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ABSTRACT Objective: To evaluate glycemic control according to the number of daily basal rates (BRs) in type 1 diabetes patients using continuous subcutaneous insulin infusion (CSII). Subjects and methods: Cross-sectional study of patients treated with an open-loop CSII for at least 6 months and using a flash glucose monitoring system. Patients were divided into 2 groups: group 1 (G1) and group 2 (G2), with ≤4 and >4 BRs/24h, respectively. The groups were compared regarding HbA1c, time in range (TIR), time above range (TAR), time below range (TBR), glucose management indicator (GMI), glucose variability and data related to hypoglycemia. Regression models were performed. Results: The study included 99 patients (n = 55 in G1; n = 44 in G2). Median (Interquartile range) overall age was 30 (17) years, with 19.5 (48) and 51 (77) months of CSII use, respectively. The median number of different BRs was 3 (2) for G1 and 6 (2) for G2. There were no differences concerning age, sex, educational stage, weight, and insulin analog used. G2 had longer disease duration, longer CSII use, and higher total basal daily dose/kg. No significant differences regarding HbA1c, median glucose, GMI, TIR, TAR, and CV were found. G2 patients had more hypoglycemia, more asymptomatic hypoglycemia, and higher TBR. After adjusting for potential confounders, G1 maintained a lower risk of asymptomatic hypoglycemia. Conclusion: Programming open-loop CSII devices with more than 4 BRs does not improve metabolic control. Additionally, it seems to be a risk factor for hypoglycemia and was an independent predictor for asymptomatic hypoglycemia.

Abstract Background The COVID-19 pandemic put healthcare professionals, including residents (postgraduate trainees of health professions), under intense physical and psychological stress, hence at risk for mental disorders. We evaluated the prevalence of mental disorders among healthcare residents during the pandemic. Methods From July to September 2020, residents in medicine and other healthcare specialties in Brazil were recruited. The participants completed electronic forms with validated questionnaires (DASS-21, PHQ-9, BRCS) to screen for depression, anxiety, and stress, and to evaluate resilience. Data on potential predisposing factors for mental disorders were also collected. Descriptive statistics, chi-squared, students t, correlation and logistic regression models were applied. The study received ethical approval, and all participants provided informed consent. Results We included 1313 participants (51.3% medical; 48.7% nonmedical) from 135 Brazilian hospitals; mean (SD) age: 27.8 (4.4) years; 78.2% females; 59.3% white race. Of all participants, 51.3%, 53.4% and 52.6% presented symptoms consistent with depression, anxiety, and stress, respectively; 61.9% showed low resilience. Nonmedical residents exhibited higher anxiety compared to medical residents (DASS-21 anxiety score, mean difference: 2.26; 95% CI: 1.15–3.37; p

Introduction Health information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this intervention. Our study will determine whether using a digital platform (Multimorbidity Management Health Information System, METHIS) to manage multimorbidity improves health-related quality of life (HR-QoL).Methods and analysis A superiority, cluster randomised trial will be conducted at primary healthcare practices (1:1 allocation ratio). All public practices in the Lisbon and Tagus Valley (LVT) Region, Portugal, not involved in a previous pilot trial, will be eligible. At the participant level, eligible patients will be people with complex multimorbidity, aged 50 years or older, with access to an internet connection and a communication technology device. Participants who cannot sign/read/write and who do not have access to an email account will not be included in the study. The intervention combines a training programme and a customised information system (METHIS). Both are designed to help clinicians adopt a goal-oriented care model approach and to encourage patients and carers to play a more active role in autonomous healthcare. The primary outcome is HR-QoL, measured at 12 months with the physical component scale of the 12-item Short Form questionnaire (SF-12). Secondary outcomes will also be measured at 12 months and include mental health (mental component Scale SF-12, Hospital Anxiety and Depression Scale). We will also assess serious adverse events during the trial, including hospitalisation and emergency services. Finally, at 18 months, we will ask the general practitioners for any potentially missed diagnoses.Ethics and dissemination The Research and Ethics Committee (LVT Region) approved the trial protocol. Clinicians and patients will sign an informed consent. A data management officer will handle all data, and the publication of several scientific papers and presentations at relevant conferences/workshops is envisaged.Trial registration number NCT05593835.

