A randomised double blind clinical trial to compare surgical field bleeding during endoscopic sinus surgery with clonidine-based or remifentanil-based hypotensive anaesthesia.

BACKGROUND: Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Anaesthesia including clonidine as an adjuntive hypotensive agent may reduce intraoperative bleeding. METHODS: A randomised comparison of clonidine-based vs remifentanil-based hypotensive anaesthetic regimen was conducted in patients undergoing FESS. The main assessment was the proportion of subjects with Boezaart scores of surgical field bleeding, as blindly assessed from video recordings by a third surgeon not involved in patient care. RESULTS: A total of 47 subjects underwent FESS and were randomised to clonidine or remifentanil. A significantly lower proportion of patients in the clonidine arm had blindly-assessed Boezaart scores higher than 2, with significantly lower mean blind Boezaart scores at 60 minutes and at 120 minutes. Similar findings were reported by the operating surgeon, and when Wormald and VAS scores were used. Objective estimates of bleeding and the duration of surgery and anaesthesia did not differ between groups. CONCLUSION: The use of clonidine- based controlled hypotensive anaesthesia achieves lower surgical field bleeding during FESS.

Hypotensive anaesthesia and bleeding during endoscopic sinus surgery: an observational study.

Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Through their hypotensive effect, adjuvant anaesthetic agents may influence intraoperative bleeding. The present study compared intraoperative bleeding in patients undergoing FESS administered a clonidine-based anaesthetic regimen and in patients receiving other an anaesthetic combination with higher acquisition costs. Prospective observational study included 37 subjects undergoing FESS in 2011. Assessment of intraoperative bleeding was according to type of anaesthesia (clonidine vs. opioid derivatives). Patients receiving clonidine (N = 11; 29.7%) presented significantly lower surgical field bleeding scores than those receiving opioid derivatives (N = 26; 70.3%) [mean (SD) Boezaart scores 1.91 (0.53) vs. 2.92 (0.79), p < 0.0001]. The multivariate analysis including baseline characteristics and risk factors related to bleeding intensity showed that the type of drug used for controlled hypotensive anaesthesia was the best predictor of bleeding during FESS, with an OR of 0.03 for clonidine based vs. opioid based anaesthesia (p = 0.014). The anaesthetic combination including clonidine for controlled hypotensive anaesthesia produces lower levels of surgical field bleeding during FESS. Compared with other hypotensive anaesthetics, clonidine is inexpensive and associated with better surgical conditions during FESS. If confirmed through randomized clinical trials, the use of clonidine during FESS can reduce surgical time and improve surgical results through a less bloody field, resulting in lower patient morbidity and improvement of operating room resources.

Effects of long-term periodized resistance training on body composition, leptin, resistin and muscle strength in elderly post-menopausal women.

AIM: Objective of the study was to determine the effects of a periodized resistance training program on body composition, plasmatic levels of leptin and resistin, and muscle strength in elderly post-menopausal women. METHODS: Twenty-three post-menopausal women (age= 63.02±4.42 years; height 1.55±0.06 m; body mass 67.56±2.26 kg) were submitted to 12 months of periodized resistance training twice a week. The training program consisted of 3 sets of 6-14 repetitions maximal (RM). Body composition (DXA), muscle strength (bench press, leg press 45º and arm curl), plasmatic levels of resistin and leptin (ELISA method) were assessed before and after the training program. Paired Student's t test was used for comparison between pre- and post-training values. RESULTS: There was a significant increase in muscle strength and lean body mass; decrease in body mass, body fat percentage and fat mass after 12 months of resistance training, a part from the decrease in leptin and resistin levels. CONCLUSION: Long-term periodized resistance training prevents aging sarcopenia, decreases body fat and systemic markers of inflammation in postmenopausal elderly women.

Effects of resistance training on matrix metalloproteinase-2 activity and biomechanical and physical properties of bone in ovariectomized and intact rats.

The purpose of this study was to investigate the influence of resistance training on the activity of matrix metalloproteinase (MMP)-2 and bone biomechanical properties in ovariectomized and intact rats. Forty-eight female rats were divided into two distinct groups, ovariectomized (OVX) and intact (Int), which were subdivided into three similar subgroups: sedentary, acute exercise and chronic exercise. Rats performed a resistance training for 12 weeks in which animals climbed a vertical ladder of 1.1 m with weights attached to their tails. Sessions were performed with an interval of 3, 4-9 and 8-12 days scaled dynamic movements of climbing. Biomechanical and physical analyses were performed using a universal testing machine, and MMP-2 activity analysis by zymography. Bone density (BD), mineral density (MD), maximum load and fracture load was reduced in sedentary and acute exercise OVX groups compared with the sedentary intact group (P<0.05); in contrast, chronically trained groups (OVX and Int) showed a significant increase in BD, MD and fracture load compared with all the other groups. MMP-2 activity in chronically trained groups also showed a significant increase, while the sedentary OVX group showed a decrease in MMP-2 activity compared with the intact sedentary group (P<0.05). Our results suggest that the resistance training proposed in our work was efficient in reverting the deleterious effects of ovariectomy on bone tissue, and also produced modeling effects in intact rats. On the other hand, ovariectomy reduced the activity of MMP-2 and produced deleterious effects on bone tissue, mimicking menopause intrinsically.

