Practical application of the Crohn's disease exclusion diet as therapy in an adult Australian population.

There is demand from patients and clinicians to use the Crohn's disease exclusion diet (CDED) with or without partial enteral nutrition (PEN). However, the therapeutic efficacy and nutritional adequacy of this therapy are rudimentary in an adult population. This review examines the evidence for the CDED in adults with active luminal Crohn's disease and aims to provide practical guidance on the use of the CDED in Australian adults. A working group of nine inflammatory bowel disease (IBD) dietitians of DECCAN (Dietitians Crohn's and Colitis Australian Network) and an IBD gastroenterologist was established. A literature review was undertaken to examine (1) clinical indications, (2) monitoring, (3) dietary adequacy, (4) guidance for remission phase, and (5) diet reintroduction after therapy. Each diet phase was compared with Australian reference ranges for food groups and micronutrients. CDED with PEN is nutritionally adequate for adults containing sufficient energy and protein and meeting > 80% of the recommended daily intake of key micronutrients. An optimal care pathway for the clinical use of the CDED in an adult population was developed with accompanying consensus statements, clinician toolkit, and patient education brochure. Recommendations for weaning from the CDED to the Australian dietary guidelines were developed. The CDED + PEN provides an alternate partial food-based therapy for remission induction of active luminal Crohn's disease in an adult population. The CDED + PEN should be prioritized over CDED alone and prescribed by a specialist IBD dietitian. DECCAN cautions against using the maintenance diet beyond 12 weeks until further evidence becomes available.

Diagnosis of Pregnancy Complications Using Blind Ultrasound Sweeps Performed by Individuals Without Prior Formal Ultrasound Training.

OBJECTIVE: To estimate the diagnostic accuracy of blind ultrasound sweeps performed with a low-cost, portable ultrasound system by individuals with no prior formal ultrasound training to diagnose common pregnancy complications. METHODS: This is a single-center, prospective cohort study conducted from October 2020 to January 2022 among people with second- and third-trimester pregnancies. Nonspecialists with no prior formal ultrasound training underwent a brief training on a simple eight-step approach to performing a limited obstetric ultrasound examination that uses blind sweeps of a portable ultrasound probe based on external body landmarks. The sweeps were interpreted by five blinded maternal-fetal medicine subspecialists. Sensitivity, specificity, and positive and negative predictive values for blinded ultrasound sweep identification of pregnancy complications (fetal malpresentation, multiple gestations, placenta previa, and abnormal amniotic fluid volume) were compared with a reference standard ultrasonogram as the primary analysis. Kappa for agreement was also assessed. RESULTS: Trainees performed 194 blinded ultrasound examinations on 168 unique pregnant people (248 fetuses) at a mean of 28±5.85 weeks of gestation for a total of 1,552 blinded sweep cine clips. There were 49 ultrasonograms with normal results (control group) and 145 ultrasonograms with abnormal results with known pregnancy complications. In this cohort, the sensitivity for detecting a prespecified pregnancy complication was 91.7% (95% CI 87.2-96.2%) overall, with the highest detection rate for multiple gestations (100%, 95% CI 100-100%) and noncephalic presentation (91.8%, 95% CI 86.4-97.3%). There was high negative predictive value for placenta previa (96.1%, 95% CI 93.5-98.8%) and abnormal amniotic fluid volume (89.5%, 95% CI 85.3-93.6%). There was also substantial to perfect mean agreement for these same outcomes (range 87-99.6% agreement, Cohen κ range 0.59-0.91, P<.001 for all). CONCLUSION: Blind ultrasound sweeps of the gravid abdomen guided by an eight-step protocol using only external anatomic landmarks and performed by previously untrained operators with a low-cost, portable, battery-powered device had excellent sensitivity and specificity for high-risk pregnancy complications such as malpresentation, placenta previa, multiple gestations, and abnormal amniotic fluid volume, similar to results of a diagnostic ultrasound examination using a trained ultrasonographer and standard-of-care ultrasound machine. This approach has the potential to improve access to obstetric ultrasonography globally.

