Does the intensity of dissociation predict antidepressant effects 24 hours after infusion of racemic ketamine and esketamine in treatment-resistant depression? A secondary analysis from a randomized controlled trial

BACKGROUND

Ketamine and esketamine have both shown significant antidepressant effects in treatment-resistant depression (TRD), and conflicting evidence suggests that induced dissociation by these drugs can be a clinical predictor of esketamine/ketamine's efficacy.

METHODS

This study is a secondary analysis from a bi-center, randomized, controlled trial. Participants were randomly assigned 1:1 to receive an IV infusion of esketamine (.25 mg/kg) or racemic ketamine (.50 mg/kg) over 40 minutes. Dissociative symptoms were assessed using the Clinician-Administered Dissociative State Scale (CADSS) 40 minutes following the beginning of the infusion. The variation in depression scores was measured with the Montgomery-Asberg Depression Rating Scale (MADRS), which was administered before the intervention as a baseline measure and 24 hrs, 72 hrs, and 7 days following infusion.

RESULTS

Sixty-one patients were included in the analysis. Examining CADSS scores of 15 or below, for every 1-point increment in the CADSS score, there was a mean change of -0.5 (SD = 0.25; p-value 0.04) of predicted MADRS score from baseline to 24 hrs. The results for 72 hrs and 7 days following infusion were not significant. Limitations: This study was not designed to assess the relationship between ketamine or esketamine-induced dissociation and antidepressant effects as the main outcome, therefore confounding variables for this relationship were not controlled.

CONCLUSION

We suggest a positive relationship between dissociation intensity, measured by CADSS, and antidepressant effect 24 hours after ketamine and esketamine infusion for a CADSS score of up to 15 points.

Arketamine for bipolar depression: Open-label, dose-escalation, pilot study

There are significantly fewer options for the treatment of bipolar depression than major depressive disorder, with an urgent need for alternative therapies. In this pilot study, we treated six subjects with bipolar disorder types I and II (according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria) who had been in a current depressive episode for at least four weeks. Four subjects were female (66.66%), and the mean age was 45.33 (±12.32). Subjects received adjunct treatment with two arketamine intravenous infusions one week apart-0.5 mg/kg first and then 1 mg/kg. The mean baseline Montgomery-Åsberg Depression Rating Scale (MADRS) total score was 36.66, which decreased to 27.83 24h after the first infusion of 0.5 mg/kg of arketamine (p = 0.036). In respect of the 1 mg/kg dose, the mean MADRS total score before the second infusion was 32.0, which dropped to 17.66 after 24h (p < 0.001). Arketamine appears to have rapid-acting antidepressant properties, consistent with previous animal studies on major depression. All individuals tolerated both doses, exhibiting nearly absent dissociation, and no manic symptoms. To the best of our knowledge, this pilot trial is the first to test the feasibility and safety of the (R)-enantiomer of ketamine (arketamine) for bipolar depression.

External and internal load during the effort tests in different ages in young futsal players: association between leg power, shot speed and fatigue levels

Futsal is a sports game that features high intensity movements with change of speed or direction, present in several actions during the game. With this study is intended to analyse, compare and evaluate the predictive factor of leg power on shooting speed and fatigue levels in young futsal athletes in order to establish effort patterns in these ages, to prescribe training sessions adequately in terms of external/internal load. The study had 32 participants, male, aged between 12 and 17 years (Mean = 14.56}1.66). Participants were evaluated in relation to their lower limb power through the Chronojump system, the speed was measured through a radar placed on the goal line, and in relation to their fatigue levels through the Running Anaerobic Sprint Test (RAST). To identify the differences between groups, the tests of Kruskal Wallis and Mann Whitney were used, and also a simple linear regression tests for predictive values between variables. In relation to the shots speed, higher values were found in the older groups (P≤0.001), which is directly and significantly related to the higher values of lower limb power, also verified in the older athletes (P≤0.001). In relation to the fatigue levels, it increases as the age of the athletes is higher, verifying that the power of the lower limbs is a predictor variable of the fatigue index (P≤0.001). The analysis conducted indicate that there are significant differences in the association between shooting speed, lower limb power and fatigue indices according to the players levels studied.

Clinical predictors of depressive symptom remission and response after racemic ketamine and esketamine infusion in treatment-resistant depression

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disability worldwide and most people do not achieve symptom remission. Treatment-resistant depression (TRD) is characterized by the failure of at least one adequate trial of a major class of antidepressant, with adequate time and dosage. We aimed to identify clinical predictors of depressive symptom remission and response 24 h and 7 days after racemic ketamine and esketamine infusions.

METHODS

A randomized, double-blind, active-controlled, non-inferiority trial using ketamine and esketamine in TRD. Individuals diagnosed with MDD according to Diagnostic and Statistical Manual of Mental Disorders version IV and fulfilling TRD criteria were recruited from March 2017 to June 2018. Participants received a single subanesthetic dose of ketamine (0.5 mg/kg) or esketamine (0.25 mg/kg) for 40 min. Depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) and symptom remission was defined as a MADRS score ≤7 and response defined as ≥50% reduction in depressive symptom severity, 24 h and 7 days after the infusion. Clinical variables were selected based on previous clinical trials. Stepwise backward logistic regression was used, considering a confidence level of 95%.

