Methotrexate-Induced Stroke-Like Syndrome: A Typical Presentation of a Rare Complication.

Methotrexate (MTX) is one of the mainstay drugs used in acute lymphoblastic leukemia (ALL) management; however, it can cause damage to the central nervous system (CNS), typically to the subcortical white matter. Stroke-like syndrome is one particular form of MTX-related neurotoxicity that occurs within 21 days of methotrexate administration (intrathecal or high-dose intravenous treatment). The clinical picture comprehends fluctuating neurological symptoms evoking acute cerebral ischemia or hemorrhage (paresis or paralysis, speech disorders - aphasia and/or dysarthria, altered mental status, and occasionally seizures), with spontaneous resolution in the majority of cases, without other identifiable cause. The typical neuroimage includes areas of restricted diffusion on diffusion-weighted imaging and non-enhancing T2 hyper-intense lesions in the white matter, on brain MRI. We report a 12-year-old boy with low-risk B-ALL without CNS involvement, who presented to the emergency department with complaints of sudden paresis of the four limbs (more severe on the right side), aphasia, and confusion. He had received one dose of intrathecal MTX 11 days prior to this episode. An angio-MRI of the brain revealed bilateral restricted diffusion areas in the centrum semiovale, and symptoms fluctuated until complete neurological recovery without any medical intervention, which is very suggestive of MTX-related neurotoxicity. This case illustrates a rare complication of MTX administration that presented with typical clinical and radiological characteristics, in an adolescent with hematological malignancy who experienced swift and full neurological recovery.

Challenging Diagnosis of a Congenital Tracheal Malformation: Considerations From an Intensive Care Perspective.

Congenital tracheal stenosis is a rare airway malformation. A high index of suspicion is fundamental. The authors report a case of congenital tracheal stenosis in a 13-month-old male infant, with a challenging diagnosis from the intensive care perspective. At birth, the patient presented an anorectal malformation with a recto-urethral fistula so a colostomy with mucous fistula was performed in the neonatal period. At the age of seven months, he was admitted due to a respiratory infection, treated with steroids and bronchodilators, and discharged after three days without any complications. He underwent complete repair of tetralogy of Fallot when he was 11 months old, which was performed without any reported perioperative complications. However, at the age of 13 months, due to another respiratory infection, he presented more severe symptoms and required admission to the pediatric intensive care unit (PICU) for invasive mechanical ventilation. He was intubated on the first attempt. While monitoring the difference between peak inspiratory and plateau pressures, we observed a sustained elevated difference between pressures suggestive of increased airway resistance, thus raising the possibility of an anatomical obstruction. Laryngotracheoscopy confirmed distal tracheal stenosis (grade II) with four complete tracheal rings. In our case, the absences of perioperative challenges or complications in previous respiratory infections were not suggestive of a tracheal malformation. Furthermore, no difficulties were encountered during intubation due to the distal location of the tracheal stenosis. A careful appreciation of respiratory mechanics on the ventilator at rest and during tracheal aspirations was essential to suspect an anatomical defect.

Comparison of inspiratory effort with three variable-flow nasal continuous positive airway pressure devices in preterm infants: a cross-over study.

OBJECTIVE: Patient's work of breathing may vary between different neonatal nasal continuous positive airway pressure (NCPAP) devices. Therefore, we aimed to compare the inspiratory effort of three variable-flow NCPAP delivery systems used in preterm infants. DESIGN: Cross-over study. PATIENTS/SETTING: From June 2015 to August 2016, 20 preterm infants weighing ≤2500 g requiring NCPAP for mild respiratory distress syndrome were enrolled. INTERVENTIONS: Each patient was successively supported by three randomly assigned variable-flow NCPAP systems (MedinCNO, Infant Flow and Servo-i) for 20 min while maintaining the same continuous positive airway pressure level as the patient was on before the study period. MAIN OUTCOME MEASURES: Patients' inspiratory effort was estimated by calculating the sum of the difference between maximal inspiratory and baseline electrical activity of the diaphragm (∆EAdi) for 30 consecutive breaths, and after normalising this obtained value for the timing of the 30 breaths. RESULTS: Physiological parameters (oxygen saturation measured by pulse oximetry, respiratory rate, heart beat, transcutaneous partial pressure CO2) and oxygen requirements remained identical between the three NCPAP systems. Although a wide variability in inspiratory effort could be observed, there were no statistically significant differences between the three systems for the sum of ∆EAdi for 30 breaths: CNO, 262 (±119) µV; IF, 352 (±262) µV; and SERVO-i, 286 (±126) µV, and the ∆EAdi reported on the timing of 30 breaths (sum ∆EAdi/s): CNO, 6.1 (±2.3) µV/s; IF, 7.9 (±4.9) µV/s; SERVO-i, 7.6 (±3.6) µV/s. CONCLUSION: In a neonatal population of preterm infants, inspiratory effort is comparable between the three tested modern variable-flow NCPAP devices.

