Nutritive value of fermented soybean grains for ruminants.

Fermented soybean grain (FSBG) is considered improper to use as a protein source in animal nutrition, since it is assumed that defects cause changes on its chemical composition and favor mycotoxins production, but chemical composition data does not support this theory and in vivo studies are missing. Thus, this study aimed to evaluate the effects of FSBG in feedlot lamb diets. For that, two types of FSBG (partially fermented and completely fermented, PFSBG and CFSBG) and one standard soybean grain (SSBG) were obtained and evaluated alone or as a component of experimental diets by in vitro and in vivo studies, where FSBG totally replaced SSBG in feedlot lamb diets, which was included in the experimental diets in 17.4% on dry matter basis as protein source. Before the studies, both soybeans were sent to a specialized laboratory where no mycotoxins were detected. As a result, lower DM and carbohydrate contents but higher crude protein, fiber, and indigestible NDF contents were measured in CFSBG than in SSBG. Furthermore, both types of FSBG showed lower digestibility in vitro dry matter (IVDMD) than SSBG when evaluated separately; however, when evaluated in experimental diets, the substitution of SSBG for FSBG did not affect IVDMD. It was also observed that FSBG also had less rumen-degradable protein than SSBG (mean 47.9 vs 86.4%). In the in vivo study, FSBG did not affect nutrient intake, apparent digestibility, or animal performance (i.e., average daily gain and carcass gain). Thus, mycotoxins-free FSBG may be an alternative to totally replace SSBG in feedlot lamb diets.

Association of ionophores, yeast, and bacterial probiotics alters the abundance of ruminal microbial species of pasture intensively finished beef cattle.

The effect of the association of non-protein nitrogen, yeast, and bacterial probiotics on the ruminal microbiome of beef cattle intensively finished on pasture was evaluated. The experiment was carried out in a completely randomized design with five treatments and four replications. The treatments consisted of a group of animals kept on pasture that received low consumption supplementation (LS) and four groups that received for 98 days, 17.5 g concentrate kg-1 body weight. The supplements were composed of the association of additives: urea (U), slow-release non-protein nitrogen (U+SRN), yeast (Saccharomyces cerevisiae; U+SRN+Y), and bacterial probiotics (live strains of bacteria; U+SRN+Y+BP). All supplements also contained salinomycin and virginiamycin. After slaughtering the animals, samples of ruminal content were collected to quantify groups of fibrolytic bacteria (Ruminococcus albus and Fibrobacter succinogenes), non-fibrolytic (Prevotella ruminicola, Selenomonas ruminantium, and Streptococcus bovis), Archaea, and ciliate protozoa, using the qPCR technique. The abundance of F. succinogenes was the same for the LS animals and those that received the supplement U+SRN+Y (1.42×108 copies mL-1) but higher than the other treatments. Supplementation reduced by 90% the abundance of S. bovis compared to the LS. The inclusion of yeast increased the abundance of fibrolytic bacteria by 2.2-fold. For animals that received the supplement U+SRN+Y+BP and the LS, there was no difference for non-fibrolytic bacteria (3.07×109 copies mL-1). The use of yeasts and sources of non-protein nitrogen in high-concentrate diets for beef cattle stimulates the growth of fibrolytic bacteria, which can contribute to the reduction of digestive disorders and metabolic diseases in animals that receive diets with high concentrate in pasture intensive termination systems.

Improvement of thermal comfort indices in agroforestry systems in the southern Brazilian Amazon.