RESULTS

61 subjects were included: 39 (63.9%) were females with a mean age of 47.2 ± 14.9. Higher number of therapeutic failures (Odds Ratio (OR) = 0.677; 95% confidence interval (CI): 0.47-0.97) and higher severity of illness (OR = 0.912; 95% CI: 0.83-0.99) were associated with fewer remissions of depressive symptoms 7 days after intervention, and with fewer response in 24 h (OR = 0.583; 95% CI: 0,40; 0,84 and OR = 0.909; 95% CI: 0,83; 0,99, respectively).

CONCLUSION

Number of treatment failures and severity of illness were predictors of fewer remissions and responses of depressive symptoms in this TRD population. Study of predictors of remission may contribute to better selection patients that may benefit from receiving ketamine.

Suicide attempt, impulsivity, and exposure to trauma in college students

OBJECTIVES

Past suicide attempt (SA) is one of the most important risk factors for suicide death. An ideation-to-action framework posits that impulsivity, potentially traumatic events, and mental disorders also play a role in increasing suicide risk. This study aimed to assess the association between trait impulsivity, lifetime exposure to trauma, and post-traumatic stress disorder (PTSD) with SA in a sample of Brazilian college students.

METHODS

A total of 2,137 participants filled self-reported questionnaires consisting of a sociodemographic and clinical questionnaire, Trauma History Questionnaire, Post-Traumatic Stress Disorder Checklist - Civilian version, and Barratt Impulsiveness Scale.

RESULTS

Our findings suggest that trait impulsivity may be interpreted as exerting a distal effect on SA, even in the presence of other variables - such as trauma history, psychological neglect, and PTSD - which also increase the odds of SA. High and medium levels of impulsivity, history of trauma, and PTSD increased the likelihood of SA.

CONCLUSIONS

Intervention strategies to prevent SA may target trait impulsivity and exposure to traumatic experiences.

Neuropsychological effects of direct-acting antiviral treatment for Hepatitis C virus subjects: A systematic review

Direct-acting antivirals (DAAs) have been approved in recent years to treat patients infected by the Hepatitis C virus (HCV). The DAAs treatment is well tolerated and increases sustained virological responses, but there is no consensus about the neuropsychological functioning related to the treatment. This systematic review aims to provide an overview of the recent findings exploring the cognitive effects of DAAs treatment in patients with HCV. After a systematic search on PubMed, Embase, Scopus and LILACS, studies that assessed neuropsychological data related to DAAs treatment were included. We found nine articles, considering the inclusion and exclusion criteria. Three other manuscripts were included after searching for the references listed in the previously mentioned articles. We observed methodological heterogeneity in terms of neuropsychological tests used, cognitive domain explored and the sample characteristic presented between the studies. Studies presented data from HCV subjects monoinfected with or without cirrhosis, advanced liver disease and post-transplant patients; and HCV subjects coinfected with human immunodeficiency virus (HIV). Most results from the 12 studies that explored the effect of DAAs treatment in HCV subjects' neurocognitive functioning demonstrated cognitive improvement following treatment. In general, HCV and HCV/HIV subjects improved processing speed, verbal fluency and verbal/visual episodic memory. The DAAs treatment is effective for neurocognitive functioning in HCV monoinfected and coinfected subjects, with or without advanced liver disease, since neuropsychological scores increased after treatment. Further studies, however, are needed to confirm these findings.

Hydrostatic pressure mimicking diurnal spinal movements maintains anabolic turnover in bovine nucleus pulposus cells in vitro

Treatment strategies for progressive intervertebral-disc degeneration often alleviate pain and other symptoms. With the goal of developing strategies to promote the regeneration of the nucleus pulposus (NP), the present study tried to identify the biological effects of hydrostatic (HP) and osmotic pressures on NP cells. The study hypothesis was that a repetitive regimen of cyclic HP followed by constant HP in high-osmolality medium would increase anabolic molecules in NP cells. Bovine NP cells/clusters were enclosed within semi-permeable membrane pouches and incubated under a regimen of cyclic HP for 2 d followed by constant HP for 1 d, repeated 6 times over 18 d. NP cells showed a significantly increased expression of anabolic genes over time: aggrecan, chondroitin sulfate N-acetylgalactosaminyltransferase 1, hyaluronan synthase 2, collagen type 2 (p < 0.05). In addition, the expression of catabolic or degenerative genes (matrix metalloproteinase 13, collagen type 1) and cellular characteristic genes (proliferating cell nucleic antigen, E-cadherin) was suppressed. The amount of sulfated glycosaminoglycan increased significantly at day 18 compared to day 3 (p < 0.01). Immunostaining revealed deposition of extracellular-matrix molecules and localization of other specific molecules corresponding to their genetic expression. An improved understanding of how cells respond to physicochemical stresses will help to better treat the degenerating disc using either cell- or gene-based therapies as well as other potential matrix-enhancing therapies. Efforts to apply these tissue-engineering and regenerative-medicine strategies will need to consider these important physicochemical stresses that may have a major impact on the survivability of such treatments.

