Country experiences on the path to exclusive use of validated automated blood pressure measuring devices within the HEARTS in the Americas Initiative.

The aim of the HEARTS in the Americas initiative is to promote the adoption of global best practices in the prevention and control of cardiovascular diseases, and improve the control of hypertension. HEARTS is being implemented in 21 countries and a diverse set of actions and measures are in progress to improve exclusive access in primary health care facilities to automated blood pressure measuring devices that have been validated for accuracy. The purpose of this manuscript is to illustrate these efforts, mainly in the regulatory and public procurement arena, and to present information on common challenges and solutions identified. Examples from six countries confirm the need for not only a robust regulatory framework to increase availability of validated automated blood pressure measuring devices but also a comprehensive strategic approach that involves relevant stakeholders, includes a multi-pronged approach and is associated with a national program to prevent and control non communicable diseases.

Evaluating the performance of automated sphygmomanometers using a patient simulator.

BACKGROUND AND OBJECTIVE: Automated sphygmomanometers use the oscillometric method to measure blood pressure, which is based on an algorithm that relates the amplitude of the oscillometric waveform pulses and the pressure inside the cuff. Validation uses empirical information from clinical trials conducted by each manufacturer. Consequently, measurement algorithms are not harmonized, being based on distinct arterial waveforms, according to each group of volunteers of the clinical test. In the present study, a patient simulator was used to generate standardized, consistent oscillometric waveform pulses to test the algorithms used in six sphygmomanometers. MATERIALS AND METHODS: Six different upper arm and wrist-based automated sphygmomanometers were tested using a patient simulator comprising four different blood pressure levels, Psys/dia (mmHg): 80/50; 120/80; 150/100; 200/150. The devices were also submitted to conformity assessment. The variance of repeatable measurements was also analyzed. RESULTS: All tested automated sphygmomanometers complied with metrological requirements, presenting results within the range of ±2 mmHg for static calibration. Systematic discrepancies, greater than 20 mmHg, were observed between sphygmomanometers' results from upper arm and wrist-based models. Differences reaching 12.8 mmHg in diastolic pressure results were observed among upper arm devices. CONCLUSION: These results may have a clinical impact and indicate the need for a standardized algorithm, with a harmonized approach for validation. Moreover, the algorithm of the wrist-based devices is being affected by the use of the brachial artery waveform as reference for its validation, which also reveals that the current approach needs standardization, especially regarding the use of patient simulators.24299305.

Mars walking simulation: An electromyographic analysis.

CONTEXT: With a long duration return mission to Mars on the horizon, we must learn as much about the environment and its influence on the musculoskeletal system as possible to develop countermeasures and mitigate deleterious health effects and maladaptation. AIMS: To determine the influence of simulated Mars gravity on the activity of four locomotor muscles while walking, in comparison to 1 G, using lower body positive pressure (LBPP). MATERIAL AND METHODS: A total of 14 male subjects (mean age: 20.6 ± 2.4 years) performed bouts of walking in both simulated Mars gravity (0.38 G) and Earth gravity (1 G) using an LBPP device. The dependent variables were the muscle activity evoked in the tibialis anterior, vastus lateralis, gluteus maximus and lateral portion of the gastrocnemius, measured using electromyography and expressed as percentages of maximum voluntary isometric contractions, and heart rate (HR). For statistical analysis, a paired t-test was performed. Statistical significance was defined as P < 0.05. RESULTS: No significant differences in muscle activity were found across conditions for any of the investigated muscles. A significant mean difference in the HR was identified between Earth (105.15 ± 8.1 bpm) and Mars (98.15 ± 10.44 bpm) conditions (P = 0.027), wherein the HR was lower during the Mars trial. CONCLUSIONS: The Mars environment may not result in any deteriorative implications for the musculoskeletal system. However, if future research should report that stride frequency and thus activation frequency is decreased in the simulated Mars gravity, negative implications may be posed for muscle retention and reconditioning efforts on the Red Planet.

Evaluating the impact of measurement uncertainty in blood pressure measurement on hypertension diagnosis.

