Ketamine subcutaneous continuous infusion for depressive symptoms at home: A case report beyond pain use

OBJECTIVES

Ketamine has been widely used in refractory pain as an opioid adjuvant. Evidence suggests that ketamine can also have an essential role in easing depressive symptoms. Its rapid onset of action makes it a valuable choice in palliative care.

METHODS

We present a case of a 70-year-old man with stage IV renal carcinoma and bone metastasis. The main symptoms included neuropathic pain, depression, and a persistent and severe desire for death.

RESULTS

We started continuous subcutaneous infusion with morphine 30 mg and ketamine 100 mg/day. The dose of ketamine was incremented to the maximum of 250 mg/day. During the 28-day treatment, we observed an overall improvement in neuropathic pain, depressive symptoms, and other end-of-life psychological aspects of distress. Only minor psychological side effects were identified, which were controlled by using midazolam in the continuous subcutaneous infusion.

SIGNIFICANCE OF RESULTS

Some studies have already demonstrated the benefits of ketamine use in alleviating depression, using parental infusion or oral formulas, which are administered in hospice care. Our report enhances the benefit of the subcutaneous route for palliative patients cared for at home.

Optimized 3D printed zirconia-reinforced leucite with antibacterial coating for dental applications

OBJECTIVES

This study aims to produce by robocasting leucite/zirconia pieces with suitable mechanical and tribological performance, convenient aesthetics, and antibacterial properties to be used in dental crown replacement.

METHODS

Leucite pastes reinforced with 12.5%, 25%, and 37.5% wt. ZrO2 nanoparticles were prepared and used to print samples that after sintering were characterized in terms of density, shrinkage, morphology, porosity, mechanical and tribological properties and translucency. A coating of silver diamine fluoride (SDF) and potassium iodide (KI) was applied over the most promising material. The material's antibacterial activity and cytotoxicity were assessed.

RESULTS

It was found that the increase of ZrO2 reinforcement up to 25% enhanced both microhardness and fracture toughness of the sintered composite. However, for a superior content of ZrO2, the increase of the porosity negatively affected the mechanical behaviour of the composite. Moreover, the composite with 25% ZrO2 exhibited neglectable wear in chewing simulator tests and induced the lowest wear on the antagonist dental cusps. Although this composite exhibited lower translucency than human teeth, it was three times higher than the ZrO2 glazed material. Coating this composite material with SDF+KI conferred antibacterial properties without inducing cytotoxicity.

SIGNIFICANCE

Robocasting of leucite reinforced with 25% ZrO2 led to best results. The obtained material revealed superior optical properties and tribomechanical behaviour compared to glazed ZrO2 (that is a common option in dental practice). Moreover, the application of SDF+KI coating impaired S. aureus proliferation, which anticipates its potential benefit for preventing pathogenic bacterial complications associated with prosthetic crown placement.

Chronic gastric volvulus with diaphragmatic eventration: Case presentation

INTRODUCTION AND IMPORTANCE

Gastric volvulus is a rare clinical entity which occurs due to the rotation of the stomach and can have life-threatening complications. This condition can have an acute or chronic presentation and its symptoms will vary according to the degree of obstruction and rapidity of onset.

CASE PRESENTATION

We report a case of a 84-year-old male with history of frequent periods of constipation and lack of appetite who presented to the emergency room with left-sided abdominal pain and distension and persistent nausea, without the ability to vomit. Abdominal radiograph, computed tomography scan of the abdomen, contrast-enhanced examination and upper endoscopy were consistent with a gastric volvulus secondary to diaphragmatic eventration. The patient's symptoms resolved after nasogastric tube placement and fluid resuscitation. However, he was proposed to a laparoscopic anterior gastropexy to prevent symptom recurrence. He remains asymptomatic after 3 years of follow-up.

CLINICAL DISCUSSION

The diagnosis of gastric volvulus is based mainly on clinical presentation and abdominal imaging. The main principles of surgical intervention include stomach decompression with volvulus reduction, followed by gastropexy and correction of any predisposing intra-abdominal factors.

CONCLUSION

Definitive treatment of both acute and chronic gastric volvulus includes a surgical approach. Laparoscopic anterior gastropexy has been found to be a viable alternative in these patients.

Bioelectrical Impedance Analysis (BIA) for the Assessment of Body Composition in Oncology: A Scoping Review

Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.

Does pro-environmental attitude predicts pro-environmental behavior? Comparing sustainability connection in emotional and cognitive environments among football fans and university students

Environmental sustainability is an imperative topic in contemporary business-related research, aiming to understand and predict how individuals' environmentally friendly behaviors can be encouraged. This research aims to empirically examine the relationship between individuals' pro-environmental attitude and pro-environmental behavior; and to compare two groups of individuals that encompass emotional and cognitive links to environmental sustainability: emotionally involved sport fans and socially conscious university students. Two studies, involving more than 1400 respondents, were conducted. Study 1 uses structural equation modelling (SEM) to test the relationship between consumers' environmental attitudes and environmental behaviors. Study 2 uses SEM multigroup analysis to compare the attitudes and behaviors of sport fans and university students. The results showed that participants' pro-environmental attitude had a positive and significant effect on pro-environmental behavior. The type of consumer plays an important role in strengthening the relationship between pro-environmental attitude and pro-environmental behavior. Despite the higher average levels of pro-environmental attitude and pro-environment behavior evidenced by the sport fans, the influence of attitude on behavior is higher on socially conscious students, the group with a more cognitive and intrinsic link with the natural environment and sustainability initiatives. Despite the positive link attitudes-behaviors, empirical insights suggest that the connection between sport fans and the club is vital to reinforce the commitment with a stronger match between attitudes and behaviors. The findings also have implications for practitioners and policymakers in optimizing their strategies to encourage effective pro-environmental actions.

