Contextuality and context-sensitivity in probabilistic models of cognition

The context-sensitivity of cognition has been demonstrated across a wide range of cognitive functions such as perception, memory, judgement and decision making. A related term, 'contextuality', has appeared from the field of quantum cognition, with mounting empirical evidence demonstrating that cognitive phenomena are sometimes contextual. Contextuality is a subtle notion that influences how we must view the properties of the cognitive phenomenon being studied. This article addresses the questions: What does it mean for a cognitive phenomenon to be contextual? What are the implications of contextuality for probabilistic models of cognition? How does contextuality differ from context-sensitivity? Starting from George Boole's "conditions of possible experience", we argue that a probabilistic model of a cognitive phenomenon is necessarily subject to an assumption of realism. By this we mean that the phenomenon being studied is assumed to have cognitive properties with a definite value independent of observation. In contrast, quantum cognition holds that a cognitive property maybe indeterminate, i.e., its properties do not have well established values prior to observation. We argue that indeterminacy is sufficient for incompatibility between cognitive properties. In turn, incompatibility is necessary for their contextuality. The significance of this argument for cognitive psychology is the following:if a cognitive phenomenon is found to be contextual, then there is reason to believe it may be indeterminate. We illustrate by means of two crowdsourced experiments how context-sensitivity and contextuality of cognitive properties in the form of facial trait judgements can be characterized from empirical data. Finally, we conceptually and formally contrast contextuality with context-sensitivity. We propose that both involve a form of context dependence, with causality being the differentiating factor: the context dependence in context-sensitivity has a causal basis, whereas the context dependence in contextuality is acausal. The resulting implications for probabilistic models of cognition are discussed.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Anti-NMDA Receptor Encephalitis or Psychiatric disorder?

Introduction

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis commonly begins with a prodromal phase characterized by flu-like symptoms, subsequently the patients experience a rapid deterioration with psychiatric symptoms that may include anxiety, irritability, insomnia, paranoia, aggression, auditory or visual hallucinations, sexual disinhibition, mania, cognitive disorder, and psychosis; seizures; motor and autonomic dysfunction. The triggers of the disorder comprise viral infections, tumors, and other unknown factors. Taking in count the prominence of psychiatric symptoms, it is relevant to rise the question whether patients with anti-NMDA receptor encephalitis are being misdiagnosed with psychiatric disorders.

Objectives

Non-systematic literature review of the relationship between anti-NMDA receptor encephalitis and psychiatric disorders.

Methods

From the review performed, 2 studies stand out: In one study, 459 serum samples for NMDA receptor antibodies were evaluated. The analysis compared samples from patients diagnosed with schizophrenia, major depressive disorder, and borderline personality disorder with nonpsychiatric controls. In another study, serum was obtained prospectively from a cohort (n = 46) of patients at first presentation of psychosis and NMDA receptor antibodies were measured.

Results

In the first study, the authors found that 9.9%, 2.8%, and 0% of patients with schizophrenia, major depressive disorder, and borderline personality disorder, respectively, were antibody positive. In the second study, it was found that 7% of the patients were serum NMDA receptor antibody positive.

Conclusions

It is unclear yet if patients with primary psychotic disorders have higher rates of pathogenic NMDA receptor antibodies. More evidence is needed to study this relationship.

Disclosure

No significant relationships.

Semiquantitative analysis of interim 18F-FDG PET is superior in predicting outcome in Hodgkin lymphoma patients compared to visual analysis

PURPOSE

To investigate the prognostic value of interim PET (PETi) in adult HL patients, comparing visual with semiquantitative analysis.

MATERIAL AND METHODS

Retrospective analysis of Hodgkin's lymphoma (HL) patients diagnosed between 2012 and 2016 in the Onco-hematology Department of Instituto Português de Oncologia - Porto (median follow-up: 46.5 months [2.6-66.4]). Fifty-eight patients with available PET at diagnosis (PET0) and PETi data were included. PETi scans were analyzed according to Deauville 5-point scale (5-PS), and cut-off values for changes in maximum standardized uptake value [SUVmax], peak SUV [SUVpeak], metabolic tumour volume [MTV] and total lesion glycolysis index [TLG] between PETi and PET0 were computed using ROC analysis. Visual and semiquantitative data were compared with each other in the prediction of patient outcomes.

