[COVID-19 in transplant recipients: Multicentric report of Mexican experience]. / COVID-19 en receptores de trasplante: reporte multicéntrico de la experiencia mexicana.

Background: Solid Organ Transplant recipients (SOTR) appear to be at particular high risk for critical COVID-19 due to immunosuppressive drugs and comorbidities. We report the first description of clinical course and short-term outcomes of kidney and liver transplant recipients with confirmed COVID-19 in Mexico. The objective of this paper was evaluate the clinical course of transplant patients with COVID-19 infection. Material and methods: We retrospectively evaluated SOTR (kidney and liver) over 18 years of age with confirmed diagnosis of COVID-19 from tertiary care centers in Mexico. Results: Data from 45 kidney transplant recipients were recorded. Median (IQR) age was 43 (IQR 25-70) years. Admission to hospital was required in 37 (75.5 %) patients, of which 8 (16.3%) were hospitalized at Intensive Care Unit (ICU). Acute kidney injury (AKI) stage was documented in 33 (67%) patients. The time of hospitalization was 8 (IQR 6-12) days. Six patients died (12.2%). Additionally, data from 10 liver transplant recipients were included. During their evolution, 5 / 10 required hospital admission and there were no deaths in this group. Conclusions: Transplant recipients show a higher fatality rate and complications from SARS-CoV-2 infection; more studies are needed to identify prognostic factors and effective anti-SARS-CoV-2 therapies.

Antecedentes: Los receptores de trasplante de órgano sólido (RTOS) parecen estar en un riesgo particularmente alto de cuadros severos de infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2) debido al uso crónico de medicamentos inmunosupresores y sus comorbilidades. Reportamos la primera descripción del curso clínico y desenlaces a corto plazo de los receptores de trasplante con enfermedad por coronavirus 2019 (COVID-19) confirmada en México. El objetivo de este trabajo es evaluar el curso clínico de estos pacientes. Material y métodos: Evaluamos de manera retrospectiva los RTOS (riñón e hígado) mayores de 18 años de edad, con diagnóstico confirmado de infección por SARS-CoV-2 provenientes de cinco centros de tercer nivel en México. Resultados: Se incluyeron 45 receptores de trasplante renal con una edad de 43 (intervalo intercuartílico [IQR]: 25-70) años. El ingreso hospitalario se requirió en 37 (75.5%) pacientes, de los cuales ocho (16.3%) fueron hospitalizados en la unidad de terapia intensiva. Se documentó lesión renal aguda en 33 (67%) pacientes. El tiempo de hospitalización fue de 8 (IQR: 6-12) días. Seis pacientes fallecieron (12.2%). Adicionalmente, 10 receptores de trasplante hepático fueron incluidos. Durante su evolución, 5 / 10 requirieron ingreso hospitalario; no se presentaron fallecimientos en este grupo de pacientes. Conclusiones: Los receptores de trasplante mostraron una alta tasa de mortalidad y complicaciones por la infección por SARS-CoV-2. Son necesarios más estudios para identificar los factores pronósticos y modalidades de tratamiento eficaces.

Insomnia and nightmare profiles during the COVID-19 pandemic in Portugal: characterization and associated factors.

OBJECTIVE/BACKGROUND: To describe and characterize insomnia symptoms and nightmare profiles in Portugal during the first six weeks of a national lockdown due to COVID-19. PATIENTS/METHODS: An open cohort study was conducted to collect information of the general population during the first wave of SARS-CoV-2/COVID-19 pandemic in Portugal. We analyzed data from 5011 participants (≥16 years) who answered a weekly questionnaire about their well-being. Two questions about the frequency of insomnia and nightmares about COVID-19 were consecutively applied during six weeks (March-May 2020). Latent class analysis was conducted and different insomnia and nightmare profiles were identified. Associations between individual characteristics and both profiles were estimated using odds ratios (ORs) and 95% confidence intervals (CI). RESULTS: Five insomnia (No insomnia, Stable-mild, Decreasing-moderate, Stable-severe, Increasing-severe) and three nightmares profiles (Stable-mild, Stable-moderate, Stable-severe) were identified. Being female, younger, perceiving their income as insufficient and feelings of fear towards COVID-19 were associated with higher odds of insomnia (Women: OR = 6.98 95%CI: 4.18-11.64; ≥60 years: OR = 0.30 95%CI: 0.18-0.53; Insufficient income: adjusted OR (aOR) = 8.413 95%CI: 3.93-16.84; Often presenting fear of being infected with SARS-CoV-2 infection: aOR = 9.13 95%CI: 6.36-13.11), and nightmares (Women: OR = 2.60 95%CI: 1.74-3.86; ≥60 years: OR = 0.45 95%CI: 0.28-0.74; Insufficient income: aOR = 2.60 95%CI: 1.20-5.20; Often/almost always presenting fear of being infected with SARS-CoV-2 infection: aOR = 6.62 95%CI: 5.01-8.74). Having a diagnosis of SARS-CoV-2 virus infection was associated with worse patterns of nightmares about the pandemic. CONCLUSIONS: Social and psychological individual factors are important characteristics to consider in the development of therapeutic strategies to support people with sleep problems during the COVID-19 pandemic.