Diagnostic procedures in infrared thermography for the human face: a scoping review protocol / Procedimentos diagnósticos em termografia infravermelha para a face humana: um protocolo de revisão de escopo

ABSTRACT Purpose: to present the scoping review protocol that will describe the diagnostic procedures used in infrared thermography to evaluate the human face. Methods: based on the Joanna Briggs Institute and PRISMA-ScR checklist, with the mnemonic: population (P) - human face, concept (C) - infrared thermography, and context (C) - diagnostic procedures in infrared thermography for the human face. The methodological structure will have six stages. The PubMed, LILACS, SciELO, BBO, Web of Science, EMBASE, Scopus, Cochrane Library, and Grey Literature Report databases will be searched, with no restriction on time or language. The review will include qualitative and quantitative studies. Two reviewers will independently select studies and extract data. Results will be analyzed using a variable approach. Conclusion: this scoping review protocol followed the methodological precepts and is apt to be carried out. It will serve as the basis for other scoping reviews. Conducting a scoping review is important and the prior publication of the scoping review protocol is essential to make the review process transparent.

RESUMO Objetivo: apresentar um protocolo de revisão de escopo para identificar os procedimentos diagnósticos utilizados na termografia infravermelha para a avaliação da face humana. Métodos: baseado no The Joanna Briggs Institute e no checklist PRISMA-ScR, com o mnemônico: população (P) - face humana, conceito (C) - termografia infravermelha e contexto (C) - procedimentos diagnósticos na termografia infravermelha para a região da face humana. A estrutura metodológica consistirá em seis etapas. As bases de dados consultadas serão o PubMed, LILACS, SciELO, BBO, Web of Science, Embase, Scopus, Cochrane Library e Grey Literature Report. A busca será realizada sem delimitação temporal ou restrição de idioma. A revisão incluirá estudos qualitativos e quantitativos. Dois revisores selecionarão os estudos independentemente e extrairão os dados. Os resultados serão analisados utilizando uma abordagem variável. Conclusão: este protocolo de revisão de escopo seguiu os preceitos metodológicos e se encontra em condições de execução, servindo também como base para outras revisões de escopo. A realização de uma revisão de escopo é importante e a prévia publicação do protocolo de revisão de escopo fundamental, pois tem a finalidade de trazer transparência ao processo a ser realizado.

Cost and accessibility of empiric food elimination diets for treatment of eosinophilic oesophagitis.

AIM: This study aimed to investigate and compare the cost, affordability, and accessibility of three elimination diet approaches for the treatment of patients with eosinophilic esophagitis: the two-, four- and six-food elimination diets and with comparison to a standard diet. METHODS: An evidence-based modelling process was undertaken for costing and accessibility, including the development of three hypothetical reference families; four food baskets were modified from an established benchmark for each diet. Baskets were costed across eastern Melbourne, Australia. Affordability was modelled using two incomes: the equivalised disposable household income and welfare payments for reference families. Affordability was defined as <30% of the median weekly household income and food stress defined as >25% of a median weekly household income. RESULTS: All elimination diets were significantly more expensive than a standard diet and may be unaffordable for those receiving welfare. Prices significantly increased as the number of food allergens eliminated increased. Most items for a two-food elimination diet were available at major supermarkets; however, items for nutritionally complete four- and six-food elimination diets required a visit to a second store. CONCLUSION: A step-up approach, commencing with a two-food elimination diet, instead of starting with a six-food elimination diet, may alleviate affordability barriers for most family types, which may enhance compliance. Clinicians should consider family type, financial situation, as well as accessibility of allergen-free foods in the patient's residential area when deciding on the most appropriate dietary or therapeutic treatment approach for eosinophilic oesophagitis.

Zinc supplementation and its benefits in the management of chronic liver disease: An in-depth literature review.

Malnutrition among patients with chronic liver disease (CLD) is a common complication with significant prognostic implications for patients with liver cirrhosis. Micronutrient deficiency has been associated with an increased risk of hepatic decompensation and is an independent risk factor for mortality among cirrhotic patients. Micronutrient deficiencies in patients with CLD include zinc, vitamin A, vitamin D and selenium. This review article aims to evaluate the literature to date on the complications of zinc deficiency in patients with CLD. A management algorithm for zinc replacement has also been proposed.

Markers of activated inflammatory cells are associated with disease severity and intestinal microbiota in adults with non­alcoholic fatty liver disease.

