Cheeks appearance as a novel predictor of obstructive sleep apnea: the CASA score study

STUDY OBJECTIVES

Four well-established predictors of obstructive sleep apnea risk are body mass index, age, gender, and neck circumference. We have previously reported cheeks appearance as an OSA predictor, which may represent a combination of such predictors in a single readily available feature. This study sought to answer the question: Is cheeks appearance an OSA risk predictor?

METHODS

A prospective cross-sectional diagnostic accuracy study based on STARD. Patients undergoing polysomnography to investigate sleep complaints at a sleep clinic affiliated to a university hospital were assessed using cheeks appearance scored 0-3 for volume from and 0-3 for flaccidity to create the cheeks appearance for sleep apnea (CASA) score ranging from 0-6. Appearance was judged by three blinded and independent evaluators.

RESULTS

Among 265 patients evaluated, 248 were included. Fifty-seven patients had a CASA score of 0, 191 had a CASA score between 1-6. Polysomnography diagnosed 177 of the individuals with OSA; of these 167 had altered CASA score. Sensitivity was 87%, specificity 82%, positive predictive value 94%, negative predictive value 66%, accuracy 86%.

CONCLUSIONS

Our results suggest that combining volume and flaccidity of cheeks appearance in a single index may constitute a reliable OSA predictor. CASA score is a novel predictor of obstructive sleep apnea with internal validity in sleep laboratory adult population. Our findings support further studies to confirm external validity of this practical diagnostic tool.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Cheeks Appearance as a Novel Predictor of Obstructive Sleep Apnea: The CASA Score Study (CASA); Identifier: NCT04980586; URL: https://clinicaltrials.gov/study/NCT04980586.

Choking, gagging and complementary feeding methods in the first year of life: a randomized clinical trial

OBJECTIVE

Compare the occurrence of choking and gagging in infants subjected to three complementary feeding (CF) methods.

METHODS

Randomized clinical trial with mother-infant pairs, allocated according to the following methods of CF: a) Parent-Led Weaning (PLW) - group control, b) Baby-Led Introduction to SolidS (BLISS), and c) mixed (initially BLISS and if the infant presents a lack of interest or dissatisfaction, PLW), with the last two methods guided by the infant. Mothers received nutritional intervention on CF and prevention of choking and gagging according to the method at 5.5 months of age and remained in follow-up until 12 months. Frequencies of choking and gagging were collected by questionnaire at nine and 12 months. The comparison between groups was performed using the analysis of variance test (p < 0.05).

RESULTS

130 infants were followed, and 34 (26.2%) children presented choking between six and 12 months of age, 13 (30.2%) in PLW, 10 (22.2%) BLISS, and 11 (26.2%) mixed method, no significative difference between methods (p > 0.05). The choking was caused mainly by the semi-solid/solid consistency. Moreover, 100 (80%) infants aged from six to 12 months presented gagging and their characteristics were not statistically different among groups (p > 0.05).

CONCLUSION

Infants following a baby-led feeding method that includes advice on minimizing choking risk do not seem more likely to choke than infants following traditional feeding practice that includes advice on minimizing choking risk.

Adherence to different methods for introducing complementary food to 7-month-old babies: a randomized clinical trial

Objective:

To assess the adherence to three methods of food introduction for 7-month-old babies.

Methods:

This is a randomized clinical trial conducted with mother-infant pairs, submitted to the intervention with five and a half months of age and three different methods for food introduction according to randomization: Parent-Led Weaning (PLW), Baby-Led Introduction to SolidS (BLISS), or mixed (specially developed for this study). Adherence to the method was assessed at the seventh month of age, via telephone call to the caregiver by a researcher blinded to the method. The analyses were performed using the Chi-Square test and data are presented in absolute numbers and percentages.

Results:

A total of 139 mother-infant pairs were evaluated; 46 of them were allocated to the PLW method; 47, to the BLISS; and 46, to the mixed. At seven months of age, 60 (43.2%) mothers reported that the infants were following the proposed feeding method. When analyzing each approach, the mixed method showed a higher likelihood of adherence (71.7%, n=33), followed by the PLW method (39.1%, n=18) and by the BLISS (19.2%, n=9) (p<0.001). Among the sample that did not follow the proposed method, those that had been randomized to the PLW and BLISS methods mostly migrated to the mixed method (92.9%; n=26 and 92.1%; n=35, respectively) (p<0.001).

Conclusions:

Complementary feeding in a mixed approach obtained greater adherence in 7-month-old babies.

Complementary feeding methods and introduction of ultra-processed foods: A randomized clinical trial

Introduction

Complementary feeding (CF) is defined as a period when foods, other than milk, are introduced to the infant's diet. Unfortunately, frequent consumption of ultra-processed foods (UPF) has become highly prevalent early in an infant's life. The aim was to verify the association of CF methods with the introduction of UPF in early childhood.

Methods

This randomized clinical trial involved pairs of mother-infants, allocated in groups receiving different CF interventions: strict Parent-Led Weaning (PLW); strict Baby-Led Introduction to SolidS (BLISS), or mixed-method. The intervention consisted of a counseling session on healthy eating at the child's 5.5 months of age. A structured questionnaire was created based on the NOVA classification for the definition of UPF and applied at 9 and 12 months. The effect of the CF method intervention was measured by a survival curve for UPF offered for the first time in early childhood between groups. Cox regression was used to estimate its magnitude. The primary analysis was done in three groups (PLW, BLISS, and Mixed) and the secondary analysis was done in two groups (PLW, and BLISS + Mixed).

Results

A total of 139 mother-infant pairs were eligible and 129 followed the study. The prevalence of infants who were exposed to UPF in early childhood was 58.9% (n = 76), being 71.4% in the PLW group, 53.3% in the BLISS group, and 52.4% in the Mixed group, without differences between them (p = 0.133). The PLW group intervention had a greater chance of exposure to ice cream or popsicles (p = 0.032) and sweet crackers (p = 0.009), compared with the other two CF groups. The Cox regression did not find significant differences between the three groups. However, the regression with two groups estimated a 38% reduction in the offer of UPF in the BLISS + Mixed group intervention (p = 0.049).

