Assessment of friction in aged soft contact lenses by an innovative method

In the present research work, we intend to evaluate the effect of aging of CL (contact lenses) on friction and, in case there are alterations in the value of the coefficient of friction after aging, to understand which modifications in the material incite these variations. For this, a simulation of the aging process to which the CL are subject in vivo is carried out and the friction and stiffness of the CL are characterized, before and after aging. The aging procedure of SCLs (soft contact lenses) was simulated by a cycling process considering that the main parameter influencing the material surface is the transition between the closed and open eye and the exposure to environmental aggressions, particularly ultraviolet radiation. The values of the coefficient of friction and elastic modulus before and after the aging process were compared and was verified the increase of both parameters for all contact lenses. The hydrogel lens was the least affected by aging and the silicone - hydrogel lens based on delefilcon A was the one that showed the least stability of properties.

The Effect of Vitamin D Adequacy on Thyroid Hormones and Inflammatory Markers after Bariatric Surgery

Vitamin D status affects the clinical and corporal outcomes of postoperative patients who undergo a Roux-en-Y gastric bypass (RYGB). The aim of this study was to evaluate the effect of adequate vitamin D serum concentrations on thyroid hormones, body weight, blood cell count, and inflammation after an RYGB. A prospective observational study was conducted with eighty-eight patients from whom we collected blood samples before and 6 months after surgery to evaluate their levels of 25-hydroxyvitamin D 25(OH)D, thyroid hormones, and their blood cell count. Their body weight, body mass index (BMI), total weight loss, and excess weight loss were also evaluated 6 and 12 months after surgery. After 6 months, 58% of the patients achieved an adequate vitamin D nutritional status. Patients in the adequate group showed a decrease in the concentration of thyroid-stimulating hormone (TSH) (3.01 vs. 2.22 µUI/mL, p = 0.017) with lower concentrations than the inadequate group at 6 months (2.22 vs. 2.84 µUI/mL, p = 0.020). Six months after surgery, the group with vitamin D adequacy showed a significantly lower BMI compared with the inadequate group at 12 months (31.51 vs. 35.04 kg/m², p = 0.018). An adequate vitamin D nutritional status seems to favor a significant improvement in one's thyroid hormone levels, immune inflammatory profile, and weight loss performance after an RYGB.

Vitamin A Deficiency and Its Association with Visceral Adiposity in Women

Body adiposity is associated with increased metabolic risk, and evidence indicates that vitamin A is important in regulating body fat. The aim of this study was to evaluate serum concentrations of vitamin A and its association with body adiposity in women with the recommended intake of vitamin A. A cross-sectional study was designed with 200 women divided into four groups according to Body Mass Index (BMI): normal weight (NW), overweight (OW), class I obesity (OI), and class 2 obesity (OII). The cut-off points to assess inadequate participants were retinol < 1.05 µmol/L and β-carotene < 40 µg/dL. Body adiposity was assessed through different parameters and indexes, including waist circumference (WC), waist-to-height ratio (WHtR), hypertriglyceridemic waist (HW), lipid accumulation product (LAP), Visceral Adiposity Index (VAI), and Body Adiposity Index (BAI). It was observed that 55.5% of women had low serum concentrations of β-carotene (34.9 ± 13.8 µmol/L, p < 0.001) and 43.5% had low concentrations of retinol (0.71 ± 0.3 µmol/L, p < 0.001). Women classified as OI and OII had lower mean values of β-carotene (OI—35.9 ± 4.3 µg/dL: OII—32.0 ± 0.9 µg/dL [p < 0.001]). IAV showed significant negative correlation with retinol (r = −0.73, p < 0.001). Vitamin A deficiency is associated with excess body adiposity in women with the recommended intake of vitamin. Greater body adiposity, especially visceral, was correlated with reduced serum concentrations of vitamin A.

Evaluation of Liver Metabolism Biomarkers in Metabolic Associated Fatty Liver Disease According to Obesity Phenotype

OBJECTIVE

To analyze the relationship between the biochemical markers of liver metabolism in different stages of Metabolic Associated Fatty Liver Disease (MAFLD) according to the obesity phenotype.

METHODOLOGY

This is a cross-sectional study with individuals with class III obesity classified according to the obesity phenotypes proposed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. Biochemical and anthropometric variables were analyzed according to the staging of MAFLD and obesity phenotype.

RESULTS

A total of 50 subjects with MAFLD, 62% (n = 31) with steatosis and 38% (n = 19) with steatohepatitis without fibrosis; 36% were classified as metabolically healthy obesity (MHO) and 64% as metabolically unhealthy obesity (MUHO), respectively. Mean values of alkaline phosphatase were 85.44 ± 27.27 vs. 61.92 ± 17.57 (p = 0.006); gamma-glutamyl transpeptidase, 25.77 ± 15.36 vs. 30.63 ± 19.49 (p = 0.025); and albumin, 3.99 ± 0.34 vs. 4.24 ± 0.23 (p = 0.037), were lower and statistically significant in the MHO group with steatosis. The results show when considering individuals with IR, only AP is a predictor of unhealthy phenotype (B-0.934, 0.848- 1.029, p = 0.031).

CONCLUSION

MHO individuals with steatosis present lower severe changes related to markers of liver damage and function and AP is considered the predictor of MUHO phenotype.

Impairment of Vitamin D Nutritional Status and Metabolic Profile Are Associated with Worsening of Obesity According to the Edmonton Obesity Staging System

Obesity is associated with a higher risk of Vitamin D (VD) inadequacy and metabolic diseases. The Edmonton Obesity Staging System (EOSS) is an innovative tool for the evaluation of obesity that goes beyond body weight and considers clinic, functional and menta- health issues. This study aimed to evaluate the nutritional status of VD according to the stages of EOSS and its relationship with the metabolic profile. In the cross-sectional study, we evaluated anthropometric parameters, physical activity, blood pressure, biochemical and metabolic variables, and VD nutritional status. A total of 226 individuals were categorized using EOSS: 1.3%, 22.1%, 62.9%, and 13.7% were in stages 0, 1, 2 and 3, respectively. Regarding the metabolic changes and comorbidities, insulin resistance and hyperuricemia were diagnosed in some individuals in EOSS 1, 2, and 3. EOSS 2 and 3 presented a significant relative-risk for the development of arterial hypertension, metabolic syndrome, and liver disease, compared with EOSS 0. In all stages, there were observed means of 25(OH)D serum concentrations below 30 ng/mL (EOSS 0 24.9 ± 3.3 ng/mL; EOSS 3 15.9 ± 5.4 ng/mL; p = 0.031), and 25(OH)D deficiency was present in all stages. Individuals with obesity classified in more advanced stages of EOSS had lower serum concentrations of 25(OH)D and a worse metabolic profile.

