Evaluation of morphology and biventricular cardiac function in children with congenital zika syndrome

Introduction

The infection caused by the Zika virus during pregnancy causes microcephaly and brain damage in fetus, and the systemic involvement with diffuse muscle impairment, high frequency of arthrogryposis and microphthalmia, characterizes congenital Zika syndrome (CZS). The cardiac impairment in CZS was rarely evaluated.

Purpose

To evaluate the morphology and biventricular cardiac function in children affected by CZS, using electrocardiogram (EKG), echocardiogram and biomarkers dosage.

Methods

This is a cross-sectional study conducted with 52 children with CZS (GZ) compared with 25 healthy children (CG). Clinical evaluation, EKG, and echocardiogram were performed in all of them. Also, troponin I and natriuretic peptide type B (BNP) dosages were performed in GZ.

Results

The median age of the studied population was 5 years in groups, GZ (3 to 6 years), CG (3 to 8 years), 40.4% (GZ) and 60% (CG) of female gender. The most prevalent electrocardiographic alteration was sinus arrhythmia, GZ: 9 (17.3%) and CG: 4 (16%). The echocardiographic evaluation showed the morphological parameters adjusted for the Z score: left ventricular (LV) end-diastolic diameter in GZ: −2.36 [−5.10, 2.63] vs CG: −1.07 [−3.43, 0.61], p<0.001; LV end-systolic diameter in GZ: −1.02 [−4.49, 0.62] vs CG: −0.06 [−1.98, 2.28], p<0.01; ascending aorta in GZ: −0.09 [−2.08, 1.60] vs CG: 0.43 [−1.47, 2.2], p: 0.021; basal diameter of the right ventricle (RV) in GZ: −2.34 [−4.90, 0.97] vs CG: −0.96 [−2.21, 0.40], p<0.01; pulmonary artery dimension in GZ: −2.13 [−5.99, 0.98] vs CG: −0.24 [−2.53, 0.59], p<0.01. The left atrium volume index (ml/m2) was in GZ: 13.15 [6.80, 18.00] vs CG: 18.80 [5.90, 25.30], p<0.01; right atrium volume index (ml/m2) in GZ: 10.10 [4.90, 15.30] vs CG: 15.80 [4.10, 24.80], p<0.01. The septum systolic excursion of the mitral annular plane (MAPSE, cm) was in GZ: 0.98 [0.78, 1.66] vs CG: 1.25 [1.07, 1.56], p<0.01; and lateral annulus: 1.25 [0.81, 1.86] vs CG: 1.46 [1.07, 1.83], p<0.001; tricuspid annular plane systolic excursion (cm) in GZ: 1.52 [1.13, 2.34] vs CG: 1.90 [1.62, 2.35], p<0.01; S' of the RV (cm/s) was in GZ: 10.60 [6.49, 21.00] vs CG: 12.80 [9.19, 16.20], p<0.01. The peak of late mitral inflow (A wave, cm/s) was in GZ: 64 [24, 134] vs CG: 52 [26, 94], p=0.02; peak of late diastolic mitral annular wave (e') of septum (cm/s) was GZ: 15 [7, 23] vs CG: 17 [12, 27], p<0.01; peak of e' lateral (cm/s) was in GZ: 11 [7, 19], CG: 12 [9, 15], p<0,016; E/e' ratio was GZ: 7.52 [4.57, 10.78] vs CG: 6.41 [4.75, 12.64], p<0.01. The LV longitudinal and circumferential and RV longitudinal strain measurements showed no difference between the groups.

Conclusion

A reduction in cardiac dimensions and biventricular dysfunction was found in CZS, showing an early cardiac impairment, which will enable to establishment early therapies, avoiding severe heart failure.

Funding Acknowledgement

Type of funding sources: None.

Positive selection over the mitochondrial genome and its role in the diversification of gentoo penguins in response to adaptation in isolation

Although mitochondrial DNA has been widely used in phylogeography, evidence has emerged that factors such as climate, food availability, and environmental pressures that produce high levels of stress can exert a strong influence on mitochondrial genomes, to the point of promoting the persistence of certain genotypes in order to compensate for the metabolic requirements of the local environment. As recently discovered, the gentoo penguins (Pygoscelis papua) comprise four highly divergent lineages across their distribution spanning the Antarctic and sub-Antarctic regions. Gentoo penguins therefore represent a suitable animal model to study adaptive processes across divergent environments. Based on 62 mitogenomes that we obtained from nine locations spanning all four gentoo penguin lineages, we demonstrated lineage-specific nucleotide substitutions for various genes, but only lineage-specific amino acid replacements for the ND1 and ND5 protein-coding genes. Purifying selection (dN/dS < 1) is the main driving force in the protein-coding genes that shape the diversity of mitogenomes in gentoo penguins. Positive selection (dN/dS > 1) was mostly present in codons of the Complex I (NADH genes), supported by two different codon-based methods at the ND1 and ND4 in the most divergent lineages, the eastern gentoo penguin from Crozet and Marion Islands and the southern gentoo penguin from Antarctica respectively. Additionally, ND5 and ATP6 were under selection in the branches of the phylogeny involving all gentoo penguins except the eastern lineage. Our study suggests that local adaptation of gentoo penguins has emerged as a response to environmental variability promoting the fixation of mitochondrial haplotypes in a non-random manner. Mitogenome adaptation is thus likely to have been associated with gentoo penguin diversification across the Southern Ocean and to have promoted their survival in extreme environments such as Antarctica. Such selective processes on the mitochondrial genome may also be responsible for the discordance detected between nuclear- and mitochondrial-based phylogenies of gentoo penguin lineages.

