Innocent heart murmurs

Innocent heart murmur is a frequent auscultatory finding in children. The diagnosis is essentially clinical, without need for further investigation. However, excluding heart disease can be a difficult task. This review article describes some features of medical history and physical examination that help in this differentiation. The role of diagnostic tests is also examined

Estudo de efectividade do Palivizumab

O Vírus Sincicial Respiratório (VSR) é o agente mais frequente das infecções respiratórias baixas nos primeiros dois anos de vida, sendo responsável por 50-90% dos episódios de bronquiolite nessa faixa etária. Embora a maioria dos casos tenha uma evolução relativamente benigna, surgem com alguma frequência manifestações e complicações associadas ao VSR. A ausência de consenso sobre a maioria das terapêuticas de suporte e antiviricas e a controvérsia sobre a sua efectividade levou à busca de estratégias de prevenção dirigidas especificamente à infecção pelo VSR. A introdução no arsenal medicamentoso, há cerca de uma década, do anticorpo monoclonal humanizado anti-VSR – palivizumab, veio trazer uma nova oportunidade de abordagem desta situação. No entanto, pela possibilidade de aplicação de barreiras físicas de prevenção da transmissão pessoa a pessoa, bem como pelos elevados custos da utilização de palivizumab, vários autores têm questionado ao longo doa anos, não só a eficácia, mas sobretudo a relação custo-eficácia desta profilaxia. Vários estudos definiram grupos restrito de maior risco para complicações e necessidade de internamento, nos quais se poderia obter maior custo-benefício da referida profilaxia. Em Portugal, primeiro alguns Hospitais de Apoio Perinatal Diferenciado, e mais tarde, a Secção de Neonatologia da Sociedade Portuguesa de Pediatria (SNN-SPP), estabeleceram práticas mais restritivas que as indicadas pelo fabricante, limitando o seu uso à extrema prematuridade e/ou a prematuros com doença pulmonar crónica da prematuridade. Os custos da profilaxia têm sido suportados integralmente pelo SNS. O objectivo deste trabalho tentar estimar a efectividade da profilaxia com palivizumab em crianças ex-prematuras nascidas na maternidade do Hospital de Dona Estefânia no triénio 2006-2008 e seleccionadas segundo as recomendações da SNN-SPP. O instrumento de investigação utilizado foi um questionário, com perguntas fechadas, aplicado aos pais ou tutores das crianças seleccionadas segundo os critérios. Da amostra de 146 doentes no HDE, 9,6% das crianças foram alvo de profilaxia. Em termos gerais, nos doentes sob profilaxia, não só ocorreu uma menor proporção relativa de episódios de bronquiolite, como não ocorreram reinternamentos por essa patologia. Ao contrário, nos doentes não sujeitos a profilaxia não só ocorreu uma maior taxa de bronquiolites, como de internamentos. De facto, a taxa global de doentes com bronquiolite foi de 24,6%, mas 26,5% das crianças a que não foi administrado palizivumab desenvolveram bronquiolite contra apenas 7,1% das sujeitas a essa profilaxia. Esse facto foi também evidente entre os grupos com co-morbilidades. Concluiu-se que este estudo desenvolvido não permitiu demonstrar retrospectivamente uma estimativa de efectividade favorável à administração de Palivizumab segundo recomendações da SNN-SPP.The respiratory syncytial virus (RSV) is the most frequent agent of low respiratory infection in the first two years of living, being responsible for 50-90% episodes of bronchiolitis in that range of ages. Though most of the cases have a benign evolution, there frequently are manifestations and complications associated with RSV. The absence of agreement on most of support and antiviral therapies and the controversy about its effectiveness had left to the search of strategies for prevention specifically directed to RSV’s infection. The introduction, for about a decade, of the humanized monoclonal antibody against RSV – palivizumab, has created a new possibility to approach this situation. However, in the latest years, some authors have questioned not only its efficacy, but most of all the cost-efficacy relationship of this prophylaxis, because of the possibility of physical barriers amongst people, as well as, its high costs and several studies defined restricted groups with bigger risk factors to complications and needing for hospitalization, in witch it was possible obtain a bigger cost-benefit relationship. In Portugal, firstly some hospitals and later the Neonatology’s Section of Portuguese Paediatrics Society had established more restricted practises than the indicated by the producers, limitating its use to extreme prematurity and/or prematures with chronic lung disease. The cost of prophilaxy has been totally supported by the National Health System. The main purpose of this work is to try to explain the effectiveness of the prophylaxis with palivizumab in ex prematures that were born at the maternity hospital of the Hospital de Dona Estefânia and of the CHCB in the triennial 2006-2008 that were selected by the recommendations of the SNN-PP. The instrument of investigation used was a questionnaire, with closed questions, applied to selected children’s parents or tutors. From the sample of 146 children at the HDE, 9,6% of the children were marked for prophylaxis. In general terms, the patients under prophylaxis, not only had a less relative proportion of episodes of bronchiolitis, but also didn’t have interns caused by this pathogy. Otherwise, the patients that were not exposed to the prophylaxis, not only occurred a biggest tax of bronchiolitis, but also of interns. In fact, the global tax of patients with bronchiolitis was 24,6%, but 26,5% of the children to witch didn’t were administered palivizumab developed bronchiolitis against only 7,1% of the subjected to that prophylaxis. That fact was also evident between the groups with co-morbidities. It’s concluding that this developed study didn’t allow retrospectively a effectiveness calculation propitious to the administration of the palivizumab according to the recommendations of the SNN-SPP

