Analysis of adrenaline autoinjectors acquisition in Portugal over 15 years.

Summary: Background. The adrenaline autoinjector (AAi) is universally recommended as the first-line treatment for anaphylactic reactions occurring outside the medical setting. The quantification of its acquisition may help estimate the prevalence of patients at risk of anaphylaxis with an indication for AAi. Objective. Evaluation of the global and regional frequency of AAi purchases in Mainland Portugal between 2003-2017 and calculate the inherent costs in 2017. Methods. AAi acquisition distribution analysis along this period. The population was divided in two age groups according to the adrenaline dosage. Results. A total of 10,993 AAi units of 0.15mg/0.3mL and 28,619 of 0.3mg/0.3mL were acquired in these 15 years, with an annual average of 733 and 1908 units, respectively. In cumulative values terms, Lisbon showed the highest number of AAI acquired and higher prevalence per region/100,000 inhabitants in both groups. In 2017, the annual cost for each age group was 64,202.71 € 187,447.70 € for patients and € 37,706.35 / 110,113.30 € for the National Health System. Conclusions. In the last 15 years, there was a progressive increase in AAi acquisition. We estimate a rate of anaphylaxis occurrence in Portugal according to AAi aquisition of 0.165%.

Subcutaneous immunotherapy with aeroallergens: safety profile assessment.

SUMMARY: Introduction. Severe systemic reactions (SR) to allergen subcutaneous immunotherapy (SCIT) are rare but local reactions (LR) are common. We aimed to characterize the type of reactions and safety profile. Methods. Retrospective analysis of medical record from patients under SCIT between 2013-2016. Results. Total of 7372 SCIT injections in 323 patients: 52% female; mean age 30 years (SD 13); mean treatment time 19 months (SD 13). There were 57 patients (17.6% of population, 70% female) with at least one adverse reaction, for 93 reactions described (1.3% injections). There were 79 LR (1.1% injections) in 46(14.2%) patients: 36 in build-up, 43 in maintenance. There were 14 SR (0.19% injections) in 12(3.7%) patients: 12 in build-up, 2 in maintenance. All SR were grade 1. The majority of reactions were caused by mite SCIT (69.9%). Conclusions. SCIT is safe and well tolerated, with no report of SR grade > 1.

Climate change vulnerability of cetaceans in Macaronesia: Insights from a trait-based assessment.

Over the last decades global warming has caused an increase in ocean temperature, acidification and oxygen loss which has led to changes in nutrient cycling and primary production affecting marine species at multiple trophic levels. While knowledge about the impacts of climate change in cetacean's species is still scarce, practitioners and policymakers need information about the species at risk to guide the implementation of conservation measures. To assess cetacean's vulnerability to climate change in the biogeographic region of Macaronesia, we adapted the Marine Mammal Climate Vulnerability Assessment (MMCVA) method and applied it to 21 species management units using an expert elicitation approach. Results showed that over half (62%) of the units assessed presented Very High (5 units) or High (8 units) vulnerability scores. Very High vulnerability scores were found in archipelago associated units of short-finned pilot whales (Globicephala macrorhynchus) and common bottlenose dolphins (Tursiops truncatus), namely in the Canary Islands and Madeira, as well as Risso's dolphins (Grampus griseus) in the Canary Islands. Overall, certainty scores ranged from Very High to Moderate for 67% of units. Over 50% of units showed a high potential for distribution, abundance and phenology changes as a response to climate change. With this study we target current and future information needs of conservation managers in the region, and guide research and monitoring efforts, while contributing to the improvement and validation of trait-based vulnerability approaches under a changing climate.

Increased levels of IL-17A in serum and amniotic fluid of pregnant women with acute toxoplasmosis.

