Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Measures of women's empowerment based on individual-level data: a literature review with a focus on the methodological approaches

Background

Quantifying women's empowerment has become the focus of attention of many international organizations and scholars. We aimed to describe quantitative indicators of women's empowerment that are based on individual-level data.

Methods

In this scoping review, we searched PubMed, Scopus, Web of Science, Science Direct, Google, and Google Scholar for publications describing the operationalization of measures of women's empowerment.

Results

We identified 36 studies published since 2004, half of them since 2019, and most from low- and middle-income countries. Twelve studies were based on data from the Demographic and Health Surveys and used 56 different variables from the questionnaires (ranging from one to 25 per study) to measure the overall empowerment of women 15-49 years. One study focused on rural women, two included married and unmarried women, and one analyzed the couple's responses. Factor analysis and principal component analysis were the most common approaches used. Among the 24 studies based on other surveys, ten analyzed overall empowerment, while the others addressed sexual and reproductive health (4 studies), agriculture (3) and livestock (1), water and sanitation (2), nutrition (2), agency (1), and psychological empowerment (1). These measures were mainly based on data from single countries and factor analysis was the most frequently analytical method used. We observed a diversity of indicator definitions and domains and a lack of consensus in terms of what the proposed indicators measure.

Conclusion

The proposed women's empowerment indicators represent an advance in the field of gender and development monitoring. However, the empowerment definitions used vary widely in concept and in the domains/dimensions considered, which, in turn influence or are influenced by the adopted methodologies. It remains a challenge to find a balance between the need for a measure suitable for comparisons across populations and over time and the incorporation of country-specific elements.

Trends and inequities in adolescent childbearing in Latin American and Caribbean countries across generations and over time: a population-based study

BACKGROUND

Latin America and the Caribbean present the second highest adolescent fertility rate in the world, only after sub-Saharan Africa, and have reached the third position globally in the incidence of motherhood in adolescence. We aimed to explore trends and inequities in adolescent childbearing in the region.

METHODS

We used nationally representative household surveys from Latin American and Caribbean countries to address trends in early childbearing (proportion of women having their first livebirth before age 18 years) over generations and in adolescent fertility rates (AFRs; livebirths per 1000 women aged 15-19 years) over time. For early childbearing, we analysed the most recent survey conducted since 2010 from 21 countries (2010-20); for AFR, we analysed nine countries with two or more surveys, with the most recent being conducted from 2010 onwards. For both indicators, variance-weighted least-square regression was used to estimate the average absolute changes (AACs) at the national level and by wealth (bottom 40% vs top 60%), urban versus rural residence, and ethnicity.

FINDINGS

Among 21 countries studied, we noted a decrease in early childbearing along generations in 13 of them, with declines varying from -0·6 percentage points (95% CI -1·1 to -0·1) in Haiti to -2·7 percentage points (-4·0 to -1·4) in Saint Lucia. We observed increases over generations in Colombia (1·2 percentage points [0·8 to 1·5]) and Mexico (1·3 percentage points [0·5 to 2·0]) and no changes in Bolivia and Honduras. The fastest early childbearing decline occurred among rural women, whereas no clear pattern was observed for wealth groups. Decreasing estimates from oldest to youngest generations were found among Afro-descendants and non-Afro-descendant and non-indigenous groups, but results were mixed for indigenous people. All nine countries with data for AFR presented reductions over time (-0·7 to -6·5 births per 1000 women per year), with the steepest declines observed in Ecuador, Guyana, Guatemala, and the Dominican Republic. In general, adolescents in rural areas and the poorest adolescents had the largest reductions in AFR. If current trends persist, by 2030 most countries will present AFR values ranging between 45 and 89 births per 1000 women, with notable wealth-related inequalities.

INTERPRETATION

Our results indicate a reduction in AFR in Latin American and Caribbean countries that was not necessarily accompanied by a decrease in early childbearing overall. Large inequalities both between countries and within countries were observed, with no clear reduction over time. Understanding trends in adolescent childbearing and its determinants is essential for planning and designing programmes to ensure the desired reductions in rates and gaps across population subgroups.

FUNDING

PAHO, Bill & Melinda Gates Foundation, and Wellcome Trust.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Differences in food consumption of the Brazilian population by race/skin color in 2017-2018

OBJECTIVE

To evaluate food consumption in Brazil by race/skin color of the population.

METHODS

Food consumption data from the Pesquisa de Orçamentos Familiares (POF - Household Budget Survey) 2017-2018 were analyzed. Food and culinary preparations were grouped into 31 items, composing three main groups, defined by industrial processing characteristics: 1 - in natura/minimally processed, 2 - processed, and 3 - ultra-processed. The percentage of calories from each group was estimated by categories of race/skin color - White, Black, Mixed-race, Indigenous, and Yellow- using crude and adjusted linear regression for gender, age, schooling, income, macro-region, and area.

RESULTS

In the crude analyses, the consumption of in natura/minimally processed foods was lower for Yellow [66.0% (95% Confidence Interval 62.4-69.6)] and White [66.6% (95%CI 66.1-67.1)] groups than for Blacks [69.8% (95%CI 68.9-70.8)] and Mixed-race people [70.2% (95%CI 69.7-70.7)]. Yellow individuals consumed fewer processed foods, with 9.2% of energy (95%CI 7.2-11.1) whereas the other groups consumed approximately 13%. Ultra-processed foods were less consumed by Blacks [16.6% (95%CI 15.6-17.6)] and Mixed-race [16.6% (95%CI 16.2-17.1)], with the highest consumption among White [20.1% (95%CI 19.6-20.6)] and Yellow [24.5% (95%CI 20.0-29.1)] groups. The adjustment of the models reduced the magnitude of the differences between the categories of race/skin color. The difference between Black and Mixed-race individuals from the White ones decreased from 3 percentage points (pp) to 1.2 pp in the consumption of in natura/minimally processed foods and the largest differences remained in the consumption of rice and beans, with a higher percentage in the diet of Black and Mixed-race people. The contribution of processed foods remained approximately 4 pp lower for Yellow individuals. The consumption of ultra-processed products decreased by approximately 2 pp for White and Yellow groups; on the other hand, it increased by 1 pp in the consumption of Black, Mixed-race, and Indigenous peoples.

CONCLUSION

Differences in food consumption according to race/skin color were found and are influenced by socioeconomic and demographic conditions.

Changes in socioeconomic inequalities in food consumption among Brazilian adults in a 10-years period

Objective

To evaluate changes in socioeconomic inequalities in food consumption in Brazil over a 10-year period.

Methods

Data on 24-h recalls of adults (aged 20 years or more) from the 2008/9 (n = 26,327) and 2017/8 (n = 37,689). Brazilian Dietary Survey were analyzed. We used the Nova classification system to group food items and estimate the percentage of total energy from ultra-processed foods and plant-based natural or minimally processed foods. For sex and area of residence, we calculated the percentage points (p.p.) difference between the estimates for women and men, and rural and urban populations. Negative values indicate higher consumption among men or urban residents, positive values indicate higher consumption among women or rural residents, and zero indicates equality. For education and wealth levels we calculated the slope index of inequality (SII). The SII varies from -100 to 100, with positive values indicating higher consumption among more educated or wealthiest groups, negative values indicating higher consumption among less educated or poorest groups, and zero equality.

