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ABSTRACT The aim of this study is to assess the effects of once-daily oral orforglipron on weight and metabolic markers in adult patients. PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases were systematically searched until February 2024 for randomized controlled trials (RCTs) comparing orforglipron versus placebo or other anti-obesity medications in adult patients. Weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) or risk differences for binary endpoints were computed, with 95% confidence intervals (CIs). Heterogeneity and risk of bias were assessed with I2 statistics and Rob-2, respectively. Statistical analyses were performed using R, version 4.2.2. A total of four studies were included, comprising 815 patients, of whom 620 (76.1%) were prescribed orforglipron. Compared with placebo, orforglipron reduced body weight (WMD -6.14 kg, 95% CI -9.62 to -2.66 kg), body mass index (WMD -2.87 kg/m2, 95% CI -4.65 to -1.10 kg/m2), and waist circumference (WMD -5.32 cm, 95% CI -9.13 to -1.51 cm). More patients treated with orforglipron than placebo achieved a weight loss of ≥ 5% (RR 3.31, 95% CI 2.23-4.93), ≥ 10% (RR 5.24, 95% CI 2.07-13.31), and ≥ 15% (RR 9.53, 95% CI 1.26-71.89). The most common adverse events were related to the gastrointestinal tract. In this meta-analysis, the use of once-daily oral orforglipron by adult patients was associated with a significant decrease in body weight, as compared with placebo, with an increase in non-severe gastrointestinal adverse events. Phase 3 RCTs are expected to shed further light on the efficacy and safety of once-daily oral orforglipron over the long term.

ABSTRACT Objective: The quality of care and safety for Telemedicine-discharged patients with suspected respiratory infections are closely related to low rates of prescriptions of unjustified and high-risk medications. This retrospective study aimed to assess adherence to the current COVID-19 guidelines in direct-to-consumer telemedicine encounters at a large center using multidrug stewardship protocols. Methods: A quarterly electronic survey utilizing medical records of individual physician care assessed various quality indicators. Physicians received ongoing adaptive feedback based on personal metrics, with Telemedicine Center recommendations derived from the 2020 Infectious Diseases Society of America guidelines. The study included all consecutive adults with new respiratory symptoms in the last 14 days who sought spontaneous Telemedicine consultations between March 2020 and August 2021. This study analyzed patients with suspected or confirmed COVID-19 and other airway infections. Results: Of the 221,128 evaluated patients, 42,042 (19%) had confirmed COVID-19; 104,021 (47%) were suspected to have COVID-19; and, 75,065 (33%) had other diagnoses. Patients with suspected or confirmed COVID-19 had a mean (+DP) age of 35±12 years. A total of 125,107 (85.65%) patients were managed at home, 2,552 (1.74%) were referred for non-urgent in-office reassessment, and 17,185 (11.7%) were referred to the emergency department for whom there was no further treatment recommendation. The antibiotic rate in confirmed or suspected COVID-19 cases was 0.46%/0.65% and that for non-evidence-based prescriptions was 0.01%/0.005%. Conclusion: Guideline training and Telemedicine consultation feedback may lead to lower antibiotic and antimicrobial prescriptions in suspected and confirmed COVID-19 cases. Multidrug stewardship protocols may improve guideline adherence and reinforce the quality of care and safety in Telemedicine encounters.

ABSTRACT The aim of this study was to assess the efficacy and safety of hybrid closed-loop (HCL) systems for insulin delivery in children and adolescents with type 1 diabetes (T1D). We searched Embase, PubMed, and Cochrane Library for randomized controlled trials (RCTs) published until March 2023 comparing the HCL therapy with control therapies for children and adolescents with T1D. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) with 95% confidence intervals (CIs) for binary endpoints. Four RCTs and 501 patients were included, of whom 323 were randomized to HCL therapy. Compared with control therapies, HCL significantly improved the period during which glucose level was 70-180 mg/dL (WMD 10.89%, 95% CI 8.22-13.56%) and the number of participants with glycated hemoglobin (HbA1c) level < 7% (RR 2.61, 95% CI 1.29-5.28). Also, HCL significantly reduced the time during which glucose level was > 180 mg/dL (WMD -10.46%, 95% CI -13.99 to -6.93%) and the mean levels of glucose (WMD -16.67 mg/dL, 95% CI -22.25 to -11.09 mg/dL) and HbA1c (WMD -0.50%, 95% CI -0.68 to -0.31). There were no significant differences between therapies regarding time during which glucose level was < 70 mg/dL or

Obstructive sleep apnea (OSA) affects neurobehavioral, cognitive, and cardiovascular aspects, particularly in children, by obstructing the upper airways during sleep. While its impact in adult ocular health is recognized, there is ongoing debate about OSA’s relevance in pediatrics. This review explores the relationship between OSA and ocular health in children, focusing on the effects and potential improvements through treatment. A systematic search found 287 articles through PubMeD/MEDLINE, Scopus, Web of Science, and ScienceDirect; 94.4% were excluded. After careful selection, six English articles were included, addressing the effects of OSA on children’s eyes. Three studies examined choroidal alterations, three explored retinal and optic nerve changes, and two analyzed ocular changes following otorhinolaryngological intervention. The immediate correlation in children is inconclusive, but age may be a contributing factor. Pediatric OSA patients exhibit corneal anomalies and increased optic nerve thickness, possibly due to intermittent hypoxia. OSA influences retinal vascular density in children, with increased density after treatment and reduced choroidal thickness in cases of adenotonsillar hypertrophy. This review emphasized OSA’s significant impact on children’s ocular health, revealing alterations in the optic nerve, choroid, retina, and cornea. While the direct correlation with the optic nerve is not always evident, OSA raises intraocular pressure and induces structural changes. Treatment holds promise, highlighting the need for regular monitoring to promptly address childhood OSA.

