Care transition and network activation in Portugal

Purpose

Theory

Methods

Results and conclusions

Multidisciplinary home training for stroke patients in Portugal: the perspective of care professionals

Purpose

To systematize the content of home-care interventions for stroke patients in Portugal and assess their relevance, feasibility and acceptability from the perspective of care professionals.

Theory

Research seems to show that Integrated Home Care (IHC) is an excellent form of rehabilitation as the domicile is the place where the patient feels safe, participate most and have direct feedback from ADL training [1]. Moreover, recent results show that IHC has the potential to lower the costs of post-stroke rehabilitation [2]. Cost-effectiveness analysis would then be an important tool for decision-makers regarding alternative IHC interventions. However, in practice the realization of the potential benefits of IHC has to overcome serious barriers and the dissemination of IHC in the European Union will depend “on the upgrade of health professionals from a defensive kind of monodisciplinary professionalism towards an open-ended multidisciplinary professionalism” [1]. Therefore, it is fundamental to assess health professionals’ perceptions and experiences regarding the relevance, feasibility and acceptability of home-based rehabilitation and their willingness to participate.

Methods

In Portugal, the home rehabilitation teams include a gerontologist which is the case manager, a physiotherapist, an occupational therapist and a psychologist. A mixed method was used to analyse the teams’ interventions at home. Information about each session was recorded by all professionals in a standardized form. Additionally, case managers have written qualitative reports, according to a pre-defined minimum structure and the psychologist has written patient specific psychology reports. We analysed the sessions’ reports of 80 patients who have received rehabilitation services at home. This information was coded, keyed into a database and analyzed with PASW Statistics 18. In the qualitative phase, we have explored health professional’s perceptions on experiences with home-care rehabilitation process. Data were collected within a focus group composed by two physiotherapists, two occupational therapists, a psychologist and two gerontologists. A group of three researchers with specific roles joined the focus group, namely a moderator, a recorder and a coordinator. The session’s content was recorded, transcript and analyzed with NVivo 9.

Results and conclusions

Quantitative results consist on the average number of sessions at home per specialty, the duration of sessions, the reasons for therapeutic rehabilitation, the type of intervention executed by the professionals, the specific content of treatments in home care and strategies used by professionals in this type of rehabilitation. Qualitative results include health professionals individual and collective understanding of patients’ achievements and effort required from the professionals and their assessment of the measures used to evaluate the results.

Biomass burning contributions to urban aerosols in a coastal Mediterranean city

Mean annual biomass burning contributions to the bulk particulate matter (PM(X)) load were quantified in a southern-European urban environment (Barcelona, Spain) with special attention to typical Mediterranean winter and summer conditions. In spite of the complexity of the local air pollution cocktail and the expected low contribution of biomass burning emissions to PM levels in Southern Europe, the impact of these emissions was detected at an urban background site by means of tracers such as levoglucosan, K(+) and organic carbon (OC). The significant correlation between levoglucosan and OC (r(2)=0.77) and K(+) (r(2)=0.65), as well as a marked day/night variability of the levoglucosan levels and levoglucosan/OC ratios was indicative of the contribution from regional scale biomass burning emissions during night-time transported by land breezes. In addition, on specific days (21-22 March), the contribution from long-range transported biomass burning aerosols was detected. Quantification of the contribution of biomass burning aerosols to PM levels on an annual basis was possible by means of the Multilinear Engine (ME). Biomass burning emissions accounted for 3% of PM(10) and PM(2.5) (annual mean), while this percentage increased up to 5% of PM(1). During the winter period, regional-scale biomass burning emissions (agricultural waste burning) were estimated to contribute with 7±4% of PM(2.5) aerosols during night-time (period when emissions were clearly detected). Long-range transported biomass burning aerosols (possibly from forest fires and/or agricultural waste burning) accounted for 5±2% of PM(2.5) during specific episodes. Annually, biomass burning emissions accounted for 19%-21% of OC levels in PM(10), PM(2.5) and PM(1). The contribution of this source to K(+) ranged between 48% for PM(10) and 97% for PM(1) (annual mean). Results for K(+) from biomass burning evidenced that this tracer is mostly emitted in the fine fraction, and thus coarse K(+) could not be taken as an appropriate tracer of biomass burning.

