Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis.

AIMS: Frailty is common in patients with atrial fibrillation (AF), with possible impact on therapies and outcomes. However, definitions of frailty are variable, and may not overlap with frailty perception among physicians. We evaluated the prevalence of frailty as perceived by enrolling physicians in the Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular AF (ETNA-AF)-Europe registry (NCT02944019), and compared it with an objective frailty assessment. METHODS AND RESULTS: ETNA-AF-Europe is a prospective, multi-centre, post-authorization, observational study. There we assessed the presence of frailty according to (i) a binary subjective investigators' judgement and (ii) an objective measure, the Modified Frailty Index. Baseline data on frailty were available in 13 621/13 980 patients. Prevalence of perceived frailty was 10.6%, with high variability among participating countries and healthcare settings (range 5.9-19.6%). Conversely, only 5.0% of patients had objective frailty, with minimal variability (range 4.5-6.7%); and only <1% of patients were identified as frail by both approaches. Compared with non-frailty-perceived, perceived frail patients were older, more frequently female, and with lower body weight; conversely, objectively frail patients had more comorbidities. Non-recommended edoxaban dose regimens were more frequently prescribed in both frail patient categories. CONCLUSIONS: Physicians' perception of frailty in AF patients is variable, mainly driven by age, sex, and weight, and quite different compared with the results of an objective frailty assessment. Whatever the approach, frailty appears to be associated with non-recommended anticoagulant dosages. Whether this apparent inappropriateness influences hard outcomes remains to be assessed.

2,5-Diketopiperazines via Intramolecular N-Alkylation of Ugi Adducts: A Contribution to the Synthesis, Density Functional Theory Study, X-ray Characterization, and Potential Herbicide Application.

To investigate the herbicidal potential of 2,5-diketopiperazines (2,5-DKPs), we applied a known protocol to produce a series of 2,5-DKPs through intramolecular N-alkylation of Ugi adducts. However, the method was not successful for the cyclization of adducts presenting aromatic rings with some substituents at the ortho position. Results from DFT calculations showed that the presence of voluminous groups at the ortho position of a benzene ring results in destabilization of the transition structure. Lower activation enthalpies for the SN2-type cyclization of Ugi adducts were obtained when bromine, instead of a chlorine anion, is the leaving group, indicating that the activation enthalpy for the cyclization step controls the formation of the 2,5-DKP. Some Ugi adducts and 2,5-DKPs formed crystals with suitable qualities for single-crystal X-ray diffraction data collection. Phytotoxic damage of some 2,5-DKPs on leaves of the weed Euphorbia heterophylla did not differ from those caused by the commercial herbicide diquat.

A pressão arterial central como fator de risco cardiovascular / Central blood pressure as cardiovascular risk factor

A pressão arterial central (PAC) é o valor de pressão obtido na aorta ou nos demais vasos centrais. A ejeção ventricular gera uma onda de pulso que é transmitida pela árvore arterial e refletida na periferia, voltando em direção ao coração. A análise não-invasiva desta onda permite calcular a PAC e outros parâmetros relacionados a circulação central e rigidez arterial. O interesse pela PAC cresceu muito após o desenvolvimento de métodos não-invasivos e confiáveis para sua determinação. Desta forma, é crescente o número de publicações sobre o assunto, demonstrando que a PAC se correlaciona muito bem tanto com desfechos subclínicos, como p. ex. a extensão da aterosclerose coronária e hipertrofia ventricular esquerda, quanto com eventos cardiovasculares maiores e mortalidade. Em geral, esta correlação é mais intensa que com a pressão braquial convencional. A relação entre a PA central e periférica também pode ser muito útil. Fisiologicamente existe um aumento da pressão arterial sistólica (PAS) e da pressão de pulso (PP) da circulação central para a periférica. Uma menor amplificação da pressão, que está relacionada a rigidez arterial, também se associa com desfechos negativos. Neste artigo descreveremos os principais estudos que demonstram ser a PAC um fator de risco independente para eventos cardiovasculares e mortalidade cardiovascular e global.

