Dietary nitrate supplementation and cognitive health: the nitric oxide-dependent neurovascular coupling hypothesis.

Diet is currently recognized as a major modifiable agent of human health. In particular, dietary nitrate has been increasingly explored as a strategy to modulate different physiological mechanisms with demonstrated benefits in multiple organs, including gastrointestinal, cardiovascular, metabolic, and endocrine systems. An intriguing exception in this scenario has been the brain, for which the evidence of the nitrate benefits remains controversial. Upon consumption, nitrate can undergo sequential reduction reactions in vivo to produce nitric oxide (•NO), a ubiquitous paracrine messenger that supports multiple physiological events such as vasodilation and neuromodulation. In the brain, •NO plays a key role in neurovascular coupling, a fine process associated with the dynamic regulation of cerebral blood flow matching the metabolic needs of neurons and crucial for sustaining brain function. Neurovascular coupling dysregulation has been associated with neurodegeneration and cognitive dysfunction during different pathological conditions and aging. We discuss the potential biological action of nitrate on brain health, concerning the molecular mechanisms underpinning this association, particularly via modulation of •NO-dependent neurovascular coupling. The impact of nitrate supplementation on cognitive performance was scrutinized through preclinical and clinical data, suggesting that intervention length and the health condition of the participants are determinants of the outcome. Also, it stresses the need for multimodal quantitative studies relating cellular and mechanistic approaches to function coupled with behavior clinical outputs to understand whether a mechanistic relationship between dietary nitrate and cognitive health is operative in the brain. If proven, it supports the exciting hypothesis of cognitive enhancement via diet.

Individual satisfaction with HIV/AIDS care in Belo Horizonte, Brazil.

Individual satisfaction is associated with increased retention in HIV/AIDS care services and adherence to treatment. This study assessed factors associated with individual satisfaction at the initiation of antiretroviral therapy and compared the proportions of satisfaction at the initiation of antiretroviral therapy and after three months of follow-up. Face-to-face interviews were carried out among 398 individuals of three HIV/ AIDS healthcare services in Belo Horizonte, Brazil. Variables included sociodemographic and clinical characteristics, perception about healthcare services, and domains of quality of life. Individuals that rated the quality of healthcare services as good or very good were classified as satisfied. A logistic regression analysis of the association between independent variables and individual satisfaction was performed. The proportion of individual satisfaction with healthcare services was 95.5% at the initiation of antiretroviral therapy and 96.7% after three months and these changes were not statistically significant (p = 0.472). The physical domain of quality of life was found to be associated with satisfaction at the initiation of antiretroviral therapy (OR = 1.38; CI = 1.11-1.71; p = 0.003). Training and supervision of health professionals for addressing the needs of individuals with lower levels of physical domain of quality of life may improve satisfaction with HIV/ AIDS care.

Identification of hospitalized patients with community-acquired infection in whom treatment guidelines do not apply: a validated model.

OBJECTIVES: To develop and validate a clinical model to identify patients admitted to hospital with community-acquired infection (CAI) caused by pathogens resistant to antimicrobials recommended in current CAI treatment guidelines. METHODS: International prospective cohort study of consecutive patients admitted with bacterial infection. Logistic regression was used to associate risk factors with infection by a resistant organism. The final model was validated in an independent cohort. RESULTS: There were 527 patients in the derivation and 89 in the validation cohort. Independent risk factors identified were: atherosclerosis with functional impairment (Karnofsky index <70) [adjusted OR (aOR) (95% CI) = 2.19 (1.41-3.40)]; previous invasive procedures [adjusted OR (95% CI) = 1.98 (1.28-3.05)]; previous colonization with an MDR organism (MDRO) [aOR (95% CI) = 2.67 (1.48-4.81)]; and previous antimicrobial therapy [aOR (95% CI) = 2.81 (1.81-4.38)]. The area under the receiver operating characteristics (AU-ROC) curve (95% CI) for the final model was 0.75 (0.70-0.79). For a predicted probability ≥22% the sensitivity of the model was 82%, with a negative predictive value of 85%. In the validation cohort the sensitivity of the model was 96%. Using this model, unnecessary broad-spectrum therapy would be recommended in 30% of cases whereas undertreatment would occur in only 6% of cases. CONCLUSIONS: For patients hospitalized with CAI and none of the following risk factors: atherosclerosis with functional impairment; previous invasive procedures; antimicrobial therapy; or MDRO colonization, CAI guidelines can safely be applied. Whereas, for those with some of these risk factors, particularly if more than one, alternative antimicrobial regimens should be considered.