The impact of mitral regurgitation grade on exercise capacity following cardiac rehabilitation program after transcatheter aortic valve implantation

Introduction

Severe aortic stenosis (AS) and mitral regurgitation (MR) often coexist. Transcatheter aortic valve implantation (TAVI) is becoming widely used for the treatment of patients (pts) with symptomatic severe AS. However, conflicting data reside concerning the impact of MR on outcomes after TAVI. Also, very few data exist regarding the benefits of a cardiac rehabilitation program (CRP) following TAVI in pts with MR.

Purpose

To evaluate the effect of a CRP in functional parameters after TAVI, particularly in pts with MR grade ≥ II.

Methods

Retrospective study which included all pts submitted to TAVI between 2014 and 2020 that completed a CRP following the procedure. Cardiopulmonary exercise tests (CPET) were performed after TAVI at baseline (pre-CRP) and post-CRP. We evaluated pre- and post-CRP peak oxygen consumption (pVO2), pVO2 at the anaerobic threshold (AT), respiratory exchange ratio (RER), VE/VCO2 and CPET duration. The exercise protocol included low/medium intensity exercises and consisted of sessions 3 times per week carried over 3 months. MR grading severity was assessed with transthoracic echocardiography performed after TAVI and was divided into 2 groups (grade &lt; II vs grade ≥ II).

Results

Fifty-two pts were included, 59,6% were male, mean age of 78,6±8,6 years-old. Mean Society of Thoracic Surgery (STS) risk score was 4,9. Mean pre-TAVI aortic valve area was 0,68 cm2, with a mean gradient of 45,5 mmHg and a mean ejection fraction (EF) of 51%. The majority of pts implanted a self-expandable prosthesis (55,8%).

Twenty-seven (51,9%) pts had MR grade ≥ II. Baseline characteristics were similar between pts with MR grade &lt; II vs MR grade ≥ II, with the exception of the prevalence of coronary artery disease which was higher in MR grade ≥ II (p=0,036). Patients with MR grade &lt; II had higher maximum and median aortic gradients before TAVI (p&lt;0,05 for all). The mean number of cardiac rehabilitation sessions was 21±7, without differences between both groups. In pts with MR grade ≥ II, there was an improvement in CPET duration after CRP (HF protocol from 03:57 min to 05:02 min; p=0,017 and modified Bruce protocol from 06:03 min to 06:41 min; p=0,049) but without significant changes in pVO2 (14,7 mL/kg/min to 14,9 mL/kg/min; p=0,990), RER or VEVCO2/VO2 ratio. Patients with MR grade &lt; II significantly improved pVO2 (13,8 mL/kg/min to 14,7 mL/kg/min; p=0,015), and CPET duration with HF protocol from 05:04 min to 06:23 min; p=0,006 after CRP. There was also an improvement in VEVCO2/VO2 ratio, although not statically significant.

Conclusions

Patients with MR grade &lt; II after TAVI who underwent a CRP significantly improved pVO2 and CPET duration. Although pts with MR grade ≥ II did not improved pVO2 after a CRP, an improvement in CPET duration may translate into a clinical benefit in these pts. These results highlight the importance of further research and personalization among this potentially higher risk subset of pts.

Funding Acknowledgement

Type of funding sources: None.

Blueberries effects in experimental diet-induced prediabetes: a focus on renal impairment

Introduction Benefits arising from blueberry (BB) consumption are well-described in type 2 diabetes evolution and inherent complications. Lending further support to this thesis, previous work from our group unequivocally demonstrates BB supplementation efficacy to manage prediabetic hepatic liver steatosis. Whether a similar effect also holds truth in early renal impairment is an unsolved issue.

Objectives To address blueberry juice (BJ) ability to exert renoprotective effects in experimental prediabetes.

Methodology Diet-induced prediabetes [high-sucrose (35% Hsu) and high-fat (60% HF)] was developed in adult male Wistar rats through the ingestion of HSu for 9 weeks supplemented by HF for another 14 weeks (HSuHF, n = 16). On W9, half of the former animals orally received BJ (25g/kg BW, HSuHF+BJ). Control animals (n = 8) received standard diet during the entire protocol. Functional [serum and urinary creatinine, uric acid, glucose; glomerular filtration rate (GFR)], structural [H&E and Oil Red O staining] and molecular [triglycerides content and inflammation (RT-qPCR, WB)] markers of renal injury were assessed along with metabolic profile.