Discussion

The CF intervention promoting greater infant autonomy (BLISS and Mixed) was associated with a reduction in the offer of UPF in early childhood. This knowledge may contribute to supporting strategies aimed at reducing UPF consumption by the young infant.

Brazilian registry of clinical trials ReBEC

[https://ensaiosclinicos.gov.br/rg/RBR-229scm], identifier [RBR-229scm U1111-1226-9516].

The Effectiveness of Lingual Frenectomy and Myofunctional Therapy for Children: A Randomized Controlled Clinical Trial

Purpose: To evaluate the effectiveness of lingual frenectomy, as a standalone treatment or in association with myofunctional therapy, on the general and functional aspects of six- to 12-year-old children with anomalies in the lingual frenulum.<br/> Methods: This randomized controlled clinical trial involved 40 children diagnosed with altered lingual frenulum. Children who received a frenectomy were evaluated 15 and 30 days after the procedure. After 15 days, the children were randomized into two groups: a group that received isotonic tongue exercises (Study Group [SG]) and a group that did not receive isotonic tongue exercises (Control Group [CG]). The outcome evaluator was blinded to group assignment. Statistical tests were used to compare between and within groups (P <0.05).<br/> Results: There were 20 children in each group. SG children improved significantly when compared to CG subjects regarding tongue mobility (P =0.016), maximum mouth opening (MMO; P =0.024), and MMO with the tip of the tongue touching the incisive papilla (P =0.026).<br/> Conclusion: Frenectomy associated with myofunctional therapy benefitted tongue mobility.

Aspectos anatômicos e funcionais da língua após frenectomia em gemelares: relato de casos clínicos

Aim: to report two clinical cases of alteration of the lingual frenulum in twins, aged 10 years, both female, evaluated in the anatomical and functional aspects of the tongue before and 15 days after the frenectomy. Case reports: Initially, the paediatric dentistry performed the anamnesis with the mother. Then, the participants were submitted to a dental clinical evaluation and, subsequently, the speech language pathologist evaluation of the lingual frenulum was performed. The speech language pathologist assessment was performed using the Tongue Frenulum Evaluation Protocol, which was applied before and 15 days after the frenectomy. Both participants performed better in anatomical tests after the surgical procedure. However, some changes, especially when elevating the tongue, continued to be observed in one of the patients 15 days after the frenectomy. In addition, the two participants started to perform most of the tongue movements with greater precision. About speech, only the participant who had a greater number of previous phonetic changes, remained with some speech disorders after 15 days of surgery. Discussion: Some difficulties involving mobility of the tongue and changes in speech may persist after surgery, indicating the need for specific speech therapy intervention. Conclusion: Both cases showed improvement in performance both in anatomical and functional tests after frenectomy.

Association between respiratory clinical signs and respiratory localization in dogs and cats with abnormal breathing patterns

The diagnostic values of respiratory signs have been under-investigated in pets. The study aim was to explore commonly assumed associations between respiratory signs and disease localization in pets with abnormal breathing patterns (ABP). Dogs and cats with ABP presenting to three hospitals were included if investigations permitted disease localization. Hypothesized associations between respiratory signs and disease location were evaluated via mixed-effects logistic regression. Sensitivity, specificity, and positive diagnostic likelihood ratio were calculated. One-hundred and fifteen dogs and 49 cats with ABP were recruited. Confirmed associations included: inspiratory effort with extra-thoracic airway disease (odds ratio [OR], 9.1; 95% confidence interval [95% CI] 3.0-27.2); expiratory effort with intra-thoracic airway disease (OR, 6.5; 95% CI, 2.3-18.1); paradoxical breathing and attenuation of heart/lung sounds with pleural space disease (paradoxical breathing: OR, 4.5; 95% CI 1.7-12.1; sound attenuation: OR, 11.5; 95% CI 4.0-33.3); decreased nasal airflow and stertor with nasal/pharyngeal disease (nasal airflow: OR, 26.2; 95% CI 8.1-84.8; stertor: OR, 155.2; 95% CI 24.9-968.8); stridor with laryngeal or tracheal disease (laryngeal disease: OR, 39.9; 95% CI 7.6-209.0; tracheal disease: OR, 32.4; 95% CI 4.2-248.0); tracheal sensitivity with bronchial disease (OR, 3.8; 95% CI 1.5-9.6); crackles with pulmonary or bronchial disease (pulmonary disease: OR, 5.4; 95% CI 2.1-13.8; bronchial disease: OR, 3.9; 95% CI 1.6-9.8); and goose honking with tracheal disease (all dogs with goose honking had tracheal involvement). Select respiratory signs provide guidance to localize and prioritize causes of the underlying respiratory disease in pets, allowing targeted interventions in animals with ABP.

Complementary feeding methods in the first year of life: a study protocol for a randomized clinical trial

Background

The traditional spoon-feeding approach to introduction of solid foods during the complementary feeding period is supported by consensus in the scientific literature. However, a method called Baby-Led Introduction to SolidS (BLISS) has been proposed as an alternative, allowing infants to self-feed with no adult interference. To date, there have been no trials in the Brazilian population to evaluate the effectiveness of BLISS in comparison to the traditional approach.

Methods/design

To evaluate and compare three different complementary feeding methods. Data on 144 mother-child pairs will be randomized into intervention groups by methods: (A) strict Parent-Led Weaning; (B) strict Baby-Led Introduction to SolidS; and (C) a mixed method. Prospective participants from Porto Alegre, Brazil, and nearby cities will be recruited through the Internet. The interventions will be performed by nutritionists and speech therapists, at 5.5 months of age of the child, at a private nutrition office equipped with a test kitchen where meals will be prepared according to the randomized method. The pairs will be followed up at 7, 9, and 12 months of age. Data will be collected through questionnaires designed especially for this study, which will include a 24h child food recall, questionnaires on the child’s and parents’ eating behavior, oral habits, eating difficulties, and choking prevalence. At 12 months of age, children will undergo blood collection to measure hemoglobin, ferritin, and C-reactive protein, saliva collection for analysis of genetic polymorphisms, and oral examination. Anthropometric parameters (child and maternal) will be measured at the baseline intervention, at a 9 month home visit, and at the end-of-study visit at the hospital. The primary outcome will be child growth and nutritional status z-scores at 12 months; secondary outcomes will include iron status, feeding behavior, acceptability of the methods, dietary variety, choking, eating behaviors, food preferences, acceptance of bitter and sweet flavors, suction, oral habits, oral hygiene behavior, dental caries, gingival health status, and functional constipation.

