[Neurodevelopmental Pediatrics in Portugal: Hospital Patient Volume, Resources and Needs - Changes After Ten Years]

INTRODUCTION

Neurodevelopmental disorders are, in modern societies, the most common chronic pediatric conditions. Many remain in adulthood. Organizing the national health care network to respond efficiently and effectively requires grounded knowledge of care needs. The Neurodevelopmental Pediatrics Society of the Portuguese Society of Pediatrics in order to know the current hospital care reality of Neurodevelopmental Pediatrics, carried out a national survey in 2007, repeating it ten years later. Material e Methods: In the 2016-2017 biennium, a survey of 45 hospital units was conducted on the patient volume of Neurodevelopmental clinics, the allocation of human resources, and the needs for professional reinforcement.

RESULTS

We obtained a 100% response rate. The total number of Neurodevelopmental Pediatrics consultations rose from 38 238 (2007) to 99 815 (2017). The number of professionals has also increased: pediatricians increased from 82 to 156. A median of 101 children were awaiting first consultation, compared with 185 in 2007.

DISCUSSION

In a decade, the patient volume almost tripled. The reinforcement of professionals, even though it was beneficial, did not increase accordingly; even so, the number of children on the waiting list for their first appointment has almost halved, reflecting the commitment of professionals.

CONCLUSION

It is noteworthy that the overall improvement of the national response in the area of Neurodevelopmental Pediatrics is remarkable. However, the requested reinforcement of human resources from a multidisciplinary perspective should not be neglected in view of the continuous improvement in care delivery in an area of great chronicity and complexity.

Individualized care for patients with intersex (disorders/differences of sex development): Part 3

The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment. We recommend an individualized approach by a multidisciplinary team utilizing a range of evolving strategies, including outcome data (or lack thereof) to support families during the decision-making process.

Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce

The number of practicing female urologists has increased from < 2% in 1980 to 9.2% in 2018. Despite this increase, urology trails far behind medical fields overall and surgical subspecialties, in achieving gender parity. Barriers, such as pervasive biases and institutional policies, exist at the medical student, resident, and practicing urologist levels. Once recognized as detrimental, action can be taken to combat these forces to allow for advancement of women in the field of urology. This will result in a richer workforce better able to serve its patient population and advance the field.

205 Preliminary characterization of ovarian stem cells from bovine ovaries

Ovarian stem cells (OSCs) have been reportedly isolated from ovaries of rodents, pigs, humans, and cattle by targeting the germ cell marker protein DDX4. Although the role of OSCs in female reproduction is unknown, the ability to culture OSCs and differentiate oocytes invitro could benefit the cattle industry and the study of oogenesis. The aim of this study was to describe isolation and preliminary characterisation of putative bovine OSCs. Slaughterhouse-derived ovaries from adult cows were processed by mechanical and enzymatic dissociation into a single cell suspension followed by immunostaining. Cells were incubated in blocking solution followed by 10µgmL−1 rabbit anti-human polyclonal DDX4 antibody (#13840; Abcam) for 15min and 2µgmL−1 goat anti-rabbit IgG labelled with Alexa Fluor 647 for 15min in the dark. Next, cells were resuspended in Hanks’ balanced salt solution with 1% bovine serum albumin/25mM HEPES, filtered through a 30-µm strainer and subjected to fluorescence-activated cell sorting. Controls used to establish gates were unstained cells and cells incubated with secondary antibody only. 4’,6-Diamidino-2-phenylindole (DAPI) exclusion was used as a viability test. Putative OSCs were placed in culture in OSC medium (MEMα Glutamax containing 10% fetal bovine serum, 1mM sodium pyruvate, 1× nonessential amino acids, 103 units of leukemia inhibitory factor, 10µgmL−1 glial cell-derived neurotrophic factor, 10µgmL−1 basic fibroblast growth factor, 1µgmL−1 epidermal growth factor, 1× N2-max, penicillin/streptomycin) for expansion and characterisation by gene expression using reverse transcription-PCR and protein expression using immunolocalization and confocal microscopy. To ensure specificity against bovine DDX4, the same antibody used for cell sorting was used to label oocytes within ovarian follicles in histological sections. Two cell lines were obtained and expanded invitro. Gene expression was performed in putative OSCs at passages 1 to 3; cumulus-oocyte complexes (COCs) were used as positive controls and adult skin fibroblasts as negative controls, and ACTB was used as an endogenous control. Both putative OSC lines and COCs expressed the germ cell markers DAZL and C-KIT, and COCs also expressed BMP15. Only ACTB was detected in fibroblasts. Immunolocalization was performed in putative OSCs at passage 4, with oocytes and fibroblasts used as positive and negative controls. Additional controls were cells exposed to secondary antibody only. Both putative OSC lines and oocytes expressed DAZL and DDX4 and no marker was detected in fibroblasts. Next, OSC line #2 was transfected with a retroviral vector using the EF1α promoter for green fluorescent protein (GFP) expression. This is a critical step to ensure the success of experiments requiring cell tracking. Transfected cells were expanded and sorted to establish a pure population of GFP+ OSCs. To verify replication deficiency of the viral particles, supernatant from GFP+ OSCs was collected 1 passage after transfection and applied to GFP- OSCs. No GFP+ cells were observed after 24, 48, or 72h. These preliminary results confirm the presence of putative OSCs in the ovaries of cows of reproductive age. If these cells are capable of invitro differentiation, they could provide a powerful tool to study oogenesis and further develop assisted reproductive technologies.

