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In critically ill patients, overweight and obesity are associated with acute respiratory distress syndrome and acute kidney injury (AKI). Although obesity is known to increase oxidative stress, worsen inflammation, and induce a state of Klotho deficiency, its effect on ischemia–reperfusion injury (IRI)-induced AKI is unknown. We hypothesized that obesity would aggravate renal IRI in mice. We fed mice a standard or high-fat diet for eight weeks. The mice were divided into four groups and submitted to sham surgery or IRI: obese, normal, normal + IRI, obese, and obese + IRI. All studies were performed 48 h after the procedures. Body weights were higher in the obese and obese + IRI groups than in the normal and normal + IRI groups, respectively. Serum glucose and cholesterol did not differ among the groups. Creatinine clearance also did not differ among the groups. Survival and urinary osmolality were lower in the obese + IRI group than in the normal + IRI group, whereas urinary neutrophil gelatinase-associated lipocalin levels, tubular injury scores, and caspase 3 expression were higher. In the obese + IRI group, the PCNA-positive cell counts were highest, as were the levels of oxidative stress (urinary levels of thiobarbituric acid-reactive substances and renal heme oxygenase-1 protein expression), and renal Klotho protein expression was lowest. Notably, macrophage infiltration was greater in the obese group mice than in the normal group mice, despite the fact that none of those mice were induced to AKI. In conclusion, greater oxidative stress might aggravate IRI in obese individuals, and Klotho could be a therapeutic target in those with AKI.

O artigo tem o objetivo de descrever o desenvolvimento de um indicador sintético de risco para avaliação da ocorrência dos acidentes de motocicleta em Pernambuco. Foi realizado um estudo ecológico de corte transversal, que utilizou dados dos anos de 2014 a 2016 dos sistemas de informações do Ministério da Saúde e da Secretaria Estadual de Saúde. Com base no conceito de risco, foram estudados os acidentes de motocicleta (AM), classificados entre V20 e V29 na Classificação Internacional de Doenças, 10ª revisão, nas regionais do estado, agrupados nos eixos Mortalidade, Morbidade e Motorização. O desenvolvimento do indicador seguiu as etapas de: identificação e seleção das variáveis; construção de indicadores simples; elaboração dos indicadores compostos e construção do índice. Foram identificadas 101 e selecionadas 12 variáveis a partir dos sistemas de informação, considerando os critérios de confiabilidade e relevância. Posteriormente, foram construídos 16 indicadores simples. Em seguida, foram elaborados os indicadores compostos segundo os eixos de avaliação e por fim, o indicador sintético que hierarquizou o risco para ocorrência dos acidentes em: muito baixo, baixo, médio, alto e muito alto risco. Três regiões foram classificadas em muito alto risco; quatro delas em alto risco e as demais regiões classificaram-se em médio risco. No contexto dos acidentes de motocicleta, os indicadores são essenciais ao seu monitoramento e avaliação. O indicador elaborado demonstrou-se importante ferramenta para o enfrentamento desse agravo e definição de prioridades.

Introduction: Due to its frequency and potential consequences, malnutrition is a worrisome condition in the hospital environment, especially in the case of adults admitted to intensive care units and others at high risk; malnutrition is associated with a higher risk of morbidity and mortality, prolonged hospital stay, higher frequency of readmissions, and increased costs. Although the absence of a planning for hospital discharge can aggravate these consequences, there are no guidelines for nutritional planning for hospital discharge that can be widely adopted in Brazil. Methods: A panel of experts was convened to assess the most relevant topics in the literature related to hospital discharge planning, discuss their experience in this regard, and propose an instrument that could guide and justify the importance of planned and safe nutrition discharge. Results: An organized and explicit discharge plan brings clinical and nutritional benefits to the patient, as well as advantages for family members and the health-care service. Nutritional care and better communication and guidance from the multiprofessional team prepare the patient and family members to reduce length of hospital stay and may avoid readmissions. Discharge planning requires the development of an individualized plan, as well as the education of the patient, family and caregivers; the nutritional care plan is inserted in the discharge plan. Based on these considerations, we propose an instrument that aims to systematize the nutritional discharge through the collection of the most relevant information related to the nutritional risk and the therapeutic approach to this risk, standardizing the communication with the patient, their caregivers, and the health-care team. Conclusions: The instrument presented here should be tested in clinical practice, and it is hoped that it can allow a better follow-up of the patient’s journey, leading to a more successful hospital discharge.

