Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis.

BACKGROUND: Secondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD. METHODS: We included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD. RESULTS: 799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16-1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7-9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59-0.69)). CONCLUSIONS: The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.

Brazilian guideline for pediatric cycloplegia and mydriasis / Diretrizes brasileiras para cicloplegia e midríase em crianças

ABSTRACT Cycloplegia is crucial for reliable pediatric ophthalmology examinations. This document provides a re­commendation for pediatric cycloplegia and mydriasis for Brazilian ophthalmologists. This article was developed based on literature reviews; the clinical experience of Brazilian specialists, as obtained through questionnaires; and the consensus of the Expert Committee of the Brazilian Pediatric Ophthalmology Society. According to the best evidence and formulations available in Brazil, this committee recommends the use of one drop of 1% cyclopentolate plus one drop of 1% tropicamide in children older than 6 months and two drops of 1% tropicamide 0-5 minutes apart for those younger than 6 months. Mydriasis may be increased by a single drop of 2.5% phenylephrine. For retinopathy of prematurity screening, the recommendation is 0.5% or 1% tropicamide, administered two or three times, 5 minutes apart, and 2.5% phenylephrine, used preferably once. In all scenarios, we recommend the use of a prior drop of 0.5% proxymetacaine.

RESUMO A cicloplegia é crucial para um exame oftalmológico pediátrico acurado. Este documento visa a fornecer uma recomendação para cicloplegia e midríase pediátrica para oftalmologistas brasileiros. Foi desenvolvido com base em revisão literária, na experiência clínica de especialistas brasileiros, por meio de questionários, e no consenso do comitê de especialistas da Sociedade Brasileira de Oftalmologia Pediátrica (SBOP). De acordo com as melhores evidências, este comitê recomenda o uso de uma gota de ciclopentolato 1%, mais uma gota de tropicamida 1% em crianças maiores de 6 meses e duas gotas de tropicamida 1% com intervalo de 0-5 minutos para menores de 6 meses. A midríase pode ser potencializada por uma gota de fenilefrina 2,5%. Para o rastreamento da retinopatia da prematuridade, a recomendação é tropicamida 0,5 ou 1%, duas ou três vezes, com 5 minutos de intervalo, e 2,5% de fenilefrina, preferencialmente uma vez. O uso prévio de proxymetacaína 0,5% é sempre recomendado.

Use of Continuous Ketamine Infusion as an Adjunctive Agent in Young Infants With Refractory and Super Refractory Status Epilepticus: A Case Series.

Continuous ketamine infusions have been studied as an adjunctive agent for refractory status epilepticus (RSE) and super refractory status epilepticus (SRSE) in older children and adults. However, minimal information exists on the efficacy, safety, and dosing for continuous ketamine in young infants. We present the clinical course of 3 young infants with RSE and SRSE who received continuous ketamine in conjunction with other antiseizure medications. The condition of these patients was refractory to an average of 6 antiseizure medications before initiation of continuous ketamine infusion. For each patient, a continuous ketamine infusion was initiated at a rate of 1 mg/kg/hr with 1 patient requiring titration to a maximum of 6 mg/kg/hr. In 1 case, the concomitant use of continuous ketamine allowed for a reduction in the benzodiazepine continuous infusion rate. In all cases, ketamine was well tolerated especially in the setting of hemodynamic instability. Ketamine may provide a safe adjunct in the acute setting in severe RSE and SRSE. This is the first case series to document the use of continuous ketamine as a treatment modality in young infants with RSE or SRSE secondary to various underlying etiologies, without adverse events. Further studies are needed to evaluate the long-term safety and efficacy of continuous ketamine in this patient population.

Factors important for bull purchasing decisions and management in extensive rangeland production systems of New Mexico: a producer survey.