Several mechanisms contribute to the pathogenesis of non­alcoholic fatty liver disease (NAFLD). The intestinal microbiota (IM) and liver immune cells (LIC) may serve a role, but there has been no previous study assessing potential associations between IM and LIC. The aim of the present study was to investigate whether there are differences in LIC markers between patients with NAFLD and healthy controls (HC), and to determine whether these markers are associated with specific IM. The present prospective, cross­sectional study examined a cohort of adults with liver biopsy­confirmed NAFLD and HC. Clinical and laboratory data were collected. Fecal IM was assessed by quantitative polymerase chain reaction and LIC, by immunohistochemistry. NAFLD activity score (NAS) was used for disease severity. Liver immune cell counts were increased in patients with NAFLD (n=34) vs. HC (n=8) and this was associated with disease severity. Hematopoietic cell marker cluster of differentiation (CD)45+ and Kupffer cell marker CD163+ were higher in NAFLD compared with HC, and those with an NAS ≥5 had higher levels of CD20+ cells, a marker of B cells, vs. a NAS of 0 or 1­4. Additionally, from those patients (5 HC, 34 NAFLD), IM was measured. Specific immune cells in portal or lobular areas correlated with specific fecal IM, suggesting a potential association between IM and liver inflammation in patients with NAFLD. Specifically, Faecalibacterium prausnitzii was negatively correlated with CD45+ (r= ­0.394; P=0.015) and CD163+ (r= ­0.371; P=0.022) cells in the portal tract and Prevotella was negatively correlated with CD20+ (r= ­0.353; P=0.028) cells in the liver lobule. Other taxa exhibited no correlation. In conclusion, the present study demonstrated a potential association between IM and liver inflammation in NAFLD.

Nonalcoholic fatty liver disease is associated with dysbiosis independent of body mass index and insulin resistance.

This study aimed to determine if there is an association between dysbiosis and nonalcoholic fatty liver disease (NAFLD) independent of obesity and insulin resistance (IR). This is a prospective cross-sectional study assessing the intestinal microbiome (IM) of 39 adults with biopsy-proven NAFLD (15 simple steatosis [SS]; 24 nonalcoholic steatohepatitis [NASH]) and 28 healthy controls (HC). IM composition (llumina MiSeq Platform) in NAFLD patients compared to HC were identified by two statistical methods (Metastats, Wilcoxon). Selected taxa was validated using quantitative PCR (qPCR). Metabolites in feces and serum were also analyzed. In NAFLD, 8 operational taxonomic units, 6 genera, 6 families and 2 phyla (Bacteroidetes, Firmicutes) were less abundant and; 1 genus (Lactobacillus) and 1 family (Lactobacillaceae) were more abundant compared to HC. Lower abundance in both NASH and SS patients compared to HC were confirmed by qPCR for Ruminococcus, Faecalibacterium prausnitzii and Coprococcus. No difference was found between NASH and SS. This lower abundance in NAFLD (NASH+SS) was independent of BMI and IR. NAFLD patients had higher concentrations of fecal propionate and isobutyric acid and serum 2-hydroxybutyrate and L-lactic acid. These findings suggest a potential role for a specific IM community and functional profile in the pathogenesis of NAFLD.

Anafilaxia na sala de emergência: tão longe do desejado! / Anaphylaxis in the emergency room: still a long way to go

Objetivo: Anafilaxia é a mais dramática condição clínica da emergência em alergia. O objetivo deste estudo foi verificar o conhecimento de médicos em serviços de urgência e emergência sobre o manejo da anafilaxia. Métodos: Estudo transversal, onde foi aplicado questionário escrito para 119 médicos em oito hospitais (grupo Hospital) e 210 médicos de nove Unidades de Pronto Atendimento/Serviço de Atendimento Móvel de Urgência (grupo UPA/SAMU) entre abril e setembro/2016. Resultados: Entre os convidados, responderam ao questionário 79 (66,4%) médicos que atuavam em Hospital, e 78 (37,1%) em UPA/SAMU. Cento e vinte e dois participantes (78,7%) se formaram há até 10 anos. Sessenta e nove médicos (43,9%) acertaram o diagnóstico de anafilaxia, e apenas 29 (18,5%) identificaram os sistemas que podem ser acometidos na reação anafilática. A adrenalina intramuscular foi referida como primeira opção de tratamento da anafilaxia por 64 (40,7%), e o glucagon foi escolhido como opção em pacientes que utilizam ß-bloqueadores por 19 (12,1%) dos médicos. A orientação quanto aos autoinjetores foi referida por 71 (45,3%) dos médicos. Conclusão: O nível de conhecimento médico em serviços de urgência e emergência sobre o manejo da anafilaxia é baixo. As diretrizes não são seguidas e podem resultar em desfecho desfavorável ao paciente com reação anafilática.

