Impact of telemedicine on the management of heart failure patients during coronavirus disease 2019 pandemic.

AIMS: Chronic heart failure (HF) is a major comorbidity accounting for an increased severity and mortality related to coronavirus disease 2019 (COVID-19). To reduce the risk of COVID-19 in HF patients, telemedicine has been encouraged. METHODS AND RESULTS: During the COVID-19 pandemic, telemedical management with mainly over-the-phone appointments became a major strategy of follow-up of our HF clinic patients. Previously, the large majority of patients have been seen in the hospital with direct patient-provider contact. We compared both strategies of follow-up, in pre-pandemic (PPP) and pandemic (PP) periods, regarding total mortality and hospitalizations/emergency department (ED) visits due to HF exacerbation. We prospectively studied a cohort of 196 patients. The mean follow-up time in PPP was 1.4 years. In this period, 20 patients died. In PP (follow-up of 71 days), there was one additional death. Total mortality in the first year of follow-up was 12.0%, matching the mortality predicted by the Meta-Analysis Global Group in Chronic Heart Failure score. Considering hospitalizations/ED visits due to decompensated HF, there was no statistically significant difference between PPP and PP. Only one patient was diagnosed with COVID-19. CONCLUSIONS: In the light of an increase in telemedical management of this cohort of HF patients, we were able to maintain a low rate of admissions due to HF decompensation, without an increment in mortality. Regarding these results, we encourage the incremental use of telemedicine in HF patients in the context of this or future pandemics and also in situations in which physical consultation might not be possible due to logistic issues.

Impact of Inoculation with Pseudomonas aestus CMAA 1215T on the Non-target Resident Bacterial Community in a Saline Rhizosphere Soil.

Plant growth reduction caused by osmotic stress, pathogens, and nutrient scarcity can be overcome by inoculation with plant growth-promoting rhizobacteria (PGPR). Knowing the effects of PGPR on the microbial community beyond those on plant growth can bring new options of soil microbiota management. The present study aimed to investigate the effect of inoculation with the newly described Pseudomonas aestus CMAA 1215T [a 1-aminocyclopropane-1-carboxylate (ACC) deaminase and glycine-betaine producer] on the rhizosphere bacterial community of Zea mays in natural (non-salinized) and saline soil. The bacterial community structure was assessed by sequencing the V6-V7 16S ribosomal RNA using the Ion Personal Genome Machine™. The non-metric multidimensional scaling (NMDS) of the OTU profile (ANOSIM P < 0.01) distinguishes all the treatments (with and without inoculation under saline and natural soils). Inoculated samples shared 1234 OTUs with non-inoculated soil. The most abundant classes in all samples were Alphaproteobacteria, Gammaproteobacteria, Actinobacteria, Acidobacteriia, Bacteroidia, Thermoleophilia, Verrucomicrobiae, Ktenodobacteria, and Bacilli. The inoculation, on the other hand, caused an increase in the abundance of the genera Bacillus, Bryobacter, Bradyrhizobium, "Candidatus Xiphinematobacter", and "Candidatus Udaeobacter" independent of soil salinization. "Candidatus Udaeobacter" has the largest Mean Decrease in Gini Values with higher abundance on inoculated salted soil. In addition, Pseudomonas inoculation reduced the abundance of Gammaproteobacteria and Phycisphaerae. Understanding how inoculation modifies the bacterial community is essential to manage the rhizospheric microbiome to create a multi-inoculant approach and to understand its effects on ecological function.

Cost Modifications during the Early Years of the Use of the National Cardiovascular Data Registry for Quality Improvement.

