A review on the diversity and distribution of athecate dinoflagellates in South Atlantic and in the Atlantic sector of the Southern Ocean: Research insights and gaps.

This review summarizes the state of knowledge on athecate dinoflagellates occurring within the South Atlantic Ocean and Atlantic sector of the Southern Ocean. We compiled data from 105 articles and selected 33 addressing any aspect of athecate dinoflagellate studies. Our aim is to discuss the patterns in athecate dinoflagellate distribution by building a thorough species list and an occurrence map based on species recorded in coastal and oceanic waters. We found 69 species totaling 141 occurrences in the entire South Atlantic Ocean basin. Contradicting global trends, most species distributed throughout this region are subtropical. We linked this trend to a higher local effort in dinoflagellate research instead of higher biodiversity, especially when compared to usual hotspots in biodiversity attributed to tropical oceans. The Subantarctic and Antarctic regions had a low number of occurrences, with 12 and 5, respectively. Except for the occurrence of Gyrodinium lachryma in the Antarctic Zone, all records are unique, poorly described and never recorded again for species such as Gymnodinium baccatum and Gymnodinium antarcticum. This demonstrates that the state of knowledge regarding athecate dinoflagellates in the South Atlantic and especially in the Antarctic region is still limited due to a lack of directed investigation.

Cryptophytes: An emerging algal group in the rapidly changing Antarctic Peninsula marine environments.

The western Antarctic Peninsula (WAP) is a climatically sensitive region where foundational changes at the basis of the food web have been recorded; cryptophytes are gradually outgrowing diatoms together with a decreased size spectrum of the phytoplankton community. Based on a 11-year (2008-2018) in-situ dataset, we demonstrate a strong coupling between biomass accumulation of cryptophytes, summer upper ocean stability, and the mixed layer depth. Our results shed light on the environmental conditions favoring the cryptophyte success in coastal regions of the WAP, especially during situations of shallower mixed layers associated with lower diatom biomass, which evidences a clear competition or niche segregation between diatoms and cryptophytes. We also unravel the cryptophyte photo-physiological niche by exploring its capacity to thrive under high light stress normally found in confined stratified upper layers. Such conditions are becoming more frequent in the Antarctic coastal waters and will likely have significant future implications at various levels of the marine food web. The competitive advantage of cryptophytes in environments with significant light level fluctuations was supported by laboratory experiments that revealed a high flexibility of cryptophytes to grow in different light conditions driven by a fast photo-regulating response. All tested physiological parameters support the hypothesis that cryptophytes are highly flexible regarding their growing light conditions and extremely efficient in rapidly photo-regulating changes to environmental light levels. This plasticity would give them a competitive advantage in exploiting an ecological niche where light levels fluctuate quickly. These findings provide new insights on niche separation between diatoms and cryptophytes, which is vital for a thorough understanding of the WAP marine ecosystem.

Physical-biological drivers modulating phytoplankton seasonal succession along the Northern Antarctic Peninsula.

The Northern Antarctic Peninsula (NAP) shows shifts in phytoplankton distribution and composition along its warming marine ecosystems. However, despite recent efforts to mechanistically understand these changes, little focus has been given to the phytoplankton seasonal succession, remaining uncertainties regarding to distribution patterns of emerging taxa along the NAP. To fill this gap, we collected phytoplankton (pigment and microscopy analysis) and physico-chemical datasets during spring and summer (November, February and March) of 2013/2014 and 2014/2015 off the NAP. Satellite measurements (sea surface temperature, sea ice concentration and chlorophyll-a) were used to extend the temporal coverage of analysis associated with the in situ sampling. We improved the quantification and distribution pattern of emerging taxa, such as dinoflagellates and cryptophytes, and described a contrasting seasonal behavior and distinct fundamental niche between centric and pennate diatoms. Cryptophytes and pennate diatoms preferentially occupied relatively shallower mixing layers compared with centric diatoms and dinoflagellates, suggesting differences between these groups in distribution and environment occupation over the phytoplankton seasonal succession. Under colder conditions, negative sea surface temperature anomalies were associated with positive anomalies of sea ice concentration and duration. Therefore, based on sea ice-phytoplankton growth relationship, large phytoplankton biomass accumulation was expected during the spring/summer of 2013/2014 and 2014/2015 along the NAP. However, there was a decoupling between sea ice concentration/duration and phytoplankton biomass, characterizing two seasonal periods of low biomass accumulation (negative chlorophyll-a anomalies), associated with the top-down control in the region. These results provide an improved mechanistic understanding on physical-biological drivers modulating phytoplankton seasonal succession along the Antarctic coastal waters.

