From a Pollutant Byproduct to a Feed Ingredient

The hypothesis to be tested in this chapter is that an industrial byproduct may undergo a biological treatment yielding biological treatment yielding a product with application. The objective of this chapter was to describe a study on the transformation of a fish processing wastewater into a product with potential of use in animal rearing.Cap. 23

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Programa de Capacitação Permanente de Conselheiros Populares de Saúde na cidade de São Paulo

The popular health movement from São Paulo City has been electing Popular Health Councils since 1979. The issue of political and technical capabilities of its leaders has been an important point for the movement. During the years 1993 to 2000, the communication channels between the municipal government and popular leadership have been broken, leading back the social movement related to public health. However, in the beginningof 1988, the organized health movements located both at the east and southeast parts of São Paulo City, were succeeded in electing 1.039 members for those popular councils. After several scattered efforts to provide capability and skills to the councilors, it was decided to join the different regions and movements in only one project named Permanent Skills Improvement Course for elected representatives to the municipal health councils. The Ministry of Health and the Center for Permanent Education of the School of Public Health of Public Health of the University of São Paulo, Brazil, sponsored the initiative, with an amount of 52 courses attended by 1.011 councilors. This article contains both a description of the course process and the councilors social profiles, besides theirs evaluation over the initiative.O Movimento Popular de Saúde do Município de São Paulo vem elegendo Conselhos Populares de Saúde desde 1979. A questão da formação política e capacitação técnica de lideranças sempre foi uma preocupação do movimento de saúde. Durante a gestão municipal de 1993 a 2000 a interlocução entre o governo local e a representação popular foi rompida e disto decorreu um período de refluxo dos movimentos sociais. Porém, no início de 1998, os movimentos organizados de saúde das regiões leste e sudeste conseguiram se articular para eleger conselheiros para os Conselhos Populares de Saúde. Foram eleitos 1.039 conselheiros. Após vários esforços isolados de capacitação de conselheiros optou-se por realizar um Programa de Capacitação Permanente de Conselheiros de Saúde como forma de envolver o conjunto de bairros e regiões. Por meio de um convênio entre o Ministério da Saúde e o Centro de Educação Permanente da Faculdade de Saúde Pública da Universidade de São Paulo foram realizados 52 cursos para 1.011 desses conselheiros eleitos. Neste trabalho, a partir de análise documental, os autores descrevem esse processo de capacitação, caracterizam o perfil sócio econômico dos conselheiros e analisam a avaliação dos participantes nos cursos de capacitação

A shift from distal to proximal neoplasia in the colon: a decade of polyps and CRC in Italy

<p>Abstract</p> <p>Background</p> <p>In the last years a trend towards proximalization of colorectal carcinomas (CRC) has been reported. This study aims to evaluate the distribution of CRC and adenomatous polyps (ADP) to establish the presence of proximalization and to assess the potential predictors.</p> <p>Methods</p> <p>We retrieved histology reports of colonic specimens excised during colonoscopy, considering the exams performed between 1997 and 2006 at Cuneo Hospital, Italy. We compared the proportion of proximal lesions in the period 1997-2001 and in the period 2002-2006.</p> <p>Results</p> <p>Neoplastic lesions were detected in 3087 people. Proximal CRC moved from 25.9% (1997-2001) to 30.0% (2002-2006). Adjusting for sex and age, the difference was not significant (OR 1.23; 95% CI: 0,95-1,58). The proximal ADP proportion increased from 19.2% (1997-2001) to 26.0% (2002-2006) (OR: 1.43; 95% CI: 1.17-1.89). The corresponding figures for advanced proximal ADP were 6.6% and 9.5% (OR: 1.48; 95% CI: 1.02-2.17). Adjusting for gender, age, diagnostic period, symptoms and number of polyps the prevalence of proximal advanced ADP was increased among people ≥ 70 years compared to those aged 55-69 years (OR 1.49; 95% CI: 1.032.16). The main predictor of proximal advanced neoplasia was the number of polyps detected per exam (> 1 polyp versus 1 polyp: considering all ADP: OR 2.16; 95% CI: 1.59-2.93; considering advanced ADP OR 1.63; 95% CI: 1.08-2.46). Adjusting for these factors, the difference between the two periods was no longer significant.</p> <p>Conclusions</p> <p>CRC do not proximalize while a trend towards a proximal shift in adenomas was observed among people ≥ 70 years.</p

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)

Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF.

