Recent updates in the therapeutic uses of Pembrolizumab: a brief narrative review

INTRODUCTION

Treatment of cancer has been improved with the discovery of biological drugs that act as immune checkpoint inhibitors. In 2017, FDA designated pembrolizumab, an immune checkpoint inhibitor employed in immunotherapy, as the first tissue-agnostic cancer treatment.

OBJECTIVES

To review pembrolizumab's use in oncology, gather and examine the latest discoveries regarding the effectiveness of pembrolizumab in cancer treatment.

METHODOLOGY

A literature review was conducted through PubMed(Medline) from January 2015 to December 2023 using "pembrolizumab", "cancer" and "treatment" as search terms.

RESULTS

Pembrolizumab demonstrated effectiveness as primary treatment for metastatic nonsmall cell lung cancer, unresectable esophageal cancer, head and neck squamous cell carcinoma and alternative treatment for notable triple-negative breast cancer, biliary, colorectal, endometrial, renal cell, cervical carcinoma, and high microsatellite instability or mismatch repair deficiencies tumors. Pediatric applications include treatment for refractory Hodgkin lymphoma.

CONCLUSION

Evolving research on pembrolizumab allows a deeper clinical understanding, despite challenges as variable patient responses. Pembrolizumab has emerged as a pivotal breakthrough in cancer treatment, improving patient outcomes and safety.

Implementation and impact of integrated health and social care services: an umbrella review

Governments in many European countries have been working towards integrating health and social care services to eliminate the fragmentation that leads to poor care coordination for patients. We conducted a systematic review to identify and synthesize knowledge about the integration of health and social care services in Europe. We identified 490 records, in 14 systematic reviews that reported on 1148 primary studies and assessed outcomes of integration of health care and social care. We categorized records according to three purposes: health outcomes, service quality and integration procedures outcomes. Health outcomes include improved clinical outcomes, enhanced quality of life, and positive effects on quality of care. Service quality improvements encompass better access to services, reduced waiting times, and increased patient satisfaction. Integration procedure outcomes involve cost reduction, enhanced collaboration, and improved staff perceptions; however, some findings rely on limited evidence. This umbrella review provides a quality-appraised overview of existing systematic reviews.

Towards a consensus for nurse education of methotrexate for people with rheumatic and musculoskeletal diseases: A scoping review

INTRODUCTION

Patient education (PE) is a key role of nurses, which includes providing information, training, and support about methotrexate (MTX), an anchor drug in rheumatology. However, there is a wide variation in the access to rheumatology nurse consultations in Europe, and there is a lack of consensus regarding the delivery, context and timing of PE in these cases. This study aimed to provide a comprehensive overview of the existing research on nurse education of MTX for children/youth and adults with Rheumatic and Musculoskeletal Diseases (RMDs).

METHODS

This scoping review was conducted in accordance with Arksey and O'Malley's framework. A search on PubMed (MEDLINE), Scopus and Cochrane Database, and CINAHL, from inception until March 2022 was conducted. Articles on PE with a focus on MTX exclusively were included. Published and unpublished studies, from any world region, conducted with a qualitative, quantitative, or mixed-methods design and focused on defined research questions, were eligible for inclusion. Broad inclusion criteria were used if a research paper on PE focused on MTX for people with RMDs (PE or patient engagement, self-management, medication knowledge, or health literacy in patients). The reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist. Two independent reviewers performed standardized data extraction and synthesis.

RESULTS

From 292 references identified, the total number of studies which met the inclusion criteria was relatively small (n = 14). The results identified that knowledge of MTX improves when education by nurses is provided.

CONCLUSION

This scoping review showed that there is no universal worldwide strategy for MTX education of children/youths and adults with RMDs. However, PE regarding MTX can be delivered in different forms, resulting in better satisfaction and adherence. More randomized controlled trials with powered samples are required.

Adverse Drug Reactions to Opioids: A Study in a National Pharmacovigilance Database

INTRODUCTION

Opioids are commonly used as analgesics; however, like any medicine, they can produce adverse drug reactions (ADRs), including nausea, constipation, dependence, and respiratory depression, that result in harmful and fatal events. Therefore, it is essential to monitor the safety of these drugs in clinical practice.

OBJECTIVE

This study aimed to characterize the safety profile of opioids by conducting a descriptive study based on a spontaneous reporting system (SRS) for ADRs in The Netherlands, focusing on abuse, misuse, medication errors, and differences between sexes.

METHODS

Reports submitted to the Netherlands Pharmacovigilance Centre Lareb from January 2003 to December 2021 with an opioid drug as the suspected/interacting medicine were analyzed. Reporting odds ratios (RORs) for drug-ADR combinations were calculated, analyzed, and corrected for sex and drug utilization (expenditure) for the Dutch population.

