Diagnosis of Congenital Toxoplasmosis: Challenges and Management Outcomes

Introduction Congenital toxoplasmosis (CT), despite being mostly subclinical at birth, can cause disabling disease in the fetus and lead to long-term sequelae. It is an important cause of chorioretinitis in infants and adolescents. Data on postnatal treatment are controversial, and there is a lack of universal guidelines. Methods A cross-sectional study of newborns with suspected CT was conducted between January 2007 and December 2021. Results Seventy-one patients with suspected CT were included. During pregnancy, 64 (90.1%) of the mothers underwent therapy, of which 59 (83.1%) with spiramycin. Amniocentesis identified one positive polymerase chain reaction assay. Most newborns were asymptomatic with normal laboratory, ophthalmological, and hearing screening. There was one case of hyperproteinorrachia. Fifty-seven patients (80.3%) started treatment: 42 (73.7%) with spiramycin, seven (12.3%) with pyrimethamine, sulfadiazine, and folinic acid (P+S+FA), and eight (14%) with P+S+FA intercalated with spiramycin. Adverse effects were found in 11 (19.3%) cases, mainly neutropenia. After investigation, we found three confirmed CT cases corresponding to 4.2% of suspected cases and an incidence of 0.4 per 10,000 births. All had normal clinical and laboratory exams in the neonatal period and started P+S+FA, fulfilling 12 months of therapy. During the follow-up, all presented normal psychomotor development without any long-term sequelae. Conclusion The lower incidence in our study, compared to the incidence in Europe, may be related to the decline in the prevalence of toxoplasmosis as well as the effectiveness of measures to prevent primary infection and a well-established program of antenatal screening, followed by the early initiation of treatment during pregnancy to prevent vertical transmission.

Decline of tuberculosis notification rate in different populations and regions in Portugal, 2010-2017

BACKGROUND

Tuberculosis (TB) incidence declined in Portugal in recent decades, but trends differ between regions and population subgroups. We investigated these differences to inform prevention and control programmes.

METHODS

We extracted TB notifications from the Portuguese National TB Surveillance System (SVIG-TB) in 2010-2017, disaggregated by region, age group, nationality and HIV status. We calculated notification rates using denominators from the Portuguese National Institute of Statistics and the Joint United Nations Programme on HIV/AIDS and performed stratified time series analysis. We estimated interannual decline percentages and 95% confidence intervals (CI) using Poisson and binomial negative regression models.

RESULTS

The overall TB notification rate decreased from 25.7 to 17.5/100,000 population from 2010 to 2017 (5.2%/year) in Portugal. Interannual decline did not differ significantly between regions, but it was smaller amongst non-Portuguese nationals (-1.57% [CI: -4.79%, 1.75%] vs -5.85% [CI: -6.98%, -4.70%] in Portuguese nationals); children under five years of age (+1.77% [CI: -4.61%, 8.58%] vs -5.38% [CI: -6.33%, -4.42%] in other age groups); and HIV-negative people (-6.47% [CI: -9.10%, -3.77%] vs -11.29% [CI; -17.51%, -4.60%] in HIV-positive).

CONCLUSIONS

The decline in TB notification rates in Portugal during the study period has been steady. However, the decline amongst non-Portuguese nationals, children under five years of age and non-infected-HIV patients was lower. No significant differences were observed between regions. Changes in TB epidemiology in specific risk groups and geographical areas should be closely monitored to achieve the objectives of the End TB Strategy. We recommend intensifying screening of TB in the subpopulations identified.

