Access to rehabilitation after stroke in Brazil (AReA study): multicenter study protocol.

BACKGROUND: Most of the Brazilian population relies on public healthcare and stroke is a major cause of disability in this country of continental dimensions. There is limited information about access to rehabilitation after stroke in Brazil. OBJECTIVE: To provide comprehensive information about Access to Rehabilitation After discharge from public hospitals in Brazil (AReA study), up to 6 months after stroke. METHODS: The present study intends to collect information from 17 public health centers in 16 Brazilian cities in the 5 macroregions of the country. Each center will include 36 participants (n = 612). The inclusion criteria are: age ≥ 18 years old; ischemic or hemorrhagic stroke, from 6 months to 1 year prior to the interview; admission to a public hospital in the acute phase after stroke; any neurological impairment poststroke; patient or caregiver able to provide informed consent and answer the survey. Patients can only be recruited in public neurology or internal medicine outpatient clinics. Outcomes will be assessed by a standard questionnaire about rehabilitation referrals, the rehabilitation program (current status, duration in months, number of sessions per week) and instructions received. In addition, patients will be asked about preferences for locations of rehabilitation (hospitals, clinics, or at home). TRIAL STATUS: The study is ongoing. Recruitment started on January 31st, 2020 and is planned to continue until June 2022. CONCLUSION: The AReA study will fill a gap in knowledge about access to stroke rehabilitation in the public health system in different Brazilian regions.

ANTECEDENTES: Grande parte da população brasileira depende de saúde pública e o acidente vascular cerebral (AVC) é uma das principais causas de incapacidade neste país de dimensões continentais. As informações sobre o acesso à reabilitação após AVC em instalações públicas no Brasil são limitadas. OBJETIVO: Fornecer informações abrangentes sobre o Acesso à Reabilitação pós-AVC (estudo AReA) nos primeiros 6 meses após a alta hospitalar da rede pública. MéTODOS: Serão coletadas informações de 17 centros de saúde públicos em 16 cidades brasileiras das cinco macrorregiões do país. Cada centro incluirá 36 participantes (n = 612). Os critérios de inclusão são: idade ≥ 18 anos; AVC isquêmico ou hemorrágico, com tempo de lesão entre 6 meses e 1 ano; admissão em hospital público na fase aguda; qualquer comprometimento neurológico pós-AVC; paciente ou cuidador capaz de fornecer consentimento informado e responder à pesquisa. Os pacientes só podem ser recrutados em ambulatórios públicos de neurologia ou medicina interna. Os resultados serão avaliados por um questionário padrão sobre encaminhamentos de reabilitação, o programa de reabilitação (estado atual, duração em meses, número de sessões por semana) e instruções recebidas. Além disso, os pacientes serão questionados sobre as preferências de locais de reabilitação (hospitais, clínicas ou casa). STATUS DO ESTUDO: O estudo está em andamento. O recrutamento começou em 31 de janeiro de 2020 e está previsto para continuar até junho de 2022. CONCLUSãO: O estudo AReA preencherá uma lacuna no conhecimento sobre o acesso à reabilitação para AVC no sistema público de saúde em diferentes regiões brasileiras.

Analyzes of the ICF Domain of Activity After a Neurological Early Mobility Protocol in a Public Hospital in Brazil.