Dose-Response Relationship of Resistance Training on Metabolic Phenotypes, Body Composition and Lipid Profile in Menopausal Women

The relationship between volume training of resistance training (RT), body composition and cardiometabolic profile in menopausal women is poorly understand. This study aimed to evaluate the dose−response relationship of RT on lipid profile, body composition and metabolic phenotypes in menopausal women. A total of 31 women were categorized according to different volume of RT. Body composition was evaluated by DEXA and the cardiometabolic risk by metabolic phenotypes and lipid profile. There was a higher frequency of metabolically unhealthy phenotype in women who practiced RT for less than two years and had a weekly frequency lower than three days a week (p > 0.05). Women with more than two years and a higher weekly frequency of RT had lower trunk fat mass than their counterparties (15.33 ± 7.56 versus 10.57 ± 4.87, p = 0.04; 16.31 ± 7.46 versus 10.98 ± 5.49, p = 0.03, respectively). There was an association between HDL-c and time of RT in years. A moderate correlation was identified between variables of body adiposity, time in years and weekly frequency of RT. The present study concludes that more time in years and weekly frequency of RT practice are associated with lower body adiposity in menopausal women, the first also being associated with HDL-c.

Vitamin D Supplementation and Its Relationship with Loss of Visceral Adiposity

PURPOSE

An inverse relationship between vitamin D (VD) nutritional status and obesity is frequent, and the distribution of body fat is an important aspect to assess the risks of obesity-related metabolic dysfunction. The purpose of the study was to evaluate the relationship between serum VD concentrations and body fat reduction after 12 months of bariatric surgery, using two different vitamin D3 (VD3) supplementation protocols.

MATERIAL AND METHODS

A randomized controlled trial consisted of 41 patients divided into G1 (800 IU/day) and G2 (1800 IU/day) according to the VD3 supplementation. At baseline (T0) and follow-up (T1), 25(OH)D, waist circumference (WC), visceral adiposity index (VAI), body adiposity index (BAI), and waist/height ratio (WHtR) were evaluated.

RESULTS

In T0, the mean of 25(OH)D was lower in G2 compared to that in G1 (22.6 vs 23.6 ng/mL; p = 0.000). At T1, it had a significant increase in G2 (32.1 vs 29.9 ng/mL; p = 0.000), with 60% sufficiency. A significant negative correlation was observed between VAI, BAI, and WHtR with 25(OH)D in G2 (r =  - 0.746, p = 0.024; r =  - 0.411, p = 0.036; r =  - 0.441, p = 0.032) after surgery. Higher mean changes from baseline of visceral fat loss, represented by VAI, were observed in G2 (176.2 ± 149.0-75.5 ± 55.0, p = 0.000).

CONCLUSION

Patients submitted to the 1800 IU/day protocol, 12 months after the surgical procedure, had a higher percentage of sufficient vitamin D levels compared to those submitted to the 800 IU/day protocol. Additionally, higher dose supplementation promoted a significant improvement in VAI.

Adipose tissue dysfunction and MAFLD in obesity on the scene of COVID-19

Obesity is a known risk factor for respiratory infection and many other chronic diseases, including metabolic dysfunction-associated fatty liver disease (MAFLD), previously known as nonalcoholic fatty liver disease (NAFLD). Recently, it has been considered an important and independent predictor for coronavirus disease 2019 (COVID-19) complications in adults, especially cardiopulmonary, presenting in a great number of individuals in critical care. In obesity, adipose tissue (AT) undergoes expansion via several processes: expansion of adipocytes and insufficient vascularization lead to hypoxia; adipocyte apoptosis/necrosis; irregular fatty acid flux; and enhanced secretion of inflammatory adipokines, cytokines, and chemokines. In individuals with obesity the liver can also become a target of COVID-19 infection, although major liver damage is uncommon. COVID-19 acute pandemic often develops in patients with major metabolic abnormalities, including fatty liver disease, which is part of a chronic pandemic together with body fat accumulation. During metabolic abnormalities, the expansion of metabolically active fat parallels chronic inflammatory changes, the development of Insulin Resistance (IR), and in the liver, the accumulation of fat, possibly, an underlying fibrosis. SARS-Cov-2 virus might affect the liver by direct or indirect mechanisms. The current epidemic of obesity and related metabolic diseases has extensively contributed to increase the number of severe cases and deaths from COVID-19, resulting in a health, political and economic crisis with long-lasting consequences. In this review, the authors explore the relationship between AT dysfunction and MAFLD in obesity on the scene of COVID-19.

Body Composition, Basal Metabolic Rate and Leptin in Long-Term Weight Regain After Roux-en-Y Gastric Bypass Are Similar to Pre-surgical Obesity

PURPOSE

The purpose of this study is to evaluate the relationship between body composition, basal metabolic rate (BMR), and serum concentrations of leptin with long-term weight regain after Roux-en-Y gastric bypass (RYGB) and compare it with obesity before surgery.

MATERIALS AND METHODS

Prospective longitudinal analytical study. Three groups were formed: individuals 60 months post RYGB, with weight regain (G1) and without it (G2), and individuals with obesity who had not undergone bariatric surgery (G3). Body fat (BF), body fat mass (BFM), visceral fat (VF), fat-free mass (FFM), skeletal muscle mass (SMM), and BMR were assessed by octapolar and multi-frequency electrical bioimpedance. Fasting serum concentrations of leptin were measured.

RESULTS

Seventy-two individuals were included, 24 in each group. Higher means of BF, BFM, VF, and leptin levels were observed in G1, when compared to G2 (BF: 47.5 ± 5.6 vs. 32.0 ± 8.0, p < 0.05; FBM: 47.8 ± 11.6 vs. 23.9 ± 7.0, p < 0.05; VF: 156.8 ± 30.2 vs. 96.1 ± 23.8, p < 0.05; leptin: 45,251.2 pg/mL ± 20,071.8 vs. 11,525.7 pg/mL ± 9177.5, p < 0.000). G1 and G2 did not differ in FFM, SMM, and BMR. G1 and G3 were similar according to BF, FFM, BMR, and leptin levels. Body composition, but not leptin, was correlated with %weight regain in G1 (FBM: r = 0.666, p < 0.000; BF: r = 0.428, p = 0.037; VF: r = 0.544, p = 0.006).