Clinical standards for the management of adverse effects during treatment for TB

BACKGROUND: Adverse effects (AE) to TB treatment cause morbidity, mortality and treatment interruption. The aim of these clinical standards is to encourage best practise for the diagnosis and management of AE.METHODS: 65/81 invited experts participated in a Delphi process using a 5-point Likert scale to score draft standards.RESULTS: We identified eight clinical standards. Each person commencing treatment for TB should: Standard 1, be counselled regarding AE before and during treatment; Standard 2, be evaluated for factors that might increase AE risk with regular review to actively identify and manage these; Standard 3, when AE occur, carefully assessed and possible allergic or hypersensitivity reactions considered; Standard 4, receive appropriate care to minimise morbidity and mortality associated with AE; Standard 5, be restarted on TB drugs after a serious AE according to a standardised protocol that includes active drug safety monitoring. In addition: Standard 6, healthcare workers should be trained on AE including how to counsel people undertaking TB treatment, as well as active AE monitoring and management; Standard 7, there should be active AE monitoring and reporting for all new TB drugs and regimens; and Standard 8, knowledge gaps identified from active AE monitoring should be systematically addressed through clinical research.CONCLUSION: These standards provide a person-centred, consensus-based approach to minimise the impact of AE during TB treatment.

Aquatic wild meat consumption of cetaceans in São Tomé and Príncipe (Gulf of Guinea)

Relatively little is known about cetaceans in São Tomé and Príncipe and in recent years, some episodes of cetacean bycatch and human consumption have been described. Aiming to provide insight into the reliance upon cetaceans as a source of meat, we present findings from complementary studies conducted in the islands of São Tomé and Príncipe from 2012 to 2021. Based on interviews with local residents, we assessed the prevalence of human consumption of cetaceans and identified potential sociodemographic drivers. This study provides the first comprehensive assessment of harvest (direct remove or incidental take) and consumption of cetaceans (mainly the family Delphinidae) in the country. These findings will be useful in the development of regional conservation measures and contribute to our understanding of anthropogenic activities affecting cetacean populations in the Gulf of Guinea.

Clinical standards for drug-susceptible pulmonary TB

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice´ for diagnosis, treatment and management of drug-susceptible pulmonary TB (PTB).METHODS: A panel of 54 global experts in the field of TB care, public health, microbiology, and pharmacology were identified; 46 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all 46 participants.RESULTS: Seven clinical standards were defined: Standard 1, all patients (adult or child) who have symptoms and signs compatible with PTB should undergo investigations to reach a diagnosis; Standard 2, adequate bacteriological tests should be conducted to exclude drug-resistant TB; Standard 3, an appropriate regimen recommended by WHO and national guidelines for the treatment of PTB should be identified; Standard 4, health education and counselling should be provided for each patient starting treatment; Standard 5, treatment monitoring should be conducted to assess adherence, follow patient progress, identify and manage adverse events, and detect development of resistance; Standard 6, a recommended series of patient examinations should be performed at the end of treatment; Standard 7, necessary public health actions should be conducted for each patient. We also identified priorities for future research into PTB.CONCLUSION: These consensus-based clinical standards will help to improve patient care by guiding clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment for PTB.

Epileptic Seizures or not, that is the question: a case report

Introduction

Psychogenic nonepileptic seizures (PNES) consist of paroxysmal changes in responsiveness, movements, or behaviour that superficially resemble epileptic seizures.

Objectives

Presentation of a clinical case of a PNES in a patient with a diagnose of secondary epilepsy, illustrating the relevance of an adequate evaluation, differential diagnosis, and intervention.

Methods

Description of the clinical case, with brief literature review and discussion. A search was conducted on PubMed and other databases, using the MeSH terms “nonepileptic seizure”, and “epileptic seizure”.

Results

We report the case of a 45-year-old female patient, brought to the emergency department because of tonic axial and limb nonsynchronous movements, closed eyes, long duration, with immediate awareness, no desaturation, tongue bite, facial flushing, dyspnoea or sphincter incontinency. She was medicated with clonazepam 1 mg and levetiracetam 1000 mg ev. TC-CE had no acute alteration. Bloodwork had no other major alteration except valproic acid below therapeutic levels (her usual medication, along with other antiepileptic drugs, antidepressant and antipsychotic). The antecedents of the patient: mild intellectual disability and an accidental traumatic brain injury in infancy, with secondary epilepsy. She was transferred to Psychiatry department. No electroencephalogram (EEG) was realized, because she had a recent one confirming PNES, and many other emergency observations with the diagnosis of PNES.

