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The grading of urinary tract dilatation (UTD) on postnatal sonography is a fundamental step to establish rational management for infants with antenatal hydronephrosis (ANH). The aim of this study was to compare the prediction accuracy of UTD grading systems for relevant clinical outcomes. In addition, we propose a refinement of the UTD classification by adding quantitative measurements and evaluate its impact on accuracy. Between 1989 and 2019, 447 infants diagnosed with isolated AHN were prospectively followed. The events of interest were surgical interventions and kidney injury. Comparison of performance of the grading systems and the impact on the accuracy of a modified UTD classification (including the size of the kidney parenchyma) was assessed by the area under the receiver-operating characteristic curve (AUC). Of 447 infants, 131 (29%) underwent surgical intervention and 26 (5.8%) had developed kidney injury. The median follow-up time was 9 years (IQ range, 7–12 years). The performance for detecting the need for surgical intervention was excellent for all grading systems (AUC > 0.90). However, for predicting kidney injury, the modified UTD classification exhibited significant improvement in accuracy (AUC = 0.913, 95%CI, 0.883–0.937) as compared with UTD classification (AUC = 0.887, 95%CI, 0.854–0.915) (P = 0.027). Our study confirms that the hydronephrosis grading systems provide excellent accuracy in discriminating patients who need surgical intervention among infants with AHN. Our findings suggest that the inclusion of kidney parenchymal thickness to UTD classification might increase the accuracy for predicting infants who may develop kidney injury. A higher resolution version of the Graphical abstract is available as Supplementary information.

BACKGROUND: Neuromuscular diseases are characterized by the compromise of respiratory muscles, thoracic ventilation, muscle strength and coughing capacity. Patients have low quality of life and increased morbidity and mortality mostly due to respiratory impairment. OBJECTIVE: To assess the benefits of adding inspiratory muscle training to neuromuscular patients’ treatment and their compliance to the approach. METHODS: We conducted a single-center prospective study with neuromuscular patients with decreased maximal inspiratory pressure. We developed an inspiratory muscle training protocol with three-month duration and once-daily training. The protocol had a progressive intensity that was individually tailored based on patients’ baseline characteristics and tolerance. We used Powerbreathe Medic Classic devices to perform the training. RESULTS: There were 21 patients who met the inclusion criteria and were enrolled in the study. Muscular dystrophy (n= 12, 57.3%) and amyotrophic lateral sclerosis (n= 4, 19%) were the most common diseases. After three months of training, patients increased their maximal inspiratory muscle pressure (p= 0.002) and peak cough flow (p= 0.011). Compliance to the protocol was 99 ± 5.5%. CONCLUSIONS: This protocol showed significant improvements on pulmonary muscles function and might be considered as an adjunct treatment to neuromuscular treatment. However, these positive results require larger further studies to validate the clinical benefits long-term.

Objectives Tuberculosis (TB) is the most common opportunistic infection and cause of mortality among people living with HIV, and it is possible that it may also influence the evolution of the HIV infection. We assessed the differences between HIV-positive and -negative people infected with TB. Methods The present study is a cross-sectional retrospective study by electronic record revision. We included patients admitted to a tertiary hospital with a diagnosis of TB between 2011 and 2016, comparing those with HIV coinfection with non-HIV patients, according to demographic and clinical characteristics. Results This study included 591 patients, of whom 32% were HIV-coinfected. HIV-TB patients were younger, with a predominance of male gender. Considering TB risk factors, there was a higher prevalence of homelessness and intravenous drug use in the HIV group. In the non-HIV group, direct contact with other patients with TB and immunosuppression were more prevalent. Relative to TB characteristics, the HIV-coinfected group presents with a higher prevalence of disseminated disease and a higher occurrence of previous TB infection. Cancer was the most frequent cause of immunosuppression in the HIV group and the number testing positive for TB via microbiological culture was lower. Assessment of microbiological resistance and in-hospital mortality showed similar numbers in both groups. Conclusions There are few papers comparing clinical course of TB between HIV-infected and non-infected patients. Our study differs from others in the literature as we focused on a country with middling incidence of TB and further characterized the differences between HIV-infected and non-infected patients which can contribute to the management of these patients.

Determining the timing of intracranial injuries in general, and abusive head trauma (AHT) in particular, is important to the care of children with traumatic brain injury. Additionally, identifying the time of the injury provides important information as to who might have, and who did not, inflict the trauma. Understanding the appearance and evolution of intracranial findings on neuroimaging has been an important factor in assessing the time of the injury. However, a number of studies in the last two decades have both suggested greater uncertainty about the reliability of this process and advanced our knowledge in this area. In this review, the authors consider the biophysical factors that contribute to the appearance and evolution of intracranial hemorrhage and, in particular, subdural hemorrhage (SDH). The traditional view of SDH is predicated largely on prior studies of intracerebral hemorrhage, although a number of variables make this comparison untenable. Moreover, more recent studies have suggested a number of factors that could alter the density (CT) or signal intensity (MRI) and produce mixed density/intensity SDH. These factors need to be considered in interpreting neuroimaging studies. A number of these recent studies evaluating serial neuroimaging in children with AHT have modified our understanding of intracranial hemorrhage and its evolution in this context. Taken together, the studies to date, having important limitations, provide only broad ranges over which to time injuries. The authors conclude that neuroimaging studies at this time are not likely, in isolation, to be able to accurately pinpoint a specific time of injury; rather, neuroimaging can only provide a range of possible times and should instead be used as a means to supplement or corroborate timing based on clinical presentation and other imaging findings.

OBJECTIVE The aims of this study were to review the National Spina Bifida Patient Registry (NSBPR) data set to study the rates of tethered spinal cord release (TCR) among patients with myelomeningocele and variability between centers, to compare TCR rates between males and females, and to study the relationships between TCR rates and other condition-specific characteristics. METHODS The NSBPR registry was queried to identify all patients with myelomeningocele. TCR rates were calculated over time using survival analyses; rates between centers and between males and females were compared. Cox proportional hazards models were constructed to identify relationships between TCR rates and sex, functional lesion level, ambulation status, treated hydrocephalus, and prior Chiari decompression. RESULTS Of 6339 patients with information about their operations, 1366 (21.5%) underwent TCR, with significant variability between centers. The majority (75.8%) underwent a single TCR. The annual TCR rate was linear between birth and 13 years (1.8%/year) but declined sharply from 14 to 21 years (0.7%/year). There was no period of time at which the TCR rate accelerated. There were no significant differences in TCR rates between males and females. TCR rate was not related to functional lesion level but was lower among nonambulators compared with community ambulators (p = 0.005) and among those with treated hydrocephalus (HR 0.30, p < 0.001), and higher among those having prior Chiari decompression (HR 1.71, p < 0.001). CONCLUSIONS These results extend the results of prior single-institution studies, demonstrate significant treatment variability between institutions, and challenge the traditional concept that tethering is related to spinal cord stretching due to spinal growth.

Pediatric radiologists are frequently summoned to testify in court regarding the imaging of child abuse. This essay provides guidance on how to prepare for trial and what to expect in court. Preparation is paramount and includes meeting with the attorney and reviewing imaging studies, medical records and pertinent reports in anticipation of questioning in court. We also provide guidance to aid in testimony in court. Legal standards for testimony are discussed herein.

