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Uma das estratégias para melhorar a eficiência nas instituições é a gestão por processos, que inclui a criação de uma estrutura formal, o Escritório de Processos, prática pouco utilizada na gestão em saúde pública. Nesse sentido, esta pesquisa objetivou apresentar um estudo de caso para implantação de um Escritório de Processos na Secretaria de Estado de Saúde do Paraná. Para tanto, de maneira descritiva exploratória, aplicou-se um método que perpassa sete fases. Os resultados apontam que o contexto institucional e técnico favorece a implementação, enquanto o ambiente político pode trazer desafios, como resistências a mudanças. O escritório terá como objetivos alinhar estratégias, melhorar práticas de gestão e capacitar equipes, sendo estruturado em divisões especializadas em modelagem e governança de processos. Tal implantação reforça a gestão por processos como ferramenta potente para transformar a gestão em pública de saúde, com vistas a proporcionar serviços de qualidade à população.

ABSTRACTThere is an ongoing burden of pneumococcal disease in children despite the use of pneumococcal conjugate vaccines (PCVs). This phase 3, open-label, single-arm, multisite, descriptive study was designed to evaluate the safety and immunogenicity of a 3 + 1 regimen of V114 (VAXNEUVANCE™), a 15-valent PCV, in South Korean infants and toddlers. Adverse events (AEs) were reported for 14 d following any vaccination, and throughout the study period for serious AEs. Serotype-specific immunoglobulin G (IgG) response rates (proportion of participants meeting an IgG threshold value of ≥0.35 μg/mL) and geometric mean concentrations (GMCs) for the 15 serotypes at 30 d postdose 3 (PD3) and at 30 d postdose 4 (PD4) were evaluated as endpoints. Healthy infants enrolled at 42–90 d after birth were vaccinated with V114 (N = 57). The most commonly reported AEs were those solicited in the trial. The majority of reported AEs were transient and of mild or moderate intensity. Few serious AEs were reported; none were vaccine related. No participants died nor discontinued the study vaccine because of an AE. V114 was immunogenic for all 15 serotypes contained in the vaccine, as assessed by IgG response rates at 30 d PD3 and IgG GMCs at 30 d PD3 and at 30 d PD4. V114 was well tolerated and immunogenic when administered as a 3 + 1 regimen in healthy South Korean infants and toddlers.

BackgroundIncreasing research suggests that gait abnormalities can be a risk factor for Alzheimer's Disease (AD). Notably, there is growing evidence highlighting this risk factor in individuals with amnestic Mild Cognitive Impairment (aMCI), however further studies are needed. The aim of this study is to analyze cognitive tests results and brain-related measures over time in aMCI and examine how the presence of gait abnormalities (neurological or orthopedic) or normal gait affects these trends. Additionally, we sought to assess the significance of gait and gait-related measures as prognostic indicators for the progression from aMCI to AD dementia, comparing those who converted to AD with those who remained with a stable aMCI diagnosis during the follow-up.MethodsFour hundred two individuals with aMCI from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database were included. Robust linear mixed-effects models were used to study the impact of gait abnormalities on a comprehensive neuropsychological battery over 36 months while controlling for relevant medical variables at baseline. The impact of gait on brain measures was also investigated. Lastly, the Cox proportional-hazards model was used to explore the prognostic relevance of abnormal gait and neuropsychological associated tests.ResultsWhile controlling for relevant covariates, we found that gait abnormalities led to a greater decline over time in attention (DSST) and global cognition (MMSE). Intriguingly, psychomotor speed (TMT-A) and divided attention (TMT-B) declined uniquely in the abnormal gait group. Conversely, specific AD global cognition tests (ADAS-13) and auditory-verbal memory (RAVLT immediate recall) declined over time independently of gait profile. All the other cognitive tests were not significantly affected by time or by gait profile. In addition, we found that ventricles size increased faster in the abnormal gait group compared to the normal gait group. In terms of prognosis, abnormal gait (HR = 1.7), MMSE (HR = 1.09), and DSST (HR = 1.03) covariates showed a higher impact on AD dementia conversion.ConclusionsThe importance of the link between gait and related cognitive functions in terms of diagnosis, prognosis, and rehabilitation in aMCI is critical. We showed that in aMCI gait abnormalities lead to executive functions/attention deterioration and conversion to AD dementia.