Objectives Using dynamic transmission models we evaluated the health and cost outcomes of adding acellular pertussis (aP) vaccination of pregnant women to infant vaccination in three Brazilian states that represent different socioeconomic conditions. The primary objective was to determine whether the same model structure could be used to represent pertussis disease dynamics in differing socioeconomic conditions. Methods We tested three model structures (SIR, SIRS, SIRSIs) to represent population-level transmission in three socio-demographically distinct Brazilian states: Sao Paulo, Parana and Bahia. Two strategies were evaluated: infant wP vaccination alone versus maternal aP immunization plus infant wP vaccination. Model projections for 2014–2029 include outpatient and inpatient pertussis cases, pertussis deaths, years of life lost, disability-adjusted life-years (DALYs) lost, and costs (in 2014 USD) of maternal aP vaccination, infant vaccination, and pertussis medical treatment. Incremental cost per DALY averted is presented from the perspective of the Brazilian National Health System. Results Based on goodness-of-fit statistics, the SIRSIs model fit best, although it had only a modest improvement in statistical quantitative assessments relative to the SIRS model. For all three Brazilian states, maternal aP immunization led to higher costs but also saved infant lives and averted DALYs. The 2014 USD cost/DALY averted was $3068 in Sao Paulo, $2962 in Parana, and $2022 in Bahia. These results were robust in sensitivity analyses with the incremental cost-effectiveness ratios exceeding per capita gross regional product only when the probability that a pertussis case is reported was assumed higher than base case implying more overt cases and deaths and therefore more medical costs. Conclusions The same model structure fit all three states best, supporting the idea that the disease behaves similarly across different socioeconomic conditions. We also found that immunization of pregnant women with aP is cost-effective in diverse Brazilian states.

This text, critically addresses, the issue of education management in order to apprehend elements of a formative planning process based on the relationship between the Secretariat's Action Plan and the Municipal Education Plan (PME) and Political Pedagogical Project instruments. In general, we can declare that the principles of democratic management and participation are basic elements in a planning process for these instruments and that, according to the consonance of subnational plans with the National Education Plan, they are also articulators of education in the municipality. The data analyzed make it possible to indicate that the Secretariat's Action Plan planning process is developed in a distinct and disputed manner, with the idea of a plan standing out as an end in itself and without articulation.

This article focuses on the management of municipal education in the system and educational networks of the state of Tocantins, regarding the guarantee of the right to education in the period of the Covid-19 pandemic. It aims to understand the challenges and dilemmas faced by the Secretaries of Education in municipalities of Tocantins in the pandemic period, more precisely about remote, hybrid education and the use of digital information and communication technologies (ICT) as a way to ensure the educational rights established by law. This is bibliographic-documentary research that deals with the management of education grounded in the regulations of the state and federal spheres and based on field research developed by the National Union of Municipal Education Directors (UNDIME). The study presents the results of the situational diagnosis of the municipalities at the start of the pandemic in 2020 and evidences: the difficulties of the Municipal Secretaries of Education, the implications of the non-face-to-face teaching, the plan to resume face-to-face classes for the 2020 and 2021 school years. Also, the panorama of the educational reality in the state of Tocantins lacks of major investments in technology and connectivity in the schools; better training for education professionals and improvements in the infrastructure of educational units in order to fulfill the right to education.

Highlights • Dynamic transmission models of infectious disease capture the herd immunity effects of vaccination. • We compared dynamic and static models of maternal acellular pertussis (aP) immunization built with Brazilian data. • At infant vaccine coverage 90–95%. • The background effect of routine infant vaccination is critical to the cost-effectiveness of maternal aP immunization., Background This paper compares cost-effectiveness results from two models of maternal immunization to prevent pertussis in infants in Brazil, one static, one dynamic, to explore when static models are adequate for public health decisions and when the extra effort required by dynamic models is worthwhile. Methods We defined two scenarios to explore key differences between static and dynamic models, herd immunity and time horizon. Scenario 1 evaluates the incremental cost/DALY of maternal acellular pertussis (aP) immunization as routine infant vaccination coverage ranges from low/moderate up to, and above, the threshold at which herd immunity begins to eliminate pertussis. Scenario 2 compares cost-effectiveness estimates over the models’ different time horizons. Maternal vaccine prices of $9.55/dose (base case) and $1/dose were evaluated. Results The dynamic model shows that maternal immunization could be cost-saving as well as life-saving at low levels of infant vaccination coverage. When infant coverage reaches the threshold range (90–95%), it is expensive: the dynamic model estimates that maternal immunization costs $2 million/DALY at infant coverage > 95% and maternal vaccine price of $9.55/dose; at $1/dose, cost/DALY is $200,000. By contrast, the static model estimates costs/DALY only modestly higher at high than at low infant coverage. When the models’ estimates over their different time horizons are compared at infant coverage

Background Pertussis is associated with significant disease burden in children worldwide. In addition to its cyclical nature, resurgences of pertussis cases, hospitalizations and deaths have been reported by many countries. We describe the dynamics of pertussis in Brazil, a middle-income country that has experienced a resurgence and that provides good quality data to allow building a dynamic transmission disease model. Methods We conducted a descriptive analysis of pertussis burden considering data from the national disease surveillance system, national hospitalization information system and national mortality registry. Study period was 2000–2016. Absolute numbers and rates per 100,000 inhabitants over time, by age sub-groups and geographical regions are presented. Results From 2000 to 2016, a total of 37,299 reported pertussis cases, 25,240 hospitalizations, and 601 deaths due to pertussis were reported. Although the outcomes – pertussis cases, hospitalizations, and deaths – come from independent information systems, our results document low disease burden with periodic increases every 3–4 years during the years 2000–2010, followed by a sharp increase which peaked in 2014. In both periods, disease burden is concentrated in young children, while its more serious outcomes – hospitalizations and deaths, are concentrated in infants. Pre-outbreak and outbreak disease burden as well as timing of peak during the outbreak period vary by states and within geographical regions, representing valuable resources of data for modelling purposes. Conclusion Consistent disease burden patterns were observed over time in Brazil using a variety of data sources. Given the scarcity of good epidemiological data on pertussis available from low- and middle-income countries, our reported data provide valuable information for the assessment of the public health impact and cost-effectiveness modelling studies of newer strategies to prevent and control pertussis. These data were used to build and calibrate a national dynamic transmission model, which was used to evaluate the cost-effectiveness of maternal immunization. Clinical Trial registry name and registration number: Not applicable.

