Palliative Care in Children with Inherited Metabolic Diseases: Why does it matter?

BACKGROUND: Inherited metabolic diseases (IMD) bring considerable burden on the child and family. Challenging areas for health care include the identification of distressing symptoms, prognostic uncertainty, and bereavement. Literature regarding the impact of paediatric palliative care (PPC) is scarce. OBJECTIVE: This study aims to evaluate children with IMD referred to a PPC team (PPCT) and to analyse its impact on home care, decision to limit treatment (DLT), use of hospital resources (emergency department admissions - EDA, hospital admissions - HA, intensive care admissions - ICA) and end of life support. METHODS: Retrospective cohort study of children with IMD referred to a specialized PPCT (2016-2022). We assessed clinical data: symptoms control, time of referral and length of the follow-up period, DLT, device dependency, use of hospital resources prior to and after referral, place of death and end-of-life support. RESULTS: Fifteen children with IMD were referred to PPCT (8% of total referrals), with median age of 7 years (4 months - 17 years); 53% female. All children were non or pre-verbal. Most prevalent symptoms were neurologic and motor impairment (100%), respiratory and gastrointestinal (75%). 80% had tube feeding, 90% had some respiratory device (non-invasive ventilation in 23%). All children had multidrug use, with a mean of 6 drugs per child (2-9). 73% had home PPC and 80% had DLT planned. Nine children died (78% in hospital), after a mean of 17 months of follow-up (2 months to 4 years), all with DLT planned. 67% had support from PPCT at the end of life. All these families received emotional support. Decrease in EDA (10 vs 2) was noticed before and after PPCT. No impact was seen in HA and ICA (6 vs 5 and 1 vs 1, respectively) and there was a longer mean of hospitalisation stay (15 vs 32 days). CONCLUSION: Our cohort includes a group of children with severe, complex and neurodegenerative IMD. They need multiple medications for symptoms control, are highly dependent on medical devices and consume significant healthcare resources. Communication impairment adds complexity being a major barrier to symptom assessment. PPCT referral allowed home support, anticipated care plans development with end of life and bereavement support, as well as a tendency towards a reduction in EDA. These findings reinforce the need for holistic approach to identify and address the PPC needs of children with IMD.

A Comparative Study between Onion Peel Extracts, Free and Complexed with ß-Cyclodextrin, as a Natural UV Filter to Cosmetic Formulations.

The growing concern regarding the adverse effects of synthetic UV filters found in sunscreens has spurred significant attention due to their potential harm to aquatic ecosystems and human health. To address this, the present study aimed to extract and microencapsulate sensitive bioactive compounds derived from by-product onion peel (OP) by molecular inclusion using ß-cyclodextrin as the wall material. Identification and quantification of bioactive compounds within the extract were conducted through high-performance liquid chromatography (HPLC-DAD) analysis, revealing quercetin and resveratrol as the primary constituents. The photoprotection capacity, evaluated by the sun protection factor (SPF), revealed a protection factor comparable to the value for a synthetic UV filter. The produced microparticles presented high antioxidant capacity, significant photoprotection capacity, encapsulation efficiency of 91.8%, mean diameter of 31 µm, and polydispersity of 2.09. Furthermore, to comprehensively evaluate the performance of OP extract and its potential as a natural UV filter, five O/W emulsions were produced. Results demonstrated that microparticles displayed superior ability in maintaining SPF values over a five-week period. Photoprotection evaluation-skin reactivity tests revealed that both extract and microparticles absorb UV radiation in other regions of UV radiation, revealing their potential to be used as a natural UV filter to produce a sustainable and eco-friendly value-added sunscreen.

A Novel Approach in Skin Care: By-Product Extracts as Natural UV Filters and an Alternative to Synthetic Ones.

