methods for adhering to dietary restrictions and alternative medications, including plant-based options and specific foods, and how they modified their daily activities to reduce AF complications and symptoms. Theme two was rationality, where participants described three main ways that they cope with taking long-term medication (often warfarin): thinking that it controls their AF symptoms; it is an obligation; it prevents morbidity and premature death. Theme three was attitude and emotions, where participants described their initial reactions of shock and fear after diagnosis and ongoing emotions of sadness and frustration due to required self-management activities and regular blood tests. Theme four was medication regimen, where participants discussed difficulties with polypharmacy, changes to AF medication (particularly from non-vitamin K antagonist OACs (NOACs) to warfarin), side effects from taking warfarin and various methods of medication management.ConclusionsThis study presents three key findings with implications for patient care and support. First, the shock and fear experienced during diagnosis due to a lack of knowledge about AF suggests that improvements in public knowledge about AF are needed. Second, people with additional chronic conditions may need improved care and support, given the concern participants had regarding when and how to take their medications safely. Third, improved access to NOACs may reduce the difficulties, frustrations and concerns participants had regarding warfarin use (eg, diet, dose adjustments, self-management and monthly international normalised ratio tests).

Background Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs). Methods This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data. Results One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care. Conclusions Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.

IntroductionAtrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is often underdiagnosed, particularly in low-income and middle-income countries (LMICs) where screening for AF is not always feasible or considered common practice in primary care settings. Epidemiological data on AF in LMICs is often incomplete particularly in vulnerable populations. This LMIC research collaborative aims to identify the prevalence of AF in the Northern Sri Lankan community.Methods and analysisA cross-sectional household survey piloted and codesigned through a series of community engagement events will be administered in all five districts in Northern Province, Sri Lanka. A multistage cluster sampling approach will be used starting at district level, then the Divisional Secretariats followed by Grama Niladhari divisions. Twenty households will be selected from each cluster. The study aims to recruit 10 000 participants aged 50 years or older, 1 participant per household. Demographic and socioeconomic characteristics, well-being and lifestyle and anthropometric measurements will be collected using a digital data platform (REDCap, Research Electronic Data Capture) by trained data collectors. Participants will be screened for AF using a fingertip single-lead ECG via a smartphone application (AliveCor) with rhythm strips reviewed by a consultant cardiologist. Prevalence of AF and risk factors will be established at province and district-levels. Adjusted ORs and population attributable fractions for AF risk factors will be determined.Ethics and disseminationThis study was approved by the Ethics Review Committee of Faculty of Medicine at University of Jaffna. Written informed consent will be obtained from all participants. Findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences. The findings will enable early treatment for new AF diagnoses and inform interventions to improve community-based management of AF in LMICs.

IntroductionInformation continuity and self-care are important for optimal management of atrial fibrillation (AF) to reduce complications (eg, stroke) and improve prognosis and patient satisfaction. This can be achieved through handover of information from healthcare professionals (HCPs) to patients.MethodsIn Brazil, China and Sri Lanka, we conducted a mixed-methods study to identify cross-country differences, similarities, barriers and facilitators regarding HCP-to-patient handover on AF. Adults (≥18 years) with AF who spoke the local languages were included. Anyone with hearing or cognitive impairment was excluded. A questionnaire was administered and focus group discussions (FGDs) conducted. χ2 tests identified differences within and between countries on use of patient-held health records (PHRs); a content analysis identified perspectives and experiences of HCP-to-patient handover. Data were then triangulated using a convergence model to compare and contrast quantitative and qualitative findings to identify barriers and facilitators for improving HCP-to-patient handover.Results716 participants completed the questionnaire and 13 FGDs were conducted. People with AF receive a range of information on living with AF and AF management, though information given varies between countries. All three countries had PHRs and most patients said they were important and were used by doctors; however, PHRs were inconsistently given to patients and updated by doctors. Although patients valued the information provided, PHRs were not often used for their dual purpose (self-care and information continuity), and often, patients used external sources for seeking additional information which was difficult for disadvantaged patients, particularly in China.ConclusionOur findings highlight inefficiencies of HCP-to-patient handover for AF that have implications on healthcare and patient safety in low- and middle-income countries (LMICs). A global standard is needed to describe what information PHRs should include. Additionally, HCPs and patients should be informed on how to optimise PHRs and handover practices to improve self-care, support, prognosis and healthcare resilience of AF care in LMICs.

