Respiratory medicine curriculum in Portuguese family medicine training: A Delphi study

BACKGROUND

Respiratory diseases (RD) constitute a significant part of the workload of family physicians. There is no consensus on what family doctors should know in this area but established methods for achieving consensus may help to overcome this.

OBJECTIVES

The purpose of the study was to obtain a national consensus on the required knowledge and skills in respiratory medicine for family medicine trainees after vocational training.

METHODS

A Delphi study was conducted via e-mail with a diverse panel of experts. We developed a Learning Curriculum Framework (LCF) with 399 items adapted from the Royal Australasian College of Physicians ..÷ Respiratory Medicine Advanced Training Curriculum. The LCF was submitted to the experts in two rounds for consensus. Consensus was considered for items that had an agreement of 80% in the classifications above 4 on a scale of importance that ranged from 1 (not important) to 5 (very important).

RESULTS

Consensus was obtained for 159 items (38.8%). These included structure and function of the respiratory tract (0.6%), presenting problems (21.4%), diagnosis (7.5%), interventions and prevention (11.3%), COPD-emphysema (12.6%), tumours (3.1%), infections (10.7%), tuberculosis (5.7%), HIV (1.3%), thromboembolic disease (2.5%), pleural-pulmonary disease (3.1%), pregnancy (0.6%) and sleep disorders (3.8%). Items on iatrogenic diseases and respiratory research did not reach consensus.

CONCLUSIONS

Consensus on the respiratory medicine curriculum may contribute to further development of the vocational training curriculum in Portugal. This approach may help teachers in other countries in Europe to develop curricula for respiratory medicine and other areas of general practice.

Left ventricular myocardial and cavity velocity disturbances are stronger predictors of stress induced ischaemia in patients with significant coronary artery disease

Background and aim

Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for significant coronary artery disease (CAD). The aim of this study was to evaluate the accuracy of cardiac Doppler parameters in predecting CAD.

Methods

We prospectively studied 103 consecutive patients with suspected CAD based on typical symptoms, 59 proved to have CAD and 44 patients proved to have no-CAD (n=44). All patients underwent a complete stress Doppler echocardiographic examination, including tissue Doppler, long axis velocities and total isovolumic time (T-IVT) as a marker of cavity dyssynchrony, determined as [60 − (total ejection time (ET) + total filling time (FT))]. The wall motion score index (WMSI) was also calculated.

Results

CAD patients were older, had less females, less prevalent cardiac risk factors and higher CT calcium score compared to patients with no-CAD (p<0.05, for all). At peak dobutamine stress the compromised LV longitudinal excursion (MAPSE), systolic septal and lateral velocities (s'), TAPSE and diastolic indices were more pronounced in the CAD patients compared to those without CAD, but LV dimension did not differ between groups (p>0.05). The WMSI was higher and t-IVT more prolonged in patients with CAD (p<0.01, for both). Similarly, the changes were more pronounced in patients with significant CAD compared to insignificant CAD.

On multivariate model, delta mean s' OR 2.016 (1.610–3.490, p<0.001), delta E velocity OR 1.822 (1.179–2.360, p<0.001), delta t-IVT OR 1.406 (1.180–2.180, p<0.001), and delta FT OR 1.911 (1.401–2.710, p=0.001), were the most powerful independent predictors of the presence of CAD, particularly when significant (>50%). Delta mean s' <5.0 was 85% sensitive, 89% specific with AUC 0.92. Respective values for delta E velocity <6.0 cm/s were 82%, 90% and 0.91; for delta t-IVT >4.5, 78%, 77% and 0.81 and for delta FT ≥150ms, 76%, 78% and 0.84 in predicating significant CAD. WMSI≥0.7 was 75% sensitive, 77% specific with AUC of 0.81 in predicting significant CAD. The accuracy of DSE was higher in significant CAD compared to insignificant CAD (80% vs 74%; p=0.03).

Conclusions

Compromised LV longitudinal systolic function, lower delta E wave, prolonged t-IVT and increased WMSI were the most powerful independent predictors of the presence and significance of CAD. These finding strengthen the role of comprehensive DSE analysis in diagnosing ischaemic disturbances secondary to significant CAD.