Conclusions

This clinical case showcases the diagnostic difficulties that clinicians face when there is an overlap in symptoms, emphasizing the need to combine patient history, witness reports, clinician observations, and ictal and interictal EEG to help distinguish these different clinical identities.

Disclosure

No significant relationships.

Exercise addiction, body dysmorphic disorder, and use of enhancement drugs during the COVID-19 pandemic confinement period: A transcultural study

Introduction

The Coronavirus pandemic has originated unprecedented sanitary control measures that have conditioned people’s lifestyles and habits. Little is known about the impact of such measures, especially the most restrictive, on recent and growing phenomena such as exercise addiction, use of enhancement drugs, and Body Dysmorphic Disorder (BDD).

Objectives

The objective was to investigate the above-mentioned phenomena during COVID-19 pandemic and how they relate.

Methods

The sample consisted of 3161 participants (65% women), from Portugal (11%), Italy (41%), Spain (16%), the UK (12%), Lithuania (12%), Japan (6%), and Hungary (4%). Mean age was 35.05 (SD = 12.10). Participants responded online to the Exercise Addiction Inventory (EAI), the Appearance Anxiety Inventory (AAI), and questions about use of enhancement drugs.

Results

4.3% of the participants scored above the cut-off point of the EAI, with higher values registered in the UK and Spain. Exercise addiction was higher among men. Appearance anxiety and body satisfaction problems were found in participants of all participating countries, with 15.2% scoring over the cut-off point for BDD. Higher numbers of those at risk of BDD were found in Italy, Japan, and Portugal. About 29% reported the use of fitness supplements to make them look better, with 6.4% starting a new use during the lockdown. Change in supplements use and exercise are predicted by EAI scores. Change in mental health is predicted by AAI scores.

Conclusions

This study helps to shed light on how COVID-19 lookdown induced behavioral changes and how they affect physical and mental health-related aspects in different countries.

Web-based tools applied to therapy and counseling during the COVID-19 pandemic

Introduction

Web-based tools allowed the provision of psychological counseling and therapy at-distance during the COVID-19 lockdown. Nevertheless, psychologists’ attitudes towards the adoption of these tools and its impact in their professional practices need to be further explored.

Objectives

The objective was to study the use of web-based tools on psychological practices before and during COVID-19 lockdown, trying to identify changes on psychologists’ professional practices related to the pandemic, as well as to explore factors that could have affected such changes.

Methods

One-hundred and eight psychologists filled-in an online survey, developed for the purposes of this study, during mandatory lockdown. The study was disseminated by mailing list, social networks, and by the Portuguese Psychologists Association.

Results

The results have shown that psychologists kept providing their services during lockdown thanks to the adoption of web-based tools. Although psychologists have recognized that additional precautions were needed for at-distance practice in comparison to in-person interventions, the experience of using IC technologies in clinical practice was described as positive, ensuring clients’ adherence with positive results. Additionally, despite psychological services were maintained on a larger scale by psychologists with more years of experience, professionals with average experience stated more favorable attitudes towards the use of web-based tools in counseling and therapy.

Conclusions

Although the implementation of ICT based practice was enforced by current circumstances, the experience that psychologists gathered and shared during the lockdown can guide future professional practice, improving and fostering the replication of best practices at distance.

Cultural explanations of sleep paralysis: The spiritual phenomena

Introduction

Sleep paralysis (SP) is relatively frequent condition, occurring either at sleep onset or sleep offset. It occurs at least once in a lifetime in 40–50% of normal subjects. During SP, the patient experiences gross motor paralysis, while the sensory system is clear. Hypnogogic and hypnopompic hallucinations are common. This experience might be interpreted as a spiritual phenomenon in several cultures, each one with different interpretations and attributions.