Agroforestry systems can minimize heat stress and improve cattle welfare, but the influence of the forest component in microclimatic changes in the southern Amazon remains unclear. This study aimed to compare the thermal comfort indices in grass monoculture and integrated systems. The three systems were pasture under full sunlight (PFS), integrated (triple-row) livestock-forestry (ILFT), and integrated (single-row) livestock-forestry (ILFs), across four seasons, for two years, from June 2017 to June 2019. We assessed photosynthetically active radiation (PAR), air temperature, relative humidity, black globe temperature, and wind speed. Thermal comfort indices such as temperature-humidity index (THI), black globe temperature-humidity index (BGHI), and radiant thermal load (RTL) were calculated based on microclimate data daily-collected from 8:00 to 16:00. The ILFT mean THI (76.8) was slightly lower than ILFS and PFS. The BGHI and RTL values decreased as shading increased (PFS > ILFs > ILFT). The most challenging heat stress conditions for grazing animals occurred predominately during winter and autumn. In conclusion, the presence of trees in pastures of the southern Amazon improved the microclimate and, consequently, the thermal comfort indices. Agroforestry systems can foster an environment with a more suitable thermal comfort or less restrictive to animal performance, which contribute to mitigating global climate change for forage-livestock systems in Brazilian Amazon.

Corn silage rehydrated with crude glycerin in lambs' diets.

We investigated whether the feed intake efficiency, digestibility, microbial efficiency, and nitrogen balance would be affected by inclusion of rehydrated corn grain silage with crude glycerin or water to substitute the dry corn in diets for feedlot lambs. Ten crossbred (Santa Ines × Dorper) uncastrated male lambs (25.6 ± 4.0 kg body weight) were assigned in a replicated 5 × 5 Latin square design and subjected to five experimental diets, one containing dry corn and four diets containing corn grain silage rehydrated with crude glycerin in levels of 0, 75, 150, and 225 in g/kg of natural matter. The moisture of 32.5% was maintained in all silages. The inclusion of crude glycerin represented 0, 40, 80, and 120 g/kg of total diet. The inclusion of rehydrated corn silage did not affect the DM, CP, EE, and ED intake. The diets with rehydrated corn silage improved the digestibility of DM, without affecting the fiber digestibility. The nitrogen losses were insignificant, resulting in the efficient use of dietary nutrients. In conclusion, corn silage rehydrated with 150 g/kg NM of crude glycerin is recommended as a feed to substitute dry corn diet, as it did not influence the nutrients intake, increased the dry matter digestibility with efficient use of the dietary nutrients, improving the animal performance in the feedlot.

Frequency, associated features, and burden of neurological disorders in older adult inpatients in Brazil: a retrospective cross-sectional study.

BACKGROUND: The burden of neurological disorders (NDs) in older adult inpatients is often underestimated. We studied diagnostic frequency and comorbidity of NDs among inpatients aged ≥60 years. We compared rates of hospital mortality, length of stay (LOS), and readmission with younger patient counterparts (aged 18-59 years) and older adult non-neurological patients. METHODS: This was a retrospective cross-sectional study of inpatients in a tertiary care center in Brazil. We compiled data for all patients admitted between 1 January 2009 and 31 December 2010, and selected those aged ≥18 years for inclusion in the study. We collected data for inpatients under care of a clinical neurologist who were discharged with primary diagnoses of NDs or underlying acute clinical disorders, and data for complications in clinical or surgical inpatients. Patients who remained hospitalized for more than 9 days were categorized as having long LOS. RESULTS: Older adult inpatients with NDs (n = 798) represented 56% of all neurological inpatients aged ≥18 years (n = 1430), and 14% of all geriatric inpatients (n = 5587). The mean age of older adult inpatients was 75 ± 9.1 years. Women represented 55% of participants. The most common NDs were cerebrovascular diseases (51%), although multimorbidity was observed. Hospital mortality rate was 18% (95% confidence interval [CI], 15-21) and readmission rate was 31% (95% CI, 28-35), with 40% of patients readmitted 1.8 ± 1.5 times. The long LOS rate was 51% and the median LOS was 9 days (interquartile interval, 1-20 days). In younger inpatients mortality rate was 1.4%, readmission rate was 34%, and long LOS rate was 14%. In older adult non-neurological inpatients, mortality rate was 22%, readmission rate was 49%, and long LOS rate was 30%. CONCLUSIONS: Older adult neurological inpatients had the highest long LOS rate of all patient groups, and a higher mortality rate than neurological patients aged 18-59 years. Readmissions were high in all groups studied, particularly among older adult non-neurological inpatients. Improved structures and concerted efforts are required in hospitals in Brazil to reduce burden of NDs in older adult patients.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology.

