[3 cases of abomasitis in calves associated with Sarcina sp. infection]. / 3 Fälle von Abomasitis im Zusammenhang mit einer Infektion mit Sarcina sp. beim Kalb.

In this case report - to the best knowledge of the authors for the first time in the German-speaking region - 3 calves with ulcerating or emphysematous abomasitis respectively are presented, in which intralesional bacteria of the Sarcina species were identified. The unusual appearance of these bacteria is described, their etiopathogenic relevance discussed.

Ultrasonography as an instrument to evaluate lymphedema secondary to breast cancer: systematic review.

Lymphedema is a chronic and progressive disease characterized by fluid accumulation, causing tissue edema as a result of a compromised lymphatic system. Diagnostic ultrasound (DUS) is a method capable of assessing soft tissue characteristics that can be used reliably to diagnose lymphedema as well as for measuring tissue compliance in a clinical setting. This is a systematic review, aiming to evaluate articles that made use of DUS in management of lymphedema secondary to breast cancer. A total of 570 articles were selected, exported to the Rayyan QCRI review program, and then screened by two researchers. From this search, 25 articles were selected after the authors reached consensus and were catalogued as to their main results. Diagnostic ultrasound was identified as an advantageous method that is safe, minimally invasive, low cost, and radiation free and is useful for evaluating the efficacy of therapies used in lymphedema treatment.

Ultrassonografia como instrumento de avaliação do linfedema secundário ao câncer de mama: revisão sistemática / Ultrasonography as an instrument to evaluate lymphedema secondary to breast cancer: systematic review

Resumo O linfedema é uma doença crônica e progressiva caracterizada pelo acúmulo de fluidos, provocando edema tecidual em decorrência de um sistema linfático comprometido. A ultrassonografia diagnóstica (USD) é um método capaz de avaliar as características dos tecidos moles, podendo ser utilizada de maneira confiável para o diagnóstico do linfedema, além de mensurar a complacência tecidual em um cenário clínico. Esta é uma revisão sistemática, objetivando avaliar artigos que fizessem o uso da USD na abordagem do linfedema secundário ao câncer de mama. Foram selecionados 565 artigos, que foram exportados para o programa de revisão Rayyan QCRI e, em seguida, triados por dois pesquisadores. Dessa busca, foram obtidos 25 artigos selecionados após consenso entre os autores e que foram catalogados quanto aos seus resultados principais. A USD foi identificada como um método vantajoso por ser seguro, pouco invasivo, de baixo custo, sem uso de radiação, além de ser útil para avaliar a eficácia de terapias no tratamento do linfedema.

Abstract Lymphedema is a chronic and progressive disease characterized by fluid accumulation, causing tissue edema as a result of a compromised lymphatic system. Diagnostic ultrasound (DUS) is a method capable of assessing soft tissue characteristics that can be used reliably to diagnose lymphedema as well as for measuring tissue compliance in a clinical setting. This is a systematic review, aiming to evaluate articles that made use of DUS in management of lymphedema secondary to breast cancer. A total of 570 articles were selected, exported to the Rayyan QCRI review program, and then screened by two researchers. From this search, 25 articles were selected after the authors reached consensus and were catalogued as to their main results. Diagnostic ultrasound was identified as an advantageous method that is safe, minimally invasive, low cost, and radiation free and is useful for evaluating the efficacy of therapies used in lymphedema treatment.

[Vetch poisoning in a Bavarian cattle herd - A case report from a pathological perspective]. / Wickenvergiftung in einem bayerischen Rinderbestand.

In a herd of 40 cattle of the Holstein-Friesian breed, 6 animals were euthanized for severe pruritus, fever and skin lesions. Pathomorphological examination of 3 animals revealed multisystemic granulomatous inflammation involving multinuclear giant cells. The content of vetch in the feed used and the characteristic histology led to the diagnosis of vetch poisoning.

A phase II study of talimogene laherparepvec for patients with inoperable locoregional recurrence of breast cancer.