Discussion

The trial intends to ascertain whether there are potential advantages to the BLISS complementary feeding method in this specific population, generating data to support families and healthcare providers.

Trial registration

Brazilian Clinical Trials Registry (ReBEC): RBR- 229scm number U1111-1226-9516. Registered on September 24, 2019.

All day-long pacifier use and intelligence quotient in childhood: A birth cohort study

BACKGROUND

Literature on pacifier use remains controversial, but mostly suggests an inverse association with childhood intelligence.

OBJECTIVES

The objective of this study was to assess the association between pacifier use and intelligence quotient (IQ) in six-year-old children from a birth cohort.

METHODS

Data from 3532 children from the 2004 Pelotas (Brazil) Birth Cohort were analysed. Children were recruited and assessed at birth and followed up at 3 months, and 1, 2, 4, and 6 years. Data on pacifier use duration and intensity were obtained via interviews with mothers in all six follow-up visits. IQ was estimated at 6 years using the Wechsler Intelligence Scale for Children and standardised for the analyses. Crude and adjusted coefficients were calculated (linear regression) for all the data collected in follow-up assessments for pacifier use.

RESULTS

IQ was inversely associated with all pacifier use indicators. Children who used a pacifier all day long (ADL) at any follow-up showed an IQ 0.18 (95% confidence interval [CI] 0.11, 0.24) standard deviations below those who never used it ADL, after adjusting for confounders. The strength of association increased with number of assessments reporting ADL pacifier use, from a reduction in IQ of 0.13 (95% CI 0.06, 0.21) to 0.34 (95% CI 0.15, 0.52) standard deviations for ADL use in one and in all four follow-up visits, respectively.

CONCLUSIONS

We found a strong association between intense pacifier use up to 4 years of age and lower IQ at 6 years. A dose-response gradient was observed, with greater IQ deficits in children who used a ADL pacifier for longer durations. The mechanisms underlying this association need to be clarified. One hypothesis is that children using a pacifier, especially those who use it more intensely, are less stimulated.

Anaphylaxis: A Decade of a Nationwide Allergy Society Registry

BACKGROUND AND OBJECTIVES

Anaphylaxis is an acute, life-threatening, multiorgan hypersensitivity reaction. Objective: The aim of this study was to identify the causes of anaphylaxis in Portugal in order to improve our knowledge of epidemiology and management.

METHODS

We implemented a nationwide notification system for anaphylaxis over a 10-year period, with voluntary reporting by allergists. Data on 1783 patients with anaphylaxis were included. Etiopathogenesis, manifestations, and clinical management were characterized in detail for both children and adults.

RESULTS

The mean age was 32.7 (20.3) years, and 30% were under 18 years of age; 58% were female. The mean age at the first anaphylaxis episode was 27.5 (20.4) years (ranging from 1 month to 88 years). The main culprits of anaphylaxis were foods (48%), drugs (37%) (main trigger in adults, 48%), and hymenoptera venom (7%). The main culprit foods were shellfish (27%), fresh fruit (17%), cow's milk (16%), tree nuts (15%), fish (8%), egg (7%), and peanut (7%). The main drugs were nonsteroidal anti-inflammatory drugs (43%), antibiotics (39%), and anesthetic agents (6%). Other causes included exercise (3%), latex (2%), cold-induced anaphylaxis (2%), and idiopathic anaphylaxis (2%). Most patients (80%) were admitted to the emergency department; only 43% received adrenaline. Anaphylaxis recurred in 41% of patients (21% with ≥3 anaphylactic episodes); 7% used an adrenaline autoinjector device.

CONCLUSION

Food is the leading cause of anaphylaxis in Portugal, while drugs were the main elicitors in adults. We emphasize undertreatment with adrenaline and recurrent episodes, highlighting the need to improve diagnostic and therapeutic approaches to anaphylaxis.

Growth kinetics of Myceliophthora thermophila M.7·7 in solid-state cultivation

AIMS

This work aimed to estimate the growth of Myceliophthora thermophila M.7·7 in solid-state cultivation (SSC) through quantification of N-acetyl-d-glucosamine (NAG) and enzyme activity.

METHODS AND RESULTS

The fungus was cultivated in sugarcane bagasse and wheat bran. A consistent statistical analysis was done to assess the reliability of experimental data. Logistic model equation was fitted to experimental data and growth parameters were estimated. The results showed strong influence of the sample size on NAG and a minimum recommended sample size was identified. Scanning electron microscopy (SEM) was used to identify the strategy of substrate colonization. Wheat bran was attacked firstly, while sugarcane bagasse was consumed after wheat bran depletion. The biomass growth was poorly estimated by secretion kinetics of α-amylase, endoglucanase, protease and xylanase, but enzyme kinetics were important for understanding substrate colonization.

CONCLUSIONS

In conclusion, the NAG concentration was strongly affected by the sample size and sampling procedure. The strategy of fungal colonization on the substrates was well characterized through SEM analysis. The colonization strategy has direct influence on the kinetic parameters of the logistic model. Myceliophthora thermophila has a well-defined dynamic of enzyme secretion to degrade the substrate, although the kinetics of enzyme secretion has shown not adequate to characterize the kinetics of fungal growth.

SIGNIFICANCE AND IMPACT OF THE STUDY

The paper provides reliable growth kinetic parameters in the SSC of the cellulase producer fungus M. thermophila M.7·7, as well as a robust analysis on three indirect methods (NAG, enzymes and SEM) for estimation of fungal development.

