Psychometric properties of the Brazilian-Portuguese Flow State Scale Short (FSS-BR-S)

"Flow experience" is a term used to describe the state of being fully immersed in what you are doing. The Flow State Scale (FSS-2) was developed to assess how people feel when they are in the flow state while participating in certain sports activities. The goal of this study was to obtain a short adapted version of the FSS-2 for the Brazilian-Portuguese language and for general activities (FSS-BR-S). To do this, we translated it both ways (forwards and backwards) and verified that the translation was accurate. Methods: After getting answers from 396 Brazilian participants, we performed (1) the construct validity of the FSS-BR-S and (2) the psychometric item quality analysis. The confirmatory factorial analysis shows that a FSS-BR-S factorial model is the best fit for the data (χ2 = 44.36, p = .023, df = 27, χ2/df = 1.64, CFI = 0.99, TLI = 0.98, and RMSEA = 0.04). Reliability tests done in this structure show that the FSS-BR-S (which only has nine items) has good internal consistency. The item quality analysis reveals that its difficulty and differentiating parameters are good for estimating the overall flow state. The test information curve for the short version demonstrates that it is very useful for estimating the flow states of each disposition. Discussion and Conclusions: Based on these findings, we can conclude that the FSS-BR-S has demonstrated sufficient validity to be used with Brazilians.

Unsupervised clustering to differentiate rheumatoid arthritis patients based on proteomic signatures

OBJECTIVE

Patients with rheumatoid arthritis (RA) have different presentations and prognoses. Cluster analysis based on proteomic signatures creates independent phenogroups of patients with different pathophysiological backgrounds. We aimed to identify distinct pathophysiological clusters of RA patients based on circulating proteomic biomarkers.

METHOD

This was a cohort study including 399 RA patients. Clustering was performed on 94 circulating proteins (92 CVDII Olink®, high-sensitivity troponin T, and C-reactive protein). Unsupervised clustering was performed using a partitioning cluster algorithm.

RESULTS

The clustering algorithm identified two distinct clusters: cluster 1 (n = 223) and cluster 2 (n = 176). Compared with cluster 1, cluster 2 included older patients with a higher burden of comorbidities (cardiovascular and RA related), more erosive and longer RA duration, more dyspnoea and fatigue, walking a shorter distance in the Six-Minute Walk Test, with more severe diastolic dysfunction, and a 4.5-fold higher risk of death or hospitalization for cardiovascular reasons. Tumour necrosis factor (TNF) receptor superfamily-related pathways were mainly responsible for the model's discriminative ability.

CONCLUSION

Using unsupervised cluster analysis based on proteomic phenotypes, we identified two clusters of RA patients with distinct biomarkers profiles, clinical characteristics, and different outcomes that could reflect different pathophysiological backgrounds. TNF receptor superfamily-related proteins may be used to distinguish subgroups.

Validation and psychometric properties of the Brazilian-Portuguese dispositional flow scale 2 (DFS-BR)

INTRODUCTION

Flow state is a psychological concept used to describe the optimal engagement in different activities. Therefore, the DFS-2 has been developed as an instrument to measure an individual's dispositional tendency to flow state as a personality trait.

OBJECTIVE

Aiming to obtain an adapted version of the DFS-2 for the Brazilian-Portuguese language (DFS-BR) and for general activities, we performed its forward- and backward-translation, and we validated it.

METHODS

After gathering answers from 681 Brazilian participants, we performed: (1) the construct validity of the DFS-BR; and (2) the psychometric item quality analysis.

RESULTS

the Confirmatory Factorial Analysis (CFA) indicates the best fit for the gathered data is a nine multi-correlated factorial model (χ2/df = 4.23, CFI = 0.94, TLI = 0.93 and RMSEA = 0.069). Reliability tests performed in this structure indicates excellent internal consistency for the DFS-BR. The item quality analysis indicates that its difficulty and discriminating parameters have a good endorsement to estimate the dispositional flow state. Additionally, we proposed and validated a short version of the DFS-BR (composed of only nine items). The validation results indicates good fit (χ2/df = 2.94, CFI = 0.98, TLI = 0.97 and RMSEA = 0.053) and good internal consistency. The Test Information Curve of the short version indicates that it is very informative in the estimation of individual dispositional flow state.

DISCUSSION AND CONCLUSIONS

In view of these results, we conclude that the DFS-BR showed good evidence of its validity to be used with Brazilian people. We also suggest the use of a short version when we need only measure the person's flow state based on the principle of Occam's razor. This principle is supported by the analysis presented in this article.

