Long-term outcome of neuroparacoccidioidomycosis treatment

INTRODUCTION: Neuroparacoccidioidomycosis (NPCM) is a term used to describe the invasion of the central nervous system by the pathogenic fungus Paracoccidioides brasiliensis. NPCM has been described sporadically in some case reports and small case series, with little or no focus on treatment outcome and long-term follow-up. METHODS: All patients with NPCM from January 1991 to December 2006 were analyzed and were followed until December 2009. RESULTS: Fourteen (3.8%) cases of NPCM were identified out of 367 patients with paracoccidioidomycosis (PCM). A combination of oral fluconazole and sulfamethoxazole/trimethoprim (SMZ/TMP) was the regimen of choice, with no documented death due to Paracoccidioides brasiliensis infection. Residual neurological deficits were observed in 8 patients. Residual calcification was a common finding in neuroimaging follow-up. CONCLUSIONS: All the patients in this study responded positively to the association of oral fluconazole and sulfamethoxazole/trimethoprim, a regimen that should be considered a treatment option in cases of NPCM. Neurological sequela was a relatively common finding. For proper management of these patients, anticonvulsant treatment and physical therapy support were also needed.

Métodos estatísticos aplicados à modelação de dados oncológicos

RESUMO: A estrutura demográfica portuguesa é marcada por baixas taxas de natalidade e mortalidade, onde a população idosa representa uma fatia cada vez mais representativa, fruto de uma maior longevidade. A incidência do cancro, na sua generalidade, é maior precisamente nessa classe etária. A par de outras doenças igualmente lesivas (e.g. cardiovasculares, degenerativas) cuja incidência aumenta com a idade, o cancro merece relevo. Estudos epidemiológicos apresentam o cancro como líder mundial na mortalidade. Em países desenvolvidos, o seu peso representa 25% do número total de óbitos, percentagem essa que mais que duplica noutros países. A obesidade, a baixa ingestão de frutas e vegetais, o sedentarismo, o consumo de tabaco e a ingestão de álcool, configuram-se como cinco dos fatores de risco presentes em 30% das mortes diagnosticadas por cancro. A nível mundial e, em particular no Sul de Portugal, os cancros do estômago, recto e cólon apresentam elevadas taxas de incidência e de mortalidade. Do ponto de vista estritamente económico, o cancro é a doença que mais recursos consome enquanto que do ponto de vista físico e psicológico é uma doença que não limita o seu raio de ação ao doente. O cancro é, portanto, uma doença sempre atual e cada vez mais presente, pois reflete os hábitos e o ambiente de uma sociedade, não obstante as características intrínsecas a cada indivíduo. A adoção de metodologia estatística aplicada à modelação de dados oncológicos é, sobretudo, valiosa e pertinente quando a informação é oriunda de Registos de Cancro de Base Populacional (RCBP). A pertinência é justificada pelo fato destes registos permitirem aferir numa população específica, o risco desta sofrer e/ou vir a sofrer de uma dada neoplasia. O peso que as neoplasias do estômago, cólon e recto assumem foi um dos elementos que motivou o presente estudo que tem por objetivo analisar tendências, projeções, sobrevivências relativas e a distribuição espacial destas neoplasias. Foram considerados neste estudo todos os casos diagnosticados no período 1998-2006, pelo RCBP da região sul de Portugal (ROR-Sul). O estudo descritivo inicial das taxas de incidência e da tendência em cada uma das referidas neoplasias teve como base uma única variável temporal - o ano de diagnóstico - também designada por período. Todavia, uma metodologia que contemple apenas uma única variável temporal é limitativa. No cancro, para além do período, a idade à data do diagnóstico e a coorte de nascimento, são variáveis temporais que poderão prestar um contributo adicional na caracterização das taxas de incidência. A relevância assumida por estas variáveis temporais justificou a sua inclusão numaclasse de modelos designada por modelos Idade-Período-Coorte (Age-Period-Cohort models - APC), utilizada na modelação das taxas de incidência para as neoplasias em estudo. Os referidos modelos permitem ultrapassar o problema de relações não lineares e/ou de mudanças súbitas na tendência linear das taxas. Nos modelos APC foram consideradas a abordagem clássica e a abordagem com recurso a funções suavizadoras. A modelação das taxas foi estratificada por sexo. Foram ainda estudados os respectivos submodelos (apenas com uma ou duas variáveis temporais). Conhecido o comportamento das taxas de incidência, uma questão subsequente prende-se com a sua projeção em períodos futuros. Porém, o efeito de mudanças estruturais na população, ao qual Portugal não é alheio, altera substancialmente o número esperado de casos futuros com cancro. Estimativas da incidência de cancro a nível mundial obtidas a partir de projeções demográficas apontam para um aumento de 25% dos casos de cancro nas próximas duas décadas. Embora a projeção da incidência esteja associada a alguma incerteza, as projeções auxiliam no planeamento de políticas de saúde para a afetação de recursos e permitem a avaliação de cenários e de intervenções que tenham como objetivo a redução do impacto do cancro. O desconhecimento de projeções da taxa de incidência destas neoplasias na área abrangida pelo ROR-Sul, levou à utilização de modelos de projeção que diferem entre si quanto à sua estrutura, linearidade (ou não) dos seus coeficientes e comportamento das taxas na série histórica de dados (e.g. crescente, decrescente ou estável). Os referidos modelos pautaram-se por duas abordagens: (i)modelos lineares no que concerne ao tempo e (ii) extrapolação de efeitos temporais identificados pelos modelos APC para períodos futuros. Foi feita a projeção das taxas de incidência para os anos de 2007 a 2010 tendo em conta o género, idade e neoplasia. É ainda apresentada uma estimativa do impacto económico destas neoplasias no período de projeção. Uma questão pertinente e habitual no contexto clínico e a que o presente estudo pretende dar resposta, reside em saber qual a contribuição da neoplasia em si para a sobrevivência do doente. Nesse sentido, a mortalidade por causa específica é habitualmente utilizada para estimar a mortalidade atribuível apenas ao cancro em estudo. Porém, existem muitas situações em que a causa de morte é desconhecida e, mesmo que esta informação esteja disponível através dos certificados de óbito, não é fácil distinguir os casos em que a principal causa de morte é devida ao cancro. A sobrevivência relativa surge como uma medida objetiva que não necessita do conhecimento da causa específica da morte para o seu cálculo e dar-nos-á uma estimativa da probabilidade de sobrevivência caso o cancro em análise, num cenário hipotético, seja a única causa de morte. Desconhecida a principal causa de morte nos casos diagnosticados com cancro no registo ROR-Sul, foi determinada a sobrevivência relativa para cada uma das neoplasias em estudo, para um período de follow-up de 5 anos, tendo em conta o sexo, a idade e cada uma das regiões que constituem o registo. Foi adotada uma análise por período e as abordagens convencional e por modelos. No epílogo deste estudo, é analisada a influência da variabilidade espaço-temporal nas taxas de incidência. O longo período de latência das doenças oncológicas, a dificuldade em identificar mudanças súbitas no comportamento das taxas, populações com dimensão e riscos reduzidos, são alguns dos elementos que dificultam a análise da variação temporal das taxas. Nalguns casos, estas variações podem ser reflexo de flutuações aleatórias. O efeito da componente temporal aferida pelos modelos APC dá-nos um retrato incompleto da incidência do cancro. A etiologia desta doença, quando conhecida, está associada com alguma frequência a fatores de risco tais como condições socioeconómicas, hábitos alimentares e estilo de vida, atividade profissional, localização geográfica e componente genética. O “contributo”, dos fatores de risco é, por vezes, determinante e não deve ser ignorado. Surge, assim, a necessidade em complementar o estudo temporal das taxas com uma abordagem de cariz espacial. Assim, procurar-se-á aferir se as variações nas taxas de incidência observadas entre os concelhos inseridos na área do registo ROR-Sul poderiam ser explicadas quer pela variabilidade temporal e geográfica quer por fatores socioeconómicos ou, ainda, pelos desiguais estilos de vida. Foram utilizados os Modelos Bayesianos Hierárquicos Espaço-Temporais com o objetivo de identificar tendências espaço-temporais nas taxas de incidência bem como quantificar alguns fatores de risco ajustados à influência simultânea da região e do tempo. Os resultados obtidos pela implementação de todas estas metodologias considera-se ser uma mais valia para o conhecimento destas neoplasias em Portugal.