Cardiovascular diseases represent the frst cause of death globally. Infammatory rheumatic disease (IRMD) patients, due to their lifelong infammatory status, are at increased risk of developing premature cardiovascular disease. We aimed to assess the risk for cardiovascular events (CVE) in a population-based study. We followed 10,153 adults from the EpiDoC Cohort, a large Portuguese population-based prospective study (2011–2016). IRMD patients were identifed at baseline and followed during 5 years. CVE were defned as a composite of self-reported myocardial infarction or angina pectoris, arrhythmias, valvular disease, stroke or transient ischemic attack and peripheral artery disease. Statistical analysis was performed by utilizing multivariate logistic regression and goodness-of-ft and area under ROC curve. At baseline, IRMD patients had similar age as the non-IRMD participants (mean age 55 vs 53 years-old; 72.1% female); dyslipidaemia and sedentary lifestyle were more common (40.7% vs 31.4%, p=0.033; 87.3% vs 67%, p=0.016, respectively). During an average follow-up of 2.6 years, 26 CVE were reported among IRMD patients. IRMD patients had higher odd of CVE (OR 1.64, 95% CI 1.04–2.58; p=0.03), despite comparable mortality rates (1.7% vs 0.7%, p=0.806). A stepwise approach attained that gender, age, history of hypertension, body mass index, IRMD and follow-up time are the most important predictive variables of CVE (AUC 0.80). IRMD patients, at community level, have an increased short-term risk of major CVE when compared to non-IRMD, and that highlights the potential beneft of a systematic screening and more aggressive cardiovascular risk assessment and management of these patients. info:eu-repo/semantics/publishedVersion

Aim: Quality of life (QoL) is one of the most important patient-reported outcomes in chronic diseases. Using a population-based cohort, our objective was to assess health-related QoL in individuals with a previous myocardial infarction (MI). Methods: This study was conducted on a large database representative of the adult Portuguese population aged 18 years or over, living in the community. Participants were assessed through telephone interview. A standardized questionnaire was applied to every individual about self-reported chronic diseases, including previous MI. QoL was assessed with the EQ-5D-3L version of EuroQol. The prevalence of previous MI was calculated and linear regression analysis was performed. Results: The estimated prevalence of previous MI in the adult Portuguese population was 1.1%. These patients were older and more often male, had lower income and lower education levels, and were more often from urban areas. Respondents with self-reported MI assigned a lower self-perception to their health status in all domains, particularly in mobility and anxiety/depression. The mean EQ-5D-3L score in patients with MI was 0.73±0.34, significantly lower than in patients without MI (0.78±0.29). Also, the number of chronic diseases was significantly higher in patients with MI (5.0±2.2 vs. 1.7±1.8). Previous MI was not independently associated with QoL, which was related to age, gender and number of comorbidities. Conclusions: Adults with previous MI have a worse self-perceived health status and QoL. Previous MI was not an independent predictor of health-related QoL after controlling for age, gender and associated chronic diseases. Resumo: Introdução: A qualidade de vida (QOL) é um dos mais importantes resultados reportados por doentes em doenças crónicas. Utilizando uma coorte baseada na população, foi nosso objetivo avaliar a qualidade de vida relacionada com a saúde em doentes com enfarte do miocárdio (EM) prévio. Métodos: Estudo realizado numa grande base de dados representativa da população portuguesa adulta com ≥ 18 anos, a viver na comunidade. Os participantes foram avaliados por entrevista telefónica e foi aplicado um questionário estandardizado a cada indivíduo sobre doenças crónicas autotreportadas, incluindo EM no passado. A QOL foi avaliada com a ferramenta EuroQol (EQ-5D-3L). Resultados: A prevalência estimada de EM prévio foi de 1,1%. Estes doentes são mais idosos e mais homens, com menor rendimento e nível de educação e mais frequentemente de áreas urbanas. Os indivíduos com EM prévio têm pior perceção do seu estado de saúde em todos os domínios, em particular na mobilidade e ansiedade/depressão. O índice EQ-5D-3L médio foi 0,73±0,34, significativamente inferior quando comparado com doentes sem EM (0,78±0,29). O número de doenças crónicas é significativamente superior em doentes com EM (5,6±2,2 versus 1,7±1,8). O EM prévio não se associa de forma independente à QOL, estando esta relacionada com idade, género e número de comorbilidades associadas. Conclusões: Adultos com EM prévio apresentam uma pior percepção da sua saúde e QOL. O EM prévio não é preditor independente de QOL após controlo para idade, género e doenças crónicas associadas.

In utero hematopoietic cell transplantation (IUHCT) has the potential to cure congenital hematologic disorders including sickle cell disease. However, the window of opportunity for IUHCT closes with the acquisition of T-cell immunity, beginning at approximately 14 weeks gestation, posing significant technical challenges and excluding from treatment fetuses evaluated after the first trimester. Here we report that regulatory T cells can promote alloengraftment and preserve allograft tolerance after the acquisition of T-cell immunity in a mouse model of late-gestation IUHCT. We show that allografts enriched with regulatory T cells harvested from either IUHCT-tolerant or naive mice engraft at 20 days post coitum (DPC) with equal frequency to unenriched allografts transplanted at 14 DPC. Long-term, multilineage donor cell chimerism was achieved in the absence of graft-versus-host disease or mortality. Decreased alloreactivity among recipient T cells was observed consistent with donor-specific tolerance. These findings suggest that donor graft enrichment with regulatory T cells could be used to successfully perform IUHCT later in gestation.

In July 2019, a group of multidisciplinary dementia researchers from Brazil and the United Kingdom (UK) met in the city of Belo Horizonte, Minas Gerais, Brazil, to discuss and propose solutions to current challenges faced in the diagnosis, public perception and care of dementia. Here we summarize the outcomes from the workshop addressing challenges in diagnosis. Brazil faces a major problem in dementia underdiagnosis, particularly involving the population in an adverse socioeconomic context. There is poor availability of resources and specialists, and the knowledge of general practitioners and other healthcare professionals is far from satisfactory. Low education level is a further obstacle in diagnosing dementia, as the most commonly used screening tests are not designed to evaluate this population. Patients and their families must overcome the stigma of a diagnosis of dementia, which is still prevalent in Brazil and increases the burden of this condition. Whilst the UK has greater resources, dedicated memory services and a National Dementia Strategy plan, the National Health Service (NHS) has limited funding. Therefore, some challenges regarding diagnosis are common across both countries. The authors suggest possible solutions to confront these, with the goal of improving assessment and recognition of dementia and reducing misdiagnosis. RESUMO. Em julho de 2019, um grupo multidisciplinar de pesquisadores em demência do Brasil e do Reino Unido se reuniu em Belo Horizonte para discutir e propor soluções para os desafios no diagnóstico, percepção pública e tratamento dessa condição. Neste artigo, sintetizamos as conclusões do workshop sobre os desafios no diagnóstico de demência. O Brasil enfrenta um grande problema no subdiagnóstico de demência, principalmente entre a população em condições socioeconômicas adversas. Há pouca disponibilidade de recursos e de especialistas e o conhecimento de médicos generalistas e de outros profissionais de saúde é pouco abrangente. Baixa escolaridade é também um obstáculo no diagnóstico de demência, uma vez que os testes de rastreio mais utilizados na prática clínica não são estruturados para avaliar a população com esse perfil. Os pacientes com demência e suas famílias ainda têm que superar o estigma do diagnóstico, que é ainda muito prevalente no Brasil e colabora para a piora da qualidade de vida. O Reino Unido, por outro lado, dispõe de mais recursos financeiros e de pessoal, possui serviços dedicados à avaliação de problemas de memória e um plano estratégico nacional para demência. Contudo, o National Health Service (NHS) tem verbas limitadas, o que faz com que alguns dos desafios no diagnóstico de demência sejam comuns aos dois países. Os autores sugerem possíveis soluções para enfrentá-los, com o objetivo de melhorar a avaliação e o reconhecimento da demência e reduzir os erros de diagnóstico.

The diagnosis of visceral leishmaniasis (VL) has improved with the search of novel antigens; however, their performance is limited when samples from VL/human immunodeficiency virus (HIV)-coinfected patients are tested. In this context, studies conducted to identify more suitable antigens to detect both VL and VL/HIC coinfection cases should be performed. In the current study, phage display was performed using serum samples from healthy subjects and VL, HIV-infected and VL/HIV-coinfected patients; aiming to identify novel phage-exposed epitopes to be evaluated with this diagnostic purpose. Nine non-repetitive and valid sequences were identified, synthetized and tested as peptides in enzyme-linked immunosorbent assay experiments. Results showed that three (Pep2, Pep3 and Pep4) peptides showed excellent performance to diagnose VL and VL/HIV coinfection, with 100% sensitivity and specificity values. The other peptides showed sensitivity varying from 50.9 to 80.0%, as well as specificity ranging from 60.0 to 95.6%. Pep2, Pep3 and Pep4 also showed a potential prognostic effect, since specific serological reactivity was significantly decreased after patient treatment. Bioinformatics assays indicated that Leishmania trypanothione reductase protein was predicted to contain these three conformational epitopes. In conclusion, data suggest that Pep2, Pep3 and Pep4 could be tested for the diagnosis of VL and VL/HIV coinfection.

