Neuromuscular Electrical Stimulation on Hemodynamic and Respiratory Response in Patients Submitted to Cardiac Surgery: Pilot Randomized Clinical Trial

Neuromuscular electrical stimulation seems to be a promising option to intensify the rehabilitation and improve the exercise capacity of patients in the immediate postoperative period of cardiac surgery. Objective: This study aimed to evaluate the hemodynamic (heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure) and respiratory (respiratory rate and oxygen saturation) responses to neuromuscular electrical stimulation in the immediate postoperative period in patients submitted to cardiac surgery and to verify its feasibility and safety. Methods: This is a pilot randomized controlled trial, wherein critical patients in the immediate postoperative period of cardiac surgery were randomly assigned to a control group, using sham neuromuscular electrical stimulation, or an experimental group, submitted to neuromuscular electrical stimulation sessions (FES), for 60 min, with a 50-Hz frequency, 200-µs pulse duration, time on: 3 s, and time off: 9 s. Data distribution was evaluated by the Shapiro-Wilk test. The analysis of variance was used and a p-value < 0.05 was considered significant. Results: Thirty patients were included in the study. The neuromuscular electrical stimulation was applied within the first 23.13 ± 5.24 h after cardiac surgery, and no changes were found regarding the hemodynamic and respiratory variables between the patients who underwent neuromuscular electrical stimulation, and those in the control group. Conclusions: In the present study, neuromuscular electrical stimulation did not promote changes in hemodynamic and respiratory responses of patients in the immediate postoperative period of cardiac surgery

Ambulation capacity and functional outcome in patients undergoing neuromuscular electrical stimulation after cardiac valve surgery: A randomised clinical trial.

BACKGROUND: Early mobilization and physical exercise are considered fundamental components in cardiovascular surgery rehabilitation; however, occasionally they are inadequate for inhibiting functional decline. Neuromuscular electrical stimulation (NMES) is a promising tool in cardiovascular rehabilitation; however, to date, no randomized clinical trial has measured the effects of NMES on functional capacity and quality of life in patients who undergo routine cardiac surgery with a short intensive care unit (ICU) stay. Therefore, we aimed to investigate the effects of NMES on walking ability, muscle strength, functional independence, and quality of life in cardiac valve surgery patients in the immediate postoperative period. METHODS: A randomized, parallel, controlled, 2-arm clinical trial with assessor blinding was conducted. Fifty-nine adult patients in the preoperative period after cardiac valve reconstruction and/or replacement were randomly assigned to a control or intervention group. The intervention group underwent NMES in the quadriceps and gastrocnemius, bilaterally, for 60 minutes, for up to 10 sessions. The primary outcome was ambulation ability, assessed through the Six-Minute Walk Test and Walking Speed Test at postoperative day 5 (5PO). Secondary outcomes were muscular strength (assessed through the Medical Research Council scale), functional independence measure (assessed through the Functional Independence Measurement Questionnaire), and quality of life (assessed through the Nottingham Health Profile) at baseline (preoperative) and at postoperative days 3 and 5. RESULTS: The baseline characteristics were similar in both groups, except for body mass index. There was no statistically significant difference, with a small effect size, between both groups regarding the distance walked (95% CI, -64.87 to 65.97) and walking speed (95% CI, -0.55 to 0.57). There was a statistically significant difference in upper-limb muscle strength loss and decline in mobility at postoperative day 3, which had a tendency to recover to initial values at 5PO, in both groups. No significant between-group difference was noted for muscle strength, functional independence, and quality of life. CONCLUSIONS: The use of NMES had no effect on walking ability, strength, quality of life, or functional outcome in the postoperative period for patients that underwent regular valve replacement.

Validation of the Brazilian version of Behavioral Pain Scale in adult sedated and mechanically ventilated patients / Validação da versão Brasileira da Escala Comportamental de Dor (Behavioral Pain Scale) em adultos sedados e sob ventilação mecânica