ABSTRACT Objective: To develop and validate predictive models to estimate the number of COVID-19 patients hospitalized in the intensive care units and general wards of a private not-for-profit hospital in São Paulo, Brazil. Methods: Two main models were developed. The first model calculated hospital occupation as the difference between predicted COVID-19 patient admissions, transfers between departments, and discharges, estimating admissions based on their weekly moving averages, segmented by general wards and intensive care units. Patient discharge predictions were based on a length of stay predictive model, assessing the clinical characteristics of patients hospitalized with COVID-19, including age group and usage of mechanical ventilation devices. The second model estimated hospital occupation based on the correlation with the number of telemedicine visits by patients diagnosed with COVID-19, utilizing correlational analysis to define the lag that maximized the correlation between the studied series. Both models were monitored for 365 days, from May 20th, 2021, to May 20th, 2022. Results: The first model predicted the number of hospitalized patients by department within an interval of up to 14 days. The second model estimated the total number of hospitalized patients for the following 8 days, considering calls attended by Hospital Israelita Albert Einstein’s telemedicine department. Considering the average daily predicted values for the intensive care unit and general ward across a forecast horizon of 8 days, as limited by the second model, the first and second models obtained R² values of 0.900 and 0.996, respectively and mean absolute errors of 8.885 and 2.524 beds, respectively. The performances of both models were monitored using the mean error, mean absolute error, and root mean squared error as a function of the forecast horizon in days. Conclusion: The model based on telemedicine use was the most accurate in the current analysis and was used to estimate COVID-19 hospital occupancy 8 days in advance, validating predictions of this nature in similar clinical contexts. The results encourage the expansion of this method to other pathologies, aiming to guarantee the standards of hospital care and conscious consumption of resources.

ABSTRACT Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.

Objective To evaluate the technical notes (TNs) issued by the Center for Technical Support of the Judiciary (Núcleo de Apoio Técnico do Poder Judiciário, NAT-Jus, in Portuguese) of the Brazilian Ministry of Justice regarding lawsuits against the Brazilian Unified Health System (Sistema Único de Saúde, SUS, in Portuguese) concerning bladder/ureteral cancer, in order to better advise the formulation of public policies regarding oncologic care.

Abstract In recent years, the report of loggerhead sea turtle (Caretta caretta) Mediterranean nesting range has expanded together with new records of nests becoming northward on the Italian coastline of the Tyrrhenian and Adriatic seas. These areas are characterized by intensive human activities, such as tourism, fishery, and marine traffic, all possibly involved in the influence of the use of coastal habitat by marine species. These anthropic threats, in addition to the natural ones and the changing environmental characteristics of the beach, may influence the growth of microorganisms causing hatching failures. Among microorganisms, fungal infection by the genus Fusarium (Link, 1809) is considered one of the main causes of globally declining sea turtle populations. In summer 2021, the two northernmost worldwide loggerhead sea turtle nests were monitored along the Northern Adriatic coastline (Veneto, Italy). These first records may potentially candidate this area as suitable for a large part of the loggerhead turtle’s life cycle and it could represent a minor sea turtle nesting area that, according to Prato and colleagues, remained unnoticed due to the lack of specific monitoring. Sea Turtle Egg Fusariosis (STEF) was deemed to have deeply compromised the hatching success of the northmost one. Climate change and anthropogenic impacts have been scored as one of the highest hazards to sea turtle health and could have played a role in the STEF development. Environmental changes, human activities, and emerging pathogens deserve the highest attention in terms of health research, and conservation management.

ABSTRACT Objective The primary aim of this study was to understand the difference in the use of Telemedicine by Brazilian physicians before and after the onset of COVID-19 pandemic and their intention to continue using it post the pandemic period. The secondary objective was to analyze the differences of opinion between physicians in the private and public sectors. Methods We conducted an online medical survey through the SurveyMonkey platform in a large hospital in São Paulo, Brazil, from May to July 2022. Results Three-hundred-and -two physicians responded to the survey. We found that there was a significant increase in the number of physicians who started using Telemedicine in both the public and private sectors (p50% of them intend to continue using Telemedicine in their daily practice. Most responders consider that Telemedicine is useful in screening, diagnosis and management of patients; that it facilitates the physician’s daily practice; that it can maintain or even add financial gains through reducing office expenses; and that is another medium for dispensing medical care. They also believe that Telemedicine should be regulated by the Brazilian Federal Council of Medicine. There were no significant differences between the responses from private and public sector physicians. Conclusion Telemedicine has played a major role in healthcare since the onset of COVID-19 pandemic and most of the physicians approve its use and intend to continue using Telemedicine in their daily practice.

Abstract This study investigates the impact of antenatal and postnatal infection or inflammation on the onset and progression of Retinopathy of Prematurity (ROP). We retrospectively collected clinical and demographic data of preterm infants with birth weight ≤ 1500 g or gestational age