En la presente investigación de campo tiene como propósito difundir los resultados más relevantes obtenidos, que se desarrolló con 22 niños del Nivel Inicial II, en la Unidad Educativa Manuel Agustín Cabrera Lozano de la Ciudad de Loja, Periodo 2015-2016. Los métodos que se utilizaron fueron: El Método científico, analítico -sintético, hermenéutico, estadístico. La técnica que se utilizó fue la observación, dirigida a las docentes del nivel inicial, donde no había variedad de técnicas grafo plásticas y los instrumentos fueron: Tabla de Habilidades de Christine Miles, aplicada a los niños para conocer el nivel de desarrollo de la creatividad. Se concluye que las maestras desconocen el análisis teórico que vinculan las actividades sobre las técnicas grafo plásticas, esto demuestra la falta de interés en la actualización educativa infantil

Patients undergoing coronary angiography after myocardial infarction (MI) often develop cardiac and renal dysfunction. We hypothesized that the apolipoprotein A-I mimetic peptide 4F (4F) would prevent those complications. Male Wistar rats were fed a high-cholesterol diet for 8 days. The rats were then anesthetized with isoflurane and randomly divided into five groups: a control group (sham-operated rats), and four groups of rats induced to MI by left coronary artery ligation, the rats in three of those groups being injected 6 h later, with the nonionic contrast agent iopamidol, 4F, and iopamidol plus 4F, respectively. At postprocedure hour 24, we performed the following experiments/tests ( n = 8 rats/group): metabolic cage studies; creatinine clearance studies; analysis of creatinine, urea, sodium, potassium, triglycerides, total cholesterol, very low-, low- and high-density lipoproteins (VLDL, LDL, and HDL); immunohistochemistry; histomorphometry; Western blot analysis; and transmission electron microscopy. In another set of experiments ( n = 8 rats/group), also performed at postprocedure hour 24, we measured mean arterial pressure, heart rate, heart rate variability, echocardiographic parameters, left ventricular systolic pressure, and left ventricular end-diastolic pressure. 4F protected against MI-induced increases in total cholesterol, triglycerides, and LDL; increased HDL levels; reversed autonomic and cardiac dysfunction; decreased the myocardial ischemic area; minimized renal and cardiac apoptosis; protected mitochondria; and strengthened endothelia possibly by minimizing Toll-like receptor 4 upregulation (thus restoring endothelial nitric oxide synthase protein expression) and by upregulating vascular endothelial growth factor protein expression. 4F-treated animals showed signs of cardiac neovascularization. The nitric oxide-dependent cardioprotection and renoprotection provided by 4F could have implications for post-MI treatment.

Hemorrhagic shock (HS), a major cause of trauma-related mortality, is mainly treated by crystalloid fluid administration, typically with lactated Ringer’s (LR). Despite beneficial hemodynamic effects, such as the restoration of mean arterial pressure (MAP), LR administration has major side effects, including organ damage due to edema. One strategy to avoid such effects is pre-hospitalization intravenous administration of the potent vasoconstrictor terlipressin, which can restore hemodynamic stability/homeostasis and has anti-inflammatory effects. Wistar rats were subjected to HS for 60 min, at a target MAP of 30–40 mmHg, thereafter being allocated to receive LR infusion at 3 times the volume of the blood withdrawn; at 2 times the volume, plus terlipressin (10 µg/100 g body weight); and at an equal volume, plus terlipressin (10 µg/100 g body weight). A control group comprised rats not subjected to HS and receiving no fluid resuscitation or treatment. At 15 min after fluid resuscitation/treatment, the blood previously withdrawn was reinfused. At 24 h after HS, MAP was higher among the terlipressin-treated animals. Terlipressin also improved post-HS survival and provided significant improvements in glomerular/tubular function (creatinine clearance), neutrophil gelatinase-associated lipocalin expression, fractional excretion of sodium, aquaporin 2 expression, tubular injury, macrophage infiltration, IL-6 levels, IL-18 levels, and NF-κB expression. In terlipressin-treated animals, there was also significantly higher ANG II type 1 receptor expression and normalization of AVP 1a receptor expression. Terlipressin could be a viable therapy for HS-induced acute kidney injury, likely attenuating such injury by modulating the inflammatory response via the AVP 1a receptor.