Results

Over the period, we observed a reduction in the percentage of total energy from plant-based natural/minimally processed foods from 13.0 to 12.2% and an increase in that of ultra-processed foods from 17.0 to 18.3%. The urban population and those in the wealthier and more educated groups presented higher consumption of ultra-processed foods and lower consumption of plant-based natural/minimally processed foods in both survey years. Over the 10-year period, there was an overall reduction of the socioeconomic inequalities, mainly explained by the greater increase in ultra-processed food consumption by the rural population and those from the poorest and less educated groups (difference for area -7.2 p.p. in 2008/9 and -5.9 p.p. in 2017/8; SII for education 17.7 p.p. in 2008/9 and 13.8 p.p. in 2017/8; SII for wealth 17.0 p.p. in 2008/9 and 11.2 p.p. in 2017/8).

Conclusion

Socioeconomic inequalities in food consumption decreased in Brazil, but it may lead to the overall deterioration of the dietary quality of the more vulnerable groups.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries

BACKGROUND

Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries.

METHODS

Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group.

FINDINGS

Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries.

INTERPRETATION

Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants.

FUNDING

Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

Growth patterns by sex and age among under-5 children from 87 low-income and middle-income countries

Introduction

Although boys tend to be more affected by linear growth faltering than girls, little is known about sex differences across distinct age groups. We aimed to compare sex differences in linear growth throughout the first 5 years of life among children from low-income and middle-income countries.

Methods

We analysed 87 cross-sectional Demographic and Health Surveys and Multiple Cluster Indicator Surveys (2010–2019). Growth was expressed as height-for-age z-scores (HAZ) based on the 2006 WHO Growth Standards. Sex-specific means were estimated for each country and results were pooled through random-effects meta-analysis for all children and by 12-month age groups. Using linear regression, we assessed the association between sex differences in HAZ and gross domestic product as a proxy for national economic development.

Results

Boys presented lower mean HAZ than girls in the first 30 months. Sex differences were mostly absent between 30 and 45 months, and in several countries, girls had lower HAZ at ages over 45 months. The pooled sex difference (boys minus girls) for the whole sample was −0.10 (95% CI −0.12 to −0.08). The difference was −0.17 (95% CI −0.20 to −0.14) at 0–11 months and −0.22 (95% CI −0.25 to −0.19) at 12–23 months. This was followed by a narrowing of the sex gap to −0.10 (95% CI −0.13 to −0.07) and −0.04 (95% CI −0.07 to −0.01) among children aged 24–35 and 36–47 months, respectively. At 48–59 months, there was evidence of female disadvantage; the mean height-for-age of boys was 0.02 (95% CI 0.00 to 0.05) SDs higher than for girls. Ecological analyses showed that in all age groups, male disadvantage decreased with increasing national income, and this was no longer present for the 4-year-old children, particularly in wealthier countries.

Conclusion

Male disadvantage in linear growth is most evident in the first years, but by the age of 4 years, the sex gap has mostly disappeared, and in some countries, the gap has been reversed.

Cardiac rehabilitation in COVID-19 pandemic period

Background

The current COVID-19 pandemic constitutes a challenge in cardiovascular disease (CVD) management. Little is known on how the virus impacts cardiac rehabilitation (CR) programs (CRP) safety and efficacy.

Aim

To evaluate the efficacy of basic sanitary procedures to limit the risk of virus spreading in patients undergoing cardiac rehabilitation in ambulatory setting.

Methods

From august to October 2020, all patients admitted in a single ambulatory CR program were screened for COVID-19 infection before and after CR. Negative naso-pharyngeal swab through RT-PCR was mandatory within seven days before starting the program, and advised after leaving the program. Serologic tests were also advised before and after the CRP. Number of patients were reduced from 9 to 4 in each group, 2 meters distancing respected, and all patients and staff had to wear surgical mask during sessions. Regular hand washing and hydro-alcoholic solutions use were mandatory for both patients and health professionnals. Material disinfection was systematic before and after each session.

Results

Among the 81 patients included, 63 (76%) were male, mean age was 57±11 years (see table). Sanitary protection measures were well applied and tolerated, especially use of surgical mask during exercice sessions. After RT-PCR on nasal swab, none (0%) were positive before entering CR and only 2 (2.7%) were tested positive after CR. These two patients were asymptomatic. The other patients in the same group as those having positive nasal test after CR were tested negative and were asymptomatic. According to serological analysis, the same 3 patients (3.8%) had anti-bodies against SARS-COV-2 before and after participating CR (see graph). These 3 patients were negative on nasal swab before and after CR. No seroconversion was observed. Mean delay between first and second RT-PCR on nasal swab and serological analysis were 30±15 and 32±15 days, respectively. In total (before and after CR), 5 patients (6.0%) were tested positive with SARS-COV-2. Those 5 patients were younger (mean age 51 years old versus 58, p=0.2), with better functional capacity before and after CR: respectively 7.1 METs (versus 5.2 METs, p=0.014) and 8.3 METs (versus 6.3 METs, p=0.03). In COVID+ patients, improvement of functional capacity was similar to COVID− patients: respectively 0.8 METs (p=0.9) and 15 Watts (p=0.9).

Conclusion

During COVID-19 pandemic, cardiac rehabilitation is not associated with risk of infection with SARS-CoV-2, provided that basic sanitary measures are stricly applied. It is also associated with functionnal capacity improvement, especially in patients who previously had COVID-19.

Funding Acknowledgement

Type of funding sources: None. Patients baseline characteristics in CRPatients COVID-19 status in CR

1214Coverage of maternal and child health in slums, rural and urban areas from 42 countries

Background

Rural populations are traditionally considered to have the lowest coverage on health interventions, but little is known about urban slums. Our aim was to analyse inequalities on the composite coverage index (CCI) – a weighted average of eight interventions on reproductive health, antenatal and delivery care, immunization and management of illnesses – according to place of residence in low- and middle-income countries.

Methods

We analysed the most recent Demographic and Health Surveys (2006-2018) from 42 countries. We estimated the CCI coverage according to the classification of the clusters women and children were living in (urban non-slums; urban slums; or rural areas). Slums were defined as clusters where at least 75% of the households did not have at least two of the following characteristics: access to improved water, access to basic sanitation, solid floor material, and sufficient rooms for sleeping.

Results

The CCI coverage ranged from 24% to 86% (median 63%), being higher in urban non-slums for all 42 countries. In 14 countries, the lowest CCI coverage was found in slums. The main drivers of the lowest estimates in slums were the coverage of care seeking for pneumonia, family planning, measles and DPT immunization, which were respectively 51%, 25%, 19%, and 15% lower in slums compared to rural areas.

Conclusions

It is important that public policies are designed in order to prioritise the urban poor populations, aiming to achieve an equitable coverage of essential health interventions.

Key messages

We studied a novel inequality dimension using national standardised surveys, expanding the assessment of the health situation according to the place of residence beyond a dichotomous approach (urban/rural). Investigating maternal and child health conditions in urban slums – a group that is often marginalised in urban areas – is very important to support the design of public policies that focus on those most in need.

Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries

BACKGROUND

Non-biological childhood mortality sex ratios may reflect community sex preferences and gender discrimination in health care.

OBJECTIVE

We assessed the association between contextual factors and gender bias in under-five mortality rates (U5MR) in low- and middle-income countries.

METHODS

Full birth histories available from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010-2018) in 80 countries were used to estimate U5MR male-to-female sex ratios. Expected sex ratios and their residuals (difference of observed and expected) were derived from a linear regression model, adjusted for overall mortality. Negative residuals indicate more likelihood of discrimination against girls, and we refer to this as a measure of potential gender bias. Associations between residuals and national development and gender inequality indices and with survey-derived child health care indicators were tested using Spearman's correlation.