Objective: Anaphylaxis is the most dramatic clinical presentation of allergy in the emergency setting. The aim of this study was to assess knowledge on anaphylaxis management among physicians working at emergency services. Methods: A cross-sectional study was carried out and a written questionnaire was applied to 119 physicians working at eight hospitals (Hospital group) and to 210 physicians working at nine emergency services/mobile emergency services (UPA/SAMU group) between April and September 2016. Results: Among the respondents, 79 (66.4%) physicians worked at hospitals and 78 (37.1%) at emergency services. One hundred twenty-two participants (78.7%) had graduated less than ten years earlier. Sixty-nine physicians (43.9%) correctly diagnosed anaphylaxis, and only 29 (18.5%) identified the systems that could be affected in an anaphylactic reaction. Intramuscular adrenaline was reported as the first treatment option for anaphylaxis by 64 physicians (40.7%), and glucagon was chosen as an option in patients using ß-blockers by 19 (12.1%). The use of auto-injectors was referred by 71 (45.3%) of the physicians. Conclusion: The level of medical knowledge on anaphylaxis management in emergency departments is low. Guidelines are not followed and may result in an unfavorable outcome for patients presenting with an anaphylactic reaction.

Cocaine craving during protracted withdrawal requires PKCε priming within vmPFC.

In individuals with a history of drug taking, the capacity of drug-associated cues to elicit indices of drug craving intensifies or incubates with the passage of time during drug abstinence. This incubation of cocaine craving, as well as difficulties with learning to suppress drug-seeking behavior during protracted withdrawal, are associated with a time-dependent deregulation of ventromedial prefrontal cortex (vmPFC) function. As the molecular bases for cocaine-related vmPFC deregulation remain elusive, the present study assayed the consequences of extended access to intravenous cocaine (6 hours/day; 0.25 mg/infusion for 10 day) on the activational state of protein kinase C epsilon (PKCε), an enzyme highly implicated in drug-induced neuroplasticity. The opportunity to engage in cocaine seeking during cocaine abstinence time-dependently altered PKCε phosphorylation within vmPFC, with reduced and increased p-PKCε expression observed in early (3 days) and protracted (30 days) withdrawal, respectively. This effect was more robust within the ventromedial versus dorsomedial PFC, was not observed in comparable cocaine-experienced rats not tested for drug-seeking behavior and was distinct from the rise in phosphorylated extracellular signal-regulated kinase observed in cocaine-seeking rats. Further, the impact of inhibiting PKCε translocation within the vmPFC using TAT infusion proteins upon cue-elicited responding was determined and inhibition coinciding with the period of testing attenuated cocaine-seeking behavior, with an effect also apparent the next day. In contrast, inhibitor pretreatment prior to testing during early withdrawal was without effect. Thus, a history of excessive cocaine taking influences the cue reactivity of important intracellular signaling molecules within the vmPFC, with PKCε playing a critical role in the manifestation of cue-elicited cocaine seeking during protracted drug withdrawal.

A cross-sectional study assessing dietary intake and physical activity in Canadian patients with nonalcoholic fatty liver disease vs healthy controls.