Antimicrobial resistance in companion animals - Veterinarians' attitudes and prescription drivers in Portugal.

Antimicrobial resistance transmitted from companion animals is a threat to public health increased by the pet's relationship with humans. This study aims to understand the attitude and drivers of antimicrobial (AM) prescription among companion animal veterinarians in Portugal and identify actions to combat antimicrobial resistance (AMR). This cross-sectional study is based on a questionnaire with 417 respondents representing the Portuguese veterinary population. The results allowed grouping the respondents according to the attitude of prescription. Two types of veterinarians were identified: those who prefer to prescribe treatments based on the animals' signs and their own experience - empirical-oriented type - and those who refer to a guidance protocol to assist the prescription decision - protocol-oriented type. Respondents working in hospitals displayed a positive association with the use of guidance protocols. Efficacy was the main driver of prescription for both groups, suggesting that no matter the attitude in prescribing, the veterinarian's aim is achieving positive clinical results. Most respondents prefer empirical-oriented prescriptions, declare the absence of protocols for the prudent use of AM at the workplace and do not refer to AMR issues nor the need for hygiene reinforcement measures with owners. Owners are less likely to request AMs from veterinarians aged over 43 years old. It was discovered that communication between owners and veterinarians about risks associated with AMR was poor and must be improved and the adoption of a national guideline for the adequate use of AM directed for companion animals would be beneficial.

Trajectories of depressive symptoms through adolescence and young adulthood: social and health outcomes.

Depressive symptoms display heterogeneous trajectories across adolescence, which can lead to different consequences. This study aimed to identify trajectories of depressive symptoms from adolescence to young adulthood, assessing the association with social and health outcomes at young adulthood. Adolescents born in 1990, enrolled in schools of Porto, Portugal, in 2003-2004 (EPITeen study) completed the Beck Depression Inventory II (BDI-II) at 13, 17 and 21 years. Mixed models and model-based clustering were used to describe the trajectories in the BDI-II score (n = 2010). Outcomes were assessed at age 21 years with self-administered questionnaires and face-to-face interviews (n = 1594). Odds ratios or regression coefficients, with 95% confidence intervals, were estimated using logistic and linear regression. Three trajectory classes of depressive symptoms were identified, similar in shape in both sexes: High (8.4%), Moderate (31.3%) and Low (60.2%). Participants in High or Moderate classes were more likely to describe lower scores of community involvement, more medical appointments during the last year, higher levels of pain and had higher probability of self-rating health as "good" or "fair or poor". Females in the High and Moderate classes were more likely to be current smokers, to describe ever using drugs and to report more sexual partners, emergency room visits and the use of antidepressants. The risk of depressive symptoms in adulthood is likely to be early determined in adolescence. The trajectory classes with higher levels of symptoms were associated with worse social and health outcomes.

Electives in the medical curriculum - an opportunity to achieve students' satisfaction?

