The role of primary healthcare amid the COVID-19 pandemic: Evidence from the Family Health Strategy in Brazil.

This paper investigates the role of primary healthcare in mitigating the consequences of the COVID-19 pandemic, focusing on the Brazilian Family Health Strategy (ESF) as a case study. ESF is Brazil's major primary care initiative, with prior evidence indicating its effectiveness in improving various health outcomes. The COVID-19 pandemic submitted the Brazilian healthcare system to a rigorous and unprecedented stress test, whose repercussions are still under study. Using comprehensive administrative microdata from 2016 to 2022 encompassing dimensions related to mortality, healthcare service, supply of family health teams, and vaccination coverage, our empirical strategy accounts for heterogeneous effects based on program intensity and pandemic evolution of the 5570 Brazilian municipalities. Our findings reveal that municipalities with high-intensity of ESF coverage (i.e. stronger primary care) experienced 347.93 (95% CI: 289.04, 406.81) fewer COVID-19 and cardiorespiratory deaths per million inhabitants throughout the pandemic period, compared to those in low-intensity ESF areas, despite sharing similar profiles of deaths from respiratory and cardiovascular causes. Among the channels contributing to this relative performance, high-intensity ESF municipalities were found to engage in more home-based primary care visits and health promotion activities while maintaining a similar supply of community health workers. Additionally, they achieved higher vaccination coverage, and these effects were more pronounced in areas with greater ESF presence, emphasising the importance of primary care coverage. In conclusion, our findings underscore the relevance of strong primary care in mitigating the consequences of the pandemic and addressing post-pandemic health challenges.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease.

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Carbon footprints of tailings dams' disasters: A study in the Brumadinho region (Brazil).

Tailings dams' breaks are environmental disasters with direct and intense degradation of soil. This study analyzed the impacts of B1 tailings dam rupture occurred in the Ribeirão Ferro-Carvão watershed (Brumadinho, Brazil) in January 25, 2019. Soil organic carbon (SOC) approached environmental degradation. The analysis encompassed wetlands (high-SOC pools) located in the so-called Zones of Decreasing Destructive Capacity (DCZ5 to DCZ1) defined along the Ferro-Carvão's stream bed and banks after the disaster. Remote sensed water indices were extracted from Landsat 8 and Sentinel-2 satellite images spanning the 2017-2021 period and used to distinguish the wetlands from other land covers. The annual SOC was extracted from the MapBiomas repository inside and outside the DCZs in the same period, and assessed in the field in 2023. Before the dam collapse, the DCZs maintained stable levels of SOC, while afterwards they decreased substantially reaching minimum values in 2023. The reductions were abrupt: for example, in the DCZ3 the decrease was from 51.28 ton/ha in 2017 to 4.19 ton/ha in 2023. Besides, the SOC increased from DCZs located near to DCZs located farther from the dam site, a result attributed to differences in the percentages of clay and silt in the tailings, which also increased in the same direction. The Ferro-Carvão stream watershed as whole also experienced a slight reduction in the average SOC levels after the dam collapse, from nearly 43 ton/ha in 2017 to 38 ton/ha in 2021. This result was attributed to land use changes related with the management of tailings, namely opening of accesses to remove them from the stream valley, creation of spaces for temporary deposits, among others. Overall, the study highlighted the footprints of tailings dams' accidents on SOC, which affect not only the areas impacted with the mudflow but systemically the surrounding watersheds. This is noteworthy.

Case Report: Molecular Analyses of Cell-Cycle-Related Genes in Cortical Brain Tissue of a Patient with Rasmussen Encephalitis.

Rasmussen's encephalitis (RE) stands as a rare neurological disorder marked by progressive cerebral hemiatrophy and epilepsy resistant to medical treatment. Despite extensive study, the primary cause of RE remains elusive, while its histopathological features encompass cortical inflammation, neuronal degeneration, and gliosis. The underlying molecular mechanisms driving disease progression remain largely unexplored. In this case study, we present a patient with RE who underwent hemispherotomy and has remained seizure-free for over six months, experiencing gradual motor improvement. Furthermore, we conducted molecular analysis on the excised brain tissue, unveiling a decrease in the expression of cell-cycle-associated genes coupled with elevated levels of BDNF and TNF-α proteins. These findings suggest the potential involvement of cell cycle regulators in the progression of RE.

