Edema, hyperalgesia and myonecrosis induced by Brazilian bothropic venoms: overview of the last decade.

Snakebite accidents are considered serious public health problems. They are often neglected, and individuals who have received insufficient treatment are subjected to various disabling alterations. Snake venoms are secretions composed of biologically active molecules capable of triggering local and systemic effects in envenomation victims. Bothropic snakes are responsible for most of the ophidian accidents in Brazil; their venoms are mainly related to local manifestations, due to a composition that is especially rich in proteases and phospholipases A2. The most common local damages are inflammation, with consequent cellular activation and release of inflammatory mediators, hemorrhage, edema, pain and (myo)necrosis, which may lead to amputation of the affected areas. Antivenom therapy is the main treatment for snakebites. However, the efficiency is mainly due to the neutralization of the toxins responsible for the systemic alterations. Thus, the local damages can evolve to markedly compromise the tissue. The complexity of these local effects associated with the toxicity of the snake venom components of the genus Bothrops, arouse interest in the study of the biochemical and pathophysiological mechanisms involved with the actions caused by toxins of the venom. Therefore, this review aims to analyze the edematogenic, hyperalgesic and myotoxic effects caused by Brazilian bothropic venoms in order to contribute to the study and elucidation of the mechanisms of action of its components and, consequently, enable discoveries of more effective combined therapies in the treatment of local damages resulting from envenoming.

Predictors of relapse of visceral leishmaniasis in inner São Paulo State, Brazil.

OBJECTIVES: Visceral leishmaniasis (VL) is a public health threat for several tropical countries, including Brazil. Therapy failures and relapses aggravate VL morbidity and mortality. Our study aimed at identifying predictors of relapse and thus contributes to directing therapeutic options and patient follow-up. METHODS: A nonconcurrent cohort of 571 subjects who completed successful therapy for VL in the city of Bauru, São Paulo State, Brazil, was followed for 24 months in order to identify the incidence and predictors of relapse. Extensive review of medical charts and laboratory files was conducted. Univariate and multivariable Cox regression models were used to identify predictors for the outcome of interest. A hierarchical strategy was used for variable selection in multivariable models. RESULTS: Relapses occurred in 6.8% of treated subjects, after a median of 6 months (interquartile range, 4-9). In a comprehensive multivariable model, relapse was associated with: HIV-coinfection (hazard ratio [HR], 7.47; 95% confidence interval [CI], 2.58-21.55); the presence of lower limb edema (HR, 6.06; 95%CI, 1.38-26.77) and low platelet count upon admission (HR for platelet count × 1000, 0.99; 95%CI, 0.98-0.99) ; and secondary pneumonia (HR, 5.49; 95%CI, 1.49-20.18). On the other hand, therapy with Liposomal Amphotericin (as opposed to Antimoniate) was not independently associated with relapse (HR, 5.97; 95%CI, 0.63-56.29). CONCLUSION: Besides reinforcing the impact of HIV coinfection on the outcome of VL, our study points to clinical and laboratory findings that characterize patients who were more likely to relapse. Those groups should be more closely followed, and possibly could benefit from novel therapeutic options.

