PT EMT - Portuguese Emergency Medical Team Type 1 Relief Mission in Mozambique.

INTRODUCTION: The tropical cyclone Idai hit Mozambique in the city of Beira on March 15, 2019. During the following days, the Portuguese Emergency Medical Team (PT EMT) and its infrastructure deployed to Mozambique with the mission of helping local people and collaborating with the authorities. METHODS: Data analyzed were collected in the period of the deployment, from April 1-April 30, 2019. All patients admitted to PT EMT were registered through the Clinical Record of PT EMT. RESULTS: In total, 1,662 patients were admitted to PT EMT during the 30-day mission. The five most prevalent diagnoses were: 61.49% classified with "code 29" (which corresponds to "other unspecified diagnoses"), 9.15% of cases of skin disease, 8.90% of minor injuries, 6.74% of acute respiratory infection, and 3.19% of obstetric/genecology complications. DISCUSSION AND CHALLENGES: An important challenge identified was the need for a robust and effective network for transporting patients, allowing transfers between EMTs, enabling a true network response in the provision of care to disaster victims. CONCLUSIONS: The benefit of the deployment of PT EMT in Mozambique after Cyclone Idai was in line with the EMT initiative standards, allowing a direct delivery of care to the affected Mozambican population and support to the local health authorities.

Neuro-mesenchymal units control ILC2 and obesity via a brain-adipose circuit.

Signals from sympathetic neurons and immune cells regulate adipocytes and thereby contribute to fat tissue biology. Interactions between the nervous and immune systems have recently emerged as important regulators of host defence and inflammation1-4. Nevertheless, it is unclear whether neuronal and immune cells co-operate in brain-body axes to orchestrate metabolism and obesity. Here we describe a neuro-mesenchymal unit that controls group 2 innate lymphoid cells (ILC2s), adipose tissue physiology, metabolism and obesity via a brain-adipose circuit. We found that sympathetic nerve terminals act on neighbouring adipose mesenchymal cells via the ß2-adrenergic receptor to control the expression of glial-derived neurotrophic factor (GDNF) and the activity of ILC2s in gonadal fat. Accordingly, ILC2-autonomous manipulation of the GDNF receptor machinery led to alterations in ILC2 function, energy expenditure, insulin resistance and propensity to obesity. Retrograde tracing and chemical, surgical and chemogenetic manipulations identified a sympathetic aorticorenal circuit that modulates ILC2s in gonadal fat and connects to higher-order brain areas, including the paraventricular nucleus of the hypothalamus. Our results identify a neuro-mesenchymal unit that translates cues from long-range neuronal circuitry into adipose-resident ILC2 function, thereby shaping host metabolism and obesity.

Sépsis na pessoa em situação crítica em contexto extra-hospitalar: intervenção especializada do enfermeiro / Sepsis in critically ill people in an out-of-hospital context: specialized intervention by nurses

Os serviços de emergência médica conduzem aos serviços de urgência um número crescente de pessoas com situações de sépsis, o que representa cerca de metade dos internamentos relacionados com sépsis nas unidades de cuidados intensivos. Na gestão desta situação, o reconhecimento precoce e o tratamento imediato são essenciais, situando-se assim num quadro clínico tempo-dependente, onde o intervalo tempo extra-hospitalar representa uma importante oportunidade para o seu reconhecimento e tratamento. Salientando esta relevância no contexto de saúde e definindo a sua abordagem, em 2010 a Direção Geral de Saúde, emite uma circular normativa referente à Criação e Implementação da Via Verde Sépsis. O presente relatório de estágio representa a análise do percurso de aquisição e desenvolvimento de competências especializadas na prestação de cuidados de enfermagem à pessoa em situação crítica com enfoque no cuidado especializado à pessoa em situação de sépsis em contexto extra-hospitalar. Neste âmbito, realizei uma revisão da literatura acerca da problemática e desenvolvi atividades que sustentaram o alcançar dos objetivos definidos nesta arquitetura de percurso. Realizei estágios em três contextos distintos. No serviço de urgência onde consolidei competências no cuidar da pessoa em situação de sépsis ou suspeita de sépsis, especificamente na sua identificação e abordagem inicial. Na unidade de cuidados intensivos, onde desenvolvi competências no cuidar da pessoa/família a vivenciar processos complexos de doença crítica e/ou falência orgânica em situação de sépsis ou suspeita de sépsis. E, por fim no contexto extra-hospitalar de ambulância de suporte imediato de vida, onde promovi a adaptação dos saberes anteriormente adquiridos e desenvolvi a especificidade no cuidar extra-hospitalar, ao nível da identificação, abordagem e prestação de cuidados emergentes à pessoa em situação de sépsis ou suspeita de sépsis, contribuindo ainda no desenvolvimento do protocolo de abordagem a doentes nesta circunstância. Este percurso, possibilitou-me o ensejo de contribuir na promoção e na melhoria da qualidade assistencial dos cuidados de enfermagem em âmbito extra-hospitalar à pessoa em situação de sépsis.