Abstract Background and objectives: The Behavioral Pain Scale is a pain assessment tool for uncommunicative and sedated Intensive Care Unit patients. The lack of a Brazilian scale for pain assessment in adults mechanically ventilated justifies the relevance of this study that aimed to validate the Brazilian version of Behavioral Pain Scale as well as to correlate its scores with the records of physiological parameters, sedation level and severity of disease. Methods: Twenty-five Intensive Care Unit adult patients were included in this study. The Brazilian Behavioral Pain Scale version (previously translated and culturally adapted) and the recording of physiological parameters were performed by two investigators simultaneously during rest, during eye cleaning (non-painful stimulus) and during endotracheal suctioning (painful stimulus). Results: High values of responsiveness coefficient (coefficient = 3.22) were observed. The Cronbach's alpha of total Behavioral Pain Scale score at eye cleaning and endotracheal suctioning was 0.8. The intraclass correlation coefficient of total Behavioral Pain Scale score was ≥ 0.8 at eye cleaning and endotracheal suctioning. There was a significant highest Behavioral Pain Scale score during application of painful procedure when compared with rest period (p ≤ 0.0001). However, no correlations were observed between pain and hemodynamic parameters, sedation level, and severity of disease. Conclusions: This pioneer validation study of Brazilian Behavioral Pain Scale exhibits satisfactory index of internal consistency, interrater reliability, responsiveness and validity. Therefore, the Brazilian Behavioral Pain Scale version was considered a valid instrument for being used in adult sedated and mechanically ventilated patients in Brazil.

Resumo Justificativa e objetivos: A Escala Comportamental de Dor (Behavioral Pain Scale) é uma ferramenta de avaliação da dor para pacientes não-comunicativos e sedados em unidade de tratamento intensivo (UTI). A falta de uma escala brasileira para a avaliação da dor em adultos sob ventilação mecânica justifica a relevância deste estudo que teve por objetivo validar a versão brasileira da Escala Comportamental de Dor (ECD), bem como correlacionar seus escores com os registros de parâmetros fisiológicos, nível de sedação e gravidade da doença. Métodos: Vinte e cinco pacientes adultos internados em UTI foram incluídos neste estudo. A versão brasileira da ECD (previamente traduzida e adaptada culturalmente) e os registros dos parâmetros fisiológicos foram realizados simultaneamente por dois avaliadores durante o repouso, durante a limpeza dos olhos (estímulo não doloroso) e durante a aspiração endotraqueal (estímulo doloroso). Resultados: Valores elevados do coeficiente de coeficiente de responsividade (coeficiente = 3,22) foram observados. O coeficiente alfa de Cronbach do escore total da ECD durante a limpeza dos olhos e aspiração endotraqueal foi de 0,8. O coeficiente de correlação intraclasse do escore total da ECD foi ≥ 0,8 durante a limpeza dos olhos e aspiração endotraqueal. Houve um escore significativamente mais alto na ECD durante a aplicação do estímulo doloroso em comparação com o período de descanso (p ≤ 0,0001). No entanto, não foram observadas correlações entre dor e parâmetros hemodinâmicos, nível de sedação e gravidade da doença. Conclusões: Este estudo pioneiro de validação da ECD brasileira apresenta índices satisfatórios de consistência interna, confiabilidade entre avaliadores, responsividade e validade. Portanto, a versão da ECD brasileira foi considerada um instrumento válido para ser usado em pacientes adultos sedados e ventilados mecanicamente no Brasil.

[Validation of the Brazilian version of Behavioral Pain Scale in adult sedated and mechanically ventilated patients]. / Validação da versão Brasileira da Escala Comportamental de Dor (Behavioral Pain Scale) em adultos sedados e sob ventilação mecânica.

BACKGROUND AND OBJECTIVES: The Behavioral Pain Scale is a pain assessment tool for uncommunicative and sedated Intensive Care Unit patients. The lack of a Brazilian scale for pain assessment in adults mechanically ventilated justifies the relevance of this study that aimed to validate the Brazilian version of Behavioral Pain Scale as well as to correlate its scores with the records of physiological parameters, sedation level and severity of disease. METHODS: Twenty-five Intensive Care Unit adult patients were included in this study. The Brazilian Behavioral Pain Scale version (previously translated and culturally adapted) and the recording of physiological parameters were performed by two investigators simultaneously during rest, during eye cleaning (non-painful stimulus) and during endotracheal suctioning (painful stimulus). RESULTS: High values of responsiveness coefficient (coefficient=3.22) were observed. The Cronbach's alpha of total Behavioral Pain Scale score at eye cleaning and endotracheal suctioning was 0.8. The intraclass correlation coefficient of total Behavioral Pain Scale score was ≥ 0.8 at eye cleaning and endotracheal suctioning. There was a significant highest Behavioral Pain Scale score during application of painful procedure when compared with rest period (p≤0.0001). However, no correlations were observed between pain and hemodynamic parameters, sedation level, and severity of disease. CONCLUSIONS: This pioneer validation study of Brazilian Behavioral Pain Scale exhibits satisfactory index of internal consistency, interrater reliability, responsiveness and validity. Therefore, the Brazilian Behavioral Pain Scale version was considered a valid instrument for being used in adult sedated and mechanically ventilated patients in Brazil.