RESULTS

Mortality residuals for under-five mortality were not associated with national development, education, religion, or gender inequality indices. Negative residuals were more common in countries where boys were more likely to be taken to health services than girls (rho -0.24, 95% confidence interval -0.45, -0.01).

CONCLUSIONS

Countries where girls were more likely to die than boys, accounting for overall mortality levels, were also countries where boys were more likely to receive health care than girls. Further research is needed to understand which national characteristics explain the presence of gender bias, given that the analyses of development levels and gender equality did not discriminate between countries with or without excess mortality of girls. Reporting on child mortality separately by sex is required to enable such advances.

A scoping review of methods for assessment of sex differentials in early childhood mortality

BACKGROUND

While assessment of sex differentials in child mortality is straightforward, their interpretation must consider that, in the absence of gender bias, boys are more likely to die than girls. The expected differences are also influenced by levels and causes of death. However, there is no standard approach for determining expected sex differences.

METHODS

We performed a scoping review of studies on sex differentials in under-five mortality, using PubMed, Web of Science, and Scopus databases. Publication characteristics were described, and studies were grouped according to their methodology.

RESULTS

From the 17,693 references initially retrieved we included 154 studies published since 1929. Indian, Bangladeshi, and Chinese populations were the focus of 44% of the works, and most studies addressed infant mortality. Fourteen publications were classified as reference studies, as these aimed to estimate expected sex differentials based upon the demographic experience of selected populations, either considered as gender-neutral or not. These studies used a variety of methods - from simple averages to sophisticated modeling - to define values against which observed estimates could be compared. The 21 comparative studies mostly used life tables from European populations as standard for expected values, but also relied on groups without assuming those values as expected, otherwise, just as comparison parameters. The remaining 119 studies were categorized as narrative and did not use reference values, being limited to reporting observed sex-specific estimates or used a variety of statistical models, and in general, did not account for mortality levels.

CONCLUSION

Studies aimed at identifying sex differentials in child mortality should consider overall mortality levels, and report on more than one age group. The comparison of results with one or more reference values, and the use of statistical testing, are strongly recommended. Time trends analyses will help understand changes in population characteristics and interpret findings from a historical perspective.

Ciência & Saúde Coletiva - 25 years: contributions to pregnancy, delivery, and childhood studies

We reviewed the scientific production on maternal health and the health of children under ten years of age, published in Journal Ciência & Saúde Coletiva during the last 25 years, focusing on quantitative studies. The authors' characteristics, populations under study, thematic areas, and methodology are described. A total of 170 publications were identified and grouped into 12 major themes. Pregnancy, delivery, and puerperium were the subject of 47 studies, followed by child anthropometric assessments (29), breastfeeding (24), and mortality (13). The selected publications represented 3.5% of the total original papers published by the Journal since its creation in 1996 and about 5% of the publications in the 2015-2020 period. The primary data sources were health service records, information systems, and population surveys. The cross-sectional design was used in 113 of the 170 articles, and 70% covered only one municipality. The Southeast and Northeast Regions of Brazil were the target of most studies, and the North Region was the least represented. The publications reflect the complexity of maternal and child health themes, with a particular focus on the importance of the Unified Health System and showing how open access data can contribute to public health research.

Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa

BACKGROUND

Although religious affiliation has been identified as a potential barrier to immunization in some African countries, there are no systematic multi-country analyses, including within-country variability, on this issue. We investigated whether immunization varied according to religious affiliation and sex of the child in sub-Saharan African (SSA) countries.

METHODS

We used data from 15 nationally representative surveys from 2010 to 2016. The major religious groups were described by country in terms of wealth, residence, and education. Proportions of fully immunized and unvaccinated children were stratified by country, maternal religion, and sex of the child. Poisson regression with robust variance was used to assess whether the outcomes varied according to religion, with and without adjustment for the above cited sociodemographic confounders. Interactions between child sex and religion were investigated.

RESULTS

Fifteen countries had >10% of families affiliated with Christianity and >10% affiliated with Islam, and four also had >10% practicing folk religions. In general, Christians were wealthier, more educated and more urban. Nine countries had significantly lower full immunization coverage among Muslims than Christians (pooled prevalence ratio = 0.81; 95%CI: 0.79-0.83), of which seven remained significant after adjustment for confounders (pooled ratio = 0.90; 0.87-0.92). Four countries had higher coverage among Muslims, of which two remained significant after adjustment. Regarding unvaccinated children, six countries showed higher proportions among Muslims, all of which remained significant after adjustment [crude pooled ratio = 1.83 (1.59-2.07); adjusted = 1.31 (1.14-1.48)]. Children from families practicing folk religions did not show any consistent patterns in immunization. Child sex was not consistently associated with vaccination.

CONCLUSION

Muslim religion was associated with lower vaccine coverage in several SSA countries, both for boys and girls. The involvement of religious leaders is essential for increasing immunization coverage and supporting the leave no one behind agenda of the Sustainable Development Goals.

Parent-Related Normative Perceptions of Adolescents and Later Weight Control Behavior: Longitudinal Analysis of Cohort Data From Brazil

PURPOSE

Body image-related norms can be imposed by parents and can shape adolescents' body satisfaction in consequential ways, yet evidence on long-term effects is scarce. Longitudinal data from a country with strong body image focus provided a unique opportunity to investigate long-term influences of normative parent-related perceptions.

METHODS

Multinomial logistic regression was used on data from a 1993 birth cohort in Brazil to investigate the association of normal-body mass index (BMI) adolescents' perception of their parent's opinion of their weight at age 11 years with their weight control attempts at 18 years, testing a mediating role for body dissatisfaction at age 15 years. All models controlled for body dissatisfaction at age 11 years and BMI change between ages 11 and 15 years.

RESULTS

A total of 1150 boys and 1336 girls were included. Girls were more likely than boys to diet without nutritionist advice to lose weight (51.5% vs. 34.3% among boys) and use medication to gain weight (12.7% vs. 4.2%). Normal-BMI adolescents who reported at age 11 years that their parents thought they were thin had higher odds of feeling thinner than ideal at age 15 years (odds ratio 2.8, 95% confidence interval 1.8-3.2; and odds ratio 2.0, 95% confidence interval 1.5-2.7) among boys and girls, respectively). Feeling thinner than ideal at age 15 years was associated among girls with higher odds of weight gain attempts at age 18 years. Similar patterns appeared among girls reporting that their parents thought they were fat at age 11 years, feeling fatter than ideal at age 15 years and having higher odds of weight loss attempts at age 18 years. Body dissatisfaction was a statistically significant mediator among girls but not boys.

CONCLUSIONS

A long-term influence of parent-related perceptions via a likely trajectory of body dissatisfaction is evident among girls.

Crises econômicas, mortalidade de crianças e o papel protetor do gasto público em saúde

Resumo O objetivo do estudo foi analisar como as crises econômicas afetam a saúde infantil a nível global e entre subgrupos de países com diferentes níveis de renda. Foram utilizados dados do Banco Mundial e da OMS para 127 países entre os anos de 1995 e 2014. Foi utilizado um modelo de efeitos fixos, avaliando o efeito da mudança em indicadores macroeconômicos (PIB per capita, taxa de desemprego e de inflação, e taxa de desconforto) na taxa de mortalidade neonatal, infantil, e de menores de cinco anos. Adicionalmente, avaliou-se a modificação do efeito da associação de acordo com a renda dos países e também a influência do gasto público em saúde nessa relação. As evidências mostraram que piores indicadores econômicos (menor PIB per capita e maiores inflação, taxa de desemprego e taxa de desconforto) estão associados com maiores taxas de mortalidade infantil. Nas subamostras por estrato de renda, observa-se a mesma relação, porém com efeitos de maior magnitude entre os países de renda baixa e média. Verificou-se ainda que um maior percentual nos gastos públicos em saúde ameniza os efeitos dos indicadores econômicos nas taxas de mortalidade infantil. Desta forma, é necessário aumentar a atenção aos efeitos nocivos das crises macroeconômicas para garantir melhorias na saúde infantil.