Influence of pacifier use on the association between duration of breastfeeding and anterior open bite in primary dentition

Background

The literature is controversial with regard to the association between longer breastfeeding duration and lower prevalence of anterior open bite. Pacifier use may be involved in this controversy. Thus, the objective of the study was to assess the influence of pacifier use and its duration on the association between longer breastfeeding duration and lower prevalence of anterior open bite in children with primary dentition.

Methods

This was a cross-sectional study nested in a cohort study involving 153 infants recruited at a maternity hospital in the municipality of Porto Alegre, southern Brazil. The study outcome (anterior open bite) was assessed when the children were between 3 and 5 years old. Data on breastfeeding and pacifier use were collected at 7, 30, 60, 120, and 180 days of life and on the date of the evaluation here described. Poisson regression with robust variance was used to analyze the association between the prevalence of anterior open bite and breastfeeding duration, expressed in months.

Results

The univariate analysis showed a protective effect of breastfeeding against anterior open bite (prevalence ratio [PR] 0.96; 95% confidence interval [95%CI] 0.95–0.98). This effect remained significant after adjustment for pacifier use at any time between birth and the date of dental assessment (PR0.98; 95%CI; 0.96–0.99), i.e., there was a reduction of 2% in the prevalence of anterior open bite for each month of breastfeeding. However, this effect lost significance when pacifier use duration was included in the multivariate analysis (PR1.00; 95%CI; 0.99–1.01).

Conclusions

Pacifier use duration influences the association between longer breastfeeding duration and lower prevalence of anterior open bite. It is likely that prolonged pacifier use reduces the magnitude of this association.

Improving medical emergency system: Results of a multi-professional questionnaire

OBJECTIVE

This study aimed to identify ways to improve the Medical Emergency System (MES) in its different components and infer Medical Emergency Team (MET) activation failure causes.

METHODS

A questionnaire regarding opinions and attitudes towards the MES was conducted, targeting all professionals at the hospital, which has an implemented MES with Basic Life Support (BLS) since 1998.

RESULTS

Thirty two percent (n=585) of hospital professionals answered, from these 37.8% were neither doctors nor nurses. In mean six years passed since the BLS certification, yet 102 professionals (17.4%) had not done it. A relevant percentage admitted to not being familiarized with the different components of the MES (activation criteria 16.4%, telephone number 4.1%, content of the resuscitation trolleys 42.4% and defibrillator-monitor 47.4%), percentages lessened among those had taken the BLS course. The majority highly valued MET, however 83 (23%) could not confirm that debriefingand 17 (4.4%) that allocation of tasks happened after and during activation, respectively. When activating MET 52 (18.1%) admitted fear of criticism and 38 (13.3%) agreed that they needed validation by another professional, factors not influenced by BLS course completion. Excessive workload as a barrier to recognize ill patients was pointed by 127 (45.7%) of the respondents.

CONCLUSION

Despite educational and auditing efforts, the MES is not fully integrated into hospital culture. BLS certification for all professionals and non-technical skills of MET were identified has major areas for MES improvement. Unfamiliarity with activation criteria, fear of criticism and excessive workload were identified as failure of activation causes.

Structure, conductivity and magnetism of orthorhombic and fluorite polymorphs in MoO3-Ln2O3 (Ln = Gd, Dy, Ho) systems

Phase-pure orthorhombic compositions at a Ln/Mo ratio ∼ 5.2-5.7 (Ln = Gd, Dy, Ho) have been obtained for the first time by prolonged (40-160 h) heat treatment of mechanically activated 5Ln2O3 + 2MoO3 (Ln = Gd, Dy, Ho) oxide mixtures at 1200 °C. Although the starting Ln : Mo ratio was 5 : 1 (Ln10Mo2O21 (Ln = Dy, Ho)), it changed slightly in the final product due to the volatility of molybdenum oxide at 1200 °C (40-160 h) (ICP-MS analysis). Brief high-temperature firing (1600 °C, 3 h) of 5Ln2O3 + 2MoO3 (Ln = Gd, Dy, Ho) oxide mixtures leads to the formation of phase-pure fluorites with compositions close to Ln10Mo2O21 (Ln = Gd, Dy, Ho). Gd10Mo2O21 molybdate seems to undergo an order-disorder (orthorhombic-fluorite) phase transition in the range of 1200-1600 °C. For the first time, using the neutron diffraction method, it was shown that low-temperature phases with a Ln/Mo ratio ∼ 5.2-5.7 (Ln = Gd, Dy, Ho) have an orthorhombic structure rather than a tetragonal structure. Proton contribution to the total conductivity of Ln10Mo2O21 (Ln = Gd, Dy, Ho) fluorites and gadolinium and dysprosium orthorhombic phases in a wet atmosphere was observed for the first time. In both orthorhombic and fluorite phases, the total conductivity in wet air decreases with decreasing lanthanide ionic radii. In a wide temperature range, the compounds under study exhibit paramagnetic behaviour. However, the orthorhombic phases of Dy and Ho compounds reach the antiferromagnetic state at 2.4 K and 2.6 K, respectively.

Challenges in handling congenital anomalies clusters: a recent mediatic example in France

Issue

In 2018 in France, reports of aggregated cases of isolated transverse limb reduction defects, a rare congenital anomaly (1.7 for 10,000 total births) generated a large mediatic interest with environmental factors overtly pointed out. Our aim is to describe the investigations carried out and to share the challenges we met.

Description of the response

Over a period of 5 years (2010-2015), 3 aggregates were signaled by health professionals in 3 different areas in France. Investigations included case ascertainment, epidemiological analyses, and search for a common exposure. Standardized Incidence Ratios were computed using the 6 French registries’s data as reference. In one area, the local registry performed a concurrent analysis using satscan. Parents filled a questionnaire addressing environmental and occupational exposures. Environmental databases were consulted as well as animal health surveillance data.

Results

Fourteen cases met the case definition. The excess of cases was ascertained in two aggregates located in a two small towns in the western part of France and comprising respectively 3 children born in 2007-2008 (SIR: 87.8 CI95%:[17-256]) and 4 children born in 2011-2013 (79.8 [2.5-204.2]). The third signal included 7 cases born between 2009 and 2014 residing in 7 towns located above the Alps and did not yield a significant excess when related to expected cases in the administrative subdivision (0.94 [0.38-1.95]). The concurrent analysis found a significant excess, generating a lengthy debate. None of the investigations identified a common cause or notable exposure. Delayed feedback and negative conclusions led to incomprehension among families.

