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Given the importance of aerosols and clouds and their interactions in the climate system, it is imperative that the global Earth system models accurately represent processes associated with them. This is an important prerequisite if we are to narrow the uncertainties in future climate projections. In practice, this means that continuous model evaluations and improvements grounded in observations are necessary. Numerous studies in the past few decades have shown both the usability and the limitations of utilizing satellite-based observations in understanding and evaluating aerosol–cloud interactions, particularly under varying meteorological and satellite sensor sensitivity paradigms. Furthermore, the vast range of spatio-temporal scales at which aerosol and cloud processes occur adds another dimension to the challenges faced when evaluating climate models. In this context, the aim of this study is two-fold. (1) We evaluate the most recent, significant changes in the representation of aerosol and cloud processes implemented in the EC-Earth3-AerChem model in the framework of the EU project FORCeS compared with its previous CMIP6 version (Coupled Model Intercomparison Project Phase 6; https://pcmdi.llnl.gov/CMIP6/, last access: 13 February 2019). We focus particularly on evaluating cloud physical properties and radiative effects, wherever possible, using a satellite simulator. We report on the overall improvements in the EC-Earth3-AerChem model. In particular, the strong warm bias chronically seen over the Southern Ocean is reduced significantly. (2) A statistical, maximum covariance analysis is carried out between aerosol optical depth (AOD) and cloud droplet (CD) effective radius based on the recent EC-Earth3-AerChem/FORCeS simulation to understand to what extent the Twomey effect can manifest itself in the larger spatio-temporal scales. We focus on the three oceanic low-level cloud regimes that are important due to their strong net cooling effect and where pollution outflow from the nearby continent is simultaneously pervasive. We report that the statistical covariability between AOD and CD effective radius is indeed dominantly visible even at the climate scale when the aerosol amount and composition are favourably preconditioned to allow for aerosol–cloud interactions. Despite this strong covariability, our analysis shows a strong cooling/warming in shortwave cloud radiative effects at the top of the atmosphere in our study regions associated with an increase/decrease in CD effective radius. This cooling/warming can be attributed to the increase/decrease in low cloud fraction, in line with previous observational studies.

Mineralogical composition drives dust impacts on Earth's climate systems. However, most climate models still use homogeneous dust, without accounting for the temporal and spatial variation in mineralogy. To quantify the radiative impact of resolving dust mineralogy on Earth's climate, we implement and simulate the distribution of dust minerals (i.e., illite, kaolinite, smectite, hematite, calcite, feldspar, quartz, and gypsum) from Claquin et al. (1999) (C1999) and activate their interaction with radiation in the GFDL AM4.0 model. Resolving mineralogy reduces dust absorption compared to the homogeneous dust used in the standard GFDL AM4.0 model that assumes a globally uniform hematite volume content of 2.7 % (HD27). The reduction in dust absorption results in improved agreement with observation-based single-scattering albedo (SSA), radiative fluxes from CERES (the Clouds and the Earth's Radiant Energy System), and land surface temperature from the CRU (Climatic Research Unit) compared to the baseline HD27 model version. It also results in distinct radiative impacts on Earth's climate over North Africa. Over the 19-year (from 2001 to 2019) modeled period during JJA (June–July–August), the reduction in dust absorption in AM4.0 leads to a reduction of over 50 % in net downward radiation across the Sahara and approximately 20 % over the Sahel at the top of the atmosphere (TOA) compared to the baseline HD27 model version. The reduced dust absorption weakens the atmospheric warming effect of dust aerosols and leads to an alteration in land surface temperature, resulting in a decrease of 0.66 K over the Sahara and an increase of 0.7 K over the Sahel. The less warming in the atmosphere suppresses ascent and weakens the monsoon inflow from the Gulf of Guinea. This brings less moisture to the Sahel, which combined with decreased ascent induces a reduction of precipitation. To isolate the effect of reduced absorption compared to resolving spatial and temporal mineralogy, we carry out a simulation where the hematite volume content of homogeneous dust is reduced from 2.7 % to 0.9 % (HD09). The dust absorption (e.g., single-scattering albedo) of HD09 is comparable to that of the mineralogically speciated model on a global mean scale, albeit with a lower spatial variation that arises solely from particle size. Comparison of the two models indicates that the spatial inhomogeneity in dust absorption resulting from resolving mineralogy does not have significant impacts on Earth's radiation and climate, provided there is a similar level of dust absorption on a global mean scale before and after resolving dust mineralogy. However, uncertainties related to emission and distribution of minerals may blur the advantages of resolving minerals to study their impact on radiation, cloud properties, ocean biogeochemistry, air quality, and photochemistry. On the other hand, lumping together clay minerals (i.e., illite, kaolinite, and smectite), but excluding externally mixed hematite and gypsum, appears to provide both computational efficiency and relative accuracy. Nevertheless, for specific research, it may be necessary to fully resolve mineralogy to achieve accuracy.

The composition of soil dust aerosols derives from the mineral abundances in the parent soils that vary across dust source regions. Nonetheless, Earth system models (ESMs) have traditionally represented mineral dust as a globally homogeneous species. The growing interest in modeling dust mineralogy, facilitated by the recognized sensitivity of the dust climate impacts to composition, has motivated state-of-the-art ESMs to incorporate the mineral speciation of dust along with its effect upon the dust direct radiative effect (DRE). In this work, we enable the NASA Goddard Institute for Space Studies ModelE2.1 to calculate the shortwave (SW) DRE accounting for the regionally varying soil mineralogy. Mineral–radiation interaction at solar wavelengths is calculated according to two alternative coupling schemes: (1) external mixing of three mineral components that are optically distinguished, one of which contains embedded iron oxides; (2) a single internal mixture of all dust minerals with a dynamic fraction of iron oxides that varies regionally and temporally. We link dust absorption to the fractional mass of iron oxides based on recent chamber measurements using natural dust aerosol samples. We show that coupled mineralogy overall enhances the scattering by dust, and thus the global cooling, compared to our control run with globally uniform composition. According to the external mixing scheme, the SW DRE at the top of atmosphere (TOA) changes from −0.25 to -0.30Wm-2, corresponding to a change in the net DRE, including the longwave effect, from −0.08 to -0.12Wm-2. The cooling increase is accentuated when the internal mixing scheme is configured: the SW DRE at the TOA becomes -0.34Wm-2 with a net DRE of -0.15Wm-2. The varying composition modifies the regional distribution of single scattering albedo (SSA), whose variations in specific regions can be remarkable (above 0.03) and significantly modify the regional SW DRE. Evaluation against the AErosol RObotic NETwork (AERONET) shows that explicit representation of soil mineralogy and its regional variations reduces the low bias of model dust SSA while improving the range of variability across stations and calendar months. Despite these improvements, the moderate spatiotemporal correlation with AERONET reveals remaining modeling challenges and the need for more accurate measurements of mineral fractions in soils.

Introduction Early-onset dementia (EOD) is defined as any type of dementia with an onset before the age of 65. Despite its profound impact on patients and their families, EOD has garnered less attention when compared to late-onset dementia (LOD), often resulting in its underestimation. In comparison to LOD, EOD commonly manifests with atypical and heterogeneous symptoms, encompassing mainly non-memory problems, ranging from language and executive impairments to behavioral-led dysfunction. Despite the importance of accurate data to organize appropriate healthcare, evidence regarding EOD patients in Portugal is lacking. Objectives The primary aims of this study include identifying the causes for hospitalization in EOD patients, diagnosed with dementia either as a primary or secondary diagnosis, and comparing them with inpatients aged 65 and older (LOD). Additionally, the study aims to analyze key hospitalization outcomes for both groups, including length of stay, in-hospital mortality, and readmissions. As a secondary aim, this study seeks to describe subtypes of EOD. Methods A retrospective observational study will be conducted following the RECORD statement. Data will be retrieved from an administrative database that gathers de-identified routinely collected hospitalization data from all Portuguese mainland public hospitals. Hospitalization episodes of inpatients younger than 65 years old, with a primary or secondary diagnosis of dementia (ascertained by ICD-9-CM codes 290.0-290.4, 294.0-294.2, 331.0, 331.1, and 331.82), will be extracted. Comparison patients will be selected by propensity score-matching from inpatients over 65 years with a dementia ICD-9-CM code (in any position), matched for Charlson Comorbidity Index (CCI). Results Descriptive and analytical statistics will be conducted to describe and characterize both group of inpatients. Variables such as age at admission, sex, place of residence, causes and type of admission, psychiatric comorbidities, length of stay (LoS), destination after discharge, readmissions, in-hospital mortality and hospital charges will be analyzed. Conclusions With this nationwide analysis of EOD hospitalizations, we aim to reveal critical aspects of this condition, including common causes of admission, diagnostic features and health outcomes, allowing for appropriate medical interventions and support tailored to the specific needs of this clinical group. Disclosure of Interest None Declared