OBJECTIVES: Quality improvement (QI) initiatives based on data from international registries have been reported previously; however, there is a lack of information on the impact on the costs of medical care associated with the use of these tools. METHODS: Patients admitted due to myocardial infarction (MI), included in the ACTION Registry® and CathPCI Registry®, in a private Brazilian hospital (i.e., the reference hospital) were analyzed. The costs of care of these patients were compared to the costs of MI admissions in nine similar hospitals not included in the same QI program. Regression models were used to analyze the cost change over time between the two groups of hospitals. Readmission rates were compared using logistic regression, adjusting for the same variables as in the cost model. RESULTS: Overall, the annual medical cost inflation in Brazil was higher than the annual cost trend in the reference hospital during the period of analysis. Moreover, the annual in-hospital costs indicate that the reference hospital has a statistically significant 6% lower cost trend for patients with acute MI, compared to patients with the same diagnostic code in the comparison hospitals group, in an adjusted analysis (p-value=0.041). Using multivariable analysis, the readmission rates were also found to be significantly lower in the reference hospital than in the comparison hospitals, with an odds ratio of 0.68 (p-value=0.042). CONCLUSION: The use of the NCDR® as a benchmark to guide QI programs outside the United States was associated with the positive impact of bending the cost curve to below that of national medical inflation and the comparison hospitals' costs, with a lower incidence of hospital readmission.

Anticoagulation Therapy in Patients with Non-valvular Atrial Fibrillation in a Private Setting in Brazil: A Real-World Study / Terapia de Anticoagulação em Pacientes com Fibrilação Atrial não Valvar em Ambiente de Cuidado de Saúde Privado no Brasil: Um Estudo de Mundo Real

Abstract Background: The safety and effectiveness of warfarin depend on anticoagulation control quality. Observational studies associate poor control with increased morbidity, mortality and healthcare costs. Objectives: To develop a profile of non-valvular atrial fibrillation (NVAF) patients treated with warfarin in a Brazilian private ambulatory and hospital setting, evaluate the quality of anticoagulation control, and its association with clinical and economic outcomes. Methods: This retrospective study, through a private health insurance dataset in Brazil, identified NVAF patients treated with warfarin between 01 MAY 2014 to 30 APRIL 2016, described their anticoagulation management, and quantified disease-related costs. Data on demographics, clinical history, concomitant medication and time in therapeutic range (TTR) of international normalized ratio (INR) values were retrieved. Patients were grouped into TTR quartiles, with good control defined as TTR ≥ 65% (Rosendaal method). Major bleeds and all-cause direct medical costs were calculated and compared between good and poor control subgroups. P-values < 0.05 were considered statistically significant. Results: The analysis included 1220 patients (median follow-up: 1.5 years; IQR: 0.5-2.0). On average, each patient received 0.95 monthly INR measurements (mean INR: 2.60 ± 0.88, with 26.1% of values < 2 and 24.8% > 3), (median TTR: 58%; IQR: 47-68%), (mean TTR: 56.6% ± 18.9%). Only 31% of patients were well-controlled (mean TTR: 78% ± 10%), with 1.6% having major bleeds within median follow-up, and direct medical costs per member per year (PMPY) of R$25,352(± R$ 37,762). Poorly controlled patients (69%) were associated with 3.3 times more major bleeds (5.3% vs. 1.6%; p < 0.01) and 40% higher costs (R$35,384 vs. R$25,352; p < 0.01). Conclusions: More than 60% of the patients were below the desired target and the associated costs were higher.

