Environment diagnosis for land-use planning based on a tectonic and multidimensional methodology.

In this research, emphasis is placed on the information and diagnostic phase of the physical environment for land-use planning (LUP). Our work is mainly focused on a land-planning case study of a tectonic depression, the Tulum Valley, which extends into the Pampean flat-slab segment. We propose the use of tectonic structures to define Environment Units (EUs) as necessary boundaries for the LUP. For this purpose, we have studied tectonic structures using geophysical methods and, subsequently, subjected multiple dimensions of the physical environment in the territory to an exhaustive analysis. Moreover, we have examined the influence of structural geology on water, soils, processes, materials and forms in the landscape. The study revealed the close and significant relationship between the different elements of the physical environment observable on the surface (shape, distribution, appearance, degree of development) and the tectonic structures, which supported the use of this criterion to define EUs. In order to test it, we applied the same methodology in another area of South America, the city of Bucaramanga, where it was possible to define EUs based on tectonics and to also establish comparisons. The methodology proposed for the diagnostic phase based mainly on the tectonic factor represents a challenge as regards its application in other active tectonic zones. Some limitations could arise such as fragmented environmental information from different institutions or the small to non-existent number of tectonic studies available. As a strong point, we find that the method allows achieving a comprehensive study of the environmental setting and thus to propose activities and land uses in each EU according to the real reception capacity of the land. This exhaustive analysis of the physical environment will also help decision-makers to understand and manage the socio-natural risks of the territory where communities develop.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

A pilot study of safety of sulfamethoxazole, trimethoprim and guaifenesin in pediatric and adult patients with acute bronchitis.

OBJECTIVE: This exploratory study assessed the safety of the combination of sulfamethoxazole, trimethoprim and guaifenesin (STG) in adult and pediatric patients with acute bronchitis according to local labelling in Peru. RESULTS: We enrolled 51 pediatric and 52 adult participants diagnosed with acute bronchitis and indication of STG. The mean ages were 7.6 years (SD ± 3.2 years) and 42.8 years (SD ± 16.1) and the proportion of female patients were 51% and 65%, respectively. The duration of treatment in pediatric patients was < 5 days in 2% of patients, 5 days in 13.7%, 6-7 days, in 82.4% and > 7 days in 2% while in adults patients it was < 5 days in 17%, 5 days in 69.2%; 6-7 days in 28.8% of patients. Adverse events (AEs) were registered in 9.6% and 19.2% of pediatric and adult patients, respectively. These AEs had definite relation of causality with the study drugs in 2 adults (20% of AEs) and possible causality with the study drugs in 4 pediatric (80% of AEs) and 2 adult cases (20% of AEs). Our results provide valuable data to develop trials of pharmacovigilance where different statistical parameters should be considered to calculate an adequate sample size in studies evaluating STG in pediatric or adult patients. Trial registration NCT02879981 and NCT02902640.

Precision medicine for locally advanced breast cancer: frontiers and challenges in Latin America.

Advances in high-throughput technologies and their involvement in the 'omics' of cancer have made possible the identification of hundreds of biomarkers and the development of predictive and prognostic platforms that model the management of cancer from evidence-based medicine to precision medicine. Latin America (LATAM) is a region characterised by fragmented healthcare, high rates of poverty and disparities to access to a basic standard of care not only for cancer but also for other complex diseases. Patients from the public setting cannot afford targeted therapy, the facilities offering genomic platforms are scarce and the use of high-precision radiotherapy is limited to few facilities. Despite the fact that LATAM oncologists are well-trained in the use of genomic platforms and constantly participate in genomic projects, a medical practice based in precision oncology is a great challenge and frequently limited to private practice. In breast cancer, we are waiting for the results of large basket trials to incorporate the detection of actionable mutations to select targeted treatments, in a similar way to the management of lung cancer. On the other hand and paradoxically, in the 'one fit is not for all' era, clinical and genomic studies continue grouping our patients under the single label 'Latin American' or 'Hispanic' despite the different ancestries and genomic backgrounds seen in the region. More regional cancer genomic initiatives and public availability of this data are needed in order to develop more precise oncology in locally advanced breast cancer.

Rivaroxaban for treatment of intraventricular thrombus in Chagas disease.

Chagas disease leads to congestive heart failure, apical aneurysm, and may cause stroke or systemic embolism for intraventricular thrombus. We present a case of a 61-year-old man admitted for stroke 5 months after a renal embolism. An intraventricular thrombus was observed, probably the source of the cerebral and renal embolisms. The patient refused warfarin and rivaroxaban was used instead. After 40 days of treatment the thrombus had dissolved, after 20 months of regular use of rivaroxaban no more embolic events were observed. The use of rivaroxaban was effective in preventing embolic events in Chagas disease and intraventricular thrombus. .