Abstract Background Periprostatic adipose tissue (PPAT) plays a role in prostate cancer (PCa) progression. PPAT lipidomic composition study may allow us to understand the tumor metabolic microenvironment and provide new stratification factors. Methods We used ultra-high-performance liquid chromatography-mass spectrometry-based non-targeted lipidomics to profile lipids in the PPAT of 40 patients with PCa (n = 20 with low-risk and n = 20 high-risk). Partial least squares-discriminant analysis (PLS-DA) and variable importance in projection (VIP) analysis were used to identify the most relevant features of PPAT between low- and high-risk PCa, and metabolite set enrichment analysis was used to detect disrupted metabolic pathways. Metabolic crosstalk between PPAT and PCa cell lines (PC-3 and LNCaP) was studied using ex vivo experiments. Lipid uptake and lipid accumulation were measured. Lipid metabolic-related genes (SREBP1, FASN, ACACA, LIPE, PPARG, CD36, PNPLA2, FABP4, CPT1A, FATP5, ADIPOQ), inflammatory markers (IL-6, IL-1B, TNFα), and tumor-related markers (ESRRA, MMP-9, TWIST1) were measured by RT-qPCR. Results Significant differences in the content of 67 lipid species were identified in PPAT samples between high- and low-risk PCa. PLS-DA and VIP analyses revealed a discriminating lipidomic panel between low- and high-risk PCa, suggesting the occurrence of disordered lipid metabolism in patients related to PCa aggressiveness. Functional analysis revealed that alterations in fatty acid biosynthesis, linoleic acid metabolism, and β-oxidation of very long-chain fatty acids had the greatest impact in the PPAT lipidome. Gene analyses of PPAT samples demonstrated that the expression of genes associated with de novo fatty acid synthesis such as FASN and ACACA were significantly lower in PPAT from high-risk PCa than in low-risk counterparts. This was accompanied by the overexpression of inflammatory markers (IL-6, IL-1B, and TNFα). Co-culture of PPAT explants with PCa cell lines revealed a reduced gene expression of lipid metabolic-related genes (CD36, FASN, PPARG, and CPT1A), contrary to that observed in co-cultured PCa cell lines. This was followed by an increase in lipid uptake and lipid accumulation in PCa cells. Tumor-related genes were increased in co-cultured PCa cell lines. Conclusions Disturbances in PPAT lipid metabolism of patients with high-risk PCa are associated with tumor cell metabolic changes.

BackgroundNewborns with one-or-more adverse birth outcomes (ABOs) are at greater risk of mortality or long-term morbidity with health impacts into adulthood. Hence, identifying ABO-associated factors is crucial for devising relevant interventions. For this study, ABOs were defined as prematurity (PTB) for gestational age 4 kg, asphyxia for a 5-minute Apgar score MethodsA hospital-based unmatched case‒control study was conducted among newborns from randomly selected mothers. Newborns with one-or-more ABO were the cases (ABO group), while healthy newborns were the controls (no-ABO group). Data were collected by a face-to-face interview and abstracted from antenatal care (ANC) pregnancy cards and medical records. Multivariable logistic regression analysis was performed to identify ABO-associated factors considering a level of significance of α = 0.05.ResultsA total of 519 newborns (176 with ABO and 343 no-ABO) were enrolled. The mean gestational age and birthweight of cases and controls were 36 (SD = 3.7) weeks with 2659 (SD = 881.44) g and 39.6 (SD = 1.0) weeks with 3256 (SD = 345.83) g, respectively. In the multivariable analysis, twin pregnancy [aOR 4.92, 95% CI 2.25-10.74], prolonged rupture of membranes [aOR 3.43, 95% CI 1.69-6.95], and meconium- fluid [aOR 1.59, 95% CI 0.97-2.62] were significantly associated with ABOs. Eight or more ANC contacts were found to be protective [aOR 0.33, 95% CI 0.18-0.60, pConclusionModifiable factors were associated with ABOs in this study and should be considered in cost-effective interventions. The provision of high-quality ANC should be a priority. Twin pregnancies and intrapartum factors such as prolonged rupture of membranes and meconium-stained amniotic fluid are red flags for ABOs that should receive prompt intervention and follow-up.

Introduction: The pathological status of obesity can influence COVID-19 from its initial clinical presentation, therefore, the identification of clinical and laboratory parameters most affected in the presence of obesity can contribute to improving the treatment of the disease. Objective: To identify the clinical, laboratory, and tomographic characteristics associated with obesity and BMI at t hospital admission in adult patients with COVID-19. Methods: This is a cross-sectional observational study with a total of 315 participants with COVID-19 confirmed by rt-PCR. The participants were divided into non-Obese (n=203) and Obese (n=112). Physical examinations, laboratory tests, and computed tomography of the chest were performed during the first 2 days of hospitalization. Results: Patients with obesity were younger, and they had higher systolic and diastolic blood pressure, higher frequency of alcoholism, fever, cough, and headache, higher ALT, LDH, and red blood cell count (RBC), hemoglobin, hematocrit, and percentage of lymphocytes. Also, they presented a lower value of leukocyte count and Neutrophil/Lymphocyte Ratio (RNL). The parameters positively correlated with BMI were alcoholism, systolic and diastolic blood pressure, fever, cough, sore throat, number of symptoms, ALT in men, LDH, magnesium, RBC, hemoglobin, hematocrit, and percentage of lymphocytes. The parameters negatively correlated with the BMI were: age and RNL. Conclusion: Several parameters were associated with obesity at hospital admission, revealing better than expected results. However, these results should be interpreted with great caution, as there may be some influence of a phenomenon called the Obesity Paradox that can distort the severity and prognosis of the patient.

External cervical resorption is a relatively uncommon, often misdiagnosed, destructive form of external resorption. It consists of an uncontrolled growth of resorptive tissue and consequent loss of mineralized tooth tissue, in an apical direction. The clastic cells are responsible for the process, which can lead to severe deterioration and, eventually, tooth loss. To date, however, an etiological factor has not yet been found. Dentists and students still have difficulties in diagnosing and treating it. In May 2023, a structural questionnaire about external cervical resorption was distributed via Google Forms to 104 people between dentists and fourth- and fifth-year students.