Talimogene laherparepvec (T-VEC) is an immunotherapy that generates local tumor lysis and systemic antitumor immune response. We studied the efficacy of intratumoral administration of T-VEC as monotherapy for inoperable locoregional recurrence of breast cancer. T-VEC was injected intratumorally at 106 PFU/mL on day 1 (cycle 1), 108 PFU/mL on day 22 (cycle 2), and 108 PFU/mL every 2 weeks thereafter (cycles ≥ 3). Nine patients were enrolled, 6 with only locoregional disease and 3 with both locoregional and distant disease. No patient completed the planned 10 cycles or achieved complete or partial response. The median number of cycles administered was 4 (range, 3-8). Seven patients withdrew prematurely because of uncontrolled disease progression, 1 withdrew after cycle 3 because of fatigue, and 1 withdrew after cycle 4 for reasons unrelated to study treatment. Median progression-free survival and overall survival were 77 days (95% CI, 63-NA) and 361 days (95% CI, 240-NA). Two patients received 8 cycles with clinically stable disease as the best response. The most common grade 2 or higher adverse event was injection site reaction (n = 7, 78%). Future studies could examine whether combining intratumoral T-VEC with concurrent systemic therapy produces better outcomes.

Microcystic Cerebral Neoplasm in a Nilgai Antelope (Boselaphus tragocamelus): Putative Microcystic Meningioma.

Tumours of the nervous system are rare in wild and captive mammals. In this report, we describe an intracranial, solid, space-occupying lesion originating from the meninges in a Nilgai antelope (Boselaphus tragocamelus). Histologically, the tumour had a conspicuous microcystic appearance with features similar to the histological subtype of microcystic meningioma described in humans. This is the first such tumour reported in this species.

Bovine Alphaherpesvirus 2 infections in Bavaria: an analysis of the current situation - several years after eradicating Bovine Alphaherpesvirus 1.

BACKGROUND: Bavaria, a large federal state in Germany, has been declared free from infections with Bovine Alphaherpesvirus 1 (BoHV-1) in 2011. To maintain this status the cattle population is monitored for antibodies against BoHV-1 regularly. Several years ago, infrequent but recurrent problems in this sero-surveillance were statistically put into correlation with the presence of antibodies against Bovine Alphaherpesvirus 2 (BoHV-2). In Europe, BoHV-2 is primarily known as the agent causing bovine herpes mammillitis. However, very little information about BoHV-2 infections in Bavaria is available so far. Therefore, the aims of this study were to determine BoHV-2 seroprevalences and to detect virus genomes in potential clinical samples. RESULTS: 6801 blood sera of healthy cattle from all over Bavaria were tested for antibodies against BoHV-2, revealing an overall seroprevalence of 5.51%. Interestingly, seroprevalences markedly varied between the North and the South of Bavaria, namely from 0.42 to 11.17%. Concurrently, the previously reported relation between the epidemiologically inexplicable sero-reactivities in BoHV-1 ELISAs and the presence of BoHV-2 infections were statistically corroborated in this study. To detect BoHV-2 genomes a fast and sensitive real time PCR was established. Using a multiple PCR strategy, tissue samples from skin lesions at relevant localizations, corresponding lymph nodes, and trigeminal ganglia from 111 animals, as well as nasal swabs from 918 bovines with respiratory symptoms were tested. However, BoHV-2 genomes were not detected in any of these samples. CONCLUSIONS: BoHV-2 antibodies were found in samples from bovines all over Bavaria, albeit with an explicit South-North-divide. BoHV-2 genomes, however, could not be detected in any of the analyzed samples, indicating that acute clinical cases as well as obvious virus reactivation are relatively rare. Consequently, the future spread of BoHV-2 infections throughout Bavaria, particularly, after eradicating BoHV-1, has to be further monitored.

Shedding of Mycobacterium caprae by wild red deer (Cervus elaphus) in the Bavarian alpine regions, Germany.

The number of natural infections with Mycobacterium caprae in wildlife and in cattle in the Bavarian and Austrian alpine regions has increased over the last decade. Red deer (Cervus elaphus) have been recognized as maintenance reservoir; however, the transmission routes of M. caprae among and from naturally infected red deer are unknown. The unexpected high prevalence in some hot spot regions might suggest an effective indirect transmission of infection. Therefore, this study was undertaken to diagnose the occurrence of M. caprae in faeces and secretions of red deer in their natural habitat. A total of 2,806 red deer hunted in this region during 2014-2016 were included in this study. After pathological examination, organs (lymph nodes, lung, heart), excretions and secretions (faeces, urine, saliva and tonsil swabs) were further investigated by qPCR specific for Mycobacterium tuberculosis complex (MTC), M. bovis and M. caprae. Samples tested positive by qPCR were processed for culturing of mycobacteria. In total, 55 (2.0%) animals were confirmed positive for M. caprae by pathological examination, PCR and culturing of the affected organ material. With the exception of one sample, all of the secretion and excretion samples were negative for mycobacteria of the Mycobacterium tuberculosis complex (MTC). From one red deer, M. caprae could be isolated from the heart sac as well as from the faeces. Whole-genome sequencing confirmed that both strains were clonally related. This is the first confirmation that M. caprae can be shed with the faeces of a naturally infected red deer. However, further studies focusing on a higher number of infected animals, sample standardization and coordinated multiple sampling are necessary to improve the understanding of transmission routes under natural conditions.

