[Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests by the SPCPTGI]

Cervical cancer is one of the most common types of cancer in women. Cervical cancer screening is needed for the detection and treatment of cervical neoplastic lesions that can evolve to neoplasia and to reduce the incidence of cervical cancer. Recently, changes were made to increase the efficiency of the screening process such as employing the human papilloma virus detection test as the gold standard for cervical cancer screening and acknowledging the importance of adapting clinical practice to consider the risk of developing this neoplasia. Considering this paradigm shift, new clinical practice guidelines are now needed. For this purpose, a group of experts analyzed and discussed the most recent literature, defining recommendations and proposing clinical practice guidelines that focus on risk stratification, diagnostic evaluation, and on the therapeutical approach and follow-up of women with altered screening results. The aim of this article is to guide clinical practice regarding actions to take in face of altered results of cervical cancer screening and, consequently, to improve the secondary prevention of this condition.

Management of Helicobacter pylori infection in paediatric patients in Europe: results from the EuroPedHp Registry

Purpose

The EuroPedHp-registry aims to monitor guideline-conform management, antibiotic resistance, and eradication success of 2-week triple therapy tailored to antibiotic susceptibility (TTT) in Helicobacter pylori-infected children.

Methods

From 2017 to 2020, 30 centres from 17 European countries reported anonymized demographic, clinical, antibiotic susceptibility, treatment, and follow-up data. Multivariable logistic regression identified factors associated with treatment failure.

Results

Of 1605 patients, 873 had follow-up data (53.2% female, median age 13.0 years, 7.5% with ulcer), thereof 741 (85%) treatment naïve (group A) and 132 (15%) after failed therapy (group B). Resistance to metronidazole was present in 21% (A: 17.7%, B: 40.2%), clarithromycin in 28.8% (A: 25%, B: 51.4%), and both in 7.1% (A: 3.8%, B: 26.5%). The majority received 2-week tailored triple therapy combining proton pump inhibitor (PPI), amoxicillin with clarithromycin (PAC) or metronidazole (PAM). Dosing was lower than recommended for PPI (A: 49%, B: 41%) and amoxicillin (A: 6%, B: 56%). In treatment naïve patients, eradication reached 90% (n = 503, 95% CI 87–93%) and 93% in compliant children (n = 447, 95% CI 90–95%). Tailored triple therapy cured 59% patients after failed therapy (n = 69, 95% CI 48–71%). Treatment failure was associated with PAM in single clarithromycin resistance (OR = 2.47, 95% CI 1.10–5.53), with PAC in single metronidazole resistance (OR = 3.44, 95% CI 1.47–8.08), and with low compliance (OR = 5.89, 95% CI 2.49–13.95).

Conclusions

Guideline-conform 2-weeks therapy with PPI, amoxicillin, clarithromycin or metronidazole tailored to antibiotic susceptibility achieves primary eradication of ≥ 90%. Higher failure rates in single-resistant strains despite tailored treatment indicate missed resistance by sampling error.

[Neurosurgical Residency in Portugal: What is the National Panorama?]

INTRODUCTION

In Portugal, the number of neurosurgery residents has been rising steadily. However, there are no robust studies assessing the level of satisfaction and quality of the current training programs. The aim of this study was to describe and quantify the level of satisfaction about Neurosurgery residency in 2019, in Portugal.

MATERIAL AND METHODS

Quantitative observational cross-sectional study based on an original questionnaire about the level of satisfaction of neurosurgical training in Portugal in 2019, sent electronically to residents and young consultants between October and December 2019.

RESULTS

A total of 37 responses were obtained from physicians aged around 29.0 (± 4.0) years old, of which 78.4% were men and 54.1% from centers in the center/south of the country/islands. Overall, 51.4% of the answers came from first three years' residents. As for the theoretical training, there was dissatisfaction with the morbidity and mortality meetings (59.5%), existence of sessions/anatomical lab (89.2%), participation in medical education (64.9%) and in research (64.9%). As for practical training, there was dissatisfaction only towards outpatient clinics (56.8%). There is a tendency for the first surgery to occur in the first month of residency and, in ascending order, firstly a cranial trauma surgery (5.09 ± 4.59 months), then for cerebrospinal fluid diseases (5.95 ± 4.3 months), peripheral nerves (6.0 ± 7.0 months), craniotomy (6.59 ± 3.88 months) and lumbar spine diseases (11.41 ± 1.5 months). Pediatric surgery was the last type of surgery to begin (19.36 ± 20.0 months). There seems to be a generalized satisfaction with the annual (59.5%) but not with the final examination (37.8%).

CONCLUSION

This study has succeed at being a better description of the Portuguese neurosurgical centers and of the level of satisfaction about neurosurgical training in Portugal.

Systematic Review and Meta-analysis of Histological Gastric Biopsy Aspects According to the Updated Sydney System in Children

OBJECTIVES

A descriptive and comparative study of gastric histological aspects according to the updated Sydney classification (USC), obtained from Helicobacter pylori-positive versus H pylori-negative children referred for upper gastrointestinal endoscopy.

METHODS

The Prisma method was used to perform a systematic review and meta-analysis. Selection criteria were based on following key words USC, H pylori, children, endoscopy, or biopsy. Publication biases were assessed according to the Newcastle-Ottawa Scale, and a meta-regression analysis was done. The study was registered on the PROSPERO platform.

RESULTS

Between 1994 and 2017, 1238 references were found; 97 studies were retained for the systematic review with a total number of 25,867 children; 75 studies were selected for the meta-analysis concerning 5990 H pylori-infected and 17,782 uninfected children.H pylori-positive versus H pylori-negative children, according to the USC, showed significantly higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, and of lymphoid follicles, and gastric mucosa atrophy, whereas, intestinal metaplasia showed a significantly higher RR only in antral biopsies. The meta-regression analysis showed that H pylori-positive versus H pylori-negative children had significantly higher risk only for corpus activity according to age, recurrent abdominal pain, and geographical area of low H pylori prevalence.