Resumo Fundamento: A segurança e a eficácia da varfarina dependem da qualidade do controle da anticoagulação. Estudos observacionais associam controle deficiente com aumento de morbidade, mortalidade e custos com saúde. Objetivos: Desenvolver um perfil de pacientes com fibrilação atrial não valvar (FANV) tratados com varfarina em ambiente ambulatorial e hospitalar privado brasileiro, avaliar a qualidade do controle da anticoagulação e sua associação com resultados clínicos e econômicos. Métodos: Este estudo retrospectivo, por meio de um conjunto de dados de seguros privados de saúde no Brasil, identificou pacientes com FANV tratados com varfarina entre 01 de maio de 2014 a 30 de abril de 2016, descreveu seu manejo da anticoagulação e quantificou os custos relacionados à doença. Foram recuperados dados demográficos, histórico clínico, medicação concomitante e tempo na faixa terapêutica (TTR) dos valores da razão normalizada internacional (RNI). Os pacientes foram agrupados em quartis de TTR, com um bom controle sendo definido como TTR ≥65% (método de Rosendaal). Sangramentos maiores e custos médicos diretos por todas as causas foram calculados e comparados entre subgrupos de controle bons e ruins. Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados: A análise incluiu 1220 pacientes (mediana de seguimento: 1,5 anos; IIQ: 0,5-2,0). Em média, cada paciente recebeu 0,95 medidas mensais de RNI (RNI média: 2,60 ± 0,88, com 26,1% dos valores < 2 e 24,8% > 3), (mediana de TTR: 58%; IIQ: 47-68%), (TTR médio: 56,6% ± 18,9%). Apenas 31% dos pacientes estavam bem controlados (TTR médio: 78% ± 10%), com 1,6% apresentando grandes sangramentos na mediana do seguimento e custos médicos diretos por membro por ano (PMPY) de R$25.352 (± R$37.762). Pacientes com controle abaixo do ideal (69%) foram associados a 3,3 vezes mais sangramentos graves (5,3% vs. 1,6%; p <0,01) e custos 40% maiores (R$35.384 vs. R$25.352; p < 0,01). Conclusões: Mais de 60% dos pacientes estavam abaixo da meta desejada e os custos associados foram significativamente maiores nesta população.

Anticoagulation Therapy in Patients with Non-valvular Atrial Fibrillation in a Private Setting in Brazil: A Real-World Study.

BACKGROUND: The safety and effectiveness of warfarin depend on anticoagulation control quality. Observational studies associate poor control with increased morbidity, mortality and healthcare costs. OBJECTIVES: To develop a profile of non-valvular atrial fibrillation (NVAF) patients treated with warfarin in a Brazilian private ambulatory and hospital setting, evaluate the quality of anticoagulation control, and its association with clinical and economic outcomes. METHODS: This retrospective study, through a private health insurance dataset in Brazil, identified NVAF patients treated with warfarin between 01 MAY 2014 to 30 APRIL 2016, described their anticoagulation management, and quantified disease-related costs. Data on demographics, clinical history, concomitant medication and time in therapeutic range (TTR) of international normalized ratio (INR) values were retrieved. Patients were grouped into TTR quartiles, with good control defined as TTR ≥ 65% (Rosendaal method). Major bleeds and all-cause direct medical costs were calculated and compared between good and poor control subgroups. P-values < 0.05 were considered statistically significant. RESULTS: The analysis included 1220 patients (median follow-up: 1.5 years; IQR: 0.5-2.0). On average, each patient received 0.95 monthly INR measurements (mean INR: 2.60 ± 0.88, with 26.1% of values < 2 and 24.8% > 3), (median TTR: 58%; IQR: 47-68%), (mean TTR: 56.6% ± 18.9%). Only 31% of patients were well-controlled (mean TTR: 78% ± 10%), with 1.6% having major bleeds within median follow-up, and direct medical costs per member per year (PMPY) of R$25,352(± R$ 37,762). Poorly controlled patients (69%) were associated with 3.3 times more major bleeds (5.3% vs. 1.6%; p < 0.01) and 40% higher costs (R$35,384 vs. R$25,352; p < 0.01). CONCLUSIONS: More than 60% of the patients were below the desired target and the associated costs were higher.