BACKGROUND AND OBJECTIVE: The sphygmomanometer is a well-known device used widely for blood pressure (BP)measurement in primary cares to diagnose hypertension. It is also vastly used by patients to monitor BP for medication. Deviations in measurement might affect significantly the diagnosis. For example, a hypertensive patient might be diagnosed as normal and consequently not receive proper treatment or a healthy patient might be diagnosed as hypertensive and may receive treatment for a nonexistent disease. A measurement has two components, the error and the measurement uncertainty, both affecting the interpretation of the results yielded by the sphygmomanometer. As the impact of measurement uncertainty has not been considered properly, the present study aims to evaluate how it influences the misdiagnosis of hypertension. MATERIALS AND METHODS: A theoretical approach is applied, using two samples from the literature, simulating how the measurement uncertainty affects the diagnosis of a sample with known BP for a sphygmomanometer indicating the threshold pressures of diagnosis. We also carried out a study evaluating how the number of measurements taken affects the probability of misdiagnosis. RESULTS: For one of the samples, the results show an increase in misdiagnosis of 227% for diastolic pressure and 225% for systolic pressure, considering the threshold of 90 and 140 mmHg, for a measurement error of -5 mmHg when considering a ±5 mmHg uncertainty in comparison with when it is disregarded. The probability of a correct diagnosis also converges to over 98% for four measurements taken. CONCLUSION: The significant impact of misdiagnosis is an indicator of the importance of considering the uncertainties as a component to medical decision. The number of measurements taken also plays a major role in hypertension diagnosis.

Blood Flow Restriction Training Reduces Blood Pressure During Exercise Without Affecting Metaboreflex Activity.

Objective: Blood flow restriction training (BFRT) has been proposed to induce muscle hypertrophy, but its safety remains controversial as it may increase mean arterial pressure (MAP) due to muscle metaboreflex activation. However, BFR training also causes metabolite accumulation that may desensitize type III and IV nerve endings, which trigger muscle metaboreflex. Then, we hypothesized that a period of BFR training would result in blunted hemodynamic activation during muscle metaboreflex. Methods: 17 young healthy males aged 18-25 yrs enrolled in this study. Hemodynamic responses during muscle metaboreflex were assessed by means of postexercise muscle ischemia (PEMI) at baseline (T0) and after 1 month (T1) of dynamic BFRT. BFRT consisted of 3-min rhythmic handgrip exercise applied 3 days/week (30 contractions per minute at 30% of maximum voluntary contraction) in the dominant arm. On the first week, the occlusion was set at 75% of resting systolic blood pressure (always obtained after 3 min of resting) and increased 25% every week, until reaching 150% of resting systolic pressure at week four. Hemodynamic measurements were assessed by means of impedance cardiography. Results: BFRT reduced MAP during handgrip exercise (T1: 96.3 ± 8.3 mmHg vs. T0: 102.0 ± 9.53 mmHg, p = 0.012). However, no significant time effect was detected for MAP during the metaboreflex activation (P > 0.05). Additionally, none of the observed hemodynamic outcomes, including systemic vascular resistance (SVR), showed significant difference between T0 and T1 during the metaboreflex activation (P > 0.05). Conclusion: BFRT reduced blood pressure during handgrip exercise, thereby suggesting a potential hypotensive effect of this modality of training. However, MAP reduction during handgrip seemed not to be provoked by lowered metaboreflex activity.

Inventory of Ferns and Lycophytes of the RPPN Pedra D'Antas, Pernambuco state, northeastern Brazil / Inventário de Samambaias e Licófitas da RPPN Pedra D'Antas, estado de Pernambuco, nordeste do Brasil

Abstract The Northeastern Atlantic Forest (NAF) has a historic of intense habitat loss and fragmentation. In this context, knowledge of the species from forest remnants is urgently needed and represents a key tool for future studies and conservation strategies. Here, we present the floristic inventory of ferns and lycophytes from the Private Natural Heritage Reserve - RPPN Pedra D'Antas, located in a NAF area. The study area associated with the RPPN Frei Caneca is the Serra do Urubu, which is a hotspot for the diversity of several biological groups in the NAF. We recorded 74 fern species, distributed in 17 families and 46 genera. The most diverse families were Pteridaceae (17 species), Polypodiaceae (14 spp.), Dryopteridaceae (nine spp.) and Thelypteridaceae (seven spp.). Lycophytes were represented by four species, two families and two genera. A new record for the Northeast of Brazil, Serpocaulon hirsutulum, is presented in this study. The area has a large number of species, some of which are restricted to the NAF (e.g. Megalastrum umbrinum). Based on the richness of the study area associated with another inventory held at the RPPN Frei Caneca (138 spp.), the Serra do Urubu is corroborated as a hot-spot for the diversity of ferns and lycophytes in the NAF.