BACKGROUND: Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. OBJECTIVES: The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. METHODS: We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. RESULTS: We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). CONCLUSIONS: In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

ANTECEDENTES: Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. OBJETIVOS: O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. MéTODOS: Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. RESULTADOS: Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2­16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3­18) versus 3 (1­8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65­3,15). CONCLUSõES: Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Multimorbidity and associated outcomes among older adult inpatients with neurological disorders.

BACKGROUND: Multimorbidity is common among adults and associated with socioeconomic deprivation, polypharmacy, poor quality of life, functional impairment, and mortality. OBJECTIVES: To identify the frequency of multimorbidity among older adults inpatients with neurological disorders (NDs), stratify clusters of chronic comorbidities associated with NDs in degrees, and verify whether multimorbidity was associated with demographic data, readmission, long length of hospital stay (LOS), and hospital mortality in this population. METHODS: We enrolled patients aged ≥60 years successively admitted to a tertiary medical center with NDs between January 1, 2009, and December 31, 2010. RESULTS: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥60 years (mean: 75.76±9.12). Women comprised 435 (54.51%) of patients. Multimorbidity was detected in 92.61% (739) of patients, with a mean of 3.88±1.67 (median: 4.0), ranging from 2 to 10 chronic diseases. Patients with epilepsy, dementia, and movement disorders had the highest degrees of clusters of chronic morbidities (>50% of them with ≥5 chronic disorders), followed by those with cerebrovascular and neuromuscular disorders. Multimorbidity was associated with long LOS (p<0.001) and readmission (p=0.039), but not with hospital mortality (p=0.999). CONCLUSIONS: Multimorbidity was preponderant among older adults inpatients with NDs, and NDs had a high degree of associated chronic comorbidities. Multimorbidity, but not isolated NDs, was associated with readmission and long LOS. These results support ward-based, neurohospitalist-directed, interdisciplinary care for older adults inpatients with NDs to face multimorbidity.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study.

OBJECTIVE: Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures. METHODS: We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors. RESULTS: The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014). CONCLUSION: Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation.

OBJECTIVE: Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). METHODS: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. RESULTS: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%-55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. CONCLUSIONS: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.

Hospital Mortality Among Elderly Patients Admitted With Neurological Disorders Was Not Predicted by any Particular Diagnosis in a Tertiary Medical Center.

BACKGROUND: Neurological disorders (NDs) are associated with high hospital mortality. We aimed to identify predictors of hospital mortality among elderly inpatients with NDs. METHODS: Patients aged ≥60 years admitted to the hospital between January 1, 2009 and December 31, 2010 with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic data, NDs, and comorbidities as independent predictors of hospital mortality. Logistic regression was performed for multivariable analysis. RESULTS: Overall, 1540 NDs and 2679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8±9.1). Of these, 54.5% were female. Diagnostic frequency of NDs ranged between 0.3% and 50.8%. Diagnostic frequency of comorbidities ranged from 5.6% to 84.5%. Comorbidities varied from 0 to 9 per patient (90% of patients had ≥2 comorbidities), mean 3.2±1.47(CI, 3.1-3.3). Patients with multimorbidities presented with a mean of 4.7±1.7 morbidities per patient. Each ND and comorbidity were associated with high hospital mortality, producing narrow ranges between the lowest and highest incidences of death (hospital mortality = 18%) (95% CI, 15%-21%). After multivariable analysis, advanced age (P<0.001) and low socioeconomic status (P=0.003) were recognized as predictors of mortality, totaling 9% of the variables associated with hospital mortality. CONCLUSION: Neither a particular ND nor an individual comorbidity predicted hospital mortality. Age and low socioeconomic class accounted for 9% of predictors. We suggest evaluating whether functional, cognitive, or comorbidity scores will improve the risk model of hospital mortality in elderly patients admitted with ND.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology / Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida

Abstract Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. Objective The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. Objetivo O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2-16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3-18) versus 3 (1-8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65-3,15). Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Multimorbidity and associated outcomes among older adult inpatients with neurological disorders / Multimorbidade e desfechos associados entre idosos hospitalizados com doenças neurológicas

ABSTRACT Background: Multimorbidity is common among adults and associated with socioeconomic deprivation, polypharmacy, poor quality of life, functional impairment, and mortality. Objectives: To identify the frequency of multimorbidity among older adults inpatients with neurological disorders (NDs), stratify clusters of chronic comorbidities associated with NDs in degrees, and verify whether multimorbidity was associated with demographic data, readmission, long length of hospital stay (LOS), and hospital mortality in this population. Methods: We enrolled patients aged ≥60 years successively admitted to a tertiary medical center with NDs between January 1, 2009, and December 31, 2010. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥60 years (mean: 75.76±9.12). Women comprised 435 (54.51%) of patients. Multimorbidity was detected in 92.61% (739) of patients, with a mean of 3.88±1.67 (median: 4.0), ranging from 2 to 10 chronic diseases. Patients with epilepsy, dementia, and movement disorders had the highest degrees of clusters of chronic morbidities (>50% of them with ≥5 chronic disorders), followed by those with cerebrovascular and neuromuscular disorders. Multimorbidity was associated with long LOS (p<0.001) and readmission (p=0.039), but not with hospital mortality (p=0.999). Conclusions: Multimorbidity was preponderant among older adults inpatients with NDs, and NDs had a high degree of associated chronic comorbidities. Multimorbidity, but not isolated NDs, was associated with readmission and long LOS. These results support ward-based, neurohospitalist-directed, interdisciplinary care for older adults inpatients with NDs to face multimorbidity.

RESUMO Introdução: A multimorbidade é comum entre idosos e está associada a privação socioeconômica, polifarmácia, má qualidade de vida, déficit funcional e mortalidade. Objetivos: Identificar a frequência da multimorbidade entre pacientes idosos hospitalizados com doenças neurológicas (DN), estratificar combinações de comorbidades crônicas associadas às DN em graus e verificar se a multimorbidade foi associada a dados demográficos, readmissão, longo tempo de internação (TDI) e mortalidade hospitalar nessa população. Métodos: Foram incluídos pacientes com ≥60 anos sucessivamente admitidos com DN em um centro médico terciário entre 1º de janeiro de 2009 e 31 de dezembro de 2010. Resultados: Um total de 1.154 DN e 2.679 comorbidades foram identificados entre 798 pacientes com idade ≥60 anos (média: 75,76±9,12). Mulheres representaram 435 (54,51%) dos pacientes. A multimorbidade foi detectada em 92,61% (739) dos pacientes (média de 3,88±1,67; mediana de 4), variando de 2 a 10 doenças crônicas. Pacientes com epilepsia, demência e distúrbios do movimento apresentaram os maiores graus de morbidades crônicas (>50% deles com ≥5 doenças crônicas), seguidos por doenças cerebrovasculares e neuromusculares. A multimorbidade foi associada com longo TDI (p<0,001) e readmissão (p=0,039), mas não com mortalidade hospitalar (p=0,999). Conclusões: A multimorbidade foi preponderante entre os pacientes idosos internados com DN, as quais tiveram altos graus de comorbidades crônicas. A multimorbidade, mas não as DN isoladas, foi associada a readmissões e longo TDI. Esses resultados respaldam uma assistência interdisciplinar para idosos hospitalizados com DN em enfermarias lideradas por neurologistas hospitalistas para enfrentar a multimorbidade.

The existence and evolution of diffusion-perfusion mismatched tissue in white and gray matter after acute stroke.