RESULTS

Semiquantitative analysis obtained a higher sensitivity for persistent/relapsed disease compared to the 5-PS (70% vs. 10%, respectively), but lower specificity. It also demonstrated better predictive performance for response to first-line therapy (negative predictive value >92%). The positive predictive value was similar for all five measurements. At 60 months of follow-up, there was a significant difference between the progression free survival (PFS) curves of patients with positive and negative PETi according to ΔSUVmax (56.9% vs. 88.0%, p<0.05), ΔSUVpeak (55.9% vs. 88.1%, p<0.05), ΔMTV (35.3% vs. 88.7%, p<0.05), and ΔTLG (42.4% vs. 88.1%, p<0.05). Statistical significance was not reached when considering 5-PS results.

DISCUSSION

PETi interpretation according to a semiquantitative approach appears to discriminate HL patients better than the visual 5-PS analysis. This could allow better detection of persistent or early relapsed disease, while a negative PETi result could support de-escalating therapy intensity.

Pancreatic adenocarcinoma metastasis to the oral cavity: A rare case report and literature review

A patient suffering from metastatic pancreatobiliary adenocarcinoma was referred to our hospital's stomatology department after a rapidly progressing swelling in the right mandibular angle, trismus and preauricular pain of 3-month duration. A mandible CT scan showed extensive bone rarefaction and a thickening of the contiguous soft tissues that involved the medial masseter and pterygoid muscle. The morphological findings and immunohistochemical profile were compatible with bone metastasis from pancreatic adenocarcinoma. Therefore, palliative treatment was proposed to the patient. Pancreatic cancer metastases to the oral cavity are extremely rare and characterized by its poor prognosis. Herein we describe the ninth case of metastatic spread to the jaw which is also remarkably the longest surviving reported case up to date.

Integrating a palliative approach into the healthcare provided by the French-African Pediatric Oncology Group's pilot units. Insights from a 3-year training program

Working alongside local stakeholders, members of the French-African Pediatric Oncology Group developed a 3-year program to train pediatric oncology teams from 15 French-speaking countries in Africa in using analgesics and providing palliative care. This program was rolled out in three phases: initial training, in situ assessment, and advanced training in selected topics. To access this program, multidisciplinary teams had to come up with a project to improve their existing palliative care and pain management practices, and commit themselves to implementing it. All the teams invited agreed to take part in the program, which explicitly broached a subject that is often avoided in oncology teaching. The first phase was rolled out in 2017, with 65 trainees from 19 units attending one of three sessions held in Dakar, Senegal, Abidjan, Côte d'Ivoire, and Rabat, Morocco. The subsequent assessment revealed that only half the teams had started to implement their projects. The advanced training phase was therefore adjusted accordingly. A collective training session held in Marseille was attended by 15 trainees from seven teams whose projects were already underway, while in situ mentoring was provided for six other teams, through French-African twinnings in four cases. The length and openness of the program meant that we were able to identify and share the units' diverse realities, and fine-tune their projects accordingly, as well as plan ways of continuing the training both locally and collectively.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Bacillus toyonensis BCT-7112T transient supplementation improves vaccine efficacy in ewes vaccinated against Clostridium perfringens epsilon toxin

AIM

The aim of the present study was to examine the vaccine immune response in ewes supplemented with Bacillus toyonensis BCT-7112^T during a period of 5-day supplementation before vaccination against a recombinant Clostridium perfringens epsilon toxin (rETX).

METHODS AND RESULTS

Ewes were vaccinated with 200 µg of rETX adjuvanted with 10% aluminium hydroxide. The treat group was orally supplemented with B. toyonensis BCT-7112^T (3 × 10⁸ viable spores) for 5 days prior to the first and second vaccination. Ewes supplemented with B. toyonensis BCT-7112^T showed higher neutralizing antibody titres than the non-supplemented ewes (P < 0·05), with an increase in serum levels for total IgG anti-rETX by 3·2-fold (P < 0·0001), and for both IgG isotypes IgG1 and IgG2 by 2·1-fold and 2·3-fold (P < 0·01), respectively, compared with the control group. The peripheral blood mononuclear cells of ewes in the supplemented group had a higher (P < 0·05) cytokine mRNA transcription levels for IL-2 (6·4-fold increase), IFN-γ (2·9-fold increase) and transcription factor Bcl6 (2·3-fold increase) compared with the control group.

