Characterization of Novel Pathogenic Variants Leading to Caspase-8 Cleavage-Resistant RIPK1-Induced Autoinflammatory Syndrome.

Pathogenic RIPK1 variants have been described as the cause of two different inborn errors of immunity. Biallelic loss-of-function variants cause the recessively inherited RIPK1 deficiency, while monoallelic variants impairing the caspase-8-mediated RIPK1 cleavage provoke a novel autoinflammatory disease (AID) called cleavage-resistant RIPK1-induced autoinflammatory (CRIA) syndrome. The aim of this study was to characterize the pathogenicity of two novel RIPK1 variants located at the cleavage site of caspase-8 detected in patients with dominantly-inherited, early-onset undefined AID. RIPK1 genotyping was performed by Sanger and next-generation sequencing. Clinical and analytical data were collected from medical charts, and in silico and in vitro assays were performed to evaluate the functional consequences. Genetic analyses identified two novel heterozygous RIPK1 variants at the caspase-8 cleavage site (p.Leu321Arg and p.Asp324Gly), which displayed a perfect intrafamilial phenotype-genotype segregation following a dominant inheritance pattern. Structural analyses suggested that these variants disrupt the normal RIPK1 structure, probably making it less accessible to and/or less cleavable by caspase-8. In vitro experiments confirmed that the p.Leu321Arg and p.Asp324Gly RIPK1 variants were resistant to caspase-8-mediated cleavage and induced a constitutive activation of necroptotic pathway in a similar manner that previously characterized RIPK1 variants causing CRIA syndrome. All these results strongly supported the pathogenicity of the two novel RIPK1 variants and the diagnosis of CRIA syndrome in all enrolled patients. Moreover, the evidences here collected expand the phenotypic and genetic diversity of this recently described AID, and provide interesting data about effectiveness of treatments that may benefit future patients.

Tubulointerstitial Nephritis and Uveitis in a Pediatric Patient.

Tubulointerstitial nephritis and uveitis syndrome (TINU) is a rare autoimmune disease. It is characterized by uveitis and kidney damage. The presentation of uveitis is typically anterior and bilateral, while the renal lesion is an acute interstitial nephritis. We report a case of an adolescent diagnosed with this disease, who presented with ocular and constitutional symptoms. An ophthalmologic examination confirmed the diagnosis of uveitis, and subsequent systemic evaluation revealed impaired renal function. The findings of the renal biopsy established the diagnosis after ruling out other systemic diseases. Given the rarity and nonspecific clinical presentation of this condition, a high level of suspicion is required for early diagnosis and treatment. Clinicians should consider this diagnosis in a pediatric patient with uveitis and impaired renal function.

End-of-life Zn-MnO2 batteries: electrode materials characterization.

Physical and chemical characterization of several sizes and shapes of alkaline and saline spent Zn-MnO2 batteries was carried out, aiming at contributing for a better definition of the applicable recycling processes. The characterization essays included the mass balance of the components, cathode and anode elemental analysis, the identification of zinc and manganese bearing phases and the morphology analysis of the electrode particles. The electrode materials correspond to 64-79% of the total weigh of the batteries, with the cathodes having clearly the highest contribution (usually more than 50%). The steel components, mainly from the cases, are also important (17-30%). Elemental analysis showed that the electrodes are highly concentrated in zinc (from 48-87% in anodes) and manganese (from 35-50% in cathodes). X-Ray powder diffraction allowed for identifying several phases in the electrodes, namely zinc oxide, in the anodes of all the types of saline and alkaline batteries tested, while zinc hydroxide chloride and ammine zinc chloride only appear in some types of saline batteries. The manganese found in the cathode materials is present as two main phases, MnO x Mn2O3 and ZnO x Mn2O3, the latter corroborating that zinc migration from anode to cathode occurs during the batteries lifespan. A unreacted MnO2 phase was also found presenting a low crystalline level. Leaching trials with diluted HCI solutions of alkaline and saline battery samples showed that all zinc species are reactive attaining easily over than 90% leaching yields, and about 30% of manganese, present as Mn(II/III) forms. The MnO2 phase is less reactive and requires higher temperatures to achieve a more efficient solubilization.