Chronic health conditions and school experience in school-aged children in 19 European countries

This study investigates chronic conditions (CC) prevalence among children in mainstream schools, their school experience and life satisfaction in Europe. Data were collected from the 2017/2018 HBSC survey, a cross-national study using self-reported questionnaires administered in classrooms. Nationally representative samples of children aged 11, 13, and 15 years in mainstream schools from 19 European countries (n = 104,812) were used. School experience was assessed using four variables: low school satisfaction, schoolwork pressure, low teacher support, and peer-victimization, which were related to life satisfaction. Latent class analysis (LCA) was conducted to identify patterns of school experience among students with CC. The prevalence of CC varied from 8.4 (Armenia) to 28.2% (Finland). Children with CC (n = 17,514) rated their school experience and life satisfaction lower than children without CC. LCA identified three school experience patterns: "negative on all items" (37%), "negative on all items, except school pressure" (40%) and "overall positive" (23%). The distribution of subgroups varied across countries-in countries with a higher proportion of children with CC in mainstream schools, children reported more negative school experiences. Compared to the "overall positive" group, low life satisfaction was highest for students classified as "negative on all items" (relative risk (RR) = 2.9; 95% CI 2.2-3.8) with a lesser effect for "negative on all items, except school pressure" (RR) = 1.8; 95% CI 1.4-2.4). These findings provide cross-national data documenting the diversity in inclusive educational practices regarding school placement and school experiences, and suggest that efforts are still needed to allow a fully inclusive environment.

Reuse of lime sludge from immediate one-step lime precipitation process as a coagulant (aid) in slaughterhouse wastewater treatment

The circularity of wastewater treatment subproducts is on the worldwide agenda. In this way, this work aims to evaluate alternatives for the reuse of sludge from slaughterhouse wastewater treatment. Wetted sludges produced in the immediate one-step lime precipitation process were applied directly or first calcined, as a coagulant or coagulant aid, in the absence or presence of Ca(OH)₂, to slaughterhouse wastewaters with different characteristics. For the best sludge reuse, successive reuses of the sludge were carried out and the characteristics of treated slaughterhouse wastewater were evaluated after each reuse. Results showed a great similarity between slaughterhouse and treated slaughterhouse wastewaters using wetted and calcined sludges as a coagulant for highly contaminated slaughterhouse wastewater. In addition, a great similarity was also observed between the calcined and the wetted sludges, both as a coagulant aid, for all the slaughterhouse wastewaters tested. However, the latter consumed more hydrated lime, more volume of sludge sedimented, and higher concentrations phosphorus and organic matter in the treated wastewater. Calcined sludge as a coagulant aid guaranteed the best slaughterhouse wastewater quality for almost of the tested paramenters (≥94% for absorbances at 254 nm and 410 nm, E. coli, turbidity, and phosphorus, chemical oxygen demand between 3 and 91%, and total Kjeldahl nitrogen between 3 and 62%) independently of the wastewater characteristics. Calcined sludge as a coagulant aid can be three times reused for the tested parameters and slaughterhouse wastewater characteristics without significantly decreasing the quality. The successive sludge reused saves the hydrated lime dose applied (up to 28.4%) and the sedimented sludge volume (up to 24.7%), and can be a solution to stabilize sludge due to the pH increase (sludge pH = 12).

Chorea as a Manifestation of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease with multisystemic manifestations, including central nervous system involvement. Chorea is a hyperkinetic movement disorder, characterized by involuntary, dance-like and poorly coordinated movements. Acute-onset chorea is a rare neuropsychiatric inaugural manifestation of SLE. This presentation is frequently associated with positive antiphospholipid antibodies, and it usually improves with immunosuppressive treatment. We report the case of a 20-year-old female, who presented with acute onset left hemichorea and fever. Analysis showed active urine sediment. A detailed anamnesis and evaluation revealed several clinical manifestations suggestive of SLE with multiorgan involvement: neurological, renal, cardiac, hematological, joint and mucocutaneous. This case emphasizes the importance of keeping a high clinical awareness for rarer presentations of common autoimmune disorders, such as SLE, which can be severe and should be promptly treated. Furthermore, the relevance of SLE in the differential diagnosis of acute-onset movement disorders in young patients is highlighted in this report.

Reef Location and Client Diversity Influence the Skin Microbiome of the Caribbean Cleaner Goby Elacatinus evelynae

Fish-associated microorganisms are known to be affected by the environment and other external factors, such as microbial transfer between interacting partners. One of the most iconic mutualistic interactions on coral reefs is the cleaning interactions between cleaner fishes and their clients, during which direct physical contact occurs. Here, we characterized the skin bacteria of the Caribbean cleaner sharknose goby, Elacatinus evelynae, in four coral reefs of the US Virgin Islands using sequencing of the V4 region of the 16S rRNA gene. We specifically tested the relationship between gobies' level of interaction with clients and skin microbiota diversity and composition. Our results showed differences in microbial alpha- and beta-diversity in the skin of gobies from different reef habitats and high inter-individual variation in microbiota diversity and structure. Overall, the results showed that fish-to-fish direct contact and specifically, access to a diverse clientele, influences the bacterial diversity and structure of cleaner gobies' skin. Because of their frequent contact with clients, and therefore, high potential for microbial exchange, cleaner fish may serve as models in future studies aiming to understand the role of social microbial transfer in reef fish communities.