AMP-activated protein kinase mediates effects of oxidative stress on embryo gene expression in a mouse model of diabetic embryopathy

AIMS/HYPOTHESIS

Neural tube defects (NTDs) are a common malformation associated with diabetic embryopathy. Maternal hyperglycaemia-induced oxidative stress inhibits the expression of Pax3, a gene that is essential for neural tube closure, and increases the incidence of NTDs. Because oxidative stress can stimulate AMP-activated kinase (AMPK) activity, and AMPK can regulate gene transcription, we hypothesised that increased AMPK activity would mediate the adverse effects of maternal hyperglycaemia-induced oxidative stress on Pax3 expression and NTDs.

METHODS

Pregnant mice were made transiently hyperglycaemic by glucose injection, or hypoxic by housing in a hypoxic chamber, or were treated with antimycin A to induce oxidative stress, and AMPK activity in the embryos was assayed. The effects of stimulating AMPK activity with 5-aminoimidazole-4-carboxamide-1-beta-4-ribofuranoside (AICAR) on Pax3 expression and NTDs were determined. Vitamin E or glutathione ethyl ester was used to reduce oxidative stress, and compound C was used to inhibit AMPK activation. Murine embryonic stem cells were employed as an in vitro model to study the effects of oxidative stress on AMPK activity and the effects of AMPK stimulation on Pax3 expression.

RESULTS

Maternal hyperglycaemia stimulated AMPK activity, and stimulation of AMPK with AICAR inhibited Pax3 expression (in vivo and in vitro) and increased NTDs (in vivo). Stimulation of AMPK by hyperglycaemia, hypoxia or antimycin A was inhibited by antioxidants. The AMPK inhibitor compound C blocked the effects of hyperglycaemia or AA on Pax3 expression and NTDs.

CONCLUSIONS/INTERPRETATION

Stimulation of AMPK in embryos during a diabetic pregnancy mediates the effects of hyperglycaemia-induced oxidative stress to disturb the expression of the critical Pax3 gene, thereby causing NTDs.

Implication of low level inflammation in the insulin resistance of adipose tissue at late pregnancy

Insulin resistance is a characteristic of late pregnancy, and adipose tissue is one of the tissues that most actively contributes to the reduced maternal insulin sensitivity. There is evidence that pregnancy is a condition of moderate inflammation, although the physiological role of this low-grade inflammation remains unclear. The present study was designed to validate whether low-grade inflammation plays a role in the development of insulin resistance in adipose tissue during late pregnancy. To this end, we analyzed proinflammatory adipokines and kinases in lumbar adipose tissue of nonpregnant and late pregnant rats at d 18 and 20 of gestation. We found that circulating and tissue levels of adipokines, such as IL-1β, plasminogen activator inhibitor-1, and TNF-α, were increased at late pregnancy, which correlated with insulin resistance. The observed increase in adipokines coincided with an enhanced activation of p38 MAPK in adipose tissue. Treatment of pregnant rats with the p38 MAPK inhibitor SB 202190 increased insulin-stimulated tyrosine phosphorylation of the insulin receptor (IR) and IR substrate-1 in adipose tissue, which was paralleled by a reduction of IR substrate-1 serine phosphorylation and an enhancement of the metabolic actions of insulin. These results indicate that activation of p38 MAPK in adipose tissue contributes to adipose tissue insulin resistance at late pregnancy. Furthermore, the results of the present study support the hypothesis that physiological low-grade inflammation in the maternal organism is relevant to the development of pregnancy-associated insulin resistance.

