Respiratory syncytial virus: challenges in diagnosis and impact on the elderly: Recommendations from a multidisciplinary panel.

Respiratory syncytial virus (RSV) is an important cause of respiratory illness. While most attention is paid to childhood infection, the RSV burden in adults ≥60 y should also be considered. In Brazil, this is generally underrecognized, where greater focus is toward other respiratory pathogens. This article presents insights from a multidisciplinary panel gathered to review epidemiologic data and current diagnostic approaches to RSV in Brazil (and their limitations) and develop communication strategies to improve knowledge and awareness. National surveillance data indicate a steady increase in cases of RSV-related severe acute respiratory illness (RSV-SARI) in those aged ≥60 y in recent years, with high fatality rates (>30%). Routine RSV testing in older individuals with respiratory symptoms is relatively low. Educational activities targeted toward health-care professionals and the general public are critical to raising awareness of the importance of RSV in older individuals, particularly as protective vaccines are now available.

Clinical Review: The Approach to the Evaluation and Management of Bilateral Adrenal Masses.

OBJECTIVE: This white paper provides practical guidance for clinicians encountering bilateral adrenal masses. METHODS: A case-based approach to the evaluation and management of bilateral adrenal masses. Specific clinical scenarios presented here include cases of bilateral adrenal adenomas, hemorrhage, pheochromocytomas, metastatic disease, myelolipomas, as well as primary bilateral macronodular adrenal hyperplasia. RESULTS: Bilateral adrenal masses represent approximately 10% to 20% of incidentally discovered adrenal masses. The general approach to the evaluation and management of bilateral adrenal masses follows the same protocol as the evaluation of unilateral adrenal masses, determined based on the patient's clinical history and examination as well as the imaging characteristics of each lesion, whether the lesions could represent a malignancy, demonstrate hormone excess, or possibly represent a familial syndrome. Furthermore, there are features unique to bilateral adrenal masses that must be considered, including the differential diagnosis, the evaluation, and the management depending on the etiology. Therefore, considerations for the optimal imaging modality, treatment (medical vs surgical therapy), and surveillance are included. These recommendations were developed through careful examination of existing published studies as well as expert clinical opinion consensus. CONCLUSION: The evaluation and management of bilateral adrenal masses require a comprehensive systematic approach which includes the assessment and interpretation of the patient's clinical history, physical examination, dynamic hormone evaluation, and imaging modalities to determine the key radiographic features of each adrenal nodule. In addition, familial syndromes should be considered. Any final treatment options and approaches should always be considered individually.

A low-cost, portable device for the study of the malaria parasite's growth inhibition via microwave exposure.

Recently, a novel method for the growth inhibition of malaria parasites using microwaves was proposed. However, the apparatuses used to demonstrate this method are high-cost and immovable, hindering the progression in this field of research, which is still in its early stages. This paper presents the redesign, construction, and validation of an equivalent system, converting it into a portable and low-cost system, capable of replacing the existing one. The proposed system is mainly composed of an RF generator (MAX2870), an RF amplifier (SKYWORKS 66292-11) and a graphical user interface. Likewise, the RF applicator proposed by the original study was redesigned, resulting in a five-fold improvement in return loss. The obtained results indicate that the proposed system achieves 90% parasite growth inhibition, matching the performance of its counterpart at less than 1% of its cost. These results represent a breakthrough for the creation of smaller, enhanced devices that open new possibilities for an alternative treatment to combat this devastating disease.

Obturator prostheses with intramucosal retention system in patients with maxillectomy.

PURPOSE: To evaluate the intramucosal retention system in patients' masticatory efficiency and quality of life in this case series. MATERIAL AND METHODS: A total of 3 individuals with maxillectomy were included for rehabilitation with a complete obturator prostheses with an intramucosal retention system (OPI). The complete obturator prostheses was made for 60 days, and electromyography assessments and bite force were applied before, after 30, 60, and 90 days of surgery and prostheses installation. The University of Washington Quality of Life Questionnaire (UW-QoL) and the Obturator Functional Scale (OFS) were also administered at baseline and in the same follow-up periods. The electromyography was evaluated on both sides of the masseter, temporalis, and buccinator muscles while chewing hard and soft food. The maximum bite force was recorded in the central incisors and both sides of the first molar region. RESULTS: Bite force values increased in the first molar region, and muscular electrical activity remained constant. Items related to the taste and swallowing of the UW-QOL impacted. Most OFS questionnaire data responses indicated that patients improved in swallowing liquid foods and appearance. CONCLUSIONS: The rehabilitative capacity improves masticatory efficiency and QoL in adults maxilectomized and rehabilitated with OPI analysis in the study. Further clinical studies should be encouraged to determine the effectiveness of this retentive system.

