Pre- and post-COVID practice of interventional pulmonology in adults in Portugal.

INTRODUCTION AND OBJECTIVES: There is a lack of information regarding bronchoscopy practice in adults in Portugal. Our objective was to obtain an overview of the characteristics, resources, techniques and behaviors in national interventional pulmonology (IP) units, before and after SARS-CoV-2 outbreak. MATERIALS AND METHODS: An online survey was developed by an expert panel with a total of 46 questions comprising the specifications of each unit, namely physical space, equipment, staff, procedure planning, monitoring, technical differentiation, and numbers pre- and post-COVID-19. Forty-one interventional pulmonology centers were invited to participate between April and May 2021. RESULTS: 37 units (90.2%) responded to the survey. The majority (64.9%) have a fully dedicated space with a weekly presence of ≥3 chest physicians (82.1%) and support of an anesthesiologist on specific days (48.6%). There is marked heterogeneity in the IP unit's equipment, and 56.8% acquired disposable bronchoscopes after COVID-19 pandemics. Pre-bronchoscopy hemogram, platelet count and coagulation tests are regularly asked by more than 90% of the units, even when deep sedation or biopsies are not planned. In 97.3% of cases, topical anesthesia and midazolam are utilized. Propofol (21.6%) and fentanyl (29.7%) are occasionally employed in some institutions. Most units use ancillary sampling techniques to diagnose central or peripheral lesions, with radial EBUS being used for guidance of distal procedures in 37.8% of centers, linear EBUS and EUS-B-FNA for mediastinal diagnosis and/or staging in 45.9% and 27.0% of units, respectively. Cryobiopsies are used by 21.6% of respondents to diagnose diffuse lung diseases. Rigid bronchoscopy is performed in 37.8% of centers. There was a decrease in the number of flexible (p < 0.001) and rigid (p = 0.005) bronchoscopies and an upscale of personal protective equipment (PPE) during the COVID-19 outbreak. CONCLUSIONS: IP units have variable bronchoscopic practices, but during the COVID-19 pandemic, they complied with most international recommendations, as elective procedures were postponed and PPE levels increased.

Utility of stent double palliation for esophageal cancer with airway involvement: the extremis of care.

Primary esophageal cancer (EC) frequently presents as a locally advanced disease with airway involvement. Placement of combined esophageal and airway stents has been reported in small series to be an effective palliation strategy. Our aims are to present the largest cohort of EC patients who underwent double stent palliation and to evaluate the safety and efficacy of this approach. Longitudinal cohort study of patients with primary EC undergoing two-stage esophageal and airway stent placement at an oncology referral institute (January 2000-January 2019). Assessments: baseline demographics and clinical variables; baseline and week 2 dysphagia, dyspnea and performance status (PS) scores; baseline and week 8 body mass index (BMI); overall survival. Statistics: paired t-test; Kaplan-Meier method. Seventy patients (89% men, mean age 60.20 ± 8.41) underwent double stenting. Esophageal stent was placed for esophageal stenosis and dysphagia (n = 41; placement of a second stent due to recurrence in nine cases) or esophagorespiratory fistulas (ERFs) (n = 29); airway stent was required for ERF sealing (n = 29 + 7 new ERFs after esophageal stent) and to ensure airway patency due to malignant stenosis (n = 29; placement of a second stent due to recurrence in 13 cases) or compression (n = 5). There were 13, endoscopically managed, major complications after esophageal stent [hemorrage (n = 1), migration (n = 5) and new fistulas (n = 7)]. As for airway stents, four major complications were recorded [hemorrage (n = 1) and three deaths due to respiratory infection and ultimately respiratory failure 3-7 days after the procedure]. Overall, patients showed significant improvement in dysphagia and dyspnea symptoms (3.21 vs. 1.31 e 15.56 vs. 10.87; P < 0.001). There was a PS improvement for 89.2% (n = 58) of the patients. BMI at week 8 was comparable to baseline records. Mean survival was 137.83 ± 24.14 days (95% CI: 90.51-185.15). Survival was longer for better PS (PS1, 249.95 days; PS2, 83.74 days; PS3, 22.43 days; PS4, 30.00 days). This is the largest comprehensive assessment of double stent palliation in advanced incurable EC. For both esophageal or airway stenosis and fistula, placement of combined esophageal and airway stents was a feasible, effective, fast-acting and safe modality for symptom palliation and body mass maintenance. Patient autonomy followed symptom improvement. Since it is impossible to provide treatment for cure in most of these cases, this endoscopic strategy, performed in differentiated units with the required technical capacity, may guarantee treatment for the relief of palliative EC.

Surveillance Training for Ebola Preparedness in Côte d'Ivoire, Guinea-Bissau, Senegal, and Mali.

The 2014-2015 epidemic of Ebola virus disease in West Africa primarily affected Guinea, Liberia, and Sierra Leone. Several countries, including Mali, Nigeria, and Senegal, experienced Ebola importations. Realizing the importance of a trained field epidemiology workforce in neighboring countries to respond to Ebola importations, the Centers for Disease Control and Prevention Field Epidemiology Training Program unit implemented the Surveillance Training for Ebola Preparedness (STEP) initiative. STEP was a mentored, competency-based initiative to rapidly build up surveillance capacity along the borders of the at-risk neighboring countries Côte d'Ivoire, Mali, Senegal, and Guinea-Bissau. The target audience was district surveillance officers. STEP was delivered to 185 participants from 72 health units (districts or regions). Timeliness of reporting and the quality of surveillance analyses improved 3 months after training. STEP demonstrated that mentored, competency-based training, where learners attain competencies while delivering essential public health services, can be successfully implemented in an emergency response setting.

Key Ethical Issues Discussed at CDC-Sponsored International, Regional Meetings to Explore Cultural Perspectives and Contexts on Pandemic Influenza Preparedness and Response.

BACKGROUND: Recognizing the importance of having a broad exploration of how cultural perspectives may shape thinking about ethical considerations, the Centers for Disease Control and Prevention (CDC) funded four regional meetings in Africa, Asia, Latin America, and the Eastern Mediterranean to explore these perspectives relevant to pandemic influenza preparedness and response. The meetings were attended by 168 health professionals, scientists, academics, ethicists, religious leaders, and other community members representing 40 countries in these regions. METHODS: We reviewed the meeting reports, notes and stories and mapped outcomes to the key ethical challenges for pandemic influenza response described in the World Health Organization's (WHO's) guidance, Ethical Considerations in Developing a Public Health Response to Pandemic Influenza: transparency and public engagement, allocation of resources, social distancing, obligations to and of healthcare workers, and international collaboration. RESULTS: The important role of transparency and public engagement were widely accepted among participants. However, there was general agreement that no "one size fits all" approach to allocating resources can address the variety of economic, cultural and other contextual factors that must be taken into account. The importance of social distancing as a tool to limit disease transmission was also recognized, but the difficulties associated with this measure were acknowledged. There was agreement that healthcare workers often have competing obligations and that government has a responsibility to assist healthcare workers in doing their job by providing appropriate training and equipment. Finally, there was agreement about the importance of international collaboration for combating global health threats. CONCLUSION: Although some cultural differences in the values that frame pandemic preparedness and response efforts were observed, participants generally agreed on the key ethical principles discussed in the WHO's guidance. Most significantly the input gathered from these regional meetings pointed to the important role that procedural ethics can play in bringing people and countries together to respond to the shared health threat posed by a pandemic influenza despite the existence of cultural differences.

Modelling zinc changes at the hippocampal mossy fiber synaptic cleft.