The cosmetic industry has been focusing on replacing synthetic ingredients with natural ones, taking advantage of their bioactive compounds. This work assessed the biological properties of onion peel (OP) and passion fruit peel (PFP) extracts in topical formulations as an alternative to synthetic antioxidants and UV filters. The extracts were characterized regarding their antioxidant capacity, antibacterial capacity and sun protection factor (SPF) value. Results revealed that the OP extract exhibited better results, which can result from the high concentrations of quercetin, as identified and quantified in HPLC analysis. Afterward, nine formulations of O/W creams were produced with minor changes in the quantity of additives: OP and PFP extract (natural antioxidants and UV filters), BHT (synthetic antioxidant) and oxybenzone (synthetic UV filter). The stability of the formulations was determined for 28 days; it was verified that they remained stable throughout the study period. The assays of the formulations' antioxidant capacity and SPF value revealed that OP and PFP extracts have some photoprotective properties and are excellent sources of antioxidants. As a result, they can be incorporated in daily moisturizers with SPF and sunscreens replacing and/or diminishing the quantities of synthetic ingredients, reducing their negative effects on human health and the environment.

Prevalence and maternal determinants of early and late introduction of complementary foods: results from the Growing Up in New Zealand cohort study.

A nationally generalisable cohort (n 5770) was used to determine the prevalence of non-timely (early/late) introduction of complementary food and core food groups and associations with maternal sociodemographic and health behaviours in New Zealand (NZ). Variables describing maternal characteristics and infant food introduction were sourced, respectively, from interviews completed antenatally and during late infancy. The NZ Infant Feeding Guidelines were used to define early (≤ 4 months) and late (≥ 7 months) introduction. Associations were examined using multivariable multinomial regression, presented as adjusted relative risk ratios and 95 % confidence intervals (RRR; 95% CI). Complementary food introduction was early for 40·2 % and late for 3·2 %. The prevalence of early food group introduction were fruit/vegetables (23·8 %), breads/cereals (36·3 %), iron-rich foods (34·1 %) and of late were meat/meat alternatives (45·9 %), dairy products (46·2 %) and fruits/vegetables (9·9 %). Compared with infants with timely food introduction, risk of early food introduction was increased for infants: breastfed < 6months (2·52; 2·19-2·90), whose mothers were < 30 years old (1·69; 1·46-1·94), had a diploma/trade certificate v. tertiary education (1·39; 1·1-1·70), of Maori v. European ethnicity (1·40; 1·12-1·75) or smoked during pregnancy (1·88; 1·44-2·46). Risk of late food introduction decreased for infants breastfed < 6 months (0·47; 0.27-0·80) and increased for infants whose mothers had secondary v. tertiary education (2·04; 1·16-3·60) were of Asian v. European ethnicity (2·22; 1·35, 3·63) or did not attend childbirth preparation classes (2·23; 1·24-4·01). Non-timely food introduction, specifically early food introduction, is prevalent in NZ. Interventions to improve food introduction timeliness should be ethnic-specific and support longer breast-feeding.

Sustainability in Skin Care: Incorporation of Avocado Peel Extracts in Topical Formulations.

The avocado peel is an agro-industrial by-product that has exhibited a massive increase in its production in the last few years. The reuse and valorisation of this by-product are essential since its disposal raises environmental concerns. In the present study, ethanolic extracts of avocado peels of the Hass variety were obtained, for three extraction times (1.5 h, 3 h and 4 h) and analysed for their antioxidant and antibacterial properties. Antioxidant evaluations of the extracts revealed that the extraction time of 1.5 h exhibited the best results amongst the three, with a DPPH inhibition percentage of 93.92 ± 1.29 and an IC50 percentage, the necessary concentration of the extract to inhibit 50% of DPPH, of 37.30 ± 1.00. The antibacterial capacity of the extracts was evaluated and it was revealed that they were able to inhibit the growth and development of bacteria of the Staphylococcus family. The obtained extract was incorporated in two types of cosmetic formulations (oil-in-water and water-in-oil) and their stability was evaluated and compared with formulations containing synthetic preservatives (BHT and phenoxyethanol). The results of the stability evaluation suggest that the avocado peel extract has the potential to be incorporated in both types of emulsions, acting as an antioxidant and antibacterial agent, proving it to be a viable option to reduce/replace the use of synthetic preservatives. Furthermore, the avocado peel extract proved to be more effective and stable in oil-in-water emulsions. These results highlight the possibility of obtaining sustainable cosmetics, significantly reducing the negative impacts on the environment by the incorporation of extracts sourced from the avocado peel, an interesting source of phenolic compounds, an abundant and low-cost by-product.