Effects of transcutaneous electrical diaphragmatic stimulation on the cardiac autonomic balance in healthy individuals: a randomized clinical trial / Efeitos da estimulação diafragmática elétrica transcutânea sobre o balanço autonômico cardíaco de indivíduos hígidos: ensaio clínico randomizado / Los efectos de la estimulación eléctrica transcutánea del diafragma en el balance autónomo cardiaco en individuos sanos: estudio clínico aleatorio

ABSTRACT The transcutaneous electrical diaphragmatic stimulation (TEDS) is a technique of respiratory muscle activation that affects breathing pattern and rhythm. In an attempt to evaluate changes in cardiac autonomic balance in response to TEDS in healthy individuals, we used a well-established TEDS model. Twenty-two volunteers aged between 22 and 35 years old, with no cardiac pathology history, were randomized into two groups (control, n = 8; TEDS, n = 14). The individuals were allowed to rest in supine position and were then subjected to the electrical stimulation protocol. The control group was subjected to electrical stimulation at perceptive level, whereas for the TEDS group the electric stimulus generated diaphragm contraction. Cardiac intervals (CI) were sampled by a Polar RS800CX monitor. Cardiac interval variability was studied in the time and frequency domains. In the control group, electrical stimulation did not change cardiac interval length and variability (CI: 761±44 vs. 807±39 ms; RMSSD: 37±9 vs. 42±13 ms ; LF: 69±6 vs. 67±5 nu; HF: 31±6 vs. 33±5 nu; all comparisons versus baseline). Nevertheless, as compared to baseline, TEDS group showed decreased sympathetic cardiac modulation (LF: 43±3 vs. 63±4 nu) and increased parasympathetic cardiac modulation (RMSSD: 109±10 vs. 41±6 ms; HF: 57±3 vs. 37±4 nu) during diaphragmatic stimulation. However, cardiac interval length was not changed by electrical stimulation (CI: 686±59 vs. 780±31 ms). It can be suggested that the use of TEDS stimulus leads to pronounced changes in the cardiac sympathovagal balance, with higher parasympathetic cardiac modulation, possibly induced by increased diaphragmatic excursion.

RESUMO A estimulação diafragmática elétrica transcutânea (EDET) é uma técnica de mobilização da musculatura respiratória que interfere no padrão e no ritmo respiratório. Na tentativa de avaliar as alterações no balanço autonômico cardíaco à EDET em indivíduos saudáveis, foi utilizado um modelo já estabelecido de eletroestimulação diafragmática. 22 voluntários com idades entre 22 e 35 anos, sem histórico cardíaco, foram randomizados em dois grupos (controle, n=8; EDET, n=14). O protocolo de eletroestimulação foi aplicado nos indivíduos em repouso (posição supina). O grupo controle foi submetido a estimulação elétrica em nível perceptivo, enquanto no grupo EDET o estímulo gerava contração diafragmática. Os intervalos cardíacos (CI) foram registrados por cardiofrequencímetro Polar (RS800CX). A variabilidade do intervalo cardíaco foi estudada nos domínios de tempo e frequência. No grupo controle, a estimulação elétrica não alterou a duração do intervalo cardíaco e sua variabilidade (CI: 761±44 vs. 807±39ms; RMSSD: 37±9 vs. 42±13ms; LF: 69±6 vs. 67±5nu; HF: 31±6 vs. 33±5nu), em comparação às condições basais). No entanto, o grupo EDET apresentou diminuição na modulação simpática cardíaca (LF: 43 ±3 vs. 63±4nu) e aumento da modulação parassimpática cardíaca (RMSSD: 109±10 vs. 41±6ms; HF: 57±3 vs. 37±4nu) durante a eletroestimulação diafragmática. No entanto, a duração do intervalo cardíaco não foi alterada por estimulação elétrica (CI: 686±59 vs. 780±31ms). Pode-se sugerir que o uso da EDET promove mudanças acentuadas no balanço simpatovagal, resultando em maior modulação parassimpática cardíaca, possivelmente induzida pelo aumento da mobilidade diafragmática.