Balneotherapy for chronic venous insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction, or a combination of these with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It can result in a large financial burden on health systems. There is a wide variety of treatment options or therapies for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) is a relatively cheap option and potentially efficient way to deliver physical therapy for people with CVI. OBJECTIVES: To assess the efficacy and safety of balneotherapy for the treatment of people with chronic venous insufficiency (CVI). SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the Clinical Trials.gov trials register to August 2018. We searched the LILACS and IBECS databases. We also checked references, searched citations and contacted study authors to identify additional studies. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing balneotherapy with no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed studies retrieved by the search strategies. Both review authors independently assessed selected studies for complete analysis. We resolved conflicts through discussion. We attempted to contact trial authors for missing data, obtaining additional information. For binary outcomes (leg ulcer incidence and adverse events), we presented the results using odds ratio (OR) with 95% confidence intervals (CI). For continuous outcomes (disease severity, health-related quality of life (HRQoL), pain, oedema, skin pigmentation), we presented the results as a mean difference (MD) with 95% CI. MAIN RESULTS: We included seven randomised controlled trials with 891 participants (outpatients in secondary care). We found no quasi-randomised controlled trials. Six studies (836 participants) evaluated balneotherapy versus no treatment. One study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis) (55 participants). There was a lack of blinding of participants and investigators, imprecision and inconsistency, which downgraded the certainty of the evidence.For the balneotherapy versus no treatment comparison, there probably was no improvement in favour of balneotherapy in disease severity signs and symptom score as assessed using the Venous Clinical Severity Score (VCSS) (MD -1.66, 95% CI -4.14 to 0.83; 2 studies, 484 participants; moderate-certainty evidence). Balneotherapy probably resulted in a moderate improvement in HRQoL as assessed by the Chronic Venous Insufficiency Questionnaire 2 (CVIQ2) at three months (MD -9.38, 95% CI -18.18 to -0.57; 2 studies, 149 participants; moderate-certainty evidence), nine months (MD -10.46, 95% CI -11.81 to -9.11; 1 study; 55 participants; moderate-certainty evidence), and 12 months (MD -4.99, 95% CI -9.19 to -0.78; 2 studies, 455 participants; moderate-certainty evidence). There was no clear difference in HRQoL between balneotherapy and no treatment at six months (MD -1.64, 95% CI -9.18 to 5.89; 2 studies, 445 participants; moderate-certainty evidence). Balneotherapy probably slightly improved pain compared with no treatment (MD -1.23, 95% CI -1.33 to -1.13; 1 study; 390 participants; moderate-certainty evidence). There was no clear effect related to oedema between the two groups at 24 days (MD 43.28 mL, 95% CI -102.74 to 189.30; 2 studies, 153 participants; very-low certainty evidence). There probably was no improvement in favour of balneotherapy in the incidence of leg ulcers (OR 1.69, 95% CI 0.82 to 3.48; 2 studies, 449 participants; moderate-certainty evidence). There was probably a reduction in incidence of skin pigmentation changes in favour of balneotherapy at 12 months (pigmentation index: MD -3.59, 95% CI -4.02 to -3.16; 1 study; 59 participants; low-certainty evidence). The main complications reported included erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; moderate-certainty evidence), thromboembolic events (OR 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; moderate-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study; 59 participants; low-certainty evidence), with no clear evidence of an increase in reported adverse effects with balneotherapy. There were no serious adverse events reported in any of the studies.For the balneotherapy versus a phlebotonic drug (melilotus officinalis) comparison, we observed no clear difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study; 35 participants; very low-certainty evidence) and oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study; 35 participants; very low-certainty evidence). This single study did not report on the other outcomes of interest. AUTHORS' CONCLUSIONS: We identified moderate- to low-certainty evidence that suggests that balneotherapy may result in a moderate improvement in pain, quality of life and skin pigmentation changes and has no clear effect on disease severity signs and symptoms score, adverse effects, leg ulcers and oedema when compared with no treatment. For future studies, measurements of outcomes such as disease severity sign and symptom score, quality of life, pain and oedema and choice of time points during follow-up must be standardised for adequate comparison between trials.

Predictive clinical factors for ocular dryness in patients admitted to the Intensive Care Unit. / Fatores clínicos preditores para o ressecamento ocular em pacientes internados na Unidade de Terapia Intensiva.

