An algorithm for the National Institute of Health Stroke Scale assessment: A multicenter, two-arm and cluster randomized study.

BACKGROUND: The NIH Stroke Scale (NIHSS) is a validated tool for assessing stroke severity, increasingly used by general practitioners in telemedicine services. Mobile apps may enhance its reliability. We aim to validate a digital platform (SPOKES) for NIHSS assessment in telemedicine and healthcare settings. METHODS: Hospitals using a telemedicine service were randomly allocated to control or SPOKES-user groups. The discrepancy between the NIHSS scores reported and those confirmed by experts was evaluated. Healthcare providers from comprehensive stroke centers were invited for interrater validation. Participants were randomized to assess the NIHSS using videos of real patients. Weighted Kappa (wk) statistics analyzed the agreement, and logistic regression determined the correlation with the congruency. RESULTS: A total of 299 telemedicine consultations from 12 hospitals were included. The difference between the NIHSS scores reported and double-checked was lower in the SPOKES group (p = 0.03), with a significantly higher level of complete agreement (72.5 % vs. 50.4 %, p = 0.005). Adoption of SPOKES was associated with complete congruency (OR 4.01, 95 %CI 1.42-11.35, p = 0.009). For interrater validation, 20 participants were considered. In the SPOKES group, almost-perfect and strong agreement occurred in 13.3 %(n = 6/45) and 84.4 %(n = 38/45) of ratings, respectively; in the control group, 6.7 %(n = 3/45) were almost-perfect, 28.9 %(n = 13/45) strong and 51 %(n = 23/45) were minimal. CONCLUSION: A free and reliable mobile application for NIHSS assessment can significantly improve interrater agreement between healthcare professionals, and between NIHSS-certified neurologists and general practitioners. Our results underscore the importance of ongoing training and education in enhancing the consistency and reliability of NIHSS scores.

Current perspectives on the management of refractory or relapsed classic hodgkin lymphoma in brazil: Balancing efficacy, safety, and tolerability.

Classic Hodgkin lymphoma (CHL), which accounts for 90-95% of all cases of Hodgkin lymphoma, is the most frequent cancer in adolescents and the most frequent lymphoma in adolescents and young adults. Despite progressive improvements over past decades and the general sensitivity of CHL to frontline chemotherapy, approximately 10-15% of patients have refractory disease that either does not respond to such therapy or progresses after an initial partial response. In patients with refractory or relapsed disease, standard treatment until recently consisted mainly of salvage chemotherapy, in many cases followed by high-dose chemotherapy and autologous stem-cell transplantation. However, improved understanding of the pathobiology of CHL, coupled with the introduction of novel agents, has markedly changed the treatment landscape in the past decade. Although refractory or relapsed CHL continues to be challenging, the therapeutic landscape is undergoing profound changes brought about by novel agents, particularly brentuximab vedotin and immunotherapy. In this review, we discuss the most salient treatment options for adult patients with refractory or relapsed CHL, with a special focus on the Brazilian healthcare setting, which is constrained by inherent characteristics of this system. In the attempt to balance efficacy, safety and tolerability, practicing physicians must rely on clinical trials and on results from real-world studies, and use their own point of view and experience, as well as patient characteristics and previous therapy, to make treatment decisions for refractory or relapsed CHL.

Therapeutic Ultrasound Alone and Associated with Lymphatic Drainage in Women with Breast Engorgement: A Clinical Trial.