A 3-step intervention to improve adherence to cervical cancer screening: The SCAN randomized controlled trial.

The aim of this study was to test the effectiveness of a stepwise intervention with an increasing level of complexity and cost to increase adherence to organized cervical cancer screening. This was a randomized (1: 1) controlled trial, conducted among 13 Portuguese primary health care units. Participants (n = 1220) were women aged 25-49 years, eligible for cervical cancer screening, with a mobile phone number available. The tested intervention was a 3-step invitation to screening, based on automated text messages/phone calls (step 1), manual phone calls (step 2) and face-to-face interviews (step 3), applied sequentially to non-adherent women after each step. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women screened, which was assessed after step 1 (45 days after the initial invitation), steps 1 + 2 (90 days after the initial invitation) and steps 1 + 2 + 3 (150 days after the initial invitation). Adherence to cervical cancer screening was significantly higher among women assigned to the intervention than those in the control group for step 1 (39.9% vs. 25.7%, p < 0.001), steps 1 + 2 (48.6% vs. 30.7%, p < 0.001) and steps 1 + 2 + 3 (51.2% vs. 34.0%, p < 0.001). In conclusion, adherence to cervical cancer screening was higher by 17% among women invited through the 3-step intervention, compared to those receiving the standard invitation letter. The former strategy has the potential to be broadly implemented due to the low requirements of technology and training. Clinical Trial Registration: NCT03122275.

Breaking Through Disciplinary Barriers: Human-Wildlife Interactions and Multispecies Ethnography.

One of the main challenges when integrating biological and social perspectives in primatology is overcoming interdisciplinary barriers. Unfamiliarity with subject-specific theory and language, distinct disciplinary-bound approaches to research, and academic boundaries aimed at "preserving the integrity" of subject disciplines can hinder developments in interdisciplinary research. With growing interest in how humans and other primates share landscapes, and recognition of the importance of combining biological and social information to do this effectively, the disparate use of terminology is becoming more evident. To tackle this problem, we dissect the meaning of what the biological sciences term studies in "human-wildlife conflict" or more recently "human-wildlife interactions" and compare it to what anthropology terms "multispecies ethnography." In the biological sciences, human-wildlife interactions are the actions resulting from people and wild animals sharing landscapes and resources, with outcomes ranging from being beneficial or harmful to one or both species. In the social sciences, human-nonhuman relationships have been explored on a philosophical, analytical, and empirical level. Building on previous work, we advocate viewing landscapes through an interdisciplinary "multispecies lens" in which humans are observed as one of multiple organisms that interact with other species to shape and create environments. To illustrate these interconnections we use the case study of coexistence between people of the Nalu ethnic group and Critically Endangered western chimpanzees (Pan troglodytes verus) at Cantanhez National Park in Guinea-Bissau, to demonstrate how biological and social research approaches can be complementary and can inform conservation initiatives at the human-primate interface. Finally, we discuss how combining perspectives from ethnoprimatology with those from multispecies ethnography can advance the study of ethnoprimatology to aid productive discourse and enhance future interdisciplinary research.

