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PURPOSE: This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO). METHODS: In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), "double-robust" approximation (DR), traditional regression (TR), and mixed-effects model (MEM). RESULTS: Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10-18) hours/day, compared to 10 (7-14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67-5.11), 3.35 (1.55-5.14), 3.95 (2.63-5.28), and 3.72 (2.5-4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15-0.76), 0.23 (0.10-0.50), 0.42 (0.23-0.77), and 0.48 (0.16-0.49), and for in-hospital mortality were 0.38 (0.11-1.27), 0.43 (0.14-1.26), 0.47 (0.22-0.91), and 0.46 (0.12-1.43) in the respective models. CONCLUSION: In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022. STUDY TYPE: Observational.

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BACKGROUND: Parkinson's disease (PD) is a degenerative, progressive, chronic disease that mainly affects the central nervous system, caused by dopamine deficiency. One of the ways to evaluate the central nervous system is with auditory evoked potentials (AEP). OBJECTIVE: To characterize the audiometric responses, and the auditory brainstem response (ABR), and cortical auditory evoked potentials (CAEP) in individuals with PD. METHODS: Thirty-two patients aged between 40 and 81 of both sexes were assessed, 16 with PD (study group [SG]) and 16 without PD (control group [CG]) matched for sex and age. The subjects were assessed using pure tone audiometry, ABR with click stimuli, and CAEP using the oddball paradigm with tone burst and speech stimuli. The results were compared between the groups using a repeated measures analysis of variance (ANOVA) test. RESULTS: In pure-tone audiometry, significantly higher hearing thresholds were found in the SG at 6 and 8 kHz. For the ABR, no differences were observed between groups. The CAEP analysis did not find statistical differences in the latencies between the groups, however, the SG presented smaller amplitudes of P1-N1, P2-N2, and N2-P3 than the CG. CONCLUSION: The results of this study showed a significantly higher threshold in higher frequencies in PD. Although no differences were observed at the brainstem level, the decrease in amplitude of all components in patients with PD in the CAEP suggests a deficit in both automatic and attentional cortical processing of acoustic stimuli.

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PURPOSE: The present study aims to describe initial changes in muscle thickness and composition, muscle growth signaling mediators, and systemic inflammation in critically ill patients after major trauma. METHODS: This observational study was carried out in a Level-I nonprofit trauma center. Thirty adults requiring mechanical ventilation were assessed within 24 h post-admission. Skeletal muscle wasting was evaluated using ultrasound for muscle thickness and echogenicity along with circulating insulin-like growth factor 1 (IGF-1) and inflammatory cytokines over five consecutive days. Changes over time were assessed using ANOVA repeated-measures analysis with a Bonferroni post-hoc test. Bivariate correlations were evaluated using Pearson or Spearman coefficients. RESULTS: Over five days, a significant decrease (11%) in rectus femoris thickness (3.91 ± 0.86 to 3.47 ± 0.64, cm, p = 0.01) and an increase (29%) in echogenicity (62.1 ± 13.1 to 80.4 ± 17.3, AU, p < 0.01) were observed among the 30 patients included in this study. Circulating levels of IGF-1 exhibited a 38% reduction (68.8 ± 43.6 to 42.4 ± 29.4, ng/mL, p = 0.01). Furthermore, pro-inflammatory cytokine (IFN-y) increased by 17% (4.83 ± 1.39 to 5.66 ± 1.61, pg./mL, p = 0.02) from day 1 to day 5. CONCLUSIONS: These findings reveal substantial thickness and muscle composition alterations within 48 h post-admission, worsening over five days. Despite standard rehabilitation care, changes in IGF-1 and IFN-y levels suggest early declines in muscle growth stimulus and increased inflammation.