This study detected and compared the levels of Il-17A, IFN-gamma and IL-10 in the amniotic fluid (AF) and serum of pregnant women with acute toxoplasmosis in southern Brazil. It also compared the serum levels of these mediators in pregnant women with acute or chronic toxoplasmosis and with uninfected women. The serological investigations of anti-T. gondii IgM and IgG from the 60 pregnant women were determined by chemiluminescence microparticle immunoassay (CMIA). Twenty patients were uninfected, twenty were in the chronic phase and twenty were in the acute phase of toxoplasmosis. The 20 pregnant women in acute phase all agreed with amniocentesis. Serum and AF cytokines were evaluated by sandwich enzyme-linked immunosorbent assay. The analyzed cytokines showed no significant difference in blood versus amniotic fluid levels of pregnant women in the acute toxoplasmosis. Furthermore, we observed that serum IL-17A was significantly higher in pregnant women in the acute phase of infection compared to pregnant women with chronic toxoplasmosis and seronegative pregnant women. T. gondii DNA was not amplified in any of the samples of amniotic fluid by the nested-PCR reaction. Serum IL-10 levels were also higher in negative pregnant women than in infected pregnant women. Our findings indicate the activation of an inflammatory response to infection by T. gondii and suggest that increased production of IL-17A may be a protective factor against infection of the fetus.

Evolution of Api m10 Specific IgE and IgG4 After One Year of Bee Venom Immunotherapy.

Summary: Background. Bee-venom (BV) anaphylaxis can be life-threatening, requiring treatment with BV immunotherapy (bVIT). Different molecular profiles may be associated with different outcomes after bVIT. Methods. In 19 patients with BV anaphylaxis, sensitized both to Api m1 and Api m10, we evaluated sIgE and sIgG4 Api m1 and Api m10 levels before and after 1 year bVIT.Results.7 patients (37%) had higher baseline Api m10 than Api m1 sIgE levels (Api m10 predominant). bVIT reduced sIgE to both components but sIgG4 levels were increased only for Api m1. 5 patients (2 in the Api m10 predominant group) were re-stung without anaphylaxis. Conclusions. Although there was no increase in Api m10 sIgG4 levels after 1 year bVIT, we did not observe relevant differences in other outcomes between patients with predominant Api m1 or Api m10 sensitization.

Subcutaneous immunotherapy with aeroallergens Evaluation of adherence in real life.

Summary: Introduction. Adherence in allergen immunotherapy is crucial for its efficacy. At least 3 years of treatment are recommended for achieving a long-term modifying effect. Objectives. To assess patient's adherence and to identify determinant factors for allergen subcutaneous immunotherapy (SCIT) suspension in patients with respiratory allergy. Methods. Retrospective analysis of the medical record of patients submitted to SCIT between January 2013 and December 2016 in our Department. Results. 323 patients were included: 52% female; mean age 30±13 years; average treatment time 19±13 months. 52 patients (16%) stopped SCIT: 54% female; mean age 30±9 years; average treatment time 12±6 months; 67% dropped the treatment during the 1st year, 27% in the 2nd and 6% during the 3rd year of treatment. Adherence rate determined was 77%. The most frequent reasons for withdrawal were due to economic reasons (47.9%), followed by patients' perception of no clinical improvement (23%) and change to sublingual immunotherapy (11.6%). Conclusion. Adherence rate in our study was 77%. Economic reasons were the main cause of abandonment in the first year, while the perception of non improvement was the main reason for abandonment in subsequent years. Adequate information on SCIT prescribing and rigorous monitoring of patients during the treatment can improve adherence.

Análise do controle da toxoplasmose gestacional e ocular nos serviços de Atenção Primária da 15ª Regional de Saúde do Paraná / Control analysis of pregnancy and ocular toxoplasmosis in Primary Care centers of the 15th Health Division of the state of Parana

Introdução: A primo-infecção pelo Toxoplasma gondii na gestação causa um risco de transmissão fetal entre 10% e 100%. Em 2006, a 15ª Regional de Saúde do Paraná criou a Rede de Controle da Toxoplasmose Gestacional e Congênita com referência para o Hospital Universitário de Maringá. Objetivo: avaliar as medidas adotadas pelos profissionais da Atenção Primária, para o controle da toxoplasmose gestacional e ocular. Método: Foram sorteadas 20% das 39 Unidades Básicas de Saúde de quatro municípios pertencentes à 15ª Regional de Saúde. A abordagem aos profissionais que assistiam as gestantes foi mediada por um questionário estruturado. Os dados coletados foram sobre as medidas realizadas: com gestantes soro não reagentes, com suspeita aguda, e com toxoplasmose ocular. Resultados: A maioria dos profissionais desconhecia a rede de controle, maneiras de infecção e medidas profiláticas para toxoplasmose. Conclusão: Isto mostra a importância da atualização profissional e perseverança da educação continuada (AU)