Fungal Osteomyelitis of the Hip with Septic Arthritis: Case Report.

Fungal osteomyelitis, especially associated with septic arthritis, is uncommon in Brazil; therefore, sometimes it is difficult to diagnose and treat it. We report the case of a young patient, with no immunosuppressive risk factor, with osteomyelitis leading to septic arthritis of the hip. The diagnosis was performed after surgical drainage and visualization of Cryptococcus neoformans at pathological anatomy. Antifungal treatment resulted in complete remission of the symptoms. Since there is no consensus on the treatment of fungal osteomyelitis, this case report aims to inform orthopedists about the importance of hip arthritis differential diagnosis and the good evolution of clinical treatment after drainage and pathogen isolation.

One Health Approach to Toxoplasmosis: Owner and Dog Seropositivity as Spatial Indicators of Risk Areas for Acquired, Gestational and Congenital Transmission.

BACKGROUND: Toxoplasmosis has been of public health concern due to direct associations with socioeconomic vulnerability and inadequate living conditions. METHODS: Accordingly, the present study aimed to assess antibodies against T. gondii, historical reported toxoplasmosis cases and associated socio-environmental risk factors in Pinhais, a full urban area of Curitiba, currently the eighth biggest metropolitan area of Brazil. Anti-Toxoplasma gondii antibodies were assessed by an indirect immunofluorescence reaction (RIFI). Owner and dog samples were also tested by IFAT to anti-Leishmania spp. and anti-Trypanosoma cruzi antibodies. RESULTS: Overall, 20/135 (14.8%) persons and 13/133 (9.8%) dogs from 25 different households were considered seropositive to T. gondii. All samples were seronegative to Leishmania spp. and Trypanosoma cruzi. CONCLUSIONS: Although no significant covariates were found in the regression model, statistically associated risk factors in the bivariate analysis included no public water use (p = 0.016) and drinking raw milk (p = 0.041) for owners, and obesity (p = 0.028) and tick infestation (p = 0.03) for dogs. In addition, a spatial cluster of T. gondii seropositivity for both owners and their dogs overlapped the location of historic reported cases of human acquired, gestational and congenital toxoplasmosis. Finally, the results herein showed tick infestation as an indicator of socio-environmental risk for T. gondii exposure in the household environment, and dogs may be used as sentinels for human toxoplasmosis cases.

Deep Learning Models to Reduce Stray Light in TJ-II Thomson Scattering Diagnostic.

Nuclear fusion is a potential source of energy that could supply the growing needs of the world population for millions of years. Several experimental thermonuclear fusion devices try to understand and control the nuclear fusion process. A very interesting diagnostic called Thomson scattering (TS) is performed in the Spanish fusion device TJ-II. This diagnostic takes images to measure the temperature and density profiles of the plasma, which is heated to very high temperatures to produce fusion plasma. Each image captures spectra of laser light scattered by the plasma under different conditions. Unfortunately, some images are corrupted by noise called stray light that affects the measurement of the profiles. In this work, we propose the use of deep learning models to reduce the stray light that appears in the diagnostic. The proposed approach utilizes a Pix2Pix neural network, which is an image-to-image translation based on a generative adversarial network (GAN). This network learns to translateimages affected by stray light to images without stray light. This allows for the effective removal of the noise that affects the measurements of the TS diagnostic, avoiding the need for manual image processing adjustments. The proposed method shows a better performance, reducing the noise up to 98% inimages, which surpassesprevious works that obtained 85% for the validation dataset.

Mechanical Characterization of the Erythrocyte Membrane Using a Capacitor-Based Technique.