CONCLUSION

Long-term weight regain after RYGB is similar to pre-surgical obesity in body composition, BMR, and leptin concentrations, indicating relapse of metabolic and hormonal impairments associated with excessive body fat.

Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators

AIMS

This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators.

METHODS

We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium.

RESULTS

The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%.

CONCLUSIONS

This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.

Association between serum and dietary antioxidant micronutrients and advanced liver fibrosis in non-alcoholic fatty liver disease: an observational study

Background

Despite clinical trials with antioxidant supplementation, few studies have been conducted to evaluate the nutritional status of antioxidant vitamins and minerals, and none have reported on the status of these serum antioxidants associated with the dietary intake of antioxidants by non-alcoholic fatty liver disease (NAFLD) patients.

Objective

To evaluate association between serum and dietetics antioxidants with liver fibrosis in patients with NAFLD.

Methods

Across-section analysis with out with 72 patients diagnosed with NAFLD. Hepatic fibrosis was measured by FibroScan^®, and liver stiffness ≥7.9 kPa was considered to indicate advanced fibrosis. Retinol, alpha-tocopherol, ascorbic acid, beta-carotene, serum zinc, and selenium were evaluated, as was the dietary intake of these micronutrients in the previous 24 h (using 24-h dietary recall). The Mann-Whitney test was used to compare the fibrosis groups and, a linear regression analysis was performed to determine associated risk factors between age, sex, BMI, hepatic fibrosis, and serum antioxidants.

Results

A high proportion of inadequate serum retinol (20.8%), vitamin C (27%), and selenium (73.6%) was observed in the patients with NAFLD, in addition to a significant inadequacy of vitamin A (98.3%) and vitamin E (100%) intake. Patients with advanced liver fibrosis had reduced levels of serum retinol (P = 0.002), with liver fibrosis being the independent risk factor associated with serum retinol lower.

Conclusion

Hepatic fibrosis was associated with a reduction in serum retinol and was reduced in advanced fibrosis. NAFLD patients showed an important serum deficiency and insufficient dietary intake of the evaluated micronutrients.

Primary care organizational model mix and avoidable hospitalization: an ecological study in Portugal

Background

In Portugal, there are different organizational models in primary health care (PHC), mainly regarding the payment scheme. USF-B is the only type with financial incentives to the professional (pay-for-performance). Our goal was to assess the relationship between groups of primary healthcare centres (ACES) with higher proportion of patients within USF-B model and the rate of avoidable hospitalizations, as proxy of primary care quality.

Methods

We conducted a cross-sectional study considering the 55 ACES from mainland Portugal, in 2017. We used data from public hospitalizations to calculate the prevention quality indicator (avoidable hospitalizations) adjusted for age and sex, using direct standardization. The main independent variable was the proportion of patients in one ACES registered in the USF-B model. Unemployment rate, proportion of patients with family doctor and presence of Local Health Unit (different organization model) within ACES were also considered. The association was assessed by means of a linear regression model.

Results

Age-sex adjusted PQI value varied between 490 and 1715 hospitalizations per 100,000 inhabitants across ACES. We observed a significant effect of the proportion of patients within USF-B in the crude PQI rate (p = 0.001). However, using the age-sex adjusted PQI, there was not a statistical significant association (p = 0.504). This last model was also adjusted for confounding variables and the association remains non-significant (p = 0.865).

Conclusions

Our findings suggest that, when adjusting for age and sex, there is no evidence that ACES with more patients enrolled in a pay-for-performance model is associated with higher quality of PHC (using avoidable hospitalizations as proxy). Further studies addressing individual data should be performed.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Adjusting PQI to sex and age seems to influence its value more than the type of organizational model of primary health care. Groups of primary healthcare centres with more units under the pay-for-performance scheme was not associated with different rate of avoidable hospitalizations.

Efficiency of groups of primary healthcare centres: a frontier analysis of primary care in Portugal

Background

Primary health care (PHC) is the cornerstone of several health systems. The Portuguese PHC is organized in five mainland regions (ARS), that oversee 55 local groups of primary healthcare centres (ACES). We assessed the efficiency of all 55 ACES in mainland Portugal, as well as organizational and socioeconomic determinants of the efficiency.

Methods

A cross-sectional non-parametric frontier analysis was performed for 2017. The first model included two inputs (i.e. number of physicians and number of nurses) and a single output (i.e. number of PHC visits), while the second model included an additional output, i.e. Prevention Quality Indicator (PQI) overall composite (avoidable hospitalizations) adjusted for age and sex - as undesirable output. In a second stage, a (multivariate) Tobit regression was used to assess organizational and socioeconomic determinants of efficiency.

Results

In the first model, only 8 ACES (14.5%) were on the efficiency frontier, while 25 ACES should readjust their human resource balance. In the second model, 9 ACES (16.4%) were considered efficient. When considering quality, one ACES previously considered inefficient moved to the frontier and two ACES lost their benchmark position. The second-stage analysis indicates that groups with a higher proportion of PHC units with pay-for-performance incentives were associated with higher efficiency.

Conclusions

Most ACES have the potential to improve their production levels., A better management of human resources can contribute to improve overall efficiency. ACES with a higher proportion of units with pay-for-performance schemes seem to be more efficient. These findings contribute to the evaluation of policies to integrate and scale up PHC services locally, such as the recent primary care networks in the NHS UK.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Most Portuguese ACES have the potential to improve their outputs given their current level of human resources. Local groups that aggregate more PHC units with pay-for-performance schemes are associated with high efficiency.

Inadequacy of Vitamin D Nutritional Status in Individuals with Metabolically Unhealthy Obesity Phenotype: The Relevance of Insulin Resistance

PURPOSE

The aim was to evaluate 25(OH)D serum concentrations in metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUHO) and its relation with biochemical and clinical parameters in both groups according to homeostatic model assessment-insulin resistance (HOMA-IR) definition of the obesity phenotypes.