Emergency medical services lead to an increasing number of sepsis situations in emergency services, which represents about half of the hospitalizations with sepsis in the intensive care units. In the management of a sepsis situation, early recognition and immediate treatment are essential, being classified as a time-dependent pathology, where the time interval in the extra-hospital scope constitutes an important opportunity for its detection and treatment. Giving emphasis to this relevance in the health context and defining its approach, in 2010, Direção Geral de Saúde issues a normative circular regarding the "Criação e Implementação da Via Verde Sépsis". The present internship report depicts the analysis of the acquisition and development of specialized skills path in the provision of nursing care to the person in critical condition with emphasis in the specialized care provided to the person in sepsis situation in the extra-hospital context. Within this scope, I carried out a revision of the literature surrounding this problem and developed activities that sustain the accomplishment of the objectives set in the frame of this path. I performed internships in three distinct contexts. In the emergency service, where I consolidated skill's in the person's care in sepsis situation or suspicion of sepsis, specifically in its detection and initial approach. In the intensive care unit, where I developed skills related to the person's/family´s care while experiencing complex processes of critical illness and/or organic failure in a situation of sepsis or suspicion of sepsis. And at last, in the extrahospital context of immediate life support ambulance, where I promoted the adaptation of the previously acquired knowledge and developed the specificity in extra-hospital care, at a level of detection, approach and emergency care provision to the person in sepsis situation or suspicion of sepsis, contributing yet indirectly to the development of the approach protocol to this type of patients. This skill development path allowed me the opportunity to contribute to the promotion and improvement of the assistance quality of nursing care in the extra-hospital scope to the person in sepsis situation.

Author Correction: Light-entrained and brain-tuned circadian circuits regulate ILC3s and gut homeostasis.

An Amendment to this paper has been published and can be accessed via a link at the top of the paper.

Light-entrained and brain-tuned circadian circuits regulate ILC3s and gut homeostasis.

Group 3 innate lymphoid cells (ILC3s) are major regulators of inflammation, infection, microbiota composition and metabolism1. ILC3s and neuronal cells have been shown to interact at discrete mucosal locations to steer mucosal defence2,3. Nevertheless, it is unclear whether neuroimmune circuits operate at an organismal level, integrating extrinsic environmental signals to orchestrate ILC3 responses. Here we show that light-entrained and brain-tuned circadian circuits regulate enteric ILC3s, intestinal homeostasis, gut defence and host lipid metabolism in mice. We found that enteric ILC3s display circadian expression of clock genes and ILC3-related transcription factors. ILC3-autonomous ablation of the circadian regulator Arntl led to disrupted gut ILC3 homeostasis, impaired epithelial reactivity, a deregulated microbiome, increased susceptibility to bowel infection and disrupted lipid metabolism. Loss of ILC3-intrinsic Arntl shaped the gut 'postcode receptors' of ILC3s. Strikingly, light-dark cycles, feeding rhythms and microbial cues differentially regulated ILC3 clocks, with light signals being the major entraining cues of ILC3s. Accordingly, surgically or genetically induced deregulation of brain rhythmicity led to disrupted circadian ILC3 oscillations, a deregulated microbiome and altered lipid metabolism. Our work reveals a circadian circuitry that translates environmental light cues into enteric ILC3s, shaping intestinal health, metabolism and organismal homeostasis.