Introduction The presence of psychiatric comorbidity significantly impacts the quality of life for patients and often goes unnoticed within the realm of neurology. Objectives This study’s objective was to elucidate and characterize psychiatric comorbidity among patients hospitalized for neurological disorders in mainland Portugal. Methods This retrospective observational study analyzed hospitalizations categorized with a primary diagnosis of neurological disorders, defined by Clinical Classification Software (CSS) for ICD-9-CM codes 76, 77, 79-85, 95, and 109, occurring in adult patients (≥18 years) between 2008 and 2015. Psychiatric comorbidity was determined by the presence of secondary diagnoses falling under CCS categories 650-670. Results A total of 294,806 hospitalization episodes were documented with a primary diagnosis of neurological disorders in adult patients between 2008 and 2015 in Portuguese public hospitals. Approximately 26.9% (n=79,442) of these episodes were associated with documented psychiatric comorbidity (22.1% for female hospitalizations and 32.2% for male hospitalizations). Patients with recorded psychiatric comorbidity were younger (66.2±16.2 vs. 68.6±17.2 for those without psychiatric comorbidity, p

Soil dust aerosols are a key component of the climate system, as they interact with short- and long-wave radiation, alter cloud formation processes, affect atmospheric chemistry and play a role in biogeochemical cycles by providing nutrient inputs such as iron and phosphorus. The influence of dust on these processes depends on its physicochemical properties, which, far from being homogeneous, are shaped by its regionally varying mineral composition. The relative amount of minerals in dust depends on the source region and shows a large geographical variability. However, many state-of-the-art Earth system models (ESMs), upon which climate analyses and projections rely, still consider dust mineralogy to be invariant. The explicit representation of minerals in ESMs is more hindered by our limited knowledge of the global soil composition along with the resulting size-resolved airborne mineralogy than by computational constraints. In this work we introduce an explicit mineralogy representation within the state-of-the-art Multiscale Online Nonhydrostatic AtmospheRe CHemistry (MONARCH) model. We review and compare two existing soil mineralogy datasets, which remain a source of uncertainty for dust mineralogy modeling and provide an evaluation of multiannual simulations against available mineralogy observations. Soil mineralogy datasets are based on measurements performed after wet sieving, which breaks the aggregates found in the parent soil. Our model predicts the emitted particle size distribution (PSD) in terms of its constituent minerals based on brittle fragmentation theory (BFT), which reconstructs the emitted mineral aggregates destroyed by wet sieving. Our simulations broadly reproduce the most abundant mineral fractions independently of the soil composition data used. Feldspars and calcite are highly sensitive to the soil mineralogy map, mainly due to the different assumptions made in each soil dataset to extrapolate a handful of soil measurements to arid and semi-arid regions worldwide. For the least abundant or more difficult-to-determine minerals, such as iron oxides, uncertainties in soil mineralogy yield differences in annual mean aerosol mass fractions of up to ∼ 100 %. Although BFT restores coarse aggregates including phyllosilicates that usually break during soil analysis, we still identify an overestimation of coarse quartz mass fractions (above 2 µm in diameter). In a dedicated experiment, we estimate the fraction of dust with undetermined composition as given by a soil map, which makes up ∼ 10 % of the emitted dust mass at the global scale and can be regionally larger. Changes in the underlying soil mineralogy impact our estimates of climate-relevant variables, particularly affecting the regional variability of the single-scattering albedo at solar wavelengths or the total iron deposited over oceans. All in all, this assessment represents a baseline for future model experiments including new mineralogical maps constrained by high-quality spaceborne hyperspectral measurements, such as those arising from the NASA Earth Surface Mineral Dust Source Investigation (EMIT) mission.

Ice-nucleating particles (INPs) enable ice formation, profoundly affecting the microphysical and radiative properties, lifetimes, and precipitation rates of clouds. Mineral dust emitted from arid regions, particularly potassium-containing feldspar (K-feldspar), has been shown to be a very effective INP through immersion freezing in mixed-phase clouds. However, despite the fact that quartz has a significantly lower ice nucleation activity, it is more abundant than K-feldspar in atmospheric desert dust and therefore may be a significant source of INPs. In this contribution, we test this hypothesis by investigating the global and regional importance of quartz as a contributor to INPs in the atmosphere relative to K-feldspar. We have extended a global 3-D chemistry transport model (TM4-ECPL) to predict INP concentrations from both K-feldspar and quartz mineral dust particles with state-of-the-art parameterizations using the ice-active surface-site approach for immersion freezing. Our results show that, although K-feldspar remains the most important contributor to INP concentrations globally, affecting mid-level mixed-phase clouds, the contribution of quartz can also be significant. Quartz dominates the lowest and the highest altitudes of dust-derived INPs, affecting mainly low-level and high-level mixed-phase clouds. The consideration of quartz INPs also improves the comparison between simulations and observations at low temperatures. Our simulated INP concentrations predict ∼ 51 % of the observations gathered from different campaigns within 1 order of magnitude and ∼ 69 % within 1.5 orders of magnitude, despite the omission of other potentially important INP aerosol precursors like marine bioaerosols. Our findings support the inclusion of quartz in addition to K-feldspar as an INP in climate models and highlight the need for further constraining their abundance in arid soil surfaces along with their abundance, size distribution, and mixing state in the emitted dust atmospheric particles.

One of the challenges in studying desert dust aerosol along with its numerous interactions and impacts is the paucity of direct in situ measurements, particularly in the areas most affected by dust storms. Satellites typically provide column-integrated aerosol measurements, but observationally constrained continuous 3D dust fields are needed to assess dust variability, climate effects and impacts upon a variety of socio-economic sectors. Here, we present a high-resolution regional reanalysis data set of desert dust aerosols that covers Northern Africa, the Middle East and Europe along with the Mediterranean Sea and parts of central Asia and the Atlantic and Indian oceans between 2007 and 2016. The horizontal resolution is 0.1∘ latitude × 0.1∘ longitude in a rotated grid, and the temporal resolution is 3 h. The reanalysis was produced using local ensemble transform Kalman filter (LETKF) data assimilation in the Multiscale Online Nonhydrostatic AtmospheRe CHemistry model (MONARCH) developed at the Barcelona Supercomputing Center (BSC). The assimilated data are coarse-mode dust optical depth retrieved from the Moderate Resolution Imaging Spectroradiometer (MODIS) Deep Blue Level 2 products. The reanalysis data set consists of upper-air variables (dust mass concentrations and the extinction coefficient), surface variables (dust deposition and solar irradiance fields among them) and total column variables (e.g. dust optical depth and load). Some dust variables, such as concentrations and wet and dry deposition, are expressed for a binned size distribution that ranges from 0.2 to 20 µm in particle diameter. Both analysis and first-guess (analysis-initialized simulation) fields are available for the variables that are diagnosed from the state vector. A set of ensemble statistics is archived for each output variable, namely the ensemble mean, standard deviation, maximum and median. The spatial and temporal distribution of the dust fields follows well-known dust cycle features controlled by seasonal changes in meteorology and vegetation cover. The analysis is statistically closer to the assimilated retrievals than the first guess, which proves the consistency of the data assimilation method. Independent evaluation using Aerosol Robotic Network (AERONET) dust-filtered optical depth retrievals indicates that the reanalysis data set is highly accurate (mean bias = −0.05, RMSE = 0.12 and r = 0.81 when compared to retrievals from the spectral de-convolution algorithm on a 3-hourly basis). Verification statistics are broadly homogeneous in space and time with regional differences that can be partly attributed to model limitations (e.g. poor representation of small-scale emission processes), the presence of aerosols other than dust in the observations used in the evaluation and differences in the number of observations among seasons. Such a reliable high-resolution historical record of atmospheric desert dust will allow a better quantification of dust impacts upon key sectors of society and economy, including health, solar energy production and transportation. The reanalysis data set (Di Tomaso et al., 2021) is distributed via Thematic Real-time Environmental Distributed Data Services (THREDDS) at BSC and is freely available at http://hdl.handle.net/21.12146/c6d4a608-5de3-47f6-a004-67cb1d498d98 (last access: 10 June 2022).

Increasing end-of-life material recovery and its application in new products is essential to reduce resource consumption. This paper assesses the cradle-to-gate life cycle energy and carbon dioxide (CO2) emissions of a new road safety barrier product to be installed around guardrails’ poles. To analyze​ the potential life cycle benefit of incorporating recycled materials, a base case product A, produced with conventional virgin synthetic rubber and polypropylene (PP), was compared with two equivalent alternatives under study: B (using recycled end-of-life tire rubber granulate (TRG) and PP), and C (using TRG and recycled polypropylene). The results show that the incorporation of recycled TRG has a positive effect in primary energy and carbon emissions. Product B presents less 38% CO2 emissions and 47% non-renewable primary energy than product A. The combination of TRG and recycled polypropylene (C), presents even more benefits: less 69% CO2 and 86% non-renewable primary energy than A. Supply chain processes and material production have much higher impacts than the product manufacturing (e.g. product molding only represents 5% of the primary energy of product A). To conclude, recycled materials incorporation should be strongly encouraged since it has a great potential to reduce current carbon emissions and primary energy of products.