PATIENTS AND METHODS

Descriptive cross-sectional study was conducted with individuals of both genders. Anthropometric data [waist circumference, body mass index (BMI)] and metabolic parameters: blood glucose, glycated hemoglobin, insulin, lipid profile, calcium, phosphorus, parathyroid hormone (PTH) and high-sensitivity c-reactive protein (hs-CRP) and (25(OH)D) were obtained. The cutoff points for vitamin D deficiency and insufficiency were ≤20 and 21-29 ng/mL, respectively. Individuals were classified as MUHO according to HOMA-IR≥2.5.

RESULTS

This study comprised 232 individuals with obesity (BMI≥35 kg/m²; 42.6±4.7 kg/m²). The MUHO phenotype was observed in 76.7% of the population. The mean values of glucose (P<0.001), insulin (P<0.001), HOMA-IR (P<0.001), and triglycerides (P=0.049) were significantly higher in the MUHO than in the MHO phenotype group. The mean value of 25(OH)D showed a significant difference between the MHO and MUHO phenotype groups (P=0.011). Additionally, and in line, lower mean 25(OH)D values were found in the MUHO vs the MHO phenotype group in the deficiency (14.5±3.6 ng/mL/17.1±2.7 ng/mL, P=0.004) and insufficiency (24.5±2.9 ng/mL/25.7±2.6 ng/mL, P=0.077) 25(OH)D groups. An increase of 1 ng/mL of vitamin D increased in 1.051 (95% CI= 1.011-1.093, P=0.012) the odds of the healthy phenotype.

CONCLUSION

The highest prevalence of inadequacy of serum concentrations of 25(OH)D and greater severity of this deficiency in individuals with MUHO phenotype were observed. Low serum concentrations of this vitamin were associated, mainly, with insulin resistance. Monitoring the nutritional status of vitamin D in individuals with obesity that present with MUHO phenotype may contribute to minimize the occurrence and aggravation of diseases associated with obesity.

Prevalence of Malnutrition in Older Hospitalized Cancer Patients: A Multicenter and Multiregional Study

BACKGROUND

Malnutrition is frequent in older cancer patients, with a prevalence that ranges from 25% to 85%. The aging process is associated with several physiological changes, which may have implications for nutritional status. Screening tools can be useful for identifying malnutrition status among older patients with cancer.

METHODS

A hospital-based multicenter cohort study that included 44 institutions in Brazil. The Mini Nutritional Assessment-Short Form (MNA-SF) was administered to 3061 older hospitalized cancer patients within 48 hoursof admission. The Kolmogorov-Smirnov test was used to test the sample distribution, considering sex, age range, calf circumference, body mass index, and MNA-SF score and classification. The categorical data were expressed by frequencies (n) and percentages (%)and compared using the chi-square test or Tukey test.

RESULTS

According to the results of the MNA-SF, 33.4% of the patients were malnourished, 39.3% were at risk of malnutrition, and 27.3% were classified as having normal nutritional status. Length of hospital stay (in days) was found to be longer for those patients with a poorer nutritional status (malnourished: 7.07±7.58; at risk of malnutrition: 5.45±10.73; normal status: 3.9±5,84; p <0.001).

CONCLUSIONS

The prevalence of malnutrition and nutritional risk is high in older hospitalized cancer patients in all the regions of Brazil and a worse nutritional status is associated with a longer hospital stay. Using a low-cost, effective nutritional screening tool for older cancer patients will enable specialized nutritional interventions and avoid inequities in the quality of cancer care worldwide.

Clinic, Anthropometric And Metabolic Changes In Adults With Class III Obesity Classified As Metabolically Healthy And Metabolically Unhealthy

PURPOSE

To describe clinical, biochemical and anthropometric profiles in adults with class III obesity classified as metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUHO).

PATIENTS AND METHODS

This is a cross-sectional study with patients classified as MHO and MUHO according to the NCEP-ATP III. Anthropometric, biochemical and clinical variables were analyzed.

RESULTS

A total of 223 subjects were evaluated and 32.73% were classified as MHO and 67.26% as MUHO, respectively. The insulin resistance homeostasis model (HOMA-IR) showed elevation in the MUHO group (p=0.003) and anthropometric variables were correlated with bone markers [body index mass (BMI) vs phosphorus: r=0.31, p<0.001; BMI vs 25(OH)D: r=-0.31, p=0.041]. Visceral adiposity index was lower in MHO (p=0.001). Negative correlations between inflammatory markers and bone markers were observed in the MHO group (calcium vs C-reactive protein: -0.30, p=0.017; parathyroid hormone vs HOMA-IR: r=-0.28, p=0.017.

CONCLUSION

MHO individuals showed important metabolic changes, such as those observed in MUHO, despite lower prevalence and severity. Continuous monitoring of these individuals is suggested, given the transient nature of the MHO phenotype.

Time trends of primary care quality across Portuguese regions: using prevention quality indicators

Background

Primary care quality is one of the main dimensions of primary care performance and can be evaluated by several methods, e.g. studying hospitalizations for conditions that could be treated, or less severe, if appropriately managed in primary care. Accordingly, the Agency for Healthcare Research and Quality (AHRQ) developed prevention quality indicators (PQIs). In this study, we aimed to compare PQIs and their time trends across Portuguese regions.

Methods

We performed a retrospective study, using all adult public hospital discharges in mainland Portugal, between 2011 and 2015. PQI rates for the overall (PQI 90) and composite indicators (i.e. 91 - acute, 92 - chronic, 93 - diabetes) were computed using AHRQ specifications. These rates were compared between the 5 Portuguese NUTS 2 regions of residence.

Results

From the total of 407,792 hospital discharges in mainland Portugal (2011-2015) 11.9% comprised the selected PQIs, the majority related the acute composite PQI, followed by the chronic composite PQI. The hospitalization rate of the overall PQI increased from 999.5 hospitalizations (2011) to 1231,0 hospitalizations/100,000 inhabitants (2015), with an increase in all NUTS 2 regions. In 2015, while Algarve and North had the lowest PQI rates, Centro and Alentejo showed the highest ones.

Conclusions

Between 2011 and 2015, there was an increasing trend of overall and composite PQI rates. Also, important differences between Portuguese regions were found that must be further studied.

The authors thank the support given by the Project ’POCI-01-0145-FEDER-030766’ (1st.IndiQare - Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool), funded by Fundação para a Ciência e a Tecnologia (FCT) and co-funded by Fundo de Desenvolvimento Regional (FEDER) through Operacional Competitividade e Internacionalização (COMPETE 2020).