Association Between Serum Magnesium and Glycemic Control, Lipid Profile and Diabetic Retinopathy in Type 1 Diabetes.

INTRODUCTION: Many studies have shown an association between decreased serum magnesium (Mg) levels and poor glycemic control and dyslipidemia in individuals with type 1 diabetes (T1D). Few studies evaluated the association between magnesium (Mg) levels and diabetic retinopathy (DR) in individuals with type 1 diabetes (T1D). METHODS: Retrospective study of adults with T1D, with an ophthalmological evaluation and a serum Mg level determination. According to Mg levels, the individuals were stratified into two groups: normal Mg levels (1.81-2.60 mg/dL) and low Mg levels (≤1.80 mg/dL). Exclusion criteria were individuals on diuretics or proton-pump inhibitors, malabsorption or diarrhea, oral magnesium supplementation in the recent past, pregnancy, or sepsis. RESULTS: 105 individuals, with median Mg levels of 1.96 (interquartile range 0.23) mg/dL. Hypomagnesemia (≤1.80 mg/dL) was detected in 20.0% individuals and 26.7% had DR. Individuals with hypomagnesemia had higher HbA1c (p = 0.014) and triglycerides (p = 0.024). Mg levels were negatively correlated with systolic blood pressure (r = -0.200, p = 0.041), HbA1c (r = -0.281, p = 0.004) and body mass index (BMI) (r = -0.197, p = 0.041). There was no significant difference between Mg levels or prevalence of hypomagnesemia in individuals with or without DR. Also, there was no significant difference between Mg levels and the severity of DR. CONCLUSION: Hypomagnesemia is a common problem in adults with T1D, and it was correlated with poor glycemic control, although we did not find a significant association between Mg levels and prevalence or severity of DR.

A Potential Valorization Strategy of Wine Industry by-Products and Their Application in Cosmetics-Case Study: Grape Pomace and Grapeseed.

Grape pomace and grapeseed are agro-industrial by-products, whose inadequate treatment generates socioeconomic and environmental concerns. Nevertheless, it is possible to valorize them by extracting their bioactive compounds, such as antioxidants (phenolic compounds), vitamin E and fatty acids. The bioactive compounds were extracted using solid-liquid extraction. The yields for phenolic compounds were 18.4 ± 0.4% for grape pomace, and 17.4 ± 0.4%, for grapeseed. For the oil, the yields were 13.3 ± 0.2% and 14.5 ± 0.3% for grape pomace and grapeseed. Antioxidant capacity was assessed by the assay with 2,2-diphenyl-1-picrylhydrazyl (DPPH), and showed that phenolic extract has higher antioxidant capacity than the oils. Grape pomace and grapeseed extracts exhibit, correspondingly, values of 90.8 ± 0.8 and 87.5 ± 0.5 of DPPH inhibition and IC50 of 48.9 ± 0.5 and 55.9 ± 0.7 µgextract·mLDPPH-1. The antimicrobial capacity was assessed by the disk diffusion test, and revealed that, phenolic extracts inhibit the growth of Staphylococcus aureus and Staphylococcus epidermidis. The obtained extracts were incorporated in 10 face cream formulations, with slight modifications in quantities of formulation stabilizers. Their stability was studied for 35 days, and this revealed the possibility of incorporating extracts and oils obtained from by-products as antioxidants in cosmetics, and replacing synthetic ones. As a future recommendation, microencapsulation of the extracts should be performed, in order to increase their stability.

Anesthetic management of child with Gitelman Syndrome: case report.

