Appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: analysis of a retrospective longitudinal study using real-world data from Northern Portugal (AF-React Study)

OBJECTIVES

This study aimed to assess the appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF).

DESIGN

Retrospective longitudinal study.

SETTING

The study was conducted in the Regional Health Administration of Northern Portugal.

PARTICIPANTS

The authors selected a database of 21 854 patients with prescriptions for NOACs between January 2016 and December 2018 and were classified with AF until December 2018.

OUTCOME MEASURES

The appropriate dosage of NOAC for patients with AF divided into three categories: contraindicated, inconsistent and consistent, based on the 2020 European Society of Cardiology guidelines for AF.

RESULTS

Dabigatran had a lower percentage of guideline-consistent doses (n=1657, 50.1%) than other drugs such as rivaroxaban (n=4737, 81.6%), apixaban (n=3830, 78.7%) and edoxaban (n=436, 82.1%). Most patients with an inconsistent dose were prescribed a lower dose than recommended based on their glomerular filtration rate (GFR). Among patients younger than 75 years with GFR >60 mL/min, 59.8% (n=10 028) had an adequate GFR range, while 27.8% (n=7166) of GFR measurements from patients older than 75 years old and 29.4% (n=913) of GFR measurements from patients younger than 75 years with GFR <60 mL/min were within an adequate time range. Adherence to NOACs varied across different drugs, with 59.1% (n=540) adhering to edoxaban, 56.3% (n=5443) to rivaroxaban, 55.3% (n=3143) to dabigatran and 53.3% (n=4211) to apixaban.

CONCLUSIONS

Dabigatran had the lowest percentage of guideline-consistent doses. Patients younger than 75 years with GFR >60 mL/min had the highest percentage with an adequate GFR range, while other groups who require closer GFR monitoring had lower percentages within an adequate GFR range. Adherence to NOACs differed among different drugs, with greater adherence to treatment with edoxaban and less adherence to apixaban.

AF-React study: Prevalence of thrombotic events in patients with atrial fibrillation receiving NOACs - real-world data analysis from northern Portugal primary healthcare

Introduction

Anticoagulation is recommended for stroke prevention in patients with atrial fibrillation (AF). The guidelines suggest non-vitamin K antagonist anticoagulants (NOACs) as the primary therapy for anticoagulation in AF. Several patient-related factors increase the risk of thrombotic events: elderly individuals, a previous history of stroke, and chronic kidney disease. This study aims to determine the association between NOACs and other patient variables in AF and the occurrence of thrombotic events.

Methods

The database included all adults with the code K78 (ICPC-2 code for AF) who received clinical care in Northern Portugal's Primary Health Care between January 2016 and December 2018 and were dispensed the same NOAC at the pharmacy.

Results

The results indicate that 10.2% of AF patients on NOAC anticoagulation experienced a stroke. Furthermore, patients treated with apixaban and dabigatran had higher odds of experiencing a stroke compared to those treated with rivaroxaban. Among patients with the same age, gender, and CHA2DS2Vasc Score, apixaban was significantly associated with a higher likelihood of thrombotic events than rivaroxaban.

Discussion

These results have not been previously reported in studies with real-world data; therefore, a more detailed analysis should be conducted to enhance the validity of these findings.

The pathogen-encoded signalling receptor Tir exploits host-like intrinsic disorder for infection

The translocated intimin receptor (Tir) is an essential type III secretion system (T3SS) effector of attaching and effacing pathogens contributing to the global foodborne disease burden. Tir acts as a cell-surface receptor in host cells, rewiring intracellular processes by targeting multiple host proteins. We investigated the molecular basis for Tir's binding diversity in signalling, finding that Tir is a disordered protein with host-like binding motifs. Unexpectedly, also are several other T3SS effectors. By an integrative approach, we reveal that Tir dimerises via an antiparallel OB-fold within a highly disordered N-terminal cytosolic domain. Also, it has a long disordered C-terminal cytosolic domain partially structured at host-like motifs that bind lipids. Membrane affinity depends on lipid composition and phosphorylation, highlighting a previously unrecognised host interaction impacting Tir-induced actin polymerisation and cell death. Furthermore, multi-site tyrosine phosphorylation enables Tir to engage host SH2 domains in a multivalent fuzzy complex, consistent with Tir's scaffolding role and binding promiscuity. Our findings provide insights into the intracellular Tir domains, highlighting the ability of T3SS effectors to exploit host-like protein disorder as a strategy for host evasion.