Lessons

Informing stakeholders timely is crucial but communicating effectively about methods used and negative results can be challenging.

Key messages

Congenital anomalies clusters are sensitive topics. Cluster investigations involve a scientific and a societal component that must both be taken into account in organizing the public health response.

Evolution of Oxygen-Ion and Proton Conductivity in Ca-Doped Ln2Zr2O7 (Ln = Sm, Gd), Located Near Pyrochlore-Fluorite Phase Boundary

Sm_2-xCa_xZr₂O_7-x/2 (x = 0, 0.05, 0.1) and Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) mixed oxides in a pyrochlore-fluorite morphotropic phase region were prepared via the mechanical activation of oxide mixtures, followed by annealing at 1600 °C. The structure of the solid solutions was studied by X-ray diffraction and refined by the Rietveld method, water content was determined by thermogravimetry (TG), their bulk and grain-boundary conductivity was determined by impedance spectroscopy in dry and wet air (100-900 °C), and their total conductivity was measured as a function of oxygen partial pressure in the temperature range: 700-950 °C. The Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) pyrochlore solid solutions, lying near the morphotropic phase boundary, have proton conductivity contribution both in the grain bulk and on grain boundaries below 600 °C, and pure oxygen-ion conductivity above 700 °C. The 500 °C proton conductivity contribution of Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) is ~ 1 × 10^-4 S/cm. The fluorite-like Gd_2-xCa_xZr₂O_7-x/2 (x = 0.1) solid solution has oxygen-ion bulk conductivity in entire temperature range studied, whereas proton transport contributes to its grain-boundary conductivity below 700 °C. As a result, of the morphotropic phase transition from pyrochlore Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) to fluorite-like Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1), the bulk proton conductivity disappears and oxygen-ion conductivity decreases. The loss of bulk proton conductivity of Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) can be associated with the fluorite structure formation. It is important to note that the degree of Ca substitution in such solid solutions (Ln_2-xCa_x)Zr₂O_7-δ (Ln = Sm, Gd) is low, x < 0.1. In both series, grain-boundary conductivity usually exceeds bulk conductivity. The high grain-boundary proton conductivity of Ln_2-xCa_xZr₂O_7-x/2 (Ln = Sm, Gd; x = 0.1) is attributable to the formation of an intergranular CaZrO₃-based cubic perovskite phase doped with Sm or Gd in Zr sublattice.

Aleitamento materno, introdução alimentar, hábitos orais e má oclusão em crianças de três a cinco anos

Objetivo: descrever o tipo de aleitamento materno, a idade em que ocorreu a introdução alimentar, as características da instalação dos hábitos orais e a ocorrência das más oclusões em crianças de três a cinco anos. Materiais e métodos: estudo transversal realizado com 93 crianças por meio da aplicação de questionário aos responsáveis acerca do aleitamento materno, introdução alimentar e hábitos orais. Foi realizado exame clínico odontológico para avaliação da oclusão dentária. O nível de significância utilizado foi de 5%. Resultados: 93,5% das crianças foram amamentados no seio materno, destas, 6,4% foram amamentadas exclusivamente por mais de 6 meses. A mediana de idade da introdução da água e chá foi de cinco meses. O uso da mamadeira foi observado em 86% das crianças e a utilização da chupeta em 49,5%. A associação entre o tempo de aleitamento materno exclusivo e a presença de hábitos orais foi significativa (p=0,035). Crianças com o hábito de ficar com a boca aberta durante a noite apresentaram maior frequência do hábito de onicofagia (p=0,043). As más oclusões estavam presentes em 46,2% das crianças e, destas, 22,6% apresentaram mordida aberta anterior. Foi observada a associação entre alterações oclusais e o hábito de ficar com a boca aberta durante a noite (p=0,034). Conclusão: O aleitamento materno exclusivo foi fator de proteção para a instalação dos hábitos orais na amostra avaliada. A introdução dos alimentos ocorreu precocemente. Dentre os hábitos orais, o hábito de ficar com a boca aberta durante a noite indicou associação com as alterações oclusais.

O ENSINO DE FONOAUDIOLOGIA NO BRASIL: RETRATO DOS CURSOS DE GRADUAÇÃO

Resumo O presente estudo foi realizado em setembro de 2018, e teve como objetivo verificar o estado atual do ensino de fonoaudiologia no Brasil, por meio da caracterização de seus cursos de graduação. Para tal, foi realizada uma pesquisa documental e descritiva, de abordagem quantitativa e qualitativa. O levantamento de dados ocorreu no portal do Ministério da Educação. Analisaram-se 87 cursos de fonoaudiologia vinculados a instituições de ensino superior públicas (27,6%) e privadas (72,4%), num total de 7.044 vagas anuais ofertadas, com carga horária média de 3.681 horas, num prazo de integralização entre oito e dez semestres. Os cursos estavam distribuídos em 23 estados brasileiros, com maior concentração na região Sudeste. A maioria dos cursos teve nota três nos indicadores de qualidade propostos pelo Ministério da Educação. Concluiu-se que o ensino da fonoaudiologia no Brasil é fundamentalmente presencial, privado, distribuído pelo país, com baixa ocupação de vagas - aspecto inferido pelo número pequeno de concluintes quando comparado ao número de vagas ofertadas, carga horária mínima maior nas instituições de ensino superior públicas, cumprida entre oito e dez semestres, bem como apresenta indicadores de qualidade satisfatórios.

Structure and conductivity of Nd6MoO12-based potential electron–proton conductors under dry and wet redox conditions

Based on rhombohedral structure (R3̄) complex Nd₁₀Mo₂O₂₁ compound has proton conductivity ∼8 × 10⁻⁴ S cm⁻¹ at 600 °C.