Gitelman syndrome is a rare autosomal recessive inherited disease that affects the thiazidesensitive sodium-chloride cotransport channels and the magnesium channels in the distal convoluted tubule, leading to hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria. There is no cure for this condition and supportive treatment relies on ionic supplementation and symptom management. Literature regarding the anesthetic approach is scarce. This case report presents the anesthetic management of a child with Gitelman syndrome and its difficult electrolyte optimization.

The use of photobiomodulation for the muscles of head and neck: an integrative review / O uso da fotobiomodulação nos músculos da cabeça e pescoço: revisão integrativa da literatura

ABSTRACT Purpose To carry out an integrative review of the literature on the use of photobiomodulation (PBM) for the head and neck muscles. Research strategy The research took place between June/2019 and March/2021, in the following databases: PubMed, Scopus, Web of Science, LILACS, and SciELO. The MeSH used were Low-Level Light Therapy, Phototherapy, Masseter Muscle, Masticatory Muscles, Tongue, Palate, Mouth, Neck Muscles, and Facial Muscles in English and Portuguese. No limitation was imposed on the year and language of publication. Selection criteria studies that answered the guiding question: what is the use of photobiomodulation to the head and neck muscles?. Results 2857 articles were found, of which 102 were selected for full reading, 52 of those were excluded, giving a total of 50 articles included. The included publications date from 2003 to 2020. Brazil was the country that most published on the topic. With regard to the objectives, 82% of the studies aimed to investigate the analgesic effect of PBM, of these, 50% were related to articular or muscular temporomandibular disorders (TMD). The heterogeneity of the studies makes it impossible to define the dose protocols. Conclusion PBM has been applied to the head and neck muscles mainly for the treatment of pain caused by TMD. There is no treatment protocol to define the doses to be used, due the heterogeneity of the methodologies applied and results found.

RESUMO Objetivos realizar uma revisão integrativa da literatura sobre o uso da fotobiomodulação nos músculos de cabeça e pescoço. Estratégia de pesquisa As buscar foram realizadas nas bases de dados: PubMed, Scopus, Web of Science, LILACS e SciELO. A pesquisa ocorreu entre junho de 2019 e março de 2021. Os descritores utilizados foram Terapia com Luz de Baixa Intensidade, Fototerapia, Músculo Masseter, Músculos Mastigatórios, Língua, Palato, Boca, Pescoço, Músculos do Pescoço, Músculos Faciais e seus respectivos termos em inglês. Não houve limitação de ano de publicação e idioma. Critérios de seleção estudos que respondessem a pergunta norteadora: qual o uso da fotobiomodulação na musculatura de cabeça e pescoço?. Resultados Foram encontrados 2857 artigos, sendo selecionados 102 para leitura completa, dos quais 52 foram excluídos, totalizando 50 artigos incluídos. As publicações incluídas datam de 2003 a 2020. O Brasil foi o país que mais publicou sobre o tema. Quanto aos objetivos, 82% dos estudos pesquisaram o efeito analgésico da fotobiomodulação, e desses, 50% eram relacionados à disfunção temporomandibular (DTM) articular ou muscular. A heterogeneidade dos estudos impossibilita a definição de protocolos dosimétricos. Conclusão A fotobiomodulação tem sido utilizada na musculatura de cabeça e pescoço principalmente para o tratamento da dor proveniente de DTM. Não existe um protocolo de aplicação que defina os parâmetros dosimétricos a serem utilizados, devido a heterogeneidade das metodologias e dos resultados encontrados.

Effect of EDTA enriched diets on farmed fish allergenicity and muscle quality; a proteomics approach.

Fish is one of the most common elicitors of food-allergic reactions worldwide. These reactions are triggered by the calcium-binding muscle protein ß-parvalbumin, which was shown to have reduced immunoglobulin E (IgE)-binding capacity upon calcium depletion. This work aimed to reduce gilthead seabream allergenicity using diets supplemented with a calcium chelator. Three experimental feeds were tested, differing in ethylenediaminetetraacetic acid (EDTA) supplementation, and its effects on muscle and parvalbumin's IgE-reactivity were analyzed. Chromatographic determination of EDTA showed no accumulation in the muscle and sensory results demonstrated that the lowest concentration did not affect fish quality as edible fish. Proteomics revealed one protein related to muscle contraction with significantly different relative abundance. Immunoblot assays performed with fish-allergic patients sera indicated a 50% reduction in IgE-reactivity upon EDTA presence. These preliminary results provide the basis for the further development of a non-GMO approach to modulate fish allergenicity and improve safety of aquaculture fish.

