Atrial fibrillation as a new prognosis factor in chronic patients after hospitalization: the CHRONIBERIA index

A collaborative project in different areas of Spain and Portugal was designed to find out the variables that influence the mortality after discharge and develop a prognostic model adapted to the current healthcare needs of chronic patients in an internal medicine ward. Inclusion criteria were being admitted to an Internal Medicine department and at least one chronic disease. Patients’ physical dependence was measured through Barthel index (BI). Pfeiffer test (PT) was used to establish cognitive status. We conducted logistic regression and Cox proportional hazard models to analyze the influence of those variables on one-year mortality. We also developed an external validation once decided the variables included in the index. We enrolled 1406 patients. Mean age was 79.5 (SD = 11.5) and females were 56.5%. After the follow-up period, 514 patients (36.6%) died. Five variables were identified as significantly associated with 1 year mortality: age, being male, lower BI punctuation, neoplasia and atrial fibrillation. A model with such variables was created to estimate one-year mortality risk, leading to the CHRONIBERIA. A ROC curve was made to determine the reliability of this index when applied to the global sample. An AUC of 0.72 (0.7–0.75) was obtained. The external validation of the index was successful and showed an AUC of 0.73 (0.67–0.79). Atrial fibrillation along with an advanced age, being male, low BI score, or an active neoplasia in chronic patients could be critical to identify high risk multiple chronic conditions patients. Together, these variables constitute the new CHRONIBERIA index

In Vivo Approaches Reveal a Key Role for DCs in CD4+ T Cell Activation and Parasite Clearance during the Acute Phase of Experimental Blood-Stage Malaria

Dendritic cells (DCs) are phagocytes that are highly specialized for antigen presentation. Heterogeneous populations of macrophages and DCs form a phagocyte network inside the red pulp (RP) of the spleen, which is a major site for the control of blood-borne infections such as malaria. However, the dynamics of splenic DCs during Plasmodium infections are poorly understood, limiting our knowledge regarding their protective role in malaria. Here, we used in vivo experimental approaches that enabled us to deplete or visualize DCs in order to clarify these issues. To elucidate the roles of DCs and marginal zone macrophages in the protection against blood-stage malaria, we infected DTx (diphtheria toxin)-treated C57BL/6.CD11c-DTR mice, as well as C57BL/6 mice treated with low doses of clodronate liposomes (ClLip), with Plasmodium chabaudi AS (Pc) parasites. The first evidence suggesting that DCs could contribute directly to parasite clearance was an early effect of the DTx treatment, but not of the ClLip treatment, in parasitemia control. DCs were also required for CD4+ T cell responses during infection. The phagocytosis of infected red blood cells (iRBCs) by splenic DCs was analyzed by confocal intravital microscopy, as well as by flow cytometry and immunofluorescence, at three distinct phases of Pc malaria: at the first encounter, at pre-crisis concomitant with parasitemia growth and at crisis when the parasitemia decline coincides with spleen closure. In vivo and ex vivo imaging of the spleen revealed that DCs actively phagocytize iRBCs and interact with CD4+ T cells both in T cell-rich areas and in the RP. Subcapsular RP DCs were highly efficient in the recognition and capture of iRBCs during pre-crisis, while complete DC maturation was only achieved during crisis. These findings indicate that, beyond their classical role in antigen presentation, DCs also contribute to the direct elimination of iRBCs during acute Plasmodium infection.São Paulo Research Foundation grants: (2011/24038-1 [MRDL], 2009/08559-1 [HBdS], CAPES/IGC 04/ 2012 [MRDL, CET])