Analyses of inequalities in RMNCH: rising to the challenge of the SDGs

The Sustainable Development Goal (SDG) 17.18 recommends efforts to increase the availability of data disaggregated by income, gender, age, race, ethnicity, migratory status, disability and geographic location in developing countries. Surveys will continue to be the leading data source for disaggregated data for most dimensions of inequality. We discuss potential advances in the disaggregation of data from national surveys, with a focus on the coverage of reproductive, maternal, newborn and child health indicators (RMNCH). Even though the Millennium Development Goals were focused on national-level progress, monitoring initiatives such as Countdown to 2015 reported on progress in RMNCH coverage according to wealth quintiles, sex of the child, women’s education and age, urban/rural residence and subnational geographic regions. We describe how the granularity of equity analyses may be increased by including additional stratification variables such as wealth deciles, estimated absolute income, ethnicity, migratory status and disability. We also provide examples of analyses of intersectionality between wealth and urban/rural residence (also known as double stratification), sex of the child and age of the woman. Based on these examples, we describe the advantages and limitations of stratified analyses of survey data, including sample size issues and lack of information on the necessary variables in some surveys. We conclude by recommending that, whenever possible, stratified analyses should go beyond the traditional breakdowns by wealth quintiles, sex and residence, to also incorporate the wider dimensions of inequality. Greater granularity of equity analyses will contribute to identify subgroups of women and children who are being left behind and monitor the impact of efforts to reduce inequalities in order to achieve the health SDGs.

Gender bias in careseeking practices in 57 low- and middle-income countries

BACKGROUND

Preventive and curative medical interventions can reduce child mortality. It is important to assess whether there is gender bias in access to these interventions, which can lead to preferential treatment of children of a given sex.

METHODS

Data from Demographic and Health Surveys carried out in 57 low- and middle-income countries were used. The outcome variable was a composite careseeking indicator, which represents the proportion of children with common childhood symptoms or illnesses (diarrhea, fever, or suspected pneumonia) who were taken to an appropriate provider. Results were stratified by sex at the national level and within each wealth quintile. Ecological analyses were carried out to assess if sex ratios varied by world region, religion, national income and its distribution, and gender inequality indices. Linear multilevel regression models were used to estimate time trends in careseeking by sex between 1994 and 2014.

FINDINGS

Eight out of 57 countries showed significant differences in careseeking; in six countries, girls were less likely to receive care (Colombia, Egypt, India, Liberia, Senegal and Yemen). Seven countries had significant interactions between sex and wealth quintile, but the patterns varied from country to country. In the ecological analyses, lower careseeking for girls tended to be more common in countries with higher income concentration (P = 0.039) and higher Muslim population (P = 0.006). Coverage increased for both sexes; 0.95 percent points (pp) a year among girls (32.9% to 51.9%), and 0.91 pp (34.8% to 52.9%) among boys.

CONCLUSION

The overall frequency of careseeking is similar for girls and boys, but not in all countries, where there is evidence of gender bias. A gender perspective should be an integral part of monitoring, accountability and programming. Countries where bias is present need renewed attention by national and international initiatives, in order to ensure that girls receive adequate care and protection.

Measurement of social inequalities in health: concepts and methodological approaches in the Brazilian context

This study aims to describe methodological approaches to measure and monitor health inequalities and to illustrate their applicability. The measures most frequently used in the literature were reviewed. Data on coverage and quality of pre-natal care in Brazil, from the Demographic and Maternal and Child Health Survey (PNDS-2006) and the National Health Survey (PNS-2013) were used to illustrate their applicability. Absolute and relative measures of inequalities were presented, highlighting their complementary character. Despite the progress achieved in the national indicators of pre-natal care, important inequalities were still identified between population subgroups, with no change in the magnitude of the differences throughout the studied period. Brazil has important social inequalities, whose consequences still lead to health inequalities. Their description and monitoring are highly relevant to support polices focused on those vulnerable population groups who have been left behind.

The Bronchiectasis Severity Index and FACED score for assessment of the severity of bronchiectasis

INTRODUCTION

Bronchiectasis (BC) is a multidimensional and etiologically diverse disease and, therefore, no single parameter can be used to determine its overall severity and prognosis. In this regard, two different validated scores are currently used to assess the severity of non-cystic fibrosis bronchiectasis (NCFB): the FACED score and the Bronchiectasis Severity Index (BSI).

OBJECTIVE

To describe the etiology of NCFB and compare the results of the assessment of NCFB severity obtained via FACED and BSI scores.

METHODS

Retrospective study of demographic and clinical data of a convenience sample of NCFB patients attending the Functional Breathing Re-adaptation appointment at the Pneumology B Unit, University Hospital Center of Coimbra. All patients underwent evaluation of the variables incorporated in the FACED score (FEV1% predicted, age, chronic colonization by Pseudomonas aeruginosa, radiological extent of the disease, and dyspnea) and in the BSI (age, body mass index, FEV1% predicted, hospitalization and exacerbations before study, dyspnea, chronic colonization by P. aeruginosa and other microrganisms, and radiological extent of the disease). Statistical analysis of the data was performed using Microsoft Excel® and IBM SPSS® v23.

RESULTS

The sample included 40 patients, 22 females and 18 males, aged 39-87 years. Regarding the etiology of NCFB, we found: idiopathic (60%), post-infectious (20%), sequelae of pulmonary tuberculosis (12.5%) and primary immunodeficiency related (7.5%). According to the FACED score we found 20 patients (50%) with mild BC, 15 patients (37.5%) with moderate and 5 patients (12.5%) with severe BC. The frequency of patients with low, intermediate and high BSI was 13 (32.5%), 13 (32.5%) and 14 (35%), respectively in relation to derived BSI, Moreover, we observed a weak but statistically significant association between FACED and BSI scores: Fisher's exact test (p=0.004), tau-b de Kendall (0.469; p=0.001). The Kappa test (0.330; p=0.002) also shows us that there is 55% agreement between the two scales.

CONCLUSION

There is a small but significant correlation between the two scales: a tendency is observed for patients to be classified with a higher BSI compared to the FACED score. This can be explained by the fact that BSI (and not FACED) evaluates parameters including BMI, hospitalization and exacerbations before study, chronic colonization by other microorganisms and development of cystic bronchiectasis. Further studies should address how these scores may impact clinical practice.

Is Brazil going to achieve the road traffic deaths target? An analysis about the sustainable development goals

OBJECTIVE

To describe the temporal relationship between the road traffic mortality rate and gross domestic product (GDP) per capita in Brazil, and make an annual prediction of the evolution of both indicators until 2020, the end of the Sustainable Development Goals (SDGs) monitoring period.

METHODS

Brazilian road traffic mortality rate official data were described from 2000 to 2015, while the GDP per capita official data were described from 2000 to 2013. GDP per capita and traffic mortality rate predictions were performed until 2020 using fractional polynomial analysis. Correlations were assessed using Pearson's correlation coefficient.