There were 463,000 head of beef cows in New Mexico as of January 1, 2021 (NASS, 2020), down roughly 4% from 2020 (NASS, 2019). Frequent drought often results in herd reduction and loss of valuable genetic progress. Bull selection is critical due to their influence on herd development. A survey was conducted to identify traits important to bull selection in New Mexico. Surveys were collected digitally (n = 83) and via the mail (n = 74). Responses were largely by cow/calf producers averaging 57 ± 1 years old with 24 ± 1 years' experience. Survey respondents represented 4,384,296 acres of private owned, private leased, and leased public rangeland and irrigated pasture meadow in New Mexico and surrounding states. Average cow/calf operation size was 294 ± 39 head and average bull herd size was 21 ± 3 head. Average price paid for a bull in the past 2 years was $3,981 ± 213. Physical characteristics, individual bull performance information, and genetic information are all important traits to New Mexico bull buyers; however, most producers (56%) indicated that structural soundness was the most important factor influencing their selection decisions. Amongst expected progeny differences (EPDs), New Mexico producers consider the calving ease direct (CED) and birth weight (BW) EPDS to be most important (40% and 35%, respectively). Producers also indicated that multitrait selection indexes used by the American Angus Association were important to their selection decisions, with the beef value ($B) and weaned calf value ($W) indexes being cited most often (35% and 31%, respectively). Elements important to bull purchase include the bull's sale preview (87%), body condition score (86%), feed efficiency/average daily gain information (85%), and actual scrotal circumference (82%). Following purchase of a new bull, most (60%) keep the bull separate from the cow herd until the following breeding season, while the remaining 40% of producers turn newly purchased bulls out within 30 days of purchase. Sixty eight percent of producers evaluate semen quality annually or prior to the start of the breeding season. Interestingly, 39% of producers indicated they used reproductive technologies like artificial insemination and synchronization of estrus while most (80%) test for trichomoniasis. The primary factor influencing culling decisions is age, followed by soundness and fertility.

Quadrivalent meningococcal tetanus toxoid-conjugate booster vaccination in adolescents and adults: phase III randomized study.

BACKGROUND: The immunogenicity and safety of a booster dose of tetanus toxoid-conjugate quadrivalent meningococcal vaccine (MenACYW-TT), alone or co-administered with MenB vaccine, were assessed in healthy 13-25-year olds who received MenACYW-TT or a CRM-conjugate vaccine (MCV4-CRM) 3-6 years earlier. METHODS: This phase IIIb open-label trial (NCT04084769) evaluated MenACYW-TT-primed participants, randomized to receive MenACYW-TT alone or with a MenB vaccine, and MCV4-CRM-primed participants who received MenACYW-TT alone. Functional antibodies against serogroups A, C, W and Y were measured using human complement serum bactericidal antibody assay (hSBA). The primary endpoint was vaccine seroresponse (post-vaccination titers ≥1:16 if pre-vaccination titers <1:8; or a ≥4-fold increase if pre-vaccination titers ≥1:8) 30 days post booster. Safety was evaluated throughout the study. RESULTS: The persistence of the immune response following primary vaccination with MenACYW-TT was demonstrated. Seroresponse after MenACYW-TT booster was high regardless of priming vaccine (serogroup A: 94.8% vs 93.2%; C: 97.1% vs 98.9%; W: 97.7% vs 98.9%; and Y; 98.9% vs 100% for MenACWY-TT-primed and MCV4-CRM-primed groups, respectively). Co-administration with MenB vaccines did not affect MenACWY-TT immunogenicity. No vaccine-related serious adverse events were reported. CONCLUSIONS: MenACYW-TT booster induced robust immunogenicity against all serogroups, regardless of the primary vaccine received, and had an acceptable safety profile. IMPACT: A booster dose of MenACYW-TT induces robust immune responses in children and adolescents primed with MenACYW-TT or another MCV4 (MCV4-DT or MCV4-CRM), respectively. Here, we demonstrate that MenACYW-TT booster 3-6 years after primary vaccination induced robust immunogenicity against all serogroups, regardless of the priming vaccine (MenACWY-TT or MCV4-CRM), and was well tolerated. Persistence of the immune response following previous primary vaccination with MenACYW-TT was demonstrated. MenACYW-TT booster with MenB vaccine co-administration did not affect MenACWY-TT immunogenicity and was well tolerated. These findings will facilitate the provision of broader protection against IMD particularly in higher-risk groups such as adolescents.

Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo.

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

Genome-wide analysis of the chromatin sites targeted by HEX 70a storage protein in the honeybee brain and fat body.

