Effectiveness and long-term retention of anti-tumour necrosis factor treatment in juvenile and adult patients with juvenile idiopathic arthritis: data from Reuma.pt

Methods. We prospectively collected patient and disease characteristics from patients with JIA who started biological therapy. Adverse events were collected during the follow-up period. Predictors of response at 1 year and drug retention rates were assessed at 4 years of treatment for the first biologic agent.Results. A total of 812 JIA patients [65% females, mean age at JIA onset 6.9 years (s.d. 4.7)], 227 received biologic therapy; 205 patients (90.3%) were treated with an anti-TNF as the first biologic. All the parameters used to evaluate disease activity, namely number of active joints, ESR and Childhood HAQ/HAQ, decreased significantly at 6 months and 1 year of treatment. The mean reduction in Juvenile Disease Activity Score 10 (JADAS10) after 1 year of treatment was 10.4 (s.d. 7.4). According to the definition of improvement using the JADAS10 score, 83.3% respond to biologic therapy after 1 year. Fourteen patients discontinued biologic therapies due to adverse events. Retention rates were 92.9% at 1 year, 85.5% at 2 years, 78.4% at 3 years and 68.1% at 4 years of treatment. Among all JIA subtypes, only concomitant therapy with corticosteroids was found to be univariately associated with withdrawal of biologic treatment (P = 0.016).Conclusion. Biologic therapies seem effective and safe in patients with JIA. In addition, the retention rates for the first biologic agent are high throughout 4 years

description of the methodological approach

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Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Efeito da data de arranque no viveiro e do tratamento pelo frio no crescimento e produtividade do morangueiro (Fragaria x ananassa Duch.)

The aim of this study was to evaluate the effects of digging date at the nursery and duration of cold storage treatments applied after digging on the vegetative growth, flower production and fruit quality of two Californian short-day cultivars, "Chandler" and "Douglas", when winter planted in south-west Portugal. During four consecutive years, three field (1991/92, 1992/93 and 1993/94) and one growth chamber (1994/95) trials were layer out with three digging dates (middle of October, beginning and middle of November) and three cold storage treatments at 2#+-#1deg C (0,2 and 4 weeks). vegetative and flowering responses to digging dates and cold storage treatments varied between years and cultivars. The highest productivity of both cultivars was obtained with the 3"r"d digging date with no cold storage treatment. However, in 199394, when the plants had received a greater number of chilling hours in the nursery, chilling had an inhibitory effect on flower production of "Chandler" dug on the latest date, resulting in reduced fruit yield and increased vegetative vigor. "Douglas" had a relatively high chilling requirement compared to "Chandler" and did not respond to early chilling. Increased field chilling promoted higher leaf and stolen numbers and greater leaf area in both cultivars, and also higher crown number in "Chandler" and petiole length in "Douglas". Additional cold storage treatments stimulated vegetative development and decreased flower and inflorescence number. However, in 199192, when the plants received less number of chilling hours in the nursery, cold storage treatment in early digging dates increased plant productivity. Inflorescence number per plant was the main yield component responsible for differences in yield between years, Thus, improving growing conditions, namely by increasing the temperature in the winter months (January and February) will improve plant productivityAvailable from Fundacao para a Ciencia e a Tecnologia, Servico de Informacao e Documentacao, Av. D. Carlos I, 126, 1200 Lisboa / FCT - Fundação para o Ciência e a TecnologiaSIGLEPTPortuga