Introduction: Breast engorgement (BE) is a problem that affects many women, especially in the first days of breastfeeding, producing inflammatory symptoms. Nonpharmacological therapies are inexpensive, safe, and can produce symptom relief. Objective: This study aims to analyze the safety of therapeutic ultrasound regarding possible risks of overheating and the effects of its use alone and associated with lymphatic drainage (LD) in women. Material and Methods: Effectiveness is measured through thermography, visual analog scale, and six-point scale of BE. This is a nonrandomized clinical trial with a sample of 34 in the ultrasound group (G1), 28 in the ultrasound and LD group (G2), and 37 in the control group (G3). Results: The mean reduction for engorgement was 1.3 ± 0.8 to G1, 1.4 ± 1.0 to G2, and 1.2 ± 0.9 to G3 according to the six-point scale. The mean reduction for pain level was 3.6 ± 2.1 to G1, 4.0 ± 3.1 to G2, and 4.0 ± 2.2 to G3 according to the visual analogue scale. Conclusion: It was observed that all therapies were effective in reducing the level of engorgement, according to the six-point scale. However, combined ultrasound and LD therapy has been shown to be more effective in reducing the level of pain. Brazilian Registry of Clinical Trials (RBR-6btb6zz).

Do Neuroprognostic Studies Account for Self-Fulfilling Prophecy Bias in Their Methodology? The SPIN Protocol for a Systematic Review.

Self-fulfilling prophecy bias occurs when a perceived prognosis leads to treatment decisions that inherently modify outcomes of a patient, and thus, overinflate the prediction performance of prognostic methods. The goal of this series of systematic reviews is to characterize the extent to which neuroprognostic studies account for the potential impact of self-fulfilling prophecy bias in their methodology by assessing their adequacy of disclosing factors relevant to this bias. Methods: Studies evaluating the prediction performance of neuroprognostic tools in cardiac arrest, malignant ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and spontaneous intracerebral hemorrhage will be identified through PubMed, Cochrane, and Embase database searches. Two reviewers blinded to each other's assessment will perform screening and data extraction of included studies using Distiller SR and following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will abstract data pertinent to the methodology of the studies relevant to self-fulfilling prophecy bias. Results: We will conduct a descriptive analysis of the data. We will summarize the reporting of mortality according to timing and mode of death, rates of exposure to withdrawal of life-sustaining therapy, reasoning behind limitations of supportive care, systematic use of standardized neuroprognostication algorithms and whether the tool being investigated is part of such assessments, and blinding of treatment team to results of neuroprognostic test being evaluated. CONCLUSIONS: We will identify if neuroprognostic studies have been transparent in their methodology to factors that affect the self-fulfilling prophecy bias. Our results will serve as the foundation for standardization of neuroprognostic study methodologies by refining the quality of the data derived from such studies.

Strokes in Patients With Injection Drug Use and Tricuspid Valve Endocarditis - A Case Series.

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients.

Circulating extracellular vesicles as a predictive biomarker for acute graft-versus-host disease.

The diagnosis and management of graft-versus-host disease (GVHD) have remained important challenges in allogeneic stem cell transplantation (allo-SCT). Novel diagnostic methods and therapeutic interventions are needed to further improve on patient outcomes. Extracellular vesicles (EV) are microvesicles formed by the inversion of the phospholipid bilayer of different cellular subtypes and have been described as biomarkers of cellular damage, activation, and intercellular signaling in numerous clinical scenarios. We studied the association between the levels of EV and the incidence of acute GVHD (aGVHD). Forty patients undergoing allo-SCT for hematological malignancies had their plasma collected at neutrophil engraftment. Using flow cytometry combined with fluorescent beads, the total circulating EV count (TEV) was established with annexin V positivity; CD61 positivity was used for platelet-derived EV (PEV), and CD235 positivity, for erythrocyte-derived EV (EryEV). TEV counts greater than 516/µL were associated with a higher cumulative incidence (CI) of grade II to IV aGVHD (54% vs. 21%; p = 0.02), as were EryEV counts above 357 /µL (CI of aGVHD: 59% vs. 26%; p = 0.04). In patients who are exposed to reduced intensity conditioning (RIC), stronger associations of both high TEV and EryEV counts with aGVHD were observed (77% vs. 22%; p = 0.003 and 89% vs. 27%; p = 0.002, respectively). PEV levels were not associated with the risk of aGVHD. Our data suggest that the measurement of cell-derived EV at engraftment can be used as a preemptive biomarker for acute GVHD.