OBJECTIVE: To evaluate the predictive clinical factors for ocular dryness and for the nursing diagnosis Risk for dry eye in the ocular surface of hospitalized adult patients in an intensive care unit. METHOD: A cross-sectional study was conducted between January and July 2016, with 206 patients (412 eyes). An inference about the presence of the diagnosis in the evaluated patients was performed by diagnostic nurses. The descriptive and inferential statistics subsidized the data analysis. RESULTS: 47.6% of the patients presented Risk for dry eye, and 52.4% were already diagnosed with ocular dryness. Statistical differences between the ocular dryness diagnosis in the right eye with hyperemia, mucous secretion, eyelid edema and lagophthalmia were identified. In addition, statistical differences were observed between hyperemia and eyelid edema with Risk for dry eye in the left eye and with the nursing diagnosis Risk for dry eye. CONCLUSION: Hyperemia, mucous secretion, eyelid edema and lagophthalmia are the predictive clinical factors for the nursing diagnosis Risk for dry eye and also of ocular dryness in the intensive care unit environment which deserve special attention in the preventive evaluation.

Pathogen Risk Analysis for Wild Amphibian Populations Following the First Report of a Ranavirus Outbreak in Farmed American Bullfrogs (Lithobates catesbeianus) from Northern Mexico.

Ranaviruses are the second deadliest pathogens for amphibian populations throughout the world. Despite their wide distribution in America, these viruses have never been reported in Mexico, the country with the fifth highest amphibian diversity in the world. This paper is the first to address an outbreak of ranavirus in captive American bullfrogs (Lithobates catesbeianus) from Sinaloa, Mexico. The farm experienced high mortality in an undetermined number of juveniles and sub-adult bullfrogs. Affected animals displayed clinical signs and gross lesions such as lethargy, edema, skin ulcers, and hemorrhages consistent with ranavirus infection. The main microscopic lesions included mild renal tubular necrosis and moderate congestion in several organs. Immunohistochemical analyses revealed scant infected hepatocytes and renal tubular epithelial cells. Phylogenetic analysis of five partial ranavirus genes showed that the causative agent clustered within the Frog virus 3 clade. Risk assessment with the Pandora⁺ protocol demonstrated a high risk for the pathogen to affect amphibians from neighboring regions (overall Pandora risk score: 0.619). Given the risk of American bullfrogs escaping and spreading the disease to wild amphibians, efforts should focus on implementing effective containment strategies and surveillance programs for ranavirus at facilities undertaking intensive farming of amphibians.

Edema and gingival bleeding in anterior region have a negative influence on quality of life of adolescents.

The aim of the present study was to verify if clinical signs of gingivitis such as color changes, edema, and bleeding in the anterior region influence the OHRQoL of adolescents. We followed a cross-sectional convenience sample of 67 adolescents aged 11 to 16 years receiving dental treatment at the Federal University of Santa Maria (UFSM), in southern Brazil. The participants were evaluated for the following clinical variables: edema, gingival color alteration, and marginal bleeding of the gingival tissues, collected at 6 sites per tooth in the anterior region of the mouth. Socioeconomic variables were collected through questionnaires and OHRQoL was evaluated through the Brazilian version of the Children Perception Questionnaire (CPQ 11-14) short form. A Poisson regression model was used to verify associations between clinical variables and general CPQ11-14 scores. In the unadjusted analysis, edema, color alterations, and marginal bleeding in the anterior region were associated with worse scores of OHRQoL. Edema and marginal bleeding remained associated after adjusting for clinical and sociodemographic variables. Adolescents with higher levels of marginal bleeding and edema in the anterior region had higher mean CPQ11-14 scores. Therefore, the presence of bleeding and gingival edema in the anterior region can be considered clinical signs of gingivitis that are associated with a worse OHRQoL in adolescents.

Early detection of acute tubulointerstitial nephritis in the genesis of Mesoamerican nephropathy.