Prevalência e fatores maternos associados à introdução não oportuna da alimentação complementar na coorte de nascimento neozelandesa Growing Up in New Zealand / Prevalence and maternal factors associated with no timely introduction of complementary feeding within the New Zealand birth cohort Growing Up in New Zealand

INTRODUÇÃO: Os primeiros 1000 dias de vida, da concepção até os dois anos de idade, são críticos para a saúde da criança. A introdução não oportuna (precoce ou tardia) dos alimentos está associada à infecções do trato gastrointestinal e respiratório, deficiência de ferro, obesidade e alergia alimentar. A Nova Zelândia não possui informações nacionalmente generalizáveis sobre a tempo de introdução dos alimentos e os determinantes sociodemográficos da introdução não oportuna dos alimentos. OBJETIVOS: i) Investigar a idade de introdução da alimentação complementar e de grupos alimentantes recomendados na coorte Growing Up in New Zealand-GUiNZ; ii) Investigar os fatores maternos e infantis associados à introdução precoce e tardia destes alimentos. MATERIAIS E MÉTODOS: O estudo GUiNZ é uma coorte de nascimento neozelandesa que acompanha quase 7000 crianças. As informações maternas sociodemográficas e de estilo de vida foram coletadas na entrevista antenatal e os informações infantis nas entrevistas de seis semanas, nove e 31 meses. Alimento complementar foi considerado qualquer alimento diferente de leite materno ou fórmula infantil ofertados para as crianças. A prevalência de introdução precoce, oportuna e tardia dos alimentos foi determinada de acordo com as recomendações do Ministério da Saúde da Nova Zelândia e da Organização Mundial da Saúde (geral e de acordo com o sexo e a duração do aleitamento materno total). Associação entre os fatores maternos e infantis e a introdução precoce e tardia dos alimentos foi investigada usando modelos múltiplos de regressão multinominal. Modelos múltiplos de regressão de Poisson com variância robusta foram utilizados para investigar os fatores maternos e infantis associados à introdução de guloseimas e bebidas açucaradas até a entrevista de 9 meses (sim/não). RESULTADOS: Dentre as 5770 crianças incluídas neste estudo, a alimentação complementar foi introduzida precocemente (<=4 meses) para 40% e tardiamente (>= 7 meses) para 3,2%. Os grupos "frutas e vegetais", "pães e cereais" e "alimentos ricos em ferro" foram introduzidos precocemente para 24%, 36% e 34% das crianças, respectivamente. O grupo "carnes e alternativas", que inclui alimentos ricos em proteínas de origem animal e vegetal e o grupo "laticínios" foram introduzidos tardiamente (>=7 meses) para 46% das crianças. A prevalência de introdução de guloseimas e bebidas açucaradas até a entrevista de nove meses foi de 52% e 38%, respectivamente. Mães que amamentaram por menor de 6 meses e/ou nunca amamentaram, com menos de 30 anos de idade, de etnia maori, com menor escolaridade, com IMC prégestacional elevado, que não planejaram a gravidez, que não frequentaram os cursos de maternidade e fumaram antes e/ou durante a gestação tiveram maior risco de introduzir os alimentos precocemente (em comparação às mães que introduziram oportunamente). Mães que amamentaram por menos de 6 meses, não frequentaram os cursos de maternidade, de etnia maori, pacífica ou asiática e com menor escolaridade apresentaram maior risco de introduzir os alimentos tardiamente (em comparação às mães que introduziram oportunamente). CONCLUSÃO: A prevalência de introdução não oportuna na coorte foi elevada e apresentou inequidade étnica, demográfica e socioeconômica nas taxas de introdução não oportuna da alimentação complementar.