Background Since the beginning of the COVID-19 pandemic, health professionals have been working under extreme conditions, increasing the risk of physical and mental illness. We evaluated the prevalence of burnout and its associated factors among postgraduate student residents in health professions during the global health crisis. Methods Healthcare residents were recruited from all across Brazil between July and September 2020 through digital forms containing instruments for assessing burnout (Oldenburg Burnout Inventory (OLBI)), resilience (brief resilient coping scale (BRCS)) and anxiety, stress and depression (depression, anxiety and stress scale (DASS-21) and Patient Health Questionnaire (PHQ-9)). Additionally, the relationships between burnout and chronic diseases, autonomy and educational adequacy in the residency programme, personal protective equipment (PPE), workload and care for patients with COVID-19 were evaluated. The chi-square test, Student’s t test, Pearson’s correlation test and logistic regression were performed. Results A total of 1,313 participants were included: mean (standard deviation) age, 27.8 (4.4) years; female gender, 78.1%; white race, 59.3%; and physicians, 51.3%. The overall prevalence of burnout was 33.4%. The odds (odds ratio [95% confidence interval]) of burnout were higher in the presence of pre-existing diseases (1.76 [1.26–2.47]) and weekly work > 60 h (1.36 [1.03–1.79]) and were lower in the presence of high resilience (0.84 [0.81–0.88]), autonomy (0.87 [0.81–0.93]), and educational structure (0.77 [0.73–0.82]), adequate availability of PPE (0.72 [0.63–0.83]) and non-white race (0.63 [0.47–0.83]). Burnout was correlated with anxiety (r = 0.47; p < 0.05), stress (r: 0.58; p < 0.05) and depression (r: 0.65; p < 0.05). Conclusions We observed a high prevalence of burnout among residents during the COVID-19 pandemic. Individual characteristics and conditions related to the work environment were associated with a higher or lower occurrence of the syndrome.

Background: Somatosensation depends on primary sensory neurons of the trigeminal and dorsal root ganglia (DRG). Transcriptional profiling of mouse DRG sensory neurons has defined at least 18 distinct neuronal cell types. Using an advillin promoter, we have generated a transgenic mouse line that only expresses diphtheria toxin A (DTA) in sensory neurons in the presence of Cre recombinase. This has allowed us to ablate specific neuronal subsets within the DRG using a range of established and novel Cre lines that encompass all sets of sensory neurons. Methods: A floxed-tdTomato-stop-DTA bacterial artificial chromosome (BAC) transgenic reporter line (AdvDTA) under the control of the mouse advillin DRG promoter was generated. The line was first validated using a Nav1.8Cre and then crossed to CGRPCreER (Calca), ThCreERT2, Tmem45bCre, Tmem233Cre, Ntng1Cre and TrkBCreER (Ntrk2) lines. Pain behavioural assays included Hargreaves’, hot plate, Randall-Selitto, cold plantar, partial sciatic nerve ligation and formalin tests. Results: Motor activity, as assessed by the rotarod test, was normal for all lines tested. Noxious mechanosensation was significantly reduced when either Nav1.8 positive neurons or Tmem45b positive neurons were ablated whilst acute heat pain was unaffected. In contrast, noxious mechanosensation was normal following ablation of CGRP-positive neurons but acute heat pain thresholds were significantly elevated and a reduction in nocifensive responses was observed in the second phase of the formalin test. Ablation of TrkB-positive neurons led to significant deficits in mechanical hypersensitivity in the partial sciatic nerve ligation neuropathic pain model. Conclusions: Ablation of specific DRG neuronal subsets using the AdvDTA line will be a useful resource for further functional characterization of somatosensory processing, neuro-immune interactions and chronic pain disorders.

Abstract Background Conventional clinical biomarkers cannot accurately differentiate indolent from aggressive prostate cancer (PCa). We investigated the usefulness of a biomarker panel measured exclusively in biofluids for assessment of PCa aggressiveness. Methods We collected biofluid samples (plasma/serum/semen/post-prostatic massage urine) from 98 patients that had undergone radical prostatectomy. Clinical biochemistry was performed and several cytokines/chemokines including soluble(s) TWEAK, sFn14, sCD163, sCXCL5 and sCCL7 were quantified by ELISA in selected biofluids. Also, the expression of KLK2, KLK3, Fn14, CD163, CXCR2 and CCR3 was quantified by real-time PCR in semen cell sediment. Univariate, logistic regression, and receiver operating characteristic (ROC) analyses were used to assess the predictive ability of the selected biomarker panel in conjunction with clinical and metabolic variables for the evaluation of PCa aggressiveness. Results Total serum levels of prostate-specific antigen (PSA), semen levels of sTWEAK, fasting glycemia and mRNA levels of Fn14, KLK2, CXCR2 and CCR3 in semen cell sediment constituted a panel of markers that was significantly different between patients with less aggressive tumors [International Society of Urological Pathology (ISUP) grade I and II] and those with more aggressive tumors (ISUP grade III, IV and V). ROC curve analysis showed that this panel could be used to correctly classify tumor aggressiveness in 90.9% of patients. Area under the curve (AUC) analysis revealed that this combination was more accurate [AUC = 0.913 95% confidence interval (CI) 0.782–1] than a classical non-invasive selected clinical panel comprising age, tumor clinical stage (T-classification) and total serum PSA (AUC = 0.721 95% CI 0.613–0.830). Conclusions TWEAK/Fn14 axis in combination with a selected non-invasive biomarker panel, including conventional clinical biochemistry, can improve the predictive power of serum PSA levels and could be used to classify PCa aggressiveness.