[Melanosis of adipose tissue in a 17-month-old German Fleckvieh bull (Bos taurus)]. / Melanose von Fettgewebe bei einem 17 Monate alten Stier der Rasse Deutsches Fleckvieh (Bos taurus).

At meat inspection of a 17-month-old bull (German Fleckvieh), patchy dark discoloration of various organs and tissue sites was noted that was most prominent in perirenal adipose tissue. Microscopic analysis revealed melanosis, that is a congenital melanocytic dystopia, as the underlying cause. To the best of our knowledge, this is the first case of melanosis detected in adipose tissue in cattle. We speculate that there is a possible pathogenetic link between obesity and melanosis in the animal.

High-Frequency Generator in Wound Healing of Marjolin's Ulcer After Carcinoma Resection.

Marjolin's ulcers (MU) are skin malignancies that form over burn injuries. These very aggressive ulcers can result in functional and wound healing impairment, and require a well thought out treatment plan. Physiotherapy offers resources to help promote recovery of these patients, as described in this case report, in which the patient with a history of burn in the lower limbs evolved to malignancy 32 years later. This patient underwent tumor resection of the left foot, with recurrence and lymphadenectomy. Physical therapy included the application of high-frequency generator (HFG) for wound healing and exercises for functional recovery. The treatment lasted for many months and resulted in the improvement of the surgical wound areas, pain, swelling, sensitivity, strength muscle, and gait. It was observed that the use of HFG can be a tool in the tissue repair of surgical wound after the resection of MU; however, further studies need to be carried out to suit parameters and ensure safety of cancer patients.

Androgen receptor expression on circulating tumor cells in metastatic breast cancer.

PURPOSE: Androgen receptor (AR) is frequently detected in breast cancers, and AR-targeted therapies are showing activity in AR-positive (AR+) breast cancer. However, the role of AR in breast cancers is still not fully elucidated and the biology of AR in breast cancer remains incompletely understood. Circulating tumor cells (CTCs) can serve as prognostic and diagnostic tools, prompting us to measure AR protein expression and conduct genomic analyses on CTCs in patients with metastatic breast cancer. METHODS: Blood samples from patients with metastatic breast cancer were deposited on glass slides, subjected to nuclear staining with DAPI, and reacted with fluorescent-labeled antibodies to detect CD45, cytokeratin (CK), and biomarkers of interest (AR, estrogen receptor [ER], and HER2) on all nucleated cells. The stained slides were scanned and enumerated by non-enrichment-based non-biased approach independent of cell surface epithelial cell adhesion molecule (EpCAM) using the Epic Sciences CTC platform. Data were analyzed using established digital pathology algorithms. RESULTS: Of 68 patients, 51 (75%) had at least 1 CTC, and 49 of these 51 (96%) had hormone-receptor-positive (HR+)/HER2-negative primary tumors. AR was expressed in CK+ CTCs in 10 patients. Of these 10 patients, 3 also had ER expression in CK+ CTCs. Single cell genomic analysis of 78 CTCs from 1 of these 3 patients identified three distinct copy number patterns. AR+ cells had a lower frequency of chromosomal changes than ER+ and HER2+ cells. CONCLUSIONS: CTC enumeration and analysis using no enrichment or selection provides a non-biased approach to detect AR expression and chromosomal aberrations in CTCs in patients with metastatic breast cancer. The heterogeneity of intrapatient AR expression in CTCs leads to the new hypothesis that patients with AR+ CTCs have heterogeneous disease with multiple drivers. Further studies are warranted to investigate the clinical applicability of AR+ CTCs and their heterogeneity.