Rationale and Study Design for an Individualized Perioperative Open Lung Ventilatory Strategy in Patients on One-Lung Ventilation (iPROVE-OLV).

OBJECTIVE: The aim of this clinical trial is to examine whether it is possible to reduce postoperative complications using an individualized perioperative ventilatory strategy versus using a standard lung-protective ventilation strategy in patients scheduled for thoracic surgery requiring one-lung ventilation. DESIGN: International, multicenter, prospective, randomized controlled clinical trial. SETTING: A network of university hospitals. PARTICIPANTS: The study comprises 1,380 patients scheduled for thoracic surgery. INTERVENTIONS: The individualized group will receive intraoperative recruitment maneuvers followed by individualized positive end-expiratory pressure (open lung approach) during the intraoperative period plus postoperative ventilatory support with high-flow nasal cannula, whereas the control group will be managed with conventional lung-protective ventilation. MEASUREMENTS AND MAIN RESULTS: Individual and total number of postoperative complications, including atelectasis, pneumothorax, pleural effusion, pneumonia, acute lung injury; unplanned readmission and reintubation; length of stay and death in the critical care unit and in the hospital will be analyzed for both groups. The authors hypothesize that the intraoperative application of an open lung approach followed by an individual indication of high-flow nasal cannula in the postoperative period will reduce pulmonary complications and length of hospital stay in high-risk surgical patients.

Neuronal regulation of type 2 innate lymphoid cells via neuromedin U.

Group 2 innate lymphoid cells (ILC2s) regulate inflammation, tissue repair and metabolic homeostasis, and are activated by host-derived cytokines and alarmins. Discrete subsets of immune cells integrate nervous system cues, but it remains unclear whether neuron-derived signals control ILC2s. Here we show that neuromedin U (NMU) in mice is a fast and potent regulator of type 2 innate immunity in the context of a functional neuron-ILC2 unit. We found that ILC2s selectively express neuromedin U receptor 1 (Nmur1), and mucosal neurons express NMU. Cell-autonomous activation of ILC2s with NMU resulted in immediate and strong NMUR1-dependent production of innate inflammatory and tissue repair cytokines. NMU controls ILC2s downstream of extracellular signal-regulated kinase and calcium-influx-dependent activation of both calcineurin and nuclear factor of activated T cells (NFAT). NMU treatment in vivo resulted in immediate protective type 2 responses. Accordingly, ILC2-autonomous ablation of Nmur1 led to impaired type 2 responses and poor control of worm infection. Notably, mucosal neurons were found adjacent to ILC2s, and these neurons directly sensed worm products and alarmins to induce NMU and to control innate type 2 cytokines. Our work reveals that neuron-ILC2 cell units confer immediate tissue protection through coordinated neuroimmune sensory responses.

Glial-cell-derived neuroregulators control type 3 innate lymphoid cells and gut defence.

Group 3 innate lymphoid cells (ILC3) are major regulators of inflammation and infection at mucosal barriers. ILC3 development is thought to be programmed, but how ILC3 perceive, integrate and respond to local environmental signals remains unclear. Here we show that ILC3 in mice sense their environment and control gut defence as part of a glial­ILC3­epithelial cell unit orchestrated by neurotrophic factors. We found that enteric ILC3 express the neuroregulatory receptor RET. ILC3-autonomous Ret ablation led to decreased innate interleukin-22 (IL-22), impaired epithelial reactivity, dysbiosis and increased susceptibility to bowel inflammation and infection. Neurotrophic factors directly controlled innate Il22 downstream of the p38 MAPK/ERK-AKT cascade and STAT3 activation. Notably, ILC3 were adjacent to neurotrophic-factor-expressing glial cells that exhibited stellate-shaped projections into ILC3 aggregates. Glial cells sensed microenvironmental cues in a MYD88-dependent manner to control neurotrophic factors and innate IL-22. Accordingly, glial-intrinsic Myd88 deletion led to impaired production of ILC3-derived IL-22 and a pronounced propensity towards gut inflammation and infection. Our work sheds light on a novel multi-tissue defence unit, revealing that glial cells are central hubs of neuron and innate immune regulation by neurotrophic factor signals.