BACKGROUND: Electives are perceived by medical students as a valuable, highly regarded experience, allowing them to customize learning experiences and enabling them to early differentiate during medical training. The present work aims to uncover students' major determinants of satisfaction and how they interfere with their future elective choices in order to identify the best approach to implement electives in medical curricula. METHODS: A cross-sectional study was conducted through a written evaluation survey concerning the electives available in the academic year 2015-2016. Our institution provides 106 electives to students from the 2nd to the 5th year. Students' satisfaction was assessed through a validated questionnaire with eight sentences expressing opinions related to electives global satisfaction. Data from 538 inquiries from 229 students were analyzed quantitatively using regression and correlation models, and qualitatively through phenomenography. RESULTS: Quantitative analysis of the questionnaires allowed to establish both: 1) The determinants of students' satisfaction with electives, which were Agreement with teaching and learning methodologies, followed by Agreement with assessment methodologies employed, Perception of the workload demanded and Requirement for continuous work and 2) The predictors of students preferences in the following years, namely, Agreement with assessment methodologies employed, Classes attendance and Ranking of the allocated elective established in the previous year. Qualitative analysis of questionnaires revealed that students consider electives as being innovative and interesting, claiming that some, for their relevant content, could be integrated into the medical core curriculum. CONCLUSIONS: Our work raises awareness on the best practices when it comes to electives' organization to meet students' satisfaction. We can conclude that medical schools should measure students satisfaction as a tool to organize and predict future needs of electives and placements when designing and implementing this alternative student-centred curriculum or even to improve the existing practices regarding electives in medical courses.

Socioeconomic position and quality of life among older people: The mediating role of social support.

Social support can obscure social gradients in health, but its role as a mediator between socioeconomic position (SEP) and quality of life (QoL) in older populations remains unknown. We aimed to examine to what extent social support mediates the association between SEP and overall QoL among older adults (aged 60-84 years). We studied a population-based cohort of 585 noninstitutionalized adults in Porto, Portugal, who were evaluated in 2009. Education, occupation, and perceived income adequacy were used as SEP indicators. The WHOQOL-OLD was used to determine overall QoL. Social support was assessed using the Multidimensional Scale of Perceived Social Support. Path analysis was conducted to quantify direct, indirect, and total effects of SEP on QoL. There was a positive total effect of education on QoL (ß = 0.28; 95% CI: 0.05-0.48). In this model, we found an indirect effect through social support (ß = 0.15; 95% CI: 0.05-0.26), explaining 54% of the pathway between education and QoL. A similar pattern was identified for the association between occupation and QoL. Perceived income adequacy had a total effect of 2.74 (95% CI: 1.68-3.93) on QoL. Although an indirect effect through social support was found (ß = 0.98; 95% CI: 0.42-1.55), a direct effect from this variable remained (ß = 1.76; 95% CI: 0.65-2.90). Social support can be a mechanism through which SEP impacts the QoL of older people. Strengthening social support ties may attenuate the impact of social inequalities and improve the QoL of this population.

Effects of indoor endocrine-disrupting chemicals on childhood rhinitis

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Longitudinal association of adiposity and high-sensitivity C-reactive protein from adolescence into early adulthood.

BACKGROUND AND AIMS: Longitudinal studies relating adiposity with low-grade inflammation are scarce. We aimed to examine the longitudinal association between the cumulative exposure to adiposity and low-grade inflammation from adolescence into early adulthood. METHODS AND RESULTS: Data from a population-based cohort (EPITeen) (n = 1147) was analyzed. Body mass index (BMI), body fat percentage (BF%), waist circumference (WC), and waist-to-height ratio (WHtR) and high-sensitivity C-reactive protein (hsCRP) were ascertained at 13, 17 and 21 years of age and standardized for each wave. Generalized least squares models with a compound symmetry correlation structure were fitted to estimate the longitudinal effect of adiposity on hsCRP and results were presented as linear regression coefficients and 95% confidence intervals [ß (95%CI)].The final model estimated the association between the difference in adiposity between two consecutive evaluations (13-17 and 17 to 21-years-old), adjusted for previous adiposity and hsCRP levels, sex, parental education, leisure-time physical activity and fruits and vegetables intake. A positive association between the cumulative exposure to adiposity and final hsCRP was observed, in which the difference between adiposity indicators of two consecutive study waves was independently associated with hsCRP: 0.382 (0.299; 0.465) for BMI, 0.234 (0.164; 0.304) for WC, 0.395 (0.314; 0.477) for BF% and 0.195 (0.133; 0.258) for WHtR. CONCLUSION: A significant longitudinal effect of the accumulation of adiposity on low-grade inflammation was observed. The change in adiposity from consecutive study waves was shown to have a stronger effect on final hsCRP concentrations than both previous adiposity and hsCRP levels.

Measuring depressive symptoms during adolescence: what is the role of gender?