Background Coronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk. Methods This was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV + AKI and COV − AKI, respectively), who were submitted to CRRT. Filter clotting risks were compared among groups. Results Between January 2019 and July 2020, 238 patients were evaluated: 188 in the COV + AKI group and 50 in the COV − AKI group. Filter clotting during the first filter use occurred in 111 patients (46.6%). Heparin use conferred protection against filter clotting (HR = 0.37, 95% CI 0.25–0.55), resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV + AKI patients than among the COV − AKI patients, although it was similar between the COV + AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (5990 ng/ml). In the multivariate analysis, heparin was associated with a lower risk of filter clotting (HR = 0.28, 95% CI 0.18–0.43), whereas an elevated D-dimer level and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was marginally associated with an increased risk of circuit clotting (HR = 2.15, 95% CI 0.99–4.68). Conclusions In COV + AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with a low risk of complications.

Orientador: Li Li Min Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas Resumo: A prevalência de epilepsia ao redor do mundo é estimada em 10/1.000 pessoas; no entanto, o acesso ao tratamento é muito variável. Muitas pessoas não são tratadas, principalmente nos países com desenvolvimento não equilibrado entre as diversas áreas. No Brasil, os estudos epidemiológicos realizados até o momento não haviam abordado o assunto da lacuna de tratamento farmacológico, sendo que este nunca houvera sido medido e suas causas não haviam ainda sido estudadas. Este trabalho teve como objetivo: 1) definir a prevalência da epilepsia em duas áreas urbanas do sudeste do Brasil; 2) definir a lacuna de tratamento farmacológico em pessoas com epilepsia ativa identificadas nessas regiões e 3) extrapolar os dados epidemiológicos encontrados para o Brasil. Foi realizada uma estimativa da lacuna de tratamento da epilepsia, de forma indireta, que nos motivou a investigar melhor a epidemiologia da condição. Posteriormente, nós realizamos um levantamento epidemiológico, utilizando um questionário de rastreamento (sensibilidade 95,8%, especificidade 97,8%) e um questionário validado para classificação sócio-econômica, para determinar a prevalência e a lacuna de tratamento da epilepsia e a influência do fator sócio-econômico sobre elas, em duas áreas urbanas do sudeste do Brasil. De acordo com as estimativas da primeira fase do estudo, a lacuna de tratamento farmacológico da epilepsia em Campinas foi de 56% e em São José do Rio Preto, 59%. Na segunda fase do estudo, em uma população de 96.300 pessoas, encontramos a prevalência acumulada da epilepsia de 9,2/1.000 pessoas [CI 95% 8,4-10,0] e a prevalência de epilepsia ativa, de 5,4/1.000 pessoas [CI 95% 4,8-6,0]. A lacuna de tratamento farmacológico encontrada foi 37,6%. Pudemos identificar influência das diferenças entre os extratos sociais na prevalência da epilepsia, pois nos extratos mais privilegiados (A e B) houve menor prevalência do que nos menos favorecidos (C e D+E): 1,6 e 3,1/1.000 pessoas e 6,3 e 7,5/1.000 pessoas, respectivamente, como prevalência da epilepsia ativa. Não houve interferência dos extratos sociais sobre a lacuna de tratamento. A prevalência de epilepsia em nossa área de estudo é semelhante à de outros países e a lacuna de tratamento farmacológico é alta. A epilepsia é mais prevalente entre os menos ricos. O compromisso do sistema de saúde brasileiro com a melhora da qualidade de manejo de saúde das pessoas com epilepsia e a educação continuada sobre a condição são urgentemente necessários Abstract: The worldwide prevalence of epilepsy is estimated at 10/1,000; however, access to treatment is variable. Many people go untreated, particularly in resource-poor countries. In Brazil, the epidemiologic studies never have approached the pharmacological treatment gap of epilepsy. The objectives of this study are: 1) to determine the epilepsy prevalence in two urban areas in South-East of Brazil; 2) to determine the epilepsy pharmacological treatment gap in people with active epilepsy identified in those regions; and 3) extrapolate the epidemiological data to Brazil. The epilepsy treatment gap had been indirect estimated, and the results prompted us to further investigate this situation. Subsequently, we carried out an epidemiologic survey, using a validated screening questionnaire (sensitivity 95.8%, specificity 97.8%) and a validated instrument for socio-economic classification, to determine the epilepsy prevalence and treatment gap and the influence of socioeconomic factor in two urban areas in South-East of Brazil. According to estimative at the first step of the study, the epilepsy pharmacological treatment gap in Campinas was 56% and in São José do Rio Preto was 59%. At the second step of the study, a epidemiological survey in 96.300 people, we found the cumulative prevalence of 9.2/1,000 people [CI 95% 8.4-10.0] and the active epilepsy prevalence of 5.4/1,000 people [CI 95% 4.8-6.0]. The pharmacological treatment gap in the catchment area was 37.6%. We could identify the differences among social classes in epilepsy prevalence, as the wealthier ones (A and B) had smaller prevalence active prevalence than in poorer ones (C and D+E): 1.6 and 3.1/1,000 people for class A and B and 6.3 and 7.5/1,000 people for class C and D+E. There was not social class interference over treatment gap. Epilepsy prevalence in our studied area is similar to other countries, and the pharmacological treatment gap is high. Epilepsy is more prevalent among the less wealth people. Commitment of the Brazilian health system towards improvement of the quality of health management for people with epilepsy and the continue education about the condition are urgently needed. Doutorado Neurologia Doutor em Ciências Médicas