Neurocognitive aspects of ketamine and esketamine on subjects with treatment-resistant depression: A comparative, randomized and double-blind study

The objective of this study is to evaluate cognition in patients using either ketamine or esketamine to treat TRD. We also evaluate if both ketamine and esketamine as one group influence cognition in patients with TRD. Fifty-four patients with TRD were infused with either ketamine or esketamine and were assessed at three time points: baseline, 24 h, and 7 days after infusion. We applied neuropsychological tests to evaluate executive functions, processing speed, short term memory, and auditory-verbal episodic memory. There is no cognitive difference between ketamine and esketamine, with the exception of one variable. When considered as one group, ketamine and esketamine do not impair cognition; on the contrary, they improve some neuropsychological functions such as visuospatial short-term memory, executive functions, processing speed, and several measures related to episodic verbal memory. Ketamine and esketamine do not present differing cognitive effects when used in antidepressant doses to treat TRD. Furthermore, they rapidly improve many cognitive aspects of patients with TRD at 24 h after the infusion and maintain these effects for at least 7 days.

Traumatic brain injury in forensic psychiatry

Introduction

Assessment of neuropsychiatric sequelae of traumatic brain injury (TBI) brings about challenges in the forensic setting, comprising analysis of neurobiological variables, preinjury variables (personality/psychiatric disturbances), postinjury psychosocial, allowing the expert witness to provide clear and appropriate explanations, so the court can decide with justice, particularly in civil law cases.

Objectives

Discuss the main clinical and neuroimagiologic aspects to consider in civil litigation of TBI cases.

Methods

Comprehensive literature review.

Results

Although accurate predictions are difficult, some generalizations can be made. Recovery from hypoxic and diffuse axonal injury (DAI) takes longer and is less complete than focal contusions. Posttraumatic amnesia is the main predictor of long-term cognitive outcome. In moderate/severe TBI (m/sTBI) occurs chronic lesion expansion (axonal degeneration) and brain atrophy. DAI topography determinates the cognitive disfunction pattern yet underestimated in conventional neuroimaging. Diffusion-Tension-Imaging (DTI) may be valuable to outcome predictions in m/sTBI: structural disconnection within the Default Mode and the Salience Networks are linked to attention and executive impairments; hippocampus and fornix damage correlates with memory/learning impairments. Conversely, DTI findings can be misleading in mild TBI (mTBI), and case-by-case analysis seldomly prove its scientific validity.

Conclusions

To elaborate formulations within reasonable medical certainty, outcome predictions should not be made until at least six months following the TBI, considering that most mTBI symptoms resolve in few months, and up to 1-½ years, when m/sTBI neuropathologic changes stabilize. The neurobiological underpinnings are fundamental for causality formulations, however atypical outcomes in mTBI are frequently predicated upon non–brain-injury psychiatric conditions and psychosocial factors.

Disclosure

No significant relationships.

Small for gestational age very preterm infants present a higher risk of developing bronchopulmonary dysplasia

INTRODUCTION

Several studies assessed the influence of a low birth weight on bronchopulmonary dysplasia (BPD), but not all could find a significant association. Our aim was to assess the association between low birth weight and BPD in preterm infants, prospectively recruited at 11 level III Portuguese neonatal centers.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 after a surveilled pregnancy, were analyzed. Neonates were considered small for gestational age (SGA) when their birthweight was below the 10th centile of Fenton's growth chats and BPD was defined as the dependency for oxygen therapy until 36 weeks of corrected age. Statistical analysis was performed using IBM SPSS® statistics 23 and a p-value <0.05 was considered statistically significant.

RESULTS

Out of 614, a total of 494 preterm infants delivered from 410 women were enrolled in the study; 40 (8.0%) infants with SGA criteria. SGA were more often associated with a single pregnancy, had greater use of antenatal corticosteroids, increased prevalence of gestational hypertensive disorders, C-section, rupture of membranes below 18 hours, rate of intubation in the delivery room, use of surfactant treatment, oxygen therapy, mechanical ventilation need, BPD, cystic periventricular leukomalacia, nosocomial sepsis and pneumonia; had lower prevalence of chorioamnionitis, and lower Apgar scores. The multivariate analysis by logistic regression, adjusted for BPD risk factors revealed a significant association between SGA and BPD: OR = 5.2 [CI: 1.46-18.58]; p = 0.01.

CONCLUSION

The results of this study increase the scientific evidence that SGA is an independent risk factor for BPD.

Efficacy and safety of adjunctive therapy using esketamine or racemic ketamine for adult treatment-resistant depression: A randomized, double-blind, non-inferiority study

BACKGROUND

Ketamine and its enantiomers have recently been highlighted as one of the most effective therapeutic options in refractory depression. However, racemic ketamine and esketamine have not been directly compared. The aim of this study is to assess the efficacy and safety of esketamine compared to ketamine in patients with treatment-resistant depression (TRD).

METHODS

This is a randomized, double-blind, active-controlled, bicentre, non-inferiority clinical trial, with two parallel groups. Participants were randomly assigned to a 40-min single intravenous infusion of ketamine 0.5 mg/kg or esketamine 0.25 mg/kg. The primary outcome was the difference in remission rates for depression 24 h following intervention using the Montgomery-Åsberg Depression Rating Scale (MADRS), with a non-inferiority margin of 20%.