CONCLUSIONS

H pylori infection in children was associated with higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, lymphoid follicles, and rare gastric mucosa atrophy, whereas, rare intestinal metaplasia was only significantly higher in the antral area.

Rapid encoding of musical tones discovered in whole-brain connectivity

Information encoding has received a wide neuroscientific attention, but the underlying rapid spatiotemporal brain dynamics remain largely unknown. Here, we investigated the rapid brain mechanisms for encoding of sounds forming a complex temporal sequence. Specifically, we used magnetoencephalography (MEG) to record the brain activity of 68 participants while they listened to a highly structured musical prelude. Functional connectivity analyses performed using phase synchronisation and graph theoretical measures showed a large network of brain areas recruited during encoding of sounds, comprising primary and secondary auditory cortices, frontal operculum, insula, hippocampus and basal ganglia. Moreover, our results highlighted the rapid transition of brain activity from primary auditory cortex to higher order association areas including insula and superior temporal pole within a whole-brain network, occurring during the first 220 ms of the encoding process. Further, we discovered that individual differences along cognitive abilities and musicianship modulated the degree centrality of the brain areas implicated in the encoding process. Indeed, participants with higher musical expertise presented a stronger centrality of superior temporal gyrus and insula, while individuals with high working memory abilities showed a stronger centrality of frontal operculum. In conclusion, our study revealed the rapid unfolding of brain network dynamics responsible for the encoding of sounds and their relationship with individual differences, showing a complex picture which extends beyond the well-known involvement of auditory areas. Indeed, our results expanded our understanding of the general mechanisms underlying auditory pattern encoding in the human brain.

Integrating ecosystem services into sustainable landscape management: A collaborative approach

The Paiva River is considered one of the least polluted rivers in Europe and its watershed has a high conservation value. However, the Paiva River basin suffers pressures related with recurrent disturbances in land use, such as forest fires, agricultural activities, urbanization and pressures that affect the natural hydromorphological conditions and the continuity of watercourses. Blue and Green Infrastructures (BGINs) emerge to improve biodiversity, sustainability and the supply of ecosystem services while improving socioeconomic aspects. Thus, this article aims to identify priority areas in the basin, for intervention with these infrastructures. For that, a spatial multicriteria decision analysis (MDCA) was carried out according to several data related to the Paiva River Basin. As local politicians and responsible entities for the natural resources management are the main experts on the problems and their possible solutions at the local level, they were involved in this decision-making model. Therefore, these specialized stakeholders did the weighting assignment according to the most or least importance of the same for the work. The map of priority locations to implement BGINs was obtained in the sequel. To the top 5 priority areas, stakeholders attributed the best solutions based on nature. The most recommended BGINs were recovery/maintenance of riparian vegetation and conservation and reforestation of the native forest, both presented in four of the five areas, and introduction of fuel management strips presented in three of the five areas. Thus, we concluded that it is extremely important to include the communities and the competent entities of nature and environment management in scientific projects related to conservation, forming a synergy that makes it possible to combine scientific knowledge with local experience acquired in the field. This project uses a very flexible methodology of local data and can be a great example to be implemented in other hydrographic basins anywhere in the world.

Protein-losing enteropathy caused by Yersinia enterocolitica colitis

A 7-month-old boy was admitted with acute gastro-enteritis accompanied by fever and hyponatraemic dehydration. The clinical course was complicated by severe hypokalaemia and hypo-albuminaemia with anasarca. Protein-losing enteropathy (PLE) owing to Yersinia enterocolitica colitis was diagnosed and was complicated by fungal sepsis owing to Kodomaea ohmeri. Colonoscopy demonstrated multiple diffuse ulcers and sub-epithelial haemorrhages extending from the rectum to the hepatic angle. He required prolonged nutritional support comprising partial parenteral feeding for 10 days, followed by a hypo-allergenic diet until 13 months of age when cow milk was tolerated. He was discharged on a normal diet and in good health at 19 months of age.Abbreviations AVPU scale: A alert, V verbally responsive, P painfully responsive, U unresponsive; CMV: cytomegalovirus; EBV: Epstein-Barr virus; HIV: human immunodeficiency virus; Ig: immunoglobulin; IBD: inflammatory bowel disease; IPEX: immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome; PICU: paediatric intensive care unit; PLE: protein-losing enteropathy.

Comparison of the GRACE score, TIMI score and a New Laboratorial Score to predict adverse outcomes in acute coronary syndrome

Introduction

Acute coronary syndrome (ACS) is a clinical entity which includes a heterogeneous group of patients with different outcomes. Risk scores are in this setting a resourceful tool to identify the subset of patients with a worse prognosis, in order to plan therapeutic and surveillance strategies.

Aim

To create a risk score – Laboratory Risk Score (LRS) – which exclusively includes analytical and echocardiographic parameters, as a predictor of adverse outcomes (in-hospital mortality and 1-year mortality), and compare it with other well-known scores: GRACE Score (GS) and TIMI-score (TS).

Methods

A retrospective cohort study was conducted, which included patients admitted in the Cardiology Department with the diagnosis of ACS. In order to calculate the new LRS, the authors attributed the value of 1 to each of the satisfied condition from the following: leucocytes >11,7g/L, hemoglobin <13.3g/dL, red cell distribution width >14%, prothrombinemia <90%, glycaemia at admission >143mg/dL, urea >53.5mg/dL, creatinine >1.16mg/dL, reactive C-protein >1.0mg/dL, maximum troponin >35.0ng/dL, natriuretic brain peptide >416 pg/dL and left ventricular ejection fraction <40%. LRS resulted from the sum of the satisfied conditions.

ROC curves for LRS, GS and TS to predict in-hospital mortality and to predict 1-year mortality were constructed. The statistical analysis was performed in SPSS and Medcalc. p value <0.05 was considered statistically significant.

Results

1714 patients (70.4% male, average age 69±13 years-old) were included in this study. Intra-hospital mortality rate was 6.8% and 1-year mortality rate after de discharge was 4.8%.