Using Natural Deep Eutectic Systems as Alternative Media for Ocular Applications

The major goal of this work was to study the potential of natural deep eutectic systems (NADES) as new media for ocular formulations. In formulating eye drops, it is important to increase the retention time of the drug on the surface of eye; hence, due to their high viscosity, NADES may be interesting candidates for formulation. Different systems composed of combinations of sugars, polyols, amino acids, and choline derivatives were prepared and then characterized in terms of rheological and physicochemical properties. Our results showed that 5-10% (w/v) aqueous solutions of NADES have a good profile in terms of viscosity (0.8 to 1.2 mPa.s), osmolarity (412 to 1883 mOsmol), and pH (7.4) for their incorporation of ocular drops. Additionally, contact angle and refractive index were determined. Acetazolamide (ACZ), a highly insoluble drug used to treat glaucoma, was used as proof-of-concept. Herein, we show that NADES can increase the solubility of ACZ in aqueous solutions by at least up to 3 times, making it useful for the formulation of ACZ into ocular drops and thereby enabling more efficient treatment. The cytotoxicity assays demonstrated that NADES are biocompatible up to 5% (w/v) in aqueous media, promoting cell viability (above 80%) when compared to the control after 24 h incubation in ARPE-19 cells. Furthermore, when ACZ is dissolved in aqueous solutions of NADES, the cytotoxicity is not affected in this range of concentrations. Although further studies are necessary to design an optimal formulation incorporating NADES, this study shows that these eutectics can be powerful tools in the formulation of ocular drugs.

Characterization of an obese population: a retrospective longitudinal study from real-world data in northern Portugal

BACKGROUND

Obesity is a serious and largely preventable global health problem. Obesity-related electronic health records can be a useful resource to identify and address obesity. The analysis of real-world data from T82-coded (International Classification of Primary Care coding, for obesity) primary care individuals can be an excellent national source of data on obesity's prevalence, characteristics, and impact on the National Health Service.

METHODS

Retrospective longitudinal study, based on a database of electronic medical records, from the Regional Health Administration of northern Portugal. The study objectives were to determine the prevalence of obesity and to characterize an adult obese population in northern Portugal from a bio-demographic point of view along with profiles of comorbidities and the use of health resources. This study used a database of 266,872 patients in December 2019 and screened for diagnostic code T82 from the International Classification of Primary Care.

RESULTS

The prevalence of obesity was 10.2% and the highest prevalence of obesity was in the 65-74 age group (16.1%). The most prevalent morbidities in patients with obesity as coded through ICPC-2 were K86 (uncomplicated hypertension), T90 (non-insulin-dependent diabetes), and K87 (complicated hypertension). Descriptive information showed that T82 subjects used more consultations, medications, and diagnostic tests than non-T82 subjects.

CONCLUSIONS

Routine recording of weight and height deserves special attention to allow obesity recognition at an early stage and move on to the appropriate intervention. Future work is necessary to automate the codification of obesity for subjects under 18 years of age, to raise awareness and anticipate the prevention of problems associated with obesity. Practical strategies need to be implemented, such as the creation of a specific program consultation with truly targeted approaches to obesity.

[Promoting Better Indoor Air Quality in Portugal for Disease Prevention and Control]

N/a.

Association of lifestyle and sociodemographic factors on multimorbidity: a cross-sectional study in Portugal

Background

Lifestyle factors are widely recognized as modifiers and major risk factors for non-communicable diseases. Previous studies on the prevalence of multimorbidity in Portugal predict an unfavourable reality. The aim of the present study was to analyse 1) the prevalence of multimorbidity in Portugal and 2) the association of individuals’ lifestyles and sociodemographic factors with multimorbidity.

Methods

A cross-sectional, population-wide study was conducted on a representative sample of the general population of Portuguese adults aged ≥ 20 years. Categorical variables were described by their respective absolute and relative frequencies (n (%)). All variables with a p-value < 20% were included in the multiple logistic regression model. The variables were removed one by one in descending order of p-value (p) until the model contained only significant variables. The results are presented using the odds ratio and 95% confidence intervals. P-values ​​ < 5% were considered significant.