Key messages

Between 2011 and 2015, overall prevention quality indicator rate increased in Portugal. There are great differences between Portuguese NUTS 2 regions regarding prevention quality indicators.

Serum Antioxidant Associations with Metabolic Characteristics in Metabolically Healthy and Unhealthy Adolescents with Severe Obesity: An Observational Study

Considering the inadequacy of some antioxidant nutrients in severely obese adolescents, this study aimed to assess the relationship between antioxidant micronutrients status and metabolic syndrome components in metabolically healthy obesity (MHO) and unhealthy obesity (MUO). We performed an observational study in severely obese adolescents (body mass index > 99th percentile) and they were classified into MHO or MUO, according to the criteria adapted for adolescents. Anthropometric, biochemical, and clinical variables were analyzed to characterize the sample of adolescents. The serum antioxidant nutrients assessed were retinol, β-carotene, Vitamin E, Vitamin C, zinc and selenium. A total of 60 adolescents aged 17.31 ± 1.34 years were enrolled. MHO was identified in 23.3% of adolescents. The MHO group showed lower frequency of non-alcoholic fatty liver disease (14.3% vs. 78.3%, p < 0.001) when compared to MUO. A correlation was found between retinol and β-carotene concentrations with glycemia (r = -0.372; p = 0.011 and r = -0.314; p = 0.034, respectively) and between Vitamin E with waist circumference (r = -0.306; p = 0.038) in the MUO group. The current study shows that some antioxidant nutrients status, specifically retinol, β-carotene, and Vitamin E, are negatively associated with metabolic alterations in MUO. Further studies are necessary to determine the existing differences in the serum antioxidant profile of metabolically healthy and unhealthy obese adolescents.

Vitamin D metabolism in human adipose tissue: could it explain low vitamin D status in obesity?

Obesity and a low vitamin D (VD) status, as well as a positive association between them, are prevalent worldwide. Additionally, a low VD status has been positively correlated with metabolic dysfunction (although not so convincingly as for obesity). The VD receptor (VDR) mediates VD biological actions in adipose tissue (AT), where VD can be activated or inactivated/degraded through specific hydroxylation steps. Additionally, AT can also store and release VD when needed. A lower VD activation/VD inactivation ratio and an impaired VDR signaling in AT could contribute to metabolic dysfunction besides the aforementioned association between obesity and VD status. However, subcutaneous (SAT) and visceral AT (VAT) are not expected to be similarly accountable as these two fat depots play differential roles in metabolic regulation/dysfunction. To our knowledge, only three articles disclose the evaluation of the expression of VDR and/or VD hydroxylating enzymes in human SAT and VAT. A clear dependence on the subcutaneous and/or the visceral fat depot is missing for the relationships of a) obesity and/or metabolic dysfunction with VD status and b) adipose VDR signaling and adipose VD activation/VD inactivation ratio with VD status, obesity and/or metabolic dysfunction. Further studies are warranted to unravel the influence of adipose VD metabolism on VD status.

Relationship between Nonalcoholic Fatty Liver Disease and Vitamin D Nutritional Status in Extreme Obesity

AIM

To evaluate the relationship of nonalcoholic fatty liver disease (NAFLD) with nutritional status of vitamin D in extreme obesity.

METHODS

Descriptive cross-sectional study in individuals with class III obesity (BMI ≥ 40 kg/m2), aged ≥ 20 years to < 60 years. Data were obtained for weight, height, waist circumference (WC), and serum 25-hydroxyvitamin D (25(OH)D) levels. Vitamin D analysis was performed by high performance liquid chromatography (HPLC) and the cutoff points used for its classification were < 20 ng/mL for deficiency and 20-29.9 ng/ml for insufficiency. NAFLD gradation was conducted through histological evaluation by liver biopsy.

RESULTS

The sample is comprised of 50 individuals (86% female). BMI and average weight were 44.1 ± 3.8 kg/m2 and 121.4 ± 21.4 kg, respectively. Sample distribution according to serum 25(OH)D levels showed 42% of deficiency and 48% of insufficiency. The diagnosis of NAFLD was confirmed in 100% of the individuals, of which 70% had steatosis and 30% had steatohepatitis. The highest percentage of 25(OH)D insufficiency was seen in individuals with steatosis (66%/n = 21) and steatohepatitis (93%/n = 16). All individuals with steatohepatitis presented VDD (p < 0.01).

CONCLUSION

The results of this study showed high prevalence of serum 25(OH)D inadequacy in individuals with class III obesity, which worsens as the stage of liver disease progresses.

Dietary counseling adherence during tuberculosis treatment: A longitudinal study

BACKGROUND

The World Health Organization (WHO) recommends the use of dietary counseling to overcome malnutrition for patients with tuberculosis, with or without HIV, however the response to nutritional treatment depends on patient's adherence to nutritional counseling.

OBJECTIVE

Identify the degree of adherence to dietary counseling and predictors of adherence among patients undergoing tuberculosis treatment.

DESIGN

Observational prospective follow-up study conducted in adults treating for tuberculosis with or without HIV. Self-reported adherence and 24-h diet recall were checked. Diet counseling according to WHO strategy was offered at each visit for all patients. The endpoint was the adherence to the recommended dietary allowance (RDA) and total calories consumed during tuberculosis treatment. Data were mainly analyzed with marginal models to estimate adjusted trajectories.

RESULTS

Sixty-eight patients were included in the study. The maximum probability of total calories consumption of at least one RDA was 80%. The adherence to dietary counseling was low regardless of HIV infection. The negative determinants of adherence were the presence of loss of appetite and nausea/vomiting. For patients with loss of appetite and nausea/vomiting, the probability of total calories consumption of at least one RDA is less than 20% at any time.

CONCLUSION

The loss of appetite and nausea/vomiting are highly prevalents and were the main causes of non-adherence to dietary counseling.

High prevalence of vitamin A deficiency in Crohn's disease patients according to serum retinol levels and the relative dose-response test

AIM: To assess the vitamin A status of patients with Crohn’s disease (CD) by evaluating serum retinol levels and the relative dose response (RDR) test (liver retinol stores).

METHODS: Vitamin A nutritional status was measured by serum retinol obtained by high performance liquid chromatography and the RDR test for evaluation of the hepatic stores. Body composition was performed by densitometry by dual-energy X-ray absorptiometry. Vitamin A dietary intake was assessed from a semi-quantitative food frequency questionnaire.