RESULTS

A total of 8769 reports were analyzed. Tramadol was the opioid with the most reports during the period (n = 2746), while oxycodone or tramadol had the highest number of reports per year in the study period. The most reported ADRs from opioid use were nausea, followed by dizziness and vomiting, independent of sex, and all of them were more often reported in women. Vomiting associated with tramadol (ROR females/males = 2.17) was significantly higher in women. Buprenorphine was responsible for most ADRs when corrected for expenditure, with high RORs observed with application site hypersensitivity, application site reaction, and application site rash. Fentanyl gave rise to most of the reports of ADRs concerning abuse, misuse, and medication errors.

CONCLUSION

Patients treated with opioids experienced ADRs, primarily nausea, dizziness, and vomiting. For those groups of drugs, no significant differences were found between the sexes, except for the vomiting associated with tramadol. In general, ADRs related to opioids presented higher RORs when uncorrected and corrected for sexes and expenditure than other drugs. There was more disproportionate reporting for ADRs concerning abuse, misuse, and medication errors for opioids than other drugs in the Dutch SRS.

Iopromide safety assessment in a radiology department: A seven-year retrospective characterization of adverse events

BACKGROUND

Since the mid-20th century, contrast agents have been widely used in radiology due to their ability to provide high-definition radiographic images and greater precision in diagnostic exams. Different types of contrast agents are used in image diagnosis, namely radiological media. Despite being considered safe, there are still uncertainties about their safety profile, interactions, and incidence of adverse drug reactions in real-world settings.

OBJECTIVE

To characterise the pattern of adverse events, during 7 years, in a radiology unit.

METHODS

We performed a retrospective observational and descriptive study at an Image Center in Portugal between August 2012 and October 2019. A total of 77,449 computed tomography (CT) were registered, and from those 15,640 cases of iopromide were used as a contrast agent. The authors have accessed, under the authorization, the data of adverse events and procedures after the event.

RESULTS

Most of the hypersensitivity events were immediate or with a short time of onset, with the majority of cases developing events with skin involvement and mild degree, where the most common events were papules (n = 60), pruritus (n = 42), erythema (n = 27) and urticaria (n = 14). Severe events, including hypersensitivity, were mainly represented by vomiting (n = 11), stridor (n = 8), breathing difficulties (n = 7) and syncope (n = 3). Abdominal-pelvic CT exam presented a higher frequency of adverse events.

CONCLUSION

Despite all the current information about iopromide usage, the utilization of this agent is not abstent of risks and its safety profile not fully established. Most frequent symptoms were local, as skin adverse events, including papules, pruritus and erythema. Common medications used to treat or control adverse events were frequently hydrocortisone, clemastine and methylprednisolone.

Translation and cultural adaptation of MedStopper®-A web-based decision aid for deprescribing in older adults: A protocol

BACKGROUND

Older patients are more likely to have medication-related problems, which are associated with changes in pharmacokinetics and pharmacodynamics, multimorbidity, and polypharmacy. Polypharmacy and inappropriate prescribing are well-known risk factors which commonly cause adverse clinical outcomes in older people. Prescribers struggle to identify potentially inappropriate medications and to choose an adequate tapering approach.

METHODS/DESIGN

The goal of the study is to translate and culturally adapt MedStopper®, an original English language web-based decision aid system in deprescribing medication, to the Portuguese population. A translation-back translation method, with validation of the obtained Portuguese version of MedStopper® will be used, followed by a comprehension test.

DISCUSSION

This is the first research in the Portuguese primary care setting that aims to provide a useful online tool for the appropriate prescription of older patients. The translated version in Portuguese version of the MedStopper® tool will represent an advance that seeks to continue improving the management of medications in the elderly. The adaptation into Portuguese of the educational tool provides clinicians with a screening tool to detect potentially inappropriate prescribing in patients older than 65 that reliable and easier to use.

TRIAL REGISTRATION

Retrospectively registered.

Differences in physical activity in subjects with psychosis versus a control group

Introduction

Psychiatric illnesses are related with a reduced life expectancy and an increase of mortality rates (around 60%) mainly associated with cardiovascular diseases [1]. The high prevalence of obesity, metabolic syndrome, diabetes mellitus and tobacco use among these patients undoubtelly predispose to the impairment in physical health and mortaility increase. Regular physical activity in the general population is associated with a decrease in cardiovascular risk but litle is know about iss influence in some chronic and severe mental disorders like schizophrenia ^[2].

Objectives

To quantify the physical activity performed by a sample of subjects with psychosis, borth males and female, compared to a control group.