RESULTS

From 2000 to 2015, there were over 446 000 road crashes fatal victims in Brazil. The road traffic mortality rate was positively related to the Brazilian GDP per capita, with a strong correlation (r=0.89; p<0.001) from 2000 to 2013 and a mild correlation (r=0.55; p<0.001) considering the whole period (2000-2020). The predictions show a reduction on the road traffic mortality rates in Brazil; however, if this same reduction pace continues, we estimate that the country will reach 12.4 road crash deaths per 100 000 inhabitants in 2020, a reduction of only 13.4% compared with 2015.

CONCLUSION

If the same mortality reduction pace continues in Brazil, the country will not reach the proposed SDG, which is to reduce by half the number of deaths per 100 000 inhabitants. In addition, an intertwined conciliation between economical growth, sustainable development and public policies is needed in order to meet such an overwhelming goal.

Gender bias in under-five mortality in low/middle-income countries

Introduction

Due to biological reasons, boys are more likely to die than girls. The detection of gender bias requires knowing the expected relation between male and female mortality rates at different levels of overall mortality, in the absence of discrimination. Our objective was to compare two approaches aimed at assessing excess female under-five mortality rate (U5MR) in low/middle-income countries.

Methods

We compared the two approaches using data from 60 Demographic and Health Surveys (2005–2014). The prescriptive approach compares observed mortality rates with historical patterns in Western societies where gender discrimination was assumed to be low or absent. The descriptive approach is derived from global estimates of all countries with available data, including those affected by gender bias.

Results

The prescriptive approach showed significant excess female U5MR in 20 countries, compared with only one country according to the descriptive approach. Nevertheless, both models showed similar country rankings. The 13 countries with the highest and the 10 countries with the lowest rankings were the same according to both approaches. Differences in excess female mortality among world regions were significant, but not among country income groups.

Conclusion

Both methods are useful for monitoring time trends, detecting gender-based inequalities and identifying and addressing its causes. The prescriptive approach seems to be more sensitive in the identification of gender bias, but needs to be updated using data from populations with current-day structures of causes of death.

Genetic diversity of Desmanthus sp accessions using ISSR markers and morphological traits

Desmanthus is a genus of forage legumes with high nutritional value, productive potential, and ability to obtain nitrogen in association with diazotrophic bacteria. The use of accurate techniques for genotype identification and characterization is essential for breeding programs. Morphological markers are widely used to know the genetic diversity and the molecular markers are fundamental in these studies. We investigated the genetic diversity among Desmanthus sp genotypes in Pernambuco (Brazilian Northeast State), using morphological traits and ISSR markers. Morphological and molecular characterizations were performed in 18 and 26 accessions, respectively, in plants belonging to the germplasm bank of forage legumes of Universidade Federal Rural de Pernambuco (UFRPE), Academic Unit of Serra Talhada, PE, Brazil. Eight ISSR primers were selected, and 95 loci were generated, with polymorphism of 95.79%. The allele number observed was 1.958, where the effective number was 1.359, and the Nei diversity genetic index was 0.226. About the morphological markers, seed number was the variable that most contributed to the genetic divergence. A large amount of genetic diversity was observed among Desmanthus species, occurring spontaneously in Pernambuco, Brazil. Thus, the variability found in morphological and ISSR markers is importance for the improvement of Desmanthus spp. Our findings showed that 17L, 27L, 25F, 22F, 19S, 13Au, and 28G accessions could be used in breeding programs to explore the maximum genetic divergence.

Optimization of biogas production from Sargassum sp. using a design of experiments to assess the co-digestion with glycerol and waste frying oil

A design of experiments was adopted to assess the optimal conditions for methane production from the macroalgae Sargassum sp. co-digested with glycerol (Gly) and waste frying oil (WFO). Three variables were tested: % total solids of algae (%TSSargassumsp.), co-substrate concentration (gGly/WFOL(-1)), and co-substrate type (Gly or WFO). The biochemical methane potential (BMP) of Sargassum sp. was 181±1L CH4kg(-1) COD. The co-digestion with Gly and WFO increased the BMP by 56% and 46%, respectively. The methane production rate (k), showed similar behaviour as the BMP, increasing 38% and 19% with Gly and WFO, respectively. The higher BMP (283±18L CH4kg(-1) COD) and k (65.9±2.1L CH4kg(-1) CODd(-1)) was obtained in the assay with 0.5% TS and 3.0gGlyL(-1). Co-digestion with glycerol or WFO is a promising process to enhance the BMP from the macroalgae Sargassum sp.

Design of experiments to assess pre-treatment and co-digestion strategies that optimize biogas production from macroalgae Gracilaria vermiculophylla

A design of experiments was applied to evaluate different strategies to enhance the methane yield of macroalgae Gracilaria vermiculophylla. Biochemical Methane Potential (BMP) of G. vermiculophylla after physical pre-treatment (washing and maceration) reached 481±9 L CH4 kg(-1) VS, corresponding to a methane yield of 79±2%. No significant effects were achieved in the BMP after thermochemical pre-treatment, although the seaweeds solubilisation increased up to 44%. Co-digestion with glycerol or sewage sludge has proved to be effective for increasing the methane production. Addition of 2% glycerol (w:w) increased the BMP by 18%, achieving almost complete methanation of the substrate (96±3%). Co-digestion of seaweed and secondary sludge (15:85%, TS/TS) increased the BMP by 25% (605±4 L CH4 kg(-1) VS) compared to the seaweed individual digestion.

Quantitative image analysis for the characterization of microbial aggregates in biological wastewater treatment: a review

Quantitative image analysis techniques have gained an undeniable role in several fields of research during the last decade. In the field of biological wastewater treatment (WWT) processes, several computer applications have been developed for monitoring microbial entities, either as individual cells or in different types of aggregates. New descriptors have been defined that are more reliable, objective, and useful than the subjective and time-consuming parameters classically used to monitor biological WWT processes. Examples of this application include the objective prediction of filamentous bulking, known to be one of the most problematic phenomena occurring in activated sludge technology. It also demonstrated its usefulness in classifying protozoa and metazoa populations. In high-rate anaerobic processes, based on granular sludge, aggregation times and fragmentation phenomena could be detected during critical events, e.g., toxic and organic overloads. Currently, the major efforts and needs are in the development of quantitative image analysis techniques focusing on its application coupled with stained samples, either by classical or fluorescent-based techniques. The use of quantitative morphological parameters in process control and online applications is also being investigated. This work reviews the major advances of quantitative image analysis applied to biological WWT processes.

Effects of pre-treatment and bioaugmentation strategies on the anaerobic digestion of chicken feathers

Anaerobic digestion of raw chicken feather waste and its co-digestion with poultry litter were assessed in batch assays. Following, two strategies were evaluated to improve methane production from chicken feathers: (i) waste pre-hydrolysis through thermochemical treatment using lime and sodium hydroxide, and (ii) amendment of digestion broth with the proteolytic bacterium Fervidobacterium pennivorans. Anaerobic digestion of the raw waste (2.5% total solids) allowed a specific methane production of 123 ± 3 L CH(4) kg(-1) VS. Pre-treatment and bioaugmentation strategies did not improve methane production from feather waste, despite the significant increase in waste solubilisation, from 45 ± 5% up to 64 ± 1% using F. pennivorans and up to 96% after pre-treatment with 2g NaOH g(-1) waste. These results indicate that conversion of soluble organic matter to methane, and not the hydrolysis rate, was the limiting step for the anaerobic digestion of chicken feather waste.