Are COVID-19 Polymorphisms in ACE and ACE2 Prognosis Predictors?

Regardless of the containment of the SARS-CoV-2 pandemic, it remains paramount to comprehensively understand its underlying mechanisms to mitigate potential future health and economic impacts, comparable to those experienced throughout the course of the pandemic. The angiotensin-converting enzyme 2 (ACE2) provides anchorage for SARS-CoV-2 binding, thus implicating that ACE and ACE2 might contribute to the variability in infection severity. This study aimed to elucidate predisposing factors influencing the disease course among people infected by SARS-CoV-2, focusing on angiotensin-converting enzyme (ACE) and ACE2 polymorphisms. Notably, despite similar demographics and comorbidities, COVID-19 patients exhibit substantial differences in prognosis. Genetic polymorphisms in ACE and ACE2 have been implicated in disease progression, prompting our investigation into their role in COVID-19 evolution. Using next-generation sequencing (NGS), we analyzed ACE and ACE2 genes in a sample group comprising six subjects infected by SARS-CoV-2. Our findings revealed a correlation between specific polymorphisms and COVID-19 outcomes. Specifically, ACE and ACE2 intronic deletions were observed in all deceased patients, suggesting a potential association with mortality. These results highlight the significance of genetic factors in shaping the clinical course of COVID-19, emphasizing the importance of further research into the impact of genetic variations on COVID-19 severity.

Shedding reduction and immunity modulation in piglets with an inactivated Mycoplasma hyopneumoniae vaccine encapsulated in nanostructured SBA-15 silica.

Mycoplasma (M.) hyopneumoniae is a primary etiological agent of porcine enzootic pneumonia (PEP), a disease that causes significant economic losses to pig farming worldwide. Current commercial M. hyopneumoniae vaccines induce partial protection, decline in preventing transmission of this pathogen or inducing complete immunity, evidencing the need for improving vaccines against PEP. In our study, we aimed to test the effectiveness of the SBA-15 ordered mesoporous silica nanostructured particles as an immune adjuvant of a vaccine composed of M. hyopneumoniae strain 232 proteins encapsulated in SBA-15 and administered by intramuscular route in piglets to evaluate the immune responses and immune-protection against challenge. Forty-eight 24-day-old M. hyopneumoniae-free piglets were divided into four experimental groups with different protocols, encompassing a commercial vaccine against M. hyopneumoniae, SBA-15 vaccine, SBA-15 adjuvant without antigens and a non-immunized group. All piglets were challenged with the virulent strain 232 of M. hyopneumoniae. Piglets that received the SBA-15 and commercial vaccine presented marked immune responses characterized by anti-M. hyopneumoniae IgA and IgG antibodies in serum, anti-M. hyopneumoniae IgA antibodies in nasal mucosa and showed an upregulation of IL-17 and IL-4 cytokines and downregulation of IFN-γ in lungs 35 days post-infection. Piglets immunized with SBA-15 vaccine presented a reduction of bacterial shedding compared to piglets immunized with a commercial bacterin. In addition, piglets from SBA-15 adjuvant suspension group presented increased IL-17 gene expression in the lungs without involvement of Th1 and Th2 responses after challenge. These results indicated that SBA-15 vaccine induced both humoral and cell-mediated responses in the upper respiratory tract and lungs, first site of replication and provided protection against M. hyopneumoniae infection with a homologous strain with reduction of lung lesions and bacterial shedding. Finally, these results enhance the potential use of new technologies such as nanostructured particles applied in vaccines for the pig farming industry.

Integrating policy, data and technology in pursuing effective management of ecosystem services.