Predictors of nutritional and inflammation risk in hemodialysis patients

BACKGROUND

Malnutrition and chronic inflammation are prevalent complications in hemodialysis (HD) patients. Different nutritional assessment tools are used to identify patients at risk. A composite and comprehensive malnutrition inflammation score (MIS) has been correlated with morbidity and mortality, and appears to be a robust and quantitative tool.

OBJECTIVES

Determine malnutrition risk profile in a sample of portuguese HD patients; determine the association of clinical and laboratory factors with MIS, and the impact of each parameter on MIS.

METHODS AND RESULTS

We performed, between September 15th of 2015 and January 31st of 2016, a cross sectional analysis of 2975 patients, representing 25% of portuguese HD patients. 59% were men (66.7 ± 14.8 years); 31% diabetic; 79% and 21% performed, respectively, high-flux HD and HDF. A MIS >5 was considered to indicate higher risk and was present in 1489 patients (50%). Amongst all parameters, comorbilities/dialysis vintage, transferrin, functional capacity, changes in body weight and decreased fat stores showed the higher impact, while albumin had one of the lowest impact on the nutritional risk.

MULTIVARIABLE ANALYSIS

Higher age (>75 years, OR 1.71, p < 0.001), diabetes (OR 1.25, p = 0.026), lower P levels (OR 1.57,p = 0.001), higher Ca levels (OR 1.51, p < 0.001), higher ERI (OR 1.05, p < 0.001), higher Kt/V (OR 2.14, p < 0.001) and higher CRP (OR 1.01, p < 0.001) were independently associated with a higher risk of MIS>5; higher nPNA (OR 0.29, p < 0.001) and higher Pcreat (OR 0.88, p < 0.001) were associated with a risk reduction of MIS>5 (95% CI).

CONCLUSIONS

Routine clinical and analytic parameters were found to be associated with MIS range that might indicate higher risk, and may represent a simple alert sign for the need of further assessments.

Histopathology in Ureteropelvic Junction Obstruction With and Without Crossing Vessels

OBJECTIVE

To determine if the histopathology of the ureteropelvic junction differs between those with and without crossing vessels who present with a ureteropelvic junction obstruction (UPJO).

MATERIALS AND METHODS

Our database was queried for patients undergoing pyeloplasty (Current procedural terminology 50400, 50405, and 50544) between June 1, 2002, and March 10, 2016. We excluded patients with other renal anatomic abnormalities and patients undergoing surgery for upper tract tumor. One genitourinary pathologist reviewed all slides for muscle hypertrophy, fibrosis, edema, and inflammation. Statistics were modeled in SAS 9.4 (SAS, Cary, NC) using logistic regression with maximum likelihood.

RESULTS

A total of 178 patients met the inclusion criteria, and pathology slides were available for 136 patients. Thirty-three patients had crossing vessels in association with a UPJO. The degrees of muscle hypertrophy (P = .89) and fibrosis (P = .17) were not predictive of etiology. The odds of a crossing vessel increased by 4.3 times (95% confidence interval 1.8-9.9) when edema was present (P = .009) and by 4.4 (95% confidence interval 1.4-13.7) times when inflammation was present (P = .0103).

CONCLUSION

In the largest pathology series to date, histopathology showed increased inflammation in the presence of a crossing vessel but a similar composition of muscle and fibrosis. These data suggest that UPJO with an associated lower-pole vessel may represent a chronic process, which would explain why patients with a crossing vessel present later in life.

A Case of High-grade Transitional Cell Carcinoma of the Bladder in a Pediatric Patient With Turner Syndrome

Transitional cell carcinoma is a rare entity in children, especially in the first decade of life. The majority of these tumors are of low grade and noninvasive. We report an interesting case of a high-grade superficial transitional cell carcinoma in a 3-year-old girl with Turner syndrome.

Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: A 6-month randomized controlled trial

CONTEXT

Generalized anxiety disorder (GAD) is a chronic disorder that is associated with debilitating psychic and somatic symptoms. Venlafaxine extended-release (XR) capsules have been shown to be effective in short-term treatment of patients with GAD without major depressive disorder (MDD), but long-term data are needed to establish whether this agent confers persistent benefits.

OBJECTIVE

To compare the 6-month efficacy and safety of a flexible dosage of venlafaxine XR in outpatients with GAD without associated MDD.

DESIGN

Six-month, randomized, double-blind, placebo-controlled, parallel-group trial conducted May 1996 to October 1997.