------------ABSTRACT: mortality rates, with the elderly being an increasingly representative sector of the population, mainly due to greater longevity. The incidence of cancer, in general, is greater precisely in that age group. Alongside with other equally damaging diseases (e.g. cardiovascular,degenerative), whose incidence rates increases with age, cancer is of special note. In epidemiological studies, cancer is the global leader in mortality. In developed countries its weight represents 25% of the total number of deaths, with this percentage being doubled in other countries. Obesity, a reduce consumption of fruit and vegetables, physical inactivity, smoking and alcohol consumption, are the five risk factors present in 30% of deaths due to cancer. Globally, and in particular in the South of Portugal, the stomach, rectum and colon cancer have high incidence and mortality rates. From a strictly economic perspective, cancer is the disease that consumes more resources, while from a physical and psychological point of view, it is a disease that is not limited to the patient. Cancer is therefore na up to date disease and one of increased importance, since it reflects the habits and the environment of a society, regardless the intrinsic characteristics of each individual. The adoption of statistical methodology applied to cancer data modelling is especially valuable and relevant when the information comes from population-based cancer registries (PBCR). In such cases, these registries allow for the assessment of the risk and the suffering associated to a given neoplasm in a specific population. The weight that stomach, colon and rectum cancers assume in Portugal was one of the motivations of the present study, that focus on analyzing trends, projections, relative survival and spatial distribution of these neoplasms. The data considered in this study, are all cases diagnosed between 1998 and 2006, by the PBCR of Portugal, ROR-Sul.Only year of diagnosis, also called period, was the only time variable considered in the initial descriptive analysis of the incidence rates and trends for each of the three neoplasms considered. However, a methodology that only considers one single time variable will probably fall short on the conclusions that could be drawn from the data under study. In cancer, apart from the variable period, the age at diagnosis and the birth cohort are also temporal variables and may provide an additional contribution to the characterization of the incidence. The relevance assumed by these temporal variables justified its inclusion in a class of models called Age-Period-Cohort models (APC). This class of models was used for the analysis of the incidence rates of the three cancers under study. APC models allow to model nonlinearity and/or sudden changes in linear relationships of rate trends. Two approaches of APC models were considered: the classical and the one using smoothing functions. The models were stratified by gender and, when justified, further studies explored other sub-models where only one or two temporal variables were considered. After the analysis of the incidence rates, a subsequent goal is related to their projections in future periods. Although the effect of structural changes in the population, of which Portugal is not oblivious, may substantially change the expected number of future cancer cases, the results of these projections could help planning health policies with the proper allocation of resources, allowing for the evaluation of scenarios and interventions that aim to reduce the impact of cancer in a population. Worth noting that cancer incidence worldwide obtained from demographic projections point out to an increase of 25% of cancer cases in the next two decades. The lack of projections of incidence rates of the three cancers under study in the area covered by ROR-Sul, led us to use a variety of forecasting models that differ in the nature and structure. For example, linearity or nonlinearity in their coefficients and the trend of the incidence rates in historical data series (e.g. increasing, decreasing or stable).The models followed two approaches: (i) linear models regarding time and (ii) extrapolation of temporal effects identified by the APC models for future periods. The study provide incidence rates projections and the numbers of newly diagnosed cases for the year, 2007 to 2010, taking into account gender, age and the type of cancer. In addition, an estimate of the economic impact of these neoplasms is presented for the projection period considered. This research also try to address a relevant and common clinical question in these type of studies, regarding the contribution of the type of cancer to the patient survival. In such studies, the primary cause of death is commonly used to estimate the mortality specifically due to the cancer. However, there are many situations in which the cause of death is unknown, or, even if this information is available through the death certificates, it is not easy to distinguish the cases where the primary cause of death is the cancer. With this in mind, the relative survival is an alternative measure that does not need the knowledge of the specific cause of death to be calculated. This estimate will represent the survival probability in the hypothetical scenario of a certain cancer be the only cause of death. For the patients with unknown cause of death that were diagnosed with cancer in the ROR-Sul, the relative survival was calculated for each of the cancers under study, for a follow-up period of 5 years, considering gender, age and each one of the regions that are part the registry. A period analysis was undertaken, considering both the conventional and the model approaches. In final part of this study, we analyzed the influence of space-time variability in the incidence rates. The long latency period of oncologic diseases, the difficulty in identifying subtle changes in the rates behavior, populations of reduced size and low risk are some of the elements that can be a challenge in the analysis of temporal variations in rates, that, in some cases, can reflect simple random fluctuations. The effect of the temporal component measured by the APC models gives an incomplete picture of the cancer incidence. The etiology of this disease, when known, is frequently associated to risk factors such as socioeconomic conditions, eating habits and lifestyle, occupation, geographic location and genetic component. The "contribution"of such risk factors is sometimes decisive in the evolution of the disease and should not be ignored. Therefore, there was the need to consider an additional approach in this study, one of spatial nature, addressing the fact that changes in incidence rates observed in the ROR-Sul area, could be explained either by temporal and geographical variability or by unequal socio-economic or lifestyle factors. Thus, Bayesian hierarchical space-time models were used with the purpose of identifying space-time trends in incidence rates together with the the analysis of the effect of the risk factors considered in the study. The results obtained and the implementation of all these methodologies are considered to be an added value to the knowledge of these neoplasms in Portugal.