Funding Acknowledgement

Type of funding sources: None.

Production of nanocellulose gels and films from invasive tree species

Wood/wastes from invasive tree species Acacia dealbata and Ailanthus altissima were used to produce high-value added nanocellulose. Firstly, bleached pulps were produced from the wood of these tree species after kraft cooking. Afterwards, the resultant pulps were pre-treated by TEMPO-mediated oxidation (Acacia dealbata) or enzymatic hydrolysis (Ailanthus altissima) followed by high-pressure homogenization. Hydrogels were obtained and characterized for their main physical and chemical properties, including rheology and evaluation of the surface properties of the freeze-dried materials by inverse gas chromatography. Results showed that micro/nanofibrils could be obtained from the wood of these invasive species. Rheometry studies showed that Acacia-TEMPO cellulose nanofibrils form strong gels with high yield stress point and viscosities (reaching ca. 100,000 Pa·s). Additionally, the surfaces of the obtained nanocelluloses showed a dispersive component of the surface energy near 40 mJ/m² and a prevalence of the Lewis acidic character over the basic one, as typical for cellulose-based materials. Finally, films with good mechanical and optical properties could be obtained from the cellulose hydrogels. Acacia-TEMPO film (produced by filtration/hot pressing) showed a tensile strength of 79 MPa, Young's modulus of 7.9 GPa, and a transparency of 88%. The water vapor barrier, however, was modest (permeability of 4.9 × 10^-6 g/(Pa·day·m)).

The impact of the cardiac rehabilitation program in patients with mid-range heart failure (40-50%) in improving cardio respiratory predictors

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Universitário Lisboa Central

Methods

We studied 30 patients (P) with ejection fraction (EF) 40-50%, in a number of 198 P that participated in cardiac rehabilitation program (CRP). Of these P, 24 (80%) male and 6 (20%) female, 20 P were diagnosed myocardial infarction with ST-segment elevation, 2 P myocardial infarction non ST and 8 P with myocardial hypertrophy non ischemic. Of these P 30% were diabetics, 56% hypertension, 70% dyslipidemia, 36% smokers previous to CRP and body mass index 26,3 medium.

All P were submitted to previous echocardiogram, cardiopulmonary exercise testing (CET) and a rehabilitation program minimum 4 sessions and maximum 52 sessions. At the end of the total sessions the echocardiogram and CET were repeated.

Results

Of the 30 P that participated in CRP only 20 completed the program, while the other 10 P dropped out because of social and economic problems. Of the P that completed the CRP, 70% got better on EF, 80% improved VE/VCO2 slope < 33 therefore are classified VC-II in ventilatory classification (VC), 5% VE/VCO2 slope > 40  VC-III classification, and 15% maintained the initial classification.  50% of the P increased at least one level metabolic equivalent of task (MET) from the first CET. Only 3 of the 20 patients came, once, to the hospital after the CRP with heart failure, and one died but did not fulfill the program.

Conclusion

Patients with mid-range heart failure submitted to a CRP can improve cardiorespiratory predictors, leading to a better quality of life. However, it is important to find solutions to minimize the causes that make patients to give up CRP.

The temporal stability of premorbid intelligence: A non-clinical 10-year follow-up study using the Irregular Word Reading Test (TeLPI)

INTRODUCTION

The Cognitive Reserve (CR) describes the brain's ability to actively cope with neurological damage, enabling the maintenance of premorbid cognitive functioning through compensatory processes. The most common way to estimate CR is through formal education, the intelligence quotient (IQ) and participation in cognitive stimulating activities. In the absence of IQ data, the Irregular Word Reading Test (TeLPI) allows you to estimate the premorbid intelligence.

OBJECTIVE

The comparison of the TeLPI results between two times of assessment (baseline and re-assessment) with an interval time (IT) of 9 years. To analyze of the stability of their results as a valid dimension for the CR estimation.

