Contribution to the discriminant power of some of the variables involved in the staging of severe equine asthma syndrome

Tese de Doutoramento em Ciências Veterinárias na especialidade de ClínicaSevere Equine Asthma Syndrome (EAS) is a highly prevalent, chronic and recurrent respiratory disease which appears to be related to equine domestication. Due to its insidious nature, treatment may sometimes be frustrating and severe economic loses occur. Genetically susceptible individuals develop airway inflammation, hyperresponsiveness and obstruction when exposed to environments with high concentrations of respirable dust particles, which include mould spores, mites, endotoxins, pollen and other antigenic materials. These hazardous respirable dust concentrations are usually found in traditional equine housing systems, while lower concentrations tend to be present in outdoor systems (pasture). The management of severe EAS essentially requires environmental control to ensure improvement of lung function and in some cases medical treatment with corticosteroids and bronchodilators to ameliorate the clinical signs of airway inflammation and bronchospasm. Considering the clinical importance of this syndrome, the dissertation focuses on further contributing to scientific knowledge of severe EAS. As such, we investigated the influence of lung function tests on the diagnosis and staging of the disease and developed a staging method using only portable equipment, which has the potential of being used in equine ambulatory practice. We also investigated the relation between severe EAS and resistance to gastrointestinal parasites, which had not been, to the author’s knowledge, previously reported in the Lusitano breed horses. This association has been reported in other equine breeds with severe EAS or with other multiple hypersensitivities (MHS). Lastly, because allergen avoidance is fundamental for the remission of severe EAS we examined owner compliance to a set of recommended guidelines for environmental management.RESUMO - A síndrome de asma equina (SAE) grave é uma doença respiratória crónica, recorrente e altamente prevalente em animais adultos, estando associada à domesticação dos equinos. Devido à sua natureza insidiosa, o tratamento é muitas vezes frustrante, originando perdas económicas significantes. Quando expostos a ambientes com elevadas concentrações de partículas respiráveis, tais como esporos de fungos, ácaros, endotoxinas, pólen e outras partículas antigénicas, os animais geneticamente suscetíveis desenvolvem inflamação, hiper-reactividade e obstrução das vias aéreas. As concentrações de partículas respiráveis elevadas encontram-se normalmente presentes em sistemas de estabulação de equinos tradicionais, enquanto que em sistemas em extensivo (pastagem) estas concentrações tendem a ser menores. Assim, no maneio da SAE grave é essencial o controlo ambiental de modo a assegurar a melhoria da função pulmonar e em alguns casos o tratamento médico com corticosteroides e broncodilatadores para reduzir os sinais clínicos de inflamação das vias aéreas e broncospasmo. Tendo em conta a importância clínica desta síndrome, esta dissertação tem por objetivo contribuir para o conhecimento científico da SAE grave. Assim sendo, investigámos a influencia dos testes de função pulmonar no diagnóstico e estadiamento da doença e desenvolvemos um método de estadiamento, utilizando apenas equipamento portátil, o qual poderá ser utilizado na clínica em regime de ambulatório. Ainda, investigámos a relação entre SAE grave e a resistência a parasitas gastrointestinais, a qual até à data ainda não havia sido reportada em cavalos Puro Sangue Lusitanos. Esta associação foi, contudo, descrita em equinos de outras raças diagnosticados com SAE grave ou outras hipersensibilidades múltiplas. Por fim, considerando que a remoção de aeroalérgenos é fundamental para a remissão da SAE grave, procurámos avaliar a complacência dos donos dos animais asmáticos a um conjunto de recomendações de maneio ambiental.CIISA through the project INOV CIISA 8.N/

Utilização de gastroscopia no despiste da EGUS / SUGE (Equine Gastric Ulcer Syndrome / Síndrome de Úlcera Gástrica Equina)

