Health inequity assessment in Brazil: is EQ-5D-3L sensible enough to detect differences among distinct socioeconomic groups?

BACKGROUND: Multidimensional health-related quality of life (HRQOL) instruments, such as the EQ-5D, are increasingly used to assess inequalities in health. However, it is necessary to explore the ability of these instruments to capture differences between population groups, especially in low/middle-income countries. This study aimed to investigate whether the EQ-5D-3L instrument can detect differences in HRQOL between groups of different socioeconomic status (SES) in Brazil. METHODS: Data collection occurred during the Brazilian EQ-5D-3L valuation study and included respondents aged 18 to 64 years enrolled in urban areas. SES was aggregated into three categories: "higher" (A and B), "intermediate" (C) and "lower" (D and E). EQ-5D-3L index was calculated considering the Brazilian value set. A mixed-effects regression model was estimated with random effects on individuals and marginal effects on SES, sex, and educational attainment. Odds ratios for the chance of reporting problems for each EQ-5D dimension were estimated by logistic regression. RESULTS: A total of 9,148 respondents were included in the study. Mean age was 37.80 ± 13.13 years, 47.4% were men and the majority was ranked as classes B or C (38.4% and 50.7%, respectively). Participants in lower SES classes reported increasingly poorer health compared to individuals in higher classes. The mean EQ-5D-3L index decreased as SES deteriorates being significantly higher for classes A and B (0.874 ± 0.14) compared to class C (0.842 ± 0.15) and classes D and E (0.804 ± 0.17) (p < 0.001). The same was observed for the mean EQ-VAS scores (84.0 ± 13.8 in classes A and B, 81.0 ± 17 in class C and 78.3 ± 18.7 in class C [p < 0.001]). The multivariate analysis confirmed that SES is an independent factor that effects EQ-5D-3L index measures. Participants in intermediate and lower SES classes have a statistically significant lower EQ-5D-3L index compared to participants in classes A and B, regardless of age, sex, and educational attainment. CONCLUSION: In a Brazilian population sample, the EQ-5D-3L instrument was able to detect important differences between groups with distinct socioeconomic statuses (SES). The EQ-5D-3L is useful for exploring inequities in health.

Impact and economic analysis of human T-cell lymphotropic virus type 1 (HTLV-1)-targeted antenatal screening, England and Wales, 2021.

BackgroundHuman T-cell lymphotropic virus type 1 (HTLV-1) is a neglected virus that can cause severe disease and be transmitted from mother to child through breastfeeding. Avoidance of breastfeeding prevents 80% of vertical transmission. The United Kingdom (UK) is currently assessing whether HTLV-1-targeted antenatal screening should be implemented.AimWe aimed to assess the impact and cost-effectiveness of a targeted programme to prevent HTLV-1 vertical transmission in England and Wales.MethodsWe estimated the number of pregnant women who have high risk of HTLV-1 infection based on their or their partner's country of birth. With data from 2021, we used a mathematical model to assess cost-effectiveness of HTLV-1 antenatal screening. We also estimated the annual number of infant infections and the number that could be prevented with screening and intervention.ResultsWe estimate that ca 99,000 pregnant women in England and Wales have high risk of HTLV-1 infection. In the absence of screening, 74 (range: 25-211) HTLV-1 infections in infants would be expected to occur every year in England and Wales. Implementation of targeted screening would prevent 58 (range: 19-164) infant infections annually. The intervention is effective (incremental 0.00333 quality-adjusted life years (QALY)) and cost-saving (GBP -57.56 (EUR -66.85)).ConclusionOur findings support implementation of HTLV-1 targeted antenatal screening to reduce vertical transmission from mothers to infants in the UK.

Improving nutritional quality of unripe tomato through fermentation by a consortium of yeast and lactic acid bacteria.

