Raquel Lucas

Severe imported malaria in an intensive care unit: a review of 59 cases

BackgroundIn view of the close relationship of Portugal with African countries, particularly former Portuguese colonies, the diagnosis of malaria is not a rare thing. When a traveller returns ill from endemic areas, malaria should be the number one suspect. World Health Organization treatment guidelines recommend that adults with severe malaria should be admitted to an intensive care unit (ICU).MethodsSevere cases of malaria in patients admitted to an ICU were reviewed retrospectively (1990-2011) and identification of variables associated with in-ICU mortality performed. Malaria prediction score (MPS), malaria score for adults (MSA), simplified acute physiology score (SAPSII) and a score based on WHOs malaria severe criteria were applied. Statistical analysis was performed using StataV12.ResultsFifty nine patients were included in the study, all but three were adults; 47 (79,6%) were male; parasitaemia on admission, quantified in 48/59 (81.3%) patients, was equal or greater than 2% in 47 of them (97.9%); the most common complications were thrombocytopaenia in 54 (91.5%) patients, associated with disseminated intravascular coagulation (DIC) in seven (11.8%), renal failure in 31 (52.5%) patients, 18 of which (30.5%) oliguric, shock in 29 (49.1%) patients, liver dysfunction in 27 (45.7%) patients, acidaemia in 23 (38.9%) patients, cerebral dysfunction in 22 (37.2%) patients, 11 of whom with unrousable coma, pulmonary oedema/ARDS in 22 (37.2%) patients, hypoglycaemia in 18 (30.5%) patients; 29 (49.1%) patients presented five or more dysfunctions. The case fatality rate was 15.2%. Comparing the four scores, the SAPS II and the WHO score were the most sensitive to death prediction. In the univariate analysis, death was associated with the SAPS II score, cerebral malaria, acute renal and respiratory failure, DIC, spontaneous bleeding, acidosis and hypoglycaemia. Age, partial immunity to malaria, delay in malaria diagnosis and the level of parasitaemia were not associated with death in this cohort.ConclusionSevere malaria cases should be continued monitored in the ICUs. SAPS II and the WHO score are good predictors of mortality in malaria patients, but other specific scores deserve to be studied prospectively.

Sleepiness at the wheel across Europe: a survey of 19 countries.

The European Sleep Research Society aimed to estimate the prevalence, determinants and consequences of falling asleep at the wheel. In total, 12 434 questionnaires were obtained from 19 countries using an anonymous online questionnaire that collected demographic and sleep‐related data, driving behaviour, history of drowsy driving and accidents. Associations were quantified using multivariate logistic regression. The average prevalence of falling asleep at the wheel in the previous 2 years was 17%. Among respondents who fell asleep, the median prevalence of sleep‐related accidents was 7.0% (13.2% involved hospital care and 3.6% caused fatalities). The most frequently perceived reasons for falling asleep at the wheel were poor sleep in the previous night (42.5%) and poor sleeping habits in general (34.1%). Falling asleep was more frequent in the Netherlands [odds ratio = 3.55 (95% confidence interval: 1.97; 6.39)] and Austria [2.34 (1.75; 3.13)], followed by Belgium [1.52 (1.28; 1.81)], Portugal [1.34 (1.13, 1.58)], Poland [1.22 (1.06; 1.40)] and France [1.20 (1.05; 1.38)]. Lower odds were found in Croatia [0.36 (0.21; 0.61)], Slovenia [0.62 (0.43; 0.89)] and Italy [0.65 (0.53; 0.79)]. Individual determinants of falling asleep were younger age; male gender [1.79 (1.61; 2.00)]; driving ≥20 000 km year [2.02 (1.74; 2.35)]; higher daytime sleepiness [7.49 (6.26; 8.95)] and high risk of obstructive sleep apnea syndrome [3.48 (2.78; 4.36) in men]. This Pan European survey demonstrates that drowsy driving is a major safety hazard throughout Europe. It emphasizes the importance of joint research and policy efforts to reduce the burden of sleepiness at the wheel for European drivers.

Upregulation of Inflammatory Genes and Downregulation of Sclerostin Gene Expression Are Key Elements in the Early Phase of Fragility Fracture Healing

Background Fracture healing is orchestrated by a specific set of events that culminates in the repair of bone and reachievement of its biomechanical properties. The aim of our work was to study the sequence of gene expression events involved in inflammation and bone remodeling occurring in the early phases of callus formation in osteoporotic patients. Methodology/Principal Findings Fifty-six patients submitted to hip replacement surgery after a low-energy hip fracture were enrolled in this study. The patients were grouped according to the time interval between fracture and surgery: bone collected within 3 days after fracture (n = 13); between the 4th and 7th day (n = 33); and after one week from the fracture (n = 10). Inflammation- and bone metabolism-related genes were assessed at the fracture site. The expression of pro-inflammatory cytokines was increased in the first days after fracture. The genes responsible for bone formation and resorption were upregulated one week after fracture. The increase in RANKL expression occurred just before that, between the 4th–7th days after fracture. Sclerostin expression diminished during the first days after fracture. Conclusions The expression of inflammation-related genes, especially IL-6, is highest at the very first days after fracture but from day 4 onwards there is a shift towards bone remodeling genes, suggesting that the inflammatory phase triggers bone healing. We propose that an initial inflammatory stimulus and a decrease in sclerostin-related effects are the key components in fracture healing. In osteoporotic patients, cellular machinery seems to adequately react to the inflammatory stimulus, therefore local promotion of these events might constitute a promising medical intervention to accelerate fracture healing.

