Human intake assessment of triclosan associated with the daily use of polypropylene-made antimicrobial food packaging.

In this work, we aimed to evaluate human intake of triclosan (TCS) associated with real-life use of different brands of Microban™ microwave-safe food packaging. Calculations were based on: TCS migration data (under the worst-case foreseeable conditions), MPs abundance and TCS bioaccessibility from microplastics (MPs), leached from containers under microwave heating. Bioaccessibility studies were performed with in vitro digestion of MPs, followed by liquid-liquid extraction of TCS from digestive fluids and LC-QqQ-MS analysis yielding values of 46 ± 9%. The estimated weekly intake (EWI) of TCS ranged between 11 and 42 µg/kg body weight/week, with migration being the largest contribution (0.6-2.3 mg/week), compared to leaching of MPs (75-300 µg/week). These values represent a significant source of human exposure to TCS, emphasizing the need to harmonize the ban of TCS in food contact materials worldwide and improve compliance testing of food contact articles, particularly those marketed through online sales platforms.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Risk assessment of silver and microplastics release from antibacterial food containers under conventional use and microwave heating.

The evaluation of the migration of ionic silver and nanoparticulated silver (AgNPs) from antimicrobial plastic packaging to food is crucial to ensure its safety. Migration assays were performed on reusable silver-containing polypropylene (PP) food containers and a silicone baby bottle, using food simulants, under conventional or microwave heating and repeated use. The PP containers released significant amounts of silver, increasing with temperature, contact time, acidity and lower crystallinity. Silver migration in the silicone bottle was much lower. Risk assessment of released silver was done considering European authorities safety recommendations, with some containers far exceeding these levels. No significant AgNPs release was detected in the simulants by single particle-ICPMS. Silver-containing microplastics and silicone microparticles were detected by SEM in the food simulants after the migration assays. Consumers may be continuously exposed to the harmful effects of ionic silver and microplastics, which can potentially lead to health issues.

An Immunochemical Approach to Detect the Quorum Sensing-Regulated Virulence Factor 2-Heptyl-4-Quinoline N-Oxide (HQNO) Produced by Pseudomonas aeruginosa Clinical Isolates.

Understanding quorum sensing (QS) and its role in the development of pathogenesis may provide new avenues for diagnosing, surveillance, and treatment of infectious diseases. For this purpose, the availability of reliable and efficient analytical diagnostic tools suitable to specifically detect and quantify these essential QS small molecules and QS regulated virulence factors is crucial. Here, we reported the development and evaluation of antibodies and an enzyme-linked immunosorbent assay (ELISA) for HQNO (2-heptyl-4-quinoline N-oxide), a QS product of the PqsR system, which has been found to act as a major virulence factor that interferes with the growth of other microorganisms. Despite the nonimmunogenic character of HQNO, the antibodies produced showed high avidity and the microplate-based ELISA developed could detect HQNO in the low nM range. Hence, a limit of detection (LOD) of 0.60 ± 0.13 nM had been reached in Müeller Hinton (MH) broth, which was below previously reported levels using sophisticated equipment based on liquid chromatography coupled to mass spectrometry. The HQNO profile of release of different Pseudomonas aeruginosa clinical isolates analyzed using this ELISA showed significant differences depending on whether the clinical isolates belonged to patients with acute or chronic infections. These data point to the possibility of using HQNO as a specific biomarker to diagnose P. aeruginosa infections and for patient surveillance. Considering the role of HQNO in inhibiting the growth of coinfecting bacteria, the present ELISA will allow the investigation of these complex bacterial interactions underlying infections. IMPORTANCE Bacteria use quorum sensing (QS) as a communication mechanism that releases small signaling molecules which allow synchronizing a series of activities involved in the pathogenesis, such as the biosynthesis of virulence factors or the regulation of growth of other bacterial species. HQNO is a metabolite of the Pseudomonas aeruginosa-specific QS signaling molecule PQS (Pseudomonas quinolone signal). In this work, the development of highly specific antibodies and an immunochemical diagnostic technology (ELISA) for the detection and quantification of HQNO was reported. The ELISA allowed profiling of the release of HQNO by clinical bacterial isolates, showing its potential value for diagnosing and surveillance of P. aeruginosa infections. Moreover, the antibodies and the ELISA reported here may contribute to the knowledge of other underlying conditions related to the pathology, such as the role of the interactions with other bacteria of a particular microbiota environment.