BACKGROUND: Portugal is one of the main producers of industrial tomato and tomato paste, an important intermediate ingredient used in many added-value foods. The tomato processing industry rigorously selects the fruits by colour during mechanical harvest, picking only completely ripe fruits to produce high quality tomato paste. The latest available data shows that about 1.12 × 108 kg yr-1 of non-red/not-ripe tomatoes are left in the field, representing a major side product/field residue with great impact on the environment and for tomato producers. RESULTS: The aim of the work was to use fermentation by a consortium of yeast and lactic acid bacteria to improve the nutritional quality of unripe tomato paste. A consortium of Lactobacillus plantarum, Leuconostoc mesenteroides and Kluyveromyces marxianus was selected, producing an acidic paste with olive-like flavours after 4 days of fermentation. Nutritional characterization revealed a significant improvement (P < 0.05) in the content of ascorbic acid and antioxidant potential. In addition, ultrahigh-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) analysis showed that the fermented green tomato paste content in glycoalkaloid α-tomatine represents no hazard to the consumer. CONCLUSION: Therefore, the obtained fermented green tomato paste can be further used to produce new food products, such as salad dressings and sauces. © 2021 Society of Chemical Industry.

EQ-5D Brazilian population norms.

BACKGROUND: The EQ-5D-3L is a widely used generic health-related quality of life measure commonly applied to describe health outcomes and to measure disease burden. The aim of this study was to generate Brazilian population norms, stratified by age and gender, based on Brazilian preference weights for EQ-5D-3L. METHODS: A multicenter cross-sectional study was conducted in three Brazilian urban areas. The final sample consisted of 5774 respondents, aged from 18 to 64 years. Amongst other information, respondents were asked to self-report their health status using the EQ-5D-3L descriptive system and visual analog scale (EQ-VAS). Data on socio-demographic characteristics was obtained through specific questionnaires. The Brazilian TTO scoring algorithm was used to derive the utility values. Multivariate logistic regression models were fitted to analyze the influence of age, sex, education status and sample site on the presence of any problem for each dimension of EQ5D. RESULTS: Mean values were computed for both weighted index scores and self-rated health status (EQ-VAS), and stratified by gender and age groups. Health status declines with age, ranging between 0.87 for the youngest group 18-29 year-olds and 0.76 for 60-64-year-old. Men reported higher scores (0.85) than the woman (0.79). Lower education levels were associated with lower EQ-5D index score in most age groups. CONCLUSION: This study provides EQ-5D reference values for the Brazilian population. These values can be used by local decision-makers and researchers in economic evaluations and population health studies.

Industrial sustainability of microbial keratinases: production and potential applications.

Keratinases are proteolytic enzymes with a particular ability to cleave peptide bonds in keratin, and in other proteins. Due to their broad-spectrum of activity, keratinases are considered viable substitutes for chemical and thermal treatments of protein-rich industrial by-products. Among these protein residues, special attention has been given to keratinous materials (feathers, hair, horns, etc.), which disposal through harsh conditions methods, such as acid/alkaline hydrolysis or incineration, is not considered ecologically safe. Microbial keratinolytic enzymes allow for keratin degradation under mild conditions, resulting in keratin hydrolysates containing undamaged amino acids and peptides. In this review article, we offer perspectives on the relevance of these unique biocatalysts and their revolutionary ascent in industries that generate keratin-rich wastes. Additionally, we share insights for applications of keratinases and protein hydrolysates in agriculture, animal feed, cosmetics, phamaceuticals, detergent additives, leather processing, and others. Due to the scientific importance of keratinases and their potential use in green technologies, searching for bacterial and fungal species that efficiently produce these enzymes may contribute to the sustainability of industries.

Cellular alteration and differential protein profile explain effects of GA3 and ABA and their inhibitor on Trichocline catharinensis (Asteraceae) seed germination.

Seed physiology of wild species has not been studied as deeply as that of domesticated crop species. Trichocline catharinensis (Asteraceae) is an endemic wildflower species from the high-altitude fields of southern Brazil. This species is of interest as a source of genes to improve cultivated Asteraceae because of its ornamental features, disease resistance and ability to tolerate drought and poor soil conditions. We studied the effects of abscisic acid (ABA) and gibberellic acid (GA3 ) and their inhibitors, fluridone (FLU) and paclobutrazol (PAC), on seed germination. We individually assessed ultrastructural changes and differential protein accumulation. The principal component analysis explained 69.66% of differential accumulation for 32 proteins at phase II of seed germination in response to hormone and inhibitor treatment. GA3 -imbibed seed germination (98.75%) resulted in increased protein accumulation to meet energy demand, redox regulation, and reserve metabolism activation. FLU-imbibed seeds showed a higher germination speed index as a consequence of metabolism activation. ABA-imbibed seeds (58.75%) showed osmotolerance and flattened cells in the hypocotyl-radicular axis, suggesting that ABA inhibits cell expansion. PAC-imbibed seeds remained at phase II for 300 h, and germination was suppressed (7.5%) because of the increased signaling proteins and halted reserve mobilization. Therefore, our findings provide insight into the behavior of Asteraceae non-dormant seed germination, which broadens our knowledge of seed germination in a wild and endemic plant species from a threatened ecosystem.