The areas under the ROC curves for predicting in-hospital mortality were the following: 0,790 (LRS, p<0,001), 0,793 (GS, p<0.01), 0.817 (TS, p<0.001). For predicting 1-year mortality, the areas under the ROC curves were: 0,715 (LRS, p<0,001), 0,761 (GS, p<0,001), 0.742 (TS, p<0.001). Pairwise comparison of ROC curves showed no significant differences between the scores.

Conclusion

The above-mentioned risk scores, including the new LRS, are obtained with non-invasive and widely available parameters and displayed a good performance in predicting in-hospital and 1-year mortality. Pairwise comparison of ROC curves demonstrated that the new laboratorial score was not inferior predicting adverse outcomes. The SRL is an easily obtained score, that shows a statistical significance in predicting mortality, especially the prediction of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular noncompaction and EcoScore: prognostic value of a new echographic risk score

Introduction

Left Ventricular Non-Compaction (LVNC) is a rare and underdiagnosed cardiomyopathy, characterized by hypertrabeculation of the left ventricle. This disease is associated with high rates of morbidity and mortality; however, its main adverse prognostic factors are not well established.

Aim

To create a risk score for LVNC based on echocardiographic criteria (EcoScore) to predict the occurrence of adverse events.

Methods

The authors included patients with the diagnosis of LVNC, according to the Jenni Criteria. Clinical and echocardiographic data were evaluated and the occurrence of the following adverse events was reported: hospitalizations due to supraventricular or ventricular tachyarrythmias and heart failure, acute myocardial infarction, stroke, heart transplant and death. The follow-up time was 24 months. ROC curves to predict the occurrence of at least one adverse event were constructed for each echocardiographic parameter. The optimal cut-off obtained from each ROC curve was then used to attribute points (1 point per parameter). The EcoScore resulted from the sum of the obtained points. The authors finally created a ROC curve to predict the occurrence of any adverse event for the EcoScore. The statistical analysis was performed in SPSS. p value <0.05 was considered statistically significant.

Results

33 patients (48.5% male, age at diagnosis 45.9±21 years) were included in this study. The optimal cut-offs for each parameter obtained from the ROC curves were the following: left ventricle dyastolic diameter >55mm, left atrial diameter >40mm, pulmonary artery systolic pressure >22mmHg and left ventricle ejection fraction <40%. The area under the curve for the EcoScore to predict any adverse event was 0.850 (p=0.017) and an EcoScore >1 had a sensibility of 85.7% and a specificity of 70%.

Conclusion

The EcoScore accurately predicted the occurrence of at least one adverse event in this population. Thus, it could be a good tool in the daily practice to select patients who may benefit from a more aggressive surveillance and treatment.

Funding Acknowledgement

Type of funding sources: None.

NISAR-F SCORE: a simple risk stratification tool for patients implanted with cardiac resynchronization therapy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Outcomes in this group of patients are influenced by multiple factors and a comprehensive and customized approach to estimate prognosis after CRT is lacking

Aims

To develop and validate a simple prognostic score for patients implanted with CRT (NISAR-F score), based on readily available clinical and echocardiographic variables to predict the combined endpoints of death or hospitalization in 24 months.

Methods

A single-centre retrospective study was conducted with inclusion of all consecutive patients who underwent CRT implantation between 2012 and 2019. Follow-up started after CRT implantation and ended upon death, hospitalization or 24 months after study entry. Survival analysis was performed using a multivariate Cox regression model, in order to analyze the effect on survival /hospitalization in 24 months of the following factors: age, gender, NYHA Class III-IV, ischemic heart failure, type 2 diabetes, arterial hypertension, dyslipidemia and ejection fraction < 21%. According to the analysis, points were attributed to each factor. Afterwards, the NISAR-F score was calculated for each patient, summing the points of each variable. The authors finally created ROC curves for the NISAR-F score to predict the occurrence of the combined endpoint in 2 groups of patients: CRT responders (ejection fraction increase of at least 10% after CRT implantation) and CRT non-responders. The statistical analysis was performed in SPSS.

Results

102 patients were included in the study (75.4% male, mean age 68 ± 10.46 years). 10(9.8%) of the patients were re-hospitalized and 8 (7.8%) died during the 24-month follow-up.  After calculating NISAR-F score for each patient, area under ROC curves were obtained. The analysis of the ROC curves allows us to confirm the good performance of the score created [responders group (AUC 0.812) vs non-responders (AUC 0.721)].

Conclusion The NISAR-F score is a useful tool to predict the combined endpoint (mortality and hospitalization in 24 months) after CRT implantation, in both responders and non-responders, revealing good performance of this new and simple score based only on clinical and echocardiographic variables.

The impact of lipid profile in acute coronary syndrome: young patient vs old patient

Funding Acknowledgements

Type of funding sources: None.

Introduction

Several studies have suggested a relationship between dyslipidemia and atherogenesis, which displays a main role in the pathophysiology of Acute Coronary Syndrome (ACS).

Aim

To compare the lipid profile between younger (<55 years) and older (≥55 years) patients admitted due to ACS.

Methods

A single-centre retrospective study was conducted, with inclusion of all consecutive patients admitted in the Cardiology Department due to ACS. Several analytical parameters were evaluated, including total cholesterol (CT), HDL cholesterol (HDL), LDL cholesterol (LDL) and triglycerides (TG) and CT/HDL, LDL/HDL and TG/HDL ratios were calculated. All parameters are presented in mg/dL. Afterwards, comparison of these data between younger (age < 55 years, Group-A) and older (age≥55 years, Group-B) patients was done. Statistical analysis was performed with SPSS and a p value < 0.05 was considered statistically significant.

Results

1168 patients (70.1% male, mean age 69 ±12 years) were included in this study. 15.8% of patients were from Group-A. Mean levels of the analysed parameters were the following: CT 176 ± 55, LDL 111 ± 45, HDL 40 ± 12 and TG 137 ± 102. The following mean ratios were obtained: CT/HDL 4.6 ± 1.9, LDL/HDL 2.9 ± 1.4 and TG/HDL 3.8 ± 3.5. Comparison of the analysed parameters and calculated ratios is exhibited in table 1.