Health-related quality of life in caregivers of community-dwelling individuals with disabilities or chronic conditions. A gender-differentiated analysis in a cross-sectional study.

BACKGROUND: Most care for people with chronic or disabling conditions living in the community is provided in the family context, and this care is traditionally provided by women. Providing informal care has a negative impact on caregivers' quality of life, which adds to existing health inequalities associated with gender. The aim of this study was to analyze factors associated with the health-related quality of life of caregivers and to determine their differences in a gender-differentiated analysis. METHODS: An observational, cross-sectional, multicenter study was conducted in primary healthcare. A total of 218 caregivers aged 65 years or older were included, all of whom assumed the primary responsibility for caring for people with disabling conditions for at least 6 months per year and agreed to participate in the CuidaCare study. The dependent variable was health-related quality of life, assessed with the EQ-5D. The explanatory variables tested were grouped into sociodemographic variables, subjective burden, caregiving role, social support and variables related to the dependent person. The associations between these variables and health-related quality of life were estimated by fitting robust linear regression models. Separate analyses were conducted for women and men. RESULTS: A total of 72.8% of the sample were women, and 27.2% were men. The mean score on the EQ-5D for female caregivers was 0.64 (0.31); for male caregivers, it was 0.79 (0.23). There were differences by gender in the frequency of reported problems in the dimensions of pain/comfort and anxiety/depression. The variables that were associated with quality of life also differed. Having a positive depression screening was negatively associated with quality of life for both genders: -0.31 points (95% CI: -0.47; -0.15) for female caregivers and -0.48 points (95% CI: -0.92; -0.03) for male caregivers. Perceived burden was associated with quality of life in the adjusted model for women (-0.12 points; 95% CI: -0.19; -0.06), and domestic help was associated in the adjusted model for male caregivers (-0.12 points; 95% CI: -0.19; -0.05). CONCLUSIONS: Gender differences are present in informal caregiving. The impact of providing informal care is different for male and female caregivers, and so are the factors that affect their perceived quality of life. It could be useful it incorporates a gender perspective in the design of nursing support interventions for caregivers to individualize care and improve the quality of life of caregivers. TRIAL REGISTRATION: NCT01478295 [ https://ClinicalTrials.gov ]. 23/11/2011.

Rendimiento y validación del puntaje NoSAS en la evaluación inicial del síndrome de apnea/hipopnea del sueño / Performance and validation of NoSAS score in sleep apnea-hypopnea syndrome initial assessment

Introducción: El método de referencia para diagnosticar el síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) es la polisomnografía, esta no es diagnóstica en otros trastornos respiratorios del sueño, por lo que es necesario la implementación de puntajes predictivos para diferenciar aquellos pacientes que tienen más riesgos de padecer SAHOS y necesiten de una polisomnografía. El objetivo de este estudio fue validar el puntaje NoSAS y la escala de Berlín frente a la polisomnografía tipo 1 en pacientes con sospecha de SAHOS. Materiales y métodos: Estudio de pruebas diagnósticas. A 264 pacientes se les realizó una polisomnografía basal, la aplicación del puntaje NoSAS y la escala de Berlín; luego, se hizo el análisis de las pruebas diagnósticas y se calculó el rendimiento de cada una en relación con el índice de apnea hipopnea (IAH). Resultados: La sensibilidad del puntaje NoSAS para un IAH ≥ 20 fue 88,57% con intervalo de confianza (IC) 95% 80,4-96,74; especificidad 56,70 %; IC 95% 49,47-63,93 y valor predictivo negativo (VPN) de 93,22, IC 95% 91,70- 99,82. Para la escala de Berlín, la sensibilidad fue de 81,43%, IC 95% 71,60-91,25; especificidad de 58,76%, IC 95% 51,58-65,95 y VPN 89,76%, IC 95% 89,08-98,32. Conclusión: Se demostró que el puntaje NoSAS y la escala de Berlín tienen una buena sensibilidad para descartar a las personas con un menor riesgo de SAHOS. Un paciente clasificado de bajo riesgo probablemente está sano o tiene bajo riesgo para SAHOS moderado a severo y no requeriría de una polisomnografía inicial.

