The southernmost record and an update of the geographical range of the Atlantic chupare, Styracura schmardae (Chondrichthyes: Myliobatiformes).

The present study established the southernmost distribution range for the Chupare stingray Styracura schmardae based on a specimen caught on the easternmost portion of Ceará State, northeastern Brazil. Identification was based on diagnostic morphological characters and molecular data (sequence of the mitochondrial DNA gene nd2; 1046 bp). This record expands the known distribution range for this species by more than 1200 km and confirms that S. schmardae is distributed in more than one biogeographical province. SIGNIFICANCE STATEMENT: There are few records of the Atlantic Chupare stingray for Brazil and most of them are associated with the Amazon River mouth. New records indicate that this species is also present in the South Atlantic portion of the Brazilian coast. Apparently having a low abundance throughout its range, these new records increase the range of occurrence of this species.

River ecosystem endangerment from climate change-driven regulated flow regimes.

Major threats of freshwater systems are river damming and habitat degradation, further amplified by climate change, another major driver of biodiversity loss. This study aims to understand the effects of climate change, and its repercussions on hydropower production, on the instream biota of a regulated river. Particularly, it aims to ascertain how mesohabitat availability downstream of hydropower plants changes due to modified flow regimes driven by climate change; how mesohabitat changes will influence the instream biota; and if instream biota changes will be similar within and between biological groups. We used a mesohabitat-level ecohydraulic approach with four biological elements - macrophytes, macroalgae, diatoms and macroinvertebrates - to encompass a holistic ecosystem perspective of the river system. The ecological preferences of the biological groups for specific mesohabitats were established by field survey. The mesohabitat availability in three expected climate change-driven flow regime scenarios was determined by hydrodynamic modeling. The biota abundance/cover was computed for the mesohabitat indicator species of each biological group. Results show that climate-changed flow regimes are characterized by a significant water shortage during summer months already for 2050. Accordingly, the regulated rivers' hydraulics are expected to change towards more homogeneous flow conditions where run habitats should prevail. As a result, the biological elements are expected to face abundance/cover modifications ranging from decreases of 76% up to 67% increase, depending on the biological element and indicator taxa. Diatoms seem to endure the greatest range of modifications while macrophytes the slightest (15% decrease to 38% increase). The greatest modifications would occur on decreasing abundance/cover responses. Such underlies an important risk to fluvial biodiversity in the future, indicting climate change as a significant threat to the fluvial system in regulated rivers.

Effect of environmental education on the knowledge of aquatic ecosystems and reconnection with nature in early childhood.

Blue and green ecosystems are considered a key for the improvement of cities sustainability, providing numerous ecosystem services and habitat for many species. However, urban streams are still neglected and degraded, specially in southern European countries. One important step towards the rehabilitation of these ecosystems is the awareness of their importance by citizens. This study aimed to assess the effect of 1-year of activities (field and laboratory) of an environmental education project on primary school children, in improving their knowledge on urban stream ecosystems and their problems. We analyzed students' questionnaires before and after field and laboratory activities, drawings and group interviews. Initially, most children had incipient contact with rivers and streams, showing fears and lack of knowledge about them. As the project progressed, their perceptions changed, with a clear increase in the proportion of students recognizing the biodiversity associated to rivers (e.g., names of riparian trees, aquatic plants and invertebrates). Also, their fears decreased significantly, while their awareness to the impacts of artificialization and lack of riparian vegetation increased. Our results show that direct contact with nature have a positive role in the way it is understood by children, as well as promoting responsible and sustainable behaviors, being effective from the early primary-school years.

A useful and brief cognitive assessment for advanced dementia in a population with low levels of education.

BACKGROUND/AIMS: Almost half of community-dwelling patients and 59.6% of institutionalized residents with dementia are in moderate or severe stages of this disease. The Mini-Mental State Examination (MMSE) has limited applicability to these patients due to floor effects. We aimed to determine the correlation between the MMSE and the Severe Mini-Mental State Examination (SMMSE), as well as SMMSE association with functional scales in patients having moderate to severe dementia and low levels of education. METHODS: A cross-sectional study of patients 60 years or older attending an outpatient clinic was conducted. The MMSE, SMMSE and functional scales were applied. Clinical and demographic data from medical records were reviewed. RESULTS: Seventy-five patients with a mean of 4.1±3.6 years of education were analyzed. The mean scores on the MMSE and SMMSE were 7.8±7.0 and 17.8±9.4, respectively. The results indicated that the MMSE and SMMSE correlated only in patients who had an MMSE score of less than 10 (r=0.87; p<0.001). In addition, significant correlations were found between the SMMSE and functional scales (p<0.001). It was observed that educational level did not interact with SMMSE performance. CONCLUSION: The SMMSE is a useful and reliable tool for a brief cognitive assessment of advanced dementia patients with low educational levels.

Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care.

The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE®/PubMed. The keywords utilized were: "advance directives", "living wills", "physicians", "attitude", "decision making", "advance care planning". The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients' autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.

Effects of Adjuvant Chemotherapy on Cognitive Function of Patients With Early-stage Colorectal Cancer.

PURPOSE: Chemotherapy-related cognitive impairment can occur in cancer survivors after treatment, especially those patients who have undergone chemotherapy for breast cancer. The frequency and to what extent such toxicity develops in colorectal cancer (CRC) survivors is unknown. The present prospective study evaluated the effects of adjuvant chemotherapy on the cognitive performance of patients with localized CRC compared with a control group who had not undergone chemotherapy. PATIENTS AND METHODS: Consecutive patients with localized stage II and III CRC completed neuropsychological assessments, self-reported cognitive complaint questionnaires, and depressive symptom evaluations before starting fluoropyrimidine-based adjuvant chemotherapy and after 12 months. Blood was collected for apolipoprotein E genotyping. Diffusion tensor imaging data were acquired from a subset of participants at both evaluation points. RESULTS: From December 2012 to December 2014, 137 patients were approached and 85 were included. Of these 85 patients, 49 had undergone chemotherapy and 26 had not, in accordance with the standard recommendations for adjuvant therapy for CRC. The mean age was 62.5 ± 9.4 years, 60% were men, and the mean educational attainment was 7.6 ± 3.7 years. No difference was found in the global composite score (P = .38), attention (P = .84), or memory (P = .97) between the 2 groups during the follow-up period (mean ± standard deviation, 375 ± 29 days). However, a statistically significant difference was found for executive function after adjustment for age, sex, education, and depressive symptoms at baseline (ß -1.80; 95% confidence interval, -3.50 to -0.11; P = .04), suggesting worse performance for the chemotherapy group. For the 32 patients who had undergone magnetic resonance imaging, tract-based spatial statistics did not show voxelwise significant differences in structural brain connectivity at baseline or during follow-up. Apolipoprotein E polymorphisms were not predictive of cognitive dysfunction. CONCLUSION: Patients with CRC who received adjuvant 5-fluorouracil with or without oxaliplatin presented with a decline in executive function after 12 months compared with patients with localized disease who had not received chemotherapy.

Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care / Variáveis que influenciam na decisão médica frente a uma Diretiva Antecipada de Vontade e seu impacto nos cuidados de fim de vida

ABSTRACT The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE®/PubMed. The keywords utilized were: "advance directives", "living wills", "physicians", "attitude", "decision making", "advance care planning". The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients' autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.

RESUMO O objetivo deste estudo foi identificar as variáveis que influenciam na aderência dos médicos às Diretivas Antecipadas de Vontade e avaliar seu impacto nos cuidados de fim de vida. Trata-se de revisão narrativa de literatura, com levantamento de 25 artigos publicados nos bancos de dados Capes, EBSCOhost, BDTD, BVS, Google Scholar, MEDLINE®/PubMed, no período de 1997 a 2018. Os descritores de saúde utilizados foram: "diretivas antecipadas", "testamentos quanto à vida", "médicos", "atitude", "tomada de decisões" e "planejamento antecipado de cuidados". Os principais fatores que influenciaram os médicos na aderência às diretivas foram prognóstico do paciente, paternalismo médico, e entendimento do paciente sobre sua condição clínica. Respeito à autonomia, falta de conhecimento e experiência no uso de diretivas, preocupações legais, influência de familiares, fatores culturais e religiosos também contribuíram para a decisão médica. A maioria dos estudos (86%) evidenciou que a presença de uma diretiva foi responsável por menores taxas de intervenções invasivas nos últimos dias de vida dos pacientes. Médicos apresentaram interesse em respeitar a autonomia de seus pacientes e concordaram que a existência de uma diretiva avançada auxilia no processo de tomada de decisão, porém afirmam que outros fatores são levados em consideração, principalmente o prognóstico do paciente e as condições de reversibilidade. A presença de diretivas contribuiu para a redução do uso de terapias de suporte de vida e adoção de medidas de conforto.