Conclusion

Overall, a worse lipid profile was observed in younger patients. This data reveals the role of dyslipidemia in coronary heart disease, which displays a main role in atherosclerosis at a younger age. This fact highlights the importance of adopting a healthy lifestyle and the adherence to primary and secondary prevention measures of cardiovascular events.

Lipid profile: young vs old patient Group A Group B Total Cholesterol 199 ± 44 170 ± 56 p < 0.001 LDL Cholesterol 128 ± 37 107 ± 46 p < 0.001 HDL Cholesterol 39 ± 10 40 ± 12 p = 0.307 Triglycerides 195 ± 189 125 ± 66 p < 0.001 CT/HDL 5.3 ± 1.5 6.8 ± 2.0 p < 0.001 LDL/HDL 3.4 ± 1.1 2.8 ± 1.4 p < 0.001 TG/HDL 5.6 ± 6.3 3.5 ± 2.5 p < 0.001

The effects of smoking and alcoholism in acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

Several studies have concluded that smoking increases mortality in patients with coronary disease. On the other hand, a J-shaped dose-effect curve has been used to describe the relationship between alcohol and cardiovascular mortality. According to the majority of studies, a moderate intake of alcohol is associated with a decrease in mortality, while an excessive alcohol intake appears to increase mortality.

Aim

To evaluate the effect of smoking and excessive alcohol intake in hospital mortality and 1-year mortality in patients hospitalized due to acute coronary syndrome (ACS).

Methods

A single-centre retrospective study was conducted, with inclusion of all consecutive patients admitted in the Cardiology Department due to ACS. Follow-up started after hospital admission and ended upon hospital death, death within the following 12 months or 12 months after study entry. Patients were divided in two groups: smokers (Group-A) and non-smokers (Group-B), to analyse the effect of smoking in hospital mortality and 1-year mortality. To analyse the effect of excessive alcohol intake, patients were also divided in other two groups: Group-C (excessive drinkers) and Group-D (non-excessive drinkers). Statistical analysis was performed with SPSS and a p value < 0.05 was considered statistically significant.

Results

1120 patients (68.9% male, mean age 69.12 ± 12.67 years) were included in this study. 20.5% were smokers and 3.2% had a previous excessive alcohol intake.

Between Group-A and Group-B, a statistically significant difference was observed in gender (93.1% male in Group-A vs 62.9% male in Group-B, p = 0.002), but not in age (p = 0.116). Hospital mortality rates in Group-A and Group-B were respectively 6.0% and 8.7% (p = 0.191) and 1-year mortality rates were 3.1% vs 5.1% (p = 0.239).

Between Group-C and Group-D, a statistically significant difference was observed in gender (94.4% male in Group-C vs 69.8% male in Group-B, p < 0.001), but not in age (p = 0.730). Hospital mortality rates in Group-C and Group-D were respectively 25% and 9.6% (p = 0.003) and 1-year mortality were 3.8% vs 6.6% (p = 0.577).

Conclusions

Smoking did not have a positive or negative effect in hospital mortality and 1-year mortality. However, excessive alcohol intake was associated with increased hospital mortality in this population.

A dual high-energy radiography platform with 15 μm resolution at the National Ignition Facility

To study matter at extreme densities and pressures, we need mega laser facilities such as the National Ignition Facility as well as creative methods to make observations during timescales of a billionth of a second. To facilitate this, we developed a platform and diagnostic to characterize a new point-projection radiography configuration using two micro-wires irradiated by a short pulse laser system that provides a large field of view with up to 3.6 ns separation between images. We used tungsten-carbide solid spheres as reference objects and inferred characteristics of the back-lighter source using a forward-fitting algorithm. The resolution of the system is inferred to be 15 μm (using 12.5 μm diameter wires). The bremsstrahlung temperature of the source is 70-300 keV, depending on laser energy and coupling efficiency. By adding the images recorded on multiple stacked image plates, the signal-to-noise of the system is nearly doubled. The imaging characterization technique described here can be adapted to most point-projection platforms where the resolution, spectral contrast, and signal-to-noise are important.

Portuguese Consensus on Diagnosis, Treatment, and Management of Anemia in Pediatric Inflammatory Bowel Disease

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), both in pediatric and in adult patients. Iron deficiency is the main cause of anemia in patients with IBD. Anemia is a clinically relevant comorbidity, with impact on patients' quality of life and it should be timely diagnosed and adequately treated. Currently, an active treatment approach is the recommended strategy, with evidence showing efficacy and safety of intravenous iron formulations. However, evidence in pediatric age remains scarce and no clinical recommendations exist for the diagnosis and treatment of this particular age group. The present document represents the first national consensus on the management of anemia in pediatric IBD and is therefore particularly relevant. The authors anticipate that the proposed recommendations will be useful in daily clinical practice for diagnosing and managing iron deficiency and iron-deficiency anemia in the pediatric population with IBD.

Erratum: Martins, M.S., et al. Wideband and Wide Beam Polyvinylidene Difluoride (PVDF) Acoustic Transducer for Broadband Underwater. Sensors 2019, 19, 3991

The authors wish to make the following erratum to this paper [...].

Wideband and Wide Beam Polyvinylidene Difluoride (PVDF) Acoustic Transducer for Broadband Underwater Communications

The advances in wireless communications are still very limited when intended to be used on Underwater Communication Systems mainly due to the adverse proprieties of the submarine channel to the acoustic and radio frequency (RF) waves propagation. This work describes the development and characterization of a polyvinylidene difluoride ultrasound transducer to be used as an emitter in underwater wireless communications. The transducer has a beam up to 10° × 70° degrees and a usable frequency band up to 1 MHz. The transducer was designed using Finite Elements Methods and compared with real measurements. Pool trials show a transmitting voltage response (TVR) of approximately 150 dB re µPa/V@1 m from 750 kHz to 1 MHz. Sea trials were carried in Ria Formosa, Faro (Portugal) over a 15 m source-receiver communication link. All the signals were successfully detected by cross-correlation using 10 chirp signals between 10 to 900 kHz.