NFIL3 orchestrates the emergence of common helper innate lymphoid cell precursors.

Innate lymphoid cells (ILCs) are a family of effectors that originate from a common innate lymphoid cell progenitor. However, the transcriptional program that sets the identity of the ILC lineage remains elusive. Here, we show that NFIL3 is a critical regulator of the common helper-like innate lymphoid cell progenitor (CHILP). Cell-intrinsic Nfil3 ablation led to variably impaired development of fetal and adult ILC subsets. Conditional gene targeting demonstrated that NFIL3 exerted its function prior to ILC subset commitment. Accordingly, NFIL3 ablation resulted in loss of ID2(+) CHILP and PLZF(+) ILC progenitors. Nfil3 expression in lymphoid progenitors was under the control of the mesenchyme-derived hematopoietin IL-7, and NFIL3 exerted its function via direct Id2 regulation in the CHILP. Moreover, ectopic Id2 expression in Nfil3-null precursors rescued defective ILC lineage development in vivo. Our data establish NFIL3 as a key regulator of common helper-like ILC progenitors as they emerge during early lymphopoiesis.

The neurotrophic factor receptor RET drives haematopoietic stem cell survival and function.

Haematopoiesis is a developmental cascade that generates all blood cell lineages in health and disease. This process relies on quiescent haematopoietic stem cells capable of differentiating, self renewing and expanding upon physiological demand. However, the mechanisms that regulate haematopoietic stem cell homeostasis and function remain largely unknown. Here we show that the neurotrophic factor receptor RET (rearranged during transfection) drives haematopoietic stem cell survival, expansion and function. We find that haematopoietic stem cells express RET and that its neurotrophic factor partners are produced in the haematopoietic stem cell environment. Ablation of Ret leads to impaired survival and reduced numbers of haematopoietic stem cells with normal differentiation potential, but loss of cell-autonomous stress response and reconstitution potential. Strikingly, RET signals provide haematopoietic stem cells with critical Bcl2 and Bcl2l1 surviving cues, downstream of p38 mitogen-activated protein (MAP) kinase and cyclic-AMP-response element binding protein (CREB) activation. Accordingly, enforced expression of RET downstream targets, Bcl2 or Bcl2l1, is sufficient to restore the activity of Ret null progenitors in vivo. Activation of RET results in improved haematopoietic stem cell survival, expansion and in vivo transplantation efficiency. Remarkably, human cord-blood progenitor expansion and transplantation is also improved by neurotrophic factors, opening the way for exploration of RET agonists in human haematopoietic stem cell transplantation. Our work shows that neurotrophic factors are novel components of the haematopoietic stem cell microenvironment, revealing that haematopoietic stem cells and neurons are regulated by similar signals.

The neurotrophic factor receptor RET regulates IL-10 production by in vitro polarised T helper 2 cells.

T helper (Th) cells are critical players in the modulation of immune response outcomes. Activation of Th cells gives rise to various subsets of effector cells that are controlled via specialised regulatory T cells or through self-regulation via production of IL-10. However, the environmental factors that regulate IL-10 production by Th cells remain poorly understood. Here, we show that the neurotrophic factor receptor rearranged during transfection (RET) downregulates IL-10 production by Th cells from C57BL/6 mice. We found that effector Th cells express RET and that RET's neurotrophic factor partners are mainly produced by LN stromal cells, allowing context-dependent Th-cell regulation. Despite being dispensable for Th-cell homeostasis, RET controls IL-10 production in Th2 cells: RET-deficient Th cells exhibited increased IL-10 production, while triggering of Th1/2 cells with neurotrophic factors, namely glial-derived neurotrophic factor and neurturin, decreased the expression of IL-10. In agreement, the important IL-10 transcription factor Maf was upregulated in RET-deficient Th2 cells and down-regulated upon RET signalling activation by glial-derived neurotrophic factor family ligands. Thus, our study uncovers neurotrophic factors as novel regulators of Th-cell function, revealing that Th cells and neurons can be regulated by similar signals in tissue-specific responses.