This paper explores the pivotal transformations in postwar Portuguese architecture, tracing the oscillation between traditional styles and modernist influences from 1923 to 1953. During a period marked by ideological conflict and cultural reassessment, Portuguese architecture experienced a profound metamorphosis, mirroring the nation’s struggle between conservative nationalism and the burgeoning force of modernity. This study delves into the role of key figures such as Fernando Távora and the influence of international movements, notably from Italy and the CIAM, in shaping a new architectural ethos that navigated between heritage and innovation. Through a meticulous examination of architectural projects, periodicals (Arquitectura, Arquitectura portuguesa, Domus, Casabella), and ideological discourses, the paper illuminates how architects negotiated with political and cultural currents to forge the architectural language. A form characterized by its duality, attempted to reconcile the traditionalist values imposed by the Estado Novo regime with a modernist vision inspired by global trends. The transition from the “Português Suave” aesthetic to a more resistant form of modernism, underscored by a critique of superficial stylistic nationalism, encapsulates a broader narrative of resistance and adaptation. The findings underscore the importance of interdisciplinary approaches in understanding architectural evolution, revealing how shifts in political ideology, cultural identity, and international influences converge in the realm of architecture. The paper contributes to a deeper understanding on how the Portuguese architecture context surrounding Fernando Távora’s formative years not only reflected but also contested and reshaped the socio-political landscape of mid-20th century Portugal.

ABSTRACT Objective: To evaluate the role of being human immunodeficiency virus (HIV) positive for predicting the risk of recurrence in women with a cervical high grade squamous intraepithelial lesion (HSIL) diagnosis. Methods: Retrospective observational case-control study, comprising HIV positive (case) and HIV negative (control) women in a 1:4 ratio. Women assisted by the Erasto Gaertner Hospital, between 2009-2018, with cervical HSIL diagnosis, submitted to treatment by Loop electrosurgical excision procedure (LEEP), and with a minimum follow-up of 18 months, were included. The immunological status, number and time to recurrence were analyzed, with p

Voice preferences are an integral part of interpersonal interactions and shape how people connect with each other. While a large number of studies have investigated the mechanisms behind (speaking) voice attractiveness, very little research was dedicated to other types of vocalizations. In this Registered Report, we proposed to investigate voice preferences with an integrative approach. To this end, we used a newly recorded and validated stimulus set of contrasting vocalizations by 22 highly trained female singers speaking and singing the same material (in Brazilian Portuguese) in contrasting styles (sung as a lullaby, as a pop song or as an opera aria; and spoken aloud as if directed to an adult audience and as if directed to an infant). We asked 62 participants to rate these vocalizations in terms of how much they liked them; and we compared the amount of shared taste (that is, how much participants agreed in their preferences) across styles. We found highly idiosyncratic preferences across all styles. Our predictions concerning shared taste were not confirmed: although shared taste was higher for lullaby than for pop singing, it was unexpectedly higher for operatic than pop singing, and higher for infant-directed than adult-directed speech. Conversely, our prediction of limited consistency in average preferences for some singers across styles was confirmed, contradicting sexual selection-based ideas of singing and speaking as ‘backup’ signals of individual fitness. Our findings draw attention to the role of individual differences in voice preferences and highlight the need for a broader approach to understanding the underlying mechanisms of voice preferences. Stage 1 recommendation and review history: https://rr.peercommunityin.org/articles/rec?id=357. Stage 2 recommendation and review history: https://rr.peercommunityin.org/articles/rec?id=802.