RESULTS

The TeLPI presented temporal stability of its results between the two evaluation times (IT = 9.07 ± 1.02). The sample, composed by 63 cognitively healthy participants, showed no differences for the estimated Full Scale IQ (t(62) = 0.49, p = .63), for the Estimated Verbal IQ (t(62) = 0.71, p = .48) and for the estimated Performance IQ (t(62) = 0.64, p = .52). Likewise, no differences were found in the number of TeLPI errors at the two assessment times (t(62) = -0.61, p = .54).

CONCLUSIONS

Considering that CR is characterized as being relatively stable, the TeLPI should be included in its assessment, as an indicator with proved stability over a long period of time, on the physiological aging spectrum.

Supplementation of Curcuma longa hydrolate improves immunomodulatory response in Nile tilapia reared in a recirculation aquaculture system

ABSTRACT The objective of this study was to evaluate the effects of dietary supplementation with different doses of Curcuma longa hydrolate on the hematological, immunological and zootechnical parameters of Nile tilapia cultivated in a recirculation system (RAS). Nile tilapia (Oreochromis niloticus) were used, distributed in 16 polyethylene boxes, divided into four treatments: 0.0%; 2.5%; 7.5% and 10.0% of Curcuma longa hydrolate, in quadruplicate. After 45 days of treatment, four fish per experimental unit were anesthetized to remove blood aliquot for hematological and immunological analyzes and dissect the liver to evaluate the hepatosomatic index and final biometry. In the haematological analysis, the fish fed with 2.5% had a higher number of leukocytes, monocytes and lymphocytes than control, while the doses of 7.5% and 10.0% did not differ. Antimicrobial activity showed a significant decrease as the dose of C. longa hydrolate increased. The other hematological, immunological, hepatosomatic index and zootechnical data did not differ between treatments. Thus, supplementation of the hydrolate of Curcuma longa at a dosage of 2.5%, improved and maintained blood-immune homeostasis parameters in these animals, being suggested for further studies.

Composites of nanofibrillated cellulose with clay minerals: A review

Biopolymers-based composites are, in general, environmentally friendly materials, which can be obtained from renewable sources. Some of them can also present promising properties to be used in food packaging and electronic devices, being thus logical substitutes to petroleum-based polymers, specifically plastics. Cellulose nanofibrils (CNF) obtained by chemical/enzymatic pre-treatments followed by a mechanical treatment appear as a new suitable biomaterial. However, CNF are still quite expensive materials, due to the required chemicals/equipment/energy involved, and additionally, they present some limitations such as high hydrophilicity/high water vapour permeability. The combination of CNF with clay minerals, such as montmorillonite or kaolinite, as widely available geo-resources, represents an excellent way to reduce the amount of CNF used, enabling the production of valuable materials and reducing costs; and, at the same time it is possible to improve the characteristics of the formed materials, such as mechanical, gas barrier and fire retardancy properties, if appropriate conditions of preparation are used. Nevertheless, to obtain hybrid CNF/clay composites with superior properties it is necessary to ensure a good dispersion of the inorganic material in the CNF suspension and a good compatibility among the inorganic and organic components. To fulfil this goal, several strategies can be considered, including physical treatments of the suspensions, CNF and clay surface chemical modifications, and the use of a coupling agent. In this review article, the state-of-the-art on a new emerging generation of composites (films, foams or coatings) based on nanofibrillated cellulose and nanoclay, with focus on strategies for their preparation and most relevant achievements is critically reviewed, bearing in mind their potential application as substitutes for common plastics. A third component has been eventually added to these organic-inorganic hybrids, e.g., chitosan, carboxymethylcellulose, borate or epoxy resin, to enhance specific characteristics of the material. Some general background on the production of different types of CNF and their main properties is previously provided.