CONCLUSION

We conclude that a 5 days of supplementation with B. toyonensis BCT-7112^T prior vaccination is sufficient to significantly improve the humoral immune response of ewes against C. perfringens recombinant ETX vaccine.

SIGNIFICANCE AND IMPACT OF THE STUDY

These findings open a new perspective in the utilization of B. toyonensis BCT-7112^T as an immunomodulator since a 5 days period of probiotic supplementation is sufficient to improve the vaccine immune response.

Advanced Burkitt Lymphoma in Sub-Saharan Africa Pediatric Units: Results of the Third Prospective Multicenter Study of the Groupe Franco-Africain d'Oncologie Pédiatrique

PURPOSE

To evaluate the results of an intensive polychemotherapy regimen for Burkitt lymphoma (BL) in sub-Saharan African pediatric centers.

PATIENTS AND METHODS

Children with advanced-stage BL (stages II bulky, III, and IV) treated with the GFAOP–Lymphomes Malins B (GFALMB) 2009 protocol in 7 centers between April 2009 and September 2015 were prospectively registered. Treatment regimen contained a prephase with cyclophosphamide followed by 2 induction courses (cyclophosphamide, vincristine, prednisone, high-dose methotrexate [HDMTX]), 2 consolidation courses (cytarabine, HDMTX), and a maintenance phase only for stage IV. HDMTX was given at the dose of 3 g/m².

RESULTS

Four hundred patients were analyzed: 7% had stage II bulky, 76% stage III, and 17% stage IV disease. Median age was 7.3 years, and sex ratio was 1.9:1 (male:female). A total of 221 patients received the whole protocol treatment and 195 achieved complete remission (CR), 11 of them after a second-line treatment. Treatment abandonment rate was 22%. One hundred twenty-five patients died, of whom 49 deaths were related to treatment toxicity. A total of 275 patients are alive, including 25 despite treatment abandonment, but only 110 are known to be in CR with a follow-up > 1 year, indicating a high rate of loss to follow-up. Twelve-month overall survival (OS) was 60% (95% CI, 54% to 66%) and 63%, 60%, and 31%, respectively, for stage II bulky, III, and IV. Patients with stage III disease who started second induction course within 34 days had OS of 76%, versus 57% (P = .0062) beyond 34 days.

CONCLUSION

The GFA-LMB2009 protocol improved patients’ survival. Early dose intensity of treatment is a strong prognostic factor. Improving supportive care and decreasing loss to follow-up are crucial.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Treatment of Wilms Tumor in Sub-Saharan Africa: Results of the Second French African Pediatric Oncology Group Study

PURPOSE

Multidisciplinary management of Wilms tumor has been defined through multicenter prospective studies and an average expected patient cure rate of 90%. In sub-Saharan Africa, such studies are uncommon. After the encouraging results of the first Groupe Franco-Africain d'Oncologie Pédiatrique (GFAOP) study, we report the results of the GFAOP-NEPHRO-02 study using an adaptation of the International Society of Paediatric Oncology 2001 protocol.

PATIENTS AND METHODS

From April 1, 2005, to March 31, 2011, seven African units participated in a nonrandomized prospective study. All patients who were referred with a clinical and radiologic diagnosis of renal tumor were screened. Those older than age 6 months and younger than 18 years with a unilateral tumor previously untreated were pre-included and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms, or with a nonresponding stage IV tumor were excluded secondarily.

RESULTS

Three hundred thirteen patients were initially screened. Two hundred fifty-seven patients were pre-included and 169 with histologic confirmation of intermediate-risk nephroblastoma were registered in the study and administered postoperative treatment. Thirty-one percent of patients were classified as stage I, 38% stage II, 24% stage III, and 7% stage IV. Radiotherapy was not available for any stage III patients. Three-year overall survival rate was 72% for all study patients and 73% for those with localized disease.