Ultrasound-guided removal of vegetal foreign bodies in the lower extremities of dogs: a retrospective study of 19 cases

Subcutaneous abscesses or granulomas in the lower extremities of dogs commonly occur secondary to the penetration and migration of vegetal foreign bodies (FBs). The aim of this study was to describe the clinical presentation and ultrasonographic appearance of intact grass awn FBs in the lower extremities of dogs, and their ultrasound-guided retrieval with particular emphasis on the feasibility, effectiveness and prognosis associated with this technique. In this retrospective study, 22 FBs were identified ultrasonographically in 19 dogs. The procedure resulted in the successful retrieval of the FB in 100% of dogs, and the clinical signs resolved in 90% (n=17) in less than ten days. No complications or recurrence were encountered. This study shows that ultrasonographic examination should be the first-choice modality when a vegetal FB is suspected within the distal extremity, as it allows both identification and removal of the FB with a minimally invasive procedure, with short- and long-term effectiveness and good prognosis.

Chest CT findings in patients with dysphagia and aspiration: a systematic review

The objective of this systematic review was to characterize chest CT findings in patients with dysphagia and pulmonary aspiration, identifying the characteristics and the methods used. The studies were selected from among those indexed in the Brazilian Virtual Library of Health, LILACS, Indice Bibliográfico Español de Ciencias de la Salud, Medline, Cochrane Library, SciELO, and PubMed databases. The search was carried out between June and July of 2016. Five articles were included and reviewed, all of them carried out in the last five years, published in English, and coming from different countries. The sample size in the selected studies ranged from 43 to 56 patients, with a predominance of adult and elderly subjects. The tomographic findings in patients with dysphagia-related aspiration were varied, including bronchiectasis, bronchial wall thickening, pulmonary nodules, consolidations, pleural effusion, ground-glass attenuation, atelectasis, septal thickening, fibrosis, and air trapping. Evidence suggests that chest CT findings in patients with aspiration are diverse. In this review, it was not possible to establish a consensus that could characterize a pattern of pulmonary aspiration in patients with dysphagia, further studies of the topic being needed.

The impact of the patient post-intensive care syndrome components upon caregiver burden

OBJECTIVE

To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden.

DESIGN

A prospective observational study was conducted over 26 months (January 2013-February 2015).

SETTING

Medical-surgical ICU and follow-up consultation in Portugal.

PATIENTS OR PARTICIPANTS

Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study.

MAIN VARIABLES OF INTEREST

In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder).

RESULTS

A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden. Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008). When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden.

CONCLUSIONS

The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

Non-steroidal anti-inflammatory drug hypersensitivity in children

INTRODUCTION

There are rather few publications about hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAID) in the paediatric age. In this study, we aimed to assess the frequency of confirmed NSAID hypersensitivity in children with a previous reported reaction to NSAID in order to investigate the role of the drug provocation test (DPT) in the diagnostic workup and to explore the factors associated with confirmed NSAID hypersensitivity.

METHODS

We conducted a retrospective analysis of the clinical files from every patient under 18 years old who attended two Portuguese paediatric allergy outpatient clinics, from January 2009 to August 2014, due to a suspected NSAID hypersensitivity.

RESULTS

We included 119 patients, with a median age of nine years (P₂₅-P₇₅: 5-14). Ibuprofen was the commonest implicated NSAID in the patients' reports (n=94-79%). After DPT, NSAID hypersensitivity was confirmed in nine (7.6%) patients, excluded in 93 (78.2%) and was inconclusive in 17 (14.3%). In the majority (n=95-79.8%), the reaction occurred in the first 24h after intake. Eighty-four patients (70.6%) reported only cutaneous manifestations and 18 (15.1%) had systemic symptoms. Anaphylaxis represented a relative risk to NSAID hypersensitivity confirmation. No association was found for atopy and the number of previous reactions.

CONCLUSION

In our study, NSAID hypersensitivity was confirmed in a small proportion of the patients with a previous reported reaction. Ibuprofen was the most implicated drug with urticaria/angio-oedema as the commonest manifestation. Anaphylaxis was associated with confirmed drug hypersensitivity. The drug provocation test was essential to establish the diagnosis.

Drug allergy passport and other documentation for patients with drug hypersensitivity - An ENDA/EAACI Drug Allergy Interest Group Position Paper

The strongest and best-documented risk factor for drug hypersensitivity (DH) is the history of a previous reaction. Accidental exposures to drugs may lead to severe or even fatal reactions in sensitized patients. Preventable prescription errors are common. They are often due to inadequate medical history or poor risk assessment of recurrence of drug reaction. Proper documentation is essential information for the doctor to make sound therapeutic decision. The European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology have formed a task force and developed a drug allergy passport as well as general guidelines of drug allergy documentation. A drug allergy passport, a drug allergy alert card, a certificate, and a discharge letter after medical evaluation are adequate means to document DH in a patient. They are to be handed to the patient who is advised to carry the documentation at all times especially when away from home. A drug allergy passport should at least contain information on the culprit drug(s) including international nonproprietary name, clinical manifestations including severity, diagnostic measures, potential cross-reactivity, alternative drugs to prescribe, and where more detailed information can be obtained from the issuer. It should be given to patients only after full allergy workup. In the future, electronic prescription systems with alert functions will become more common and should include the same information as in paper-based documentation.

Interventions in the Alteration on Lingual Frenum: Systematic Review

Introduction

 Altered lingual frenum modifies the normal tongue mobility, which may influence the stomatognathic functions, resulting in anatomical, physiological and social damage to the subject. It is necessary that health professionals are aware of the process of evaluation, diagnostics and treatment used today, guiding their intervention.

Objective

 To perform a systematic review of what are the treatment methods used in cases of lingual frenum alteration.

Data Synthesis

 The literature searches were conducted in MEDLINE, LILACS, SciELO, Cochrane and IBECS, delimited by language (Portuguese, English, Spanish), date of publication (January 2000 to January 2014) and studies performed in humans. The selection order used to verify the eligibility of the studies were related to: full text availability; review the abstract; text analysis; final selection. Of the total 443 publications, 26 remained for analysis. The surgical approach was used in all studies, regardless of the study population (infants, children and adults), with a range of tools and techniques employed; speech therapy was recommended in the post surgical in 4 studies. Only 4 studies, all with infants, showed scientific evidence.