The aim of this present clinical trial is to evaluate the effectiveness of a multicomponent prehabilitation programme administered through educational videos versus another programme based on written exercise recommendations, in patients scheduled for lumbar radiculopathy surgery. This study will be a multicentre, controlled, randomised, parallel clinical trial. One hundred participants undergoing lumbar radiculopathy surgery who meet the established inclusion criteria will be recruited at different Spanish hospitals. The experimental group will follow a 4-week prehabilitation programme combining therapeutic exercise, back care education, and pain neuroscience education delivered through videos designed for consumption at home. The control group will be provided with written instructions to perform therapeutic exercises during the same prehabilitation time period. The primary outcome of the study will be disability, assessed using the Spanish version of the Oswestry Disability Index. The secondary outcomes will be pain perception, health-related quality of life, fear avoidance, kinesiophobia, catastrophising, anxiety, depression, physical activity, and the treatment satisfaction of the patients. This study will provide evidence for the effectiveness of a home-based multicomponent prehabilitation programme that addresses some already identified barriers to patient attendance in face-to-face programmes. Understanding the medium and long-term effects of pre-surgery lumbar muscle training and pain neuroscience education administered via instructional videos watched by patients at home, will help improve the design of prehabilitation programmes in this population while also improving the cost-effectiveness of such interventions.

ObjectiveTo evaluate trends in respiratory care practices and bronchopulmonary dysplasia (BPD) among very preterm infants born in Spain between 2010 and 2019.Study designThis was a retrospective cohort study of data obtained from a national population-based database (SEN1500 network). Changes in respiratory care and BPD-free survival of infants with gestational age (GA) of 230–316 weeks and <1500 g were assessed over two 5-year periods. Temporal trends were examined by joinpoint and Poisson regression models and expressed as the annual per cent change and adjusted relative risk (RR) for the change per year.ResultsA total of 17 952 infants were included. In the second period, infants were less frequently intubated in the delivery room and during neonatal intensive care unit stay. This corresponded with an increase in use of non-invasive ventilation techniques. There were no significant differences between the periods in BPD-free survival or survival without moderate-to-severe BPD. After adjusting for covariates, the RR for the change per year was significant for the following variables: never intubated (RR 1.03, 95% CI 1.02 to 1.04); intubation in the delivery room (RR 0.98, 95% CI 0.97 to 0.99); use of nasal intermittent positive pressure ventilation (RR 1.08, 95% CI 1.05 to 1.11); and BPD-free survival (only in the group with the lowest GA; RR 0.98, 95% CI 0.97 to 0.99).ConclusionOur findings reveal significant changes in respiratory care practices between 2009 and 2019. Despite an increase in use of non-invasive respiratory strategies, BPD-free survival did not improve and even worsened in the group with the lowest GA (230–256).