With the growing concerns about the protection of ecosystem functions and services, governments have developed public policies and organizations have produced an awesome volume of digital data freely available through their websites. On the other hand, advances in data acquisition through remote sensed sources and processing through geographic information systems (GIS) and statistical tools, allowed an unprecedent capacity to manage ecosystems efficiently. However, the real-world scenario in that regard remains paradoxically challenging. The reasons can be many and diverse, but a strong candidate relates with the limited engagement among the interest parties that hampers bringing all these assets into action. The aim of the study is to demonstrate that management of ecosystem services can be significantly improved by integrating existing environmental policies with environmental big data and low-cost GIS and data processing tools. Using the Upper Rio das Velhas hydrographic basin located in the state of Minas Gerais (Brazil) as example, the study demonstrated how Principal Components Analysis based on a diversity of environmental variables assembled sub-basins into urban, agriculture, mining and heterogeneous profiles, directing management of ecosystem services to the most appropriate officially established conservation plans. The use of GIS tools, on the other hand, allowed narrowing the implementation of each plan to specific sub-basins. This optimized allocation of preferential management plans to priority areas was discussed for a number of conservation plans. A paradigmatic example was the so-called Conservation Use Potential (CUP) devoted to the protection of aquifer recharge (provision service) and control of water erosion (regulation service), as well as to the allocation of uses as function of soil capability (support service). In all cases, the efficiency gains in readiness for plans' implementation and economy of resources were prognosed as noteworthy.

Functional autoantibodies against G protein-coupled receptors in hepatic and pulmonary hypertensions in human schistosomiasis.

Introduction: Schistosomiasis (SM) is a parasitic disease caused by Schistosoma mansoni. SM causes chronic inflammation induced by parasitic eggs, with collagen/fibrosis deposition in the granuloma process in the liver, spleen, central nervous system, kidneys, and lungs. Pulmonary arterial hypertension (PAH) is a clinical manifestation characterized by high pressure in the pulmonary circulation and right ventricular overload. This study investigated the production of functional autoantibodies (fAABs) against the second loop of the G-protein-coupled receptor (GPCR) in the presence of hepatic and PAH forms of human SM. Methods: Uninfected and infected individuals presenting acute and chronic manifestations (e.g., hepatointestinal, hepato-splenic without PAH, and hepato-splenic with PAH) of SM were clinically evaluated and their blood was collected to identify fAABs/GPCRs capable of recognizing endothelin 1, angiotensin II, and a-1 adrenergic receptor. Human serum was analyzed in rat cardiomyocytes cultured in the presence of the receptor antagonists urapidil, losartan, and BQ123. Results: The fAABs/GPCRs from chronic hepatic and PAH SM individuals, but not from acute SM individuals, recognized the three receptors. In the presence of the antagonists, there was a reduction in beating rate changes in cultured cardiomyocytes. In addition, binding sites on the extracellular domain functionality of fAABs were identified, and IgG1 and/or IgG3 antibodies were found to be related to fAABs. Conclusion: Our data suggest that fAABs against GPCR play an essential role in vascular activity in chronic SM (hepatic and PAH) and might be involved in the development of hypertensive forms of SM.

A method to describe attenuation of river contamination under peak flows: Can the public water supply from Paraopeba River finally return after the Brumadinho dam disaster?

Tailings dams' disasters begin a stage of river water contamination with no endpoint at first sight. But when the river was formerly used for public water supply and the use was suspended as consequence of a dam break, a time window for safe suspension lift must be anticipated to help water managers. The purpose of this study was to seek for that moment in the case of Brumadinho dam disaster which occurred in 2019 and injected millions of cubic meters of iron- and manganese-rich tailings into the Paraopeba River, leading to the suspension of public water supply to Belo Horizonte metropolitan region with this resource, until now. To accomplish the proposed goal, an assemblage of artificial intelligence and socio-economic development models were used to anticipate precipitation, river discharge and metal concentrations (iron, manganese) until 2033. Then, the ratios of metal concentrations between impacted and non-impacted sites were determined and values representing extreme events of river discharge were selected for further assessment. A ratio ≈1 generally indicates a similarity between impacted and non-impacted areas or, put another way, a return of impacted areas to a pre-rupture condition. Moreover, when the ratio is estimated under the influence of peak flows, then a value of ≈1 indicates a return to pre-rupture conditions under the most unfavorable hydrologic regimes, thus a safe return. So, the extreme ratios were plotted against time and fitted to a straight line with intercept-x representing the requested safe time. The results pointed to 6.57 years after the accident, while using iron as contaminant indicator, or 8.71 years when manganese was considered. Despite of being a relatively low-risk timeframe, the suspension lift should be implemented in phases and monitored for precaution of potential sporadic contamination events, while dredging of the tailings from impacted areas should continue and be accelerated.