Rigid pavements distresses - pavement condition index evaluation

Pavements require maintenance in order to provide good service levels during their life period. Because of the significant costs of this operation and the importance of a proper planning, a pavement evaluation methodology, named Pavement Condition Index (PCI), was created by the U.S. Army Corps of Engineers. This methodology allows for the evaluation of the pavement condition along the life period, generally yearly, with minimum costs and, in this way, it is possible to plan the maintenance action and to adopt adequate measures, minimising the rehabilitation costs. The PCI methodology provides an evaluation based on visual inspection, namely on the distresses observed on the pavement. This condition index of the pavement is classified from 0 to 100, where 0 it is the worst possible condition and 100 the best possible condition. This methodology of pavement assessment represents a significant tool for management methods such as airport pavement management system (APMS) and life-cycle costs analysis (LCCA). Nevertheless, it has some limitations which can jeopardize the correct evaluation of the pavement behavior. Therefore the objective of this dissertation is to help reducing its limitations and make it easier and faster to use. Thus, an automated process of PCI calculation was developed, avoiding the abaci consultation, and consequently, minimizing the human error. To facilitate also the visual inspection a Tablet application was developed to replace the common inspection data sheet and thus making the survey easier to be undertaken. Following, an airport pavement condition was study accordingly with the methodology described at Standard Test Method for Airport Pavement Condition Index Surveys D5340, 2011 where its original condition level is compared with the condition level after iterate possible erroneous considered distresses as well as possible rehabilitations. Afterwards, the results obtained were analyzed and the main conclusions presented together with some future developments.