SETTING

Fourteen outpatient clinics and private psychiatric practices in the United States.

PARTICIPANTS

A total of 251 outpatients aged 18 years or older who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for GAD, had sufficient symptoms to require treatment, and did not have coexisting MDD.

INTERVENTIONS

Participants were randomly assigned to receive either placebo (n=127) or venlafaxine XR (75, 150, or 225 mg/d, as required to control symptoms; n=124) for 28 weeks.

MAIN OUTCOME MEASURES

Changes from baseline in the Hamilton Rating Scale for Anxiety (HAM-A) total score, the HAM-A psychic anxiety factor score, and the Clinical Global Impressions (CGI) scale Severity of Illness and Global Improvement scores, compared by intervention group.

RESULTS

During weeks 6 through 28, response rates in the venlafaxine XR group were 69% or higher compared with rates of 42% to 46% in the placebo group (P<.001). By an evaluable-patient analysis, venlafaxine XR compared with placebo significantly improved anxiety scores from week 1 or 2 through week 28 on all primary efficacy measures, including the HAM-A total (P<.001), the HAM-A psychic anxiety factor (P<.001), and the CGI scale scores (P<.001). Adjusted mean changes from baseline to week 28 using last-observation-carried-forward methods were for HAM-A, venlafaxine XR -13.4, placebo -8.7 (P<.001); for HAM-A psychic anxiety score, venlafaxine XR -7.4, placebo -4.2 (P<.001); and for CGI-Improvement, venlafaxine XR 2.2, placebo 3.0 (P<.001). The most common treatment-emergent adverse event was nausea, followed by somnolence and dry mouth.

CONCLUSIONS

This study is the first placebo-controlled demonstration of the long-term efficacy of any drug class in treating outpatients with DSM-IV-diagnosed GAD. Venlafaxine XR is an effective, rapidly acting, safe, once-daily agent for both the short- and long-term treatment of anxiety and may provide an important alternative to currently available anxiolytics. JAMA. 2000.

Color vision discrimination in the capuchin monkey Cebus apella: evidence for trichromaticity

Primates display significant differences in color vision. The purpose of this study was to assess the ability of capuchin monkeys in discriminating chromatic and achromatic Munsell color chips through behavioral tests. The subjects were trained in a simple and reverse discrimination learning procedure. All subjects were capable of discriminations along five color categories investigated. The results are discussed in terms of the hypothesis of male dichromatism in New World monkeys, the role of color vision in adaptation to feeding ecology, as well as to aspects regarding primate evolution.

[Anomalous venous drainage of the left lung. Clinical and surgical findings and diagnostic difficulties]

PURPOSE

To analyze clinical and surgical aspects of patients with anomalous left pulmonary venous drainage (ALPVD).

METHODS

Seven patients, 3 males, with ages ranging from 18 months to 29 years were retrospectively studied, by analyzing the symptoms, electrocardiograms, chest X-ray, echocardiograms, angiography and surgical technique.

RESULTS

All patients, but one, were symptomatic being the effort dyspnea the most prevalent symptom. Electrocardiogram showed incomplete right bundle branch block in all but one case. Chest X-ray showed prominent pulmonic vessels (6 patients), different degrees of cardiomegaly (6) and a left superior vena cava like image (3). Echocardiography correctly depicted the anomaly in 4 cases. The ALPVD was lobar in 4 cases and total in 3. In 3 patients there was pulmonary hypertension and in one venous drainage obstruction (8mmHg gradient). Six patients were operated on, 3 through a sternotomy approach with cardiopulmonary bypass and other 3 through a left thoracotomy without cardiopulmonary bypass.

CONCLUSION

ALPVD has varying clinical repercussion and its clinical picture resembles atrial septal defect. Some cases may present diagnostic difficulties and echocardiograms may result in false negative findings. Cardiac catheterization is important to obtain detailed anatomic diagnosis, to evaluate the degree of pulmonary hypertension and to rule out venous obstruction. Left thoracotomy without extracorporeal circulation is indicated in ALPVD without associated defects.

Comparison of processed bovine internal mammary arteries and autologous veins as arterial femoral substitutes in dogs: blood compatibility and pathological characteristics

This study was undertaken to compare the chemically processed internal mammary artery (BIMA) and the autologous femoral vein as arterial grafts. The BIMA prosthesis was implanted as a left femoral artery bypass and the femoral vein as a right femoral artery bypass graft in 27 dogs. In groups of three dogs the grafts were implanted for predetermined durations: 4, 24 and 48 hours (short term), 1, 2 and 4 weeks (medium term) and 3, 6 and 9 months (long term). All autologous veins were patent when the dogs were killed. The patency rates of the BIMA grafts were 100% in the short-term group, 67% in the medium-term group and 29% in the long-term group. The deposition of labelled fibrinogen and platelets on flow surfaces, the structural preservation of the wall of the BIMA prosthesis and accumulation of thrombi during the period of implantation were studied.