Fulminant myocarditis associated with pandemic H1N1 influenza A virus.

Fulminant myocarditis associated with influenza A virus is exceedingly rare, with only a few cases reported in the literature. We describe a previously healthy 10-year-old boy, with a three-day history of flu-like symptoms without antiviral treatment. He was hospitalized with dehydration and hypothermia in the context of persistent vomiting, when he suddenly developed heart failure secondary to fulminant myocarditis. Despite aggressive management, including circulatory support and cardiopulmonary resuscitation measures, the patient died of cardiogenic shock. The postmortem histopathology was compatible with a multisystem viral infection with myocarditis and pulmonary involvement, and H1N1v polymerase chain reaction was positive. The prevalence of influenza-associated fulminant myocarditis remains unknown. Findings reported in the literature raise the possibility that the novel H1N1 influenza A virus is more commonly associated with a severe form of myocarditis than previously encountered influenza strains.

An Educational Intervention to Raise Awareness of Contraceptive Options Among Young People.

Background: Young people in the United States know little about contraceptive options available to them, although method use is sensitive to individual preferences, and method switching is common. For young people to gain reproductive autonomy, a first step is to be aware of different contraceptives, including hormonal and nonhormonal methods. We tested whether an educational intervention delivered on community college campuses was effective in increasing contraceptive awareness. Materials and Methods: We developed a low-cost educational intervention featuring youth-friendly visual tools and tested its impact on method awareness and knowledge among 1,051 students of all genders, aged 18-25 years, at five community colleges. We used generalized estimating equations to test changes in awareness of a range of methods, including male and female (internal) condoms, the pill, patch, vaginal ring, shot, intrauterine devices, implant, and emergency contraception. Results: Over 90% of participants were aware of male condoms and the pill at baseline, but fewer had heard of other options (ranging from 31% to 76% for different methods). Across all methods, awareness increased to a mean of 88% among female participants and 82% among male participants postintervention. Awareness of the full range of methods increased from 31% to 55% (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 3.1-6.2]) among female participants and 11% to 36% (aOR: 10.8, 95% CI: 5.3-21.8) among male participants postintervention. The intervention was similarly effective by sexual orientation, race/ethnicity, nativity, or insurance coverage. Conclusion: This educational intervention significantly improved all students' awareness of a range of contraceptives, supporting one important aspect of reproductive health for young people in community settings.

Assessment of the outcomes of SARS-CoV-2 infection in children and young people followed at Portuguese pediatric rheumatology clinics.

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) generally appears to have milder clinical symptoms and fewer laboratory abnormalities in children. It remains unknown whether children and young people with inflammatory chronic diseases who acquire SARS-CoV-2 infection have a more severe course, due to either underlying disease or immunosuppressive treatments. OBJECTIVES: To assess the epidemiological features and clinical outcomes of children and young people with inflammatory chronic diseases followed at Pediatric Rheumatology Clinics who were infected with SARS-CoV-2. METHODS: A multicentric prospective observational study was performed. Data on demographic variables, clinical features and treatment were collected between March 2020 and September 2021, using the Rheumatic Diseases Portuguese Register (Reuma.pt) and complemented with data from the hospital clinical records. RESULTS: Thirty-four patients were included, 62% were female, with a median age of 13 [8-16] years and a median time of inflammatory chronic disease of 6 [3-10] years. The most common diagnoses were juvenile idiopathic arthritis (n=22, 64.7%), juvenile dermatomyositis (n=3, 8.8%) and idiopathic uveitis (n=3, 8.8%). Twenty patients were on conventional synthetic disease modifying drugs (csDMARDs) and 10 on biologic DMARDs (bDMARDs). Five patients had an active inflammatory disease at the time of infection (low activity). Seven patients had an asymptomatic infection while 27 patients (79%) had symptoms: cough (n=12), fever (n=11), rhinorrhea (n=10), headache (n=8), malaise (n=8), fatigue (n=7), anosmia (n=5), myalgia (n=5),dysgeusia (n=4), odynophagia (n=4), chest pain (n=2), diarrhea (n=2), arthralgia (n=1), vomiting (n=1) and conjunctivitis (n=1). No patient required hospitalization or directed treatment, and all recovered without sequelae. In 8 patients there was a change in the baseline medication during the infection: suspension of bDMARDs (n=4), reduction of bDMARDs (n=1), suspension of csDMARDs (n=4) and reduction of csDMARDs (n=2). Only in one patient with juvenile dermatomyositis (who discontinued bDMARDs and csDMARDs), the underlying disease worsened. CONCLUSIONS: This is the first study involving children with inflammatory chronic diseases followed at Rheumatology Clinics and SARS-CoV-2 infection in Portugal. In our cohort, mild illness was predominant, which is consistent with the literature. There was no need for hospitalization or specific treatment, and, in most cases, no worsening of the underlying disease was identified.