Mesoamerican nephropathy is a devastating disease of unknown etiology that affects mostly young agricultural workers in Central America. An understanding of the mechanism of injury and the early disease process is urgently needed and will aid in identification of the underlying cause and direct treatment and prevention efforts. We sought to describe the renal pathology in Mesoamerican nephropathy at its earliest clinical appearance in prospectively identified acute case patients in Nicaragua. We considered those with elevated (or increased at least 0.3 mg/dL or 1.5-fold from baseline) serum creatinine, leukocyturia, and either leukocytosis or neutrophilia for inclusion in this biopsy study. Renal tissue was obtained by ultrasound-guided biopsy for examination by light, immunofluorescence, and electron microscopy. All 11 individuals who underwent renal biopsy showed tubulointerstitial nephritis, with varying degrees of inflammation and chronicity. Interstitial cellular infiltrates (predominantly T lymphocytes and monocytes), mostly in the corticomedullary junction; neutrophilic accumulation in the tubular lumens; largely preserved glomeruli; few mild ischemic changes; and no immune deposits were noted. The acute components of tubulointerstitial nephritis were acute tubular cell injury, interstitial edema, and early fibrosis. Chronic tubulointerstitial nephritis included severe tubular atrophy, thickened tubular basement membrane, and interstitial fibrosis. Thus, renal histopathology in Mesoamerican nephropathy reveals primary interstitial disease with intact glomeruli.

Edema and gingival bleeding in anterior region have a negative influence on quality of life of adolescents

Abstract The aim of the present study was to verify if clinical signs of gingivitis such as color changes, edema, and bleeding in the anterior region influence the OHRQoL of adolescents. We followed a cross-sectional convenience sample of 67 adolescents aged 11 to 16 years receiving dental treatment at the Federal University of Santa Maria (UFSM), in southern Brazil. The participants were evaluated for the following clinical variables: edema, gingival color alteration, and marginal bleeding of the gingival tissues, collected at 6 sites per tooth in the anterior region of the mouth. Socioeconomic variables were collected through questionnaires and OHRQoL was evaluated through the Brazilian version of the Children Perception Questionnaire (CPQ 11-14) short form. A Poisson regression model was used to verify associations between clinical variables and general CPQ11-14 scores. In the unadjusted analysis, edema, color alterations, and marginal bleeding in the anterior region were associated with worse scores of OHRQoL. Edema and marginal bleeding remained associated after adjusting for clinical and sociodemographic variables. Adolescents with higher levels of marginal bleeding and edema in the anterior region had higher mean CPQ11-14 scores. Therefore, the presence of bleeding and gingival edema in the anterior region can be considered clinical signs of gingivitis that are associated with a worse OHRQoL in adolescents.

Influence of uncomplicated phacoemulsification on central macular thickness in diabetic patients: a meta-analysis.

OBJECTIVE: To evaluate the effect of uncomplicated phacoemulsification on central macular thickness (CMT) and best corrected visual acuity (BCVA) in both diabetic patients without diabetic retinopathy (DR) and diabetic patients with mild to moderate non-proliferative diabetic retinopathy (NPDR). METHODS: Potential prospective observational studies were searched through PubMed and EMBASE. Standardized mean difference (SMD) and 95% confidence interval (CI) for changes in CMT and BCVA were evaluated at postoperative 1, 3 and 6 months. The pooled effect estimates were calculated in the use of a random-effects model. RESULTS: A total of 10 studies involving 190 eyes of diabetic patients without diabetic retinopathy and 143 eyes of diabetic patients with NPDR were identified. CMT values demonstrated a statistically significant increase after uncomplicated phacoemulsification at 1 month (SMD, -0.814; 95%CI, -1.230 to -0.399), 3 months (SMD, -0.565; 95%CI, -0.927 to -0.202) and 6 months (SMD, -0.458; 95%CI, -0.739 to -0.177) in diabetic patients with NPDR. There was no statistical difference in CMT values at postoperative 1 month (SMD, -1.206; 95%CI, -2.433 to 0.021)and no statistically significant increase in CMT values at postoperative3 months (SMD, -0.535; 95%CI, -1.252 to 0.182) and 6 months (SMD, -1.181; 95%CI, -2.625 to 0.263) in diabetic patients without DR.BCVA was significantly increased at postoperative 1 month (SMD, 1.149; 95%CI, 0.251 to 2.047; and SMD,1.349; 95%CI, 0.264 to 2.434, respectively) and 6 months (SMD, 1.295; 95%CI, 0.494 to 2.096; and SMD, 2.146; 95%CI, 0.172 to 4.120, respectively) in both diabetic patients without DR and diabetic patients with NPDR. Sensitivity analysis showed that the results were relatively stable and reliable. CONCLUSION: Uncomplicated phacoemulsification in diabetic patients with mild to moderate NPDR seemed to influence significantly the subclinical thickening of the macular zones at postoperative 1, 3 and 6 months compared with diabetic patients without DR. BCVA was significantly improved in both diabetic patients without DR and diabetic patients with mild to moderate NPDR.