Abstract Backgroud Cenegermin (Oxervate, Dompè Farmaceutici, Milan, IT), a recombinant human NGF, is a potentially healing new drug for neurotrophic keratopathy (NK), a rare but challenging disease affecting the cornea. To date, studies that evaluate its mid-term effect on corneal nerves and sensitivity are lacking. Objective To evaluate the recovery and morphology of subbasal corneal nerves in patients treated with Cenegermin for NK and assess their correlation with corneal sensitivity. Methods This prospective, observational case series study was carried out between May 2018 and August 2020 at the Ophthalmic Clinic of the University of Verona. Clinical evaluation, sensitivity, and in vivo confocal microscopy (IVCM) were performed in the central and all four corneal sectors at baseline, the end of therapy (8 weeks), and 2, 4, and 8 months after therapy. Consecutive patients with NK (stage 2–3), treated with Cenegermin (1 drop 6 times daily for 8 weeks), were enrolled. During each visit, Corneal nerve fiber length (CNFL), corneal nerve fiber total branch density (CTBD), corneal nerve fiber fractal dimension (CNFraD) and Cochet-Bonnet esthesiometry (CBE) were measured. Results We enrolled 18 patients. Complete NK healing was noted in 14/18(78%) patients after 8 weeks of treatment; then in 14(78%), 15(83%), and 13(72%) patients at 2-, 4-, and 8-months, respectively. Starting at 8 weeks through 4-month follow-up there was progressive improvement in CBE in all corneal sectors (p ≤ 0.01), which continued thereafter. There was significant corneal nerve regrowth especially in the peripheral cornea: centripetal progression starting at 8 weeks (CNFL and CNFrad) and significant branching starting at 2 months (CTBD), which continued through to the end of follow up. Sector-coupled IVCM and CBE findings correlated at all evaluations (all r ≥ 0.62 starting at 2 months, with highest values in the peripheral sectors). Conclusions After Cenegermin we observed a subbasal corneal nerve regeneration, a recovery of sensitivity and a lasting epithelial healing, suggesting that the effect of its action persists several months after discontinuation in patients with NK.

Abstract Human T-lymphotropic virus type 1 (HTLV-1) infection may cause serious disease, while pathogenicity of HTLV-2 is less certain. There are no screening or surveillance programs for HTLV-1/-2 infection in Brazil. By performing this systematic review, we aimed to estimate the prevalence of HTLV-1/-2 infections in pregnant women in Brazil. This review included cohort and cross-sectional studies that assessed the presence of either HTLV-1/-2 infection in pregnant women in Brazil. We searched BVS/LILACS, Cochrane Library/CENTRAL, EMBASE, PubMed/MEDLINE, Scopus, Web of Science and gray literature from inception to August 2020. We identified 246 records in total. Twenty-six of those were included in the qualitative synthesis, while 17 of them were included in the meta-analysis. The prevalence of HTLV-1 in Brazilian pregnant women, as diagnosed by a positive screening test and a subsequent positive confirmatory test, was 0.32% (95% CI 0.19–1.54), while of HTLV-2 was 0.04% (95% CI 0.02–0.08). Subgroup analysis by region showed the highest prevalence in the Northeast region (0.60%; 95% CI 0.37–0.97) for HTLV-1 and in the South region (0.16%; 95% CI 0.02–1.10) for HTLV-2. The prevalence of HTLV-1 is much higher than HTLV-2 infection in pregnant Brazilian women with important differences between regions. The prevalence of both HTLV-1/-2 are higher in the Northeast compared to Center-West region.

ABSTRACT Objective To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. Methods Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. Results Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). Conclusion Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477

Abstract Food neophobia, i.e., the aversion to novel foods, and olfaction are both factors strongly affecting food choices. Mounting evidence suggests a higher arousal towards food as a key factor underlying the reluctance to eat what is unfamiliar to us. As the role of olfaction behind this phenomenon is poorly understood, we explored the associations between food neophobia and trait anxiety, olfactory functions (odor threshold, discrimination and identification) and retronasal aroma release from a reference food in a healthy cohort of 83 adult volunteers. We grouped participants in Low-Neophobics or neophilics (n = 35), Medium-Neophobics (n = 32) and High-Neophobics (n = 16) according to the widely recognized Food Neophobia Scale. Participants with higher neophobic tendencies were found to have marginally higher trait anxiety levels than neophilics (p = 0.10). A lower global olfactory functioning and odor discrimination abilities characterized High-Neophobics, while Medium-Neophobics showed a higher odor sensitiveness than Low-Neophobics. Lastly, High-Neophobics showed a lower extent of retronasal aroma release, likely due to a shorter duration of oral processing and higher anxiety-related physiological responses (such as breathing rate). In summary, this study supports the assumption that the conflicting relationship that neophobics have with food may be led by higher levels of arousal toward foods, rather than different chemosensory functions.

ObjectiveTo relate preevacuation platelet count and leukogram findings, especially neutrophil/lymphocyte ratios (NLR) and platelet/lymphocyte ratios with the occurrence of gestational trophoblastic neoplasia (GTN) after complete hydatidiform mole (CHM) among Brazilian women.MethodsRetrospective cohort study of patients with CHM followed at Rio de Janeiro Federal University, from January/2015-December/2020. Before molar evacuation, all patients underwent a medical evaluation, complete blood count and hCG measurement, in addition to other routine preoperative tests. The primary outcome was the occurrence of postmolar GTN.ResultsFrom 827 cases of CHM treated initially at the Reference Center, 696 (84.15%) had spontaneous remission and 131 (15.85%) developed postmolar GTN. Using optimal cut-offs from receiver operating characteristic curves and multivariable logistic regression adjusted for the possible confounding variables of age and preevacuation hCG level (already known to be associated with the development of GTN) we found that ≥2 medical complications at presentation (aOR: 1.96, CI 95%: 1.29-2.98, pConclusionAlthough blood count is a widely available test, being a low-cost test and mandatory before molar evacuation, and prognostic for outcome in other neoplasms, its findings were not able to predict the occurrence of GTN after CHM. In contrast, the occurrence of medical complications at presentation and higher preevacuation hCG levels were significantly associated with postmolar GTN and may be useful to guide individualized clinical decisions in post-molar follow-up and treatment of these patients.