Summary: Heterozygous mutations in SLC40A1, encoding a multi-pass membrane protein of the major facilitator superfamily known as ferroportin 1 (FPN1), are responsible for two distinct hereditary iron-overload diseases: ferroportin disease, which is associated with reduced FPN1 activity (i.e., decrease in cellular iron export), and SLC40A1-related hemochromatosis, which is associated with abnormally high FPN1 activity (i.e., resistance to hepcidin). Here, we report three SLC40A1 missense variants with opposite functional consequences. In cultured cells, the p.Arg40Gln and p.Ser47Phe substitutions partially reduced the ability of FPN1 to export iron and also partially reduced its sensitivity to hepcidin. The p.Ala350Val substitution had more profound effects, resulting in low FPN1 iron egress and weak FPN1/hepcidin interaction. Structural analyses helped to differentiate the first two substitutions, which are predicted to cause local instabilities, and the third, which is thought to prevent critical rigid-body movements that are essential to the iron transport cycle. The phenotypic traits observed in a total of 12 affected individuals are highly suggestive of ferroportin disease. Our findings dismantle the classical dualism of FPN1 loss versus gain of function, highlight some specific and unexpected functions of FPN1 transmembrane helices in the molecular mechanism of iron export and its regulation by hepcidin, and extend the spectrum of rare genetic variants that may cause ferroportin disease.

Background: Urinary tract infections (UTIs) are the most common bacterial infections in children. The high variability in pathogen susceptibility rates leads to the lack of clear guidelines for empiric and targeted therapies. In this view, local microbiological surveillance and locally adapted stewardship interventions need to be implemented. Objective: The study aims to describe the results of a pediatric antimicrobial stewardship program on antibiotic prescriptions for UTIs over 8 years in a pediatric general ward of a tertiary center. Design: This quasi-experimental study was conducted between 2015 and 2022, with two different implementations, one in 2018 and one in 2021. Methods: Demographic, clinical, microbiological, and therapeutic data were retrieved from the electronic clinical records of included patients. The primary outcomes were adherence to local guidelines for empiric therapies and the adequacy of targeted therapy. Secondary outcomes were evaluating antibiotic prescription patterns stratified by antibiotics during hospital stay and at discharge, and assessing the microbiological characteristics of UTI episodes. Results: During the study period, 7038 patients were admitted to the pediatric acute care unit (PACU), and 264 (3.7%) were included in this study. Adherence to local guidelines was highest immediately after the interventions, and it slightly decreased thereafter. Use of cephalosporins remained high throughout the 8 years but the changing microbiological scenario observed led to changing recommendations within the study period. An increase in E. coli strains resistant to co-amoxiclav was observed in the last years. Oral second-line agent consumption remained high but was adequate considering the prevalence of resistant bacteria. Conclusion: The variability of antimicrobial consumption reflects the changing resistance patterns for UTIs pathogens, underlying the importance of locally adapted, persevering antimicrobial stewardship interventions.

Epstein-Barr virus (EBV) uses latency programs to colonize the memory B-cell reservoir, and each program is associated with human malignancies. However, knowledge remains incomplete of epigenetic mechanisms that maintain the highly restricted latency I program, present in memory and Burkitt lymphoma cells, in which EBNA1 is the only EBV-encoded protein expressed. Given increasing appreciation that higher order chromatin architecture is an important determinant of viral and host gene expression, we investigated roles of Wings Apart-Like Protein Homolog (WAPL), a host factor that unloads cohesin to control DNA loop size and that was discovered as an EBNA2-associated protein. WAPL knockout (KO) in Burkitt cells de-repressed LMP1 and LMP2A expression, but not other EBV oncogenes, to yield a viral program reminiscent of EBV latency II, which is rarely observed in B-cells. WAPL KO also increased LMP1/2A levels in latency III lymphoblastoid cells. WAPL KO altered EBV genome architecture, triggering formation of DNA loops between the LMP promoter region and the EBV origins of lytic replication (oriLyt). Hi-C analysis further demonstrated that WAPL KO reprogrammed EBV genomic DNA looping. LMP1 and LMP2A de-repression correlated with decreased histone repressive marks at their promoters. We propose that EBV coopts WAPL to negatively regulate latent membrane protein expression to maintain Burkitt latency I.