Results Even though diet-induced glucose intolerance, insulin insensitivity and plasmatic hypertriglyceridemia were significantly ameliorated upon BJ treatment, this nutraceutical intervention was unable to halt or slow down renal lipidosis and glomerular crescent-like lesions apart from a slight amelioration of both GFR and IL-6 levels in HSuHF-treated rats.

Conclusion Unlike previous results clearly demonstrating the ability of BJ nutraceutical intervention to afford protection against metabolic impairment and hepatic steatosis evolution in experimentally diet-induced prediabetes, only a modest renoprotective effect was observed in functional and morphological renal endpoints. Future studies are warranted to dissect the divergent effects of BJ on early liver and kidney impairment.

Caregiving and bereavement in palliative care: A cross-cultural study between Brazil and Portugal

Caregiving and bereavement outcomes are strongly influenced by socio-cultural context. Past research has found higher levels of caregiver burden and psychological morbidity in Portuguese compared to Brazilian caregivers. This study compared Brazilian and Portuguese family caregivers in palliative care to identify differences in psychological morbidity and caregiver burden and their relationship with psychosocial factors such as sociodemographic variables, circumstances of end-of-life care and dying, social support, family functioning, and perception of quality of care. Prospective data were collected from convenience samples of family caregivers in Brazil (T0 n = 60; T1 n = 35) and Portugal (T0 n = 75; T1 n = 29) at two separate time points-during caregiving (T0), and during the first two months of bereavement (T1). The study samples consisted mostly of women, offspring, and spouses. In both countries, family caregivers devoted most of their day to taking care of their sick relatives and reported a lack of practical support. Portuguese caregivers had higher levels of burden than Brazilian caregivers, and in both populations a greater burden was associated with more psychopathological symptoms. Higher caregiver burden among Portuguese caregivers was associated with the circumstances of death and the perceived lack of emotional support. Among Portuguese caregivers, symptomatology persisted during bereavement, reaching significantly higher levels of anxiety, somatization, and peritraumatic symptoms compared to the Brazilian sample. These results show differences between family caregiver samples in Portugal and Brazil during the bereavement process. Understanding the underlying cultural patterns and mechanisms requires future research.

Antidepressant-like Effect of Baccharis Ilimita in the Forced Swimming Test in Mice

The aim of the present work was to investigate if flowers extract (FE) and leaf extract (LE) of Baccharis ilimita (Asteraceae) induced antidepressant-like effect. Previous phytochemical investigations have shown the presence of structurally and biogenetically diverse secondary metabolites in this gene, such as flavonoids, diterpenes and triterpenes. Male Swiss mice were injected with FE and LE (12.5; 25.0 or 50.0 mg/kg; i.p.) or saline (S) and after 30 min, they were tested in the forced swimming test (FST). The results showed that FE and LE (50 mg/kg) decreased the duration of immobility time in comparison to the control group (S: 114.8s ± 10.23; FE50: 47.52s ± 9.45; LE50: 53.36s ± 10.38). However, the 12.5 and 25.0 mg/kg doses had no effect on the immobility time in comparison to the control group. The FE and LE did not produce any change in ambulation in mice when tested in an open field. The imipramine (IMP; 15.0 mg/kg i.p.) was used as the positive control. Our results suggested that FE and LE of Baccharis ilimita presents antidepressant-like effect in mice. Such results suggest that the antidepressant-like effect may be attributed at lest partially the flavonoids or the interaction of the active(s) principle(s) present in this plant.

Descritores:

Baccharis ilimita. Forced swimming test. Depression. Mice.

Relational ethics and psychiatry

In relationship centred medicine perspective it is essential to take into account an ethical principle model for our actions, in a meta-analytical foundational perspective, facing concrete and at the same time complex problems in health care, we have to frame them not in terms of strictly defined principles, either formulate them by general acontextual interpretations or resolve them through abstract procedures.

Clinical ethics has been enriched by several contributions that deepen a strict principalist perspective. It is from the observation that the clinic relationship creates, in a space and a time, conditions for the emergence of experiential values of the patient and of the professionals through which you can build a relationship of trust (and not through a process merely procedural), that other ethical questionings emerged in this problematization area (ethics of care, hermeneutics, narrative ethics, responsibility ethics).

We describe the way this theoretical and deliberative relational ethical model can be easily applied to different ethical issues in psychiatry practice and research.

Relational ethics integrates three basic polarities: creating conditions of personhood authenticity, developing a process of reciprocal mutuality and generating an opportunity of growth, development and enhancement. The hermeneutic helical deliberative process takes always in consideration the context relativity and contingency, the other's perspectives and, by creative co-authorship cooperation, allows the emergence of new possibilities of transformative developmental issues.