INTRODUCTION The primary infection by Toxoplasma gondii in pregnancy leads to a 10%--100% risk of fetal transmission. In 2006, the15th Health Division of the state of Paraná created the Network for Gestational and Congenital Toxoplasmosis Control with reference to the University Hospital of the city of Maringá. OBJECTIVE to evaluate the measures taken by primary care professionals regarding the control of gestational and ocular toxoplasmosis. METHOD Twenty percent of the 39 Basic Health Units in four municipalities belonging to the 15th Health Division of Paraná. The professionals who attended the pregnant women were interviewed through structured questionnaires. Data were collected on the measures carried out with non-reactive pregnant women, with acute suspicion, and ocular toxoplasmosis. RESULTS Most professionals were unaware of this control network, of the mode of infection, and the toxoplasmosis prophylactic measures. CONCLUSION This shows the importance of professional updating, and perseverance in continuing education (AU)

Clinical and microbiological parameters of naturally occurring periodontitis in the non-human primate Macaca mulatta.

Background: Non-human primates appear to represent the most faithful model of human disease, but to date the oral microbiome in macaques has not been fully characterized using next-generation sequencing. Objective: In the present study, we characterized the clinical and microbiological features of naturally occurring periodontitis in non-human primates (Macaca mulatta). Design: Clinical parameters of periodontitis including probing pocket depth (PD) and bleeding on probing (BOP) were measured in 40 adult macaques (7-22 yrs), at six sites per tooth. Subgingival plaque was collected from diseased and healthy sites, and subjected to 16S rDNA sequencing and identification at the species or higher taxon level. Results: All macaques had mild periodontitis at minimum, with numerous sites of PD ≥ 4 mm and BOP. A subset (14/40) had moderate-severe disease, with >2 sites with PD ≥ 5mm, deeper mean PD, and more BOP. Animals with mild vs moderate-severe disease were identical in age, suggesting genetic heterogeneity. 16S rDNA sequencing revealed that all macaques had species that were identical to those in humans or closely related to human counterparts, including Porphyromonas gingivalis which was present in all animals. Diseased and healthy sites harboured distinct microbiomes; however there were no significant differences in the microbiomes in moderate-severe vs. mild periodontitis. Conclusions: Naturally occurring periodontitis in older macaques closely resembles human adult periodontitis, thus validating a useful model to evaluate novel anti-microbial therapies.

Rice root curling, a response to mechanosensing, is modulated by the rice E3-ubiquitin ligase HIGH EXPRESSION OF OSMOTICALLY RESPONSIVE GENE1 (OsHOS1).

Plant development depends on the perception of external cues, such as light, gravity, touch, wind or nutrients, among others. Nevertheless, little is known regarding signal transduction pathways integrating these stimuli. Recently, we have reported the involvement of a rice E3-ubiquitin ligase (OsHOS1, HIGH EXPRESSION OF OSMOTICALLY RESPONSIVE GENE1), previously associated with abiotic stress response, in root responses to mechanical stimuli. We showed that OsHOS1 is involved in the regulation of root curling after mechanosensing and that RNAi::OsHOS1 plants failed to exhibit the root curling phenotype observed in WT. Interestingly, the straight root phenotype of these transgenics correlated with the up-regulation of rice ROOT MEANDER CURLING (OsRMC, a negative regulator of rice root curling) and was reverted by the exogenous application of jasmonic acid. Altogether, our results highlight the role of the proteasome modulating plant responses to mechanical stimuli and suggest that OsHOS1 is a hub integrating environmental and hormonal signaling into plant growth and development.

Toxoplasma gondii genotypes isolated from pregnant women with follow-up of infected children in southern Brazil.

