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Depression affects over 300 million individuals worldwide and is responsible for most of the 800,000 annual suicides. Clinical practice guidelines (CPGs) for treatment of depression, founded on scientific evidence, are essential to improve patient care. However, economic and sociocultural factors may influence CPG elaboration, potentially leading to divergences in their recommendations. Consequently, we analyzed pharmacological recommendations for the treatment of depression from the most relevant CPGs. We included four CPGs with scores ≥ 80% for Domain 3 (rigor of development) on the Appraisal of Guidelines for Research and Evaluation and two other commonly used CPGs. The recommendations, their strengths, and the level of evidence were extracted from each CPG by two independent researchers and grouped as follows: (1) general recommendations for the pharmacological treatment for depression (suicide risk, acute treatment, continuation and maintenance phases, and treatment discontinuation); (2) treatment of non-responsive or partially responsive patients; and (3) treatment for subtypes of depression (chronic, psychotic, catatonic, melancholic, seasonal, somatic, mixed, and atypical). Only 50% of CPGs included recommendations for the risk of suicide associated with pharmacotherapy. All CPGs included serotonin selective reuptake inhibitors (SSRIs) as first-line treatment; however, one CPG also included agomelatine, milnacipran, and mianserin as first-line alternatives. Recommendations for depression subtypes (catatonic, atypical, melancholic) were included in three CPGs. The strength of recommendation and level of evidence clearly differed among CPGs, especially regarding treatment augmentation strategies. We conclude that, although CPGs converged in some recommendations (e.g., SSRIs as first-line treatment), they diverged in cardinal topics including the absence of recommendations regarding the risk of suicide associated with pharmacotherapy. Consequently, the recommendations listed in a specific CPG should be followed with caution.

Introduction. Spontaneous bacterial peritonitis (SBP) has a deleterious clinical impact in end-stage liver disease, and multidrug resistance has increased, raising concern about effectiveness of traditional antibiotic regimens. Patients and Methods. Single-center retrospective study of ascitic fluid infections in cirrhotic patients. Results. We analyzed medical records related to 2129 culture-positive ascitic fluid and found 183 samples from cirrhotic patients. There were 113 monobacterial SBP cases from 97 cirrhotic patients; 57% of patients were male; hepatitis C and alcohol were the main etiologies for cirrhosis. Multidrug resistant bacteria were isolated in 46.9% of SBP samples, and third-generation cephalosporin and quinolone resistant reached 38.9% and 25.7% of SBP cases. Conclusion. SBP due to multidrug resistant bacteria is a growing problem, and one should consider reported resistance profiles for the decision-making process of empirical first-line treatment prescription.

This study aimed to evaluate the prevalence of serum IgG dengue in children in an Amazonian population, to assess the seroconversion rate in 12 months, and to estimate how many seropositive children had a prior clinical diagnosis of dengue. We conducted a population-based study between 2010 and 2011, with children aged 6 months to 12 years that were living in the urban area of a small town in the Brazilian Amazon. The prevalence of IgG antibodies against dengue antigens was determined by indirect ELISA technique, and seronegative children were reexamined after 12 months to determine seroconversion rates. Results showed seroprevalence of IgG antibodies against dengue type of 2.9%, with no significant association between age, race, and sex. In seropositive children, only 8.4% had received a clinical diagnosis of dengue, and the ratio of clinically diagnosed cases and subclinical cases was 1 : 11. The seroconversion rate between 2010 and 2011 was 1.4% (CI 3.8% to 35.1%). The seroprevalence of dengue in this pediatric population was low, and the vast majority of cases were not clinically detected, suggesting a difficulty in making the clinical diagnosis in children and a high frequency of asymptomatic infections.

Background and aimsQuantifying systemic inflammation (SI) in acutely decompensated cirrhosis (ADC) is of major importance because SI is a driver of the most severe forms of ADC, including acute-on-chronic liver failure (ACLF). Blood biomarkers of SI already evaluated in ADC failed to appropriately assess SI in ADC. We aimed to investigate whether gene expression related to circulating immune cells could quantify SI in ADC.MethodsStandard biomarkers (white cell count, C reactive protein, cytokines) and genome-wide RNA expression (RNA-sequencing) were obtained in blood from 700 patients with ADC at the time of their hospital admission. A composite score based on standard biomarkers of SI (Chronic Liver Failure-Standard Biomarkers Composite (CLIF-SBC) score) and a gene score (CLIF-Systemic Inflammation Gene (SIG) score) composed of the 28 top differentially expressed immune cell-related genes in the comparison between high-severity and low-severity clinical phenotypes were computed. Among the 700 patients, the CLIF-SIG score was repeated once during follow-up in 375 patients, and 3 times or more in 46 patients.ResultsThe CLIF-SIG score was more accurate in reflecting clinical severity induced by SI than the CLIF-SBC score (area under the curve 0.803 vs 0.658). A CLIF-SIG score of 0.386 (Youden Index) was the best cut-off level discriminating patients with poor outcomes from the others, in all clinical scenarios. Sequential measurement of the CLIF-SIG score showed that 78% of patients were admitted at the peak or descending part of the SI-wave. ACLF developed during hospitalisation in 80% of patients with a CLIF-SIG score >0.386 on admission.ConclusionsIn patients with ADC, the CLIF-SIG score is an accurate estimator of SI, clinical course severity and prognosis.