Pathological processes often change the mechanical properties of cells. Increased rigidity could be a marker of cellular malfunction. Erythrocytes are a type of cell that deforms to squeeze through tiny capillaries; changes in their rigidity can dramatically affect their functionality. Furthermore, differences in the homeostatic elasticity of the cell can be used as a tool for diagnosis and even for choosing the adequate treatment for some illnesses. More accurate types of equipment needed to study biomechanical phenomena at the single-cell level are very costly and thus out of reach for many laboratories around the world. This study presents a simple and low-cost technique to study the rigidity of red blood cells (RBCs) through the application of electric fields in a hand-made microfluidic chamber that uses a capacitor principle. As RBCs are deformed with the application of voltage, cells are observed under a light microscope. From mechanical force vs. deformation data, the elastic constant of the cells is determined. The results obtained with the capacitor-based method were compared with those obtained using optical tweezers, finding good agreement. In addition, P. falciparum-infected erythrocytes were tested with the electric field applicator. Our technique provides a simple means of testing the mechanical properties of individual cells.

Understanding the Burden of Respiratory Syncytial Virus in Older Adults in Latin America: An Expert Perspective on Knowledge Gaps.

Respiratory syncytial virus (RSV) is a significant global health concern and major cause of hospitalization, particularly among infants and older adults. The clinical impact of RSV is well characterized in infants; however, in many countries, the burden and risk of RSV in older populations are overlooked. In Latin America, there are limited data on RSV epidemiology and disease management in older adults. Therefore, the impact of RSV in this region needs to be addressed. Here, current insights on RSV infections in older populations in Latin America, including those with underlying health conditions, are discussed. We also outline the key challenges limiting our understanding of the burden of RSV in Latin America in a worldwide context and propose an expert consensus to improve our understanding of the burden of RSV in the region. By so doing, we aim to ultimately improve disease management and outcomes of those at risk and to alleviate the impact on healthcare systems.A graphical plain language summary is available with this article.

2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia.

RATIONALE: New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency. OBJECTIVES: To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP. PANEL DESIGN: The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting. METHODS: After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework. RESULTS: In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence. CONCLUSIONS: The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.

Is pulmonary arterial hypertension associated with schistosomiasis distinct from pulmonary arterial hypertension associated with portal hypertension?

Pulmonary arterial hypertension associated with schistosomiasis (SchPAH) and pulmonary arterial hypertension associated with portal hypertension (PoPAH) are lung diseases that develop in the presence of liver diseases. However, mechanistic pathways by which the underlying liver conditions and other drivers contribute to the development and progression of pulmonary arterial hypertension (PAH) are unclear for both etiologies. In turn, these unknowns limit certainty of strategies to prevent, diagnose, and reverse the resultant PAH. Here we consider specific mechanisms that contribute to SchPAH and PoPAH, identifying those that may be shared and those that appear to be unique to each etiology, in the hope that this exploration will both highlight known causal drivers and identify knowledge gaps appropriate for future research. Overall, the key pathophysiologic differences that we identify between SchPAH and PoPAH suggest that they are not variants of a single condition.

Factors associated with pulmonary infection in kidney and kidney-pancreas transplant recipients: a case-control study.

OBJECTIVE: To evaluate the etiology of and factors associated with pulmonary infection in kidney and kidney-pancreas transplant recipients. METHODS: This was a single-center case-control study conducted between December of 2017 and March of 2020 at a referral center for kidney transplantation in the city of Belo Horizonte, Brazil. The case:control ratio was 1:1.8. Cases included kidney or kidney-pancreas transplant recipients hospitalized with pulmonary infection. Controls included kidney or kidney-pancreas transplant recipients without pulmonary infection and matched to cases for sex, age group, and donor type (living or deceased). RESULTS: A total of 197 patients were included in the study. Of those, 70 were cases and 127 were controls. The mean age was 55 years (for cases) and 53 years (for controls), with a predominance of males. Corticosteroid use, bronchiectasis, and being overweight were associated with pulmonary infection risk in the multivariate logistic regression model. The most common etiologic agent of infection was cytomegalovirus (in 14.3% of the cases), followed by Mycobacterium tuberculosis (in 10%), Histoplasma capsulatum (in 7.1%), and Pseudomonas aeruginosa (in 7.1%). CONCLUSIONS: Corticosteroid use, bronchiectasis, and being overweight appear to be risk factors for pulmonary infection in kidney/kidney-pancreas transplant recipients, endemic mycoses being prevalent in this population. Appropriate planning and follow-up play an important role in identifying kidney and kidney-pancreas transplant recipients at risk of pulmonary infection.