Heme oxygenase-1 gene promoter polymorphism is associated with the development of necrotizing acute pancreatitis.

OBJECTIVES: Acute pancreatitis is a severe and frequently life-threatening disease, which can lead to pancreatic necrosis, acute lung injury, systemic inflammatory response syndrome, and other complications. In this study, we hypothesized that the expression of heme oxygenase-1 determined by the number of guanidinium thiocyanate (GT) repeats can influence the occurrence of acute pancreatitis. METHODS: Patients with acute pancreatitis (n = 131) and age- and sex-matched healthy controls (n = 108) were studied. The polymerase chain reaction products were analyzed by ABI 3130 genetic analyzer and the exact size of the polymerase chain reaction products was determined by GeneMapper software. A short allele was defined as containing 27 GT repeats or fewer, whereas a long allele was more than 27 repeats. RESULTS: The subjects were categorized into 3 groups on the basis of the genotype results: 1 short and 1 long, 2 short, and 2 long alleles (L/L). Patients with necrotizing disease more frequently were carriers of LL genotype compared with those who had edematous acute pancreatitis. Furthermore, logistic regression analysis revealed that the presence of L/L allele type doubles the risk for developing pancreatic necrosis in patients with acute pancreatitis. CONCLUSIONS: The polymorphism of the GT repeats in the heme oxygenase-1 promoter region may be a risk factor for developing severe and necrotizing acute pancreatitis.

Long-lasting morphofunctional remodelling of liver parenchyma and stroma after a single exposure to low and moderate doses of cadmium in rats.

Frequent exposure to cadmium (Cd) in low doses is common; however, the long-lasting effects of this exposure are still poorly understood. Therefore in this study we have evaluated long-lasting hepatic morphofunctional adaptations in rats exposed to low and moderate doses of Cd. Five experimental groups were tested: control (0.9% saline) and other four receiving single intraperitoneal doses of 0.67, 0.74, 0.86 and 1.1 mg of Cd/kg. The animals were killed after eight weeks and the following parameters were analysed: biometrics, oedema, Cd bio-accumulation, collagen, glycogen, lipid droplets, superoxide dismutase (SOD) and catalase (CAT), serum transaminases, liver histopathology and stereology. In all groups exposed to Cd there was significant increase in SOD and CAT activities, ALP levels, proportion of binucleated hepatocytes, nuclei/cytoplasm ratio, macrophages (Kupffer cells) and collagen fibres. In these groups, glycogen accumulation by hepatocytes and the proportion of sinusoidal capillaries were significantly reduced compared with controls. The liver somatic index was increased, and liver oedema was evident in animals exposed to higher dose of Cd. Areas of necrosis were found in animals exposed to the three highest doses. These results indicate that Cd is an extremely toxic bioactive heavy metal, which even at low doses is able to disrupt liver homeostasis. At low and moderate doses, Cd exposure induces morphofunctional pathological remodelling of the hepatic stroma and parenchyma, which remain active after eight weeks. In response to injury, the liver tissue triggers a reactive process by enhancing activation of antioxidant enzymes and collagenogenesis.

