Os circuitos diagnósticos da tuberculose na lógica do paciente: um estudo de caso num centro de tratamento para a tuberculose na área metropolitana de Lisboa

Introdução: A tuberculose (TB) é uma doença intrinsecamente relacionada com determinantes sociais de saúde. Em países da União Europeia, tende a concentrar-se em zonas urbanas críticas tipicamente mais desfavorecidas, e por vezes, associada a pessoas estrangeiras. A área metropolitana de Lisboa obedece a essas características. A principal estratégia para o controle da doença preconizada pela Organização Mundial da Saúde, a EndTB, prevê um cuidado centrado no paciente. Este pode ser analisado através dos circuitos de cuidados de saúde. Objetivos: A pesquisa teve dois objetivos principais: analisar os comportamentos de procura de cuidados de saúde e os itinerários, nacionais e transnacionais, percorridos pelos doentes de tuberculose nos circuitos pré-diagnósticos da doença. Quantificar os casos notificados de TB em doentes nascidos no estrangeiro e explorar as dinâmicas que motivam a sua migração recente enquadrando-as no contexto do adoecimento. Métodos: Um estudo de caso único e crítico utilizando metodologia mista foi realizado entre novembro 2018 e janeiro 2019 num Centro de Diagnóstico Pneumológico (CDP) situado numa zona metropolitana de Lisboa que acumula fatores de risco para a doença. Realizaram-se entrevistas semi-estruturadas a doentes de tuberculose, e análise temática da informação obtida. Quantitativamente realizou-se uma análise exploratória dos casos notificados de TB para o CDP objeto de estudo (2008-2018), utilizando dados do sistema de vigilância da tuberculose. Resultados: Os circuitos pré-diagnósticos dos doentes foram descritos e analisados. Os comportamentos de procura de cuidados de saúde foram categorizados em quatro tipos: inibido, atempado, prolongado e ausente, de acordo com os atrasos associados. Na área de estudo, entre 2008 e 2018, 46.7% dos casos notificados de TB deveram-se a doentes nascidos no estrangeiro, entre migrantes recentes e migrantes longo-termo. Alguns doentes TB com entrada recente no país empreenderam circuitos transnacionais em busca de cuidados de saúde essencialmente devido a uma perceção de baixa qualidade dos cuidados de saúde nos seus países de origem. O serviço de urgência foi a principal porta de entrada para o diagnóstico da tuberculose na área de estudo e os cuidados de saúde primários foram infrautilizados. Conclusão: A prestação de um cuidado de saúde centrado no doente pode ser analisada através dos itinerários dos doentes e os seus atrasos associados; assume-se que quanto maiores os atrasos diagnósticos, menos a prestação de cuidados é centrada no doente. O comportamento de procura de cuidados de saúde reflete uma relação entre os serviços de saúde e a população servida; a sua categorização ajuda na identificação de padrões de comportamento que pode ser útil no desenho de intervenções na saúde. A sobreutilização dos serviços de urgência pode significar uma falha na prestação de serviços de saúde na área de estudo e deve ser analisada nas suas causas e consequências. A tuberculose no contexto estudado apresenta uma componente considerada de origem endógena e outra exógena. Os circuitos transnacionais de procura de cuidados de saúde por parte de pacientes migrantes recentes refletem as perceções e experiências negativas de adoecimento nos seus países de origem.Introduction: Tuberculosis (TB) is a disease intrinsically related to social determinants of heath. In the European Union countries, tuberculosis tends to cluster in typically unequal critical urban areas, sometimes associated with foreign-born people (migrants). The Lisbon Metropolitan Area follows this pattern. The main strategy for disease control endorsed by the World Health Organisation, the EndTB, supports a patient centred care. This type of care can be analysed through patients´ healthcare pathways. Objectives: This research presented two main goals: analyse TB patients´ healthcare seeking behaviour and healthcare pathways in their national and transnational (migrants) pre- diagnostic itineraries. Quantify the number of notified TB cases in foreign-born patients and explore the dynamics motivating their recent migration in the context of illness. Methods: A critical single mixed-method case study was performed, and field work carried out between November 2018 and January 2019, in a Centre for Pneumological Diseases (CDP) localised in an urban setting of the Lisbon Metropolitan Area accumulating TB risk factors. Semi-structures interviews were conducted with TB patients and thematic analysis of the information was performed. Quantitatively, an exploratory analysis of the notified tuberculosis cases (2008-2018) for the studied CDP was conducted using data from the tuberculosis surveillance system. Results: Patients´ pre-diagnostic pathways were described and analysed. Healthcare seeking behaviour was categorised in four groups according to delays, which were: inhibited, timely, prolonged, and absent. For the period of 2008-2018, 46.7% of notified cases in the studied area were due to foreign-born patients; some were recently arrived migrants and others long-term migrants. Perception of low-quality healthcare in origin countries led recently arrived migrants to travel over transnational pathways of healthcare. The emergency room was the main entry point for TB diagnosis in the studied area and primary healthcare was underused. Conclusion: A patient-centred care can be analysed through patients´ healthcare circuits of care and its associated delays; we assumed the longer the delays presented by healthcare delivery services, the less patient-centred it is. Healthcare seeking behaviour reflects a relationship between health delivery service and the population served; its categorization helps to identify patterns of behaviours that can shape healthcare interventions. The overuse of emergency room services may suggest a failure of health delivery services in the studied area and should be analysed in its causes and consequences. Tuberculosis in the studied context presents an exogenous and an endogenous component regarding its origin. Recent migrant patients´ transnational circuits of healthcare reflect negative illness experiences and perceptions in their origin countries