Carbon Monoxide and Cyanide Intoxication: An Association to Remember.

Carbon monoxide and cyanide are toxins that induce cellular hypoxia; both can be produced in the context of domestic fires and may have a synergistic effect. We present the case of a man, victim of a house fire, who was initially diagnosed as having carbon monoxide poisoning, but that afterwards also presented signs and symptoms compatible with cyanide poisoning. He was successfully treated with an antidote. We want to highlight this relatively frequent association of poisonings and the need for urgent empirical treatment.

O monóxido de carbono e o cianeto são toxinas que induzem hipóxia celular; ambos podem ser produzidos em contexto de incêndios domésticos e podem exercer um efeito tóxico sinérgico. Apresentamos o caso de um homem, vítima de incêndio doméstico, que foi inicialmente diagnosticado como intoxicação por monóxido de carbono, mas que posteriormente apresentou também sinais e sintomas compatíveis com intoxicação por cianeto, tendo sido tratado com sucesso com antídotos dirigidos. Pretendemos alertar para esta associação de intoxicações relativamente frequente e para a necessidade de tratamento empírico urgente.

Revisão de escopo da aplicação do Postgraduate Hospital Educational Environment Measure (PHEEM) na residência médica / Scoping review of the application of the Postgraduate Hospital Educational Environment Measure (PHEEM) in medical residency

Resumo Introdução: O Postgraduate Hospital Educational Environment Measure (PHEEM) é um instrumento validado e confiável para avaliar o ambiente educacional nos programas de residência médica. Objetivo: Este estudo teve como objetivos mapear a aplicação do questionário PHEEM na residência médica e avaliar os resultados, os aspectos positivos e negativos e os pontos passíveis de melhoria. Método: Trata-se de uma revisão de escopo de acordo com a metodologia do Instituto Joanna Briggs de revisões de escopo. Foram incluídos estudos seguindo a estrutura PCC: P (participantes) = médicos residentes de qualquer especialidade; C (conceito) = o PHEEM é um instrumento utilizado para avaliar o ambiente educacional na residência médica, por meio de um questionário de 40 itens divididos em três subescalas que incluem percepção de autonomia, ensino e suporte social; C (cenário) = pesquisas sobre o PHEEM na residência médica de qualquer especialidade. As bases eletrônicas pesquisadas foram: PubMed, Embase e Biblioteca Virtual em Saúde (BVS). Resultado: As estratégias de busca rodadas resultaram em 1.588 estudos, 50 foram lidos na íntegra, e incluíram-se 36. Os estudos foram realizados em 22 países, e a maioria revelou um ambiente educacional mais positivo que negativo, entretanto com espaço para melhorias. Nas subescalas, a percepção de autonomia se mostrou mais positiva que negativa, e a percepção de ensino revelou que a maioria dos programas está caminhando na direção certa. Entretanto, na avaliação do suporte social, os resultados foram divididos entre um ambiente não agradável e um ambiente com mais prós do que contras. Os principais pontos positivos destacados foram baixa discriminação racial e sexual, possibilidade de trabalhar em equipe, nível adequado de responsabilidades, professores acessíveis e com boas habilidades de ensino, oportunidades de aprendizado e participação em eventos educacionais. Os principais pontos negativos foram falta de alimentação e acomodação adequadas durante o plantão, carga horária excessiva, falta de feedback por parte dos preceptores, falta de tempo protegido para estudo e cultura de culpar o residente. Conclusão: A aplicação do PHEEM revelou que, na maioria dos programas de residência médica, o ambiente educacional se mostrou mais positivo que negativo, entretanto com espaço para melhorias. São necessários esforços para a melhoria do ambiente educacional, especialmente do suporte social, nos programas de residência médica.