Dissertação de Mestrado Integrado em Medicina VeterináriaA Síndrome de Úlcera Gástrica Equina (SUGE) tem recebido nas últimas décadas uma atenção crescente, devido à sua elevada prevalência, e às suas repercussões económicas e no bem-estar dos animais. Pensa-se que a SUGE terá uma etiologia multifactorial, envolvendo vários factores de risco que predispõem à lesão da mucosa ao alterarem a acidez gástrica, a concentração de ácidos gordos voláteis ou o aporte sanguíneo. São considerados factores de risco a intensidade e regime de exercício físico, a dieta, a estabulação permanente, a terapêutica com anti-inflamatórios não esteroides e o stress. A bactéria Helicobacter pylori não foi isolada até à data em equinos, embora tenha sido descoberta outra espécie enterohepática – Helicobacter equorum. Contudo, foi identificado ADN tipo-Helicobacter em vários cavalos com ulceração gástrica. A gastroscopia é o único método de diagnóstico definitivo in vivo disponível e as úlceras são frequentemente achados gastroscópicos em animais assintomáticos, já que os sinais clínicos são normalmente inespecíficos e ligeiros. Este trabalho teve como objectivo avaliar a presença da SUGE num grupo de 12 cavalos Puro Sangue Lusitanos (PSL) por meio de gastroscopia, procurando identificar factores de risco que contribuam para a presença de lesões gástricas, incluindo a pesquisa de Helicobacter spp.. Assim, todos os cavalos foram submetidos a gastroscopia, biópsia da mucosa glandular gástrica e medição do pH gástrico. Os cavalos que apresentaram graus de ulceração elevados foram submetidos a terapêutica com omeprazol, formulação pasta oral (GastroGard™, Merial). Os doze cavalos avaliados apresentavam lesões na mucosa gástrica, contudo apenas 9 foram medicados com GastroGard™. Os resultados obtidos vão de encontro à eficácia, já testada, do GastroGard™ no tratamento da ulceração gástrica, já que mesmo não se observando uma remissão completa das lesões, estas tendiam para a cicatrização. Também após administração do fármaco observou-se melhoria dos sinais clínicos que alguns cavalos manifestavam. Os resultados deste trabalho mostram que factores de risco como o maneio, alimentação, exercício e stress terão importância preponderante na ocorrência da SUGE. Os antiinflamatórios não esteróides são considerados ulcerogénicos em equinos, contudo o único animal medicado com estes fármacos apresentava uma mucosa gástrica saudável.ABSTRACT - The use of gastroscopy in the diagnosis of EGUS/SUGE (Equine Gastric Ulcer Syndrome / Síndrome de Úlcera Gástrica Equina) - Equine Gastric Ulcer Syndrome has received an increasing attention in the last decade due to its high prevalence, economic repercussions and impact on animal welfare. It’s believed that EGUS has a multifactorial etiology, involving several risk factors that predispose to gastric lesion by altering gastric acidity, concentration of volatile fatty acids or mucosal irrigation. Exercise intensity, diet, stall confinement, use of nonsteroidal antiinflammatory drugs and stress are considered to be risk factors. Helicobacter pylori has not to date been isolated in equines, though another enterohepatic specie has been identified – Helicobacter equorum. However, Helicobacter-like DNA has been found in several horses with gastric ulceration. Gastroscopy is the only in vivo definite diagnostic method and ulcers are frequently a gastroscopic finding in assymptomatic animals, since clinical sings are generally mild and non-specific. This work’s objective was to evaluate the presence of EGUS in a group of 12 Pure Blood Lusitano horses by means of gastroscopy, while trying to identify risk factors that may contribute to the apearence of gastric lesions, including the presence of Helicobacter spp.. Therefore, all the horses were submitted to gastroscopy, gastric glandular mucosa biopsy and the evaluation of gastric pH. The horses that had high scores of ulceration were submitted to treatment with omeprazol, oral paste formulation (GastroGard™, Merial). The twelve horses evaluated had gastric lesions, although only nine were treated with GastroGard™. Our results are in agreement with the efficacy already proven of GastroGard™ in the treatment of gastric ulceration. Even when complete remission of lesions was not observed, there was a tendency to healing. Also after the drug administration improvement of clinical signs was shown by some of the horses. Results show that risk factors such as environment, diet, exercise and stress play an important role in the development of EGUS. Although, nonsteroidal anti-inflammatory are considered ulcerogenic in horses, the only animal medicated with these drugs had a healthy gastric mucosa

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study

Background and study aims Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.info:eu-repo/semantics/publishedVersio

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

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

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 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

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

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: 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. Funding: National Institute for Health and Care Research

Delaying surgery for patients with a previous SARS-CoV-2 infection

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