Systematic review of dengue vaccine efficacy.

BACKGROUND: Dengue is an arbovirus that has rapidly spread worldwide, and the incidence of dengue has greatly increased in recent decades. The actual numbers of dengue cases are underreported, and many cases are not classified correctly. Recent estimates indicate that 390 million dengue infections occur per year (95% CI, 284-528 million), of which 96 million (67-136 million) are symptomatic infections of any severity. One of the goals of the World Health Organization is to reduce dengue mortality by 50% by the year 2020. The use of a vaccine can be an important strategy to achieve this goal. Vaccines for dengue are in various stages of development; in Brazil, only one commercial formulation is available (CYD-TDV), which was developed by Sanofi Pasteur. METHODS: To evaluate the efficacy of Dengue vaccine, a systematic review with a meta-analysis was conducted using randomized controlled clinical trials published between 2000 and 2017 that were identified in the MEDLINE databases via PubMed, LILACS, Cochrane Library, and EMBASE. The selection was performed by two reviewers independently, with disagreements resolved by a third reviewer. RESULTS: Seven clinical trials were included, with a total of 36,371 participants (66,511 person-years) between the ages of 2 and 45 years. The meta-analysis using the random-effects model estimated the efficacy of the vaccine at 44%, with a range from 25 to 59% and high heterogeneity (I2 = 80.1%). The serotype-stratified meta-analysis was homogeneous, except for serotype 2, with the heterogeneity of 64.5%. Most of the vaccinated individuals had previous immunity for at least one serotype, which generated safety concerns in individuals without previous immunity. CONCLUSIONS: Compared with other commercially available vaccines, the dengue vaccine showed poor efficacy.

Miniprobe endoscopic ultrasonography for the diagnosis of colon hemangiolymphangioma.

Hemangiolymphangioma is a very rare benign vascular tumor that affects the gastrointestinal tract in less than 1% of cases. We present the case of an asymptomatic 52-year-old female referred for endoscopic colorectal cancer screening. A sub-epithelial pediculated polypoid lesion in the splenic angle of the colon was identified. An endoscopic ultrasonography with a miniprobe was performed, which identified an anechoic lesion in the submucosal layer. Surgery was performed and the histologic findings were compatible with two hemangiolymphangioma lesions. This is one of the few cases reported in the literature of hemangiolymphangioma diagnosed by miniprobe endoscopic ultrasonography and the first to describe two lesions in the same patient.

Further evidence on EQ-5D-5L preference inversion: a Brazil/U.S. collaboration.

PURPOSE: A preference inversion occurs when "worse" health (instead of "better" health) along a scale or score is preferred. Our aim was to confirm past findings of EQ-5D-5L preference inversions among English-speaking respondents and to explore inversions among Portuguese-speaking respondents. Anecdotal evidence suggests that inversions may be more common in the Portuguese version, where the translation of the fourth level "severely" (gravemente) means "gravely." METHODS: Through an infusion clinic in Tampa, Florida, United States and a cardiology clinic in Rio de Janeiro, Brazil, 740 respondents completed a tablet-based survey, which included the EQ-5D-3L and -5L followed by paired comparisons designed to assess preference inversions between the fourth and fifth levels of each of the five domains: Mobility (MO), Self-Care (SC), Usual Activity (UA), Pain/Discomfort (PD), and Anxiety/Depression (AD). An example from the AD dimension would be: "Which do you prefer? Starting today, 30 days with health problems: Severely anxious or depressed or Extremely anxious or depressed" (i.e., Level 4 AD vs. Level 5 AD). RESULTS: In the English-speaking respondents, preference inversion was only observed to a substantial extent in the AD dimension (U.S. N = 470; 7% MO, 14% SC, 14% UA, 20% PD, and 45% AD). Inversions were more common among the Portuguese-speaking respondents (Brazil N = 270; 11% MO, 32% SC, 35% UA, 49% PD, and 65% AD). Specifically, 44 out of 68 Brazilian respondents (65%) preferred "extremamente" (Level 5 AD) over "gravemente ansioso (a) ou deprimido (a)" (Level 4 AD). CONCLUSIONS: This evidence confirms previous findings for the U.S. English version of the EQ-5D-5L and led to a relabeling on the Portuguese version. It demonstrates the usefulness of collaboration between psychometric, econometric, and linguistic experts in developing the wording for and translating preference-based measures of health-related quality of life. Further research may explore inversions in other translations. The authors recommend that preference inversion tests should be included in the development and translation process.