The water cycle of small catchments impacted with tailings mudflows: A study in the Ferro-Carvão watershed after the breakup of B1 dam in Brumadinho.

The B1 tailings dam of Córrego do Feijão iron-ore mine owned by Vale, S.A. company collapsed in 25 January 2019 releasing to the Ferro-Carvão stream watershed (32.6 km2) as much as 11.7 Mm3 of mine waste. A major share (8.9 Mm3) has been deposited along the stream channel and margins forming a 2.7 km2 patch. The main purpose of this study was to question whether the tailings deposit impacted the local water cycle and how. Using the Soil and Water Assessment Tool (SWAT) hydrologic model, the water balance components of 36 hydrologic response units (HRU) were calculated for pre- (S1) and post- (S2) B1 dam rupture scenarios represented by appropriate soil, land use and tailings cover. The results revealed an increase of evapotranspiration from S1 to S2, related to the sudden removal of vegetation from the stream valley and replacement with a blanket of mud, which raised the exposure of Earth's surface to sunlight and hence soil evaporation. For 11 HRU (10.3 km2) located around the tailings deposit, a decrease in lateral flow was observed, accompanied by an increase in percolation and a slight increase in groundwater flow. In this case, the water balance changes observed between S1 and S2 reflected a barrier effect imposed to the lateral flows by the tailings, which shifted the flows towards the vertical direction (percolation). Thus, the water followed an easier vertical route until reaching the shallow aquifer and being converted into groundwater flow. As per the modelling outcomes, the hydrologic impacts of B1 dam rupture are relevant because they affected 1/3 of Ferro-Carvão stream watershed, and hence claim for the complete removal of the tailings.

Extracellular Vesicles: The Next Generation of Biomarkers and Treatment for Central Nervous System Diseases.

It has been widely established that the characterization of extracellular vesicles (EVs), particularly small EVs (sEVs), shed by different cell types into biofluids, helps to identify biomarkers and therapeutic targets in neurological and neurodegenerative diseases. Recent studies are also exploring the efficacy of mesenchymal stem cell-derived extracellular vesicles naturally enriched with therapeutic microRNAs and proteins for treating various diseases. In addition, EVs released by various neural cells play a crucial function in the modulation of signal transmission in the brain in physiological conditions. However, in pathological conditions, such EVs can facilitate the spread of pathological proteins from one brain region to the other. On the other hand, the analysis of EVs in biofluids can identify sensitive biomarkers for diagnosis, prognosis, and disease progression. This review discusses the potential therapeutic use of stem cell-derived EVs in several central nervous system diseases. It lists their differences and similarities and confers various studies exploring EVs as biomarkers. Further advances in EV research in the coming years will likely lead to the routine use of EVs in therapeutic settings.

Effect of Autoclave Sterilization on the Number of Uses and Resistance to Cyclic Fatigue of WaveOne Gold and Four Replica-Like Endodontic Instruments.