Methods

A sample composed of 141 patients with schizoprenia was compared to 103 healthy subjects as a control group. The International Physical Activity Questionnaire - Short Form (IPAQ) scale was applied to all participants. The time (minutes) of physical activity performed in a week (METs) was collected by each participant ^[3].

Results

The differences in the total physical activity Mets for the patients with schizophrenia were highly significant (p = 0.001), showing a lower degree of physical activity compared to the control group. A higher and significant percentage of sedentary lifestyle among the psychiatric group (64.5%), compared to 35.5% in the control group was found.

Conclusions

The group of pateints with Schizophrenia showed a significant higher sedentary lifestile including less physical activity. This finding could be highly related with a higher risk of cardiovascular disease and deterioration of the physical health.

Disclosure

No significant relationships.

Hormonal alterations due to antipsychotic-related hyperprolactinemia

Introduction

The use of antipsychotics (APS) is essential. Despite their great efficacy, some of them are associated with an increase in prolactin levels that can lead to hormonal changes needing to be identified and managed [1,2,3]. Hormonal changes use to have clinical implications including hypogonadism, infertility and sexual dysfunction

Objectives

To evaluate possible hormonal alterations and some clinical implications produced by hyperprolactinemia (HPRL) derived from the use of some antipsychotic compounds.

Methods

A complete fasting blood test was performed on a sample of 113 subjects (69 men and 44 women). 54% (n = 61) showed a normal prolactin level and 46% (n = 52) showed hyperprolactinaemia ( >50ng / ml). On the global sample, 39.8% (n = 45) was treated with some hyperprolactinemic drug , mostly risperidone and paliperidone.

Results

Some differences were found depending on the gender of the subjects. A highly significant inverse relationship between the values of prolactin and testosterone was found in males (p=0.020, r=-0.285). In females, increased prolactin level was significantly related to decreased cortisol values.

Conclusions

Antipsychotic-related Hyperprolactinaemia ( mainly risperidone and paliperidone) is related with a decrease in testosterone levels in males and with an increase in cortisol levels in females.

Disclosure

No significant relationships.

Physical and rehabilitation medicine intervention in stroke in the acute hospital setting: A cross-sectional study

INTRODUCTION

Stroke represents the main cause of death and disability in Portugal. Resulting functional deficits are widely recognized. This work aims to evaluate the variation in functionality of stroke patients in the acute hospital setting under a rehabilitation program.

MATERIAL AND METHODS

Cross-sectional study of patients admitted to the Neurology department, from January to June 2019, with acute stroke. The variation in functionality was assessed using the Barthel index. Statistical analysis used Student's t-test and Spearman's correlation coefficient, with a p-value≤0.05 as significant.

RESULTS

106 patients with mean age of 63.7±14.2 years and a male predominance (60.4%) were included. Patients started rehabilitation program at 1.37±1.19 days after admission. A gain in functionality between admission and discharge was identified (50.18±32.37 versus 68.73±28.94, p<0.001). A significantly greater increase was observed in patients diagnosed under code stroke protocol (CSP) (p=0.021) and undergoing some type of acute phase treatment (p=0.017). From 90.5% of the patients that pursued rehabilitation after discharge, 40.6% were referred to an inpatient unit on average 12.7±7.0 days after admission.

DISCUSSION

In this study, Physical and Rehabilitation Medicine (PRM) provided early rehabilitation care to stroke patients. According to international evidence this is associated with greater functional gains. The variation in functionality verified during hospitalization demonstrates the importance of PRM in the acute hospital, assessing the rehabilitation needs after hospital discharge and maximizing outpatient rehabilitation. Diagnosis under CSP and undergoing acute treatment were determinants of greater functional improvement.

CONCLUSION

PRM plays a central role in the early management of functional impairment resulting from stroke and in the post-discharge guidance of patients.

Drug-Induced Sexual Dysfunction: An Analysis of Reports to a National Pharmacovigilance Database

INTRODUCTION

Sexual dysfunction (SD) is a problem that can affect any phase of the sexual response cycle (such as sexual desire, arousal and orgasm) and individuals of any age. SD can be caused by physical reasons, such as medical conditions, alcoholism or drug abuse; psychological factors, such as stress and anxiety; and different medicines, such as selective serotonin reuptake inhibitors (SSRIs), and their associated adverse effects.

AIM

The aim of this study was to characterise drugs suspected to have caused SD adverse drug reactions (ADRs) in patients, by conducting a descriptive study based on pharmacovigilance reports.

METHODS

Reports submitted to the Netherlands Pharmacovigilance Centre Lareb from January 2003 to December 2019 were used to investigate drug-induced sexual disorders. Selected reports had at least one ADR reported in the Medical Dictionary for Regulatory Activities (MedDRA^®) System Organ Class (SOC) 'Reproductive system and breast disorders' and the SOC 'Psychiatric disorders' relating to sexual disorders and corrected for drug utilisation (expenditure) for the Dutch population.