Patterns in the use of medicines by university students in Maputo, Mozambique

Patterns in the use of medicines are expected to reflect distinct health features between populations. This study aimed to describe the self-reported use of medication by a sample of university students in Maputo, Mozambique. We conducted a survey of 797 students in a private university in Maputo. Participants completed a questionnaire including socio-demographic data and pattern of medication use in the preceding month. Information was collected on the number and names of drugs, duration of use, and prescription. The drugs were grouped according to therapeutic indication. In the previous month, 56% of students had used at least one pharmaceutical drug, with higher prevalence for women (65.2% vs. 42.2%) and men attending health-related courses (67.4% vs. 53.2%). The most commonly used medicines were anti-inflammatory/analgesic drugs (62.2%), anti-infectives (25.9%), and vitamins/minerals (13.6%). The most frequently used single drugs were paracetamol (42.8%), amoxicillin (12.6%), and ibuprofen (8.4%). Duration of use was lowest for anti-inflammatory/analgesic drugs and highest for oral contraceptives. Use of medication by Mozambican students was similar to that observed in other university populations.

Sagittal standing posture, back pain, and quality of life among adults from the general population: a sex-specific association.

Study Design. A prospective radiographical study of sagittal standing posture among adults consecutively recruited from the general population. Objective. To analyze the relation of suboptimal sagittal standing posture with back pain and health-related quality of life in general adult males and females. Summary of Background Data. Clinical studies have shown the association of sagittal standing posture with pain and reduced quality of life, but this relation has not been assessed in the general adult population. Methods. As part of the EPIPorto population-based study of adults, 178 males and 311 females were evaluated. Age, education, and body mass index were recorded. Radiographical data collection consisted of 36-in. standing sagittal radiographs. Creation of 3 groups for individual spinopelvic parameters was performed (low, intermediate, or high), and 1 of 4 sagittal types of postural patterns attributed to each participant (Roussouly classification). Back pain prevalence and severity were assessed on the basis of self-reported data and health-related quality of life using 2 main components of the 36-Item Short Form Health Survey. Results. In males, differences in back pain severity were observed only among pelvic tilt/pelvic incidence ratio groups. Females presenting high pelvic incidence and sacral slope exhibited higher odds of severe back pain than those with intermediate values (adjusted odds ratios = 2.21 and 2.15; 95% confidence interval, 1.24–3.97 and 1.21–3.86; respectively). Sagittal vertical axis showed the largest differences in physical quality of life of females: high group had 8.8 lower score than the low group (P < 0.001), but this result lost statistical significance after adjustment for age, education, and body mass index. Conclusion. Sagittal standing posture was not consistently associated with quality of life measures in males. Increased pelvic incidence and sacral slope may be involved in causing severe back pain among females. Monitoring sagittal postural parameters has limited usefulness as a screening tool for causes of unspecific musculoskeletal symptoms in the general adult population. Level of Evidence: 3

HIV testing among Portuguese men who have sex with men – results from the European MSM Internet Survey (EMIS)

To describe HIV testing behaviour and context of MSM in Portugal participating in the European MSM Internet Survey (EMIS).

Early Initiation of Smoking and Alcohol Drinking as a Predictor of Lower Forearm Bone Mineral Density in Late Adolescence: A Cohort Study in Girls

Background Adolescence is a critical stage for bone accrual. It is also decisive for the establishment of behaviors such as smoking and alcohol drinking. Objective To quantify the short- and long-term associations between smoking and drinking initiation and bone mineral density in adolescent girls. Methods We used prospective data from 731 girls identified in public and private schools in Porto, Portugal. Evaluations were conducted when participants were 13 and 17 years old. Bone mineral density (BMD) was measured at the forearm by dual-energy X-ray absorptiometry and weight, height and fat-free mass were measured. Pubertal development status was estimated using menarche age. Self-administered questionnaires were used to collect data on smoking and alcohol drinking, physical exercise and calcium and vitamin D intakes. BMD in early and late adolescence was analyzed as a continuous or dichotomous (Z-score cutoff: −1.0) variable. Associations were calculated using linear or logistic regression. Results Over one quarter of these girls had tried smoking by 13, while 59% had drunk alcoholic beverages and 20% had experienced both behaviors by that age. Lower mean BMD at 17 years of age was observed in girls who had ever smoked by 13, as well as in those who reported drinking at that age. There were no significant cross-sectional associations between experience and frequency of smoking or drinking and BMD at 13 years of age. However, we observed significant associations between BMD z-score<−1 in late adolescence and having ever smoked by 13, after adjustment for menarche age and sports practice, (OR = 1.92; 95% CI: 1.21, 3.05) and with ever smoking and drinking in the same period (OR = 2.33; 95% CI: 1.36, 4.00). Conclusion Our study adds prospective evidence to the role of early initiation of smoking and alcohol drinking as relevant markers of lower bone mineral density in late adolescence.