Microfibers, whether synthetic or natural, have increased dramatically in the environment, becoming the most common type of particles in the ocean, and exposing aquatic organisms to multiple negative impacts. Using an approach combining morphology (scanning electron microscopy-SEM) and molecular taxonomy (High-Throughput DNA Sequencing- HTS), we investigated the bacterial composition from floating microfibers (MFs) collected in the northwestern Mediterranean Sea. The average number of bacteria in 100 μm2 on the surface of a fiber is 8 ± 5.9 cells; by extrapolating it to a whole fiber, this represents 2663 ± 1981 bacteria/fiber. Attached bacterial communities were dominated by Alteromonadales, Rhodobacterales, and Vibrionales, including the potentially human/animal pathogen Vibrio parahaemolyticus. This study reveals a high rate of bacterial colonization on MFs, and shows that these particles can host numerous bacterial species, including putative pathogens. Even if we cannot confirm its pathogenicity based only on the taxonomy, this is the first description of such pathogenic Vibrio living attached to MFs in the Mediterranean Sea. The identification of MFs colonizers is valuable in assessing health risks, as their presence can be a threat to bathing and seafood consumption. Considering that MFs can serve as vector for potentially pathogenic microorganisms and other pollutants throughout the ocean, this type of pollution can have both ecological and economic consequences.

Introduction Real-world data on COVID-19 vaccine effectiveness are needed to validate evidence from randomized clinical trials. Accordingly, this study aims to evaluate, in a real-world setting in Brazil, the effectiveness of Pfizer-BioNTech BNT162b2 against symptomatic COVID-19 and COVID-19-related complications across diverse populations. Materials and methods A test-negative case-control study with follow-up of cases is currently being conducted in Toledo, a city in southern Brazil, following a mass COVID-19 vaccination campaign with BNT162b2. The study is being conducted among patients aged 12 years or older seeking care in the public health system with acute respiratory symptoms and tested for SARS-CoV-2 on reverse transcription polymerase chain reaction (RT-PCR). Cases are RT-PCR positive and controls RT-PCR negative. Test-positive cases are prospectively followed through structured telephone interviews performed at 15 days post-enrollment, and at 1, 3, 6, 9 and 12 months. Baseline demographic, clinical, and vaccination data are being collected by means of structured interviews and medical registry records reviews at the time of enrollment. All RT-PCR-positive samples are screened for mutations to identify SARS-CoV-2 variants. Ethics and dissemination The study protocol has been approved by the research ethics committee of all participant sites. Study findings will be disseminated through peer-reviewed publications and conference presentations. Trail registration Clinicatrials.gov:NCT05052307.

[This corrects the article DOI: 10.1371/journal.pone.0235537.].

BackgroundFeasibility and safety of ambulance transport between healthcare facilities with medical support exclusively via telemedicine are unknown.MethodsThis was a retrospective study with a single telemedicine center reference for satellite emergency departments of the same hospital. The study population was all critically ill patients admitted to one of the peripheral units from November 2016 to May 2020 and who needed to be transferred to the main building. Telemedicine-assisted transportation was performed by an emergency specialist. The inclusion criteria included patients above the age of 15 and initial stabilization performed at the emergency department. Unstable, intubated, ST-elevation myocardial infarction and acute stroke patients were excluded. There was a double-check of safety conditions by the nurse and the remote doctor before the ambulance departure. The primary endpoint was the number of telemedicine-guided interventions during transport.Results2840 patients were enrolled. The population was predominantly male (53.2%) with a median age of 60 years. Sepsis was the most prevalent diagnosis in 28% of patients, followed by acute coronary syndromes (8.5%), arrhythmia (6.7%), venous thromboembolism (6.1%), stroke (6.1%), acute abdomen (3.6%), respiratory distress (3.3%), and heart failure (2.5%). Only 22 (0.8%) patients required telemedicine-assisted support during transport. Administration of oxygen therapy and analgesics were the most common recommendations made by telemedicine emergency physicians. There were no communication problems in the telemedicine-assisted group.ConclusionsTelemedicine-assisted ambulance transportation between healthcare facilities of stabilized critically ill patients may be an option instead of an onboard physician. The frequency of clinical support requests by telemedicine is minimal, and most evaluations are of low complexity and easily and safely performed by trained nurses.

Introduction: Syphilis is a major public health problem. Its incidence has increased in Brazil, particularly in the Southern Region. New tools are available, and immediate action is necessary. Objective: To describe the pilot study of an investigation aimed to assess the prevalence of syphilis, hepatitis B and C, and HIV and evaluate three strategies for adherence to syphilis treatment. Methods: A spontaneous sample of participants was evaluated with a structured questionnaire and underwent rapid tests for syphilis, HIV, and hepatitis B and C after signing an informed consent form (ICF). Rapid tests reagent for syphilis were confirmed by quantitative venereal disease research laboratory (VDRL) and Treponema pallidum hemagglutination assay (TPHA). Participants with confirmation of syphilis were randomized into three groups for follow-up: telephone calls, SIM app, and usual care at the health unit. Results: During a two-day pilot, 68 participants were included. Fourteen (20.6%) had tests reagent for syphilis, 1 (1.5%) for hepatitis B, 3 (4.4%) for hepatitis C, and 1 (1.5%) for HIV. Eight (57.1%) of the initial 14 individuals with rapid tests reagent for syphilis agreed to participate in the study. Out of the 8 rapid tests for syphilis, 2 (25%) were confirmed as active syphilis (>1/8). Conclusion: The prevalence of active syphilis estimated in this population was 3.5%. The demand for tests was high. The COVID-19 epidemic had a negative impact on the development of the study, which is ready for implementation. Discussions on the role of such a testing unit and the coverage of the research project in a context that requires increasing COVID-19-focused testing are fundamental for the future development of the project.

