ACOMPANHAMENTO PRÉ-NATAL PRECOCE E A INFLUÊNCIA NO DESFECHO DA GESTAÇÃO: ANÁLISE DO PERFIL EPIDEMIOLÓGICO DE GESTANTES EM UNIDADES DE SAÚDE DO MUNICÍPIO DE PALMAS-TO

Objetivos: Analisar o acompanhamento pré-natal precoce e sua influência no desfecho da gestação. Observar o perfil epidemiológico das gestantes em Palmas, Tocantins. Métodos: Estudo quantitativo e transversal realizado entre o período de janeiro de 2016 a janeiro de 2019 nos centros de saúde comunitária (CSC) das quadras 406 norte e 210 sul em Palmas- Tocantins. Foram avaliadas 178 gestantes por meio de análise do prontuário eletrônico (E-SUS). As análises obervacionais foram realizadas usando Microsoft Excel-2010. As variáveis descritas relacionadas a um pré-natal, foram: idade da paciente, raça, estado marital, escolaridade, renda, início do pré-natal, consultas ambulatoriais e visitas domiciliares. Resultados: O perfil epidemiológico encontrado no estudo foi de mulheres com idade média de 26 anos, as pacientes pardas totalizaram 54% das gestantes, o nível de escolaridade das gestantes participantes do estudo, cerca de 51% do total possuía nível de escolaridade de ensino básico completo (alfabetização), 77% das gestantes iniciaram o pré-natal no primeiro trimestre, cerca de 65% das pacientes tiveram sete ou mais consultas durante o pré-natal e  foram encaminhadas ao serviço de pré-natal de alto risco 19% das gestantes participantes do estudo. Conclusão: O acompanhamento pré-natal de forma precoce contribui para uma gestação mais segura, além de possibilitar intervenções precoces e um tratamento adequado para mãe e feto

EPIDEMIOLOGICAL PROFILE AND DEATHS IN PATIENTS WITH CHRONIC RHEUMATIC HEARTDISEASE AMONG 2011 TO 2018 IN THE STATE OF TOCANTINS.

Introdução: A cardiopatia reumática crônica é uma complicação não supurativa porinfecção da faringoamigdalite pelo streptococcus b-hemolítico do grupo A. Ocorre emindivíduos genéticamente susceptíveis e que tiveram uma resposta imune tardia. É amanifestação crônica mais severa da febre reumática, que se caracteriza por fibrose ecalcificação valvar. É uma patologia de alta incidência no Tocantins, mas que tempoucos estudos que informam sobre o perfil do paciente e sua relevância, algofundamental para a prevenção dos agravos. O objetivo desse trabalho foi descrever ascaracterísticas sociodemográficas e epidemiológicas dos pacientes internados emHospitais do SUS entre 2011 a 2018 no Estado de Tocantins. Método: Estudoepidemiológico, descritivo, retrospectivo com uma população (n) de 268 pacientesadmitidos entre 2011 e 2018 no eEstado do Tocantins. Os dados foram coletados dabase de dados do Departamento de Informática do Sistema Único de Saúde(DATASUS). Foram analisadas as características epidemiológicas como sexo,raça/cor, faixa etária, média de permanência e taxa de mortalidade. Resultados: Noperíodo analisado de 2011 a 2018, as doenças do aparelho circulatório com ênfase nadoença reumática crônica do coração, teve maior prevalência o ano de 2012, n=56, oque equivale 20,8% de um total de 268 internações. Dentre todas as faixas etáriasanalisadas, menor que 1 ano até maior que 80 anos, a idade de maior predomínio foide 40-49 anos, n=49, correspondente a 18,2% do total analisado. De todas as raçasapuradas, a parda foi dominante, n=189, com 70,5%. O maior número de óbitos foiem 2014, tendo 33,3%, n=4 de um total de 12 óbitos do período estudado.Conclusões: A incidência de internação hospitalar foi elevada quando comparada àmédia da região Norte. A descrição das características sociodemográficas eepidemiológicas norteia o planejamento das ações dos profissionais de saúde parafornecer um atendimento de melhor qualidade. O estudo apresentou limitações vistoque a fontes de dados (SIH/SUS) registra somente informações realizadas no sistemapúblico de saúde. Ressalta-se que o tratamento da febre reumática para ser eficientedeve ser precoce e se possível, antes do comprometimento do coração.Palavras-chave: Epidemiologia, Doença reumática, Saúde pública, Cardiopatiareumática.Introduction: Chronic rheumatic heart disease is a complication of non-suppurativeinfection of the pharyngotonsillitis by b-hemolytic Streptococcus Group A, occurs ingenetically susceptible individuals and had a late immune response. Is the most severechronic manifestation of rheumatic fever, which is characterized by fibrosis andvalvular calcification. Is a pathology of high incidence in Tocantins, but that has veryfew studies that inform about the patient profile and your relevance, somethingessential for the prevention of aggravations. The objective of this work was to describethe socio-demographic and epidemiological characteristics of patients admitted toHospitals of the SUS between 2011 to 2018 in the State of Tocantins. Material andMethods: Epidemiological study, descriptive and retrospective with a population of 265patients admitted between 2011 to 2018 in the Tocantins State. The data were collected from the Department of Informatics of the unified health system (DATASUS).Epidemiological characteristics were analysed by sex, race/color, age range, averageof permanence and mortality rate. Results: fifty nine comma sixty two percent werefemale, 71,32% race/brown color and the most prevalent age group was 40 to 49 years(17,73%) and the average stay of hospitalization of patients with chronic rheumaticdisease was 10.5 days. The in Hospital death rate was 4.52%. Conclusion: Theincidence of hospitalization was elevated when compared to the average in thenorthernregion. The description of the socio-demographic andepidemiological featuresguides the planning ofhealth professionals to provide a service a better quality service.The study presented limitations since the datasources (SIH/SUS) records onlyinformation heldin the public health system. It should be noted that the treatmentof rheumaticfever to be effective must be early and if possible, before the impairmentof the heart.Keywords: Epidemiology; Infections; Rheumatic disease, Public health, RheumaticHeart