O presente artigo tem, a priori, pretensão de analisar bibliograficamente a temática dos CAPS AD numa perspectiva de totalidade, contemplando da origem à contemporaneidade desta expressão da “Questão Social” para logo em seguida, de forma sucinta articular com atuação do Centro de Atenção Psicossocial Álcool e Drogas do município de Iguatu-CE, elencando sua gênese ligada ao contexto socioeconômico e social da região explicitados através dos marcos históricos acerca da temática. Descortina o funcionamento da instituição, apresentando de que forma atua na viabilização de direitos a usuários de álcool e outras drogas, além de analisar o uso progressivo de drogas como uma problemática da expressão da questão social, partindo do pressuposto de que a questão do uso abusivo não é especificamente da sociedade contemporânea, à vista disso, verificar a intervenção realizada pelo CAPSad (Centro de Atenção Psicossocial – Álcool e Drogas) visto que é um equipamento que busca intervir frente às demandas postas referentes ao uso prejudicial. A posteriori, faz-se mister, também uma reflexão crítica quanto à superação ou alívio desta expressão da questão social”, através do equipamento referido. Confeccionado a partir de levantamentos bibliográficos que objetivam fundamentar o texto e procura se aprofundar no ínterim da pesquisa qualitativa de campo.

A Idade Média é componente curricular básico para o estudo de História, logo como um dos pilares para a compreensão da formação da identidade do Ocidente, é vislumbrada até os dias de hoje como um período de estagnação cultural, intelectual e econômica. Tais mitos acerca desta era permeiam a historiografia desde sua concepção tradicional e vem se proliferando até os tempos contemporâneos penetrando no senso comum e influenciando os mais diversos materiais e mídias. Tal realidade adentra nas escolas através destes objetos e através do principal recurso utilizado no processo de ensino-aprendizagem: o livro didático. Esta pesquisa apresenta a análise realizada no espaço da Escola de Ensino Médio Coronel Murilo Serpa tendo como referencial o livro utilizado naquela escola: História: sociedade e cidadania, 1° Ano de Alfredo Boulos Júnior (2013) e a perspectiva de quem leciona História da Idade Média na citada instituição de ensino, buscando obter de forma objetiva a compreensão de como a visão acerca da Idade Média é conceituada no ambiente em questão. O estudo contou com pesquisa bibliográfica, pesquisa documental e pesquisa de campo, além de utilizar um questionário com quatro questões abertas como instrumental para coleta de dados. Constatou-se que existem diferentes formas de apresentar os temas relativos à Idade Média, enquanto alguns autores são mais factuais e historiográficos, outros optam por apresentar as questões mais culturais. E isso repercute na fala dos alunos em que muitos se lembram de uma Idade Média construída historicamente e onde outros se reportam mais a lendas e mitos.

Introduction: We aim to define the iron deficiency prevalence and eventual differences between obese patients with and without metabolic syndrome. Material and Methods: Analysis of patients evaluated at multidisciplinary consultation of obesity in our institution between 2013 and 2015 (n = 260). Iron deficiency: ferritin levels < 15 ng/mL. Exclusion criteria: prior bariatric surgery; lack of ferritin or hemoglobin determinations. Results: We analyzed data from 215 patients (84.2% female) with a mean age of 42.0 ± 10.3 years. The median body mass index was 42.5 (40.0 - 46.8) kg/m2 and 52.1% had metabolic syndrome. Iron deficiency was present in 7.0%, with no differences between genders or between patients with or without metabolic syndrome. Hypertension was associated with lower prevalence of iron deficiency. Type 2 diabetes and hypertension patients had higher levels of ferritin. The multivariate analysis showed that metabolic syndrome and increasing body mass index were predictive of higher risk of iron deficiency while hypertension predicted lower odds of iron deficiency. Discussion: The prevalence of iron deficiency was similar in other published studies. Iron deficiency may be underdiagnosed if based only on ferritin concentrations. In our study, diabetes and hypertension appear to contribute to the increase in ferritin levels described in obesity. Conclusion: Ferritin may not be a reliable index for evaluating iron stores in obese patients, particularly when associated with comorbidities such as type 2 diabetes and hypertension. Further studies are needed to guide the diagnosis and iron supplementation in these patients.

Abstract Background The use of impedance cardiography (ICG) may play a role in the assessment of cardiac effects of hypertension (HT), especially its hemodynamic features. Hypertensive heart disease involves structural changes and alterations in left ventricular geometry that end up causing systolic and/or diastolic dysfunction. The IMPEDDANS study aims to assess the usefulness of ICG for the screening of left ventricular diastolic dysfunction (LVDD) in patients with HT. Methods Patients with HT were assessed by echocardiography and ICG. Receiver-operating characteristic curve and the area under the curve were used to assess the discriminative ability of the parameters obtained by ICG to identify LVDD, as diagnosed by echocardiography. Results ICG derived pre-ejection period (PEP), left ventricle ejection time (LVET), systolic time ratio (STR) and D wave were associated (p