Objective

The authors revisit the clinical presentation of sleep paralysis and how this sleep disorder is seen from a cultural perspective.

Aims

To describe several cultural interpretations of SP.

Methods

A literature review of the theme is shortly surveyed.

Results

It is very common during an episode of SP sensing the presence of menacing intruders in one's bedroom. Supernatural accounts of this hallucinated intruder are common across cultures. It has been traditionally labeled “ghost oppression” among the Chinese. In the Abruzzo region (Italy), the supernatural interpretation of the phenomena is called the Pandafeche attack. One study found that nearly half (48%) of the participants from the general Egyptian population believed their SP to be caused by the Jinn, a spirit-like creature. In Southwest Nigeria, Ogun Oru is a traditional explanation for nocturnal neuropsychiatric disturbances. The characteristics of the ‘a dead body climbed on top of me’ phenomenon suggest that is identical to sleep paralysis and a frequent experience among Mexican adolescents.

Conclusions

Depending on the etiological interpretations of SP, which is largely culturally determined, patients react to the event in specific ways.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Preventive therapy compliance in pediatric tuberculosis - A single center experience

INTRODUCTION

Despite its importance, there are some barriers to patient compliance in preventive therapy (PT) of tuberculosis (TB). The purpose of this study was to evaluate the compliance to appointments, PT and follow-up in a pediatric population after TB exposure, followed in a single TB outpatient center, and the subsequent identification of compliance determinants.

METHODS

Retrospective analysis of all pediatric patients who underwent PT in Gaia TB outpatient center from January 2015 to June 2016. Patients were divided into two groups: compliant and non-compliant, according to adherence to screening, visits and medication. The data collection was based on review of medical records.

RESULTS

A total of 72 patients were enrolled, 33 (45.8%) on chemoprophylaxis and 39 (54.2%) on latent tuberculosis infection (LTBI) treatment. The majority of patients were compliant (63.9%, n=46). Non-compliance was found in 36.1% (n=26): in 12 patients to contact screening, in 11 patients to PT and 22 patients did not attend medical appointments in the first place. In 10 patients, non-compliance was related to social problems/family dysfunction (low socioeconomic status and parent's unemployment). After putting in place several strategies, such as telephone contact, activating social services and direct observation of therapy, a compliance of 98.6% was achieved. Isoniazid was the main drug used (91.7%), during 9 months for LBTI.

CONCLUSION

PT compliance in TB can be challenging, probably related to the lack of risk perception and caregiver's reluctance to undergo a prolonged treatment to an asymptomatic condition. We conclude that implementing interventions can considerably improve treatment compliance and reduce the risk of future tuberculosis development. We emphasize the success in compliance to a 9 month regimen of isoniazid in the vast majority of patients with LTBI.

Managing latent tuberculosis infection and tuberculosis in children

Tuberculosis (TB) is a major cause of childhood morbidity and mortality worldwide. The aim of this review is to describe the management of the child with TB and latent tuberculosis infection (LTBI). To develop this article, a working group reviewed relevant epidemiological and other scientific studies and established practices in conducting LBTI and TB in children. The article describes how to manage the child with LTBI, considering transmission and infectiousness of tuberculosis, contact screening and prioritization of contacts and recommendations on treatment of children with LTBI and how to manage the child with TB considering the susceptibility of children to developing tuberculosis, epidemiology and classification of tuberculosis in children, diagnosis and treatment.

Tuberculosis in children from diagnosis to decision to treat

SETTING

Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

OBJECTIVE

Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

DESIGN

A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

RESULTS

We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

CONCLUSION

TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

Patients with schizophrenia assessing psychiatrists’ communication skills

The doctor-patient relationship constitutes the matrix of the entire medical practice. One way in which doctors develop a positive rapport with their patients is through appropriate communication. Evidence suggests that doctors do not communicate with their patients as they should. Important gaps are observed in doctors’ communication with patients with schizophrenia.