Suboptimal survival of male germ-cell tumors in southern Portugal--a population-based retrospective study for cases diagnosed in 1999 and 2000.

BACKGROUND: The outcome of germ-cell tumors (GCTs) is a hallmark of good-quality cancer care. In the Eurocare-4 study, the mean 5-year survival for patients diagnosed from 1995 to 1999 was 95.5%. PATIENTS AND METHODS: We carried out a population-based retrospective chart review study of male patients diagnosed with GCT in 1999 and 2000 in southern Portugal (2 119 065 males). RESULTS: There were 87 GCTs-79 testicular, 2 retroperitoneal, 3 mediastinal, 2 of the central nervous system and 1 of the stomach. For the 81 patients with testicular or retroperitoneal primaries, 35 had stage I, 13 stage II and 30 stage III at presentation (3 unknown). Classification by International Germ Cell Consensus Classification Group criteria, 17 belonged to the poor prognosis group (mediastinal primary 3, liver metastases 11 and very elevated markers 3). With median follow-up of 89 months, the 5-year absolute overall survival was 80% (100% for stage I, 92% for stage II and 53% for stage III disease). CONCLUSIONS: While GCT incidence was similar to neighboring Spain, the 5-year overall survival was lower than that of other European countries. This may result from delays in diagnosis, suggested by high proportion of high-stage and large-burden disease, and poor adherence to recommended treatment algorithms.

Exploratory factor analysis of the Brazilian OHIP for edentulous subjects.

The use of seven domains for the Oral Health Impact Profile (OHIP)-EDENT was not supported for its Brazilian version, making data interpretation in clinical settings difficult. Thus, the aim of this study was to assess patients' responses for the translated OHIP-EDENT in a group of edentulous subjects and to develop factor scales for application in future studies. Data from 103 conventional and implant-retained complete denture wearers (36 men, mean age of 69.1 +/- 10.3 years) were assessed using the Brazilian version of the OHIP-EDENT. Oral health-related quality of life domains were identified by factor analysis using principal component analysis as the extraction method, followed by varimax rotation. Factor analysis identified four factors that accounted for 63% of the 19 items total variance, named masticatory discomfort and disability (four items), psychological discomfort and disability (five items), social disability (five items) and oral pain and discomfort (five items). Four factors/domains of the Brazilian OHIP-EDENT version represent patient-important aspects of oral health-related quality of life.

Impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and adverse events of special interest in patients with rheumatoid arthritis or spondyloarthritis: a systematic analysis of the literature and meta-analysis.

OBJECTIVES: To systematically review the impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and severe adverse events (SAEs) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) in remission or low disease activity (LDA) state. MATERIALS AND METHODS: A meta-analysis based on a systematic review of PubMed, Embase, Cochrane, until August 2019, as well as relevant databases of international conferences, was used to evaluate the risk difference (RD) at 95% confidence interval (95% CI) of incidence density of serious infections, SAEs, malignancies, cardiovascular adverse events (CV AEs), or deaths after tapering (dose reduction or spacing) compared to continuation of targeted therapies. RESULTS: Of the 1957 studies initially identified, 13 controlled trials (9 RA and 4 SpA trials) were included in the meta-analysis. 1174 patient-years were studied in the tapering group (TG) versus 1086 in the usual care group (UC). There were 1.7/100 patient-year (p-y) serious infections in TG versus 2.6/100 p-y in UC (RD (95% CI) 0.01 (0.00 to 0.02), p = 0.13) and 7.4/100 p-y SAEs in TG versus 6.7/100 p-y in UC (RD 0.00 (- 0.02 to 0.02), p = 0.82). The risk of malignancies, CV AEs, or deaths did not differ between the tapering and the usual care groups. Subgroup analysis (RA and SpA) detected no significant differences between the two groups. CONCLUSION: We could not show significant impact of tapering bDMARD or JAKi over continuation concerning the risk of serious infections, SAEs, malignancies, CV AEs, or deaths in RA and SpA patients in remission or LDA state.

Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students.

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final-year medical students across Europe. In a cross-sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final-year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final-year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

The auditory cortical projections onto the medial geniculate body in the cat. An experimental anatomical study with silver and autoradiographic methods.

The auditory cortical projections to the medial geniculate body (MGB) were studied in the cat. Lesions carefully restricted to each one of the subdivisions of the auditory and peri-auditory cortex were made and degenerating fibres were mapped in the MGB. In other experiments L-[4-5-3-H]leucine was injected into the cortex of AI, AII and SF and its transport to the MGB was studied by autoradiography. The results show that fibres arise in the deep layers of the cortex of AI, pass through the deep subdivision of the dorsal nucleus of the MGB as well as through the magnocellular MGB. and end in the pars lateralis of the ventral nucleus of the MGB, Arising from AII, axons pass through the magnocellular MGB and end in the superficial and deep subdivisions of the dorsal nucleus extending to the most caudal part of the MGB. The ectosylvian posterior auditory cortex projects diffusely to all subdivisions of the MGB as well as to its magnocellular part. Of the peri-auditory areas, only the suprasylvian fringe projects to the parvicellular MGB, and it sends axons to the dorsal nucleus of the MGB. The SF and the ectosylvian anterior periauditory area send fibres to the magnocellular MGB. The insular cortex does not project to the MGB but sends heavy projections to lower nuclei of the auditory pathway. The complementary use of degeneration and autoradiographic methods shows that each method may be used to eliminate the drawbacks of the other. This strategy appears as being most adequate for the study of reciprocal projections such as those found between the MGB and the three auditory areas AI, AII, and the ectosylvian posterior auditory area.

Comparison of the antihypertensive effects of the fixed dose combination enalapril 10 mg/nitrendipine 20 mg vs losartan 50 mg/hydrochlorothiazide 12.5 mg, assessed by 24-h ambulatory blood pressure monitoring, in essential hypertensive patients.

Fixed combinations of calcium channel blockers and angiotensin converting enzyme inhibitors represent an alternative to diuretic-based combination therapy. The aim of the present study was to compare the antihypertensive efficacy of the combination enalapril 10 mg/nitrendipine 20 mg (E/N) vs losartan 50 mg/hydrochlorothiazide 12.5 mg (L/H), assessed by 24-h ambulatory blood pressure monitoring. This multicentre, double-blind, parallel study included 97 hypertensive patients (office diastolic blood pressure (DBP) 90-109 mmHg and daytime DBP > 85 mmHg). After a 2- to 3-week period of single-blind placebo, they were randomized to receive double-blind treatment with E/N (n = 48) or L/H (n = 49) for a 4-week period. The primary outcome measure was the difference in 24-h DBP reduction between treatments from randomization to the end of the double-blind period. Secondary efficacy variables included differences in 24-h systolic (S) BP reduction, daytime, night-time and office SBP and DBP reduction, proportion of responders and controlled patients, trough-to-peak ratio and smoothness indexes. Safety was assessed by the proportion of patients with adverse events and the detection of laboratory abnormalities. No significant differences were observed in the primary outcome measure. The group receiving E/N tended to show greater reductions in most measures (24 h, daytime and office SBP and DBP) and higher BP control rates, but only the difference in the rate of office SBP control (< 140 mmHg) reached statistical significance (42.2 vs 22.4%; P = 0.048). The trough-to-peak ratios and smoothness indexes were similar in both groups. The incidence of adverse events related to the treatment was 27.1% (95% CI 14.5-39.6%) in E/N-treated patients and 14.3% (95% CI 4.5-45.8%) in the L/H group, but differences were not significant. The kind of event more frequently observed were flushing and headache in E/N, and dizziness and asthenia in L/H; all observed adverse events were mild. We conclude that E/N and L/H have a similar antihypertensive efficacy, assessed by office or ambulatory blood pressure monitoring. E/N achieved a significantly higher office SBP control rate, but this was accompanied by an apparently higher proportion of mild adverse events.

Respiratory mechanics after tube thoracostomy in rats.