ABSTRACT Objective: To characterize variables associated with referral to the emergency department following Telemedicine consultation during the COVID-19 pandemic. Methods: Cross-sectional retrospective study conducted between March and May 2020, with a sample of 500 adult patients. The inclusion criterion was the manifestation of respiratory symptoms, regardless of type. Results: The mean age of patients was 34.7±10.5 years, and 59% were women. Most patients (62.6%) perceived their own health status as malaise and some (41.4%) self-diagnosed COVID-19. Cough (74.4%), rhinorrhea (65.6%), sore throat (38.6%) and sneezing (20.6%) were the most common infection-related symptoms. Overall, 29.4% and 16% of patients reported dyspnea and chest pain, respectively. The Roth score was calculated for a sizeable number of patients (67.6%) and was normal, moderately altered or severely altered in 83.5%, 10.7% and 5.6% of patients, respectively. The percentage of suspected COVID-19 cases was 67.6%. Of these, 75% were managed remotely and only one quarter referred for emergency assessment. Conclusion: Telemedicine assessment is associated with reclassification of patient's subjective impression, better inspection of coronavirus disease 2019 and identification of risk patients. Referral is therefore optimized to avoid inappropriate in-person assessment, and low-risk patients can be properly guided. Telemedicine should be implemented in the health care system as a cost-effective strategy for initial assessment of acute patients.

Recent studies describe the use of UAVs in collecting blow samples from large whales to analyze the microbial and viral community in exhaled air. Unfortunately, attempts to collect blow from small cetaceans have not been successful due to their swimming and diving behavior. In order to overcome these limitations, in this study we investigated the application of a specific sampling tool attached to a UAV to analyze the blow from small cetaceans and their respiratory microbiome. Preliminary trials to set up the sampling tool were conducted on a group of 6 bottlenose dolphins (Tursiops truncatus) under human care, housed at Acquario di Genova, with approximately 1 meter distance between the blowing animal and the tool to obtain suitable samples. The same sampling kit, suspended via a 2 meter rope assembled on a waterproof UAV, flying 3 meters above the animals, was used to sample the blows of 5 wild bottlenose dolphins in the Gulf of Ambracia (Greece) and a sperm whale (Physeter macrocephalus) in the southern Tyrrhenian Sea (Italy), to investigate whether this experimental assembly also works for large whale sampling. In order to distinguish between blow-associated microbes and seawater microbes, we pooled 5 seawater samples from the same area where blow samples' collection were carried out. The the respiratory microbiota was assessed by using the V3-V4 region of the 16S rRNA gene via Illumina Amplicon Sequencing. The pooled water samples contained more bacterial taxa than the blow samples of both wild animals and the sequenced dolphin maintained under human care. The composition of the bacterial community differed between the water samples and between the blow samples of wild cetaceans and that under human care, but these differences may have been mediated by different microbial communities between seawater and aquarium water. The sperm whale's respiratory microbiome was more similar to the results obtained from wild bottlenose dolphins. Although the number of samples used in this study was limited and sampling and analyses were impaired by several limitations, the results are rather encouraging, as shown by the evident microbial differences between seawater and blow samples, confirmed also by the meta-analysis carried out comparing our results with those obtained in previous studies. Collecting exhaled air from small cetaceans using drones is a challenging process, both logistically and technically. The success in obtaining samples from small cetacean blow in this study in comparison to previous studies is likely due to the distance the sampling kit is suspended from the drone, which reduced the likelihood that the turbulence of the drone propeller interfered with successfully sampling blow, suggested as a factor leading to poor success in previous studies.

Olfactory groove schwannomas (OGSs) are rare benign tumors of the anterior skull base region. Considering the lack of Schwann cells in the optic and olfactory nerves, their origin remains enigmatic. Despite the precursor cell, total resection of the lesion is curative, as long as the histopathological features of the tumor are compatible with schwannoma. We report the case of a 32-year-old woman, addicted to crack, who was brought to the hospital presenting with cognitive dysfunction after being physically assaulted, whose neuroimaging revealed a large extra-axial mass in the subfrontal sagittal region. The presentation, immunohistochemical markers and histogenesis are discussed in the present study, along with a literature review.

Atypical rhabdoid teratoid tumors (ARTTs) are rare embryonic tumors, usually localized in the posterior fossa and diagnosed in children under 3 years-old. The treatment includes surgical resection, radio and chemotherapy, and the prognostic is unfavorable, with an average median survival of 1 year. We present the case of a 3-year-old patient, with history of headache and vomiting, followed by absence seizures, temporal automatism, syncope accompanied by sialorrhea and sphincteric loss succeeded by a postictal period. Surgical excision was performed and the anatomopathological study confirmed ARTT. The ARTTs are embryonic tumors, a category in which medulloblastoma and primitive neuroectodermal tumors (PNETs) represent the most common central nervous system (CNS) malignancies in childhood.