Predictive factors of relapse after methotrexate discontinuation in juvenile idiopathic arthritis patients with inactive disease.

OBJECTIVE: To identify predictive factors of relapse after discontinuation of Methotrexate (MTX) in Juvenile Idiopathic Arthritis (JIA) patients with inactive disease. METHODS: We conducted a prospective multicenter cohort study of patients diagnosed with JIA using real world data from the Portuguese national register database, Reuma.pt. Patients with JIA who have reached JADAS27 inactive disease and discontinued MTX before the age of 18 were evaluated. RESULTS: A total of 1470 patients with JIA were registered in Reuma.pt. Of the 119 bionaive patients who discontinued MTX due to inactive disease, 32.8% have relapsed. Median time of persistence (using the Kaplan-Meier method and log-rank tests) with inactive disease was significantly higher in patients with more than two years of remission before MTX discontinuation and in those who did not use NSAIDs at time of MTX discontinuation. In Cox regression analyses and after adjustment for age at diagnosis, MTX tapering and JIA category, the use of NSAIDs at the time of MTX discontinuation (HR, 1.98 95%CI 1.03-3.82) and remission time of less than two years before suspension (HR, 3.12 95%CI 1.35-7.13) remained associated with relapse. No association was found between JIA category or the regimen of MTX discontinuation and the risk of relapse. CONCLUSIONS: In this large cohort we found that the use of NSAIDs at the time of MTX discontinuation was associated with a two times higher likelihood of relapse. In addition, longer duration of remission before MTX withdrawal reduces the chance of relapse in bionaive JIA patients.

Spotlight on latent tuberculosis infection screening for juvenile idiopathic arthritis in two countries, comparing high and low risk patients.

BACKGROUND: Rheumatic diseases are associated with an increase in overall risks of tuberculosis (TB). The aim of this study was to evaluate the frequency of TB and the frequency of latent TB infection (LTBI), in clinical practice, for juvenile idiopathic arthritis (JIA) patients from high and low risk of TB incidence endemic countries. METHODS: This is an international, multicenter, cross-sectional, observational study of data collection from Brazil and Registry of Portugal at REUMA.PT. The inclusion criteria were patients with Juvenile Idiopathic Arthritis (JIA) with age ≤ 18 years who underwent screening for Mycobacterium tuberculosis infection [tuberculin skin test (TST) and/or interferon gamma release assay (IGRA)]. Chest X-rays and history of exposure to TB were also assessed. RESULTS: 292 JIA patients were included; mean age 14.3 years, mean disease duration 7.5 years, 194 patients (66.4%) performed only TST, 14 (4.8%) only IGRA and 84 (28.8%) both. The frequency of LTBI (10.6%) and TB was similar between the two countries. The reasons for TB screening were different; in Brazil it was performed more often at JIA onset while in Portugal it was performed when starting Disease Modified Anti-Rheumatic Drugs (DMARD) treatment (p < 0.001). Isoniazid therapy was prescribed in 40 (13.7%) patients (31 with LTBI and 9 with epidemiologic risks and/or due to contact with sick people). Only three patients (1%) developed active TB. CONCLUSION: We found nearly 10% of patients with LTBI, a small percentage of patients with treatment due to epidemiologic risks and only 1% with active TB. Distinct reasons and screening methods for LTBI were observed between the two countries.