BackgroundOxidative stress is increased in Systemic Lupus Erythematosus (SLE) patients, and contributes to the immune system imbalance, abnormal activation of apoptotic processes, autoantibodies production and the development of serious complications, such as cardiovascular comorbidities.ObjectivesTo evaluate the influence of oxidative stress as an additional factor to the classical cardiovascular risk ones, in SLE patients.MethodsCross-sectional prospective study of SLE patients according to the SLICC-2012 criteria, coming from the Rheumatology Service of Arnau de Vilanova Hospital and La Fe Hospital. In all patients we analyzed the serum concentration of GS-Nem (GSH) and GSSG by UPLC-MS/MS (Acquity UPLC System). We have also taken healthy individuals as negative controls, who had the same blood-test. In patients was also made a complete blood-test, and clinical, treatment and biometric data were collected by personal interview. Biostatistical analysis was performed by the R software version 3.2.3., using a simple, binominal and logistic lineal regression.ResultsA total of 140 patients were evaluated; (95% women) with 33.39±13.63 year-old average at the diagnosis time with a 10.05± 11.42 year-evolution of SLE. We used GSH/GSSG ratio to assess the oxidative stress rate, being this value higher in patients than in healthy controls (P=0.005).We observed a statistically significant relationship between the presence of oxidative stress and accumulated damage assessed by SLICC-ACR (P<0.0001). No differences according to the disease activity, specific autoimmune profile or by organ or systems affected. However, we found a slight difference in the GSH/GSSG ratio among patients who have had a CVD (1±0.39) and those who have not suffered CVD (1.19±0.55). No differences in the levels of oxidative stress are observed according to treatment with folic acid or the administration of biological therapies.ConclusionsWe observed increased levels of oxidative stress in our SLE patients compared to healthy controls. Data suggest a rise of oxidative stress in patients with a greater cumulative damage, which is consistent with the presence of severe comorbidities in these patients. It seems to be a slight tendency to increased oxidative stress levels measured with GSH/GSSG ratio in patients with SLE and cardiovascular involvement, but more independent studies are needed to confirm it.Disclosure of InterestNone declared

BackgroundSystemic lupus erythematous (SLE) shows increased DNA demethylation. An intermediate step to DNA demethylation is the DNA hydroxymethylation, where 5-mC is oxidized into 5-hmC. Hydroxymethylation is not completely understood and it may be related to oxidative stress in SLE patient.ObjectivesTo analyze the association between the hydroxymethylation and demethylation, with the antioxidant response and SLE pathophysiology.MethodsWe analyzed in 142 SLE patients and 34 healthy controls the serum concentration of glutathione (GSH) and glutathione disulphide (GSSG) by UPLC-MS/MS, superoxide dismutase (SOD) and total antioxidant capacity (TAC) by colorimetric methods. 5-mC and 5-hmC levels were measured by colorimetric methods. Complete blood-test was made and clinical data by personal interview was collected. Biostatistical analysis with R (3.3.2.) was performed.ResultsThere is a correlation between the methylation and hydroxymethylation rate (P<0.001), and both were lower in patients than in controls (P=0.024; P<0.001). GSH and GSSG values were lower in patients (P=0.033 y P=0.003), but GSH/GSSG ratio was not statistically different in both groups. SOD levels were higher in patients (P=0.001), but TAC did not show significant differences. Higher demethylation is associated to lower TAC values in patients and healthy controls (P=0.005; P=0.01). In patients, decreased SOD values are associated with higher demethylation and lower hydroxymethylation rates (P<0.001; P=0.007). SOD and TAC levels are increased in SLE patients with higher demethylation and lower hydroxymethylation (P=0.001; P<0.001). We did not observe any association between 5-mC or 5-hmC levels and GSH, GSSG or GSH/GSSG ratio. Higher demethylation is associated to vascular symptoms (defined by RELESSER study) and lupus anticoagulant (AL) positivity (P=0.041; P=0.015), and lower hydroxymethylation to mucocutaneous damage (defined by RELESSER study) and AL positivity (P=0.015; P=0.009). Lower levels of GSH and GSSG were associated to increased accumulated damage assessed by SLICC (P=0.01; P=0.005), and lower SOD values with longer disease duration (P=0.001).ConclusionsWe observed higher demethylation and lower hydroxymethylation in SLE patients than in controls, related to increased SOD activity. Moreover higher demethylation leads to lower TAC levels. These epigenetic disorders are related to antioxidant response disruptions in SLE patients, probably because of the chronic inflammatory condition. Our results suggest that epigenetic processes are involved in SLE physiopathology.AcknowledgementsFinancial support by GVA (GV15/83) is acknowledged.Disclosure of InterestNone declared