Cost modifications during the early years of the use of the national cardiovascular data registry for quality improvement

OBJECTIVES: Quality improvement (QI) initiatives based on data from international registries have been reported previously; however, there is a lack of information on the impact on the costs of medical care associated with the use of these tools. METHODS: Patients admitted due to myocardial infarction (MI), included in the ACTION Registry® and CathPCI Registry®, in a private Brazilian hospital (i.e., the reference hospital) were analyzed. The costs of care of these patients were compared to the costs of MI admissions in nine similar hospitals not included in the same QI program. Regression models were used to analyze the cost change over time between the two groups of hospitals. Readmission rates were compared using logistic regression, adjusting for the same variables as in the cost model. RESULTS: Overall, the annual medical cost inflation in Brazil was higher than the annual cost trend in the reference hospital during the period of analysis. Moreover, the annual in-hospital costs indicate that the reference hospital has a statistically significant 6% lower cost trend for patients with acute MI, compared to patients with the same diagnostic code in the comparison hospitals group, in an adjusted analysis (p-value=0.041). Using multivariable analysis, the readmission rates were also found to be significantly lower in the reference hospital than in the comparison hospitals, with an odds ratio of 0.68 (p-value=0.042). CONCLUSION: The use of the NCDR® as a benchmark to guide QI programs outside the United States was associated with the positive impact of bending the cost curve to below that of national medical inflation and the comparison hospitals' costs, with a lower incidence of hospital readmission.

Pseudomonas aestus sp. nov., a plant growth-promoting bacterium isolated from mangrove sediments.

Strain CMAA 1215T, a Gram-reaction-negative, aerobic, catalase positive, polarly flagellated, motile, rod-shaped (0.5-0.8 × 1.3-1.9 µm) bacterium, was isolated from mangrove sediments, Cananéia Island, Brazil. Analysis of the 16S rRNA gene sequences showed that strain CMAA 1215T forms a distinct phyletic line within the Pseudomonas putida subclade, being closely related to P. plecoglossicida ATCC 700383T, P. monteilii NBRC 103158T, and P. taiwanensis BCRC 17751T of sequence similarity of 98.86, 98.73, and 98.71%, respectively. Genomic comparisons of the strain CMAA 1215T with its closest phylogenetic type strains using average nucleotide index (ANI) and DNA:DNA relatedness approaches revealed 84.3-85.3% and 56.0-63.0%, respectively. A multilocus sequence analysis (MLSA) performed concatenating 16S rRNA, gyrB and rpoB gene sequences from the novel species was related with Pseudomonas putida subcluster and formed a new phylogenetic lineage. The phenotypic, physiological, biochemical, and genetic characteristics support the assignment of CMAA 1215T to the genus Pseudomonas, representing a novel species. The name Pseudomonas aestus sp.nov. is proposed, with CMAA 1215T (=NRRL B-653100T = CBMAI 1962T) as the type strain.

Draft Genome Sequence of Plant Growth-Promoting Drought-Tolerant Bacillus sp. Strain CMAA 1363 Isolated from the Brazilian Caatinga Biome.

The strain of Bacillus sp. CMAA 1363 was isolated from the Brazilian Caatinga biome and showed plant growth-promoting traits and ability to promote maize growth under drought stress. Sequencing revealed genes involved in stress response and plant growth promotion. These genomic features might aid in the protection of plants against the negative effects imposed by drought.

Streptomyces atlanticus sp. nov., a novel actinomycete isolated from marine sponge Aplysina fulva (Pallas, 1766).

The taxonomic position of a novel marine actinomycete isolated from a marine sponge, Aplysina fulva, which had been collected in the Archipelago of Saint Peter and Saint Paul (Equatorial Atlantic Ocean), was determined by using a polyphasic approach. The organism showed a combination of morphological and chemotaxonomic characteristics consistent with its classification in the genus Streptomyces and forms a distinct branch within the Streptomyces somaliensis 16S rRNA gene tree subclade. It is closely related to Streptomyces violascens ISP 5183T (97.27 % 16S rRNA gene sequence similarity) and Streptomyces hydrogenans NBRC 13475T (97.15 % 16S rRNA gene sequence similarity). The 16S rRNA gene similarities between the isolate and the remaining members of the subclade are lower than 96.77 %. The organism can be distinguished readily from other members of the S. violacens subclade using a combination of phenotypic properties. On the basis of these results, it is proposed that isolate 103T (=NRRL B-65309T = CMAA 1378T) merits recognition as the type strain of a new Streptomyces species, namely Streptomyces atlanticus sp. nov.