Catastrophic antiphospholipid syndrome: first signs in the neonatal period.

The term "catastrophic" antiphospholipid syndrome (CAPS) is used to define a subset of the antiphospholipid syndrome (APS) characterized by the clinical evidence of three or more organ involvement by thrombotic events in a short period of time and with laboratory confirmation of the presence of antiphospholipid antibodies. We describe a male infant first admitted at 17 days old for necrotizing enteritis complicated by cardiac and renal failure. Because of progressive renal function deterioration, a renal biopsy was performed at 8 months old, and histopathologic examination was compatible with renal venous thrombosis. Laboratory searching for vascular, prothrombotic, and metabolic disease was negative. Five months later, he developed two different episodes (20-day range) of ischemic stroke. Genetic test for thrombophilic conditions was positive for two different mutations, and repeatedly high titers of lupus anticoagulant, anticardiolipin, and anti-ß2glicoprotein I antibodies were found. He was treated successfully with anticoagulants and showed a favorable clinical evolution. To the best of our knowledge, this is the youngest patient reported with probable CAPS. Although rare, APS/CAPS in the neonatal period or in the first year of life must be suspected in infants presenting with thrombotic phenomena. The present case illustrates the importance of an early diagnosis and treatment to enhance possibilities of survival.

Concerns About the Cost of Contraception Among Young Women Attending Community College.

INTRODUCTION: Contraceptive use is lower among students attending community college than 4-year college students, which may be due to financial barriers to accessing contraceptives. This study examined insurance coverage, access to free or low-cost birth control, and concerns about contraceptive costs among women in community college. METHODS: We analyzed data from a study conducted at five community colleges in California and Oregon, which have expanded Medicaid coverage of family planning services for low-income individuals. Participants were students aged 18-25 years who self-identified as female, had vaginal sex, and were not pregnant or trying to become pregnant (N = 389). Multivariate analyses were conducted to examine concerns about the cost of contraception among these young women and how cost concerns varied by insurance coverage and access to free or low-cost birth control. RESULTS: Nearly one-half of participants (49%) were concerned about the cost of contraception. In multivariate models, privately insured women had lower odds of being concerned about the cost of birth control than the uninsured (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.83), yet women with public insurance had cost concerns similar to those of women without insurance. Women who reported they knew where to get free or low-cost birth control had lower odds of reporting cost concerns (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.75), as did the few women enrolled in a state family planning program (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-1.00). CONCLUSIONS: Even in states with publicly funded services for young people, concerns about the affordability of contraception were common among women, particularly the uninsured or publicly insured. Addressing students' cost concerns is an important aspect of ensuring access to contraception during their pursuit of higher education.

Association of body mass index with Juvenile Idiopathic Arthritis disease activity: a Portuguese and Brazilian collaborative analysis.

OBJECTIVE: To investigate the relationship between body mass index (BMI) and disease activity in patients with Juvenile Idiopathic Arthritis (JIA). METHODS: Patients with JIA, aged ≤18 years, registered at the Rheumatic Diseases Portuguese Register (Reuma.pt) in Portugal and Brazil were included. Age- and sex-specific BMI percentiles were calculated based on WHO growth standard charts and categorized into underweight (P <3), normal weight (3≤P≤85), overweight (85