FLUTTER ATRIAL EM PACIENTE PORTADORA DE SÍNDROME DE EBSTEIN SUBMETIDA À ANESTESIA GERAL ENDOVENOSA: UM RELATO DE CASO

RESUMO A anomalia de Ebstein (AE) é uma cardiopatia congênita rara. Caracteriza-se pela implantação anormal da valva tricúspide. Ocasionando fenômenos de sobrecarga de volume e disfunção ventricular direitas, o que aumenta o risco operatório e a morbidade pós-operatória com advento de arritmias de difícil controle, além de deterioração da função ventricular. O presente relato de caso tem por objetivo relatar uma ocorrência médica rara: estímulo mecânico servindo como gatilho arritmogênico para Flutter Atrial após indução anestésica em paciente portadora da Síndrome de Ebstein e meduloblastoma volumoso em linha mediana de fossa posterior, associados a hipertensão intracraniana, que necessitou de derivação ventrículo-peritoneal de urgência. O procedimento foi realizado e paciente seguiu internada em tratamento intensivo por 4 dias, quando evoluiu a óbito em decorrência de complicações cardioembólicas. Palavras-chave: Anomalia de Ebstein; Arritmias Cardíacas; Flutter Atrial; Anestesia Geral; Meduloblastoma; Hipertensão Intracraniana. ABSTRACT Ebstein's anomaly (EA) is a rare congenital heart disease. It is characterized by abnormal implantation of the tricuspid valve. Causing phenomena of volume overload and right ventricular dysfunction, which increases the operative risk and postoperative morbidity with the advent of difficult to control arrhythmias, in addition to deterioration of ventricular function. The present case report aims to report a rare medical occurrence: mechanical stimulus serving as an arrhythmogenic trigger for Atrial Flutter after anesthetic induction in a patient with Ebstein Syndrome and large medulloblastoma in the midline of the posterior fossa, associated with intracranial hypertension, which required emergency ventriculo-peritoneal shunt. The procedure was performed and the patient remained in intensive care for 4 days, when she died due to cardioembolic complications. Keywords: Ebstein Anomaly, Arrhythmias, Cardiac; Atrial Flutter; Anesthesia, General; Medulloblastoma; Intracranial Hypertension

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

PERFIL EPIDEMIOLÓGICO E ÓBITOS EM PACIENTES INTERNADOS COM DOENÇA REUMÁTICA CRÔNICA DO CORAÇÃO ENTRE 2012 A 2018 EM ESTADO DE TOCANTINS.

Introdução: A cardiopatia reumática crônica é uma complicação não supurativa porinfecção da faringoamigdalite pelo streptococcus b-hemolítico do grupo A. Ocorre emindivíduos genéticamente susceptíveis e que tiveram uma resposta imune tardia. É amanifestação crônica mais severa da febre reumática, que se caracteriza por fibrose ecalcificação valvar. É uma patologia de alta incidência no Tocantins, mas que tempoucos estudos que informam sobre o perfil do paciente e sua relevância, algofundamental para a prevenção dos agravos. O objetivo desse trabalho foi descrever ascaracterísticas sociodemográficas e epidemiológicas dos pacientes internados emHospitais do SUS entre 2011 a 2018 no Estado de Tocantins. Método: Estudoepidemiológico, descritivo, retrospectivo com uma população (n) de 268 pacientesadmitidos entre 2011 e 2018 no eEstado do Tocantins. Os dados foram coletados dabase de dados do Departamento de Informática do Sistema Único de Saúde(DATASUS). Foram analisadas as características epidemiológicas como sexo,raça/cor, faixa etária, média de permanência e taxa de mortalidade. Resultados: Noperíodo analisado de 2011 a 2018, as doenças do aparelho circulatório com ênfase nadoença reumática crônica do coração, teve maior prevalência o ano de 2012, n=56, o que equivale 20,8% de um total de 268 internações. Dentre todas as faixas etáriasanalisadas, menor que 1 ano até maior que 80 anos, a idade de maior predomínio foide 40-49 anos, n=49, correspondente a 18,2% do total analisado. De todas as raçasapuradas, a parda foi dominante, n=189, com 70,5%. O maior número de óbitos foiem 2014, tendo 33,3%, n=4 de um total de 12 óbitos do período estudado.Conclusões: A incidência de internação hospitalar foi elevada quando comparada àmédia da região Norte. A descrição das características sociodemográficas eepidemiológicas norteia o planejamento das ações dos profissionais de saúde parafornecer um atendimento de melhor qualidade. O estudo apresentou limitações vistoque a fontes de dados (SIH/SUS) registra somente informações realizadas no sistemapúblico de saúde. Ressalta-se que o tratamento da febre reumática para ser eficientedeve ser precoce e se possível, antes do comprometimento do coração

NEOTROPICAL CARNIVORES: a data set on carnivore distribution in the Neotropics

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity

Background The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries.Methods The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria.Results A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)).Conclusion Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population. Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay. Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity. Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes