Performance of risk scores in patients with acute exacerbations of COPD.

OBJECTIVE: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. METHODS: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. RESULTS: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. CONCLUSIONS: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

Sinusitis and Late-Onset Asthma: A Red Flag of Eosinophilic Granulomatosis With Polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic disease that develops with necrotizing granulomatous inflammation and is characterized by eosinophilia, asthma, and small vessel vasculitis. We report the case of a 74-year-old woman with a history of asthma, admitted to the Emergency Room with fever, headache, general malaise, weight loss and night sweats with one-month evolution, previously medicated with antibiotics without improvement. She presented with sinus palpation tenderness and lower leg bilateral sensitivity impairment. Laboratory tests showed neutrophilia and eosinophilia, normocytic anemia and elevated erythrocyte sedimentation rate and C-reactive protein. A computed tomography revealed sphenoid and maxillary sinusitis. Blood cultures and lumbar puncture were innocent. An extended autoimmune panel exposed a strong positive perinuclear anti-neutrophil cytoplasmic antibody - myeloperoxidase (pANCA-MPO). Sinus biopsy showed tissue infiltration by eosinophils, confirming EGPA. Corticosteroid (1 mg/kg/day) treatment was started with gradual improvement. Six months later there were no signs of active disease under prednisolone 10 mg and azathioprine 50 mg/day. This case highlights that refractory sinusitis in the presence of constitutional syndrome and peripheral eosinophilia should alert clinicians to the possibility of EGPA, particularly in patients with late-onset asthma.

Performance of risk scores in patients with acute exacerbations of COPD / Desempenho de escores de risco em pacientes com exacerbações agudas da DPOC

ABSTRACT Objective: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. Methods: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. Results: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. Conclusions: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

RESUMO Objetivo: As exacerbações agudas da DPOC (EADPOC) são causas comuns de hospitalização. Vários escores foram propostos para classificar o risco de deterioração clínica ou mortalidade em pacientes hospitalizados com EADPOC. Buscamos investigar se escores de deterioração clínica e mortalidade no momento da admissão podem prever eventos adversos durante a hospitalização e após a alta de pacientes com EADPOC. Métodos: Realizamos um estudo retrospectivo a respeito de pacientes admitidos com EADPOC. O National Early Warning Score 2 (NEWS2), o NEWS288-92%, o escore Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF, Dispneia, Eosinopenia, Consolidação, Acidemia e Fibrilação atrial) e o escore DECAF modificado (DECAFm) foram calculados no momento da admissão. Avaliamos a sensibilidade, a especificidade e o desempenho geral dos escores quanto aos seguintes desfechos: mortalidade hospitalar; necessidade de ventilação mecânica invasiva ou ventilação não invasiva (VNI); longas internações hospitalares; readmissões hospitalares e futuras AECOPD. Resultados: Incluímos 119 pacientes admitidos com EADPOC. A mediana da idade foi de 75 anos, e 87,9% eram do sexo masculino. O NEWS288-92% associou-se a uma redução de 8,9% no número de indivíduos classificados em pacientes com necessidade de observação atenta e contínua, sem aumento do risco de morte no grupo de indivíduos classificados em pacientes de baixo risco. O NEWS288-92% e o NEWS2 foram considerados adequados para prever a necessidade de VNI aguda e internações hospitalares mais longas. O DECAF e o DECAFm foram considerados melhores em prever a mortalidade hospitalar do que o NEWS2 e o NEWS288-92%. Conclusões: Em comparação com o NEWS2, o NEWS288-92% reduz com segurança a necessidade de monitoramento clínico em pacientes com EADPOC. O NEWS2 e o NEWS288-92% aparentemente são bons preditores do tempo de internação hospitalar e da necessidade de VNI, mas não substituem o DECAF e o DECAFm como preditores de mortalidade.

Healthcare Responses to Gender-Based Violence in Timor-Leste: Women Want Empathy, Information and Safety From an Integrated Support System.