BACKGROUND: Poor diet and a sedentary lifestyle can contribute to nonalcoholic fatty liver disease (NAFLD). OBJECTIVE: Our aim was to compare diet and physical activity of patients with NAFLD and healthy controls with current recommendations. DESIGN: This was a cross-sectional study. PARTICIPANTS/SETTINGS: Seventy-four patients with biopsy-proven NAFLD (33 simple steatosis and 41 steatohepatitis [NASH]) and 27 healthy controls participated between 2003 and 2011. MAIN OUTCOME MEASURES: Food records and activity logs were completed for 7 days. Results were compared with Dietary Reference Intakes and Canadian Physical Activity Guidelines. Plasma vitamin C was measured to assess food record accuracy. STATISTICAL ANALYSES PERFORMED: Intake/activity for each participant was compared with the recommendations and proportion of subjects not meeting the requirements was calculated. Groups were compared by Kruskal-Wallis and Mann-Whitney U test or z-test with Bonferroni adjustment. RESULTS: More patients with NASH (58.5%) were obese compared with patients with simple steatosis (24.2%) and healthy controls (7.4%; P<0.01). Patients with NAFLD showed more insulin resistance than healthy controls. The reported energy intake was below estimated requirements in all groups (P≤0.001). The proportion of subjects from each group exceeding acceptable energy intake from fat was as follows: simple steatosis: 27.3%; NASH: 46.3%; healthy controls: 63.0% (simple steatosis vs health controls; P<0.05) and from saturated fat: simple steatosis: 42.4%; NASH: 70.7%; healthy controls: 63.0% (simple steatosis vs. NASH; P<0.05). In each group, >80% of subjects did not consume enough linoleic or linolenic acid, vitamin D, and vitamin E, and >60% exceeded the upper intake level for sodium. Only 53.1% of patients with simple steatosis and 53.8% of patients with NASH, but 84.6% of healthy controls, met recommendations for physical activity (P=0.020). Plasma vitamin C was normal, similar among groups, and correlated with vitamin C intakes. CONCLUSIONS: All participants followed a similar Western diet with high fat and sodium intakes and suboptimal micronutrient intakes. However, physical activity was lower in NAFLD compared with healthy controls and was associated with higher body mass index and insulin resistance.

Deficits in ventromedial prefrontal cortex group 1 metabotropic glutamate receptor function mediate resistance to extinction during protracted withdrawal from an extensive history of cocaine self-administration.

Anomalies in prefrontal cortex (PFC) function are posited to underpin difficulties in learning to suppress drug-seeking behavior during abstinence. Because group 1 metabotropic glutamate receptors (mGluRs) regulate drug-related learning, we assayed the consequences of extended access to intravenous cocaine (6 h/d; 0.25 mg/infusion for 10 d) on the PFC expression of group 1 mGluRs and the relevance of observed changes for cocaine seeking. After protracted withdrawal, cocaine-experienced animals exhibited a time-dependent intensification of cue-induced cocaine-seeking behavior and an impaired extinction of this behavior. These behavioral phenomena were associated with a time-dependent reduction in mGluR1/5 expression within ventromedial PFC (vmPFC) of cocaine-experienced animals exposed to extinction testing but not in untested ones. Interestingly, pharmacological manipulations of vmPFC mGluR1/5 produced no immediate effects on cue-induced cocaine-seeking behavior but produced residual effects on a subsequent test for cocaine seeking. At 3 d withdrawal, cocaine-experienced rats infused intra-vmPFC with mGluR1/5 antagonists, either before or after an initial test for cocaine seeking, persisted in their cocaine seeking akin to cocaine-experienced rats in protracted withdrawal. Conversely, cocaine-experienced rats infused with an mGluR1/5 agonist before the initial test for cocaine-seeking at 30 d withdrawal exhibited a facilitation of extinction learning. These data indicate that cue-elicited deficits in vmPFC group 1 mGluR function mediate resistance to extinction during protracted withdrawal from a history of extensive cocaine self-administration and pose pharmacological stimulation of these receptors as a potential approach to facilitate learned suppression of drug-seeking behavior that may aid drug abstinence.

Conflito intergeracional na família: relato de um projeto terapêutico singular / Intergenerational conflicts to a family: a case reporting of a singular therapeutic project