This study aimed to evaluate the effect of autoclave sterilization on the integrity and instruments' fracture number after multiple uses and cyclic fatigue of the original WaveOne Gold (Dentsply Sirona Endodontics) compared to four replica-like instruments (TF4-Gold, Roll-Wave-Gold, W-File, and Micro-Gold). The instruments were analyzed by scanning electron microscope (SEM) before being used in root canal instrumentation (baseline). One hundred and fifty human molars, freshly extracted for orthodontic reasons or periodontal disease and with severe curvature (between 30° and 60°), were used. Fifty teeth were instrumented with 10 instruments from each group and were evaluated for integrity. After sterilization in an autoclave, the instruments were analyzed by SEM. This procedure was repeated twice more, totaling three rounds of instrumentation, sterilization, and SEM analysis. Ten unused instruments from each group were evaluated for resistance to cyclic fatigue in a static test using a motor and a device simulating a canal with a 60° curvature angle. The instruments were driven by the motor until separation, visually verified, and the time measured in seconds. Data were analyzed by Chi-square, one-way ANOVA, and Tukey analysis, considering a significance level of 5%. It was found that there was no statistically significant difference between the groups tested in the effect of sterilization on the number of uses. The SEM analysis showed distortions in the instruments after the 3rd use. There was a statistically significant difference in the cyclic fatigue test between the results of WaveOne Gold, TF4 Gold, and Roll Wave Gold compared to W File and Micro Gold (P < 0.0001) and a statistically significant difference between the W File and Micro Gold groups (P < 0.0001). In conclusion, this study affirmed that WaveOne Gold, TF4-Gold, and Roll-Wave-Gold instruments exhibit comparable cyclic fatigue resistance. Besides, all examined instruments can be reliably employed for up to two cases.

Induced Pluripotent Stem Cells and Organoids in Advancing Neuropathology Research and Therapies.

This review delves into the groundbreaking impact of induced pluripotent stem cells (iPSCs) and three-dimensional organoid models in propelling forward neuropathology research. With a focus on neurodegenerative diseases, neuromotor disorders, and related conditions, iPSCs provide a platform for personalized disease modeling, holding significant potential for regenerative therapy and drug discovery. The adaptability of iPSCs, along with associated methodologies, enables the generation of various types of neural cell differentiations and their integration into three-dimensional organoid models, effectively replicating complex tissue structures in vitro. Key advancements in organoid and iPSC generation protocols, alongside the careful selection of donor cell types, are emphasized as critical steps in harnessing these technologies to mitigate tumorigenic risks and other hurdles. Encouragingly, iPSCs show promising outcomes in regenerative therapies, as evidenced by their successful application in animal models.

Short- and Long-Term Effects of Subchronic Stress Exposure in Male and Female Brain-Derived Neurotrophic Factor Knock-In Val66Met Mice.

Stress is an important risk factor for the onset of anxiety and depression. The ability to cope with stressful events varies among different subjects, probably depending on different genetic variants, sex and previous life experiences. The Val66Met variant of Brain-Derived Neurotrophic Factor (BDNF), which impairs the activity-dependent secretion of BDNF, has been associated with increased susceptibility to the development of various neuropsychiatric disorders. Adult male and female wild-type Val/Val (BDNFV/V) and heterozygous Val/Met (BDNFV/M) mice were exposed to two sessions of forced swimming stress (FSS) per day for two consecutive days. The mice were behaviorally tested 1 day (short-term effect) or 11 days (long-term effect) after the last stress session. Protein and mRNA levels were measured in the hippocampus 16 days after the end of stress exposure. Stressed mice showed a higher anxiety-like phenotype compared to non-stressed mice, regardless of the sex and genotype, when analyzed following the short period of stress. In the prolonged period, anxiety-like behavior persisted only in male BDNFV/M mice (p < 0.0001). Interestingly, recovery in male BDNFV/V mice was accompanied by an increase in pCREB (p < 0.001) and Bdnf4 (p < 0.01) transcript and a decrease in HDAC1 (p < 0.05) and Dnmt3a (p = 0.01) in the hippocampus. Overall, our results show that male and female BDNF Val66Met knock-in mice can recover from subchronic stress in different ways.

Factors Associated with the Treatment Costs within the First Year after Pacemaker Implantation or Pulse Generator Replacement. / Fatores Associados aos Custos do Tratamento no Primeiro Ano após Implantes Iniciais ou Trocas de Geradores de Pulsos de Marca-passos Cardíacos.