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Pulmão do Cuspidor de Fogo

Apresenta-se o caso de um homem de 31 anos, fumador sem outras doenças conhecidas. É agente comercial numa empresa de produtos de higiene e, desde há 3 meses, iniciou a prática de cuspir fogo em espectáculos de rua. Recorre ao Serviço de Urgência (SU) por dor torácica anterior direita com características pleuríticas, tosse seca e febre (40ºC), quadro que iniciou poucas horas após a aspiração do líquido “água de fogo” (composto por derivados do petróleo) durante uma performance a cuspir fogo. Do estudo realizado, apresentava aumento dos marcadores inflamatórios e hipotransparência do lobo médio na radiografia torácica, pelo que teve alta medicado com azitromicina 500mg uma vez dia. Por persistência e agravamento dos sintomas, recorre novamente ao SU 3 dias depois. Objectivadas febre e crepitações no 1/3 inferior do hemitórax direito. TAC torácica a mostrar consolidação do segmento anterior do lobo inferior esquerdo e do segmento medial do lobo médio (figuras 1 e 2), com áreas de baixa densidade (-77HU) - seta da figura 1-, áreas em vidro despolido no lobo médio (figura 2) e ainda algumas opacidades lineares nos segmentos basais dos lobos inferiores. Apresentava também aumento franco dos marcadores analíticos de inflamação, com leucocitose 16000/µL, neutrofilia e PCR 233 mg/L. A gasimetria arterial excluiu insuficiência respiratória. Assumiu-se Pneumonia Lipóide Exógena Aguda com possível sobreinfecção, pelo que iniciou amoxicilina-clavulanato após colheita de rastreio séptico. Realizou broncofibroscopia, que não revelou alterações da mucosa brônquica, e colheu lavado brônquico (LB), tendo-se observado células muco-secretoras, macrófagos alveolares e escassos polimorfonucleares. Não foi isolado agente infeccioso e apresentou evolução clínica e analítica favorável, tendo tido alta após 4 dias de internamento, a completar antibioterapia empírica em ambulatório. A Pneumonia Lipóide Exógena é uma entidade rara, que resulta da inalação e/ou aspiração de substâncias lipídicas, podendo ocorrer de forma crónica ou aguda, sendo esta última uma condição rara e consequente de aspiração acidental de uma grande quantidade de material lipídico num curto espaço de tempo.1 Os sintomas mais comuns são tosse, dor torácica, dispneia, febre e hemoptises, sendo habitual surgirem nas primeiras 12 horas após aspiração da substância.1 O melhor método de imagem para o diagnóstico é o TAC de alta resolução, que frequentemente mostra consolidação e/ou áreas em vidro despolido, habitualmente bilateral e nos lobos inferiores (quando unilateral o pulmão direito é o mais afectado), podendo ainda observar-se espessamentos septais interlobulares.2 O achado imagiológico mais característico é a presença de consolidação com áreas de baixa densidade (entre -150 a -30HU), fenómeno que se deve à atenuação da gordura1-4. O estudo citológico do lavado broncoalveolar pode evidenciar macrófagos xantomatosos, o que corrobora o dignóstico. Contudo, este achado não é específico e os falsos negativos são frequentes.1,3 O diagnóstico é baseado na histórica clínica e nos achados imagiológicos e citológicos, sendo que nenhum isoladamente faz o diagnóstico1. Dado ser uma entidade pouco frequente, com poucos casos descritos, o tratamento baseia-se na experiência clínica, sendo essencial: a evicção do agente causal; o tratamento de suporte e das complicações, nomeadamente sobreinfecção bacteriana. O uso de corticóides é controverso devendo ser reservado para as situação clínicas mais graves.1-2 No nosso caso não foi possível constatar os macrófagos típicos no LB. Atendendo à evolução favorável, pareceu-nos desnecessário expor o doente a métodos mais invasivos, até porque a história clínica e os achados imagiológicos característicos apoiam fortemente o diagnóstico. 1. Marchiori E, Zanetti G, Mano CM et al: Exogenous lipoid pneumonia. Clinical and radiological manifestations. Respir Med, 2011; 105(5): 659–66 2. Pielaszkiewicz-Wydra M. , Homola-Piekarska B. et al: Exogenous lipoid pneumonia – a case report of a fire-eater. Pol J radiol, 2012; 7(4):60-64. 3. Gondouin A, Manzoni P, Ranfaing E et al: Exogenous lipoid pneumonia: a retrospective multicentre study of 44 cases in France. Eur Respir J, 1996; 9: 1463–69 4. Betancourt SL, Martinez-Jimenez S, Rossi SE, Truong MT, Carrillo J, Erasmus JJ. Lipoid pneumonia: spectrum of clinical and radiologic manifestations. AJR Am J Roentgenol 2010; 194:103-