Hexamerins, the proteins massively stored in the larval haemolymph of insects, are gradually used throughout metamorphosis as a source of raw material and energy for the development of adult tissues. Such behaviour defined hexamerins as storage proteins. Immunofluorescence experiments coupled with confocal microscopy show a hexamerin, HEX 70a, in the nucleus of the brain and fat body cells from honeybee workers, an unexpected localization for a storage protein. HEX 70a colocalizes with fibrillarin, a nucleolar-specific protein and H3 histone, thus suggesting a potential role as a chromatin-binding protein. This was investigated through chromatin immunoprecipitation and high-throughput DNA sequencing (ChIP-seq). The significant HEX 70a-DNA binding sites were mainly localized at the intergenic, promoter and intronic regions. HEX 70a targeted DNA stretches mapped to the genomic regions encompassing genes with relevant functional attributes. Several HEX 70a targeted genes were associated with H3K27ac or/and H3K27me3, known as active and repressive histone marks. Brain and fat body tissues shared a fraction of the HEX 70 targeted genes, and tissue-specific targets were also detected. The presence of overrepresented DNA motifs in the binding sites is consistent with specific HEX 70a-chromatin association. In addition, a search for HEX 70a targets in RNA-seq public libraries of fat bodies from nurses and foragers revealed differentially expressed targets displaying hex 70a-correlated developmental expression, thus supporting a regulatory activity for HEX 70a. Our results support the premise that HEX 70a is a moonlighting protein that binds chromatin and has roles in the brain and fat body cell nuclei, apart from its canonical role as a storage protein.

Brazilian guideline for pediatric cycloplegia and mydriasis.

Cycloplegia is crucial for reliable pediatric ophthalmology examinations. This document provides a re-commendation for pediatric cycloplegia and mydriasis for Brazilian ophthalmologists. This article was developed based on literature reviews; the clinical experience of Brazilian specialists, as obtained through questionnaires; and the consensus of the Expert Committee of the Brazilian Pediatric Ophthalmology Society. According to the best evidence and formulations available in Brazil, this committee recommends the use of one drop of 1% cyclopentolate plus one drop of 1% tropicamide in children older than 6 months and two drops of 1% tropicamide 0-5 minutes apart for those younger than 6 months. Mydriasis may be increased by a single drop of 2.5% phenylephrine. For retinopathy of prematurity screening, the recommendation is 0.5% or 1% tropicamide, administered two or three times, 5 minutes apart, and 2.5% phenylephrine, used preferably once. In all scenarios, we recommend the use of a prior drop of 0.5% proxymetacaine.

Suboxic DOM is bioavailable to surface prokaryotes in a simulated overturn of an oxygen minimum zone, Devil's Hole, Bermuda.

Oxygen minimum zones (OMZs) are expanding due to increased sea surface temperatures, subsequent increased oxygen demand through respiration, reduced oxygen solubility, and thermal stratification driven in part by anthropogenic climate change. Devil's Hole, Bermuda is a model ecosystem to study OMZ microbial biogeochemistry because the formation and subsequent overturn of the suboxic zone occur annually. During thermally driven stratification, suboxic conditions develop, with organic matter and nutrients accumulating at depth. In this study, the bioavailability of the accumulated dissolved organic carbon (DOC) and the microbial community response to reoxygenation of suboxic waters was assessed using a simulated overturn experiment. The surface inoculated prokaryotic community responded to the deep (formerly suboxic) 0.2 µm filtrate with cell densities increasing 2.5-fold over 6 days while removing 5 µmol L-1 of DOC. After 12 days, the surface community began to shift, and DOC quality became less diagenetically altered along with an increase in SAR202, a Chloroflexi that can degrade recalcitrant dissolved organic matter (DOM). Labile DOC production after 12 days coincided with an increase of Nitrosopumilales, a chemoautotrophic ammonia oxidizing archaea (AOA) that converts ammonia to nitrite based on the ammonia monooxygenase (amoA) gene copy number and nutrient data. In comparison, the inoculation of the deep anaerobic prokaryotic community into surface 0.2 µm filtrate demonstrated a die-off of 25.5% of the initial inoculum community followed by a 1.5-fold increase in cell densities over 6 days. Within 2 days, the prokaryotic community shifted from a Chlorobiales dominated assemblage to a surface-like heterotrophic community devoid of Chlorobiales. The DOM quality changed to less diagenetically altered material and coincided with an increase in the ribulose-1,5-bisphosphate carboxylase/oxygenase form I (cbbL) gene number followed by an influx of labile DOM. Upon reoxygenation, the deep DOM that accumulated under suboxic conditions is bioavailable to surface prokaryotes that utilize the accumulated DOC initially before switching to a community that can both produce labile DOM via chemoautotrophy and degrade the more recalcitrant DOM.