Abstract Introduction: The PHEEM (postgraduate hospital educational environment measure) is a validated and reliable instrument to assess the educational environment in medical residency programs. Objective: To map the application of the PHEEM questionnaire in medical residency, evaluate the results found, positive and negative aspects and points for improvement. Method: We performed a scoping review according to the Joanna Briggs institution's methodology. Studies that followed the PCC structure were included, as follows: P (participants) = resident physicians of any specialty; C (concept) = The PHEEM is an instrument used to assess the educational environment in medical residency, through a 40-item questionnaire divided into 3 subscales that include perception of autonomy, teaching and social support. C (context)= studies on PHEEM in medical residency of any specialty. PubMed, EMBASE and the Virtual Health Library databases were the data sources. Results: We identified 1588 references, and after reading the title and abstract, 50 references were selected for full reading, and 36 studies were included. The studies were carried out in 22 countries, and most revealed a more positive than negative educational environment, albeit with room for improvement. In the subscales, the perception of autonomy was more positive than negative, and the perception of teaching revealed that most programs are moving in the right direction. However, when evaluating social support, the results were divided between an unpleasant environment and an environment with more pros than cons. The main highlighted positive points were low racial and sexual discrimination, possibility of working in a team, adequate level of responsibilities, accessible teachers with good teaching skills, learning opportunities and participation in educational events. The main negative points were lack of adequate food and accommodation during the shifts, excessive workload, lack of feedback from preceptors and lack of protected time for study and the culture of blaming the resident. Conclusion: The application of PHEEM revealed that in most medical residency programs the educational environment was more positive than negative, albeit with room for improvement. Efforts are needed to improve the educational environment, especially social support, in medical residency programs.

Use of unlicensed and off-label drugs in neonates in a Brazilian university hospital

ABSTRACT This study was designed to investigate the use of off-label and unlicensed drugs in a Neonatal Care Unit (NCU) and to compare the frequency of use of off-label drugs according to the drug regulatory agencies in Brazil (Agência Nacional de Vigilância Sanitária-ANVISA) and the United States Food and Drug Administration (FDA). A prospective observational study was carried out in the NCU. Prescriptions were classified as off-label and unlicensed using both ANVISA and FDA criteria. A total of 157 newborns and 1187 prescriptions were analyzed. The most prescribed drug was fentanyl (9.3%), followed by multivitamin (8.4%) and gentamicin (7.9%). According to ANVISA criteria, there were 665 (56.0%) off-label prescriptions and 86 (7.2%) unlicensed prescriptions and 95.5% of newborns received at least one drug off-label. By contrast, according to FDA criteria, there were 592 (49.9%) off-label prescriptions and 84 (7.1%) unlicensed prescriptions, and 72.0% of newborns received at least one drug off-label. The off-label use of drugs registered by ANVISA differed significantly from that of drugs registered by the FDA. There was a high frequency of off-label and unlicensed drug use in the investigated NCU, and there was an inverse relationship between off-label and unlicensed usage and the gestational age of the newborns.

Anasarca congênita em cães da raça buldogue inglês: relato de caso / Congenital anasarca treatmen in english bulldog breed dogs: case report / Tratamiento de anasarca congenita en perros de la raza buldog inglés: relato de caso