Evaluating diagnostic tests for bovine tuberculosis in the southern part of Germany: A latent class analysis.

Germany has been officially free of bovine tuberculosis since 1996. However, in the last years there has been an increase of bovine tuberculosis cases, particularly in the southern part of Germany, in the Allgäu region. As a consequence a one-time tuberculosis surveillance program was revisited with different premortal and postmortal tests. The aim of this paper was to estimate diagnostic sensitivities and specificities of the different tests used within this surveillance program. In the absence of a perfect test with 100% sensitivity and 100% specificity, thus in the absence of a gold standard, a Bayesian latent class approach with two different datasets was performed. The first dataset included 389 animals, tested with single intra-dermal comparative cervical tuberculin (SICCT) test, PCR and pathology; the second dataset contained 175 animals, tested with single intra-dermal cervical tuberculin (SICT) test, Bovigam® assay, pathology and culture. Two-way conditional dependencies were considered within the models. Additionally, inter-laboratory agreement (five officially approved laboratories) of the Bovigam® assay was assessed with Cohen's kappa test (21 blood samples). The results are given in posterior means and 95% credibility intervals. The specificities of the SICT test, SICCT test, PCR and pathology ranged between 75.8% [68.8-82.2%] and 99.0% [96.8-100%]. The Bovigam® assay stood out with a very low specificity (6.9% [3.6-11.1%]), though it had the highest sensitivity (95.7% [91.3-99.2%]). The sensitivities of the SICCT test, PCR, SICT test, pathology and culture varied from 57.8% [48.0-67.6%] to 88.9% [65.5-99.7%]. The prevalences were 19.8% [14.6-26.5%] (three-test dataset) and 7.7% [4.2-12.3%] (four-test dataset). Among all pairwise comparisons the highest agreement was 0.62 [0.15-1]). In conclusion, the specificity of the Bovigam® assay and the inter-laboratory agreement were lower than expected.

[Primary malignant melanoma in the brain of a 7-month-old sheep (Ovis aries f. domestica)]. / Primäres malignes Melanom im Gehirn eines 7 Monate alten Schafs (Ovis aries f. domestica).

A case of malignant melanoma in a sheep's brain is described for the first time. In a 7-month-old sheep that had been euthanized due to ataxia, post-mortem and histopathologic examinations were performed. Both the brain and the calvarium were heavily infiltrated with neoplastic tissue. Metastases were found in the liver and kidneys. Histomorphology confirmed the gross pathologic impression of malignancy. Congenital melanosis, which is regularly present in the meninx of sheep, could have been the origin of the malignant melanoma in the present case. The young age of the animal appears to favour this supposition. This case demonstrates that even in farm animals - including sheep - a neoplasm should be considered as a differential diagnosis in diagnostically doubtful cases.

Early transcriptional events in the udder and teat after intra-mammary Escherichia coli and Staphylococcus aureus challenge.

Intra-mammary bacterial infections can result in harmful clinical mastitis or subclinical mastitis with persistent infections. Research during the last decades closely examined the pathophysiology of inflamed udders. Initial events after pathogen perception but before the onset of mastitis have not been examined in vivo The objective of this study was to develop a mastitis model in cows by monitoring initial transcriptional pathogen-specific host response before clinical signs occur. We applied a short-term infection model to analyse transcripts encoding chemokines, cytokines and antimicrobial molecules in the teat cistern (TC) and lobulo-alveolar parenchyma (LP) up to 3 h after challenge with E and Staphylococcus aureus Both pathogens elicited an immune reaction by 1 h after challenge. Escherichia coli induced all analysed factors (CCL20, CXCL8, TNF, IL6, IL12B, IL10, LAP, S100A9); however, S. aureus failed to induce IL12B, IL10, LAP and S100A9 expression. The E. coli-induced up-regulation was 25-105 times greater than that after S. aureus challenge. Almost all the responses were restricted to the TC. The short-term mastitis model demonstrates that a divergent pathogen-specific response is generated during the first h. It confirms that the first transcripts are generated in the TC prior to a response in the LP.

Retrospective study of the physical therapy modalities applied in head and neck l ymphedema treatment.