RESULTS

63 subjects were included and randomly assigned (29 to receive ketamine and 34 to receive esketamine). At 24 h, 24.1% of participants in the ketamine group and 29.4% of participants in the esketamine group showed remission, with a difference of 5.3% (95% CILB -13.6%), confirming non-inferiority. MADRS scores improved from 33 (SD 9.3) to 16.2 (SD 10.7) in the ketamine group and from 33 (SD 5.3) to 17.5 (SD 12.2) in the esketamine one, with a difference of -5.27% (95% CILB, -13.6). Both groups presented similar mild side effects.

CONCLUSIONS

Esketamine was non-inferior to ketamine for TRD 24 h following infusion. Both treatments were effective, safe, and well tolerated.

TRIAL REGISTRATION

Registered in Japan Primary Registries Network: UMIN000032355.

IL-1α promotes liver inflammation and necrosis during blood-stage Plasmodium chabaudi malaria

Malaria causes hepatic inflammation and damage, which contribute to disease severity. The pro-inflammatory cytokine interleukin (IL)-1α is released by non-hematopoietic or hematopoietic cells during liver injury. This study established the role of IL-1α in the liver pathology caused by blood-stage P. chabaudi malaria. During acute infection, hepatic inflammation and necrosis were accompanied by NLRP3 inflammasome-independent IL-1α production. Systemically, IL-1α deficiency attenuated weight loss and hypothermia but had minor effects on parasitemia control. In the liver, the absence of IL-1α reduced the number of TUNEL⁺ cells and necrotic lesions. This finding was associated with a lower inflammatory response, including TNF-α production. The main source of IL-1α in the liver of infected mice was inflammatory cells, particularly neutrophils. The implication of IL-1α in liver inflammation and necrosis caused by P. chabaudi infection, as well as in weight loss and hypothermia, opens up new perspectives for improving malaria outcomes by inhibiting IL-1 signaling.

Comparative study of esketamine and racemic ketamine in treatment-resistant depression: Protocol for a non-inferiority clinical trial

INTRODUCTION

The use of ketamine as an option in the treatment of depressive disorder is growing rapidly, supported by numerous clinical trials attesting its efficacy and safety. Esketamine, the S (+) enantiomer of ketamine, is the most widely used form in the anesthetic environment in some countries, and new studies have shown that it may also be effective in depression and with better tolerability. However, no study so far has directly compared esketamine with racemic ketamine. Here we propose a protocol of a clinical trial to evaluate esketamine as a noninferior medication when compared to ketamine in the treatment of patients with treatment-resistant depression.

METHODS/DESIGN

This study protocol is for a randomized, controlled, double-blind noninferiority clinical trial. Subjects will be 18 years or older, with major depression characterized as treatment-resistant. Participants will receive a single infusion of either esketamine (0.25 mg/kg) or ketamine (0.5 mg/kg) over 40 minutes. The primary outcome will be the difference in remission rates between the 2 treatment arms at 24 and 72 hours after drug infusion. Secondary outcomes will include other timepoints, measurements of cognition, dissociation, and blood biomarkers.

DISCUSSION

A head-to-head study is the best way to evaluate whether the esketamine is in fact comparable to the racemic ketamine in terms of both efficacy and safety, and, if positive, it would be an initial step to increase the access to that type of treatment worldwide.

ETHICS AND DISSEMINATION

The study was approved by the local Institutional Review Board (University Hospital Professor Edgard Santos-Federal University of Bahia-Number: 46657415.0.0000.0049). Subjects will only participate after voluntarily agreeing and signing the Informed Consent Form. The study findings will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION

This trial has been registered in the Japan Primary Registries Network (JPRN): UMIN000032355, which is affiliated with the World Health Organization.

Risk Factors of Increased Mortality During Hospitalization in Acutely-ill Elderly Patients with Altered State of Consciousness

Introduction

A significant proportion of acutely ill hospitalised elderly patients have impaired consciousness and this has been associated with increased mortality. It remains unclear which factors underlie this relation. Identification of mortality predictors in this population is important to improve care.

Objectives

Determine if advanced age, cognitive impairment, high burden of comorbidities and poor functional status are predictors of increased mortality during hospitalisation in acutely-ill medical hospitalised elderly patients with altered state of consciousness.

Methods

All male patients (> 65 years) admitted to a medical ward (> 48 h) between 01/03/2015 to 31/08/2015 with delirium or RASS lower than–2 were included in the study. Patients were excluded if unable to be assessed due to sensorial deficits, communication problems or medical condition precluding the evaluation. Baseline evaluation included socio-demographic variables, RASS, CAM, IQCODE-SF, DSM-IV-TR criteria for dementia, Charlson Comorbidity Index and Barthel Index. The variables were entered in a logistic regression model (significance level < 0.05).

Results

The final sample consisted of 75 male subjects with altered state of consciousness, 14 of them died during hospitalisation. Dementia and Barthel Index were significantly associated with mortality during hospitalisation (P = 0.01 and P < 0.01, respectively). On the other hand, age and Charlson Co-morbidity Index were not associated significantly with mortality during hospitalisation (P = 0.22 and P = 0.1, respectively).