RESULTS

A total of 2815 SD ADRs were reported in the observed period. Data were divided according to three variables: pharmacotherapeutic group, the drug itself, and sex. A total of 722 different SD/pharmacotherapeutic group pairs were observed. The pharmacotherapeutic groups with the highest frequency of SD reports were SSRIs (n = 488, 17.58%), other antidepressants (n = 172, 6.20%) and HMG-CoA reductase inhibitors (n = 149, 5.37%). Distinguishing ADRs by sex, men suffered more from erectile dysfunction, decreased libido and ejaculation disorders, while among women, libido disorders, dyspareunia and SD were the most common ADRs.

CONCLUSION

Different reactions and disproportionality of reactions were detected between the sexes. Antidepressants, antihypertensives, oral contraceptives, α-blockers, and anti-androgens were the pharmacotherapeutic groups with the highest number of SD reports and corresponding high odds ratios.

Diabetes patient’s pharmacovigilance knowledge and risk perception: the influence of being part of a patient organisation

Objective:

The aim was to assess the perception of risk for developing adverse drug reaction (ADRs) and knowledge, attitudes and opinions regarding pharmacovigilance in diabetic patients, and to investigate the effect of being a member of a patient organisation for diabetes on these factors, in comparison with other patients.

Methods:

A cross-sectional study looking for patients’ risk perception of experiencing ADRs. Diabetes patients followed at the Portuguese Diabetes Association (APDP) were included, together with two comparison groups (patients with and without diabetes). Kruskal-Wallis followed by post hoc Dunn’s multiple-comparison test were used to compare patients’ groups.

Results:

A total of 314 patients participated in the survey (104 followed at APDP, 106 with diabetes not followed at APDP and 104 without diabetes diagnosis that used chronic medication). APDP patients presented higher risk perception scores for medicines related to their disease compared with two groups. Those patients affirmed that doctors explained possible ADRs on medication to them, and showed higher intention to report ADRs in the future if serious or unexpected.

Conclusions:

Patients with diabetes showed greater understanding of ADRs and higher need to report them than patients without diabetes. They would like to have more information about general ADRs related to anti-diabetic medication and present higher intention to acquire information on how and when to report compared with non-diabetic patients. Patients followed in APDP presented higher score of risk perception, which could be influenced by the presence of the diabetes disease in the patients’ life, by their previous experiences using medicines, but also by information received from the patient organisation. The two groups of patients with diabetes have different experiences of the disease, but both present higher perception of side effects related with medicines they use respectively in their diabetes type. Hence, patient organisations are well positioned to be a source where patients can obtain reliable information, changing their attitudes and perceptions about the disease and drug treatments.

The effect of climate change on domestic Rainwater Harvesting

One of the main strategies that are being applied to improve the efficiency of water consumption in buildings is the use of non-potable water for pavement washing, toilet flushing, irrigation, and others. According to several guidelines, the design and assessment of a Rainwater Harvesting System (RWHS) should be made using recent official records of precipitation. However, there is not an indication whether historical or future projections should be used, leaving space for the designer to choose. This article presents the study of RWHS in southern Europe, namely in Portugal, considering two case studies (a dwelling in Oporto and an apartment in Vila Real). The main goal was to explore the impacts that climate change will have on these systems and, for that purpose, a daily simulation using future rainfall data was performed for both cases considering two scenarios: RCP 4.5 which is more optimistic, and RCP 8.5 which is more pessimistic. The RWHS in Oporto showed a better performance in the future decades, comparing with simulations based on recent decades, for both scenarios. However, the savings will not have a significant variation (less than 5 €/year). In the future, this system will provide around 47 (±2.4) m³ of rainwater per year to the selected non-potable purposes, leading to savings of around 66 (±3.3) €/year. Vila Real case study also revealed a slight improvement of the system's efficiency in the future decades but the results for rainwater collected and used are so similar to the recent ones that it can be concluded that the performance will be sustained. This system will provide around 50 (±2.5) m³ of rainwater per year to the selected non-potable purposes, leading to savings of around 200 (±10.2) €/year. It can be concluded that there will be no significant changes in RWHS performance in the future, in the studied areas.