O presente trabalho teve como objetivo relatar o tratamento efetivo de anasarca congênita em neonatos caninos, uma vez que há poucos relatos de sucesso no tratamento desta enfermidade. Uma fêmea canina da raça Buldogue Inglês de 2 anos e 9 meses de idade, gestante, chegou à clínica veterinária apresentando grande dificuldade respiratória e distocia. A cadela veio a óbito durante os primeiros procedimentos pré-operatórios para realização da cesariana, apesar das manobras de reanimação. Após a conclusão do procedimento cirúrgico, nasceram 4 filhotes normais, 4 filhotes com edema subcutâneo generalizado leve e 1 filhote com edema subcutâneo generalizado grave, o qual nasceu sem vida. Os filhotes que apresentaram edema generalizado leve foram tratados com dose única de 0,2mg/100g de peso de furosemida por via intramuscular (1M), 1 Miliequivalente (mEq) de cloreto de potássio, VO (via oral), a cada 30g de peso perdido e 1ml de soro subcutâneo obtido de cão adulto saudável. No terceiro dia após o nascimento os filhotes tiveram alta e foram adotados por duas cadelas de raças diferentes que apresentavam galactorreia. O tratamento realizado se mostrou efetivo, uma vez que resultou na sobrevivência de todos os filhotes que nasceram com edema subcutâneo generalizado leve.

The aim of the present study is to report an effective treatment of congenital anasarca in canine neonates, since there are few reports of success about treatment of this disease. A pregnant 2 years and 9 month old female English Bulldog breed arrived at veterinary clinic presenting great respiratory difficulty and dystocia. The bitch died during first preoperative procedures for cesarean section despite resuscitation maneuvers. After surgical procedure 4 normal puppies, 4 puppies with mild generalized subcutaneous edema and 1 puppy with severe generalized subcutaneous edema were born. This last one was born dead. Puppies that presented mild generalized edema were treated with a single dose of 0.2 mg/100g body weight of furosemide intramuscular (1M), 1 Miliequivalent (mEq) of potassium chloride per os every 30g of lost weight, and 1ml subcutaneous serum obtained from a healthy adult dog. On third day after birth the puppies were discharged and adopted by two dogs of different breeds that presented galactorrhea. The treatment was effective since it resulted in survival of ali puppies that were born with mild generalized subcutaneous edema.

El presente trabajo tiene como objetivo relatar el tratamiento efectivo de anasarca congênita den neonatos caninos, ya que son pocos los relatos sobre esta enfermedad con tratamiento efectivo. Una hembra canina de raza Bulldog Ingles de 2 anos y 9 meses de edad, gestante, llega a la clínica presentando disnea y distocia. Durante los primeros procedimientos pre-operatorios para realizar la cesaría, la hembra muere a pesar de las maniobras de reanimación. Terminado el procedimiento quirúrgico nacieron 4 cachorros normales, 4 con edema subcutáneo generalizado leve y uno con edema generalizado grave el cual nació sin vida. Los cachorros que presentaron edema generalizado leve fueron tratados con una dosis única de 0,2mg/1 OOgde peso de furosemida por vía intramuscular (1M), 1 Miliequivalente (mEq) de cloruro de potasio vía oral (VO) a cada 30g de peso perdido y 1 ml de suero subcutáneo obtenido de un perro adulto saludable. Al tercer día pos parto los cachorros fueron dados de alta y fueron adoptados por dos hembras de razas diferentes que presentaban galactorrea. El tratamiento realizado se mostró efectivo, una vez que resulto en la sobrevivencia de los 4 cachorros que presentaron edema subcutáneo generalizado leve.

Anasarca congênita em cães da raça buldogue inglês: relato de caso / Congenital anasarca treatmen in english bulldog breed dogs: case report / Tratamiento de anasarca congenita en perros de la raza buldog inglés: relato de caso

O presente trabalho teve como objetivo relatar o tratamento efetivo de anasarca congênita em neonatos caninos, uma vez que há poucos relatos de sucesso no tratamento desta enfermidade. Uma fêmea canina da raça Buldogue Inglês de 2 anos e 9 meses de idade, gestante, chegou à clínica veterinária apresentando grande dificuldade respiratória e distocia. A cadela veio a óbito durante os primeiros procedimentos pré-operatórios para realização da cesariana, apesar das manobras de reanimação. Após a conclusão do procedimento cirúrgico, nasceram 4 filhotes normais, 4 filhotes com edema subcutâneo generalizado leve e 1 filhote com edema subcutâneo generalizado grave, o qual nasceu sem vida. Os filhotes que apresentaram edema generalizado leve foram tratados com dose única de 0,2mg/100g de peso de furosemida por via intramuscular (1M), 1 Miliequivalente (mEq) de cloreto de potássio, VO (via oral), a cada 30g de peso perdido e 1ml de soro subcutâneo obtido de cão adulto saudável. No terceiro dia após o nascimento os filhotes tiveram alta e foram adotados por duas cadelas de raças diferentes que apresentavam galactorreia. O tratamento realizado se mostrou efetivo, uma vez que resultou na sobrevivência de todos os filhotes que nasceram com edema subcutâneo generalizado leve.(AU)