Evaluation of the biomethane potential of solid fish waste

Manufacturing processes in fish canning industries generate a considerable amount of solid waste that can be digested anaerobically. The aim of this research was to study the biochemical methane potential of different solid fish waste. For tuna, sardine and needle fish waste, around 0.47g COD-CH(4)/g COD(added) was obtained in batch experiments with 1%TS; whereas for mackerel waste, the methane production attained 0.59g COD-CH(4)/g COD(added). The increase in the waste/inoculum ratio, from 1.1-1.3 to 2.8-3.3g VS(waste)/g VS(inoculum), led to overload due to VFA and LCFA accumulation. Afterward, co-digestion assays of fish waste with gorse were undertaken but the biochemical methane potential did not improve.

Biomethanation potential of macroalgae Ulva spp. and Gracilaria spp. and in co-digestion with waste activated sludge

Biochemical methane potential of four species of Ulva and Gracilaria genus was assessed in batch assays at mesophilic temperature. The results indicate a higher specific methane production (per volatile solids) for one of the Ulva sp. compared with other macroalgae and for tests running with 2.5% of total solids (196±9 L CH(4) kg(-1)VS). Considering that macroalgae can potentially be a post treatment of municipal wastewater for nutrients removal, co-digestion of macroalgae with waste activated sludge (WAS) was assessed. The co-digestion of macroalgae (15%) with WAS (85%) is feasible at a rate of methane production 26% higher than WAS alone without decreasing the overall biodegradability of the substrate (42-45% methane yield). The use of anoxic marine sediment as inoculum had no positive effect on the methane production in batch assays. The limiting step of the overall anaerobic digestion process was the hydrolysis.

Thermochemical pre- and biological co-treatments to improve hydrolysis and methane production from poultry litter

The biochemical methane potential (BMP) of raw poultry litter waste was assessed in batch assays. Biological co-treatment with Clostridium cellulolyticum, Caldicellulosiruptor saccharolyticum and Clostridium thermocellum as bioaugmentation strains, and thermochemical pre-treatments with lime and sodium hydroxide performed at different temperatures and pressures were applied as strategies to improve the BMP by favouring the hydrolysis of the cellulolytic material in the waste. Anaerobic digestion of the raw waste allowed a specific methane production of 145 ± 14 LCH(4)kg(-1)VS, with 1% total solids and 0.72 g VS(inoculum)g(-1)VS(waste). The pre- and co-treatments contributed to a significant increase (up to 74%) in the waste solubilisation when using C. saccharolyticum, but methane production did not improve considerably. Therefore, the conversion of soluble organic matter to methane was the limiting step of the anaerobic digestion process of poultry litter waste.

Strategies for lipids and phenolics degradation in the anaerobic treatment of olive mill wastewater

Strategies are proposed for the anaerobic treatment of lipid and phenolic-rich effluents, specifically the raw olive mill wastewater (OMW). Two reactors were operated under OMW influent concentrations from 5 to 48 g COD L(-1) and Hydraulic Retention Time between 10 and 5 days. An intermittent feeding was applied whenever the reactors showed a severe decay in the methane yield. This strategy improved the mineralization of oleate and palmitate, which were the main accumulated Long-Chain Fatty Acids (LCFA), and also promoted the removal of resilient phenolic compounds, reaching remarkable removal efficiencies of 60% and 81% for two parallel reactors at the end of a feed-less period. A maximum biogas production of 1.4m(3)m(-3)d(-1) at an Organic Loading Rate of 4.8 kg COD m(-3)d(-1) was obtained. Patterns of individual LCFA oxidation during the OMW anaerobic digestion are presented and discussed for the first time. The supplementation of a nitrogen source boosted immediately the methane yield from 21 and 18 to 76 and 93% in both reactors. The typical problems of sludge flotation and washout during the anaerobic treatment of this oily wastewater were overcome by biomass retention, according to the Inverted Anaerobic Sludge Blanket (IASB) reactor concepts. This work demonstrates that it is possible to avoid a previous detoxification step by implementing adequate operational strategies to the anaerobic treatment of OMW.

Morphology and physiology of anaerobic granular sludge exposed to an organic solvent

The use of quantitative image analysis techniques, together with physiological information might be used to monitor and detect operational problems in advance to reactor performance failure. Industrial organic solvents, such as White Spirit, are potentially harmful to granular sludge. In preliminary batch assays, 33 mg L(-1) of solvent caused 50% relative biomass activity loss. In an expanded granular sludge blanket reactor fed with 40 mg L(-1) of solvent, during 222h, the reactor performance seemed to be unaffected, presenting COD removal efficiency consistently >95%. However, in the last days of exposure, the biogas production and the methane content were inhibited. Afterwards, already during recovery phase, the COD removal efficiency decreased to 33%, probably because the reactor was underloaded and the biomass became saturated in solvent only at this stage. In the first hours of exposure the specific acetoclastic and the specific hydrogenotrophic methanogenic activities decreased 29% and 21%, respectively. The % of aggregates projected area with equivalent diameter (D(eq))>1mm decreased from 81% to 53%. The mean D(eq) of the aggregates > or =0.2mm decreased, as well as the settling velocity, showing that the granules experienced fragmentation phenomenon caused by the solvent shock load. The ratio between total filaments length and total aggregates projected area (LfA) increased 2 days before effluent volatile suspended solids, suggesting that LfA could be an early-warning indicator of washout events.

Principal component analysis and quantitative image analysis to predict effects of toxics in anaerobic granular sludge

Principal component analysis (PCA) was applied to datasets gathering morphological, physiological and reactor performance information, from three toxic shock loads (SL1 - 1.6 mg(detergent)/L; SL2 - 3.1mg(detergent)/L; SL3 - 40 mg(solvent)/L) applied in an expanded granular sludge bed (EGSB) reactor. The PCA allowed the visualization of the main effects caused by the toxics, by clustering the samples according to its operational phase, exposure or recovery. The aim was to investigate the variables or group of variables that mostly contribute for the early detection of operational problems. The morphological parameters showed to be sensitive enough to detect the operational problems even before the COD removal efficiency decreased. As observed by the high loadings in the plane defined by the first and second principal components. PCA defined a new latent variable t[1], gathering the most relevant variability in dataset, that showed an immediate variation after the toxics were fed to the reactors. t[1] varied 262%, 254% and 80%, respectively, in SL1, SL2 and SL3. The high loadings/weights of the morphological parameters associated with this new variable express its influence in shock load monitoring and control, and consequently in operational problems recognition.

[Infantile hepatic hemangioendothelioma. A multifocal, bilobular and asymptomatic case with spontaneous regression]

Infantile hepatic hemangioendothelioma is a severe disease with a high mortality rate. Nevertheless these vascular lesions may experience spontaneous regression within 12 to 18 months. The decision of trying a specific treatment and the choice among the several therapeutic options remains controversial, particularly in those asymptomatic cases of multifocal, bilobular involvement. We describe a case of multifocal, bilobular and asymptomatic infantile hepatic hemangioendothelioma, untreated, and with spontaneous regression before 2 years of age.