BACKGROUND: Toxoplasma gondii populations that perpetuate in South America's natural ecosystems display broad genetic diversity, but the impact of this diversity on humans is generally unknown. In this short communication, we depict the genotypic traits of four isolates related to congenital parasitism as it emerges in Southern Brazil. METHODS: Using the PCR-restriction fragment length polymorphism markers SAG1, 5'3'SAG2, alt. SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1, Apico, and CS3. Three of the four strains (TgCTBral, TgCTBrv, and TgCTBrac) were identified as ToxoDB genotype #166. RESULTS: Three children displayed normal cognitive/psychomotor development, and one child displayed Sabin's tetrad (TgCTBral). CONCLUSION: Vertical transmission of the two genotypes was observed and contributes to knowledge of T. gondii strains isolated from humans in Brazil.

Clinical and molecular characterization of Diastrophic Dysplasia in the Portuguese population.

SLC26A2-related dysplasias encompass a spectrum of diseases: from lethal achondrogenesis type 1B (ACG1B; MIM #600972) and atelosteogenesis type 2 (AO2; MIM #256050) to classical diastrophic dysplasia (cDTD; MIM #222600) and recessive multiple epiphyseal dysplasia (rMED; MIM #226900). This study aimed at characterizing clinically, radiologically and molecularly 14 patients affected by non-lethal SLC26A2-related dysplasias and at evaluating genotype-phenotype correlation. Phenotypically, eight patients were classified as cDTD, four patients as rMED and two patients had an intermediate phenotype (mild DTD - mDTD, previously 'DTD variant'). The Arg279Trp mutation was present in all patients, either in homozygosity (resulting in rMED) or in compound heterozygosity with the known severe alleles Arg178Ter or Asn425Asp (resulting in DTD) or with the mutation c.727-1G>C (causing mDTD). The 'Finnish mutation', c.-26+2T>C, and the p.Cys653Ser, both frequent mutations in non-Portuguese populations, were not identified in any of the patients of our cohort and are probably very rare in the Portuguese population. A targeted mutation analysis for p.Arg279Trp and p.Arg178Ter in the Portuguese population allows the identification of approximately 90% of the pathogenic alleles.

A prospective study of Toxoplasma-positive pregnant women in southern Brazil: a health alert.

We evaluated anti-Toxoplasma gondii IgM-reactive pregnant women seen at a high-risk pregnancy outpatient clinic. From March 2005 to January 2008 in Paraná, Brazil, pregnant women seen by the Brazilian Public Health System, in any gestational period, who were anti-T. gondii IgM-positive, were followed. Clinical symptoms were noted, and tests performed including IgA, IgG avidity, ultrasonogram, and amniocentesis (PCR/inoculation in mice). Of 75 patients, 8 showed low, 3 intermediate and 31 high IgG avidity. Of those who underwent the avidity test, 31 (70.5%) were in the second trimester of pregnancy. Thirty-two (42.7%) pregnant women received specific treatment. Six received triple combination treatment; in three, tachyzoites were isolated, although only one was PCR-positive, showing changes in the cerebral sonogram, borderline IgA, and the Sabin tetrad. One fetus died, and one non-reactive IgM pregnant woman showed ocular recurrence. The municipality of residence, contact with cats during adulthood, and ingestion of unpasteurized milk were shown to be important risk factors. Congenital toxoplasmosis was observed in a pregnancy referred late for treatment. Follow-up of children born to mothers with diagnosed or suspected acute toxoplasmosis is crucial in the management of the changes that toxoplasmosis may cause.

Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement.