Using data envelopment analysis and the bootstrap method to evaluate organ transplantation efficiency in Brazil

Brazil has the most extensive public program for organ transplantation in the world, and the Brazilian National Health System (SUS) provides full coverage of all costs involved in organ donation, transplants, and post-transplant. Despite the relevance of the subject and the shortage of organs for transplants, transplantation process efficiency assessments are still uncommon in Brazil and abroad. This study aims to evaluate the efficiency of the Brazilian states and the Federal District in transforming potential organ donors into actual donations. We applied data envelopment analysis (DEA) in conjunction with the bootstrap technique, using organ transplantation data from 2018. The bootstrap methods applied (bootstrap technique, the bootstrap-biased scores of efficiency, and the bootstrap bias-corrected scores of efficiency) allow to obtain a confidence interval for DEA scores and provide greater robustness to studies based on DEA methodology. The bootstrap bias-corrected model indicates that there is significant room for improvement in terms of converting potential donors into actual donors. The mean corrected score is 0.55, signalizing that altogether the Brazilian states could maximize in 45% the number of transplanted organs without necessarily increasing the pool of potential donors. The study provides insights into the Brazilian processes of organ donation and transplantation, helping to identify locations in need of resource allocation improvements. Given the scarcity of studies with a joint application of DEA and bootstrap techniques in this crucial health activity, we also intend to methodologically contribute to this type of benchmark analysis, emphasizing the importance of considering measurement errors, randomness, and bias at DEA models.

Targeted nanostructured lipid carriers for doxorubicin oral delivery

The treatment with anticancer drugs remains a challenge, as available drugs still entail the risk of deleterious off-target effects. The present study describes folic acid conjugated nanostructured lipid carriers (NLCs) as an effective doxorubicin delivery approach targeted to breast cancer cells. Two distinct NLCs formulations were designed and optimized leading to an encapsulation efficiency over than 65%. Cytotoxic and targeting potential of NLCs were studied in vitro, using MDA-MB-231 cell line. Results showed an enhanced cellular uptake of conjugated NLCs. In vitro release studies, mimicking the path in the body after oral administration, show that all formulations would reach the tumor microenvironment bearing 50% of the encapsulated doxorubicin. Moreover, NLCs demonstrated storage stability at 25 °C for at least 42 days. Overall, results revealed that the developed NLCs enable the possibility of oral administration and are a promising approach for the targeted delivery of doxorubicin to breast cancer cells.

AB0406 HUMAN PAPILLOMA VIRUS (HPV) VACCINATION SAFETY IN SYSTEMIC LUPUS ERYTHEMATOSUS COHORT - PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER COHORT STUDY

Background:

Cervical cancer is a potentially preventable consequence of Human Papillomavirus (HPV). HPV vaccination is recommended in most countries for all young women, preferentially before sexual activity begins. In Portugal, HPV vaccination is available in either bivalent (genotypes 6, 18) or tetravalent (6, 11, 16 e 18) vaccines. Both have aluminum as an adjuvant, a substance arguably capable of inducing inflammatory adjuvant syndromes. Systemic Lupus Erythematosus (SLE) mostly afflicts women of childbearing age, the very target population for HPV vaccination. There are conflicting reports in the literature regarding both the efficacy and safety of this vaccine in SLE patients. This question is particularly pressing as HPV infection prevalence seems to be increased in SLE patients.

Objectives:

To analyze the safety of HPV vaccination in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 436 SLE patient cohort) review of all female SLE patients’ local and online national records on HPV vaccination and cervical cancer screening. Data on activity (using SLEDAI-2K scoring) and concomitant drug use were reviewed for the two years before and after vaccination date.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had clinical information about yes/no HPV vaccination. Twenty-seven of the patients (8%) had one of HPV vaccines, but only 13 (4%) had full information on activity before and after vaccination. Mean current age was 33,8 years and a minimum of 8,4 years of follow-up after HPV vaccination. Twenty-there (85%) were vaccinated with the tetravalent vaccine. Pre-vaccination mean SLEDAI score of was 5.9: due to arthritis (n= 5; 38,5%), low complement (n=4; 31%), dsDNA (n=4; 31%); with a medium dose of 10mg prednisolone/day and 265mg/day of hydroxychloroquine. Post-vaccination mean SLEDAI was 5.8: due to arthritis (n=6; 46%), rash (n= 5; 38,5%) and low complement (n=6; 46%); with a medium dose of 8mg prednisolone/day and 288mg/day of hydroxychloroquine. There was not a difference in organ involvement before and after vaccination, but rash was slightly more prevalent after vaccination.

Conclusion:

In our population, HPV vaccination didn’t significantly change disease activity and organ involvement or mean dose need of prednisolone or hydroxychloroquine. Although it is a small size SLE sample, it suggests that is safe to administer HPV vaccination to SLE patients.