Imposed Work of Breathing During High-Frequency Oscillatory Ventilation in Spontaneously Breathing Neonatal and Pediatric Models.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) is used in cases of neonatal and pediatric acute respiratory failure, sometimes even as the primary ventilatory mode. Allowing patients (at least neonates) on HFOV to breathe spontaneously soon after intubation has been shown to be feasible, and this is becoming a more generally used approach for infants and small children. However, such an approach may increase the imposed work of breathing (WOB), raising the question of whether the imposed WOB varies with the use of newer-generation HFOV devices, which operate according to different functional principles. METHODS: A bench test was designed to compare the pressure-time product (PTP), a surrogate marker of the imposed WOB, produced with the use of 7 HFOV devices. Scenarios corresponding to various age groups (preterm newborn [1 kg], term newborn [3.5 kg], infant [10 kg], and child [25 kg]) and 2 respiratory system conditions (physiologic and pathologic) were tested. RESULTS: The PTP varied between devices and increased with the oscillation frequency for all devices, independent of the respiratory system condition. Furthermore, the PTP increased with age and was higher for physiologic than for pathologic respiratory system conditions. We considered a change of ≥ 20% as being of clinically relevant; the effect of oscillation frequency was the most important parameter influencing imposed WOB during spontaneous breathing. CONCLUSIONS: Variations in imposed WOB, as expressed by PTP values, during spontaneous breathing depend mainly on the oscillator frequency, respiratory system condition, and, though to a lesser extent, on the device itself.

Stepwise strategy to improve cervical cancer screening adherence (SCAN-Cervical Cancer) - Automated text messages, phone calls and reminders: Population based randomized controlled trial.

The aim of this study was to test the effectiveness of invitation to cervical cancer screening through a very low-cost strategy based on automated and customized text messages, phone calls and reminders. A randomized (1:1) controlled trial was conducted among 13 Portuguese primary care units, recruiting women aged 25 to 49 years, eligible for cervical cancer screening, with an available mobile phone number. In the intervention group, participants were invited for cervical cancer screening through automated/customized text messages and phone calls, followed by text message reminders. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women adherent to screening up to 45 days after invitation and the secondary outcome was defined as the adherence proportion after invitation based only on text messages and reminders. A total of 1220 women were randomized, 605 to intervention and 615 to control group. The adherence to cervical cancer was significantly higher among women assigned to intervention (39.0% vs. 25.7%, p < 0.001); this corresponds to a difference of 13.3% (95% CI 8.1 to 18.5). The difference in adherence between an invitation strategy based only on text messages and reminders and the standard of care was -0.4%, 95% CI -5.3 to 4.5. In conclusion, an invitation to cervical cancer screening using automated text messages/phone calls and reminders increases the adherence to cervical cancer screening. Such a low-cost and operator-independent strategy of invitation may contribute to the sustainability of organized screening programs. TRIAL REGISTRATION NUMBER: NCT03122275.

Primate occurrence across a human-impacted landscape in Guinea-Bissau and neighbouring regions in West Africa: using a systematic literature review to highlight the next conservation steps.

BACKGROUND: West African landscapes are largely characterised by complex agroforest mosaics. Although the West African forests are considered a nonhuman primate hotspot, knowledge on the distribution of many species is often lacking and out-of-date. Considering the fast-changing nature of the landscapes in this region, up-to-date information on primate occurrence is urgently needed, particularly of taxa such as colobines, which may be more sensitive to habitat modification than others. Understanding wildlife occurrence and mechanisms of persistence in these human-dominated landscapes is fundamental for developing effective conservation strategies. METHODS: In this paper, we aim to review current knowledge on the distribution of three threatened primates in Guinea-Bissau and neighbouring regions, highlighting research gaps and identifying priority research and conservation action. We conducted a systematic literature review of primate studies from 1976 to 2016 in Guinea-Bissau, southern Senegal and western Guinea (Boké Region). We mapped historical observation records of chimpanzee (Pan troglodytes verus), Temminck's red colobus (Pilicolobus badius temminckii) and king colobus (Colobus polykomos), including our preliminary survey data from Dulombi, a newly established National Park (NP) in Guinea-Bissau. RESULTS: We found 151 documents, including 87 journal articles, that contained field data on primates in this region. In Guinea-Bissau, nearly all studies focussed south of the Corubal River, including mainly Cantanhez, Cufada, and Boé NP's. In Senegal, most of the data came from Fongoli and Niokolo-Koba NP. In Boké (Guinea) studies are few, with the most recent data coming from Sangarédi. In Dulombi NP we recorded eight primate species, including chimpanzees, red colobus and king colobus. Across the selected region, chimpanzees, red colobus and king colobus were reported in eleven, twelve and seven protected areas, respectively. DISCUSSION: Our study demonstrates large geographical research gaps particularly for the two colobines. For the first time after more than two decades, we confirm the presence of red colobus and king colobus north of the Corubal River in Guinea-Bissau. The little information available from large parts of the red colobus range raises questions regarding levels of population fragmentation in this species, particularly in Casamance and across northern Guinea-Bissau. There are still no records demonstrating the occurrence of king colobus in Senegal, and the presence of a viable population in north-eastern Guinea-Bissau remains uncertain. While the occurrence of chimpanzees in Guinea-Bissau and Senegal is well documented, data from Boké (Guinea) are sparse and out-of-date. Our approach-the mapping of data gathered from a systematic literature review-allows us to provide recommendations for selecting future geographical survey locations and planning further research and conservation strategies in this region.