Oral Hygiene in Patients with Stroke: A Best Practice Implementation Project Protocol

Oral hygiene has been shown to reduce adverse events and promote the quality of life of patients with stroke. However, a stroke can result in the impairment of physical, sensory, and cognitive abilities, and comprise self-care. Although nurses recognize its benefits, there are areas for improvement in the implementation of the best evidence-based recommendations. The aim is to promote compliance with the best evidence-based recommendations on oral hygiene in patients with stroke. This project will follow the JBI Evidence Implementation approach. The JBI Practical Application of Clinical Evidence System (JBI PACES) and the Getting Research into Practice (GRiP) audit and feedback tool will be used. The implementation process will be divided into three phases: (i) establishing a project team and undertaking the baseline audit; (ii) providing feedback to the healthcare team, identifying barriers to the implementation of best practices, and co-designing and implementing strategies using GRIP, and (iii) undertaking a follow-up audit to assess the outcomes and plan for sustainability. So, the successful adoption of the best evidence-based recommendations on oral hygiene in patients with stroke will reduce the adverse events related to poor oral care and may improve patients' quality of care. This implementation project has great transferability potential to other contexts.

Fungating Breast Wound: A Rare Manifestation of Primary Breast Leiomyosarcoma

Leiomyosarcomas are the least frequent primary breast sarcomas, making it an extraordinarily rare malignancy. The clinical manifestation of this entity as a fungating breast wound is, on its own, highly unusual in developed nations, mainly due to the improvement of worldwide screening programs and easier access to health care. Management of this breast wound remains challenging, and an accurate histopathological diagnosis is essential for a proper treatment plan. Thus, we present this rare case of metastatic breast leiomyosarcoma to contribute to the scarce literature regarding this disease.

Quality of health care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Norway and trends over time

OBJECTIVE

To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic.

METHODS

Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time.

RESULTS

Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83-4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time.

CONCLUSION

Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored.

Quality of maternal and newborn care around the time of childbirth for migrant versus nonmigrant women during the COVID-19 pandemic: Results of the IMAgiNE EURO study in 11 countries of the WHO European region

OBJECTIVE

To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe.

METHODS

Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women.

RESULTS

Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women.

CONCLUSION

Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all.

Women's perspectives on the quality of hospital maternal and newborn care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina

OBJECTIVE

To assess the quality of maternal and newborn care (QMNC) in countries of the former Yugoslavia.

METHOD

Women giving birth in a facility in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina between March 1, 2020 and July 1, 2021 answered an online questionnaire including 40 WHO standards-based quality measures.

RESULTS

A total of 4817 women were included in the analysis. Significant differences were observed across countries. Among those experiencing labor, 47.4%-62.3% of women perceived a reduction in QMNC due to the COVID-19 pandemic, 40.1%-69.7% experienced difficulties in accessing routine antenatal care, 60.3%-98.1% were not allowed a companion of choice, 17.4%-39.2% reported that health workers were not always using personal protective equipment, and 21.2%-53.8% rated the number of health workers as insufficient. Episiotomy was performed in 30.9%-62.8% of spontaneous vaginal births. Additionally, 22.6%-55.9% of women received inadequate breastfeeding support, 21.5%-62.8% reported not being treated with dignity, 11.0%-30.5% suffered abuse, and 0.7%-26.5% made informal payments. Multivariate analyses confirmed significant differences among countries, with Slovenia showing the highest QMNC index, followed by Croatia, Bosnia-Herzegovina, and Serbia.

CONCLUSION

Differences in QMNC among the countries of the former Yugoslavia during the COVID-19 pandemic were significant. Activities to promote high-quality, evidence-based, respectful care for all mothers and newborns are urgently needed.

CLINICALTRIALS

gov Identifier: NCT04847336.

Rates of instrumental vaginal birth and cesarean and quality of maternal and newborn health care in private versus public facilities: Results of the IMAgiNE EURO study in 16 countries

OBJECTIVE

To explore the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic by facility type among 16 European countries, comparing rates of instrumental vaginal birth and cesarean.

METHODS

Women who gave birth in the WHO European Region from March 1, 2020, to February 7, 2022, answered a validated online questionnaire. Rates of instrumental birth, instrumental vaginal birth, and cesarean, and a QMNC index were calculated for births in public versus private facilities.

RESULTS

Responses from 25 206 participants were analyzed. Women giving birth in private compared with public facilities reported significantly more frequent total cesarean (32.5% vs 19.0%; aOR 1.70; 95% CI 1.52-1.90), elective cesarean (17.3% vs 7.8%; aOR 1.90; 95% CI 1.65-2.19), and emergency cesarean before labor (7.4% vs 3.9%; aOR 1.39; 95% CI 1.14-1.70) (P < 0.001 for all comparisons), with analyses by country confirming these results. QMNC index results were heterogeneous across countries and regions in the same country and were largely affected by geographical distribution of regions rather than by type of facility alone.