The aim of the present study is to report an effective treatment of congenital anasarca in canine neonates, since there are few reports of success about treatment of this disease. A pregnant 2 years and 9 month old female English Bulldog breed arrived at veterinary clinic presenting great respiratory difficulty and dystocia. The bitch died during first preoperative procedures for cesarean section despite resuscitation maneuvers. After surgical procedure 4 normal puppies, 4 puppies with mild generalized subcutaneous edema and 1 puppy with severe generalized subcutaneous edema were born. This last one was born dead. Puppies that presented mild generalized edema were treated with a single dose of 0.2 mg/100g body weight of furosemide intramuscular (1M), 1 Miliequivalent (mEq) of potassium chloride per os every 30g of lost weight, and 1ml subcutaneous serum obtained from a healthy adult dog. On third day after birth the puppies were discharged and adopted by two dogs of different breeds that presented galactorrhea. The treatment was effective since it resulted in survival of ali puppies that were born with mild generalized subcutaneous edema.(AU)

El presente trabajo tiene como objetivo relatar el tratamiento efectivo de anasarca congênita den neonatos caninos, ya que son pocos los relatos sobre esta enfermedad con tratamiento efectivo. Una hembra canina de raza Bulldog Ingles de 2 anos y 9 meses de edad, gestante, llega a la clínica presentando disnea y distocia. Durante los primeros procedimientos pre-operatorios para realizar la cesaría, la hembra muere a pesar de las maniobras de reanimación. Terminado el procedimiento quirúrgico nacieron 4 cachorros normales, 4 con edema subcutáneo generalizado leve y uno con edema generalizado grave el cual nació sin vida. Los cachorros que presentaron edema generalizado leve fueron tratados con una dosis única de 0,2mg/1 OOgde peso de furosemida por vía intramuscular (1M), 1 Miliequivalente (mEq) de cloruro de potasio vía oral (VO) a cada 30g de peso perdido y 1 ml de suero subcutáneo obtenido de un perro adulto saludable. Al tercer día pos parto los cachorros fueron dados de alta y fueron adoptados por dos hembras de razas diferentes que presentaban galactorrea. El tratamiento realizado se mostró efectivo, una vez que resulto en la sobrevivencia de los 4 cachorros que presentaron edema subcutáneo generalizado leve.(AU)

Classificação do nível da mobilidade fucional dos pacientes com paralisia cerebral da Reabilitação Pediátrica da Irmandade da Santa Casa de Misericórdia de São Paulo através do Sistema de Classificação da Função Motora Grossa (GMFCS) / Rating the level of functional mobility of patients with cerebral palsy in Pediatric Rehabilitation of the Irmandade da Santa Casa de Misericórdia de São Paulo through the Classification System of gross motor function (GMFCS)

A Paralisia Cerebral é uma desordem de movimento e postura devido a uma lesão do encéfalo em desenvolvimento. O Sistema de Classificação Motora grossa é baseado no movimento auto-iniciado, com ênfase no sentar e andar, contendo cinco níveis diferenciados pela limitação funcional e necessidade de assistência externa. O objetivo deste estudo foi avaliar o nível de mobilidade fucional das crianças com paralisia cerebral do Ambulatório de Reabilitação da Irmandade da Santa Casa da Misericórdia de São Paulo através da escala GMFCS. O resultado do estudo foi que a maioria das crianças avaliadas apresentou nível 1, observando resultados semelhantes na literatura.