Knowledge on biodiversity is fundamental for conservation strategies. The Brazilian Pampa region, located in subtropical southern Brazil, is neglected in terms of conservation, and knowledge of its biodiversity is fragmented. We aim to answer the question: how many, and which, species occur in the Brazilian Pampa? In a collaborative effort, we built species lists for plants, animals, bacteria, and fungi that occur in the Brazilian Pampa. We included information on distribution patterns, main habitat types, and conservation status. Our study resulted in referenced lists totaling 12,503 species (12,854 taxa, when considering infraspecific taxonomic categories [or units]). Vascular plants amount to 3,642 species (including 165 Pteridophytes), while algae have 2,046 species (2,378 taxa) and bryophytes 316 species (318 taxa). Fungi (incl. lichenized fungi) contains 1,141 species (1,144 taxa). Animals total 5,358 species (5,372 taxa). Among the latter, vertebrates comprise 1,136 species, while invertebrates are represented by 4,222 species. Our data indicate that, according to current knowledge, the Pampa holds approximately 9% of the Brazilian biodiversity in an area of little more than 2% of Brazil’s total land. The proportion of species restricted to the Brazilian Pampa is low (with few groups as exceptions), as it is part of a larger grassland ecoregion and in a transitional climatic setting. Our study yielded considerably higher species numbers than previously known for many species groups; for some, it provides the first published compilation. Further efforts are needed to increase knowledge in the Pampa and other regions of Brazil. Considering the strategic importance of biodiversity and its conservation, appropriate government policies are needed to fund studies on biodiversity, create accessible and constantly updated biodiversity databases, and consider biodiversity in school curricula and other outreach activities.

Background'Nebbiolo' is a grapevine cultivar typical of north-western Italy, appreciated for producing high-quality red wines. Grapevine cultivars are characterized by possessing highly heterozygous genomes, including a great incidence of genomic rearrangements larger than 50 bp, so called structural variations (SVs). Even though abundant, SVs are an under-explored source of genetic variation mainly due to methodological limitations at their detection.ResultsWe employed a multiple platform approach to produce long-range genomic data for two different 'Nebbiolo' clones, namely: optical mapping, long-reads and linked-reads. We performed a haplotype-resolved de novo assembly for cultivar 'Nebbiolo' (clone CVT 71) and used an ab-initio strategy to annotate it. The annotated assembly enhanced our ability to detect SVs, enabling the study of genomic regions not present in the grapevines' reference genome and accounting for their functional implications. We performed variant calling analyses at three different organizational levels: i) between haplotypes of clone CVT 71 (primary assembly vs haplotigs), ii) between 'Nebbiolo' and 'Cabernet Sauvignon' assemblies and iii) between clones CVT 71 and CVT 185, representing different 'Nebbiolo' biotypes. The cumulative size of non-redundant merged SVs indicated a total of 79.6 Mbp for the first comparison and 136.1 Mbp for the second one, while no SVs were detected for the third comparison. Interestingly, SVs differentiating cultivars and haplotypes affected similar numbers of coding genes.ConclusionsOur results suggest that SVs accumulation rate and their functional implications in 'Nebbiolo' genome are highly-dependent on the organizational level under study. SVs are abundant when comparing 'Nebbiolo' to a different cultivar or the two haplotypes of the same individual, while they turned absent between the two analysed clones.