An approach to the implementation of Low Impact Development measures towards an EcoCampus classification

Impervious cover has important hydrologic impacts, namely the increased runoff volume and peak discharges in the rainwater network, which can lead to significant consequences like rapid urban floods with social, environmental and economic implications. LID (Low Impact Development) consist of distributed runoff management measures, like green roofs, pervious pavements, waterways covered with vegetation and filter trails, among others, that seek to control stormwater in the origin, reducing imperviousness. These solutions avoid increased runoff rate and volume, increase infiltration and groundwater recharge. The main goal of the research work here presented is to study the hydrological impact of LID's in UTAD (University of Trás-os-Montes e Alto Douro) campus, which is an institution focused on sustainability, since it has defined in its Strategic Plan to achieve, in a near future, an EcoCampus classification. To achieve the proposed goal, the campus area was studied in detail in order to evaluate the technical possibility of LID's implementation. A peak discharge comparison was made between the current situation and the one with LID's implementation, using the rational method. The results showed that peak discharges reduction between 68 and 95% may be achieved with LID solutions in UTAD campus.

Energy consumption, CO2 emissions and costs related to baths water consumption depending on the temperature and the use of flow reducing valves

In the domestic segment, various appliances and processes consume great amount of water and, consequently, energy. In this context, the main aim of this study is to analyse the impact of water temperature, flow and bath duration in water and energy consumptions. The impact on CO₂ emissions and a simple costs analysis were also carried out. It included a monitoring plan of 197 baths taken under different scenarios of water temperature and flow. It was concluded that increasing water consumption leads to an increase on energy consumption and that both resources consumptions increase with bath duration. Bath temperature had influence not only on energy consumption, as expected, but also in water consumption, what may be explained by the user's satisfaction during baths with higher temperatures. The use of a flow reducing valve is not a guarantee of water saving which can also be related to the user's satisfaction patterns, given that the introduction of a flow reducing valve can lead to a bath duration increase. In what concerns to the CO₂ emissions, it was concluded, as expected, that higher values are obtained for baths with higher temperatures given their relation with higher energy consumptions patterns. A simple costs analysis revealed that having flow reducing valves, with a bath temperature of 75 °C, increased the costs with electricity and water in 119% and 32%, respectively, when compared with a temperature of 60 °C.

Which are the factors that may explain the differences in water and energy consumptions in urban and rural environments?

Rural and urban environments present significant differences between water and energy consumptions. It is important to know, in detail, which factors related to the consumption of these two resources are different in both environments, once that will be those important to manage and discuss in order to improve its use efficiency and sustainability. This research work involves a survey whose aim is to find the factors that in rural and urban environments may justify the differences found in water and energy consumptions. Besides the collection of water and energy consumption data, this survey analyzed 80 variables (socio-demographic, economic, household characterization, among others), that were chosen among the bibliography as possible factors that should influence water and energy consumptions. After the survey application in rural and urban areas and the data statistical treatment, 42 variables remained as truly differentiating factors of rural and urban environments and so as possible determinants of water and energy consumptions. In order to achieve these objectives, a descriptive data analysis and statistical inference (Mann-Whitney-Wilcoxon test and the Chi-square test of homogeneity) were performed. All the 42 differentiating variables that result from this study may be able to justify these differences, however this will not be presented in the paper and it is reserved for future work.

Ecological and ecotoxicological responses in the assessment of the ecological status of freshwater systems: A case-study of the temporary stream Brejo of Cagarrão (South of Portugal)

The objective of the study was to assess the integrated use of macroinvertebrate indexes and ecotoxicological parameters in the evaluation of the ecological status of a temporary stream with a strong agricultural influence. Water quality was analysed at two sampling sites along the stream, considering: chemical supporting parameters; hazardous substances (pesticides); benthic macroinvertebrate communities, through quality (Iberian Biological Monitoring Working Party and Iberian Average Score Per Taxon) and multi-metric indices (Southern Portuguese Index of Invertebrates and Ecological Quality Ratio); and ecotoxicological responses using lethal and sub-lethal bioassays. The water chemical characterization showed high levels of organic matter and nutrients, mainly in the dry period ((biochemical oxygen demand (BOD₅): 18.5-25.5mgL^-1, chemical oxygen demand (COD): 60.8-193.7mgL^-1; total phosphorus (TP): 0.17-0.33mgL^-1)), which may compromise the support of biological life. In accordance with the physicochemical results, the stream had an ecological status less than good. Of the 25 pesticides analysed, only five, namely terbuthylazine, 2-methyl-chlorophenoxyacetic acid, bentazone, mecoprop and metolachlor were quantified. In general, the concentrations of pesticides detected were low, except at the source of the stream in January 2012 (sum of pesticides 2.29μgL^-1), mainly due to the concentration of bentazone (1.77μgL^-1), both values surpassing the European Commission threshold values. The analysis of benthic macroinvertebrates showed low levels of abundance and family diversity, with communities dominated by resistant groups to organic pollution and pesticides, such as the Chironomidae family. In general, the reproduction ecotoxicological results showed a very marked decrease in the number of juveniles per female. The Spearman correlation identified pesticides, namely MCPA (R=-0.89; p<0.05), as the main responsible for the observed effect. The results showed the linearity and complementarity of the two groups of biological responses, allowing to cover the interactions between the ecosystem's species and the different types of pollutants.