BACKGROUND AND PURPOSE: Although white matter is a potential target of acute stroke therapy, there is uncertainty about its relative resistance to ischemia and whether it is capable of mounting a penumbral response. To explore these issues further, we examined the differential effects of ischemia on gray and white matter using magnetic resonance (MR) perfusion-diffusion mismatch after acute stroke. METHODS: MR imaging studies were performed within 12 hours in patients with initial hemispheric ischemic stroke. "At-risk" tissue was defined as tissue with abnormal diffusion-weighted imaging/perfusion-weight imaging or infarction on follow-up image. Tissue was segmented using a probabilistic atlas generated from age-matched controls. The proportions of "at-risk" tissue, which was penumbral at the time of imaging, were compared between gray and white matter. RESULTS: Thirty-two patients had diffusion-perfusion mismatched penumbral tissue present in both gray and white matter compartments. Although the absolute mismatch volumes were greater in gray (median 42 cm3, interquartile range 18 to 70 cm3) than in white matter (39 cm3, 17 to 49 cm3; P<0.001), the proportion of "at-risk" tissue, which was penumbral at the time of imaging (median 3.7 hours, range 1.5 to 9.9 hours) was greater in white (69%, 49% to 86%) than gray matter (62%, 52% to 75%; P=0.026). However, the proportions spontaneously salvaged by 3 months were similar in both compartments. CONCLUSIONS: These findings are consistent with white matter being able to mount an ischemic penumbral response in humans and being more resistant to cerebral ischemia than gray matter. They also raise the possibility that the therapeutic window is longer for white matter and may require alternative therapeutic strategies.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study / Preditores de longo tempo de internação hospitalar entre idosos admitidos com crises epilépticas em um centro terciário: um estudo prospectivo

ABSTRACT Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. Objective: To identify predictors of long LOS among elderly inpatients admitted with seizures. Methods: We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors. Results: The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014). Conclusion: Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

RESUMO O envelhecimento populacional é um fenômeno global e o crescimento da expectativa de vida no Brasil tem sido rápido. A epilepsia é a terceira doença neurológica crônica mais importante e sua incidência em idosos é maior do que em qualquer outro segmento populacional. A prevalência de epilepsia é maior entre pacientes internados e está relacionada a longo tempo de internação (TDI), o qual está associado a custos elevados e mortalidade hospitalar. Apesar disso, são escassos os relatos de desfechos de pacientes idosos internados com crises epilépticas e resultados associados. Objetivo: Identificar fatores de risco de longo TDI em idosos admitidos com crises epilépticas. Métodos: Recrutamos prospectivamente pacientes idosos admitidos com crises epilépticas ou que tiveram crises durante a internação hospitalar entre novembro de 2015 e agosto de 2019. Analisamos dados demográficos, distúrbios neurológicos, comorbidades clínicas e tipos de crise epiléptica para identificar fatores de risco. Resultados: A mediana do TDI foi 11 dias, com intervalo interquartil (IIQ) de 5-21 dias. A frequência de longo TDI (definido como TDI≥12 dias) foi 47%. A análise multivariada mostrou que houve um aumento exponencial de TDI quando o paciente apresentou algumas dessas condições: admissão em unidade de terapia intensiva (UTI) (OR=4,562), infecção urinária (OR=3,402), transtorno do movimento (OR=4,562), recorrência precoce de crise epiléptica (OR=2,090) e sepse (OR=4,014). Conclusão: Longo TDI é um desfecho desfavorável importante e foi comum entre idosos admitidos com crises epilépticas. Muitos dos preditores de longo TDI encontrados nessa coorte podem ser evitados, o que deve ser confirmado com pesquisas futuras.

[Pharmacologically-induced hypertension in a patient with vertebro-basilar territory ischemia associated with bilateral vertebral stenosis]. / Hipertensão induzida farmacologicamente em paciente com isquemia em território vértebro-basilar associada com estenose vertebral bilateral.

Hypertension is one of the main risk factors for stroke. However, treating hypertension in the acute phase may cause further neurological deterioration. We present a case of an 81-year-old woman, admitted after multiple infarcts in the posterior circulation. While fully anticoagulated, her neurological deficits worsened, coinciding with normalization of her blood pressure levels. Magnetic resonance angiography documented bilateral vertebral artery stenoses. Induced hypertension was followed by rapid clinical improvement. In this first report of induced hypertension in the Brazilian literature, we illustrate the potential benefit of this therapeutic strategy in patients with documented hemodynamic mechanism of clinical deterioration.

Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation / Preditores de readmissão hospitalar e de longo tempo de internação em idosos admitidos com doenças neurológicas em centro terciário: uma investigação no mundo real

ABSTRACT Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. Objective: This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). Methods: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%-55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. Conclusions: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.

RESUMO Readmissão hospitalar e tempo longo de internação aumentam a morbidade, a mortalidade hospitalar e estão associados a custos excessivos para os sistemas de saúde. Objetivo: Este estudo almejou identificar preditores de readmissões hospitalares e longo tempo de internação (TDI) entre idosos com doenças neurológicas (DN). Métodos: Pacientes de idade ≥ 60 anos admitidos no hospital entre 1 de janeiro de 2009 e 31 de dezembro de 2010 com DN aguda, DN crônica subjacente a transtorno clínico agudo e complicações neurológicas de outras doenças foram estudados. Nos analisamos fatores demográficos, DN e comorbidades como preditores independentes de readmissão hospitalar e TDI (≥ 9 dias). Utilizamos regressão logística para analise multivariada. Resultados: Um total de 1154 DN e 2679 comorbidades foram identificadas entre 798 pacientes com idade ≥ 60 anos (media 75.8 ± 9.1). Desses pacientes 54.5% foram mulheres. Foram 251(31%) readmissões de pacientes e 409 (51%) dos pacientes tiveram um TDI≥9 dias (intervalo de confiança 95%, 48%-55%). Não encontramos preditores para readmissões. Baixa classe social (p = 0,001), distúrbio respiratório (p < 0,001), infecção (p < 0,001), distúrbio genito-urinário (p = 0,033) e hipertensão arterial (p = 0,002) foram os preditores de longo tempo de internação. Esses fatores de risco compõem 22% dos preditores para longo TDI. Conclusões: A identificação de fatores de risco para readmissão hospitalar é um desafio para equipes neurológicas e gestores dos sistemas de saúde. Conquanto baixa classe social e 4 comorbidades, todavia nenhuma DN, foram identificadas como preditoras para longo TDI nós recomendamos investigar multimorbidade, escores funcionais e cognitivos para saber se eles melhoram o modelo de risco para longo TDI nesta população.

Improved grazing activity of dairy heifers in shaded tropical grasslands / Novilhas leiteiras melhoram sua atividade de pastejo em pastagens tropicais sombreadas

ABSTRACT: Trees in the production systems can effectively reduce hot weather-induced stress in the Brazilian Midwest. High temperatures cause changes in animals daily routine, and trees into pastures can promote benefits. The aim of this research was to evaluate the behavior of dairy heifers in silvopastoral systems in the state of Mato Grosso, Brazil. A herd of 24 crossbreed heifers (3/4 and 7/8 Holstein/Zebu), 350kg average weight, was evaluated over three seasons. Piatã grass was managed under three shade levels: full-sun, moderate-shade, and intensive-shade provided by 10 to 12m high Eucalyptus trees. Behavior data were collected every 15 minutes from 8:30h to 16h. Shade availability significantly impacted heifer behavior, mainly affecting grazing frequency and time during the hottest hours. Grazing behavior was affected by shade levels during the different seasons. Heifers showed preferred grazing times. Heifers in the intensive-shade system visited shady areas during the hottest hours throughout the seasons. Heifers in the full sun-system avoided grazing during the warmer times, ceasing feeding activities. Our results from the Brazilian Midwest showed that shade availability causes breed heifers to change their daily routine.