Conclusions

Acutely ill elderly patients with altered state of consciousness at admission have higher risk of death during hospitalisation if they have prior dementia or poor functional status. Health care should be improved to provide better response to this type of patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Patterns of Long Acting Injectable Antipsychotic Prescription During Criminal Acts in a Portuguese Psychiatric Hospital

Introduction

Under the Portuguese law, criminal offenders that are designated as non-criminal responsible – “inimputáveis”, similar those in the United States of America found “not guilty by reason of insanity”, are forced to be committed to inpatient forensic units either in psychiatric hospitals or prison hospitals for mandatory security measures.

Objectives/aims

To evaluate if patients committed in a regional forensic inpatient unit (RFIU) who had a psychiatric history preceding the crime, were under long acting injectable antipsychotic (LAIA) in during the period of the crime.

Methods

During September/October 2015, patients committed to the RFIU in Centro Hospitalar Psiquiátrico de Lisboa were characterized using medical and court records regarding clinical and demographic variables. The type of crime and previous number of criminal acts were also accounted for.

Results

We included 33 patients in the study. During time of the crime, 25 patients (75.8%) had history of previous psychiatric appointments, with an average of 3 commitments to the psychiatric inpatient units. The majority (n = 17; 68%) had a diagnose of “schizophrenia, schizotypal and delusional disorders” (F20–29; ICD 10) and committed “crimes against life” (n = 13; 52%). They had an average of 0.8 previous criminal acts. During the crime, 7 patients (28%) were taking LAIA. Those, 16% (n = 4) were doing an unknown antipsychotic and 12% (n = 3) were doing Haloperidol.

Conclusions

Despite several studies showing the clinical and rehabilitative benefit of using LAIA early in the disease course, most of the patients in our study, who were already being followed in outpatient psychiatric units, did not benefit from them.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Finalidades da supervisão e perfil dos supervisores: um estudo de caso em Angola

Melhorar a qualidade das escolas e da formação dos professores continua a ser uma prioridade em todo o mundo, sobretudo nos países em desenvolvimento. Angola, através do Plano Mestre de Formação de Professores, tem vindo a investir esforços na qualificação docente e na melhoria dos modelos de formação, definindo a supervisão pedagógica como uma das estratégias prioritárias a implementar nas escolas. No caso da formação inicial de professores, as instituições devem construir projetos formativos consistentes e clarificar as finalidades da supervisão e as funções dos supervisores, de forma a fomentarem estratégias adequadas ao desenvolvimento de profissionais competentes e capazes de agir em contextos adversos. Importa, desde logo, conhecer as perspetivas dos atores que nessas instituições protagonizam os processos formativos, de forma a que os movimentos de mudança incorporem as suas vivências, preocupações e aspirações. Foi com este objetivo que se iniciou em 2014 um estudo de caso na Escola de Formação de Professores Patrice Lumumba no Namibe, em Angola, onde a primeira autora exercia funções de docente e supervisora no âmbito do Projeto Saber Mais, do Camões – Instituto da Cooperação e da Língua. O estudo envolveu a recolha de perceções dos atores da supervisão dos 9 cursos de formação inicial da Escola –  399 estagiários, 56 supervisores da instituição e 105 orientadores das escolas –,  através do “Questionário Sobre Perceções da Supervisão em Estágio”. O questionário é constituído por questões fechadas e abertas acerca de diversas vertentes da supervisão: finalidades e atividades da supervisão; perfil dos supervisores; práticas das escolas; competências profissionais a desenvolver no estágio; problemas identificados no estágio e medidas de melhoria da supervisão. A análise das respostas, de natureza quantitativa e qualitativa, assenta na triangulação de vozes para a construção de conhecimento situado e útil. Na presente comunicação, apresentam-se resultados relativos às percepções dos três grupos de participantes acerca das finalidades da supervisão e do perfil do supervisor, comparando-se as suas percepções ideais (o que consideram ser importante) com as suas perceções das práticas vivenciadas (o que consideram estar presente na sua experiência). Essa comparação permite perceber aproximações e afastamentos existentes entre o valorizado e o vivido, assim como identificar boas práticas e práticas mais ausentes dos contextos da supervisão. Analisam-se, ainda, os problemas que afetam negativamente as práticas supervisivas da perspetiva dos atores, e que ajudam a compreender alguns dos desfasamentos identificados, nomeadamente os problemas relativos às condições das escolas, à falta de formação dos supervisores e às suas condições de trabalho, mas também a lacunas na formação prévia e motivação dos estagiários. Com base nos resultados, discutem-se desafios das práticas formativas neste contexto e esboçam-se linhas de ação com base em propostas de melhoria identificadas pelos participantes. Embora se trate de um estudo de caso, os resultados poderão ser idênticos em contextos semelhantes, nomeadamente onde a prática da supervisão é afetada por constrangimentos históricos e estruturais que podem reduzir a sua qualidade, ainda que os seus atores reconheçam a sua importância na mudança educativa.

Decline in overall, smear-negative and HIV-positive TB incidence while smear-positive incidence stays stable in Guinea-Bissau 2004-2011

OBJECTIVE

To calculate Tuberculosis (TB) incidence rates in Guinea-Bissau over an 8-year period.

METHODS

Since 2003, a surveillance system has registered all TB cases in six suburban districts of Bissau. In this population-based prospective follow-up study, 1205 cases of pulmonary TB were identified between January 2004 and December 2011. Incidence rates were calculated using census data from the Bandim Health and Demographic Surveillance System (HDSS).