97). Disease activity was assessed by Juvenile Arthritis Disease Activity Score (JADAS-27). Uni- and multivariate analyses were performed. RESULTS: A total of 275 patients were included. The prevalence of underweight, normal weight, overweight and obesity was 6.9%, 67.3%, 15.3% and 10.5%, respectively. Underweight patients had significantly higher number of active joints (p <0.001), patient's/parent's global assessment of disease activity (PGA) (p=0.020), physician's global assessment of disease activity (PhGA) (p <0.001), erythrocyte sedimentation rate (ESR) (p=0.032) and overall higher JADAS-27 (p <0.001), compared to patients with normal weight, overweight and obesity. In the multivariate regression, underweight persisted significantly associated with higher disease activity, compared to normal weight (B=-9.430, p <0.001), overweight (B=-9.295, p=0.001) and obesity (B=-9.120, p=0.001), when adjusted for age, gender, country, ethnicity, JIA category and therapies used. The diagnosis of RF- (B=3.653, p=0.006) or RF+ polyarticular JIA (B=5.287, p=0.024), the absence of DMARD therapy (B=5.542, p <0.001) and the use of oral GC (B=4.984, p=0.002) were also associated with higher JADAS-27. CONCLUSION: We found an independent association between underweight and higher disease activity in patients with JIA. Further studies are needed to understand the underlying mechanisms of this association.

Are steroids useful to treat cerebral venous thrombosis?

BACKGROUND AND PURPOSE: No randomized controlled trial has evaluated the efficacy of steroids in acute cerebral venous thrombosis (CVT). We aimed to analyze the effect of steroids on the outcome of patients in the International Study on Cerebral Veins and Dural Sinus Thrombosis (ISCVT). METHODS: ISCVT is a prospective observational study that included 624 CVT patients. Death or dependence at 6 months was compared between cases (patients treated with steroids) and controls (patients not treated with steroids), using 3 designs: (1) Matched case-control study (each case matched with a control for prognostic factors); (2) Nonmatched case-control study of the ISCVT cohort; (3) Case-control study in different strata according to the number of poor prognostic variables in each patient. RESULTS: One hundred and fifty (24%) patients were treated with steroids. (1) In the matched case-control study, poor outcome was similar in the two groups of patients (26/146 versus 17/149, OR=1.7; 95% CI 0.9 to 3.3, P=0.119). (2) In the ISCVT cohort, no significant difference in poor outcomes was found whether patients were treated with steroids or not (26/146 versus 60/469, OR=1.5; 95% CI 0.9 to 2.4). Patients without parenchymal lesions treated with steroids had worse prognosis than those treated without steroids (8/45 versus 9/184, OR=4.2, 95% CI 1.6 to 11.6, P=0.008). (3) Treatment with steroids was not associated with a better outcome in any strata of patients according to the number of poor prognostic factors. CONCLUSIONS: Steroids in the acute phase of CVT were not useful and were detrimental in patients without parenchymal cerebral lesions. These results do not support the use of steroids in CVT (evidence level III).

Preliminary results in the immunodiagnosis of tuberculosis in children based on T cell responses to ESAT-6 and PPD antigens.

The aim of this work was to study the difference in interferon gamma (IFN-gamma) production by T lymphocytes after early secretory antigen target 6 (ESAT-6) or purified protein derivate (PPD) stimulation in whole blood culture supernatants from children with suspected tuberculosis (TB) disease (n = 21), latent TB infection (n = 16) and negative controls (NC) (n = 22) from an endemic area in Brazil. The concentration of IFN-gamma (pg/ml) was measured by enzyme linked immunosorbent assay and the differences in the IFN-gamma levels for each group were compared and evaluated using an unpaired Student's t-test; p values < 0.05 were considered significant. Measurement of IFN-gamma levels after ESAT-6 stimulation raised the possibility of early diagnosis in the latent TB group (p = 0.0030). Nevertheless, the same group showed similar responses to the NC group (p > 0.05) after PPD stimulation. The IFN-gamma assay using ESAT-6 as an antigenic stimulus has the potential to be used as a tool for the immunodiagnosis of early TB in children.

Management of oral and maxillofacial infections in a regional unit: a seven day service?

The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29months (January 2014-May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1-14) days and for patients admitted at a weekend was 3 (1-17) days (p=0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0-8) days) than at the weekend (0.5 (0-3) days, p=0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval.