The study of microplastic pollution involves multidisciplinary analyses on a large number of microplastics. Therefore, providing an overview of plastic pollution is time consuming and, despite high throughput analyses, remains a major challenge. The objective of this study is to propose a protocol to determine how many microplastics must be analyzed to give a representative view of the particle size distribution and chemical nature, and calculate the associated margin error. Based on microplastic data from Tara Mediterranean campaign, this approach is explained through different examples. In this particular case, the results show that only 3% of the collected microplastics need to be analyzed to give a precise view on the scale of the North West Mediterranean Basin (error

Iron overload-related heart failure is the principal cause of death in transfusion dependent patients, including those with Thalassemia Major. Linking cardiac siderosis measured by T2* to therapy improves outcomes. T1 mapping can also measure iron; preliminary data suggests it may have higher sensitivity for iron, particularly for early overload (the conventional cut-point for no iron by T2* is 20ms, but this is believed insensitive). We compared T1 mapping to T2* in cardiac iron overload.In a prospectively large single centre study of 138 Thalassemia Major patients and 32 healthy controls, we compared T1 mapping to dark blood and bright blood T2* acquired at 1.5T. Linear regression analysis was used to assess the association of T2* and T1. A "moving window" approach was taken to understand the strength of the association at different levels of iron overload.The relationship between T2* (here dark blood) and T1 is described by a log-log linear regression, which can be split in three different slopes: 1) T2* low, 30ms, weak relationship. All subjects with T2*20ms, 38% had low T1 with most of the subjects in the T2* range 20-30ms having a low T1.In established cardiac iron overload, T1 and T2* are concordant. However, in the 20-30ms T2* range, T1 mapping appears to detect iron. These data support previous suggestions that T1 detects missed iron in 1 out of 3 subjects with normal T2*, and that T1 mapping is complementary to T2*. The clinical significance of a low T1 with normal T2* should be further investigated.

The Tyrolean Iceman, a 5,300-year-old glacier mummy recovered at the Tisenjoch (South Tyrol, Italy) together with his clothes and personal equipment, represents a unique opportunity for prehistoric research. The present work examines the Iceman's tools which are made from chert or are related to chert working - dagger, two arrowheads, endscraper, borer, small flake and antler retoucher - and considers also the arrowhead still embedded in the shoulder of the mummy. The interdisciplinary results achieved by study of the lithic raw material, technology, use-wear analysis, CT analysis and typology all add new information to Ötzi's individual history and his last days, and allow insights into the way of life of Alpine Copper Age communities. The chert raw material of the small assemblage originates from at least three different areas of provenance in the Southalpine region. One, or possibly two, sources derive from outcrops in the Trentino, specifically the Non Valley. Such variability suggests an extensive provisioning network, not at all limited to the Lessini mountains, which was able to reach the local communities. The Iceman's toolkit displays typological characteristics of the Northern Italian tradition, but also comprises features typical of the Swiss Horgen culture, which will come as no surprise in the toolkit of a man who lived in a territory where transalpine contacts would have been of great importance. Ötzi was not a flintknapper, but he was able to resharpen his tools with a medium to good level of skill. Wear traces reveal that he was a right-hander. Most instruments in the toolkit had reached their final stage of usability, displaying extensive usage, mostly from plant working, resharpenings and breaks. Evidently Ötzi had not had any access to chert for quite some time, which must have been problematic during his last hectic days, preventing him from repairing and integrating his weapons, in particular his arrows. Freshly modified blade tools without any wear suggest planned work which he never carried out, possibly prevented by the events which made him return to the mountains where he was killed by a Southern Alpine archer.

The evolution of organic carbon export to the deep ocean, under anthropogenic forcing such as ocean warming and acidification, needs to be investigated in order to evaluate potential positive or negative feedbacks on atmospheric CO2 concentrations, and therefore on climate. As such, modifications of aggregation processes driven by transparent exopolymer particles (TEP) formation have the potential to affect carbon export. The objectives of this study were to experimentally assess the dynamics of organic matter, after the simulation of a Saharan dust deposition event, through the measurement over one week of TEP abundance and size, and to evaluate the effects of ocean acidification on TEP formation and carbon export following a dust deposition event. Three experiments were performed in the laboratory using 300 L tanks filled with filtered seawater collected in the Mediterranean Sea, during two 'no bloom' periods (spring at the start of the stratification period and autumn at the end of this stratification period) and during the winter bloom period. For each experiment, one of the two tanks was acidified to reach pH conditions slightly below values projected for 2100 (~ 7.6-7.8). In both tanks, a dust deposition event of 10 g m-2 was simulated at the surface. Our results suggest that Saharan dust deposition triggered the abiotic formation of TEP, leading to the formation of organic-mineral aggregates. The amount of particulate organic carbon (POC) exported was proportional to the flux of lithogenic particles to the sediment traps. Depending on the season, the POC flux following artificial dust deposition ranged between 38 and 90 mg m-2 over six experimental days. Such variability is likely linked to the seasonal differences in the quality and quantity of TEP-precursors initially present in seawater. Finally, these export fluxes were not significantly different at the completion of the three experiments between the two pH conditions.

Ultraplankton [heterotrophic prokaryotes and ultraphytoplankton (

Enterobacter cloacae complex has been increasingly recognized as a nosocomial pathogen representing the third major Enterobacteriaceae species involved with infections. This study aims to evaluate virulence and antimicrobial susceptibility of subpopulations generated from macrocolonies of NDM-1 producing Enterobacter hormaechei clinical isolates. Biofilm was quantified using crystal violet method and fimbrial genes were investigated by PCR. Susceptibility of antimicrobials, alone and combined, was determined by minimum inhibitory concentration and checkerboard assays, respectively. Virulence and efficacy of antimicrobials were evaluated in Galleria mellonella larvae. Importantly, we verified that some subpopulations that originate from the same macrocolony present different biofilm production ability and distinct susceptibility to meropenem due to the loss of blaNDM-1 encoding plasmid. A more in-depth study was performed with the 798 macrocolony subpopulations. Type 3 fimbriae were straightly related with biofilm production; however, virulence in larvae was not statistically different among subpopulations. Triple combination with meropenem–rifampicin–polymyxin B showed in vitro synergistic effect against all subpopulations; while in vivo this treatment showed different efficacy rates for 798-1S and 798-4S subpopulations. The ability of multidrug resistant E. hormaechei isolates in generating bacterial subpopulations presenting different susceptible and virulence mechanisms are worrisome and may explain why these infections are hardly overcome.