Discovery of key whole-brain transitions and dynamics during human wakefulness and non-REM sleep

The modern understanding of sleep is based on the classification of sleep into stages defined by their electroencephalography (EEG) signatures, but the underlying brain dynamics remain unclear. Here we aimed to move significantly beyond the current state-of-the-art description of sleep, and in particular to characterise the spatiotemporal complexity of whole-brain networks and state transitions during sleep. In order to obtain the most unbiased estimate of how whole-brain network states evolve through the human sleep cycle, we used a Markovian data-driven analysis of continuous neuroimaging data from 57 healthy participants falling asleep during simultaneous functional magnetic resonance imaging (fMRI) and EEG. This Hidden Markov Model (HMM) facilitated discovery of the dynamic choreography between different whole-brain networks across the wake-non-REM sleep cycle. Notably, our results reveal key trajectories to switch within and between EEG-based sleep stages, while highlighting the heterogeneities of stage N1 sleep and wakefulness before and after sleep.

Sleep is composed of a number of different stages, each associated with a different pattern of brain activity. Here, using a data-driven Hidden Markov Model (HMM) of fMRI data, the authors discover a more complex set of neural activity states underlying the conventional stages of non-REM sleep.

Autoimmune pancreatitis with associated ulcerative colitis in a teenager

Autoimmune pancreatitis (AIP) is a rare entity that is extremely uncommon in children. Its diagnosis is also a clinical challenge. This form of chronic pancreatitis often presents itself with obstructive jaundice and/or a pancreatic mass and it is sometimes misdiagnosed as pancreatic cancer. We describe the case of a 13-year-old boy with obstructive jaundice and a 4 cm mass in the head of the pancreas that was diagnosed as AIP with associated ulcerative colitis.

Non-adenomatous sellar lesions: single-centre 10-year experience

OBJECTIVE

A minority of lesions found in the sellar region are non-adenomatous neoplastic, inflammatory, or cystic masses. Our study aims to describe the prevalence and characteristics of these lesions in a multidisciplinary pituitary outpatient clinic.

DESIGN

We conducted an observational study which included 36 patients (15.9% of those followed up in this outpatient clinic between 2006 and 2016 who had pituitary surgery) submitted to pituitary surgery with histological results showing a non-adenomatous sellar lesion. We evaluated clinical, radiological, and biochemical (pituitary function) characteristics during the pre-operative and post-operative period.

RESULTS

Thirty-six patients (50% female) with a mean age of 41.3 ± 21.9 years and a mean follow-up duration of 8.0 ± 9.0 years were included. Histologic diagnoses were divided into benign neoplasms (80.6%), malignant neoplasms (11.1%), inflammatory lesions (5.6%), and cystic masses (2.8%). The most common clinical presentation was headache (66.7%) and visual defects (61.1%). Forty-seven percent of patients had at least one pituitary axis insufficiency at the time of diagnosis. In the majority of cases (58.3%), a transsphenoidal approach was used for the initial pituitary surgery. Thirteen patients had more than one pituitary surgery and eight also had radiotherapy. At the time of data retrieval, five patients had no pituitary hormonal insufficiency and 13 patients had some visual defect improvement.

CONCLUSIONS

Although rare, non-adenomatous sellar lesions may be associated with significant causes of morbidity, such as hypopituitarism and visual defects, per se or due to the various treatment modalities employed. Moreover, since the lesions are difficult to distinguish from adenomas, these patients require a careful multidisciplinary approach.

Impacto Alimentar Esofágico, um Dilema Diagnóstico

O impacto alimentar esofágico é uma situação que na maioria dos casos é secundária a patologia esofágica congénita ou adquirida, podendo constituir a primeira manifestação da doença. Descreve-se um rapaz, 11 anos, saudável, com sialorreia e dor retrosternal que surgiram subitamente durante o jantar. Foi submetido a endoscopia digestiva alta, que revelou um fragmento de carne impactado no terço distal do esófago (que foi extraído) e estrias longitudinais na mucosa. A análise histológica das biópsias esofágicas foi compatível com eosinofilia esofágica. Iniciou terapêutica com inibidor da bomba de protões com melhoria clínica e histológica. O diagnóstico diferencial das principais causas de impacto alimentar associadas a eosinofilia esofágica, nomeadamente esofagite eosinofílica, doença do refluxo gastroesofágico e eosinofilia esofágica respondedora a inibidor da bomba de protões, constitui um desafio clínico. Recebido: 15/10/2016 - Aceite: 11/12/2017

"Two-step" technique with OsiriX™ to evaluate feasibility of C2 pedicle for surgical fixation

BACKGROUND

Surgical treatment of craniovertebral junction pathology has evolved considerably in recent decades with the implementation of short atlanto-axial fixation techniques, notwhithstanding increasing neurovascular risks. Also, there is strong evidence that fixation of C2 anatomical pedicle has the best biomechanical profile of the entire cervical spine. However, it is often difficult and misleading, to evaluate anatomical bony and vascular anomalies using the three orthogonal planes (axial, coronal, and sagittal) of CT.

OBJECTIVES

The authors describe an innovative and simple technique to evaluate the feasibility of C2 pedicle for surgical screw fixation using preoperative planning with the free DICOM (Digital Imaging and Communications in Medicine) software OsiriX™.

MATERIALS AND METHODS

The authors report the applicatin of this novel technique in 5 cases (3 traumatic, 1 Os Odontoideum, and 1 complex congenital malformation) collected from our general case series of the Department in the last 5 years.

RESULTS

In this proof of concept study, the pre-operative analysis with the two-step tecnique was detrimental for choosing the surgical tecnique. Detailed post-operative analysis confirmed correct position of C2 screws without cortical breach. There were no complications or mortality reported.

CONCLUSION

This two-step technique is an easy and reliable way to determine the feasibility of C2 pedicle for surgical fixation. The detailed tridimensional radiological preoperative evaluation of craniovertebral junction anatomy is critical to the sucess and safety of this surgeries, and can avoid, to certain degree, expensive intra-operative tridimensional imaging facilities.