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Dysregulated renin-angiotensin system (RAS) signaling contributes to elevated blood pressure (BP), inflammation, and organ damage in systemic arterial hypertension (HTN). We have demonstrated that hypertensive humans and rats exhibit higher expression of classic RAS components and lower expression of counterregulatory RAS components in the lungs compared with normotensive counterparts. Here, we investigated whether BP control could restore the balance between classic [angiotensin I-converting enzyme 2 (ACE)/angiotensin II (Ang II)] and counterregulatory [angiotensin I-converting enzyme 2 (ACE2)/Ang (1-7)] RAS, thereby mitigating lung inflammation. Male spontaneously hypertensive rats (SHRs) were treated with either losartan or amlodipine, both of which effectively reduced BP. These interventions up-regulated lung Ace2 and down-regulated Ace gene expression. Pulmonary membrane ACE2 abundance and activity were higher in losartan- and amlodipine-treated SHRs than in vehicle-treated SHRs, whereas ACE protein and function remained unchanged. Drug-treated SHRs exhibited lower levels of lung Ang II and higher levels of Ang (1-7) than vehicle-treated SHRs. Rebalancing the pulmonary RAS remarkably reduced macrophage number and down-regulated pro-inflammatory genes in SHR lungs, with lower expression of lung pro-inflammatory genes correlating with lower circulating levels of ACE2. Serum analysis in healthy and hypertensive individuals supported these findings, showing higher ACE2 levels in uncontrolled compared with controlled hypertension and normotension. Collectively, these findings suggest that high blood pressure may induce lung inflammation via an ACE/ACE2 imbalance. BP control with either an RAS inhibitor or a calcium channel blocker rebalances RAS in SHR lungs and alleviates inflammation. Furthermore, this study provides a mechanistic link between inflammatory lung diseases (such as COVID-19) and hypertension as a major risk factor.

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This Photo Quiz article presents a case of acute dengue fever in an American traveler returning from Puerto Rico. In addition to the relevant epidemiologic and medical history, a key finding that allowed clinical diagnosis of the infection was the characteristic rash ("isles of white in a sea of red") that our patient manifested. This physical exam finding was documented and is featured prominently in the article. Despite the fact that initial testing for dengue virus infection was negative, the characteristic exposures, incubation period, and clinical syndrome our patient presented with allowed us to provide directed care for the most likely illness. Our clinical diagnosis was later confirmed on convalescent serologic testing. We use this case to illustrate and discuss highlights of diagnosis, treatment, and prevention of both non-severe and severe dengue virus infection.

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Parkinson's disease (PD) is a multifaceted neurodegenerative disorder with both non-motor and motor symptoms. Variants in the glucosylceramidase beta 1 (GBA1) gene are the strongest genetic risk factor for PD, while homozygous or compound heterozygous variants in this gene classically cause Gaucher disease (GD). This study presents an early-onset PD patient with a homozygous GBA1 deletion. Whole-exome sequencing (WES) was performed, and the identified variant was validated via Sanger sequencing. The variant was classified according to ACMG guidelines and ClinGen updates. The patient, a Brazilian female of mixed ethnicity, exhibited the full spectrum of classical motor and non-motor PD symptoms without evident hallmarks of GD. The identified homozygous GBA1 variant (NM_000157.4:c.222_224del; p.T75del; rs761621516) has a very low global allele frequency (0.00003284) and is associated with reduced enzymatic activity. This variant exhibits a founder effect among individuals of African descent. This case highlights an intricate genotype-phenotype landscape for GBA1 variants, underscoring the role of homozygous GBA1 variants in PD pathogenesis.

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INTRODUCTION: Mechanical ventilation (MV) is one of the factors that may be associated with postoperative complications of cardiac surgeries. This study aimed to verify the clinical and biological factors related to prolonged MV and extubation failure in children and adolescents submitted to cardiac surgeries. METHOD: This retrospective cohort included all patients aged between 0 and 15 years at the Unidade de Recuperação Cardio-Torácica Pediátrica who were submitted to the first extubation after cardiac surgery. Those tracheostomized and under MV before the surgery or who suffered accidental extubation were excluded. The following data was collected - age, weight, and sex; body mass index (BMI); heart disease; surgical severity (Risk Adjustment for Congenital Heart Surgery-1); hospitalization period and length of stay at intensive care unit; MV, cardiopulmonary bypass, and anoxia duration; use of continuous sedation (midazolam and/or fentanyl); pulmonary hypertension; nitric oxide use; Down syndrome, extubation site, and failure. The outcomes were prolonged MV and extubation failure. RESULTS: A total of 233 patients were included - 79 (33.9%) aged below 12 months, 47 (20.2%) had Down syndrome, and 215 (92.3%) presented low BMI. Down syndrome patients and those under continuous sedation in the immediate postoperative period presented a higher risk of prolonged MV (P<0.001). Moreover, patients aged below 12 months (P=0.048) and those under prolonged MV (P=0.006) presented the highest risk of extubation failure. CONCLUSION: Patients with continuous sedation or Down syndrome required longer MV. In addition, children younger than 12 months or under prolonged MV presented a high extubation failure rate.