RESUMO: Introdução – A perturbação do equilíbrio após acidente vascular cerebral (AVC) é importante pela sua frequência e repercussões. Instrumentos de avaliação do equilíbrio validados e de fácil aplicação são necessários para identificar risco de queda e para adequar estratégias de intervenção. Objetivos – Verificar a concordância entre as avaliações do equilíbrio estático, dinâmico e mobilidade funcional após AVC e verificar se a concordância varia com o grau de dependência. Metodologia – Estudo transversal de amostra sequencial de adultos com marcha autónoma, até dois anos após AVC, referenciados para fisioterapia em ambulatório. O equilíbrio estático foi avaliado pelo teste de Romberg, o equilíbrio dinâmico pela Escala de Equilíbrio de Berg (EEB), a mobilidade funcional pelo Timed Up and Go test (TUG) e o grau de dependência pela Motor Assessment Scale (MAS). A concordância foi avaliada pelo coeficiente de correlação interclasse e pelo teste k de Cohen. Resultados – Foram incluídos 52 indivíduos, 26 com dependência leve, 20 moderada e seis grave. Tinham Romberg positivo 48/52; 39/52 tinham EEB14 foi observado em 42/52. A concordância global entre as três variáveis avaliadas obteve ICC=0,63. Verificou-se uma concordância global k=0,61 entre EEB e TUG, nos indivíduos com dependência leve k=0,52 e naqueles com dependência moderada k=0,64. A concordância entre Romberg e EEB obteve globalmente k=0,27 e entre Romberg e TUG k=0,04. Conclusões – A concordância entre as avaliações do equilíbrio estático, dinâmico e mobilidade funcional após AVC é total nos casos de dependência grave e elevada nos casos de dependência moderada. Estes resultados reforçam a necessidade da utilização destes três instrumentos, particularmente nos casos de dependência leve.

Introdução: As crises epiléticas são a urgência neurológica pediátrica mais frequente. Este trabalho pretendeu caracterizar as primeiras crises em apirexia, a sua abordagem diagnóstica e terapêutica e estimar a recorrência de crise na população estudada. Métodos: Estudo retrospetivo dos casos admitidos num Serviço de Pediatria de um hospital de nível II por primeira crise epilética em apirexia, entre janeiro de 2010 e setembro de 2013. Resultados: Incluíram-se 72 doentes. A maioria apresentou crise generalizada (66,7%), em vigília (84,7%) e com duração inferior a 15 minutos (80,6%). Identificou-se fator de risco para crise em 34,7%. Em 75% dos casos não se identificaram alterações de novo no exame neurológico, 22,2% apresentaram alteração da consciência e 2,8% sinais motores focais. A abordagem diagnóstica incluiu estudo analítico (100%) e exame toxicológico (61,1%). A maioria realizou eletroencefalograma (alterado em 40,3%) e neuroimagem.Das 9 lesões de novo identificadas, 6 tinham implicações na terapêutica/ prognóstico. Em 56,9% dos casos foi iniciada terapêutica com anti--epilético após primeira crise. A decisão de iniciar anti-epilético relacionou-se com alterações no eletroencefalograma. Houve recorrência em 45,8%. Conclusão: A abordagem diagnóstica dos casos foi globalmente concordante com as orientações da Academia Americana de Neurologia. Verificou-se uma elevada proporção de instituição de anti-epiléticos após primeira crise. A percentagem de recorrência foi sobreponível à de outros estudos. Conhecer as características da nossa população justifica a divulgação de séries locais, potenciais rampas para estudos nacionais.

Introduction: This observational study explores potential links between obese children’s cortisol, and parental mental state, family functioning, and the children’s symptoms of anxiety and depression. Material and Methods: A non-random sample of 104 obese children (55 boys), mean age 10.9 years (standard deviation 1.76), was recruited from a childhood obesity clinic. Obesity was defined as body mass index above the 95th age- and gender-specific percentiles. Neuroendocrine biomarkers were measured. Symptoms of anxiety and depression were assessed with self and parent-reported questionnaires (Anxiety, Depression and Stress Scales; Child Behaviour Checklist). Family functioning was assessed with parent-reported questionnaires (Family Adaptation and Cohesion Scales-III). Results: A significant, negative correlation (rs = -0.779; p = 0.003) between girls’ cortisol and their parents’ anxiety symptoms was found, limited to high functioning families. Boys scored significantly higher than girls on parent-reported internalizing symptoms but not on self-report. No association was found between cortisol in children and parental depressive symptoms. Discussion: Whether the association between cortisol levels in obese children and parental mental health is effectively restricted to girls from high functioning families or is due to study limitations, requires further research. The lack of associations between cortisol in children and parental depressive symptoms, suggests a specific association between cortisol and parental anxiety symptoms. Conclusion: These results highlight the importance of taking into account family functioning, parental mental state and gender, when investigating neuroendocrine biomarkers in obese children associated with symptoms of anxiety and depression.