RESULTS: This study included 38 CD patients and 33 controls. Low serum retinol concentrations were detected in 29% of CD patients vs 15% in controls (P < 0.005). The RDR test was positive in 37% of CD patients vs 12% in controls, which indicated inadequate hepatic vitamin A stores (P < 0.005). Individuals with hypovitaminosis A had lower BMI and body fat compared with those without this deficiency. There was no association between vitamin A deficiency and its dietary intake, ileal location, presence of disease activity and prior bowel resections.

CONCLUSION: Patients with CD have higher prevalence of vitamin A deficiency, as assessed by two independent methods.

The role of prenatal nutrition assistance on the prevalence of night blindness in pregnant adults

INTRODUCTION

In developing countries, night blindness is a very common public health problem among pregnant women.

OBJECTIVE

Evaluate the effect of the changes occurred on prenatal care concerning prenatal nutritional care on the occurrence of night blindness (XN) in adult pregnant women in public maternity hospital in Rio de Janeiro between 1999-2001 and between 2007-2008.

METHODS

Two cross-sectional studies were conducted, been the first one conducted between 1999-2001 and the second one between 2007-2008. Were studied 402 puerperal women, 225 between 1999-2001 (GI) and 177 between 2007-2008 (GII). The gestational XN was investigated during the immediate puerperium (GI) and during the prenatal/puerperium (GII), diagnosed by the World Health Organization. The study collected sociodemographic, clinical, obstetric, anthropometric and prenatal care information.

RESULTS

It verified significant reduce of prevalence of gestational XN (GI = 18.7% e GII = 0.6%, p < 0.001). The occurrence of gestational XN was associated to sanitary conditions, education level, more than six prenatal consultations, miscarriage at last pregnancy, higher average number of deliveries, average number of prenatal care consultations and prenatal nutritional (p < 0.05). There was no association between gestational XN and marital status, skin color, pre-gestational nutritional status, adequacy of gain of total gestational weight, gestational anaemia and average number of pregnancies (p > 0.05).

CONCLUSION

The inclusion of nutritional care in routine prenatal care may have contributed to the reduction of gestational XN. Studies to assess the nutritional intervention in the prevention and treatment of gestational XN at regions at greatest risk are suggested.

Effect of vitamin A supplementation on clinical evolution in patients undergoing coronary artery bypass grafting, according to serum levels of zinc

Vitamin A and zinc are powerful antioxidants with synergy between them, thus protecting the organism against oxidative stress during the pre and postoperative periods. Our aim was to investigate the evolution clinical in patients undergoing coronary artery bypass grafting while receiving vitamin A supplements according to their zinc nutritional status. They were randomly divided into two groups (2:1): Control group (G1 = 60); and Supplemented group (G2 = 30) and subdivided according to the nutritional status of zinc. Serum concentrations of retinol, β-carotene, zinc and levels of malondialdehyde were measured prior to (T0) and on the 21st day (T1) following surgery. After surgery, was found a significant difference between G1 and G2 when comparing retinol (G1 = 38.7 ± 17.1 μg/dL and G2 = 62.1 ± 20.3 μg/dL; p < 0.001) and β-carotene (G1 = 12.3 ± 5.7 μg/dL and G2 = 53.5 ± 20.9 μg/dL; p < 0.001) in the patients with adequate concentrations of zinc. Analyzing the evolution clinical, operative mortality was 8.33% in G1 and 3.33% in G2. Hospitalization time significantly smaller in the G2 was found in the patients who had adequate concentrations of zinc (p = 0.001), as well as time in the intensive care unit both in those with adequate and inadequate levels of zinc (p = 0.047; p = 0.039). Such results may indicate that vitamin A supplementation may have a positive impact in combating the oxidative stress to which these patients are exposed above all in patients with adequate levels of zinc.

Phase angle as a nutritional evaluation tool in all stages of chronic liver disease

INTRODUCTION

Malnutrition is commonly and frequently under-diagnosed in clinical settings in patients with chronic liver disease (CLD) due to the limitations of nutritional evaluation methods in this population. We hypothesized that the bioelectrical impedance analysis derived phase angle (BIA-derived PhA) might be considered as a nutritional indicator in CLD since it represents either cell death or malnutrition characterized by changes in cellular membrane integrity.

OBJECTIVE

The aim of this study was to evaluate the BIA-derived PhA as a nutritional evaluation tool in all stages of CLD, including chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). Liver-related death and survival were evaluated.

METHODS

A total of 66 patients were enrolled in a cross-sectional study. For the nutritional diagnosis, mid-arm circumference (MAC), triceps skinfold thickness (TST), mid-arm muscle circumference (MAMC) and Subject Global Assessment (SGA) were evaluated. Biochemical and clinical evaluations were performed.

RESULTS

Our results showed that PhA was higher in well-nourished patients, according to SGA and in the patients without hepatic encephalopathy. PhA correlated significantly with MAMC, MAC and albumin and was inversely correlated with age. No correlation was found between PhA values and the Child-Pugh score and ascites. PhA was strongly associated with survival and PhA ≤ 5.18º with relative risk increase of 2.5 for death.

CONCLUSIONS

We conclude that the BIA-derived PhA is a relevant nutritional evaluation tool in chronic hepatitis, liver cirrhosis and HCC and the role of PhA in the prediction of survival in CLD should be examined further in a controlled study.

Vitamin A concentration in mature human milk

OBJECTIVE

To quantify vitamin A levels in mature milk of 196 nursing women who were treated at the Maternity School of Rio de Janeiro and to evaluate its correlation with sociodemographic variables and degree of nutrition knowledge.

METHODS

To quantify retinol concentrations, 10 mL of mature milk were collected by manual expression of one breast, 2 hours after the last feed, in the morning period. Values below 1.05 µmol/L and 2.3 µmol/L were considered inadequate to meet satisfactory intake and to constitute vitamin A liver reserve, respectively. The following variables were also assessed: sex, age, familiar income, maternal education, basic sanitation conditions, number of people in the household, maternal age, prenatal care, and degree of nutrition knowledge.