INTRODUCTION: The first 1000 days of life, from conception to two years age, are critical to the infant's health. Non-timely introduction of foods (early or late) is associated with infections of the gastrointestinal and respiratory tracts, iron deficiency, obesity and food allergies. New Zealand lacks nationally generalizable information on timing of food introduction and the sociodemographic determinants of non-timely introduction of complementary feeding. OBJECTIVES: i) To investigate the age of introduction of complementary feeding and of recommended food groups within the Growing Up in New Zealand - GUiNZ cohort and; ii) To examine the maternal and infant factors associated with early and late introduction of these foods. METHODS: The GUiNZ study is a New Zealand birth cohort which follows nearly 7000 children. Maternal sociodemographic and lifestyle information was collected in the antenatal interview and infant's information was prevenient from the six-week, nine and 31-month interviews. It was considered as complementary food any food item other than breast milk or infant formula that was introduced to babies. Prevalence of early, timely and late age of food introduction were evaluated according to the recommendations of the New Zealand Ministry of Health and the World Health Organization (overall and according to sex and breastfeeding duration). Associations between maternal and infant factors with early and late introduction of foods were examined using multivariate multinomial regressions. Multivariate Poisson regressions with robust variance were performed to examine maternal and infant factors associated with the introduction of snacks and sugary drinks up until the 9-month interview (yes/no). RESULTS: Among the 5770 children included in this study, complementary feeding was introduced early (<=4th month) to 40% and late (>=7th month) to 3,2%. The groups "fruits and vegetables", "breads and cereals" and "iron rich foods" were early introduced to 24%, 36% and 34% of the infants, respectively. "Meat and alternatives", which includes foods rich in protein from animal and vegetable sources, and products from the "dairy" group were introduced late to 46% of the infants. The prevalence of introduction of 'snacks' and 'sugary drinks' by the time of the 9- month interview were 52% and 38%, respectively. Mothers who breastfed for less than 6 months and/or never breastfed, who were younger than 30 years old, who were from Maori ethnicity, who had high pre-pregnancy BMI, who had unplanned pregnancy, who did not attend to maternity preparation classes and who smoked before and/or during pregnancy were more likely to introduce their babies foods earlier (in relation to mothers of babies who were timely introduced). Mothers who breastfed for less than 6 months, who did not attend to maternity preparation classes, who were from Maori, Pacific or Asian ethnicities and who had lower level of formal education were more likely to introduce their babies foods late (in relation to mothers of babies who were timely introduced). CONCLUSION: The prevalence of non-timely food introduction within the cohort was high and there were ethnic, demographic and socioeconomic inequities in the rates of non-timely introduction of complementary feeding.

Efficacy of Long-Term Oral Vitamin B12 Supplementation after Total Gastrectomy: Results from a Prospective Study.

BACKGROUND/OBJECTIVES: Vitamin B12 (VB12) deficiency is a common complication after total gastrectomy which may be associated with megaloblastic anemia and potentially irreversible neurologic symptoms. Intramuscular supplementation of VB12 has been considered the standard treatment, although it is associated with high costs and patient discomfort. PATIENTS/METHODS: We performed a prospective uncontrolled study (ACTRN12614000107628) in order to evaluate the clinical and laboratory efficacy of long-term oral VB12 supplementation in patients submitted to total gastrectomy. All patients received daily oral VB12 (1 mg/day) and were evaluated every 3 months (clinical and laboratory evaluation: hemoglobin, VB12, total iron, ferritin, and folate). RESULTS: A total of 26 patients were included with a mean age of 64 years (29-79). Patients were included with a mean period of 65 months (3-309) after total gastrectomy. At inclusion time, 17/26 patients were under intramuscular VB12, and 9 had not started supplementation yet. There were normal serum VB12 levels in 25/26 patients (mean VB12 serum levels: 657 pg/mL). The mean follow-up period was 20 (8.5-28) months. During follow-up, all patients had normal VB12 levels and there was no need for intramuscular supplementation. The patient with low VB12 levels had an increase to adequate levels, which remained stable. There were no differences with statistical significance among VB12 levels at 6 (867 pg/mL), 12 (1,008 pg/mL), 18 (1,018 pg/mL), and 24 (1,061 pg/mL) months. Iron and folate supplementation was necessary in 21 and 7 patients, respectively. CONCLUSIONS: Oral VB12 supplementation is effective and safe in patients who underwent total gastrectomy and should be considered the preferential form of supplementation.