French Guiana, located in the Guiana Shield, is a natural reservoir for many zoonotic pathogens that are of considerable medical or veterinary importance. Until now, there has been limited data available on the description of parasites circulating in this area, especially on protozoan belonging to the phylum Apicomplexa; conversely, the neighbouring countries describe a high parasitic prevalence in animals and humans. Epidemiological surveillance is necessary, as new potentially virulent strains may emerge from these forest ecosystems, such as Amazonian toxoplasmosis. However, there is no standard tool for detecting protozoa in wildlife. In this study, we developed Meat-Borne-Parasite, a high-throughput meta-barcoding workflow for detecting Apicomplexa based on the Oxford Nanopore Technologies sequencing platform using the 18S gene of 14 Apicomplexa positive samples collected in French Guiana. Sequencing reads were then analysed with MetONTIIME pipeline. Thanks to a scoring rule, we were able to classify 10 samples out of 14 as Apicomplexa positive and reveal the presence of co-carriages. The same samples were also sequenced with the Illumina platform for validation purposes. For samples identified as Apicomplexa positive by both platforms, a strong positive correlation at up to the genus level was reported. Overall, the presented workflow represents a reliable method for Apicomplexa detection, which may pave the way for more comprehensive biomonitoring of zoonotic pathogens.

Biochar is recognized as an efficient amendment and soil improver. However, environmental and quality assessments are needed to ensure the sustainability of its use in agriculture. This work considers the biochar's chemical-physical characterization and its potential phyto- and geno-toxicity, assessed with germination and Ames tests, obtaining valuable information for a safe field application. Three biochar types, obtained from gasification at different temperatures of green biomasses from the Tuscan-Emilian Apennines (in Italy), were compared through a broad chemical, physical and biological evaluation. The results obtained showed the relevance of temperature in determining the chemical and morphological properties of biochar, which was shown with several analytical techniques such as the elemental composition, water holding capacity, ash content, but also with FTIR and X-ray spectroscopies. These techniques showed the presence of different relevant surface aliphatic and aromatic groups. The procedures for evaluating the potential toxicity using seeds germination and Ames genotoxicity assay highlights that biochar does not cause detrimental effects when it enters in contact with soil, micro- and macro-organisms, and plants. The genotoxicity test provided a new highlight in evaluating biochar environmental safety.

Several coronaviruses infect humans, with three, including the SARS-CoV2, causing diseases. While coronaviruses are especially prone to induce pandemics, we know little about their evolutionary history, host-to-host transmissions, and biogeography. One of the difficulties lies in dating the origination of the family, a particularly challenging task for RNA viruses in general. Previous cophylogenetic tests of virus-host associations, including in the Coronaviridae family, have suggested a virus-host codiversification history stretching many millions of years. Here, we establish a framework for robustly testing scenarios of ancient origination and codiversification versus recent origination and diversification by host switches. Applied to coronaviruses and their mammalian hosts, our results support a scenario of recent origination of coronaviruses in bats and diversification by host switches, with preferential host switches within mammalian orders. Hotspots of coronavirus diversity, concentrated in East Asia and Europe, are consistent with this scenario of relatively recent origination and localized host switches. Spillovers from bats to other species are rare, but have the highest probability to be towards humans than to any other mammal species, implicating humans as the evolutionary intermediate host. The high host-switching rates within orders, as well as between humans, domesticated mammals, and non-flying wild mammals, indicates the potential for rapid additional spreading of coronaviruses across the world. Our results suggest that the evolutionary history of extant mammalian coronaviruses is recent, and that cases of long-term virus–host codiversification have been largely over-estimated.