The purpose of the present study was to determine the mechanical respiratory profile after the insertion of a catheter into the pleural cavity of anesthetized, paralyzed, mechanically ventilated rats, thus stimulating the common use of chest tubes in clinical situations. Using the method of end-inflation occlusion during constant inspiratory flow in 7 adult Wistar rats, respiratory system, lung, and chest wall total resistance (0.353 +/- 0.058, 0.260 +/- 0.651, 0.091 +/- 0.012 (mean +/- SD) cmH2O.ml-1.s, respectively), viscous resistance (0.140 +/- 0.007, 0.100 +/- 0.007, 0.040 +/- 0.003 cmH2O.ml-1.s< respectively), and viscoelastic resistance (0.213 +/- 0.017, 0.160 +/- 0.022, 0.053 +/- 0.011 cmH2O.ml-1.s, respectively) as well as respiratory system, lung, and chest wall static elastance (4.51 +/- 0.27, 3.85 +/- 0.28, 0.66 +/- 0.12 cmH2O.ml-1, respectively), and dynamic elastance (5.72 +/- 0.24, 4.76 +/- 0.32, 0.96 +/- 0.17 cmH2O.ml-1, respectively) were not significantly modified after the insertion of a tube into the second right intercostal stage. We conclude that, under the present experimental conditions, a catheter inserted into the pleural space per se is not responsible for any alterations in respiratory mechanics.

[Theoretical model of a cost-effectiveness analysis of combined enalapril-nitrendipine therapy for treating hypertension]. / Modelo teórico de análisis coste-efectividad de la terapia combinada de enalapril-nitrendipino en el tratamiento de la hipertensión arterial.

OBJECTIVE: Cost-effectiveness analysis of combined enalapril-nitrendipine therapy (E/N), as second-line therapy for light or moderate hypertension. DESIGN: Theoretical model of cost-effectiveness, based on the norms of hypertension treatment in primary care, the considered view of a panel of experts and the direct costs of health resources and purchase of medication. SETTING: Spanish National Health system. PARTICIPANTS: Simulation of 1000 patients with hypertension, with a time horizon of one year. INTERVENTIONS: After a prior failure of the first-line treatment with either enalapril or nitrendipine, an evaluation was made of the possibilities of increasing dosage of the first-line treatment, changing the drug or administering the E/N combination. MAIN MEASUREMENT: The likelihoods, in the primary care context, of controlling diastolic pressure, of abandonment and of using the two strategies or not were measured, as were the use of health resources in each situation, and costs of resource use and of medication. RESULTS: The cost-effectiveness quotient of the combined E/N treatment was consistently more efficient than the increase in dose or change to another drug. This was so, whether the treatment was started with enalapril (301.06 euros vs 337.97 euros and 588.42 euros) or with nitrendipine (331.5 euros vs 469.88 euros and 579.76 euros). CONCLUSIONS: Combined therapy (E/N) is, on the basis of the assumptions made in the model, an efficient therapy option. Therefore, it can be recommended for prescription.

[The initial loss of consciousness in spontaneous subarachnoid hemorrhage. What does it mean?]. / Perda de consciência inicial na hemorragia subaracnoideia espontânea. O que significa?

BACKGROUND AND PURPOSE: Poor outcome and rebleeding, after admission to hospital of patients with spontaneous subarachnoid hemorrhage (SAH) has been found to be predicted by loss of consciousness at ictus (LOCi). In this study, we assessed the clinical and neuro-radiological significance of the LOCi in non-traumatic SAH. PATIENTS AND METHODS: The authors retrospectively studied 102 patients with SAH admitted to S. João Hospital between January 1, 1989 and December 31, 1992, who were divided into two groups with and without LOCi and compared according to clinical and imaging features. RESULTS: Loss of consciousness at ictus was statistically associated with an age over 52 years (odds ratio, 2.9; 95% confidence interval, 1.1-7.8); a Hunt and Hess Scale score > ou = 3 (4.4; 1.6-12.3); finding of subarachnoid blood on initial cranial CT scan (5.5; 1.4-26.3); existence of aneurysm (3.4; 1.3-8.9); a Glasgow Outcome Scale score > ou = 3 (4.69; 1.6-14.1). A poor clinical condition on admission (5.2;1.8-14.5) and existence of aneurysm (4.1; 1.6-10.6) were the only two findings shown to have an independent power of significant association with loss of consciousness at ictus, using logistic regression analysis, with LOCi as a dependent variable. CONCLUSIONS: In this study, LOCi has independent predictive power for a poor neurologic condition on admission and for the finding of aneurysm on angiogram. Loss of consciousness at ictus may be explained by the direct impact of the initial hemorrhage on the brain from a large tear in the aneurysmal wall, causing a quick rise in intracranial pressure (with LOCi) but a relatively short bleeding time.

Natural breeding sites of phlebotomine sand flies (Diptera: Psychodidae) on Marambaia Island, Rio de Janeiro State, Brazil.