AIMS: The relationship between outcomes and time after diagnosis for patients with non-valvular atrial fibrillation (NVAF) is poorly defined, especially beyond the first year. METHODS AND RESULTS: GARFIELD-AF is an ongoing, global observational study of adults with newly diagnosed NVAF. Two-year outcomes of 17 162 patients prospectively enrolled in GARFIELD-AF were analysed in light of baseline characteristics, risk profiles for stroke/systemic embolism (SE), and antithrombotic therapy. The mean (standard deviation) age was 69.8 (11.4) years, 43.8% were women, and the mean CHA2DS2-VASc score was 3.3 (1.6); 60.8% of patients were prescribed anticoagulant therapy with/without antiplatelet (AP) therapy, 27.4% AP monotherapy, and 11.8% no antithrombotic therapy. At 2-year follow-up, all-cause mortality, stroke/SE, and major bleeding had occurred at a rate (95% confidence interval) of 3.83 (3.62; 4.05), 1.25 (1.13; 1.38), and 0.70 (0.62; 0.81) per 100 person-years, respectively. Rates for all three major events were highest during the first 4 months. Congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, malignancy, respiratory failure, and infection/sepsis accounted for 65% of all known causes of death and strokes for <10%. Anticoagulant treatment was associated with a 35% lower risk of death. CONCLUSION: The most frequent of the three major outcome measures was death, whose most common causes are not known to be significantly influenced by anticoagulation. This suggests that a more comprehensive approach to the management of NVAF may be needed to improve outcome. This could include, in addition to anticoagulation, interventions targeting modifiable, cause-specific risk factors for death. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Performance of IFIGC/MSG/EORTC Criteria for the Diagnosis of Invasive Pulmonary Aspergillosis in the Clinical Management of Unselected Patients with Acute Leukemia.

Abstract Invasive pulmonary aspergillosis (IPA) is a severe complication in patients (pts) treated for acute leukemia. Since its diagnosis is still difficult, sets of non-invasive diagnostic criteria were recently proposed by IFIGC/MSG/EORTC for study purposes. The performance of those criteria in the clinical management of unselected leukemic pts is still unknown. We have therefore applied IFIGC/MSG/EORTC criteria to the diagnosis of pulmonary infiltrates occurred in 83 consecutive pts, aged &lt;65, with newly diagnosed acute leukemia (19 APL, 38 AML, 26 ALL) treated at a single Institution between 1/2000 and 12/2003. The frequency of the different categories of IPA as diagnosis of pulmonary infiltrates and the relative contribution of the specific sets of diagnostic criteria were analysed. Forty-one pulmonary infiltrates developed in 30/83 pts (36.1%), during 364 chemotherapy cycles. IPA was diagnosed in 22 pts (26.5%). “Proven” IPA occurred in 1 (1.2%), “probable” IPA in 7 (8.4%) and “possible” IPA in 14 pts (16.8%). IPA was significantly more frequent in AML (36,8%), than in APL (15,7%) or ALL (15,3%) (P=0.041), and during the first induction (21/83; 25.3%) than during subsequent cycles (20/281; 7.1%) (P&lt; 0.001). Considering the episodes of pulmonary infiltrate, IPA criteria were met in 27/41 (65,8%) [1 “proven”, 7 “probable” (17%) and 19 “possible” (46,3%)]. Specifically, “host criteria” were met in 41/41 (100%), “microbiological criteria” in 8/41 (17%), and “clinical criteria” in 27/41 (65,8%). The presence of one “major clinical” criterion, i.e. a typical radiological image on chest Xray or CT, was significantly associated with the positivity of a “microbiological” criterion, hence with a diagnosis of “probable” IPA (P=0,012). On the other hand, since “host” criteria were not discriminant, being positive in 100% of cases, the presence of two aspecific “minor clinical” criteria (dyspnea, cough, pleural rub, chest pain, hemophtysis) was the sole responsible for the classification of any non-typical pulmonary infiltrate either as “possible” IPA (17/19 cases; 84.2 %) or as “no IPA”. The bacterial origin of the pulmonary infiltrate was documented on follow-up in 5/19 “possible” IPA, which responded to specific antibacterial treatment. All patients had received antifungal prophylaxis, in 88% with oral itraconazole. A clinical response to ampho/voriconazole was obtained in 6/8 (71,4%) “proven/probable” and 17/19 (89,4%) “possible” IPA. Four of 22 pts with IPA (2 “probable” and 2 “possible”) died early during aplasia (multiorgan failure (MOF) 3, cerebral hemorrhage 1) compared to 2/8 pts without IPA (MOF 1, leukemia 1). In conclusion, according to IFIGC/MSG/EORTC criteria, IPA was diagnosed in 26.5% of pts with acute leukemia and in 65,8% of pulmonary infiltrates. AML and the first induction cycle were significant risk factors. “Proven” IPA was rare. “Probable” IPA was more frequent (8,4% of pts), its diagnosis being strongly supported by the association of a “major” clinical criterion with one microbiological criterion. “Possible IPA” likely represents an overestimation (43,9% of pulmonary infiltrates) since its diagnosis derived in most cases from the combined presence of a “host” criterion with two “minor” aspecific clinical criteria. These data allow a critical analysis of IFIGC/MSG/EORTC criteria in the setting of acute leukemia.</jats:p