The effect of a novel Bayesian penalised likelihood PET reconstruction algorithm on the assessment of malignancy risk in solitary pulmonary nodules according to the British Thoracic Society guidelines

PURPOSE

British Thoracic Society (BTS) guidelines advocate using FDG PET-CT with the Herder model to estimate malignancy risk in solitary pulmonary nodules (SPNs). Qualitative and semi-quantitative assessment of SPN uptake is based upon analysis of Ordered Subset Expected Maximisation (OSEM) PET images. Our aim was to assess the effect of a Bayesian Penalised Likelihood (BPL) PET reconstruction on the assessment of SPN FDG uptake and estimation of malignancy risk (Herder score).

METHODS

Subjects with SPNs who underwent FDG PET-CT between 2014-2017, with histological confirmation of malignancy or histological/imaging follow-up confirmation of benignity were included. Two blinded readers independently classified SPN uptake on both OSEM and BPL (BTS score; 1 = none; 2 = ≤ mediastinal blood pool (MBP); 3 = >MBP but ≤ 2x liver; 4 = >2x liver), with resultant calculation of the Herder score (%) for both reconstructions.

RESULTS

97 subjects with 75 (77%) malignant SPNs were included. BPL increased the BTS score in 25 (26%) SPNs; 9 SPNs (7 malignant) increased from BTS score 2 to 3, 16 (13 malignant) from BTS score 3 to 4, with a mean Herder score increase of 18 ± 22%. The mean Herder score for all SPNs with BPL was higher than OSEM (73 ± 29 vs 68 ± 32%, p = 0.001). There was no difference in Herder model diagnostic performance between BPL and OSEM, with similar areas under the curve (0.84 vs 0.83, p = 0.39).

CONCLUSION

BPL increases the Herder score in 26% of SPNs compared to OSEM but does not alter the diagnostic performance of the Herder model.

Rapid in-house method of CSF analysis utilising sedimentation direct from the spinal needle

OBJECTIVES

To establish the utility of a novel in-house method of CSF analysis using sedimentation cytology direct from the spinal needle for the detection of laboratory-defined pleocytosis.

MATERIALS AND METHODS

In dogs and cats undergoing routine CSF analysis for investigation of neurological signs, an additional preparation was made at the patient's side by inverting the spinal needle on a slide and sedimenting for at least 1 hour. Nucleated cellularity and differential counts were assessed and compared with "gold-standard" analysis. Variability of cell counts between observers and within slides using the new method was evaluated to optimise the procedure.

RESULTS

Using a ×50 objective, at least 10 fields and an average of more than five cells per field were considered appropriate guidelines to achieve correct classification of samples (normal or pleocytosis). The new method had high sensitivity (89%) and specificity (100%) for the detection of laboratory-defined pleocytosis. Agreement on the type of pleocytosis was good.

CLINICAL SIGNIFICANCE

Clinically useful information can be obtained from CSF samples in a patient-side setting without additional equipment. This technique may be of benefit if little fluid is available or if logistical constraints limit the availability of rapid specialist results.

Sugarcane bagasse delignification with potassium hydroxide for enhanced enzymatic hydrolysis

Alkali pretreatment of sugarcane bagasse biomass was shown to be effective for producing sugar-rich hydrolysates for biotechnological applications.

Jerusalem artichoke as low-cost fructose-rich feedstock for fossil fuels desulphurization by a fructophilic bacterium

AIMS

Through biodesulphurization (BDS) is possible to remove the sulphur present in fossil fuels to carry out the very strict legislation. However, this biological process is limited by the cost of the culture medium, and thus, it is important to explore cheaper alternative carbon sources, such as Jerusalem artichoke (JA). These carbon sources usually contain sulphates which interfere with the BDS process. The goal of this work was to remove the sulphates from Jerusalem artichoke juice (JAJ) through BaCl2 precipitation viewing the optimization of dibenzothiophene (DBT) desulphurization by Gordonia alkanivorans strain 1B.