CONCLUSION

The study confirms that births in private facilities have higher odds of cesarean. It also suggests that QMNC should be closely monitored in all facilities to achieve high-quality care, independent of facility type or geographical distribution.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Women's perspectives on the quality of maternal and newborn care in childbirth during the COVID-19 pandemic in Latvia: Results from the IMAgiNE EURO study on 40 WHO standards-based quality measures

OBJECTIVE

To investigate women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth during the COVID-19 pandemic in Latvia, comparing the years 2020 and 2021, among women who went into labor or had a prelabor cesarean.

METHODS

Women giving birth in healthcare facilities in Latvia from March 1, 2020, to October 28, 2021, answered an online questionnaire including 40 WHO standards-based quality measures. Descriptive and multivariate quantile regression analyses were performed to compare QMNC in 2020 and 2021.

RESULTS

2079 women were included in the analysis: 1860 women who went into labor (group 1) and 219 with prelabor cesarean (group 2). Among group 1, 66.4% (n = 99/149) of women received fundal pressure in an instrumental vaginal birth, 43.5% (n = 810) lacked involvement in choices, 17.4% (n = 317) reported suffering abuse, 32.7% (n = 609) reported inadequate breastfeeding support while 5.2% (n = 96) lack of early breastfeeding. A significant reduction in QMNC due to the COVID-19 pandemic was reported by 29.5% (n = 219) and 25.0% (n = 270) of respondents in 2020 and 2021, respectively (P = 0.045). Multivariate analyses highlighted a significantly lower QMNC index for 2020 compared with 2021 (P < 0.001).

CONCLUSION

This first study investigating QMNC in Latvia showed significant gaps in QMNC perceived by respondents, with slightly better results in 2021. Appropriate healthcare strategies to improve health care for women and newborns in Latvia are required.

CLINICALTRIALS

gov Identifier:NCT04847336.

Quality of maternal and newborn care in Switzerland during the COVID-19 pandemic: A cross-sectional study based on WHO quality standards

OBJECTIVE

To explore quality of maternal and newborn care (QMNC) in healthcare facilities during the COVID-19 pandemic in Switzerland.

METHODS

Women giving birth in Switzerland answered a validated online questionnaire including 40 WHO standards-based quality measures. QMNC score was calculated according to linguistic region and mode of birth. Differences were assessed using logistic regression analysis adjusting for relevant variables.

RESULTS

A total of 1175 women were included in the analysis. Limitations in QMNC during the pandemic were reported by 328 (27.9%) women. Several quality measures, such as deficient communication (18.0%, n = 212), insufficient number of healthcare professionals (19.7%, n = 231), no information on the newborn after cesarean (26.5%, n = 91) or maternal and newborn danger signs (34.1%, n = 401 and 41.4% n = 487, respectively) suggested preventable gaps in QMNC. Quality measures significantly differed by linguistic region and mode of birth. Multivariate analysis established a significantly lower QMNC for women in French- and Italian-speaking regions compared with the German-speaking region. Moreover, in several quality indicators reflecting communication with healthcare providers, women who did not answer the questionnaire in one of the Swiss national languages had significantly worse scores than others. A significant lower QMNC was also found for young and primiparous women and for those who experienced cesarean or instrumental vaginal birth.

CONCLUSION

Women giving birth in Switzerland during the pandemic reported notable gaps in QMNC. Providers should be attuned to women who are younger, primiparous, and those who had an emergency cesarean or instrumental vaginal birth given the lower QMNC reported by these groups. Women who did not respond in a Swiss national language may need improved communication strategies.

Regional differences in the quality of maternal and neonatal care during the COVID-19 pandemic in Portugal: Results from the IMAgiNE EURO study

OBJECTIVE

To compare women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth across Nomenclature of Territorial Units for Statistics 2 (NUTS-II) regions in Portugal during the COVID-19 pandemic.

METHODS

Women participating in the cross-sectional IMAgiNE EURO study who gave birth in Portugal from March 1, 2020, to October 28, 2021, completed a structured questionnaire with 40 key WHO standards-based quality measures. Four domains of QMNC were assessed: (1) provision of care; (2) experience of care; (3) availability of human and physical resources; and (4) reorganizational changes due to the COVID-19 pandemic. Frequencies for each quality measure within each QMNC domain were computed overall and by region.

RESULTS

Out of 1845 participants, one-third (33.7%) had a cesarean. Examples of high-quality care included: low frequencies of lack of early breastfeeding and rooming-in (8.0% and 7.7%, respectively) and informal payment (0.7%); adequate staff professionalism (94.6%); adequate room comfort and equipment (95.2%). However, substandard practices with large heterogeneity across regions were also reported. Among women who experienced labor, the percentage of instrumental vaginal births ranged from 22.3% in the Algarve to 33.5% in Center; among these, fundal pressure ranged from 34.8% in Lisbon to 66.7% in Center. Episiotomy was performed in 39.3% of noninstrumental vaginal births with variations between 31.8% in the North to 59.8% in Center. One in four women reported inadequate breastfeeding support (26.1%, ranging from 19.4% in Algarve to 31.5% in Lisbon). One in five reported no exclusive breastfeeding at discharge (22.1%; 19.5% in Lisbon to 28.2% in Algarve).