Background: Early Mobility (EM) has been recognized as a feasible and safe intervention that improves functional outcomes in hospitalized patients. The International Classification of Functioning, Disability and Health (ICF) supports understanding of functioning and disability in multidimensional concepts and efforts have been taken to apply ICF in a hospital environment. EM protocols might be linked with the ICF component of activity and participation. The correlations between ICF, EM, and functional scales might help the multidisciplinary team to conduct the best rehabilitation program, according to patients' functional demands. Objectives: The primary outcome is to analyze the activity level of neurological inpatients on admission and delivery after a Neurological Early Mobility Protocol (NEMP) at intermediate care settings in a public hospital in Brazil using Activity Level categories, HPMQ, and MBI scores. The secondary outcome is to analyze the ICF performance qualifier, specifically in the activity domain, transposing HPMQ and MBI scores to the corresponding ICF performance qualifiers. Design: An international prospective study. Methods: NEMP was used to promote patients' mobility during a hospital stay in neurological ward settings. First, patients were categorized according to their Activity Levels (ALs) to determine the NEMP phase to initiate the EM protocol. ALs also were evaluated in the first and last sessions of NEMP. Thereafter, the Hospitalized Patient Mobility Questionnaire (HPMQ) was applied to identify whether patients needed assistance during the performance of hospital activities as well as the Modified Barthel Index (MBI). Both measures were applied in NEMP admission and discharge, and the Wilcoxon Signed Rank Test was used to compare data in these two time points. HPMQ and MBI scores were re-coded in the correspondent ICF performance qualifier. Results: Fifty-two patients were included with age of 55 ± 20 (mean ± SD) years and a length of hospital stay of 33 ± 21 days. Patients were classified along ALs categories at the admission/discharge as follows: AL 0 n = 6 (12%)/n = 5 (9%); AL 1 n = 12 (23%)/n = 6 (12%); AL 2 n = 13 (25%)/n = 8 (15%); AL 3 n = 10 (19%)/n = 13 (25%); AL 4 n = 11 (21%)/n = 20 (39%). HPMQ data revealed progressions for the activities of bathing (p < 0.001), feeding (p < 0.001), sitting at the edge of the bed (p < 0.001), sit to stand transition (p < 0.001), orthostatism (p < 0.001) and walking (p < 0.001). Transposing HPMQ activities into ICF performance qualifiers, improvements were shown in bathing (d510.3 to d510.1-severe problem to mild problem) and sitting at the edge of the bed (d4153.2 to d4153.1-moderate problem to mild problem). At MBI score were observed an average of 36 [IQR-35. (95% CI 31.5; 41.1)] on NEMP admission to 52 at discharge [IQR-50 (95% CI 43.2; 60.3)] (p < 0.001). Recoding MBI scores into ICF there were improvements from severe problem (3) to moderate problem (2). Limitations: The delay in initiating NEMP compared to the period observed in the literature (24-72 h). The study was carried out at only one center. Conclusions: This study suggests that neurological inpatients, in a public hospital in Brazil had low activity levels as could be seen by MBI and HPMQ scores and in the ICF performance qualifier. However, improvements in the evaluated measures and ICF activity domain were found after NEMP. The NEMP protocol has been initiated much longer than 72 h from hospital admission, a distinct window than seen in the literature. This enlargement period could be a new perspective for hospitals that are not able to apply mobility in the earliest 24-72 h.

Access to rehabilitation after stroke in Brazil (AReA study): multicenter study protocol / Acesso à reabilitação após o AVC no Brasil (estudo AReA): protocolo de estudo multicêntrico

Abstract Background Most of the Brazilian population relies on public healthcare and stroke is a major cause of disability in this country of continental dimensions. There is limited information about access to rehabilitation after stroke in Brazil. Objective To provide comprehensive information about Access to Rehabilitation After discharge from public hospitals in Brazil (AReA study), up to 6 months after stroke. Methods The present study intends to collect information from 17 public health centers in 16 Brazilian cities in the 5 macroregions of the country. Each center will include 36 participants (n = 612). The inclusion criteria are: age ≥ 18 years old; ischemic or hemorrhagic stroke, from 6 months to 1 year prior to the interview; admission to a public hospital in the acute phase after stroke; any neurological impairment poststroke; patient or caregiver able to provide informed consent and answer the survey. Patients can only be recruited in public neurology or internal medicine outpatient clinics. Outcomes will be assessed by a standard questionnaire about rehabilitation referrals, the rehabilitation program (current status, duration in months, number of sessions per week) and instructions received. In addition, patients will be asked about preferences for locations of rehabilitation (hospitals, clinics, or at home). Trial Status The study is ongoing. Recruitment started on January 31st, 2020 and is planned to continue until June 2022. Conclusion The AReA study will fill a gap in knowledge about access to stroke rehabilitation in the public health system in different Brazilian regions.