Introduction: The gold standard for diagnosing obstructive sleep apnea-hypopnea syndrome (OSAHS) is the polysomnography, and it is not a diagnostic tool for another sleep breathing disorders, so that it is necessary to implement predictive scores to differentiate those patients who have more risk of suffering OSAHS, therefore they need a polysomnography. The aim to this study was to validate the NoSAS score and Berlin scale in relation to the polysomnography type 1, in patients who have the clinical suspicion of OSAHS. Material and methods: Diagnostic tests study. 264 patients underwent polysomnography, and the NoSAS score and Berlin scale were applied to them. After that, the diagnostic tests analysis was done and the performance of each one of them was calculated in relation to the apnea- hypopnea index (AHI). Results: The sensitivity of the NoSAS score for an AHI ≥ 20 was 88.57%, confidence interval (CI) 95% (80.4-96.74), specificity 56.70 %, CI 95% (49.47-63.93), and the negative predictive value (NPV) was 93.22, CI 95% (91.70-99.82). For Berlin scale the sensitivity was 81.43%, CI 95% (71.60-91.25), specificity 58.76%, CI 95% (51.58-65.95) and NPV 89.76%, CI 95% (89.08-98.32). Conclusions: It was shown that NoSAS score and Berlin scale have a good sensitivity to rule out people who have less OSAHS risk. A patient classified as low risk, probably is healthy or at low risk for moderate to severe OSAHS and would not require an initial polysomnography.

Use of healthcare REsources and associated COsts in controlled versus uncontrolled carcinoid SYndrome in patients with neuroendocrine tumours: the RECOSY study.

PURPOSE: To report healthcare resource use and associated costs in controlled versus uncontrolled carcinoid syndrome (CS) in patients with neuroendocrine tumours. METHODS: A cross-sectional, non-interventional multicentre study was conducted with retrospective data analysis. Resource use was compared between two patient groups: those with controlled CS (> 12 months with no uncontrolled CS episodes) and uncontrolled CS (< 12 months since last uncontrolled episode). Patients were matched for age, sex, and origin and grade of tumour. When no matching patients were available, data from deceased patients were used. Information on healthcare resource use came from review of medical records, patient history and physician reports. Working capacity was assessed using the Work Productivity and Activity Impairment General Health questionnaire. RESULTS: Twenty-six university hospitals in Spain participated, between July 2017 and April 2018. 137 patients were enrolled; 104 were analysed (2 groups of 52). Patients with uncontrolled CS had 10 times more emergency department (ED) visits (mean 1.0 vs 0.10 visits; P = 0.0167), were more likely to have a hospital admission (40.4% vs 19.2%; P = 0.0116) and had longer hospital stays (mean 7.87 vs 2.10 days; P = 0.0178) than those with controlled CS. This corresponded to higher annual hospitalisation costs (mean €5511.59 vs €1457.22; P = 0.028) and ED costs (€161.25 vs €14.85; P = 0.0236). The mean annual total healthcare costs were 60.0% higher in patients with uncontrolled than controlled CS (P = NS). CONCLUSION: This study quantifies higher health resource use, and higher hospitalisation and ED costs in patients with uncontrolled CS. Better control of CS may result 3in lower medical costs.