Family Caregivers' Anticipatory Grief: A Conceptual Framework for Understanding Its Multiple Challenges

The end-of-life trajectory of cancer patients in palliative care (PC) elicits an anticipatory grief (AG) process in family caregivers (FCs). Although widely recognized, AG lacks conceptual clarification. This study aims to qualitatively explore the experience of FCs of patients with terminal cancer to identify the core characteristics and the specific adaptive challenges related to AG in the context of end-of-life caregiving. Data were collected through in-depth semi-structured interviews conducted in a clinical sample of 26 FCs of cancer patients in PC. Findings from thematic analysis suggest that the AG experience is characterized by traumatic distress from being exposed to life-threatening conditions and the separation distress induced by loss anticipation and current relational losses, challenging the FCs to long-term emotional regulation effort demands. These results contribute to the conceptualization of AG and may inform intervention programs for the main challenges the FCs face when adjusting to loss during end-of-life caregiving.

Adult-onset systemic autoinflammatory disorders: a clinical approach

Autoinflammatory disorders (AIDs) are a subgroup of immune-mediated syndromes that result from a primary dysfunction of the innate immune system. AIDs can be either monogenic or polygenic diseases. Unlike organspecific AIDs, systemic AIDs are characterized by fever and/or elevation of acute-phase reactants. This review aims to describe the most common adult-onset systemic AIDs, focusing mostly on polygenic and mixed-pattern diseases which are expected to be more prevalent in adult patients than monogenic AIDs overall. The literature was searched in Medline database. Organ-specific or childhood-onset systemic AIDs were excluded. AIDs were divided in three distinct groups: mixed-pattern, polygenic and adult-onset monogenic AIDs. Most adult-onset AIDs are polygenic but late-onset disease is not rare among monogenic AIDs such as familial Mediterranean fever (FMF). The diagnosis of systemic AIDs in adults is often delayed due to several factors and sometimes it is only established when amyloidosis or other complications are present. Therefore, it probably makes sense to primarily exclude common AIDs in adult patients with fever of unknown origin (and probably different presentations such as polyserositis) since a high prevalence of adult-onset Still's disease or FMF is usually expected. Colchicine, nonsteroidal anti-inflammatory drugs, steroids, immunosuppressive agents, interleukin-1 inhibitors and tumor necrosis factor antagonists constitute common therapeutic options for systemic AIDs.

Effectiveness of a brief training program in relational/communication skills for medical residents

OBJECTIVE

To assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents.

METHODS

This longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters' score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3).

RESULTS

After the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3.

CONCLUSION

This study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents' ability to respond appropriately to patients' cues and concerns and to conduct a breaking bad news encounter.

PRACTICE IMPLICATIONS

Brief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs.

Contributos para a validação portuguesa do Family Relationship Index (FRI) reduzido

Objetivo

Considerando a importância das relações e do funcionamento familiar para o bem-estar psicológico dos seus membros e o desenvolvimento de psicopatologias, este estudo teve como principal objetivo contribuir para a validação portuguesa da versão reduzida do Family Relationship Index (FRI).

Método

A amostra foi constituída por 193 participantes portugueses que responderam ao questionário online. Dos participantes, 65.3% eram do sexo feminino, com idade média de 44.65 anos e 63.2% eram casados.

Resultados

Através da análise fatorial confirmatória da escala, foram encontrados dois fatores (conflito e coesão/expressividade), ao invés de três como na escala original e o modelo fatorial final apresentou bons índices de qualidade de ajustamento. A consistência interna para o fator coesão/expressividade foi de 0.902 e 0.741 para o fator conflito. À exceção do item seis, os demais itens do FRI apresentaram pesos fatoriais superiores a 0.5 e todos os itens eram estatisticamente significativos. Relativamente às tipologias familiares, os resultados revelam que a maioria das famílias pertencia à tipologia solucionadora de conflitos (34.7%).

Conclusão

Daqui se conclui que o instrumento apresenta boa consistência interna e fiabilidade de constructo, assumindo-se como um instrumento útil para a identificação de famílias disfuncionais.

Moderate to Severe Cancer Pain: Are We Taking Serious Action? The Opioid Prescribing Scenario in Portugal

N/A.

Relação entre escore de condição corporal e escore de locomoção em vacas leiteiras submetidas a manejo semiextensivo de alimentação

RESUMO Métodos observacionais subjetivos, como escore de locomoção (EL) e escore de condição corporal (ECC), têm sido amplamente utilizados para avaliação populacional de diferentes graus de claudicação e estado nutricional em bovinos. Este estudo objetivou verificar a associação longitudinal entre o escore de condição corporal e o escore de locomoção em vacas da raça Holandesa submetidas a um regime alimentar semiextensivo. O período experimental compreendeu dois anos de observações, em uma propriedade localizada no sul do Rio Grande do Sul. O grupo experimental foi constituído por 900 vacas lactantes, que foram avaliadas trimestralmente por dinâmica ortopédica pelo EL e do estado metabólico pelo ECC. A coleta desses dados foi realizada por três veterinários treinados. A fim de se verificar a correlação entre variáveis, utilizou-se o programa SAS, por meio do método de correlação de Pearson, para determinar a associação entre as variáveis avaliadas (EL e ECC), com nível de significância de 5%. A distribuição dos diferentes escores de locomoção durante o período foi a seguinte: 57,2% dos animais tiveram o escore de locomoção 1, ou seja, estavam saudáveis em relação ao sistema locomotor. O restante dos animais que apresentou algum grau de dificuldade de locomoção distribuiu-se da seguinte forma, segundo a intensidade: 21,6% dos animais apresentaram EL2, 15,5% deles EL3, 3,5% deles EL4 e 2,2% deles EL5. Quanto ao resultado da correlação, observou-se associação negativa (r= -0,57) entre ECC e EL (P= 0,03), com ECC médio de 2,97±0,33 e EL de 1,35±0,24 durante o período experimental. Portanto, há uma correlação negativa entre o escore de condição corporal e o escore de locomoção em vacas da raça Holandesa submetidas ao regime alimentar semiextensivo.