Results

The prevalence of multimorbidity was 48.9% (n = 436), and the odds of multimorbidity increased 4% (p < 0.001) for each year of increase in age. Participants with reasonable general health status had higher odds of multimorbidity (Odds ratio (OR) = 3.04; p < 0.001), and those with poor or very poor general health status had even higher odds (OR = 9.14; p < 0.001). Compared to those who never smoked, participants who quit smoking ≥ 1 year presented an increase of 91% (p = 0.005) in the odds of multimorbidity. Individuals with no good-quality sleep, non-moderate screen time, or non-moderate stress level had higher odds of multimorbidity (OR = 1.98; OR = 1.88; OR = 2.22, respectively. p < 0.001).

Conclusions

This study presented a new approach to multimorbidity in Portugal. Population-based, multidimensional lifestyle interventions are needed. It seems necessary to optimize and adjust measures to prevent non-communicable diseases to improve health in Portugal. In the future, longitudinal studies will be an asset to reinforce and clarify these conclusions.

Structure and Dynamic Properties of a Glycerol-Betaine Deep Eutectic Solvent: When Does a DES Become an Aqueous Solution?

Deep eutectic solvents (DESs) are an emerging class of green solvents with a wide spectrum of potential applications whose properties may be further tailored through the addition of water. Here, we study, through molecular dynamics, the influence of water on the properties of a betaine-glycerol-water (B:G:W) DES (1:2:ζ; ζ = 0 to 100), aiming at getting insight into the structural and dynamic crossover between a DES and an aqueous solution. The density, shear viscosity, and diffusion coefficients are found to exhibit a non-linear dependence of ζ, similar to that observed for the solvation layers' composition. Each Gly and Bet are replaced, respectively, by ∼3 and ∼5 water molecules, with the highest rates of depletion being found for Gly around Bet and Gly around Gly. Above ζ = 7 (70 mol %; 29.5 wt %), a major structural transformation occurs, with the complete disruption of the second Bet-Gly solvation layer and the formation of a new second layer at a shorter distance, accompanied by a sudden change in the rate of increase of the components' diffusion. Nonetheless, opposite to other DES, our results indicate a smooth crossover between a DES and an aqueous solution.

Colorectal Screening Program in Northern Portugal: First Findings

INTRODUCTION

In Portugal, a colorectal cancer screening program based on faecal immunochemical test followed by colonoscopy was shown to be cost-effective for individuals between 50 and 74 years old. We report the first findings of the implementation of a population-based program In Northern Portugal.

MATERIAL AND METHODS

In the pilot phase, eligible subjects were allocated either to a direct mailing invitation or to primary care centers. In the first year of program implementation, we assessed the uptake rate, the faecal immunochemical test -positivity rate, the diagnostic yield of advanced neoplasia, and the quality parameters for post-faecal immunochemical test + colonoscopy.

RESULTS

We invited 100 501 eligible subjects (49% male with a median age of 55 years). Of these, 5228 participated in the pilot phase and 95 273 participated in the first year of the program. In the first year of the program, the adherence was 29%, with a positivity rate of 5% and a 60% compliance to colonoscopy. The faecal immunochemical test-detection rate of advanced neoplasia was 0.35/1000 subjects, and the positive predictive value at post- faecal immunochemical test + colonoscopy was 44% and 2% for advanced adenoma and invasive cancer, respectively. No major adverse events were reported after colonoscopy.

DISCUSSION

The suboptimal adherence to faecal immunochemical test and post-faecal immunochemical test + colonoscopy remains the most urgent step to be addressed.

CONCLUSION

A centralized invitation system based on direct mailing was feasible and both colonoscopy quality and diagnostic yield were adequate antecipating the success of the programme.

Using Digital Technologies in Response to the COVID-19 Pandemic in Portugal

Digital technologies revolutionized the way we dealt with the COVID-19 pandemic and outstood the obvious societal change in the information age. Currently, data are an essential element of any health institution. Their use has the potential to radically reduce the cost and time needed to strengthen scientific evidence on the effectiveness of interventions. Likewise, information and the potential of these technologies have become a crucial part of the response to the pandemic. Effective implementation of data management strategies has depended on the adoption of digital technologies and their integration with health policies and care systems. In August 2020, Nature Medicine published an article about technological maturity and digital responses in the context of the COVID-19 pandemic. This paper aims to provide a contextualization of the technologies adopted in Portugal in the current crisis while highlighting, when applicable, requirements, potentials, constraints and aspects of possible improvements. The digital maturity of health services is a gradual process that requires preparation, adaptation and response. The future of public health and health care systems will be increasingly digital, and it is necessary to promote a culture of innovation, coordinate and standardize processes and make room for a new paradigm of sustainable digital transformation.

