Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil.

OBJECTIVE: • Neurology trainees and program directors recognized a lack of structured breaking bad news training. • Program directors reported that many factors hinder the implementation of breaking bad news education. • Trainees felt capable of breaking bad news, but most did not have lectures, simulations, nor feedback. • Trainees acknowledged negative feelings when breaking bad news, including sadness and helplessness. We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors. METHODS: We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic. RESULTS: We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training. CONCLUSION: This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil

ABSTRACT Objective We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors. Methods We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic. Results We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training. Conclusion This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

Perinatal malnutrition stimulates motivation through reward and enhances drd(1a) receptor expression in the ventral striatum of adult mice.

AIM: The aim of this study was to analyze the effects of protein perinatal malnutrition on the function of dopamine DRD1 and DRD2 receptors in regards to motivation and food consumption in adult mice. The study also analyzed the effect of protein perinatal malnutrition on the gene expression of these receptors in the ventral striatum. METHODS: Wistar lineage mice were divided into two groups according to maternal diet: control (17% casein), n=30 and low protein (8% casein), n=30. Between 30 and 120days of life, the following factors were measured: body weight; the effect of dopamine D1 and D2 agonists on the ingestion of palatable food; the motivational aspect under the action of the D1 (SKF 38393) and D2 Quinpirole dopaminergic agonists; and the gene expression of DRD1 and DRD2 receptors in the ventral striatum. RESULTS: The body weights of the malnourished animals remained significantly lower than those of the control group from 30 to 120days of life. Malnourished animals ingested a greater quantity of palatable food. There was a decrease in palatable diet consumption in both the control and malnourished groups after the application of D1 and D2 agonists; however, the anorexic effect of the D1 agonist was understated in malnourished animals. Perinatal malnutrition increases the motivational behavior of the animal when food reward is used. There was an increase in gene expression of the DRD1a receptor in the ventral striatum of malnourished animals, and there were no significant changes concerning the DRD2 receptor. CONCLUSIONS: Perinatal protein malnutrition stimulates hedonic control of eating behavior by promoting increased intake of palatable foods, possibly due to increased expression of dopamine receptor DRD1a in the ventral striatum.

Altered regulation of Akt signaling with murine cerebral malaria, effects on long-term neuro-cognitive function, restoration with lithium treatment.

Neurological and cognitive impairment persist in more than 20% of cerebral malaria (CM) patients long after successful anti-parasitic treatment. We recently reported that long term memory and motor coordination deficits are also present in our experimental cerebral malaria model (ECM). We also documented, in a murine model, a lack of obvious pathology or inflammation after parasite elimination, suggesting that the long-term negative neurological outcomes result from potentially reversible biochemical and physiological changes in brains of ECM mice, subsequent to acute ischemic and inflammatory processes. Here, we demonstrate for the first time that acute ECM results in significantly reduced activation of protein kinase B (PKB or Akt) leading to decreased Akt phosphorylation and inhibition of the glycogen kinase synthase (GSK3ß) in the brains of mice infected with Plasmodium berghei ANKA (PbA) compared to uninfected controls and to mice infected with the non-neurotrophic P. berghei NK65 (PbN). Though Akt activation improved to control levels after chloroquine treatment in PbA-infected mice, the addition of lithium chloride, a compound which inhibits GSK3ß activity and stimulates Akt activation, induced a modest, but significant activation of Akt in the brains of infected mice when compared to uninfected controls treated with chloroquine with and without lithium. In addition, lithium significantly reversed the long-term spatial and visual memory impairment as well as the motor coordination deficits which persisted after successful anti-parasitic treatment. GSK3ß inhibition was significantly increased after chloroquine treatment, both in lithium and non-lithium treated PbA-infected mice. These data indicate that acute ECM is associated with abnormalities in cell survival pathways that result in neuronal damage. Regulation of Akt/GSK3ß with lithium reduces neuronal degeneration and may have neuroprotective effects in ECM. Aberrant regulation of Akt/GSK3ß signaling likely underlies long-term neurological sequelae observed in ECM and may yield adjunctive therapeutic targets for the management of CM.

Treatment with bone marrow mononuclear cells induces functional recovery and decreases neurodegeneration after sensorimotor cortical ischemia in rats.

We evaluated the beneficial effect of treatment with bone marrow mononuclear cells(BMMC) in a rat model of focal ischemia induced by thermocoagulation of the blood vessels in the left sensorimotor cortex. BMMC were obtained from donor rats and injected into the femoral vein one day after ischemia. BMMC-treated animals received approx. 3×107 cells and control animals received PBS. Animals were evaluated for functional sensorimotor recovery weekly with behavioral tests and for changes in neurodegeneration and structural plasticity with histochemical and immunostaining techniques, respectively. The BMMC-treated group showed a significant recovery of function in the cylinder test 14, 21 and 28 days after ischemia. In the beam test, both groups showed improvement, with a tendency for faster recovery in the BMMC-treated group. In the adhesive test, both groups did not show significant recovery of function. FJC+ cell counting revealed significant decrease in the neurodegeneration in the periphery of the lesion in the BMMC-treated group. The analyses by immunoblotting revealed no significant difference in the expression of GAP-43 and synaptophysin between the groups. Thus, our results showed beneficial effects of the treatment with BMMC, which promoted significant functional recovery and decreased neurodegeneration. These results suggest that the therapy with BMMC is effective and might be a protocol of treatment for stroke in humans, alternative to the therapy proposed with the bone marrow-derived mesenchymal stem cells.