Learning new tricks: Corticostriatal dynamics during novel skill learning

Learning novel actions and skills is a prevalent ability across multiple species and a critical feature for survival and competence in a constantly changing world. Novel actions are generated and learned through a process of trial and error, where an animal explores the environment around itself, generates multiple patterns of behavior and selects the ones that increase the likelihood of positive outcomes. Proper adaptation and execution of the selected behavior requires the coordination of several biomechanical features by the animal. Cortico-basal ganglia circuits and loops are critically involved in the acquisition, learning and consolidation of motor skills.(...)

Africanized honeybee stings: how to treat them

INTRODUCTION: In 1956, Africanized honeybees (AHB) migrated from Brazil to other regions of the Western Hemisphere, including South, Central, and North America, except for Canada. Despite being productive, they are highly aggressive and cause fatal accidents. This study aimed to evaluate patients at the Clinical Hospital of Botucatu Medical School (HC-FMB) and to propose treatment guidelines. METHODS: From 2005 to 2006, the clinical and laboratorial aspects of 11 patients (7 male and 4 female) and the anatomopathological aspects of one patient who had died in 2003 were analyzed. RESULTS: The age of the surviving patients varied from 5 to 87 years, with a mean of 42.5 years. The majority of accidents occurred in the afternoon, and the number of stings ranged from 20 to 500. The principal signs and symptoms were pain and local inflammatory signs, nausea, tachycardia, and vomiting. Biochemical findings presented increased levels of creatine phosphokinase, lactate dehydrogenase, and aspartate/alanine aminotransferase. An 11-year-old male patient died upon entering the attic of a two-storey building where he was attacked by a swarm, receiving more than 1,000 stings. He was sent to HC-FMB where he was treated, but he died 24h later. Observed at the autopsy were erythematous-purpuric skin lesions besides necrosis at the sting locations, rhabdomyolysis, focal myocardial necrosis, tubular hydropic degeneration and focal tubular acute necrosis of the kidneys, myoglobinuria, and centrolobular necrosis in the liver. CONCLUSIONS: Accidents caused by multiple AHB stings always constitute a medical emergency. As there is no specific antivenom, we have developed guidelines, including first aid, drugs, and the proper removal of stingers.

Prospective system analysis of stationary battery systems under the frame of Constructive Technology Assessment

Based on the report for the unit “Project IV” of the PhD programme on Technology Assessment under the supervision of Dr.-Ing. Marcel Weil and Prof. Dr. António Brandão Moniz. The report was presented and discussed at the Doctorate Conference on Technologogy Assessment in July 2013 at the University Nova Lisboa, Caparica campus.

Contributo da curva de débito-volume na detecção da obstrução da via aérea central