[Mortality by COVID-19 in Spain. Approximation through public health expenditure by autonomous communities.] / Mortalidad por COVID-19 en España durante la primera oleada de la pandemia. Aproximación a través del gasto público sanitario por comunidades autónomas.

OBJECTIVE: The irruption of SARS-CoV-2 and its different incidence on the regional mortality rate could be revealing the effects of the change in the paradigm of health justice, initiated in Spain in 2010 and applied, more or less enthusiastically, by the different autonomous communities. The objective of this work was to look for if the socio-economic conditions and the policy of budgetary expenditure followed by the different Spanish autonomous communities have incidence, by themselves, on the mortality rate caused by the SARS-CoV-2. METHODS: Econometric research based on Multiple Linear Regression to determine the direct cause-effect relationship between the dependent variable, mortality associated with COVID-19, with explanatory variables of the health budget and socio-economic type. RESULTS: The number of deaths caused by COVID-19 has a positive relationship with the rate of GDP per capita and inversely with expenditure on hospital and specialized services, teaching and IRMs and with the resources allocated to health over the last nine years. A reduction in any of these health budget variables leads to an increase in mortality caused by COVID-19. CONCLUSIONS: The COVID-19 mortality rate has hit the wealthiest autonomous communities hardest but, above all, has hit those that, although richer, applied more restrictive budgetary measures in the period 2010-2018.

OBJETIVO: La irrupción del SARS-CoV-2 y su desigual incidencia sobre la tasa de mortalidad autonómica podría estar desvelando los efectos del cambio de paradigma de justicia sanitaria, iniciado en España durante 2010 y aplicado, de forma más o menos entusiasta, por las distintas comunidades autónomas. El objetivo de este trabajo fue buscar si las condiciones socio-económicas y la política de gasto presupuestario seguido por las distintas comunidades autónomas españolas tienen incidencia, por sí solas, sobre la tasa de mortalidad causada por el SARS-CoV-2. METODOS: Utilizando como fuente los datos proporcionados por el Instituto Nacional de Estadística y el Ministerio de Sanidad se elaboró un panel de datos de las diecisiete comunidades autónomas desde 2010 hasta 2018. Mediante una Regresión Lineal Múltiple, se determinó la relación causa-efecto entre la variable dependiente: la mortalidad asociada a la COVID-19, con variables explicativas de tipo presupuestarias sanitarias y socio-económicas. RESULTADOS: La tasa de mortalidad causada por COVID-19 tienen una relación positiva y directa con la tasa del PIB per Cápita e inversa con los gastos en servicios hospitalarios y especializados, en docencia y MIR y con los recursos destinados a salud pública durante los últimos nueve años. CONCLUSIONES: Una reducción en cualquiera de las variables presupuestarias sanitarias provoca un aumento en la mortalidad causada por COVID-19. La mortalidad por COVID-19 ha castigado más a las comunidades autónomas más ricas, pero sobre todo, ha castigado más a aquellas que, aun siendo más ricas, aplicaron medidas presupuestarias más restrictivas en el período 2010-2018.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Economic Studies Reinforce Efforts to Safeguard Specialty Crops in the United States.

Pathogen-tested foundation plant stocks are the cornerstone of sustainable specialty crop production. They provide the propagative units that are used to produce clean planting materials, which are essential as the first-line management option of diseases caused by graft-transmissible pathogens such as viruses, viroids, bacteria, and phytoplasmas. In the United States, efforts to produce, maintain, and distribute pathogen-tested propagative material of specialty crops are spearheaded by centers of the National Clean Plant Network (NCPN). Agricultural economists collaborated with plant pathologists, extension educators, specialty crop growers, and regulators to investigate the impacts of select diseases caused by graft-transmissible pathogens and to estimate the return on investments in NCPN centers. Economic studies have proven valuable to the NCPN in (i) incentivizing the use of clean planting material derived from pathogen-tested foundation plant stocks; (ii) documenting benefits of clean plant centers, which can outweigh operating costs by 10:1 to 150:1; (iii) aiding the development of disease management solutions that are not only ecologically driven but also profit maximizing; and (iv) disseminating integrated disease management recommendations that resonate with growers. Together, economic studies have reinforced efforts to safeguard specialty crops in the United States through the production and use of clean planting material.