BACKGROUND: Secondary lymphedema after head and neck cancer treatment is a serious complication and its management can be a challenge. The purpose of this study was to verify which physical therapy modalities were applied in the treatment of head and neck lymphedema through a retrospective analysis. METHODS: A retrospective study was developed, based on the analysis of medical records of 32 patients treated in the physiotherapy outpatient department of the Brazilian Institute of Cancer Control (IBCC). RESULTS: The physiotherapy included manual lymphatic drainage, massage, exercises, patient education, and compression therapy with an average of 23.9 ± 14.8 sessions. Measurement results showed a significant reduction of face and neck lymphedema (p < .05) and pain (from 7.8 ± 2.2 to 3.6 ± 1.6; p < .001). CONCLUSION: The physical therapy modalities based on strategic manual lymphatic drainage, shoulder girdle massage, facial, tongue and neck exercises, compressive therapy at home, and patient education showed reduction of the lymphedema and pain, both of them secondary to head and neck cancer treatment.

[Severe purulent and necrotizing glossitis in a fallow deer (Dama dama) due to an infection with the involvement of Mannheimia granulomatis]. / Hochgradige eitrig-nekrotisierende Glossitis bei einem Damwild (Dama dama) nach Infektion unter Beteiligung von Mannheimia granulomatis.

Post mortem examination of a young fallow deer (Dama dama) revealed a severe purulent and necrotizing glossitis as well as a multifocal necrotizing and ulcerative rumenitis and typhlitis. The animal was cachectic. Mannheimia (M.) sp. was isolated from the tongue lesions and identified as M. granulomatis by MALDI-TOF MS and 16S rRNA sequencing. Mycosis and BVDV infection were excluded. Few publications are dealing with similar macroscopic findings associated with the isolation of M. granulomatis in cattle and roe deer. Therefore, M. granulomatis should also be taken into consideration when such lesions occur in other ruminants. Based on our findings in case of gross pathological lesions of the tongue of ruminants a Mannheimia granulomatis-infection should be investigated as well as the possible role of Fusobacterium necrophorum, Actinobacillus lignieresii or Actinomyces bovis.

[Amyloidosis in turkeys (Meleagris gallopavo f. domestica)--a case report]. / Amyloidose beim Truthuhn (Meleagris gallopavo f. domestica)--ein Fallbericht.

High prevalence of leg disorders in fattening meat turkey farm was observed. Four birds as well as tracheal and joint swabs were submitted to the Bavarian Health and Food Safety Authority in Oberschleissheim and to the Institute of Poultry Diseases, Faculty of Veterinary Medicine, Free University of Berlin. At the post-mortem, all birds showed an inflammation of the hock joints (intertarsal joint). The histopatholical investigations revealed a chronic inflammation of the joint and amyloid deposits in the joints in two cases as well as in different tissues (liver, spleen and kidneys) in another two cases. Using polymerase chain reaction, Ornithobacterium rhinotracheale-DNA could be detected in the examined tracheal and joint swabs. On the other hand, Mycoplasma gallisepticum- and Mycoplasma synoviae-DNA could not be detected. A causal correlation between the detected infectious agent and amyloidosis in relation to the leg disorders were discussed.

Late morbidity in upper limb function and quality of life in women after breast cancer surgery.

BACKGROUND: Breast cancer is the most common malignancy in Brazilian women. In recent years, there has been great progress in and an increasing number of breast-conserving surgical techniques; however, immediate or late morbidity after surgery, in the form of functional impairment and pain, remains a significant clinical problem. OBJECTIVE: To investigate the relationship between late upper limb functional impairment and the quality of life in women subjected to breast cancer surgery. METHOD: A total of 81 women participated in the study, with the length of time since surgery ranging from one to five years. A survey of upper limb complaints reported by patients was conducted, and the questionnaires Disabilities of the Arm, Shoulder, and Hand (DASH) and the European Organization for Research and Treatment of Cancer (EORTC QLQC-30 and BR23) were applied. RESULTS: The correlation between the DASH score and the length of time since surgery determined that the longer the time since surgery, the greater the difficulties in functionality of the upper limb (r=0.459; p<0.0001). A statistically significant correlation was observed between the DASH score and health-related quality of life. CONCLUSION: Late functional impairment had a significant impact on upper limb function in everyday life and health-related quality of life for women who underwent breast cancer surgery.