OBJECTIVES: To determine the clinical effectiveness and cost utility of procedures alternative to TURP (transurethral resection of the prostate) for benign prostatic enlargement (BPE) unresponsive to expectant, non-surgical treatments. DATA SOURCES: Electronic searches of 13 databases to identify relevant randomised controlled trials (RCTs). REVIEW METHODS: Two reviewers independently assessed study quality and extracted data. The International Prostate Symptom Score/American Urological Association (IPSS/AUA) symptom score was the primary outcome; others included quality of life, peak urine flow rate and adverse effects. Cost-effectiveness was assessed using a Markov model reflecting likely care pathways. RESULTS: 156 reports describing 88 RCTs were included. Most had fewer than 100 participants (range 12-234). TURP provided consistent, high-level, long-term symptomatic improvement. Minimally invasive procedures resulted in less marked improvement. Ablative procedures gave improvements equivalent to TURP. Holmium laser enucleation of the prostate (HoLEP) additionally resulted in greater improvement in flow rate. HoLEP is unique amongst the newer technologies in offering an advantage in urodynamic outcomes over TURP, although long-term follow-up data are lacking. Severe blood loss was more common following TURP. Rates of incontinence were similar across all interventions other than transurethral needle ablation (TUNA) and laser coagulation, for which lower rates were reported. Acute retention and reoperation were commoner with newer technologies, especially minimally invasive interventions. The economic model suggested that minimally invasive procedures were unlikely to be cost-effective compared with TURP. Transurethral vaporisation of the prostate (TUVP) was both less costly and less effective than TURP. HoLEP was estimated to be more cost-effective than a single TURP but less effective than a strategy involving repeat TURP if necessary. The base-case analysis suggested an 80% chance that TUVP, followed by HoLEP if required, would be cost-effective at a threshold of 20,000 pounds per quality-adjusted life-year. At a 50,000 pounds threshold, TUVP, followed by TURP as required, would be cost-effective, although considerable uncertainty surrounds this finding. The main limitations are the quantity and quality of the data available, in the context of multiple comparisons. CONCLUSIONS: In the absence of strong evidence in favour of newer methods, the standard--TURP--remains both clinically effective and cost-effective. There is a need for further research to establish (i) how many years of medical treatment are necessary to offset the cost of treatment with a minimally invasive or ablative intervention; (ii) more cost-effective alternatives to TURP; and (iii) strategies to improve outcomes after TURP.

The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation.

OBJECTIVES: To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research. DATA SOURCES: Major electronic databases were searched up to December 2005. REVIEW METHODS: Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken. RESULTS: Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3-4% in 40 year olds with a screening interval of 10 years to approach cost-effectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as 669 pounds. If annual societal costs were 8800 pounds, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of 30,000 pounds per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty. In particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective. CONCLUSIONS: While population screening is not cost-effective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing.

Clinical effectiveness and cost-effectiveness of laparoscopic surgery for colorectal cancer: systematic reviews and economic evaluation.