The composition, size distribution, and abundance of floating plastic debris in surface waters of the Mediterranean Sea were analyzed in relation to distance to land. We combined data from previously published reports with an intensive sampling in inshore waters of the Northwestern Mediterranean. The highest plastic concentrations were found in regions distant from from land as well as in the first kilometer adjacent to the coastline. In this nearshore water strip, plastic concentrations were significantly correlated with the nearness to a coastal human population, with local areas close to large human settlements showing hundreds of thousands of plastic pieces per km2. The ratio of plastic to plankton abundance reached particularly high values for the coastal surface waters. Polyethylene, polypropylene and polyamides were the predominant plastic polymers at all distances from coast (86 to 97% of total items), although the diversity of polymers was higher in the 1-km coastal water strip due to a higher frequency of polystyrene or polyacrylic fibers. The plastic size distributions showed a gradual increase in abundance toward small sizes indicating an efficient removal of small plastics from the surface. Nevertheless, the relative abundance of small fragments (< 2 mm) was higher within the 1-km coastal water strip, suggesting a rapid fragmentation down along the shoreline, likely related with the washing ashore on the beaches. This study constitutes a first attempt to determine the impact of plastic debris in areas closest to Mediterranean coast. The presence of a high concentration of plastic including tiny plastic items could have significant environmental, health and economic impacts.

Metabolic adjustment to changing environmental conditions, particularly balancing of growth and defense responses, is crucial for all organisms to survive. The evolutionary conserved AMPK/Snf1/SnRK1 kinases are well-known metabolic master regulators in the low-energy response in animals, yeast and plants. They act at two different levels: by modulating the activity of key metabolic enzymes, and by massive transcriptional reprogramming. While the first part is well established, the latter function is only partially understood in animals and not at all in plants. Here we identified the Arabidopsis transcription factor bZIP63 as key regulator of the starvation response and direct target of the SnRK1 kinase. Phosphorylation of bZIP63 by SnRK1 changed its dimerization preference, thereby affecting target gene expression and ultimately primary metabolism. A bzip63 knock-out mutant exhibited starvation-related phenotypes, which could be functionally complemented by wild type bZIP63, but not by a version harboring point mutations in the identified SnRK1 target sites.

The aim of this study was to evaluate the bond strengths of composite restorations made with different filler amounts and resin composites that were photoactivated using a light-emitting diode (LED). Thirty bovine incisors were selected, and a conical cavity was prepared in the facial surface of each tooth. All preparations were etched with Scotchbond Etching Gel, the Adper Scotchbond Multipurpose Plus adhesive system was applied followed by photoactivation, and the cavities were filled with a single increment of Filtek Z350 XT, Filtek Z350 XT Flow, or bulk-fill X-tra fil resin composite (n = 10) followed by photoactivation. A push-out test to determine bond strength was conducted using a universal testing machine. Data (MPa) were submitted to Student’s t-test at a 5% significance level. After the test, the fractured specimens were examined using an optical microscope under magnification (10x). Although all three composites demonstrated a high prevalence of adhesive failures, the bond strength values of the different resin composites photoactivated by LED showed that the X-tra fil resin composite had a lower bond strength than the Filtek Z350 XT and Filtek Z350 XT Flow resin composites.

Ecological succession provides a widely accepted description of seasonal changes in phytoplankton and mesozooplankton assemblages in the natural environment, but concurrent changes in smaller (i.e. microbes) and larger (i.e. macroplankton) organisms are not included in the model because plankton ranging from bacteria to jellies are seldom sampled and analyzed simultaneously. Here we studied, for the first time in the aquatic literature, the succession of marine plankton in the whole-plankton assemblage that spanned 5 orders of magnitude in size from microbes to macroplankton predators (not including fish or fish larvae, for which no consistent data were available). Samples were collected in the northwestern Mediterranean Sea (Bay of Villefranche) weekly during 10 months. Simultaneously collected samples were analyzed by flow cytometry, inverse microscopy, FlowCam, and ZooScan. The whole-plankton assemblage underwent sharp reorganizations that corresponded to bottom-up events of vertical mixing in the water-column, and its development was top-down controlled by large gelatinous filter feeders and predators. Based on the results provided by our novel whole-plankton assemblage approach, we propose a new comprehensive conceptual model of the annual plankton succession (i.e. whole plankton model) characterized by both stepwise stacking of four broad trophic communities from early spring through summer, which is a new concept, and progressive replacement of ecological plankton categories within the different trophic communities, as recognised traditionally.

In contrast to the depth of knowledge on the pathological effects of parasitism in domestic animals, the impact of the vast majority of parasites on wildlife hosts is poorly understood and, besides, information from domestics is rarely usable to disclose the parasites' impact on free-ranging populations' dynamics. Here we use Toxoplasmosis as a study model since, until now, the infection process and the protozoan's effects in natural conditions has received little attention. We analysed 81 sera from red deer (Cervus elaphus) sampled in Italian Alps and through generalized linear models we evaluated (1) the epidemiological factors influencing T. gondii infection dynamics; (2) its impact on female fertility [corrected]. High seroprevalence of T. gondii infection was recorded in yearling (1 year-old; prevalence = 52.4%) and adult (>2 year-old; prevalence = 51.3%) red deer, while calves (

Infection with hepatitis C virus (HCV) is a global public health issue. The bloodborne nature of HCV transmission poses a substantial risk to healthcare workers, due to occupational exposure to needlestick injuries and blood and other body fluids containing the virus. Undiagnosed HCV infection, including in healthcare workers, represents a growing problem worldwide as the infected population ages, and HCV-related mortality and morbidity is expected to rise substantially over the coming decades. Consequently, diagnostic tests for HCV play an important role in this scenario. The aim of this study was to standardize a one-step RT-PCR assay for detection of HCV. The test demonstrated reproducibility, sensibility (100%), and the limit of detection was set at 100IU/mL. Our study indicates that this assay can be used as a diagnostic tool to follow up healthcare workers after occupational exposure.