Introduction The Coronavirus (COVID-19) pandemic and the regulations enforced to control it caused significant alterations in daily routines worldwide. Lockdowns, remote working and schooling favoured virtual interactions and increased “free-time”, with the internet posing as a preferential means of distraction. Statistics from pornographic websites have shown a rise in traffic during lockdown periods, with problematic use of pornography (POPU) emerging as a potential mental health concern. Objectives The authors aim to summarize current knowledge on the effects of the COVID-19 pandemic on online pornography use. Methods Narrative review of articles referenced on PubMed and Google Scholar. Results The increased exposure to the internet during the pandemic, combined with psychosocial factors such as social isolation, diminished physical contact and intimacy may have contributed to the reported surge in online pornography use. Other associated factors include emotional distress and less availability of other addictive substances and behaviours during confinement periods. Besides the spike in pornography consumption, other aspects were also affected, such as time of usage, search keywords and type of content, with an increase in engagement in illegal pornography. In susceptible individuals, these circumstances may lead to the development of POPU, characterized by impaired control, excessive time spent and perceived negative consequences. Currently, there is a lack of consensual diagnostic criteria for POPU, hindering the detection of these patients and timely management. Conclusions Behavioural addictions are an emerging mental health problem, particularly the ones related to internet use. In the aftermath of the pandemic, considering the reported rise in online pornography use, an increase in POPU prevalence is expected. Therefore, more accurate and consensual diagnostic criteria are required, as well as a greater amount of evidence on the treatment of this disorder, in order to improve the approach to these patients. Disclosure of Interest None Declared

Introduction In recent years, there has been a rise in misuse of low-cost prescription pills across Middle Eastern and North African (MENA) countries. In Algeria, Tunisia and Morocco, for example, the consumption of prescription medications has dramatically increased, particularly amongst young and marginalized groups. Drugs such as clonazepam and pregabalin are extremely popular in these regions, as they are relatively inexpensive and perceived as safe. With the migration of MENA citizens to Europe, it is likely that mental health services will come across substance use disorders related to these medications. Objectives The authors aim to analyse prescription medication misuse reports from MENA countries, specifically pregabalin and clonazepam, and review the pharmacological, neurobiological and social factors that contribute to their potential for abuse. Methods Narrative review of articles referenced on PubMed and Google Scholar. Results Pregabalin and clonazepam are widely used in psychiatry and neurology. Pregabalin is an alpha 2 omega ligand with supposed GABA-mimetic properties. Anecdotal reports suggest that pregabalin, used recreationally in amounts up to 3-20 times the therapeutic doses, possesses both sedative and psychedelic effects. Experimenters are mainly individuals with a history of recreational polydrug use, who are aware that pregabalin is not included in standard drug monitoring tests, with this molecule being used in some instances as a legal substitute of common illegal drugs. Clonazepam is a benzodiazepine that combines high potency and a long duration of action and is said to cause euphoria at doses over 8mg. It is very popular and affordable, placing consistently in the top three of benzodiazepines sales across the globe. Clonazepam has potential for tolerance build up and severe withdrawal symptoms. These medications are frequently used together and in combination with other substances such as alcohol and opiates, increasing the risk for respiratory failure and death. Conclusions Prescription medications such as pregabalin and clonazepam are extremely accessible, inexpensive and highly addictive substances, whose abuse is well disseminated across MENA countries. With migratory flows from this region, the prevalence of misuse of these drugs in Europe is expected to increase. Therefore, physicians should be aware of their potential for abuse and carefully evaluate patients’ previous history before prescribing these medications. Disclosure of Interest None Declared

Introduction Schizophrenia is a chronic severe mental disorder characterized by acute decompensation episodes that may lead to hospitalization. In Portugal a previous study found a total of 25,385 hospitalizations in an 8-year period, being one of the most burdensome serious mental disorders in Portugal.Rehospitalizations (hospitalization occurring after a previous discharge due to Schizophrenia) are one of the quality-of-care indicators of schizophrenia treatment. Objectives This project aims to describe and quantify hospitalization readmission rates in patients with schizophrenia in Portuguese public hospitals Methods A descriptive study was designed according to the RECORD guidelines, using a nationwide hospitalization administrative database that contains all hospitalizations registered in Portuguese mainland public hospitals. All episodes with discharges occurring between 2008 and 2015 with a primary diagnosis of Schizophrenia were selected according to the International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes of diagnosis 295.xx. Readmission rates were estimated using a methodological approach developed by the authors that identified patients who have been rehospitalized in

Introduction The COVID-19 pandemic had a major impact on mental health globally, resulting in a need for adaptation of mental health services. The psychosocial consequences of this crisis, such as psychological stress, reduction of community care and social support, are known factors that increase the risk of psychiatric decompensation. Compulsory admission is the last line of intervention in individuals who suffer from severe mental disorders and refuse treatment, based on the principles of therapeutic need and social protection. In Portugal, the last law regulating the compulsory admission is in forme since 2004 (Law 36/98 of 24 July), and configures this measure as a hospitalization by court order, happening the same in other European countries. The literature shows that in 2020 there was a significant increase in the proportion of involuntary inpatient admissions for all psychiatric diagnosis. Objectives This study aims to assess the impact of the COVID-19 pandemic on involuntary admissions to an acute psychiatric service. Methods Socio-demographic and clinical data were collected from electronic medical records. A retrospective observational study of patients who were admitted in a General Psychiatric Unit of Hospital Magalhães Lemos between March 2019 and February 2021 was conducted. The characteristics of patients admitted before the pandemic (March 2019 to February 2020) and after (March 2020 to February 2021) were compared statistically. Results A total of 850 patient admissions were obtained, of which 28% were involuntary. The authors expect to find differences between involuntary inpatient admissions before and after the COVID-19 pandemic in proportion of patients, socio-demographic and clinical factors. Conclusions The findings of this study will likely show an increase in involuntary admissions during the pandemic, in agreement with current knowledge. More studies are needed to assess the long-term impact of the pandemic on mental health. Disclosure of Interest None Declared

Introduction Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality worldwide. In Portugal, it is estimated to afflict 14.2% of the population over the age of 45 and is one of the most common causes of morbidity, with a significant social impact and excessive expenses. Moreover, COPD is associated with high levels of psychological distress and diverse psychiatric disorders that heighten the disease burden as they are associated with increased risk of exacerbations and frequent hospitalizations. Despite this overview, psychiatric conditions remain understudied compared to comorbid general medical conditions, and few studies have assessed their effect on COPD hospitalization outcomes. Objectives This study aimed to describe the occurrence of a vast array of psychiatric comorbid diagnoses in COPD hospitalizations and to understand their impact on hospitalization outcomes. Methods A retrospective observational study was conducted. All inpatient episodes from 2008 to 2015 of patients with at least 40 years and a primary diagnosis of COPD (ICD-9-CM codes 491.x, 492.x and 496) were selected from a national administrative database that included all hospitalizations in mainland public hospitals. From these sampled episodes, secondary psychiatric diagnoses were identified (ICD-9-CM codes 290.x-319.x). Age at hospitalization, sex, psychiatric comorbidities, length of stay (LoS) in days, admission type and date, destination after discharge, in-hospital mortality and hospital charges were analyzed. Results From a total of 66,661 COPD hospitalizations, 17,652 (26.5%) corresponded to episodes with a secondary psychiatric diagnosis. Patients with a comorbid psychiatric diagnosis were on average younger at admission (70.3 vs. 75.9 years, p

Introduction In 2019, there were 39.5 million patients suffering from bipolar disorder worldwide, resulting in around 8.5 million disability-adjusted life years (DALYs) and in a significant economic burden. Bipolar disorder is known to be susceptible to factors that disrupt biological and social rhythms. The COVID-19 pandemic and the measures taken to control it, such as social distancing, home confinement and lockdowns, pose a risk to the stability of bipolar patients. Other factors, for example, reduced access to treatment and stress associated with the disease could also contribute to relapses. Studies have shown that, in 2020, more people with bipolar disorder were hospitalised compared to previous years, including patients without previous history of hospitalizations. Objectives This study aims to assess the impact of the COVID-19 pandemic on inpatient admissions for bipolar disorder. Methods Socio-demographic and clinical data were collected from electronic medical records. A retrospective observational study of patients who were admitted to a psychiatric ward between March 2019 and February 2021 was conducted. The characteristics of patients admitted before the pandemic (March 2019 to February 2020) and after (March 2020 to February 2021) were compared statistically. Results A total of 850 patient admissions were obtained, 15% of which had a main diagnosis of bipolar disorder. The authors will analyze all the variables in the population admitted. The authors expect to find differences between patients hospitalized before and after the beginning of the pandemic, both in clinical presentation (manic, depressive or mixed episode), psychiatric history, comorbidities, suicide attempts and socio-demographic factors. Conclusions The COVID-19 pandemic had a significant impact on mental health on a global level, plenty of which is still unknown. The findings of this study will likely show the effects of this crisis on bipolar disorder patients. Disclosure of Interest None Declared

Introduction Psychiatric comorbidities are highly frequent in patients with epilepsy and are associated with negative outcomes. These comorbid conditions can lower the seizure threshold, increase the risk of treatment-resistant epilepsy, and reduce function and quality of life. Additionally, patients with epilepsy have an increased risk of premature mortality, including due to suicide. In this context, although hospitalizations are common in patients with epilepsy, little information on healthcare utilization associated with comorbid psychopathology is available. Objectives To characterize psychiatric comorbidities among all hospitalizations with a primary diagnosis of epilepsy and to analyze their association with key-hospitalization outcomes, including length of stay, in-hospital mortality, estimated hospital charges, and readmissions. Methods An observational retrospective study will be performed using an administrative database that comprises de-identified routinely collected hospitalization data from all Portuguese mainland public hospitals. All episodes of inpatients, discharged between 2008-2015, with a primary diagnosis of epilepsy (ICD-9-CM code 345.X) will be selected. Psychiatric comorbidities as secondary diagnoses will be identified, grouped into broader categories as defined by the Clinical Classifications Software for ICD-9-CM, and computed into binary variables. Descriptive, univariate, and multivariate analyses will be used. Results Descriptive and analytical statistics will be conducted to describe and characterize this sample of hospitalizations. Sociodemographic variables such as age at admission, sex, and place of residence will be characterized. Multivariate models will be used to quantify the association between psychiatric comorbidities and hospitalization outcomes, and results will be presented as crude and adjusted odds ratios. Conclusions With this nationwide analysis, we expect to better understand the additional burden of psychiatric comorbidities on epilepsy-related hospitalizations, including psychiatric diagnoses that have not been extensively investigated. Disclosure of Interest None Declared