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INTRODUCTION: The aim of this systematic review of prevalence is to observe and discuss the clinical manifestations of Chikungunya Virus disease in its chronic phase. METHODS: To be eligible, the observational studies should accompany the individuals for at least six months. The research was conducted using electronic databases MEDLINE and EMBASE. The methodological quality was evaluated using the "Joanna Briggs Institute's critical appraisal checklist for studies reporting prevalence data" tool. RESULTS: The search has found 175 articles. The application of the inclusion criteria defined a total of 29 selected studies. From the included studies, only one did not present arthralgia as a prevalent symptom in the chronic phase. Other signs and symptoms observed were: fatigue; sleep disorders; myalgia; skin lesions; depression; digestive disorders. CONCLUSION: Because it is an often incapacitating symptom, arthralgia can affect the individuals' quality of life, with implications in their social and work life. Since the chronic phase is common in infected individuals, all levels of health care should be prepared to monitor, in the medium to long term, the patients affected by this condition.

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BACKGROUND: Low QRS complex voltage is an important predictor of death in Chagas disease. However, the parameters applied to the low-voltage classification were described by the Minnesota Code and not specifically for Chagas disease. This study aimed to analyze low QRS voltage by determining the ADOC index and averages in the frontal and horizontal electrocardiographic planes, establishing possible clinical implications. METHODS: A cross-sectional study of patients with Chagas disease was performed using the Mann-Whitney U test and Spearman's correlation. The amplitudes of each QRS were analyzed, and the sum of the DII and V5 derivations of the ADOC index and the arithmetic means of the QRS complexes in the frontal and horizontal planes were determined. RESULTS: The ADOC index was correlated with the highest risk of stroke and death according to the Rassi score. The ADOC index (p=0.046) and mean mQRS were inversely proportional to the Rassi risk of death score (p=0.038). The ADOC index proved to be more sensitive (75.0%) and accurate (67.4%) in identifying patients at elevated death risk using the Rassi score. Finally, a positive correlation was observed between the QRSFm and QRSHm indicators and ADOC index (r=0.590 and r=0.857, respectively). DISCUSSION: The ADOC index and mean of the QRS complexes are possible tools correlated with the Rassi score and risk of stroke in patients with Chagas disease.

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Motivation for the study. The frequency of malnutrition in adult patients with grade V chronic kidney disease on hemodialysis at the High Complexity Hospital of La Libertad "Virgen de la Puerta" is unknown. Main findings. We found high frequency of malnutrition in hemodialysis patients (92.4%), with moderate/severe malnutrition predominating (72.4%). Implications. This study allows us to understand the situation of malnutrition in hemodialysis patients in order to initiate early nutritional intervention, in addition to providing important data that add to the available evidence. This was a cross-sectional observational study that aimed to determine the frequency of malnutrition in adult patients with stage V chronic kidney disease on hemodialysis. The sample consisted of 105 adult patients diagnosed stage V chronic kidney disease who received hemodialysis at the "Virgen de la Puerta" High Complexity Hospital in Trujillo, Peru. We applied the Malnutrition-Inflammation Score (MIS), 97 (92.4%) patients presented malnutrition, of which 20% had mild malnutrition, 37.1% had moderate malnutrition and 35.3% had severe malnutrition; only 8 patients (7.6%) presented normal nutritional status. In conclusion, we found a high frequency of malnutrition among patients diagnosed with stage V chronic kidney disease receiving hemodialysis.