Temporal relation between human mobility, climate, and COVID-19 disease.

Using the example of the city of São Paulo (Brazil), in this paper, we analyze the temporal relation between human mobility and meteorological variables with the number of infected individuals by the COVID-19 disease. For the temporal relation, we use the significant values of distance correlation t0(DC), which is a recently proposed quantity capable of detecting nonlinear correlations between time series. The analyzed period was from February 26, 2020 to June 28, 2020. Fewer movements in recreation and transit stations and the increase in the maximal temperature have strong correlations with the number of newly infected cases occurring 17 days after. Furthermore, more significant changes in grocery and pharmacy, parks, and recreation and sudden changes in the maximal pressure occurring 10 and 11 days before the disease begins are also correlated with it. Scanning the whole period of the data, not only the early stage of the disease, we observe that changes in human mobility also primarily affect the disease for 0-19 days after. In other words, our results demonstrate the crucial role of the municipal decree declaring an emergency in the city to influence the number of infected individuals.

Chemotaxonomic characterization of the key genera of diatoms in the Northern Antarctic Peninsula.

Diatoms are successful in occupying a wide range of ecological niches and biomes along the global ocean. Although there is a recognized importance of diatoms for the Southern Ocean ecosystems and biogeochemical cycles, the current knowledge on their ecology and distribution along the impacted Antarctic coastal regions remains generalized at best. HPLC-CHEMTAX approaches have been extensively used to this purpose, providing valuable information about the whole phytoplankton community, even for those small-size species which are normally difficult to identify by light microscopy. Despite that, the chemotaxonomic method has reserved minimal focus on great diversity of types associated with diatom genera or species. Here, we show a coupling between the key genera and the corresponding chemotaxonomic subgroup type-A or type-B of diatoms via HPLC-CHEMTAX and microscopic analysis, using chlorophyll-c 1 and chlorophyll-c 3 as biomarker pigments, respectively. The results demonstrated strong correlations for nine of the fifteen most abundant diatom genera observed along the Northern Antarctic Peninsula, from which five (four) were statistically associated with chlorophyll-c 1 (chlorophyll-c 3). Our study highlights the importance to observe diatoms in greater detail, beyond being only one functional group, for a better understanding on their responses under a climate change scenario.

Scrutinizing the heterogeneous spreading of COVID-19 outbreak in large territorial countries.

After the spread of COVID-19 out of China, the evolution of the pandemic has shown remarkable similarities and differences between countries around the world. Eventually, such characteristics are also observed between different regions of the same country. Herewith, we introduce a general method that allows us to compare the evolution of the pandemic in different localities inside a large territorial country: in the case of the present study, Brazil. To evaluate our method, we study the heterogeneous spreading of the COVID-19 outbreak until May 30th, 2020, in Brazil and its 27 federative units, which has been seen as the current epicenter of the pandemic in South America. Each one of the federative units may be considered a cluster of interacting people with similar habits and distributed to a highly heterogeneous demographic density over the entire country. Our first set of results regarding the time-series analysis shows that: (i) a power-law growth of the cumulative number of infected people is observed for federative units of the five regions of Brazil; and (ii) the distance correlation calculated between the time series of the most affected federative units and the curve that describes the evolution of the pandemic in Brazil remains about 1 over most of the time, while such quantity calculated for the federative units with a low incidence of newly infected people remains about 0.95. In the second set of results, we focus on the heterogeneous distribution of the confirmed cases and deaths. By applying the epidemiological susceptible-infected-recovered-dead model we estimated the effective reproduction number (ERN) [Formula: see text] during the pandemic evolution and found that: (i) the mean value of [Formula: see text] for the eight most affected federative units in Brazil is about 2; (ii) the current value of [Formula: see text] for Brazil is greater than 1, which indicates that the epidemic peak is far off; and (iii) Ceará was the only federative unit for which the current [Formula: see text]. Based on these findings, we projected the effects of increase or decrease of the ERN and concluded that if the value of [Formula: see text] increases 20%, not only the peak might grow at least 40% but also its occurrence might be anticipated, which hastens the collapse of the public health-care system. In all cases, keeping the ERN 20% below the current value can save thousands of people in the long term.