RESULTS

The overall incidence of pulmonary TB was 279 per 100,000 person-years of observation; the male incidence being 385, and the female 191. TB incidence rates increased significantly with age in both sexes, regardless of smear or HIV status. Despite a peak with unknown cause of 352 per 100,000 in 2007, the overall incidence of pulmonary TB declined over the period. The incidence of HIV infected TB cases declined significantly from 108 to 39 per 100,000, while the incidence of smear-positive TB cases remained stable; the overall figure was 188 per 100,000.

CONCLUSIONS

Overall incidence of pulmonary TB in Guinea-Bissau has declined from 2004 to 2011. The decline was also seen in the subgroups of smear-negative and HIV-positive TB cases, probably due to antiretroviral treatment. Smear-positive TB incidence remains stable over the period.

Morphological and physical fitness characteristics of under-16 Portuguese male handball players with different levels of practice

AIM

The aim of this study was to compare the morphology and physical fitness of 104 under-16 male handball athletes with different competitive levels in function of their bone maturation.

METHODS

Athletes were divided into two groups, 59 competed in the NL-national league, with higher competitive level (14.06±0.66 years) and 45 competed in the RL-regional league (14.24±0.60 years). The morphology was evaluated by measuring body mass, height, sitting height, arm span, four lengths, four breadths, five girths and eleven skinfolds. The physical fitness assessment used eight tests (20-m shuttle run; 30-m sprint; sit-and-reach; horizontal and vertical jump with counter movement; overhead medicine ball throw-3 kg; handgrip; handball specific agility test). Bone age was determined using the TW3 method.

RESULTS

In morphological terms, NL athletes showed greater dimensions for all anthropometric variables except for hand length (transversal and longitudinal), biepicondylar femur breadth, mid-thigh girth and skinfolds. In physical fitness terms, these athletes have better results for VO2max, velocity, agility, arm strength and handgrip than athletes competing in the RL. Maturational differences explain the morphological profile superiority of NL athletes in terms of arm span, lower limb length, biacromial breadth and physical fitness profile for VO2max and arm strength.

CONCLUSION

Maturation should be considered as a covariate when one intends to distinguish the morphological characteristics and physical fitness of under-16 athletes with different levels of practice.

Value of SPET/CT image fusion in the assessment of neuroendocrine tumours with 111In-Pentetreotide scintigraphy

OBJECTIVE

The purpose of this study was to evaluate the impact and clinical value of anatomical-functional image fusion in the study interpretation and clinical management of patients with neuroendocrine tumours (NET) using somatostatin receptor scintigraphy (SRS) and combined transmission and emission tomography -- single-photon emission tomography/CT (SPET/CT).

MATERIAL AND METHODS

Twelve patients (8 female and 4 male; age range 32-74 y, mean 56 y) with proven or clinically suspected NET were studied with routine planar SRS and SPET/CT at 2 and 24 hours after injection of 111-222 MBq 111In-Pentetreotide. Seven patients came for staging/follow-up and 5 patients for primary tumour localization with staging. Analysis of fused images (SPET/CT) was done on a patient basis, with separated evaluation of SPET, low-dose CT images and fusion images. The gold standard for presence or absence of malignancy was pathology or clinical and imaging follow-up data.

RESULTS

SRS was negative in 6 patients and positive in 6. SPET/CT provided no additional information in 6 patients, including all 6 negative studies. SPET/CT improved localization of SPET detected lesions in 6 positive studies. It defined the extent of the disease and showed bone involvement in 3 of the 6 positive studies. SPET/CT affected the diagnostic interpretation in 6 patients (50 %) and induced changes of management in 3 (25 %).

CONCLUSION

The results of this study indicate that combined anatomical-functional imaging with SPET/CT significantly improves tumour localization and characterization, contributing to a better therapeutic management of patients with NET.

Bone or cartilage invasion by advanced head and neck cancer: intra-arterial supradose cisplatin chemotherapy and concomitant radiotherapy for organ preservation

BACKGROUND

Invasion of bony or cartilaginous structures by advanced upper aerodigestive tract cancer has been considered an indication for surgery on the basis of historic experience of poor responsiveness to radiation therapy. At University of Tennessee-Memphis, patients with advanced head and neck cancer have been treated on a protocol of concomitant intra-arterial (targeted) cisplatin and conventional radiation therapy.

OBJECTIVE

To compare the efficacy, in terms of disease control and survival, of this protocol in patients with T4 squamous cell cancers and invasion of bony or cartilaginous structures (group 1; n = 45) vs those with T4 disease but no bone or cartilage involvement (group 2; n = 90).

DESIGN

Subset analysis of protocol database and retrospective chart review.

METHODS

Treatment consisted of 4 weekly intra-arterial infusions of cisplatin (150 mg/m(2) per week), with simultaneous systemic neutralization by intravenous sodium thiosulfate (9 mg/m(2)), and concurrent radiation therapy at 180 rad (1.8 Gy) or 200 rad (2 Gy) per fraction to a planned total of 6600 to 7400 rad (66-74 Gy) to the primary site or overt nodal disease. Presence of bone or cartilage invasion was established by review of tumor diagrams of clinical findings and computed tomography or magnetic resonance imaging reports.