El objetivo fue determinar la frecuencia de desnutrición en pacientes adultos con enfermedad renal crónica grado V en hemodiálisis, para ello se realizó un estudio observacional transversal. La muestra estuvo constituida por 105 pacientes adultos con diagnóstico de enfermedad renal crónica grado V que recibieron hemodiálisis en el Hospital de Alta Complejidad «Virgen de la Puerta¼ de Trujillo, Perú. Se aplicó la Escala Malnutrition-Inflamation Score (MIS), 97 (92,4%) pacientes presentaron desnutrición, dividido en 20% con desnutrición leve, 37,1% con desnutrición moderada y 35,3% con desnutrición grave; solo 8 pacientes (7,6%) presentaron estado nutricional normal. En conclusión, existe una alta frecuencia de desnutrición entre los pacientes con diagnóstico de enfermedad renal crónica grado V que reciben hemodiálisis. Motivación para realizar el estudio. Se desconoce la frecuencia de la desnutrición en pacientes adultos con enfermedad renal crónica grado V en hemodiálisis en el Hospital de Alta Complejidad De La Libertad «Virgen de la Puerta¼. Principales hallazgos. Existe una alta frecuencia de desnutrición en los pacientes en hemodiálisis (92,4%), predominando la desnutrición moderada/severa (72,4%). Implicancias. Este estudio permite conocer la situación de la desnutrición en los pacientes en hemodiálisis con la finalidad de iniciar la intervención nutricional temprana, además se brindan datos importantes que se suman a la evidencia disponible.

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Expanded dengue syndrome are unusual conditions, such as subacute thyroiditis (SAT). We present the case of a 38-year-old woman who had dengue without alarm signs for a month, along with cervical pain and increased cervical volume, palpitations, tremor and dysphagia. Hormonal evaluation, ultrasound and thyroid scintigraphy were consistent with SAT. She received corticoids for two months, with remission after four months. SAT is characterized by neck pain, fever and symptoms of thyrotoxicosis. It is associated with viral infections and it comprises a phase of thyrotoxicosis followed by hypothyroidism. Diagnosis involves hormonal and biochemical tests, thyroid ultrasound with Doppler and scintigraphy. This condition is managed with non-steroidal anti-inflammatory drugs and corticosteroids, according to severity. SAT, an infrequent manifestation of dengue, requires a high degree of suspicion and appropriate management. A review of published cases of SAT due to dengue was carried out in the Scopus, PubMed and Web of Science databases, finding six reported cases, mostly in men.

El síndrome de dengue expandido son afectaciones poco habituales, como la tiroiditis subaguda (TSA). Presentamos el caso de una mujer de 38 años quien tuvo dengue sin signos de alarma un mes atrás, presentó dolor y aumento de volumen cervical, palpitaciones, tremor y disfagia. La evaluación hormonal, ecografía y gammagrafía tiroidea fueron consistentes con TSA. Recibió corticoterapia durante dos meses, remitiendo el cuadro a los cuatro meses. La TSA se caracteriza por dolor cervical, fiebre y síntomas de tirotoxicosis. Está asociada con infecciones virales. Comprende una fase de tirotoxicosis seguida de hipotiroidismo. Su diagnóstico involucra exámenes hormonales, bioquímicos, ecografía tiroidea con Doppler y gammagrafía. Se maneja con antiinflamatorios no esteroideos y corticoides, según la severidad. La TSA, una manifestación infrecuente del dengue, requiere un alto grado de sospecha y manejo adecuado. Se realizó una revisión de casos publicados de TSA por dengue, en las bases de datos de Scopus, PubMed y Web of Science, encontrando seis casos reportados, en su mayoría en varones.