Laparoscopic colorectal surgery and discharge within 24 h-who is at risk for readmission?

AIM: The aim was to describe risk factors for hospital readmission in patients undergoing laparoscopic colorectal procedures and being discharged in ≤24 h. METHOD: All consecutive patients undergoing minimally invasive colorectal surgery between 2010 and 2019 from a single institution were retrospectively reviewed. All patients were included in an enhanced recovery programme. Patients who met criteria for hospital discharge were compared according to the need for readmission in a 45-day follow-up. RESULTS: In all, 664 patients underwent minimally invasive colorectal surgery during the study period and 237 (35.7%) were discharged in ≤24 h. Readmission was required in 16 (6.8%) patients discharged in ≤24 h and no postoperative mortality was observed in this group. Patients discharged in ≤24 h were more likely to have benign disease (P < 0.001), fewer associated procedures (P < 0.025) and intracorporeal anastomoses (P < 0.001). The type of surgical procedure (abdominoperineal resection), low rectal tumour, malignant disease, older age and longer operating time were associated with readmission. Age (OR 1.06; P = 0.037), malignant disease (OR 4.39; P = 0.05) and operating time (OR 1.03; P < 0.001) were identified as independent predictive factors for readmission amongst patients being discharged in ≤24 h. CONCLUSION: Highly selected patients undergoing minimally invasive procedures in colorectal surgery may be safely discharged within 24 h following the procedure. High-risk features for readmission include older age, malignant disease and longer operating time.

Mechanisms to decrease the diseases spreading on generalized scale-free networks.

In this work, an epidemiological model is constructed based on a target problem that consists of a chemical reaction on a lattice. We choose the generalized scale-free network to be the underlying lattice. Susceptible individuals become the targets of random walkers (infectious individuals) that are moving over the network. The time behavior of the susceptible individuals' survival is analyzed using parameters like the connectivity γ of the network and the minimum (Kmin) and maximum (Kmax) allowed degrees, which control the influence of social distancing and isolation or spatial restrictions. In all cases, we found power-law behaviors, whose exponents are strongly influenced by the parameter γ and to a lesser extent by Kmax and Kmin, in this order. The number of infected individuals diminished more efficiently by changing the parameter γ, which controls the topology of the scale-free networks. A similar efficiency is also reached by varying Kmax to extremely low values, i.e., the number of contacts of each individual is drastically diminished.

Pseudothrombocytopenia: a case of platelet satellitism and phagocytosis by neutrophils.

Thrombocytopenia is a clinically important condition that can lead to several problems when not correctly diagnosed. A decrease of platelet counts due to an in vitro phenomenon, Pseudothrombocytopenia, can be misunderstood and unnecessarily treated. The present case study describes a 57-year-old male with a history of pancreas adenocarcinoma and a current Staphylococcus aureus infection without any signs or symptoms that could explain the low levels of platelets obtained after blood analysis. Blood smear evaluation detected both platelet satellitism and phagocytosis by neutrophils. As this sample was anticoagulated with ethylenediaminetetraacetic acid (EDTA), a new blood sample with citrate was analyzed. Platelet count was normal and no morphological abnormalities were detected. This case emphasizes the need for considering not only laboratory results but also the patient clinical information to guarantee the correct diagnosis and the best treatment possible.

Strong correlations between power-law growth of COVID-19 in four continents and the inefficiency of soft quarantine strategies.