RESULTS

Of 135 patients who had T4 disease and a minimum follow-up of 9 months (median, 40 months), 45 had clinical or radiologic evidence of bone (n = 29: mandible, 12; maxilla, 9; sphenoid, 3; hyoid, 6) and/or cartilage (n = 18: thyroid, 16; cricoid, 4) invasion (some patients had involvement of more than 1 site). The rate of complete response in group 1 (66.7%) was not significantly different from that in group 2 (71.1%) (chi(2) test, P = .79). The 2-year overall actuarial survival for group 1 (46.3%; 95% confidence interval, 30.3%-62.3%) was not significantly different (generalized Wilcoxon test, P = .36) from that of group 2 (36.9%; 95% confidence interval, 25.5%-48.4%). A marked trend was noted for higher response rates in cases of cartilage invasion (81.2%) than in those with bone invasion (58.6%) (P = .15).

CONCLUSION

Equivalent efficacy of treatment in the 2 groups suggests that targeted chemoradiation can be a definitive therapeutic option in patients with advanced head and neck cancer invading bony or cartilaginous structures.

Analysis of risk factors predictive of distant failure after targeted chemoradiation for advanced head and neck cancer

BACKGROUND

Distant metastasis (DM) is the most common mode of recurrence among patients with advanced head and neck carcinoma treated with intra-arterial cisplatin and radiotherapy (RADPLAT).

OBJECTIVE

To identify which patients are at greatest risk for DM and would benefit the most from new strategies designed to treat occult metastases.

METHODS

Between 1993 and 1999, 250 patients with advanced head and neck cancer were treated by RADPLAT. Excluded from the analysis were 10 patients who either did not complete the protocol or were unavailable for follow-up and 39 patients with persistent disease or local recurrence. The incidence and the risk factors for DM in these patients were evaluated in a model that included the following factors: age, T and N classification, site of tumor, histologic grade, number (0, 1, or >1) and position (high vs low) of neck levels involved, and bilateral nodal disease. Multiple stepwise logistic regression was used for the analysis.

RESULTS

In a univariate analysis, the following variables correlated to DM: N classification (P =.02), site of tumor (P =.01), lower neck nodes (P =.002), number of neck levels involved (P =.001), and bilateral nodal disease (P =.02). In a multivariate analysis, the most significant risk factors for DM were the number of neck levels involved and the site of the primary tumor (P<.001). The highest odds ratios for DM were among patients with multiple levels of nodal involvement (3.17) and patients with hypopharyngeal carcinoma (2.8).

CONCLUSIONS

Patients with more than 1 level of clinical nodal involvement and patients with hypopharyngeal carcinoma have the highest risk of developing DM as the initial site of failure and would benefit most from treatment strategies that address occult distant disease.

Targeted chemoradiation for advanced head and neck cancer: analysis of 213 patients

BACKGROUND

To determine the survival results, patterns of relapse, and organ preservation effects of a targeted chemoradiation protocol for patients with advanced (stage III-IV) carcinoma of the head and neck.

METHODS

Analysis of 213 patients with stage III-IV squamous cell carcinoma treated at UT Memphis between June 1993 and March 1998. Treatment included weekly intra-arterial infusions of cisplatin (150 mg/m(2)/ week x 4) rapidly delivered to the tumor bulk, simultaneous intravenous thiosulfate for systemic drug neutralization, and conventional external-beam irradiation (180-200 cGy/fraction) to a total dose of 68-72 Gy.

RESULTS

Tumor response, toxicity, disease control above the clavicle, pattern of relapse, and survival. There were 89 events of grade III-IV toxicity and 6 treatment-related deaths (grade V). Complete response in the primary and regional sites was obtained in 171 of 213 (80%) and 92 of 151 (61%), respectively. The rate of clearance of regional disease after neck dissection was 98%. There were 51 of 195 recurrences (26%): 11 local (5.6%), 5 regional (2.6%), and 35 distant (17.9%). The Kaplan Meier plot projections for overall and cancer-related 5-year survival was 38.8% and 53.6%, respectively, whereas disease control above the clavicle was 74.3%.

CONCLUSIONS

We believe this chemoradiation protocol represents an effective management scheme for patients with advanced head and neck cancer with a high rate of organ preservation and possibly improved survival.

Occult papillary carcinoma of the thyroid gland with extensive osseous metastases--a case report with review of the literature

The authors report a case of extensive osseous metastases from a clinically occult papillary carcinoma of the thyroid gland without evidence of regional lymph node metastases. Some features of the primary tumour, namely focal "tall-cell" morphology and higher nuclear grade, raise the possibility of including such a tumour into the poorly differentiated category of thyroid carcinomas. Literature review only disclosed one similar reported case.

Concomitant radiation therapy and targeted cisplatin chemotherapy for the treatment of advanced pyriform sinus carcinoma: disease control and preservation of organ function

BACKGROUND

Squamous cell carcinoma of the pyriform sinus is an unfavorable disease which frequently presents in advanced stages. Despite aggressive "standard treatment" involving debilitating surgery and postoperative radiation therapy treatments, the survival and functional outcome for pyriform sinus carcinoma remains poor. Hence, we reviewed our experience in the management of advanced pyriform sinus carcinoma using "organ preservation" chemoradiation therapy.