CONCLUSION

Urgent actions are needed to harmonize QMNC and reduce inequities across regions in Portugal.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

Invasive Lobular Carcinoma Arising in Ectopic Breast Tissue: A Case Report

Incomplete regression of the embryonic mammary line occurs in 0.3-6% of the population. Ectopic breast tissue is mostly asymptomatic and can undergo malignant transformation. Ectopic breast cancer accounts for 0.2-0.6% of all breast cancers. Screening breast examinations can miss these lesions due to their location making the diagnosis more challenging. We describe a case of a primary invasive lobular carcinoma in an ectopic breast on the left axilla detected in a 49-year-old woman. Firstly diagnosed as a sebaceous cyst, the lesion was excised under local anesthesia. Histopathology showed breast tissue widely infiltrated by an invasive carcinoma. Excision of the remnant tissue with axillary lymph node dissection was performed. Ectopic breast carcinoma is a rare diagnosis and there is a general lack of awareness. The presence of an abnormal mass along the mammary ridge should raise clinicians’ attention. Management of primary ectopic breast carcinoma should be based on a multidisciplinary approach under the same principles as breast cancer. Furthermore, it does not appear to bring a worse prognosis when diagnosed at similar disease stages.

Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic: online survey investigating maternal perspectives in 12 countries of the WHO European Region

BACKGROUND

Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic, as defined by WHO Standards, are lacking.

METHODS

Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures.

FINDINGS

21,027 mothers were included in the analysis. Among those who experienced labour (N=18,063), 41·8% (26·1%- 63·5%) experienced difficulties in accessing antenatal care, 62% (12·6%-99·0%) were not allowed a companion of choice, 31·1% (16·5%-56·9%) received inadequate breastfeeding support, 34·4% (5·2%-64·8%) reported that health workers were not always using protective personal equipment, and 31·8% (17·8%-53·1%) rated the health workers' number as "insufficient". Episiotomy was performed in 20·1% (6·1%-66·0%) of spontaneous vaginal births and fundal pressure applied in 41·2% (11·5% -100%) of instrumental vaginal births. In addition, 23·9% women felt they were not treated with dignity (12·8%-59·8%), 12·5% (7·0%-23·4%) suffered abuse, and 2·4% (0·1%-26·2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N=2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significant lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes.

INTERPRETATION

Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed.

FUNDING

The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT04847336.

Quality of care at childbirth: findings of IMAgiNE EURO in Italy during the first year of the COVID‐19 pandemic

Objective

Investigate the quality of maternal and newborn care (QMNC) during childbirth in the first year of COVID‐19 pandemic in Italy, from the mothers' perspective, as key service users.

Methods

Women who gave birth in an Italian facility from March 1, 2020 to February 29, 2021 answered an online questionnaire including 40 WHO Standard‐based Quality Measures. Descriptive and multivariate quantile regression analyses were performed.

Results

In total, 4824 women were included, reporting heterogeneity of practices across regions: among 3981 women who underwent labour 78.4% (63.0%–92.0%) were not allowed a companion of choice, 44.6% (28.9%–53.3%) had difficulties in attending routine antenatal visits, 36.3% (24.9%–61.1%) reported inadequate breastfeeding support, 39.2% (23.3%–62.2%) felt not involved in medical choices, 33.0% (23.9%–49.3%) experienced unclear communication from staff, 24.8% (15.9%–39.4%) were not always treated with dignity and 12.7% (10.1%–29.3%) reported abuses. Findings in the group of women who did not experience labour were substantially similar. Multivariate analyses confirmed a significant lower QMNC index for regions in southern Italy compared to North and Central regions.

Conclusion

Mothers reported substantial inequities in the QMNC across Italian regions. Future studies should monitor QMNC over time. Meanwhile, actions to ensure high QMNC for all mothers and newborns across Italy are urgently required.

Mothers giving birth in the first year of the COVID‐19 pandemic reported substantial inequities across Italian regions in the QMNC around the time of childbirth.

Managing Severe Dysgeusia and Dysosmia in Lung Cancer Patients: A Systematic Scoping Review

Introduction

Lung cancer (LC) is highly prevalent worldwide, with elevated mortality. In this population, taste and smell alterations (TSAs) are frequent but overlooked symptoms. The absence of effective therapeutic strategies and evidence-based guidelines constrain TSAs’ early recognition, prevention and treatment (Tx), promoting cancer-related malnutrition and jeopardizing survival outcomes and quality of life.

Objectives

To systematically review the literature on TSAs in LC patients, understand the physiopathology, identify potential preventive and Tx strategies and to further encourage research in this area.

Methods

Literature search on English language articles indexed to PubMed, CINALH, SCOPUS and Web of Science using MeSH terms “Lung neoplasms”,”Dysgeusia”, “Olfaction Disorders”, “Carcinoma, Small Cell”,”Carcinoma, Non- Small-Cell Lung “Adenocarcinoma of Lung”,”Carcinoma, Large Cell”, and non-MeSH terms “Parageusia”, “Altered Taste”, “Smell Disorder”, “Paraosmia”, “Dysosmia”,”Lung Cancer” and “Oat Cell Carcinoma”.

Results

Thirty-four articles were reviewed. TSAs may follow the diagnosis of LC or develop during cancer Tx. The estimated prevalence of self-reported dysgeusia is 35-38% in treatment-naïve LC patients, and 35-69% in those undergoing Tx, based on studies involving LC patients only.

One prospective pilot trial and 1 RCT demonstrated a clinically significant benefit in combining flavor enhancement, smell and taste training and individualized nutritional counselling; a systematic review, 1 RCT and 1 retrospective study favored using intravenous or oral zinc-based solutions (150mg 2-3 times a day) for the prevention and Tx of chemotherapy (CT) and radiotherapy (RT) -induced mucositis and subsequent dysgeusia.