CONCLUSION

It was possible to conduct sub-Saharan African multicenter therapeutic studies within the framework of GFAOP. Survival results were satisfactory. Improvements in procedure, data collection, and outcome are expected in a new study. Radiotherapy is needed to reduce the relapse rate in patients with stage III disease.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Retinoblastoma in children: a case series from Senegal

Retinoblastoma is the most common tumor of the eye in Senegalese children. Diagnosis occurs often at a late stage, when enucleation is unavoidable. In this report, we describe all recorded cases occurring in Senegal over a 10-year period (2005-14). For the 106 cases clinically and radiological identified, the mean age at diagnosis was 30 months (2 months / 10 years). Leucocoria (74.6%) and exophthalmos (42.3%) were common signs of the disease. For the 67 cases identified through patient-file examination, extra-ocular forms were present in 30% of cases at the time of diagnosis and retinal detachment in 19% of cases. Chemotherapy and surgery were the only available therapeutic methods. Overall survival at 5 years was 70%. Retinoblastoma is a serious illness that threatens the lives and sight of affected children. There are about 10 cases per year in Senegal. Management can be enhanced by improving existing technical platforms and training medical staff.

Influence of volumetric loading rate on aerobic sewage treatment for indigenous algal growth

Many rural areas of Latin America and the Caribbean (LAC) region are economically depressed. Rural sewage treatment in most areas of LAC is deficient or non-existent. Consequently, the possibility of generating economic revenue from treated sewage is an attractive option for deprived areas of developing countries. Given its peculiar characteristics, rural sewage may be coupled with biological systems such as algae for nutrient cycling. Acceptable algae growth and nutrient elimination were obtained from rural sewage whose treatment may have fallen short of current disposal standards. In this study, aerobic systems working on an 8-month cycle at three different volumetric loading rates (Bv) were assessed in relation to the lifetime growth of three algae strains native to Ecuador. Results indicate Chlorella sp. M2 as the optimal algal strain, with the highest growth rate at Bv of 1 g COD L^-1 d^{- 1} and a removal of organic-N (30%), PO₄ ^3--P (87%) and NH₄ ⁺-N (95%). Concomitantly, the kinetic constants of the sewage resulted in a low biomass yield coefficient, making the proposed system highly suitable for developing countries. Finally, the proposed partial recovery stream method, combining nutrient recovery with economic resource generation, appears to contain great potential.

Associations between anthropometric indicators in early life and low-grade inflammation, insulin resistance and lipid profile in adolescence

BACKGROUND AND AIMS

The long-term relations between excessive adiposity in early childhood and unfavourable cardiometabolic profiles in later ages are not yet completely understood. We aimed to assess the associations between birth weight (BW) and BMI from 6 months to 6 years of age, with biomarkers indicative of low-grade inflammation, insulin resistance and lipid profiles in adolescence.

METHODS AND RESULTS

Retrospective school-based study with 415 Portuguese adolescents (220 girls), mean age of 14.08 ± 1.6 years old. Anthropometric data from birth to 6 years old was extracted from individual child health book records. Actual weight and height were measured and BMI calculated. Participants were classified at each time point as normal weight or overweight according to WHO reference values. Biomarkers were obtained from venous blood samples. Linear regressions were used to explore the associations between the biomarkers and early life anthropometric indicators. From 2 years onwards, BMI associated positively with the inflammatory score and HOMA-IR in adolescence. Children who were overweight/obese from 2 to 6 years of age presented significantly higher inflammatory score and HOMA-IR later in adolescence. TC/HDL ratio was also positively associated with BMI from the age of 5 years onwards. The associations between BMI and cardiometabolic outcomes remained positive in adolescence, with overweight adolescents presenting a higher inflammatory score, HOMA-IR and TC/HDL than normal weight adolescents.

CONCLUSION

A high BMI from an early age was consistently associated with worse inflammatory and lipid profiles and insulin resistance in adolescence. No associations were found between BW and the same studied outcomes.