Understanding how multiphase processes affect the iron-containing aerosol cycle is key to predicting ocean biogeochemistry changes and hence the feedback effects on climate. For this work, the EC-Earth Earth system model in its climate–chemistry configuration is used to simulate the global atmospheric oxalate (OXL), sulfate (SO42-), and iron (Fe) cycles after incorporating a comprehensive representation of the multiphase chemistry in cloud droplets and aerosol water. The model considers a detailed gas-phase chemistry scheme, all major aerosol components, and the partitioning of gases in aerosol and atmospheric water phases. The dissolution of Fe-containing aerosols accounts kinetically for the solution's acidity, oxalic acid, and irradiation. Aerosol acidity is explicitly calculated in the model, both for accumulation and coarse modes, accounting for thermodynamic processes involving inorganic and crustal species from sea salt and dust. Simulations for present-day conditions (2000–2014) have been carried out with both EC-Earth and the atmospheric composition component of the model in standalone mode driven by meteorological fields from ECMWF's ERA-Interim reanalysis. The calculated global budgets are presented and the links between the (1) aqueous-phase processes, (2) aerosol dissolution, and (3) atmospheric composition are demonstrated and quantified. The model results are supported by comparison to available observations. We obtain an average global OXL net chemical production of 12.615 ± 0.064 Tg yr−1 in EC-Earth, with glyoxal being by far the most important precursor of oxalic acid. In comparison to the ERA-Interim simulation, differences in atmospheric dynamics and the simulated weaker oxidizing capacity in EC-Earth overall result in a ∼ 30 % lower OXL source. On the other hand, the more explicit representation of the aqueous-phase chemistry in EC-Earth compared to the previous versions of the model leads to an overall ∼ 20 % higher sulfate production, but this is still well correlated with atmospheric observations. The total Fe dissolution rate in EC-Earth is calculated at 0.806 ± 0.014 Tg yr−1 and is added to the primary dissolved Fe (DFe) sources from dust and combustion aerosols in the model (0.072 ± 0.001 Tg yr−1). The simulated DFe concentrations show a satisfactory comparison with available observations, indicating an atmospheric burden of ∼0.007 Tg, resulting in an overall atmospheric deposition flux into the global ocean of 0.376 ± 0.005 Tg yr−1, which is well within the range reported in the literature. All in all, this work is a first step towards the development of EC-Earth into an Earth system model with fully interactive bioavailable atmospheric Fe inputs to the marine biogeochemistry component of the model.

Atmospheric mineral dust has a rich tri-dimensional spatial and temporal structure that is poorly constrained in forecasts and analyses when only column-integrated aerosol optical depth (AOD) is assimilated. At present, this is the case of most operational global aerosol assimilation products. Aerosol vertical distributions obtained from spaceborne lidars can be assimilated in aerosol models, but questions about the extent of their benefit upon analyses and forecasts along with their consistency with AOD assimilation remain unresolved. Our study thoroughly explores the added value of assimilating spaceborne vertical dust profiles, with and without the joint assimilation of dust optical depth (DOD). We also discuss the consistency in the assimilation of both sources of information and analyse the role of the smaller footprint of the spaceborne lidar profiles in the results. To that end, we have performed data assimilation experiments using dedicated dust observations for a period of 2 months over northern Africa, the Middle East, and Europe. We assimilate DOD derived from the Visible Infrared Imaging Radiometer Suite (VIIRS) on board Suomi National Polar-Orbiting Partnership (SUOMI-NPP) Deep Blue and for the first time Cloud-Aerosol Lidar with Orthogonal Polarisation (CALIOP)-based LIdar climatology of Vertical Aerosol Structure for space-based lidar simulation studies (LIVAS) pure-dust extinction coefficient profiles on an aerosol model. The evaluation is performed against independent ground-based DOD derived from AErosol RObotic NETwork (AERONET) Sun photometers and ground-based lidar dust extinction profiles from the Cyprus Clouds Aerosol and Rain Experiment (CyCARE) and PREparatory: does dust TriboElectrification affect our ClimaTe (Pre-TECT) field campaigns. Jointly assimilating LIVAS and Deep Blue data reduces the root mean square error (RMSE) in the DOD by 39 % and in the dust extinction coefficient by 65 % compared to a control simulation that excludes assimilation. We show that the assimilation of dust extinction coefficient profiles provides a strong added value to the analyses and forecasts. When only Deep Blue data are assimilated, the RMSE in the DOD is reduced further, by 42 %. However, when only LIVAS data are assimilated, the RMSE in the dust extinction coefficient decreases by 72 %, the largest improvement across experiments. We also show that the assimilation of dust extinction profiles yields better skill scores than the assimilation of DOD under an equivalent sensor footprint. Our results demonstrate the strong potential of future lidar space missions to improve desert dust forecasts, particularly if they foresee a depolarization lidar channel to allow discrimination of desert dust from other aerosol types.

We present the dust module in the Multiscale Online Non-hydrostatic AtmospheRe CHemistry model (MONARCH) version 2.0, a chemical weather prediction system that can be used for regional and global modeling at a range of resolutions. The representations of dust processes in MONARCH were upgraded with a focus on dust emission (emission parameterizations, entrainment thresholds, considerations of soil moisture and surface cover), lower boundary conditions (roughness, potential dust sources), and dust–radiation interactions. MONARCH now allows modeling of global and regional mineral dust cycles using fundamentally different paradigms, ranging from strongly simplified to physics-based parameterizations. We present a detailed description of these updates along with four global benchmark simulations, which use conceptually different dust emission parameterizations, and we evaluate the simulations against observations of dust optical depth. We determine key dust parameters, such as global annual emission/deposition flux, dust loading, dust optical depth, mass-extinction efficiency, single-scattering albedo, and direct radiative effects. For dust-particle diameters up to 20 µm, the total annual dust emission and deposition fluxes obtained with our four experiments range between about 3500 and 6000 Tg, which largely depend upon differences in the emitted size distribution. Considering ellipsoidal particle shapes and dust refractive indices that account for size-resolved mineralogy, we estimate the global total (longwave and shortwave) dust direct radiative effect (DRE) at the surface to range between about −0.90 and −0.63 W m−2 and at the top of the atmosphere between −0.20 and −0.28 W m−2. Our evaluation demonstrates that MONARCH is able to reproduce key features of the spatiotemporal variability of the global dust cycle with important and insightful differences between the different configurations.

This paper documents the global climate model EC-Earth3-AerChem, one of the members of the EC-Earth3 family of models participating in the Coupled Model Intercomparison Project Phase 6 (CMIP6). EC-Earth3-AerChem has interactive aerosols and atmospheric chemistry and contributes to the Aerosols and Chemistry Model Intercomparison Project (AerChemMIP). In this paper, we give an overview of the model, describe in detail how it differs from the other EC-Earth3 configurations, and outline the new features compared with the previously documented version of the model (EC-Earth 2.4). We explain how the model was tuned and spun up under preindustrial conditions and characterize the model's general performance on the basis of a selection of coupled simulations conducted for CMIP6. The net energy imbalance at the top of the atmosphere in the preindustrial control simulation is on average −0.09 W m−2 with a standard deviation due to interannual variability of 0.25 W m−2, showing no significant drift. The global surface air temperature in the simulation is on average 14.08 ∘C with an interannual standard deviation of 0.17 ∘C, exhibiting a small drift of 0.015 ± 0.005 ∘C per century. The model's effective equilibrium climate sensitivity is estimated at 3.9 ∘C, and its transient climate response is estimated at 2.1 ∘C. The CMIP6 historical simulation displays spurious interdecadal variability in Northern Hemisphere temperatures, resulting in a large spread across ensemble members and a tendency to underestimate observed annual surface temperature anomalies from the early 20th century onwards. The observed warming of the Southern Hemisphere is well reproduced by the model. Compared with the ECMWF (European Centre for Medium-Range Weather Forecasts) Reanalysis version 5 (ERA5), the surface air temperature climatology for 1995–2014 has an average bias of −0.86 ± 0.05 ∘C with a standard deviation across ensemble members of 0.35 ∘C in the Northern Hemisphere and 1.29 ± 0.02 ∘C with a corresponding standard deviation of 0.05 ∘C in the Southern Hemisphere. The Southern Hemisphere warm bias is largely caused by errors in shortwave cloud radiative effects over the Southern Ocean, a deficiency of many climate models. Changes in the emissions of near-term climate forcers (NTCFs) have significant effects on the global climate from the second half of the 20th century onwards. For the SSP3-7.0 Shared Socioeconomic Pathway, the model gives a global warming at the end of the 21st century (2091–2100) of 4.9 ∘C above the preindustrial mean. A 0.5 ∘C stronger warming is obtained for the AerChemMIP scenario with reduced emissions of NTCFs. With concurrent reductions of future methane concentrations, the warming is projected to be reduced by 0.5 ∘C.