Deep Learning for Identification of Acute Illness and Facial Cues of Illness

Background: The inclusion of facial and bodily cues (clinical gestalt) in machine learning (ML) models improves the assessment of patients' health status, as shown in genetic syndromes and acute coronary syndrome. It is unknown if the inclusion of clinical gestalt improves ML-based classification of acutely ill patients. As in previous research in ML analysis of medical images, simulated or augmented data may be used to assess the usability of clinical gestalt. Objective: To assess whether a deep learning algorithm trained on a dataset of simulated and augmented facial photographs reflecting acutely ill patients can distinguish between healthy and LPS-infused, acutely ill individuals. Methods: Photographs from twenty-six volunteers whose facial features were manipulated to resemble a state of acute illness were used to extract features of illness and generate a synthetic dataset of acutely ill photographs, using a neural transfer convolutional neural network (NT-CNN) for data augmentation. Then, four distinct CNNs were trained on different parts of the facial photographs and concatenated into one final, stacked CNN which classified individuals as healthy or acutely ill. Finally, the stacked CNN was validated in an external dataset of volunteers injected with lipopolysaccharide (LPS). Results: In the external validation set, the four individual feature models distinguished acutely ill patients with sensitivities ranging from 10.5% (95% CI, 1.3–33.1% for the skin model) to 89.4% (66.9–98.7%, for the nose model). Specificity ranged from 42.1% (20.3–66.5%) for the nose model and 94.7% (73.9–99.9%) for skin. The stacked model combining all four facial features achieved an area under the receiver characteristic operating curve (AUROC) of 0.67 (0.62–0.71) and distinguished acutely ill patients with a sensitivity of 100% (82.35–100.00%) and specificity of 42.11% (20.25–66.50%). Conclusion: A deep learning algorithm trained on a synthetic, augmented dataset of facial photographs distinguished between healthy and simulated acutely ill individuals, demonstrating that synthetically generated data can be used to develop algorithms for health conditions in which large datasets are difficult to obtain. These results support the potential of facial feature analysis algorithms to support the diagnosis of acute illness

Projeto de Desenvolvimento de um Sistema de Gestão de Destinos (SGD): O Caso das Entidades Regionais de Turismo em Portugal