BackgroundAcute-on-chronic liver failure (ACLF) of various aetiologies is a complex syndrome with high short-term mortality and significant global burden.ObjectiveTo explore easily applicable diagnostic criteria and an accurate prognostic score for ACLF.DesignClinical data from 5288 patients (after exclusions from 7388 screened) with acute deterioration of chronic liver disease across various aetiologies were used to evaluate the performance of European Chronic Liver Failure (CLIF) and Chinese Group on the Study of Severe Hepatitis B (COSSH) criteria. Three non-Asian cohorts were performed to validate the results.ResultsCLIF criteria categorised 844 patients as ACLF (28-day/90-day liver transplantation (LT)-free mortality: 40.7%/57.0%; 321 with non-hepatitis B virus (HBV) aetiology, 523 with HBV aetiology), while COSSH criteria categorised 2038 patients as ACLF (mortality: 27.3%/41.0%; 602 with non-HBV aetiology, 1436 with HBV aetiology). COSSH criteria identified 22.6% (1194/5288) more patients (mortality: 19.1%/31.4%) compared with CLIF criteria, including 14.2% non-HBV patients (mortality: 15.9%/33.3%). COSSH criteria produced a more reasonable epidemiological pyramid-like distribution across severity grades (grades 1–3: 63.4%/27.5%/9.1% vs CLIF’s grades 1–3: 25.8%/56.3%/17.9%). COSSH-ACLF II score showed the highest predictive values for 28-day/90-day LT-free mortality in both cirrhotic and all ACLF patients with various aetiologies, outperforming the CLIF-C ACLF and other scores. The comparable performance of China-CLIFs (renamed from COSSH-ACLFs) was validated in three non-Asian cohorts.ConclusionsThis study evaluated the broader applicability of the China-CLIF framework across diverse aetiologies and varying severity levels of ACLF. These findings may provide a valuable foundation for harmonising ACLF diagnostic and prognostic system.

Introduction Vaccines are very important to reduce morbidity and mortality by preventable infectious diseases, especially during childhood. Optimal coverage is not always achieved, for several reasons. Here we assessed vaccine coverage for the first 12 months of age in children between 12 and 59 months old, residing in the urban area of a small Amazonian city, and factors associated with incomplete vaccination. Methods A census was performed in the urban area of Assis Brasil, in the Brazilian Amazon, in January 2010, with mothers of 282 children aged 12 to 59 months old, using structured interviews and data from vaccination cards. Mixed logistic regression was used to determine factors associated with incomplete vaccination schemes. Results Only 82.6% of all children had a completed the basic vaccine scheme for the first year of life. Vaccine coverage ranged from 52.7% coverage (oral rotavirus vaccine) to 99.7% coverage (for Bacille Calmette-Guérin). The major deficiencies occurred in doses administered after the first six months of life. Incomplete vaccination was associated with not having enough income to buy a house (aOR = 2.12, 95% CI 1.06-4.21), low maternal schooling (aOR = 2.60, 95% CI 1.28 – 5.29) , and time of residence of the child in the urban area of the city (aOR = 0.73, 95% CI 0.55 – 0.95). Conclusions This study showed that vaccine coverage in the first twelve months of life in Assis Brasil is similar to other areas in the Amazon and it is below the coverage postulated by the Brazilian Ministry of Health. Low vaccine coverage was associated with socioeconomic inequities that still prevail in the Brazilian Amazon. Short and long-term strategies must be taken to update child vaccines and increase vaccine coverage in the Amazon.