On the Not So Anomalous Water-induced Structural Transformations of Choline Chloride-Urea (Reline) Deep Eutectic System

The choline chloride-urea binary mixture in the molar ratio (1:2), commonly known as reline, is an archetypal solvent among deep eutectic solvents (DES). Neutron diffraction (ND) and empirical potential structure...

Molecular Dynamics Studies of Therapeutic Liquid Mixtures and Their Binding to Mycobacteria

Tuberculosis is an highly contagious disease still considered by the WHO as one of most infectious diseases worldwide. The therapeutic approach, used to prevent and treat tuberculosis targets the Mycobacterium tuberculosis complex, comprises a combination of drugs administrated for long periods of time, which, in many cases, could cause several adverse effects and, consequently, low compliance of the patient to the treatment and drug-resistance. Therefore, therapeutic liquid mixtures formulated with anti-tuberculosis drugs and/or adjuvants in tuberculosis therapy are an interesting approach to prevent toxic effects and resistance to anti-tuberculosis drugs. The herein formulated therapeutic liquid mixtures, including ethambutol, arginine, citric acid and water under different molar ratios, were studied through a molecular dynamics approach to understand how ethambutol and arginine could be stabilized by the presence of citric acid and/or water in the mixture. To gain insights on how the uptake of these mixtures into the mycobacteria cell may occur and how a mycobacterial ABC transporter could contribute to this transport, multiple simultaneous ligand docking was performed. Interactions between citric acid and ethambutol involving the carboxyl and hydroxyl groups of citric acid with the amines of ethambutol were identified as the most critical ones. Water molecules present in the mixture provides the necessary network of hydrogen bonds that stabilize the mixture. Molecular docking additionally provided an interesting hypothesis on how the different mixture components may favor binding of ethambutol to an ABC importer. The data presented in this work helps to better understand these mixtures as well as to provide cues on the mechanisms that allow them to cross the mycobacterial cell membrane.

AF-React study: atrial fibrillation management strategies in clinical practice-retrospective longitudinal study from real-world data in Northern Portugal

OBJECTIVES

To determine the prevalence of atrial fibrillation (AF) and to assess how these patients are being cared for: what anticoagulants are being prescribed and are they being prescribed as recommended?

DESIGN

Retrospective longitudinal study.

SETTING

This study was conducted in the Regional Health Administration of Northern Portugal.

PARTICIPANTS

This study used a database that included 63526 patients with code K78 of the International Classification of Primary Care between January 2016 and December 2018.

RESULTS

The prevalence of AF among adults over 40 years in the northern region of Portugal was 2.3% in 2016, 2.8% in 2017 and 3% in 2018. From a total of 63 526 patients, 95.8% had an indication to receive anticoagulation therapy. Of these, 44 326 (72.9%) are being treated with anticoagulants: 17 936 (40.5%) were prescribed vitamin K antagonists (VKAs) and 26 390 (59.5%) were prescribed non-VKA anticoagulants. On the other hand, 2688 patients of the total (4.2%) had no indication to receive anticoagulation therapy. Of these 2688 patients, 1100 (40.9%) were receiving anticoagulants.

CONCLUSIONS

The prevalence of AF is 3%. Here, we report evidence of both undertreatment and overtreatment. Although having an indication, a considerable proportion of patients (27.1%) are not anticoagulated, and among patients with AF without an indication to receive anticoagulation therapy, a considerable proportion (40.9%) are receiving anticoagulants. The AF-React study brings extremely relevant conclusions to Portugal and follows real-world studies in patients with AF in Europe, presenting some data not yet studied.