Diversity of Arbuscular Mycorrhizal Fungi in a Brazilian Atlantic Forest Toposequence.

The diversity of arbuscular mycorrhizal fungi (AMF) was studied in the Atlantic Forest in Serra do Mar Park (SE Brazil), based on seven host plants in relationship to their soil environment, altitude and seasonality. The studied plots along an elevation gradient are located at 80, 600, and 1,000 m. Soil samples (0-20 cm) were collected in four seasons from SE Brazilian winter 2012 to autumn 2013. AMF spores in rhizosperic soils were morphologically classified and chemical, physical and microbiological soil caracteristics were determined. AMF diversity in roots was evaluated using the NS31/AM1 primer pair, with subsequent cloning and sequencing. In the rhizosphere, 58 AMF species were identified. The genera Acaulospora and Glomus were predominant. However, in the roots, only 14 AMF sequencing groups were found and all had high similarity to Glomeraceae. AMF species identities varied between altitudes and seasons. There were species that contributed the most to this variation. Some soil characteristics (pH, organic matter, microbial activity and microbial biomass carbon) showed a strong relationship with the occurrence of certain species. The highest AMF species diversity, based on Shannon's diversity index, was found for the highest altitude. Seasonality did not affect the diversity. Our results show a high AMF diversity, higher than commonly found in the Atlantic Forest. The AMF detected in roots were not identical to those detected in rhizosperic soil and differences in AMF communities were found in different altitudes even in geographically close-lying sites.

Estresse na Formação Médica: como Lidar com Essa Realidade? / Stress in Medical Education: How to Face This Reality?

RESUMO Ao ingressarem no curso de Medicina, os estudantes se sentem eufóricos e realizados. No entanto, os desafios inerentes à formação podem ser fonte de estresse e angústia, comprometendo o bem-estar desses estudantes. Assim, este estudo se propôs a explorar as causas do estresse na formação médica e os modos de enfrentamento dos estudantes de uma universidade em Montreal, Canadá. Trata-se de um estudo exploratório, com abordagem metodológica qualitativa, mediante um questionário semiestruturado. Participaram do estudo 18 estudantes distribuídos entre o primeiro e o quarto ano do curso de Medicina. Os principais eventos estressores mencionados pelos entrevistados foram: dificuldade em conciliar as atividades acadêmicas e a vida pessoal, avaliações de desempenho, relação com professores/residentes e pacientes, além de terem que morar longe da família. Diante desses eventos, os estudantes desenvolveram estratégias adaptativas e algumas não adaptativas. Entre as estratégias adaptativas, eles mencionaram: falar sobre sentimentos negativos, apoio psicológico, atividades de lazer e apoio espiritual. Em relação às respostas não adaptativas, foram observados sentimentos negativos, como angústia e tristeza, negação da realidade, bebida alcoólica e drogas para recreação. Nesse contexto, as universidades precisam reconhecer essa realidade, de modo a construir estratégias institucionais que possam ajudar os estudantes a lidar com os eventos estressores, para que, assistidos nas próprias necessidades, consigam enxergar as necessidades psicossociais dos pacientes.

