Brazilian guide to nutrition in bariatric and metabolic surgery.

PURPOSE: Brazilian nutrition recommendations for bariatric and metabolic surgery aim to provide knowledge, based on scientific evidence, on nutritional practices related to different surgical techniques in the surgical treatment of obesity and metabolic diseases. MATERIALS AND METHODS: A systematic literature search was carried out with the appropriate MeSH terms using Medline/Pubmed/LiLACS and the Cochrane database, with the established criteria being based on the inclusion of articles according to the degree of recommendation and strength of evidence of the Classification of Recommendations, Evaluation, Development, and Evaluation System (GRADE). RESULTS: The recommendations that make up this guide were gathered to assist in the individualized clinical practice of nutritionists in the nutritional management of patients with obesity, including nutritional management in the intragastric balloon; pre and postoperative nutritional treatment and supplementation in bariatric and metabolic surgeries (adolescents, adults, elderly, pregnant women, and vegetarians); hypoglycemia and reactive hyperinsulinemia; and recurrence of obesity, gut microbiota, and inflammatory bowel diseases. CONCLUSION: We believe that this guide of recommendations will play a decisive role in the clinical practice of nutritionists who work in bariatric and metabolic surgery, with its implementation in health services, thus promoting quality and safety in the treatment of patients with obesity. The concept of precision nutrition is expected to change the way we understand and treat these patients.

Evaluation of the ratio of different major and trace elements in the lens of dogs with cataract.

BACKGROUND: Understanding the elements that support cataract development and searching for available therapeutic methods is essential for scientific and social interest. For that purpose, the role of trace elements has been investigated in this study to better understand the development of cataracts in dogs. OBJECTIVE: The aim of this study was to evaluate the ratio of the major and trace elements by X-ray fluorescence spectrometry in dog cataract lenses to contribute to diagnostic, non-surgical, and ophthalmological preventive data. METHODS: A single lens with a cataract from each of a total of 88 dogs (cataract group) and a healthy lens from each of 6 dogs (control group) were evaluated. The elements calcium (Ca), iron (Fe), copper (Cu), zinc (Zn), magnesium (Mg), manganese (Mn), and potassium (K) were analyzed by energy dispersive X-ray fluorescence and X-ray microfluorescence. RESULTS: The results indicated an increase of Ca, Fe, Cu, and Zn, in association with the reabsorption mechanism of hypermature cataracts. CONCLUSIONS: The ratio of elements Ca, Fe, Cu, and Zn was different in cataract lenses than in healthy lenses, and our results may support the development of therapeutic strategies for cataracts in dogs. The Ca concentrations were distinct in the cataract development stages, and the Fe concentration was relatively higher in males when compared to females. Finally, this research stands out with a particular contribution to the understanding of both cataract formation and prevention.

Detection of Streptococcus mutans in symptomatic and asymptomatic infected root canals.

OBJECTIVES: To investigate the presence of Streptococcus mutans in root canals of symptomatic necrotic teeth (SNT) and their associated acute apical abscesses (AAA) and in the root canals of asymptomatic necrotic teeth (ANT). It also aimed to investigate the presence of the cnm and cbm genes in specimens that harbored S. mutans. MATERIALS AND METHODS: DNA was extracted from samples collected from 10 patients presenting pulpal necrosis associated with radiographic evidence of apical periodontitis (ANT) and from 10 patients in need of endodontic therapy due to the presence of pulpal necrosis (SNT) and AAA. The control group consisted of 10 patients with teeth with normal vital pulp and requiring endodontic treatment for prosthetic reasons. The presence of S. mutans was detected by quantitative real-time-PCR (qPCR) using species-specific primers. Samples harboring S. mutans were further evaluated for the presence of CBP genes by qPCR as well. RESULTS: All studied sites showed a high prevalence of S. mutans, except the control group. Specifically, 60% of ANT and 70% of AAA/SNT paired samples were positive for S. mutans. The cnm gene was detected positive for S. mutans only in ANT samples (66.6%). The cbm gene was not detected in any of the investigated sites. CONCLUSIONS: S. mutans was found in high prevalence in both asymptomatic and symptomatic endodontic infections, including in abscesses, but it was not detected in the root canals of teeth with normal vital pulp. Interestingly, cnm+ S. mutans was only detected in asymptomatic/chronic primary endodontic infections associated with apical lesion. Therefore, it appears that cnm, and possibly other CBPs, may play an underestimated role in chronic endodontic infections. CLINICAL RELEVANCE: A high prevalence of Streptococcus mutans cnm+ gene was detected only in asymptomatic primary endodontic infections associated with apical lesion. Therefore, it appears that this collagen-binding protein gene plays an underestimated role in asymptomatic/chronic endodontic infections.