Aim

Examine psychiatrists’ communication skills as assessed by their patients with schizophrenia and through external observation, considering patients’ socio-demographic and clinical variables and analyse the importance that aspects of communication have for patients.

Methodology

This cross-sectional study involved a sample of 30 patients and 11 doctors. An adapted and culturally validated version of the Communication Assessment Tool was used for data collection. Data were analysed in IBM SPSS Statistics®, version 24.

Results

Male patients constituted 86.7% of the sample and mean age was 46.7 ± 13.3. The overall mean percentage of items rated as excellent by patients was 57.4%. On the other hand, external observer percentage of excellent scores was much lower when compared with patients’ scores. Single, divorced or widower/widow patients, patients with higher educational level and patients with shorter number of years in medical treatment gave significantly higher scores to psychiatrists’ communication. Patients’ sex, age, occupation residence and family type did not yield statistically significant effects on patients’ ratings.

Conclusions

Communication is at the heart of psychiatrists’ daily practice. Many communication styles might be needed, depending on the nature of clinical encounters and patient expectations. Specific training is required to optimise psychiatrists’ communication skills on everyday practice.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Onset of Psychotic Disorders and the Immigration Status – A Look Into A Growing Reality

Introduction

Recent studies point for an increased incidence of psychotic disorders among immigrants when compared to nom-immigrant population, with a substantial risk variation being observed among different ethnic minority groups and diverse host countries/societies.

Objective

This communication explores the relation between immigration and the onset of psychosis disease, namely the individual and socio-environmental factors implicated in this association.

Aims

Accessing the implications of immigration in the establishment of psychotic disorders.

Methods

The authors conducted a literary search on Medline and PsychInfo databases regarding the subject immigration and psychotic disorders, elaborating a bibliographic review of the topic.

Results

A greater incidence of psychotic disorders in immigrants (in comparison to nom-immigrant population) has been established. In actuality a range of studies carried out in different socio demographic contexts and with different ethnic groups (of immigrants) identify ethnicity, neighbourhood characteristics (namely level ethnic density), discrimination and refugee status, as some of the probable factors that modulate the rate of psychotic disorder and influence its incidence in immigrants.

Conclusions

With regard to the relationship between immigration and the development of psychosis, much is still to be understood. Future studies with focuses on different individual, social, cultural and demographic aspects need to be developed in order to better understand and addressed this phenomenon.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Religious and spiritual implication in the assessment and management of bipolar disorder

Introduction

Religion/spirituality and medicine have been related in one way or another sense the beginning of our know History. Patients’ beliefs, values and practices influence the way disease is perceived and managed. In order to provide adequate care the physician must have proper knowledge of the patients’ spiritual/religious context, otherwise it may fall prey to errors of diagnostic, inappropriate management and subsequent poor compliance.

Objectives

To present the case of an adult male (a preacher whose beliefs include mediunity) with delusional ideation of mystical content and mood elation, identified during a religious ceremony.

Aims

Questioning the frontier between spiritual/religious beliefs and psychopathology.

Methods

A case report is presented and a literature review of the theme is shortly surveyed.

Results

The case reports to a 53 years old man, who during a religious ceremony presented himself with agitation and disinhibition, removing all his cloths and living the church naked. Additionally it was identified the presence of insomnia, heteroaggressiveness, accelerated speech, mood elation and delusional ideation of mystical and megalomaniac content. Several studies demonstrate the importance of acknowledging the religious/spiritual beliefs of patients. This knowledge allows the psychiatry to correctly identify the existing psychopathology and organize an appropriate intervention plan for the patient.