AIMS: The higher prevalence of depressive symptoms among females is well recognised but the reasons for this gender difference are not fully understood. There is growing evidence that current diagnostic criteria and instruments used to assess depression are less sensitive to depression in men, but studies about this issue among adolescents are scarce, especially in Latin countries. Our aim was to assess sex differences in the intensity of depressive symptoms, measured using the Beck Depression Inventory second edition (BDI-II), among Portuguese adolescents, at 13 and 17 years of age. METHODS: Urban adolescents born in 1990 and enrolled in schools of Porto, Portugal, in 2003-2004 (EPITeen study) completed the BDI-II at 13 and 17 years of age. The final sample included 1988 (52.2% girls) and 2131 (53.0% girls) adolescents at 13 and 17 years, respectively. Sex differences in the frequency of endorsing the statements on the 21 items of the BDI-II were examined using the χ2 test and effect sizes were estimated (Cohen's w). To examine whether responses were linked systematically to sex, we used a differential item functioning (DIF), based on the logistic regression approach. Option characteristic curves were estimated for items with differential endorsement and a new BDI-II score was computed excluding those items. RESULTS: Girls and boys at the same level of depression expressed similar severity ratings for most of the depressive symptoms. We had four items with DIF at 13 and 17 years of age. At 13 years, two items provided lower scores (sadness and crying items) and two higher scores (punishment feelings and loss of interest in sex items) among boys, comparing with equally depressed girls. At 17 years, the four items with DIF provided lower scores among boys (sadness, crying, self-dislike and tiredness or fatigue items). After excluding these items the prevalence of depression remained higher among girls but at 17 years the difference between sexes was attenuated. CONCLUSIONS: Sex differences were found in the functioning of the BDI-II, more relevant at 17 years of age, which may lead to an overestimation of symptoms among girls as well as to lower reported rates of depression among boys. For a higher diagnostic accuracy it is important that the criteria and instruments used to assess depression adequately reflect female and male common symptoms and experiences of depression.

Epidemiologic study of odontogenic and non-odontogenic cysts in children and adolescents of a Brazilian population.

BACKGROUND: the objective of this study was to describe the frequency of cystic lesions in a Brazilian population of patients histopathologically diagnosed in the first and second decade of life. MATERIAL AND METHODS: Retrospective descriptive cross-sectional study was performed. Biopsy records were obtained from the archives of a Brazilian referral center between 1980 and 2016. RESULTS: A total of 2.114 biopsy records of pediatric patients were analyzed with oral and maxillofacial lesions. Data such as gender, age, anatomical location, and histopathological diagnosis were collected and categorized. Among all oral and maxillofacial lesions (n=2.114), were diagnosed 294 cases of odontogenic cysts (13.9%) and 16 cases of non-odontogenic cysts (0.8%). The most frequent lesions in each group were, respectively: radicular cyst (n=145) and epidermoid cyst (n=4). These lesions were most common in female (n=158), with a mean age of 14 years. For intraosseous lesions, the mandible (n=148) was the most affected anatomic site; moreover, the floor of the mouth (n=6) was most affected by cysts in soft tissues. CONCLUSIONS: Odontogenic cysts were relatively common in population studied, but non-odontogenic cysts were rare in these patients.

Duration and degree of adiposity: effect on cardiovascular risk factors at early adulthood.

BACKGROUND/OBJECTIVES: The effect of adiposity dynamics throughout adolescence on adult cardiometabolic outcomes is not well known. We aimed to assess the effect of duration and degree of adiposity from adolescence to early adulthood on blood pressure and insulin resistance at 24 years. SUBJECTS/METHODS: We used data from 2253 participants evaluated at 13, 17, 21 and 24 years of age in the EPITeen cohort, Porto, Portugal. The area under the curve of body mass index (BMIAUC) was computed to summarize duration and degree of BMI for the 11-year period. Outcomes were systolic blood pressure (SBP) and insulin resistance at 24 years. The homeostasis model assessment of insulin resistance (HOMA-IR) was used as an indicator of insulin resistance and the variable was log-transformed. Associations between BMIAUC and each outcome were estimated by linear regression models. RESULTS: The median BMIAUC was 243.1 (223.9-268.6) kg m-2 in 11 years, corresponding to 22.1 kg m-2 on average per year. In crude analyses, both BMIAUC and BMI at 24 years were positively associated with SBP (ß=0.096 mm Hg, 95% confidence interval (CI) 0.077; 0.115 for BMIAUC; ß=4.616 mm Hg, 95% CI 3.082; 6.151 for BMI at 24 years) and ln HOMA-IR (ß=0.004, 95% CI 0.003; 0.005 for BMIAUC; ß=0.047, 95% CI 0.036; 0.057 for BMI at 24 years). After adjustment for confounders and for BMI at 24 years, the magnitude of the association of BMIAUC attenuated for both outcomes, mostly for SBP, but the association remained statistically significant. Results using standardized variables confirmed that both outcomes were more strongly associated with BMI at 24 years than with BMIAUC. CONCLUSIONS: In addition to the effect of adult attained BMI, cumulative exposure to higher BMI throughout adolescence, taking into account duration and degree, was also relevant for adult cardiovascular risk factors, mainly for insulin resistance.