In this work, we analyze the growth of the cumulative number of confirmed infected cases by a novel coronavirus (COVID-19) until March 27, 2020, from countries of Asia, Europe, North America, and South America. Our results show that (i) power-law growth is observed in all countries; (ii) by using the distance correlation, the power-law curves between countries are statistically highly correlated, suggesting the universality of such curves around the world; and (iii) soft quarantine strategies are inefficient to flatten the growth curves. Furthermore, we present a model and strategies that allow the government to reach the flattening of the power-law curves. We found that besides the social distancing of individuals, of well known relevance, the strategy of identifying and isolating infected individuals in a large daily rate can help to flatten the power-laws. These are the essential strategies followed in the Republic of Korea. The high correlation between the power-law curves of different countries strongly indicates that the government containment measures can be applied with success around the whole world. These measures are scathing and to be applied as soon as possible.

Fabrication, Measurement and Time Decay of the Electromagnetic Properties of Semi-Solid Water-Based Phantoms.

This paper presents a complete and detailed description of the fabrication and measurement of the electromagnetic properties of water-based semi-solid phantoms with emphasis on the analysis of the time evolution of the complex permittivity of several samples stored in different conditions. A known recipe for a 2/3 muscle equivalent phantom is used as test material, and the several phantom sample properties are measured with an in-house developed coaxial probe technique. It is shown that the storing condition is of paramount importance to extend the lifetime of a given phantom. This behavior stems from the way the storing condition affects the water evaporation rate of the sample. In particular, while an unprotected sample can preserve its electromagnetic properties only for a few days, a very well-sealed one can last at least up to a year.

The knowledge and use of population-based methods for caries detection.

BACKGROUND: Since the 1980s, a wide variety of methods have been proposed to measure dental caries in the population, demonstrating a lack of consensus regarding the procedure that should be used for this purpose. The current study investigated the methods that are known and used by public oral health researchers and professors as well as the reasons that lead to the choice of a particular method. METHOD: In the context of an interview, a questionnaire was administered to public oral health researchers and professors who used caries indices and worked in Salvador and Feira de Santana, Bahia, Brazil from 2005 to 2015. A quantitative and descriptive approach was applied that adopted the multiple correspondence analysis (MCA) technique to assess the associations among responses. RESULTS: The decayed, missing, and filled index (DMF) was the only measurement known by all respondents, and although 45 of the 47 professors/researchers were dissatisfied with this index, only six had used other methods. This index was chosen because of its comparability and ease of application. The MCA revealed response associations among older, male participants who graduated from the Federal University of Bahia (UFBA) and who continued to use this index because of its comparability and because it is the index recommended by the World Health Organization (WHO) and the Brazilian Ministry of Health (MS). Another group was also observed that consisted of younger females who graduated from the State University of Feira de Santana (UEFS) or another university and who used the DMF because it is well-known, simple, and easy to apply. CONCLUSIONS: The DMF index was the most known and used method. Many respondents demonstrated a desire for change and were critical of the DMF; however, they did not know of and had not used newer methods for measuring dental caries. Greater importance should be placed on the problem of dental caries assessment in the population.

Comparison of caries lesion detection methods in epidemiological surveys: CAST, ICDAS and DMF.

BACKGROUND: Although dental caries is a globally widespread disease, there is no consensus regarding the method that should be used for their detection. In recent decades, a variety of new methods have been proposed for measuring caries in a population. Three caries detection methods, the decayed, missing and filled (DMF) index, the International Caries Detection and Assessment System (ICDAS) and the Caries Assessment Spectrum and Treatment (CAST), were compared to provide information to guide future method choices. METHODS: This was a descriptive, cross-sectional study in which three methods were used to measure caries in students, staff and their dependents at UNEB (State University of Bahia), Salvador, Brazil. We compared the mean application time of each method and the frequencies obtained by each method using the following indicators: the most severe caries lesion per individual; the mean number of missing, filled and decayed teeth; and the disease extent. RESULTS: The mean time taken to apply the DMF was 3.8 min; for ICDAS, it took 8.9 min, and for CAST, 4.7 min. When calculating the indicator the most severe caries lesion per individual, the prevalence rates were as follows: 28.1% for DMF, 84.0% for ICDAS and 75.0% for CAST. The mean numbers of decayed, missing and filled teeth were 6.0 according to the DMF, 6.2 according to ICDAS and 5.9 according to CAST. When the disease extension indicator was used, the following percentages of teeth were affected by caries: DMF 22.12%, ICDAS 49.11% and CAST 33.2%. CONCLUSIONS: The DMF underestimated the occurrence of caries lesions in individuals but was the fastest method to apply. ICDAS obtained detailed information regarding lesion severity, but it was a time-consuming method and difficult to analyse. CAST described disease distributions very well and identified lesion severities and preventive and curative needs in the examined group, and the time required to apply CAST was similar to that of the DMF.