INTRODUÇÃO: O défice de vitamina B12 (vitB12) ocorre de forma quase universal e precocemente após gastrectomia total (GT), podendo associar-se a anemia megaloblástica e alterações neurológicas potencialmente irreversíveis. A administração intramuscular de vitB12 é considerada a forma de suplementação adequada, sendo, contudo, desconfortável, dispendiosa e, atualmente, de acesso difícil. MÉTODOS/OBJETIVO: Estudo prospetivo, não controlado (ACTRN12614000107628), cujo objetivo principal foi avaliar a eficácia clínica e laboratorial a longo prazo da suplementação oral com vitB12 em doentes com GT. O objetivo secundário foi avaliar outros défices nutricionais (ferro e folatos). Os doentes foram medicados com vitB12 oral (1mg/dia) e sujeitos a avaliação clínica e laboratorial trimestral (hemoglobina, vitB12, ferro, ferritina e ácido fólico). SPSS 23 (Wilcoxon test). RESULTADOS: Incluídos 26 doentes (M-18; F-8), idade média 64 anos (29­79), com diagnósticos de adenocarcinoma (n = 25) e linfoma MALT (n = 1). Os doentes foram incluídos em média 65 meses (3­309) após GT. À data de inclusão, 17/25 doentes encontravam-se medicados com vitB12 intramuscular e 9 ainda não tinham iniciado suplementação, verificando-se níveis séricos adequados de vitB12 em 25/26 doentes (1/26 com níveis de vitB12 baixos por incumprimento da terap'utica intramuscular), sendo o valor médio de 657 pg/mL (136­1,642). Os doentes foram avaliados durante uma mediana de 23 meses (IQR 8,8). No follow-up todos os doentes apresentaram níveis normais de vitB12, não sendo necessária terap'utica intramuscular. O doente com vitB12 baixa registou um incremento para níveis adequados, que se mantiveram estáveis. Não houve diferenças com significado estatístico nos níveis de vitB12 aos 6 (867 pg/mL), 12 (1,008 pg/mL) e 24 (1,061 pg/mL) meses, embora com aumento progressivo dos mesmos. A suplementação com ferro e folatos foi necessária em 21 e 7 doentes, respetivamente. CONCLUSÃO: A suplementação oral de vitB12 é eficaz e segura em doentes com GT, pelo que esta deve ser considerada a forma preferencial de administração neste grupo de doentes.

A devices' game of thrones: cardiac resynchronization therapy vs. pacemaker.

AIMS: Oversensing can interfere with biventricular pacing. Cardiac Resynchronization Therapy (CRT) output inhibition due to automatic brady mode change from a sensing to a pacing mode of a previously implanted pacemaker as it reached battery capacity depleted indicator has not been previously published in the medical literature. METHODS AND RESULTS: We report the first case of CRT output inhibition in a pacemaker dependent patient due to electrical stimuli from a previously right-sided implanted pacemaker, after unaware reversion of OVO mode (O = no chambers paced; V = ventricular sensing; O = no response to sensing) to backup VVI (V = ventricular pacing; V = ventricular sensing; I = inhibitory response to sensing) when it reached the elective replacement interval. CONCLUSION: This paper emphasizes the importance of knowing the distinct pacemaker brady mode behaviours after battery capacity depleted indicator has been reached, according to the pacemakers' manufacturer, including the possibility of automatic brady mode change from sensing to pacing mode. It also highlights the potential for severe bradycardia or asystole of this automatic brady mode change from a previously implanted pacemaker in pacemaker dependent patients submitted to CRT upgrade.