Predictors of high-quality cord blood units.

BACKGROUND: Analysis of umbilical cord blood (UCB) transplants shows a correlation between engraftment and total number of infused cells. Thus, it is worth evaluating what maternal and neonatal characteristics and collection techniques may affect the quality of UCB units. STUDY DESIGN AND METHODS: A cross-sectional study was performed with 7897 donors sequentially selected in three health care institutions in Brazil from October 2004 to March 2012, in which both quantitative and qualitative approaches were applied. All donors were considered suitable for cord blood collection. RESULTS: The maternal and neonatal characteristics and techniques of collection that influenced the total number of nucleated cells (TNCs; p < 0.001) were type of delivery, newborn weight and sex, and institution of UCB collection. The TNC count was associated with gestational age (p = 0.008), type of delivery (p < 0.001), newborn sex (p < 0.001), newborn weight (p < 0.001), and UCB collection technique (p = 0.003). Center B presented the largest number of nucleated cells in its results (p < 0.001), followed by Center A (p = 0.001). Other characteristics, such as maternal age, were analyzed but were not relevant for the nucleated cell number. CONCLUSION: This study provides elements for a model that allows an efficient selection of UCB donors, prioritizing candidates who have a better chance to lead to an optimized use of cord blood cells units.

Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country.

Myocardial perfusion imaging is widely used for the risk stratification of coronary artery disease. In view of its cost, besides radiation issues, judicious evaluation of the appropriateness of its indications is essential to prevent an unnecessary economic burden on the health system. We evaluated, at a tertiary-care, public Brazilian hospital, the appropriateness of myocardial perfusion scintigraphy indications, and estimated the budget impact of applying appropriateness criteria. An observational, cross-sectional study of 190 patients with suspected or known coronary artery disease referred for myocardial perfusion imaging was conducted. The appropriateness of myocardial perfusion imaging indications was evaluated with the Appropriate Use Criteria for Cardiac Radionuclide Imaging published in 2009. Budget impact analysis was performed with a deterministic model. The prevalence of appropriate requests was 78%; of inappropriate indications, 12%; and of uncertain indications, 10%. Budget impact analysis showed that the use of appropriateness criteria, applied to the population referred to myocardial perfusion scintigraphy within 1 year, could generate savings of $ 64,252.04 dollars. The 12% inappropriate requests for myocardial perfusion scintigraphy at a tertiary-care hospital suggest that a reappraisal of MPI indications is needed. Budget impact analysis estimated resource savings of 18.6% with the establishment of appropriateness criteria for MPI.

EFFICACY OF CARPENTIER-EDWARDS PERICARDIAL PROSTHESES: A SYSTEMATIC REVIEW AND META-ANALYSIS.