Objective We aimed to compare patient’s and physician’s ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.Design Baseline data from two prospective multicentre observational studies.Setting 29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.Participants 395 patients (≥13 years old) with persistent asthma.Measures Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0–50; medium 51–80; high 81–100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients’ and physicians’ VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.Results High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65–95) mm; 53% VAS>80) and by physicians (84 (68–95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p

Introduction: Biliary complications occur in 10-30% of liver transplants. The aim of this study was to compare the incidence of these complications in liver transplants when the T-tube was or was not used during the biliary anastomosis. Material and Methods: Analysis of 2 groups of patients undergoing liver transplantation between 2008 and 2012. Patients were divided considering if the T-tube was used (G1) or if it was not (G2). We sought explanatory models of the occurrence of biliary complications by logistic regression, including the variables identified in the univariate analysis. Results: We reviewed 506 consecutive patients who underwent a first liver transplant (G1 = 363, G2 = 143). The overall incidence of biliary complications was 24.7% (95% CI 21.1 to 28.6): 27.0% in G1 and 18.9% in G2 (p = 0.057). The incidences of stenosis and biliary fistula tended to be higher in G1: 19.6% (95% CI 15.7 to 23.8) vs 15.4% (95% CI 10.1 to 22.0) (p = 0.275) and 6.6% (95% CI 4.4 to 9.5) vs 2.8% (95% CI 0.9 to 6.6) (p = 0.091). We did not find statistically significant differences in the rates of endoscopic retrograde cholangiopancreatography, reoperation and retransplantation. There were two deaths in G1. There was no association between the occurrence of biliary complications and the diameters of the biliary tract nor the time of cold ischemia. The explanatory model, adjusted to the recipient and the donor age’s and to the initial diagnosis, identifies the use of the T-tube as increasing the possibility of the occurrence of biliary complications (AdjOR 1.71, 95% CI 1.04 to 2.80; p = 0.034). Discussion and Conclusion: The use of the T-tube should be a decision taken on a case-based intraoperative judgment of experienced surgeons

O objetivo deste artigo foi analisar o perfil dos atendimentos de emergência por acidentes e violências envolvendo crianças menores de 10 anos no Brasil no ano de 2011. Foi realizado estudo transversal, descritivo, em 71 serviços de urgência e emergência no âmbito do SUS, localizados no Distrito Federal e em 24 capitais brasileiras. Os dados foram obtidos no sistema de serviços sentinelas de Vigilância de Violências e Acidentes (VIVA Inquérito), do Ministério da Saúde. A maior proporção das lesões (67,4%) ocorreu no ambiente domiciliar. Dentre as injúrias não intencionais, as quedas foram a ocorrência mais frequente (52,4%), seguidas de choque contra objetos/pessoas (21,8%) e lesões no trânsito (10,9%), destacando-se as vítimas na condição de passageiros, e dentre os meios de locomoção da vítima são destaque as bicicletas. As injúrias não intencionais na grande maioria são evitáveis e devem ser adotadas medidas educativas, em especial junto aos pais, educadores, comunidade, profissionais de saúde e educação, alertando para os riscos e adoção de comportamentos seguros em relação ao ambiente doméstico, escola e de lazer. As violências são objeto de notificação obrigatória, e as ações de proteção às vítimas devem ser instituídas prontamente.

O artigo tem a modesta pretensão de organizar panoramicamente a trajetória da modalidade EAD no mundo, no Brasil e no Instituto Federal de Educação, Ciência e Tecnologia do Ceará (IFCE), com o propósito de evidenciar os ranços e avanços acerca dos conteúdos, metodologia, didática e avalia- ção da aprendizagem dos alunos, ou seja, investigar se a prática está de acordo com as teorias pedagógicas para caracterizar a práxis. Objetiva ainda divulgar os resultados para os participantes da pesquisa, como forma de incentivá-los a refletir sobre suas insatifações, demandas e fatores positivos; propor mudanças importantes para que haja maior êxito na relação ensino-aprendizagem; servir de referência para a Direção de Ensino a Distância do IFCE para que nas próximas turmas possam ratificar os pontos positivos e corrigir os erros, de modo que a formação teórico-metodológica, ético-política e técnico-operacional sejam condizentes com a práxis pedagógica, e mais, que tecnologias contemporâneas de informação e de comunicabilidade no contexto educacional, principalmente Educação a Distância, sejam transformadoras, pois elas potencializam e pressupõem um outro paradigma educacional, que passa pela descentralização do currículo e do empoderamento dos alunos. A priori, utilizou-se de pesquisa bibliográfica para fundamentação e uso de questionário e a posteriori de pesquisa de campo, tendo em vista o estudo ocorrer in lócus, percebeu-se que a maioria dos participantes do estudo elucidaram algumas lacunas no curso como conteúdos insuficientes entre outras peculiaridades.

Introdução: A dor é uma experiência frequente nos doentes com cancro, especialmente naqueles em fase final de vida. Com este estudo, pretendemos estudar a intensidade de dor nos doentes com cancro avançado, referenciados aos cuidados paliativos, analisar os factores associados à ocorrência de dor moderada ou intensa e avaliar a sua relação com o tempo até à morte destes doentes. Material e Métodos: Estudo prospectivo observacional que incluiu consecutivamente todos os doentes referenciados aos cuidados paliativos com tumores sólidos metastizados e sem tratamento oncológico específico. Foi considerada a intensidade de dor da escala de Edmonton, de acordo com a graduação zero a 10, onde 0 = ausência de dor e 10 = máxima dor possível. Resultados: Entre outubro de 2012 e junho de 2015, foram incluídos 301 doentes, com idade mediana de 69 anos (37 - 94), 57% homens e 64,8% dos doentes com performance status 3/4. Aproximadamente 42% dos doentes apresentaram dor ≥ 4 e cerca de 74,4% estavam medicados com analgesia opióide. A intensidade de dor esteve associada ao performance status dos doentes, de acordo com a análise multivariável (OR: 1,7; IC 95%: 1,0 - 2,7; p = 0,045). A mediana do tempo de sobrevivência foi de 37 dias (IC 95%: 28 - 46), tendo os doentes com dor moderada ou intensa (intensidade de dor ≥ 4) uma mediana de sobrevivência de 29 dias (IC 95%: 21 - 37), comparada com os 49 dias (IC 95%: 35 - 63) para os doentes sem dor ou dor ligeira (p = 0,022). Discussão: O performance status, para além de ter estado associado a uma maior intensidade de dor, esteve associado a um menor tempo até à morte dos doentes com cancro avançado referenciados aos cuidados paliativos. Também o internamento, a presença de metastização intra-abdominal e a analgesia opióide estiveram associados de forma negativa ao tempo até à morte destes doentes. Conclusão: A dor oncológica continua a ser um problema clinicamente relevante nos doentes com cancro avançado.