RESULTS

Among the 196 lactating mothers analyzed, the average vitamin A concentration observed in mature milk was 1.76±0.85 µmol/L and prevalence of vitamin A deficiency was observed in 20.5% mothers. There was no significant difference between vitamin A levels in maternal milk and the variables socioeconomic status and nutrition knowledge. Only 38.9% of lactating women presented enough vitamin A concentrations in milk for the infants' liver reserves (2.3 µmol/L).

CONCLUSIONS

These findings reveal high prevalence of inadequate vitamin A nutritional status of mothers and infants, consistent with the national prevalence reported in women of childbearing age and Brazilian children, and that the intervention measures to fight this shortage should be extended to all pregnant and postpartum women, regardless of sociodemographic conditions and degree of nutrition knowledge, in order to improve the health of mother and child.

Assessment of the relative dose-response test as indicators of hepatic vitamin A stores in various stages of chronic liver disease

Hepatic vitamin A stores should be the best early indicator of vitamin A status because more than 90% of total body vitamin A is stored in the liver. The objective of the present study was to evaluate the hepatic vitamin A stores in all stages of chronic liver disease (CLD), including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma (HCC). One hundred forty-four patients (age 55.34 ± 9.38 years) were evaluated in a cross-sectional study. Vitamin A nutrition status was analyzed by serum retinol levels and relative dose-response (RDR) method. Patients with cholestasis were excluded from the sample group. Biochemical, clinical, and anthropometric evaluations were performed. Vitamin A deficiency (VAD) was detected in 51.4% of all patients. Patients with adequate levels of serum retinol presented adequate liver vitamin A reserves; in contrast, nearly half the patients with low serum retinol levels presented adequate levels of retinol in the liver, although none of the patients with hepatitis had this condition. Therefore, the effectiveness of the RDR method for evaluating vitamin A nutrition status was limited in patients with cirrhosis and HCC, perhaps due to the advanced age of these patients, since those in the chronic hepatitis group, who were younger, responded adequately to the test. Thus, the RDR method should be modified when applied to later stages of CLD, considering the time and dose of retinyl palmitate supplementation, as VAD may be a risk factor for the progression of the disease.

Reduction of vitamin A deficiency and anemia in pregnancy after implementing proposed prenatal nutritional assistance

INTRODUCTION

Micronutrient deficiency is an unquestionable public health problem, specially anemia and vitamin A deficiency (VAD). This is due to the collective dimension of these carencies, which reflects on morbimortality rates in the maternal and infant group.

OBJECTIVE

to evaluate the impact of a proposal for prenatal nutritional assistance, comparing the prevalence of anemia and VAD, in pre-intervention (GI) and intervention (GII) groups.

METHODS

this is a prospective intervention study in a cohort of pregnant women. The GI group was made up of 225 the GII group of 208 pregnant adults and their respective newborns, attended a Public Maternity Ward in Rio de Janeiro, Brazil. Concentration of hemoglobin was used to diagnose anemia and a standardized interview to diagnose night blindness (XN).

RESULTS AND CONCLUSION

after adjusting for confounding variables, through logistic regression, the protective effect of intervention at the onset of anemia (OR = 0.420; IC 95% = 0.251-0.702), with a significant reduction in prevalence, of 28.4% in the GI to 16.8% in the GII, also observed at the onset of XN (OR = 0.377; IC95% = 0.187- 0.759), with a reduction in prevalence of 18.7 % in the GI to 6.2% in the GII. Nutritional intervention has a beneficial effect on maternal health, reducing nutritional deficiencies most prevalent during pregnancy and the impact of these on the obstetric ailment.

Graphene oxide versus functionalized carbon nanotubes as a reinforcing agent in a PMMA/HA bone cement

Graphene oxide (GO) and functionalized carbon nanotubes (f-CNTs) (each in the concentration range of 0.01-1.00 wt/wt%) were investigated as the reinforcing agent in a poly(methyl methacrylate) (PMMA)/hydroxyapatite (HA) bone cement. Mixed results were obtained for the changes in the mechanical properties determined (storage modulus, bending strength, and elastic modulus) for the reinforced cement relative to the unreinforced counterpart; that is, some property changes were increased while others were decreased. We postulate that this outcome is a consequence of the fact that each of the nanofillers hampered the polymerization process in the cement; specifically, the nanofiller acts as a scavenger of the radicals produced during polymerization reaction due to the delocalized π-bonds. Results obtained from the chemical structure and polymer chain size distribution determined, respectively, by nuclear magnetic resonance and size exclusion chromatography analysis, on the polymer extracted from the specimens support the postulated mechanism. Furthermore, in the case of the 0.5 wt/wt% GO-reinforced cement, we showed that when the concentration of the radical species in the PMMA bone cement was doubled, mechanical properties markedly improved (relative to the value in the unreinforced cement), suggesting suppression of the aforementioned scavenger activity.

The effectiveness of relative dose response to retinol intake as an evaluation of vitamin A status of cirrhotic patients

BACKGROUND

The liver is the main organ involved in homeostasis, metabolism and the storage of retinol. During the fibrotic process, hepatic stellate cells lose their lipid drops, and retinol reserves may deplete. Thus, the present study aimed to evaluate serum retinol levels (RL), hepatic retinol storage and dietary vitamin A intake in cirrhotic patients.

METHODS

RL were measured by high-performance liquid chromatography in fifty-eight cirrhotic patients. Fasting RL <1.05 μmol L⁻¹ indicates vitamin A deficiency (VAD). A relative dose response (RDR) to oral retinol ≥20% indicates an inadequate hepatic retinol reserve (positive test). Severe malnutrition was defined as a mid-arm muscle circumference (MAMC) and/or triceps skinfold thickness (TSF) below the 5th percentile and moderate malnutrition as MAMC and/or TSF below the 10th percentile. Vitamin A daily intake was estimated by a specific questionnaire. The Child-Pugh classification of liver disease severity and the Model for End-Stage Liver Disease were used.

RESULTS

Low RL were found in 60% of the patients. Twenty-three cirrhotic patients had adequate fasting RL (RL = 1.34; 1.05-2.12 μmol L⁻¹) and negative RDR, indicating efficient liver stores. Among thirty-five cirrhotic patients with low RL, 43% had negative RDR (RL = 0.42; 0.06-0.82 μmol L⁻¹) and 57% had positive RDR (RL = 0.45; 0.09-0.93 μmol L⁻¹). Malnutrition (36%) and inadequate vitamin A intake (55%) were not associated with fasting RL or RDR.