OBJECTIVE: The aim of this study was to determine the clinical effectiveness and cost-effectiveness of laparoscopic, laparoscopically assisted (hereafter together described as laparoscopic surgery) and hand-assisted laparoscopic surgery (HALS) in comparison with open surgery for the treatment of colorectal cancer. DATA SOURCES: Electronic databases were searched from 2000 to May 2005. A review of economic evaluations was undertaken by the National Institute for Health and Clinical Excellence in 2001. This review was updated from 2000 until July 2005. REVIEW METHODS: Data from selected studies were extracted and assessed. Dichotomous outcome data from individual trials were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Summaries of the results from individual patient data (IPD) meta-analyses were also presented. An economic evaluation was also carried out using a Markov model incorporating the data from the systematic review. The results were first presented as a balance sheet for comparison of the surgical techniques. It was then used to estimate cost-effectiveness measured in terms of incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) for a time horizon up to 25 years. RESULTS: Forty-six reports on 20 studies [19 randomised controlled trials (RCTs) and one IPD meta-analysis] were included in the review of clinical effectiveness. The RCTs were of generally moderate quality with the number of participants varying between 16 and 1082, with 10 having less than 100 participants. The total numbers of trial participants who underwent laparoscopic or open surgery were 2429 and 2139, respectively. A systematic review of four papers suggested that laparoscopic surgery is more costly than open surgery. However, the data they provided on effectiveness was poorer than the evidence from the review of effectiveness. The estimates from the systematic review of clinical effectiveness were incorporated into a Markov model used to estimate cost-effectiveness for a time horizon of up to 25 years. In terms of incremental cost per life-year, laparoscopic surgery was found to be more costly and no more effective than open surgery. With respect to incremental cost per QALY, few data were available to differentiate between laparoscopic and open surgery. The results of the base-case analysis indicate that there is an approximately 40% chance that laparoscopic surgery is the more cost-effective intervention at a threshold willingness to pay for a QALY of pound 30,000. A second analysis assuming equal mortality and disease-free survival found that there was an approximately 50% likelihood at a similar threshold value. Broadly similar results were found in the sensitivity analyses. A threshold analysis was performed to investigate the magnitude of QALY gain associated with quicker recovery following laparoscopic surgery required to provide an incremental cost per QALY of pound 30,000. The implied number of additional QALYs required would be 0.009-0.010 compared with open surgery. CONCLUSIONS: Laparoscopic resection is associated with a quicker recovery (shorter time to return to usual activities and length of hospitalisation) and no evidence of a difference in mortality or disease-free survival up to 3 years following surgery. However, operation times are longer and a significant number of procedures initiated laparoscopically may need to be converted to open surgery. The rate of conversion may be dependent on experience in terms of both patient selection and performing the technique. Laparoscopic resection appears more costly to the health service than open resection, with an estimated extra total cost of between pound 250 and pound 300 per patient. In terms of relative cost-effectiveness, laparoscopic resection is associated with a modest additional cost, short-term benefits associated with more rapid recovery and similar long-term outcomes in terms of survival and cure rates up to 3 years. Assuming equivalence of long-term outcomes, a judgement is required as to whether the benefits associated with earlier recovery are worth this extra cost. The long-term follow-up of the RCT cohorts would be very useful further research and ideally these data should be incorporated into a wider IPD meta-analysis. Data on the long-term complications of surgery such as incisional hernias and differences in outcomes such as persisting pain would also be valuable. Once available, further data on both costs and utilities should be included in an updated model. At this point, further consideration should then be given as to whether additional data should be collected within ongoing trials. Few data were available to assess the relative merits of HALS. Ideally, there should be more data from methodologically sound RCTs. Further research is needed on whether the balance of advantages and disadvantages of laparoscopic surgery varies within subgroups based on the different stages and locations of disease. Research relating to the effect of experience on performance is also required.

[Predictive factors of hospital and 6-month morbidity and mortality in hospitalized elderly patients]. / Factores preditivos de morbilidade e mortalidade hospitalar e aos seis meses em doentes idosos hospitalizados.

This article presents the results of a prospective multivariable study of elderly patients aged over 70 years, hospitalized in an Internal Medicine Department of a Central Lisbon Hospital. The study aimed to identify, at the beginning of hospital admission (HA), predictive factors of hospital mortality (HM) and mortality at 6 months, of duration of HA, of admission to a nursing home at the time of discharge and during a period of 6 months thereafter and of hospital readmission during the 6 months following discharge. The study included 158 patients with a mean hospital stay of 15 days and a hospital mortality of 12%. The main pathologies responsible for hospital admission were cerebrovascular accident (22%), heart failure (20%) and pneumonia (16%). Mortality at 6 months was 29% and hospital readmission in the 6 months thereafter was 24%. When the patient was cared for by the spouse there was a statistically significant correlation with a shorter duration of admission (p = 0.006). Mean hospital stay was not significantly associated with any other variable. A subjective medical evaluation (SME) at the start of HA (p = 0.001), a low Barthel score prior to and at the time of HA, low serum albumin (p = 0.001) and a high leucocyte count (p = 0.005) were correlated with a higher HM. Nursing home admission was only positively correlated with cerebrovascular pathology. Mortality at 6 months was significantly correlated with the SME (p = 0.001), a low Barthel score prior to admission (p < 0.008) and at the time of HA (p < 0.001), nursing home residency (p < 0.005) and a low mental test score (p < 0.01). Hospital readmission at 6 months was influenced by the SME (p < 0.04) and by the reduction in the Barthel score caused by the illness and HA (p = 0.004). These correlations enabled the development of mathematical models that predict HM and mortality at 6 months and admission to a nursing home at the time of discharge and during a period of 6 months thereafter. They could be important in identifying elderly patients' needs early in the hospital admission and in the improvement of the strategy necessary for a successful and dignified hospital discharge.