References:

[1]eularSegal Yahel, Zabludowicz Center for Autoimmune Diseases, Tel Aviv (2017), “HPV and systemic lupus erythematosus: a mosai of potential crossreaction”, SLE Research and Clinical Update, 23 January 2017

[2]Geier David Institute of Chronic Illnesses, USA, (2016), “Quadrivalent human pappilomavirus vaccine and autoimmune adverse events: a case-control assessment of the vaccine adverse event reporting system (VAERS) database, Environment and Autoimmunity, 13 July 2016

Disclosure of Interests: :

None declared

AB1026 INFLAMMATORY MANIFESTATIONS IN PATIENTS WITH HUMAN LEUKOCYTE ANTIGEN-B*51 POSITIVE AND WITHOUT BEHÇET’S DISEASE

Background:

Human leukocyte antigen (HLA) B*51 allele is the most important genetic factor in susceptibility to Behçet’s disease (BD), an immune-mediated systemic disorder of unknown etiology, characterized by recurrent episodes of inflammatory manifestations. In fact there is a considerable clinical overlap of BD with autoinflammatory syndromes. As it’s known, the majority of HLA-B*51 positive individuals do not develop BD. But do these individuals also present inflammatory manifestations?

Objectives:

Characterize the group of individuals in our hospital with positive HLA-B*51, without BD diagnosis and review whether inflammatory manifestations are present in these individuals.

Methods:

A retrospective study of HLA-B*51 positive patients between 2000 and 2019. Genomic DNA was obtained from peripheral blood and HLA genotyping was performed using a PCR with Sequence Specific Primers (PCR–SSP) methodology. From the group of 289 B*51 positive patients, BD diagnosis were excluded. Demographic and clinical data were collected by review of clinical files in December 2019.

Results:

176 patients, mean age of 48.5 ± 16.5 years (5 to 84 years). Most were female (68%). The HLA study was motivated by multiple diagnostic suspicions: spondyloarthritis (SpA, 25.0%), BD (22.7%) and systemic sclerosis (SSc, 10.8%). The mean time elapsed since the immunogenetic study was 8.3 years, with 12 deaths recorded. 69 (39.2%) subjects had no diagnosis for immune-mediated disease (IMD). Of the other 107 patients, the majority had 1 IMD (64.5%), and the rest were diagnosed with 2 to 4 IMD. The most frequent IMD were SpA (20.8%), psoriasis (10.4%), psoriatic arthritis (9.7%), SSc (9.7%) and rheumatoid arthritis (7.1%). Autoantibodies were detected in 94 individuals (53.4%): antinuclear antibodies (64 patients), rheumatoid factor (26 patients) and CCP antibodies (11 patients). In 55 individuals no inflammatory manifestation was identified but the 68.8% of them presented between 1 to 7 manifestations:

System involvedClinical manifestationFrequencyEars, nose and throatChronic rhinitis32 (13.2%)∑ = 76 (31.4%)Recurrent tonsillitis20 (8.3%)Other24 (9.9%)Cutaneous, mucous and serousRecurrent oral aphtous ulcers34 (14.0%)∑ = 57 (23.6%)Serositis10 (4.1%)Other13 (5.4%)NeurologicalChronic headache34 (14.0%)∑ = 36 (14.9%)Asseptic meningitis2 (0.8%)OcularOcular inflammation31 (12.8%)∑ = 31 (12.8%)UrinaryRecurrent cystitis15 (6.2%)∑ = 15 (6.2%)VascularVenous thromboembolism7 (2.9%)∑ = 14 (5.8%)Aneurysm6 (2.5%)Spontaneous coronary dissection1 (0.4%)RheumaticArthromyalgia6 (2.5%)∑ = 9 (3.7%)Gout3 (1.2%)ConstitutionalRecurrent fever syndrome1 (0.4%)∑ = 1 (0.4%)DigestiveRecurrent abdominal pain1 (0.4%)∑ = 1 (0.4%)LymphaticAxillary and inguinal adenopathies1 (0.4%)∑ = 1 (0.4%)PulmonaryChronic pulmonary infiltrate1 (0.4%)∑ = 1 (0.4%)

Conclusion:

Inflammatory manifestations are common in HLA-B*51 positive individuals, even in those without BD diagnosis. Further research is needed, considering other HLA alleles associated with increased risk of BD and including control groups.

References:

[1]Burillo-Sanz S, Montes-Cano M, García-Lozano J,et al. Behçet´s disease and genetic interactions between HLA-B*51 and variants in genes of autoinflammatory syndromes.Sci Rep2019;9:2777.

[2]McGonagle D, McDermott MF. A Proposed Classification on the Immunological Diseases.PLoS Med2006;3(8):e297.

[3]Tong B, Liu X, Xiao J, Su G. Immunopathogenesis of Behcet´s Disease.Front. Immunol2019;10:665.