Non-adherence to the medication has been a serious health issue, leading to lower therapy results and possibly even death. One of the largest non-adherence causes is a complex drug regimen. To ease this issue, the researchers evaluated the use of a calendar blister pack, individually prepared for each patient. Pharmacies have been offering services of individually prepared medication with successful results and significant acceptability from the patients. Nowadays, numerous solutions on the market, namely pill organizers and dispensers, aim to remind patients about the medication and help them to manage medication stock. This document aims to be a steppingstone for those who want to improve and further develop medication organizing and dispensing devices.

Background Antenatal hydronephrosis (ANH) affects ∼1–5% of pregnancies. The aim of this study was to develop a clinical prediction model of renal injury in a large cohort of infants with isolated ANH. Methods This is a longitudinal cohort study of 447 infants with ANH admitted since birth between 1989 and 2015 at a tertiary care center. The primary endpoint was time until the occurrence of a composite event of renal injury, which includes proteinuria, hypertension and chronic kidney disease (CKD). A predictive model was developed using a Cox proportional hazards model and evaluated by C-statistics. Results Renal pelvic dilatation (RPD) was classified into two groups [Grades 1–2 (n = 255) versus Grades 3–4 (n = 192)]. The median follow-up time was 6.4 years (interquartile range 2.8–12.5). Thirteen patients (2.9%) developed proteinuria, 6 (1.3%) hypertension and 14 (3.1%) CKD Stage 2. All events occurred in patients with RPD Grades 3–4. After adjustment, three covariables remained as predictors of the composite event: creatinine {hazard ratio [HR] 1.27, [95% confidence interval (CI) 1.05–1.56]}, renal parenchyma thickness at birth [HR 0.78(95% CI 0.625–0.991)] and recurrent urinary tract infections [HR 4.52 (95% CI 1.49–13.6)]. The probability of renal injury at 15 years of age was estimated as 0, 15 and 24% for patients assigned to the low-risk, medium-risk and high-risk groups, respectively (P Conclusion Our findings indicate an uneventful clinical course for patients with Society for Fetal Urology (SFU) Grades 1–2 ANH. Conversely, for infants with SFU Grades 3–4 ANH, our prediction model enabled the identification of a subgroup of patients with increased risk of renal injury over time.

Background The global financial crisis and the economic and financial adjustment programme (EFAP) forced the Portuguese government to adopt austerity measures, which also included the health sector. The aim of this study was to analyse factors associated with HIV/AIDS patients’ length of stay (LOS) among Portuguese hospitals, and the potential impact of the EFAP measures on hospitalizations among HIV/AIDS patients. Methods Data used in this analysis were collected from the Portuguese database of Diagnosis Related Groups (DRG). We considered only discharges classified under MCD 24 created for patients with HIV infection. A total of 20,361 hospitalizations occurring between 2009 and 2014 in 41 public hospitals were included in the analysis. The outcome was the number of days between hospital admission and discharge dates (LOS). Hierarchical Poisson regression model with random effects was used to analyse the relation between LOS and patient, treatment and setting characteristics. To more effectively analyse the impact of the EFAP implementation on HIV/AIDS hospitalizations, yearly variables, as well as a variable measuring hospitals’ financial situation (current ratio) was included. Results For the 5% level, having HIV/AIDS as the principal diagnosis, the number of secondary diagnoses, the number of procedures, and having tuberculosis have a positive impact in HIV/AIDS LOS; while being female, urgent admission, in-hospital mortality, pneumocystis pneumonia, hepatitis C, and hospital’s current ratio contribute to the decrease of LOS. Additionally, LOS between 2010 and 2014 was significantly shorter in comparison to 2009. Differences in LOS across hospitals are significant after controlling for these variables. Conclusion Following the EFAP, a number of cost-containment measures in the health sector were implemented. Results from our analysis suggest that the implementation of these measures contributed to a significant decrease is LOS among HIV/AIDS patients in Portuguese hospitals.

Aims: Clinical risk factors and bone mineral densitometry underestimate low-energy fracture (LEF) risk in people with diabetes. We aim to estimate the prevalence of LEF in diabetics, compare with nondiabetics; and evaluate possible predictors of LEF in people with diabetes. Methods: Cross-sectional, population-based study in Portuguese subjects over 40 years-old. Estimates computed as weighted proportions/means, considering sample design. Multivariate logistic regression models to evaluate the association of diabetes and LEF; and predictors of LEF in diabetics. Results: 7675 subjects were analysed, of which 1173 reported diabetes. Diabetics were older (mean age 66.0 ± 11.49y), more frequently reported osteoporosis and falls in the previous 12 months (32.4% vs. 22.9%). Prevalence of self-reported LEF was 16.2% (95% CI:13.68-19.13) among diabetics (vs. 13.3%, 95% CI:12.14-14.57, in nondiabetics); OR for the association diabetes and LEF:1.26, 95% CI:1.01-1.58, p = 0.045 (in women, adjusted OR:1.41, 95% CI:1.05-1.89, p = 0.02). Thirty percent of diabetics reported at least one major LEF and 70% in other sites. In diabetics, LEF was independently associated with self-reported osteoporosis and falls in the previous 12 months. Conclusion: People with diabetes reported more falls and had higher prevalence of self-reported LEF. Self-reported osteoporosis and falls were associated with LEF in diabetics. Our findings emphasize the need for fracture and falls preventive measures in diabetics. info:eu-repo/semantics/publishedVersion

The aim of this study was to evaluate the performance of the new classification of urinary tract dilatation (UTD) to predict long-term clinical outcomes in infants with isolated antenatal hydronephrosis (ANH).Between 1989 and 2019, 447 infants diagnosed with isolated severe ANH and were prospectively followed. The main predictive variable for the analysis was the new UTD classification system. The events of interest were surgical interventions, urinary tract infections, chronic kidney disease stage II or higher, hypertension and proteinuria. The primary end-point was time until the occurrence of a composite event of renal injury, including proteinuria, hypertension and chronic kidney disease.Among 447 infants with ANH included in the analysis, 255 (57%) had UTD P1, 93 (20.8%) UTD P2 and 99 (22.2%) UTD P3. Median followup time was 9 years (IQR 7-12 years). Of 447 patients included in the analysis, 11 (2.5%) had hypertension, 13 (2.9%) exhibited persistent mild proteinuria, 14 (3%) developed chronic kidney disease Stage 2 and 26 (5.8%) had the composite outcome of renal injury. By survival analysis, the UTD system predicted accurately all events of interest. According to the Kaplan-Meier survival analysis, the probability of renal injury at 20 years of age was estimated at about 0%, 14% and 56% for patients assigned to UTD P1, UTD P2 and UTD P3, respectively (p0.001).Our findings provide insights that the new UTD classification has a good performance for discriminating not only mid-term, but also long-term clinical outcomes, including renal injury.