OBJECTIVES: The Carpentier-Edwards pericardial (CEP) prostheses are the type of bioprostheses most used worldwide. Although they were designed to minimize the rate of valve deterioration and reoperation, their clinical superiority over other prostheses models still lacks confirmation. The objective of this study was to evaluate its effectiveness. METHODS: We performed a systematic review and meta-analysis in the PubMed, Embase, Cochrane, and Lilacs databases. Operative mortality, overall mortality and reoperation rates after heart valve surgery were compared between the use of CEP and other cardiac prostheses. Two independent reviewers screened studies for inclusion and extracted the data. Disagreements were resolved by consensus. The GRADE criterion was used to assess the evidence quality. RESULTS: A total of twenty-eight studies were selected, including 19,615 individuals. The studies presented a high heterogeneity and low quality of evidence what limited the reliability of the results. The pooled data from the selected studies did not demonstrate significant differences between CEP and porcine, pericardial or stentless prostheses regarding operative mortality, overall mortality and reoperation rates. However, the pooled data from 3 observational trials pointed out a higher risk for reoperation after valve replacement using CEP prostheses against mechanical prostheses (OR 4.92 [95 percent confidence interval 2.43-9.96]). CONCLUSIONS: The current data present in the literature still does not support a clinical advantage for the use of CEP prostheses over other bioprostheses. The quality of the studies in the literature is limited and further studies are needed to address if CEP prostheses will have a clinical advantage over other prostheses.

Dormancy-breaking requirements of Sophora tomentosa and Erythrina speciosa (Fabaceae) seeds.

The physical dormancy of seeds has been poorly studied in species from tropical forests, such as the Atlantic Forest. This study aimed to examine the effect of moderate alternating temperatures on breaking the physical dormancy of seeds, the morphoanatomy and histochemistry of seed coats, and to locate the structure/region responsible for water entrance into the seed, after breaking the physical dormancy of seeds of two woody Fabaceae (subfamily Faboideae) species that occur in the Brazilian Atlantic Forest: Sophora tomentosa and Erythrina speciosa. To assess temperature effect, seeds were incubated in several temperature values that occur in the Atlantic Forest. For morphological and histochemical studies, sections of fixed seeds were subjected to different reagents, and were observed using light or epifluorescence microscopy, to analyze the anatomy and histochemistry of the seed coat. Treated and nonreated seeds were also analyzed using a scanning electron microscope (SEM) to observe the morphology of the seed coat. To localize the specific site of water entrance, the seeds were blocked with glue in different regions and also immersed in ink. In the present work a maximum temperature fluctuation of 15 degrees C was applied during a period of 20 days and these conditions did not increase the germination of S. tomentosa or E. speciosa. These results may indicate that these seeds require larger fluctuation of temperature than the applied or/and longer period of exposition to the temperature fluctuation. Blocking experiments water inlet combined with SEM analysis of the structures of seed coat for both species showed that besides the lens, the hilum and micropyle are involved in water absorption in seeds scarified with hot water. In seeds of E. speciosa the immersion of scarified seeds into an aniline aqueous solution showed that the solution first entered the seed through the hilum. Both species showed seed morphological and anatomical features for seed coats of the subfamily Faboideae. Lignin and callose were found around all palisade layers and the water impermeability and ecological role of these substances are discussed in the work.

Viability of human adenovirus from hospital fomites.

The monitoring of environmental microbial contamination in healthcare facilities may be a valuable tool to determine pathogens transmission in those settings; however, such procedure is limited to bacterial indicators. Viruses are found commonly in those environments and are rarely used for these procedures. The aim of this study was to assess distribution and viability of a human DNA virus on fomites in an Adult Intensive Care Unit of a private hospital in Rio de Janeiro, Brazil. Human adenoviruses (HAdV) were investigated in 141 fomites by scraping the surface area and screening by quantitative PCR (qPCR) using TaqMan® System (Carlsbad, CA). Ten positive samples were selected for virus isolation in A549 and/or HEp2c cell lines. A total of 63 samples (44.7%) were positive and presented viral load ranging from 2.48 × 10(1) to 2.1 × 10(3) genomic copies per millilitre (gc/ml). The viability was demonstrated by integrated cell culture/nested-PCR in 5 out of 10 samples. Nucleotide sequencing confirmed all samples as HAdV and characterized one of them as specie B, serotype 3 (HAdV-3). The results indicate the risk of nosocomial transmission via contaminated fomites and point out the use of HAdV as biomarkers of environmental contamination.

Conversion of cellulosic materials into glycolipid biosurfactants, mannosylerythritol lipids, by Pseudozyma spp. under SHF and SSF processes.

