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Zusammenfassung: Systemischer Lupus erythematodes (SLE), das Antiphospholipid-Syndrom (APS) und das Sjögren-Syndrom (SS) sind heterogene Autoimmunerkrankungen. Schwere Ausprägungen sowie Therapieresistenz bzw. -unverträglichkeit gegenüber herkömmlichen Immunsuppressiva erfordern andere Behandlungsoptionen, d.h. biologische Arzneimittel und kleine Moleküle. Unser Ziel war es, evidenz- und praxisbasierte Leitlinien für die zulassungsüberschreitende Anwendung von Biologika bei SLE, APS und SS zu definieren. Die Empfehlungen wurden nach einem umfassenden Literaturreview und 2 Konsensrunden durch ein unabhängiges Expertengremium abgegeben. Das Gremium umfasste 17 Experten für Innere Medizin mit anerkannter Praxis im Bereich der Behandlung von Autoimmunerkrankungen. Die Literaturrecherche erfolgte systematisch für die Jahre von 2014 bis 2019 und wurde später durch Querverweisprüfungen und Experteninformationen bis 2021 aktualisiert. Es wurden vorläufige Empfehlungen von Arbeitsgruppen für jede Krankheit erarbeitet. Ein Revisionsmeeting mit allen Experten fand vor dem Konsensmeeting im Juni 2021 statt. Alle Experten stimmten in 2 Runden ab (stimme zu, stimme nicht zu, stimme weder zu noch widerspreche ich), und Empfehlungen mit mindestens 75% Zustimmung wurden anerkannt. Insgesamt 32 abschließende Empfehlungen (20 für die SLE-, 5 für die APS- und 7 für die SS-Behandlung) wurden von den Experten anerkannt. Diese Empfehlungen berücksichtigen die Organbeteiligung, die Ausprägung, den Schweregrad und das Ansprechen auf frühere Behandlungen. Bei diesen 3 Autoimmunkrankheiten beziehen sich die meisten Empfehlungen auf Rituximab, was auf die höhere Anzahl von Studien und der klinischen Erfahrung mit diesem biologischen Wirkstoff zurückzuführen ist. Eine sequenzielle Behandlung mit Belimumab nach Rituximab kann auch bei schweren Fällen von SLE und SS indiziert sein. Eine Zweitlinientherapie mit Baricitinib, Bortezomib, Eculizumab, Secukinumab oder Tocilizumab kann bei SLE-spezifischen Ausprägungen erwogen werden. Diese evidenz- und praxisbasierten Empfehlungen können die Behandlungsentscheidung unterstützen und letztendlich das Behandlungsergebnis bei Patienten mit SLE, APS oder SS verbessern. [ABSTRACT FROM AUTHOR]

With the COVID-19 pandemic, many productive sectors were impacted and had to make changes to survive in the context of uncertainties, including organic agriculture. Thus, the objective of the research was to highlight the changes in the organic cotton production chain arising from the COVID-19 pandemic. The research characterizes by a qualitative approach based on a case study on the production chain of the Justa Trama cooperative, which has production links in different regions of Brazil. Data collection was carried out through semi-structured interviews with six people, one from each link. Data were interpreted using content analysis by analysis categories, according to pre-defined keywords. It was concluded that the pandemic changed the way of working in the links, but there was no damage to Justa Trama. In addition, the organic cotton production chain is subject to some challenges, such as drought, lack of technical assistance, little incentive to adhere to organic production, and difficulty finding qualified labor. These are relevant points found in the research, which indicate the need for workers in the production chain to access public policies and funding. [ABSTRACT FROM AUTHOR]