Conclusions

Spiritual and religious beliefs’ influence the way disease is perceiver and managed. Physician should collect a brief spiritual story of the patient and learn about the different religious/spiritual beliefs and practices of their community, in order to understand the full dimension of the individual illness.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

MC3T3-E1 Cell Response to Ti1-xAgx and Ag-TiNx Electrodes Deposited on Piezoelectric Poly(vinylidene fluoride) Substrates for Sensor Applications

In the sensors field, titanium based coatings are being used for the acquisition/application of electrical signals from/to piezoelectric materials. In this particular case, sensors are used to detect dynamic mechanical loads at early stages after intervention of problems associated with prostheses implantation. The aim of this work is to select an adequate electrode for sensor applications capable, in an initial stage to avoid bone cell adhesion, but at a long stage, permit osteointegration and osteoinduction. This work reports on the evaluation of osteoblast MC3T3-E1 cells behavior in terms of proliferation, adhesion and long-term differentiation of two different systems used as sensor electrodes: Ti1-xAgx and Ag-TiNx deposited by d.c. and pulsed magnetron sputtering at room temperature on poly(vinylidene fluoride) (PVDF). The results indicated an improved effect of Ag-TiNx electrodes compared with Ti1-xAgx and TiN, in terms of diminished cell adhesion and proliferation at an initial cell culture stage. Nevertheless, when cell culture time is longer, cells grown onto Ag-TiNx electrodes are capable to proliferate and also differentiate at proper rates, indicating the suitability of this coating for sensor application in prostheses devices. Thus, the Ag-TiNx system was considered the most promising electrode for tissue engineering applications in the design of sensors for prostheses to detect dynamic mechanical loads.

Prediagnosis lifestyle exposures and survival of gastric cancer patients: a cohort study from Portugal

BACKGROUND

Dietary habits and smoking are recognised as important gastric cancer determinants. However, their impact on prognosis remains poorly understood. We aimed to quantify the association between lifestyles and survival of gastric cancer patients.

METHODS

In 2001-2006, 568 patients were recruited in the two major public hospitals in the north of Portugal. Participants were inquired about smoking and dietary habits regarding the year preceding the diagnosis. The vital status of all participants, up to 2011 (maximum follow-up: 10 years), was assessed through the North Region Cancer Registry. Cox proportional hazards regression models were used to estimate adjusted (at least for age, sex and education) hazard ratios (HR) and 95% confidence intervals (95% CI).

RESULTS

No significant differences in gastric cancer survival were observed according to smoking status (current vs never smokers, HR=1.00, 95% CI: 0.72-1.38) or alcohol intake (current vs never consumers, HR=0.87, 95% CI: 0.61-1.25). Only a dietary pattern (high consumptions of most food groups and low vegetable soup intake) was significantly associated with a better prognosis among patients with the extent of disease classified as regional spread (HR=0.45, 95% CI: 0.22-0.93).

CONCLUSION

This study shows that prediagnosis lifestyles have a small impact in the survival of gastric cancer patients.

How plants cope with water stress in the field. Photosynthesis and growth

Plants are often subjected to periods of soil and atmospheric water deficit during their life cycle. The frequency of such phenomena is likely to increase in the future even outside today's arid/semi-arid regions. Plant responses to water scarcity are complex, involving deleterious and/or adaptive changes, and under field conditions these responses can be synergistically or antagonistically modified by the superimposition of other stresses. This complexity is illustrated using examples of woody and herbaceous species mostly from Mediterranean-type ecosystems, with strategies ranging from drought-avoidance, as in winter/spring annuals or in deep-rooted perennials, to the stress resistance of sclerophylls. Differences among species that can be traced to different capacities for water acquisition, rather than to differences in metabolism at a given water status, are described. Changes in the root : shoot ratio or the temporary accumulation of reserves in the stem are accompanied by alterations in nitrogen and carbon metabolism, the fine regulation of which is still largely unknown. At the leaf level, the dissipation of excitation energy through processes other than photosynthetic C-metabolism is an important defence mechanism under conditions of water stress and is accompanied by down-regulation of photochemistry and, in the longer term, of carbon metabolism.