Monoallelic thyroid peroxidase gene mutation in a patient with congenital hypothyroidism with total iodide organification defect

The aim of this study was to identify the genetic defect of a patient with dyshormonogenetic congenital hypothyroidisms (CH) with total iodide organification defect (TIOD). A male child diagnosed with CH during neonatal screening. Laboratory tests confirmed the permanent and severe CH with TIOD (99% perchlorate release). The coding sequence of TPO, DUOX2, and DUOXA2 genes and 2957 base pairs (bp) of the TPO promoter were sequenced. Molecular analysis of patient's DNA identified the heterozygous duplication GGCC (c.1186_1187insGGCC) in exon 8 of the TPO gene. No additional mutation was detected either in the TPO gene, TPO promoter, DUOX2 or DUOXA2 genes. We have described a patient with a clear TIOD causing severe goitrous CH due to a monoallelic TPO mutation. A plausible explanation for the association between an autosomal recessive disorder with a single TPO-mutated allele is the presence of monoallelic TPO expression.

Cocaine and other illicit drugs in airborne particulates in urban environments: a reflection of social conduct and population size

Levels of cocaine and other psychoactive substances in atmospheric particulate matter (PM) were determined in urban environments representing distinct social behaviours with regard to drug abuse: night-life, university and residential areas. Three cities (with population>1 million and <0.3 million inhabitants) were selected. Mean daily levels of drugs in PM were 11-336 pg/m3 for cocaine, 23-34 pg/m3 for cannabinoids, and 5-90 pg/m3 for heroin. The highest levels were recorded on weekends, with factors with respect to weekdays of 1-3 for cocaine, 1-2 for cannabinoids and 1.1-1.7 for heroin. Higher levels were detected in the night-life areas, pointing towards consumption and trafficking as major emission sources, and possibly ruling out drug manufacture. The similarities in temporal trends at all sites suggested a city-scale transport of psychoactive substances. Correlations were detected between cocaine and amphetamine consumption (r2=0.98), and between heroin and cannabinoids (r2>0.82).

Drugs of abuse in airborne particulates in urban environments

The presence of cocaine, heroin, cannabinoids and amphetamines, among other drugs of abuse, was detected in airborne particulates in urban environments in Spain. The levels of these compounds were determined at air quality monitoring sites by the application of a novel and specifically targeted analytical methodology, by which mean daily concentrations of cocaine (204-480 pg/m(3), up to one order of magnitude higher than in Italy and Portugal), cannabinoids (THC, 27-44 pg/m(3)), amphetamine (1.4-2.3 pg/m(3)) and heroin (9-143 pg/m(3)) were determined in the atmosphere. Results allowed detecting common temporal consumption patterns between cocaine and cannabis (with week-end maxima), but markedly distinct consumer groups. Personal exposure to the levels of all the drugs detected may be considered negligible, posing no harm for human health. Given the worldwide scarcity of data on drug levels in atmospheric particulates, we present this methodology as a fast, economic and reliable tool to obtain high quality data for the monitoring of drug abuse and drug dealing in cities. Applications include the detection of changes in drug consumption trends, the mapping of drug consumption and/or dealing areas in cities, and the identification of new emerging drugs.

Ibuprofen-loaded calcium phosphate granules: combination of innovative characterization methods to relate mechanical strength to drug location

This paper studies the impact of the location of a drug substance on the physicochemical and mechanical properties of two types of calcium phosphate granules loaded with seven different contents of ibuprofen, ranging from 1.75% to 46%. These implantable agglomerates were produced by either low or high shear granulation. Unloaded Mi-Pro pellets presented higher sphericity and mechanical properties, but were slightly less porous than Kenwood granules (57.7% vs 61.2%). Nevertheless, the whole expected quantity of ibuprofen could be integrated into both types of granules. A combination of surface analysis, using near-infrared (NIR) spectroscopy coupling chemical imaging, and pellet porosity, by mercury intrusion measurements, allowed ibuprofen to be located. It was shown that, from 0% to 22% drug content, ibuprofen deposited simultaneously on the granule surface, as evidenced by the increase in surface NIR signal, and inside the pores, as highlighted by the decrease in pore volume. From 22%, porosity was almost filled, and additional drug substance coated the granule surfaces, leading to a large increase in the surface NIR signal. This coating was more regular for Mi-Pro pellets owing to their higher sphericity and greater surface deposition of drug substance. Unit crush tests using a microindenter revealed that ibuprofen loading enhanced the mechanical strength of granules, especially above 22% drug content, which was favorable to further application of the granules as a bone defect filler.