Background: Chronic benzodiazepine use is a challenge in primary care practice. Protocols to support safe discontinuation are still needed, especially in countries with high utilization rates.Objectives: To evaluate the feasibility, effectiveness, and safety of a benzodiazepine discontinuation protocol in primary care setting.Methods: Nonrandomized, single-arm interventional study, at primary care units. Family physicians (FPs) recruited patients (18-85 years-old) with benzodiazepine dependence and chronic daily use ≥3 months. Patients with daily dosages ≥30 mg diazepam-equivalent, taking zolpidem, with a history of other substance abuse or major psychiatric disease were excluded. After the switch to diazepam, the dosage was gradually tapered according to a standardized protocol. Primary endpoint was the percentage of patients who stopped benzodiazepine at the intervention last visit. Dosage reduction, withdrawal symptoms, patients' and FPs' satisfaction with the protocol were evaluated.Results: From 66 enrolled patients (74% female; 66.7% aged >64 years; median time of benzodiazepine use was 120 months), 2 withdrew due to medical reasons and 3 presented protocol deviations. Overall, 59.4% of participants successfully stopped benzodiazepine (60.7% when excluding protocol deviations). Men had higher probability of success (relative risk = 0.51, P = 0.001). A total of 31 patients reported at least 1 withdrawal symptom, most frequently insomnia and anxiety. Most of participating FP considered the clinical protocol useful and feasible in daily practice. Among patients completing the protocol, 77% were satisfied. For the patients who reduced dosage, 85% kept without benzodiazepines after 12 months.Conclusion: The discontinuation protocol with standardized dosage reduction was feasible at primary care and showed long-term effectiveness. [ABSTRACT FROM AUTHOR]

Guidance about treatment-resistant depression (TRD) in Portugal is very limited, even though depression prevalence is among the highest in European countries. A questionnaire was conducted, followed by two advisory boards with seven Portuguese psychiatry experts, to characterize and discuss MDD and TRD epidemiology, diagnosis, patient journey, treatment options, and unmet clinical needs. Consensus was reached on the main issues. In daily practice, TRD can be defined as moderate to severe MDD episodes with insufficient clinical improvement after two antidepressant treatments, taken in adequate doses and duration. TRD diagnosis and treatment are mostly decided by psychiatrists at public hospitals. Treatment type and duration must be adjusted to characteristics of the patient and the depressive episode, including symptoms, number of previous episodes, comorbidities, and previous treatment response and side effects. The most relevant objectives of TRD treatment are reaching response and remission, prevention of suicide, and improvement of quality of life, functionality, and wellbeing. Regarding pharmacotherapy, antidepressant switch occurs more frequently with non-response, while optimization, combination, and augmentation are considered for patients with partial response. Psychotherapy should be considered in parallel to pharmacological treatment. Brain stimulation techniques are underused. Lifelong treatment is required for recurrent or more chronic TRD episodes, but patient adherence is also poorer in these cases. In Portugal, TRD management is limited by lack of access to specialist care and to many treatment options. These aspects highlight that conventional pharmacotherapy does not lead to remission in many patients and that optimization strategies are frequently necessary to achieve satisfactory treatment outcomes. [ABSTRACT FROM AUTHOR]

The relationship between cardiovascular health and climatic conditions is a central issue of cardiological research in order to face the global warming challenge. This article analyses 15 locations in rural Spain between 1920 and 1950. The main objective is to know how temperature affected mortality due to cardiovascular causes in a historical context. Based on historical data on the cause of death, age, sex, time of death and temperature, an analysis has been carried out using descriptive statistics and MLS regressions to determine the effects of extreme temperatures on cardiovascular health. The results evidence that mortality from cardiovascular causes was concentrated on the coldest and hottest days of the year, and on subsequent days, being especially important in the case of deaths from ischemic heart disease. There is a pattern of summer-winter differentiated mortality depending on the hottest and coldest hours of the day. [ABSTRACT FROM AUTHOR]

This article analyses the evolution of the weekly distribution of weddings, over about 250 years, in the municipality of Fafe, located in the north of Portugal, based on a sample of microdata made up of 26,841 wedding dates that allow to observe the weekly pattern of weddings in the municipality of Minho, establishing a relation to the differential indicators: demographic and socioeconomic behaviours of the bride and groom, between 1650 and 1905. The results showed trends according to the characteristics of the bride and the groom. Over more than two centuries, there was a predominance of Sunday and Monday acts. However, these results do not cover all individuals since premarital conceptions and socio-professional indicators influenced the choice of the wedding day. [ABSTRACT FROM AUTHOR]

Background: Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients.Objective: To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients.Setting: Non-institutionalised elderly patients in Denmark.Methods: Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different.Main Outcome Measure: Medication adherence based on pill-count.Results: A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18–0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions.Conclusion: Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately. [ABSTRACT FROM AUTHOR]