Healthcare providers are one of the first professionals women are likely to come into contact with after experiencing violence as they seek care for injuries and associated health problems or in routine care such as reproductive health services. Systematic reviews of women's experiences and expectations when disclosing abuse in health settings reveal a dearth of research with women in low-income countries and from rural areas. The aim of this study was to understand the information and interventions women who have experienced domestic violence or sexual assault want from their health providers in Timor-Leste, a country with a largely rural population and very high rates of violence against women. The mixed-methods study consisted of in-depth qualitative interviews with 28 women survivors of violence, followed by a 'pile-sort' activity in which they rated their preference for different types of interventions they wanted from their healthcare provider. The pile-sort activity showed the highest-ranked interventions centred around emotional support, information and safety, the middle-ranked interventions centred around empowering women and playing an advocacy role, and the lowestranked interventions were around intervening at the relationship level and mandatory reporting to the police. The qualitative interviews provided rich insights that affirmed women value empathy and kindness from service providers, they want to be supported to make their own decisions and the importance of formal as well as informal sources of support such as community leaders and family. There are significant implications for the content of existing training programmes on gender-based violence in Timor-Leste and similar contexts, particularly the need to build capacity on how to respond in an empathic and empowering way and how to balance mandatory reporting obligations, while also practising woman-centred care and providing the kind of support women value.Abstratu TetunFornesedór kuidadu saúde nuudar profisionál dahuluk ida ne'ebé iha posibilidade atu halo kontaktu ho feto sira depoiz de hetan violénsia tanba sira buka tratamentu ba kanek no problema saúde ne'ebe iha ligasaun ka iha kuidadu rutina sira hanesan servisu saúde reprodutiva nian. Estudu sistemátiku kona-ba feto sira nia esperiénsia no espetativa bainhira fósai abuzu iha kontestu saúde nian dehan katak ladun barak peskiza ho feto sira iha nasaun ho rendimentu kiik no husi área rurál sira. Estudu ida nee ezamina informasaun no intervensaun feto sira neebé hetan violénsia doméstika ka asaltu seksuál sira nia hakarak hosi fornesedor saúde iha Timor-Leste, nasaun ida neebé ho populasaun rurál barak no númeru ne'ebe mak aas tebes hosi violénsia hasoru feto. Métodu estudu mistura ne'ebé kompostu hosi entrevista kualitativa profundu ho sobrevivente feto na'in 28 ne'ebé sofre violénsia, tuir fali ho atividade 'pile sort' iha ne'ebé sira klasifika sira nia preferénsia ba tipu intervensaun ne'ebé diferente. Atividade pile sort hatudu intervensaun sira ne'ebé hetan klasifikasaun boot liu mak iha apoiu emosionál, informasaun no seguransa, intervensaun ho klasifikasaun médiu foka liu ba empoderamentu feto no hala'o papél advokasia, no intervensaun ho klasifikasaun kik liu mak iha intervensaun iha nivel relasaun, no keixa obrigatóriu (mandatory reporting) ba iha polisia. Entrevista kualitativu fórnese persepsaun barak ne'ebe feto sira koalia sai kona-ba sira nia valor empatia no laran-di'ak hosi prestadór servisu, sira hakarak atu hetan apoia atu halo desizaun rasik, no importánsia husi fonte formal no mos informál sira nia apoiu, hanesan lider komunitáriu no família. Iha implikasaun signifikativu ba konteúdu programa formasaun ne'ebé eziste kona-ba violénsia bazeia ba jéneru iha Timor-Leste no kontextu ne'ebe mak hanesan, liu-liu presiza atu hasa'e kapasidade kona-ba oinsá atu responde ho maneira empatia no empodera feto sira no oinsa halo balansu obrigasaun relatóriu mandatóriu (mandatory reporting) enkuantu mós prátika kuidadu feto sira no fornese apoiu ne'ebe mak iha valor ba feto sira.DisclaimerReaders should be aware that this article contains stories of trauma and abuse that some people may find difficult to read. If you experience any distress or something similar has happened or is happening to you, there are support services available in most countries. If you are in Timor-Leste, where this research was conducted, the following website has a list of services and contact details to get further assistance www.hamahon.tl.Nota: Le nain sira tenke hatene katak artigu ida ne'e kontein istória trauma no abuzu ne'ebé ema balun dalaruma sente defisil atu lee. Karik ita boot esperiensia difikuldade ruma ka iha esperiensia ruma neebé hanesan akontese ona ka akontese hela ba ita boot, iha servisu apoiu neebé mka disponivel iha nasaun barak. Karik ita boot hela iha Timor-Leste, iha nasaun ne'ebé hala'o peskiza ida ne'e, website tuir mai ne'e iha lista servisu no kontaktu detallu hodi hetan liu tan asisténsia www.hamahon.tl.