Effects of aldehydes on CD36 expression

INTRODUCTION

During the oil frying process lipid peroxidation compounds are formed. These products can modulate gene expression and alter cellular behaviour. The cellular uptake of oxidized LDL, a key step in the development of atherosclerosis, is mediated by the CD36 scavenger receptor, whose expression is down-regulated by alpha-tocopherol.

OBJECTIVE

To determine the effects of water-soluble aldehydes, obtained from thermally oxidized sunflower oil on the expression of CD36 scavenger receptor in human monocytes (THP-1 cells). We also wanted to study the effects of alpha-tocopherol on CD36 expression in the presence of water-soluble aldehydes.

MATERIALS AND METHODS

Sunflower oil was heated in a frying pan, at 180--200 degrees C for 40 min, water-soluble aldehydes were isolated, and the content of thiobarbituric acid reacting substances (TBARS) was determined. THP-1 monocytes were cultured in RPMI medium during 24 h and incubated with increasing concentrations of the water-soluble aldehydes (ranging from 0.05 to 1 microM) and with or without 50 microM of alpha-tocopherol. In parallel, THP-1 cells were cultured with the same volume of an extract obtained from non-oxidized oil or distilled water. The CD36 expression at the cell surface was studied with fluorescence-activated cell sorting (FACS).

RESULTS

Monocytes incubated in a medium containing water-soluble aldehydes, showed a dose dependent increase in the expression of the CD36 protein on the cell surface, compared to with the control groups. When the cells were treated simultaneously with 50 microM of alpha-tocopherol a significant reduction in the expression of the CD36 protein was observed.

CONCLUSION

Water-soluble aldehydes, extracted from thermally oxidized culinary oil, increase the expression of CD36. This effect is partially decreased by the presence of alpha-tocopherol.

Profiling transient daytime peaks in urban air pollutants: city centre traffic hotspot versus urban background concentrations

Averaged annual and daily limit values imposed for the protection of human health from urban air pollutants fail to address the potential influence of variations in personal exposure during the day, even though asthma attacks, myocardial ischaemia, and other effects have been linked to highly transient rises in atmospheric contamination. There is, therefore, a general need for the wider availability of information on hourly variations in urban pollutant levels, as well as on spatial differences between urban background and localised contamination hotspots. We compare data from urban background and traffic hotspot monitoring stations over a 12-month period to demonstrate the hourly flux of air pollutants, notably NO(x), SO(2) and PM(10), and illustrate the effects of controlling influences, such as traffic movements and exotic dust intrusions. Our methodology focuses on daytime transient peaks, which occur when much of the urban population is awake and active, and when striking increases in pollutant concentrations are especially common at traffic hotspots. Greater emphasis on the daily reality of transient peaks in urban atmospheric pollutants offers a higher degree of spatial and temporal data resolution for use in epidemiological studies.

Comparison of single pot and multiphase granulation. Part 1: Effect of the high shear granulator on granule properties according to the drug substance and its concentration

Pharmaceutical granulations are usually developed with regard to a specific manufacturing process but switching from one piece of equipment to another can be necessary to comply with the available industrial equipment. Investigations were undertaken on formulations differing in the drug substance and in its concentration. Our aim was to highlight the effect of the granulation process on granules manufactured in a pilot scale Moritz Turbosphere TS50 or in Fielder PMA 65 and dried in a Glatt GPCG1 fluid bed dryer. The granulation process and formulation parameters showed a significant impact on granule size distribution, behaviour under pressure, and on tablet mechanical properties and dissolution kinetics.

Health-related quality of life measures and psychiatric comorbidity in patients with migraine

BACKGROUND AND PURPOSE

The identification of factors associated to health-related quality of life (HRQoL) measures in patients with migraine has major implications in terms of prognosis and treatment. This study aimed at investigating associations between HRQoL and comorbid mood and anxiety disorders.

METHODS

Consecutive adult outpatients with a diagnosis of migraine with or without aura were assessed using the Mini International Neuropsychiatric Interview (M.I.N.I.) Plus version 5.0.0 and the Migraine-Specific Quality-of-Life Questionnaire (MSQ).