Zinc, a transition metal existing in very high concentrations in the hippocampal mossy fibers from CA3 area, is assumed to be co-released with glutamate and to have a neuromodulatory role at the corresponding synapses. The synaptic action of zinc is determined both by the spatiotemporal characteristics of the zinc release process and by the kinetics of zinc binding to sites located in the cleft area, as well as by their concentrations. This work addresses total, free and complexed zinc concentration changes, in an individual synaptic cleft, following single, short and long periods of evoked zinc release. The results estimate the magnitude and time course of the concentrations of zinc complexes, assuming that the dynamics of the release processes are similar to those of glutamate. It is also considered that, for the cleft zinc concentrations used in the model (≤ 1 µM), there is no postsynaptic zinc entry. For this reason, all released zinc ends up being reuptaken in a process that is several orders of magnitude slower than that of release and has thus a much smaller amplitude. The time derivative of the total zinc concentration in the cleft is represented by the difference between two alpha functions, corresponding to the released and uptaken components. These include specific parameters that were chosen assuming zinc and glutamate co-release, with similar time courses. The peak amplitudes of free zinc in the cleft were selected based on previously reported experimental cleft zinc concentration changes evoked by single and multiple stimulation protocols. The results suggest that following a low amount of zinc release, similar to that associated with one or a few stimuli, zinc clearance is mainly mediated by zinc binding to the high-affinity sites on the NMDA receptors and to the low-affinity sites on the highly abundant GLAST glutamate transporters. In the case of higher zinc release brought about by a larger group of stimuli, most zinc binding occurs essentially to the GLAST transporters, having the corresponding zinc complex a maximum concentration that is more than one order of magnitude larger than that for the high and low affinity NMDA sites. The other zinc complexes considered in the model, namely those formed with sites on the AMPA receptors, calcium and KATP channels and with ATP molecules, have much smaller contributions to the synaptic zinc clearance.

Outcome and complications of chronically implanted subdural electrodes for the treatment of medically resistant epilepsy.

BACKGROUND: Surgery for medically resistant epilepsy is safe and effective. However, when noninvasive techniques are insufficient, then consideration is given to invasive electrocorticography (EcoG). OBJECTIVE: The aim of the study was to analyze results and complications of subdural electrodes placement in the treatment of intractable epilepsy. METHODS: Ninety-one consecutive patients who underwent placement of subdural electrodes (1999-2010) were considered for this study. All patients underwent a standardized pre-operative evaluation. Invasive subdural electrode placement was considered when there were inadequate ictal recordings, there was discordance between EEG and neuroimaging or the epileptogenic zone was localized near eloquent cortex. RESULTS: Resective epilepsy surgery was performed in 70/91 patients (76.9%). Twenty-four out of seventy (34.3%) who underwent surgical resection were seizure-free (CL-I) at last follow-up. A statistical evaluation revealed a very strong trend for patients with positive lesional pre-operative MRI to have improved outcomes compared to normal brain MRI population (p=.028). There were 10 surgical related complications (11%), but no mortality or permanent morbidity. Statistical analysis demonstrated that placement of a subdural grid in any combination was statistically significant (p=.01) for surgical complications. CONCLUSIONS: Invasive monitoring is a useful and necessary technique for the surgical treatment of intractable epilepsy. Careful surveillance is required during the monitoring period especially when the patient has undergone large subdural grid placement. A good working hypothesis can minimize complications and achieve better outcomes.

Diagnostic flexible bronchoscopy and accessory techniques.

We reviewed the most important diagnostic procedures implemented by means of flexible bronchoscopy, including bronchoalveolar lavage, bronchial brushing and biopsy, transbronchial lung biopsy and transbronchial needle aspiration. We reviewed the tools, techniques and potential complications of this examination.

Fobia social em uma amostra de adolescentes / Social phobia in a sample of adolescents

Este estudo relata a prevalência e o impacto na escolaridade da fobia social em uma amostra de adolescentes da cidade de São Paulo, SP, Brasil. O Inventário de Fobia Social (SPIN) foi administrado em 116 estudantes adolescentes de 5ª, 6ª, 7ª e 8ª séries de ambos os sexos. A prevalência da fobia social foi de 7,8 por cento na amostra de adolescentes, com maior incidência entre estudantes do sexo feminino, com idade entre 12 e 15. O impacto negativo na escolaridade foi grande, aproximadamente 89 por cento dos adolescentes com fobia social repetiram o ano na escola ao menos uma vez.

This study reports the prevalence and the impact in the education of social phobia in a sample of adolescents of the city of São Paulo, SP, Brazil. The Social Phobia Inventory (SPIN) was administrated to 116 students of 5th, 6th, 7th and 8th grades of both sexes. The prevalence of the social phobia was 7.8 percent in the sample of adolescents, with higher incidence among female students, between 12 and 15 years old. The negative impact on the education was great, approximately 89 percent of the adolescents with social phobia repeated the year in the school at least one time.