RESUMEN La estimulación eléctrica transcutánea del diafragma (EETD) es un método que moviliza la musculatura respiratoria que interfiere en el patrón y en la frecuencia respiratoria. Para evaluar las alteraciones en el balance autónomo cardiaco por la EETD en individuos sanos, se empleó un modelo prestablecido de estimulación eléctrica muscular del diagrama. Han participado 22 voluntarios con edad entre 22 y 35 años, sin enfermedades cardiacas, puestos en grupos aleatorios: Grupo control (n=8) y EETD (n=14). Se aplicó el protocolo de estimulación eléctrica en individuos en posición decúbito supino. Al grupo control se lo sometió a la estimulación eléctrica a nivel perceptual, mientras que en el EETD la estimulación le generaba contracción del diafragma. Los intervalos cardiacos (CI) se registraron a través del monitor de ritmo cardiaco polar (RS800CX). Se estudió la variabilidad del intervalo cardiaco en los dominios tiempo y frecuencia. En el grupo control, la estimulación eléctrica no presentó alteraciones en la duración del intervalo cardiaco y su variabilidad (CI: 761±44 vs. 807±39ms; RMSSD: 37±9 vs. 42±13ms; LF: 69±6 vs. 67±5nu; HF: 31±6 vs. 33±5nu; comparado con las condiciones de base). Pero si comparado las condiciones de base en el grupo EETD presentó una disminución en la modulación simpática cardiaca (LF: 43±3 vs. 63±4nu) y un aumento en la modulación parasimpática cardiaca (RMSSD: 109±10 vs. 41±6ms; HF: 57±3 vs. 37±4nu) durante la realización de este método. Sin embargo, la duración del intervalo cardiaco no presentó alteraciones por la estimulación eléctrica del diafragma (CI: 686±59 vs. 780±31ms). Se puede concluir que el empleo de la EETD promueve cambios significativos en el balance simpático, resultando en una modulación parasimpática cardiaca más grande, posiblemente inducida del aumento de la movilidad del diafragma.

Evaluation of peripheral muscle strength of patients undergoing elective cardiac surgery: a longitudinal study.

INTRODUCTION: Peripheral muscle strength has been little explored in the literature in the context of cardiac rehabilitation. OBJECTIVE: To evaluate the peripheral muscle strength of patients undergoing elective cardiac surgery. METHODS: This was a longitudinal observational study. The peripheral muscle strength was measured using isometric dynamometry lower limb (knee extensors and flexors) at three different times: preoperatively (M1), the day of discharge (M2) and hospital discharge (M3). Participants received physiotherapy pre and postoperatively during the days of hospitalization during the morning and afternoon. RESULTS: Twenty-two patients were evaluated. The values of peripheral muscle strength of knee extensors preoperative found were about 50% lower than those predicted for the healthy population. When comparing muscle strength prior (M1), with the remaining evaluation, found himself in a fall of 29% for the movement of knee extension and 25% for knee flexion in M2 and a decrease of 10% movement for knee extension and 13% for knee flexion in M3 when comparing with M1. CONCLUSION: The values of peripheral muscle strength prior of the study patients were lower than predicted for the healthy population of the same age. After the surgical event this reduction is even more remarkable, being reestablished until the time of discharge, to values close to baseline.

Evaluation of peripheral muscle strength of patients undergoing elective cardiac surgery: a longitudinal study / Avaliação da força muscular periférica de pacientes submetidos à cirurgia cardíaca eletiva: estudo longitudinal

Introduction: Peripheral muscle strength has been little explored in the literature in the context of cardiac rehabilitation. Objective: To evaluate the peripheral muscle strength of patients undergoing elective cardiac surgery. Methods: This was a longitudinal observational study. The peripheral muscle strength was measured using isometric dynamometry lower limb (knee extensors and flexors) at three different times: preoperatively (M1), the day of discharge (M2) and hospital discharge (M3). Participants received physiotherapy pre and postoperatively during the days of hospitalization during the morning and afternoon. Results: Twenty-two patients were evaluated. The values of peripheral muscle strength of knee extensors preoperative found were about 50% lower than those predicted for the healthy population. When comparing muscle strength prior (M1), with the remaining evaluation, found himself in a fall of 29% for the movement of knee extension and 25% for knee flexion in M2 and a decrease of 10% movement for knee extension and 13% for knee flexion in M3 when comparing with M1. Conclusion: The values of peripheral muscle strength prior of the study patients were lower than predicted for the healthy population of the same age. After the surgical event this reduction is even more remarkable, being reestablished until the time of discharge, to values close to baseline. .