Disclosure of Interests:

None declared

AB0407 HUMAN PAPILLOMA VIRUS (HPV) INFECTION AND CERVICAL CANCER PREVALENCE IN A PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER SYSTEMIC LUPUS ERYTHEMATOSUS COHORT

Background:

About 12% of women worldwide are infected with Human Papillomavirus (HPV), the most frequent cause of cervical cancer (CC) - very prevalent (~ 7,5%) and preventable. National screening efforts are in use in several countries, including Portugal. Patients with Systemic Lupus Erythematosus (SLE) are at increased risk of HPV infection and CC when compared to the healthy population.

Objectives:

To evaluate the prevalence of HPV infection and rate of incidence of cervical neoplastic lesions in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 463 SLE patient cohort) review of all female SLE patients’ local and online national health care records on HPV vaccination and CC screening.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had records on of HPV infection or CC developed. Mean patients’ current age was 48 years and all had screening for cervical pathology in the last 3 years. Thirty-three patients (11%) had HPV infection diagnosed at a mean age of 44 years. Twenty-seven (8%) of SLE patients were vaccinated for HPV: 8 (22%) of the infected patients had the vaccine, half after the HPV infection. Despite HPV infection, 49 patients (15%) had developed some cervical lesion, of which 41 (84% of cervical lesion) were suggestive of malignancy, and ultimately CC was diagnosed in 20 women (41%; 6% of total women), with a mean age at diagnosis of 45 years. All CC patients had history of HPV infection, but only 3 women (15%; 0,9% of total women) had been vaccinated against HPV, 2 after the diagnoses of CC and 1 before.

Conclusion:

In our population the prevalence of HPV was higher than reported for the general population using the World Health Organization database, conforming the higher risk of HPV infection in SLE patients. The prevalence of cervical cancer, however, was similar to the healthy population.

References:

[1]https://www.who.int/immunization/diseases/hpv/en/

[2]Forman David (2012); “Global Burden of Human Papillomavirus and Related Diseases”, Vaccine, Elsevier Volume 30, Supplement 5, 20 November 2012

[3]Grein Ingrid (2016), Department of Pediatric Immunology and Rheumatology, Netherland (2016), HPV infection and vaccination in Systemic Lupus Erythematosus patients: what we really should know, Pediatric Rheumatology, 2016

Disclosure of Interests: :

None declared

Two separate effects contribute to regulatory T cell defect in systemic lupus erythematosus patients and their unaffected relatives

Forkhead box P3 (FoxP3)⁺ regulatory T cells (T_regs) are functionally deficient in systemic lupus erythematosus (SLE), characterized by reduced surface CD25 [the interleukin (IL)‐2 receptor alpha chain]. Low‐dose IL‐2 therapy is a promising current approach to correct this defect. To elucidate the origins of the SLE T_reg phenotype, we studied its role through developmentally defined regulatory T cell (T_reg) subsets in 45 SLE patients, 103 SLE‐unaffected first‐degree relatives and 61 unrelated healthy control subjects, and genetic association with the CD25‐encoding IL2RA locus. We identified two separate, uncorrelated effects contributing to T_reg CD25. (1) SLE patients and unaffected relatives remarkably shared CD25 reduction versus controls, particularly in the developmentally earliest CD4⁺FoxP3⁺CD45RO^–CD31⁺ recent thymic emigrant T_regs. This first component effect influenced the proportions of circulating CD4⁺FoxP3^highCD45RO⁺ activated T_regs. (2) In contrast, patients and unaffected relatives differed sharply in their activated T_reg CD25 state: while relatives as control subjects up‐regulated CD25 strongly in these cells during differentiation from naive T_regs, SLE patients specifically failed to do so. This CD25 up‐regulation depended upon IL2RA genetic variation and was related functionally to the proliferation of activated T_regs, but not to their circulating numbers. Both effects were found related to T cell IL‐2 production. Our results point to (1) a heritable, intrathymic mechanism responsible for reduced CD25 on early T_regs and decreased activation capacity in an extended risk population, which can be compensated by (2) functionally independent CD25 up‐regulation upon peripheral T_reg activation that is selectively deficient in patients. We expect that T_reg‐directed therapies can be monitored more effectively when taking this distinction into account.

Prevalence of late-onset pompe disease in Portuguese patients with diaphragmatic paralysis - DIPPER study

Pompe disease is a rare autosomal recessive neuromuscular disorder caused by acid α-glucosidase enzyme (GAA) deficiency and divided into two distinct variants, infantile- and late-onset. The late-onset variant is characterized by a spectrum of phenotypic variation that may range from asymptomatic, to reduced muscle strength and/or diaphragmatic paralysis. Since muscle strength loss is characteristic of several different conditions, which may also cause diaphragmatic paralysis, a protocol was created to search for the diagnosis of Pompe disease and exclude other possible causes.