Continuous ambulatory peritoneal dialysis (CAPD) in children: a successful case for a bright future in a developing country

The authors report the first case of successful peritoneal dialysis (PD) in a developing country performed about a 13-year-old adolescent followed-up for stage V chronic kidney disease (CKD) with anuria. After 3 months of hemodialysis, the parents opted for continuous ambulatory peritoneal dialysis (CAPD) as they wished to return home located 121km from Dakar. After PD catheter insertion, the plan proposed to the patient consisted 3-4 hours stasis of isotonic dialysate during the day and a night stasis of 8 hours of icodextrin for an injection volume of 1L per session. The patient and his mother were trained and assessed on the PD technique. After dialysis adequacy was tested while hospitalised, they were able to return home and continued the sessions following the same plan prescribed and while keeping in touch, by telephone, with the medical team. The technique assessment at the day hospital every 2 weeks revealed dialysis adequacy and satisfactory tolerance of PD at home after 04 months of observation. It was the first case of successful CAPD in the pediatrics unit in this context. Scaling this technique is a challenge for the pediatric nephrologist in developing countries like Senegal.

The Externalities of Advocacy: The High Cost of Standing Up for Patients' Dignity in Senegal

Background and context: In Senegal, pediatric oncology patients arrive at the hospital at advanced stages of disease. Their large tumors, as well as the side effects of chemotherapy make children experience intense pain. In this low-resource setting, morphine supply was quite irregular. Doctors don´t prescribe morphine due to shortages; but few prescriptions also lead to limited orders. A vicious circle with only 1 victim: the patient. Hearing children in pain was agonizing for everyone: patients, caregivers and healthcare practitioners. Aim: This advocacy narrative illustrates how the fight for access to morphine in pediatric oncology has led to both positive and negative externalities. We will highlight ways in which this fight for morphine has provoked political tensions moving the issue forward, but has also affected the careers of health workers involved. Strategy/Tactics: Morphine is a cheap drug, yet it is extremely regulated by international laws. It takes political will to influence national morphine orders. This advocacy strategy was built on raising awareness and setting morphine shortage on the political agenda. Not providing morphine in oncology goes against international standards of care. But most importantly, letting patients suffer without “existing” relief is a breach of basic human right to live - and also die - in dignity. Program/Policy process: Conversations began within the pediatric oncology department. Focus groups highlighted caregivers' feelings of powerlessness before their suffering child. Interviews with key informants (doctor and nurses) were instrumental to a widely diffused Human Rights Watch report exploring the medical and political causes to morphine supply shortages, as well as its psychological repercussions on patient care. A BBC documentary was broadcasted soon after. Subsequently, meetings were held between the Ministry of Health, the National Supply Pharmacy and leading local oncologists. Outcomes: Morphine orders were multiplied by 10, leading to much improved pain management for patients. However, Senegal was portrayed negatively on the international scenes, much to the Health Minister´s dismay. The consequences were incurred by the health workers who contributed to the international publications/reports. What was learned: Health practices can inform policy just like policy can inform health practices. It is a cyclical process. Creating advocacy coalitions and rallying the help of the international community are effective strategies. However, in the political arena, health workers need more than commitment to human rights and quality care. Even in democratic republics, systems can penalise outspoken activists. We have learned that health care practitioners (especially working in public settings) who wish improvement for their patients must learn to be tactical and diplomatic. International partners will return to their home countries, but local actors will pay the high cost of advocacy.

Fruit, vegetable consumption and blood pressure in healthy adolescents: A longitudinal analysis from the LabMed study

BACKGROUND AND AIMS

The associations between fruit and vegetable consumption and high blood pressure among adults are well studied. Nonetheless, data on the influence of a low consumption of fruit and vegetables on cardiovascular disease risk, particularly blood pressure, among healthy adolescents are scarce. Therefore, we aim to analyse the associations between fruit and/or vegetable intake and blood pressure over a two-year period in healthy adolescents.