Central blood pressure (CBP) is the pressure obtained at the aortic root or other central vessels. The left ventricular ejection create a pulse wave that travels through the arterial tree and is reflected at the peripheral circulation, going back towards the heart. This pulse wave can be analyzed non-invasively to calculate CBP and other parameters of central circulation. The interest on CBP has greatly increased after the development of these non-invasive and reliable methods to its assessment. Therefore, the number of publications regarding this matter has greatly increased. They demonstrate that CBP has a good correlation with subclinical outcomes as the extent of coronary atherosclerosis and left ventricular hypertrophy, as well as major cardiovascular events and mortality. On an overview, outcomes better relate to CBP than conventional brachial blood pressure. The relation between CBP and peripheral blood pressure can also be useful. There is a physiological increase of the systolic blood pressure and pulse pressure from the central circulation towards the peripheral circulation, which can be reduced by arterial stiffness. This lesser pressure amplification correlates directly to arterial stiffness and negative outcomes. The major studies that demonstrated that CBP is an independent risk factor for cardiovascular events, cardiovascular death and mortality for all causes, will be discussed in this article.

Hipertensão arterial, diabetes mellitus e síndrome metabólica: do conceito à terapêutica / Hypertension, diabetes mellitus and metabolic syndrome: from concept to therapy

Apesar dos avanços ocorridos na prevenção e tratamento da Hipertensão Arterial Sistêmica (HAS), esta continua sendo a mais frequente das doenças crônicas não transmissíveis e o principal fator de risco para doenças cardiovasculares e mortalidade. É um importante problema de saúde pública, estando frequentemente associada ao Diabetes Mellitus (DM) e à Síndrome Metabólica (SM), condições também altamente prevalentes que compartilham com a HAS algumas características: elevado risco cardiovascular; aumento progressivo de prevalência com a idade; relação direta com hábitos de vida inadequados; além de um número cada vez maior de indivíduos afetados. Quando presentes no mesmo indivíduo, estas enfermidades aumentam ainda mais o risco de morbidade e mortalidade cardiovascular (CV). São essenciais medidas preventivas, reconhecimento precoce destas enfermidades e abordagem terapêutica adequada. Esse artigo revisa os conceitos e os principais aspectos da Fisiopatologia, do risco CV e da abordagem terapêutica da HAS, do DM e da SM, com base em estudos clínicos e nas principais diretrizes dessas áreas.

Despite recent discoveries in prevention and treatment of hypertension, it remains the most frequent chronic disease and the main risk factor for cardiovascular morbidity and mortality. It constitutes an important public health problem and is often associated with diabetes mellitus and metabolic syndrome. These conditions share important features with hypertension: progressive prevalence with age, direct association with inadequate life habits, and an increasing number of affected persons in population. When coexisting in the same person, these disorders greatly increase the risk of cardiovascular morbidity and mortality. Preventive measures, early recognition and adequate therapeutic approaches are very important. This article reviews the concepts and the main aspects of the pathophysiology of cardiovascular risk and therapeutic management of hypertension, diabetes and metabolic syndrome from clinical studies and the main guidelines in these areas.

Chemical alterations in soils fertirrigated with wastewater from swine facilities / Alteraciones químicas en suelos fertirrigados con aguas residuales porcícolas / Alterações químicas em solos fertirrigados com águas residuais suinicolas

The increasing size of swine farms poses an environmental risk to water bodies, considering that manure is generally applied to croplands without appropriate agronomic criteria. Objective: the present work aimed to evaluate various chemical changes occurring in soils fertirrigated with filtrated wastewater from swine facilities (FWS). Methods: 21 drainage lysimeters filled with Dystrophic Red-Yellow Latossoil were cultivated with tomato plants in protected environments, and fertirrigated with several doses of FWS, with and without fertilizer addition. Treatments were: T1: control (provided the recommended irrigation and fertilization needs for tomato plants). Treatments T2, T3, and T4, provided 100, 150, and 200% of recommended nitrogen (N), respectively, by adding filtered swine wastewater. Treatments T5, T6, and T7 provided equivalent N percentages with fertilizer addition. The experiment was conducted in a completely randomized design (seven treatments and three replications). Results: compared with initial conditions, an increase in the concentration of available phosphorus was observed, mainly in the superficial layers. The FWS addition resulted in increments in N concentration in the superficial layers, while chemical fertilizer application resulted in larger displacements in the soil profile. Conclusion: chemical fertilization was more effective than FWS for ionizing the soil solution.