Patient Reporting of Adverse Drug Reactions: An International Survey of National Competent Authorities' Views and Needs

INTRODUCTION

Patient reporting of adverse drug reactions (ADRs) to spontaneous reporting systems can make a valuable contribution to pharmacovigilance. However, the implementation and promotion of patient reporting systems (PRSs) differ worldwide.

OBJECTIVE

The objective of the study was to describe attitudes toward PRSs, and progress toward implementing such systems among national competent authorities participating in the World Health Organization Programme for International Drug Monitoring.

METHODS

A web-based questionnaire was constructed based on qualitative interviews, and distributed through SurveyMonkey ^® to all countries listed on the World Health Organization Programme for International Drug Monitoring (n = 178) during November and December of 2015. Data were analyzed using descriptive statistics and Chi-square tests.

RESULTS

A total of 143 valid questionnaires were received from 141 countries (79.2 %). A spontaneous reporting system for both healthcare professionals and patients was present in 58 countries (41.1 %). An official PRS to report ADRs directly was implemented in 44 countries (31.2 %) and in a pilot stage in five countries (3.5 %). Patients were not allowed to report in 34 countries (24.1 %). The reasons for not having an official PRS were mainly a lack of resources/budget (56.5 %) or a lack of information/education for patients (56.5 %). When analyzing the attitudes among the respondents toward a PRS, most acknowledge that the general public contributes to the detection or strength of drug safety signals (82.2 % agree or strongly agree) and with information that is not present in healthcare professional reports (80.7 % agree or strongly agree). For respondents, giving feedback to patients could be an incentive for patients to report more (80.8 % agree or strongly agree). To be able to further PRSs, guidelines on promoting a PRS efficiently to the general public (87.4 % agree or strongly agree), training courses/conferences (86.7 % agree or strongly agree), or a public list of Lareb's scientific publications (86.7 % agree or strongly agree) were the support measures most well accepted by the respondents.

CONCLUSIONS

Most countries accept ADR reports from patients by an official reporting system designed for patients or through the existing system for healthcare professionals. The main reasons for not having a PRS is financial restraints and a lack of information/education of patients. Attitudes toward a PRS are positive, but some countries fear that they will not be able to handle an increase in reports.

In situ evaluation of water and energy consumptions at the end use level: The influence of flow reducers and temperature in baths

Nowadays, water and energy consumption is intensifying every year in most of the countries. This perpetual increase will not be supportable in the long run, making urgently to manage these resources on a sustainable way. Domestic consumptions of water and electric energy usually are related and it's important to study that relation, identifying opportunities for use efficient improvement. In fact, without an understanding of water-energy relations, there are water efficiency measures that may lead to unintentional costs in the energy efficiency field. In order to take full advantage of combined effect between water and energy water management methodologies, it is necessary to collect data to ensure that the efforts are directed through the most effective paths. This paper presents a study based in the characterization, measurement and analysis of water and electricity consumption in a single family house (2months period) in order to find an interdependent relationship between consumptions at the end user level. The study was carried out on about 200 baths, divided in four different scenarios where the influence of two variables was tested: the flow reducer valve and the bath temperature. Data showed that the presence of flow reducer valve decreased electric energy consumption and water consumption, but increased the bath duration. Setting a lower temperature in water-heater, decreased electric consumption, water consumption and bath duration. Analysing the influence of the flow reducer valve and 60°C temperature simultaneously, it was concluded that it had a significant influence on electric energy consumption and on the baths duration but had no influence on water consumption.

[Rehabilitation after total knee arthroplasty of hip and knee]

Numbers of total hip and knee arthroplasties are increasing on a regular basis. Clinical pathways tend to shorten the duration of hospitalization in acute care after surgery. Therefore, the preoperative preparation of the patient and his abilities for postoperative rehabilitation should be carefully addressed. Before the surgical intervention, it is recommended that the patient receives an educational program and a physical preparation. After the surgical intervention, the patient can benefit from a home-based rehabilitation program supervised by a physiotherapist, if there were no preoperative reasons for prolonging the hospital stay and if the surgery took place without complications. Some patients may benefit from postsurgical rehabilitation in a specialized locomotor rehabilitation long-stay care unit. The indications for inpatient multidisciplinary rehabilitation are : two simultaneous arthroplasties, revision of a previous hip or knee arthroplasty, postsurgical complications, advanced age, comorbidities influencing the rehabilitation process, social difficulties, necessity for adaptation of the environment, insufficient or unadapted out-patient (para)medical care. The goals of the rehabilitation treatment depend on the patient's characteristics and environment, on the properties of the prosthesis and on the postsurgical complications. The functional prognosis of a total joint arthroplasty of the knee or hip is excellent, provided that there are no post-surgical complications and that the patient benefits from adequate rehabilitation therapy. The present paper describes the different phases of rehabilitation treatment and the general and specific complications of total hip and knee arthroplasties that may influence the rehabilitation outcome.