METHODS AND RESULTS

As part of a cohort, 606 adolescents from the LabMed Physical Activity study were evaluated in 2011 (baseline) and 2013 (follow-up). Blood pressure was measured according to standardized procedures and fruit and vegetable consumption was assessed with a food frequency questionnaire. Anthropometric variables, socioeconomic status, pubertal stage and lifestyle determinants were gathered and used as confounders. Prospective associations between fruit and/or vegetable intake and blood pressure were examined using generalized linear models. Girls who consumed more fruit at baseline had a significant decrease in diastolic blood pressure at follow-up [unstandardized beta: -0.005 mmHg (95%CI: -0.01; -0.0002) (p = 0.038)].

CONCLUSION

In apparently healthy adolescents, fruit intake may already start to have an effect in blood pressure. Girls who consumed more fruit exhibited lower levels of diastolic blood pressure.

Longitudinal association between ideal cardiovascular health status and muscular fitness in adolescents: The LabMed Physical Activity Study

BACKGROUND AND AIMS

Muscular fitness is an emerging predictor for cardiovascular disease mortality. The ideal cardiovascular health metrics has been inversely related to a subsequent cardiometabolic health in adulthood. However, evidence regarding muscular fitness and ideal cardiovascular health in adolescents is scarce. This study aimed to examine the longitudinal association between ideal cardiovascular health index and muscular fitness.

METHODS AND RESULTS

This study cohort consisted of 331 adolescents (183 girls) from the LabMed Physical Activity Study who were followed from 2011 to 2013. Ideal cardiovascular health, as defined by the American Heart Association, was determined as meeting ideal health factors (total cholesterol, blood pressure, and glucose) and behaviors (smoking status, body mass index, physical activity, and diet). Handgrip strength and standing long jump tests assessed muscular fitness and were transformed into standardized values according to age and sex. ANCOVA showed a significant association between the accumulation of ideal cardiovascular health metrics at baseline and muscular fitness indices at follow-up (F_{(4, 322)} = 2.280, p = 0.04). In addition, the higher the number of ideal cardiovascular health metrics accumulated, the higher the likelihood of having a high muscular fitness over a two-year period (p for trend = 0.01), after adjustments for age, sex, pubertal stage and socioeconomic status and muscular fitness at baseline.

CONCLUSION

The ideal cardiovascular health status during adolescence was associated with high muscular fitness levels over a two-year period.

[Fatal female genital mutilation in a 10-year-old girl]

Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external genitalia and/or any other procedures affecting the female genitalia, for cultural or religious reasons or for nontherapeutic purposes in general. FGM is responsible for a number of short-, medium-, and long-term complications that can engage the vital and functional prognosis, especially in African countries. We report on a case in a 10-year-old girl who underwent genital mutilation, a traditional type of total excision during the neonatal period. She was followed for urethral meatus stenosis, which then was complicated by obstructive chronic kidney failure and urinary sepsis, whose progression was fatal.

Muscular fitness, adherence to the Southern European Atlantic Diet and cardiometabolic risk factors in adolescents

BACKGROUND AND AIM

Muscular fitness and an adherence to the Southern European Atlantic Diet (SEADiet) have been inversely associated with cardiometabolic risk. Our aim was to assess the independent and combined associations of muscular fitness and adherence to the SEADiet on cardiometabolic risk in adolescents.

METHODS AND RESULTS

A total of 467 Portuguese adolescents (275 girls) participated in this cross-sectional study. Sum of the Z-Scores of Curl-Up and Push-Up tests was used to create a muscular fitness score. Adherence to SEADiet was obtained using a food frequency questionnaire. A cardiometabolic risk score was computed from sum of Z-score of triglycerides, systolic blood pressure, total cholesterol/HDL ratio, HOMA-IR and waist circumference. Adolescents with low muscular fitness and low adherence to the SEADiet had the poorest cardiovascular profile F_(5, 452) = 5.074 (p < 0.001) and the highest odds of having a high cardiometabolic risk score (OR = 4.5; 95% CI: 2.1-14) when compared to those with High muscular fitness/High adherence to the SEADiet after adjustments for age, sex, pubertal stage, socioeconomic status, total energy intake, low-energy reporter and cardiorespiratory fitness.

CONCLUSIONS

Our findings seem suggest that improving muscular fitness as well as an adherence to the SEADiet could be an important strategy to reduce clustered cardiometabolic risk in youth.