Autoimmune hepatitis: trust in transaminases

A rational and appropriate evaluation of liver biochemical tests is essential, given the increased number of abnormal laboratory results in asymptomatic patients. Critical judgement allows early diagnosis in the absence of typical clinical signs. Autoimmune hepatitis is a rare disease with high clinical variability. We present a child investigated for unexplained increase in aminotransferases, discovered accidentally 2 months earlier in a standard laboratory panel approach. She was asymptomatic and no physical signs of chronic or acute liver disease were found. Laboratory investigation showed hypergammaglobulinaemia with selective elevation of IgG and a positive anti-liver cytosol type 1. Severe interface hepatitis was found on liver biopsy and treatment was initiated with steroids and azathioprine with good response. This case highlights the importance of trusting in any serum aminotransferase abnormality, even in asymptomatic children and emphasises the value of clinical suspicion and specific immunosuppressive therapy in prognosis.

Living versus cadaveric-donor renal transplant recipients: a comparison on sexual function

Erectile dysfunction is experienced by 50% of men with end-stage renal disease (ESRD) and uremia. The origin of this dysfunction is multifactorial. The aim of this study was to compare living donor versus cadaveric donor transplant recipients regarding male sexual function. Seventy-seven sexually active male kidney transplant recipients (44 from living donors; 33 from cadaveric donors) were randomly selected from our single-center prospective database of 2016 renal transplants. Epidemiological and clinical data were collected between June 2010 and June 2011. Male sexual function was evaluated with the International Index of Erectile Function questionnaire (IIEF-15). We assessed the prevalence of male sexual dysfunction according to established cutoff points for each of the IIEF-15 domains. Mann-Whitney and Pearson's chi- square statistical tests were used to compare continuous and categorical variables, respectively. The median age at the time of completion of the questionnaires was 43 and 51 years (P = .003) with median times from transplantation was of 36 and 42 months for living donor and cadaveric donor recipients, respectively (P = .31). Median durations of ESRD before surgery were 17.5 and 57 months for living donor and cadaveric donor recipients, respectively (P < .001). Living donor and cadaveric donor recipients had median creatinine clearance values of 55 and 57 mL/min, respectively (P = .44). Median time after renal transplantation for first sexual intercourse was 1 and 2 months for living donor and cadaveric donor recipients, respectively (P = .35). Median body mass indices for living donor and cadaveric donor recipients were 24.8 and 24, respectively (P = .31). Regarding sexual function domains, there were significant differences only for intercourse satisfaction. In our cohort, living donor recipients tended to be younger, have shorter time of ESRD, and less incidence of hypertension or diabetes mellitus but with greater tobacco use. In conclusion, living donor transplantation exerted a favorable impact on sexual function.

Functional graph alterations in schizophrenia: a result from a global anatomic decoupling?

During rest, the brain exhibits slow hemodynamic fluctuations (<0.1 Hz) that are correlated across spatially segregated brain regions, defining functional networks. Resting-state functional networks of people with schizophrenia were found to have graph properties that differ from those of control subjects. Namely, functional graphs from patients exhibit reduced small-worldness, increased hierarchy, lower clustering, improved efficiency and greater robustness. Notably, most of these parameters correlate with patients' cognitive performance.To test if a brain-wide coupling deficit could be at the origin of such network reorganization, we use a model of resting-state activity where the coupling strength can be manipulated. For a range of coupling values, the simulated functional graphs obtained were characterized using graph theory.For a coupling range, simulated graphs shared properties of healthy resting-state functional graphs. On decreasing the coupling strength, the resultant functional graphs exhibited a topological reorganization, in the same way as described in schizophrenia.This work shows how complex functional graph alterations reported in schizophrenia can be accounted for by a decrease in the structural coupling strength. These results are corroborated by reports of lower white matter density in schizophrenia.

[Pediatric inflammatory bowel disease: is it still increasing?]

INTRODUCTION

Crohn's disease (CD), Ulcerative Colitis (UC) and Indeterminate Colitis (IC), commonly known as Inflammatory Bowel Disease (IBD) represent a heterogeneous group of chronic diseases of unknown origin and varying course, diagnosed in pediatric age at 25 to 30% of cases. Epidemiological international studies studies show IBD incidence has increased exponentially in industrialized nations over the last 50 years.

OBJECTIVES

Characterization of the pediatric population diagnosed with IBD, followed at medical consultation in Gastroenterology at Hospital de Dona Estefânia (HDE).

MATERIAL AND METHODS

Descriptive and retrospective study by consulting the medical files of patients diagnosed with IBD followed between 1987 and 2009 (23 years). Clinical, radiological and histological criteria were used to define IBD. The following variables were studied: sex, family history, race, characterization of IBD, age at diagnosis, time from onset of symptoms to diagnosis and clinical presentation. Four different periods of time were compared: 1987-1992, 1993-1998, 1999-2004 and 2005-2009.

RESULTS

100 children were included (51 female), of which 59% are CD, 38% UC and 3% IC. Family history of IBD was present in 7 cases, with no sex difference between UC and CD. During the period of time between 2005-2009, it was registered the highest number of new cases (55 total, mean: 11 cases / year) and between 1987-1992 the lowest (9, 1.5 cases / year). Time from onset of symptoms to diagnosis was highly variable, ranging from 9 months (1987-1992) to 4 months (2005-2009). Children's age at the time of diagnosis varied from 14 months to 17 years, with a mean of 10.5 years. The most common symptoms at time of presentation were abdominal pain, diarrhea, and hematochezia.

CONCLUSION

IBD are a heterogeneous group of diseases, not always easy to diagnose and difficult to classify as diagnostic criteria are not always uniform. The results show the number of IBD new cases has been rising during the last two decades, mainly CD, with no difference between gender. Time from onset of symptoms to diagnosis has been decreasing although age at time of diagnosis and clinical presentation has showed no difference in the last 20 years.

Prevalence and incidence of Helicobacter pylori Infection in a healthy pediatric population in the Lisbon area

BACKGROUND

Helicobacter pylori is mainly acquired in childhood. Although adult studies reported a high prevalence of H. pylori infection in Portugal, the actual rate in children remains unknown. This study aimed to determine the prevalence and the incidence of H. pylori infection in an asymptomatic pediatric population of the Lisbon area and to correlate prevalence with sociodemographic determinants.