ABSTRACT When undergraduate students enter medical school they feel euphoric and fulfilled. However, challenges related to academic development may cause feelings of stress and torment, which compromises students’ wellbeing. This study is aimed at exploring the main causes of stress on medical training, and strategies of facing it used by the medical students of the University of Montreal, Canada. This is an exploratory approach, using a qualitative methodology through a semi-structured survey. Eighteen medical students from first to fourth-year were examined. The major stressing events cited by the students were the following: difficulty in reconciling academic work and personal life, performance exams, interaction with teachers and residents, relationship with patients, as well as the fact of living far from their hometown. In order to face these events, medical students develop adaptive and some non-adaptive strategies. Among the adaptive strategies, students mentioned: expressing their negative feelings, psychological support, leisure activities and spiritual support. As far as the non-adaptive answers are concerned, negative feelings were observed, such as distress and sorrow, denial of reality, alcohol use and recreational drug use. In this context, university authorities must review this situation, in such a way as to provide institutional strategies capable of promoting the recognition of their students’ emotional demands. Students could then take better care of the psychosocial aspects of their patients.

Draft Genome Sequence of Bacillus sp. Strain CMAA 1185, a Cellullolytic Bacterium Isolated from Stain House Lake, Antarctic Peninsula.

The aim of this study was to report the genome sequence of the cellulolytic Bacillus sp. strain CMAA 1185, isolated from Stain House Lake, Antarctica.

Bacterial community characterization in the soils of native and restored rainforest fragments.

The Brazilian Atlantic Forest ("Mata Atlântica") has been largely studied due to its valuable and unique biodiversity. Unfortunately, this priceless ecosystem has been widely deforested and only 10 % of its original area is still untouched. Some projects have been successfully implemented to restore its fauna and flora but there is a lack of information on how the soil bacterial communities respond to this process. Thus, our aim was to evaluate the influence of soil attributes and seasonality on soil bacterial communities of rainforest fragments under restoration processes. Soil samples from a native site and two ongoing restoration fragments with different times of implementation (10 and 20 years) were collected and assayed by using culture-independent approaches. Our findings demonstrate that seasonality barely altered the bacterial distribution whereas soil chemical attributes and plant species were related to bacterial community structure during the restoration process. Moreover, the strict relationship observed for two bacterial groups, Solibacteriaceae and Verrucomicrobia, increasing from the more recently planted (10 years) to the native site, with the 20 year old restoration site in the middle, which may suggest their use as bioindicators of soil quality and recovery of forest fragments being restored.

Indole-3-acetic acid producing root-associated bacteria on growth of Brazil Pine (Araucaria angustifolia) and Slash Pine (Pinus elliottii).

Araucaria forests in Brazil today correspond to only 0.7 % of the original 200 km(2) of natural forest that covered a great part of the southern and southeastern area of the Atlantic Forest and, although Araucaria angustifolia is an endangered species, illegal exploitation is still going on. As an alternative to the use of hardwoods, Pinus elliottii presents rapid growth and high tolerance to climatic stress and low soil fertility or degraded areas. Thus, the objective of this study was to evaluate the effect of IAA-producing bacteria on the development of A. angustifolia and P. elliottii. We used five bacterial strains previously isolated from the rhizosphere of A. angustifolia, which produce quantities of IAA ranging from 3 to 126 µg mL(-1). Microbiolized seeds were sown in a new gnotobiotic system developed for this work, that allowed the quantification of the plant hormone IAA produced by bacteria, and the evaluation of its effect on seedling development. Also, it was shown that P. elliottii roots were almost as satisfactory as hosts for these IAA producers as A. angustifolia, while different magnitudes of mass increases were found for each species. Thus, we suggest that these microbial groups can be helpful for the development and reestablishment of already degraded forests and that PGPR isolated from Araucaria rhizosphere have the potential to be beneficial in seedling production of P. elliottii. Another finding is that our newly developed gnotobiotic system is highly satisfactory for the evaluation of this effect.

Draft Genome Sequence of Pseudomonas sp. Strain CMAA 1215, a Plant Growth-Promoting Bacterium Isolated from a Brazilian Mangrove.

The aim of this study was to sequence the genome of the plant growth-promoting Pseudomonas sp. strain CMAA 1215, an osmotolerant bacterium isolated from mangrove soil.