Aims: Chronic heart failure (HF) is a major comorbidity accounting for an increased severity and mortality related to coronavirus disease 2019 (COVID-19). To reduce the risk of COVID-19 in HF patients, telemedicine has been encouraged. Methods and results: During the COVID-19 pandemic, telemedical management with mainly over-the-phone appointments became a major strategy of follow-up of our HF clinic patients. Previously, the large majority of patients have been seen in the hospital with direct patient-provider contact. We compared both strategies of follow-up, in pre-pandemic (PPP) and pandemic (PP) periods, regarding total mortality and hospitalizations/emergency department (ED) visits due to HF exacerbation. We prospectively studied a cohort of 196 patients. The mean follow-up time in PPP was 1.4 years. In this period, 20 patients died. In PP (follow-up of 71 days), there was one additional death. Total mortality in the first year of follow-up was 12.0%, matching the mortality predicted by the Meta-Analysis Global Group in Chronic Heart Failure score. Considering hospitalizations/ED visits due to decompensated HF, there was no statistically significant difference between PPP and PP. Only one patient was diagnosed with COVID-19. Conclusions: In the light of an increase in telemedical management of this cohort of HF patients, we were able to maintain a low rate of admissions due to HF decompensation, without an increment in mortality. Regarding these results, we encourage the incremental use of telemedicine in HF patients in the context of this or future pandemics and also in situations in which physical consultation might not be possible due to logistic issues. publishersversion published

BackgroundThe introduction of the bacteriumWolbachia(wMel strain) intoAedes aegyptimosquitoes reduces their capacity to transmit dengue and other arboviruses. Evidence of a reduction in dengue case incidence following field releases ofwMel-infectedAe. aegyptihas been reported previously from a cluster randomised controlled trial in Indonesia, and quasi-experimental studies in Indonesia and northern Australia.MethodsFollowing pilot releases in 2015 – 2016 and a period of intensive community engagement, deployments of adultwMel-infectedAe. aegyptimosquitoes were conducted in Niterói, Brazil during 2017 – 2019. Deployments were phased across four release zones, with a total area of 83 km2and a residential population of approximately 373,000. A quasi-experimental design was used to evaluate the effectiveness ofwMel deployments in reducing dengue, chikungunya and Zika incidence. An untreated control zone was pre-defined, which was comparable to the intervention area in historical dengue trends. ThewMel intervention effect was estimated by controlled interrupted time series analysis of monthly dengue, chikungunya and Zika case notifications to the public health surveillance system before, during and after releases, from release zones and the control zone.ResultsThree years after commencement of releases,wMel introgression into localAe. aegyptipopulations was heterogeneous throughout Niterói, reaching a high prevalence (>80%) in the earliest release zone, and more moderate levels (prevalence 40 -70%) elsewhere. Despite this spatial heterogeneity in entomological outcomes, thewMel intervention was associated with a 69% reduction in dengue incidence (95% confidence interval 54%, 79%), a 56% reduction in chikungunya incidence (95%CI 16%, 77%) and a 37% reduction in Zika incidence (95%CI 1%, 60%), in the aggregate release area compared with the pre-defined control area. This significant intervention effect on dengue was replicated across all four release zones, and in three of four zones for chikungunya, though not in individual release zones for Zika.ConclusionsWe demonstrate thatwMelWolbachiacan be successfully introgressed intoAe. aegyptipopulations in a large and complex urban setting, and that a significant public health benefit from reduced incidence ofAedes-borne disease accrues even where the prevalence ofwMel in local mosquito populations is moderate and spatially heterogeneous. These findings are consistent with the results of randomised and non-randomised field trials in Indonesia and northern Australia, and are supportive of theWolbachiabiocontrol method as a multivalent intervention against dengue, chikungunya and Zika.

Agromyzidae (Insecta: Diptera) is a cosmopolitan family of acalyptrate flies, with almost 3,000 species worldwide distributed. Most species are leaf miners on a large number of plants. Among them, Liriomyza Mik, 1894 is a large genus of leaf-miner species that can cause significant damage to economically important crops and is considered agricultural pests, such as Liriomyza sativae Blanchard, 1938 and Liriomyza huidobrensis (Blanchard, 1926), which are herein investigated. The present study deals with the impact of climatic factors (temperature, humidity, and precipitation), seasonality, and parasitoid abundance on leaf-miner infestation during one year in five cultivated crops in Northeastern Brazil. Climatic factors for instance had different effects on L. sativae populations in melon and watermelon crops. Larval abundances were greater during the dry season for both species, L. sativae and L. huidobrensis, and abundance of adult parasitoids followed the increase of mining larvae.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the agent of a major global outbreak of respiratory tract disease known as coronavirus disease-2019 (COVID-19). SARS-CoV-2 infects mainly lungs and may cause several immune-related complications, such as lymphocytopenia and cytokine storm, which are associated with the severity of the disease and predict mortality1,2. The mechanism by which SARS-CoV-2 infection may result in immune system dysfunction is still not fully understood. Here we show that SARS-CoV-2 infects human CD4+T helper cells, but not CD8+T cells, and is present in blood and bronchoalveolar lavage T helper cells of severe COVID-19 patients. We demonstrated that SARS-CoV-2 spike glycoprotein (S) directly binds to the CD4 molecule, which in turn mediates the entry of SARS-CoV-2 in T helper cells. This leads to impaired CD4 T cell function and may cause cell death. SARS-CoV-2-infected T helper cells express higher levels of IL-10, which is associated with viral persistence and disease severity. Thus, CD4-mediated SARS-CoV-2 infection of T helper cells may contribute to a poor immune response in COVID-19 patients.

Background Obesity leeds to poor health and may afffect work productivity. We aim to investigate the association between obesity and absenteeism and its indirect costs. Methods Individuals employeed and actively working at baseline form the EpiDoC Cohort, a large portuguese population-based prospective study analized from 2011 to 2016. Body mass index was assessed during baseline appointment. Follow-up assessment was performed through a phone interview and self reported absenteeism defined by the question”did you have a sick leave in previous 12 months? yes/no”, followed by the number of days missed work due to sickness in the previous twelve months.(1) Negative Binomial Regression model estimated the association between obesity and absenteeism. Indirect costs were computed using the human-capital method. Results EpiDoC cohort had 4338 participants who were working adults at baseline. The prevalence of obesity among working adults was 15.2% and of absenteeism was 29.4%. Obesity was associated with an increase in absenteeism incidence rate ratio by 31% (p Conclusions Obesity is an independent risk factor for absenteeism among working adults wich leads to high societal burden in terms of costs. Food and nutrition policies are needed in order improve food patterns and reduce obesity levels among south european population. Key messages Obesity is an independent risk factor for absenteeism among working adults. Obesity increases absenteeism mainly in women and has a major impact on economies.

Pediatric care providers, pediatricians, pediatric subspecialty physicians, and other health care providers should be able to recognize children with abnormal head shapes that occur as a result of both synostotic and deformational processes. The purpose of this clinical report is to review the characteristic head shape changes, as well as secondary craniofacial characteristics, that occur in the setting of the various primary craniosynostoses and deformations. As an introduction, the physiology and genetics of skull growth as well as the pathophysiology underlying craniosynostosis are reviewed. This is followed by a description of each type of primary craniosynostosis (metopic, unicoronal, bicoronal, sagittal, lambdoid, and frontosphenoidal) and their resultant head shape changes, with an emphasis on differentiating conditions that require surgical correction from those (bathrocephaly, deformational plagiocephaly/brachycephaly, and neonatal intensive care unit-associated skill deformation, known as NICUcephaly) that do not. The report ends with a brief discussion of microcephaly as it relates to craniosynostosis as well as fontanelle closure. The intent is to improve pediatric care providers’ recognition and timely referral for craniosynostosis and their differentiation of synostotic from deformational and other nonoperative head shape changes.

Myelomeningoceles (MMCs) represent a localized failure of primary neurulation during the fourth week of embryonic development. There are a number of misconceptions concerning the proper identification, classification, and surgical repair of these lesions. To provide surgeons with a working knowledge of early neural embryology as it relates to MMC closure as a localized failure of primary neurulation. We review the embryology of early neural development as a means of providing neurosurgeons with a better understanding of MMC closure techniques. Early neural development predicts the anatomy of MMC and knowledge of embryology helps guide repair. Repair of MMC is enhanced by knowing early neural development.

The original version of this article, published on 02 March 2020, unfortunately contained an error on “Fig. 3 Prevalence of Vitamin D Levels by NUTSII.”