Pacientes com acidente vascular cerebral (avc) agudo em cuidados paliativos: uma revisão sistemática / Acute stroke patients in palliative care: a systematic review

INTRODUÇÃO: O acidente vascular encefálico (AVC), um importante problema de saúde pública, pode ter consequências catastróficas para o indivíduo e seus familiares. Cuidados paliativos (CP) são promovidos por equipe multiprofissional, com intuito de prevenir e aliviar sofrimentos de pacientes com doença ameaçadora à vida e de seus familiares. OBJETIVOS: Identificar necessidades de CP em pacientes com AVC agudo grave e seus familiares. MÉTODOS: Uma revisão sistemática foi conduzida nas bases de dados: MEDLINE, PubMed, SciELO, LILACS, DOAJ e Cochrane, em artigos publicados no período de 2000 a 2018. RESULTADOS: Dos 114 artigos encontrados na busca inicial, 16 foram selecionados após aplicação de critérios de inclusão e exclusão. Mostraram discussões sobre prognóstico; prevalência de sintomas e principais barreiras de comunicação. Foi evidenciado que estes pacientes e seus familiares têm necessidades multidimensionais não atendidas. O principal motivo para solicitar CP foi a abordagem de diretivas avançadas de vontade e de cuidados de fim-de-vida. CONCLUSÃO: Há indicação e beneficio à inserção de cuidados paliativos em pacientes acometidos por AVC agudo grave. Para isto, são fundamentais: o trabalho interdisciplinar da equipe de saúde, boa comunicação, estratégias educacionais e deliberação política.

BACKGROUND: Stroke, an important public health problem, can have catastrophic consequences for the individual and his or her family. Palliative care (PC) is promoted by a multiprofessional team to prevent and alleviate the suffering of patients with life-threatening illness and their relatives. OBJECTIVES: To identify needs to PC in severe acute stroke patients and their relatives. METHODS: A systematic review was conducted in the databases MEDLINE, PubMed, SciELO, LILACS, DOAJ and Cochrane in articles published from 2000 to 2018. RESULTS: Of the 114 articles found in the initial search, 16 were selected after application of inclusion and exclusion criteria. They showed discussions about prognosis; prevalence of symptoms and main communication barriers. It was evidenced that these patients and their families have multidimensional needs not met. The main reason for requesting PC was an approach to end-of-life decision-making and end-of-life care. CONCLUSION: There is indication and benefit the insertion of palliative care in patients affected by severe acute stroke. For this, the interdisciplinary work of the health team, good communication, educational strategies and political deliberation are fundamental.

Effects of a non-focal plasticity protocol on apathy in moderate Alzheimer's disease: a randomized, double-blind, sham-controlled trial.

BACKGROUND: Apathy is the most common neuropsychiatric symptom in Alzheimer's disease (AD) and it is associated with changes in prefrontal neural circuits involved with generation of voluntary actions. To date no effective treatment for apathy has been demonstrated. OBJECTIVE: We aimed to investigate the effects and safety of repetitive transcranial direct current stimulation (tDCS) on apathy in moderate AD patients. METHODS: Forty patients were randomized to receive either active or sham-tDCS over the left dorsolateral prefrontal cortex (DLPFC). Patients received six sessions of intervention during 2 weeks and were evaluated at baseline, at week 1 and 2, and after 1 week without intervention. Clinical raters, patients, and caregivers were blinded. The primary outcome was apathy. Global cognition and neuropsychiatric symptoms were examined as secondary outcomes. RESULTS: The mean MMSE score at baseline was 15.2 ± 2.9 and the mean Apathy Scale score was 27.7 ± 6.7. Changes on apathy scores over time were not different between active and sham tDCS (P = 0.552 for repeated measures). Further analyses confirm that changes from baseline did not differ between groups after the sixth session (active tDCS -1.95 (95%CI -3.49, -0.41); sham-tDCS -2.05 (95%CI -3.68, -0.42); P = 0.989]. Similarly, tDCS had no effect on secondary outcomes (P > 0.40). tDCS was well tolerated and not associated with significant adverse effects. CONCLUSION: In this adequately powered study for minimal clinically significant difference, our findings show that using the parameters we chose for this study, repeated anodal tDCS over the left DLPFC had no effect on apathy in elderly patients with moderate AD.