Taxonomy, phylogeny and ecology of cultivable fungi present in seawater gradients across the Northern Antarctica Peninsula.

Thirty-six seawater samples collected at different depths of the Gerlache and Bransfield Straits in the Northern Antarctic Peninsula were analyzed, and the average of the total fungal counts ranged from 0.3 to >300 colony forming units per liter (CFU/L) in density. The fungal were purified and identified as 15 taxa belonged to the genera Acremonium, Aspergillus, Cladosporium, Cystobasidium, Exophiala, Glaciozyma, Graphium, Lecanicillium, Metschnikowia, Penicillium, Purpureocillium and Simplicillium. Penicillium chrysogenum, Cladosporium sphaerospermum, and Graphium rubrum were found at high densities in at least two different sites and depths. Our results show at the first time that in the seawater of Antarctic Ocean occur diverse fungal assemblages despite extreme conditions, which suggests the presence of a complex aquatic fungi food web, including species reported as barophiles, symbionts, weak and strong saprobes, parasites and pathogens, as well as those found in the polluted environments of the world. Additionally, some taxa were found in different sites, suggesting that the underwater current might contribute to fungal (and microbial) dispersal across the Antarctic Ocean, and nearby areas such as South America and Australia.

Factors Associated with Insulin Resistance in Patients with Chronic HCV Genotype 1 Infection without Obesity or Type 2 Diabetes.

OBJECTIVE: To investigate the prevalence of insulin resistance (IR) and its association with clinical parameters in patients with hepatitis C virus (HCV) genotype 1 without obesity or type 2 diabetes. METHODS: One hundred and twenty-seven HCV-infected patients admitted to the Nutrition and Hepatology Clinic were included. Statistical analysis was performed using the Mann-Whitney test, Fisher's exact test, and Poisson regression analysis. RESULTS: The prevalence of IR (homeostasis model assessment [HOMA]-IR ≥ 3.0) was 37.0%. The independent predictors for IR included the following: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) 1.5 times the upper normal limit (odds ratio [PR] = 2.06, 95% CI, 1.16-3.66; PR = 2.32, 95% CI, 1.26-4.49, respectively); gamma glutamyl transferase (γGT) ≥ 85 U/L (PR = 2.09, 95% CI, 1.12-4.12); increased waist circumference (PR = 2.24, 95% CI, 1.25-4.17); increased waist : hip ratio (PR = 2.24, 95% CI, 1.11-5.17); increased body fat percentage (PR = 2.21, 95% CI, 1.01-5.79); overweight (PR = 2.54, 95% CI, 1.40-4.82); and metabolic syndrome (PR = 3.05, 95% CI, 1.69-5.44). High ALT levels and anthropometric parameters remained in the model of multivariate regression analysis. CONCLUSIONS: Our findings showed a significantly high prevalence of insulin resistance in nondiabetic, nonobese patients with hepatitis C genotype 1. High ALT levels and anthropometric parameters were significantly associated with IR after multivariate regression analysis. Our data show the importance of monitoring IR, weight, and body composition in patients with chronic hepatitis C. Nutritional management seems to be important in the control of comorbidities related to excess weight and the enhancement of therapeutic responses.

Modeling simultaneous carbon and nitrogen removal (SCNR) in anaerobic/anoxic reactor treating domestic wastewater.