CONCLUSIONS

VAD was highly prevalent in cirrhotic patients. However, in those with low serum RL and negative RDR, factors other than inadequate vitamin A intake, such as impaired hepatic vitamin A mobilization and intestinal vitamin A malabsorption, which were not examined in the present study, could have influenced the negative results obtained by the RDR method.

Serum concentrations of vitamin A and oxidative stress in critically ill patients with sepsis

INTRODUCTION

Sepsis is one of the main causes of mortality in patients in Intensive Care Units. As a result of the systemic inflammatory response and of the decrease of the aerobic metabolism in sepsis, the oxidative stress occurs. Vitamin A is recognized by the favorable effect that it exerts on the immune response to infections and antioxidant action.

OBJECTIVE

To bring new elements for reviewing of the nutritional support addressed to critically ill patients with sepsis, with emphasis to vitamin A.

METHODS

Critically ill patients with sepsis had circulating concentrations of retinol, beta-carotene, thiobarbituric acid-reactive substances (TBARS) and C-reactive protein (CRP) measured in Medicosurgical Intensive Care Unit in the city of Rio de Janeiro, Brazil. The patients were divided into two groups: patients who were receiving nutritional support and those without support. At the act of the patient's admission, APACHE II score was calculated.

RESULTS

46 patients were studied (with diet n = 24 and without diet n = 22). Reduced levels of retinol and beta-carotene were found in 65.2% and 73.9% of the patients, respectively. Among the patients who presented lower concentrations of CRP it was found higher beta-carotene inadequacy (64.8%) and 50% of retinol inadequacy. There was no significant difference as regards retinol, TBARS and APACHE II levels among the patients with and without nutritional support. However, higher levels of CRP (p = 0.001) and lower levels of serum beta-carotene (p = 0.047) were found in patients without nutritional support.

CONCLUSIONS

Septic patients presented an important inadequacy of retinol and beta-carotene. The present study bring elements to the elaboration/review of the nutritional protocol directed to the group studied, especially as regards vitamin A intake.

[Use of food composition tables in evaluation of risk of vitamin A deficiency]

One hundred and ninety-eight 24 h-recall questionnaires from pregnant attendees of the public health services in Rio de Janeiro, Brazil, were analyzed, using 5 different Food Composition Tables. The differences in calculated intakes were as high as 88% (793 to 1494 micrograms RE). The differences were significant at the 5% level using Fishers test. The INCAP table was considered more adequate because it gives more attention to the different conversion factors for carotenoids. However, the INCAP Table does not include several foods frequently consumed in Brazil, neither does it show values for culinary preparations and industrialized foods. This study shows that there is a need to improve the tools to evaluate vitamin A intake if we wish to assess nutritional risk in populations.

A randomised controlled trial with a diphtheria-tetanus-acellular pertussis (dTpa) vaccine in adults

The aim of this assessor-blinded trial was to compare the immunogenicity and reactogenicity of a candidate diphtheria, tetanus toxoids and acellular pertussis vaccine with reduced antigen content for diphtheria and pertussis (dTpa) with a licensed reduced adult-type diphtheria-tetanus vaccine Td (reduced diphtheria content) and with an experimental candidate monovalent acellular pertussis vaccine with reduced antigen content (pa). The dTpa and pa vaccines had identical pertussis antigen content. A total of 299 healthy adults (> or =18 years, mean age: 30.1 years+/-10.7) were randomised into 3 groups to receive a single dose of one of the study vaccines. In all groups, clinically significant reactions (severe) were infrequent (0-6%) and no serious adverse events were reported during the study. The incidence of local and systemic reactions following the administration of dTpa was comparable to the Td vaccine group. Of the total study group, prior to vaccination 52. 3 and 93.2% of the subjects had anti-diphtheria and anti-tetanus antibody levels > or = 0.1 IU/ml, respectively; and 73.1, 98.2 and 74.5% of the subjects were seropositive for pertussis toxin (PT), filamentous hemagglutinin (FHA) and pertactin (PRN) antibodies, respectively. One month after vaccination, a similar percentage of subjects in the dTpa and Td groups had anti-diphtheria (88.4% vs 90. 1%) and anti-tetanus (100% vs 98.9%) antibody levels > or =0.1 IU/ml. Similar anti-FHA (100%) and anti-PRN (98.9%) vaccine response rates were seen in the dTpa and pa groups, while the anti-PT vaccine response rates were 96.8 and 100.0%, respectively. The dTpa vaccine is as well tolerated and immunogenic as the licensed Td vaccine, and additionally, can also boost antibodies against pertussis.

Acellular vaccines containing reduced quantities of pertussis antigens as a booster in adolescents

OBJECTIVE

To evaluate the immunogenicity and reactogenicity of an acellular pertussis vaccine (pa) either formulated with diphtheria and tetanus toxoids (dTpa) or administered consecutively with a licensed tetanus and diphtheria vaccine (Td) as a 5th dose in adolescents.

METHODS

A total of 510 healthy children 10 to 13 years of age were assigned randomly, using a single-blind design, to receive either the dTpa vaccine or the Td vaccine with the pa vaccine 1 month later. The quantities of 3 pertussis antigens (pertussis toxin, filamentous hemagglutinin, and pertactin) in the dTpa and the pa vaccines were one third of those of the Infanrix vaccine (SmithKline Beecham Biologicals, Rixensart, Beligium) licensed for use in infants. For enzyme-linked immunosorbent assay measurement of serum immunoglobulin G antibodies and proliferation assay of peripheral blood mononuclear cells, blood samples were obtained before and 1 month after immunization. Local and systemic reactions were recorded on diary cards for 15 days after immunization.

RESULTS

After immunization with dTpa or pa, significant and comparable rises in geometric mean values of antibodies (12- to 46-fold) and proliferations (8- to 18-fold) to each of the pertussis antigens were noted. After immunization with dTpa or Td, significant rises in geometric mean values of antidiphtheria and antitetanus antibodies (35- to 76-fold) were noted, and all subjects had values of these antibodies >/=.1 international units/mL. The dTpa and pa vaccines were at least as well tolerated as the licensed Td vaccine.

CONCLUSIONS

Booster immunization of adolescents with an acellular vaccine containing reduced quantities of pertussis antigens in addition to diphtheria and tetanus toxoids induces good responses in both arms of the immune system without an increase in adverse reactions.