General public and workers exposure to high-frequency electric fields in spanish hospitals / Exposición de trabajadores y usuarios a campos eléctricos de alta frecuencia en hospitales españoles

Introduction: Electromagnetic fields (EMF) are commonly used in hospitals to detect and treat certain diseases or ailments, exposing healthcare workers daily to such fields and casting doubts about workers and patients safety. Objectives: To quantify the actual exposure to high-frequency electric fields of workers and public hospitals users in the Balearic Islands (Spain) and the compliance with the references levels established by the International Commission on Non-Ionizing Radiation Protection (ICNIRP).Material and Methods: High-frequency radiation exposure levels were measured in different areas and compared with ICNIRP levels and Spanish regulation, using a broadband field strength meter and a spectrum analyzer. Results: 1,290 measurements were performed obtaining a median electric field of 0.31 V/m (1st quartile: 0.16 V/m; 3rd quartile: 0.67 V/m). Users and workers are exposed to electric fields from 0.19 V/m to 0.25 V/m in all areas, but Rehabilitation and Radiology. In the former, the patients (not under microwave therapy) are exposed to EMF between 1.87 V/m and 25.71 V/m. Discussion and conclusions: Although effective electric field values are lower than the reference levels, measures should be taken to reduce exposure of especially sensitive people (infants, children, pregnant women,...) and ensure regular monitoring of the exposure (AU)

Introducción: Los campos electromagnéticos (CEM) se utilizan con frecuencia en los hospitales para detectar y tratar ciertas enfermedades o dolencias, exponiendo diariamente a los trabajadores sanitarios a esos campos y sembrando dudas sobre la seguridad de trabajadores y pacientes. Objetivos: Cuantificar la exposición real de trabajadores y usuarios de los hospitales públicos de las Islas Baleares (España) a campos eléctricos de alta frecuencia y el cumplimiento de los niveles de referencia establecidos por la Comisión Internacional de Protección contra la Radiación No Ionizante (ICNIRP).Material y métodos: Se midieron los niveles de exposición a radiaciones de alta frecuencia y se compararon con los niveles de ICNIRP y normativa española, usando un equipo de banda ancha y un analizador de espectro. Resultados: Se realizaron 1,290 mediciones obteniendo una mediana del campo eléctrico de 0.31 V/m (1er cuartil: 0.16 V/m; 3er cuartil: 0.67 V/m). Usuarios y trabajadores están expuestos a campos eléctricos de 0.19 V/m a 0.25 V/m en todas las áreas, excepto Rehabilitación y Radiología. En la primera, los pacientes (no tratados con microondas) están expuestos a CEM entre 1.87 V/m y 25.71 V/m. Discusión y conclusiones: Aunque los valores eficaces de campo eléctrico están por debajo de los niveles de referencias, se deben tomar medidas para reducir la exposición de personas especialmente sensibles (bebés, niños, gestantes,...) y asegurar un control periódico de la exposición (AU)

Estudio longitudinal de la exposición a formaldehído en el Laboratorio de Anatomía Patológica del Hosptial Universitario Son Dureta / Longitudinal study of the occupational exposure to formaldehyde in the pathology labortory of the Son Dureta University Hospital

Objetivo: Presentación de las concentraciones ambientales de formaldehído en el Laboratorio de Anatomía Patológica obtenidas durante el periodo 2003- 2007, análisis de su evolución con la implantación progresiva de medidas preventivas y determinación de las condiciones de trabajo para minimizar la exposición. Métodos: Mediciones personales (facultativo y técnico especialista en los dos puestos de tallado) y ambientales. Las mediciones personales de los trabajadores más expuestos (facultativos) se han diferenciado entre piezas pequeñas/medianas y grandes (mama, placenta, etc.). Resultados: Las concentraciones personales han disminuido de 12,07 mg/m3 (2003) a 0,10 mg/m3 (2007), y las ambientales, de 3,95 mg/m3 (2003) a 0,03 mg/m3 (2007). Conclusiones: Las medidas organizativas y de ingeniería adoptadas han reducido los niveles de formaldehído a concentraciones inferiores al VLA-EC, excepto durante el tallado de piezas grandes y el lavado de piezas (AU)

Aims: The Pathology Laboratory’s formaldehyde environmental concentrations from 2003 to 2007 are shown, analyzing its evolution with the progressive introduction of preventive measures, determining the workplace conditions to minimize the exposure. Methods: Personal (pathologists and specialized technicians in two grossing workstations) and environmental samples were collected. The most exposed workers’ personal measurements (pathologists) have been differentiated between small/medium-sized and big pieces (breast, placenta, etc.). Results: The personal formaldehyde levels have decreased from 12.07 mg/m3 (2003) to 0.10 mg/m3 (2007), and the environmental ones, from 3.95 mg/m3 (2003) to 0.03 mg/m3 (2007). Conclusions: The adoption of organization and engineering measures have reduced formaldehyde levels, resulting concentrations below VLA-EC, except for the big pieces grossing and the pieces rinsing (AU)

Síndrome de Sneddon: relato de três casos / Sneddon's syndrome: report of 3 cases

Descrita por Sneddon (1965) a síndrome consiste na ocorrência de acidente vascular encefálico (AVE) isquêmico em pacientes com livedo reticular. Trata-se de doença vascular sistêmica de causa desconhecida, em que há comprometimento de artérias de médio e pequeno calibres. Pode haver positividade dos anticorpos antifosfolípides. Säo apresentados três casos desta entidade, todos do sexo masculino com 7, 16 e 54 anos de idade. Em todos a instalaçäo do quadro deu-se por convulsöes focais seguidas de hemiparesia ou paralisia labio-glossofaríngea. Os pacientes näo tiveram outras manifestaçöes neurológicas em 2 anos de acompanhamento. A investigaçäo laboratorial demonstrou presença de anticorpos antifosfolípides e anticardiolipina em 1 caso. A investigaçäo neuro-radiológica forneceu os seguintes resultados: TCC e RM com infarto nos 3 casos, e angiografia com obstruçäo de vasos de médio e pequeno calibre. A síndrome de Sneddon näo parece ser täo rara e deve fazer parte de protocolos de investigaçäo de AVE, especialmente em grupos mais jovens