BACKGROUND: Mannosylerythritol lipids (MEL) are glycolipids with unique biosurfactant properties and are produced by Pseudozyma spp. from different substrates, preferably vegetable oils, but also sugars, glycerol or hydrocarbons. However, solvent intensive downstream processing and the relatively high prices of raw materials currently used for MEL production are drawbacks in its sustainable commercial deployment. The present work aims to demonstrate MEL production from cellulosic materials and investigate the requirements and consequences of combining commercial cellulolytic enzymes and Pseudozyma spp. under separate hydrolysis and fermentation (SHF) and simultaneous saccharification and fermentation (SSF) processes. RESULTS: MEL was produced from cellulosic substrates, Avicel® as reference (>99% cellulose) and hydrothermally pretreated wheat straw, using commercial cellulolytic enzymes (Celluclast 1.5 L® and Novozyme 188®) and Pseudozyma antarctica PYCC 5048(T) or Pseudozyma aphidis PYCC 5535(T). The strategies included SHF, SSF and fed-batch SSF with pre-hydrolysis. While SSF was isothermal at 28°C, in SHF and fed-batch SSF, yeast fermentation was preceded by an enzymatic (pre-)hydrolysis step at 50°C for 48 h. Pseudozyma antarctica showed the highest MEL yields from both cellulosic substrates, reaching titres of 4.0 and 1.4 g/l by SHF of Avicel® and wheat straw (40 g/l glucan), respectively, using enzymes at low dosage (3.6 and 8.5 FPU/gglucan at 28°C and 50°C, respectively) with prior dialysis. Higher MEL titres were obtained by fed-batch SSF with pre-hydrolysis, reaching 4.5 and 2.5 g/l from Avicel® and wheat straw (80 g/l glucan), respectively. CONCLUSIONS: This work reports for the first time MEL production from cellulosic materials. The process was successfully performed through SHF, SSF or Fed-batch SSF, requiring, for maximal performance, dialysed commercial cellulolytic enzymes. The use of inexpensive lignocellulosic substrates associated to straightforward downstream processing from sugary broths is expected to have a great impact in the economy of MEL production for the biosurfactant market, inasmuch as low enzyme dosage is sufficient for good systems performance.

The epiphytic fern Elaphoglossum luridum (Fée) Christ. (Dryopteridaceae) from Central and South America: morphological and physiological responses to water stress.

Elaphoglossum luridum (Fée) Christ. (Dryopteridaceae) is an epiphytic fern of the Atlantic Forest (Brazil). Anatomical and physiological studies were conducted to understand how this plant responds to water stress. The E. luridum frond is coriaceus and succulent, presenting trichomes, relatively thick cuticle, and sinuous cell walls in both abaxial and adaxial epidermis. Three treatments were analyzed: control, water deficit, and abscisic acid (ABA). Physiological studies were conducted through analysis of relative water content (RWC), photosynthetic pigments, chlorophyll a fluorescence, and malate content. No changes in RWC were observed among treatments; however, significant decreases in chlorophyll a content and photosynthetic parameters, including optimal irradiance (I opt) and maximum electron transport rate (ETRmax), were determined by rapid light curves (RLC). No evidence of crassulacean acid metabolism (CAM) pathway was observed in E. luridum in response to either water deficit or exogenous application of ABA. On the other hand, malate content decreased in the E. luridum frond after ABA treatment, seeming to downregulate malate metabolism at night, possibly through tricarboxylic acid (TCA) cycle regulation.

Morphological and micromorphological characteristics of Desmodium fruits (Leguminosae: Papilionoideae).

The genus Desmodium is represented in Santa Catarina State, Brazil, by 13 species, all with lomen- taceous fruits. Shape, size and isthmus margin of loments vary, while the surface is glabrous, or covered by trichomes of different types. Morphological diversity of trichomes becomes particularly relevant to taxonomic description. The trichome types present on the surface of Desmodium fruits provide data for the identification and classification of species in the State. To assess this, three fruits of each species were collected and deposited at two herbaria, HBR and FLOR, in Santa Catarina, Brazil. Some rehydrated samples were examined using light microscopy (LM); and some sections were exposed to the following histochemical reagents: Sudan III for oils and Thionine for mucilage. The structural aspects of trichomes can be classified into uni- or multicellular and may still be simple, i.e., nonglandular or glandular. Using scanning electron microscopy (SEM), five types of trichomes were identified and analyzed among the Desmodium species studied: uncinate, uniseriate, globose multicellular, globose unicellular and subulate. Characteristics, such as loment margin and article form, glabrescent or pillous indument, trichome type, with or without papillous epidermal cells and epicuticular striations, showed relevant diagnostic value. An identification key was developed for Desmodium species from Santa Catarina State, Brazil, based on macro and micromorphological characters of the fruit.