Sepsis is the leading cause of acute kidney injury (AKI) and lung injury worldwide. Despite therapeutic advances, sepsis continues to be associated with high mortality. Because Brazilian green propolis (GP) has promising anti-inflammatory, antioxidant, and immunomodulatory properties, we hypothesized that it would protect kidneys and lungs in rats induced to sepsis by cecal ligation and puncture (CLP). Male Wistar rats were divided into groups—control (sham-operated); CLP (CLP only); and CLP + GP (CLP and treatment with GP at 6 h thereafter)—all receiving volume expansion and antibiotic therapy at 6 h after the procedures. By 24 h after the procedures, treatment with GP improved survival, attenuated sepsis-induced AKI, and restored renal tubular function. Whole-blood levels of reduced glutathione were higher in the CLP + GP group. Sepsis upregulated the Toll-like receptor 4/nuclear factor-kappa B axis in lung and renal tissues, as well as increasing inflammatory cytokine levels and macrophage infiltration; all of those effects were attenuated by GP. Treatment with GP decreased the numbers of terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling-positive cells in renal and lung tissue, as well as protecting the morphology of the renal mitochondria. Our data open the prospect for clinical trials of the use of GP in sepsis.

Background: Coronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk.Methods: This was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV+ AKI and COV− AKI, respectively), submitted to CRRT. Filter clotting risks in the first 72 hours were compared between groups.Results: Between January 2019 and July 2020, 248 patients were evaluated: 189 in the COV+ AKI group and 59 in the COV− AKI group. Filter clotting occurred during the first 72 hours of CRRT in 96 patients (38.7%). Heparin use conferred protection against filter clotting, resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV+ AKI patients than among the COV− AKI patients, although it was similar between the COV+ AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (6086 ng/ml). In the multivariate analysis, the protective effect of heparin against filter clotting persisted, whereas an elevated D-dimer level, high platelet count, and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was not a risk factor for filter clotting.Conclusions: In COV+ AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with low risk of complications.

Cuestionamos cómo ha sido el desenlace de la nueva pandemia de coronavirus para la educación pública en el país y en Tocantins, con la educación como campo de lucha con sus actores imponiendo sus opciones políticas y culturales arbitrarias y sus legítimas categorías de percepción y valoración. En general, se busca discutir cómo esta situación ha influido en la educación pública, así como, a partir de ahí, reflexionar sobre las posibilidades abiertas para esta educación. Se basa en análisis bibliográficos, documentales e hipertextuales. La situación reaviva la discusión sobre la no prioridad de la educación por parte del Estado y revela que el vínculo con su destrucción es tenue y frágil. En una perspectiva crítica, la coyuntura presenta posibilidades, implicando la organización, articulación y movilización de una amplia lucha política en defensa de la educación pública en el país.

AUTHOR CONTRIBUTIONS Arantes MF was responsible for the editorial idea and conception, manuscript drafting and final approval of the version to be published.Rodrigues CE, Seabra VF, Seabra VF, Reichert BV, Sales GTM, Smolentzov I and Cabrera CPS were responsible for critical review of the manuscript, intellectual content, and final approval of the version to be published. Andrade L was responsible for mentoring, critical review, and final approval of the version to be published. […] Renal involvement in patients with COVID-19

Sepsis is a dysregulated hyperinflammatory disease caused by infection. Sepsis leads to multiple organ dysfunction syndrome (MODS), which is associated with high rates of mortality. The cecal ligation and puncture (CLP) model has been widely used in animals and has become the gold-standard method of replicating features of sepsis in humans. Despite several studies and modified CLP protocols, there are still open questions regarding the multifactorial determinants of its reproducibility and medical significance. In our protocol, which is also aimed at mimicking the sepsis observed in clinical practice, male Wistar rats are submitted to CLP with adequate fluid resuscitation (0.15 M NaCl, 25 ml/kg BW i.p.) immediately after surgery. At 6 h after CLP, additional fluid therapy (0.15 M NaCl, 25 ml/kg BW s.c.) and antibiotic therapy with imipenem-cilastatin (single dose of 14 mg/kg BW s.c.) are administered. The timing of the fluid and antibiotic therapy correspond to the initial care given when patients are admitted to the intensive care unit. This model of sepsis provides a useful platform for simulating human sepsis and could lay the groundwork for the development of new treatments.

The coronavirus disease 2019 (COVID-19) was first reported in December 2019 in Wuhan, China...

OBJECTIVES: The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia. METHODS: A total of 46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer’s, n=23) or restrictive (250 ml of lactated Ringer’s, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186. RESULTS: The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p