Hipotermia induzida na encefalopatia hipóxico-isquémica : experiência de 10 anos

© Author(s) (or their employer(s)) and Portuguese Journal of Pediatrics 2020. Re-use permitted under CC BY-NC. No commercial re-useIntroduction: Therapeutic hypothermia (TH) is the standard of care treatment for brain injury following perinatal hypoxia-ischemia in term infants. Accumulated evidence from clinical trials, systematic reviews and continuous experience shows a reduction in both mortality and long-term neurodevelopmental disability. The aim of our study was to: (i) present the 10-year experience of the neonatal intensive care unit (NICU) that pioneered hypothermia program in Portugal; (ii) evaluate the use of neurologic monitoring and (iii) describe outcomes and adverse events. Methods: Prospective observational study of neonates who underwent TH between November 2009 and October 2019 in a single tertiary level NICU. Results: 128 newborns were treated. 91% were outborn. The median gestational age was 39 weeks. 91% neonates needed advanced resuscitation, and 22% prolonged resuscitation (>10 minutes). On admission, 60% had severe, 26% had moderate and 14% had mild encephalopathy. Hypotension was the most common complication, affecting 66% of the newborns. 21 (16%) patients died during hospital stay. Expected outcome based on aEEG and MRI was favorable in 40%, intermediate in 32% and adverse in 28%. Discussion: Effectiveness and safety profile of TH was confirmed in our population. A national register would be important to achieve and maintain high homogenous and national wide standards of care.Resumo:Introdução: A hipotermia terapêutica é o tratamento padrão para lesões cerebrais consequentes a hipóxia-isquemia perinatal em recém-nascidos de termo. A evidência acumulada de ensaios clínicos, revisões sistemáticas e experiência revela uma redução da mortalidade e alterações do neurodesenvolvimento a longo prazo. Os objetivos do presente estudo foram apresentar a experiência de 10 anos da unidade de cuidados intensivos neonatais pioneira no programa de hipotermia em Portugal, avaliar o uso de monitorização neurológica e descrever resultados de curto prazo e eventos adversos.Métodos: Estudo observacional prospetivo de recém-nascidos submetidos a hipotermia terapêutica entre novembro de 2009 e outubro de 2019 numa unidade de cuidados intensivos neonatais de nível terciário. Foram coligidas variáveis clínicas da base de dados de hipotermia. Os resultados esperados foram calculados usando uma combinação de eletroencefalograma de amplitude integrada e imagens de ressonância magnética, de acordo com evidência robusta publicada.Resultados: O estudo incluiu 128 recém-nascidos tratados, 91% nascidos noutros hospitais. A mediana da idade gestacional foi de 39 semanas, 91% dos recém-nascidos precisaram de reanimação avançada e 22% de reanimação prolongada (> 10 minutos). Na admissão, 60% tinham encefalopatia grave, 26% encefalopatia moderada e 14% encefalopatia leve. A complicação mais comum foi hipotensão, que afetou 66% dos recém-nascidos. Durante o internamento, 21 (16%) dos doentes faleceram. O resultado esperado foi favorável em 40%, intermédio em 32% e adverso em 28%.Discussão: A eficácia e o perfil de segurança da hipotermia terapêutica foram confirmados na nossa população. No futuro, a criação de um registo nacional seria importante para atingir e manter padrões nacionais de atendimento e de cuidados homogéneos e elevadosinfo:eu-repo/semantics/publishedVersio

Practical guide for the use of biotechnological therapies in Rheumatoid Arthritis

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Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Characteristics associated with poor COVID-19 outcomes in individuals with systemic lupus erythematosus: data from the COVID-19 Global Rheumatology Alliance.

AimTo determine characteristics associated with more severe outcomes in a global registry of people with systemic lupus erythematosus (SLE) and COVID-19.MethodsPeople with SLE and COVID-19 reported in the COVID-19 Global Rheumatology Alliance registry from March 2020 to June 2021 were included. The ordinal outcome was defined as: (1) not hospitalised, (2) hospitalised with no oxygenation, (3) hospitalised with any ventilation or oxygenation and (4) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics, comorbidities, medications and disease activity.ResultsA total of 1606 people with SLE were included. In the multivariable model, older age (OR 1.03, 95% CI 1.02 to 1.04), male sex (1.50, 1.01 to 2.23), prednisone dose (1-5 mg/day 1.86, 1.20 to 2.66, 6-9 mg/day 2.47, 1.24 to 4.86 and ≥10 mg/day 1.95, 1.27 to 2.99), no current treatment (1.80, 1.17 to 2.75), comorbidities (eg, kidney disease 3.51, 2.42 to 5.09, cardiovascular disease/hypertension 1.69, 1.25 to 2.29) and moderate or high SLE disease activity (vs remission; 1.61, 1.02 to 2.54 and 3.94, 2.11 to 7.34, respectively) were associated with more severe outcomes. In age-adjusted and sex-adjusted models, mycophenolate, rituximab and cyclophosphamide were associated with worse outcomes compared with hydroxychloroquine; outcomes were more favourable with methotrexate and belimumab.ConclusionsMore severe COVID-19 outcomes in individuals with SLE are largely driven by demographic factors, comorbidities and untreated or active SLE. Patients using glucocorticoids also experienced more severe outcomes