Resíduo úmido de cervejaria na terminação de cordeiros em confinamento e seus efeitos sobre as características da carcaça e dos componentes não carcaça / Wet brewery residue in the finishing of feedlot lambs and its effects on the carcass characteristics and non-carcass components

O objetivo deste trabalho foi avaliar o efeito de níveis crescentes de substituição da silagem de sorgo por resíduo úmido de cervejaria sobre as características da carcaça e dos componentes não carcaça de cordeiros terminados em confinamento. Foram utilizados 24 cordeiros machos, não castrados, oriundos de parto simples e mantidos em baias individuais. Os tratamentos foram constituídos por quatro níveis de substituição de silagem de sorgo por resíduo úmido de cervejaria, sendo: 0%; 33,5%; 66,5% e 100% de substituição. Utilizou-se uma relação volumoso:concentrado de 50:50, com base na matéria seca. O concentrado era constituído por milho desintegrado, farelo de soja e mistura mineral. As dietas eram isoproteicas, contendo 18,81% de proteína bruta. Os cordeiros foram abatidos quando atingiram o escore de condição corporal estabelecido em 3 (escala de 1 a 5). As características de carcaça analisadas não foram influenciadas significativamente (P>0,05) pela substituição de silagem de sorgo por resíduo úmido de cervejaria, sendo obtidos valores médios de 18,92kg para peso de carcaça quente, 18,22 kg para peso de carcaça fria, 47,03% para rendimento de carcaça quente, 45,29% para rendimento de carcaça fria e 3,41% para índice de quebra ao resfriamento. Quanto às proporções dos diferentes cortes comerciais avaliados, em relação ao peso de carcaça fria, foram verificados valores médios de 31,86% para perna, 18,12% para paleta, 39,46% para costilhar e 9,08% para pescoço. As proporções de diafragma, omaso cheio e omaso vazio, em relação ao peso vivo ao abate dos cordeiros, diminuíram linearmente (P≤0,05). As demais variáveis dos componentes não carcaça avaliadas não foram influenciadas (P>0,05) pelos níveis de resíduo úmido de cervejaria das dietas. Pode-se recomendar o uso de resíduo úmido de cervejaria como fonte exclusiva de alimento volumoso quando se utiliza uma relação volumoso:concentrado de 50:50, em base de matéria seca, para terminação de cordeiros em sistema de confinamento.(AU)

The objective of this study was to evaluate the effect of increasing levels of substitution of sorghum silage by wet brewery residue as forage food on carcass characteristics and non-carcass components of lambs finished in feedlot. Twenty four non castrated male lambs, Suffolk breed, single birth were maintained in individual stalls. The treatments consisted of four substitution levels of sorghum silage by wet brewery residue (0%; 33.5%; 66.5% or 100% of substitution). Roughage and concentrate were used at a 50:50 ratio, based on dry matter. The concentrate was composed of ground corn, soybean meal and mineral mixture. The diets were isoproteic containing 18.81% crude protein. The lambs were slaughtered when they reached the body condition score of 3 (ranging from 1 to 5). The carcass traits were not affected significantly (P>0,05) by substitution of sorghum silage by wet brewery residue. The average values of hot carcass weight, cold carcass weight, hot carcass yield, cold carcass yield and cooling weight losses were 18.92 kg, 18.22 kg, 47.03%, 45.29%, 3.41%, respectively. The proportion of commercial cuts in relation to the cold carcass weight, was 31.86% for leg, 18.12% for shoulder, 39.46% for ribs and 9.08% for neck. The proportion of diaphragm, omasum full and empty omasum in relation to body weight at slaughter decreased linearly (P≤0.05). The remaining variables of non-carcass components were not affected (P>0.05) by wet brewery residue inclusion. We recommend the use of wet brewery residue as exclusive source of roughage food when using roughage:concentrate at 50:50 ratio on a dry matter basis, for finishing feedlot lambs.(AU)

Life course path analysis of total and central adiposity throughout adolescence on adult blood pressure and insulin resistance.