Abordaje integrativo del insomnio en atención primaria: medidas no farmacológicas y fitoterapia frente al tratamiento convencional

ResumenIntroducciónEl insomnio es un trastorno del sueño que imposibilita iniciarlo o mantenerlo. En algún momento de la vida, hasta un 50% de adultos lo padecen ante situaciones estresantes.ObjetivoEvaluar el impacto de medidas higiénicas del sueño, técnicas de relajación y fitoterapia para abordar el insomnio, comparado con medidas habituales (tratamiento farmacológico).MetodologíaEstudio experimental, retrospectivo, sin asignación aleatorizada. Revisión de pacientes diagnosticados de insomnio (2008-2010).Los pacientes de grupo intervención (GI) recibieron abordaje integrativo (medidas higiénicas, técnicas de relajación y fitoterapia), y los del grupo control (GC), tratamiento convencional.Se compararon resultados de uso de recursos (media mensual de visitas pre y posdiagnóstico), tipo de tratamiento farmacológico prescrito y dosis total.Evaluación de la calidad del sueño a los 18-24meses (test de Epworth).ResultadosSe incluyeron 48 pacientes en GI y 47 en GC (70% mujeres, media de edad 46años (DE: 14,3).La media mensual de visitas prediagnóstico fue 0,54(DE: 0,42) en GI y 0,53 (DE: 0,53) en GC (p=0,88). La media posterior fue 0,36 (DE: 0,24) y 0,65(DE: 0,46), respectivamente (p<0,0001), observándose reducción estadísticamente significativa en GI.Recibieron alguna benzodiacepina el 52,5% de los pacientes GI y el 93,6% de los del GC (p<0,0001). En GC se prescribió más alprazolam y lorazepam, con dosis acumuladas superiores.En la evaluación posterior no presentaban insomnio el 17% de los pacientes del GI y el 5% del GC. Presentaban insomnio severo el 13% de los pacientes del GC y ninguno del GI (p<0,0001).ConclusionesEl abordaje integrativo del insomnio puede ser resolutivo, disminuyendo las visitas y los efectos secundarios y la dependencia a benzodiacepinas.AbstractIntroductionInsomnia is a sleep disorder in which there is an inability to fall asleep or to stay asleep. At some point in life, 50% of adults suffer from it, usually in stress situations.AimTo evaluate the impact of sleep hygiene measures, relaxations techniques, and herbal medicine to deal with insomnia, compared with standard measures (drug treatment).MethodologyAn experimental, retrospective, non-randomized study was conducted by means of a review of patients diagnosed with insomnia (2008-2010).Patients in the intervention group (IG) received an integrative approach (hygiene measures, relaxation techniques, and herbal medicine) and a control group (CG) with conventional treatment.A comparison was made of the resources used in the two groups (average monthly visits pre- and post-diagnosis), type of prescribed drug therapy and total dose.Sleep quality was evaluated at 18-24months (Epworth test).ResultsA total of 48 patients were included in the IG and 47 in the CG (70% women, mean age 46years (SD: 14.3).Average monthly visit pre-diagnosis was 0.54 (SD: 0.42) in the IG and 0.53 (SD: 0.53) in the CG (P=.88). Post-diagnosis it was 0.36 (SD: 0.24) and 0.65 (SD: 0.46), respectively (P<.0001), with a statistically significant reduction being observed in the IG.More than half (52.5%) of the IG patients and 93.6% in the CG had received a benzodiazepine (P<.0001). Alprazolam and lorazepam were the most prescribed in the CG and with higher cumulative dose.In the subsequent evaluation, 17% of patients in the IG and 5% in CG did not have insomnia. Severe insomnia was present in 13% of patients in the IG and none in CG (P<.0001).ConclusionsThe integrative approach to insomnia may be worthwhile as it reduces resource use and side effects, as well as dependence to benzodiazepines