This paper presents a mathematical model based on the Anaerobic Digestion Model No. 1 (ADM1) to simulate the effects of nitrate concentration and hydraulic retention time (HRT) on the simultaneous carbon and nitrogen removal (SCNR) in anaerobic/anoxic reactor treating domestic wastewater. The model was calibrated using previously published experimental data obtained from anaerobic batch tests for different COD/ [Formula: see text] ratios. Model simulations were performed to predict the SCNR in a completely mixed reactor (CSTR) operating under mesophilic conditions (35 °C). Six different scenarios were evaluated to investigate the performance of the SCNR based on typical influent characteristics of domestic wastewater. The variables analyzed were chemical oxygen demand (COD) removal, nitrate concentration, methane production, nitrogen gas, volatile fatty acids (VFA) concentration, pH and percentage of COD used by the denitrifying and methanogenic microorganisms. The HRT was decreased stepwise from 15 to 4 h. The results indicate that Scenario (S5) with a COD/ [Formula: see text] ratio equal to 10 and an HRT equal to 15 h ensures the occurrence of the stable SCNR. Furthermore, the accumulation of denitrification intermediates and a significant reduction in the biogas production when the organic matter is limited was verified.

Surgeons' perceptions of transanal endoscopic microsurgery using minilaparoscopic instruments in a simulator: the thinner the better.

BACKGROUND: Several issues have limited the widespread adoption of transanal endoscopic microsurgery (TEM). The need for specialized equipment and the steep learning curve represent one of them. To operate on within a 4-cm diameter, rectoscope represents a major technical challenge. However, minilaparoscopic surgery has been introduced to reduce invasiveness and abdominal wall trauma. In TEM, instrument miniaturization may lead to technique optimization. We hypothesized that visualization and maneuverability during TEM performed with 3-mm minilaparoscopic instruments would be superior to TEM performed with conventional 5-mm instruments. METHODS: Eighteen general and colorectal surgeons with experience with TEM under ten cases were recruited. Two tasks should be accomplished using the TEO(®)-Neoderma simulator. First, using conventional 5-mm TEO(®) curved-tip instruments, a "polypoid lesion" should be excised. Next, closure of the "rectal" defect should be undertaken. In the second part, the same participants repeated the same excision/closure tasks using 3-mm minilaparoscopic instruments. After tasks conclusion, participants fulfilled an evaluation questionnaire with seven questions regarding visualization and maneuverability when using 3-mm compared to 5-mm instruments. RESULTS: For each one of the seven questions in the questionnaire, the score results were significantly higher for the 3-mm instruments indicating that performance with the 3-mm minilaparoscopic instruments in the TEO simulator was in all cases between "better than expected" and "much better than expected." Appropriateness of the diameter of the minilaparoscopic instruments was the best evaluated parameter. The question addressing the ease of performing the tasks in the simulator presented the lowest mean score. CONCLUSIONS: The perceptions of participating surgeons indicated that there is better visualization and maneuverability during basic transanal endoscopic microsurgery tasks conducted in a simulator using 3-mm minilaparoscopic instruments when compared to conventional 5-mm instruments.

Antimicrobial activity of apitoxin, melittin and phospholipase A2 of honey bee (Apis mellifera) venom against oral pathogens.

In this work, we used the Minimum Inhibitory Concentration (MIC) technique to evaluate the antibacterial potential of the apitoxin produced by Apis mellifera bees against the causative agents of tooth decay. Apitoxin was assayed in natura and in the commercially available form. The antibacterial actions of the main components of this apitoxin, phospholipase A2, and melittin were also assessed, alone and in combination. The following bacteria were tested: Streptococcus salivarius, S. sobrinus, S. mutans, S. mitis, S. sanguinis, Lactobacillus casei, and Enterococcus faecalis. The MIC results obtained for the commercially available apitoxin and for the apitoxin in natura were close and lay between 20 and 40 µg / mL, which indicated good antibacterial activity. Melittin was the most active component in apitoxin; it displayed very promising MIC values, from 4 to 40 µg / mL. Phospholipase A2 presented MIC values higher than 400 µg / mL. Association of mellitin with phospholipase A2 yielded MIC values ranging between 6 and 80 µg / mL. Considering that tooth decay affects people's health, apitoxin and its component melittin have potential application against oral pathogens.