Preliminary findings on the gastrointestinal parasites of the brown bear (Ursus arctos) in the Cantabrian mountains, Spain.

No study is currently available on the parasitofauna of the population of brown bears (Ursus arctos) inhabiting the Cantabrian Mountains in Spain. The aim of the present study was to obtain novel information on diversity and prevalence of gastrointestinal parasites in these individuals. During August 2016 and from May to July 2017, 14 fecal samples were collected from the western Cantabrian bear subpopulation, in the Somiedo Natural Park, in the Spanish province of Asturias. The prevalence of parasites detected was 71% and two genera were identified: Dicrocoelium sp. and Trichuris sp. Since the impact that pathogens such as endoparasites can have on the health of bears, together with other stressors, is still poorly understood, research efforts that include disease surveillance are critical to the successful protection of this emblematic species. Our preliminary findings require further investigations, with a wider sampling effort, and bring awareness for the need of carrying further studies on this area as a part of a proactive species management plan.

Implementation of Mini-FLOTAC in Routine Diagnosis of Coccidia and Helminth Infections in Domestic and Exotic Birds.

Mini-FLOTAC (MF) has recently been proposed for the fecal quantification of gastrointestinal (GI) parasites in birds due to its higher sensitivity and precision in comparison with the McMaster method. The current research aimed to test the use of MF in routine diagnosis of coccidia and helminth infections in several domestic and exotic bird collections in Portugal. Between July 2020 and April 2021, a total of 142 fecal samples from organic layers, peacocks and ratites were collected in four Portuguese bird collections and processed using MF and fecal cultures to identify and calculate GI parasite shedding and prevalence. The McMaster method was also used to compare the shedding levels obtained for both quantitative techniques. MF's relative sensitivity and specificity were also assessed, using McMaster as the reference technique. The implementation of MF resulted in an average Eimeria spp. shedding higher in peacocks from bird collection 2 (502 OPG), followed by peacocks from collection 1 (107 OPG) and organic layers (24 OPG) and peacocks from collection 3 (9 OPG). Peacocks were also positive for Capillaria spp., Trichostrongylus tenuis and Strongyloides pavonis, whereas ostriches and emus were infected by L. douglassii. The MF protocol for exotic animals and the McMaster method did not differ significantly for each parasitic agent and bird species, and MF achieved relative sensitivities and specificities higher than 70% for Galliform Eimeria spp., peacock helminths and ratites' L. douglassii infections. Higher L. douglassii EPG values were identified using the MF protocol for exotic species (2 g of feces/38 mL of sucrose solution), followed by McMaster 2/28, MF 5/45 and MF 2/18. The use of MF allowed for obtaining different intestinal parasitic populations in several bird species and locations, and MF 2/38 is globally proposed as the most suitable protocol for bird fecal samples as an alternative to the McMaster method in the diagnosis of avian intestinal parasitic infections.

Comparative survey of gastrointestinal parasites in sympatric Iberian ibex (Capra pyrenaica) and domestic goats using molecular host specific identification.