A abordagem dermatológica da Síndrome dos Ovários Policísticos: uma revisão bibliográfica

Este artigo buscou explorar a abordagem dermatológica da Síndrome dos Ovários Policísticos (SOP) em mulheres em idade reprodutiva. Apesar de ainda apresentar etiologia incerta, os componentes relacionados à SOP abrangem fatores genético e endócrino, por exemplo, o comprometimento de&nbsp;genes, o aumento da secreção do Hormônio Luteinizante (LH) e a diminuição da produção do Hormônio Folículo Estimulante (FSH). Suas manifestações cutâneas cursam, principalmente, com acne, dermatite seborreica, hirsutismo, alopecia androgenética e acantose nigricans, apresentando repercussões negativas no bem-estar e no estado psicossocial da paciente. Para realizar o diagnóstico, pelo menos dois entre os três critérios estabelecidos pelo Consenso de Rotterdam devem ser contemplados, sendo eles o hiperandrogenismo, a irregularidade do ciclo menstrual e a presença de ovários policísticos em ultrassonografia. As mudanças no estilo de vida aliadas ao tratamento multiprofissional têm apresentado benefícios como medida terapêutica. Nesse contexto, torna-se importante conciliar a atuação dermatológica às abordagens voltadas para o controle da síndrome, a fim de controlar as manifestações clínicas e prevenir o surgimento de maiores repercussões emocionais e metabólicas que alteram a qualidade de vida dessas pacientes

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure &lt;= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Evermifugação utilizando levamizol, ivermectina e alho desidratado (Allium sativum) em ovelhas da raça Santa Inês

Objetivou-se avaliar a utilização de alho como vermífugo, isoladamente ou em combinação com princípios comerciais, além dos princípios comerciais também isoladamente, sobre a redução dos parasitas gastrintestinais em ovinos. Para tanto foram utilizadas 30 ovelhas da raça Santa Inês, distribuídas nos tratamentos: alho, alho + levamizol, alho + ivermectina, ivermectina, levamizol e controle, respeitando-se a utilização de 6 gramas de alho desidratado por animal ao dia nos tratamentos que o continham e no caso dos princípios comerciais  doses segundo recomendação dos fabricantes. Em intervalos de 10 dias foram feitas coletas de fezes e contagem de ovos por grama de fezes (OPG). Aos 10 dias do início do tratamento houve redução de 22,0; 34,2; 16,9; 10,9; 19,9 e 10,3%, aos 20 dias de 35,4; 40,8; 32,2; 36,1; 45,9 e 41,3% e após 30 dias 71,3; 63,5; 60,9; 62,6; 65,9 e 68% para os tratamentos alho, alho + levamizol, alho + ivermectina, ivermectina, levamizol e controle, respectivamente. Nos grupos que receberam alho ocorreu redução média aos 10, 20 e 30 dias de 24,4; 36,1 e 65,2% e para aqueles que não receberam: 13,7; 41,1 e 65,8%, respectivamente. Com base nos resultados, recomenda-se a utilização de medicamentos fitoterápicos contra parasitas gastrintestinais e como alternativa à resistência helmíntica

Floristic survey of vascular plants of a poorly known area in the Brazilian Atlantic Forest (Flona do Rio Preto, Espírito Santo)

The Atlantic Forest is one of the most threatened biomes in the world. Despite that, this biome still includes many areas that are poorly known floristically, including several protected areas, such as the "Floresta Nacional do Rio Preto" ("Flona do Rio Preto"), located in the Brazilian State of Espírito Santo. This study used a published vascular plant species list for this protected area from the "Catálogo de Plantas das Unidades de Conservação do Brasil" as the basis to synthesise the species richness, endemism, conservation and new species occurrences found in the "Flona do Rio Preto".The published list of vascular plants was based on field expeditions conducted between 2018 and 2020 and data obtained from herbarium collections available in online databases. Overall, 722 species were documented for the "Flona do Rio Preto", 711 of which are native to Brazil and 349 are endemic to the Atlantic Forest. In addition, 60 species are geographically disjunct between the Atlantic and the Amazon Forests. Most of the documented species are woody and more than 50% of these are trees. Twenty-three species are threatened (CR, EN and VU), while five are Data Deficient (DD). Thirty-two species are new records for the State of Espírito Santo. Our results expand the knowledge of the flora of the Atlantic Forest and provide support for the development of new conservation policies for this protected area