BACKGROUND AND AIM: We aimed to study whether the effect of adolescent adiposity on adult blood pressure and insulin resistance was mediated by adult adiposity. METHODS AND RESULTS: Data from the EPITeen cohort at 13, 17 and 21 years was used (n = 2211). Sex- and age-specific body mass index z-scores (BMIz) and waist-to-hip ratio (WHR) were used as indicators of total and central adiposity, respectively. Systolic blood pressure (SBP), glucose and insulin were assessed at 21 years and the homeostasis model assessment (HOMA-IR) was used as a marker of insulin resistance. Path analysis was applied to evaluate direct and indirect effects of adiposity (13, 17 and 21y) on adult SBP and HOMA-IR, separately for total and central adiposity and for each outcome. Results are presented as standardized regression coefficients [ß (95%CI)]. The total effect of BMIz at 13 years on SBP at 21 years was 0.211 (0.178; 0.244), totally mediated by adult BMIz. Total effect of BMIz 13y on HOMA-IR was 0.248 (0.196; 0.299). Although this effect was mostly mediated by BMIz 21y, an additional direct effect from BMIz 17y was found [ß = -0.240 (-0.315; -0.164)]. Central adiposity was also positively associated with SBP and HOMA-IR at 21 years, and the effect of adolescent WHR was totally mediated by adult WHR for both outcomes. CONCLUSIONS: The effect of adolescent adiposity on adult SBP and HOMA-IR was mostly mediated by adult adiposity. However, for HOMA-IR an additional direct effect from total adiposity at 17 years was found.

The impact of students and curriculum on self-study during clinical training in medical school: a multilevel approach.

BACKGROUND: In higher education, the focus has shifted from the acquisition of knowledge to learning objectives and skills. This means that, the majority of student learning time is spent independently working outside the classroom. Students take an active role in setting goals, deciding how to achieve them, and planning individual study time. Although extensive research has recognized the importance of curriculum and students' characteristics in time devoted to self-study, it is still unclear to what extent these variables affect time to study. Due to the growing reliance on self-directed learning in medical education, and in an attempt to elucidate this issue, this research aims to evaluate self-study time during clinical training and assess whether this is more influenced by the student or the curriculum. METHODS: A questionnaire was given to 1220 medical students (43.3% of the enrolled students). The students were asked to indicate the average number of study hours per week beyond the time allocated to classes for each clerkship (rotation) attended. Variation and generalizability of students' self-study were estimated using linear mixed models. RESULTS: Findings showed that the intrinsic differences within students were a greater source of variation in self-study time than differences within clerkships (56.0% vs. 6.9%). If the amount of self-study dedicated to an individual clerkship is to be determined, at least 32 students are needed to achieve acceptable reliability. However, this data with two clerkships per student can used to retrospectively measure the self-study reported by students in clinical training. CONCLUSIONS: The findings suggest that, both, curriculum and student characteristics influence self-study in undergraduate clinical training. Indeed, students' characteristics play a significant role in time devoted to study. Further research should be undertaken to investigate students' characteristics that may predict self-study during undergraduate medical training.

Protein intake and dietary glycemic load of 4-year-olds and association with adiposity and serum insulin at 7 years of age: sex-nutrient and nutrient-nutrient interactions.