Field Evaluation of Novel Spatial Repellent Controlled Release Devices (CRDs) against Mosquitoes in an Outdoor Setting in the Northern Peruvian Amazon.

U.S. military troops are exposed to mosquito-borne pathogens when deployed to endemic regions. Personal protective measures such as permethrin-treated uniforms and dermal repellents are the cornerstones of mosquito-borne disease prevention for the U.S. military. These measures have limitations and additional personal protection tools, such as spatial repellent devices to decrease the risk of vector-borne pathogen transmission, are required. Novel spatial repellent controlled-release devices formulated with metofluthrin were evaluated in an outdoor setting in the northern Amazon of Peru to evaluate performance under field conditions. The metofluthrin emitting devices lowered the number of mosquitoes captured in protected human landing collections (HLC) compared to blank devices, although there were effect differences between Anopheles spp. and species in other mosquito genera. A computational-experimental model was developed to correlate HLC and active ingredient (AI) concentrations as a function of time and space. Results show a strong correlation between the released AI and the decrease in HLC. This model represents the first effort to obtain a predictive analytical tool on device performance using HLC as the entomological endpoint.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study.

BACKGROUND: There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP). OBJECTIVE: To identify the most relevant clinical descriptors for diagnosing RCRSP. METHODS: A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. RESULTS: Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. CONCLUSION: In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Investigation of the Familial Risk of Rheumatic Heart Disease with Systematic Echocardiographic Screening: Data from the PROVAR+ Family Study.

We aimed to use echocardiographic (echo) screening to evaluate the risk of Rheumatic Heart Disease (RHD) among the relatives of patients with advanced RHD, who were enrolled in the University Hospital's outpatient clinics from February 2020 to September 2021. Consenting first-degree relatives were invited for echo screening using handheld devices (GE VSCAN) by non-physicians, with remote interpretation. Matched controls (spouses, neighbors) living in the same household were enrolled in a 1:5 fashion. A standard echo (GE Vivid-IQ) was scheduled if abnormalities were observed. In 16 months, 226 relatives and 47 controls of 121 patients were screened, including 129 children, 77 siblings and 20 parents. The mean age was 40 ± 17 years, 67% of the patients were women, and 239 (88%) lived with the index case for >10 years. Echo findings suggestive of RHD were confirmed in zero controls and 14 (7.5%) relatives (p = 0.05): 11 patients had mild/moderate mitral regurgitation, and four were associated with mitral stenosis and abnormal morphology. Two patients had mild aortic regurgitation and abnormal morphology, which were associated with mild aortic and mitral stenosis, and two patients with advanced RHD had bioprostheses in the mitral (2) and aortic (1) positions. In conclusion, first-degree relatives of individuals with clinical RHD are at greater risk of having RHD, on top of socioeconomic conditions.

Cardiac assessments of bottlenose dolphins (Tursiops truncatus) in the Northern Gulf of Mexico following exposure to Deepwater Horizon oil.

The Deepwater Horizon (DWH) oil spill profoundly impacted the health of bottlenose dolphins (Tursiops truncatus) in Barataria Bay, LA (BB). To comprehensively assess the cardiac health of dolphins living within the DWH oil spill footprint, techniques for in-water cardiac evaluation were refined with dolphins cared for by the U.S. Navy Marine Mammal Program in 2018 and applied to free-ranging bottlenose dolphins in BB (n = 34) and Sarasota Bay, Florida (SB) (n = 19), a non-oiled reference population. Cardiac auscultation detected systolic murmurs in the majority of dolphins from both sites (88% BB, 89% SB) and echocardiography showed most of the murmurs were innocent flow murmurs attributed to elevated blood flow velocity [1]. Telemetric six-lead electrocardiography detected arrhythmias in BB dolphins (43%) and SB dolphins (31%), all of which were considered low to moderate risk for adverse cardiac events. Echocardiography showed BB dolphins had thinner left ventricular walls, with significant differences in intraventricular septum thickness at the end of diastole (p = 0.002), and left ventricular posterior wall thickness at the end of diastole (p = 0.033). BB dolphins also had smaller left atrial size (p = 0.004), higher prevalence of tricuspid valve prolapse (p = 0.003), higher prevalence of tricuspid valve thickening (p = 0.033), and higher prevalence of aortic valve thickening (p = 0.008). Two dolphins in BB were diagnosed with pulmonary arterial hypertension based on Doppler echocardiography-derived estimates and supporting echocardiographic findings. Histopathology of dolphins who stranded within the DWH oil spill footprint showed a significantly higher prevalence of myocardial fibrosis (p = 0.003), regardless of age, compared to dolphins outside the oil spill footprint. In conclusion, there were substantial cardiac abnormalities identified in BB dolphins which may be related to DWH oil exposure, however, future work is needed to rule out other hypotheses and further elucidate the connection between oil exposure, pulmonary disease, and the observed cardiac abnormalities.