In cases of child abuse, the leading cause of death is head trauma. Due to the developing skull and brain, the vast majority of victims are less than one year old. An estimated 4 cases of abusive head trauma (AHT) occurs for every 10,000 babies born each year, with a 25% mortality rate. In standard cases, infants undergo X-ray (CT) or magnetic resonance (MRI) imaging when AHT is suspected. Repeated imaging of these patients is desired, since the symptoms associated with abusive head trauma change over time. By measuring the rate of change the precise time and likely cause of the trauma can be more easily identified. CT and MRI are not attractive options for the desired repeated imaging, due to the radiation, high cost, and unavailability at the bedside. Diagnosis of head trauma using imaging is based on several factors, including the presence of skull fractures, subdural hematoma, and hydrocephalus. Thermoacoustic combined tomography (TACT), which synergistically integrates ultrasound tomography (UT), photoacoustic tomography (PAT), and radio frequency acoustic tomography (RAT) is uniquely suited for imaging these symptoms at point-of-care. To verify this hypothesis, in silico experiments were performed on clinical MRI data of infants using our custom developed TACT simulation platform. Speed of sound measurements made using ultrasound are able to identify fractures in the skull, while photoacoustics is sensitive to the molecular contrast of blood, and is able to image subdural hematomas. Radio frequency acoustic tomography is most sensitive to cerebrospinal fluid, necessary for imaging hydrocephalus. Since this technology may be utilized for repeated imaging at the bedside, these multimodal TACT images can provide crucial information for the timing, and therefore cause of infant head trauma, as well as monitor the effect of treatment.

The relationship between depressive disorders in the elderly and dementia, particularly Alzheimer's disease (AD), is highly complex. While the nature of this relationship is still a matter of debate, differential diagnosis and treatment remain a great clinical challenge. We review recent findings on the conundrum of depressive disorders in the elderly and AD. There is a biological continuum between depressive disorders in the elderly - or at least a subgroup of them - and AD. While elderly subjects with depression and patients with AD exhibit higher circulating levels of pro-inflammatory molecules and lower BDNF than matched controls, CSF levels of Aβ42 can discriminate AD from depressive disorders in the elderly. The role of antidepressant treatment as a strategy to minimize the risk of AD remains to be established.A relação entre transtornos depressivos em idosos e demência, particularmente a doença de Alzheimer (DA), é altamente complexa. Embora a natureza desse relacionamento ainda seja motivo de debate, o diagnóstico e o tratamento diferenciais continuam sendo um grande desafio clínico. Revisamos descobertas recentes sobre o dilema de transtornos depressivos em idosos e DA. Existe um contínuo biológico entre os transtornos depressivos em idosos – ou pelo menos um subgrupo deles – e a DA. Enquanto indivíduos idosos com depressão e pacientes com DA exibem níveis circulantes mais altos de moléculas pró-inflamatórias e menor BDNF do que os controles correspondentes, os níveis de Aβ42 no LCR podem discriminar a DA de distúrbios depressivos em idosos. O papel do tratamento antidepressivo como estratégia para minimizar o risco de DA ainda precisa ser estabelecido.

Background: Thirty-day hospital readmission is receiving growing attention as an indicator of the quality of hospital care. Understanding factors associated with 30-day hospital readmission among HIV patients in Portugal is essential given the high burden cost of HIV hospitalizations in Portugal, a country suffering from financial constrains for almost 10 years. Objectives: We aimed to estimate the 30-day hospital readmission rates among HIV patients in Portugal and to identify its determinants using population-based data for Portuguese public hospitals. Study Design: A multilevel longitudinal population-based study. Methods: Between January 2009 and December 2014, a total of 37,134 registered discharges in the Portuguese National Health Service (NHS) facilities with HIV/AIDS as a main or secondary cause of admission were analyzed. Logistic regression was used to compare 30-day hospital readmission categories by computing odds ratio (OR) and corresponding 95% confidence intervals (95% CIs). A normal random effects model was used to determine unmeasured factors specific to each hospital. Results: A total of 4914 (13.2%, 95% CI: 12.9%−13.6%) hospitalizations had a subsequent 30-day readmission. Hospitalizations that included exit against medical opinion (OR = 1.18, 95% CI: 1.01–1.39), scheduled admissions (OR = 1.71, 95% CI: 1.58–1.85), and tuberculosis infection (OR = 1.20, 95% CI: 1.05–1.38) exhibited a higher risk of hospitalizations with subsequent 30-day readmission. In contrast, hospitalizations that included females (OR = 0.87, 95% CI: 0.81–0.94), a transfer to another facility (OR = 0.78, 95% CI: 0.67–0.91), and having a responsible financial institution (OR = 0.63, 95% CI: 0.55–0.72) exhibited a lower risk of hospitalizations with subsequent 30-day readmission. Hospitalizations associated with higher number of diagnosis, older ages, or hospitalizations during the economic crisis showed an increasing trend of 30-day readmission, whereas an opposite trend was observed for hospitalizations with higher number of procedures. Significant differences exist between hospital quality, adjusting for other factors. Conclusion: This study analyzes the indicators of 30-day hospital readmission among HIV patients in Portugal and provides useful information for enlightening policymakers and health care providers for developing health policies that can reduce costs associated with HIV hospitalizations. This work was supported by the Foundation for Science and Technology—FCT (Portuguese Ministry of Science, Technology and Higher Education) [grant number PD/BD/128066/2016 (AS)] and the Department of Global Health and Tropical Medicine, Institute of Hygiene, and Tropical Medicine (IHMT), NOVA University of Lisbon.

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

Portuguese adults have a long lifespan, but it is unclear whether they live a healthy life in their final years. We aimed to determine the prevalence of multimorbidity and characterize lifestyle and other health outcomes among older Portuguese adults.We performed a cross-sectional evaluation of 2393 adults, aged 65 and older, during the second wave of follow-up of the EpiDoC cohort, a population-based study involving long-term follow-up of a representative sample of the Portuguese population. Subjects completed a structured questionnaire during a telephone interview. Socioeconomic, demographic, lifestyle behaviours, chronic diseases, and health resources consumption were assessed. Cluster analysis was done to identify dietary patterns. Descriptive and analytic analysis was performed to estimate multimorbidity prevalence and its associated factors.Multimorbidity prevalence among older adults was 78.3%, increased with age strata (72.8% for 65 - 69 years to 83.4% for ≥ 80 years), and was highest in Azores (84.9%) and Alentejo (83.6%). The most common chronic diseases were hypertension (57.3%), rheumatic disease (51.9%), hypercholesterolemia (49.4%), and diabetes (22.7%). Depression symptoms were frequent (11.8%) and highest in the oldest strata. The mean health-related quality of life (EQ-5D-3L) score was 0.59 ± 0.38. Hospitalization in the previous 12 months was reported by 25.8% of individuals. Overall, 66.6% of older adults were physically inactive. 'Fruit and vegetables dietary pattern' was followed by 85.4% of individuals; however, regional inequalities were found (69% in Azores). Obesity prevalence was 22.3% overall and was highest among Azoreans (33%).The high prevalence of multimorbidity, combined with unhealthy lifestyle behaviours, suggests that the elderly populationconstitutes a vulnerable group warranting dedicated intervention.Introdução: A esperança de vida está a aumentar em Portugal, contudo desconhece-se o estado de saúde dos idosos. Pretende-se determinar a prevalência de multimorbilidade, caracterizar estilos de vida e outros fatores relacionados com a saúde dos idosos. Material e Métodos: Efetuou-se uma avaliação transversal a 2393 adultos com 65 ou mais anos de idade, da coorte EpiDoC que é constituída por uma amostra representativa da população portuguesa. Os inquiridos responderam a um questionário estruturado através de uma entrevista telefónica, tendo-se recolhido dados socioeconómicos demográficos, estilo de vida, doenças crónicas e consumo de recursos em saúde. Análise de clusters foi realizada para a identificação de padrões alimentares. Efetuou-se análise descritiva e analítica para estimar a prevalência de multimorbilidade e fatores associados. Resultados: A prevalência de multimorbilidade nos idosos foi de 78,3% (72,8% entre os 65 - 69 anos, 83,4% com 80 + anos) e foi superior nos Açores (84,9%) e no Alentejo (83,6%). As doenças crónicas mais prevalentes foram a hipertensão arterial (57,3%), doenças reumáticas (51,9%), hipercolesterolemia (49,4%) e diabetes (22,7%). Os sintomas de depressão (11,8%) foram frequentes, aumentando ao longo dos grupos etários. A qualidade de vida (EQ-5D-3L) foi em média de 0,59 ± 0,38 e 25,8% dos idosos reportaram ter sido hospitalizados nos 12 meses prévios à entrevista. Cerca de 66,6% dos idosos são fisicamente inativos. O padrão alimentar caracterizado por ‘+ fruta e + hortícolas’ foi reportado por 85,4% dos idosos, contudo foram encontradas iniquidades regionais (69% para os idosos açorianos). A prevalência de obesidade foi de 22,3%, sendo superior nos açorianos (33%). Conclusões: A elevada prevalência de multimorbilidade combinada com estilos de vida pouco saudáveis sugere que a população idosa constitui um grupo vulnerável que requer uma intervenção direcionada.