ESGAR consensus statement on liver MR imaging and clinical use of liver-specific contrast agents

Objectives

To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents.

Methods

The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) formed a multinational European panel of experts, selected on the basis of a literature review and their leadership in the field of liver MR imaging. A modified Delphi process was adopted to draft a list of statements. Descriptive and Cronbach’s statistics were used to rate levels of agreement and internal reliability of the consensus.

Results

Three Delphi rounds were conducted and 76 statements composed on MR technique (n = 17), clinical application of liver-specific contrast agents in benign, focal liver lesions (n = 7), malignant liver lesions in non-cirrhotic (n = 9) and in cirrhotic patients (n = 18), diffuse and vascular liver diseases (n = 12), and bile ducts (n = 13). The overall mean score of agreement was 4.84 (SD ±0.17). Full consensus was reached in 22 % of all statements in all working groups, with no full consensus reached on diffuse and vascular diseases.

Conclusions

The consensus provided updated recommendations on the methodology, and clinical indications, of MRI with liver specific contrast agents in the study of liver diseases.

Key points

• Liver-specific contrast agents are recommended in MRI of the liver.

• The hepatobiliary phase improves the detection and characterization of hepatocellular lesions.

• Liver-specific contrast agents can improve the detection of HCC.

Patterns of tick infestation and their Borrelia burgdorferi s.l. infection in wild birds in Portugal

Wild birds may act as reservoirs for zoonotic pathogens and may be mechanical carriers of pathogen infected vector ticks through long distances during migration. The aim of this study was to assess tick infestation patterns in birds in Portugal and the prevalence of tick infection by Borrelia burgdorferi s.l. using PCR techniques. Seven tick species were collected from birds including Haemaphysalis punctata, Hyalomma spp., Ixodes acuminatus, Ixodes arboricola, Ixodes frontalis, Ixodes ricinus and Ixodes ventalloi. We found that I. frontalis and Hyalomma spp. were the most common ticks infesting birds of several species and that they were widespread in Portugal. Turdus merula was the bird species that presented the highest diversity of infesting ticks and had one of the highest infestation intensities. B. burgdorferi s.l. was detected in 7.3% (37/505) of Ixodidae ticks derived from birds. The most common genospecies was Borrelia turdi (6.9%), detected in ticks collected from Parus major, T. merula and Turdus philomelos, but Borrelia valaisiana (0.2%) and one Borrelia sp. (0.2%) similar to Borrelia bissettii (96% of similarity of the flaB gene in Blastn) were also detected. This study contributed to a better knowledge of the Ixodidae tick fauna parasitizing birds in Western Europe and to the assessment of the prevalence of B. burgdorferi s.l. associated with birds and their ticks.

Wastewater and greywater reuse on irrigation in centralized and decentralized systems--an integrated approach on water quality, energy consumption and CO2 emissions

Wastewater and greywater have different scales of end-uses in irrigation in Portugal. Wastewater is treated in a central wastewater treatment plant and reused in public/private large areas of irrigation, like agriculture, public gardens and golf courses. On the contrary, greywater reuse is generally applied in in situ small scales, treated and used in the same place, generally in the production site. The main aim of this paper is to compare the two types of systems: a wastewater centralized reuse system (WWCRS) and a greywater decentralized reuse system (GWDRS) in terms of water quality, energy consumption and CO2 emissions. In this paper, the main characteristics of both streams are presented and the degree of treatment required in each stream is analyzed. The advantages and disadvantages of its reuse in different scales, in terms of water quality, energy consumption and CO2 emissions are discussed. A methodology to calculate the energy consumptions and CO2 emissions related to wastewater treatment that may be applied in different cases is presented. A hypothetical example of the two systems: one referring to a WWCRS and the other to a GWDRS is presented. The energy consumption and the CO2 emissions are analyzed and compared. The WWCRS needs a higher degree of treatment and so it spends more energy and leads to more CO2 emissions to the environment than the GWDRS that consumed between 11.8 and 37.5% of the energy consumed in the WWCRS considering the same number of inhabitants served.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

A pilot study of common health problems in smallholder pigs in Angónia and Boane districts, Mozambique

Apilot survey was conducted in 2 districts in Mozambique to determine the most important health problems facing smallholder pig producers. While African swine fever is the most serious disease that affects pigs at all levels of production in Mozambique, it is likely that productivity is reduced by the presence of mange and gastrointestinal parasites, while in traditional systems the conditions are favourable for the development of porcine cysticercosis caused by the pork tapeworm Taenia solium, which poses a health risk to communities. Results of the pilot survey confirmed that, with the exception of African swine fever, ecto- and endoparasites are probably the most important health risks for producers. Porcine cysticercosis is more prevalent among pigs in traditional, free-ranging systems, while mange becomes a serious factor when pigs are permanently confined.