Antifungal analysis of incorporation of the essential oil of Cymbopogon citratus (D.C.) Stapf into polymethyl methacrylate / Análise antifúngica da incorporação do óleo essencial de Cymbopogon citratus (d.c.) Stapf em polimetacrilato de metila

ABSTRACT Objective: Evaluated the antifungal effect of the incorporation of different concentrations of the essential oil Cymbopogon citratus (capim santo), into polymethylmethacrylate (PMMA) against Candida albicans. Methods: Fifty specimens were fabricated and divided into five groups: Group 1, PMMA + 10% essential oil (n=10); Group 2, PMMA + 15% essential oil (n=10); Group 3, PMMA + 20% essential oil (n=10); Group 4, PMMA + 25% essential oil (n=10); Group 5, PMMA (n=10). PMMA powder was mixed with the monomer and the mixture was placed in disc-shaped cavities measuring 15 mm in diameter, 2 mm thick. To evaluate the antifungal activity of the experimental specimens, the standard strain of Candida albicans was tested. After incubation, the colony count of each plate was performed using a digital colony counter, obtaining the number of colony forming units (CFU) and the Kruskal-Wallis test was applied. Results: There was statistically significant difference in the CFU count of Candida albicans as a consequence of the addition of Cymbopogon citratus essential oil to PMMA (p < 0.001) and values were significantly higher in comparison with those of all the other groups, when the essential oil was incorporated as incorporated into the PMMA in the concentration of 20%. In the other concentrations, no difference in values was observed in comparison with the Control Group without essential oil of Cymbopogon citratus. Conclusion: The acrylic resin with the essential oil incorporated into it in different concentrations provided no effect against development of the genus Candida.

RESUMO Objetivo: Avaliar o efeito antifúngico da incorporação de diferentes concentrações do óleo essencial Cymbopogon citratus (capim santo), em polimetilmetacrilato (PMMA) contra Candida albicans. Métodos: Cinquenta corpos de prova foram confeccionados e divididos em cinco grupos: Grupo 1, PMMA + 10% de óleo essencial (n=10); Grupo 2, PMMA + 15% de óleo essencial (n=10); Grupo 3, PMMA + 20% de óleo essencial (n=10); Grupo 4, PMMA + 25% de óleo essencial (n=10); Grupo 5, PMMA (n=10). O pó de PMMA foi misturado ao monômero e a mistura foi colocada em cavidades em forma de disco medindo 15 mm de diâmetro por 2 mm de espessura. Para avaliar a atividade antifúngica dos espécimes experimentais, foi testada a cepa padrão de Candida albicans. Após a incubação, foi realizada a contagem de colônias de cada placa por meio de um contador digital de colônias, obtendo-se o número de unidades formadoras de colônias (UFC) e para isso foi aplicado o teste de Kruskal-Wallis. Resultados: Houve diferença estatisticamente significativa na contagem de UFC de Candida albicans como consequência da adição do óleo essencial de Cymbopogon citratus ao PMMA (p < 0,001) e os valores foram significativamente maiores em comparação com todos os outros grupos, quando o essencial óleo foi incorporado como incorporado ao PMMA na concentração de 20%. Nas demais concentrações, não houve diferença nos valores em relação ao Grupo Controle sem óleo essencial de Cymbopogon citratus. Conclusão: A resina acrílica com o óleo essencial incorporado a ela em diferentes concentrações não apresentou efeito contra o desenvolvimento do gênero Candida.

Chronic Myelogenous Leukemia with Double Philadelphia Chromosome and Coexpression of p210 and p190 Fusion Transcripts.