BACKGROUND: The use of artificial cardiac pacemakers has grown steadily in line with the aging population. OBJECTIVES: To determine the rates of hospital readmissions and complications after pacemaker implantation or pulse generator replacement and to assess the impact of these events on annual treatment costs from the perspective of the Unified Health System (SUS). METHODS: A prospective registry, with data derived from clinical practice, collected during index hospitalization and during the first 12 months after the surgical procedure. The cost of index hospitalization, the procedure, and clinical follow-up were estimated according to the values reimbursed by SUS and analyzed at the patient level. Generalized linear models were used to study factors associated with the total annual treatment cost, adopting a significance level of 5%. RESULTS: A total of 1,223 consecutive patients underwent initial implantation (n=634) or pulse generator replacement (n=589). Seventy episodes of complication were observed in 63 patients (5.1%). The incidence of hospital readmissions within one year was 16.4% (95% CI 13.7% - 19.6%) after initial implants and 10.6% (95% CI 8.3% - 13.4%) after generator replacements. Chronic kidney disease, history of stroke, length of hospital stays, need for postoperative intensive care, complications, and hospital readmissions showed a significant impact on the total annual treatment cost. CONCLUSIONS: The results confirm the influence of age, comorbidities, postoperative complications, and hospital readmissions as factors associated with increased total annual treatment cost for patients with pacemakers.

FUNDAMENTO: O uso de marca-passos cardíacos artificiais tem crescido constantemente, acompanhando o envelhecimento populacional. OBJETIVOS: Determinar as taxas de readmissões hospitalares e complicações após implante de marca-passo ou troca de gerador de pulsos e avaliar o impacto desses eventos nos custos anuais do tratamento sob a perspectiva do Sistema Único de Saúde (SUS). MÉTODOS: Registro prospectivo, com dados derivados da prática clínica assistencial, coletados na hospitalização índice e durante os primeiros 12 meses após o procedimento cirúrgico. O custo da hospitalização índice, do procedimento e do seguimento clínico foram estimados de acordo com os valores reembolsados pelo SUS e analisados ao nível do paciente. Modelos lineares generalizados foram utilizados para estudar fatores associados ao custo total anual do tratamento, adotando-se um nível de significância de 5%. RESULTADOS: No total, 1.223 pacientes consecutivos foram submetidos a implante inicial (n= 634) ou troca do gerador de pulsos (n= 589). Foram observados 70 episódios de complicação em 63 pacientes (5,1%). A incidência de readmissões hospitalares em um ano foi de 16,4% (IC 95% 13,7% - 19,6%) após implantes iniciais e 10,6% (IC 95% 8,3% - 13,4%) após trocas de geradores. Doença renal crônica, histórico de acidente vascular encefálico, tempo de permanência hospitalar, necessidade de cuidados intensivos pós-operatórios, complicações e readmissões hospitalares mostraram um impacto significativo sobre o custo anual total do tratamento. CONCLUSÕES: Os resultados confirmam a influência da idade, comorbidades, complicações pós-operatórias e readmissões hospitalares como fatores associados ao incremento do custo total anual do tratamento de pacientes com marca-passo.

A systematic analysis on the efficiency and sustainability of green facades and roofs.

In the modern urban space, green infrastructures have been gaining increasing relevance due to their positive impacts on sustainability issues, visual appeal, and the well-being of individuals. On the other hand, environmental sustainability has become mandatory in the agenda of governments and organizations. Thus, a systematic analysis on the efficiency and sustainability of green facades and roofs spanning key applications, benefits and implementation constraints is welcome. In this paper, we employed the PRISMA method to investigate how these matters were addressed in the recent literature, comprising articles published in scientific journals indexed to the SCOPUS database. Following the web search, selection, systematization, and analysis of that literature, it was revealed that the efficiency of green facades and roofs has been mostly associated with energy and thermal performance in buildings, which brings unequivocal multiple benefits (e.g., consumption savings, mitigation of urban heat island effects) despite of some barriers (e.g., installation and maintenance costs). Other discussions about green facades and roofs involved their valuable roles in stormwater management, considering their retention capacity, and in the treatment of wastewater for reuse in non-potable applications, considering their filtering capacity. It was also discovered the need to improve green infrastructures through the use of cleaner technologies and recycled materials, selection of plants that are appropriate for the local climate, and minimization of construction, transportation, disposal and maintenance costs. Efficiency and sustainability in these cases was prognosed to succeed if the costs were minimized throughout the entire life cycle, and complemented with incentive policies (e.g., tax reduction, agile administrative processes) and collaboration among multidisciplinary teams comprising designers, builders, municipality planners and the academic and market worlds.