Introdução: Os glicocorticóides associam-se a vários efeitos adversos, entre os quais se destaca uma importante ação diabetogénica. A hiperglicemia induzida pelos glicocorticóides trata-se de uma condição com elevada prevalência e que condiciona importante morbimortalidade. Material e Métodos: Realizou-se uma revisão da literatura relativa à abordagem e tratamento da hiperglicemia induzida pelos glicocorticóides Resultados: Embora não totalmente esclarecidos, sabe-se que vários mecanismos concorrem de forma sinérgica, propiciando o aparecimento da hiperglicemia em doentes não diabéticos e o agravamento do controlo glicémico em diabéticos. A hiperglicemia induzida por glicocorticóides apresenta padrões característicos, mais marcada no momento pós-prandial e muito dependente do horário da toma do glicocorticóide. Apesar da existência de normas de orientação gerais para o tratamento da hiperglicemia em doentes em ambulatório e em doentes hospitalizados não críticos, o mesmo não acontece no que diz respeito ao tratamento da hiperglicemia induzida por glicocorticóides. E, de facto, frequentemente é difícil e exigente a abordagem deste tipo de hiperglicemia, sendo necessária uma atuação específica. Esta abordagem depende não só do glicocorticóide em causa, como também da sua dose, frequência e horário de administração. De igual forma, a escolha do esquema de tratamento também depende do tipo de terapêutica previamente usado. Discussão e Conclusão: Os autores fizeram uma revisão do tema, congregando e definindo linhas orientadoras para o tratamento da hiperglicemia induzida por glicocorticóides, em doentes diabéticos e não diabéticos, em regime de ambulatório ou internamento, que serão úteis em diferentes contextos e transversalmente às diversas especialidades.

Introduction: Quality of the parent-infant relationship influences the mechanisms of development of the child’s physiological stress regulation. This study explored associations between attachment strategies and both cortisol and thyroid stimulating hormone, hypothesized to be respectively a potential mediator and a potential intervening variable of the mother-child relationship in obese children. Material and Methods: A sample of 83 obese children (46 boys), aged 10.9 (1.8) years was recruited from a child obesity clinic. Obesity was defined by body mass index percentile adjusted for age and sex. Metabolic biomarkers were measured by routine methods. Attachment strategies were assessed with self and parent-report questionnaires. Family functioning was assessed with parent-reported questionnaires (FACES-III). Multivariate linear regression analyses were performed. Results: Type A, avoidant attachment strategies, had significant positive association with thyroid stimulating hormone levels and negative association with cortisol levels (R2 = 0.352). Type B, secure attachment strategies, had significant positive associations with both hypothyroidism and body mass index percentile (R2 = 0.541). “Insecure attachment” (types A and C combined) strategies showed some evidence of positive association with thyroid stimulating hormone (R2 = 0.250). Discussion: These findings suggest that there may be commonalities in the regulation of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes. Processes involved in development of the type A attachment strategy appear to be associated with effects on the regulatory mechanisms of the hypothalamic-pituitary-adrenal axis. Conclusions: In obese children, different attachment strategies are associated with diverse metabolic profiles. How this may contribute to developing differentiated treatment approaches remains to be explored.