Cervical cancer screening information flow in Northern regional administrative service in Portugal

Management of a population-based screening program circuit depends on characteristics and technical barriers of its application and implementation. The aim is to clarify the information flow, to understand and build a vision of cervical screening information flows in Northern Regional Health Administration Portuguese Public System and to identify the constraints among them. A total of 5 cluster meetings were presented and two expert interviews were conducted allowing to present an informational flow and its constraints. Aims addressed in each interview where based on the expertise of the interviewed. Cervical cancer screening program depends on the use of SiiMA application. This is an information system for the management of population-based screening program which involves mainly 3 entities and allows a longitudinal data collection and study. Three main constraints were reported. The time for updating data for the list of eligible women was bigger than accorded reaching up to 3 months delay. A duplicate of records and discharges in hospital care since the discharge was done both in the hospital system and the SiiMA platform manually in order to the woman re-enter the screening program. Pendencies were seen due to other screening programs running in parallel which had to be sorted out manually in the regional level or by the entity involved. The existence of a screening application is vital for the implementation purposes of a screening program. The lack of integration of the systems increases bureaucratic work, costs and causes time delay. To improve the efficiency of digital transformation ensuring the quality of the process it is necessary to adapt the design of the health informatic systems to the daily practice and its wants and needs. The strategies of forcing an ever-increasing number of frameworks have demonstrated not to be so effective. Therefore, it is a cornerstone to understand these flows in order to improve its structure, intervention and optimization.

Key messages

The existence of a screening digital application is vital but its expanding use arises constraints. Due to the complexity of such programs, a digital strategy is crucial for management and monitoring of the screening at this scale.

Double Monoubiquitination Modifies the Molecular Recognition Properties of p15PAF Promoting Binding to the Reader Module of Dnmt1

The proliferating cell nuclear antigen (PCNA)-associated factor p15^PAF is a nuclear protein that acts as a regulator of DNA repair during DNA replication. The p15^PAF gene is overexpressed in several types of human cancer, and its function is regulated by monoubiquitination of two lysines (K15 and K24) at the protein N-terminal region. We have previously shown that p15^PAF is an intrinsically disordered protein which partially folds upon binding to PCNA and independently contacts DNA through its N-terminal tail. Here we present an NMR conformational characterization of p15^PAF monoubiquitinated at both K15 and K24 via a disulfide bridge mimicking the isopeptide bond. We show that doubly monoubiquitinated p15^PAF is monomeric, intrinsically disordered, and binds to PCNA as nonubiquitinated p15^PAF does but interacts with DNA with reduced affinity. Our SAXS-derived conformational ensemble of doubly monoubiquitinated p15^PAF shows that the ubiquitin moieties, separated by eight disordered residues, form transient dimers because of the high local effective ubiquitin concentration. This observation and the sequence similarity with histone H3 N-terminal tail suggest that doubly monoubiquitinated p15^PAF is a binding target of DNA methyl transferase Dnmt1, as confirmed by calorimetry. Therefore, doubly monoubiquitinated p15^PAF directly interacts with PCNA and recruits Dnmt1 for maintenance of DNA methylation during replication.

Asparagopsis armata and Sphaerococcus coronopifolius as a natural source of antimicrobial compounds

Methanol, n-hexane and dichloromethane extracts of twelve marine macro-algae (Rhodophyta, Chlorophyta and Heterokontophyta divisions) from Peniche coast (Portugal) were evaluated for their antibacterial and antifungal activity. The antibacterial activity was evaluated by disc diffusion method against Bacillus subtilis (gram positive bacteria) and Escherichia coli (gram negative bacteria). Saccharomyces cerevisiae was used as a model for the antifungal activity by evaluating the growth inhibitory activity of the extracts. The high antibacterial activity was obtained by the Asparagopsis armata methanolic extract (10 mm-0.1 mg/disc), followed by the Sphaerococcus coronopifolius n-hexane extract (8 mm-0.1 mg/disc), and the Asparagopsis armata dichloromethane extract (12 mm-0.3 mg/disc) against Bacillus subtilis. There were no positive results against Escherichia coli. Sphaerococcus coronopifolius revealed high antifungal potential for n-hexane (IC50 = 40.2 µg/ml), dichloromethane (IC50 = 78.9 µg/ml) and methanolic (IC50 = 55.18 µg/ml) extracts against Saccharomyces cerevisiae growth. The antifungal potency of the Sphaerococcus coronopifolius extracts was similar with the standard amphotericin B. Asparagopsis armata and Sphaerococcus coronopifolius reveal to be interesting sources of natural compounds with antimicrobial properties.

Bladder metastasis of gastric adenocarcinoma. Report of 2 cases and bibliographic review

OBJECTIVE

Metastases to the urinary bladder are rare, representing less than 2% of bladder tumors. We report two cases of bladder involvement by primary gastric adenocarcinoma and perform a bibliographic review of the literature on this subject.