The Philadelphia (Ph+) chromosome, t(9;22)(q34;q11.2), originates from a chimeric gene called BCR-ABL and is present in more than 90% of CML patients. Most patients with CML express the protein p210 BCR-ABL and, with a frequency lower than 5%, express rare isoforms, the main one being p190. In the transition from the chronic phase to the blast phase (BP), additional chromosomal abnormalities, such as the presence of the double Ph+ chromosome, are revealed. Of the 1132 patients analyzed via molecular biology in this study, two patients (0.17%) showed the co-expression of the p210 and p190 isoforms for the BCR-ABL transcript, with the concomitant presence of a double Ph+ chromosome, which was observed via conventional cytogenetics and confirmed by fluorescent in situ hybridization. The BCR-ABL/ABL% p210 and p190 ratio increased in these two patients from diagnosis to progression to blast crisis. To our knowledge, this is the first report in the literature of patients who co-expressed the two main BCR-ABL transcript isoforms and concomitantly presented Ph+ chromosome duplication. The evolution from the chronic phase to BP often occurs within 5 to 7 years, and, in this study, the evolution to BP was earlier, since disease-free survival was on average 4.5 months and overall survival was on average 9.5 months. The presence of the p190 transcript and the double Ph+ chromosome in CML may be related to the vertiginous progression of the disease.

Coxsackievirus A6 strains causing an outbreak of hand-foot-and-mouth disease in Northeastern Brazil in 2018.

Hand-foot-and-mouth disease (HFMD) is a highly contagious viral disease commonly associated to Enteroviruses (EV). During 2018, Brazil faced massive HFMD outbreaks spread across the country. This study aimed to characterize the EV responsible for the HFMD outbreak that occurred in Paraiba State, Brazilian Northeastern region, in 2018, followed by a phylogenetic analysis to detail information on its genetic diversity. A total of 49 serum samples (one from each patient) collected from children ≤ 15 years old, clinically diagnosed with HFMD were tested for EV using conventional RT-PCR and RT-qPCR. EV infection was confirmed in 71.4% (35/49) of samples. The mean and median ages were 1.83 years and one year old, respectively. Twenty-two EV-positive samples were successfully sequenced and classified as EV-A species; 13 samples were also identified with the CV-A6 genotype. The phylogenetic analysis (VP1 region) of three samples revealed that the detected CV-A6 strains belonged to sub-lineage D3. The CV-A6 strains detected here clustered with strains from South America, Europe and West Asia strains that were also involved in HFMD cases during the 2017-2018 seasons, in addition to the previously detected Brazilian CV-A6 strains from 2012 to 2017, suggesting a global co-circulation of a set of different CV-A6 strains introduced in the country at different times. The growing circulation of the emerging CV-A6 associated with HFMD, together with the detection of more severe cases worldwide, suggests the need for a more intense surveillance system of HFMD in Brazil. In addition, this investigation was performed exclusively on serum samples, and the analysis of whole blood samples should be considered and could have shown advantages when employed in the diagnosis of enteroviral HFMD outbreaks.

Coxsackievirus A6 strains causing an outbreak of hand-foot-and-mouth disease in Northeastern Brazil in 2018

ABSTRACT Hand-foot-and-mouth disease (HFMD) is a highly contagious viral disease commonly associated to Enteroviruses (EV). During 2018, Brazil faced massive HFMD outbreaks spread across the country. This study aimed to characterize the EV responsible for the HFMD outbreak that occurred in Paraiba State, Brazilian Northeastern region, in 2018, followed by a phylogenetic analysis to detail information on its genetic diversity. A total of 49 serum samples (one from each patient) collected from children ≤ 15 years old, clinically diagnosed with HFMD were tested for EV using conventional RT-PCR and RT-qPCR. EV infection was confirmed in 71.4% (35/49) of samples. The mean and median ages were 1.83 years and one year old, respectively. Twenty-two EV-positive samples were successfully sequenced and classified as EV-A species; 13 samples were also identified with the CV-A6 genotype. The phylogenetic analysis (VP1 region) of three samples revealed that the detected CV-A6 strains belonged to sub-lineage D3. The CV-A6 strains detected here clustered with strains from South America, Europe and West Asia strains that were also involved in HFMD cases during the 2017-2018 seasons, in addition to the previously detected Brazilian CV-A6 strains from 2012 to 2017, suggesting a global co-circulation of a set of different CV-A6 strains introduced in the country at different times. The growing circulation of the emerging CV-A6 associated with HFMD, together with the detection of more severe cases worldwide, suggests the need for a more intense surveillance system of HFMD in Brazil. In addition, this investigation was performed exclusively on serum samples, and the analysis of whole blood samples should be considered and could have shown advantages when employed in the diagnosis of enteroviral HFMD outbreaks.