IntroductionExcessive daytime sleepiness (EDS) is a common and debilitating symptom in both forms of myotonic dystrophy (DM), significantly impacting patients’ quality of life. The review focuses on the purpose of examining the current understanding of EDS in these conditions, the difficulty in correctly accessing it, the recent findings related to its etiology and prevalence, and a summary of potential therapeutic implications.MethodsWe conducted a comprehensive search through PubMed, selecting studies that provided significant insights into the mechanisms, prevalence, and management of EDS in DM1 and DM2.Results and discussionEDS is highly prevalent in both DM1 and DM2. Polysomnographic studies have revealed prominent dysregulation of REM sleep in DM1, suggesting a possible narcoleptic-like phenotype and alterations in NREM sleep that contributes to daytime sleepiness. Other factors have been proposed to explain EDS in DM1, including dysregulation of the sleep-wake circadian rhythm through nocturnal actigraphy analysis. The central origin of EDS is increasingly delineated supported by serotonin and orexin pathways dysfunction, and recent neuroradiological findings showing that in DM1 hippocampus volume was positively correlated with self-reported fatigue and somnolence. Sleep-disordered breathing and respiratory dysfunctions are prevalent in DM, their direct correlation with EDS remains complex and inconclusive, but respiratory evaluation should be recommended if obstructive sleep apneas or respiratory muscle dysfunctions are suspected. Drug interventions, such as modafinil and mexiletine, have shown promise in managing excessive daytime sleepiness and reducing myotonia without significant cardiac conduction effects. Enhancing EDS management in myotonic dystrophy is key to improving overall patient well-being.

Background: Exercise is recommended for patients with chronic heart failure (CHF) and its intensity is usually set as a percentage of the maximal work rate (MWR) during cardiopulmonary exercise testing (CPX) or a symptom-limited incremental test (SLIT). As these tests are not always available in cardiac rehabilitation due to logistic/cost constraints, we aimed to develop a predictive model to estimate MWR at CPX (estMWR@CPX) in CHF patients using anthropometric and clinical measures and the 6-min walk test (6 MWT), the most widely used exercise field test. Methods: This is a multicentre cross-sectional retrospective study in a cardiac rehabilitation setting. Six hundred patients with HF in New York Heart Association (NYHA) functional class I-III underwent both CPX and 6 MWT and, through multivariable linear regression analysis, we defined several predictive models to define estMWR@CPX. Results: The best model included 6 MWT, sex, age, weight, NYHA class, left ventricular ejection fraction (LVEF), smoking status and chronic obstructive pulmonary disease COPD (adjusted R2 = 0.55; 95% LoA −39 to 33 W). When LVEF was excluded as a predictor, the resulting model performed only slightly worse (adjusted R2 = 0.54; 95% LoA −42 to 34 W). Only in 34% of cases was the percentage difference between estMWR@CPX and real MWR@CPX

Regulation coefficients assessment in a particle accelerator power conversion system depends on the topology, the magnet and the desired transient response. The series/parallel combination of a generic power converter (a brick) to develop a larger one (e.g., the SIRIUS power converter family developed at CERN) allows to feed several magnets with different parameters. Then, such standardization allows to develop a control platform and associated regulation system that is common to all the possible configurations. Regardless of the clear flexibility, the commissioning of these converters faces some drawbacks, like the large amount of coefficient sets and the tuning performed for different workers: this leads to certain inconsistency and spread in the transient responses obtained, which is coherent with the inherent subjectivity of the adopted approach. In this work, a methodology for automatic identification of regulator coefficients is developed. From the definition of a desired time transient response, the method uses the response to a step voltage test to evaluate some figures of merit and the particle swarm technique to change the coefficients accordingly to the error obtained. A MATLAB-based app to implement the method in a user-friendly environment is developed. Experimental results based on a $400\operatorname{kW}$ prototype validate the proposal.

Introduction. In the last decade, the significant expenditure and consumption increase of vitamin D in Italy led some regions to adopt strategies to improve prescribing appropriateness and contain expenditure. Materials and methods. Using the statistical analysis method of interrupted time series for consumption and expenditure of cholecalciferol, different types of interventions adopted in four Italian regions and their efficacy were evaluated. Results. Molise achieved the best results by adopting a health professionals’ education program in addition to a prescriber-sanction system. Emilia-Romagna also opted for a medical education strategy, but the results were less relevant due to the lack of penalties. Lazio obtained a slowdown in consumption growth by targeting on the utilization of lower-cost per defined daily dose (DDD) packs and adopting a therapeutic plan. Sardinia showed a decrease in expenditure by adopting a target threshold of lower-cost formulation. Conclusion. The reimbursement of the lowest-cost packs within the National Health Service (NHS) undoubtedly influences spending trend, but it does not solve prescriptive inappropriateness.