Fobia social em uma amostra de adolescentes / Social phobia in a sample of adolescents

Este estudo relata a prevalência e o impacto na escolaridade da fobia social em uma amostra de adolescentes da cidade de São Paulo, SP, Brasil. O Inventário de Fobia Social (SPIN) foi administrado em 116 estudantes adolescentes de 5ª, 6ª, 7ª e 8ª séries de ambos os sexos. A prevalência da fobia social foi de 7,8 por cento na amostra de adolescentes, com maior incidência entre estudantes do sexo feminino, com idade entre 12 e 15. O impacto negativo na escolaridade foi grande, aproximadamente 89 por cento dos adolescentes com fobia social repetiram o ano na escola ao menos uma vez.(AU)

This study reports the prevalence and the impact in the education of social phobia in a sample of adolescents of the city of São Paulo, SP, Brazil. The Social Phobia Inventory (SPIN) was administrated to 116 students of 5th, 6th, 7th and 8th grades of both sexes. The prevalence of the social phobia was 7.8 percent in the sample of adolescents, with higher incidence among female students, between 12 and 15 years old. The negative impact on the education was great, approximately 89 percent of the adolescents with social phobia repeated the year in the school at least one time.(AU)

A simple intra-operative maneuver to decrease a duodenal ulcer hemorrhage temporarily: description and anatomical bases.

Intraoperative hemostatic suture to treat a bleeding duodenal ulcer is sometimes difficult when there is massive hemorrhage. The aims of this paper are: (1) to describe a practical and easy intraoperative procedure which quickly decreases a massively bleeding duodenal ulcer, allowing the surgeon to identify the bleeding site clearly and obtain definitive hemostasis by suturing the involved vessels with a low risk of common bile duct lesion; and (2) to study in cadavers the anatomical basis of this surgical procedure already successfully performed on patients. Fourteen patients with massive duodenal ulcer bleeding, after unsuccessful endoscopic hemostasis, were operated on and included in this study. After surgical anterior gastroduodenotomy, the surgeon introduced a finger in a downward and forward direction in the bursa omentalis vestibule through the omental foramen. This simple and quick procedure decreased hemorrhage by compressing the gastroduodenal artery against the first part of the posterior surface of the duodenum. Twenty-four fresh blocks of normal tissue were removed from cadavers and were injected with silicone rubber through the common hepatic artery. The distance between the gastroduodenal artery and the omental foramen was measured. With this maneuver the surgeon can clearly see the exact bleeding site and perform an adequate suture with a minor risk of common bile duct lesion.

Measurement of presynaptic zinc changes in hippocampal mossy fibers.

The hippocampal mossy fiber terminals of CA3 area contain high levels of vesicular zinc that is released in a calcium-dependent way, following high-frequency stimulation. However the properties of zinc release during normal synaptic transmission, paired-pulse facilitation and mossy fiber long-term potentiation are still unknown. Using the fluorescent zinc probe N-(6-methoxy-8-quinolyl)-para-toluenesulfonamide, we measured fast mossy fiber zinc changes indicating that zinc is released following single and low levels of electrical stimulation. The observed presynaptic zinc signals are maintained during the expression of mossy fiber long-term potentiation, assumed to be mediated by an increase in transmitter release, and are enhanced during paired-pulse facilitation. This zinc enhancement is, like paired-pulse facilitation, reduced during established long-term potentiation. The correlation between the paired-pulse evoked zinc and field potential responses supports the idea that zinc is co-released with glutamate.

Evaluation of SNOMED3.5 in representing concepts in chest radiology reports: integration of a SNOMED mapper with a radiology reporting workstation.

Standardized medical terminologies are gaining importance in the representation of medical data. In this paper, we present the evaluation of the SNOMED3.5 medical terminology to code concepts routinely used in chest radiology reports. Integration of this terminology mapper into a radiology reporting workstation that incorporates a speech recognition system and a natural language processor is also discussed. A total of 700 anatomical location terms (including synonyms) were tested and 72% of the terms had corresponding SNOMED terms. Of the 28% that did not result in a match, 16% were either morphological variants of SNOMED terms or could be found from a combination of terms from two or more SNOMED axes. Only 12% of the terms (primarily specialized radiology terms) were concepts not actually included in the SNOMED terminology.