An isolated population of several hundred Iberian ibex (Capra pyrenaica) inhabits the Gerês-Xurés Transboundary Biosphere Reserve (GXTBR) in north-western Iberian Peninsula, in partial sympatry with tens of thousands domestic goats (Capra hircus). This study aimed to assess the prevalence and shedding intensity of gastrointestinal parasites from sympatric herds of domestic goat and Iberian ibex in autumn 2018. A total of 93 pooled faecal samples were collected from GXTBR (39 from domestic goats and 54 from Iberian ibex) and the host species was identified using molecular techniques, whenever defecation was not visualised in the field. Parasitological analysis was achieved by joint Willis flotation/sedimentation, McMaster and Mini-FLOTAC techniques. Seventy-two samples (25 domestic goats and 47 Iberian ibex) were retained for analysis after discarding the least fresh and those with uncertain specific identification. Generalized linear mixed models compared prevalence and shedding intensity between caprine species. Domestic goats showed a non-significant tendency to be more parasitized than Iberian ibex, as assessed by overall prevalence (100.0%, CI95 86.7-100.0 vs. 74.5%, CI95 69.5-84.8), and shedding intensity. This study reveals a similar community of gastrointestinal parasites in an abundant livestock species and an isolated population of wild caprine, living in partial sympatry. It is the first study on the health status of this endangered Iberian ibex population, in close contact with livestock, highlighting the need for further sanitary surveillance.

Prevalência do burnout nos enfermeiros: estudo numa equipe de urgência hospitalar / Prevalence of burnout in nurses: study in a hospital emergency team

A síndrome de burnout é um fenómeno prevalente nos cuidados de saúde nos dias atuais, considerada como um estado de esgotamento físico e mental causado pelo exercício de uma atividade profissional, é reconhecida como um constructo multidimensional com diversas implicações negativas quer a nível individual, quer a nível organizacional, sendo considerada característica das "profissões de ajuda", nomeadamente nos enfermeiros. A presente investigação intitulada "Prevalência do burnout nos enfermeiros: estudo numa equipe de urgência hospitalar" teve como objetivos orientadores: 1) proceder à caracterização sociodemográfica e profissional do trabalho dos enfermeiros de um serviço de urgência; 2) avaliar dos níveis de burnout dos enfermeiros de um serviço de urgência; e, 3) explorar do efeito das variáveis sociodemográficas e profissionais nos níveis de burnout dos enfermeiros de um serviço de urgência. Uma amostra de 102 enfermeiros participou neste estudo de natureza transversal, com uma abordagem do tipo quantitativo, exploratório, descritivo e correlacional. Os participantes responderam a dois instrumentos de recolha de dados: 1) um Questionário Sociodemográfico e Profissional; e, 2) a versão portuguesa da Medida de Burnout de Shirom-Melamed (MBSM; tradução e adaptação de Gomes, 2012). Os resultados obtidos evidenciam que a Fadiga Física (33,3%; n = 34) constituiu a componente mais prevalente nestes participantes, seguida da Fadiga Cognitiva (13,7%; n = 14), da Exaustão Emocional (6,9%; n = 7), e por fim, 6,9 % (n = 7) dos enfermeiros apresentaram níveis moderados a elevados de burnout (Burnout-Total ≥ 5). Constatou-se existir uma associação negativa, estatisticamente significativa, entre a média mensal de turnos de trabalho realizada ao fim-de-semana/feriados e os níveis de Fadiga Cognitiva (p = - 0,23) e Burnout-Total (p = - 0,28). Ainda, ao nível da Fadiga Física evidenciou-se níveis elevados de burnout nos participantes do sexo feminino (M = 4,47; DP = 1,15; Mdn = 4,75; n = 68); nos que não possuíam hobby/atividades de lazer (M = 4,74; DP = 1,20; Mdn = 5,00; n = 31); e nos que não praticavam exercício físico (M = 4,69; DP = 1,12; Mdn = 5,00; n = 47). Ao nível da Fadiga Cognitiva, os participantes que não praticavam exercício físico (M = 3,80; DP = 1,44; Mdn = 4,00; n = 47) e os que possuíam o 1º ciclo de estudos (M = 3,53; DP = 1,30; Mdn = 3,40; n = 68) acusavam maiores níveis de burnout. Ao nível da Exaustão Emocional, os participantes que não praticavam exercício físico (M = 3,06; DP = 1,41; Mdn = 2,67; n = 47) apresentavam maiores níveis de burnout. Na medida global de burnout (Burnout-Total), os participantes que exibiram maiores níveis de burnout foram os participantes do sexo feminino (M = 3,58, DP = 1,09); os que não possuíam hobby/atividades de lazer (M = 3,74; DP = 1,14); os que não praticavam exercício físico (M = 3,85; DP = 1,12); e os que detinham o 1º ciclo de estudos (M = 3,55; DP = 1,01). Verificou-se ainda, que as habilitações académicas (p = 0,046) e a prática de exercício físico (p = 0,001) foram fatores preditores significativos dos níveis de burnout. Conclui-se que os participantes deste estudo empírico, que trabalham num serviço de urgência, onde todos os dias lidam com situações complexas de tomada rápida de decisão clínica, apresentam níveis de burnout que são merecedores de atenção. Sugere-se a importância da realização de futuros estudos, contemplando a avaliação das fontes de stress e a adoção de estratégias de intervenção e/ou prevenção do burnout dirigidas aos enfermeiros e à organização. Como futura enfermeira especialista é expectável a vigilância e controlo dos níveis de burnout, que permitirá uma contínua reflexão e atualização do fenómeno, podendo criar estratégias de intervenção/prevenção face a esta problemática, para que os enfermeiros possam prestar melhores cuidados de saúde com maior segurança, e de qualidade dos mesmos, à pessoa em situação crítica.