Traditional birth attendants and their practices in the State of Pernambuco rural area, Brazil, 1996

OBJECTIVE

To obtain socioeconomic information about TBAs in the State of Pernambuco and information concerning their practices.

METHOD

Statistical analysis of the answers to structured questionnaires applied to 127 TBAs.

RESULTS

The results of a survey with 127 TBAs conducted in the rural area of the State of Pernambuco (Brazil) is presented in this paper. TBAs in rural Pernambuco are a group of basically old and very poor and uneducated women. Most of them learned to attend births by themselves or by helping another TBA. Thirty percent learned midwifery in hospital delivery rooms, helping doctors and nurses. How the TBAs learned to help births seemed to be the most influential factor on the kind of practices they use. TBAs who learned from other TBAs from the community seem to have the least interventionist approach, followed by the TBAs who learned by themselves. They are more likely to perform more home births and avoid practices such as shaving the pubic hair, vaginal exams, artificial rupture of the membranes, episiotomy and early cord clamping.

CONCLUSION

The way women learned midwifery is the most important determinant of their practice.

Tensile strength and histological changes of abdominal aorta of malnourished rats

The resistance of the abdominal aorta of rats after 6, 7 and 8 weeks of malnutrition, compared with control animals, was evaluated by longitudinal tensiometry. Weakness of this vessel in malnourished rats was demonstrated; microscopic examination of the aorta stained by Masson, Calleja and hematoxylin-eosin methods showed a decrease in amorphous ground substance and an increase in the width of elastic laminae. There was no visible alteration either in the endothelial lining layer or in the smooth muscle fibers. Such alterations of the aorta are, to the authors' knowledge, the first reported modifications in the peripheral vasculature after malnutrition.

[Hospital prevalence of kidney failure. Consequences and reflections for the planning of nephrology services]

A prospective prevalence study of Renal Failure (RF) in inhospital patients (creatinine > = 1.7 mg/dl) was carried out during March 1994, in two hospitals covering well defined and mutually exclusive populations. Cases were selected by screening all urea and creatinine blood tests performed in both laboratories, and registered in an individual form for daily follow-up of their nephrologic outcome. We registered 242 RF cases among 3525 patients admitted (6.8%), with an A.R.F. prevalence of 5.2%, 46% of all patients had a serum creatinine > 3 mg/dl and 71% were older than 65 years. In 55% RF was acquired inside the hospital. The most frequent cause of A.R.F. was pre-renal failure with 37%, followed by 32% of ischemic acute tubular necrosis and 13% toxic ATN. Nephrology was consulted in only 29% of all hospital RF cases. Only 17% of the RF patients were submitted to dialysis procedures, overall mortality was 31%, and 30% had normal renal function at discharge. Our results provide a data base to rethink the organization, staffing and role of nephrology departments inside general hospitals.

Evaluation of platelet number and function and fibrinogen level in patients bitten by snakes of the Bothrops genus

Platelet function and plasma fibrinogen levels were evaluated in 14 patients, 10 males and 4 females, aged 13-59 years bitten by Bothrops genus snakes. There was a statistical difference (p < 0.05) among plasma fibrinogen levels evaluated 24 and 48 hours after envenomation. There was a tendency towards normalization after 48 hours of treatment. The low platelet number was clear in 24-48 hour evaluations with a tendency towards normalization after 48 hours of treatment (p < 0.05). When platelet function was stimulated by collagen and epinephrine, it appeared to be within normal values. On the other hand, when it was stimulated by adenosine diphosphate (ADP), platelet function was hypoaggregated by a single micromol concentration until 48 hours after treatment. At a 3 micromol concentration, there were alterations only before specific treatment (p < 0.05). Fibrinogen levels and fibrin degradation product (FDP) levels appeared to be altered in 83.33% of patients evaluated. The authors suggest that platelet hypoaggregation is related to decreased fibrinogen and increased FDP levels.