RESULTS

Data of 112 patients (82 females), 69 without aura, mean age 41.2 +/- 13.3 years were analyzed. According to the M.I.N.I., 50% patients had a lifetime or current DSM-IV diagnosis of mood or anxiety disorder. There was no between-groups difference in MSQ total and subscale scores in relation to the presence/absence of psychiatric comorbidity, independently whether that was current or lifetime. In the group of subjects with psychiatric disorders, age at onset of migraine correlated with MSQ-total (rho = -0.407 P = 0.002), and subscale scores (Role Function-Restrictive, rho = -0.397, P = 0.002; Emotional Function, rho = -0.487, P < 0.001).

CONCLUSIONS

Our findings suggest that current and/or lifetime psychiatric comorbidities are not associated with HRQoL measures in patients with migraine. However, patients with migraine and psychiatric comorbidities may represent a specific subgroup deserving particular attention for targeted interventions.

Bipolar Disorder Treatment in an Acute Inpatient Unit

Bipolar disorder is a chronic, debilitating psychiatric disease. The management of this disorder involves treating current episodes and preventing their long-term recurrence.

Many patients with Bipolar Disorder are hospitalized at some point in the course of their illness. Although most bipolar patients do not require extended inpatient psychiatric hospitalizations, short-term hospitalizations may be necessary during acute or potential crises.

Hospitalization is among the most expensive treatment options available, and it is therefore offered sparingly and generally only when no other treatment options will prove sufficient to ensure patient safety.

A hospital setting should be considered when safety is in question due to suicidal, homicidal, or aggressive impulses or actions, as well as inability to care for self. Other clear indications for hospital admission are the need for diagnostic procedures, history of rapidly progressive symptoms (especially psychotic phenomena), the rupture of patient"s usual support systems and a patient"s grossly reduced ability to take care of themselves.

The aim of this study is to characterize the inpatient treatment of bipolar patients admitted in the Hospital São João's Psychiatry Department. Data were collected from clinical files using an investigation protocol especially developed for this purpose. This protocol includes sociodemographic information, the referral source, the admission path, reason for hospitalization, current phase of disease, voluntary versus involuntary status, number of previous admissions, prescribed medications and length of stay.

Interpretation of the variability of levels of regional background aerosols in the Western Mediterranean

Results on interpretation of the variability of regional background PM levels in the Western Mediterranean basin (WMB) are presented. Mean PM levels recorded at Montseny, MSY (North-Eastern Spain) in the 2002--2007 period reached 17, 13 and 11 microg/m3 of PM10, PM2.5 and PM1, respectively. The daily evolution of PM levels is regulated by the breeze circulation (mountain and sea breezes). PM levels are lower at the rural sites at night owing to the nocturnal drainage flows and to the lowering of the mixing layer height below the MSY high. These nocturnal low levels allowed us to estimate the continental background PM levels. At midday, the atmospheric pollutants accumulated in the pre-coastal depression are transported upwards by the breeze, increasing PM levels. Maximum PM10 levels were recorded in summer, and February--March and November, and minimum values in the rest of the year coinciding with the highest frequency of Atlantic advection. PM peak episodes attributed to Saharan dust outbreaks were recorded in summer and February-March. In addition, anticyclonic situations (February--March and November) may impact in elevated rural areas by increasing hourly levels of PM1 up to 75 microg/m3. This scenario induces the stagnation of pollutants in the pre-coastal depression. Solar radiation activates mountain winds, transporting polluted air masses from the valleys to elevated areas resulting in an increase of fine PM levels in areas outside the boundary layer. A significant decrease in PM annual means (40% and 34% for the entire monitoring period, 7 microgPM10/m3 and 5 microgPM2.5/m3) was recorded at MSY between 2002 and 2007. There appears to be no single cause behind these trends. This could partially be ascribed to the varying frequency and intensity of Saharan dust episodes, but also to large-scale meteorological processes or cycles, and/or to local or meso-scale processes such as nearby anthropogenic emission sources.