RESUMO: Introdução: A obstrução da via aérea central (OVAC) refere-se a um processo patológico que conduz a limitação do fluxo de ar ao nível do espaço glótico e subglótico, traqueia e brônquios principais. O seu correcto diagnóstico e tratamento constituem um território de interesse e preocupação para os profissionais de saúde, e requerem um profundo conhecimento da sua etiologia, fisiologia, diagnóstico e opções terapêuticas dado o potencial em originar significativa morbilidade e mortalidade. A avaliação da OVAC abrange múltiplas vertentes, entre as quais se salienta o componente clínico (sinais e sintomas), a repercussão fisiopatológica (função respiratória) e o estudo imagiológico (TC do tórax e broncoscopia). A compilação destes dados associada à etiologia, constituem factores importantes para estabelecer o prognóstico, determinar a necessidade de tratamento ou delinear uma futura intervenção terapêutica. A broncoscopia é o Gold Standard de avaliação desta condição, mas desde há cerca de 40 anos a curva de débito-volume constitui uma ferramenta não invasiva de detecção de OVAC. Apesar deste método ser utilizado até os nossos dias, poucos têm sido os estudos com o objectivo de verificar a sensibilidade e especificidade da curva de débito-volume na detecção de OVAC, bem como averiguar a relação entre as alterações morfológicas e quantitativas da mesma com a localização, o tipo e o grau da obstrução. Material e Métodos: Entre 1 de Novembro de 2009 e 30 de Abril de 2010, os doentes com indicação para a realização de broncoscopia diagnóstica ou terapêutica na Unidade de Técnicas Invasivas Pneumológicas (UTIP) do Centro Hospitalar Lisboa Norte – Hospital Pulido Valente (CHLN – HPV) foram seleccionados de forma consecutiva de acordo com os critérios de inclusão e exclusão. As avaliações (broncoscopia, curva de débito-volume e avaliação da dispneia) realizaram-se com um intervalo de tempo máximo de sete dias. A broncoscopia flexível foi realizada segundo as normas da British Thoracic Society e as curvas de débito-volume segundo as normas da ATS/ERS TaskForce 2005. Para a avaliação da dispneia recorreu-se à escala de dispneia MRC (Medical Research Council). Um painel de peritos realizou a avaliação da morfologia da curva de débito-volume (sugestiva ou não de OVAC) e um elemento independente a verificação dos critérios quantitativos e morfológicos (variáveis intra e extratorácica e fixa) da curva. O estudo foi aprovado pela Comissão de Ética para a Saúde do CHLN e todos os doentes assinaram um consentimento informado de participação. Resultados: Estudaram-se 82 doentes, 36 (44%) dos quais com OVAC. A predominância foi do género masculino, em relação ao feminino. A sensibilidade e especificidade dos critérios quantitativos da curva de débito-volume na detecção de OVAC foi de 91.3% e 88.9% respectivamente. Quando se utilizaram os critérios morfológicos da curva de débito-volume os valores foram de 93.5% e 30.6%. A agregação dos critérios morfológicos e quantitativos permitiu alcançar uma sensibilidade de 95.7% e especificidade de 86.1%. Nesta amostra, o critério quantitativo com maior ocorrência foi o FEF50/FIF50≥1 (83% dos doentes com OVAC). Este mostrou relacionar-se com todas as localizações de obstrução excepto o terço médio da traqueia. Mostrou, ainda, ter uma relação forte e positiva com o grau e tipo de obstrução (intra e extraluminal). O segundo foi o FEV1/PEF≥8, presente em 36% dos casos de OVAC. Relacionou-se com as obstruções no terço inferior da traqueia e brônquio principal direito (BPD). Também apresentou relação forte e positiva com o grau de obstrução e com os tipos de obstrução anteriormente descritos. Quanto à sintomatologia foi possível associar o grau de obstrução com o de dispneia e a presença de estridor com o grau e localização da obstrução na traqueia. Conclusões: Os resultados deste estudo demonstram que os critérios quantitativos da curva de débito-volume têm elevada sensibilidade e especificidade na detecção de OVAC. O critério FEV50/FIF50≥1 tem um bom poder discriminativo na detecção dessa condição, tendo sido relacionado com a localização, o grau e o tipo de obstrução. O critério FEV1/PEF≥8, embora com menor poder discriminativo, também se relaciona com o grau, a localização e o tipo de obstrução. A morfologia da curva tem uma boa sensibilidade mas baixa especificidade na detecção de OVAC, mas a agregação entre os critérios morfológicos e quantitativos aumenta a sensibilidade e especificidade. A dispneia e o estridor foram relacionados com o grau de obstrução e o último com a localização ao nível da traqueia.-------------ABSTRACT: Introduction: Central airway obstruction (CAO) refers to a pathological process that leads to restriction of airflow at the level of the glottis and subglottis, trachea and main bronchi. It’s proper diagnosis and treatment is an area of interest and concern to health professionals, and requires a deep knowledge of its etiology, physiology, diagnosis and treatment options, concerning the potential to cause significant morbidity and mortality. The evaluation of CAO covers multiple aspects: the clinical component (signs and symptoms), the pathophysiological effect (lung function) and the imaging study (bronchoscopy and chest CT). The compilation of this data associated with the etiology, are important for establishing prognosis, determine the need for treatment or outline a future therapeutic intervention. Bronchoscopy is the gold standard for evaluating this condition, but for the last 40 years the flow-volume loop has been used as a noninvasive tool for detecting CAO. Although this method is still in use, only few studies were made in order to verify its sensitivity and specificity in detecting CAO, and investigate the relation between morphological and quantitative changes of the curve to location, type and degree of obstruction. Methods: Between 1st November 2009 and 30th April 2010, patients with indication to perform diagnostic or therapeutic bronchoscopy in Interventional Pulmonology Unit - Hospital Pulido Valente (CHLN - HPV), were selected consecutively according to the inclusion and exclusion criteria. All assessments (bronchoscopy, flow-volume loop and dyspnea) were carried out within a period of seven days. The flexible bronchoscopy was performed according to the standards of the British Thoracic Society and the flow-volume loops in accordance with the standards of the ATS / ERS Taskforce 2005. For the evaluation of dyspnea was used to MRC dyspnea scale (Medical Research Council). A panel of experts evaluated the morphology of flow-volume loop (suggestive or non-suggestive of CAO) and an independent element established the quantitative criteria and morphological (intra and extrathoracic variables and fixed) of the curve. This study was approved by the Ethics Committee for Health CHLN and all the patients signed an informed consent to participate. Results: We’ve studied 82 patients, 36 (44%) of those with CAO. The majority of the patients were males, compared to females. The sensitivity and specificity of the quantitative criteria of the flow-volume curve in detecting CAO was 91.3% and 88.9% respectively. When we used the morphological criteria of flow-volume loop these values were 93.5% and 30.6%. The combination of quantitative and morphological criteria produced values of 95.7% sensitivity and 86.1% specificity. FEF50/FIF50≥1 was the most representative quantitative criterion (83% of patients with CAO) and it was correlated with all sites of obstruction except in the middle third of the trachea. It has shown a strong and positive association with the degree and type of obstruction (intra and extraluminal). The second was the FEV1/PEF ≥ 8, present in 36% of cases of CAO. It could be correlated with the obstruction in the lower third of the trachea and right main bronchus. It also showed a strong positive relation with the degree and types of obstruction described above. Regarding symptoms, we found a link between the degree of obstruction and dyspnea. The presence of stridor was correlated with the location and the degree of obstruction in the trachea. Conclusion: The results of this study demonstrate that the quantitative criteria of the flow-volume loop have a high sensitivity and specificity in detecting CAO. The criterion FEV50/FIF50 ≥ 1 has a good discriminative power to detect this condition and was related to the location, degree and type of obstruction. The criterion FEV1/PEF ≥ 8, although with a weaker discriminative power, also relates to the degree, location and type of obstruction. The morphology of the curve has a good sensitivity but low specificity in detecting CAO although the combination between the morphological and quantitative criteria increases sensitivity and specificity. Dyspnea and stridor were related to the degree of obstruction and the last one with its location in the trachea.