[Idiopathic nephrotic syndrome (INS) in children in Dakar: about 40 cases]

Introduction

L’objectif de ce travail était d’analyser les caractéristiques diagnostiques, thérapeutiques et évolutives de l’enfant atteint de néphrose dans un service de pédiatrie de Dakar.

Méthodes

L’étude était réalisée au service de pédiatrie de l’hôpital Aristide Le Dantec. Il s’agissait d’une étude rétrospective sur une période de 03 ans allant du 1^er janvier 2012 au 31 décembre 2014. Ont été inclus tous les patients âgés de 02 ans à 12 ans présentant un tableau de Syndrome néphrotique idiopathique.

Résultats

Quarante cas de néphrose étaient colligés soit une prévalence de 23% parmi les néphropathies prises en charge dans le service. L’âge moyen était de 7,11± 3,14 ans. Le syndrome néphrotique était pur chez 72,5% (n=29) des patients. Les œdèmes des membres inférieurs étaient présents chez 100% des patients, l’oligurie dans 55% (n=22) et l’HTA dans 5% (n=2) des cas. La protéinurie moyenne était de 145,05 ± 85,54 mg/kg/24heures. La protidémie moyenne était de 46,42 ±7,88 g/L et l’albuminémie moyenne de 17,90 ± 7,15 g/L. Trente-neuf patients avaient reçu une corticothérapie à base de prednisone. La corticosensibilité était retenue chez 77% (n=30) des patients et la corticorésistance chez 13% (n=5) des cas. Le facteur de mauvaise réponse à la corticothérapie était un niveau de protéinurie initiale supérieure à 150 mg/kg/jour (p = 0,024). La biopsie rénale était réalisée chez 18% (n=7) des patients et retrouvait dans 57,2% (n=4) des cas une hyalinose segmentaire et focale. Le cyclophosphamide et l’azathioprine étaient associés aux corticoïdes dans 10% (n=4) des cas chacun. Le taux de rémission globale était de 89,8%. L’évolution vers l’insuffisance rénale chronique était notée chez trois (03) des patients.

Conclusion

La néphrose représentait près du quart des néphropathies prises en charge dans notre service. Le taux de rémission globale était élevé. Le seul facteur de mauvaise réponse à la corticothérapie était le niveau de protéinurie initiale élevée. En cas d’indication de la biopsie rénale chez nos patients, la HSF était la lésion la plus fréquemment retrouvée.

[Pathological profiles of retinoblastoma in Senegal]

OBJECTIVES

Describe the macroscopic and microscopic profiles of retinoblastoma (RB) in Senegal and correlate histological criteria with progression to establish severity factors.

METHODOLOGY

We realized a retrospective study over 10 years (January 2005-December 2014). Only patients (n=67) who underwent histological analysis of the enucleation specimen (n=68) were followed until the end of the study.

RESULTS

The tumor measured an average of 3.8cm (2/4.5). Endophytic tumor development was observed in 55 cases (80.8%), exophytic in 6 cases (8.9%) and mixed in 7 cases (10.3%). Retinal detachment was present in 13 cases (19.2%). The RB was well differentiated in 11 cases (16.2%), moderately differentiated in 31 cases (45.6%) and undifferentiated in 26 cases. Optic nerve (ON) invasion was present in 18 cases (26.5%). The tumor was extraretinal in 37 cases (54.4%). The anterior chamber was invaded in 6 cases (8.8%). The global survival at 2 years was 84% and 70% at 5 years. On multivariate analysis, well differentiated tumors and stage pT1 were associated with remission. Retrolaminar ON invasion, massive choroidal invasion and stage pT3 were risk factors for recurrence. Poor tumor differentiation, invasion of the ON resection margin, tumor invasion through the sclera, and stage pT4 were predictive of death.

CONCLUSION

The pathologist is a principal actor in the management of RB because his account guide the post-surgical management strategy.

Generalized Bullous Fixed Drug Eruption due to Bromhexine

We describe a patient with a generalized bullous form of Fixed Drug Eruption (FDE) induced by bromhexine, a commonly used drug for respiratory symptoms. This is a rare association and generalized bullous FDE is also very rare. We emphasize the importance of patch tests in identifying the culprit drug.