Introdução: A nutrição adequada pode reduzir as complicações, o tempo de internação hospitalar e melhorar os desfechos clínicos dos pacientes. Objetivo: Avaliar a adequação da prescrição proteica na terapia nutricional enteral para pacientes oncológicos e comparar a prescrição nutricional proteica com as recomendações específicas disponíveis para oncologia, segundo a literatura atual. Método: Trata-se de um estudo quantitativo retrospectivo. Os dados da pesquisa foram obtidos por meio do mapa de uso diário pela nutricionista. Resultados: 54% dos pacientes eram mulheres, 41% das mulheres tinham câncer de mama e 21% dos homens, câncer de pulmão. Pelo NRS 2002, o escore de risco nutricional 3 foi prevalente em adultos e idosos de ambos os sexos. Adultos eutróficos representaram 64% e idosos desnutridos, 50%. A exigência proteica média para adultos eutróficos foi de 1,5 g ptn/kg; para desnutridos, 2,1 g ptn/kg; para sobrepeso, 1,4 g ptn/kg; e para o obesos, 1,8 g ptn/kg. Para a desnutrição em idosos, a exigência proteica média foi de 1,4 g ptn/kg; para eutróficos, 1,5 g ptn/kg; e para obesos, 1,5 g ptn/kg. Nenhum resultado avaliado apresentou significância estatística. Conclusão: A malignidade da doença de base, a idade e a presença do risco nutricional sugerem maior necessidade de incrementar o quantitativo de aporte nutricional. Evidencia-se também a necessidade da utilização de módulos de proteína para adequar a prescrição nutricional principalmente aos pacientes obesos.

The 10-valent pneumococcal conjugate vaccine (PCV10) was introduced in the Brazilian National Immunization Program in March 2010, scheduled at 2, 4, and 6 months, with a booster at 12–15 months of age. The meningococcal C conjugate vaccine (MCC) was introduced in November 2010, scheduled at 3 and 5 months, with a booster dose at 12–15 months of age and no catch-up for older age groups. In this interrupted time-series analysis study, we used Brazilian mortality data from 2005 to 2015 for children under five years of age (excluding data from the state of Bahia) to assess the combined impact of these vaccines on the overall burden of meningitis mortality among children aged 0–23 months and 2–4 years, as defined using meningitis and meningococcemia specific International Classification of Diseases - tenth revision codes. Secular trends and seasonality were taken into account. We found significant reductions for both age groups relative to those observed for the comparison group of diseases, with immediate effects after the transition period (2010-2011) of 29.2% and 27.5% for children aged 0–23 months and 2–4 years, respectively. These immediate effects were sustained throughout the post-vaccination period (2012–2015). In total, 337 deaths were averted by the combined effect of both vaccines, 238 (95%CI 169-319) for children aged 0–23 months and 99 (95%CI 56–144) for those aged 2–4 years. These results add strong evidence in support of investments in these vaccines by low and middle-income countries.

Objetivo: descrever os cuidados de enfermagem e os fatores que influenciam a assistência segura ao paciente em sala de recuperação pós-anestésica. Método: estudo descritivo exploratório de abordagem qualitativa, realizado com 14 profissionais de enfermagem atuantes em sala de recuperação pós-anestésica de hospital privado do Paraná. A coleta de dados ocorreu em agosto de 2015 com aplicação de questionário semiestruturado. Os relatos foram submetidos à análise temática. Resultados: da análise emergiram duas categorias: cuidados de enfermagem ao paciente em recuperação pós-anestésica; e dificuldades encontradas e fatores de melhoria para o cuidado de enfermagem em sala de recuperação pós-anestésica. Entre os principais cuidados de enfermagem destacaram-se a monitorização clínica e hemodinâmica. Comunicação, recursos humanos e materiais são apontados como fatores limitantes ao cuidado seguro. Considerações finais: os profissionais percebem que são necessários cuidados rotineiros no contributo à segurança do paciente e identificam fatores de melhoria e promoção do cuidado.

Aim: to describe the nursing care and the factors that influence the safe care to the patient in a postanesthetic recovery room. Method: it is an exploratory, descriptive study with qualitative approach, carried out with 14 nursing professionals working in an postanesthetic recovery room of a private hospital in Paraná. The data collection occurred in August of 2015, with the application of a semi-structured questionnaire. The reports have been submitted to thematic analysis. Results: from the analysis, two categories have emerged: nursing care to the patient in postanesthetic recovery; and the difficulties found and improvement factors for nursing care in a postanesthetic recovery room. Among the main nursing care tools, clinical and hemodynamic monitoring were highlighted. Communication, human resources and materials have been pointed out as limiting factors to safe care. Final considerations: the professionals perceived that routine care is needed in order to contribute to the patient’s safety and they identified factors for improvement and promotion of care

Objective To determine and compare hospitalization costs of bacterial community-acquired pneumonia cases via different costing methods under the Brazilian Public Unified Health System perspective. Methods Cost-of-illness study based on primary data collected from a sample of 59 children aged between 28 days and 35 months and hospitalized due to bacterial pneumonia. Direct medical and non-medical costs were considered and three costing methods employed: micro-costing based on medical record review, micro-costing based on therapeutic guidelines and gross-costing based on the Brazilian Public Unified Health System reimbursement rates. Costs estimates obtained via different methods were compared using the Friedman test. Results Cost estimates of inpatient cases of severe pneumonia amounted to R$ 780,70/$Int. 858.7 (medical record review), R$ 641,90/$Int. 706.90 (therapeutic guidelines) and R$ 594,80/$Int. 654.28 (Brazilian Public Unified Health System reimbursement rates). Costs estimated via micro-costing (medical record review or therapeutic guidelines) did not differ significantly (p=0.405), while estimates based on reimbursement rates were significantly lower compared to estimates based on therapeutic guidelines (p