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4% and 92.0%, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4 percent and 92.0 percent, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Venous ulcer: clinical characteristics and risk factors.

BACKGROUND: Lower limb venous ulceration ranks among the 10 most common medical problems in Western countries and has significant socioeconomic impact. The aim of this study was to identify the risk factors for unhealed, recurrent, and large ulcers and to characterize patients with active or recently healed venous ulcers. METHODS: We identified 97 patients and assessed 103 ulcerated limbs in 90 patients. All patients underwent clinical examination, arterial and venous system evaluation, ankle-brachial index determination, and ultrasound of the affected limb. Clinical characteristics included age, gender, race, ulcer duration, time since first episode, history of recurrence, localization of ulcer, ulcer area, eczema, ochre dermatitis, lipodermatosclerosis, pain, body mass index, and medical history data. Risk factors were identified by univariate analysis and estimated odds ratios. RESULTS: We assessed 90 patients (103 limbs) with active or healed venous leg ulcers, of whom 84.4% were Caucasian and 68.9% were female. Mean age was 56.0 ± 13.3 years. Ulcers had remained unhealed for <1 year in 40.7%. Lipodermatosclerosis, lower limb hyperpigmentation, edema, and eczema were seen in 96.7%, 95.6%, 94.4%, and 51.1% of patients, respectively. Pain was a frequent symptom in 74.4%. Body mass index was assessed in 85 patients: 30.6% were slightly, 36.5% moderately, and 7% severely obese. Patient age >60 years (odds ratio [OR] 4.0), extensive lipodermatosclerosis (OR 8.7), and previous history of ulceration (OR 19.9) were risk factors for unhealed ulcers. Time since first ulcer episode ≥ 2 years (OR 29.2) and incompetence of venous systems (OR 1.6) were risk factors for recurrence. CONCLUSIONS: Longstanding and large ulcers and recurrences are the main problems encountered by venous ulcer patients. Severe lipodermatosclerosis, previous ulcer history, and time since first ulcer episode ≥ 2 years are significant risk factors.

[Assessment of the intervention in a therapeutic feeding center for children in Nicaragua]. / Evaluación de la intervención terapéutica realizada en un centro de recuperación nutricional infantil de Nicaragua.

INTRODUCTION: Child malnutrition carries a high morbimortality worldwide. Therapeutic feeding centers are essential in the treatment of malnourished children. OBJECTIVE: To evaluate the effectiveness of the therapeutic intervention in under-5 undernourished children in a Therapeutic Feeding Center. METHODS: A retrospective descriptive research was made through the revision of the clinical histories of children under 5 years that entered the Nutritional Recovery Center for Children in Matagalpa, Nicaragua, from January 2006 to July 2010. RESULTS: Median age at admission was 17.2 months (p25:10.7-p75:27.2) and median stay in the center was 92 days (p25:61.5-p75:134.5). Prevalence of patients with severe acute malnutrition was 45%, moderate acute malnutrition 24% and risk for malnutrition 31%. At discharge 86% of patients were properly nourished. Median weight gain percentage after the first month in the center was 15% (p25:12.6-p75:17.4). Median weight gain was 3.7 g/kg/day (p25:2.6-p75:5.4), being higher in children under 6 months (4.6 g/kg/day; p25:4.3-p75:7.5). Cured rate in the center was 87.5%, being the death rate 0% and the abandonment rate 9%. DISCUSSION: The center evaluated works adequately, and fulfills the internationally recommended quality indicators. However, recommended average stay of 1-2 months and average weight gain of 8 g/kg/day are far of being fulfilled. Therefore, the Nutritional Recovery Center performs an effective intervention, but it's not efficient enough.

Endodontic flare-ups: a prospective study.