The return of the Iberian lynx to Portugal: local voices.

BACKGROUND: Ethnographic research can help to establish dialog between conservationists and local people in reintroduction areas. Considering that predator reintroductions may cause local resistance, we assessed attitudes of different key actor profiles to the return of the Iberian lynx (Lynx pardinus) to Portugal before reintroduction started in 2015. We aimed to characterize a social context from an ethnoecological perspective, including factors such as local knowledge, perceptions, emotions, and opinions. METHODS: We conducted semi-structured interviews (n = 131) in three different protected areas and observed practices and public meetings in order to describe reintroduction contestation, emotional involvement with the species, and local perceptions about conservation. Detailed content data analysis was undertaken and an open-ended codification of citations was performed with the support of ATLAS.ti. Besides the qualitative analyses, we further explored statistic associations between knowledge and opinions and compared different geographical areas and hunters with non-hunters among key actors. RESULTS: Local ecological knowledge encompassed the lynx but was not shared by the whole community. Both similarities and differences between local and scientific knowledge about the lynx were found. The discrepancies with scientific findings were not necessarily a predictor of negative attitudes towards reintroduction. Contestation issues around reintroduction differ between geographical areas but did not hinder an emotional attachment to the species and its identification as a territory emblem. Among local voices, financial compensation was significantly associated to hunters and nature tourism was cited the most frequent advantage of lynx presence. Materialistic discourses existed in parallel with non-economic factors and the existence of moral agreement with its protection. The considerable criticism and reference to restrictions by local actors concerning protected areas and conservation projects indicated the experience of an imposed model of nature conservation. Opinions about participation in the reintroduction process highlighted the need for a closer dialog between all actors and administration. CONCLUSIONS: Local voices analyzed through an ethnoecological perspective provide several views on reintroduction and nature conservation. They follow two main global trends of environmental discourse: (1) nature becomes a commodified object to exploit while contestation about wildlife is centered on financial return and (2) emblematic wild species create an emotional attachment, become symbolic, and gather moral agreement for nature protection. Lynx reintroduction has been not only just a nature protection theme but also a negotiation process with administration. Western rural communities are not the "noble savages" and nature protectors as are other traditional groups, and actors tend to claim for benefits in a situation of reintroduction. Both parties comprehend a similar version of appropriated nature. Understanding complexity and diverse interests in local communities are useful in not oversimplifying local positions towards predator conservation. We recommend that professional conservation teams rethink their image among local populations and increase proximity with different types of key actors.

Stepwise strategy to improve Cervical Cancer Screening Adherence (SCAN-CC): automated text messages, phone calls and face-to-face interviews: protocol of a population-based randomised controlled trial.