Accuracy of Transthoracic Echocardiogram as a Screening Method in the Clinical Practice of Pulmonary Hypertension Investigation. / Acurácia do Ecocardiograma Transtorácico como Método de Triagem na Prática Clínica da Investigação da Hipertensão Pulmonar.

BACKGROUND: The transthoracic echocardiogram (TTE) plays a screening role in the diagnostic algorithm of pulmonary hypertension (PH). Studies have shown a significant disagreement between TTE measurements of the systolic pulmonary artery pressure (sPAP) and right atrial pressure (RAP) and those obtained by right heart catheterization (RHC). OBJECTIVE: To compare TTE measurements of sPAP and RAP with those obtained by RHC in patients being investigated for PH. METHODS: Patients referred to a PH reference center with a high or intermediate TTE probability of PH upon admission were submitted to RHC. The agreement between sPAP and RAP from both procedures was assessed through the Bland-Altman test. Differences of up to 10 mmHg for sPAP and 5 mmHg for RAP were considered within the variability of the test. Receiver Operating Characteristic (ROC) curve was constructed to determine the most accurate sPAP and Tricuspid regurgitation maximal velocity (TRV)values associated with the diagnosis of PH by RHC. The adopted level of statistical significance was 5%. RESULTS: Ninety-five patients were included. The Bland-Altman analysis showed a bias of 8.03 mmHg (95% CI:-34.9-50.9) for sPAP and -3.30 mmHg (95% CI:-15.9-9.3) for RAP. AUC for sPAP and TRV measured by TTE for discrimination of probable PH were 0.936 (95% CI: 0.836-1.0) and 0.919 (95% CI: 0.837-1.0), respectively. However, only 33.4% of the echocardiographic estimate of sPAP and 55.1% of RAP were accurate, as compared to the measurements obtained by RHC. CONCLUSION: TTE has a high discriminatory power as a screening diagnostic method for PH despite presenting disagreements between sPAP and RAP absolute values when compared to RHC measurements.

FUNDAMENTO: O ecocardiograma transtorácico (ETT) tem um papel de triagem no algoritmo diagnóstico da hipertensão pulmonar (HP). Estudos demonstraram uma discordância significativa entre as medições do ETT da pressão arterial pulmonar sistólica (PAPs) e da pressão atrial direita (PAD) e as obtidas pelo cateterismo do coração direito (CCD). OBJETIVO: Comparar as medições do ETT da PAPs e da PAD com as obtidas pelo CCD em pacientes com suspeita de HP. MÉTODOS: Pacientes encaminhados a um centro de referência com probabilidade alta ou intermediária de PH ao ETT na admissão hospitalar passaram por CCD. A concordância entre a PAPs e a PAD em ambos os procedimentos foi avaliada pelo teste de Bland-Altman. Diferenças de até 10 mmHg na PAPs e de até 5 mmHg na PAD foram consideradas dentro da variabilidade do teste. A curva de característica de operação do receptor (ROC) foi construída para determinar os valores mais precisos de PAPs e VRT associados ao diagnóstico de HP pelo CCD. O nível de significância estatística adotado foi 5%. RESULTADOS: Foram incluídos noventa e cinco pacientes. A análise de Bland-Altman análise revelou um viés de 8,03 mmHg (IC 95%: -34,9 a 50,9) na PAPs e -3,30 mmHg (IC 95%: -15,9 a 9,3) na PAD. AUC da PAPs e VRT medidas pelo ETT para a discriminação de provável HP foram de 0,936 (IC 95%: 0,836 a 1,0) e 0,919 (IC 95%: 0,837 a 1,0), respectivamente. Entretanto, apenas 33,4% da estimativa ecocardiográfica da PAPs e 55,1% da PAD foram precisas, em comparação às medições obtidas pelo CCD. CONCLUSÃO: O ETT tem um alto poder discriminatório como método diagnóstico de triagem para HP, apesar de apresentar discordâncias entre os valores absolutos de PAPs e PAD, em comparação às medições por CCD.

Perceptions and conducts of oral and maxillofacial surgeons during the COVID-19 pandemic: A qualitative study.