BACKGROUND/OBJECTIVES: The role of Protein Intake (PI) at preschool age on later adiposity is understudied, and prospective studies also examining Dietary Glycemic Load (GL) are lacking. The current study evaluated the association of PI and GL at 4 years with adiposity and Fasting Serum Insulin (FSI) 3 years later, and examined the possible interaction between PI and GL on these associations, by sex. DESIGN: This prospective study included 1999 singleton children enrolled in the population-based birth cohort, Generation XXI (Porto, Portugal, 2005-2006). Diet at 4 years was assessed by 3-days food diaries. Energy-adjusted PI and GL (g per day) were converted into sex-specific tertiles (T). At 7 years, Body Mass Index (BMI) z-scores were defined according to the World Health Organization. Sample's sex-specific z-scores were computed for Fat Mass Index (FMI), Waist-to-Height ratio (W/Ht) and FSI. Associations were estimated by linear regression coefficients (ß) and 95% confidence intervals (95% CI). RESULTS: After adjustment for confounders, PI was positively associated with BMI in girls (T2 vs T1: ß=0.187; 95% CI: 0.015, 0.359) and boys (T3 vs T1: ß=0.205; 95% CI: 0.003, 0.406), being associated with FSI only in boys (T3 vs T1: ß=0.207; 95% CI: 0.011, 0.404; P-interaction=0.026). Also, GL was associated with BMI only in boys (T3 vs T1: ß=0.362; 95% CI: 0.031, 0.693; P-interaction=0.006), in whom significant interactions between PI and GL were found on the association with FMI (P=0.019) and W/Ht (P=0.039). Boys within the third T of both PI and GL at 4 years had higher FMI (ß=0.505; 95% CI: 0.085, 0.925) and W/Ht (ß=0.428; 95% CI: 0.022, 0.834) at 7 years. CONCLUSIONS: In both girls and boys, PI at preschool age is positively associated with later BMI, being positively associated with FSI only in boys. Dietary GL is associated with adiposity only in boys, in whom it seems to interact with PI enhancing increased adiposity.

The role of prenatal exposures on body fat patterns at 7 years: Intrauterine programming or birthweight effects?

BACKGROUND AND AIMS: It remains unknown whether the effects of prenatal exposures on child's adiposity reflect entirely intrauterine programming. We aimed to assess the effects of maternal gestational weight gain, diabetes and smoking on the child's body fat patterns, disentangling the direct (through intrauterine programming) and indirect (through birthweight) effects. METHODS AND RESULTS: We included 4747 singleton 7-year-old children from the Generation XXI birth cohort (Porto, Portugal). At birth, maternal and newborn's characteristics were obtained. Anthropometrics were measured at age 7 years and body fat patterns were identified by principal component analysis. Path analysis was used to quantify direct, indirect and total effects of gestational weight gain, diabetes and smoking on body fat patterns. Pattern 1 was characterized by strong factor loadings with body mass index, fat mass index and waist-to-height ratio (fat quantity) and pattern 2 with waist-to-hip ratio, waist-to-thigh ratio, and waist-to-weight ratio (fat distribution). The positive total effect of maternal gestational weight gain and diabetes on the child's fat quantity was mainly through a direct pathway, responsible for 91.7% and 83.7% of total effects, respectively (ß = 0.022; 95% Confidence Interval (CI): 0.017, 0.027; ß = 0.041; 95% CI: -0.011, 0.093). No effects on fat distribution were found. Maternal prenatal smoking had a positive direct effect on patterns 1 and 2, explaining 94.9% and 76.1% of total effects, respectively. CONCLUSION: The effects of maternal gestational weight gain, diabetes and smoking on a child's fat quantity seem to be mainly through intrauterine programming. Maternal smoking also showed a positive direct effect on child's fat distribution.

Velamentous cord insertion in dichorionic and monochorionic twin pregnancies - Does it make a difference?

OBJECTIVE: To estimate the prevalence of velamentous cord insertion (VCI) in dichorionic (DC) and monochorionic (MC) twins with and without twin-twin transfusion syndrome (TTTS), and to study the associated outcomes. METHODS: We recorded the type of umbilical cord insertion in all consecutive DC and MC placentas examined in two European tertiary medical centers. The association between VCI and perinatal outcomes was estimated and compared. RESULTS: A total of 1498 twin placentas were included in this study (DC placentas n = 550, MC placentas without TTTS n = 513 and MC placentas with TTTS n = 435). The prevalence of VCI in DC, MC without TTTS and MC with TTTS groups was 7.6%, 34.7% and 36.1%, respectively (P < 0.001). In MC twins (non-TTTS and TTTS groups), VCI was associated with severe birth weight discordance (odds ratio [OR] 4.76 95% CI 2.43, 10.47 and OR 4.52 95% CI 1.30, 28.59, respectively). In MC twins without TTTS, VCI was associated with small for gestational age (OR 1.66, 95% CI 1.12, 2.50). VCI was significantly associated with increased risk of intrauterine fetal demise in MC twins, and this effect was greater in the non-TTTS group (OR 2.71 95% CI 1.38, 5.47). These associations did not occur in DC group. Gestational age at birth was lower in the presence of VCI in the DC and MC twins without TTTS. CONCLUSION: Our findings confirm that the prevalence of VCI is higher in MC twins than in DC twin pregnancies. VCI is an important indicator of adverse perinatal outcome, particularly in MC twins.