Invasive pulmonary aspergillosis (IPA) has become a recognizable complication in coronavirus disease 2019 (COVID-19) patients admitted to intensive care units (ICUs). Alveolar damage in the context of acute respiratory distress syndrome (ARDS) appears to be the culprit in facilitating fungal invasion in COVID-19 patients, leading to a COVID-19-associated pulmonary aspergillosis (CAPA) phenomenon. From November 2020 to 15 February 2021, 248 COVID-19 patients were admitted to our ICUs, of whom ten patients (4% incidence) were classified as either probable (six) or possible (four) CAPA cases. Seven patients had positive cultural results: Aspergillus fumigatus sensu stricto (five), A. terreus sensu stricto (one), and A. welwitschiae (one). Five patients had positive bronchoalveolar lavage (BAL) and galactomannan (GM), and two patients had both positive cultural and GM criteria. All but two patients received voriconazole. Mortality rate was 30%. Strict interpretation of classic IPA definition would have resulted in eight overlooked CAPA cases. Broader diagnostic criteria are essential in this context, even though differentiation between Aspergillus colonization and invasive disease might be more challenging. Herein, we aim to raise awareness of CAPA in view of its potential detrimental outcome, emphasizing the relevance of a low threshold for screening and early antifungal treatment in ARDS patients. info:eu-repo/semantics/publishedVersion

Background The development of a vaccine for the prevention of visceral leishmaniasis (VL) still represents a significant unmet medical need. A human vaccine can be found if one takes into consideration that many people living in endemic areas of disease are infected but do not develop active VL, including those subjects with subclinical or asymptomatic infection. Methods In this study, a phage display was used to select phage-exposed peptides that were specific to immunoglobulin G (IgG) antibodies from asymptomatic and symptomatic VL patients, separating them from non-infected subjects. Phage clones presenting valid peptide sequences were selected and used as stimuli of peripheral blood mononuclear cells (PBMCs) obtained from both patients’ groups and controls. Those with higher interferon-gamma (IFN-γ)/interleukin (IL)-10 ratios were further selected for vaccination tests. Results Among 17 evaluated clones, two were selected, B1 and D11, and used to immunize BALB/c mice in an attempt to further validate their in vivo protective efficacy against Leishmania infantum infection. Both clones induced partial protection against the parasite challenge, which was evidenced by the reduction of parasitism in the evaluated organs, a process mediated by a specific T helper (Th)1 immune response. Conclusions To the best of our knowledge, this study is the first to use a rational strategy based on in vitro stimulation of human PBMCs with selected phage-displayed clones to obtain new immunogens against VL. Electronic supplementary material The online version of this article (10.1186/s13071-017-2576-8) contains supplementary material, which is available to authorized users.

Diagnostic and therapeutic reagents are unavailable for anaphylaxis arising from stings by Apis dorsata. Venom profiles and cross-reactivity of A. dorsata and Apis mellifera were compared, to ascertain whether venom of A. mellifera can be used for diagnosis in A. dorsata allergy. Both venom profiles were similar by High Performance Liquid Chromatography and SDS-PAGE. Sera of 29 of 30 (96.7%) patients with anaphylaxis to A. dorsata stings had IgE to the phospholipase-2 (PLA2) doublet (15 and 16 kDa) of A. dorsata venom by immunoblot, compared to 26 of 30 (86.7%) with the PLA2 of A. mellifera and a purified preparation of PLA2. Twelve patients (40%) with severe anaphylaxis had IgE reactivity to a 39 kDa protein band of venom of both species, a third band, identified in immunoblot as hyaluronidase. The cross-reactivity of PLA2 and hyaluronidase of A. dorsata and A. mellifera were further confirmed by immunoblot inhibition results. Twenty five of 30 (83.3%) of our patients had positive venom specific IgE (>0.35 KUA/L) reactivity to Phadia ImmunoCAPs of A. mellifera venom. The observed IgE cross reactivity suggests the possibility of using A. mellifera venom as a diagnostic test for A. dorsata venom allergy.

Serological methods used to diagnose visceral leishmaniasis (VL) are considered minimally invasive, but they present problems related with their sensitivity and/or specificity. In this study, a subtractive selection using the phage display technology against antibodies from healthy subjects living in endemic and non-endemic areas of disease, as well as from Chagas disease patients and those developing active VL, was developed. The aim of this study was to select bacteriophage-fused epitopes to be used in the serodiagnosis of human VL. Eight phage clones were selected after the bio-panning rounds, and their reactivity was evaluated in a phage-ELISA assay against a human serological panel. A wild-type clone and the recombinant K39-based immunochromatographic test were used as controls. In the results, it was shown that all clones showed an excellent performance to serologically identify VL patients, demonstrating the feasibility of the isolated phages for developing a specific and sensitive serodiagnosis of human VL.

Ingestion of small objects by children became worrisome as the number of cases increased over the years. Consequences such as intestinal obstruction or even infection of the gastrointestinal tract are becoming more frequent since even in majority cases there is having only an expectant conduct, complications can occur. Also, the combination of two elements such as punctiform metallic materials and imams cause fistula formation in loops with greater ease, granulomas in the intestines, perforation, and can progress to peritonitis or abscesses, as well as having considerable morbidity.

Background The HIV/AIDS Programme has been a core health programme in Portugal leading the country’s response to the HIV epidemics since the 1980s. In 2011, the severe financial and economical context forced the government to reorganize central services, including the Ministry of Health, aiming to improve efficiency and reduce costs. All vertical programmes were reformed, including the HIV/AIDS Programme. Methods For the period 2009-2018, we analyse the outcomes of core HIV prevention programmes managed by the National Programme for HIV/AIDS Infection: the syringe exchange programme, HIV testing, the distribution of preventive materials, and financial support to private non-for-profit organisations. Results This paper describes the main features of that reform and analyses selected outcomes, as well as how those financial constraints affected the response to HIV/AIDS. Despite some transitory cuts in spending, the National Programme for HIV/AIDS Infection was able to successfully expand testing and prevention interventions. Strategic partnerships with non-governmental and community-based organisations were crucial to continue delivering adequate HIV testing services and reaching most-at-risk groups. Conclusions The main goals of the National Programme for HIV/AIDS Infection for the term 2012-2016 were reached, including the decrease of new HIV infections, new AIDS cases and AIDS-related deaths, and the country is in a good position to meet UNAIDS’s 90-90-90 targets by 2020. Scaling-up access to pre-exposure prophylaxis, improving access and adherence to antiretroviral therapy, and continuously promoting access to HIV testing services and HIV self-testing stand as the main challenges of the National Programme for HIV/AIDS Infection in the near future. Key messages Prioritise spending under financial constrains can be cost-effective. Besides transitory cuts, HIV programme was able to meet its goals.