Resumo A Floresta Atlântica Nordestina (FAN) possui um histórico de intensa perda e fragmentação de hábitats. Neste contexto, o conhecimento das espécies a partir das áreas ainda remanescentes é urgentemente requerido, constituindo a ferramenta básica para estudos futuros e estratégias conservacionistas. Aqui, apresentamos o inventário de samambaias e licófitas a partir da Reserva Particular do Patrimônio Natural - RPPN Pedra D'Antas, situada em área da FAN. A área de estudo associada a RPPN Frei Caneca constitui a Serra do Urubu, conhecida como um hot-spots de diversidade para diversos grupos biológicos na FAN. Registramos 74 espécies de samambaias, distribuídas em 17 famílias e 46 gêneros. As famílias mais diversas foram Pteridaceae (17 espécies), Polypodiaceae (14 spp.), Dryopteridaceae (nove spp.) e Thelypteridaceae (sete spp.). As licófitas foram representadas por quarto espécies, duas famílias e dois gêneros. Apresentamos um novo registro para o Nordeste brasileiro, Serpocaulon hirsutulum. A área possui um número expressivo de espécies, algumas das quais com destruição restrita a FAN (e.g. Megalastrum umbrinum). A partir da riqueza da área de estudo associada a outro inventário realizado na RPPN Frei Caneca (138 spp.), corroboramos a Serra do Urubu como um hot-spot de diversidade para as samambaias e licófitas na FAN.

Comparative radiographic analysis on the anatomical axis in knee osteoarthritis cases: inter and intraobserver evaluation.

OBJECTIVE: To make a comparative inter and intraobserver analysis on measurements of the anatomical axis between panoramic radiographs of the lower limbs in anteroposterior (AP) view with bipedal weight-bearing, on short film. METHODS: An accuracy study comparing radiographic measurements on 47 knees of patients attending the knee surgery outpatient clinic due to osteoarthritis. The radiographic evaluation used was as standardized for the total knee arthroplasty program, including panoramic AP views of the lower limbs and short radiographs of the knees in AP and lateral views, all with bipedal weight-bearing. Following this, the anatomical axis of the lower limbs or the femorotibial angle was measured by five independent examiners on the panoramic and short AP radiographs; three of the examiners were considered to be more experienced and two, less experienced. All the measurements were made again by the same examiners after an interval of not less than 15 days. The statistical analysis was performed using the intraclass correlation coefficient, in order to evaluate the inter and intraobserver concordance of the anatomical axis measurements. RESULTS: From the statistical analysis, it was observed that there was strongly significant concordance between the anatomical axis measurements on the panoramic and short radiographs, for all the five examiners and for both measurements. CONCLUSIONS: Under the conditions studied, short radiographs were equivalent to panoramic radiographs for evaluating the anatomical axis of the lower limbs in patients with advanced osteoarthritis. The measurements used also showed high rates of inter and intraobserver concordance and reproducibility.

OBJETIVO: Fazer a análise comparativa inter e intraobservador da medida do eixo anatômico entre as radiografias panorâmica, dos membros inferiores (MMII) com raio anteroposterior (AP) e apoio bipodálico e AP com carga bipodal em filme curto. MÉTODOS: Foi feito estudo de acurácia que comparou medidas radiográficas em 47 joelhos de pacientes do ambulatório de cirurgia do joelho, por osteoartrite (OA). A avaliação radiográfica usada foi a padronizada para a programação de ATJ, incluindo as incidências panorâmica dos MMII em AP e as radiografias curtas dos joelhos em AP e perfil, todas com apoio bipodálico. Em seguida, as radiografias panorâmicas e curtas em AP tiveram os eixos anatômicos dos MMII ou ângulo femorotibial (AFT) medidos por cinco examinadores independentes, dos quais três eram considerados mais experientes e dois menos experientes. Todas as medidas foram refeitas pelos mesmos examinadores em um intervalo não menor do que 15 dias. A análise estatística foi feita com o uso do coeficiente de correlação intraclasses (ICC) para avaliar a concordância na medida do eixo anatômico inter e intraobservadores. RESULTADOS: Após análise estatística observou-se forte concordância significativa entre o eixo anatômico medido nas radiografias panorâmica e curta para todos os cinco examinadores e para ambas as medidas. CONCLUSÕES: Nas condições estudadas a radiografia curta equipara-se à panorâmica na avaliação do eixo anatômico dos MMII em pacientes com OA avançada. A mensuração usada também mostra alta taxa de concordância e reprodutibilidade inter e intraobsevadores.