Social inequalities, sexual tourism and HIV in Cartagena, Colombia: an ethnographic study.

BACKGROUND: Cartagena, Colombia's main port on the Caribbean Coast, reported an HIV incidence of 7.5 per 100,000 inhabitants in 2007 with 90.0% transmission by heterosexual contact and 70 identified as women with a stable partner. Studies across Colombia illustrate that HIV infection relates to social inequalities; most people with HIV live in poverty and have minimal access to health care, education, and secure jobs. The purpose of this article is to analyse the relationship between social inequalities, sexual tourism and HIV infection in Cartagena, Colombia. METHODS: Data come from a five-year participatory ethnography of HIV in Cartagena in the period 2004-2009, in which 96 citizens (30 of whom were living with HIV) participated in different data collection phases. Techniques included participant observation, in-depth interviews and thematic life histories. Out of this material, we selected three life histories of two women and a man living with HIV that are representative of the ways in which participants expressed how social inequalities make it virtually impossible to engage in safe sex practices. RESULTS: At stake is the exchange of condomless sex for goods within the widespread sexual tourism networks that promote an idealisation of dark-skinned men and women as better sexual performers. Our results illustrate the complex interplay of social inequalities based on class, skin colour, gender and sexual orientation. Furthermore, they suggest a synergistic effect between poverty, racialization, and gender inequalities in the historical maintenance of social dynamics for a fruitful growth of a sexual tourism industry that in turn increases vulnerability to HIV infection. CONCLUSIONS: Although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV vulnerability; distinctive dynamics are occurring in Cartagena, including a clear link between the contemporary globalised sexual tourism industries and a racialised social structure - both having historical roots in the colonial past-.

3D Models of Female Pelvis Structures Reconstructed and Represented in Combination with Anatomical and Radiological Sections.

We present a computer program designed to visualize and interact with three-dimensional models of the main anatomical structures of the female pelvis. They are reconstructed from serial sections of corpse, from the Visible Human project of the Medical Library of the United States and from serial sections of high-resolution magnetic resonance. It is possible to represent these three-dimensional structures in any spatial orientation, together with sectional images of corpse and magnetic resonance imaging, in the three planes of space (axial, coronal and sagittal) that facilitates the anatomical understanding and the identification of the set of visceral structures of this body region. Actually, there are few studies that analysze in detail the radiological anatomy of the female pelvis using three-dimensional models together with sectional images, making use of open applications for the representation of virtual scenes on low cost Windows® platforms. Our technological development allows the observation of the main female pelvis viscera in three dimensions with a very intuitive graphic interface. This computer application represents an important training tool for both medical students and specialists in gynecology and as a preliminary step in the planning of pelvic floor surgery.

Significado de la valoración clínica en estudiantes de licenciatura en enfermería: Una costumbre / The meaning of clinical assessment among nursing baccalaureate students: A custom / Significado da valorização clínica em estudantes de licenciatura de enfermagem: Um costume