Attenuation of water contamination in the Paraopeba River after the collapse of B1 tailings dam: Natural wash-off and dredging contributions.

Following the B1 dam collapse at Córrego do Feijão Mine, actions were taken to address environmental damage and enhance the quality of water in the Paraopeba River. Natural processes in the river involve gradual reduction of contamination through dispersion and downstream transportation of tailings-a slow, nature-driven process. Dredging, a human intervention, aimed to expedite recovery. Hence, this study aimed to explore dredging's role in reducing contamination in the impacted Paraopeba River zone. Analysis revealed a direct link between dredging and post-collapse turbidity, though recent trends suggest a lessening impact on pre-collapse conditions. Distinct seasonal variations were observed in iron and manganese concentrations, peaking during wet seasons and displaying notable upstream-downstream disparities. An analysis of ratios (downstream/upstream) was conducted to understand and even predict the return to pre-collapse conditions. Wet season averages for iron and manganese decreased by around 90 % over time, with standard deviations reducing by about 48 % and 58 %, respectively. In the dry season, the averages decreased by over 100 %, indicating water quality improvements surpassing pre-collapse levels. Standard deviations also decreased significantly, by approximately 67 % and 79 %, respectively. Employing an exponential decay model revealed that the contribution of dredging in the dry period is negligible, but in the wet period the contribution can be estimated at 28.6 % in the case of iron and 25 % in the case of manganese. While the models performed well based on extensive data, some limitations occur in estimating dredging contribution rates. The model's sensitivity might overlook influential factors, underscoring the importance of considering sediment nature and dredged area extent in understanding water quality dynamics. Despite these potential limitations, this investigation provides crucial insights into the intricate relationship between dredging and water quality in the Paraopeba River. These findings pave the way for future studies aimed at deeper exploration and more accurate assessments of this association.

Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis.

PURPOSE: The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control. MATERIALS AND METHODS: We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. RESULTS: We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea. CONCLUSION: Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management. CLINICAL IMPACT: Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.

Simulation in pediatric minimally invasive surgery: adaptation of a simple series of exercises as part of the process of an initial implementation of a resident training program.

INTRODUCTION: the simulation in minimally invasive surgery is fundamental for surgeon in training to learning and training skills, especially in pediatrics, due to the particularities, reduced spaces, specific and rare procedures. The aim of this study was to propose an adapted series of exercises and to simply evaluate the performance of pediatric surgery residents in the initial implementation of a training program. METHOD: seven basic skills exercises in video surgery, based on series and programs already published and using low-cost materials, were performed by six residents in 2 moments, with an interval of 15 days and evaluated by simple instrument. RESULTS: there was no difficulty with models. Considering the individual averages of the seven exercises together in the two moments, five of the six residents increased the score in the second moment. The average score per exercise increased in five of the seven tasks. Despite the small number of participants and repetition, it has already been possible to observe a trend of better performance with decreased time of all residents after a single repetition. All considered the exercises capable of training essential skills of the specialty, with simple and inexpensive materials. CONCLUSION: given the challenges of simulated training in pediatric video surgery, it is known the benefit of a continuous program, with exercises that can simulate real situations. A pre-established schedule, more participants and repetitions, supervision of experienced surgeons and validated instruments are fundamental to evaluate surgeons in training and show statistical benefits of simulated exercises in this series.

Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients.

OBJECTIVE: To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19. METHODS: This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality. RESULTS: We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure. CONCLUSION: In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.