Resumo Antecedentes Grande parte da população brasileira depende de saúde pública e o acidente vascular cerebral (AVC) é uma das principais causas de incapacidade neste país de dimensões continentais. As informações sobre o acesso à reabilitação após AVC em instalações públicas no Brasil são limitadas. Objetivo Fornecer informações abrangentes sobre o Acesso à Reabilitação pós-AVC (estudo AReA) nos primeiros 6 meses após a alta hospitalar da rede pública. Métodos Serão coletadas informações de 17 centros de saúde públicos em 16 cidades brasileiras das cinco macrorregiões do país. Cada centro incluirá 36 participantes (n = 612). Os critérios de inclusão são: idade ≥ 18 anos; AVC isquêmico ou hemorrágico, com tempo de lesão entre 6 meses e 1 ano; admissão em hospital público na fase aguda; qualquer comprometimento neurológico pós-AVC; paciente ou cuidador capaz de fornecer consentimento informado e responder à pesquisa. Os pacientes só podem ser recrutados em ambulatórios públicos de neurologia ou medicina interna. Os resultados serão avaliados por um questionário padrão sobre encaminhamentos de reabilitação, o programa de reabilitação (estado atual, duração em meses, número de sessões por semana) e instruções recebidas. Além disso, os pacientes serão questionados sobre as preferências de locais de reabilitação (hospitais, clínicas ou casa). Status do estudo O estudo está em andamento. O recrutamento começou em 31 de janeiro de 2020 e está previsto para continuar até junho de 2022. Conclusão O estudo AReA preencherá uma lacuna no conhecimento sobre o acesso à reabilitação para AVC no sistema público de saúde em diferentes regiões brasileiras.

Cerebellar damage affects the inference of human motion.

The present study aims at the cerebellum's role in prediction mechanisms triggered by action observation. Five cerebellar patients and six age-paired control subjects were asked to estimate the occluded end point position of the shoulder's trajectories in Sit-to-Stand (STS) or Back-to-Sit (BTS) conditions, following or not biological rules. Contrarily to the control group, the prediction accuracy of the end point position in cerebellar patients did not depend on biological rules. Interestingly, both groups presented similar results when estimating the vanishing position of the target. Taken together, these results suggest that cerebellar damage affectsthe capacity of predicting upcoming actions by observation.

Case Report: Myocardial Bypass in Left Descending Artery - A Rare Congenital Anomaly

Abstract Myocardial bypass (MB) is known to have scientific relevance and is present in several studies with great statistical significance regarding its clinical manifestations and complications. There are still questions about MB in its relationship with heart disease and repercussion in life-threatening conditions. We present a case report of a MB in the left anterior descending coronary artery, whose objective is to identify this rare congenital anomaly and to highlight the patient's clinical outcome in order to elicit greater contributions about the presence of this variant in the emergency room, its diagnosis by angiography and therapeutic management.

Is the Frequency in Somatosensory Electrical Stimulation the Key Parameter in Modulating the Corticospinal Excitability of Healthy Volunteers and Stroke Patients with Spasticity?

Somatosensory electrical stimulation (SES) has been proposed as an approach to treat patients with sensory-motor impairment such as spasticity. However, there is still no consensus regarding which would be the adequate SES parameters to treat those deficits. Therefore, the aim of this study was to evaluate the effects of applying SES over the forearm muscles at four different frequencies of stimulation (3, 30, 150, and 300 Hz) and in two intervals of time (5' and 30') by means of transcranial magnetic stimulation and Hoffmann's reflex (H-reflex) in healthy volunteers (Experiments I and II). A group of stroke patients (Experiment III) was also preliminary evaluated to ascertain SES effects at a low frequency (3 Hz) applied for 30' over the forearm spastic flexors muscles by measuring the wrist joint passive torque. Motor evoked potentials and the H-reflex were collected from different forearm and hand muscles immediately before and after SES and up to 5' (Experiment I) and 10' (Experiments I and II) later. None of the investigated frequencies of SES was able to operate as a key in switching modulatory effects in the central nervous system of healthy volunteers and stroke patients with spasticity.

Primary Motor Cortex Representation of Handgrip Muscles in Patients with Leprosy.