Circunstâncias e consequências do cuidar: estudo prospetivo em cuidados paliativos

Resumo As várias circunstâncias que afetam a prestação de cuidados em fim-de-vida podem ter um papel determinante no resultado desta experiência, nomeadamente nos níveis de morbilidade psicológica antes e depois da perda. Este estudo tem por objetivos descrever a prevalência da sobrecarga e sintomatologia psicopatológica dos cuidadores familiares em cuidados paliativos e identificar as circunstâncias que lhe estão associadas. Pretendemos ainda avaliar a evolução da sintomatologia, identificando os fatores circunstanciais que interferem na fase aguda do luto. A amostra foi constituída por 75 cuidadores portugueses, a maioria do sexo feminino e filhas do doente. Os resultados revelam que as pessoas mais envolvidas nos cuidados ao doente apresentam mais sobrecarga e estão mais propensas a sintomatologia psicopatológica, a qual tem tendência a manter-se no luto. Ficou também demonstrada a existência de sintomas peritraumáticos que parecem contribuir significativamente para o estado geral de distress no luto agudo. O suporte social tem efeito protetor nos diferentes quadros sintomatológicos e está relacionado com o funcionamento familiar. Estes resultados sugerem a possibilidade de identificar precocemente os cuidadores mais vulneráveis e as circunstâncias adversas que os afetam.

Circunstâncias e consequências do cuidar: caracterização do cuidador familiar em cuidados paliativos

Resumo Os cuidadores familiares desempenham um importante papel ao cuidar de um paciente em situação de doença avançada. Este estudo teve como objetivo caracterizar o cuidador familiar de cuidados paliativos, avaliando as circunstâncias e as consequências da prestação de cuidados e a preparação para a perda do ente querido. Trata-se de um estudo quantitativo, prospectivo e longitudinal. A amostra foi constituída por 60 cuidadores familiares, maioritariamente mulheres, casadas, com idade média de 44,53 anos. A maioria dos cuidadores coabita com o paciente, dedica a maior parte do seu dia aos cuidados ao doente e uma parcela significativa deixou de trabalhar ou reduziu as horas de trabalho para poder acompanhar o paciente. Os cuidadores mais sobrecarregados apresentaram maiores níveis de ansiedade, depressão, somatização e menos apoio social. As familiares mais disfuncionais referiram pouco apoio social e os familiares que estavam menos preparados para a morte do paciente apresentaram mais sintomas de experiência dissociativa peritraumática. A maioria dos cuidadores tinha conhecimento sobre a gravidade da doença do seu familiar e a proximidade da morte, e consideraram que o paciente foi muito bem cuidado no serviço de cuidados paliativos.

Depressive symptoms are associated with poor glycemic control among women with type 2 diabetes mellitus

Objective

In patients with type 2 diabetes mellitus, depressive symptoms may be associated with metabolic deterioration. The impact of sex on this association is unclear. The aim of this study is to analyze the relationship between depression and metabolic control by sex. The data presented is the side product of the clinical investigation by Rui Duarte, MD, Treatment Response in Type 2 Diabetes Patients with Major Depression from 2007.

Results

A sample of 628 outpatients with type 2 diabetes mellitus was taken from a specialized diabetes outpatient clinic. In a univariate analysis: women’s glycohemoglobin mean levels were 8.99% whereas men’s were 8.41% and the difference was statistically significant. The proportion of women (34.3%) with pathological levels of depression (Hospital Anxiety Depression Scale score ≥ 8) was significantly higher than men’s (15.2%). A linear regression analysis performed by sex and controlling for demographic, clinical and psychological variables, showed poorer metabolic control in women with depressive symptoms. No association was observed in men. These results support depression as a predictor for poor metabolic control in women and the need for detecting depressive symptoms when glycemic levels deteriorate.

Clinical relevance of radiographic linear branching mineral opacities in the canine liver

OBJECTIVES

To assess the prevalence, clinical significance and breed distribution of linear branching mineralisation superimposed on the hepatic radiographic silhouette in dogs.

MATERIALS AND METHODS

Retrospective review of radiographs or ultrasound images of dogs showing branching mineralisation in the liver.