Interactive software for generation and visualization of structured findings in radiology reports.

OBJECTIVE: Our objectives were to develop a user-friendly graphic interface for a module that integrates traditional radiology reporting, natural language processing, and editing capabilities; to facilitate the structuring of radiology reports as part of routine clinical practice; to use a commercial speech recognition module for online transcription; and to implement the module in a hardware-independent environment. CONCLUSION: After implementation, the module was tested with 150 chest radiology reports by two radiologists and assessed for ease of use and accuracy. Overall, accuracy was close to 90% and user satisfaction was high. When radiology reports are structured as a part of routine clinical practice, it is possible to accomplish intelligent indexing and retrieval to facilitate teaching and research.

Teleradiology as a foundation for an enterprise-wide health care delivery system.

An effective, integrated telemedicine system has been developed that allows (a) teleconsultation between local primary health care providers (primary care physicians and general radiologists) and remote imaging subspecialists and (b) active patient participation related to his or her medical condition and patient education. The initial stage of system development was a traditional teleradiology consultation service between general radiologists and specialists; this established system was expanded to include primary care physicians and patients. The system was developed by using a well-defined process model, resulting in three integrated modules: a patient module, a primary health care provider module, and a specialist module. A middle agent layer enables tailoring and customization of the modules for each specific user type. Implementation by using Java and the Common Object Request Broker Architecture standard facilitates platform independence and interoperability. The system supports (a) teleconsultation between a local primary health care provider and an imaging subspecialist regardless of geographic location and (b) patient education and online scheduling. The developed system can potentially form a foundation for an enterprise-wide health care delivery system. In such a system, the role of radiologist specialists is enhanced from that of a diagnostician to the management of a patient's process of care.

Improving the quality of care through routine teleradiology consultation.

RATIONALE AND OBJECTIVES: The hypotheses of this study were as follows: (a) University subspecialty radiologists can provide consultations effectively to general radiologists as part of routine clinical operations; (b) these consultations will improve the quality of the final radiologic report; and (c) the consultations will improve the care process and may save money, as well. MATERIALS AND METHODS: For 2,012 consecutive computed tomographic or magnetic resonance (MR) imaging studies, the initial interpretations provided by radiology generalists were subsequently reviewed by specialists, with a final consensus report available. "Truth" was established by final consensus reports. To control for potential bias, 150 adult MR imaging and 250 pediatric radiologic studies were interpreted initially by specialists and then by generalists. Again, truth was established by final consensus reports. RESULTS: There was disagreement between generalist and specialist radiologist interpretations in 427 (21.2%) of the cases reviewed. These disagreements were stratified further by independent specialists, who graded them as important, very important, or unimportant. Differences were considered important or very important in 99% of the cases reviewed. CONCLUSION: Consultations by subspecialty radiologists improved the quality of the radiology reports studied and, at least in some cases, improved the process of care by eliminating unnecessary procedures or suggesting more specific follow-up examinations. The consultation services can be provided cost-effectively from the payer's perspective and may save additional costs when unnecessary procedures can be eliminated.

Case-based explanation of non-case-based learning methods.

We show how to generate case-based explanations for non-case-based learning methods such as artificial neural nets or decision trees. The method uses the trained model (e.g., the neural net or the decision tree) as a distance metric to determine which cases in the training set are most similar to the case that needs to be explained. This approach is well suited to medical domains, where it is important to understand predictions made by complex machine learning models, and where training and clinical practice makes users adept at case interpretation.

Initial experiences with building a health care infrastructure based on Java and object-oriented database technology.

A multi-tiered telemedicine system based on Java and object-oriented database technology has yielded a number of practical insights and experiences on their effectiveness and suitability as implementation bases for a health care infrastructure. The advantages and drawbacks to their use, as seen within the context of the telemedicine system's development, are discussed. Overall, these technologies deliver on their early promise, with a few remaining issues that are due primarily to their relative newness.

Process models for telehealth: an industrial approach to quality management of distant medical practice.

Process modeling is explored as an approach for prospectively managing the quality of a telemedicine/telehealth service. This kind of prospective quality management is more appropriate for dynamic health care environments compared to traditional quality assurance programs. A vector model approach has also been developed to match a process model to the needs of a particular site.