Hybrid neural network modeling and particle swarm optimization for improved ethanol production from cashew apple juice.

A hybrid neural model (HNM) and particle swarm optimization (PSO) was used to optimize ethanol production by a flocculating yeast, grown on cashew apple juice. HNM was obtained by combining artificial neural network (ANN), which predicted reaction specific rates, to mass balance equations for substrate (S), product and biomass (X) concentration, being an alternative method for predicting the behavior of complex systems. ANNs training was conducted using an experimental set of data of X and S, temperature and stirring speed. The HNM was statistically validated against a new dataset, being capable of representing the system behavior. The model was optimized based on a multiobjective function relating efficiency and productivity by applying the PSO. Optimal estimated conditions were: S0 = 127 g L-1, X0 = 5.8 g L-1, 35 °C and 111 rpm. In this condition, an efficiency of 91.5% with a productivity of 8.0 g L-1 h-1 was obtained at approximately 7 h of fermentation.

Challenging and Practical Aspects of Nutrition in Chronic Graft-versus-Host Disease.

There is a paucity of information about nutrition in chronic graft-versus-host disease (GVHD). The role of nutrition is important because malnutrition is strongly associated with severe chronic GVHD manifestations. There is a high prevalence of metabolic syndrome and osteoporosis in this setting. Here we review the literature, describe main aspects of nutrition and discuss macronutrients (ie, vitamins), micronutrients (ie, Mg, Zn, Ca, and K) and supplements (probiotics and omega 3 fatty acids). A search was carried out in March 2020 using PubMed. Databases were screened for searching terms in titles and abstracts referring to chronic GVHD, nutrition intervention, protein, and body composition. Data were extracted for the following outcomes: nutrition, nutrition intervention, chronic GVHD, nutrition deficiencies, diet, vitamin, dry eye, probiotic, protein, and body composition. In this report, we summarize interventional nutrition studies reported in oncology and metabolic syndrome settings and describe our nutritional clinical practice in hematopoietic cell transplantation and chronic GVHD. The impact of nutrition evaluation and intervention on muscle mass loss, dry eye, dysgeusia, metabolic syndrome, osteoporosis, and comorbidities associated with chronic GVHD need to be studied prospectively.

A short overview on mycophenolic acid pharmacology and pharmacokinetics.

Immunosuppressive therapy is used in solid organ transplant treatment, and mycophenolic acid (MPA) is one of the immunosuppressive drugs most used worldwide. It is a potent, selective, non-competitive, and reversible inosine monophosphate dehydrogenase (IMPDH) inhibitor that acts to inhibit guanine synthesis. To improve solubility, MPA is used as the prodrug mycophenolate mofetil (MMF) or as an enteric-coated mycophenolate sodium salt (EC-MPS). It is metabolized into mycophenolic acid phenyl glucuronide (MPAG), the inactive and major metabolite, and into acyl glucuronide (AcMPAG), pharmacologically active. In kidney transplantation, combined immunosuppressive therapy with cyclosporine (CsA) and tacrolimus (Tac) is widely used, showing beneficial effects. This paper aimed to review papers published in the last two decades and discuss factors that can interfere with the pharmacokinetics of MPA. Data collected confirm that MPA plasma levels should be monitored to evaluate immunosuppressive therapy since pharmacokinetics can be influenced by factors such as interpatient variability, coadministration of other immunosuppressive agents, post-transplant period, renal function, and dose. However, to perform drug monitoring, costs and facility may be limitations. Monitoring MPAG together with MPA would be a great improvement in therapy as it represents a big part of MPA levels and can be related to the increase of adverse effects.