Immature phlebotomine sand flies develop in soils with essential and ideal characteristics for their life cycle, such as organic matter, humidity, temperature and low levels of light. Information regarding the potential breeding places of these dipterans is fundamental to understand the epidemiology and ecology of leishmaniasis, in addition to its importance to control them. In the present study, we aimed to find natural breeding sites of sand flies on Marambaia Island with the aid of emergence traps and direct search of immature forms using the flotation technique with saturated sugar solution in organic substrates of the region. Both methods were effective, with a total of 42 specimens of six different species - including some species that participate in the transmission cycle of American Tegumentary Leishmaniasis - collected by the emergence traps, and five immature forms obtained by floatation technique. However, further studies are still necessary, mainly with respect to the ecology and biology of immature sandfly stages, so that control measures focused on breeding sites can produce positive sustainable results in natural environments.

Association of Bartonella spp bacteremia with Chagas cardiomyopathy, endocarditis and arrhythmias in patients from South America.

Infection with Bartonella spp may cause cardiac arrhythmias, myocarditis and endocarditis in humans. The aim of the present study was to evaluate a possible association between Bartonella spp bacteremia and endocarditis, arrhythmia and Chagas cardiomyopathy in patients from Brazil and Argentina. We screened for the presence of bacterial 16S rRNA in human blood by PCR using oligonucleotides to amplify a 185-bp bacterial DNA fragment. Blood samples were taken from four groups of subjects in Brazil and Argentina: i) control patients without clinical disease, ii) patients with negative blood-culture endocarditis, iii) patients with arrhythmias, and iv) patients with chronic Chagas cardiomyopathy. PCR products were analyzed on 1.5% agarose gel to visualize the 185-bp fragment and then sequenced to confirm the identity of DNA. Sixty of 148 patients (40.5%) with cardiac disease and 1 of 56 subjects (1.8%) from the control group presented positive PCR amplification for Bartonella spp, suggesting a positive association of the bacteria with these diseases. Separate analysis of the four groups showed that the risk of a Brazilian patient with endocarditis being infected with Bartonella was 22 times higher than in the controls. In arrhythmic patients, the prevalence of infection was 45 times higher when compared to the same controls and 40 times higher for patients with Chagas cardiomyopathy. To the best of our knowledge this is the first report of the association between Bartonella spp bacteremia and Chagas disease. The present data may be useful for epidemiological and prevention studies in Brazil and Argentina.

Feeding frequency and growth performance of juvenile pink shrimp ([farfantepenaeus paulensis) / Frequência de oferta alimentar e desempenho zootécnico de juvenis do camarão rosa (farfantepenaeus paulensis)

It is generally believed that increasing feeding frequency has immediate benefits, including reduced nutrient leaching and increased shrimp growth. In this context, the aim this work was to evaluate the effect of feeding frequency in growth performance of Farfantepenaeus paulensis. Juveniles of Farfantepenaeus paulensis were grown for 30 days in pen enclosures, at a stocking density of 5 shrimp/m2. The shrimp were fed on feeding trays at a rate of 8% of their biomass per day, with treatments of one, two, three and four times per day, with four replicates each. The results showed no differences (5% probability) in biomass gain of F. paulensis when feed was offered two, three or four times per day. However, it was observed that the once a day frequency had a negative influence on weight gain for this species of shrimp. We conclude that the supply of food with 35% crude protein twice a day is sufficient for the growth of F paulensis. Feeding frequency of three or four times can provide increased spending in the cultivation of juveniles of this species.

Acredita-se que uma frequência maior de alimentação traz benefícios imediatos, incluindo a redução da lixiviação de nutrientes e o aumento do crescimento do camarão. Nesse contexto, o objetivo do presente trabalho foi avaliar o efeito de diferentes frequências de oferta de alimento sobre o crescimento de Farfantepenaeus paulensis. Juvenis de Farfantepenaeus paulensis foram criados por 30 dias em tanques-rede, na densidade de estocagem de cinco camarões/m 2. Os camarões foram alimentados em comedouros com 8% da sua biomassa/dia, ofertados em parcelamentos de uma, duas, três e quatro vezes ao dia, com quatro repetições para cada tratamento. Os resultados mostraram que não ocorreram diferenças (5% de probabilidade) no ganho de biomassa de F. paulensis quando a frequência alimentar foi de duas, três ou quatro vezes ao dia. No entanto, os dados indicam que a frequência alimentar de uma vez ao dia interferiu negativamente no ganho de peso dessa espécie. Conclui-se que o fornecimento de ração com 35% de proteína bruta duas vezes ao dia é suficiente para o crescimento de F paulensis. O fornecimento de alimento três ou quatro vezes ao dia poderia acarretar maiores gastos no manejo de juvenis dessa espécie.