Introdução: o Projeto Terapêutico Singular (PTS) é uma abordagem integral à família, que propõe intervenções biopsicossociais, priorizando ações que atenuem os agravos potencializados pelos conflitos intergeracionais. Objetivos: descrever a aplicação de um PTS a uma família com conflitos intergeracionais e morbidades para o estabelecimento de ações depromoção em saúde. Métodos: o trabalho é descritivo, modalidade de relato de caso. O PTS constituiu-se de visita familiar, formulação de hipóteses para intervenção, definição de metas, discussão das metas entre equipe e família e a reavaliação das intervenções planejadas. Nas visitas foi aplicado roteiro semiestruturado contendo o histórico, papeis e relacionamento familiar, agravos, saúde, condições de moradia e higiene, convívio social.Os dados foram compilados nos instrumentos: genograma, ecomapa,escala de risco e diagnóstico multiaxial. Após a concordância da família quanto à divulgação dos dados, os genitores assinaram o Termo de Consentimento Livre e Esclarecido (TCLE). Foi preservado o sigilo dos indivíduos e dos dados coletados. Resultados: por meio da escuta empática e construção de vinculo, a equipe e a família planejaram ações de promoção da saúde e de tratamento de doenças, com enfoque nos agravos: pré-natal de adolescentegravida, planejamento familiar, segmento e adesão ao tratamento dedoenças como hipertensão, hanseníase e erisipela que acometiam indivíduosda família, problemas relacionados ao tabagismo e etilismo; evasão escolar, atualização de vacinas e conflitos intergeracionais. Conclusão: a compreensão do contexto familiar possibilitou o entendimento e a resolução conjuntos do processo saúde-doença e dos agravos potencializados pelo conflito intergeracional.

Introduction: Singular Therapeutic Project (STP) is an integral approachto a family which proposes biopsychosocial interventions andprioritizes actions that mitigate injuries enhanced by intergenerationalconflicts. Objective: describe the application of a STP to a family and its intergenerational conflicts and morbidities to establish health promotionactions. Methods: the article is descriptive in a case reporting format. A STP is consisted of family visits, hypotheses for intervention, goal setting and discussion of goals between family and team and review of planned actions.During visits a semi-structured script with historic, documents, family relationship, injuries, health, living conditions and social interactionhas been applied. Data were compiled in genogram and ecomap, risk scale and multiaxial diagnosis. The family read the document Informed Consent Form (ICF), signed it and agreed whit the publicationof data. Individuals and data’s confidentiality have been preserved.Results: through empathic listening, team and family planned togetherhealth promotion actions and diseases treatment, focusing on the injuries:a pregnant teenager’s prenatal; family planning; adherence to treatmentof diseases such as hypertension, leprosy and erysipelas, whichhave affected members of the family; and problems related to smokingand alcoholism, high school escape, update immunization and intergenerationconflicts. Conclusion: the comprehension of family context enabled understandingand resolution of health-disease process and injuries potentiated by intergenerational conflicts.

Exame bacteriológico na Endodontia: uma alternativa para uso em consultório odontológico / Bacteriological examination in Endodontics: an alternative use in the dental office

Na presente pesquisa, testou-se uma alternativa de teste bacteriológico em Endodontia, para uso em consultório odontológico. Comparou-se o método alternativo Endotest com o método clássico de exame bacterológico em Caldo Tioglicolato, assim como o incubador biológico Endotest com a estufa comum para o cultivo de microorganismos. Analisou-se o crecimento bacteriano de culturas puras de cepas de microrganismos e material obtido de canal radicular necrosado por cáries profundas. O método alternativo denominado Endotest, se mostrou adequado como exame bacteriológico intracanal, oferecendo vantagens quando comparado com o método clássico revelando benefícios para o trabalho do endodontista e para a saúde do paciente

Exame bacteriológico em Endodontia: uma avaliaçäo da situaçäo atual / Bacteriological test in Endodontics: an actual survey

Os autores procuraram analisar como os dentistas realizam os procedimentos básicos de assepsia e antissepsia, qual a aceitaçäo atual de um teste bacteriológico de fácil manuseio, estocagem e diagnóstico no próprio consultório, como uma forma alternativa de controle de desinfecçäo dos canais radiculares e testes de contaminaçäo de materiais e instrumentais usados na clínica diária. Os dados obtidos pelos questionários enviados aos clínicos, permitiram concluir: a) ausência da manutençäo da cadeia asséptica até a obturaçäo dos canais radiculares, b) dificuldades na esterilizaçäo do instrumental endodôntico, c) que os procedimentos endodônticos säo empíricos e näo tem sido submetidos a análises científicas e d) a necessidade de um teste bacteriológico simples e prático por parte dos cirurgiöes dentistas