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Capillary leak syndrome is a unique complication characterized by extravasation of liquids in the interstitial space due to protein loss caused by snakebite envenoming. We describe the case of a 12-year-old boy from the district of Napo in the city of Iquitos in the Peruvian Amazon, who had edema and increased face volume due to the bite of a snake of the Bothrops genus in the lateral aspect of the right leg; he was the hospitalized and diagnosed with severe ophidism complicated with face edema. The patient received eight vials of antivenin, antibiotics and analgesics. Finally, the patient was discharged from the hospital after eight days of hospitalization, with favorable evolution and recovery.

El síndrome de fuga capilar es una complicación única de etiología variable que se caracteriza por la extravasación de líquidos en el espacio intersticial por la pérdida de proteínas a causa del envenenamiento por mordeduras de serpientes. Se describe el caso clínico de un niño de 12 años, natural del distrito de Napo en la ciudad de Iquitos en la Amazonía peruana, quien presentó edema y aumento del volumen del rostro por la mordedura de una serpiente del género Bothrops en cara lateral de la pierna derecha, posteriormente fue hospitalizado y se le diagnosticó de ofidismo grave complicado con edema de cara. El paciente recibió ocho viales de antiveneno, antibióticos y analgésicos. Finalmente, tras ocho días de hospitalización resultó en una evolución favorable y la recuperación siendo dado de alta.

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OBJECTIVE: To relate the self-perceived risk of dysphagia with the level of oral intake in hospitalized oncology patients. METHODS: This cross-sectional study had a convenience sample of adults and older adults diagnosed with cancer and hospitalized in an oncology hospital in southern Brazil. Data on sex, age, length of hospitalization, comorbidities, oncological diagnosis, treatment, and feeding route were obtained from the participants' medical records. The level of oral intake was classified using the Functional Oral Intake Scale (FOIS), and the risk of dysphagia was identified using the Eating Assessment Tool (EAT-10). The relationship between these variables was analyzed using Spearman's correlation coefficient. RESULTS: The study included 60 participants - 42 with solid tumors and 18 with hematological tumors; 35 females (58.3%) and 25 males(41.7%), with a mean age of 58.5 ± 13.1 years. Of these, 56 exclusively used the oral route for feeding (93.3%), and 18 were at risk of dysphagia (30%). Older patients were at higher risk for dysphagia than adults (p-value = 0.020). EAT-10 scores (median = 0; IQR = 0-4) were significantly inversely correlated (RHO = -0.463; p-value = 0.000) with FOIS classifications (N: level 2 = 2; level 3 = 2; level 4 = 2; level 5 = 12; level 7 = 42). CONCLUSION: The study found that lower EAT-10 scores corresponded to higher FOIS levels. In other words, the lower the risk of dysphagia, the lower the susceptibility to using alternative feeding routes.

OBJETIVO: Relacionar o risco de disfagia autopercebido com o nível de ingestão oral em pacientes oncológicos hospitalizados. MÉTODO: Estudo transversal, com amostra por conveniência composta por indivíduos adultos e idosos, com diagnóstico de câncer e internados em um hospital oncológico do sul do Brasil. Os dados sobre sexo, idade, tempo de internação, comorbidades, diagnóstico oncológico, tratamento e via de alimentação, foram obtidos dos prontuários dos participantes. O nível de ingestão oral foi classificado pela Functional Oral Intake Scale (FOIS), o risco de disfagia foi identificado pelo Eating Assessment Tool (EAT-10) e a relação entre eles foi feita por meio do coeficiente de correlação de Spearman. RESULTADOS: Foram incluídos 60 participantes (42 tumores sólidos e 18 tumores hematológicos), sendo 35 do sexo feminino (58,3%) e 25 do sexo masculino (41,7%), com média de idade de 58,5 ± 13,1 anos. Destes, 56 se alimentavam por via oral exclusiva (93,3%) e 18 apresentavam risco de disfagia (30%). Os idosos apresentaram maior risco para disfagia em comparação aos adultos (p-valor = 0,020). A relação entre a pontuação do EAT-10 (mediana 0; IQR = 0 - 4) e a classificação da FOIS (N: nível 2 = 2; nível 3 = 2; nível 4 = 2; nível 5 = 12; nível 7 = 42) demonstrou correlação inversa significativa (RHO = -0,463; p-valor = 0,000). CONCLUSÃO: Observou-se que quanto menor a pontuação no EAT-10, maior o nível da FOIS. Ou seja, quanto menor o risco para disfagia, menor a suscetibilidade ao uso de via alternativa de alimentação.