Bioaccessibility and Intestinal Permeability from Andean Blackberry (Rubus glaucus Benth) Powders Encapsulated with OSA-Modified FHIA-21 Banana Starch

Modified starches for bananas can be used to encapsulate underutilized fruits such as Andean blackberry due to its content of phenolic compounds. This research aimed to assess the bioaccessibility and intestinal permeability of phenolic compounds from Andean blackberry powders encapsulated in octenyl succinic anhydride (OSA)-modified Gros Michel banana starch. Although low bioaccessibilities were found for total phenolics (up to 6%) during the in vitro digestion, most of them were chlorogenic acid and quercetin, released at high apparent permeability values (5–12 × 10−4 cm/s). OSA-banana starches are suitable encapsulating matrices for blackberry polyphenols, ensuring their targeted release at the small intestine

Association between food environments and fetal growth in pregnant Brazilian women

Abstract Introduction Birth weight is described as one of the main determinants of newborns’ chances of survival. Among the associated causes, or risk factors, the mother’s nutritional status strongly influences fetal growth and birth weight outcomes of the concept. This study evaluates the association between food deserts, small for gestational age (SGA), large for gestational age (LGA) and low birth weight (LBW) newborns. Design This is a cross-sectional population study, resulting from individual data from the Live Birth Information System (SINASC), and commune data from mapping food deserts (CAISAN) in Brazil. The newborn’s size was defined as follows: appropriate for gestational age (between 10 and 90th percentile), SGA ( 90th percentile), and low birth weight < 2,500 g. To characterize food environments, we used tertiles of the density of establishments which sell in natura and ultra-processed foods. Logistic regression modeling was conducted to investigate the associations of interest. Results We analyzed 2,632,314 live births in Brazil in 2016, after appropriate adjustments, women living in municipalities with limited availability of fresh foods had a higher chance of having newborns with SGA [OR2nd tertile: 1.06 (1.05–1.07)] and LBW [OR2nd tertile: 1.11 (1.09–1.12)]. Conversely, municipalities with greater availability of ultra-processed foods had a higher chance of having newborns with SGA [OR3rd tertile: 1.04 (1.02–1.06)] and LBW [OR2nd tertile: 1.13 (1.11–1.16)]. Stratification by race showed that Black and Mixed/Brown women had a higher chance of having newborns with SGA [OR3rd tertile: 1.09 (1.01–1.18)] and [OR3rd tertile: 1.06 (1.04–1.09)], respectively, while Mixed-race women also had a higher chance of having newborns with LBW [OR3rd tertile: 1.17 (1.14–1.20)]. Indigenous women were associated with LGA [OR3rd tertile: 1.20 (1.01–1.45)]. Conclusion The study found that living in areas with limited access to healthy foods was associated with an increased risk of SGA and low birth weight among newborns, particularly among Black and Mixed/Brown women. Therefore, urgent initiatives aimed at reducing social inequalities and mitigating the impact of poor food environments are needed in Brazil

Physicians' responsibility toward environmental degradation and climate change:A position paper of the European Federation of Internal Medicine

The current data on climate change and environmental degradation are dramatic. The consequences of these changes are already having a significant impact on people's health. Physicians - as advocates of the patients, but also as citizens - have an ethical obligation to be involved in efforts to stop these changes. The European Federation of Internal Medicine (EFIM) strongly encourages the Internal Medicine societies and internists across Europe to play an active role in matters related to climate change and environmental degradation. At a national level, this includes advocating the adoption of measures that reduce greenhouse gas (GHG) emissions and environmental degradation and contributing to policy decisions related to these issues. At a hospital level and in clinical practice, supporting actions by the health sector to reduce its ecological footprint is vital. At the level of EFIM and its associated internal societies, promoting educational activities and developing a toolkit to prepare internists to better care for citizens who suffer from the consequences of climate change. In addition to advocating and implementing effective actions to reduce the ecological footprint of the health industry, recommending the introduction of these themes in scientific programs of Internal Medicine meetings and congresses and the pre- and postgraduate medical training. At a personal level, internists must be active agents in advocating sustainable practices for the environment, increasing the awareness of the community about the health risks of climate change and environmental degradation, and being role models in the adoption of environmentally friendly behaviour