As práticas comerciais desleais

The following study aims to examine a controversial and relatively unexplored subject within our system: the legal framework on unfair business-to-consumer commercial practices. Given the fact that this subject is based on the Directive 2005/29/EC, we considered to be appropriate to explore, firstly, the background and origin of such normative instrument. Nevertheless, we have centered our analysis on the interpretation of the set rules established by the Portuguese legal system (Law nr 57/2008, March 26th). For this dissertation, we have proposed a model of tripartite approach. Chapter V seeks to shed light on the general clause by analyzing a set of open concepts such as professional diligence, honest market practice, good faith or material distortion of the consumer’s economic behavior. In chapter VI, we will focus on two common types of unfair commercial practices: misleading and aggressive practices. Finally, due to the fact that chapter VII deals with the black list, we have illustrated the listed practices by giving real life examples. Taking into account the indefinite concepts used in the general prohibition and in the misleading and aggressive clauses, it is particularly difficult to demonstrate the unfairness of the professional’s behavior. In the light of this information, we have concluded that the regime fails on achieving its main goal: it does not protect proper and effectively the consumer’s interests.

A intervenção dos orgãos de polícia criminal em sede de julgamento

Currently, Portugal assumes itself as a democratic rule of substantive law State, sustained by a legal system seeking the right balance between the guarantee of fundamental rights and freedoms constitutional foreseen in Portugal’s Fundamental Law and criminal persecution. The architecture of the penal code lies with, roughly speaking, a accusatory basic structure, “deliberately attached to one of the most remarkable achievements of the civilizational democratic progress, and by obedience to the constitutional commandment”, in balance with the official investigation principle, valid both for the purpose of prosecution and trial. Regarding the principle of non self-incrimination - nemo tenetur se ipsum accusare, briefly defined as the defendant’s right of not being obliged to contribute to the self-incrimination, it should be stressed that there isn’t an explicit consecration in the Portuguese Constitution, being commonly accepted in an implicit constitutional prediction and deriving from other constitutional rights and principles, first and foremost, the meaning and scope of the concept of democratic rule of Law State, embedded in the Fundamental Law, and in the guidelines of the constitutional principles of human person dignity, freedom of action and the presumption of innocence. In any case, about the (in) applicability of the principle of the prohibition of self-incrimination to the Criminal Police Bodies in the trial hearing in Court, and sharing an idea of Guedes Valente, the truth is that the exercise of criminal action must tread a transparent path and non-compliant with methods to obtain evidence that violate the law, the public order or in violation of democratic principles and loyalty (Guedes Valente, 2013, p. 484). Within the framework of the penal process relating to the trial, which is assumed as the true phase of the process, the witness represents a relevant figure for the administration of criminal justice, for the testimonial proof is, in the idea of Othmar Jauernig, the worst proof of evidence, but also being the most frequent (Jauernig, 1998, p. 289). As coadjutant of the Public Prosecutor and, in specific cases, the investigating judge, the Criminal Police Bodies are invested with high responsibility, being "the arms and eyes of Judicial Authorities in pursuing the criminal investigation..." which has as ultimate goal the fulfillment of the Law pursuing the defense of society" (Guedes Valente, 2013, p. 485). It is in this context and as a witness that, throughout operational career, the Criminal Police Bodies are required to be at the trial hearing and clarify the Court with its view about the facts relating to occurrences of criminal context, thus contributing very significantly and, in some cases, decisively for the proper administration of the portuguese criminal justice. With regards to the intervention of Criminal Police Bodies in the trial hearing in Court, it’s important that they pay attention to a set of standards concerning the preparation of the testimony, the very provision of the testimony and, also, to its conclusion. Be emphasized that these guidelines may become crucial for the quality of the police testimony at the trial hearing, thus leading to an improvement of the enforcement of justice system. In this vein, while preparing the testimony, the Criminal Police Bodies must present itself in court with proper clothing, to read before and carefully the case files, to debate the facts being judged with other Criminal Police Bodies and prepare potential questions. Later, while giving his testimony during the trial, the Criminal Police Bodies must, summing up, to take the oath in a convincing manner, to feel comfortable, to start well by convincingly answering the first question, keep an attitude of serenity, to adopt an attitude of collaboration, to avoid the reading of documents, to demonstrate deference and seriousness before the judicial operators, to use simple and objective language, to adopt a fluent speech, to use nonverbal language correctly, to avoid spontaneity responding only to what is asked, to report only the truth, to avoid hesitations and contradictions, to be impartial and to maintain eye contact with the judge. Finally, at the conclusion of the testimony, the Criminal Police Bodies should rise in a smooth manner, avoiding to show relief, resentment or satisfaction, leaving a credible and professional image and, without much formality, requesting the judge permission to leave the courtroom. As final note, it’s important to stress that "The intervention of the Police Criminal Bodies in the trial hearing in Court” encloses itself on a theme of crucial importance not only for members of the Police and Security Forces, who must welcome this subject with the utmost seriousness and professionalism, but also for the proper administration of the criminal justice system in Portugal.