Association of oral toxicity and taste changes during hematopoietic stem cell transplantation: a preliminary study.

PURPOSE: The aim of this study was to characterize the taste changes and taste bud atrophy observed in the period of neutropenia of HCT and to determine the influence of transplantation toxicity on these changes. METHODS: Autologous and allogeneic HCT patients (n = 51) were selected to perform taste acuity tests prior to conditioning (T0) and during neutropenia (T1). The frequency and time duration of oral mucositis, presence of tongue depapillation, and salivary flow rate were also evaluated. Quality of life was assessed using specific questionnaires. RESULTS: We observed a significant increase in hypogeusia (66.6%, p = 0.001) and dysgeusia (21.4%, p = 0.013) at T1, compared with T0. Bitter taste was the most altered, mainly when the patient underwent conditioning with melphalan (OR = 4.47, p = 0.049). Prolonged oral mucositis (≥ 8 days) (OR = 5.62, p = 0.039) and autologous transplantation (OR = 4.08, p = 0.033) were predictive factors for tongue depapillation. Changes in sour taste (OR = 10.70, p = 0.045) and reduced salivary flow (OR = 21.00, p = 0.013) were associated to body weight loss at T1. Taste changes significantly reduced the quality of life at T1, compared with T0. CONCLUSIONS: Frequency of hypogeusia was high in the neutropenia period of the HCT. None of the taste changes was determined by oral mucositis, tongue depapillation, or reduced salivary flow, but melphalan conditioning reduced the bitter taste sensation. Loss of body weight and poor quality of life were associated with taste changes and reduced salivary flow. Further studies are necessary to elucidate this association and the risk factors for taste changes in HCT.

Identity leadership: Managing perceptions of conflict for collective action.

We argue that how players perceive the attack-defense game might matter far more than its actual underlying structure in determining the outcomes of intergroup conflict. Leaders can use various tactics to dynamically modify these perceptions, from collective victimization to the distortion of the perceived payoffs, with some followers being more receptive than others to such leadership tactics.

Impact of Oral and Gastrointestinal Mucositis on Body Weight Alterations during Hematopoietic Stem Cell Transplantation.

The aim of this study was to evaluate whether digestive tract mucositis is a predictive factor for body weight (BW) alterations during hematopoietic stem cell transplantation (HSCT). Data about characteristics of transplantation, initial nutritional conditions and gastrointestinal mucositis were collected from adult patients (n = 105) who underwent autologous and allogeneic HSCT. Oral mucositis (OM) was not a predictive factor for BW loss, but it was an independent factor for BW gain in autologous HSCT (ß = 0.329, P = 0.021). Busulfan-fludarabine conditioning regimen (ß = 1.531, P = 0.011) and gender (ß = 1.109, P = 0.038) were significant independent risk factors for BW loss in allogeneic HSCT. Overall survival (OS) was significantly affected by the duration of OM in autologous HSCT (HR = 1.243, P = 0.008). In allogeneic HSCT, BW loss (HR = 1.308, P = 0.049) and diarrhea (HR = 1.139, P = 0.012) interfered significantly with OS. In conclusion, OM was not a risk factor for BW loss, but it influenced BW gain and had a negative impact on OS in autologous HSCT patients. Intestinal mucositis explained partially the BW loss and had a negative impact on OS in allogeneic HSCT.

Mathematical modeling of the ethanol fermentation of cashew apple juice by a flocculent yeast: the effect of initial substrate concentration and temperature.