The burnout syndrome is a prevalent phenomenon in health care today, considered as a state of physical and mental exhaustion caused by the exercise of a professional activity, it is recognized as a multidimensional construct with a panoply of negative implications both at the individual level, or at the organizational level, being considered characteristic of the "help professions", namely in nurses. The present investigation entitled "Prevalence of burnout in nurses: study in a hospital emergency team" had as its guiding objectives: 1) to proceed to the sociodemographic and professional characterization of the work of nurses in an emergency service; 2) to assess the burnout levels of nurses in an emergency department; and, 3) explore the effect of sociodemographic and professional variables on the burnout levels of nurses in an emergency department. A sample of 102 nurses participated in this cross-sectional study, with a quantitative, exploratory, descriptive and correlational approach. Participants answered two data collection instruments: 1) a Sociodemographic and Professional Questionnaire; and, 2) the Portuguese version of the Shirom-Melamed Burnout Measure (MBSM; translation and adaptation by Gomes, 2012). The results obtained show that Physical Fatigue (33,3%; n = 34) was the most prevalent component in these participants, followed by Cognitive Fatigue (13,7%; n = 14), Emotional Exhaustion (6,9%; n = 7), and finally, 6,9% (n = 7) of nurses had moderate to high levels of burnout (Burnout-Total ≥ 5). There was a negative, statistically significant association between the monthly average of work shifts carried out at weekends/holidays and the levels of Cognitive Fatigue (p = - 0,23) and Burnout-Total (p = - 0,28). Still, at the level of Physical Fatigue, high levels of burnout were evidenced in female participants (M = 4,47; SD = 1.15; Mdn = 4,75; n = 68); in those who had no hobby/leisure activities (M = 4,74; SD = 1,20; Mdn = 5,00; n = 31); and in those who did not practice physical exercise (M = 4,69; SD = 1,12; Mdn = 5,00; n = 47). At the level of Cognitive Fatigue, participants who did not practice physical exercise (M = 3,80; SD = 1,44; Mdn = 4,00; n = 47) and those who had the 1st cycle of studies (M = 3,53; SD = 1,30; Mdn = 3,40; n = 68) showed higher levels of burnout. At the level of Emotional Exhaustion, participants who did not practice physical exercise (M = 3,06; SD = 1,41; Mdn = 2,67; n = 47) had higher levels of burnout. In the global measure of burnout (Burnout-Total), the participants who exhibited the highest levels of burnout were the female participants (M = 3,58; SD = 1,09); those who had no hobby/leisure activities (M = 3,74; SD = 1,14); those who did not practice physical exercise (M = 3,85; SD = 1,12); and those who had the 1st cycle of studies (M = 3,55; SD = 1,01). It was also found that academic qualifications (p = 0,046) and physical exercise (p = 0,001) were significant predictors of burnout levels. It is concluded that the participants of this empirical study, who work in an emergency service, where every day they deal with complex situations of rapid clinical decision-making, present burnout levels that are worthy of attention. The importance of carrying out future studies is suggested, including the assessment of sources of stress and the adoption of intervention and/or burnout prevention strategies aimed at nurses and the organization. As a future specialist nurse, surveillance and control of burnout levels are expected, which will allow continuous reflection and updating of the phenomenon, and can create intervention/prevention strategies in the face of this problem, so that nurses can provide better health care with greater safety and their quality, to the person in a critical situation.