INTRODUCTION: Screening is highly effective for cervical cancer prevention and control. Population-based screening programmes are widely implemented in high-income countries, although adherence is often low. In Portugal, just over half of the women adhere to cervical cancer screening, contributing for greater mortality rates than in other European countries. The most effective adherence raising strategies are based on patient reminders, small/mass media and face-to-face educational programmes, but sequential interventions targeting the general population have seldom been evaluated. The aim of this study is to assess the effectiveness of a stepwise approach, with increasing complexity and cost, to improve adherence to organised cervical cancer screening: step 1a-customised text message invitation; step 1b-customised automated phone call invitation; step 2-secretary phone call; step 3-family health professional phone call and face-to-face appointment. METHODS: A population-based randomised controlled trial will be implemented in Portuguese urban and rural areas. Women eligible for cervical cancer screening will be randomised (1:1) to intervention and control. In the intervention group, women will be invited for screening through text messages, automated phone calls, manual phone calls and health professional appointments, to be applied sequentially to participants remaining non-adherent after each step. Control will be the standard of care (written letter). The primary outcome is the proportion of women adherent to screening after step 1 or sequences of steps from 1 to 3. The secondary outcomes are: proportion of women screened after each step (1a, 2 and 3); proportion of text messages/phone calls delivered; proportion of women previously screened in a private health institution who change to organised screening. The intervention and control groups will be compared based on intention-to-treat and per-protocol analyses. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the Northern Health Region Administration and National Data Protection Committee. Results will be disseminated through communications in scientific meetings and peer-reviewed journals. TRIAL NUMBER: NCT03122275.

The symbolic efficacy of medicinal plants: practices, knowledge, and religious beliefs amongst the Nalu healers of Guinea-Bissau.

BACKGROUND: In attempting to understand how the use of medicinal plants is symbolically valued and transformed according to specific cosmologies, we gain valuable insight into the ethnopharmacologial practices, in terms of the major role played by healers, as custodians of local ethnobotanical knowledge, but also as ritual masters. Thus, the goal of this paper is to understand how medicinal plants are used differently depending on a combination between the healers' field of expertise and personal history on the one hand, and the diversified religious and symbolical frameworks on the other. METHODS: This essay is based on intense ethnographical research carried out amongst the Nalu people of Guinea-Bissau. Methods included participant observation and semi-directed interviews with six locally-renown healers (four men and two women). The progress of their work and the changes operated within the sets of beliefs associated with ethnopharmacological practices were registered by means of repeated field visits. RESULTS: A total of 98 species and 147 uses are accounted for, as well as a description of the plant parts that were used, as well as the methods of preparation and application according to the different healers' specialized practices. At the same time, this research describes those processes based on pre-Islamic and Muslim cosmologies through which medicinal plants are accorded their value, and treatments are granted their symbolic efficiency. CONCLUSIONS: Medicinal plants are valued differently in the pre-Islamic medicine and in the medicine practiced by Islamic masters. The increasing relevance of Islam within this context has affected the symbolic framework of ethnopharmacological practices. Nevertheless, the endurance of those processes by which symbolic efficiency is attributed to local treatments based on plants is explained not only by the syncretic nature of African Islam, but also by the fact that patients adopt different therapeutic pathways simultaneously.

Importance of local knowledge in plant resources management and conservation in two protected areas from Trás-os-Montes, Portugal.

Many European protected areas were legally created to preserve and maintain biological diversity, unique natural features and associated cultural heritage. Built over centuries as a result of geographical and historical factors interacting with human activity, these territories are reservoirs of resources, practices and knowledge that have been the essential basis of their creation. Under social and economical transformations several components of such areas tend to be affected and their protection status endangered.Carrying out ethnobotanical surveys and extensive field work using anthropological methodologies, particularly with key-informants, we report changes observed and perceived in two natural parks in Trás-os-Montes, Portugal, that affect local plant-use systems and consequently local knowledge. By means of informants' testimonies and of our own observation and experience we discuss the importance of local knowledge and of local communities' participation to protected areas design, management and maintenance. We confirm that local knowledge provides new insights and opportunities for sustainable and multipurpose use of resources and offers contemporary strategies for preserving cultural and ecological diversity, which are the main purposes and challenges of protected areas. To be successful it is absolutely necessary to make people active participants, not simply integrate and validate their knowledge and expertise. Local knowledge is also an interesting tool for educational and promotional programs.