Conclusions

This is the first review on dysgeusia and dysosmia in LC patients to our knowledge. We propose combining taste and smell training, personalized dietary counselling and flavor enhancement with oral zinc-based solutions (150mg, 2-3 times a day) during CT and/or RT in this population, in order to prevent and help ameliorate Tx-induced dysgeusia and mucositis. However due to study heterogeneity, the results should be interpreted with caution. Developing standardized TSA measurement tools and performing prospective randomized controlled trials to evaluate their effect are warranted.

Protein intake and muscle mass maintenance in patients with cancer types with high prevalence of sarcopenia: a systematic review

RATIONALE

Cancer is associated with muscle wasting. However, optimal protein intake has not been determined, limiting the efficacy of nutritional interventions. This systematic review aims to assess the effect of protein intake on muscle mass of patients with cancer types with high prevalence of sarcopenia during treatment, in longitudinal studies.

METHODS

MEDLINE, CINAHL, and Scopus databases were searched following PRISMA guidelines. Longitudinal studies written in English, including adults with high sarcopenia prevalence cancer diagnosis, submitted to (chemo)radiotherapy, with assessment of protein intake and muscle changes during treatment, published until 4 October 2020 were included. Studies including supplementation with substances, such as n-3 fatty acids, specific amino acids, or proteins, were excluded. Study appraisal was independently conducted by two reviewers, and a qualitative research synthesis was performed.

RESULTS

Overall, 575 records were identified, of which, eight studies were included (one randomized clinical trial and seven uncontrolled before and after studies). Patients with head and neck (n = 5), lung (n = 2), and esophageal cancer (n = 1) were included, comprising a total of 554 participants. The studies presented heterogeneous methodologies, objectives, and methods to assess body composition. Overall, participant groups with a mean protein intake below 1.2 g/kg presented muscle wasting, with one exception, while those reporting a mean intake above 1.4 g/kg, maintained muscle during treatment.

CONCLUSIONS

Our findings show that protein intakes below 1.2 g/kg, even when within the recommendations, have been associated with muscle wasting during treatment. Only intakes above 1.4 g/kg have been associated with muscle maintenance. High-quality research is needed to establish an optimal dose response.

Mild periconceptional hyperglycemia: predictor of adverse fetomaternal outcomes in gestational diabetes?

AIM

To clarify whether mild first trimester hyperglycaemia (characteristic of early-onset GDM) is associated with higher incidence of congenital malformations and other adverse fetomaternal outcomes compared to women with second trimester hyperglycaemia (later-onset GDM).

DESIGN AND METHODS

We analyzed the Portuguese National GDM database, containing data collected between 2011 and 2017. Two study groups were defined: Group 1-Women with GDM diagnosed during the first trimester (with fasting glycemia ≥ 92 and < 126 mg/dL); Group 2-Women with GDM diagnosed after the first 12 weeks of gestation, with either fasting glycemia or oral glucose tolerance test, according to the International Association of Pregnancy and Diabetes Study Group criteria. The fetomaternal characteristics of each group were compared.

RESULTS

A total of 18.518 pregnant women diagnosed with GDM were included which 34.4% of them belonged to Group 1. Pregnant women from this group were significantly younger and had a higher median BMI than the women from the other group. Overall, there was no significant differences in maternal morbidity parameters between groups. Non-evolutive pregnancies were significantly more frequent along the present gestation in the group 1 (1.1% vs. 0.1%, p < 0.001), as was fetal death (0.6% vs. 0.2%, p < 0.001). Congenital malformations did not differ significantly between groups (3.2% vs. 2.8%, p = 0.155).

CONCLUSIONS

The mild near conceptional hyperglycaemic state characteristic of an early-onset GDM seems to be associated with an increased prevalence of non-evolutive pregnancies and foetal deaths when compared to later-onset GDM.

The MAPKinase Signaling and the Stimulatory Protein-1 (Sp1) Transcription Factor Are Involved in the Phototherapy Effect on Cytokines Secretion from Human Bronchial Epithelial Cells Stimulated with Cigarette Smoke Extract

The present study was aimed to investigate the phototherapy effect with low-level laser on human bronchial epithelial cells activated by cigarette smoke extract (CSE). Phototherapy has been reported to actuate positively for controlling the generation/release of anti-inflammatory and pro-inflammatory mediators from different cellular type activated by distinct stimuli. It is not known whether the IL-8 and IL-10 release from CSE-stimulated human bronchial epithelium (BEAS) cells can be influenced by phototherapy. Human bronchial epithelial cell (BEAS) line was cultured in a medium with CSE and irradiated (660 nm) at 9 J. Apoptosis index was standardized with Annexin V and the cellular viability was evaluated by MTT. IL-8, IL-10, cAMP, and NF-κB were measured by ELISA as well as the Sp1, JNK, ERK1/2, and p38MAPK. Phototherapy effect was studied in the presence of mithramycin or the inhibitors of JNK or ERK. The IL-8, cAMP, NF-κB, JNK, p38, and ERK1/2 were downregulated by phototherapy. Both the JNK and the ERK inhibitors potentiated the phototherapy effect on IL-8 as well as on cAMP secretion from BEAS. On the contrary, IL-10 and Sp1 were upregulated by phototherapy. The mithramycin blocked the phototherapy effect on IL-10. The results suggest that phototherapy has a dual effect on BEAS cells because it downregulates the IL-8 secretion by interfering with CSE-mediated signaling pathways, and oppositely upregulates the IL-10 secretion through of Sp1 transcription factor. The manuscript provides evidence that the phototherapy can interfere with MAPK signaling via cAMP in order to attenuate the IL-8 secretion from CSE-stimulated BEAS. In addition, the present study showed that phototherapy effect is driven to downregulation of the both the IL-8 and the ROS secretion and at the same time the upregulation of IL-10 secretion. Besides it, the increase of Sp-1 transcription factor was crucial for laser effect in upregulating the IL-10 secretion. The dexamethasone corticoid produces a significant inhibitory effect on IL-8 as well as ROS secretion, but on the other hand, the corticoid blocked the IL-10 secretion. Taking it into consideration, it is reasonable to suggest that the beneficial effect of laser therapy on lung diseases involves its action on unbalance between pro-inflammatory and anti-inflammatory mediators secreted by human bronchial epithelial cells through different signaling pathway.