Quantitative image analysis as a diagnostic tool for identifying structural changes during a revival process of anaerobic granular sludge

Due to unspecified operational problems, the specific acetoclastic activity (SAA) of the anaerobic granular sludge present in an industrial UASB reactor was considerably damaged (from 250 to less than 10mL CH(4)@STP/gVSS.d), significantly reducing the biogas production of that industrial unit. The hydrogenotrophic methanogenic activity exhibited a value of 600mL CH4@STP/gVSS.d, the settling velocity was 31.4+/-9.8m/h, the average equivalent diameter was 0.92+/-0.43mm, and about 70% of the VSS were structured in aggregates larger than 1mm. In order to study the recovery of the SAA, this sludge was collected and inoculated in a lab-scale expanded granular sludge blanket (EGSB) reactor. Ethanol was fed as the sole carbon source during a trial period of 106 days. Process monitoring included COD removal efficiency, methane production, and periodic determination of the specific methanogenic activity in the presence of acetate, propionate, butyrate, ethanol and H(2)/CO(2). Quantitative image analysis allowed for information to be obtained on granular fragmentation/erosion and filaments release. During the first operational period, biogas production was mainly due to the hydrogenotrophic activity. However, after 40 days, the SAA steadily increased achieving a maximum value of 183+/-13mL CH4@STP/gVSS.d. The onset of SAA recovery, granules breakdown and filaments release to the bulk occurred simultaneously. Further increase in SAA was accompanied by granular growth. In the last 25 days of operation, the size distribution was stable with more than 80% of projected area of aggregates corresponding to granules larger than 1mm (equivalent diameter). Confocal images from FISH hybridized sections of the granules showed that after SAA recovery, the granules developed an organized structure where an acidogenic/acetogenic external layer was apparent. Granular fragmentation and increase of filaments in the bulk, simultaneously with the increase in the acetoclastic activity are described for the first time and might represent a structural response of granular sludge to promote the optimal substrate uptake at minimal diffusion limitations.

Quantitative image analysis as a diagnostic tool for monitoring structural changes of anaerobic granular sludge during detergent shock loads

Two shock loads of a commercial detergent (I-150 mg chemical oxygen demand (COD)/L, fed for 56 h; II-300 mg COD/L fed for 222 h) were applied in a lab-scale Expanded Granular Sludge Blanket (EGSB) reactor, fed with 1,500 mg COD/L of ethanol. The impact of the surfactant was assessed in terms of granular sludge morphology, specific methanogenic activity (SMA) in the presence of individual substrates, and reactor performance. COD removal efficiency remained unaffected in the shock I, but 80 h after starting exposure to the shock II, the COD removal efficiency decreased drastically from 75 to 17%. In the first 8 h of operation of shock I, the SMA was stimulated and decreased afterwards, being recovered 5 days after the end of exposure time. Concerning to shock II, the SMA was immediately and persistently reduced during the exposure time, although, the inhibition of SMA in presence of H(2)/CO(2) showed a trend to increase after the exposure time. Acetoclastic bacteria were observed as the most sensitive to the toxic effects of surfactant whereas the hydrogenotrophic bacteria were less affected. The inhibitory effects were dependent on surfactant concentration and exposure time. The ratio filaments length per total aggregates area (LfA) was an early-warning indicator of biomass washout, since it increased 3 and 5 days before effluent volatile suspended solids (VSS) rise, respectively, in shocks I and II.

Knowledge-based fuzzy system for diagnosis and control of an integrated biological wastewater treatment process

A supervisory expert system based on fuzzy logic rules was developed for diagnosis and control of a laboratory- scale plant comprising anaerobic digestion and anoxic/aerobic modules for combined high rate biological N and C removal. The design and implementation of a computational environment in LabVIEW for data acquisition, plant operation and distributed equipment control is described. A step increase in ammonia concentration from 20 to 60 mg N/L was applied during a trial period of 73 h. Recycle flow rate from the aerobic to the anoxic module and bypass flow rate from the influent directly to the anoxic reactor were the output variables of the fuzzy system. They were automatically changed (from 34 to 111 L/day and from 8 to 13 L/day, respectively), when new plant conditions were recognised by the expert system. Denitrification efficiency higher than 85% was achieved 30 h after the disturbance and 15 h after the system response at an HRT as low as 1.5 h. Nitrification efficiency gradually increased from 12 to 50% at an HRT of 3 h. The system proved to react properly in order to set adequate operating conditions that led to timely and efficient recovery of N and C removal rates.

Herd-level seroprevalence of fasciolosis in cattle in north central Portugal

An epidemiological study of Fasciola hepatica in cattle was implemented in the north central region of Portugal. Both an enzyme-linked immunosorbent assay and an egg shedding quantification technique were used in the follow-up of seven herds. Two of these herds were negative and the other five were positive for F. hepatica. A herd cut-off of value of 0.425 optical density was calculated and herd sensitivity (HSe) and herd specificity (HSp) were defined. Three seroprevalence studies were also implemented in the region with stratification by county sub-regions for a period of 18 months. Overall mean herd prevalence in Vagos of 11, 23 and 48% was progressively found for the three studies, respectively.

[Color vision in school children: evaluation of a new test]

OBJECTIVE: To compare standard color vision test results (Ishihara test) with a new test developed by the authors ("crayon" test) for the detection of congenital dyschromatopsia. METHODS: Cross-sectional study of 712 children from three public schools and one private school in the city of Porto Alegre, state of Rio Grande do Sul. Children with learning disabilities, or systemic and ocular diseases were excluded from this random sample. Two color vision tests, Ishihara test (short version with 14 plates) and crayon test (developed by the authors) were sequentially applied. Each test was applied by different evaluators and analyzed by a third evaluator. RESULTS: The crayon test showed a specificity of 100% (99.3-100%) and sensitivity of 38.5% (15.1-67.7%) when compared to Ishihara test. The prevalence of congenital dyschromatopsia in this population sample was 2.6% for male children, and 0.9% for female children. CONCLUSIONS: The crayon test results showed greater specificity than Ishihara test in the studied group; however, sensitivity was not adequate for a screening test. It is necessary to improve the sensitivity so that congenital dyschromatopsia can be detected by the crayon test.

[Seizures in the neonatal period]

OBJECTIVE: To characterize and differentiate neonatal seizures from those that occur at different ages, based on a critical assessment of the available literature and also on the authorś clinical experience. SOURCES: Literature review, including up-to-date and classical studies that helped us to better understand clinical, neurophysiological and physiopathological aspects related to seizures in the newborn. SUMMARY OF THE FINDINGS: The authors present clinical and electroencephalographic characteristics of neonatal seizures, discuss their classification, treatment and prognosis. CONCLUSIONS: Neonatal seizures have a distinct clinical pattern, which justifies the necessity of an appropriate classification. The etiology is predominantly symptomatic and multifactorial; the treatment should follow a routine protocol, and the prognosis seems to be closely related to etiology.

The utility of Ki-ras mutation analysis in the cytologic diagnosis of pancreatobiliary neoplasma

PURPOSE

Mutations involved in neoplastic progression may be able to serve as markers for the presence of small numbers of neoplastic cells that would otherwise escape detection in diagnostic assays. Previous retrospective studies have suggested that the sensitivity of the cytologic diagnosis of pancreatic and biliary tract carcinomas is improved when analysis includes Ki-ras exon 1, which is commonly mutated in these neoplasms. We report our experience with the systematic prospective application of Ki-ras gene analysis to the evaluation of fine-needle aspirates and brushings from the pancreatobiliary tract.

MATERIALS AND METHODS

Between September 1996 and April 1999, 75 pancreatic fine-needle aspirates and common bile duct brushings submitted for routine cytologic diagnosis were also evaluated for mutations in Ki-ras exon 1 by polymerase chain reaction/single-strand conformation polymorphism analysis. After routine preparation of the specimens, residual material was used for molecular analysis. Results are compared with the morphologic diagnosis and available clinical information.