METHODS

A search for published data was performed in the PubMed database using the key words "bladder", "secondary malignant tumors" and "metastatic gastric carcinoma". We reviewed the two cases of secondary bladder involvement by primary gastric adenocarcinoma managed at our institution.

RESULTS

Case 1: 62 year old female presenting with irritative LUTS, hypogastric pain and constitutional symptoms, with bilateral hydronephrosis. After bilateral nephrostomy, bladder wall biopsies revealed poorly differentiated metastatic gastric carcinoma. Case 2: 41 year old male with gastric adenocarcinoma diagnosed by endoscopic biopsy with pancreatic involvement, under neoadjuvant chemotherapy regimen, with sporadic macroscopic hematuria. Cistoscopy revealed a protuberant bladder mass with biopsies conclusive for secondary bladder involvement by gastric carcinoma.

CONCLUSION

Bladder metastasis from primary gastric adenocarcinoma usually means advanced disease with multiple metastatic involvement and peritoneal dissemination. The overall prognosis is very poor.

Pupil-led sex education in England (RIPPLE study): cluster-randomised intervention trial

BACKGROUND

Improvement of sex education in schools is a key part of the UK government's strategy to reduce teenage pregnancy in England. We examined the effectiveness of one form of peer-led sex education in a school-based randomised trial of over 8000 pupils.

METHODS

29 schools were randomised to either peer-led sex education (intervention) or to continue their usual teacher-led sex education (control). In intervention schools, peer educators aged 16-17 years delivered three sessions of sex education to 13-14 year-old pupils from the same schools. Primary outcome was unprotected (without condom) first heterosexual intercourse by age 16 years. Analysis was by intention to treat.

FINDINGS

By age 16 years, significantly fewer girls reported intercourse in the peer-led arm than in the control arm, but proportions were similar for boys. The proportions of pupils reporting unprotected first sex did not differ for girls (8.4% intervention vs 8.3% control) or for boys (6.2% vs 4.7%). Stratified estimates of the difference between arms were -0.4% (95% CI -3.7% to 2.8%, p=0.79) for girls and -1.4% (-4.4% to 1.6%, p=0.36) for boys. At follow-up (mean age 16.0 years [SD 0.32]), girls in the intervention arm reported fewer unintended pregnancies, although the difference was borderline (2.3% vs 3.3%, p=0.07). Girls and boys were more satisfied with peer-led than teacher-led sex education, but 57% of girls and 32% of boys wanted sex education in single-sex groups.

INTERPRETATION

Peer-led sex education was effective in some ways, but broader strategies are needed to improve young people's sexual health. The role of single-sex sessions should be investigated further.

[Symptoms of the lower urinary tract suggesting infravesical obstruction]

How should patients be investigated when they have lower urinary tract symptoms suggesting BPH or bladder outlet obstruction? How intensive should the clinical evaluation and the investigative process be? The recommended diagnostic work-up is presented for daily clinical practice.

Clinical significance of prenatal ultrasonographic intestinal dilatation in fetuses with gastroschisis

OBJECTIVE

Our purpose was to evaluate the clinical significance of intestinal dilatation detected by prenatal ultrasonographic examination in fetuses with gastroschisis.

STUDY DESIGN

A retrospective chart review was performed of all patients cared for at Los Angeles County/University of Southern California Women's and Children's Hospital with the prenatal diagnosis of gastroschisis over a 7-year period (1988 through 1995). Patients were divided into two groups on the basis of the presence or absence of ultrasonographically measured fetal bowel diameter of > or = 17 mm. Neonatal outcomes of the two groups were compared.

RESULTS

Twenty-one patients met the entry criteria during the study period. Fetuses with maximal bowel diameter of > or = 17 mm did not have a longer time to full oral feeding, a longer initial hospital stay, or a greater need for bowel resection when compared with fetuses with a bowel diameter < 17 mm. Two newborns underwent bowel resection because of intestinal atresia. Prenatal ultrasonographic examination failed to show significant bowel dilatation in either infant.

CONCLUSION

Our data suggest that prenatal evidence of intestinal dilatation in fetuses with gastroschisis does not predict immediate neonatal outcome. Thus this finding is not an appropriate indication for preterm delivery in the absence of other evidence of fetal compromise.

Behçet's syndrome and vesicovaginal fistula: an unusual complication

We present an unusual case of a spontaneous vesicovaginal fistula occurring with Behçet's syndrome. Recommendations and precautions for the management of this situation are briefly discussed.