Duration of exclusive breastfeeding in a Brazilian population: new determinants in a cohort study.

BACKGROUND: Determinants of the duration of exclusive breastfeeding (EBF) differ in effect and magnitude across populations. The present study aimed to identify factors associated with discontinuation of EBF in a municipality in northeastern Brazil, including variables that have received little or no attention in previous literature. METHODS: This cohort study involved 1,344 mother-child pairs selected from maternity hospitals in Feira de Santana, Bahia, Brazil. Subjects were followed up for 6 months through monthly home visits, and discontinuation of EBF was recorded. Possible determinants were tested using Cox's four-level hierarchical survival model, taking into consideration the temporal proximity of the predisposing factors to interruption of EBF. Median duration of EBF was estimated using Kaplan-Meier's survival curve. RESULTS: Median duration of EBF was 89 days. Out of the 19 variables tested, 9 showed an association with EBF cessation; of these, two had never been evaluated in Brazilian studies, namely, mother partner's appreciation for breastfeeding (hazard ratio [HR] 0.62; 95% confidence interval [95% CI] 0.48-0.79) and limiting the number of nighttime feeds at the breast (HR 1.58; 95% CI 1.11-2.23). Another two variables that had been previously evaluated, but had never been described as determinants of discontinuation of EBF showed association: presence of cracked nipples (HR 2.54; 95% CI 2.06-3.13) and prenatal care provided by public services (HR 1.34; 95% CI 1.17-1.55). Other variables showing associations with the outcome were: guidance on breastfeeding received at the hospital (HR 0.80; 95% CI 0.68-0.92), birth in a Baby-Friendly Hospital (HR 0.85; 95% CI 0.73-0.99), less than or equal to 8 years of maternal schooling (HR 1.34, 95% CI 1.17-1.53), mother working outside the home (HR 1.73; 95% CI 1.53-1.95), and use of a pacifier (HR 1.40; 95% CI 1.14-1.71). CONCLUSIONS: The study confirmed that the factors associated with EBF duration are multiple, variable, and dependent on the population being evaluated. Characteristics that had never been previously evaluated or described, at least in Brazilian studies, behaved as determinants of EBF in the present study, and thus allow to expand the existing list of factors determining this practice.

Blueberry Muffin Syndrome and Hyperleukocytosis in a Newborn: A Diagnostic Challenge.

Blueberry muffin syndrome (BMS) in neonates, characterized by widespread nodular lesions, presents diagnostic challenges due to its diverse etiologies. Hyperleukocytosis, with leukocyte counts exceeding 100,000/µL, is a rare phenomenon associated with severe complications in neonates. Congenital leukemia (CL), a rare diagnosis within the first month of life, is linked to high mortality. This case report presents a unique case of BMS with hyperleukocytosis as the initial presentation of CL. A full-term male newborn, born after an uncomplicated pregnancy, except for Kell isoimmunization, with an Apgar score of 9/10, and an irrelevant family history, showed widespread purple nodules consistent with BMS at birth. Laboratory workup revealed mild anemia, hyperleukocytosis with immature granulocytes on peripheral blood (PB) smear, positive direct antiglobulin test, and elevated alanine aminotransferase and lactate dehydrogenase, without hyperbilirubinemia. Empirical antibiotics and hyperhydration were started, and the neonate was transferred to a level 3 neonatal intensive care unit for further evaluation. A comprehensive etiological investigation was conducted, comprising infectious, immunological, metabolic, and neoplastic factors. A skin nodule biopsy revealed an infiltrate of blast cells, indicative of leukemia cutis, and a bone marrow aspirate confirmed acute myeloid leukemia (AML). The patient successfully completed the NOPHO-DBH-2012 chemotherapy protocol at five months and remains in complete remission at nine months. This case report contributes to the literature by highlighting the diagnostic approach and management strategies for CL presenting with BMS and hyperleukocytosis. This case aims to enhance awareness and understanding of BMS as an initial manifestation of CL. Additionally, the challenges of treating leukemia in neonates, coupled with the lack of specific guidelines for this age group, further underscore the complexities in managing such patients.