Late morbidity in upper limb function and quality of life in women after breast cancer surgery / Morbidade tardia na funcao do membro superior e na qualidade de vida de mulheres pos-cirurgia do cancer de mama

BACKGROUND: Breast cancer is the most common malignancy in Brazilian women. In recent years, there has been great progress in and an increasing number of breast-conserving surgical techniques; however, immediate or late morbidity after surgery, in the form of functional impairment and pain, remains a significant clinical problem. OBJECTIVE: To investigate the relationship between late upper limb functional impairment and the quality of life in women subjected to breast cancer surgery. METHOD: A total of 81 women participated in the study, with the length of time since surgery ranging from one to five years. A survey of upper limb complaints reported by patients was conducted, and the questionnaires Disabilities of the Arm, Shoulder, and Hand (DASH) and the European Organization for Research and Treatment of Cancer (EORTC QLQC-30 and BR23) were applied. RESULTS: The correlation between the DASH score and the length of time since surgery determined that the longer the time since surgery, the greater the difficulties in functionality of the upper limb (r=0.459; p<0.0001). A statistically significant correlation was observed between the DASH score and health-related quality of life. CONCLUSION: Late functional impairment had a significant impact on upper limb function in everyday life and health-related quality of life for women who underwent breast cancer surgery. .

CONTEXTUALIZAÇÃO: O câncer de mama é a neoplasia maligna mais frequente na população feminina brasileira. Nos últimos anos, houve grande evolução das técnicas cirúrgicas e aumento do número de cirurgias conservadoras da mama, entretanto a morbidade imediata ou tardia após a cirurgia, sob a forma de comprometimento funcional e dor, ainda é um significativo problema clínico. OBJETIVO: Verificar a relação entre o comprometimento funcional tardio do membro superior e a qualidade de vida de mulheres submetidas à cirurgia do câncer de mama. MÉTODO: Participaram da pesquisa 81 mulheres com tempo decorrido de cirurgia variando entre um a cinco anos. Realizou-se levantamento das queixas referidas pelas pacientes em relação ao membro superior e foram aplicados os questionários Disabilities of the Arm, Shoulder and Hand (DASH) e European Organization for Research and Treatment of Cancer (EORTC QLQC-30 e BR23). RESULTADOS: A correlação entre o escore DASH e o tempo decorrido de cirurgia demonstrou que, quanto maior este último, maiores são as dificuldades de funcionalidade dos membros superiores das pacientes entrevistadas (r=0,459; p<0,0001). Houve correlação estatisticamente significativa entre o escore DASH e a qualidade de vida relacionada à saúde. CONCLUSÃO: O comprometimento funcional tardio apresentou impacto significativo na função do membro superior, na vida cotidiana e na qualidade de vida relacionada à saúde das mulheres que foram submetidas à cirurgia do câncer de mama. .

Exercício físico aeróbico e câncer de pulmão: um estudo de revisão / Aerobic physical exercise and lung cancer: a review study

Introdução: O tratamento oncológico acarreta efeitos deletérios às células saudáveis, podendo representar grande impacto na vida dos pacientes. Nesse sentido, a atividade física vem demonstrando ser um opositor a esses efeitos. Objetivo: Identificar os efeitos do exercício físico aeróbico em pacientes com câncer de pulmão e suas possíveis repercussões sobre a capacidade funcional e a qualidade de vida. Método: Realizou-se uma revisão de literatura nas bases de dados computadorizadas Medline, Web of Science e PEDro, sem restrição de data de publicação. Foram incluídos estudos experimentais que avaliassem os indivíduos no pré e pós-intervenção; descrevessem claramente o programa de exercícios realizado; fossem escritos nos idiomas: português, inglês, espanhol, francês ou italiano; e estivessem publicados. Resultados: Quinze estudos preencheram os critérios de inclusão. Analisando-se os resultados em relação à capacidade funcional, é possível observar um ganho significativo na mesma na grande maioria dos estudos. Entre os artigos, somente cinco avaliaram a qualidade de vida. Os resultados referentes a essa variável foram bastante diversos, porém, a maioria dos estudos encontrou diferenças significativas em pelo menos uma escala dos questionários. Conclusão: Esses resultados indicam que os programas de exercício físico atuam positivamente sobre a capacidade funcional e a qualidade de vida desses pacientes. Apesar do aumento na produção científica nos últimos anos, nota-se a existência de importantes lacunas para a implantação segura dos programas de exercício na prática clínica.