To evaluate the effectiveness on lifestyle change of an mHealth intervention to promote healthy behaviours in adolescence (TeenPower) and to analyse the predictors of the mHealth intervention effectiveness.This study is designed as a non-randomized controlled trial with a two-arm structure.Adolescents of 12-16-year old were recruited from three school districts, with access to the Internet and smartphone/tablet devices. The intervention group was invited to engage in the mHealth intervention (TeenPower) for 6 months in addition to a school-based intervention. The control group only followed the school-based intervention. A repeated measures factorial ANOVA was used and the main effectiveness outcome was the lifestyle change measured by the adolescent lifestyle profile.The outcomes of the mHealth intervention (TeenPower) show a significant effect on nutrition (ƞAlthough the considerable dropout rate, the mHealth intervention presented significant impact on multiple lifestyle domains, providing support for the effectiveness of mHealth interventions for health promotion as an add-on to standard interdisciplinary interventions.Adolescents must have the necessary and appropriate knowledge for the correct and responsible decision-making regarding their health and lifestyle. Innovative strategies (mHealth intervention) were used to promote healthy behaviours. This study evaluates the effectiveness of an mHealth intervention (TeenPower) specifically designed for adolescents. We found a significant impact in several lifestyle domains such as health responsibility, nutrition, positive life perspective, and global lifestyle.目的: 评价促进青少年健康行为的移动医疗(mHealth)干预对生活方式改变的作用,并分析移动医疗(mHealth)干预有效性的相关因素。 设计: 该研究被设计为一项非随机对照试验(两组结构)。 方法: 从三个学区招募了12岁~16岁的青少年,他们可以使用互联网和智能手机/平板电脑设备。除接受学校干预外,干预组还接受为期6个月的移动医疗(mHealth)(TeenPower)。对照组仅接受学校干预。采用因素方差分析(factorial ANOVA)重复测量,并且主要影响结果是青少年生活方式发生变化。 结果: 移动医疗(mHealth)干预(TeenPower)的结果显示对营养(ƞ2 p = 0.03, p = .03)、积极生活观(ƞ2 p = 0.04, p = .01)和全球生活方式(ƞ2p = 0.02, p = .05)有显著影响,退学率为62.1%。对移动医疗(mHealth)干预有效性相关因素的分析表明,年龄稍大的青少年的心理压力管理率有显著提高的趋势(r=.40;p.05)。 结论: 尽管退学率相当高,但移动医疗(mHealth)干预对多个生活方式领域产生了重大影响,支持移动医疗(mHealth)干预作为附加的标准跨学科干预手段对促进健康的有效性。 影响: 青少年必须具备必要和适当的知识,能够作出与其健康生活方式相关的正确且负责任的决定。创新策略(mHealth干预)用于促进健康行为。该研究评估了专为青少年设计的健康干预(TeenPower)的有效性。我们发现,该等干预在诸如健康责任、营养、积极生活观和全球生活方式等生活方式领域有着重大影响。.

Vitamin D deficiency is prevalent worldwide, but its prevalence is unknown in adult Portuguese population. In Portugal, 66% of adults present Vitamin D insufficiency/deficiency. Winter, living in Azores, older age, and obesity were the most important risk factors. It highlights the need of strategies to prevent vitamin D deficiency in Portugal.To estimate the prevalence and risk factors of vitamin D deficiency in the adult Portuguese population.Adults (≥ 18 years old) from the EpiReumaPt Study (2011-2013) were included. Standardized questionnaires on socio-demographic and lifestyle features were obtained. Serum 25-hydroxyvitamin D [25(OH)D] concentrations were evaluated using ADVIA Centaur VitD competitive immunoassay (Siemens Healthineers) in 2015-2017 as 25 (OH)D Level 0: ≤ 10 ng/mL; Level 1: 11-19 ng/mL; Level 2: 20-29 ng/mL, and Level 3: ≥ 30 ng/mL. Weighted multinomial regression analysis was conducted to evaluate the association between socio-demographic and lifestyle variables and vitamin D status.Based on weighted analysis, the estimated prevalence of levels of 25(OH)D ≤ 10, 20, and 30 ng/mL was 21.2, 66.6, and 96.4%, respectively. The strongest independent predictors of serum 25 (OH)D ≤ 10 ng/mL were living in the Azores archipelagos (OR 9.39; 95%CI 1.27-69.6) and having the blood sample collection in winter (OR 18.53; 95%CI 7.83-43.87) or spring (11.55; 95%CI 5.18-25.74). Other significant predictors included older age (OR 5.65, 95%CI 2.08-15.35), obesity (OR 2.61; 95%CI 1.35-5.08), current smoking (OR 2.33; 95%CI 1.23-4.43), and female gender (OR 1.9, 95%CI 1.1-3.28). Conversely, physical exercise (OR 0.48, 95%CI 0.28-0.81) and occasional alcohol intake (OR 0.48, 95%CI 0.29-0.81) were associated with a lower risk of 25(OH)D ≤ 10 ng/mL.Vitamin D deficiency/insufficiency [25(OH)D 20 ng/ml] is highly prevalent in Portugal, affecting 60% of all Portuguese adults, with strong geographical and seasonal variation. This study highlights the need to critically assess the relevance of vitamin D deficiency as a public health problem and the urgent need for a wide and scientifically robust debate about the most appropriate interventions at the individual and societal levels.

Objectives To evaluate the feasibility of leaving the surgical vulvar open for secondary healing in situations where primary closure of the vulvar wound is not possible. Methods This is a case control pilot study analyzing 16 women with the diagnosis of squamous-cell carcinoma of the vulva that underwent first to inguinofemoral lymphadenectomy, them to 6 weeks sections of chemotherapy and 25 daily sessions of radiotherapy. After all, excision of the vulvar lesion with free margins was performed, between January 2011 to July of 2017. 12 patients underwent to the primary closure of the wound (control), and in 4 patients, the surgical defect was left open for secondary healing, by the use of hydrofiber (case). Inclusion criteria were a) FIGO-2009 stage II up to IIIC; b) squamous cell carcinoma; c) no evidence of pelvic or extrapelvic disease nor pelvic nodal involvement. Exclusion criteria was pelvic extra pelvic desease, pelvic nodal involment. Results The mean age of the patients at the time of intervention was 62,1. The distribution of the stages was as follows: II, n=6 (37%); IIIA, n=1 (6%), IIIB, n=1 (6%) and IIIC, n=8 (51%). The mean operative time was 45 minutes. Hospital stay was 2 days. Full vulvar healing in the control group occurred after an average of 30 days, and in the case group, 50 days. Conclusions Secondary healing strategy may be an option for the treatment of vulvar cancer in situations of non-extensive surgical wound when primary closure of the wound is not possible.

During tumorigenesis, breast tumour cells undergo metabolic reprogramming, which generally includes enhanced glycolysis, tricarboxylic acid cycle activity, glutaminolysis and fatty acid biosynthesis. However, the extension and functional importance of these metabolic alterations may diverge not only according to breast cancer subtypes, but also depending on the interaction of cancer cells with the complex surrounding microenvironment. This microenvironment comprises a variety of non-cancerous cells, such as immune cells (e.g. macrophages, lymphocytes, natural killer cells), fibroblasts, adipocytes and endothelial cells, together with extracellular matrix components and soluble factors, which influence cancer progression and are predictive of clinical outcome. The continuous interaction between cancer and stromal cells results in metabolic competition and symbiosis, with oncogenic-driven metabolic reprogramming of cancer cells shaping the metabolism of neighbouring cells and vice versa. This review addresses current knowledge on this metabolic crosstalk within the breast tumour microenvironment (TME). Improved understanding of how metabolism in the TME modulates cancer development and evasion of tumour-suppressive mechanisms may provide clues for novel anticancer therapeutics directed to metabolic targets.