La valoración clínica es un proceso planificado, sistemático y continuo, que los profesionales de enfermería realizan mediante un pensamiento crítico para obtener y organizar la información necesaria al decidir el cuidado que se proporciona. Sin embargo, se desconocen las condiciones que configuran la forma de valorar al individuo en la práctica cotidiana. Objetivo: Comprender el significado de la valoración clínica por estudiantes de licenciatura en enfermería. Metodología: Investigación Cualitativa, método fenomenológico, diseño descriptivo, donde cuatro informantes de ambos sexos de 20 y 22 años de edad, describen el cómo valoran; se realizaron entrevistas a profundidad, observación y notas de diario. El análisis de la información fue por el método J.W. Apps, en el que se reconoce el contexto que vive el estudiante al momento de realizar la valoración. Resultado: De las narraciones de los estudiantes del acto de valorar, se obtuvieron tres categorías y 10 subcategorías que al entrelazarse dieron lugar a diferentes significados. En este escrito se presenta uno de ellos: "Te vas acostumbrando", intención que trasciende y permanece en el estudiante al momento de valorar. Conclusiones: El sentido de la valoración se configura a partir de lo que hace y dice que hace el estudiante durante la práctica clínica, quién al no visualizar su ejecución de forma tangible en tiempo y espacio, repite las conductas establecidas en el entorno por lo que se "acostumbra" a no apreciarla y mucho menos a realizarla. Significado que puede modificarse mediante la capacidad reflexiva del alumno y por aquellos que la enseñan.

Background: Clinical assessment is a planned, systematic and continuous process that nursing professionals perform in order to obtain and organize the needed information to decide on the appropriate care. However, the conditions which influence on the assessments within the daily practice have not been sufficiently studied. Objective: To explore the meanings which baccalaureate nursing students attribute to clinical assessment. Methodology: This is a qualitative, phenomenological, and descriptive study in which four 22 and 24 years old informants of both sexes describe their understandings of clinical assessment. In-depth interviews were carried out, and observations and daily notes were taken. The information was analyzed through the J.W. Apps method. Results: From the students' narratives, three categories and ten sub-categories related to the meaning of clinical assessment emerged. This study presents one of them - "You become accustomed", a posture which transcends and remains in the student when making subsequent clinical assessments. Conclusions: The sense of assessment is mediated by the students´ experiences at the clinical practices where, sometimes, they do not tangibly visualize the corresponding execution, subsequently tending to repeat previously established determinations and "becoming accustomed" to demonstrate automatic responses. The meaning of clinical assessment can be positively promoted by enhancing the professors' teaching disposition and the students' reflexive capacity.

A valorização clínica é um processo planificado, sistemático e contínuo, que os profissionais de enfermagem realizam mediante um pensamento crítico para obter e organizar a informação necessária, para decidir o cuidado que se proporciona. No entanto, desconhecem-se as condições que configuram a forma de valorizar o indivíduo na prática cotidiana. Objetivo: Compreender o significado da valorização clínica por estudantes da licenciatura em enfermagem. Metodologia: Pesquisa Qualitativa, método fenomenológico, desenho descritivo, onde quatro informantes de ambos os sexos de 20 e 22 anos de idade, descrevem "o como valorizam"; realizaram-se entrevistas a profundidade, observação e notas de diário. A análise da informação foi pelo método J.W. Apps, no qual se reconhece o contexto que vive o estudante no momento de realizar a valorização. Resultado: Das narrativas dos estudantes do ato de valorizar, obtiveram-se três categorias e 10 subcategorias que se entrelaçaram dando lugar a diferentes significados. Neste escrito apresenta-se um deles: "A gente vai se acostumando", intenção que transcende e permanece no estudante no momento de valorizar. Conclusões: O sentido da valorização configura-se a partir do que faz e diz que faz o estudante durante a prática clínica e quando não visualizar sua execução de forma tangível em tempo e espaço, repete as condutas estabelecidas no ambiente, pelo que se "acostuma" a não a apreciar e muito menos a realizá-la. Significado que pode modificar-se mediante a capacidade reflexiva do aluno e por aqueles que a ensinam.

National clinical practice guidelines for allergen immunotherapy: An international assessment applying AGREE-II.