Admission Lymphocytopenia is Associated with Urinary Tract Infection and Nosocomial Infections in Hemorrhagic Stroke.

OBJECTIVE: Growing evidence suggests that lymphocytopenia on admission (LOA) is associated with infectious complications and poor outcomes in intracerebral hemorrhage (ICH). Whether LOA preferentially increases the risk for community acquired infections or nosocomial infections is unknown. This study investigates the relationship between LOA and nosocomial infections in a cohort of patients with ICH in a safety-net hospital. MATERIAL AND METHODS: This is a single center, observational, retrospective study of 213 patients with non-traumatic ICH admitted to the neurocritical care unit between 2008 and 2014. Patients' clinical, demographic, lab and radiologic data were retrieved from institutional electronic medical records. Nosocomial infection was defined as clinical onset 48 h after admission. RESULTS: Prevalence of LOA was 24.8%. Patients with LOA showed significant associations with mechanical ventilation (67.9% versus 49.4%; p= 0.019), higher median ICH score (2 versus 1; p=0.006), nosocomial infection (43.4% versus 28.0%; p=0.038), nosocomial UTI (24.5% versus 8.9%; p=0.003). Adjusting for baseline covariates in a multivariate logistic regression, we observed an association of LOA with nosocomial UTI (OR, 3.66 [95% CI, 1.36-9.88], p=0.010). From the Cox proportional model, patients with LOA had 1.76 times the hazard of developing of nosocomial infection, compared to those without LOA ([95% CI: 1.01, 3.07], p=0.046) and had 3.27 times the hazard of developing nosocomial UTI, compared to those without LOA ([95% CI: 1.39, 7.67], p=0.007). CONCLUSIONS: This study is the first to show that LOA is associated with nosocomial urinary tract infections and significantly shorter times to develop nosocomial infections.

Ecological constraints to match field and preferred temperatures in lizards Tropidurus catalanensis (Squamata; Tropiduridae).

We compared microhabitat and body temperatures in the field with thermal preferences of Tropidurus catalanensis to investigate if they match or diverge as demonstration respectively of suitability or poor-quality of the thermal environment. As T. catalanensis is subjected to variable thermal conditions along its distribution and may be jeopardized by the climate change, we measured its thermal preferences after exposure to milder (17 °C-27 °C) and warmer (22 °C-32 °C) thermal conditions to evaluate acclimatory responses and tolerances and vulnerabilities to warming. Field body temperatures tended to be similar to minimum preferred body temperatures, and microhabitat and body temperatures in the field were cooler in the remaining comparisons with thermal preferences [preferred (Tpref), set-point range (Tset), minimum preferred (Tpref_min) and maximum preferred (Tpref_max) body temperatures], suggesting there was a constraint to warming up in nature. The minimum preferred body temperatures may be a threshold separating proper functioning from markedly noxious impacts due to progressive impairment by the cooling. Difficulties to warm and keep suitable body temperatures may jeopardize overall ecophysiological and behavioral processes with implications for maintenance, fitness, and survival. The constraints to warm may impact T. catalanensis differently depending on its body size and its properties of heat conservation (thermal inertia). Smaller and larger T. catalanensis may respectively cool down easier and have difficulties to warm up, being jeopardized by the constraints due to the cold. The warmer preferred body temperatures coupled with the cooler microhabitats and bodies in nature complicate to anticipate how individuals will respond to climate change, but the acclimation to the warmer temperatures led six of them to death, suggesting they had limited tolerance to heat and would be vulnerable to global warming.

Severe Acute Respiratory Syndrome Coronavirus 2 P.2 Lineage Associated with Reinfection Case, Brazil, June-October 2020.