MATERIALS AND METHODS

Helicobacter pylori infection was determined by stool antigen test in 844 asymptomatic children (age 0-15 years; 49.4% boys). For the incidence study, H. pylori-negative children in the prevalence study were followed-up every 6 months over a 3-year period.

RESULTS

The global prevalence of H. pylori infection was 31.6%, increasing with age (19.9, 37.0 and 51.5%, in age groups 0-5, 6-10, and 11-15, respectively), but was similar among genders (34.5% in boys and 28.4% in girls). Older age and attendance of nursery/kindergarten during preschool constituted independent risk factors. The overall estimated incidence was 11.6 per 100 child-years (CY). Although 47.5% of children acquired H. pylori infection before 5 years of age, the mean age of acquisition was 6.3. The incidence of infection was similar among the three age groups (11.5, 13.0, and 10.5 per 100 CY, in age groups 0-5, 6-10, and 11-15, respectively).

CONCLUSIONS

The prevalence of H. pylori infection in the Portuguese pediatric population is still high. Although this study confirmed that the highest acquisition rate occurs at young age, it showed that in high-prevalence populations, older children can also acquire H. pylori infection at a rate similar to that of young children.

Diabetes and other glucose metabolism abnormalities in Mexican Zapotec and Mixe Indians

AIMS

Aboriginal populations are experiencing an explosive rise in the prevalence of Type 2 diabetes. The purpose of this study was to estimate the prevalence of diabetes and other glucose metabolism abnormalities in Mexican Zapotec and Mixe Indians and to determine their association with known risk factors.

METHODS

A cross-sectional study was conducted in the southern Mexican state of Oaxaca. Two communities of Zapotec population and three of Mixe population were randomly chosen. Mexican Indians>or=35 years old were invited to participate; 394 Zapotec and 730 Mixe Indians participated. Diabetes and other glucose metabolism abnormalities were diagnosed using standard World Health Organization criteria after an oral glucose tolerance test. Prevalence and odds ratio (OR) were estimated with 95% confidence intervals (95% CI).

RESULTS

The crude prevalence of diabetes was 8.19% (95% CI 6.7-9.9%) and the age- and sex-adjusted prevalence was 8.27%, significantly higher among Zapotec (8.71%) than among Mixe Indians (6.90%). The prevalence of impaired glucose tolerance was 9.9% and 4.7% of the studied subjects had impaired fasting glucose. The main risk factors related to the occurrence of diabetes were a family history of diabetes (OR 4.1; 95% CI 1.9-8.8), obesity (OR 3.0; 95% CI 1.6-5.6), hypertension (OR 2.6; 95% CI 1.5-4.7) and a high-risk waist-hip ratio (4.6; 95% CI 1.2-17.7).

CONCLUSIONS

The prevalence of diabetes is high in this population, the highest so far reported in Mexican Indians. Mexico's health system faces a huge challenge to avert the advanced spread of diabetes in this susceptible population.

[Hereditary pancreatitis in a child]

Hereditary pancreatitis is defined as a family history of two or more relatives with pancreatitis and clinical, biochemical, or radiologic evidence of pancreatitis. This is the fourth family described with hereditary pancreatitis related to mutation c.364C>T (p.R122C) of PRSS1 gene. The index case was a four year old child who had had his first episode of abdominal pain at age three. At that time he was admitted in hospital for two days and he improved with analgesic treatment only. One year later, in a second similar episode, he had been diagnosed with pancreatitis. His father was submitted to pancreato-duodenectomy (Whipple procedure) when he was 27 years old due to recurrent pancreatitis since age 19. Paternal grandfather and the parents of this grandfather had been diagnosed with diabetes mellitus. The mutation R122C was present in heterozigoty, in the exon 3 of PRSS1 gene, in the index case and also in his father. The importance of a long term follow-up is highlighted, taking into consideration the risk of ductal pancreatic adenocarcinoma.

[Paediatric Burkitt lymphoma presenting as acute pancreatitis]

Pancreatitis in children and adolescents is uncommon and its causes are more varied in this age group than in adults. A tumoral aetiology is particularly rare. We present the case of a 13-year-old boy who was admitted to our Intensive Care Unit with the diagnosis of acute pancreatitis, bilateral pleural effusion and ascites. Serial sonographic and computed tomography evaluations were suggestive of an infiltrative process of the gastric wall. Endoscopy showed an infiltrative tumor of the gastric mucosa and duodenum with a giant ulcer. Biopsies were compatible with Burkitt Lymphoma confirmed by ascitic fluid cytology and cytometry. Because of severe progressive cholestasis a temporary biliary stent was placed in the common bile duct. After staging (stage III), the patient was treated according to FAB LMB 96 chemotherapy protocol, achieving complete remission. Acute pancreatitis and cholestasis are rare presentations of lymphoma in the paediatric age group.

Limitations in knowledge of HIV transmission among HIV-positive patients accessing case management services in a resource-poor setting

HIV has increasingly become an infection of poverty. Adequate HIV transmission knowledge among HIV-positive patients is necessary to reduce the risk of secondary infection and protect those who are uninfected from transmission. This study was conducted among individuals enrolled in a program that serves impoverished HIV patients in the Boston area. Although the mean HIV transmission knowledge score was 80% for this group, a significant proportion of patients demonstrated limitations in knowledge of HIV transmission. Highly vulnerable patients, such as those who reported not accessing HIV medications, a history of sexual abuse, or problems getting clothing, had lower levels of HIV knowledge. This paper hopes to alert providers that their most vulnerable patients may be at an increased risk of re-infection or transmission due to limited HIV knowledge. Programs that serve HIV-positive patients coping with poverty and other serious problems need to ensure adequate knowledge of HIV transmission to reduce the overall burden of HIV in resource-poor settings.