In this work, the effect of initial sugar concentration and temperature on the production of ethanol by Saccharomyces cerevisiae CCA008, a flocculent yeast, using cashew apple juice in a 1L-bioreactor was studied. The experimental results were used to develop a kinetic model relating biomass, ethanol production and total reducing sugar consumption. Monod, Andrews, Levenspiel and Ghose and Tyagi models were investigated to represent the specific growth rate without inhibition, with inhibition by substrate and with inhibition by product, respectively. Model validation was performed using a new set of experimental data obtained at 34 °C and using 100 g L-1 of initial substrate concentration. The model proposed by Ghose and Tyagi was able to accurately describe the dynamics of ethanol production by S. cerevisiae CCA008 growing on cashew apple juice, containing an initial reducing sugar concentration ranging from 70 to 170 g L-1 and temperature, from 26 to 42 °C. The model optimization was also accomplished based on the following parameters: percentage volume of ethanol per volume of solution (%V ethanol/V solution), efficiency and reaction productivity. The optimal operational conditions were determined using response surface graphs constructed with simulated data, reaching an efficiency and a productivity of 93.5% and 5.45 g L-1 h-1, respectively.

Serine/threonine acetylation of TGFß-activated kinase (TAK1) by Yersinia pestis YopJ inhibits innate immune signaling.

The Gram-negative bacteria Yersinia pestis, causative agent of plague, is extremely virulent. One mechanism contributing to Y. pestis virulence is the presence of a type-three secretion system, which injects effector proteins, Yops, directly into immune cells of the infected host. One of these Yop proteins, YopJ, is proapoptotic and inhibits mammalian NF-κB and MAP-kinase signal transduction pathways. Although the molecular mechanism remained elusive for some time, recent work has shown that YopJ acts as a serine/threonine acetyl-transferase targeting MAP2 kinases. Using Drosophila as a model system, we find that YopJ inhibits one innate immune NF-κB signaling pathway (IMD) but not the other (Toll). In fact, we show YopJ mediated serine/threonine acetylation and inhibition of dTAK1, the critical MAP3 kinase in the IMD pathway. Acetylation of critical serine/threonine residues in the activation loop of Drosophila TAK1 blocks phosphorylation of the protein and subsequent kinase activation. In addition, studies in mammalian cells show similar modification and inhibition of hTAK1. These data present evidence that TAK1 is a target for YopJ-mediated inhibition.

Obstructive sleep apnea predisposes to nonalcoholic Fatty liver disease in patients with polycystic ovary syndrome.

OBJECTIVE: Some studies have shown a higher prevalence of nonalcoholic fatty liver disease (NAFLD) and obstructive sleep apnea (OSA) in patients with polycystic ovary syndrome (PCOS). The objective of this study was to assess NAFLD in PCOS women with and without OSA. A possible role of high serum androgen levels in the development of OSA in PCOS women was also investigated. METHODS: Biochemical, hormonal, and polysomnography parameters were determined in 38 premenopausal PCOS patients. NAFLD was evaluated by ultrasound. Testosterone was measured by an immunoassay. RESULTS: Serum androgen levels and the prevalence of NAFLD (83.3% vs. 26.9%; P<.001) were higher in patients with OSA than those without OSA. The mean apnea-hypopnea index (AHI) was higher in patients with NAFLD than in those without NAFLD (16.87 events [ev]/h vs. 1.57 ev/h; P<.002). On multivariate logistic regression, where body mass index ≥30 kg/m2, homeostasis model assessment for insulin resistance ≥2.7, and OSA (AHI ≥5 ev/h) were independent variables, only OSA was an independent predictor of NAFLD (odds ratio [OR], 7.63; P = .044). Free testosterone levels ≥1.07 ng/dL were also independently associated with OSA (OR, 8.18; P = .023). CONCLUSION: In PCOS women, the occurrence of OSA strongly predisposes them to development of NAFLD and a worse metabolic profile; hence, treatment of OSA might be beneficial for NAFLD.

Photobiomodulation minimizes taste changes during hematopoietic cell transplantation: A randomized clinical trial.