METHODS

We collected a sample size of 18 patients (10 females, 8 males) with a median age of 60 years and diagnosis of diaphragmatic paralysis of unknown etiology, followed in the Pulmonology outpatient consultation of 9 centers in Portugal, over a 24-month study period. We evaluated data from patient's clinical and demographic characteristics as well as complementary diagnostic tests including blood tests, imaging, neurophysiologic and respiratory function evaluation. All patients were evaluated for GAA activity with DBS (dried blood test) or serum quantification and positive results confirmed by serum quantification and sequencing.

RESULTS

Three patients were diagnosed with Pompe's disease and recommended for enzyme replacement therapy. The prevalence of Pompe, a rare disease, in our diaphragmatic paralysis patient sample was 16.8%.

CONCLUSION

We conclude that DBS test for GAA activity should be recommended for all patients with diaphragmatic paralysis which, despite looking at all the most common causes, remains of unknown etiology; this would improve both the timing and accuracy of diagnosis for Pompe disease in this patient population. Accurate diagnosis will lead to improved care for this rare, progressively debilitating but treatable neuromuscular disease.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

The Dose Response Multicentre Investigation on Fluid Assessment (DoReMIFA) in critically ill patients

Background

The previously published “Dose Response Multicentre International Collaborative Initiative (DoReMi)” study concluded that the high mortality of critically ill patients with acute kidney injury (AKI) was unlikely to be related to an inadequate dose of renal replacement therapy (RRT) and other factors were contributing. This follow-up study aimed to investigate the impact of daily fluid balance and fluid accumulation on mortality of critically ill patients without AKI (N-AKI), with AKI (AKI) and with AKI on RRT (AKI-RRT) receiving an adequate dose of RRT.

Methods

We prospectively enrolled all consecutive patients admitted to 21 intensive care units (ICUs) from nine countries and collected baseline characteristics, comorbidities, severity of illness, presence of sepsis, daily physiologic parameters and fluid intake-output, AKI stage, need for RRT and survival status. Daily fluid balance was computed and fluid overload (FO) was defined as percentage of admission body weight (BW). Maximum fluid overload (MFO) was the peak value of FO.

Results

We analysed 1734 patients. A total of 991 (57 %) had N-AKI, 560 (32 %) had AKI but did not have RRT and 183 (11 %) had AKI-RRT. ICU mortality was 22.3 % in AKI patients and 5.6 % in those without AKI (p < 0.0001). Progressive fluid accumulation was seen in all three groups. Maximum fluid accumulation occurred on day 2 in N-AKI patients (2.8 % of BW), on day 3 in AKI patients not receiving RRT (4.3 % of BW) and on day 5 in AKI-RRT patients (7.9 % of BW). The main findings were: (1) the odds ratio (OR) for hospital mortality increased by 1.075 (95 % confidence interval 1.055–1.095) with every 1 % increase of MFO. When adjusting for severity of illness and AKI status, the OR changed to 1.044. This phenomenon was a continuum and independent of thresholds as previously reported. (2) Multivariate analysis confirmed that the speed of fluid accumulation was independently associated with ICU mortality. (3) Fluid accumulation increased significantly in the 3-day period prior to the diagnosis of AKI and peaked 3 days later.

Conclusions

In critically ill patients, the severity and speed of fluid accumulation are independent risk factors for ICU mortality. Fluid balance abnormality precedes and follows the diagnosis of AKI.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1355-9) contains supplementary material, which is available to authorized users.

Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

BACKGROUND

Bronchial artery embolisation (BAE) becomes a mainstay in the treatment of hemoptysis.

OBJECTIVE

To characterise patients with hemoptysis undergoing bronchial artery angiography (BAA) for embolisation, evaluating outcomes.

METHODS

We retrospectively evaluated patients with acute severe or chronic recurrent hemoptysis admitted to the Pulmonology department and submitted to BAA for purpose of embolisation.

RESULTS

A total of 88 patients were submitted to BAA, 47 (53.4%) were male, with a mean age of 61.4 ± 15.8 years. In 64 (72.7%) patients, hemoptysis presented as chronic recurrent episodes. Hemoptysis was considered severe in 40 (45.5%) patients. Bronchiectasis (other than cystic fibrosis) (n=35; 38.0%) and tuberculosis sequelae (n=31; 35.2) were the major aetiology for hemoptysis. The main angiographic abnormality was hypertrophy and tortuosity (n=68; 77.3%). BAE was performed in 67 (76.1%) of the 88 patients submitted to BAA. Immediate success was achieved in 66 (98.5%) patients. Recurrence of hemoptysis occurred in 25 (37.3%) patients, and was related to presence of shunting (p=0.049). The procedure-related complications were self-limited.