Introduction The concept of motivation pervades our professional and personal lives. Motivation is almost impossible to be observed directly, it is a construct for the interpretation of a behaviour that “calls the attention”. Objectives This work reviews the current available data on the phenomenological description of motivation and the abnormalities of motivation. Methods Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “motivation”, “psychopathology”, “phenomenology”. Results Abnormalities in motivation may involve diminution or exacerbation. Anhedonia is the absence of pleasure in relation to usually pleasurable activities, it occurs in depression and schizophrenia where the pleasurable intrinsic motivation that acts as incentive for behaviour may be lost. In mania it may be increased so that mundane activities become unduly fascinating and rewarding. Conclusions Countless theories have been proposed to explain human motivation but each sheds light on specific aspects of motivation, neglecting others. This diversity creates confusion because most theories have areas of conceptual overlap and disagreement. To facilitate the development of studies, an agreement should be achieved on an operational definition of motivation. Disclosure No significant relationships.

Introduction Neurocognitive deficits amongst patients with schizophrenia are considered one of schizophrenia’s central features. These deficits appear to be present from the first episode of psychosis (FEP) and certain cognitive impairments could be components of a genetic vulnerability to schizophrenia. Regarding research on cannabis and cognition in schizophrenia, different studies have assessed neurocognitive functions: memory, attention/vigilance, processing speed, verbal learning, executive functions, and verbal fluency. Objectives The aim is to do a review of recent findings concerning the association of cannabis use with cognition in schizophrenia. Methods A literature review was conducted using the PubMed search database. Results Patients with schizophrenia and concomitant cannabis use are associated with worse performance in immediate verbal learning, and in some studies with worse working memory performance. There is an improvement of verbal memory when they cease the cannabis’ consumption. Regarding attention capacity and memory types assessed, the results are controversial. In FEP, heavy cannabis use during the previous year correlates with slower processing speed. Also, FEP-patients with cannabis use but no family history of psychosis perform worse in executive functions, while those with a family history of psychosis perform better. Conclusions The studies of psychosis, cannabis and cognition differ in relevant aspects, which might be connected to the result variability. Therefore, before solid conclusions can be reached, it is important to carry out longitudinal studies to understand the changes in the cognitive variables, which can depend on the pattern of cannabis’ use (concurrent or prior to the FEP). Possible confounding variables that might be present should be acknowledged. Disclosure No significant relationships.

Introduction Bipolar disorder (BD) is usually diagnosed in adulthood, around childbearing age. Research has shown that BD has deleterious effects on pregnant women and birth outcomes. However, few nationwide studies using administrative data have approached this at-risk population focusing specifically on childbirth. Objectives This study aims to characterize hospitalizations of women with BD in the peripartum period regarding sociodemographic and clinical variables and to investigate the impact BD has on hospitalization outcomes. Methods An observational retrospective study will be performed using an administrative database that comprises routinely collected hospitalization data from all mainland Portuguese public hospitals. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes will be used to identify all women’s admissions for childbirth purposes (V27.X) and codes 296.XX (except 296.2X, 296.3X, 296.9X) will be used to ascertain BD. Episodes will be assigned to one of two mutually exclusive groups (with vs without BD). Multivariate methods will be used to compare both groups concerning key variables and outcomes. This work will comply with the RECORD statement recommendations. Results Descriptive and analytical statistics will be conducted in order to describe and characterize this group of patients. Results will be presented as crude and adjusted odds ratio quantifying the risk associated with BD in pregnancy, childbirth and hospitalization outcomes. Findings will be disseminated via publication in peer-reviewed journals. Conclusions With this nationwide analysis, we expect to contribute to a better understanding of the demographic and clinical profile of pregnant women with BD and to encourage timely medical and psychological interventions during gestation and childbirth. Disclosure No significant relationships.

Introduction Ever since the end of the 19th century that descriptions of acute and transient psychosis (ATP) have been found in the literature. Psychiatrists from different countries gave different names for these types of episodes, throughout the ages. Those early descriptions were an important part of the development of the concept of acute and transient psychotic disorders (F23: ICD-10). Objectives This review aims to provide historical background of the development of different concepts to describe ATP. Methods Non-systematic review of literature on acute and transient psychotic disorders, bouffee delirante, brief psychotic disorder, atypical psychosis. Results In 1876, K.Westphal introduced the term akute primäre Verruckheit, refering to a sudden paranoia associated with delusion ideas and hallucinations. In 1895, Magnan described Bouffée delirante, characterized by a recorrent, sudden psychosis with polymorphic symptoms. Later (1924), the term cycloid psychosis was introduced by K.Kleist: phasic psychosis with good prognosis. Different concepts appeared throughout history: psychogenic psychosis (Wimmer,1916); atypical psychosis (Mitsuda,1942), holodisfrenia (Barahona,1957). Nowadays, the classification systems include many of these concepts in the same categories: Schizophreniform disorder, Brief psychotic disorder (DSM-5), and ATP (F23 in ICD-10). Conclusions All throughout the History of Psychiatry, there was an evolution of concepts associated to ATP. They were strongly influenced by different time epochs. It is important to have context on the historical background of the concepts used in the contemporaneous Psychiatry. Diagnosis is challenging due to their heterogeneous presentation. There are not many studies available, because of ATP’s low diagnostic stability. Disclosure No significant relationships.

Introduction Valproic acid is an antiepileptic drug used in different fields of Psychiatry. It is known mostly for its use in managing patients with bipolar affective disorder. In psychiatry of addiction, there is still no approved indications for its usage, but it is widely prescribed in treating alcohol and cocaine abuse, due to the existence of studies in these addictions. Objectives This review aims to clarify the relation between valproic acid and dependences, particularly cocaine. Methods Non-systematic literature review using a PubMed search, using the following key words: “valproate”; “cocaine use”. Results Cocaine dependence can decrease GABA levels in humans. Valproic acid has multiple mechanisms that favour the synthesis of GABA, potentiating its release and postsynaptic GABAergic response. Because of this, valproic acid was found effective in promoting abstinence and in reducing the use of cocaine. There are studies that support the valproic acid’s use in alcohol and cocaine dependences. Valproic acid has been shown to be promising in relapse prevention. It has also showed efficacy in the management of impulsivity and irritability, what makes it useful in managing patients with borderline personality disorder – patients at higher risk for alcohol or substance use disorders. Conclusions Cocaine addiction involves different phenomena and may respond to distinct pharmacologic approaches. Although some studies need to be confirmed by larger clinical trials, valproic acid seems a promising agent as one of some potential treatments for cocaine dependence. Further studies are required in this field to come to more reliable conclusions. Disclosure No significant relationships.

Introduction Alzheimer’s disease (AD) is the leading cause of dementia worldwide. About 40-50% of AD patients are also affected by depression, with mounting evidence suggesting its association with worse disease prognosis and negative outcomes, such as lower quality of life, higher mortality and more hospitalizations. However, few studies have specifically measured the association of depression with AD hospitalization outcomes. Objectives To characterize depression among all hospitalizations with a registered diagnosis of AD and to explore its association with hospitalization outcomes, including in-hospital mortality, length of stay and discharge destination. Methods A retrospective observational study will be conducted following the RECORD statement. A Portuguese nationwide hospitalization database from all mainland public hospitals will be used. Episodes of inpatients ≥65 years old with a primary or secondary diagnosis of AD (ICD-9-CM code 331.0), discharged between 2008-2015, will be selected. Codes 296.2X, 296.3X, 300.4 and 311 will be used to identify episodes with a concomitant registry of depression at any diagnostic position. Descriptive, univariate and multivariate approaches will be used. Results A total of 61 361 episodes complying with the fixed criteria will be assigned to one of two groups (with vs without depression). Groups will be compared regarding sociodemographic characteristics, comorbidity profile, type of admission (planned vs urgent) and hospitalization outcomes. Results regarding the association of depression and outcomes will be presented as crude and adjusted odds ratios (OR). Conclusions With this nationwide analysis, we expect to contribute to the clarification of depression impact on AD hospitalizations, so that best-practice care may be provided to these patients. Disclosure No significant relationships.