BACKGROUND: Leprosy is an endemic infectious disease caused by Mycobacterium leprae that predominantly attacks the skin and peripheral nerves, leading to progressive impairment of motor, sensory and autonomic function. Little is known about how this peripheral neuropathy affects corticospinal excitability of handgrip muscles. Our purpose was to explore the motor cortex organization after progressive peripheral nerve injury and upper-limb dysfunction induced by leprosy using noninvasive transcranial magnetic stimulation (TMS). METHODS: In a cross-sectional study design, we mapped bilaterally in the primary motor cortex (M1) the representations of the hand flexor digitorum superficialis (FDS), as well as of the intrinsic hand muscles abductor pollicis brevis (APB), first dorsal interosseous (FDI) and abductor digiti minimi (ADM). All participants underwent clinical assessment, handgrip dynamometry and motor and sensory nerve conduction exams 30 days before mapping. Wilcoxon signed rank and Mann-Whitney tests were performed with an alpha-value of p<0.05. FINDINGS: Dynamometry performance of the patients' most affected hand (MAH), was worse than that of the less affected hand (LAH) and of healthy controls participants (p = 0.031), confirming handgrip impairment. Motor threshold (MT) of the FDS muscle was higher in both hemispheres in patients as compared to controls, and lower in the hemisphere contralateral to the MAH when compared to that of the LAH. Moreover, motor evoked potential (MEP) amplitudes collected in the FDS of the MAH were higher in comparison to those of controls. Strikingly, MEPs in the intrinsic hand muscle FDI had lower amplitudes in the hemisphere contralateral to MAH as compared to those of the LAH and the control group. Taken together, these results are suggestive of a more robust representation of an extrinsic hand flexor and impaired intrinsic hand muscle function in the hemisphere contralateral to the MAH due to leprosy. CONCLUSION: Decreased sensory-motor function induced by leprosy affects handgrip muscle representation in M1.

Physical disability and social participation in patients affected by leprosy after discontinuation of multidrug therapy.

OBJECTIVES: To describe the social participation frequency and the physical disability of patients who were discharged after the multidrug therapy (MDT/WHO) and factors associated with these variables. METHOD: A cross-sectional and analytical study, examining associations, which took place Nova Iguaçu/Brazil. A random sample of patients treated with multidrug therapy from 1997 to 2006 was selected. The rationale for sample size was determined by the estimated proportion of physical disability in the amount of 23%, with an acceptable sampling error rate of 5%; significance level was established as 5% among the 1080 patients finally a total sample of 225 patients. The evaluations were performed from January 2010 to December 2011 and Socio-demographic and clinical data were collected from the applications completed in the national notifiable diseases information system (SINAN). RESULTS: In the period of interest, 2179 cases were diagnosed with leprosy; 1080 met the criteria for inclusion. Of these, 225 were randomly selected patients who had mean age 56.12 (±17.34 years), 55.6% were women, 39.9% went to high school and 28.9% were Caucasians. A total of 55.3% (125) showed multibacillary form, with a predominant dimorphous leprosy in 40.4%. Physical disability was present in 60.9% and social restrictions in 24.9% of patients. The variable physical disability was associated with the therapeutic regimen multibacillary and social participation. CONCLUSION: We observed a high frequency of disability and social restriction after long period after the start of MDT/WHO suggesting the late diagnosis of leprosy or inadequate follow-up after discharge. This study highlights the importance of systematic monitoring of these patients with their own criteria which could be held at the Family Health Strategy.

Quality of life and its domains in leprosy patients after neurolysis: a study using WHOQOL-BREF.

Surgical nerve decompression in leprosy is indicated to prevent or treat nerve damage, and to improve sensory motor function and quality of life (QoL). The purpose of this study was to describe QoL of leprosy patients after surgical nerve decompression. Participants who underwent neurolysis in the last 5 years were recruited. The assessment consisted of collecting demographic and clinical information, QoL and its domain scores. Descriptive statistical analysis of demographic and clinical data was presented. Included 33 patients (43 +/- 11.0 years) who had neurolysis with a total of 61 nerves operated. The results of WHOQOL-bref showed that overall QoL mean was 11.2 (+/- 3.63) and domains scored as follow: physical (11.0 +/- 3.56), environment (11.47 +/- 2.11), psychological (13.29 +/- 2.79) and social relations (15.03 +/- 3.66). Measures of QoL should become part of the standard battery of tools used to assess health and well-being and it may contribute to identifying patients' needs in rehabilitation.

Perspective-taking in blindness: electrophysiological evidence of altered action representations.