The objective of this prospective clinical study was to evaluate the incidence of flare-ups (pain and/or swelling requiring endodontic interappointment and emergency treatment) and identify the risk factors associated with their occurrence in patients who received endodontic treatment from June 2006 to June 2007 at the endodontics clinic of the São Paulo Dental Association (APCD), Jardim Paulista branch, São Paulo, Brazil. The incidence of flare-ups was 1.71% out of 408 teeth that had received endodontic therapy. Statistical analysis using the chi-squared test (P < .05) indicated a direct correlation between the flare-up rate and the presence of a periradicular radiolucency.

A pilot study to validate the priority nursing interventions classification interventions and nursing outcomes classification outcomes for the nursing diagnosis "excess fluid volume" in cardiac patients.

PURPOSE: To validate the content of the priority Nursing Interventions Classification (NIC) interventions and Nursing Outcomes Classification (NOC)-suggested outcomes for cardiac patients with the nursing diagnosis excess fluid volume in the Brazilian context. METHODS: The content of the interventions and outcomes was scored by seven expert nurses using a Likert scale, using the Fehring model. FINDINGS: From the 83 activities of the priority NIC interventions, nine had scores lower than 0.5 (nonuseful) and 50 had scores higher than 0.8 (major); from the 53 indicators of the suggested NOC outcomes, eight scored lower than 0.5 and 26 had scores higher than 0.8. CONCLUSIONS: The majority of the NIC interventions and NOC outcomes were considered useful by the Brazilian Cardiology expert nurses. IMPLICATIONS FOR PRACTICE: Clinical studies are an important strategy for validation of the usefulness of North American Nursing Diagnosis Association, NIC, and NOC language in clinical protocols. Additional studies are necessary to confirm the findings of this pilot study.

Heart failure with preserved ejection fraction and systolic dysfunction in the community.

BACKGROUND: In developed countries, heart failure with preserved ejection fraction (HFpEF) is more prevalent than heart failure with reduced ejection fraction (HFrEF) in the community. However, it has not been completely established if this fact is also observed within our community. OBJECTIVE: To determine the most prevalent form of heart failure (HFpEF or HFrEF) and whether the prevalence of HFpEF is higher in the community. METHODS: This is a cross-sectional study conducted with patients clinically diagnosed with HF who were seen in community-based health care centers from January to December 2005. Echodopplercardiograms were performed for all patients. The form of HF was stratified according to the presence of abnormalities and the shortening fraction observed on the echodopplercardiogram. RESULTS: The study evaluated 170 patients (61.0 +/- 13.3 years of age), most of them women and elderly. HFpEF was the more prevalent form of HF (64.2%, p<0.001), affecting mostly elderly women (62%, p = 0.07), whereas the opposite condition, HFrEF, was observed mostly in elderly men (63.6%, p = 0.07). Patients with no HF represented one-third of the cases (27.6%). HFrEF patients had more lower-limb edema, coronary disease, diabetes, chronic renal failure, higher Boston scores and hospital readmissions. Use of alcoholic beverages and smoking were also more common among HFrEF patients. CONCLUSION: HFpEF is the most prevalent form of HF in the community especially among elderly women, whereas HFrEF affects mostly elderly men and is associated with greater clinical severity, main risk factors and no changes in lifestyle. Despite the signs and symptoms of HF, this condition was not confirmed for one-third of the cases.