BACKGROUND: Since 1988, numerous allergen immunotherapy guidelines (AIT-GLs) have been developed by national and international organizations to guide physicians in AIT. Even so, AIT is still severely underused. OBJECTIVE: To evaluate AIT-GLs with AGREE-II, developed in 2010 by McMaster University methodologists to comprehensively evaluate GL quality. METHODS: Allergist, from different continents, knowledgeable in AIT and AGREE-II trained were selected into the project team. The project received methodologists' guidance. AIT-GLs in any language were sought from 1980 to 2016; AIT-GLs were AGREE II-evaluated by at least 2 team members, independently; discrepancies were resolved in a second round, by team discussion or methodologists' consulting. RESULTS: We found 31 AIT-GLs (15 post-2010), ranging from local consensus reports to international position papers (EAACI, AAAAI-ACAAI, WAO). Pre-2010 GLs scored 1.6-4.6 (23%-67%) and post-2010 GLs scored 2.1-6 (30%-86%), on a 7-point Likert scale. The highest scores went to: German-Austrian-Swiss (6.0), Mexican (5.1), and the AAAAI/ACAAI AIT-GL (4.7). These were also the only 3 GLs that received "yes" of both evaluators to the item: "I would recommend this GL for use." The domains of "Stakeholder involvement" and "Rigor of Development" only scored 3/7, and "Applicability" scored the lowest. Strikingly, newer GLs only scored clearly better in "Editorial independence" and "Global evaluation." CONCLUSIONS: In AIT-GLs, there is still a lot of room for improvement, especially in domains crucial for the dissemination. For some GLs, the "Scientific rigor" domain flawed. When resources are limited, transculturizing a high-quality GL might be preferable over developing a GL from zero. Our study and AGREE-II could help to select the best candidate. CLINICAL IMPLICATIONS: We here evaluate allergen immunotherapy guideline (AIT-GL) quality. Only high-quality AIT-GLs should be consulted for AIT management decisions. In low-resource settings, transculturization of these is preferred over developing low-quality guidelines.

Terahertz imaging for early screening of diabetic foot syndrome: A proof of concept.

Most people with diabetes suffer some deterioration of the feet. Diabetic foot syndrome causes ulceration in about 15% of cases and such deterioration leads to amputation in about 2.5% of diabetic patients, diminishing their quality of life and generating extraordinary costs for patients and public health systems. Currently, there is no objective method for the detection of diabetic foot syndrome in its early stages. We propose terahertz imaging as a method for the evaluation of such deterioration. This screening method could aid the prevention and medical treatment of this condition in the future.

Cost-effectiveness of clinical remission by treat to target strategy in established rheumatoid arthritis: results of the CREATE registry.

To analyse the cost-effectiveness, in daily clinical practice, of the strategy of treating to the target of clinical remission (CR) in patients with established rheumatoid arthritis (RA), after 2 years of treatment with biological therapy. Adult patients with established RA were treated with biological therapy and followed up for 2 years by a multidisciplinary team responsible for their clinical management. Treatment effectiveness was evaluated by the DAS28 score. The direct costs incurred during this period were quantified from the perspective of the healthcare system. We calculated the cost-effectiveness of obtaining a DAS28 < 2.6, considered as CR. The study included 144 RA patients treated with biological therapies. After 2 years of treatment, 32.6% of patients achieved CR. The mean cost of achieving CR at 2 years was 79,681 ± 38,880 euros. The strategy of treatment to the target of CR is considered the most effective, but in actual clinical practice in patients with established RA, it has a high cost.

Sequential antimicrobial treatment with linezolid for neurosurgical infections: efficacy, safety and cost study.