Conclusion

 Surgical intervention is effective for the remission of the limitations caused by the alteration on lingual frenum, but there is a deficit of studies with higher methodological quality. The benefits of speech therapy in the post surgical period are described from improvement in the language of mobility aspects and speech articulation.

Perfil mastigatório em crianças de três a cinco anos de idade

RESUMO: Objetivo: descrever o perfil mastigatório em crianças de três a cinco anos de idade, correlacionando-o com a idade cronológica, gênero, hábitos orais, introdução alimentar e aspectos dentários. Métodos: estudo transversal realizado com 60 crianças de ambos os gêneros. Um odontopediatra avaliou o aspecto dentário, seguida da avaliação da mastigação realizada por uma fonoaudióloga, utilizando-se pão francês e o protocolo elaborado para este estudo. A coleta de dados da mastigação foi realizada por meio de registro em vídeo e posterior análise por avaliadores cegos. Os responsáveis responderam o questionário sobre os hábitos orais e introdução alimentar. Resultados: nos 10 itens avaliados na mastigação ocorreu alternância entre o padrão esperado para todas as váriaveis. Foi observada diferença estatística entre a postura de lábios das crianças de três e quatro anos quando comparadas com as de cinco anos de idade (p<0,001). Os movimentos mandibulares predominantes do tipo rotatório evoluíram conforme o aumento da idade (p=0,008). Não foi encontrada associação entre os aspectos dentários e a mastigação das crianças. Foi verificada associação entre: a mastigação de meninas e meninos (p=0,001); a evolução mastigatória conforme a idade (p=0,008); apresentar hábitos orais para o item modo de corte (p=0,003) e ser respirador oronasal foi fator significante para a criança realizar a mastigação de boca aberta (p=0,01) e para realizar os movimentos mandibulares de maceração predominantemente (p=0,04). Conclusão: para a amostra estudada, o modo mastigatório apresentou-se gradativo em sua evolução e aperfeiçoamento. Foi encontrada diferenciação na mastigação conforme a idade, gênero, hábitos orais e modo respiratório.

106 COMPARISON OF IN VITRO EMBRYO PRODUCTION IN PANAMA USING HOLSTEIN OOCYTES WITH BOS INDICUS SEXED SEMEN FROM DONORS IN DIFFERENT LOCATIONS: FIELD DATA

The objective of this work was to compare in vitro embryo production of Bos taurus × Bos indicus cross embryos using oocytes from Holstein donors under different production and environment systems. This study also examined the possibility for in vitro production using oocytes imported and transported fresh between the USA and Panama. All animals were mature Holstein cows going through a normal lactation. The first group of donors was from the University of Illinois dairy herd and went through 3 ovum pickup sessions. The second group of donors were Holstein cows already adapted to Panama and went through 10 ovum pickup sessions. The Panamanian herd of Holstein donors were born and raised in Panama in an area of mountains, on average 1300 m above sea level. This environment does not have the typical hot and humid tropical weather seen in other regions of Panama. Both groups of donors were aspirated without stimulation during the years 2013 and 2014. Oocytes recovered from donors in Illinois were imported fresh under a special sanitary research protocol between Panama and the University of Illinois. The transport of fresh oocytes from the USA to Panama was done using a portable incubator set at 39°C (Minutube of America). Oocytes were matured during transport in 5-mL tubes (~30–35 oocytes per tube) containing 400 µL of maturation media (TCM-199) that had been equilibrated with 5% CO2. Oocytes recovered from donors in Panama were matured using the same media. For both groups, oocytes were inseminated 24 h after ovum pickup using sexed semen from the same bull. All embryo production procedures followed the protocols of the In vitro Brasil™ commercial system. At 72 h postinsemination, cleavage was evaluated. On Day 7 after insemination, embryo development to the blastocyst stage (early to expanded) was recorded. Data were analysed using Chi-squared. As shown in Table 1, there was no effect of oocyte collection location on embryo development. These results indicate that it is possible to produce a viable in vitro-produced embryo using fresh oocytes collected and transported from different countries. This work opens the possibility to access superior genetics and improve herds in countries seeking to increase their production systems and potentially improve their quality of life. Table 1.Effect of oocyte collection location on embryo development This project was supported by Programa de Competitividad ProCom Senacyt, Panama.

Breast cancer under age 40: a different approach

Breast cancer (BC) under age 40 is a complex disease to manage due to the additionally fertility-related factors to be taken in consideration. More than 90% of young patients with BC are symptomatic. Women<40 years are more likely to develop BC with worse clinicopathological features and more aggressive subtype. This has been frequently associated with inferior outcomes. Recently, the prognostic significance of age<40 has been shown to differ according to the BC subtype, being associated with worst recurrence-free survival (RFS) and overall survival (OS) for luminal BC. The biology of BC<40 has also been explored through analysis of large genomic data set, and specific pathways overexpressed in these tumors have been identified which can lead to the development of targeted therapy in the future. A multidisciplinary tumor board should determine the optimal locoregional and systemic management strategies for every individual patient with BC before the start of any therapy including surgery. This applies to both early (early breast cancer (EBC)) and advanced (advanced breast cancer (ABC)) disease, before the start of any therapy. Mastectomy even in young patients confers no overall survival advantage when compared to breast-conserving treatment (BCT), followed by radiotherapy. Regarding axillary approach, indications are identical to other age groups. Young age is one of the most important risk factors for local recurrence after both breast-conserving surgery (BCS) and mastectomy, associated with a higher risk of distant metastasis and death. Radiation after BCS reduces local recurrence from 19.5 to 10.2% in BC patients 40 years and younger. The indications for and the choice of systemic treatment for invasive BC (both early and advanced disease) should not be based on age alone but driven by the biological characteristics of the individual tumor (including hormone receptor status, human epidermal growth factor receptor 2 (HER-2) status, grade, and proliferative activity), disease stage, and patient's comorbidities. Recommendations regarding the use of genomic profiles such as MammaPrint, Oncotype Dx, and Genomic grade index in young women are similar to the general BC population. Especially in the metastatic setting, patient preferences should always be taken into account, as the disease is incurable. The best strategy for these patients is the inclusion into well-designed, independent, prospective randomized clinical trials. Metastatic disease should always be biopsied whenever feasible for histological confirmation and reassessment of biology. Endocrine therapy is the preferred option for hormone receptor-positive disease (HR+ve), even in presence of visceral metastases, unless there is concern or proof of endocrine resistance or there is a need for rapid disease response and/or symptom control. Recommendations for chemotherapy (CT) should not differ from those for older patients with the same characteristics of the metastatic disease and its extent. Young age by itself should not be an indication to prescribe more intensive and combination CT regimens over the sequential use of monotherapy. Poly(ADP-ribose) polymerase inhibitors (PARP inhibitors) represent an important group of promising drugs in managing patients with breast cancer susceptibility gene (BRCA)-1- or BRCA-2-associated BC. Specific age-related side effects of systemic treatment (e.g., menopausal symptoms, change in body image, bone morbidity, cognitive function impairment, fertility damage, sexual dysfunction) and the social impact of diagnosis and treatment (job discrimination, taking care for children) should also be carefully addressed when planning systemic long-lasting therapy, such as endocrine therapy. Survivorship concerns for young women are different compared to older women, including issues of fertility, preservation, and pregnancy.