Whipple's Disease: A Rare Cause of Malabsorption Syndrome.

INTRODUCTION: Whipple's disease is a rare, chronic, systemic disease caused by the actinomycete Tropheryma whipplei. Clinical manifestations vary widely depending on the affected system, the most common being the digestive tract. CASE PRESENTATION: The authors report the case of a 52-year-old man with malabsorption syndrome, diarrhea, marked weight loss, melanoderma, and visual and proprioception disorders. Periodic acid-Schiff staining of a proximal small bowel biopsy and peripheral-blood PCR identification of T. whipplei confirmed the disease. The patient was initially treated with intravenous ceftriaxone, followed by oral trimethoprim/sulfamethoxazole with significant clinical improvement. CONCLUSIONS: This case is reported due to its rarity and the diagnostic challenge it presents. Although uncommon, Whipple's disease should be considered as a differential diagnosis of malabsorption syndrome due to its systemic impact and possible treatment with targeted antibiotic therapy.

INTRODUÇÃO: A doença de Whipple é uma doença rara, crónica, sistémica, causada pelo actinomicete Tropheryma whipplei. As manifestações clínicas variam de acordo com o órgão envolvido, sendo a sua apresentação típica predominantemente associada ao sistema digestivo. CASO CLÍNICO: Os autores descrevem um caso de um homem de 52 anos com síndrome de má absorção, diarreia, perda de peso marcada, melanodermia, bem como alterações visuais e a nível da propriocepção. A coloração com PAS na biopsia de intestino delgado proximal e a identificação por PCR no sangue periférico confirmou a doença. Iniciou antibioterapia com ceftriaxone EV, seguida de trimetropim/sulfametoxazol oral com recuperação clínica significativa. CONCLUSÃO: Este caso é descrito pela sua raridade e pelo desafio diagnóstico. Apesar de incomum deve ser considerada como diagnóstico diferencial do síndrome de má absorção atendendo ao seu impacto sistémico e ao possível tratamento com antibioterapia dirigida.

Immunophenotyping of Peripheral Blood, Lymph Node, and Bone Marrow T Lymphocytes During Canine Leishmaniosis and the Impact of Antileishmanial Chemotherapy.