Introduction Uterine cancer is the most common gynecologic malignant neoplasm in developed countries. While depression is up to 3-5 times more common in patients with cancer than in the general population, literature is still limited regarding the relation between Endometrial Cancer and depression. Objectives To analyze Depression among Endometrial Cancer hospitalizations in mainland Portuguese public hospitals (2008-2015). Methods A retrospective observational study was conducted using administrative data from all hospitalizations in Portuguese mainland public hospitals between 2008-2015. All women’s hospitalizations(≥18 years) with a primary diagnosis of Endometrial Cancer (ICD-9-CM 182.x) were selected. Secondary diagnosis of depression was identified with ICD-9-CM 296.2x, 296.3x and 311x codes. Surgical procedures codes 68.4x, 65.6x, 40.3x, 40.5x, 68.6x, 68.9x and 68.8x were used to divide the hospitalizations into surgical vs non-surgical. Groups were compared with Pearson Chi-square test and crude odds ratio(OR) was used to estimate the association between surgery and depression. Results From 10227 hospitalizations with a primary diagnosis of Endometrial Cancer, 533 had a registry of depression(5.2%). Annual depression frequency rose from 2.0% (2008) to 8.3% (2015). Among patients with a record of depression, 73.2% had surgery. Women who had surgery were significantly more likely to have registered depression (p

Introduction Serious mental illness tends to course with a higher prevalence of comorbidities and schizophrenia is a disabling disease that affects approximately 1% of the world population. Worldwide, cerebrovascular accidents are an important cause of mortality and disability and in Portugal they are one of the leading causes of death in the general population. There is growing evidence that the prevalence of strokes is higher in people with schizophrenia, with pronounced age and gender variations. Objectives To describe the sociodemographic and clinical differences among patients hospitalized with a primary diagnosis of cerebrovascular disease with and without a secondary diagnosis of schizophrenia in Portugal. Methods We performed a retrospective observational study using a natiowide hopitalization database containing all hosptalizations registered in Portuguese hosptals from 2008 to 2015. Based on the International Classification of diseases version 9, clinical modification, hospitalizations with a primary diagnosis of stroke were selected (431;433;434), and from those, the ones with a secundary diagnosis of schizophrenia (295.xx) were isolated for a sociodemographic and clinical comparative study. Comorbidities were analysed using the Chalson index score. Results Episodes associated with a secondary diagnosis of schizophrenia were younger (mean: 66 vs 73.7 years; p

Introduction Seizures occur in about 3% cases of alcohol withdrawal. They usually appear within 48 hours after abrupt cessation, and are characterized by a reduction in seizure threshold secondary to adaptation to alcohol. More than 50% of individuals will experience a new seizure and in 5% of these cases, progression to a sustained epilepticus status can occur. Objectives The aim is to do a review of the literature on alcohol withdrawal and the onset of seizures in individuals with alcohol addiction. Methods A literature review was conducted using the PubMed search database. Results Alcohol is a central nervous system (CNS) depressant and chronic consumption causes neuroadaptation in order to maintain homeostasis. This adaptation involves the upregulation of excitatory neurotransmitters systems and the downregulation of inhibitory ones. When consumption is abruptly discontinued, the depressive contribution of alcohol to a previously established balance is disrupted, resulting in withdrawal symptoms associated to a generalized CNS’ hyperexcitability state.Critical episodes increase the risk of delirium tremens, a fatal condition in 20% of untreated cases. Thus, the treatment and prevention of seizure recurrences is essential: the clinical guidelines of the American Society of Addiction Medicine 2020, offer an action proposal. Pharmacological therapy after seizures is the preferential treatment: intravenous administration of fast-acting benzodiazepines (lorazepam and diazepam) is the first line treatment. Conclusions It is essential to monitor signs and symptoms that alert us to the appearance of seizures associated to alcohol withdrawal, effectively treat these cases, prevent recurrences, and provide a quality follow-up for these patients. Disclosure No significant relationships.

Introduction Body dysmorphic disorder (BDD) is a relatively common disorder characterized by a preoccupation with non-existent or slight defects in appearance. It was first described in 1886 by Morselli as dysmorphophobia. Objectives This work reviews the current available data on BDD and its treatment options and describes a clinical case that reports an improvement in symptomatology after surgery. Methods Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “body dysmorphic disorder”, “dysmorphophobia”. Clinical file consultation. Results The usual treatment involves a combination of psychotherapy and pharmacotherapy. Antidepressant medication, mainly selective serotonin reuptake inhibitors (SSRIs) have been used. If the symptoms do not improve, a different SSRI can be considered or clomipramine, venlafaxine or second-generation antipsychotics can be useful. Conclusions The role of surgery remains controversial, several studies indicating that the symptoms typically worsen after an aesthetic procedure because the preoccupation shifts to a different body area. However a recent study reported 32 of the 41 patients that underwent surgery were highly satisfied with the outcome. In our clinical case, our patient, a 20-year-old female with non-delusional dysmorphic ideas about her nose initiated treatment with paroxetine with poor response and was, against medical opinion, submitted to a rhinoplasty. Three weeks after the surgery there was an improvement in preoccupation about her nose. More research should be made to clarify the role of surgery in this disorder that often lacks adequate therapeutical response. Disclosure No significant relationships.

The large uncertainty in the mineral dust direct radiative effect (DRE) hinders projections of future climate change due to anthropogenic activity. Resolving modeled dust mineral speciation allows for spatially and temporally varying refractive indices consistent with dust aerosol composition. Here, for the first time, we quantify the range in dust DRE at the top of the atmosphere (TOA) due to current uncertainties in the surface soil mineralogical content using a dust mineral-resolving climate model. We propagate observed uncertainties in soil mineral abundances from two soil mineralogy atlases along with the optical properties of each mineral into the DRE and compare the resultant range with other sources of uncertainty across six climate models. The shortwave DRE responds region-specifically to the dust burden depending on the mineral speciation and underlying shortwave surface albedo: positively when the regionally averaged annual surface albedo is larger than 0.28 and negatively otherwise. Among all minerals examined, the shortwave TOA DRE and single scattering albedo at the 0.44–0.63 µm band are most sensitive to the fractional contribution of iron oxides to the total dust composition. The global net (shortwave plus longwave) TOA DRE is estimated to be within −0.23 to +0.35 W m−2. Approximately 97 % of this range relates to uncertainty in the soil abundance of iron oxides. Representing iron oxide with solely hematite optical properties leads to an overestimation of shortwave DRE by +0.10 W m−2 at the TOA, as goethite is not as absorbing as hematite in the shortwave spectrum range. Our study highlights the importance of iron oxides to the shortwave DRE: they have a disproportionally large impact on climate considering their small atmospheric mineral mass fractional burden (∼2 %). An improved description of iron oxides, such as those planned in the Earth Surface Mineral Dust Source Investigation (EMIT), is thus essential for more accurate estimates of the dust DRE.

Background: Recent studies show contradictory data on the incidence of hospitalizations for acute bronchiolitis (AB) and an escalating increase in public health burden. Aims and objectives: We aimed to analyze the population-based admission rate for AB in children under 2 years of age, in Portuguese public hospitals, from 2000 to 2015, to assess trends and regional variations in admission rate; outcomes; associated direct health-care costs; and changes in management after the implementation of national guidelines. Methods: Retrospective observational study, conducted using a Portuguese administrative database, which contains all registered public hospitalizations in mainland Portugal, and demographic data from the National Statistics Institute. Results: Over the study period, we recorded 80,491 admissions for AB. The mean admission rate was 26.28 and was higher in the northernmost regions of the country. Along the time, the admission rate rose by an average of 1.6% per year (3.8% in children younger than 3 months) and the average length of stay (LOS) was 6.1 days and decreased, to a minimum of 5.5 days in 2014. The in-hospital mortality rate (0.1%) and the use of invasive ventilation remained stable, but non-invasive ventilation use increased from 0.4% in 2000 to 4% in 2015. The direct estimated total costs were of 72,420,732€. In recent years, there was a decrease in the reported tests and procedures. Conclusions: AB remains a major burden in the healthcare system. The admission rate increased but does not seem to be due to an increase in severity, as LOS decreased, and the use of invasive ventilation and mortality remained unchanged. Keywords: Bronchiolitis, Infants, Public health, Hospitalization

Introduction Psychodermatologic disorders are conditions involving an interaction between the mind and the skin. Dermatitis artefacta (DA), also known as factitial dermatitis, is a frequently unrecognized psychocutaneous illness, in which the patient creates skin lesions to satisfy the unconscious need to presume a sick role. It is more common in women and in patients with a diagnosis of psychiatric illness. This is an exclusion diagnosis and organic causes should be ruled out. Treatment of DA can be challenging and it needs to involve a multidisciplinary approach consisting of dermatologists and mental health professionals. Objectives From a case report the authors intend to present a literature review of dermatitis artefacta. Methods Observation the patient and review the clinical file. Consultation published and referenced scientific articles on PubMed. Results 60 year old man, diagnosed with Bipolar Disorder, was admitted for manic decompensation of his pathology. During physical examination he had sparse erythematous lesions, more exuberant in the neck, scalp, belly and upper limbs. The diagnosis of artifact dermatitis was made after excluding other possible causes. Conclusions Treatment of DA can be challenging and it needs to involve a multidisciplinary approach. Dermatitis artefacta is a long-term disorder, and patients need regular follow up with a dermatologist and a psychiatrist because relapses are common. These doctors must be aware of this possible pathology in order to make a correct diagnosis and treatment of psychiatric disorders that sometimes coexist with skin lesions. The prognosis for most patients is poor leading to self-injury, scarring and poor cosmesis. Disclosure No significant relationships.

Introduction Bipolar Disorder (BD) is a mental disorder characterized by long hospitalizations and frequent need for acute psychiatric care. Hospitalizations represent a valuable quality of care indicator in BD. Objectives The aim of this study was to describe a nationwide perspective of BD related hospitalizations and to use a BigData based approach in mental health research. Methods We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of BD were selected based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes of diagnosis 296.xx (excluding 296.2x; 296.3x and 296.9x). Results A total of 20,807 hospitalizations were registered belonging to 13,300 patients. 33.4% of the hospitalizations occurred in male patients and the median LoS was 16.0 days. Mean age was 47.9 years and male patients were younger(46.6 vs. 48.6; p< 0.001). 59 hospitalizations had a deadly outcome (0.3%). The most common cause of hospitalization in BD was the diagnosis code 296.4x (Bipolar I disorder, most recent episode (or current) manic) representing 34.3% of all hospitalizations, followed by the code 296.5x (Bipolar I disorder, most recent episode (or current) depressed) with 21.4%. The mean hospitalization charges were 3,508.5€ per episode, with a total charge of 73M€ in the 8-year period of this study. Conclusions This is a nationwide study using BigData analysis giving a broad perspective of BD hospitalization panorama at a nationwide level. We found differences in hospitalization characteristics by gender, age and primary diagnosis. Disclosure No significant relationships.