Self-reported data on reproductive variables were reliable among postmenopausal women

OBJECTIVE We aimed to assess the reliability of self-reported reproductive variables in postmenopausal women. STUDY DESIGN AND SETTING We evaluated 535 women in two interviews, as part of the recruitment and first follow-up of a cohort of Portuguese adults. Median time between evaluations was 5 years. Women were inquired about sociodemographic characteristics, cognitive status, and reproductive history: gravidity, parity, lifetime use of oral contraceptives, menopausal status, age at menopause, hysterectomy, oophorectomy, and lifetime use of hormone replacement therapy (HRT). RESULTS Age at menopause was consistent within 1 year for 66% of women and agreement was higher in women reporting surgical menopause. Reliability regarding age at menopause decreased with time since menopause. Gravidity was consistent for 81% of women, whereas parity was consistent for 94%. The proportion of different answers regarding number of pregnancies and number of live births was higher in women with high gravidity and parity, respectively. Agreement was 96% for hysterectomy and 92% for oophorectomy. The proportion of consistent reports was 90% for oral contraceptives and 93% for HRT. Women with higher education reported parity and HRT more reliably. CONCLUSION Agreement was over 90% for self-reported parity, hysterectomy, oophorectomy, and HRT, which supports their use in analytical studies.

Gender and psychosocial context as determinants of fibromyalgia symptoms (fibromyalgia research criteria) in young adults from the general population

OBJECTIVE To quantify the prevalence of FM (FM research criteria), to describe its components-symptom severity score (SSS) and widespread pain index (WPI)-and to identify biopsychosocial predictors of the severity of SSS as well as WPI using a population-based sample of young adults. METHODS Participants were part of the 21-year-old follow-up of the EPITeen cohort, which was set up during the 2003-04 school year and comprised subjects born in 1990 attending schools in Porto, Portugal (n = 1719, 51.4% women). Data on biopsychosocial characteristics were collected, and FM-related information was gathered using the Fibromyalgia Survey Questionnaire. Sex-specific multivariate log-binomial regression coefficients (β) and 95% CI were used to quantify the associations between adverse biopsychosocial characteristics and high scores in SSS and WPI. RESULTS The overall point-prevalence of FM was 1.0%. Women scored significantly higher in SSS and WPI when compared with men. Global psychological distress was strongly and significantly associated with high scores in SSS in women and men (respectively, low sleep quality, β = 1.44, 95% CI 1.05, 1.84 and β = 1.19, 95% CI 0.78, 1.61; depressive symptoms, β = 1.64, 95% CI 1.23, 2.06 and β = 1.14, 95% CI 0.60, 1.70; eating disorders, β = 1.17, 95% CI 0.71, 1.63 and β = 1.15, 95% CI 0.52, 1.78). In women, adverse socioeconomic factors were predictors of high scores in SSS, whereas in men these contexts were significantly associated with high scores in WPI. CONCLUSION In young adulthood, psychological distress was particularly consistent in predicting SSS and may become useful as a red flag for the establishment of clinical disease.

Associations between a priori -defined dietary patterns and longitudinal changes in bone mineral density in adolescents

OBJECTIVE To quantify short- and long-term associations between dietary patterns defined a priori and bone mineral density (BMD) during adolescence. DESIGN Dietary patterns were defined at 13 years old using a Mediterranean diet (MD) quality index, the Dietary Approaches to Stop Hypertension (DASH) diet index and the Oslo Health Study (OHS) dietary index. Linear regression coefficients were used to estimate associations between dietary patterns and forearm BMD at 13 and 17 years, measured by dual-energy X-ray absorptiometry. SETTING Public and private schools of Porto, Portugal. SUBJECTS The EPITeen cohort comprising 1180 adolescents born in 1990, recruited at schools during the 2003/2004 school year and re-evaluated in 2007/2008. RESULTS In girls, at 13 years, mean BMD (g/cm2) in the first and third tertiles was 0·369 and 0·368 for the MD pattern, 0·368 and 0·369 for the DASH diet, and 0·370 and 0·363 for the OHS index. In boys, mean BMD (g/cm2) in the first and third tertiles was 0·338 and 0·347 for the MD pattern, 0·342 and 0·346 for the DASH diet, and 0·344 and 0·342 for the OHS index. None of these differences were significant. Mean BMD at 17 years and prospective variation were also not significantly different between tertiles of adherence to each score. However, a trend of increased BMD at 13 years with greater adherence to the MD pattern was observed in boys (adjusted coefficient = 0·248; 95% CI 0·052, 0·444). CONCLUSIONS The selected dietary patterns may not capture truly important dietary differences in determining BMD or diet may not be, beyond nutrient adequacy, a limiting determinant of BMD.