Management of Short Bowel Syndrome With Chronic Intestinal Failure: A Single-Center Experience in Portugal.

INTRODUCTION: Short bowel syndrome with chronic intestinal failure (SBS/CIF) is the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance due to a short bowel. Although SBS/CIF is rare, its clinical management is complex, challenging, expensive, and time-consuming. AIM: This study aimed to analyze a single center's experience with SBS/CIF in adult patients treated with home parenteral nutrition (HPN). MATERIALS AND METHODS: A retrospective single-center analysis of all 13 consecutive adult patients with SBS/CIF was included in an HPN program between January 1994 and August 2023. RESULTS: Between 1992 and 2023, 13 patients were included in an HPN program. The primary underlying pathology was acute mesenteric ischemia. The median age of starting HPN was 44 years. Most were subjected to several surgeries of extensive intestinal resection with posterior intestinal reconstruction. Five of the 13 patients died while on HPN with a median duration of 42 months. The causes of death related to HPN were catheter sepsis, endocarditis with cardiac failure, or hepatic failure. One patient died due to underlying pathology: pelvic abscesses and bleeding related to radiotherapy. Eight patients remain alive, with a median time of HPN of 173 months. During the HPN support, the most frequent complications were venous catheter infection and venous territory thrombosis. None of the eight patients alive have hepatic failure. Two patients recently started teduglutide with good tolerance and need a reduction in HPN support. All eight patients have a satisfactory quality of life (parenteral support needs range between five and two nutrition bags per week).  Conclusion: Home parenteral nutrition remains the gold standard of SBS/CIF treatment, although teduglutide may reduce HPN needs and complications and provide a better quality of life. Despite the small number of patients, the results shown in this study are not inferior to those in large-volume centers. The existence of the commitment and interest of professionals involved in SBS/CIF at Centro Hospitalar Universitário de Santo António, Portugal, was a fundamental key to achieving those results. A multidisciplinary healthcare group for HPN support can be essential to ensuring these patients' survival and quality of life.

Cost-Utility Model of Nirmatrelvir/Ritonavir in Brazil: Analysis of a Vaccinated Population.

OBJECTIVES: The aim of this study is to conduct a cost-utility analysis of the use of the antiviral nirmatrelvir/ritonavir, applied to a vaccinated Brazilian population against COVID-19, from the perspective of the Brazilian Public Health System (SUS). METHODS: A microsimulation model was created with individual-level data and daily cycles, with a 1-year time horizon, to compare the current scenario of standard care with a scenario in which nirmatrelvir/ritonavir is offered to the population. Adults of any age group that received ≥2 doses of the COVID-19 vaccine formed the investigated population. Direct medical costs of the outpatients and inpatients admitted to the ward or intensive care unit were included. The effectiveness of the model was measured in quality-adjusted life-years (QALYs). RESULTS: In all simulations, the use of nirmatrelvir/ritonavir resulted in incremental costs per patient of US dollar (USD)245.86 and incremental effectiveness of 0.009 QALY, over a year. The incremental cost-utility ratio was USD27 220.70/QALY. The relative risk of the vaccinated population was the factor that affected the outcome most, according to the univariate sensitivity analysis. The probabilistic sensitivity analysis resulted in 100% of the simulations being more costly and effective, but that only 4% of them were below the established cost-effectiveness threshold of USD24 000.00/QALY. In the scenario considering only the population over 60 years old and immunosuppressed (of any age), the incremental cost-utility ratio was USD7589.37/QALY. CONCLUSIONS: The use of nirmatrelvir/ritonavir in the treatment of COVID-19 in a vaccinated population was cost-effective only for immunosuppressed individuals and people over 60 years of age.