It is well established that the mental simulation of actions involves visual and/or somatomotor representations of those imagined actions. To investigate whether the total absence of vision affects the brain activity associated with the retrieval of motor representations, we recorded the readiness potential (RP), a marker of motor preparation preceding the execution, as well as the motor imagery of the right middle-finger extension in the first-person (1P; imagining oneself performing the movement) and in the third-person (3P; imagining the experimenter performing the movement) modes in 19 sighted and 10 congenitally blind subjects. Our main result was found for the single RP slope values at the Cz channel (likely corresponding to the supplementary motor area). No difference in RP slope was found between 1P and 3P in the sighted group, suggesting that similar motor preparation networks are recruited to simulate our own and other people's actions in spite of explicit instructions to perform the task in 1P or 3P. Conversely, reduced RP slopes in 3P compared with 1P found in the blind group indicated that they might have used an alternative, nonmotor strategy to perform the task in 3P. Moreover, movement imagery ability, assessed both by means of mental chronometry and a modified version of the Movement Imagery Questionnaire-Revised, indicated that blind and sighted individuals had similar motor imagery performance. Taken together, these results suggest that complete visual loss early in life modifies the brain networks that associate with others' action representations.

Estudo comparativo dos custos de controle preventivo e de tratamento da hipertensäo arterial / A comparative study of the cost of the preventive control and of the hypertension's therapeutics

A hipertensäo arterial (HA) é um importante fator de risco para diversas doenças apesar de ser facilmente controlada profilaticamente. Mesmo assim, sua prevalência chega a 10 por cento, segundo alguns autores, e sua relaçäo com patologias comuns nos dias de hoje, como o infarto agudo do miocárdio (IAM), insuficiência renal crônica (IRC), acidente vascular cerebral (AVC), entre outras, já é cientificamente comprovada. Através deste estudo prospectivo busca-se provar que a profilaxia da HA apresenta um custo muito inferior em relaçäo ao tratamento de suas complicaçöes, sem mencionar o fato de que suas sequelas säo altamente debilitantes. Utilizaram-se dados referentes às mais frequentes complicaçöes, epidemiologia, pressä arterial de entrada e custo de tratamento hospitalar junto ao Hospital Universitário Regional Norte do Paraná por tres meses e informaçöes a respeito de valores médios de atendimento nas Unidades Básicas deSaúde (UBS) junto à Secretaria Municipal de Saúde de Londrina. Os resultados obtidos confirmam muitos dados contidos na literatura, como a maior prevalência feminina na faixa etária acima de 50 anos. A idade mais frequente em nosso estudo foi a de 74 anos, com média de 55,3 anos. Algumas das complicaçöes mais frequentes foram o AVC (33,3 por cento) e a ICC, com 14,8 por cento dos casos. Em 24,4 por cento dos casos a hipertensäo era idiopática. A grande maioria (83,7 por cento) dos pacientes obtiveram alta, enquanto que o restante foi a óbito. Concluímos que o tratamento profilático é menos dispendioso social e financeiramente, devendo ser empregado rotineiramente nas Unidades Básicas de Saúde

Enteroparasitose: casos no Jardim Santiago / Enteroparasitosis: Jardim Santiago

Dentro do Projeto Especial de Ensino - PEEPIN/UEL, no ano de 1994, foi realizado um levantamento de casos de enteroparasitose em crianças de 8-12 anos da 2ª série da Escola Municipal Maria José Carneiro do Jardim Santiago, zone oeste de Londrina. A fim de verificar a incidência de enteroparasitose na populaçäo alvo e orientá-la sobre a importância dos hábitos higiênicos como principal medida profilática, realizou-se exames parasitológicos de fezes e questionou-se hábitos que impliquem na infestaçäo parasitológica. Das 70 amostras analisadas pelos métodos de Faust e Hoffmann, 25 apresentaram-se positivas, o que equivaleu a 36,76 por cento da amostragem. Dos casos positivos, 72 por cento apresentaram protozoários dentre os quais:"Endolimax nana"(44 por cento); "Entamoeba coli"(24 por cento) e "Giardia lamblia"(24 por cento). Ainda em relaçäo aos casos positivos, 28 por cento referem-se à classe de helmintos tais como: "Ascaris lumbricoides"(28 por cento); "Trichocephalus trichius"(4 por cento) e "Enterobius vermiculares"(4 por cento). Os pais foram informados da positividade das amostras e aconselhados a procurarem a Unidade Básica de Saúde para o devido tratamento. Outras medidas, tais como distribuiçäo de cartazes e palestras informativas foram realizadas na escola e com a comunidade