CONCLUSION

Our results suggest that BAE is a safe and effective treatment for acute severe and chronic recurrent hemoptysis, supporting the current literature. Besides this, bleeding recurrence was relatively high, and correlated with presence of systemic pulmonary shunting.

Alveolar hemorrhage in systemic lupus erythematosus: a cohort review

Diffuse alveolar hemorrhage (DAH) is a rare but potentially catastrophic manifestation with a high mortality. Among rheumatologic diseases, it occurs most frequently in patients with systemic lupus erythematosus (SLE) and systemic vasculitis. Despite new diagnostic tools and therapies, it remains a diagnostic and therapeutic challenge. The aim of this work was to characterize the SLE patients with an episode of alveolar hemorrhage followed in our Clinical Immunology Unit (CIU). A retrospective chart review was carried out for all patients with SLE followed in CIU between 1984 and the end of 2013. We reviewed the following data: demographic characteristics, clinical and laboratory data, radiologic investigations, histologic studies, treatment, and outcome. We identified 10 episodes of DAH, corresponding to seven patients, all female. These represent 1.6% of SLE patients followed in our Unit. The age at DAH attack was 42.75 ± 18.9 years. The average time between diagnosis of SLE and the onset of DAH was 7.1 years. Three patients had the diagnosis of SLE and the DAH attack at the same time. Disease activity according to SLEDAI was high, ranging from 15 to 41. All patients were treated with methylprednisolone, 37.5% cyclophosphamide and 28.6% plasmapheresis. The overall mortality rate was 28.6%.

Association between vitamin D receptor (VDR) gene polymorphisms and systemic lupus erythematosus in Portuguese patients

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown origin, in which both genetic and environmental factors are involved. One such environmental factor is vitamin D, a vital hormone that plays a specific function in the immune system homeostasis, acting through a nuclear receptor ( VDR) expressed in all immune cells. Several polymorphisms of the gene that encodes this receptor have been described. Though inconsistently, these polymorphisms have been associated with clinical manifestations and SLE development.

The aim of this study was to determine the possible association between VDR gene polymorphisms (BsmI, ApaI, TaqI e FokI) and SLE susceptibility and severity, in a cohort of lupus patients from the north of Portugal.

A total of 170 patients (F = 155, M = 15; age = 45 ± 13.4 years) with SLE (diagnosed according the American College of Rheumatology criteria) with at least five years of disease evolution and followed in the Autoimmune Disease Clinical Immunology Unit of Centro Hospitalar do Porto were studied. Patients and 192 ethnicity-matched controls were genotyped for BsmI (rs1544410), ApaI (rs7975232), TaqI (rs731236) and FokI (rs2228570) polymorphisms by TaqMan allelic discrimination assay. Disease severity was assessed by SLICC damage score, number of affected organs, number of severe flares and pharmacological history.

SLE patients with the CT genotype of FokI polymorphism have a higher SLICC value ( p = 0.031). The same result was observed for the group of patients with the TT genotype of TaqI polymorphism ( p = 0.046). No differences were observed in VDR genotype between patients and controls. Also, we observed that the other clinical features analysed were not influenced by VDR polymorphisms.

Our study confirms a possible role of VDR gene polymorphisms in SLE. A positive association was found between VDR polymorphisms and SLE severity (chronic damage). The presence of CT genotype of FokI and TT genotype of TaqI seems to confer a worse prognosis and may constitute a risk factor for higher long-term cumulative damage in SLE patients.

CCR5-Delta32: implications in SLE development

Systemic lupus erythematosus (SLE) is a prototypical autoimmune disease with strong genetic and environmental components. Previous studies have shown increased levels of several chemokines in active SLE. C-C chemokine receptor type 5 (CCR5) is involved in the recruitment of inflammatory cells into tissues, and mechanisms modulating CCR5 expression and function may interfere in SLE development, influencing the clinical course of the disease. The aim of this study was to evaluate the possible association between the CCR5∆32 base-pair deletion polymorphism and SLE disease in a group of Portuguese patients. A total of 219 patients with SLE and 205 healthy individuals were studied. The frequency of CCR5/∆32 heterozygotes was lower in patients with SLE than in controls (8% vs. 15% OR = 0.5162; P = 0.0319), suggesting a protective association between CCR5∆32 allele and SLE. These results highlight the protective role of Th1 cells that express CCR5 in SLE pathogenesis.

Granulomatosis with polyangiitis initially misdiagnosed as lung cancer

Granulomatosis with Polyangiitis (GPA), which was formerly named Wegener's Granulomatosis (WG) is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract, as well as kidneys. Diagnosing GPA on the basis of transthoracic fine needle aspiration (TFNA) may be problematic, as it can be misdiagnosed as cancer. We describe a patient with a probable GPA which was originally diagnosed as malignancy, but who responded to lung cancer chemotherapy.