Pregnancy Intentions, Contraceptive Knowledge And Educational Aspirations Among Community College Students.

CONTEXT: Community college students, representing more than one-third of U.S. undergraduates, are a diverse population of young people motivated to seek higher education who are at elevated risk of unintended pregnancy. However, it is unknown how well prepared they are to prevent pregnancy and what they think about it in terms of their educational aspirations. METHODS: In-depth interviews were conducted with 57 students aged 18-25, inclusive of all genders, in three community colleges in California in 2015. Content analysis was used to code data and identify themes. RESULTS: All participants reported strong desires to prevent pregnancy in the next year and perceived their pregnancy risk as low, but many reported unprotected sex with opposite-sex partners. Participants had specific timelines for completing their degrees and believed pregnancy would make that far more challenging, but would not ultimately prevent them from achieving their goals. Female students expressed concern about the risks of exacerbated poverty, housing instability and unachieved career goals. Participants had little knowledge of their pregnancy risks and of the health benefits, side effects or effectiveness of contraceptives. They held negative beliefs about hormonal contraception (including emergency contraception, IUDs and the implant), fearing long-lasting effects and infertility. Gay or bisexual students shared concerns about contraceptives, although several were using methods for noncontraceptive reasons. CONCLUSION: Many community college students not desiring pregnancy have limited awareness of pregnancy risk and prevention.

Spotlight on latent tuberculosis infection screening for juvenile idiopathic arthritis in two countries, comparing high and low risk patients

Abstract Background: Rheumatic diseases are associated with an increase in overall risks of tuberculosis (TB). The aim of this study was to evaluate the frequency of TB and the frequency of latent TB infection (LTBI), in clinical practice, for juvenile idiopathic arthritis (JIA) patients from high and low risk of TB incidence endemic countries. Methods: This is an international, multicenter, cross-sectional, observational study of data collection from Brazil and Registry of Portugal at REUMA.PT. The inclusion criteria were patients with Juvenile Idiopathic Arthritis (JIA) with age ≤ 18 years who underwent screening for Mycobacterium tuberculosis infection [tuberculin skin test (TST) and/or interferon gamma release assay (IGRA)]. Chest X-rays and history of exposure to TB were also assessed. Results: 292 JIA patients were included; mean age 14.3 years, mean disease duration 7.5 years, 194 patients (66.4%) performed only TST, 14 (4.8%) only IGRA and 84 (28.8%) both. The frequency of LTBI (10.6%) and TB was similar between the two countries. The reasons for TB screening were different; in Brazil it was performed more often at JIA onset while in Portugal it was performed when starting Disease Modified Anti-Rheumatic Drugs (DMARD) treatment (p < 0.001). Isoniazid therapy was prescribed in 40 (13.7%) patients (31 with LTBI and 9 with epidemiologic risks and/or due to contact with sick people). Only three patients (1%) developed active TB. Conclusion: We found nearly 10% of patients with LTBI, a small percentage of patients with treatment due to epide-miologic risks and only 1% with active TB. Distinct reasons and screening methods for LTBI were observed between the two countries.

[Regulations, conflicts and ethics of medical research in developing countries]. / Regulamentações, conflitos e ética da pesquisa médica em países em desenvolvimento.

The patient is the subject who may meet the needs and interests of medical investigators for their research. This intrinsic conflict becomes more evident and shows particularities in the context of research projects involving clinical trials in developing countries. Target populations in these countries have inadequate access to health services, little understanding of risks involved in a study and also less capacity to claim judicially in the event of damage. In general, the discussions on ethics in research in industrialized countries are characterized by a biomedical approach of disease, and a neoliberal vision of economy and trade. In fact, most biomedical research has been directed to benefit already privileged communities. Therefore, it is necessary to minimize the risk of exploitation of developing countries populations. The present study provides an outlook of ethical protection for human research in developing countries.

Packaging waste recycling in Europe: is the industry paying for it?