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PURPOSE: To analyze the evolution of speech and swallowing decline in patients with amyotrophic lateral sclerosis (ALS) over a ten-year period. METHODS: A retrospective and longitudinal cohort study. Data were collected using the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) from 101 medical records of ALS patients treated at the multidisciplinary neuromuscular diseases clinic of a University Hospital over a ten-year period. The data were statistically analyzed, adopting a significance level of p<0.05. RESULTS: The analysis of the studied functions indicated that speech, swallowing, and salivation are altered over ten years in ALS. There are differences in patterns between the variables sex and disease type concerning symptoms related to dysarthria and dysphagia in these individuals, which may indicate the rate of progression over a given time interval. CONCLUSION: There is a decline in speech and swallowing over ten years in ALS. The bulbar type leads to a faster decline in the studied functions than the spinal type.

OBJETIVO: Analisar a evolução do declínio da fala e da deglutição em pacientes com esclerose lateral amiotrófica (ELA) ao longo de dez anos. MÉTODO: Estudo de coorte, retrospectivo e longitudinal. Foi realizado por meio da coleta de dados da escala funcional Amyotrophic Lateral Sclerosis - Functional Rating Scale-Revised (ALSFRS-R) em 101 prontuários de pacientes com ELA atendidos no ambulatório multidisciplinar de doenças neuromusculares de um Hospital Universitário, em um período de dez anos. Os dados foram analisados estatisticamente, adotando o valor de p<0,05. RESULTADOS: A análise das funções estudadas indicou que a fala, a deglutição e a salivação são alteradas ao longo de dez anos na ELA. Há diferenças de padrões entre as variáveis sexo e tipo da doença, nos sintomas relacionados à disartria e à disfagia nesses indivíduos, podendo precisar em dias o quanto esta evolução ocorre ao longo de um determinado intervalo de tempo. CONCLUSÃO: Há declínio da fala e da deglutição ao longo de dez anos na ELA. O tipo bulbar provoca um declínio mais rápido das funções estudadas, do que o tipo espinhal.

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Systemic lupus erythematosus is a clinically heterogeneous autoimmune disease that frequently affects young women. The risk of cardiovascular events is higher in patients with this disease than in the general population. In this study, we report a patient who developed a left ventricular pseudoaneurysm with no etiological factor other than systemic lupus erythematosus. Dor ventriculoplasty and mitral ring replacement were performed as surgical treatment. The case is shared because of the rarity of left ventricular pseudoaneurysm due to systemic lupus erythematosus and successful pseudoaneurysm repair.

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BACKGROUND: The COVID-19 pandemic has resulted in a critical shortage of respiratory ventilators, highlighting the urgent need to explore alternative treatment options for patients with acute respiratory distress syndrome (ARDS) caused by respiratory viruses, as an alternative to invasive mechanical ventilation (IMV) in future pandemics. OBJECTIVES: The objective of this study was to assess the effectiveness of alternative noninvasive oxygenation and ventilation strategies in comparison to invasive mechanical ventilation (IMV) in patients with virus-induced acute respiratory failure (ARF). The primary outcome was the all-cause ICU mortality rate. METHODS: A systematic review was conducted following the Cochrane guidelines and PRISMA reporting guidelines. The search encompassed databases such as Medline, Cochrane CENTRAL, and Embase to identify relevant indexed literature. Additionally, gray literature was included by consulting regulatory agencies. The included studies compared various oxygenation and ventilatory alternatives, such as high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), or noninvasive mechanical ventilation (NIMV) with IMV. An exploratory meta-analysis was performed by calculating the risk ratio (RR) by random effects and meta-regression to explore possible sources of heterogeneity and to compare ventilatory alternatives against IMV to reduce mortality, length of stay (LOS) days in ICU, nosocomial infection, and barotrauma. RESULTS: A total of forty-seven studies were included in this systematic review. NIMV had an RR of 0.70 (0.58-0.85), HFNC had an RR of 0.54 (0.42-0.71), and CPAP had an RR of 0.80 (0.71-0.90), with meta-regression models that reduced heterogeneity to 0%. For LOS days in ICU, NIMV had 0.38 (- 0.69: - 0.08) lower days and HFNC 0.29 (- 0.64: 0.06) lower days with meta-regression models that reduction heterogeneity to 0% for HFNC and 50% for NIMV. Not enough studies reported nosocomial infection or barotrauma to evaluate them in a meta-analysis. The overall quality of evidence, as assessed by GRADE evaluation, was determined to be from very low to medium certainty depending on the ventilatory strategy and outcome. CONCLUSIONS: The findings of this systematic review support the use of alternative noninvasive oxygenation and ventilation strategies as viable alternatives to conventional respiratory ventilation for managing viral-induced ARF. Although it is essential to interpret these findings with caution given the overall low to medium certainty of the evidence, the integration of these modalities as part of the management strategies of these patients could help reduce the utilization of ICU beds, invasive ventilators, and costs in both developed and developing countries.