A 37-year-old healthcare worker from the northeastern region of Brazil experienced 2 clinical episodes of coronavirus disease. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by reverse transcription PCR in samples collected 116 days apart. Whole-genome sequencing revealed that the 2 infections were caused by the most prevalent lineage in Brazil, B.1.1.33, and the emerging lineage P.2. The first infection occurred in June 2020; Bayesian analysis suggests reinfection at some point during September 14-October 11, 2020, a few days before the second episode of coronavirus disease. Of note, P.2 corresponds to an emergent viral lineage in Brazil that contains the mutation E484K in the spike protein. The P.2 lineage was initially detected in the state of Rio de Janeiro, and since then it has been found throughout the country. Our findings suggest not only a reinfection case but also geographic dissemination of the emerging Brazil clade P.2.

Amphibians and reptiles from the Parque Nacional da Tijuca, Brazil, one of the world's largest urban forests / Anfíbios e répteis do Parque Nacional da Tijuca, Brasil, uma das maiores florestas urbanas do mundo

Abstract: The Parque Nacional da Tijuca in Rio de Janeiro, Brazil, is considered to be one of the world's largest urban forests, however no systematic inventory of its herpetofauna is available. In the present study, we surveyed the amphibians and reptiles of this park to assess its species composition (including secondary data) and obtain estimates of species richness and abundance. We conducted active searches (460 hours) between January 2013 and December 2015. We identified the taxa endemic to either the Atlantic Forest or Rio de Janeiro state, and verified the conservation status of each species in the international, Brazilian, and state red lists. We also estimated the species richness and sampling sufficiency by rarefaction curves and Bootstrap richness estimator, and analyzed the distribution of the species abundance in Whittaker plots. We recorded 3,288 individuals over 36 months, representing 24 species of amphibians and 25 reptiles. The cumulative species curves, rarefaction, and the richness estimated indicated that sampling effort was adequate. Species abundance adjusted to the log-series model in both amphibians and reptiles. The four most abundant amphibians represented 70% of the individuals recorded in this group, while the two most abundant reptiles represented 60% of the total individuals. The inclusion of the secondary data raised the number of amphibian species to 38, and the number of reptiles to 36. Approximately 80% of the amphibian species and 28% of the reptile species recorded are endemic to the Atlantic Forest, and six of the amphibian species are endemic to Rio de Janeiro state. Six amphibian species and one reptile species are classified under some threat of extinction, and two reptile species were exotic. The considerable diversity of the herpetofauna of the Parque Nacional da Tijuca, which includes endemic and threatened species, reflects the effectiveness of the reforestation of this protected area and emphasizes the importance of its conservation.

Resumo: O Parque Nacional da Tijuca, no Rio de Janeiro, Brasil, é considerado uma das maiores florestas urbanas do mundo, no entanto nenhum inventário sistemático de sua herpetofauna está disponível. No presente estudo, pesquisamos os anfíbios e répteis deste parque para acessar sua composição de espécies (incluindo dados secundários) e obter estimativas da riqueza e da abundância de espécies. Realizamos buscas ativas (460 horas) entre janeiro de 2013 e dezembro de 2015. Identificamos os taxa endêmicos da Mata Atlântica ou do estado do Rio de Janeiro, e verificamos o status de conservação de cada espécie nas listas vermelhas internacional, brasileira e estadual. Também estimamos a riqueza de espécies e a suficiência amostral através de curvas de rarefação e do estimador de riqueza Bootstrap, e analisamos a distribuição de abundância das espécies através de plots de Whittaker. Registramos 3.288 indivíduos ao longo dos 36 meses, representando 24 espécies de anfíbios e 25 de répteis. As curvas cumulativas de espécies, a rarefação, e a riqueza estimada indicaram que o esforço amostral foi adequado. A abundância das espécies se ajustou ao modelo de série logarítmica tanto para os anfíbios como para os répteis. As quatro espécies de anfíbios mais abundantes representaram 70% dos indivíduos registrados neste grupo, enquanto as duas espécies de répteis mais abundantes representaram 60% do total de indivíduos. A inclusão dos dados secundários elevou o número de espécies de anfíbios para 38 e o de répteis para 36. Aproximadamente 80% dos anfíbios e 28% dos répteis registrados são endêmicos da Mata Atlântica e seis espécies de anfíbios são endêmicos do estado do Rio de Janeiro. Seis espécies de anfíbios e uma de réptil estão classificadas sob alguma ameaça de extinção, e dois répteis constituem espécies exóticas. A considerável diversidade da herpetofauna do Parque Nacional da Tijuca, que inclui espécies endêmicas e ameaçadas, reflete a efetividade do reflorestamento dessa área protegida e enfatiza a importância de sua conservação.