This paper describes and examines the schemes established in five EU countries for the recycling of packaging waste. The changes in packaging waste management were mainly implemented since the Directive 94/62/EC on packaging and packaging waste entered into force. The analysis of the five systems allowed the authors to identify very different approaches to cope with the same problem: meet the recovery and recycling targets imposed by EU law. Packaging waste is a responsibility of the industry. However, local governments are generally in charge of waste management, particularly in countries with Green Dot schemes or similar extended producer responsibility systems. This leads to the need of establishing a system of financial transfers between the industry and the local governments (particularly regarding the extra costs involved with selective collection and sorting). Using the same methodological approach, the authors also compare the costs and benefits of recycling from the perspective of local public authorities for France, Portugal and Romania. Since the purpose of the current paper is to take note of who is paying for the incremental costs of recycling and whether the industry (i.e. the consumer) is paying for the net financial costs of packaging waste management, environmental impacts are not included in the analysis. The work carried out in this paper highlights some aspects that are prone to be improved and raises several questions that will require further research. In the three countries analyzed more closely in this paper the industry is not paying the net financial cost of packaging waste management. In fact, if the savings attained by diverting packaging waste from other treatment (e.g. landfilling) and the public subsidies to the investment on the "recycling system" are not considered, it seems that the industry should increase the financial support to local authorities (by 125% in France, 50% in Portugal and 170% in Romania). However, in France and Portugal the industry is paying local authorities more than just the incremental costs of recycling (full costs of selective collection and sorting minus the avoided costs). To provide a more definitive judgment on the fairness of the systems it will be necessary to assess the cost efficiency of waste management operators (and judge whether operators are claiming costs or eliciting "prices").

Juvenile systemic lupus erythematosus in Portugal: clinical and immunological patterns of disease expression in a cohort of 56 patients.

OBJECTIVE: To define the pattern of disease expression and to gain better understanding in patients with juvenile onset systemic lupus erythematosus (SLE) in Portugal. METHODS: The features of unselected patients with systemic lupus erythematosus who had disease onset before the age of 18 years were retrospectively analysed in three Portuguese centres with Pediatric Rheumatology Clinic over a 24-year period (1987-2011). Demographic, clinical and laboratory manifestations, therapy and outcome were assessed. RESULTS: A cohort of 56 patients with a mean age at disease onset of 12.6 ± 4.04 years (mean ± 1SD) (range, 1.0-17.0 years) and a mean period of follow-up of 5.5 ± 5.4 years. Forty six (82.1%) patients were female. The most common disease manifestations were musculoskeletal (87.5%), mucocutaneous (80.3%) and haematological abnormalities (75%). Lupus nephritis was diagnosed in 46.4% of patients and consisted of glomerular nephritis in all cases. Neuropsychiatric manifestations occurred in 21.4% but severe central nervous system complications were uncommon, as brain infarcts and organic brain syndrome in 4 (7.1%) patients. Antinuclear antibodies and anti-double stranded DNA were positive in most patients in (98.2% and 71.4% respectively), as well as low C3 and/or C4 were observed frequently (85.7%). Generally, most patients had a good response to therapy as demonstrated by a significant decreasing of SLEDAI score from disease presentation to the last evaluation. The SLEDAI at diagnosis, the maximum SLEDAI and the incidence of complications were significantly higher in patients with neurolupus and/or lupus nephritis. Therapy included oral steroids (87.5%), hydroxychloroquine (85.7%), azathioprine (55.4%), IV cyclophosphamide (28.6%) along with other drugs. Six (10.7%) patients were treated with rituximab. Long-term remission was achieved in 32%, disease was active in 68%, adverse reactions to therapy occurred in 53.6% and complications/severe manifestations in 23.2%. Two patients died, being active disease and severe infection the causes of death. CONCLUSIONS: This study suggests that in our patients the clinical and laboratory features observed were similar to juvenile systemic lupus erythematosus patients from other series. Clinical outcome was favourable in the present study. Complications from therapy were frequent.