BACKGROUND: Evidence for the effectiveness of linezolid in neurosurgical infections (NSIs) is growing. The comfortable oral dosage and tolerance of linezolid opens the possibility for sequential antimicrobial treatment (SAT) in stable patients after a period of intravenous treatment. METHODS: To evaluate the efficacy and safety of SAT with oral linezolid in patients with NSI and to analyse the cost implications, an observational, non-comparative, prospective cohort study was conducted on clinically stable consecutive adult patients at the Neurosurgical Service. Following intravenous treatment, patients were discharged with SAT with oral linezolid. RESULTS: A total of 77 patients were included. The most common NSIs were: 41 surgical wound infections, 20 subdural empyemas, 18 epidural abscesses, and 16 brain abscesses. Forty-four percent of patients presented two or more concomitant NSIs. Aetiological agents commonly isolated were: Propionibacterium acnes (36 %), Staphylococcus aureus (23 %), Staphylococcus epidermidis (21 %) and Streptococcus spp. (13 %). The median duration of the SAT was 15 days (range, 3-42). The SAT was interrupted in five cases due to adverse events. The remainder of the patients were cured at the end of the SAT. A total of 1,163 days of hospitalisation were saved. An overall cost reduction of €516,188 was attributed to the SAT. Eight patients with device infections did not require removal of the device, with an additional cost reduction of €190,595. The mean cost saving per patient was €9,179. CONCLUSIONS: SAT with linezolid was safe and effective for the treatment of NSI. SAT reduces hospitalisation times, which means significant savings of health and economic resources.

The challenge of tetradic relationships in medically interpreted pediatric primary care visits: A descriptive study of communication practices.

OBJECTIVE: To examine spoken interactions between pediatricians and community-based interpreters speaking with adolescents and parents with Limited English proficiency (LEP) in primary care to identify the challenges of interpreting in a four-person or tetradic visit, its sources of co-constructed errors, and specific practices for educational intervention. METHODS: As part of a larger study of vaccine decision-making at six clinical sites in two states, this descriptive study used discourse analysis to examine 20 routine primary care visits in a Latino Clinic in interactions between adolescents, parents, community-based interpreters, and pediatricians. Specific patterns of communication practices were identified that contributed to inaccuracies in medical interpretation RESULTS: Practices needing improvement were tallied for simple frequencies and included: omissions; false fluency; substitutions; editorializing; added clarification, information, or questions; medical terminology; extra explanation to mother; and, cultural additions. Of these speaking practices, omissions were the most common (123 out of 292 total) and the most affected by pediatricians. CONCLUSION: The dynamics of both pediatricians and interpreters contributed to identification of areas for improvement, with more adolescent participation in bilingual than monolingual visits. PRACTICE IMPLICATIONS: These observations provide opportunities for mapping a communication skills training intervention based on observations for future testing of an evidence-based curriculum.

Real-world cost-effectiveness of infliximab, etanercept and adalimumab in rheumatoid arthritis patients: results of the CREATE registry.

Biological drugs have proven efficacy and effectiveness in treatment of rheumatoid arthritis (RA), although none has been shown to be superior. Few studies have evaluated the cost-effectiveness of biological drugs in real-life clinical conditions. The objective of this study was to compare the cost-effectiveness of infliximab, etanercept and adalimumab in achieving clinical remission (DAS28 < 2.6) when used as initial biological therapy. Patients were diagnosed with RA who began treatment with infliximab, etanercept or adalimumab in the Reina Sofia Hospital (Cordoba, Spain) between January 1, 2007, and December 31, 2012. Effectiveness was measured as the percentage of patients who achieved clinical remission after 2 years. The cost analysis considered the use of direct health resources (perspective of the healthcare system). Cost-effectiveness was calculated by dividing the total mean cost of each treatment by the percentage of patients who achieved remission. One hundred and thirty patients were included: 55 with infliximab, 44 with adalimumab and 31 with etanercept. After 2 years, 45.2 % of patients with adalimumab achieved clinical remission, versus 29.1 % with infliximab (p = 0.133) and 22.7 % with etanercept (p = 0.040), with no differences between etanercept and infliximab (p = 0.475). The average total cost at 2 years was €29,858, €25,329 and €23,309 for adalimumab, infliximab and etanercept, respectively, while the mean cost (95 %CI) to achieve remission was €66,057 (48,038­84,076), €87,040 (78,496­95,584) and €102,683 (94,559­110,807), respectively. Adalimumab was more efficient than etanercept (p < 0.001) and infliximab (p = 0.026), with no differences between etanercept and infliximab (p = 0.086). Adalimumab was the most cost-effective treatment in achieving clinical remission in real-life clinical conditions in RA patients during the study period.