Enquadramento: O presente projeto de investigação surge num contexto onde as tecnologias estão cada vez mais enraizadas nas sociedades e onde a web se tornou no canal preferido de distribuição para uma boa parte das Organizações de Gestão de Destinos (OGDs) e dos consumidores finais (Butler, 2002; Gretzel, Yuan, & Fesenmaier, 2000; Kramer, Modsching, ten Hagen, & Gretzel, 2007). As novas Tecnologias da Informação e Comunicação (TICs) afiguram-se, assim, como uma das áreas mais críticas para o sucesso do turismo, no presente e no futuro, sendo vitais para a forma como se promovem os destinos turísticos (Machado & Almeida, 2010). Descrição: Pretende-se apresentar uma proposta extensiva de desenvolvimento de um Sistema de Gestão de Destinos (SGD), de âmbito regional, devidamente orçada e economicamente viável, para ajudar as OGDs na gestão, promoção e distribuição holística do destino turístico Portugal. Objetivos: Desenvolvimento sustentável e integrado dos destinos turísticos portugueses, a nível regional; aposta nos canais digitais como forma de adaptação às novas tendências de mercado no setor do turismo; envolvimento de todos os stakeholders no projeto (entidades públicas e privadas), por forma a aumentar os índices de coesão nos destinos turísticos; satisfação das necessidades de planeamento e de reserva dos potenciais turistas/visitantes; e incremento da qualidade geral da experiência turística no destino Portugal. Investigação Empírica: Parte 1 – Realização de um estudo Delphi, com a participação de um painel de 12 especialistas nas áreas do turismo e das TICs, para aferição e hierarquização das principais barreiras à adoção de SGDs; Parte 2 – Estudo avaliativo da eficácia dos websites oficiais das 5 Entidades Regionais de Turismo (ERTs) portuguesas, por intermédio do modelo adaptado de ICTRT (na versão de Charoula et al., 2014), aplicado por um avaliador externo recrutado para o efeito. Resultados e Conclusões: Identificaram-se e hierarquizaram-se 55 barreiras à adoção de SGDs, para a realidade portuguesa; apresentaram-se e escrutinaram-se os índices de eficácia dos websites oficiais das 5 ERTs em Portugal; e apresentou-se uma proposta de desenvolvimento de um SGD devidamente orçada e economicamente viável. No final, discutiram-se os principais resultados, teceram-se considerações gerais sobre o projeto e enunciaram-se as principais limitações e possíveis futuras linhas de investigação

Pro-inflammatory triggers in childhood obesity: correlation between leptin, adiponectin and high-sensitivity C-reactive protein in a group of obese Portuguese children

INTRODUCTION: Pediatric obesity is increasingly prevalent in the Portuguese population. Adipocyte dysfunction results in the expression of pro-inflammatory mediators that are responsible for the low-grade inflammatory process that characterizes obesity. OBJECTIVES: The aim of this study was to investigate the relationship between markers of adiposity, inflammation and adipokines in a Portuguese obese pediatric population. METHODS: One hundred and twenty children of both sexes, aged 6-17 years, were included in this study. The control group consisted of 41 healthy normal-weight children. The variables analyzed were age, gender, body mass index, waist circumference, fat mass percentage, high-sensitivity C-reactive protein (hs-CRP), leptin and adiponectin. RESULTS: There were significant differences between controls and obese children for all parameters analyzed. In the obese group, after controlling for age and gender, hs-CRP (p=0.041), adiponectin (p=0.019) and leptin (p<0.001) still showed significant statistical differences. A direct correlation was found between hs-CRP, leptin, body mass index and waist circumference, the strongest being with leptin (r=0.568; p<0.001). This trend remained statistically significant, regardless of gender or pubertal age. CONCLUSIONS: Considering the role of leptin, adiponectin and hs-CRP in the genesis of endothelial dysfunction, they may be used in clinical practice for risk stratification, as well as in the assessment of weight control programs

Student perspectives on the relationship between a curve and its tangent in the transition from Euclidean Geometry to Analysis

The tangent line is a central concept in many mathematics and science courses. In this paper we describe a model of students’ thinking – concept images as well as ability in symbolic manipulation – about the tangent line of a curve as it has developed through students’ experiences in Euclidean Geometry and Analysis courses. Data was collected through a questionnaire administered to 196 Year 12 students. Through Latent Class Analysis, the participants were classified in three hierarchical groups representing the transition from a Geometrical Global perspective on the tangent line to an Analytical Local perspective. In the light of this classification, and through qualitative explanations of the students’ responses, we describe students’ thinking about tangents in terms of seven factors. We confirm the model constituted by these seven factors through Confirmatory Factor Analysis

‘Warrant’ revisited: Integrating mathematics teachers’ pedagogical and epistemological considerations into Toulmin’s model for argumentation