METHODS AND RESULTS

Using a statistical design (Doehlert distribution), the effect of BaCl2 concentration (0.125-0.625%) and pH (5-9) was studied on sulphate concentration in hydrolysed JAJ. A validated surface response derived from data indicated that zero sulphates can be achieved with 0.5-0.55% (w/v) BaCl2 at pH 7; however, parallel BDS assays showed that the highest desulphurization was obtained with the juice treated with 0.5% (w/v) BaCl2 at pH 8.73. Further assays demonstrated that enhanced DBT desulphurization was achieved using hydrolysed JAJ treated in these optimal conditions. A total conversion of 400 μmol l(-1) DBT into 2-hydroxybiphenyl (2-HBP) in <90 h was observed, attaining a 2-HBP maximum production rate of 28.2 μmol l(-1) h(-1) and a specific production rate of 5.06 μmol(-1) g(-1) (DCW) h(-1) .

CONCLUSIONS

These results highlight the efficacy of the treatment applied to JAJ in making this agromaterial a promising low-cost renewable feedstock for improved BDS by the fructophilic strain 1B.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study is a fundamental step viewing BDS application at the industrial level as it accounts a cost-effective production of the biocatalysts, one of the main drawbacks for BDS scale-up.

Biodesulphurization of fossil fuels: energy, emissions and cost analysis

BDS and HDS as a combined technology towards ultra low sulphur fuels.

Polarization transfer solid-state NMR: a new method for studying cellulose dissolution

Detailed molecular-level information on dissolved and solid cellulose in aqueous dissolution media with ionic liquids by polarization transfer solid-state NMR.

Acute renal failure potentiates methylmalonate-induced oxidative stress in brain and kidney of rats

Tissue methylmalonic acid (MMA) accumulation is the biochemical hallmark of methylmalonic acidemia. The disease is clinically characterized by progressive neurological deterioration and kidney failure, whose pathophysiology is still unclear. In the present work we investigated the effects of acute MMA administration on various parameters of oxidative stress in cerebral cortex and kidney of young rats, as well as the influence of acute renal failure on MMA-elicited effects on these parameters. Acute renal failure was induced by gentamicin, an aminoglycoside antibiotic whose utilization over prolonged periods causes nephrotoxicity. The administration of gentamicin alone increased carbonyl content and inhibited superoxide dismutase (SOD) activity in cerebral cortex, as well as increased thiobarbituric acid-reactive substances (TBA-RS) and sulfhydryl levels and diminished glutathione peroxidase activity in kidney. On the other hand, MMA administration increased TBA-RS levels in cerebral cortex and decreased SOD activity in kidney. Furthermore, the simultaneous administration of MMA and gentamicin to the rats provoked an augment in TBA-RS levels and superoxide generation in cerebral cortex and in TBA-RS, carbonyl and sulfhydryl levels in kidney, while diminished SOD activity in both studied tissues. Finally, nitrate/nitrite content, reduced glutathione levels, 2',7'-dihydrodichlorofluorescein oxidation and catalase activity were not affected by this animal treatment in either tissue. In conclusion, our present data are in line with the hypothesis that MMA acts as a toxin in brain and kidney of rats and suggest that renal injury potentiates the toxicity of MMA on oxidative stress parameters in brain and peripheral tissues.

Chemical functionalization of nanodiamond by amino groups: an X-ray photoelectron spectroscopy study

The development of chemical functionalization techniques for diamond nanocrystallites opens up ways with a view to altering their solubility in different solvents, improve interfacial adhesion of nanodiamonds with a composite matrix in new materials, and provide new possibilities for the modification of the electronic properties of nanodiamond crystallites. In this work, we present results on the chemical functionalization of nanodiamonds by amino groups using ammonia as a nitrogenation agent. Nanodiamond material used was formed by the detonation technique with average crystallite sizes of 4-5 nm. The final materials and intermediates products were characterized by Fourier transform infrared spectroscopy (FTIR) and X-ray photoelectron spectroscopy (XPS). Chemical functionalization of nanodiamonds by amino groups could enable the preparation of new nylon nano-composite materials. Presence of surface amino groups could alter pH of nanodiamond colloids towards basic values and improve colloidal stability of nanodiamond suspensions at pH close to 7. This could enable syntheses of new drug delivery systems based on nanodiamonds.

Toxicity evaluation of 2-hydroxybiphenyl and other compounds involved in studies of fossil fuels biodesulphurisation

The acute toxicity of some compounds used in fossil fuels biodesulphurisation studies, on the respiration activity, was evaluated by Gordonia alkanivorans and Rhodococcus erythropolis. Moreover, the effect of 2-hydroxybiphenyl on cell growth of both strains was also determined, using batch (chronic bioassays) and continuous cultures. The IC₅₀ values obtained showed the toxicity of all the compounds tested to both strains, specially the high toxicity of 2-HBP. These results were confirmed by the chronic toxicity data. The toxicity data sets highlight for a higher sensitivity to the toxicant by the strain presenting a lower growth rate, due to a lower cells number in contact with the toxicant. Thus, microorganisms exhibiting faster generation times could be more resistant to 2-HBP accumulation during a BDS process. The physiological response of both strains to 2-HBP pulse in a steady-state continuous culture shows their potential to be used in a future fossil fuel BDS process.

Polymorphisms in the ABCB1 gene in phenobarbital responsive and resistant idiopathic epileptic Border Collies

BACKGROUND

Variation in the ABCB1 gene is believed to play a role in drug resistance in epilepsy.

HYPOTHESIS/OBJECTIVES

Variation in the ABCB1 gene encoding the permeability-glycoprotein could have an influence on phenobarbital (PB) resistance, which occurs with high frequency in idiopathic epileptic Border Collies (BCs).

ANIMALS

Two hundred and thirty-six client-owned BCs from Switzerland and Germany including 25 with idiopathic epilepsy, of which 13 were resistant to PB treatment.

METHODS

Prospective and retrospective case-control study. Data were collected retrospectively regarding disease status, antiepileptic drug (AED) therapy, and drug responsiveness. The frequency of a known mutation in the ABCB1 gene (4 base-pair deletion in the ABCB1 gene [c.296_299del]) was determined in all BCs. Additionally, the ABCB1 coding exons and flanking sequences were completely sequenced to search for additional variation in 41 BCs. Association analyses were performed in 2 case-control studies: idiopathic epileptic and control BCs and PB-responsive and resistant idiopathic epileptic BCs.

RESULTS

One of 236 BCs (0.4%) was heterozygous for the mutation in the ABCB1 gene (c.296_299del). A total of 23 variations were identified in the ABCB1 gene: 4 in exons and 19 in introns. The G-allele of the c.-6-180T > G variation in intron 1 was significantly more frequent in epileptic BCs resistant to PB treatment than in epileptic BCs responsive to PB treatment (P(raw) = .0025).

CONCLUSIONS AND CLINICAL IMPORTANCE

A variation in intron 1 of the ABCB1 gene is associated with drug responsiveness in BCs. This might indicate that regulatory mutations affecting the expression level of ABCB1 could exist, which may influence the reaction of a dog to AEDs.

Preoperative pulmonary assessment of children for liver transplantation

Pulmonary assessment should be part of the preoperative investigation of pediatric patients with chronic liver disease undergoing liver transplantation, as it allows the identification of pulmonary alterations that influence candidacy for transplantation and survival. To describe pulmonary changes found in pediatric patients who were candidates for liver transplantation. Retrospective study of 17 pediatric liver transplant candidates undergoing preoperative pulmonary evaluation assessing pulmonary clinical data, arterial blood gas analysis, CXR, respiratory function test by spirometry, pulmonary scintigraphy, and CEE. Ten patients presented normal chest roentgenograms. The most common radiographic change was interstitial infiltrate in the lung bases. Of the five patients with PaO(2) <70 mmHg, four had cyanosis and dyspnea and two were diagnosed with HPS with intrapulmonary shunt evidenced by contrast echocardiogram. Two patients presented with intrapulmonary shunt but without hypoxemia. Spirometry was normal in six patients, restrictive disturbance was evidenced in one patient, obstructive in three, and combined in two. The most common scintigraphic change was heterogeneous pulmonary perfusion. Pulmonary assessment should be performed routinely in pediatric patients prior to liver transplantation, even in asymptomatic patients. Pulmonary assessment may indicate changes such as HPS that can increase postoperative morbidity/mortality.