METHODS

Twenty-five patients diagnosed with stage III/IV pyriform sinus squamous cell carcinoma treated with supradose, intra-arterial targeted cisplatin, and concomitant radiotherapy were analyzed for response rates, survival, pattern of failure, and function of the preserved organs. Our protocol consisted of weekly intra-arterial infusions of cisplatin at 150 mg/m(2) x 4 and concurrent radiation therapy at 1.8 Gy or 2.0 Gy/fraction to a planned total of 68-74 Gy to the primary site/overt nodal disease.

RESULTS

Nineteen (76%) of the 25 patients were diagnosed with stage IV disease, 17 of whom were first seen with bulky lymphadenopathy (ie, N2-N3 disease) while 10 had T4 lesions. Twenty-four of 25 patients were evaluable for response assessment. Complete response rates of 92% and 76% were achieved at the primary site and in lymph nodes, respectively. Hence, the overall complete response rate in the neck was 76% (16/21). At a median follow up interval of 42 months (range = 30-58 months), the projected 5-year overall and disease-specific survival using the Kaplan-Meier method are 23% and 50% respectively. No patient has developed recurrence at the primary site and only one patient relapsed regionally, which was surgically salvaged for an "above clavicle" disease control rate of 88% and an organ preservation rate of 88%. Almost 90% of the patients have achieved a satisfactory voice and 70% are able to swallow at 12 months postcompletion of therapy.

CONCLUSION

Our chemoradiation protocol is as effective as other treatment modalities for patients with advanced pyriform sinus carcinoma while maintaining organ preservation and function in the majority of the patients.

Efficacy of targeted chemoradiation and planned selective neck dissection to control bulky nodal disease in advanced head and neck cancer

PURPOSE

To determine the efficacy of targeted chemoradiation with the radiation plus platinum (RADPLAT) protocol and planned selective neck dissection in patients with N2 to N3 nodal disease associated with upper aerodigestive tract carcinoma.

METHODS

Analysis of 52 patients with N2a, N2b, or N3 disease involving 60 heminecks treated with intraarterial cisplatin, 150 mg/m2, and intravenous sodium thiosulfate, 9 g/m2, on days 1, 8, 15, and 22; radiation therapy, 180 to 200 cGy per fraction for 35 fractions (total dose, 68-74 Gy); and planned neck dissection (33 of 35 procedures were selective).

RESULTS

Of the 56 evaluable heminecks, a clinical complete response was achieved in 33 (59%). Within this group, 16 neck dissections were performed, none of which yielded disease on pathological examination. A clinical partial response was obtained in 21 heminecks, of which 18 subsequently had a neck dissection, yielding disease on pathological examination in 14. In all cases, it was possible to completely excise all adenopathy with clear margins on pathological examination. The rate of regional disease control among the 56 evaluable heminecks was 91% (51/56) (median follow-up, 36 months). Four failures were associated with uncontrolled disease at other sites, and 1 was an isolated neck recurrence.

CONCLUSION

Selective neck dissection appears to be an effective adjunct to targeted chemoradiation in controlling N2 to N3 neck disease.

Eating and weight changes following chemoradiation therapy for advanced head and neck cancer

OBJECTIVE

To describe the functional outcomes of weight loss and eating following a targeted chemoradiation protocol consisting of a selective supradose of intra-arterial cisplatin (150 mg/m2 per week for 4 weeks) with parenteral sodium thiosulfate and external-beam irradiation (1.8-2.0 Gy per fraction per day for 35 days).

SUBJECTS AND DESIGN

Forty-seven patients with advanced head and neck cancer treated with a targeted chemoradiation protocol were monitored for weight and eating status before treatment and as long as 18 months after treatment.

RESULTS

A statistically significant weight loss (P<.001) occurred during the targeted chemoradiation protocol, with a mean weight ratio of 90% of the starting weight. The ability to eat also declined, with an increase in reported swallowing difficulties and a need for percutaneous endoscopic gastrostomy tubes from 4 (9%) to 12 (26%). There were no significant changes in weight after the initial weight loss. Tumor stage and nodal involvement had no effect on weight loss. At the start of treatment, 18 patients (38%) reported normal eating and 4 (8%) required a feeding tube. By 18 months after treatment, 41 (87%) were eating normally, 34 (72%) reported normal eating, and 6 (13%) required a percutaneous endoscopic gastrostomy tube.

CONCLUSIONS

Patients undergoing a targeted chemoradiation protocol for head and neck cancer lost about 10% of their pretreatment weight and had a decline in eating ability. Difficulty swallowing during the treatment may be due to adverse effects such as mucositis and nausea. By 18 months after therapy, most were able to eat normally and maintain their weight.

Morphologic and anthropometric characteristics of high level Dutch korfball players

In this study a morphologic and anthropometric characterisation of Dutch korfball players (N = 36) is performed. Data, compared with those of other sports populations, showed that (1) korfball athletes are smaller and lighter than basketball and volleyball players but heavier and taller than other team-sport players; (2) korfball players have less relative body fat, more lean body mass, more limb fat, and less or similar trunk fat than the other athletes. (3) Male korfball players presented a somatotype (1.9-4.4-3.4) similar to endurance athletes and an endomorphic value lower than or similar to the other athletes. (4) The only apparent similarity between female korfball somatotype (3.2-4.0-2.8) and other athletes' somatotypes is the dominance of mesomorphy.