Dogs are a major reservoir of Leishmania infantum, etiological agent of canine leishmaniosis (CanL) a zoonotic visceral disease of worldwide concern. Therapeutic protocols based on antileishmanial drugs are commonly used to treat sick dogs and improve their clinical condition. To better understand the impact of Leishmania infection and antileishmanial drugs on the dog's immune response, this study investigates the profile of CD4+ and CD8+ T cell subsets in peripheral blood, lymph node, and bone marrow of sick dogs and after two different CanL treatments. Two CanL groups of six dogs each were treated with either miltefosine or meglumine antimoniate combined with allopurinol. Another group of 10 clinically healthy dogs was used as control. Upon diagnosis and during the following 3 months of treatment, peripheral blood, popliteal lymph node, and bone marrow mononuclear cells were collected, labeled for surface markers CD45, CD3, CD4, CD8, CD25, and intracellular nuclear factor FoxP3, and T lymphocyte subpopulations were immunophenotyped by flow cytometry. CanL dogs presented an overall increased frequency of CD8+ and CD4+CD8+ double-positive T cells in all tissues and a decreased frequency of CD4+ T cells in the blood. Furthermore, there was a higher frequency of CD8+ T cells expressing CD25+FoxP3+ in the blood and bone marrow. During treatment, these subsets recovered to levels similar to those of healthy dogs. Nevertheless, antileishmanial therapy caused an increase of CD4+CD25+FoxP3+ T cells in all tissues, associated with the decrease of CD8+CD25-FoxP3- T cell percentages. These findings may support previous studies that indicate that L. infantum manipulates the dog's immune system to avoid the development of a protective response, ensuring the parasite's survival and the conditions that allow the completion of Leishmania life cycle. Both treatments used appear to have an effect on the dog's immune response, proving to be effective in promoting the normalization of T cell subsets.

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste.

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Meglumine Antimoniate and Miltefosine Combined With Allopurinol Sustain Pro-inflammatory Immune Environments During Canine Leishmaniosis Treatment.

Canine leishmaniosis (CanL) caused by Leishmania infantum is a zoonotic disease of global concern. Antileishmanial drug therapies commonly used to treat sick dogs improve their clinical condition, although when discontinued relapses can occur. Thus, the current study aims to evaluate the effect of CanL treatments in peripheral blood, lymph node, and bone marrow cytokine profile associated with clinical recovery. Two groups of six dogs diagnosed with CanL were treated with miltefosine combined with allopurinol and meglumine antimoniate combined with allopurinol (MT+A and MG+A), respectively. At diagnosis and after treatment, during a 3-month follow-up, clinical signs, hematological and biochemical parameters, urinalysis results and antileishmanial antibody titers were registered. Furthermore, peripheral blood, popliteal lymph node, and bone marrow samples were collected to assess the gene expression of IL-2, IL-4, IL-5, IL-10, IL-12, TNF-α, TGF-ß, and IFN-γ by qPCR. In parallel, were also evaluated samples obtained from five healthy dogs. Both treatment protocols promoted the remission of clinical signs as well as normalization of hematological and biochemical parameters and urinalysis values. Antileishmanial antibodies returned to non-significant titers in all dogs. Sick dogs showed a generalized upregulation of IFN-γ and downregulation of IL-2, IL-4, and TGF-ß, while gene expression of IL-12, TNF-α, IL-5, and IL-10 varied between groups and according to evaluated tissue. A trend to the normalization of cytokine gene expression was induced by both miltefosine and meglumine antimoniate combined therapies. However, IFN-γ gene expression was still up-regulated in the three evaluated tissues. Furthermore, the effect of treatment in the gene expression of cytokines that were not significantly changed by infection, indicates that miltefosine and meglumine antimoniate combined therapy directly affects cytokine generation. Both combined therapies are effective in CanL treatment, leading to sustained pro-inflammatory immune environments that can compromise parasite survival and favor dogs' clinical cure. In the current study, anti-inflammatory and regulatory cytokines do not seem to play a prominent role in CanL or during clinical recovery.

Responding to violence against women: A qualitative study with midwives in Timor-Leste.

PROBLEM: The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. AIM: This research explores the barriers and enablers that midwives report in responding to domestic and sexual violence in Timor-Leste, a country with a very high rate of violence against women. The aim is to inform a systems approach to health provider training and engagement applicable to Timor-Leste and other low-resource settings. METHODS: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. FINDINGS: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. CONCLUSION: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managers within a health facility, work creatively to overcome barriers to implementation, and link them with wider community-based resources.