Comparison of sand fly trapping approaches for vector surveillance of Leishmania and Bartonella species in ecologically distinct, endemic regions of Peru.

BACKGROUND: In Peru, the information regarding sand fly vectors of leishmaniasis and bartonellosis in the Amazon region is limited. In this study, we carried out sand fly collections in Peruvian lowland and highland jungle areas using different trap type configurations and screened them for Leishmania and Bartonella DNA. METHODOLOGY/PRINCIPAL FINDINGS: Phlebotomine sand flies were collected in Peruvian Amazon jungle and inter Andean regions using CDC light trap, UV and color LED traps, Mosquito Magnet trap, BG Sentinel trap, and a Shannon trap placed outside the houses. Leishmania spp. screening was performed by kDNA PCR and confirmed by a nested cytochrome B gene (cytB) PCR. Bartonella spp. screening was performed by ITS PCR and confirmed by citrate synthase gene (gltA). The PCR amplicons were sequenced to identify Leishmania and Bartonella species. UV and Blue LED traps collected the highest average number of sand flies per hour in low jungle; UV, Mosquito Magnet and Shannon traps in high jungle; and Mosquito Magnet in inter Andean region. Leishmania guyanensis in Lutzomyia carrerai carrerai and L. naiffi in Lu. hirsuta hirsuta were identified based on cytB sequencing. Bartonella spp. related to Bartonella bacilliformis in Lu. whitmani, Lu. nevesi, Lu. hirsuta hirsuta and Lu. sherlocki, and a Bartonella sp. related to Candidatus B. rondoniensis in Lu. nevesi and Lu. maranonensis were identified based on gltA gene sequencing. CONCLUSIONS/SIGNIFICANCE: UV, Blue LED, Mosquito Magnet and Shannon traps were more efficient than the BG-Sentinel, Green, and Red LED traps. This is the first report of L. naiffi and of two genotypes of Bartonella spp. related to B. bacilliformis and Candidatus B. rondoniensis infecting sand fly species from the Amazon region in Peru.

Towards automatic diagnosis of rheumatic heart disease on echocardiographic exams through video-based deep learning.

OBJECTIVE: Rheumatic heart disease (RHD) affects an estimated 39 million people worldwide and is the most common acquired heart disease in children and young adults. Echocardiograms are the gold standard for diagnosis of RHD, but there is a shortage of skilled experts to allow widespread screenings for early detection and prevention of the disease progress. We propose an automated RHD diagnosis system that can help bridge this gap. MATERIALS AND METHODS: Experiments were conducted on a dataset with 11 646 echocardiography videos from 912 exams, obtained during screenings in underdeveloped areas of Brazil and Uganda. We address the challenges of RHD identification with a 3D convolutional neural network (C3D), comparing its performance with a 2D convolutional neural network (VGG16) that is commonly used in the echocardiogram literature. We also propose a supervised aggregation technique to combine video predictions into a single exam diagnosis. RESULTS: The proposed approach obtained an accuracy of 72.77% for exam diagnosis. The results for the C3D were significantly better than the ones obtained by the VGG16 network for videos, showing the importance of considering the temporal information during the diagnostic. The proposed aggregation model showed significantly better accuracy than the majority voting strategy and also appears to be capable of capturing underlying biases in the neural network output distribution, balancing them for a more correct diagnosis. CONCLUSION: Automatic diagnosis of echo-detected RHD is feasible and, with further research, has the potential to reduce the workload of experts, enabling the implementation of more widespread screening programs worldwide.