El aumento en el tamaño de las granjas porcinas supone un riesgo ambiental para los cuerpos de agua, teniendo en cuenta que el estiércol se aplica generalmente a las tierras de cultivo sin adecuados criterios agronómicos. Objetivo: el presente trabajo tuvo como objetivo evaluar los diversos cambios químicos que ocurren en los suelos fertirrigados con aguas residuales de instalaciones porcícolas (FWS). Métodos: 21 lisímetros de drenaje llenos con Latosuelo distrófico rojo-amarillo fueron cultivados con plantas de tomate en ambientes protegidos, y fertirrigados con varias dosis de FWS, con y sin adición de fertilizante. Los tratamientos fueron: T1: control (proveía la irrigación y fertilización recomendada para las necesidades de las plantas de tomate). Los tratamientos T2, T3 y T4 suministraron el 100, 150 y 200%, respectivamente, del nitrógeno (N) recomendado, mediante la adición de las aguas residuales filtradas. Los tratamientos T5, T6 y T7 proporcionaron los mismos porcentajes de N mediante la adición de fertilizantes. El experimento se realizó en un diseño completamente al azar (siete tratamientos y tres repeticiones). Resultados: al comparar con las condiciones iniciales, se observó un aumento en la concentración de fósforo disponible, sobre todo en las capas superficiales. La adición de FWS resultó en incrementos en la concentración de N en las capas superficiales, mientras que la aplicación de fertilizantes químicos resultó en grandes desplazamientos en el perfil del suelo. Conclusión: la fertilización química fue más eficaz que el FWS para ionizar la solución del suelo.

O incremento de tamanho das granjas de suínos supõe um risco ambiental para os corpos de água, tendo em conta que as fezes dos porcos aplicam-se geralmente em terras para culturas sem ter em conta critérios agronômicos adequados. Objetivo: este trabalho teve como objetivo avaliar a alteração química que ocorre em solos adubados com irrigação de água residuária de suinocultura filtrada (FWS). Métodos: 21 lisímetros de drenagem cheios com latossolo distrófico vermelho-amarelo foram cultivados com tomateiros em ambientes protegidos e fertirrigados com varias doses de FWS, com e sem adição de adubo químico. Os tratamentos foram: T1: controle (ministrou-se a irrigação e fertilização recomendada para as necessidades do tomateiro). Os tratamentos T2, T3 e T4 ministraram 100, 150 e 200%, respectivamente, do nitrogênio (N) recomendado, por médio da adição de águas residuais filtradas. Os tratamentos T5, T6 e T7 proporcionaram as mesmas percentagens de N por médio da adição de adubos químicos. O experimento se analisou com um modelo completamente aleatorizado (sete tratamentos e três repetições). Resultados: ao comparar as condições iniciais, observou-se um aumento na concentração de fósforo disponível, principalmente nas capas superficiais. A adição de FWS resultou em incrementos da concentração de N nas capas superficiais, enquanto a aplicação de adubos químicos resultou em grandes deslocamentos no perfil do solo. Conclusão: A adubação química foi mais eficaz que o FWS para ionizar a solução do solo.

[Ileocecal valve reconstruction in dogs]. / Reconstituição da válvula ileocecal em cães.

PURPOSE: The importance of keeping the ileocecal valve in the intestinal ressections has been reported by several authors. When preserved, the ileocecal valve was related to a longer survival and prevention of the short bowel syndrome, due to its ability to block the colonic content reflux into the ileum and to avoid the rapid empting of the ileal content into the cecum. It was assessed a tecnique of ileocecal valve reconstitution, based on vesicoureteral anti-reflux tecniques. METHODS: Fourteen beagles were operated. Seven underwent ileocecal valve reconstitution following the tecnique proposed and in the other seven a simple end-to-end anastomosis was performed. To assess the new valve, it was done the clinical follow up, the microbiologic analysis and the manometric study. RESULTS: Clinically, during 45 days of follow up, there was no difference between the dogs with and without ileocecal reconstitution. In the aerobic bacteria analysis, the predominant bacterium was Escherichia coli. Quantitatively, the cultures grew in an irregular way, so that it was not able to compare the bacterial growth between the groups with or without ileocecal valve. The new valve had a colo-ileal reflux pressure similar to that of the physiological valve (P > 0.05). However, when compared to the non valve group, the reflux pressures of the physiological valve and new valve were significantly higher, with P < 0.05 and P < 0.001, respectively. CONCLUSION: In this study, the reconstituted ileocecal valve served as a barrier to the colo-ileal reflux just as the physiological valve does.

[Trauma in the elderly]. / Trauma no idoso.

The populational growth of the elderly, associated to a healthier and more active life, make this group of people more exposed to accidents. In some countries, trauma in the elderly is responsible for a high mortality rate, disproportionately higher than in the adults. This fact consumes a great portion of health care resources and implies in a high social cost. The distinct physiologic characteristics of the elderly and the frequent presence of associated diseases make that these patients behave differently and in a more complex way than patients of other ages. These particularities make that health care to the elderly victims of trauma have to be different. The present revision is about aspects of epidemiology, prevention, physiology, health care and rehabilitation of the elderly victims of trauma.