Developmental trajectories of adiposity from birth until early adulthood and association with cardiometabolic risk factors.

OBJECTIVE: To identify developmental trajectories of adiposity from birth until early adulthood, and to investigate how they relate with cardiometabolic risk factors at 21 years of age. METHODS: Participants' weight and height measurements were obtained using the EPITeen cohort protocol at 13, 17 and 21 years of age, and extracted from child health books as recorded during health routine evaluations since birth. Blood pressure, triglycerides, cholesterol and insulin resistance (HOMA-IR) were assessed at 21 years. Trajectories were defined using 719 participants contributing 11 459 measurements. The individual growth curves were modelled using mixed-effects fractional polynomial, and the trajectories were estimated using normal mixture modelling for model-based clustering. Differences in cardiometabolic risk factors at 21 years according to adiposity trajectories were estimated through analysis of covariance (ANCOVA), and adjusted means are presented. RESULTS: Two trajectories-'Average body mass index (BMI) growth' (80.7%) and 'Higher BMI growth' (19.3%)-were identified. Compared with those in 'Average BMI growth', 'Higher BMI growth' participants were more frequently delivered by caesarean section, mothers were younger and had higher BMI, and parental education was lower; and at 21 years showed higher adjusted mean systolic (111.6 vs 108.3 mm Hg, P<0.001) and diastolic blood pressure (71.9 vs 68.4 mm Hg, P<0.001), and lower high-density lipoprotein cholesterol (53.3 vs 57.0 mg dl(-1), P=0.001). As there was a significant interaction between trajectories and sex, triglycerides and HOMA-IR were stratified by sex and we found significantly higher triglycerides, in males, and higher HOMA-IR in both sexes in 'Higher BMI growth' trajectory. All the differences were attenuated after adjustment for BMI at 21 years. CONCLUSIONS: In this long-term follow-up, we were able to identify two adiposity trajectories, statistically related to the BMI and cardiometabolic profile in adulthood. Our results also suggest that the impact of the adiposity trajectory on cardiometabolic profile is mediated by current BMI.

Dietary patterns and asthma prevalence, incidence and control.

BACKGROUND: The increased asthma prevalence in westernized societies has been suggested to be related to environment exposures and lifestyle changes, particularly diet. We aimed to explore the association between dietary patterns and asthma prevalence, incidence and control in a nationally representative population. METHODS: Data from 32,644 adults, 53% female, from the 4th Portuguese National Health Survey were analysed. Prevalence of asthma was 5.3%; 'current asthma', defined by asthma symptoms within previous year, 3.5%; 'current medicated asthma' defined by use of asthma medication within previous year, 3.0%; 'current severe asthma' defined by emergency visit because of asthma within previous year, 1.4%; and 'incident asthma', 0.2%. Dietary patterns (DP) were identified by latent trait models based on dietary intake. Unconditional logistic regression models were performed to analyse association between DP and asthma. Age, gender, education, family income, proxy reporting information, smoking, body mass index and physical activity level were analysed as confounders. RESULTS: Two of the five identified DP were associated with asthma: 'high fat, sugar and salt' DP (positively correlated with pastry, chocolate and sweet desserts, candies, salty snacks, chips, fruit juices, soft drinks and alcoholic beverages consumption at snacks) was associated with asthma prevalence (OR = 1.13, 95% CI = 1.03, 1.24) and current severe asthma (OR = 1.23, 95% CI = 1.03, 1.48), while 'fish, fruit and vegetables' DP (positively correlated with fish, vegetables and fruit intake at meals) was negatively associated with current (OR = 0.84, 95% CI = 0.73, 0.98), and current medicated asthma (OR = 0.84, 95% CI = 0.72, 0.98), after adjustment for confounders. CONCLUSION & CLINICAL RELEVANCE: Our results suggest a protective association between 'fish, vegetables and fruit' DP and current asthma and current medicated asthma, and a detrimental association between 'high fat, sugar and salt' DP and severe asthma prevalence, further supporting the rational for diet and lifestyle intervention studies in asthma based on whole dietary patterns and physical activity.