Introdução: A força muscular periférica tem sido pouco explorada na literatura atual no contexto da reabilitação cardiovascular. Objetivo: Avaliar a força muscular periférica de pacientes submetidos à cirurgia cardíaca eletiva. Métodos: Trata-se de um estudo observacional e longitudinal. A força muscular periférica foi mensurada por meio de dinamometria isométrica de MMII (extensores e flexores de joelho) em três momentos distintos: pré-operatório (M1), dia da alta da unidade de terapia intensiva (M2) e dia da alta hospitalar (M3). Os participantes receberam atendimento fisioterapêutico pré e pós-operatório durante os dias do internamento, nos períodos matutino e vespertino. Resultados: Foram avaliados 22 pacientes. Os valores de força muscular periférica de extensores de joelho pré-operatórios encontrados foram cerca de 50% menores do que os preditos para a população saudável. Ao comparar a força muscular prévia (M1), com os demais momentos de avaliação, encontrou-se em M2 queda de 29% para o movimento de extensão do joelho e 25% para o movimento de flexão de joelho e queda de 10% para o movimento de extensão do joelho e 13% para o movimento de flexão de joelho em M3 ao comparar com M1. Conclusão: Os valores de força muscular periférica prévia dos pacientes do estudo foram menores do que o predito para a população saudável com a mesma faixa etária. Após o evento cirúrgico, essa redução é ainda mais notável, sendo reestabelecida até o momento da alta hospitalar a valores próximos ao basal. .

Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma.

OBJECTIVE: To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables. METHOD: A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning. RESULTS: The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning. CONCLUSION: Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients.

Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma

OBJECTIVE: To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables. METHOD: A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning. RESULTS: The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning. CONCLUSION: Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients. .

The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics: a clinical trial.

OBJECTIVE: To observe the repercussion of respiratory physiotherapy techniques on the mean arterial pressure (MBP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen pressure (PjvO2) and jugular venous oxygen saturation (SjvO2). METHOD: The sample consisted of 20 patients with head trauma. The protocol consisted of physiotherapy techniques application of vibrocompression (VBC), expiratory flow increase (EFI) and suction. RESULTS: The results show the maintenance on variables of cerebral hemodynamics during the techniques of VBC and EFI. However, in relation to suction, there was an increase of MBP, ICP, with maintenance of CPP, PjvO2 and SjvO2 and return to baseline of MBP and ICP 10 minutes after the end of suction. CONCLUSION: The respiratory physiotherapy techniques (VBC, EFI) do not promote cerebral hemodynamic repercussion, unlike suction, in severe head injury patients, mechanically ventilated, sedated and paralyzed.

The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics: a clinical trial / Efeitos das manobras de fisioterapia respiratória na hemodinâmica cerebral: um ensaio clínico

OBJECTIVE: To observe the repercussion of respiratory physiotherapy techniques on the mean arterial pressure (MBP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen pressure (PjvO2) and jugular venous oxygen saturation (SjvO2). METHOD: The sample consisted of 20 patients with head trauma. The protocol consisted of physiotherapy techniques application of vibrocompression (VBC), expiratory flow increase (EFI) and suction. RESULTS: The results show the maintenance on variables of cerebral hemodynamics during the techniques of VBC and EFI. However, in relation to suction, there was an increase of MBP, ICP, with maintenance of CPP, PjvO2 and SjvO2 and return to baseline of MBP and ICP 10 minutes after the end of suction. CONCLUSION: The respiratory physiotherapy techniques (VBC, EFI) do not promote cerebral hemodynamic repercussion, unlike suction, in severe head injury patients, mechanically ventilated, sedated and paralyzed.

OBJETIVO: Observar a repercussão das técnicas de fisioterapia respiratória na pressão arterial média (PAM), pressão intracraniana (PIC), pressão de perfusão cerebral (PPC), pressão venosa jugular de oxigênio (PjO2) e saturação venosa jugular de oxigênio (SjO2). MÉTODO: Foram incluídos no estudo 20 pacientes com traumatismo cranioencefálico. O protocolo consistiu na aplicação das manobras fisioterapêuticas de vibrocompressão (VBC), aumento de fluxo expiratório (AFE) e aspiração (ASP). RESULTADOS: Os resultados mostraram a manutenção das variáveis da hemodinâmica cerebral durante as manobras de VBC e AFE. Porém, em relação à ASP, houve uma elevação da PAM e PIC, com manutenção da PPC, PjO2 e SjO2 e retorno aos valores basais da PAM e PIC dez minutos após o final da aspiração. CONCLUSÃO: As manobras de fisioterapia respiratória (VBC, AFE) não promovem alterações sobre a hemodinâmica cerebral, ao contrário da ASP traqueal, em pacientes com traumatismo cranioencefálico grave, em ventilação mecânica, sedados e curarizados.