OBJETIVO: Avaliamos a possibilidade de realizar ablaçao por cateter com uso exclusivo de mapeamento eletroanatômico (MEA), dispensando a fluoroscopia. Comparamos o tempo total de procedimento e as taxas de sucesso contra a técnica que utiliza fluoroscopia (FLUORO) com emissao de raios X. MÉTODOS: Foram selecionados e comparados todos os casos de ablaçoes realizados no IC-FUC de maio a julho de 2011, sendo excluídos estudos eletrofisiológicos diagnósticos, ablaçao de fibrilaçao atrial e casos em que as duas técnicas foram usadas. RESULTADOS: Das 87 ablaçoes realizadas no período, 82 foram com FLUORO e apenas cinco com MEA. Nao houve diferença de idade e sexo entre os grupos. Nao ocorreu diferença entre o tempo de realizaçao do exame (FLUORO = 80,9 min ± 27,8 min vs MEA = 83,4 min ± 20,3 min; p = 0,84) nem diferença entre sucesso imediato (avaliado na alta hospitalar) dos procedimentos (FLUORO = 80,5% vs MEA = 80%; p = 0,57). Nao houve complicaçoes durante os procedimentos. Conclusao: A introduçao do MEA abriu novas possibilidades terapêuticas para pacientes portadores de arritmias, diminuindo riscos da radiaçao em procedimentos que envolvam a fluoroscopia. Neste estudo, de maneira inicial, foi possível demonstrar que é viável a realizaçao de ablaçoes apenas com o uso do MEA, com tempo e sucesso semelhantes aos com uso de fluoroscopia. Sao necessários estudos maiores e randomizados comparando as duas técnicas.

O artigo busca compreender o Libra, criptomoeda anunciada por uma associação de empresas de projeção internacional, através da discussão de questionamentos jurídicos e econômicos acerca da sua viabilidade enquanto moeda e seus efeitos sobre o ambiente jurídico-institucional. Assim, como objetivos específicos, visa-se analisar o contexto por trás do desenvolvimento da criptomoeda Libra, direcionando tal estudo para o entendimento de suas bases, protocolos, e a sua conceituação diante do ambiente financeiro. Através de uma metodologia hipotético-dedutiva, são tratadas hipóteses a serem testadas, inicialmente a possibilidade econômica de sua atuação como moeda e, por outro lado, os efeitos resultantes sobre a questão da soberania estatal, ambas hipóteses direcionadas aos objetivos traçados. Os resultados obtidos apontam um conflito entre as abordagens jurídica e econômica do Libra, no qual a utilização dessa enquanto é amparada pela dinâmica econômica, no entanto, produz efeitos desmobilizadores sobre a soberania dos Estados.

Abstract Despite the process of nutritional transition in Brazil, in some places, such as the Amazon region, stunting is still an important public health problem. We identified the prevalence and factors associated with stunting in children under five years old residing in the urban area of Assis Brasil. A survey was conducted in which a questionnaire on socioeconomic, maternal and children’s conditions was applied, and height or length was measured. The children with height for age index below -2 Z-scores were considered stunted, according to the criteria by the World Health Organization. Four hundred and twenty-eight children were evaluated. Of these, 62 were stunted. Factors associated with stunting, according to adjusted models, were: the presence of open sewer, the wealth index for households, the receipt of governmental financial aid and the mother’s height, age and education. Therefore, it was observed that family and the mother’s characteristics as well as environmental and socioeconomic factors were closely related to the occurrence of stunting in the population studied, and such nutritional disturbance is still a health problem in the Brazilian Amazon. Resumo Apesar do processo de transição nutricional no Brasil, em alguns lugares, como a região amazônica, o nanismo ainda é um importante problema de saúde pública. Identificou-se a prevalência e fatores associados ao déficit de crescimento em crianças menores de cinco anos de idade residentes na área urbana de Assis Brasil. Um inquérito foi realizado utilizando instrumento semiestruturado sobre características socioeconômicas, maternas e das crianças, e foram aferidas medidas antropométricas. As crianças com índice de estatura para idade inferior a -2 escores-Z foram consideradas com déficit de crescimento, de acordo com os critérios da Organização Mundial da Saúde. Quatrocentos e vinte e oito crianças foram avaliadas. Destas, 62 apresentaram déficit de crescimento. Os fatores associados à baixa estatura, de acordo com modelos ajustados, foram: presença de esgoto a céu aberto, índice de riqueza para as famílias, recebimento de ajuda financeira governamental, altura materna, idade e escolaridade maternas. Portanto, observou-se que as características familiares e da mãe, bem como fatores ambientais e socioeconômicos estavam intimamente relacionados com a ocorrência de déficit de crescimento na população estudada, e que a desnutrição ainda é um problema de saúde na Amazônia brasileira.