Safety of Transrectal or Transvaginal Drainage of Pelvic Abscesses / Segurança da drenagem transretal ou transvaginal de abscessos pélvicos

Abstract Objective The literature on the safety and long-term sequelae of transrectal and transvaginal drainage of pelvic abscesses is limited. We evaluated the outcomes and safety of pelvic abscess drainage by interventional radiology at our institution. Methods After obtaining institutional review board approval, we retrospectively evaluated the outcomes of transrectal and transvaginal pelvic abscesses drainage using computed tomography, endorectal ultrasound, and or fluoroscopy. Results The study included 26 patients, with an age range of 24 to 88 years old, out of whom 53.8% were men. A total of 46.1% of the participants were African Americans and 26.9% were Caucasians. The average body mass index was 28.4 (range: 15.6 to 41.9). The most common etiology was penetrating abdominal injury (27%), followed by appendectomy (23%), diverticular disease (11.5%), anastomotic leak (11.5%), and disorders of gynecological causes (11.5%). The mean abscess diameter was 6.3 cm (range: 3.3 to 10.0 cm). Transrectal drainage was performed in all except one patient who had a transvaginal drainage. Transrectal ultrasound was used for drainage in 92.3% cases, and fluoroscopy was used as an additional imaging modality in 75% of the cases. An 8- or 10-Fr pigtail catheter was used in>80% of the patients. Drains were removed between 2 and 7 days in 92.3% of the cases. The average follow-up was 30.4 months (range: 1 to 107 months), and no long-term complications were reported. Only one patient required subsequent operative intervention for an anastomotic leak. Conclusions Pelvic abscess drainage by transrectal route using radiological guidance is a safe and effective procedure.

Resumo Objetivo A literatura sobre a segurança e as sequelas no longo prazo da drenagem transretal e transvaginal do abscesso pélvico é limitada. Avaliamos os resultados e a segurança da drenagem do abscesso pélvico por radiologia intervencionista em nossa instituição. Métodos Após obter a aprovação do conselho de revisão institucional, avaliamos retrospectivamente os resultados da drenagem de abscessos pélvicos transretais e transvaginais por meio de tomografia computadorizada, ultrassom endorretal, e/ou fluoroscopia. Resultados Participaram do estudo 26 pacientes, com faixa etária de 24 a 88 anos, dos quais 53,8% eram homens. Um total de 46,1% eram afro-descendentes, e 26,9% eram brancos. O índice de massa corporal médio foi de 28,4 (gama: 15,6 a 41,9). A etiologia mais comum foi lesão abdominal penetrante (27%), seguida de apendicectomia (23%), doença diverticular (11,5%), fístula anastomótica (11,5%) e distúrbios de causas ginecológicas (11,5%). O diâmetro médio do abscesso foi de 6,3 cm(gama: 3,3 a 10,0 cm). A drenagem transretal foi realizada em todos os pacientes, com exceção de uma, que foi submetida a uma drenagem transvaginal. A ultrassonografia transretal foi utilizada para drenagem em 92,3% dos casos, e a fluoroscopia como modalidade adicional de imagem, em 75% dos casos. Um catéter duplo J de 8 ou 10 Fr foi usado em>80% dos pacientes. Os drenos foram retirados entre 2 e 7 dias em 92,3% dos casos. O acompanhamentomédio foi de 30,4meses (gama: 1 a 107 meses), e nenhuma complicação de longo prazo foi relatada. Apenas um paciente necessitou de intervenção cirúrgica subsequente para um vazamento anastomótico. Conclusão A drenagem do abscesso pélvico por via transretal com orientação radiológica é um procedimento seguro e eficaz.

Impact of incorporating echocardiographic screening into a clinical prediction model to optimise utilisation of echocardiography in primary care.