Transverse stability of solitary waves propagating in coupled nonlinear dispersive transmission lines

In the semidiscrete limit and in suitably scaled coordinates, the voltage of a system of coupled nonlinear dispersive transmission lines is described by a nonlinear Schrödinger equation. This equation is used to study the transverse stability of solitary waves of the system. Exact results for the growth rate and the corresponding perturbation function of linear transverse perturbations are obtained in terms of the network's and soliton's parameters.

Influence of Process Parameters on Pellets Elaborated in a Mi-Pro High-Shear Granulator

The aim of the study was to prepare porous pellets several hundred micrometers in diameter into or onto which drug substances could be embedded. Wet granulation was carried out on a powder mix of alpha-lactose and polyvinylpyrrolidone in a Mi-Pro high-shear granulator. The process parameters were investigated to point out their influence on pellet physical properties. The reference conditions of granulation that gave the most satisfactory pellets in size and shape were determined by adjusting the volume and the distribution rate of water. Increasing impeller speed resulted in an increase in granule size and granulation yield and in a decrease in proportion of fines. The granules showed easy flowing for all granulation conditions. Adjusting process parameters enabled control of size, shape, surface area, and porosity of the granules and thus the design of ready to use granules to which drug substances could be associated by deposition or inclusion.

A novel application of the T-cell for flow-through dissolution: the case of bioceramics used as ibuprofen carrier

This paper describes the use of a novel flow cell, the T-cell, adapted to the flow-through cell apparatus, for the study of ibuprofen release from implantable loaded pellets and its performance in comparison to the compendial tablet cell. In fact, the drug targeting with a local delivery system becomes increasingly used to achieve therapeutic doses directly on the implantation site while maintaining a low systemic drug level. Due to the long and expensive in vivo studies necessary to evaluate the efficacy of such delivery systems, in vitro dissolution techniques are performed despite there being no standard method in the biomaterial field. In this work, dissolution profiles obtained with the T-cell configuration clearly indicate a prolonged release of ibuprofen. Dissolution data fitted to Higuchi, Hixson-Crowell, Ritger-Peppas and Kopcha equations indicate the coexistence of diffusion and erosion mechanisms governing ibuprofen release. T-cell adapted to the standard flow-through dissolution apparatus is shown to better simulate in vivo conditions than the tablet cell. This is relevant for in vivo/in vitro correlations.

Multiphase versus Single Pot Granulation Process: Influence of Process and Granulation Parameters on Granules Properties

High-shear wet granulation is widely used for the production of pharmaceutical dosage forms. Different equipment is available for high-shear granulation and drying. This review focuses on two main processes for granules production: multiphase consisting of high-shear granulation followed by drying in a separate apparatus, and single pot granulation/drying. At present, formulas are specifically developed with regard to the production equipment, which raises many problems when different industrial manufacturing equipment is used. Indeed, final granules properties are likely to depend on equipment design, process, and formulation parameters. Therefore, a good understanding of these parameters is essential to facilitate equipment changes. The aim of this review is to present the influence of equipment, process, and formulation parameters on granules properties, considering both the granulation and the drying steps of multiphase and single pot processes.

Measuring the level and content of consciousness during epileptic seizures: the Ictal Consciousness Inventory

Ictal alterations of the level of general awareness and subjective content of consciousness play a pivotal role in the clinical phenomenology of epilepsy, and reflect the pathological involvement of different neurobiological substrates. However, no self-reported measures have been proposed for patients experiencing altered conscious states during seizures. This study describes the development and validation of a new scale for the quantitative assessment of the level and content of ictal consciousness, the Ictal Consciousness Inventory (ICI). The ICI is a 20-item questionnaire generated on the basis of interviews with patients, literature review, and consultation with experts. It was tested on a sample of 110 patients attending three different epilepsy clinics in Northern Italy, who also completed standardized clinical scales. Standard psychometric methods were used to demonstrate that this scale satisfies criteria for acceptability, reliability, and validity. The ICI is proposed as a user-friendly and clinically sound instrument for the measurement of ictal alterations of consciousness in patients with epilepsy.