Cases distribution of leptospirosis in City of Manaus, State of Amazonas, Brazil, 2000-2010

INTRODUCTION: Leptospirosis is an infectious disease caused by microorganisms of the genus Leptospira that affects several species of animals, including the human beings. The study described the confirmed cases of leptospirosis in Manaus, from 2000 to 2010. METHODS: A descriptive study based on secondary data analysis of Secretaria Municipal de Saúde (SEMSA), Sistema de Informação de Agravos de Notificação SINAN and Sistema de Informação sobre Mortalidade (SIM) analyzing the variables: age group, gender, clinical aspects and geographic area and lethality. RESULTS: Were reported 665 cases of leptospirosis, 339 were confirmed and 35 (10.3%) died. The largest number of cases occurred in May (16.8%), March (13.3%) and April (11.4%), a period of intense rainfall. The city areas with the greatest occurrence of the disease were South (26.6%), West (23.5%) and East (19.7%), areas of the greatest precariousness socio-environment. The largest number of cases, including deaths, occurred in the age group from 14 to 44.9 years (74%), being that 291 (85.8%) were male and 48 (14.1%) females. The most frequent symptoms were fever, myalgia, headache and jaundice. In relation to the social conditions were identified low education, poor housing, absence of sanitation and low income. CONCLUSIONS: In Manaus, despite the implementation of the Social and Environmental Program of Igarapés of Manaus (PROSAMIM), there are still areas that need a proper urbanization and improvements in socio-environmental conditions, reducing the level of exposure of the human beings that living in these locations.

Factors of poor prognosis of visceral leishmaniasis among children under 12 years of age. A retrospective monocentric study in Belo Horizonte, State of Minas Gerais, Brazil, 2001-2005

INTRODUTION: A major concern with the visceral leishmaniasis (VL) is its high lethality rate, even with proper treatment. Low age, prior malnutrition, disease duration prior to diagnosis, severe anemia, fever for more than 60 days, diarrhea and jaundice are known poor prognostic factors. The goals of this study are to describe the clinical and laboratory characteristics of VL among children under 12 years of age and to identify the factors associated with VL poor outcome. METHODS: Two hundred and fifty children under 12 years of age with confirmed VL admitted to Hospital João Paulo II (FHEMIG), Belo Horizonte, Brazil, between January 2001 and December 2005 were evaluated retrospectively. The primary outcome was the poor clinical evolution: sepsis, and/or pneumonia, and/or urinary tract infection, and/or of bleeding (expect epistaxis), and/or severe neutropenia (neutrophil < 500 cells/mm3). Odds ratio (crude and adjusted) and its 95% confidence interval for each variable were calculated. Values less than 0.05 were considered significant. RESULTS: Average age was 3.3 years (3.6 months-11.6 years), 71.2% were younger than 5 years and 47.2% lived in Metropolitan Area of Belo Horizonte. The mean fatality rate was 3.6%. Sixty-six (26.4%) patients presented poor evolution. After a multivariate analysis, age <18 months, abnormal respiratory physical examination on hospital admission, and platelets <85,000/mm3 remained associated with increased chance of poor evolution. CONCLUSIONS: The results suggest that patients aged between 12 and 18 months, with platelet counts bellow 85,000/mm3, and respiratory abnormalities at admission should be considered potentially severe.