[Organ transplantation in Brazilian States: effectiveness, productivity, and capacity]

This study focused on key aspects of organ transplantation programs in various States of Brazil. The study showed wide disparities between States, based on various performance indicators. States in the South, Southeast, and Midwest regions had the highest transplantation and productivity rates and the largest per capita transplantation teams. São Paulo proved to be a benchmark due to its high performance on several indicators.

Tocilizumab: is there life beyond anti-TNF blockade?

Anti-TNF-α therapy has become the most effective biological treatment for rheumatoid arthritis. Despite having changed the prognosis of the disease establishing new targets for treatment strategy, there are several aspects that still remain unmatched. About 30% of the patients with rheumatoid arthritis have a less than satisfactory response to anti-TNF therapy, which has led the way for the pursuit of new targets and approaches to treatment. IL-6 is one of these alternative targets and data from the more recent clinical trials involving tocilizumab (an anti-IL-6 soluble receptor antibody) suggest advantages in relation to some clinical aspects which are not addressed by anti-TNF-α treatment.

Disparidades nas filas para transplantes de órgãos nos estados brasileiros

Avaliamos alguns aspectos dos transplantes de órgãos nas Unidades da Federação brasileira, nos anos de 2004, 2005 e 2006. Estimamos, com base em um modelo de teoria das filas, os tempos de espera para transplantes de coração, córnea, fígado, pulmão, rim, pâncreas, e transplante simultâneo de rim e pâncreas. Os resultados indicam redução na espera por alguns órgãos (córnea, e pâncreas); elevação em outros (fígado, coração, rim/pâncreas); e ligeiras flutuações, sem tendência muito definida, nos transplantes de rim e nos transplantes de pulmão ao longo do período estudado. Os estados das regiões Sul e Sudeste (com a exceção do Rio de Janeiro) e Centro-oeste têm os menores tempos de espera e as maiores taxas de atendimento do país.

Smoking habits in secondary school students

BACKGROUND

Smoking is an important health risk in general, and responsible for diseases with significant mortality and morbidity. Smoking habits start early and adolescence is a notorious time for starting smoking.

AIM AND METHODS

To assess knowledge on smoking and smoking habits in a population of adolescents in four Porto schools, using a confidential self administered questionnaire. Collected data were evaluated using the SPSS 1.2 statistics program (2004 version).

RESULTS

A total of 1,770 students aged 11 - 21 (median 15.1 years), mainly female, (58%), answered. Most students (n=952, 54.6%) were unaware of signs or warnings against smoking in their schools. The great majority (n=1639, 92.7%) considered themselves well informed on the harmful effects of smoking, but only 6.7% could list three or more tobacco-associated health consequences, however. Parents and friends were seen as privileged sources of information. Among these students, 194 (11.1%) were smokers and the average started to smoke at the age of 15. The majority of these (n=111, 57.2%) had parents who smoked and 96.4% had friends who smoked, versus 83.1% of non-smokers, a statistically significant difference (p < 0.001). Pocket money was the means of acquiring cigarettes in 34.8%. Most (60.8%) considered themselves able to stop smoking at any time, while 11.4% of the smokers smoked more than one pack a day and 9.8% smoked the first cigarette within 5 minutes of waking, however.

CONCLUSIONS

The percentage of smokers in this group of teenagers was considerable and indicators of nicotine dependence were found. Knowledge of the risks of smoking was poor and information on smoking given by schools had an apparently low and variable impact. Parents' and friends' behaviour may have a weighty impact on the decision to start smoking.

Nontuberculous mycobacteria in non-AIDS patients

Nontuberculous mycobacteria (NTM) play an increasingly significant pathogenic role in HIV -positive patients, in patients with chronic lung disease, in other chronic conditions and in the elderly.

AIMS

Evaluate the importance of NTM isolation in respiratory samples in patients without HIV-infection.

METHODS

Retrospective evaluation of our hospital patients with no known AIDS, with at least one NTM positive respiratory sample, from 1997 -2004.

RESULTS

We found 102 patients, with a median age of 63 years; 67% male. Sixty -three (62%) had underlying lung disease, mainly tuberculosis sequelae (n=19). The majority (47%) of the isolations were Mycobacterium avium complex (MAC). A diagnosis of Mycobacterium pulmonary disease was made in 16 patients (15.7%), 14 of which met the American Thoracic Society diagnostic criteria. Ten male and 6 female; median age 65 years. Twelve had underlying lung disease. All of them had respiratory infection complaints. Chest X -rays showed mainly pulmonary infiltrates, linear opacities and cavitation. MAC was the cause of mycobacterium respiratory disease in 12 patients (75%).

CONCLUSION

NTM isolation did not equal pulmonary NTM disease in the majority of cases, even in patients with underlying lung disease. MAC was the most commonly isolated agent and its relative importance was higher in the presence of NTM disease.