RESULTS

Over the 30-year review period, 17 cases were identified and the mineralisation had a predominantly ventral distribution. Seven of the 17 were cavalier King Charles spaniels, and four of the total 17 dogs were diagnosed with hepatobiliary system disease. Five dogs had repeat radiographs, of which four showed no change in the pattern and one developed the pattern 6 years after being diagnosed with cholangiohepatitis. Serum calcium concentrations were normal in all patients. Liver enzymes were markedly elevated only in the dog diagnosed with cholangiohepatitis. Histology performed on three patients showed no convincing evidence of primary liver disease.

CLINICAL SIGNIFICANCE

Branching mineralisation in the liver parenchyma is a rare finding in dogs with little or no clinical significance and cavalier King Charles spaniels may be predisposed. Biopsy of the liver of affected dogs with no clinical or clinicopathological evidence of liver disease is unlikely to be helpful in these cases.

Palliative care for end-of-life patients in a basic emergency service

This research sought to describe the care provided by the nursing staff of the Western Department of the Basic Emergency Service for end-of-life patients. This was a retrospective, quantitative, exploratory and descriptive (level I) study, which sought to research the nursing records of 83 patients from admission to death. Patients who met the following inclusion criteria were considered eligible: adults; had an oncological or nononcological, advanced and irreversible chronic disease; and died in the Basic Emergency Service in the period from January 2011 to December 2012. An instrument was created for data collection, the content, relevance and adequacy of which was validated by a panel of experts in the area of palliative care. The study protocol was approved by the Institutional Ethics Committee. The main results indicate that the majority of patients died in the Observation Room in a period between the first two and twenty-four hours. Nursing interventions favoured technical-instrumental care related to medical prescriptions and service routines such as venous punctures, catheterisations, taking blood samples for analysis, aspiration of secretions, intravenous administration of fluids and drugs for symptomatic control, and monitoring of vital parameters and the state of consciousness. With the proximity of death, the nurses favoured the registration of cardiorespiratory arrest, cardiopulmonary resuscitation manoeuvres and aspiration of secretions. In the recognition of predictive factors of imminent death, the nurses favoured the patient's entry into a comatose state and aggravation of asthenia. In most patients, the entry into agony phase was not diagnosed.

Trypanosomiasis in an Australian little red flying fox (Pteropus scapulatus)

Case report

An adult female Australian little red flying fox (Pteropus scapulatus) presented with icterus and anaemia. Examination of a blood smear revealed numerous trypanosomes 20.4–30.8 µm long with tapered ends. Necropsy and histological findings were consistent with trypanosome infection of lymphoid tissue and intravascular haemolysis. Sequence and phylogenetic analysis demonstrated this trypanosome species to be genetically distinct and most similar to Trypanosoma minasense and Trypanosoma rangeli (with a genetic distance of 1% at the 18S rRNA locus for both).

Conclusion

To the authors’ knowledge this is the first report of a trypanosome infection associated with clinical disease in bats.

[Burden of caregiving and its repercussions on caregivers of end-of-life patients: a systematic review of the literature]

Caring for a family member with an advanced and/or terminal illness can be a great emotional, physical and financial burden that has an impact on the quality of life of the caregivers. The scope of this study was to conduct a systematic review of the literature on the burden of caregiving, related factors and the consequences for family caregivers of advanced stage cancer patients or patients in end-of-life or palliative care. A search for scientific papers published in the EBSCO, Web of Knowledge and BIREME databases was conducted since records on this topic began in the databases through March 2014. Of the 582 articles found, only 27 were selected. The majority of the articles found that family caregivers were overburdened. Some studies found that the care-giving burden was associated with characteristics of the patients and their illnesses while, in other studies, it was associated with poor health of the caregiver, greater psychopathological symptoms (anxiety, depression, emotional distress) and with the development of complications in the grieving process. However, hope, social support, the ability of the caregiver to attribute meaning to the experience of caring and feeling comfortable with the tasks of caring were associated with lower levels of burden.

Adequacy of cancer-related pain management and predictors of undertreatment at referral to a pain clinic

Background

Several guidelines have advocated the need for adequate cancer-related pain (CRP) management. The pain management index (PMI) has been proposed as an auditable measure of the appropriateness for analgesic therapy.

Objectives

To determine the adequacy of CRP management based on the PMI status and its patient-related predictors at the point of referral to a pain clinic (PC).

Methods

Consecutive patients referred to a PC had standardized initial assessments and status documentation on the Brief Pain Inventory (BPI) ratings; pain mechanism, using a neuropathic pain diagnostic questionnaire (the Douleur Neuropathique 4 tool); episodic pain; oral morphine equivalent daily dose; the Hospital Anxiety Depression Scale and the Emotion Thermometer scores; and cancer diagnosis, metastases, treatment, and pain duration. Predictors of “negative PMI status” [PMI(−)] were examined in logistic regression models. Variables with p<0.25 in an initial bivariable analysis were entered into a multivariable model.

Results

Of 371 participants, 95 (25.6%) had PMI(−), suggesting undertreatment of CRP. Both female sex and higher scores on the BPI’s “interference with general activity” more strongly predicted PMI(−). Patients who received either radiotherapy or one or more adjuvant analgesics prior to the initial consultation at the PC, those who had neuropathic pain, those who had a greater need for emotional help, and those with higher BPI’s “relief ” scores were all less likely to be PMI(−).