El presente artículo parte de una investigación que pretende describir y analizar la forma como se configura la violencia de pareja contra la mujer en los municipios de Vetas y California entre los años 2008 a 2015 desde el análisis estadístico y de discurso. En los municipios de Vetas y California se han venido generando una serie de conflictos socio-ambientales resultado del interés de explotación de los recursos minerales de la región. El proyecto desarrollado por la UIS plantea adentrarse en análisis de los conflictos sociales expresados a través de la violencia de pareja y de género contra la mujer y su relación con la explotación aurífera. Se encontró la existencia de tres factores que subyacen a la violencia de pareja contra la mujer en Vetas y California: Una fuerte división sexual del trabajo, la minería y un alto consumo de alcohol. Las autoridades deben crear políticas públicas en estos municipios que den cuenta de la afectación del conflicto socioambiental en Santurban a la mujeres de la zona y su garantía a vivir una vida libre de violencias.

Sepsis induces organ dysfunction due to overexpression of the inflammatory host response, resulting in cardiopulmonary and autonomic dysfunction, thus increasing the associated morbidity and mortality. Wharton’s jelly-derived mesenchymal stem cells (WJ-MSCs) express genes and secrete factors with anti-inflammatory properties, neurological and immunological protection, as well as improve survival in experimental sepsis. The cholinergic anti-inflammatory pathway (CAP) is mediated by α7-nicotinic acetylcholine receptors (α7nAChRs), which play an important role in the control of systemic inflammation. We hypothesized that WJ-MSCs attenuate sepsis-induced organ injury in the presence of an activated CAP pathway. To confirm our hypothesis, we evaluated the effects of WJ-MSCs as a treatment for cardiopulmonary injury and on neuroimmunomodulation. Male Wistar rats were randomly divided into four groups: control (sham-operated); cecal ligation and puncture (CLP) alone; CLP+WJ-MSCs (1 × 106 cells, at 6 h post-CLP); and CLP+methyllycaconitine (MLA)+WJ-MSCs (5 mg/kg body wt, at 5.5 h post-CLP, and 1 × 106 cells, at 6 h post-CLP, respectively). All experiments, including the assessment of echocardiographic parameters and heart rate variability, were performed 24 h after CLP. WJ-MSC treatment attenuated diastolic dysfunction and restored baroreflex sensitivity. WJ-MSCs also increased cardiac sympathetic and cardiovagal activity. WJ-MSCs reduced leukocyte infiltration and proinflammatory cytokines, effects that were abolished by administration of a selective α7nAChR antagonist (MLA). In addition, WJ-MSC treatment also diminished apoptosis in the lungs and spleen. In cardiac and splenic tissue, WJ-MSCs downregulated α7nAChR expression, as well as reduced the phospho-STAT3-to-total STAT3 ratio in the spleen. WJ-MSCs appear to protect against sepsis-induced organ injury by reducing systemic inflammation, at least in part, via a mechanism that is dependent on an activated CAP.

Highlights • (84) Low- and middle-income countries (LMICs) have experienced a resurgence of pertussis. • (74) Maternal aP immunization could prevent pertussis among very young infants. • (84) A dynamic transmission model was used to evaluate maternal aP immunization in LMICs. • (82) Maternal aP is cost-effective when infant vaccination coverage is moderate or low. • (85) Maternal aP immunization is not cost-effective in LMICs with infant coverage 90-95%., Objective This study evaluates the cost-effectiveness of maternal acellular pertussis (aP) immunization in low- and middle-income countries using a dynamic transmission model. Methods We developed a dynamic transmission model to simulate the impact of infant vaccination with whole-cell pertussis (wP) vaccine with and without maternal aP immunization. The model was calibrated to Brazilian surveillance data and then used to project health outcomes and costs under alternative strategies in Brazil, and, after adjusting model parameter values to reflect their conditions, in Nigeria and Bangladesh. The primary measure of cost-effectiveness is incremental cost (2014 USD) per disability-adjusted life-year (DALY). Results The dynamic model shows that maternal aP immunization would be cost-effective in Brazil, a middle-income country, under the base-case assumptions, but would be very expensive at infant vaccination coverage in and above the threshold range necessary to eliminate the disease (90–95%). At 2007 infant coverage (DTP1 90%, DTP3 61% at 1 year of age), maternal immunization would cost < $4,000 per DALY averted. At high infant coverage, such as Brazil in 1996 (DTP1 94%, DTP3 74% at 1 year), cost/DALY increases to $1.27 million. When the model’s time horizon was extended from 2030 to 2100, cost/DALY increased under both infant coverage levels, but more steeply with high coverage. The results were moderately sensitive to discount rate, maternal vaccine price, and maternal aP coverage and were robust using the 100 best-fitting parameter sets. Scenarios representing low-income countries showed that maternal aP immunization could be cost-saving in countries with low infant coverage, such as Nigeria, but very expensive in countries, such as Bangladesh, with high infant coverage. Conclusion A dynamic model, which captures the herd immunity benefits of pertussis vaccination, shows that, in low- and middle-income countries, maternal aP immunization is cost-effective when infant vaccination coverage is moderate, even cost-saving when it is low, but not cost-effective when coverage levels pass 90–95%.