Introduction In this presentation we describe the case of a woman referred to the Sexology Department after having developed symptoms of Persistent Genital Arousal (PGAD) for the last 5 years, during treatment for Depression with Venlafaxine. PGAD is a clinical entity first described in 2001 by Leiblum and Nathan. Despite having received more attention in the last few years, its etiology remains unclear, with numerous causal factors of different natures being suggested. Objectives We aim to describe this clinical case of PGAD and to discuss the possible etiological factors involved as well as to make a brief revision of the literature on this topic. Methods We conducted a detailed interview, focused on the nature of the complaints, psychological history, medications, diet and neurologic disorders and performed a thorough clinical examination. We also searched for relevant articles in medical databases such as PubMed and Google Scholar. Results A 52 year-old woman previously treated for Depression with Venlafaxine complains of involuntary sensations of genital arousal, with perceived vasocongestion, tingling and pulsatlity during her journey to work in public transportations. The symptoms subsided only after getting home 8-10 hours later and reaching orgasm by masturbating. She stopped Venlafaxine in 2015, but these symptoms persisted. Some authors suggest a link between SSRIs/SNRIs and PGAD. Conclusions PGAD is a relatively recent addition to our diagnostic catalog with increasingly more cases being reported in the last few years. It is likely that the condition, however, has no discrete etiology and that a customized approach will be necessary to successfully treat most patients.

Introduction Éric Satie was a French classical music composer born in May of 1866. He composed several music pieces that did not fit the contemporaneous musical standard once he did not follow the orthodox rules of composition and harmonic expression. Objectives To analyse Erik Satie personality traits and possible psychopathological findings. Methods A narrative review was performed using Google Scholar database. Results His music, as it occurs in most musical composers, was said to translate his own personality and state of mind at the time. He was described as an eccentric with multiple descriptions demonstrating unstable and explosive personality traits of pride, determination, perfectionism and a hatred for convention that would put him near a Cluster A type of personality. Conclusions Although some authors conclude that Satie could be diagnosed with Asperger Syndrome I believe that his specificities represent more of personality traits than pathological findings. Disclosure No significant relationships.

Introduction The psychiatric care paradigm has shifted towards community-centered models. Yet, prolonged hospitalizations are still a reality, with debated impact at healthcare systems and patients. Objectives This work aims to describe prolonged hospitalizations in acute psychiatric wards through patients’ sociodemographic and clinical data. Methods We analyzed a national hospitalization database that contained all hospitalization episodes registered in Portuguese public hospitals from 2008 to 2015. All episodes with a primary diagnosis of mental disorder defined as ICD-9-CM codes 290.x-319.x were included. Prolonged hospitalizations were defined as having a LoS ≥ P97.5; LOS ≥180 days or LOS ≥1 year. Age, sex, lengh of stay, in-hospital mortality were analysed. Results The LoS ≥ P97.5(≥62 days) group comprised 3911 hospitalizations (2.3% of all psychiatric hospitalizations) and 1755 patients. The median LOS was 81 days and the mean age was 51 years. Sex was equally distributed, though a higher frequency of male patients was found on the ≥180 days (n=364) and ≥ 1 year (n=121) groups. Psychotic disorders were the main diagnosis at discharge (n= 1769, 45.2%), followed by mood disorders (n=1057, 27.0%) and dementia (n=451, 11.5%). In-hospital mortality increased in the higher LoS groups (1.1%; 4.4%; 9.1%, respectively). Conclusions Overall, middle aged patients with psychotic disorders represent most of the prolonged hospitalizations occurring in acute psychiatric wards. Community-based programs require further development to meet the existing needs. Disclosure No significant relationships.

Introduction Compulsory admission is the last line of intervention in individuals who suffer from severe mental disorders, based on the principles of therapeutic need and social protection. In Portugal, the law configures this measure as a hospitalization by court order. The SARS-CoV-2 coronavirus is a global public health emergency, with multifaceted consequences for people’s lives and health. Several studies are showing a great impact of the pandemic on the overall mental health. Objectives The aim is to assess the impact of the pandemic on the number of involuntary hospitalizations, their socio-demographic and clinical characteristics, and study the differences between 2019 and 2020. Methods Consultation of all patient’s clinical files that were involuntarily admitted in Hospital Magalhães Lemos during 2019 and 2020. Statistical analysis of data. Results The authors claim to investigate the impact of the pandemic on involuntary hospitalizations, the factors of admission and decompensation and other clinical characteristics, by comparing the involuntary hospitalizations during 2019 and 2020. The authors believe that the number of compulsory admissions increased significantly with the pandemic. They also believe that factors such as increased or relapsed consumption of alcohol and drugs, suicide attempts, missed appointments and long-term injectable medication are at the root of this increase in 2020. Conclusions This study helps to analyze the impact of the new coronavirus on compulsory hospitalizations and allows to understand the main factors that aggravate the underlying pathologies. Thus, understanding the targets of greater attention from psychiatrists to avoid the decompensation of patients in times of pandemic in which we currently live. Disclosure No significant relationships.

Introduction Schizophrenia is characterized by long hospitalizations and a recurrent use of chronic and acute psychiatric care. Objectives The aim of this study was to analyze schizophrenia related hospitalizations in Portugal. Methods A retrospective observational study was conducted using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015.Hospitalizations with a primary diagnosis of schizophrenia were selected and schizophrenia subtypes were grouped using the International Classification of Diseases version 9, Clinical Modification(ICD-9-CM) codes of diagnosis 295.xx. Results There was a total of 25,385 hospitalizations in public hospitals of Portugal between 2008 and 2015 with a primary diagnosis of Schizophrenia or other psychotic disorders. A total of 14,279 patients were hospitalized during the study period with an average of 1,78 hospitalizations episodes per patient in the 8-year interval(0.22 hospitalizations/patient/year). 68.0% of the hospitalizations occurred in male patients and the median length of stay was 18.0 days. Mean hospitalization charges were 3,509.7€ per hospitalization, summed to a total charge of 89.1M€. Throughout the study period there was a significant linear decrease in the number of hospitalizations (r = 0.940; B= -47.488; p = 0.001). The last year of the study(2015) had the lowest number of hospitalizations with a total of 2,958 (vs. 3,314 in 2008). When adjusted for the yearly population, there was also a decrease of the number of hospitalizations per 100,000 inhabitants from 31.39 to 28.56 hospitalizations per 100,000 inhabitants between 2008 and 2015, respectively. Conclusions We found differences in hospitalization characteristics by gender, age and primary diagnosis. Disclosure No significant relationships.

Introduction Catatonia is characterized by a bizarre and severe psychomotor change. According to DSM-5, the presence of three or more symptoms is necessary to affirm the diagnosis: stupor, catalepsy, brain flexibility, mutism, negativism, posturing, mannerisms, stereotypes, agitation not influenced by external stimuli, grimaces, echolalia or echopraxia. The association between first- and second-generation antipsychotics (AP) and the onset of catatonia is well established in the literature. In contrast, clozapine is one of the second-generation APs that is recognized for its effectiveness in treating catatonia, rather than inducing it. However, it has been documented that abrupt discontinuation of clozapine can induce rapid clinical deterioration with multiple presentations including: psychoses, cholinergic rebound states, serotonergic syndromes and catatonia. Objectives Review the literature on catatonia associated with abrupt interruption of clozapine. Describe a clinical case. Methods Observation of the patient and consultation the clinical file. Non-systematic literature review on catatonia, clozapine, side effects associated with rapid discontinuation and respective treatment. Results 34-year-old man, with the diagnosis of Schizoaffective Disorder. Admitted due to an acute decompensation with psychotic symptoms resistant to treatment requiring the introduction of clozapine. In the absence of a clinical response, clozapine was suspended, with the consequent appearance of catatonia resistant to benzodiazepines in high doses. Conclusions Its already well established that the abrupt discontinuation of clozapine can trigger catatonia. This clinical case and literature review suits to emphasize the importance of educating psychiatrists on the adverse effects of psychiatric drugs and, in this case, the cautious discontinuation of clozapine in order to avoid its rebound effects.

Introduction Despite being one of the oldest treatments in the field of Psychiatry, Electroconvulsive therapy (ECT) is used worldwide for various severe and treatment-resistant psychiatric disorders, establishing itself as one of the fastest and most effective treatments. Objectives The primary aim of this study was to describe a nationwide epidemiological perspective of the use of ECT in hospitalized psychiatric patients. The secondary aims were to characterize clinical and sociodemographic trends of hospitalized patients who needed ECT. Methods A retrospective-observational study was conducted using an administrative database which gathered all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. We selected all hospitalizations with a procedure code 94.27 - Other electroshock therapy defined by the International Classification of Diseases version-9, Clinical Modification.The variables included in the study were birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status from each single hospitalization episode. Results There were a total of 879 hospitalizations with ECT during the 8-year period of the study. Most of the hospitalizations occurred in female patients (53.4 vs 46.6%), belonging to the age group of 51-70 years old, with a mean age of 50.5 years old. The median LoS was 43.0 days with an IQR of 27.0-68.0 days. The specific primary diagnosis most frequent in all hospitalizations was Major depressive disorder, recurrent episode representing 19.6% of all ECT related hospitalizations. Conclusions In Portugal most of the patients who received ECT were women above middle age, and depressive disorders were the most common indication.