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Malaria, caused by Plasmodium spp., remains a major public health problem. Cerebral malaria is its deadliest form, with a 15-25% mortality rate, despite artemisinin-based treatments. In addition, the World Health Organization (WHO) strictly defines cerebral malaria as the presence of coma, 1 h after a seizure or the correction of hypoglycemia, in patients with P. falciparum parasitemia. Consequently, 25% of survivors experience neurocognitive and behavioral sequelae, particularly in children. However, more recently, neurocognitive and behavioral impairments were also reported in severe non-cerebral malaria, non-severe malaria, and even during asymptomatic Plasmodium infection. Such impairments have been observed in school-aged children, the elderly, and in animal models without classic cerebral malaria pathology. Additionally, mild vasogenic edema has been detected in neuroimaging of patients with severe non-cerebral and non-severe P. falciparum malaria. Therefore, given that approximately 98% of malaria cases in the world are non-severe, neurocognitive and behavioral sequelae may account for a significant proportion of global malaria morbidity. Taken together, these observations suggest that systemic inflammation from malaria, even without traditional cerebral malaria signs, can disrupt brain function and lead to long-term sequelae. We propose that the current definition of cerebral malaria may not fully capture the observed evidence and a new conceptualization is necessary to encompass these findings.

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Cancer is the second leading cause of death worldwide. Cancer cachexia is a multifactorial catabolic syndrome responsible for almost one third of cancer-related deaths. Drug repurposing has been used in oncological research and drugs like clenbuterol and metformin seem to be reasonable candidates in the context of cancer cachexia, because the former is a ß2-agonist that stimulates muscle gain and the latter has anti-inflammatory properties. The aim of this study was to assess the effects of a short-term treatment with metformin and clenbuterol, isolated or combined, on tumor growth and cancer cachexia parameters in Walker 256 tumor-bearing rats, a model of cancer cachexia. To this end, Wistar rats were separated into 8 groups and 4 of them were injected with Walker 256 tumor cells (W groups). Control (C) and W groups received the following treatments: metformin (M), clenbuterol (Cb), or metformin combined with clenbuterol (MCb). Body and tumor weight, metabolic parameters, and oxidative damage in the tumor were assessed. Compared to the C group, the W group showed body weight loss, hypoglycemia, hyperlactatemia, and hypertriacylglycerolemia. None of the treatments could reverse body weight loss, although they reversed the alterations of the assessed plasma metabolic parameters. Surprisingly, only clenbuterol alone reduced tumor weight. Hydrogen peroxide production and lipid peroxidation in tumor tissue was increased in this group. In conclusion, metformin and clenbuterol ameliorated metabolic cachexia parameters in Walker tumor-bearing rats, but only clenbuterol reduced the tumor weight, probably, through a lipid peroxidation-dependent cell death.