Background and Clinical Significance: Biliary tract injuries are a recognized complication of laparoscopic cholecystectomy. Early diagnosis and prompt management are crucial to minimize complications such as bile leaks, strictures, and fistula formation. This case report highlights the use of a biodegradable biliary stent in managing a complex biliary injury and discusses the impact of delayed diagnosis on treatment outcomes. Case Presentation: We present the case of a 30-year-old male who sustained a Strasberg E2 biliary tract injury during a laparoscopic cholecystectomy. Initially misdiagnosed, the injury was only recognized on the fourth postoperative day. The patient underwent a Roux-en-Y hepaticojejunostomy and subsequently developed a postoperative biliary fistula, which was managed with percutaneous drainage. A biodegradable biliary stent was later placed to address a stricture and minimize the need for future interventions. One year later, the patient presented with symptoms of cholangitis, and radiological findings revealed a narrowing of the biliary lumen. The stricture was resolved and an endoscopic gastrojejunal shunt was placed to prevent further complications. The patient is currently in good condition with no signs of further complications. Conclusions: This case emphasizes the importance of early diagnosis in managing biliary tract injuries and highlights the potential of biodegradable stents to reduce the need for repeat interventions. Despite a delayed diagnosis necessitating complex surgical procedures, the use of a biodegradable stent proved effective in managing postoperative complications. Further studies are needed to evaluate the long-term efficacy of biodegradable stents in similar clinical scenarios.

Background: Skin and soft-tissue infections (SSTIs) are common infectious syndromes in children. Overusing broad-spectrum antibiotics has contributed to rising antibiotic resistance, complicating treatment outcomes. To address this issue, antimicrobial stewardship programs (ASPs) have been implemented to optimize antibiotic use. This study evaluated the impact of a multifaceted ASP on antibiotic prescribing practices for SSTIs in a pediatric acute care setting over eight years. Methods: We conducted a quasi-experimental study at the Pediatric Acute Care Unit of the Padua University Hospital, including children admitted with SSTIs from October 2014 to September 2022, to evaluate the impact of a multifaceted ASP implemented in October 2015. The study was divided into three periods: pre-implementation (October 2014–September 2015), post-implementation (October 2015–March 2020), and COVID-19 (April 2020–August 2022). Data on antibiotic prescriptions and microbiological results were collected and analyzed. Results: The implementation of the ASP led to a significant reduction in the use of broad-spectrum antibiotics, particularly third-generation cephalosporins (from 40.4% to 9.8%) and glycopeptides (from 21.1% to 1.6%). There was a notable increase in the prescription of Access antibiotics, from 30% in the pre-implementation to over 60% in the post-implementation and 80% during COVID-19. No increase in the hospital length of stay was observed. Microbiological results showed no significant changes in bacterial profiles over time. Conclusions: The use of the ASP effectively improved antibiotic prescribing practices, reducing reliance on broad-spectrum antibiotics even during the COVID-19 pandemic. These findings highlight the value of ongoing stewardship efforts and suggest the need for similar programs in ambulatory settings to further address antibiotic resistance.