Prevention and treatment protocols for taste changes observed during hematopoietic cell transplantation (HCT) are not well-established. The purpose of this study was to assess the efficacy of photobiomodulation (PBM) in relieving taste changes and preventing lingual papillae atrophy. HCT patients received PBM (n = 42) on the tongue dorsum using an InGaAIP laser (660 nm, 100 mW, 1.1 W/cm2, 8.8 J/cm2). During the HCT conditioning (T0), severe neutropenia (T1), and after neutrophil engraftment (T2), taste acuity for sweet, bitter, sour, and salty solutions, and clinical appearance of lingual papillae were compared with those of a placebo group (n = 43). PBM significantly reduced hypogeusia, ageusia, and parageusia at T1 and T2, and also successfully prevented papillae atrophy during all the analyzed HCT periods. In conclusion, PBM enhanced taste acuity during HCT. The decrease in papillae atrophy indicated a potential regenerative effect of this therapy on tongue mucosa.

Histomorphometrical and molecular evaluation of endosseous dental implants sites in humans: correlation with clinical and radiographic aspects.

OBJECTIVE: To evaluate the correlations between clinical-radiographical aspects and histomorphometric-molecular parameters of endosseous dental implant sites in humans. MATERIAL AND METHODS: The study sample consisted of bone implant sites from the jawbones of 32 volunteers, which were classified according to two different systems: (1) based only on periapical and panoramic images (PP); (2) as proposed by Lekholm & Zarb (L&Z). Bone biopsies were removed using trephine during the first drilling for implant placement. Samples were stained with haematoxylin-eosin (HE), and histomorphometric analysis was performed to obtain the following parameters: trabecular thickness (Tb.Th), trabecular number, bone volume density (BV/TV), bone specific surface (BS/BV), bone surface density and trabecular separation (Tb.Sp). In addition, immunohistochemistry analysis was performed on bone tissue samples for the proteins, Receptor activator of nuclear factor kappa-B (RANK), RANK ligand (RANKL), osteoprotegerin (OPG) and Osteocalcin (OC). Also, the determination of the relative levels of gene expression was performed using Reverse transcription-real-time Polymerase Chain Reaction (RT-PCR). RESULTS: PP and L&Z classification systems revealed a moderate correlation with BV/TV, BS/BV, Tb.Th and Tb.Sp. L&Z's system identified differences among bone types when BV/TV, BS/BV, Tb.Th and Tb.Sp were compared. A weak correlation between PP/L&Z classifications and the expression of bone metabolism regulators (RANK, RANKL, OPG e OC) was found. The analysis of mRNA expression showed no difference between the bone types evaluated. CONCLUSIONS: Our results suggest that PP and L&Z subjective bone-type classification systems are related to histomorphometric aspects. These data may contribute to the validation of these classifications. Bone remodelling regulatory molecules do not seem to influence morphological aspects of the jawbone .

EGFR inhibitors: clinical aspects, risk factors and biomarkers for acneiform eruptions and other mucosal and cutaneous adverse effects.

The frequency of the use of drugs that act on the epidermal growth factor receptor (EGFR) is increasing, with the consequent onset of cutaneous toxicity, specifically acneiform eruption. The authors extensively review the topic, focusing on describing how these drugs can affect the skin and its appendages, that is, the pathophysiology that encompasses the cutaneous toxicity related to the use of EGFR inhibitors. In addition, it was possible to list the risk factors that may be associated with adverse effects of these drugs. Based on this recent knowledge, the authors expect to aid in the management of patients who are more vulnerable to toxicity, reduce morbidities, and improve the quality of life of patients undergoing treatment with EGFR inhibitors. Other issues related to the toxicity of EGFR inhibitors, such as the clinical aspects of the acneiform eruption grades, and other different types of cutaneous and mucosal reactions, are also included in the article.

Epidemiology and severity of traumatic dental injuries in permanent teeth: A 20-year retrospective study.