RESUMO: A presença de árvores em sistemas de produção animal pode reduzir o estresse provocado pelo calor no centro-oeste brasileiro. As altas temperaturas induzem a uma mudança na rotina dos animais e, as árvores dentro da pastagem podem promover benefícios. O objetivo desta pesquisa foi avaliar o comportamento de novilhas leiteiras em sistemas integrados no Mato Grosso, Brasil. Um grupo de 24 novilhas cruzadas (3/4 e 5/8 Holandês: Gir) de 350kg foi avaliado em três estações do ano. O capim piatã foi manejado sob três níveis de sombreamento: pleno sol e sombreamentos moderado e intenso promovidos por eucaliptos com 12m de altura. O comportamento das novilhas foi medido a cada 15 minutos entre 8h30min às 16h. A disponibilidade de sombra modificou o padrão de comportamento das novilhas, afetando a frequência e o tempo de pastejo nas horas mais quentes do dia. O comportamento de pastejo foi afetado pelos níveis de sombra e, variou nas diferentes estações do ano. As novilhas em sistemas com sombreamento intenso procuraram pela sombra nas horas mais quentes do dia durante as três estações do ano avaliadas. Já, as novilhas nas condições de pastagem a pleno sol, não pastejaram durante as horas mais quentes do dia, pois interrompiam suas atividades e permaneciam inativas durante grande período do dia. A disponibilidade de sombra induz novilhas cruzadas a mudarem sua rotina diária nas condições do Centro-Oeste brasileiro.

Aveia preta e azevém anual colhidos por interceptação de luz ou intervalo fixo de tempo em sistemas integrados de agricultura e pecuária no Estado de São Paulo / Black oats and annual ryegrass harvested by light interception or fixed rest interval in integrated crop-livestock systems in São Paulo State, Brazil

Objetivou-se caracterizar o potencial produtivo, a distribuição mensal, a composição morfológica e botânica da forragem de aveia preta e de azevém anual submetidos a estratégias de manejo de corte no estado de São Paulo. O delineamento experimental foi inteiramente casualizado, com tratamentos correspondendo a combinações entre formas de cultivo (aveia e azevém exclusivos ou combinados) e estratégias de colheita (cortes com 95% de interceptação de luz (IL) ou intervalo FIXO de 30 dias de rebrotação), em arranjo fatorial com três repetições. Os estandes colhidos por IL acumularam 1580kg MS ha-1 corte-1, e os por FIXO 2020kg de MS ha-1 corte-1. A proporção de folhas foi maior no azevém (70%), seguido do cultivo combinado (64%) e depois pela aveia (52%). Entre os manejos, a IL resultou em maiores proporções de folha e menor proporção de colmos que o FIXO. A proporção de azevém foi de 64%, sob o manejo por IL, e 70% no manejo por descanso FIXO. Ao longo do tempo, ocorreu a substituição da aveia pelo azevém na composição do dossel combinado. Ambas as estratégias de manejo podem ser adotadas para essas forrageiras de inverno em sistemas de integração agricultura e pecuária, com vantagem para o azevém.

The objective in this study was to characterize the productive potential, monthly yield distribution, and forage plant-part and botanical composition of black oats and annual ryegrass under harvest strategies in São Paulo. The experimental design was completely randomized with treatments corresponding to the combination among stand composition (exclusive oats, exclusive annual ryegrass, or oats + ryegrass, O+R) and harvest strategies (at 95% LI or every 30 days of regrowth, FIXED), in a factorial arrangement with three replications. Stands managed by LI accumulated 1580kg DM ha-1 harvest-1, and those managed by FIXED 2020kg DM ha-1 harvest-1. Leaf proportion was higher in ryegrass (70%), followed by O+R (64%) and oat (52%). Swards managed by LI had higher proportion of leaves and less stem than those harvested at FIXED intervals. The proportion of ryegrass was higher under the LI management (64%), than under the FIXED (70%). Over time there was the replacement of oats by ryegrass in the mixed canopy composition. Exclusive ryegrass stands are recommended. Both harvest strategies can be adopted for these winter forages in integrated systems of agriculture and livestock.

[Brazilian guidelines for the manegement of intracerebral hemorrhage]. / Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea.

Among the stroke subtypes, intracerebral hemorrhage (ICH) has the worst prognosis and still lacks a specific treatment. The present manuscript contains the Brazilian guidelines for the management of ICH. It was elaborated by the executive committee of the Brazilian Cerebrovascular Diseases Society and was based on a broad review of articles about the theme. The text aims to provide a rational for the management of patients with an acute ICH, with the diagnostic and therapeutic resources that are available in Brazil.