Insuficiência cardíaca com fração de ejeção preservada e com disfunção sistólica na comunidade / Heart failure with preserved ejection fraction and systolic dysfunction in the community

FUNDAMENTO: Em países desenvolvidos, a insuficiência cardíaca com fração de ejeção preservada (ICFEP) é o modelo mais prevalente que a insuficiência cardíaca com disfunção sistólica (ICDS) na comunidade. No entanto, não está plenamente estabelecido se tal fato também é observado na nossa comunidade. OBJETIVO: Determinar o tipo mais prevalente de insuficiência cardíaca (ICFEP ou ICDS) e se a prevalência de ICFEP é elevada na comunidade. MÉTODOS: Estudo transversal de pacientes atendidos na comunidade com diagnóstico clínico de IC, de janeiro a dezembro de 2005. O ecodopplercardiograma foi realizado em todos os pacientes. O tipo de IC foi estratificado pela presença de anormalidades e pela fração de encurtamento ao ecodopplercardiograma. RESULTADOS: O estudo avaliou 170 pacientes (61,0±13,3 anos), a maioria mulheres e idosos. A ICFEP foi o tipo de IC mais prevalente (64,2 por cento, p<0,001) com tendência nas mulheres idosas (62 por cento, p=0,07), e o inverso na ICDS, nos homens idosos (63,6 por cento, p=0,07). Os pacientes sem IC representaram um terço dos casos (27,6 por cento). A ICDS apresentou mais edema de membros inferiores, doença coronariana, diabete, insuficiência renal crônica, re-internações e maior escore de Boston. O etilismo e o tabagismo estiveram mais presentes na ICDS. CONCLUSÃO: A ICFEP é o tipo de IC mais prevalente na comunidade, principalmente nas mulheres idosas, enquanto a ICDS, nos homens idosos, com maior gravidade clínica e acometimento dos principais fatores de risco e sem modificação nos hábitos de vida. Apesar dos sinais e dos sintomas de IC, em um terço dos casos a IC não foi confirmada.

BACKGROUND: In developed countries, heart failure with preserved ejection fraction (HFpEF) is more prevalent than heart failure with reduced ejection fraction (HFrEF) in the community. However, it has not been completely established if this fact is also observed within our community. OBJECTIVE: To determine the most prevalent form of heart failure (HFpEF or HFrEF) and whether the prevalence of HFpEF is higher in the community. METHODS: This is a cross-sectional study conducted with patients clinically diagnosed with HF who were seen in community-based health care centers from January to December 2005. Echodopplercardiograms were performed for all patients. The form of HF was stratified according to the presence of abnormalities and the shortening fraction observed on the echodopplercardiogram. RESULTS: The study evaluated 170 patients (61.0 ± 13.3 years of age), most of them women and elderly. HFpEF was the more prevalent form of HF (64.2 percent, p<0.001), affecting mostly elderly women (62 percent, p = 0.07), whereas the opposite condition, HFrEF, was observed mostly in elderly men (63.6 percent, p = 0.07). Patients with no HF represented one-third of the cases (27.6 percent). HFrEF patients had more lower-limb edema, coronary disease, diabetes, chronic renal failure, higher Boston scores and hospital readmissions. Use of alcoholic beverages and smoking were also more common among HFrEF patients. CONCLUSION: HFpEF is the most prevalent form of HF in the community especially among elderly women, whereas HFrEF affects mostly elderly men and is associated with greater clinical severity, main risk factors and no changes in lifestyle. Despite the signs and symptoms of HF, this condition was not confirmed for one-third of the cases.

Acute hemorrhagic edema of childhood.

Acute hemorrhagic edema (AHE) of childhood, a variant of Henoch-Schönlein purpura (HSP), is a rare vasculitis with benign course, generally no systemic involvement and rare flares. From January 1983 to June 2004, 4,502 patients were followed at the Pediatric Rheumatology Unit, Hospital of Clinics. Diagnosis of HSP was made in 203 cases (4.5%), of which 5 (0.1%) had AHE. All patients with AHE were male and the mean age at onset was 18 months (range: 8 to 21 months). All five cases presented vasculitis with characteristic hemorrhagic and purpuric lesions in malar region of the face, associated with painless edema of the hands and feet. Laboratory exams were normal. Upper respiratory tract infection preceding clinical manifestations occurred in four and mononucleosis in one. Treatment with corticosteroids was necessary only in one patient with necrotic lesions on the face and ears.