Genomic analysis of two phlebotomine sand fly vectors of Leishmania from the New and Old World

Phlebotomine sand flies are of global significance as important vectors of human disease, transmitting bacterial, viral, and protozoan pathogens, including the kinetoplastid parasites of the genus Leishmania, the causative agents of devastating diseases collectively termed leishmaniasis. More than 40 pathogenic Leishmania species are transmitted to humans by approximately 35 sand fly species in 98 countries with hundreds of millions of people at risk around the world. No approved efficacious vaccine exists for leishmaniasis and available therapeutic drugs are either toxic and/or expensive, or the parasites are becoming resistant to the more recently developed drugs. Therefore, sand fly and/or reservoir control are currently the most effective strategies to break transmission. To better understand the biology of sand flies, including the mechanisms involved in their vectorial capacity, insecticide resistance, and population structures we sequenced the genomes of two geographically widespread and important sand fly vector species: Phlebotomus papatasi, a vector of Leishmania parasites that cause cutaneous leishmaniasis, (distributed in Europe, the Middle East and North Africa) and Lutzomyia longipalpis, a vector of Leishmania parasites that cause visceral leishmaniasis (distributed across Central and South America). We categorized and curated genes involved in processes important to their roles as disease vectors, including chemosensation, blood feeding, circadian rhythm, immunity, and detoxification, as well as mobile genetic elements. We also defined gene orthology and observed micro-synteny among the genomes. Finally, we present the genetic diversity and population structure of these species in their respective geographical areas. These genomes will be a foundation on which to base future efforts to prevent vector-borne transmission of Leishmania parasites. The leishmaniases are a group of neglected tropical diseases caused by protist parasites from the Genus Leishmania. Different Leishmania species present a wide clinical profile, ranging from mild, often self-resolving cutaneous lesions that can lead to protective immunity, to severe metastatic mucosal disease, to visceral disease that is ultimately fatal. Leishmania parasites are transmitted by the bites of sand flies, and as no approved human vaccine exists, available drugs are toxic and/or expensive and parasite resistance to them is emerging, new dual control strategies to combat these diseases must be developed, combining interventions on human infections and integrated sand fly population management. Effective vector control requires a comprehensive understanding of the biology of sand flies. To this end, we sequenced and annotated the genomes of two sand fly species that are important leishmaniasis vectors from the Old and New Worlds. These genomes allow us to better understand, at the genetic level, processes important in the vector biology of these species, such as finding hosts, blood-feeding, immunity, and detoxification. These genomic resources highlight the driving forces of evolution of two major Leishmania vectors and provide foundations for future research on how to better prevent leishmaniasis by control of the sand fly vectors

Genomic analysis of two phlebotomine sand fly vectors of Leishmania from the New and Old World.

Phlebotomine sand flies are of global significance as important vectors of human disease, transmitting bacterial, viral, and protozoan pathogens, including the kinetoplastid parasites of the genus Leishmania, the causative agents of devastating diseases collectively termed leishmaniasis. More than 40 pathogenic Leishmania species are transmitted to humans by approximately 35 sand fly species in 98 countries with hundreds of millions of people at risk around the world. No approved efficacious vaccine exists for leishmaniasis and available therapeutic drugs are either toxic and/or expensive, or the parasites are becoming resistant to the more recently developed drugs. Therefore, sand fly and/or reservoir control are currently the most effective strategies to break transmission. To better understand the biology of sand flies, including the mechanisms involved in their vectorial capacity, insecticide resistance, and population structures we sequenced the genomes of two geographically widespread and important sand fly vector species: Phlebotomus papatasi, a vector of Leishmania parasites that cause cutaneous leishmaniasis, (distributed in Europe, the Middle East and North Africa) and Lutzomyia longipalpis, a vector of Leishmania parasites that cause visceral leishmaniasis (distributed across Central and South America). We categorized and curated genes involved in processes important to their roles as disease vectors, including chemosensation, blood feeding, circadian rhythm, immunity, and detoxification, as well as mobile genetic elements. We also defined gene orthology and observed micro-synteny among the genomes. Finally, we present the genetic diversity and population structure of these species in their respective geographical areas. These genomes will be a foundation on which to base future efforts to prevent vector-borne transmission of Leishmania parasites

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