This study aimed to assess the traumatic dental injuries (TDIs) in permanent dentition among patients who attended at the outpatient clinic of a Brazilian dental school, during the last 20 years, and to investigate factors associated with the severity of these injuries. Clinical records of patients who attended a specialized center for dental trauma care in Brazil presenting at least one TDI in a permanent tooth, between the years 2000 and 2019, were reviewed. The data recorded were sex, age, affected arch, etiology, number, and type of the teeth affected, and classification and severity of the TDIs. The diagnosis and classification of the TDIs were based on the guidelines of the International Association of Dental Traumatology (IADT). The severity of each patient's injuries was defined as mild, moderate, or severe. Descriptive statistics, chi-square and multinomial regression analyses were used to evaluate the results. The significance level was set at 5%. A total of 837 clinical records were included, totaling 2357 teeth. Males were more prevalent than females. The patients' age ranged from 5 to 71 years. The most common traumas were avulsion (n=512) and uncomplicated enamel-dentin fracture (n=488). Univariate analyses showed that there was a statistically significant association between age group (p=0.004), etiology (p=0.000) and number of teeth affected (p=0.000) with severity of dental trauma. In conclusion, TDIs that occurred in Piracicaba and region are epidemiologically similar to those found worldwide, and that more severe injuries are related to age range, etiology and number of teeth affected.

Telehealth for Nutritional Care: A Tool for Improving Patient Flow in Hospitals.

Background: Hospitals are constantly searching for opportunities to improve efficiency, and telehealth (TH) has recently emerged as a strategy to assist in patient flow. We evaluated two methods of dietary counseling offered to patients in the time period between the medical and final hospital discharge. Counseling was given either via the TH group or the face to face (FTF) group to the patients and their respective impact was evaluated on the patients' satisfaction and on the hospital patient flow. Methods: This study was a prospective, randomized clinical trial where patients were randomized to receive dietary counseling via TH (use of tablet) or FTF at the time of hospital discharge. We evaluate the duration of time between medical discharge and hospital discharge; between requesting dietary counseling and dietitian's arrival; and duration of dietary counseling. At the end of dietary counseling, both groups received a patient satisfaction questionnaire to answer. Results: A total of 159 patients were randomized to receive dietary counseling via TH (TH, n = 78) or FTF (FTF, n = 81). The two groups TH and FTF did not differ in terms of the median time between (1) medical and hospital discharge; (2) requesting counseling and the dietitian's arrival; and (3) duration of dietary counseling. Both groups mostly reported being "satisfied" or "above expectations," and the FTF group scored "highest satisfaction" more often relative to the dietitian's work and interaction and on confidence in the dietitian's orientations. Finally, in the TH group, 90.7% graded likely-4 or very likely-5 when asked whether dietary counseling can be conducted entirely via TH, and 92% answered "4" or "5" when asked whether they would recommend dietary counseling via TH. Conclusions: Although the FTF group had a greater overall satisfaction relative to the TH group, TH proved to be a useful tool for dietary counseling.The trial has only Institutional Review Board approval (protocol 2685-16).

The Difficult Decision Not to Prescribe Artificial Nutrition by Health Professionals and Family: Bioethical Aspects.

Introduction: Bioethics and nutrition are essential issues in end of life, advanced dementia, life-sustaining therapies, permanent vegetative status, and unacceptably minimal quality of life. Even though artificially administered nutrition (AAN), for this type of health condition, does not improve quality of life and extension of life, and there is evidence of complications (pulmonary and gastrointestinal), it has been used frequently. It had been easier considering cardiopulmonary resuscitation as an ineffective treatment than AAN for a healthy team and/or family. For this reason, many times, this issue has been forgotten. Objectives: This study aimed to discuss bioethical principles and AAN in the involved patients. Discussion: The AAN has been an essential source of ethical concern and controversy. There is a conceptual doubt about AAN be or not be a medical treatment. It would be a form of nourishment, which constitutes primary care. These principles should be used to guide the decision-making of healthcare professionals in collaboration with patients and their surrogates. Conclusions: This difficult decision about whether or not to prescribe AAN in patients with a poor prognosis and without benefits should be based on discussions with the bioethics committee, encouraging the use of advanced directives, education, and support for the patient, family, and health team, in addition to the establishment of effective protocols on the subject. All of this would benefit the most important person in this process, the patient.