Association between serum adiponectin levels and muscular fitness in Portuguese adolescents: LabMed Physical Activity Study

BACKGROUND AND AIM

Paradoxically, recent investigations have showed that adiponectin levels are inversely associated with muscle strength. However, to date, there is a lack of knowledge on the relationship between muscular fitness (MF) and adiponectin levels in adolescents. We aimed to examine the independent associations between MF and adiponectin levels in adolescents, controlling for several potential confounders.

METHODS AND RESULTS

This is a cross-sectional analysis with 529 Portuguese adolescents aged 12-18 years. A MF score was computed as the mean of the handgrip strength and standing long jump standardized values by age and gender. We measured fasting glucose, insulin, HDL-cholesterol, C-reactive protein and adiponectin. Linear regression analysis showed a significant inverse association between adiponectin (Z-score by age and sex) and MF score, after adjustments for age, sex, pubertal stage, socioeconomic status, adherence to the Mediterranean diet, body mass index, HOMA-IR, HDL-cholesterol, C-reactive protein and cardiorespiratory fitness (unstandardized β = -0.176; p < 0.005). Analysis of covariance showed a significant difference between the Low MF/Non-overweight group and the High MF/Non-overweight Group (p < 0.05) and between the Low MF/Non-overweight and High MF/Overweight Group (p < 0.05) (F (5, 523) = 2.262, p = 0.047).

CONCLUSION

Adiponectin circulating levels are inversely and independently associated with MF. In non-overweight adolescents, those with high levels of MF presented lower levels of adiponectin compared to those with Low MF. Likewise, overweight adolescents with High MF presented lower levels of serum adiponectin than non-overweight adolescents with Low MF.

Why Portugal is pushing towards migration?

Background

International professional mobility is a reality, people have skills they can put in the global marketplace. The increasing migration of health professionals to wealthy countries is a phenomenon known as “brain drain”.

Objectives/Aims

This work aims to present the push factors that pressure people to migrate from Portugal.

Methods

A cross-sectional survey was carried out with the psychiatric trainees in Portugal. A self-administered structured questionnaire was distributed to collect psychiatry trainees’ demographic and educational characteristics.

Results

In Portugal, the majority of trainees have a Portuguese citizenship. Almost 2/3 did not have a short-mobility experience, and the majority never migrated to another country. Less than half consider staying in Portugal in the next years, and nearly 4/5 have considered leaving the country. Working conditions ranked first as the priority condition to be improved in psychiatry in Portugal, followed by financial conditions. In fact, an attractive job for psychiatry trainees in Portugal must have as the most important feature a pleasant work environment.

Conclusions

An alarming percentage of psychiatry trainees from Portugal intend to migrate. Impact on future career, financial conditions of doctors, job opportunities and better working conditions were some of the motivating factors behind the migration.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Boderline versus personality

Introduction

Latest classifications led to an inflamed debate urging for change or validation in the way personality disorders are classified. The placement in psychiatric classifications of several personality disorders, particularly Borderline Personality Disorder (BPD), is also a matter of discussion.

Objectives and aims

The present work aims to question BPDs place in classification alongside with other personality disorders, rather than focusing on the algorithms used to classify it. The authors review updated literature on core features of the disorder collected from online scientific databases.

Results

Studies reveal that the stability of the diagnosis of BPD over the longer term is less than what standard general definitions of personality disorders would appear to require. It is a chronic and debilitating syndrome with severe functional and psychosocial impairment that remain relevant when comparing to other personality disorders. Additionally, these measures show further declines over time in spite of improvement in psychopathology, in contrast to what happens with other personality disorders. Several misconceptions may have led to the placement of BPD on former axis II, namely being a direct consequence of trauma and merely explained by environmental factors. However, recent research on heritability shows the contrary and several neurobiological markers suggest it has got a nature of its own.

Conclusion

BPD is probably the most studied and validated personality disorder and has substantially greater empirical basis, clinical significance and public health implications, being both enduring and distinct from other personality disorders. We suggest the placement of BPD as major psychiatric disorder in classifications.

Disclosure of interest

The authors have not supplied their declaration of competing interest.