Conclusion

The potential burden of patient and family distress associated with suboptimal CRP management in one in four patients should generate major public health concern and prompt appropriate educational and health policy measures to address the deficit.

Epidemiological and sociodemographic factors associated with complicated alcohol withdrawal syndrome

OBJECTIVES

To analyse the influence of epidemiological and sociodemographic factors in complicated alcohol withdrawal syndrome (AWS).

MATERIAL AND METHODS

A multicentre, observational prospective study was conducted on consecutively added patients with AWS hospitalised in internal medicine departments. We recorded sociodemographic, epidemiological, clinical and progression data. Complicated AWS was defined as that which progressed with seizures or delirium tremens.

RESULTS

We studied 228 episodes of AWS in 219 patients. The mean age was 54.5 years (SD, 11.5), and 90.8% were men. AWS was the cause for hospitalisation in 39.9% of the patients. Some 27.1% of the cases presented seizures, and 32.4% presented delirium tremens. The daily quantity of alcohol ingested was 17.8 standard drink units (SD, 21.4), with 16.6 years of dependence (SD, 11.3). The pattern of alcohol abuse was regular in 82.8% of the patients. Some 38.4% of the patients were married or had a partner, and 45.6% had children. Some 72.7% of the patients were unemployed or retired. Some 68.5% had only completed primary studies. Some 4.8% consumed cannabis, 5.2% consumed cocaine and 3% consumed opioids. The independent variables related to complicated AWS were consumption of a drug other than alcohol (OR, 5.3; 95% CI 1.5-18.7), low education level (OR, 3.4; 95% CI 1.6-7.3) and hospitalisation for AWS (OR, 2.9; 95% CI 1.5-5.6). The model's receiver operating characteristic area was 0.718 (95% CI 0.643-0.793).

CONCLUSIONS

Concomitant drug abuse and a low educational level could help identify patients at risk of complicated AWS.

Isolation of Campylobacter spp. from Three Species of Antarctic Penguins in Different Geographic Locations

The presence of Campylobacter species was studied in three Antarctic penguin species, Adélie (Pygoscelis adeliae), chinstrap (Pygoscelis antarctica) and gentoo (Pygoscelis papua). A total of 390 penguins were captured in 12 different rookeries along the Antarctic Peninsula with differences in the amount of human visitation: six colonies were highly visited [Stranger Point, King George Island (P. papua and P. adeliae); Hannah Point, Livingston Island (P. papua and P. antarctica); Deception Island (P. antarctica); and Paradise Bay, Antarctic Peninsula (P. papua)], and six colonies were rarely visited [Devil's Point, Byers Peninsula, Livingston Island (P. papua); Cierva Cove, Antarctic Peninsula (P. papua); Rongé Island (P. papua and P. antarctica); Yalour Island (P. adeliae); and Avian Island (P. adeliae)]. A total of 23 strains were isolated from penguins from nine different rookeries. Campylobacter lari subsp. lari was isolated from eight samples (seven from P. papua and one from P. adeliae); C. lari subsp. concheus from 13 (ten from P. adeliae and three from P. antarctica) and C. volucris from two samples (both from P. papua). We did not find any significant differences in the prevalence of Campylobacter spp. between the populations in highly and rarely visited areas. This is the first report of C. lari subsp. concheus and C. volucris isolation from penguins in the Antarctic region.

[Pain Intensity and Time to Death of Cancer Patients Referred to Palliative Care]

INTRODUCTION

Pain is a common symptom experienced by cancer patients, especially in those with advanced disease. Our aim was to describe pain intensity in advanced cancer patients, referred to the palliative care unit, the factors underlying moderate to severe pain and its prognostic values.

MATERIAL AND METHODS

This was a prospective observational study. All patients with mestastatic solid tumors and with no specific oncologic treatment were included. Pain intensity was accessed using the pain scale from Edmonton Symptom Assessment Scale, rated from 0 to 10 on a numerical scale, where zero = no pain and 10 = worst possible pain.

RESULTS

Between October 2012 and June 2015, a total of 301 patients participated in the study. The median age was 69 years, (37 - 94); most of the patients were men (57%) and 64.8% had a performance status of 3/4. About 42% reported pain severity ≥ 4 and 74% were medicated with opioids. Multivariate analysis indicated a correlation between performance status and reported pain (OR: 1.7; IC 95%: 1.0 - 2.7; p = 0.045). Median overall survival was 37 days (IC 95%: 28 - 46). Patients reporting moderate to severe pain (pain severity ≥ 4) had a median survival of 29 days (IC 95%: 21 - 37), comparing with those who had no or moderate pain with median survival of 49 days (IC 95%: 35 - 63) (p = 0.022).

DISCUSSION

The performance status was associated with more intense pain. The performance status, hospitalization, intra-abdominal metastization and opioid analgesia were associated with shorter time to death in advanced cancer patients referred to palliative care.

CONCLUSION

Cancer pain continues to be a major clinical problem in advanced cancer patients.