Brazil introduced the 10-valent pneumococcal vaccine (PCV10) to the routine national immunization program (NIP) in March 2010. In 2017, we investigated the effects of PCV10 on nasopharyngeal carriage of vaccine-types (VT) and non-vaccine-types (NVT) of Streptococcus pneumoniae (Spn) among children living in São Paulo city. We also compared the prevalence of VT and NVT with previous carriage surveys performed in 2010 (baseline) and 2013.The carriage survey was conducted among 531 children, aged 12 months to24 months, recruited from public Primary Health Units during the immunization campaign, using previous surveys methodology, except for qPCR, which was performed in the 2017 survey only.No statistical difference was found in the prevalence of Spn either by culture (59.7%) or by qPCR (61.2%). Spn carriage increased from 40.3% (baseline) to 59.7% (2017 survey) (p 0.001). Colonization by VT isolates significantly decreased by 90.9% (19.8-1.8%) and 95.5% (19.8-0.9%) in the 2013 and 2017 surveys, respectively, compared to that at baseline. NVT isolates increased significantly by 128% (19.6-44.8%) and 185% (19.6-55.9%) in the respective post-PCV10 surveys, most led to high prevalence of serotypes 6C (27%), 15B (9.8%), 19A (9.2%), 15A (6.0%), and 16F (5.7%). In 2017, reduction in serotype 6A (4.2-0.6%, p 0.001) and increase in serotype 19A (1.8-6.0%, p = 0.001) were found; serotype 3 isolate was not detected in the present survey. We identified the emergence of 19A isolates CC320, associated with high penicillin (MIC ≥ 2.0 mg/L) and cefotaxime (MIC ≥ 1.0 mg/L) values.After 7 years of PCV10 introduction in the NIP, colonization by VT among toddlers decreased substantially to a residual level, along with substantial serotype replacement by novel serotypes not present in any current conjugated pneumococcal vaccine and serotype 19A. The present findings can assist policy decisions in Brazil.

Sepsis-induced organ failure is characterized by a massive inflammatory response and oxidative stress. Acute kidney injury (AKI) occurs in approximately half of patients in septic shock, and the mortality associated with sepsis-induced AKI is unacceptably high. Klotho is a protein expressed by renal cells and has anti-senescence properties. Klotho has also been shown to protect the kidneys in ischemia-reperfusion injury and to have antioxidant properties. To analyze the role of Klotho in sepsis-related organ dysfunction and AKI, we used a cecal ligation and puncture (CLP) model of sepsis in heterozygous Klotho-haploinsufficient mice and their wild-type littermates (CLP- Kl/+ and CLP-WT mice, respectively). In comparison with the CLP-WT mice, CLP- Kl/+ mice showed lower survival, impaired renal function, impaired hepatic function, greater oxidative stress, upregulation of inflammatory pathways (at the systemic and kidney tissue levels), and increased NF-κB activation. It is noteworthy that CLP- Kl/+ mice also showed lower heart-rate variability, less sympathetic activity, impaired baroreflex sensitivity to sodium nitroprusside, and a blunted blood pressure response to phenylephrine. We also demonstrated that sepsis creates a state of acute Klotho deficiency. Given that low Klotho expression exacerbates sepsis and multiple organ dysfunction, Klotho might play a protective role in sepsis, especially in elderly individuals in whom Klotho expression is naturally reduced.

We aimed to investigate the nasopharyngeal colonization (NPC) by Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus in the elderly population and to assess the demographic factors associated with NPC. This was an observational cohort study in which outpatients aged ≥60 years were enrolled from April to August 2017, with a follow-up visit from September through December 2017. Nasopharyngeal (NP) swabs were collected, bacteria were detected and isolated, and isolates were subjected to phenotypic and molecular characterization using standard microbiological techniques. At enrolment, the rates of S. aureus, methicillin-resistant S. aureus (MRSA), H. influenzae, and S. pneumoniae among 776 elderly outpatients were 15.9%, 2.3%, 2.5%, and 2.2%, respectively. Toxin production was detected in 21.1% of methicillin-susceptible S. aureus, and three SCCmec types were identified: II/IIb, IVa, and VI. At the follow-up visit, all carriage rates were similar (p > 0.05) to the rates at enrolment. Most of S. pneumoniae serotypes were not included in pneumococcal conjugate vaccines (PCVs), except for 7F, 3, and 19A. All strains of H. influenzae were non-typeable. Previous use of antibiotics and 23-valent pneumococcal polysaccharide vaccination (p < 0.05) were risk factors for S. aureus and MRSA carriage; S. aureus colonization was also associated with chronic kidney disease (p = 0.021). S. pneumoniae carriage was associated with male gender (p = 0.032) and an absence of diabetes (p = 0.034), while not receiving an influenza vaccine (p = 0.049) and chronic obstructive pulmonary disease (p = 0.031) were risk factors for H. influenzae colonization. The frailty of study participants was not associated with colonization status. We found a higher S. aureus carriage rate compared with the S. pneumoniae- and H. influenzae-carriage rates in a well-attended population in a geriatric outpatient clinic. This is one of the few studies conducted in Brazil that can support future colonization studies among elderly individuals.