In this paper, we propose an approach to analysing teacher arguments that takes into account field dependence—namely, in Toulmin’s sense, the dependence of warrants deployed in an argument on the field of activity to which the argument relates. Freeman, to circumvent issues that emerge when we attempt to determine the field(s) that an argument relates to, proposed a classification of warrants (a priori, empirical, institutional and evaluative). Our approach to analysing teacher arguments proposes an adaptation of Freeman’s classification that distinguishes between: epistemological and pedagogical a priori warrants, professional and personal empirical warrants, epistemological and curricular institutional warrants, and evaluative warrants. Our proposition emerged from analyses conducted in the course of a written response and interview study that engages secondary mathematics teachers with classroom scenarios from the mathematical areas of analysis and algebra. The scenarios are hypothetical, grounded on seminal learning and teaching issues, and likely to occur in actual practice. To illustrate our proposed approach to analysing teacher arguments here, we draw on the data we collected through the use of one such scenario, the Tangent Task. We demonstrate how teacher arguments, not analysed for their mathematical accuracy only, can be reconsidered, arguably more productively, in the light of other teacher considerations and priorities: pedagogical, curricular, professional and personal

Mild hypothermia during cardiopulmonary bypass assisted CABG is associated with improved short- and long-term survival, a 18- year cohort study

Data substantiating the optimal patient body temperature during cooling procedures in cardiac operations are currently unavailable. To explore the optimal temperature strategy, we examined the association between temperature management and survival among patients during cardiopulmonary bypass assisted coronary artery bypass grafting (CABG) procedures on 30-days and 5-year postoperative survival. Adult patients (n = 5,672, 23.6% female and mean (SD) age of 66 (10) years) operated between 1997 and 2015 were included, with continuous measured intraoperative nasopharyngeal temperatures. The association between mortality and patient characteristics, laboratory parameters, the lowest intraoperative plateau temperature and intraoperative cooling/rewarming rates were examined by multivariate Cox regression analysis. Machine learning-based cluster analysis was used to identify patient subgroups based on pre-cooling parameters and explore whether specific subgroups benefitted from a particular temperature management. Mild hypothermia (32- 35°C) was independently associated with improved 30-days and 5-year survival compared to patients in other temperature categories regardless of operation year. 30 days and 5-year survival were 98% and 88% in the mild hypothermia group, whereas it amounted 93% and 80% in the severe hypothermia (<30°C). Normothermia (35-37°C) showed the lowest survival after 30 days and 5 years amounting 93% and 72%, respectively. Cluster analysis identified 8 distinct patient subgroups principally defined by gender, age, kidney function and weight. The full cohort and all patient subgroups displayed the highest survival at a temperature of 32°C. Given these associations, further prospective randomized controlled trials are needed to ascertain optimal patient temperatures during CPB

Epidermolysis bullosa simplex generalized severe induces a T helper 17 response and is improved by apremilast treatment

International audienceBACKGROUND: Epidermolysis bullosa simplex generalized severe is a genetic disorder caused by mutation in KRT5 or KRT14 genes. Usually considered as a mechanical disease, recent data argue for additional inflammatory mechanisms. OBJECTIVES: The aim of this study was to assess the inflammation in the skin of patients with EBS. METHODS: A first immunohistochemical retrospective study was performed on frozen skin samples from 17 EBS-gen sev patients. A second multicenter prospective study was conducted on 10 patients with severe EBS-gen sev. Blister fluid and epidermis were processed for immunochemistry analysis and quantitative real time PCR. Cytokine expression was analyzed in blister fluid and compared with controls. RESULTS: Histological analysis showed a constant dermal perivascular CD4+ lymphocytes infiltrate in skin biopsies of blister (n=17) as well as in rubbed skin (n=5), an epidermal infiltration of neutrophils and eosinophils in 70% of cases and an increased immunostaining for CXCL9 and CXCL10 in blistering skin. High levels of Th17 cytokines were detected in lesional skin. Three adult patients with EBS-gen sev were treated with apremilast with a dramatic improvement of skin blistering and good tolerance. CONCLUSION: Our study demonstrates the importance of inflammation in EBS-gen sev patients and underlines the key role for Th17 cells in its pathogenesis. In addition, this study provides promising new therapeutic approaches for this disabling disorder. This article is protected by copyright. All rights reserved