A combined training program's effect on anthropometry, body composition, physical fitness and blood pressure in elite police

BACKGROUND

Combined training (CT) simultaneously associates aerobic and strength exercises. Worldwide, studies on CT´s on Police officers' physical fitness are scarce. This study aims to measure a 4-month CT program's impact in the Close Protection Unit of the Portuguese Elite Police.

METHODS

A pre-and post-test study included 32 participants (mean age 30.1±2.7 years old). Anthropometry, body composition, physical fitness, and blood pressure assessments were collected. Statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS, 26.0) with a significance level at p≤0.05.

RESULTS

The main results showed an improvement in anthropometrics; aerobic capacity, strength, muscular endurance, and systolic blood pressure. However, a lean mass decrease, a fat mass increase, and worse results in other bioimpedance measures were observed.

CONCLUSIONS

In this study, the poor body composition results may imply a closer look for health concerns, although physical fitness has improved. Thus, it might be suggested that a CT program is helpful to increase physical fitness in elite police officers. Yet, improvements for its future application can be suggested, namely to include and address hydration level, nutrition, and rest/sleep moments. Moreover, because a high physical fitness level is needed in these population throughout their lifespan, ministerial policies should develop specific training programs, that can reduce morbidity and premature mortality, and have a major cos-teffectiveness impact on public health.

Simulation of huntington’s disease in forensic psychiatry: Case report

Introduction

Huntington Disease (HD) is an autosomal-dominant, neurodegenerative disorder, with a progressive course, that typically involves a triad of cognitive, motor and psychiatric disorders. Its pathogenic mechanisms are not fully understood, although a faultily encoded version of the protein huntingtin—resulting from a cytosine-adenine-guanine (CAG) trinucleotide expansion in the HTT gene—has been shown to cause intracellular toxicity in neural tissue. Patients usually presents with prodromic psychiatric perturbances, such as depression, delusions or personality changes. Occasionally HD gives rise to criminal behavior.

Objectives

To understand HD clinical presentation and underlines the differencial diagnosis. We present a case of a 31-year-old male offender, whose mother was diagnosed with HD, and during his forensic-psychiatric evaluation, HD was considered, but not confirmed.

Methods

Case report.

Results

A 31-year-old male offender was under a forensic-psychiatric evaluation due to a crime of domestic violence, after he discovers that his wife had an affair. He reports previous personality changes and depression, and compares himself with his mother, stating she was diagnosed with HD due to psychiatric prodromic disturbances. He shows concern about having a disease, and was waiting for genetic test result. After a clinical evaluation, and despite a family history of HD and genetic suspicion, it was important to consider differential diagnosis. The case refers to a passionate crime, which attempted to simulate a HD, considering his genetic background.

Conclusions

Psychometrically identifiable features in HD appear to be important in the context of analyzing circumstances occasioning criminal acts, but the medical history is the most important part of the examination.

Disclosure

No significant relationships.

Integrated efforts to promote mental health care during the SARS-CoV-2 pandemic: Reflecting on the experience of a university helpline

Introduction

The SARS-CoV-2 pandemic is affecting numerous dimensions of our society since the beginning of the outbreak. A significant increase in emotional distress was expected in the general population, particularly among the high-risk groups such as the oldest, chronic patients, healthcare professionals, and psychopathology vulnerable people. There was an urgent need to adapt and create solutions to promote mental health. Given the recommendations to minimize face-to-face interactions, several helplines were widely developed.

Objectives

In this work, we aim to reflect on the experience of a university helpline, that integrated efforts with the regional mental health care services.

Methods

A University helpline was created to give support to the regional community outside academia. The team was created on an online teamwork platform, to communicate through the chat, carry videoconference meetings, and store useful files. A Manchester screening decision tree was adopted, to define a set of guidelines to provide support to the callers, based mainly on the guidelines defined by the Order of Portuguese Psychologists. Liaison with the mental health care services, including other specific helplines, was established.

Results

Notwithstanding all the efforts, the number of received calls was scarce, similarly to helplines created by other national universities and by other entities.

Conclusions

A new approach to psychological intervention in crisis is needed, maintaining integrated efforts, and taking advantage of the opportunity to foster personalized mental health care in the digital era. It is important to continuously assess the value of integrated efforts in patient care and to the healthcare system.