Maternal retinoids control type 3 innate lymphoid cells and set the offspring immunity.

The impact of nutritional status during fetal life on the overall health of adults has been recognized; however, dietary effects on the developing immune system are largely unknown. Development of secondary lymphoid organs occurs during embryogenesis and is considered to be developmentally programmed. Secondary lymphoid organ formation depends on a subset of type 3 innate lymphoid cells (ILC3) named lymphoid tissue inducer (LTi) cells. Here we show that mouse fetal ILC3s are controlled by cell-autonomous retinoic acid (RA) signalling in utero, which pre-sets the immune fitness in adulthood. We found that embryonic lymphoid organs contain ILC progenitors that differentiate locally into mature LTi cells. Local LTi cell differentiation was controlled by maternal retinoid intake and fetal RA signalling acting in a haematopoietic cell-autonomous manner. RA controlled LTi cell maturation upstream of the transcription factor RORγt. Accordingly, enforced expression of Rorgt restored maturation of LTi cells with impaired RA signalling, whereas RA receptors directly regulated the Rorgt locus. Finally, we established that maternal levels of dietary retinoids control the size of secondary lymphoid organs and the efficiency of immune responses in the adult offspring. Our results reveal a molecular link between maternal nutrients and the formation of immune structures required for resistance to infection in the offspring.

[Giant tumoral lesion in the left atrium: an uncommon case of undifferentiated cardiac sarcoma]. / Lesão tumoral gigante na aurícula esquerda: um caso incomum de sarcoma cardíaco indiferenciado.

Primary cardiac tumors are rare, with an incidence ranging from 0.0001% to 0.030%; 80% are benign, while sarcomas account for 95% of malignant tumors. The authors report the case of a 75-year-old patient with a giant mass in the left atrium. The final diagnosis was of an undifferentiated cardiac sarcoma. This tumor represents a real challenge not only for timely diagnosis, but especially the therapeutic approach to adopt.

[Pacemaker lead-induced tricuspid stenosis: a report of two cases]. / Estenose tricúspide induzida por eletrocateter de pacemaker: relato de 2 casos clínicos.

Tricuspid stenosis (TS) is an uncommon complication of transvenous ventricular pacemaker implantation, with few cases reported in the literature. The mechanisms described are obstruction of right ventricular inflow by tricuspid vegetations (endocarditis), multiple pacemaker leads and tricuspid valve (TV) fibrosis secondary to perforation or laceration of the TV leaflets, or adherence between redundant portions of the lead and valvular and subvalvular tissue. We report two cases of severe TS, with different etiologies and management: one caused by leaflet perforation, resolved surgically, and the other secondary to fusion between a loop of the pacemaker lead and the subvalvular apparatus, which was treated medically.

[Myocardial infarction after taking zolmitriptan]. / Enfarte agudo do miocárdio após a toma de zolmitriptano.

Zolmitriptan is a drug used in the acute treatment of migraine, which should not be used in high cardiovascular risk individuals because of its potential to induce vasospasm. We report a rare case of myocardial infarction precipitated by taking zolmitriptan.

RET/GFRα signals are dispensable for thymic T cell development in vivo.

Identification of thymocyte regulators is a central issue in T cell biology. Interestingly, growing evidence indicates that common key molecules control neuronal and immune cell functions. The neurotrophic factor receptor RET mediates critical functions in foetal hematopoietic subsets, thus raising the possibility that RET-related molecules may also control T cell development. We show that Ret, Gfra1 and Gfra2 are abundantly expressed by foetal and adult immature DN thymocytes. Despite the developmentally regulated expression of these genes, analysis of foetal thymi from Gfra1, Gfra2 or Ret deficient embryos revealed that these molecules are dispensable for foetal T cell development. Furthermore, analysis of RET gain of function and Ret conditional knockout mice showed that RET is also unnecessary for adult thymopoiesis. Finally, competitive thymic reconstitution assays indicated that Ret deficient thymocytes maintained their differentiation fitness even in stringent developmental conditions. Thus, our data demonstrate that RET/GFRα signals are dispensable for thymic T cell development in vivo, indicating that pharmacological targeting of RET signalling in tumours is not likely to result in T cell production failure.