Assistance Gaps in Physical Rehabilitation: Spatial Analysis of Physical Therapy Services and Users' Households in a Brazilian Capital. / Vazios assistenciais na reabilitação física: análise espacial dos serviços de fisioterapia e dos domicílios dos usuários em uma capital brasileira.

OBJECTIVE: The aim of this study was to analyze the spatial distribution of outpatient physical therapy rehabilitation services and associate it with the geographic location of users' households. METHODS: The public physical therapy rehabilitation services and addresses of users' households in Campo Grande (MS) were georeferenced in 2017-2019. RESULTS: Five physical therapy clinics were identified to supply the demand of 31,774 scheduled users. Most services are in the most central regions of the city, while most users reside in peripheral areas. CONCLUSION: An assistance gap in Physical therapy care was identified, with a restricted supply of services to meet demands and a geographic barrier, since the services are far from the users' households. Physical rehabilitation must be a priority in the country's public health, especially nowadays, where demands for rehabilitation of a significant number of Brazilians who evolved with sequelae of COVID-19 are so present.

OBJETIVO: O objetivo deste estudo foi analisar a distribuição espacial dos serviços ambulatoriais de reabilitação em fisioterapia e associá-la à disposição geográfica dos domicílios dos usuários da rede pública de reabilitação em uma capital brasileira. MÉTODOS: Foi realizado um georreferenciamento dos serviços públicos de reabilitação fisioterapêutica e dos endereços dos domicílios dos usuários desses serviços em Campo Grande (MS) durante o período de 2017 a 2019. RESULTADOS: Foram identificados cinco serviços de fisioterapia para atender à demanda de 31.774 usuários agendados no período estudado. A maioria dos serviços está nas regiões mais centrais da cidade, enquanto a maioria dos usuários reside nas regiões periféricas. CONCLUSÃO: Evidenciou-se um vazio assistencial na reabilitação fisioterapêutica, com oferta restrita de serviços em função das demandas, e barreira geográfica, uma vez que os serviços estão distantes dos domicílios dos usuários A reabilitação física deve ser colocada na agenda prioritária da saúde pública no país, especialmente no momento atual, com as demandas por reabilitação de um número expressivo de brasileiros que evoluem com sequelas da COVID-19.

Neutrophil lymphocyte ratio as an indicator for disease progression in Idiopathic Pulmonary Fibrosis.

RATIONALE: Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease. Patients present at different stages and disease course is varied. Blood monocytes have been linked to all-cause mortality, and neutrophils to progression to IPF in patients with the indeterminate for usual interstitial pneumonia CT pattern. OBJECTIVE: To determine association between blood monocytes, neutrophils and lymphocytes levels (and their derived indexes), with lung function decline and mortality in IPF. METHODS: We performed a retrospective analysis of an IPF cohort (n=128) who had their first clinical visit at the Oxford Interstitial Lung Disease Service between 2013 and 2017. Association between blood monocytes, neutrophils, lymphocytes and derived indexes (within 4 months of visit) and decline in forced vital capacity (FVC) and all-cause mortality were assessed using Cox proportional hazard regression analysis. Kaplan-Meier analysis was used to assess time-to-event for 10% FVC decline and mortality for patients dichotomised to high and low leucocyte counts. RESULTS: Median length of follow-up was 31.0 months (IQR 16.2-42.4); 41.4% demonstrated FVC decline >10% per year and 43.8% died. In multivariate models (incorporating age, gender and initial FVC%), raised neutrophils, lymphopaenia and neutrophil:lymphocyte ratio were associated with FVC decline (p≤0.01); while both monocytes and neutrophil levels (and their derived indexes) were associated with all-cause mortality (p≤0.01). Kaplan-Meier analysis also showed association between neutrophils and its derived indexes but not monocyte, with FVC decline. CONCLUSION: Blood neutrophil and lymphopaenia are more sensitive than monocytes as prognostic indicators of disease progression in those with established IPF.