RESULTS

Single-strand conformation polymorphism mutation patterns in Ki-ras were detected in 22 of the 70 consecutive clinical specimens with adequate DNA and at least 6 months of available clinical follow-up. Sensitivity, specificity, and positive predictive value for the presence of concurrent or subsequent pancreatobiliary carcinoma were 33%, 97%, and 93%, respectively, for definitive cytologic diagnosis alone, and 53%, 97%, and 95% for positive Ki-ras single-strand conformation polymorphism mutation pattern alone. If definitive positive cytology or atypical/suspicious cytology with a positive Ki-ras single-strand conformation polymorphism mutation pattern is used, sensitivity is 55%, specificity is 97%, and positive predictive value is 96% for the presence of pancreatobiliary carcinoma.

DISCUSSION

Results support the routine use of Ki-ras mutational analysis to increase the sensitivity of the cytologic evaluation of pancreatobiliary fine-needle aspirates and common bile duct brushings with atypical or suspicious morphology without compromising specificity.

Magnetic resonance cholangiopancreatography: comparison between respiratory-triggered turbo spin echo and breath hold single-shot turbo spin echo sequences

The purpose of this study was to compare the relative conspicuity of the pancreaticobiliary tree on respiratory-triggered three-dimensional turbo spin echo (3D TSE RT) and breath hold single-shot turbo spin echo (SSTSE BH) acquisitions respectively in MRCP imaging. Both techniques were applied to 61 patients with clinically suspected pancreaticobiliary disease using a 1.0 T MR system. All images were reviewed blindly. Qualitative comparison was made by grading subjectively the conspicuity of extrahepatic, intrahepatic, and main pancreatic ducts. Quantitative comparison included calculations of signal-to-noise ratio of the common bile duct, main pancreatic duct, gallbladder, liver, and contrast-to-noise ratio, relative contrast between common bile duct, gallbladder, and liver. 3D TSE RT provided significantly higher signal-to-noise ratio of the common bile duct (mean value 163.19) and main pancreatic duct (mean value 95.37) compared to SSTSE BH (mean values 76.24 and 26.22, respectively). 3D TSE RT was inferior to SSTSE BH for the depiction of intrahepatic ducts and pancreatic duct (head portion). 3D TSE RT and SSTSE BH sequences provide complimentary information in the visualization of the biliary and pancreatic ducts. Further comparative clinical studies are needed to redefine the sensitivity, specificity, and accuracy of MRCP using both sequences.

[Associated and prognosis in apparent life threatening events (ALTE)]

OBJECTIVE: To verify the etiology and prognosis of ALTE in infancy and its possible relationship to Sudden Infant Death Syndrome (SIDS). METHODS: We studied a group of infants that presented ALTE episodes and were evaluated in our hospital. First we reviewed their clinical history and polysomnographies, then we sent a letter to the families with questions regarding the outcome. RESULTS: 56 patients were included. 92% had ALTE during their first 6 months and 83% in the first trimester. Symptomatic ALTE predominated (71%). The disease most frequently associated was gastroesophageal reflux, followed by neurological diseases. The follow up showed 51.5% of normal outcome, 4 children repeated ALTE, no cases of SIDS were registered. CONCLUSIONS: Our results showed that multifactorial etiologies can be associated to ALTE, and the outcome is generally related to the associated disease. We did not observe any relationship between ALTE and SIDS considering a predominantly symptomatic ALTE population.

Posttraining administration of substance P and its N-terminal fragment block the amnestic effects of diazepam

This study examined the effects of posttraining administration of substance P (SP) and of certain N- or C-terminal SP-fragments on retention performance of rats treated with diazepam (DZP). Twenty minutes before the training on an inhibitory avoidance task rats were given intraperitoneal injections of either DZP (2 mg/kg) or vehicle. Immediately after they were injected with SP (50 micrograms/kg), SPN 1-7 (167 micrograms/kg), SPC 6-11 (134 micrograms/kg), or vehicle. The posttrial administration of SP and SPN, but not SPC, facilitated avoidance behavior. Animals that received DZP before training and vehicle after the conditioning trial showed impaired retention. In contrast, in animals injected with SP and SPN after the training trial, DZP did not affect retention. These findings suggest that the amnestic effects of DZP can be blocked by the administration of SP and that the amino acid sequence responsible for this effect may be encoded by its N-terminal part.

Effects of immunotherapy on symptoms, PEFR, spirometry, and airway responsiveness in patients with allergic asthma to house-dust mites (D. pteronyssinus) on inhaled steroid therapy

The present study was designed to investigate the effects of immunotherapy (IT) with an extract of Dermatophagoides pteronyssinus (Alergo-Merck Depot) during a 27-month period in patients with allergic asthma to house-dust mites. We included 11 patients (mean age 18 years) treated with a combination of IT and inhaled beclomethasone dipropionate (BDP) in comparison to another 11 (mean age 22 years) treated with BDP alone. We evaluated symptom scores, salbutamol use, peak expiratory flow rates (PEFR), spirometry, and bronchial hyperresponsiveness (BHR) during 18 months of therapy with BDP and in the 9 months after BDP interruption. The two kinds of treatment were efficient and comparable in relation to symptom score, salbutamol use, morning PEFR, FVC, and FEV1, but patients treated with IT and BDP had a faster improvement of BHR and PEFR variability. The interruption of BDP after 18 months of therapy was linked to an impairment of all end points, which were more pronounced in patients previously treated only with BDP. These findings suggest that in selected asthmatic patients allergic to house-dust mites, the association of IT and BDP is more effective than therapy with this inhaled steroid alone due to a faster and more striking improvement during the first months of treatment and to a lower rate of relapse after the interruption of therapy with BDP.

CT identification of ascaris in the biliary tract

Ascariasis is one of the most common helminthic diseases worldwide. The presence of this worm in the biliary tree causes biliary colic, recurrent pyogenic cholangitis, pancreatitis, hepatic abscesses, and septicemia. The diagnosis of biliary ascariasis is usually made by ultrasound (US). We report the computerized-tomography (CT) aspects that allowed the identification of ascaris in the biliary tract in two patients.

Paraganglioma of the spermatic cord. Report of a case with immunohistochemical and ultrastructural studies

We describe a case of paraganglioma arising in the spermatic cord, which is an extremely rare location. Immunohistochemical studies characterized two types of cells: (1) polygonal cells expressing neuron-specific enolase, chromogranin A, and synaptophysin and (2) S100 protein-positive sustentacular cells. Electron microscopy revealed that within the cytoplasm of the polygonal cells, there were electron-dense granules whose morphological appearance was consistent with that of neurosecretory granules. Paraganglioma of the spermatic cord may originate from embryonic chromaffin cells that have followed the testis into the scrotum.

Modifications of the responses of barrel field neurons to vibrissal stimulation during theta in the awake and undrugged rat

In partially restrained but awake and undrugged rats, excitatory unit responses of the somatic cortex barrel field to vibrissal stimulation, were recorded in two conditions: during spontaneous episodes of theta and in the absence of this rhythm. Two main variables were considered: a signal-to-noise ratio and an index of the "afferent inhibition". Both measures were extracted from peristimulus time histograms. "Theta effects" were characterized by an increase in signal-to-noise ratio and afferent inhibition. They were most important in neurons located in infragranular layers of the cortex; they went in the same direction but only approached significance in supragranular neurons; neurons of the granular layer were not affected. Spontaneous unit activity and latencies were not modified in any group. These data were obtained during a preliminary step of a sensory-sensory conditioning procedure which in some cases modified the receptive field of the neurons. Theta effects were less marked in future "conditioned" than in future non-conditioned neurons but this was probably due to the fact that conditioned neurons had significantly higher signal-to-noise ratio and afferent inhibition. The origin of these "theta effects", hippocampal versus non-hippocampal, and their functional significance, relation to selective attention, are discussed.