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PURPOSE: to describe sociodemographic characteristics of individuals with multiple sclerosis and correlate and compare vocal fatigue, voice handicap, and voice-related quality of life of individuals with and without the disease. METHODS: Cross-sectional, quantitative study with 52 volunteers with multiple sclerosis and 52 control volunteers, matched by sex, age, and education level. Sociodemographic and clinical data were collected through a questionnaire and medical record analysis. Participants responded to the reduced Voice Handicap Index (VHI-10), Vocal Fatigue Index (VFI), and Voice-Related Quality of Life (V-RQOL). Correlational and comparative analyses were performed, with a 5% significance level (p < 0.05). RESULTS: There was a greater predominance of females diagnosed with multiple sclerosis, with a mean age of 40 years, who graduated from high school, and with a relapsing-remitting disease course. Voice handicap was positively correlated with vocal fatigue, and voice handicap and vocal fatigue were negatively correlated with voice-related quality of life in both groups. Participants with multiple sclerosis exceeded the VHI-10 and VFI cutoff scores and were below the V-RQOL cutoff score. CONCLUSION: There was a prevalence of the disease in young, educated females with relapsing-remitting disease. The greater the voice handicap and/or vocal fatigue, the lower the voice-related quality of life in both groups. However, people with multiple sclerosis self-reported greater voice handicap and vocal fatigue and poorer voice-related quality of life.

OBJETIVO: descrever características sociodemográficas de indivíduos com esclerose múltipla, correlacionar e comparar a fadiga, desvantagem vocal e a qualidade de vida em voz de indivíduos com e sem a doença. MÉTODO: Estudo transversal, quantitativo e com 52 voluntários com esclerose múltipla e 52 voluntários-controle, pareados por sexo, idade e escolaridade. Dados sociodemográficos e clínicos foram coletados com questionário e análise de prontuários. Os participantes responderam ao Índice de Desvantagem Vocal reduzido (IDV-10), Índice de Fadiga Vocal (IFV) e Qualidade de Vida em Voz (QVV). Análises correlacionais e comparativas foram realizadas, com um nível de significância de 5% (p<0,05). RESULTADO: Maior predomínio de participantes diagnosticados com esclerose múltipla do sexo feminino, média de 40 anos, ensino médio completo e curso da doença do tipo remitente-recorrente. Houve correlação positiva entre a desvantagem e a fadiga vocal, e correlação negativa entre a desvantagem e fadiga vocal com a qualidade de vida em voz em ambos os grupos. Além disso, os participantes com esclerose múltipla ultrapassaram as notas de corte do IDV-10 e do IFV e ficaram abaixo da nota de corte do QVV. CONCLUSÃO: Houve prevalência da doença em indivíduos jovens do sexo feminino, escolarizados e do tipo remitente-recorrente. Quanto maior a desvantagem e/ou a fadiga vocal, menor é a qualidade de vida em voz em ambos os grupos. No entanto, pessoas com esclerose múltipla autorreferem maior desvantagem e fadiga vocal, além de menor qualidade de vida relacionada à voz.

RESUMO

BACKGROUND: Neurological and psychiatric manifestations occur in patients with primary Sjogren's disease (SjD) with a wide-ranging clinical presentation, affecting quality of life, social participation, and prognosis. Despite this, neither central nor peripheral neurological symptoms are systematically evaluated in the context of autoimmunity or identified as manifestations of SjD. The EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI) covers only part of them in the neurological domain. METHODS: We performed a systematic review of the diagnosis and prevalence of central, peripheral, and autonomic nervous system manifestations in primary SjD, following the recommendations proposed by the Cochrane Collaboration Handbook. Observational studies were included when their main issue was the diagnosis and the prevalence of the manifestations individually. We employed a generalized linear mixed model (GLMM) method with a random-effects model, and the results were computed using logit transformation, implemented through the 'meta' and 'metafor' packages in the R software (version 3.6.1). To present these recommendations, agreement among experts was investigated using the Delphi method in in-person meetings. RESULTS: We propose ten recommendations regarding the investigation and management of neurological involvement in SjD that had 100% agreement among participants. CONCLUSION: These recommendations add to the literature on the clinical care of patients with SjD.