INTRODUCTION: Access to public subspecialty healthcare is limited in underserved areas of Brazil, including echocardiography (echo). Long waiting lines and lack of a prioritisation system lead to diagnostic lag and may contribute to poor outcomes. We developed a prioritisation tool for use in primary care, aimed at improving resource utilisation, by predicting those at highest risk of having an abnormal echo, and thus in highest need of referral. METHODS: All patients in the existing primary care waiting list for echo were invited for participation and underwent a clinical questionnaire, simplified 7-view echo screening by non-physicians with handheld devices, and standard echo by experts. Two derivation models were developed, one including only clinical variables and a second including clinical variables and findings of major heart disease (HD) on echo screening (cut point for high/low-risk). For validation, patients were risk-classified according to the clinical score. High-risk patients and a sample of low-risk underwent standard echo. Intermediate-risk patients first had screening echo, with a standard echo if HD was suspected. Discrimination and calibration of the two models were assessed to predict HD in standard echo. RESULTS: In derivation (N = 603), clinical variables associated with HD were female gender, body mass index, Chagas disease, prior cardiac surgery, coronary disease, valve disease, hypertension and heart failure, and this model was well calibrated with C-statistic = 0.781. Performance was improved with the addition of echo screening, with C-statistic = 0.871 after cross-validation. For validation (N = 1526), 227 (14.9%) patients were classified as low risk, 1082 (70.9%) as intermediate risk and 217 (14.2%) as high risk by the clinical model. The final model with two categories had high sensitivity (99%) and negative predictive value (97%) for HD in standard echo. Model performance was good with C-statistic = 0.720. CONCLUSION: The addition of screening echo to clinical variables significantly improves the performance of a score to predict major HD.

Cytokine gene functional polymorphisms and phenotypic expression as predictors of evolution from latent to clinical rheumatic heart disease.

INTRODUCTION: Inflammation associated with rheumatic heart disease (RHD) is influenced by gene polymorphisms and inflammatory cytokines. There are currently no immunologic and genetic markers to discriminate latent versus clinical patients, critical to predict disease evolution. Employing machine-learning, we searched for predictors that could discriminate latent versus clinical RHD, and eventually identify latent patients that may progress to clinical disease. METHODS: A total of 212 individuals were included, 77 with latent, 100 with clinical RHD, and 35 healthy controls. Circulating levels of 27 soluble factors were evaluated using Bio-Plex ProTM® Human Cytokine Standard 27-plex assay. Gene polymorphism analyses were performed using RT-PCR for the following genes: IL2, IL4, IL6, IL10, IL17A, TNF and IL23. RESULTS: Serum levels of all cytokines were higher in clinical as compared to latent RHD patients, and in those groups than in controls. IL-4, IL-8, IL-1RA, IL-9, CCL5 and PDGF emerged in the final multivariate model as predictive factors for clinical, compared with latent RHD. IL-4, IL-8 and IL1RA had the greater power to predict clinical RHD. In univariate analysis, polymorphisms in IL2 and IL4 were associated with clinical RHD and in the logistic analysis, IL6 (GG + CG), IL10 (CT + TT), IL2 (CA + AA) and IL4 (CC) genotypes were associated with RHD. CONCLUSION: Despite higher levels of all cytokines in clinical RHD patients, IL-4, IL-8 and IL-1RA were the best predictors of clinical disease. An association of polymorphisms in IL2, IL4, IL6 and IL10 genes and clinical RHD was observed. Gene polymorphism and phenotypic expression of IL-4 accurately discriminate latent versus clinical RHD, potentially instructing clinical management.

Land and livelihood in the age of COVID-19: Implications for indigenous food producers in Ecuador.

Like many Latin American countries, Ecuador responded to COVID-19 by restricting trade and travel, a decision that disrupted the prevailing model of regional trade integration. Among some analysts, observations have been made that the lockdown represents a new opportunity to revitalize rural livelihoods and smallholder agriculture. This paper evaluates these claims by exploring the impact of COVID-19 on household food security and smallholder food production in Chimborazo, a highland province that is known for extremely high rates of poverty and the highest concentration of Kichwa-speaking Indigenous people in Ecuador. Drawing upon original empirical research, it makes the case that the prospects for revitalizing smallholder production remain structurally constrained by a legacy of land inequality and failed agrarian reform. According to our findings, the only sectors that thrived during the lockdown were ones that served local markets. For those requiring significant shipping and storage, merchants and traders were able to drive down farmgate prices, squeezing local producers. At the same time, new government legislation made it easier for employers to terminate wage labourers, undermining a vital source of income and employment for low-income households. Far from revitalizing smallholder agriculture, the pandemic appears to have further entrenched an economic model of supporting agribusiness at the expense of family farms and migrant labour.