Introduction Having a mental disorder is associated with increased vulnerability to the transmission of the Human Immunodeficiency Virus (HIV) and the prevalence of HIV is higher in people with a severe mental disorder. People with psychiatric comorbidities such as bipolar affective disorder and depressive disorder, post-traumatic stress disorder (physical or sexual abuse) and/or psychoactive substance use have a higher risk of HIV infection. Objectives This work is intended to expose the importance of integrating mental health care with the care of HIV patients. Methods The authors conducted a non-systematic review of the literature, conducting research through Pubmed and Medscape using the keywords ‘Preexposure prophylaxis’, ‘HIV’, ‘Mental health problems’. Results Several factors may contribute to the high comorbidity between HIV and Mental Disorders, including socio-demographic factors, weak social and environmental structures, as well as internalized stigma, social and experienced discrimination. Mental health problems may interfere with the care needed for prevention, including regular HIV testing and/or adherence to Preexposure Prophylaxis (PrEP); and influence access to and adherence to antiretroviral treatment. Conclusions This compelling evidence makes the necessary contribution of integrating mental health into an assessment and continuous treatment of the HIV patient, on the other hand, the assessment and treatment of mental disorders should address sexual health.

Introduction Bipolar disorder (BD) is a severe and chronic illness characterized by episodic changes in mood. The average onset of BD symptoms is estimated between 18 and 22 years. However, many adults retrospectively report symptoms onset in childhood or adolescence. Over the last decades, pediatric bipolar disease (PBD) has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in the pediatric population. Objectives To analyze pediatric hospitalizations related to BD held in mainland Portuguese public hospitals between 2000 and 2015. Methods This retrospective observational study analyzed all pediatric (

Introduction Administrative databases (AD) are repositories of administrative and clinical data related to patient contact episodes with all sorts of health facilities (primary care, hospitals, pharmacies,…).The large number of patients/contact episodes with pharmaceutical facilities available, the systematic and broad register and the fact that AD provides Real-world data are some of the pros in using AD data. Objectives To perform a narrative review on the role of Big Data pharmaceutical registries in Mental Health research. Methods We conducted a narrative review using MEDLINE and Google Scholar databases in order to analyse current literature regarding the role of BigData pharmaceutical registries in Mental Health Research. Results Administrative variables like drug names and prices may be used and linked to other clinical variables such as patients disease, in-hospital mortality, length of stay,(…). The use of electronic medical records may also contribute to systematic surveillance approaches like local or national pharmacovigilance strategies, identification of patients at risk of developing complications and software pop-up warnings related to medication dosage, duplication and lateral effects. The use of Big Data pharmaceutical registries allows to create predictive epidemiological models regarding drugs lateral effects or interactions and may help to perform pharmacovigilance phase 4 clinical trials. Its use may be applied to the optimization of clinical decision, monitoring of drug adverse events, drug cost and administrative monitoring and as surrogate measures of quality care indicators. Conclusions Big Data use in pharmaceutical registries allows to collect large and important clinical and administrative data that may be later used in Mental Health care and research. Disclosure No significant relationships.

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This paper presents a comprehensive description and benchmark evaluation of the tropospheric gas-phase chemistry component of the Multiscale Online Nonhydrostatic AtmospheRe CHemistry model (NMMB-MONARCH), formerly known as NMMB/BSC-CTM, that can be run on both regional and global domains. Here, we provide an extensive evaluation of a global annual cycle simulation using a variety of background surface stations (EMEP, WDCGG and CASTNET), ozonesondes (WOUDC, CMD and SHADOZ), aircraft data (MOZAIC and several campaigns), and satellite observations (SCIAMACHY and MOPITT). We also include an extensive discussion of our results in comparison to other state-of-the-art models. We note that in this study, we omitted aerosol processes and some natural emissions (lightning and volcano emissions). The model shows a realistic oxidative capacity across the globe. The seasonal cycle for CO is fairly well represented at different locations (correlations around 0.3–0.7 in surface concentrations), although concentrations are underestimated in spring and winter in the Northern Hemisphere, and are overestimated throughout the year at 800 and 500 hPa in the Southern Hemisphere. Nitrogen species are well represented in almost all locations, particularly NO2 in Europe (root mean square error – RMSE – below 5 ppb). The modeled vertical distributions of NOx and HNO3 are in excellent agreement with the observed values and the spatial and seasonal trends of tropospheric NO2 columns correspond well to observations from SCIAMACHY, capturing the highly polluted areas and the biomass burning cycle throughout the year. Over Asia, the model underestimates NOx from March to August, probably due to an underestimation of NOx emissions in the region. Overall, the comparison of the modeled CO and NO2 with MOPITT and SCIAMACHY observations emphasizes the need for more accurate emission rates from anthropogenic and biomass burning sources (i.e., specification of temporal variability). The resulting ozone (O3) burden (348 Tg) lies within the range of other state-of-the-art global atmospheric chemistry models. The model generally captures the spatial and seasonal trends of background surface O3 and its vertical distribution. However, the model tends to overestimate O3 throughout the troposphere in several stations. This may be attributed to an overestimation of CO concentration over the Southern Hemisphere leading to an excessive production of O3 or to the lack of specific chemistry (e.g., halogen chemistry, aerosol chemistry). Overall, O3 correlations range between 0.6 and 0.8 for daily mean values. The overall performance of the NMMB-MONARCH is comparable to that of other state-of-the-art global chemistry models.

A highly porous film composed of a three-dimensional network of multi-walled carbon nanotube (MWCNT), also known as buckypaper (BP), was prepared by vacuum filtration of a well-dispersed suspension of MWCNT/H20 with the aid Triton X-100 surfactant. The key contribution of this work is to achieve the best parameters during the preparation of the suspension and find the best way to remove the excess triton X-100 from the nanotube network. The stability of suspension in different pH, the adsorption capacity, and the reusability of MWCNT was also evaluated. The effects of ultrasound parameters on the BP properties were systematically investigated and characterized by Raman Spectroscopy, X-ray diffraction (XRD), high-resolution transmission electron microscopy (HR-TEM), and electric resistivity using a four-point probe technique. In addition, the results of using different solvents to wash the BP after filtration process were analyzed by Thermogravimetric analyses (TGA), Fourier transform infrared spectroscopy (FT-IR), and Field emission gun scanning electron microscopy (FEG-SEM). The optimum condition employed in this work (25 min–40%) exhibited the ID/IG ratio of 2.17 and L002 of 5.597 nm, which suggests less damage to MWCNT. This study confirms that MWCNT-BP can be used to fabricate high-loading CNT/polymer composites with improved electrical properties. Keywords: Multiwalled carbon nanotube, Buckypaper, Triton X-100, Ultrasound probe, Agglomerate

Polyacrylonitrile (PAN) was solubilized in N,N-dimethyl formamide (DMF) and the electrospinning process has been employed to obtain PAN nanofibers (PF). Multiwalled carbon nanotubes (MWCNT) were dispersed with the aid of Triton X-100 surfactant and subsequently centrifugated. Buckypapers (BP/PF) were prepared by vacuum filtration procedure of MWCNT suspension supernatant stacking four PF layers over a nylon membrane. The PF removal was carried out by immersing the BP/PF system in DMF and removal periods of 10 and 30 min were evaluated. Scanning electron microscopy (SEM) has not shown any PAN residue in the MWCNT network resulting in highly porous BP. However, by Fourier transform infrared spectroscopy (FT-IR) a PAN band was found around of 2243 cm−1 corresponding to nitrile group (C≡N). Besides, PAN leftover was evidenced by thermogravimetric analysis (TGA), high-resolution transmission electron microscopy (HR-TEM), electrical characterization through four-point probe, nitrogen adsorption at 77 K, and X-ray diffraction (XRD).

Resumo: A granulomatose com poliangeíte (GPA), previamente denominada granulomatose de Wegener, é uma doença sistémica caracterizada por inflamação granulomatosa necrotizante e vasculite que envolve principalmente o trato respiratório superior e inferior, bem como os rins. O diagnóstico de GPA com base em biopsia por agulha fina (BAF) transtorácica pode ser problemático, levando ao diagnóstico incorreto de cancro. Os autores descrevem o caso de um paciente com provável GPA, inicialmente diagnosticado como cancro do pulmão, que curiosamente respondeu à quimioterapia para cancro do pulmão. Abstract: Granulomatosis with Polyangiitis (GPA), which was formerly named Wegener's Granulomatosis (WG) is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract, as well as kidneys. Diagnosing GPA on the basis of transthoracic fine needle aspiration (TFNA) may be problematic, as it can be misdiagnosed as cancer. We describe a patient with a probable GPA which was originally diagnosed as malignancy, but who responded to lung cancer chemotherapy. Palavras-chave: Vasculite sistémica, Carcinoma não-pequenas células, Biópsia por agulha fina, Keywords: Systemic vasculitis, Non-small-cell lung carcinoma, Fine-needle biopsy