IntroductionMuscle-specific kinase (MuSK)- myasthenia gravis (MG) is caused by pathogenic autoantibodies against MuSK that correlate with disease severity and are predominantly of the IgG4 subclass. The first-line treatment for MuSK-MG is general immunosuppression with corticosteroids, but the effect of treatment on IgG4 and MuSK IgG4 levels has not been studied.MethodsWe analyzed the clinical data and sera from 52 MuSK-MG patients (45 female, 7 male, median age 49 (range 17–79) years) from Italy, the Netherlands, Greece and Belgium, and 43 AChR-MG patients (22 female, 21 male, median age 63 (range 2–82) years) from Italy, receiving different types of immunosuppression, and sera from 46 age- and sex-matched non-disease controls (with no diagnosed diseases, 38 female, 8 male, median age 51.5 (range 20–68) years) from the Netherlands. We analyzed the disease severity (assessed by MGFA or QMG score), and measured concentrations of MuSK IgG4, MuSK IgG, total IgG4 and total IgG in the sera by ELISA, RIA and nephelometry.ResultsWe observed that MuSK-MG patients showed a robust clinical improvement and reduction of MuSK IgG after therapy, and that MuSK IgG4 concentrations, but not total IgG4 concentrations, correlated with clinical severity. MuSK IgG and MuSK IgG4 concentrations were reduced after immunosuppression in 4/5 individuals with before-after data, but data from non-linked patient samples showed no difference. Total serum IgG4 levels were within the normal range, with IgG4 levels above threshold (1.35g/L) in 1/52 MuSK-MG, 2/43 AChR-MG patients and 1/45 non-disease controls. MuSK-MG patients improved within the first four years after disease onset, but no further clinical improvement or reduction of MuSK IgG4 were observed four years later, and only 14/52 (26.92%) patients in total, of which 13 (93.3%) received general immunosuppression, reached clinical remission.DiscussionWe conclude that MuSK-MG patients improve clinically with general immunosuppression but may require further treatment to reach remission. Longitudinal testing of individual patients may be clinically more useful than single measurements of MuSK IgG4. No significant differences in the serum IgG4 concentrations and IgG4/IgG ratio between AChR- and MuSK-MG patients were found during follow-up. Further studies with larger patient and control cohorts are necessary to validate the findings.

O câncer é um grupo de várias doenças em que há proliferação celular desordenada, dando origem a células anormais. Além de ser uma patologia que causa ameaça à vida, é uma doença desconhecida, que remete a perigo, sofrimento, culpa e dor. Atualmente, a mortalidade por neoplasias configura-se como a terceira principal causa de morte entre os homens brasileiros. Existe um distanciamento dos indivíduos do sexo masculino dos serviços de saúde, levando então a um diagnóstico tardio e consequentemente um nível mais avançado e grave das neoplasias. Outro aspecto importante revelado pela observação dos tipos de câncer mais comuns entre homens é que por vezes essa patologia pode acometer partes anatômicas permeadas de tabus, onde os métodos diagnósticos mais comuns compartilham de uma invasão íntima, situação que pode afrontar as percepções estabelecidas pela masculinidade estrutural, repercutindo então negativamente na relação que esse sujeito vai estabelecer com as limitações impostas pela doença. Compreender a percepção de adoecimento para o paciente masculino e o impacto causado pelo câncer em sua identidade subjetiva. Trata-se de um estudo do tipo relato de experiência, que se caracteriza como uma narração das experiências vividas em um contexto, pelo ponto de vista e entendimento do autor. Um método possível dentro das pesquisas descritivas, transmitindo conhecimento com o aporte científico relacionado. A influência do conceito de masculinidade e patriarcado é profundamente arraigada nos homens, sendo parte de uma cultura transmitida de geração em geração. Essa cultura delineia os papeis de ambos os sexos na sociedade, atribuindo ao homem a responsabilidade de prover a família, realizar trabalhos que demandem força e proteção, e sugerindo que ele não necessita de cuidados por sua suposta força e virilidade. As mudanças que são impostas pelo adoecimento oncológico acabam a exigir mais desses homens, como uma reformulação da sua autoimagem, as atitudes sobre si mesmos, redefinindo seus papeis sociais. É uma convocação para reconstruírem a percepção sobre seus corpos, ressignificando sua própria identidade. Permeando suas compreensões e comportamentos sociais, subjetivos, sexuais e sobre a possibilidade da própria morte. Os tópicos explorados e casos relatados tiram das sombras e trazem a luz a reflexão de como o homem é invadido pelas normas sociais, considerando o modelo de masculinidade hegemônica que influencia de modo total a forma como esses sujeitos enfrentam essa vivência do adoecimento oncológico, sem prazos de validade ou limites de evolução, vendo o amanhã como uma incerteza, imprevisível.