Introdução e Objetivos: Avaliar a taxa de prescrição de anticoagulantes orais na fibrilhação auricular, os fatores associados à não prescrição, os motivos referidos pelos clínicos para não prescrição de anticoagulantes incluindo os de nova geração e realizar estudo evolutivo a médio prazo. Material e Métodos: Estudo prospetivo sobre casos consecutivos de doentes com fibrilhação auricular com alta hospitalar. Registaram- se os scores CHA2DS2VASc e HASBLED, comorbilidades associadas e a medicação prévia e à data de alta. Na alta hospitalar, o médico assistente indicou em questionário o motivo de não prescrição de anticoagulantes orais e dos novos anticoagulantes orais. Exclusão: contra-indicação absoluta para anticoagulação, CHA2DS2VASc ≤ 1 e doença valvular. Os doentes foram reavaliados um ano após o recrutamento do primeiro doente. Resultados: Identificaram-se 103 candidatos a anticoagulação oral (79,6 ± 8,0 anos; CHA2DS2VASc 5,8 ± 1,4; HASBLED 2,6 ± 1,0; HASBLED ≥ 3 em 55,3%); os anticoagulantes foram prescritos em 34,0%. Fatores associados à não prescrição por ordem decrescente de relevância: uso prévio de antiagregantes, doente acamado e/ou demente, ausência de insuficiência cardíaca e número de fatores de risco hemorrágico. Razões invocadas para não prescrição por ordem decrescente de frequência: risco hemorrágico elevado, pequeno benefício, incapacidade de seguir o esquema terapêutico e dificuldade na monitorização da razão normalizada internacional (INR). Os novos anticoagulantes não foram prescritos e as razões invocadas foram, por ordem decrescente de frequência: informação insuficiente sobre estes fármacos, risco hemorrágico elevado, custo elevado e pequeno benefício. Aos 8,2 ± 2,5 meses de estudo evolutivo 33,3% dos doentes encontravam-se sob anticoagulação sem que os novos anticoagulantes tivessem sido prescritos. Conclusões: Nesta amostra, a taxa de prescrição de anticoagulação oral foi baixa e o fator mais associado à não prescrição foi o uso prévio de antiagregantes. O impedimento à prescrição mais referido foi o risco hemorrágico, seguido do pequeno benefício reconhecido. Os principais impedimentos referidos à prescrição dos novos anticoagulantes foram a informação insuficiente e o alto risco hemorrágico. A médio prazo, a proporção de doentes sob anticoagulação mantinha-se baixa e os novos anticoagulantes não tinham sido prescritos.

Thyroid associated orbitopathy is a clinical entity with pathogenic mechanisms not fully understood, and appears in about 90% of cases in association with hyperthyroidism of Graves' disease. Its approach involves the recognition of typical features and the exclusion of other diseases in the less common presentations. The treatment is conditioned by the determination of the activity and severity of the disease. The restoration of the euthyroid state and avoiding of hypothyroidism are essential in mitigating the progression of orbitopathy. Glucocorticoid intravenous therapy is the treatment of choice in the active phase and surgical treatment in the inactive phase. Radiotherapy and cyclosporine in combination with corticosteroids are alternatives when monotherapy is insufficient in the active phase. Treatment should be instituted in specialized centers, with ophthalmologists and endocrinologists acting in synergy to avoid consequences of delays in intervention and in optimizing therapy.

Continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) represent two strategies of intensive insulin therapy, obtaining a strict metabolic control. The importance of such rigorous metabolic control in reducing the frequency and severity of diabetes long-term complications was highlighted by the Diabetes Control and Complication Trial (DCCT).To review the experience in the use of ISCI at Hospital São João, comparing it with the therapeutic modality of MID, regarding metabolic control, weight and body mass index (BMI), microalbuminuria, frequency of adverse events, lipid profile and quality of life.This retrospective, observational study included 25 type 1 diabetic patients followed-up on Endocrinology outpatient at Hospital São João, receiving CSII for more than 3 months after they were treated with MDI also for a period exceeding 3 months. For both periods of treatment, clinical data were obtained on the quality of glycaemic control (assessed by the levels of glycated hemoglobin--A1c), lipid profile, weight and body mass index (BMI) and microalbuminuria. To evaluate the impact on quality of life we used the ADDQoL questionnaire. A questionnaire was also used to determine the frequency of adverse events (severe hypoglycemia and ketoacidosis).The sample of 25 subjects with mean age of 33.35 ± 9.59 years, with a duration of disease, on average, of 17.1 ± 8.15 years and receiving ISCI for an average of 2.48 ± 1 08 years, obtained a decrease of 1.1% (p = 0.001) on the median value of A1c between 3 and 6 months of treatment when compared to MDI, reduction sustained throughout the analyzed period. The variation of the daily insulin requirements after pump placement was 12.75 units of insulin (p = 0.015), equivalent to a decrease of 0.20 units/kg (p = 0.023). The median of the distribution of BMI decreased 0.48 kg/m2 (p = 0.507) during CSII. The parameters of lipid profile and microalbuminuria showed no trend upward or downward after institution of CSII. The score obtained in the ADDQoL questionnaire was greater with CSII, the difference between the medians of the score distribution, before and after pump placement, was 0.056 (p = 0.92). There was a subjective perception of reduced frequency of adverse events with ISCI.The introduction of CSII allowed optimization of metabolic control, reduction of the daily insulin requirements and achievement of a higher level of satisfaction with no change in lipid profile, no weight gain and without increasing the frequency of adverse events.

Cushing's syndrome is a diagnostic challenging endocrinous entity. Many laboratorial examinations are available for the study of these patients. Available examinations are not absolutely trustworthy for its diagnosis, so that, very often, it is necessary to conjúgate informations from different laboratory tests. In this revision one exposes the current evidence and the suggestions of different authors in the laboratorial diagnosis of Cushing's syndrome and the differential diagnosis in patients with biochemical confirmed diagnosis.

In the post-partum period the immune alterations are associated with the multiple autoimmune diseases relapse. After birth, immune-tolerance variation slowly disappear, and is observed a return to a normal state - after an exacerbation period - of autoimmune reactivity, during which a great increase in T cells and autoantibodies is observed. In this period - 3 to 9 months after birth - the thyroid autoimmune disease relapses or reappears. The reactivation of the immune system in the post-partum period unchains an acute phase of celular destruction which characterizes the post-partum thyroiditis.