Family Anticipatory Grief: An Integrative Literature Review

Despite all the investment in research, uncertainty persists in anticipatory grief (AG) literature, concerning its nuclear characteristics and definition. This review aimed to synthesize recent research in order to develop further knowledge about the family experience of AG during a patient’s end of life. An integrative review was performed using standard methods of analysis and synthesis. The electronic databases Medline, Web of Knowledge, and EBSCO and relevant journals were systematically searched since 1990 to October 2015. Twenty-nine articles were selected, the majority with samples composed of caregivers of terminally ill patients with cancer. From systematic comparison of data referring to family end-of-life experience emerged 10 themes, which correspond to AG nuclear characteristics: anticipation of death, emotional distress, intrapsychic and interpersonal protection, exclusive focus on the patient care, hope, ambivalence, personal losses, relational losses, end-of-life relational tasks, and transition. For the majority of family caregivers in occidental society, AG is a highly stressful and ambivalent experience due to anticipation of death and relational losses, while the patient is physically present and needed of care, so family must be functional and inhibit grief expressions. The present study contributes to a deeper conceptualization of this term and to a more sensitive clinical practice.

Aortic Valve Disease and Vascular Mechanics: Two-Dimensional Speckle Tracking Echocardiographic Analysis

PURPOSE

Degenerative aortic valve disease (AVD) is a complex disorder that goes beyond valve itself, also undermining aortic wall. We aimed to assess the ascending aortic mechanics with two-dimensional speckle tracking echocardiography (2DSTE) in patients with aortic regurgitation (AR) and hypothesized a relationship with degree of AR. Aortic mechanics were then compared with those of similarly studied healthy controls and patients with aortic stenosis (AS); finally, we aimed to assess the prognostic significance of vascular mechanics in AVD.

METHODS

Overall, 73 patients with moderate-to-severe AR and 22 healthy subjects were enrolled, alongside a previously examined cohort (N = 45) with moderate-to-severe AS. Global circumferential ascending aortic strain (CAAS) and strain rate (CAASR) served as indices of aortic deformation; corrected CAAS was calculated as CAAS/pulse pressure (PP). Median clinical follow-up was 438 days.

RESULTS

In patients with severe (vs. moderate) AR, CAASR (1.53 ± 0.29/sec vs. 1.90 ± 0.62/sec, P < 0.05) and corrected CAAS (0.14 ± 0.06%/mmHg vs. 0.19 ± 0.08%/mmHg, P < 0.05) were significantly lower, whereas CAAS did not differ significantly. Measurers of aortic mechanics (CAAS, corrected CAAS, CAASR) differed significantly (all P < 0.01) in patients with AS and AR and in healthy subjects, with lower values seen in patients with AS. In follow-up, survival rate of AVD patients with baseline CAASR >0.88/sec was significantly higher (log rank, 97.4% vs. 73.0%; P = 0.03).

CONCLUSIONS

Quantitative measures of aortic mechanics were lower for AS patients, suggesting a more significant derangement of aortic elastic properties. In the context of AVD, vascular mechanics assessment proved useful in gauging clinical prognosis.

Drugs pharmacokinetics interactions with cardiac and renal disease patients in consultation-liaison psychiatry

The prevalence of psychiatric disturbances in patients with cardiovascular disease is elevated. For example the prevalence of major depression can reach 15–20% and of anxiety disturbances 5–20%.

When we treat psychiatric symptoms in cardiovascular disease we must have in mind four particular effects of psychiatric drugs: (1) disturbances of atrial-ventricular conduction; (2) QTc interval prolongation that can lead to torsade de pointes and ventricular fibrillation; (3) hypertension; (4) changes in platelet aggregation.

On the other hand, there is a great prevalence of psychiatric disease in patients with renal disease. For example, about 5–25% of the patients with advanced renal disease have major depression.

Renal disease patients can evidence changes in several pharmacokinetic parameters such as: (1) biodisponibility; (2) distribution; (3) metabolism; (4) excretion. Therefore, when we treat these patients we have to keep in mind the effect of psychiatric drugs over the renal functioning, but also the effect of the deficient renal function in the pharmacokinetics of the drugs.

I this presentation we intend to reveal what are the main concerns when we prescribe psychiatric drugs in patients with cardiovascular and renal disease.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Visualizing and Interacting with Kernelized Data

Kernel-based methods have experienced a substantial progress in the last years, tuning out an essential mechanism for data classification, clustering and pattern recognition. The effectiveness of kernel-based techniques, though, depends largely on the capability of the underlying kernel to properly embed data in the feature space associated to the kernel. However, visualizing how a kernel embeds the data in a feature space is not so straightforward, as the embedding map and the feature space are implicitly defined by the kernel. In this work, we present a novel technique to visualize the action of a kernel, that is, how the kernel embeds data into a high-dimensional feature space. The proposed methodology relies on a solid mathematical formulation to map kernelized data onto a visual space. Our approach is faster and more accurate than most existing methods while still allowing interactive manipulation of the projection layout, a game-changing trait that other kernel-based projection techniques do not have.