CRYPTOSPORIDIUM SPECIES AND GIARDIA SPECIES PREVALENCE IN MARINE MAMMAL SPECIES PRESENT IN THE GERMAN NORTH AND BALTIC SEAS.

Marine mammals are known to harbor Cryptosporidium spp. and Giardia spp., especially species or genotypes commonly associated with humans. In animals of the North and Baltic Seas, this information is missing. In this study, fecal samples ( n = 97) from harbor porpoises ( Phocoena phocoena), harbor seals ( Phoca vitulina), and grey seals ( Phocoena phocoena) present in German waters were examined via microscopic examination (by using a modified Ziehl-Neelsen technique [MZN]) to estimate the prevalence of these parasites. Additionally, intestinal tissue samples ( n = 1,049) from specimens of 10 marine mammal species were submitted for histopathologic examination (HP). A low prevalence was detected (2.1 and 1.3%, for MZN and HP, respectively), associated with Cryptosporidium spp. Giardia spp. was not observed. Current results suggest a low prevalence of these parasites in marine mammals present in Germany. However, methods with higher sensitivity, such as molecular methods, are crucial to confirm the prevalence, establish origin routes, and determine epidemiologic factors associated with the low prevalence observed.

Electric-field-tuned topological phase transition in ultrathin Na3Bi.

The electric-field-induced quantum phase transition from topological to conventional insulator has been proposed as the basis of a topological field effect transistor1-4. In this scheme, 'on' is the ballistic flow of charge and spin along dissipationless edges of a two-dimensional quantum spin Hall insulator5-9, and 'off' is produced by applying an electric field that converts the exotic insulator to a conventional insulator with no conductive channels. Such a topological transistor is promising for low-energy logic circuits4, which would necessitate electric-field-switched materials with conventional and topological bandgaps much greater than the thermal energy at room temperature, substantially greater than proposed so far6-8. Topological Dirac semimetals are promising systems in which to look for topological field-effect switching, as they lie at the boundary between conventional and topological phases3,10-16. Here we use scanning tunnelling microscopy and spectroscopy and angle-resolved photoelectron spectroscopy to show that mono- and bilayer films of the topological Dirac semimetal3,17 Na3Bi are two-dimensional topological insulators with bulk bandgaps greater than 300 millielectronvolts owing to quantum confinement in the absence of electric field. On application of electric field by doping with potassium or by close approach of the scanning tunnelling microscope tip, the Stark effect completely closes the bandgap and re-opens it as a conventional gap of 90 millielectronvolts. The large bandgaps in both the conventional and quantum spin Hall phases, much greater than the thermal energy at room temperature (25 millielectronvolts), suggest that ultrathin Na3Bi is suitable for room-temperature topological transistor operation.

Urban Dog Parks as Sources of Canine Parasites: Contamination Rates and Pet Owner Behaviours in Lisbon, Portugal.

Dog parks represent a recent trend in western countries, enabling owners to spend quality time with their pets in a controlled environment. Despite their growing popularity, few studies have been performed to date on these parks to investigate dog intestinal parasitic infections and soil contamination. The present study examined 369 faecal and 18 soil samples collected from 3 dog parks in Greater Lisbon, Portugal. Additionally, 102 interviews were performed with dog owners to assess dog-walking behaviours and parasite risk. In total, 33% of the faecal dog samples were infected with at least one parasitic agent: hookworms (16.5%), Cryptosporidium spp. (11.9%), Giardia spp. (11.4%), Toxascaris leonina (1.1%), Cystoisospora spp. (1.1%), Toxocara spp. (0.5%), and Sarcocystis sp. (0.3%). The soil of all the parks was contaminated with hookworm eggs. This is the first study performed in a European urban area to assess canine faecal contamination and parasitic agents in dog parks. Our results highlight the potential of these parks as a source of transmission for canine parasites, including some with zoonotic potential. Public awareness and effective preventive measures should be promoted to minimise the health-risk impact to both animals and humans, under the scope of environmental and public health.