Assessment of the pesticides atrazine, endosulfan sulphate and chlorpyrifos for juvenoid-related endocrine activity using Daphnia magna

The water flea Daphnia magna belongs to the cyclical parthenogenic species, which can reproduce by either parthenogenesis or sexual reproduction. Recent studies have reported the involvement of the methylfarnesoate hormone, in male sex determination of D. magna. The aim of this study was to evaluate the juvenoid and anti-juvenoid activity of atrazine, endosulfan sulphate, and chlorpyrifos. To assess the juvenoid activity we exposed maternal daphnids to several concentrations of the respective pesticides, using the percentage of male production as endpoint. Fenoxycarb (1microgL(-1)) was used as a positive control. The anti-juvenoid activity was assessed using a similar bioassay after the addition of fenoxycarb (1microgL(-1)) to all test solutions. Fenoxycarb is an insect growth regulator that mimics the action of methylfarnesoate, and promoted the production of 95% of male offspring at the given concentration. Weak juvenoid-agonist activity was detected for endosulfan sulphate, with a significant increase of the percentage of male daphnids detected through logistic regression. In addition, atrazine and endosulfan sulphate antagonized the juvenoid activity of fenoxycarb. These results also corroborate the hypothesis that weak juvenoid agonists can simultaneously act as juvenoid antagonists as it has been observed in other hormonal systems.

Effects of atrazine and endosulfan sulphate on the ecdysteroid system of Daphnia magna

The ecdysteroid system is used by crustaceans and other arthropods as the major endocrine signalling molecules, regulating processes such as molting and embryonic development. The aim of this study was to evaluate the ecdysteroid activity of two pesticides (atrazine and endosulfan sulphate), with distinct modes of action and which act in the juvenoid system of the crustacean Daphnia magna as weak juvenoid compounds. To assess the ecdysteroid activity, we first exposed maternal daphnids and embryos to nominal concentrations of the pesticides and determined the effect promoted by these pesticides on the molting frequency and on abnormalities in the embryos development. Furthermore, we evaluated if the toxic effects observed with the isolated pesticides were promoted or not by the disruption of the ecdysteroids system of the crustacean, by co-administrating of them with 20-hydroxyecdysone hormone. This hormone is the prime form of the invertebrate's ecdysteroids system and it is responsible for the crustacean molting process. Both pesticides induced an increase of embryo abnormalities development. Endosulfan sulphate promoted a delay in the molting process. The effects induced by atrazine were not altered by co-exposure to 20-hydroxyecdysone. In contrast, the co-administration of 20-hydroxyecdysone allowed the reversion of the effects on both the molting process and embryonic development elicited by endosulfan sulphate. These results suggest that atrazine promotes its toxicity without interfering with the ecdysteroid activity of the crustacean. On the contrary, endosulfan sulphate is an anti-ecdysteroidal compound for D. magna.

Fatty acid profile of human milk of Portuguese lactating women: prospective study from the 1st to the 16th week of lactation

BACKGROUND/AIMS

Fatty acid (FA) composition varies over the course of the day and during lactation. The aim of this study was to evaluate FA composition and its compositional stability in human milk, from day 7 to week 16 of lactation.

METHODS

Human milk was collected from all feedings over 24 h at day 7 and weeks 4, 8, 12 and 16 of lactation in 31 lactating women. FAs were analyzed through gas chromatography. Comparisons were made with analysis of variance.

RESULTS

Total monounsaturated FAs decreased from 33.04 +/- 2.58% wt/wt at day 7 to 31.48 +/- 3.32% wt/wt at week 16 of lactation, much at the expenses of the decrease in the major monounsaturated FA found in human milk, oleic acid. Main polyunsaturated FAs n-6 and n-3 showed fluctuations from day 7 up to week 16 of lactation, but with no statistical significance. Arachidonic acid significantly decreased from transitional to mature milk.

CONCLUSIONS

The FA profile obtained throughout the study time points presented very low levels of oleic acid and very high linoleic acid/alpha-linoleic acid ratios which reflect recent changes in Portuguese women's food patterns. Despite this, the arachidonic acid/docosahexaenoic acid ratio [corrected] remained constant during the study, suggesting a protective metabolic mechanism.

Pancreatic ductal system obstruction and acute recurrent pancreatitis

Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.