Introdução: A disseminação de Klebsiella pneumoniae carbapenemase (KPC) no Brasil e recente detecção de bactérias produtoras de New Delhi metalo-β-lactamase (NDM-1) dentro das unidades hospitalares do Grupo Hospitalar Conceição (GHC) levantam interesse pelas enterobactérias resistentes a carbapenêmicos (ERC). Objetivo: Avaliar prevalência de carbapenemases nas ERC no GHC, através de PCR multiplex em tempo real. Metodologia: Estudo descritivo, período de abril a dezembro de 2013. Isolados bacterianos de pacientes internados no GHC foram identificados através do sistema automatizado VITEK 2, com realização do teste de suscetibilidade aos antimicrobianos. Amostras com isolados de ERC foram encaminhadas ao laboratório de referência para análise por PCR em tempo real para identificação de carbapenemases. Resultados: Total de 701 isolados. As ERC predominantes foram K. pneumoniae (47% das amostras positivas) e Enterobacter cloacae (18%). Os mecanismos de resistência mais frequentes foram KPC (48%), Oxa-48-like (3%) e NDM (2%). Em 47% das amostras não foi identificado o mecanismo de resistência. Isolados originados de culturas de vigilância foram associados com maior positividade para carbapenemases do que isolados de amostras clínicas (solicitadas por médico assistente) (p

Complications in pediatric anesthesia can happen, even in our modern hospitals with the most advanced equipment and skilled anesthesiologists. It is important, albeit in a tranquil and reassuring way, to inform parents of the possibility of complications and, in general, of the anesthetic risks. This is especially imperative when speaking to the parents of children who will be operated on for minor procedures: in our experience, they tend to think that the anesthesia will be a light anesthesia without risks. Often the surgeons tell them that the operation is very simple without stressing the fact that it will be done under general anesthesia which is identical to the one we give for major operations. Different is the scenario for the parents of children who are affected by malignant neoplasms: in these cases they already know that the illness is serious. They have this tremendous burden and we choose not to add another one by discussing anesthetic risks, so we usually go along with the examination of the child without bringing up the possibility of complications, unless there is some specific problem such as a mediastinal mass.

The mass digitization of books is changing the way information is created, disseminated and displayed. Electronic book readers (e-readers) generally refer to two main display technologies: the electronic ink (E-ink) and the liquid crystal display (LCD). Both technologies have advantages and disadvantages, but the question whether one or the other triggers less visual fatigue is still open. The aim of the present research was to study the effects of the display technology on visual fatigue. To this end, participants performed a longitudinal study in which two last generation e-readers (LCD, E-ink) and paper book were tested in three different prolonged reading sessions separated by--on average--ten days. Results from both objective (Blinks per second) and subjective (Visual Fatigue Scale) measures suggested that reading on the LCD (Kindle Fire HD) triggers higher visual fatigue with respect to both the E-ink (Kindle Paperwhite) and the paper book. The absence of differences between E-ink and paper suggests that, concerning visual fatigue, the E-ink is indeed very similar to the paper.

Piriformosporaindica is a basidiomycete fungus colonizing roots of a wide range of higher plants, including crop plants and the model plant Arabidopsis thaliana. Previous studies have shown that P. indica improves growth, and enhances systemic pathogen resistance in leaves of host plants. To investigate systemic effects within the root system, we established a hydroponic split-root cultivation system for Arabidopsis. Using quantitative real-time PCR, we show that initial P. indica colonization triggers a local, transient response of several defense-related transcripts, of which some were also induced in shoots and in distal, non-colonized roots of the same plant. Systemic effects on distal roots included the inhibition of secondary P. indica colonization. Faster and stronger induction of defense-related transcripts during secondary inoculation revealed that a P. indica pretreatment triggers root-wide priming of defense responses, which could cause the observed reduction of secondary colonization levels. Secondary P. indica colonization also induced defense responses in distant, already colonized parts of the root. Endophytic fungi therefore trigger a spatially specific response in directly colonized and in systemic root tissues of host plants.

Objective: To evaluate, through care indicators, the quality of services rendered to patients considered urgency and emergency cases at an advanced emergency care unit.Methods: We analyzed data from managerial reports of 64,891 medical visits performed in the Emergency Care Unit of the Ibirapuera Unit at Care during the period from June 1st, 2012 through May 31st, 2013. The proposed indicators for the assessment of care were rate of death in the emergency care unit; average length of stay of patients in the unit; rate of unplanned return visits; admission rate for patients screened as level 1 according to the Emergency Severity Index; rate of non-finalized medical consultations; rate of complaints; and door-to-electrocardiogram time.Results: The rate of death in the emergency care unit was zero. Five of the 22 patients classified as Emergency Severity Index 1 (22.7%) arrived presenting cardiac arrest. All were treated with cardiopulmonary resuscitation and reestablishment of vital functions. The average length of stay of patients in the unit was 3 hours, 33 minutes, and 7 seconds. The rate of unscheduled return visits at the emergency care unit of the Ibirapuera unit was 13.64%. Rate of complaints was 2.8/1,000 patients seen during the periodConclusion.: The model of urgency and emergency care in advanced units provides an efficient and efficaious service to patients. Both critically ill patients and those considered less complex can receive proper treatment for their needs.