Background: Hand osteoarthritis (HOA) is a highly prevalent rheumatic disease that predominates in females and causes pain, joint deformities and loss of functional capacity. Overweight and metabolic syndrome have been previously suggested to associate with the severity of HOA, but clarity on these associations is yet to be achieved. Objectives: To test the possible association between body mass index (BMI) and other individual components of metabolic syndrome with severity of HOA in females from a nationwide epidemiological study. Methods: EpiReumaPt was a three-stage national health survey where, in the first phase, 10,661 adult participants were randomly selected and interviewed using a structured face-to-face questionnaire that included screening for rheumatic diseases, such as HOA. In the second phase, positive screenings for ≥1 rheumatic complaint plus 20% of the negative screenings were invited for an assessment by rheumatologists. Finally, 3 rheumatologists revised all the information and defined the final diagnosis by consensus. Female patients with a final clinical diagnosis of primary HOA were included in this analysis. Hand functional status as assed by the Cochin questionnaire was the outcome of interest. The explanatory variables of interest were: BMI evaluated as a categorical variable (Normal: 18-24.99; overweight: 25-29.99; obesity: ≥ 30), diabetes mellitus, hypertension and hypercholesterolemia (all self-reported and as binary variables: yes/no). The possible associations between BMI and the individual components of the metabolic syndrome with the Cochin score were tested in a multivariable linear regression model. Only significant variables (p Results: Out of the 3,877 participants evaluated by Rheumatologists, 473 women had primary HOA (national prevalence: 6.6%). In this population, 40% were overweight and 29% were obese. Ninety-three (20%) participants had diabetes, 261 (56%) had hypertension and 261 (56%) had hypercholesterolemia. In the multiple regression model, BMI and diabetes were found to significantly associate with HOA severity, whereas hypertension and hypercholesterolemia did not, thus not being selected in the final model (table). Conclusion: In this study, higher BMI and the presence of diabetes mellitus associated with a worse functional capacity in women with primary HOA. These data add to the body of evidence suggesting a possible role of metabolic factors in the severity of HOA. References: [1] Yusuf E, Nelissen RG, Ioan-Facsinay A et al. Association between weight or body mass index and hand osteoarthritis: a systematic review. Ann Rheum Dis 2010. 69: 761-765 [2] Schett G, Kleyer A, Perricone C et al. Diabetes is an independent predictor for severe osteoarthritis: results from a longitudinal cohort study. Diabetes Care 2013; 36: 403-409 Acknowledgement: The authors thank all the participants of EpiReumaPt survey, the interviewers and staff and the Rheumatologists that worked in the field Disclosure of Interests: Margarida Cruz: None declared, Alexandre Sepriano: None declared, Sara Dias: None declared, Ana Maria Rodrigues: None declared, Helena Canhao: None declared, Nelia Gouveia: None declared, Monica Eusebio: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant for: AbbVie, Lilly, MSD, Novartis, Pfizer, Sanofi, Speakers bureau: AbbVie, Lilly, MSD, Novartis, Pfizer, Sanofi, Jaime Branco: None declared

Purpose Dermal sinus tract (DST) is a challenging clinical diagnosis in children. The purpose of our study was to analyze the added value of magnetic resonance imaging (MRI) in the diagnosis of DST involving the lumbosacral spine. We also sought to establish an MRI-based scoring system to simplify the diagnosis of DST. Methods MRI images of 20 patients with clinically suspected DST were retrospectively assessed by two neuroradiologists blinded to the surgical results. The MRI studies were performed from July 2003 to July 2013. Institutional Review Board (IRB) approval was obtained. All MRI studies were assessed with respect to five imaging signs: A) visualization on both sagittal and axial images, B) dural penetration, C) associated tethered cord, D) presence of tumor or inflammation, and E) attachment to conus medullaris. The frequency of each imaging sign in the study population was calculated. For the 20 patients who underwent surgery, sensitivity and specificity of each neuroradiologist’s interpretation of the MRI data were calculated using operative findings as the gold standard. Results Twelve of the 20 had confirmed DSTs. The incidences of the five imaging signs were as follows: A) visualization on both sagittal and axial images (12/12, 100%), B) dural penetration (10/12, 83.3%), C) associated tethered cord (7/12, 58.3%), D) presence of tumor or inflammation (4/12, 33.3%), and E) attachment to the conus medullaris (4/12, 33.3%). The best combination of findings predictive of DST was simply the appearance of DST on both axial and sagittal imaging, which resulted in a sensitivity of 100% and a specificity of 75-100%. Conclusion Visualization of DST on both axial and sagittal imaging is the best marker for pathology proven DST. Using a higher threshold score on the five-point scoring system that we proposed did not increase sensitivity or specificity in the diagnosis of DST; however, it may still prove clinically helpful in standardizing reporting leading to a more accurate and detailed assessment.

Two Leishmania infantum mimotopes (B10 and C01) identified by phage display showed to be antigenic and immunogenic for visceral (VL) and tegumentary (TL) leishmaniasis, however, their biological targets in the parasites have not been identified. The aim of the present study was to investigate the native antigens expressing both mimotopes, and to use them in distinct immunological assays. For this, a subtractive phage display technology was used, where a combinatorial library of single-chain variable fragments (scFv) was employed and the most reactive monoclonal antibodies for each target were captured, being the target antigens identified by mass spectrometry. Results in immunoblotting and immunoprecipitation assays showed that both monoclonal scFvs antibodies identified the &beta, tubulin protein as the target antigen in L. infantum. To validate these findings, the recombinant protein was cloned, purified and tested for the serodiagnosis of human leishmaniasis, and its immunogenicity was evaluated in PBMC derived from healthy subjects and treated or untreated VL patients. Results showed high diagnostic efficacy, as well as the development of a specific Th1 immune response in the cell cultures, since higher IFN-&gamma, and lower IL-10 production was found.

The aim of this study was to identify predictive factors and develop a model to assess individualized risk of postnatal surgical intervention in patients with antenatal hydronephrosis. This is a retrospective cohort study of 694 infants with prenatally detected congenital anomalies of kidney and urinary tract with a median follow-up time of 37 months. The main event of interest was postnatal surgical intervention. A predictive model was developed using Cox model with internal validation by bootstrap technique. Of 694 patients, 164 (24%) infants underwent surgical intervention in a median age of 7.8 months. Predictors of the surgical intervention in the model were: baseline glomerular filtration rate, associated hydronephrosis, presence of renal damage and the severity of renal pelvic dilatation. The optimism corrected c statistic for the model was 0.84 (95%CI, 0.82-0.87). The predictive model may contribute to identify infants at high risk for surgical intervention. Further studies are necessary to validate the model in patients from other settings.

Writing a chapter on the embryology of occult spinal dysraphic malformations (OSDM) is a little like writing a historical fiction novel. We begin with a substantial knowledge about the cellular events, molecular biology, and biomechanics underlying normal avian and mammalian neural development – knowledge derived from a host of embryonic experimental manipulations and genetic mutations. From this we propose, largely by extension, a paradigm for normal human neural development that comports with our clinical observations and theorize about the embryogenesis of human neural tube defects (NTD) of myelomeningocele and exencephaly/anencephaly, for which we have reasonable experimental models. We are finally left to essentially fantasize about the embryogenesis of OSDM, for which we have virtually no animal models or experimental data. Many of the theories we will discuss in this chapter were created de novo decades ago from clinical observations and a basic understanding of morphogenesis, unmodified by subsequent advances in cellular and molecular biology. It is our hope that the future will bring greater clarity to our understanding about the embryogenesis of these malformations. Until then, a work of fiction will have to suffice.

Although eradicated in Portugal, malaria keeps taking its toll on travellers and migrants from endemic countries. Completeness of hospital requiring malaria notification in Portugal 2000-11 was estimated, using two-source capture-recapture method. Data sources were: national surveillance database of notifiable diseases and the national database of the Diagnosis-Related Groups resulting from National Health Service (NHS) hospital episodes. The completeness of notification was 21,2% for all malaria cases and 26,5% for malaria deaths, indicating significant underreporting and urging for complementary data source in surveillance, for disease burden estimates and retrospective monitoring, namely hospital episodes statistics.