Oral and maxillofacial surgeons are among the frontline healthcare workers and are classified as a high-risk group for COVID-19 infection; however, it has not yet been defined how these professionals were impacted. The aim of this study was to explore the conducts and perceptions of oral and maxillofacial surgeons during the COVID-19 pandemic in Brazil. Nine individuals, mean age 34.8 years, 66.6% men, were included in the study. A semi-structured interview with a qualitative approach was applied to professionals belonging to a messaging application group (WhatsApp). Content analysis was performed in the light of Hellerian theory in its daily theoretical framework for the interpretation of the memories reported by the participants. Four themes were identified. The lack of knowledge about COVID-19 and the fear of being contaminated during care were the main factors responsible for changes in the professionals' work routine. An important point was the collective reflection of the participants about the increase in biosafety barriers, which ensured a greater sense of security. The need for social isolation to contain the virus was also described. As a result, there was a great distance between professionals and their families, which generated high levels of anxiety in the former. Repetitive reports of slowness and reduced attendance directly related to financial loss and aggravated stress were also highlighted. The findings of this study reveal that oral and maxillofacial surgeons had their professional-personal axis affected in terms of daily habits, family life and financial strain, aspects that were responsible for impacting stress and anxiety levels.

Protocol for Development of American Association of Clinical Endocrinology Clinical Practice Guidelines and Consensus Statements: Summary of Methodology, Process, and Policy - 2023 Update.

OBJECTIVE: This 2023 updated protocol summarizes the American Association of Clinical Endocrinology's (AACE's) new framework for the development of clinical practice guidelines and other guidance documents that includes changes to methodology, processes, and policies. METHODS: AACE has critically reviewed its development processes for guidance documents over the last several years against the National Academy of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines and the Council of Medical Specialty Societies Principles for Development of Specialty Society Clinical Guidelines to determine areas for improvement. RESULTS: The new AACE framework for development of guidance documents incorporates many changes, including a revised conflicts of interest (COI) policy; strengthened commitment to collection of disclosures and management of relevant COI during development; open calls to membership for authors; new requirements for authors; new diversity, equity, and inclusion (DEI) policy; new empanelment process that incorporates consideration of DEI; and adoption of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to increase the quality of evidence assessment and standardize recommendation grades and statements, among other improvements. CONCLUSIONS: AACE has revised its policies and adopted a completely new methodology for guideline development in support of the mission to elevate the practice of clinical endocrinology to improve patient care. With the use of an evidence-based medicine framework and by continually assessing and improving its processes for development of guidance, AACE strives to deliver trustworthy, unbiased, and up-to-date information that ensures clinician and patient confidence in AACE content. Further, AACE hopes that these enhancements foster a more collaborative approach to development and increase engagement with the worldwide medical community to improve global health.

Performance in field-tests and dynamic knee valgus in soccer players psychologically ready and not ready to return to sports after ACL reconstruction.

BACKGROUND: The objective was to compare the performance in field tests, dynamic knee valgus, knee function, and kinesiophobia of soccer players who were psychologically ready and not ready to return to unrestricted training or competitions after ACL reconstruction. METHODS: Thirty-five male soccer players who had undergone primary ACL reconstruction at least 6 months were divided based on the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) questionnaire score into ready (≥60) and not-ready (<60) groups. The modified Illinois change of direction test (MICODT) and reactive agility test (RAT) were used to impose the demand for directional change and reactive decision-making. We assessed the frontal plane knee projection angle (FPKPA) during a single-leg squat and distance in crossover hop test (CHD). In addition, we assessed kinesiophobia through the shortened version of the Tampa Scale of Kinesiophobia (TSK-11) and knee function using the International Knee Documentation Committee Subjective Knee Form (IKDC). Independent t-tests were used to compare the groups. RESULTS: The not-ready group had lower performance on the MICODT (effect size (ES) = -1.2; p < 0.001) and RAT (ES = -1.1; p = 0.004) tests and higher FPKPA (ES = 1.5; p < 0.001). In addition, they presented lower IKDC (ES = 3.1; p < 0.001) and higher TSK-11 (ES = -3.3; p < 0.001) scores. CONCLUSIONS: Physical and psychological deficits may persist in some individuals after rehabilitation. On-field tests and dynamic knee alignment evaluation should be included in the athlete evaluation before the decision-making about clearance to sports participation, especially in athletes who perceive themselves as psychologically not ready.