Análise radiográfica comparativa do eixo anatômico na osteoartrite do joelho: Avaliação inter e intraobservadores / Comparative radiographic analysis on the anatomical axis in knee osteoarthritis cases: inter and intraobserver evaluation

OBJETIVO:fazer a análise comparativa inter e intraobservador da medida do eixo anatômico entre as radiografias panorâmica, dos membros inferiores (MMII) com raio anteroposterior (AP) e apoio bipodálico e AP com carga bipodal em filme curto.MÉTODOS:foi feito estudo de acurácia que comparou medidas radiográficas em 47 joelhos de pacientes do ambulatório de cirurgia do joelho, por osteoartrite (OA). A avaliação radiográfica usada foi a padronizada para a programação de ATJ, incluindo as incidências panorâmica dos MMII em AP e as radiografias curtas dos joelhos em AP e perfil, todas com apoio bipodálico. Em seguida, as radiografias panorâmicas e curtas em AP tiveram os eixos anatômicos dos MMII ou ângulo femorotibial (AFT) medidos por cinco examinadores independentes, dos quais três eram considerados mais experientes e dois menos experientes. Todas as medidas foram refeitas pelos mesmos examinadores em um intervalo não menor do que 15 dias. A análise estatística foi feita com o uso do coeficiente de correlação intraclasses (ICC) para avaliar a concordância na medida do eixo anatômico inter e intraobservadores.RESULTADOS:após análise estatística observou-se forte concordância significativa entre o eixo anatômico medido nas radiografias panorâmica e curta para todos os cinco examinadores e para ambas as medidas.CONCLUSÕES:nas condições estudadas a radiografia curta equipara-se à panorâmica na avaliação do eixo anatômico dos MMII em pacientes com OA avançada. A mensuração usada também mostra alta taxa de concordância e reprodutibilidade inter e intraobservadores.

OBJECTIVE: To make a comparative inter and intraobserver analysis on measurements of the anatomical axis between panoramic radiographs of the lower limbs in anteroposterior (AP) view with bipedal weight-bearing, on short film. METHODS: An accuracy study comparing radiographic measurements on 47 knees of patients attending the knee surgery outpatient clinic due to osteoarthritis. The radiographic evaluation used was as standardized for the total knee arthroplasty program, including panoramic AP views of the lower limbs and short radiographs of the knees in AP and lateral views, all with bipedal weight-bearing. Following this, the anatomical axis of the lower limbs or the femorotibial angle was measured by five independent examiners on the panoramic and short AP radiographs; three of the examiners were considered to be more experienced and two, less experienced. All the measurements were made again by the same examiners after an interval of not less than 15 days. The statistical analysis was performed using the intraclass correlation coefficient, in order to evaluate the inter and intraobserver concordance of the anatomical axis measurements. RESULTS: From the statistical analysis, it was observed that there was strongly significant concordance between the anatomical axis measurements on the panoramic and short radiographs, for all the five examiners and for both measurements. CONCLUSIONS: Under the conditions studied, short radiographs were equivalent to panoramic radiographs for evaluating the anatomical axis of the lower limbs in patients with advanced osteoarthritis. The measurements used also showed high rates of inter and intraobserver concordance and reproducibility.

Apoptosis-inducing factor of a cytotoxic T cell line: involvement of a secretory phospholipase A2.

Natural killer (NK) cells and cytotoxic T lymphocytes (CTLs) kill target cells by the granule-exocytosis pathway and by the engagement of molecules belonging to the tumor necrosis factor family. The involvement of secretory phospholipase A(2) (sPLA(2)) in the cytotoxic process has been proposed in NK cells. However, its molecular identity and intracellular localization remain unknown, and its mechanism of action is poorly understood. Here, we have readdressed this issue by studying the cytotoxic activity of whole cell extracts of a CTL line. We observed that inactivation of the perforin-granzyme pathway at 37 degrees C in the presence of 1 mM Ca(2+) enhanced the ability of CTL extracts to induce apoptosis. This potentiation of cell death was Ca(2+)-dependent, thermo-resistant, and inhibited by 4-bromophenacyl bromide and scalaradial (two inhibitors of sPLA(2)). The involvement of an sPLA(2) was confirmed by blocking the pro-apoptotic activity of the Ca(2+)-treated cell extract with an anti-sPLA(2) polyclonal antibody. By cell fractionation assays, we showed that the pro-apoptotic sPLA(2) was localized in the cytoplasmic fraction but not in perforin-rich granules or plasma membrane fractions. Western blotting analysis revealed the presence of four distinct bands of 56, 29.5, 21, and 15 kDa. The highest molecular weight band was consistent with the expression of a group III sPLA2. Taken together, these data indicate that an apoptosis-inducing sPLA(2) is expressed in the cytosol of a CTL cell line and suggest that it plays an effector role in CTL-mediated cytotoxicity.