Evaluation of rapid test Assure Helicobacter pylori for diagnosis of H. pylori in pediatric population

Non-invasive tests are needed to assess Helicobacter pylori infection, especially to screen a pediatric population. Assure H. pylori Rapid Test (Genelabs Diagnostics, Singapore) is an immunochromatographic assay device intended for the rapid detection of antibodies to H. pylori in human serum, plasma or whole blood. The aim of this study was to evaluate the performance of the rapid test, Assure H. pylori, in the diagnosis of H. pylori infection in children, using a Portuguese pediatric population. The study group included 130 children with age ranging from 1 to 14 years old (average age 9.2+/-3.1 years). According to the gold standard, 70 of the 130 patients studied were H. pylori positive and 60 were H. pylori negative. Using Assure H. pylori Rapid Test (Genelabs Diagnostics, Singapore), 53 sera had a positive result after 15 min (resulting in 17 false negatives) and 57 sera a negative result (resulting in 3 false positives). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the test were 75.7%, 95.0%, 94.6% and 77.0% respectively. When a longer read time of 45 min is considered, the rapid test revealed a good performance (sensitivity 98.6% and specificity 95%) in the evaluation of the H. pylori infection in a pediatric population. In conclusion, the test showed a good performance, suggesting its applicability as a screening method for the H. pylori infection.

Helicobacter pylori virulence genotypes in Portuguese children and adults with gastroduodenal pathology

The aim of this study was to evaluate the prevalence of virulence genotypes, namely cagA, vacA and babA2, of Helicobacter pylori strains isolated from Portuguese adults and children presenting gastroduodenal pathology. One hundred thirty-six strains were studied, 82 isolated from adult patients (50 with nonulcerative gastritis and 32 with active peptic ulcer) and 58 isolated from children (54 with nonulcerative gastritis and 4 with duodenal ulcer). Genotyping of cagA, vacA and babA2 was assessed by polymerase chain reaction. Overall, Helicobacter pylori strains carrying more virulent genotypes were much more prevalent in adults than in children, particularly the type I ( vacAs1- and cagA-positive) and the triple-positive ( vacAs1-, cagA- and babA2-positive) strains ( P<0.001). A subpopulation of adults and children with nonulcerative gastritis was also studied, and differences in the prevalence of virulent genotypes were observed, either for individual genotypes ( P=0.017 for cagA, P=0.010 for vacAs1) or in combinations, i.e. the type I genotype ( P=0.005) and the triple-positive strains ( P=0.031). There was no difference between the two populations in the distribution of babA2 and m1/m2 genotypes. Considering the cohort effect in the epidemiology of Helicobacter pylori infection, these results suggest that different strains might circulate during different periods of time, or that, after infection in childhood, individual strains will undergo changes during the course of infection.

Study on the scale-up of human IgG3 purification using protein A affinity chromatography

The purification of human IgG3 subclass out of IgG (Immunoglobulin-G) was studied using protein A-Sepharose affinity chromatography. The effect of operational parameters such as flow rate, ionic strength, pH and size of sample was investigated, and the process was scaled-up 10-fold. The use of 0.5 m NaCl in the loading buffer had a dramatic effect in the purity of IgG3 recovered in the flowthrough fraction (values in the order of 97% were consistently obtained). This was attributed to a more effective binding of IgG subclasses 1, 2 and 4 to protein A (well known classical mechanism based in Fc fragment) and in some extent to a decrease in the binding of subclass 3 to protein A by the alternative mechanism based in the Fab fragment. The increase in residence time also increased in a relevant way the purity of IgG3. This is attributed to an increased effectiveness of the mechanisms mentioned above. The recovery yields in the IgG3 rich fraction were in the range 21-32% and are possibly a consequence of binding to protein A by the alternative mechanism and also due to deactivation during processing.

Dermatitis herpetiformis: should direct immunofluorescence be the only diagnostic criterion?

We describe a 7-year-old boy with dermatitis herpetiformis (DH) diagnosed on clinical and histologic evidence, negative direct immunofluorescence (DIF) findings for junctional IgA deposits in uninvolved skin, positive IgA endomysial and gliadin antibodies, and jejunal biopsy revealing a gluten-sensitive enteropathy. Treatment with dapsone led to the disappearance of cutaneous lesions and pruritus within 48 hours. Demonstration of IgA immune deposits in the dermal papillae has been the only acceptable criterion for the diagnosis of dermatitis herpetiformis. However, considering several reports in the literature of DH with a negative DIF and our own case, we believe that in the absence of the characteristic DIF pattern, one needs the combination of clinical, histologic, and immunologic data to support the diagnosis of DH. We also discuss recent developments in the diagnosis of DH.

Evaluation of a Western blot test, Helico blot 2.1, in the diagnosis of Helicobacter pylori infection in a pediatric population

BACKGROUND

Noninvasive diagnostic tests are useful as screening tools for Helicobacter pylori infection in pediatric populations. The aim of this study was to evaluate performance of the immunoblot assay, Helico Blot 2.1, for the diagnosis of H. pylori infection in symptomatic children.

MATERIALS AND METHODS

Immunoblot assay was used for detection of IgG antibodies to specific H. pylori proteins and to a recombinant H. pylori antigen, CIM marker. The study was performed on sera collected from 134 symptomatic, untreated children (mean age, 9.1 +/- 3.2 years; range, 1-14 years). H. pylori infection status was determined by culture, histology and rapid urease test.

RESULTS

Immunoblot assay yielded a positive result in 71 of the 72 infected patients (sensitivity 98.6%) and in eight of the 62 noninfected ones (specificity 87.1%). The predictive values for a positive and a negative result were 89.9% and 98.2%, respectively. The performance of the CIM band alone, as a marker for H. pylori infection status, was also evaluated. This band was present on the blot of 71 infected patients and on four of the 62 H. pylori-negative patients. The sensitivity, specificity, PPV and NPV of the CIM antigen were 98.6%, 93.5%, 94.7% and 98.3%, respectively.

CONCLUSIONS

The immunoblot assay Helico Blot 2.1 is a suitable noninvasive test for the serodiagnosis of H. pylori infection in children. The good level of performance demonstrated by the novel recombinant antigen CIM suggests it may be a useful contribution to the qualitative and quantitative performance of the Helico Blot 2.1 in pediatric populations.