Telehealth for the cognitively impaired older adult and their caregivers: lessons from a coordinated approach

The Covid-19 pandemic forced providers to alter their delivery of care to special populations, including older adults with cognitive impairment. The Montefiore-Einstein Center for the Aging Brain, a specialty multidisciplinary center for the evaluation and management of patients with neurodegenerative disorders, developed a coordinated approach (Coordinated Care At Risk/Remote Elderly program [CCARRE]) to reach our diverse population during the initial Covid-19 crisis in New York City, USA. In the tele-evaluation of the first 85 patients seen with CCARRE, we recognized unique factors that could improve patient care, lessen burden and optimize access to community resources. Lessons learned from the experience are shared.

Tribological performance of the pair human teeth vs 3D printed zirconia: An in vitro chewing simulation study

This study aims to evaluate the tribological performance of the pair human teeth/robocasted zirconia, with a special focus on the enamel wear mechanisms. Zirconia pieces produced by robocasting (RC) and unidirectional compression (UC) were compared in terms of crystalline structure, density, porosity, hardness and toughness. Chewing simulation tests were performed against human dental cusps. The cusps wear was quantified and the wear mechanisms identified. Although most of the properties of UC and RC samples are similar, differences were observed for surface roughness and porosity. Although the samples did not suffer wear, the antagonist cusps worn in a similar way. In conclusion, robocasting seems a promising technique to produce customized zirconia dental pieces, namely in what concerns the overall tribological behaviour.

The Effect of Muscular Strength on Depression Symptoms in Adults: A Systematic Review and Meta-Analysis

The aim was to systematically review the relationship between muscular strength (MS) and depression symptoms (DS) among adults, and conduct a meta-analysis to determine the pooled odds ratio (OR) for the relationship between MS and DS. The strategies employed in this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies published up to December 2019 were systematically identified by searching in the PubMed, Scopus, and Web of Science electronic databases. Inclusion criteria were: (1) cross-sectional, longitudinal and intervention studies; (2) outcomes included depression or DS; (3) participants were adults and older adults; and (4) the articles were published in English, French, Portuguese, or Spanish. A total of 21 studies were included in the review, totalling 87,508 adults aged ≥18 years, from 26 countries. The systematic review findings suggest that MS has a positive effect on reducing DS. Meta-analysis findings indicate that MS is inversely and significantly related to DS 0.85 (95% CI: 0.80, 0.89). Interventions aiming to improve MS have the potential to promote mental health and prevent depression. Thus, public health professionals could use MS assessment and improvement as a strategy to promote mental health and prevent depression.

Suitability of 3D printed pieces of nanocrystalline zirconia for dental applications

OBJECTIVES

The main goal of this work is to evaluate the suitability of nanostructured zirconia pieces obtained by robocasting additive manufacturing (AM), for dental applications.

METHODS

The density, crystalline structure, morphology/porosity, surface roughness, hardness, toughness, wettability and biocompatibility of the produced samples were compared with those of samples obtained by conventional subtractive manufacturing (SM) of a similar commercial zirconia material. Chewing simulation studies were carried out against dental human cusps in artificial saliva. The wear of the material was quantified and the wear mechanisms investigated, as well as the influence of glaze coating.

RESULTS

AM samples, that revealed to be biocompatible, are slightly less dense and more porous than SM samples, showing lower hardness, toughness and wettability than SM samples. After chewing tests, no wear was found both on AM and SM samples. However, the dental wear was significantly lower when AM samples were used as counterbody. Concerning the glazed samples, both coated surfaces and dental cusps suffered wear, being the cusps' wear higher than that found for unglazed samples. More, cusps tested against AM coated samples suffered less wear comparatively to those opposed to SM coated samples.

SIGNIFICANCE

Overall, the results presented in this paper show that AM processed nanostructured zirconia can be used in dental restorations, with important advantages from the point of view of processing and tribological performance. Moreover, the option for glaze finishing should be carefully considered both in SM and AM processed specimens.

Health literacy and physical activity as buffers to counter act work related stress

Background

Stress health problems affect 47.8% of the work force in Portugal. It is predicted that, in the next decade, these problems will overcome musculoskeletal disorders, the first cause of employee’s withdrawal from work. Research indicates connections between stress and dimensions of the work place (like job satisfaction). Nevertheless the conceptual understanding of these relationships is sparse. In order to better understand these relationships, this research focus on the use of job–specific models of stress, associating them with health literacy (HL) - in the context of the European Health Literacy Survey framework (HLS-EU) - and physical exercise.

Methods

A total of 748 participants from the different offices of a company in the financial sector (Portugal, main land and autonomous territories) participated in a cross sectional survey (CAWI). Age ranged from 25 to 65 years and HL was measured using the HLS-EU instrument validated to Portuguese (HLS-EU-PT). Each participant was allocated to one of the groups, either of satisfactory HL (when scores ≥30) or insufficient HL (when scores &lt;30).

Results

Out of the 748 participants (58.7% males, average age of 39 years), 80.4% sometimes and very often experience stress and tension in the workplace. Less than one in every two (44.4%) practice physical activity several times a week. Of the participants, 7.1% have inadequate, 39.0% problematic, 36.6% sufficient and 17.3% excellent HL (HLS-EU-PT). Employees that are more active are those who experience lower levels of stress.

Conclusions

The research of the effects of HL combined with physical exercise, as buffer variables to problems related to the effects of work stress, is a new area of research that may help understand patterns of adherence to activities that can help workers deal with everyday working conditions. More research is needed to integrate HL strategies in the work place.

Key messages

Stress health problems affect 47.8% of the work force in Portugal. Employees that are more active are those who experience lower levels of stress.