Environmental isolation, biochemical identification, and antifungal drug susceptibility of Cryptococcus species

Introduction The incidence of opportunistic fungal infections has increased in recent years and is considered an important public health problem. Among systemic and opportunistic mycoses, cryptococcosis is distinguished by its clinical importance due to the increased risk of infection in individuals infected by human immunodeficiency virus. Methods To determine the occurrence of pathogenic Cryptococcus in pigeon excrement in the City of Araraquara, samples were collected from nine environments, including state and municipal schools, abandoned buildings, parks, and a hospital. The isolates were identified using classical tests, and susceptibility testing for the antifungal drugs (fluconazole, itraconazole, voriconazole, and amphotericin B) independently was also performed. After collection, the excrement samples were plated on Niger agar and incubated at room temperature. Results A total of 87 bird dropping samples were collected, and 66.6% were positive for the genus Cryptococcus. The following species were identified: Cryptococcus neoformans (17.2%), Cryptococcus gattii (5.2%), Cryptococcus ater (3.5%), Cryptococcus laurentti (1.7%), and Cryptococcus luteolus (1.7%). A total of 70.7% of the isolates were not identified to the species level and are referred to as Cryptococcus spp. throughout the manuscript. Conclusions Although none of the isolates demonstrated resistance to antifungal drugs, the identification of infested areas, the proper control of birds, and the disinfection of these environments are essential for the epidemiological control of cryptococcosis.

Social impact bond feasibility study: Children and youth at risk: the Projecto Família program

Social impact bonds are an increasingly popular method of unlocking typical social investment barriers and fuelling social innovation. This feasibility study aims to understand whether a social impact bond is a suitable tool for decreasing unnecessary foster care placements in Portugal, which have been proven to cause significant social and financial damage to societies. This research question is answered through a financial model which combines the costs of this social problem with Projecto Família’s intervention model, a leading intensive family preservation service. Main findings suggest using SIB funding for a 5-year project with the goal of generating the proper impact measurement metrics lacking in the field.

Ventricular arrhythmias in Chagas disease

Sudden death is one of the most characteristic phenomena of Chagas disease, and approximately one-third of infected patients develop life-threatening heart disease, including malignant ventricular arrhythmias. Fibrotic lesions secondary to chronic cardiomyopathy produce arrhythmogenic substrates that lead to the appearance and maintenance of ventricular arrhythmias. The objective of this study is to discuss the main clinical and epidemiological aspects of ventricular arrhythmias in Chagas disease, the specific workups and treatments for these abnormalities, and the breakthroughs needed to determine a more effective approach to these arrhythmias. A literature review was performed via a search of the PubMed database from 1965 to May 31, 2014 for studies of patients with Chagas disease. Clinical management of patients with chronic Chagas disease begins with proper clinical stratification and the identification of individuals at a higher risk of sudden cardiac death. Once a patient develops malignant ventricular arrhythmia, the therapeutic approach aims to prevent the recurrence of arrhythmias and sudden cardiac death by the use of implantable cardioverter defibrillators, antiarrhythmic drugs, or both. In select cases, invasive ablation of the reentrant circuit causing tachycardia may be useful. Ventricular arrhythmias are important manifestations of Chagas cardiomyopathy. This review highlights the absence of high-quality evidence regarding the treatment of ventricular arrhythmias in Chagas disease. Recognizing high-risk patients who require specific therapies, especially invasive procedures such as the implantation of cardioverter defibrillators and ablative approaches, is a major challenge in clinical practice.

Nanocomposite polymer beads for cell detection

Circulating tumor cells (CTCs) may induce metastases when detached from the primary tumor. The numbers of these cells in blood offers a valuable prognostic indication. Magnetoresistive sensing is an attractive option for CTC counting. In this technique, cells are labeled with nancomposite polymer beads that provide the magnetic signal. Bead properties such as size and magnetic content must be optimized in order to be used as a detection tool in a magnetoresistive platform. Another important component of the platform is the magnet required for proper sensing. Both components are addressed in this work. Nanocomposite polymer beads were produced by nano-emulsion and membrane emulsification. Formulations of the oil phase comprising a mixture of aromatic monomers and iron oxide were employed. The effect of emulsifier (surfactant) concentration on bead size was studied. Formulations of polydimethilsiloxane (PDMS) with different viscosities were also prepared with nano-emulsion method resulting in colloidal beads. Polycaprolactone (PCL) beads were also synthetized by the membrane emulsification method. The beads were characterized by different techiques such as dynamic light scattering (DLS), thermogravimetric analysis (TGA) and scanning electron microscopy (SEM). Additionally, the magnet dimensions of the platform designed to detect CTCs were optimized through a COMSOL multiphysics simulation.