Evaluation of a new IOL scleral fixation technique without capsular support

PURPOSE

The purpose of this study was to compare a new intraocular lens (IOL) scleral fixation technique (scleral incision) with the scleral flap surgical technique as regards to efficacy, surgical complications, advantages, disadvantages, and surgery costs in cases with no capsular support.

MATERIAL AND METHODS

This was a retrospective study conducted on thirty patients (30 eyes), ten of whom were aphakic, eleven had traumatic cataract, seven had post-phacoemulsification complications, and two had lens luxation. The patients were divided into two groups (I - scleral incision technique and II - scleral flap technique) of fifteen patients each, during a study period lasting eighteen months. The great majority of the procedures were performed under general anesthesia and by the same surgeon. Statistical analysis was done using SPSS. The numerical variables were compared using the t test and the categorical ones using the Fisher exact test. We performed multifactorial analysis to build a model that could predict and compare the complications associated with each technique. An explicative model was built using logistic regression.

RESULTS

We observed a threefold higher rate of complications associated with the scleral flap technique when compared to the scleral incision technique. This difference was particularly relevant as regards the occurrence of free scleral flap and hyphema. No statistically significant differences were observed regarding vitreous hemorrhage, choroidal hemorrhage, retinal detachment, difficulty in the external pulling of the Prolene suture, breaking of the Prolene suture, and anterior chamber collapse. We found a significant association between intraoperative complications and the technique used (higher number of complications with the scleral flap) and also with some systemic diseases (patients with hypertension had more intraoperative complications). The number of late complications resulting from the scleral flap technique was much higher than those observed with the scleral incision technique; however, the number of the cases we studied is insufficient to reach statistical significance.

CONCLUSION

The duration of the procedure using the IOL scleral incision technique is significantly lower than using the scleral flap technique. Intraoperative complications were significantly associated with the technique used: more frequent with scleral flap. Late complications were mainly associated with systemic and previous ocular diseases.

The DOse REsponse Multicentre International Collaborative Initiative (DO-RE-MI)

BACKGROUND

Current practices for renal replacement therapy (RRT) in ICU remain poorly defined. The observational DOse REsponse Multicentre International collaborative initiative (DO-RE-MI) survey addresses the issue of how the different modes of RRT are currently chosen and performed. The primary endpoint of DO-RE-MI will be the delivered dose versus in ICU, 28-day, and hospital mortality, and the secondary endpoint, the hemodynamic response to RRT. Here, we report the first preliminary descriptive analysis after 1-year recruitment.

METHODS

Data from 431 patients in need of RRT with or without acute renal failure (mean age 61.2+15.9) from 25 centers in 5 countries (Spain, Italy, Germany, Portugal, France) were entered in electronic case report forms (CRFs) available via the website acutevision.net.

RESULTS

On admission, 51% patients came from surgery, 36% from the emergency department, and 16% from internal medicine. On admission, mean SOFA and SAPS II were 13 and 50, respectively. The first criteria to initiate RRT was the RIFLE in 38% (failure: 70%, injury: 25%, risk: 22%), the second the high urea/creatinine, and the third immunomodulation. A total of 3,010 cumulative CRF were reported: continuous venovenous hemodiafiltration (CVVHDF) 60%, continuous venovenous hemofiltration (CVVH) 15%, intermittent hemodialysis (IHD) 15%, high-volume hemofiltration (HVHF) 7%, continuous venovenous hemodialysis (CVVHD) 1%, and coupled plasma filtration adsorption/CVVD 2%. In 15% of cases, the patient was shifted to another modality. Mean blood flow rates (ml/min) in the different modalities were: 145 (CVVHDF), 200 (CVVH), 215 (IHD), 283 (HVHF), and 150 (CVVHD). Downtime ranged from 8 to 28% of the total treatment time. Clotting of the circuit accounted for 74% of treatment interruptions.

CONCLUSIONS

Despite a large variability in the criteria of choice of RRT, CVVHDF remains the most used (49%). Clotting and clinical reasons were the most common causes for RRT downtime. In continuous RRT, a large variability in the delivered dose is observed in the majority of patients and often in the same patient from one day to another. Preliminary analysis suggests that in a large number of cases the delivered dose is far from the 'adequate' 35 ml/h/kg.

[A study on organ transplantation waiting lines in Brazil's Unified National Health System]

This study analyzes the waiting lines for solid organ transplants in Brazil's Unified National Health System. By using a queuing theory model, we estimate the waiting times for different organs under alternative scenarios. The model reveals the elasticity of various waiting times with respect to arrival and service rates for organ transplantation within the system. Average waiting time for a solid organ transplant is very long and highly elastic in Brazil. The article discusses some important possibilities for reducing such waiting times.