Medidas antropométricas orofaciais em crianças de três a cinco anos de idade

OBJETIVO: obter as medidas antropométricas orofaciais em crianças pré-escolares de três a cinco anos e realizar a correlação com idade cronológica, gênero, raça e hábitos orais. MÉTODOS: estudo transversal com 93 crianças selecionadas por meio de amostra de conveniência consecutiva. Os responsáveis responderam a um questionário sobre os hábitos orais e as crianças foram submetidas a uma avaliação odontológica e antropométrica da face. O nível de significância utilizado foi p<0,05. RESULTADOS: as médias das medidas antropométricas orofaciais foram descritas. Houve diferença estatística nas medidas de altura da face (p<0,001), terço médio da face (p<0,001), canto externo do olho até a comissura labial esquerda/direita (p<0,001) e lábio inferior (p=0,015) nas faixas etárias. O gênero masculino apresentou medidas superiores na altura de face (p=0,003), terço inferior da face (p<0,001), lábio superior (p=0,001) e lábio inferior (p<0,001). Não houve diferença estatisticamente significante na altura do lábio superior em sujeitos não brancos (p=0,03). A presença de hábitos orais não influenciou os resultados. O aleitamento materno exclusivo por seis meses influenciou o aumento da medida de terço médio (p=0,022) e da altura da face (p=0,037). CONCLUSÃO: as médias descritas neste estudo foram superiores aos padrões encontrados em outros estudos. As médias orofaciais aumentaram conforme a idade. Houve superioridade nas medidas para o gênero masculino e para as crianças não brancas, mas não para presença de hábitos orais.

In vivo diagnosis of allergic diseases--allergen provocation tests

The allergen challenge test has been the mainstay of diagnosis of allergic diseases for a long time since it offers a direct proof of the clinical relevance of a particular allergen for the allergic disease symptoms and severity. Standardisation and availability for daily practice (including safety issues) are still to be refined but most of the challenge tests have safely crossed the border from research tools to diagnostic tests available for daily practice for a well trained clinical staff.

[Clinical signs of dysphagia in infants with acute viral bronchiolitis]

Objective:

To determine the occurrence of clinical signs of dysphagia in infants with acute viral bronchiolitis, to compare the respiratory parameters during deglutition, and to ensure the intra- and inter- examiners agreement, as well as to accomplish intra and interexaminators concordance of the clinical evaluation of the deglutition.

Methods:

This was a cross-sectional study of 42 infants aged 0-12 months. The clinical evaluation was accompanied by measurements of respiratory rate and pulse oximetry. A score of swallowing disorders was designed to establish associations with other studied variables and to ensure the intra- and interrater agreement of clinical feeding assessments. Caregivers also completed a questionnaire about feeding difficulties. Significance was set at p<0.05.

Results:

Changes in the oral phase (prolonged pauses) and pharyngeal phase (wheezing, coughing and gagging) of swallowing were found. A significant increase in respiratory rate between pre- and post-feeding times was found, and it was determined that almost half of the infants had tachypnea. An association was observed between the swallowing disorder scores and a decrease in oxygen saturation. Infants whose caregivers reported feeding difficulties during hospitalization stated a significantly greater number of changes in the swallowing evaluation. The intra-rater agreement was considered to be very good.

Conclusions:

Infants with acute viral bronchiolitis displayed swallowing disorders in addition to changes in respiratory rate and measures of oxygen saturation. It is suggested, therefore, that infants displaying these risk factors have a higher probability of dysphagia.

Screening tools for dysphagia: a systematic review

Purpose:To perform a systematic review of screening instruments for dysphagia available in the literature.Methods:For the selection of studies, the following descriptors were used: "questionários", "questionnaires", "transtornos de deglutição", "deglutition disorders", "programas de rastreamento", and "mass screening". The online databases used for the research were Virtual Health Library (LILACS, IBECS, MEDLINE, Cochrane Library, SciELO) and PubMed. The research was performed from April to June 2013. Selection criteria articles in English, Portuguese, and Spanish, regardless of the year of publication, whose title, abstract, or text had any relation to the purpose of the research. After reading the articles in their entirety, identification data and method of the articles were extracted for later analysis.Results:The research carried out from the proposed descriptors produced 1,012 articles. After reviewing the titles, summaries, and fully reading the articles, 20 studies were chosen. The publications on instruments for the identification of dysphagic patients started in 1999, and 50% of the analyzed studies were carried out in the USA. The methods used on the instruments were questionnaires, observation of patient's clinical signals and symptoms, the request for execution of some orofacial movements, and swallowing test with water or food.Conclusion:Screening instruments in dysphagia are fairly heterogeneous and have been developed for different audiences with the main objective of identifying patients with swallowing disorders.