Safety and Feasibility of Outpatient High Dose Cytarabine for Acute Myeloid Leukemia in the Brazilian Amazon.

Background: The attempt to manage patients with acute myeloid leukemia as outpatients has become increasingly common due to high hospitalization costs, low availability for beds and patient preference. Publications on the subject are scarce, especially in low-income regions and the safety in this population remains to be determined. The present study aims to assess the safety of consolidation with high-dose cytarabine in the outpatient setting. Materials and Methods: We retrospectively analyzed 39 patients who underwent consolidation with high-dose cytarabine, between 2009 and 2018, at Ophir Loyola Hospital, in Belém, Brazil. Patients treated after 2015 were given high-dose cytarabine as outpatients due to the decision of medical staff. Results: Twenty-seven patients received 76 cycles of cytarabine as outpatients; males were 48.14% of the total population, with a median age of approximately 45 years. The occurrence of delay between cycles was significantly lower among outpatients (48.14% vs. 83.33%, p = 0.04). There was no difference in relapse rates, transfusion requirements and non-relapse mortality between both groups. Hospitalization was required in 40.74% of patients during outpatient cycles and 18.51% of blood cultures were positive for pathogens. Non-relapse mortality was significantly higher among patients above 50 years old and treated on an outpatient basis (44.4% vs. 5.60%, p = 0.03). Conclusion: High-dose cytarabine administration on an outpatient basis appears to be safe and effective in a low-income population at the Brazilian Amazon region, but toxicity seems to be increased for patients older than 50 years.

Intravenous tPA for Acute Ischemic Stroke in Patients with COVID-19.

BACKGROUND/PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with increased risk of acute ischemic stroke (AIS), however, there is a paucity of data regarding outcomes after administration of intravenous tissue plasminogen activator (IV tPA) for stroke in patients with COVID-19. METHODS: We present a multicenter case series from 9 centers in the United States of patients with acute neurological deficits consistent with AIS and COVID-19 who were treated with IV tPA. RESULTS: We identified 13 patients (mean age 62 (±9.8) years, 9 (69.2%) male). All received IV tPA and 3 cases also underwent mechanical thrombectomy. All patients had systemic symptoms consistent with COVID-19 at the time of admission: fever (5 patients), cough (7 patients), and dyspnea (8 patients). The median admission NIH stroke scale (NIHSS) score was 14.5 (range 3-26) and most patients (61.5%) improved at follow up (median NIHSS score 7.5, range 0-25). No systemic or symptomatic intracranial hemorrhages were seen. Stroke mechanisms included cardioembolic (3 patients), large artery atherosclerosis (2 patients), small vessel disease (1 patient), embolic stroke of undetermined source (3 patients), and cryptogenic with incomplete investigation (1 patient). Three patients were determined to have transient ischemic attacks or aborted strokes. Two out of 12 (16.6%) patients had elevated fibrinogen levels on admission (mean 262.2 ± 87.5 mg/dl), and 7 out of 11 (63.6%) patients had an elevated D-dimer level (mean 4284.6 ±3368.9 ng/ml). CONCLUSIONS: IV tPA may be safe and efficacious in COVID-19, but larger studies are needed to validate these results.