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OBJECTIVES Atrial cardiopathy (AC) is more frequent in patients with embolic stroke of undetermined source (ESUS) than in patients with non-cardioembolic stroke. The aim of this work was to describe AC in patients with ESUS and to study its impact on detection of atrial fibrillation (AF) during follow-up. METHODS This is an observational study of 123 consecutive ESUS patients and 55 ESUS patients from a previous cohort. AC was defined according to the presence of one or more of the following criteria: severe left atrial enlargement, p-wave terminal force in lead V1 > 5000 μVxms, and excessive premature atrial complexes. Unadjusted and adjusted survival analyses for the occurrence of AF and stroke or transient ischemic attack (TIA) were performed. Diagnostic performance of AC for the detection of AF was analyzed. RESULTS Among 178 patients with ESUS, those with AC (42.7%) were older (p

Background Populational ageing has been increasing in a remarkable rate in developing countries. In this scenario, preventive strategies could help to decrease the burden of higher demands for healthcare services. Machine learning algorithms have been increasingly applied for identifying priority candidates for preventive actions, presenting a better predictive performance than traditional parsimonious models. Methods Data were collected from the Health, Well Being and Aging (SABE) Study, a representative sample of older residents of São Paulo, Brazil. Machine learning algorithms were applied to predict death by diseases of respiratory system (DRS), diseases of circulatory system (DCS), neoplasms and other specific causes within 5 years, using socioeconomic, demographic and health features. The algorithms were trained in a random sample of 70% of subjects, and then tested in the other 30% unseen data. Results The outcome with highest predictive performance was death by DRS (AUC−ROC = 0.89), followed by the other specific causes (AUC−ROC = 0.87), DCS (AUC−ROC = 0.67) and neoplasms (AUC−ROC = 0.52). Among only the 25% of individuals with the highest predicted risk of mortality from DRS were included 100% of the actual cases. The machine learning algorithms with the highest predictive performance were light gradient boosted machine and extreme gradient boosting. Conclusion The algorithms had a high predictive performance for DRS, but lower for DCS and neoplasms. Mortality prediction with machine learning can improve clinical decisions especially regarding targeted preventive measures for older individuals.

Purpose: To evaluate the success rates of transcanalicular diode laser-assisted dacryocystorhinostomy (TCL-DCR) during 3 years of follow-up and to find clinical factors that influence surgical outcomes.Methods: Major outcomes were the anatomical success defined as a patent neo-ostium tested by irrigation and the functional success defined as a patent osteotomy with the absence of epiphora, accessed at 6-month, 1, 2, and 3-year follow-up visits. To determine which factors influence success rates, patients were divided according to gender, age, previous lacrimal surgeries, nasosinusal anatomy, energy employed, treatment with topical prostaglandin analogs, and timing of extubation.Results: A total of 134 eyes were included. 55.2% of patients underwent peribulbar block. The surgical mean duration was 30.6 min. We obtained anatomical and functional success rates of 80.0% and 70.8% at 6 months; 69.3% and 61.4% at 1 year; 64.2% and 58.0% at 2 years; 56.4% and 46.2% at 3 years, respectively. Functional success was significantly higher in younger patients (p = .008). Bicanalicular intubation for 2 months improved anatomical and functional success rates (p = .028 and p = .001, respectively). No other factors showed a significant impact. 85.8% of patients didn´t experience any complications. Palpebral swelling was the most frequent complication.Conclusion: TCL-DCR is a minimally invasive, repeatable, and safe alternative to treat nasolacrimal duct obstructions. We found success rates comparable to literature and stated that younger patients and those intubated for 2 months show better results.

Cerebrovascular diseases / Extra 11(1), 15-21 (2021). doi:10.1159/000513503, Published by Karger, Basel

Background Red cell distribution width (RDW) has been associated with mortality and outcome in a wide variety of non-neurological and neurological diseases, namely in myocardial infarction and acute ischemic stroke, and the reason for this is not completely understood. We aimed to investigate RDW as a potential prognostic marker in patients with intracerebral hemorrhage (ICH). Methods This is a retrospective study of consecutive patients with acute non-traumatic ICH admitted to a single center during a 4-year period. We reviewed individual clinical records to collect demographic and baseline information, including RDW at admission, 3-month functional status, and incidence of death during follow-up. Baseline computed tomography imaging was reviewed to classify the location of ICH, and to measure ICH volume and perihematomal edema volume. Patients were divided according to quartile distribution of RDW (RDW-Q1-4). Results The final study population consisted of 358 patients, median age 71 years (interquartile range [IQR] 60–80), 55% were male, and median Glasgow Coma Scale was 14 (IQR 10–15), with a mean follow-up of 17.6 months. Patients with higher RDW values were older (p = 0.003), more frequently presented with an active malignancy (p = 0.005), atrial fibrillation (p p = 0.048), and were anticoagulated (p p = 0.004), but not independently associated with increased mortality after 30 days (adjusted hazards ratio = 0.71, 95%CI = 0.29–1.73, p = 0.448). Conclusions RDW is a robust and independent predictor of 30-day mortality in non-traumatic ICH patients, and further studies to understand this association are warranted.

To systematically review the evidence on the association between age at natural menopause (NM) and reproductive factors such as age at menarche, parity and ever use of oral contraceptives.A literature search was carried out in PubMed, Scielo, Scopus and LILACS databases, without restriction of publication year until July 6, 2017. We excluded clinical trials, case-control studies, case reports and studies using statistical methods other than Cox proportional hazard models to assess the factors associated with age at NM. Cross-sectional studies evaluating women aged50 years were also excluded. Random-effects models were used to pool the estimates. We registered the systematic review in the International Prospective Register of Systematic Review (PROSPERO) in August 2018, CRD42018099105.We identified 30 articles to include in the meta-analysis. We found that previous ever use of oral contraceptives (OC) (HR = 0.87, CI = 0.82, 0.93), age at menarche ≥13 years (HR = 0.90, CI = 0.84, 0.96), and having at least one live birth (HR = 0.79, CI = 0.74, 0.85) were associated with a later age of NM.Despite differences in results between countries and study design, our findings suggest that previous use of OC, age at menarche ≥13 and having at least one live birth are associated with later menopause. The results suggest that these factors could be markers of later ovarian aging.

Acta médica portuguesa 35(2), 127-134 (2022). doi:10.20344/amp.15031, Published by Ordem dos Médicos, Lisboa

While distractions and interruptions are leading causes of errors during medication preparation, most nursing students are not taught how to manage distractions in a highly-interruptive environment. To help prepare nursing students to manage distractions and interruptions in clinical practice, we developed, implemented, and evaluated a medication preparation distraction and interruption simulation.To explore student and simulation facilitators experiences and perceptions of a distraction and interruption simulation.A sequential explanatory mixed-methods design was adopted including surveys, interviews, and focus groups.A mid-sized research intensive western Canadian university.A total of 112 third year nursing students who engaged in the distraction and interruption simulation, and five simulation facilitators who facilitated the distraction and interruption simulation, participated in this study.Students were invited to complete a cross sectional survey following the distraction and interruption simulation and were then invited to participate in focus groups. Simulation facilitators were invited to participate in one-on-one interviews following facilitating the distraction and interruption simulation. All data were collected between June and December 2020.Data from surveys, interviews, and focus groups were delineated into 4 themes related to the phases of the simulation. The prebriefing provided an overview of the simulation and helped create psychological safety that was imperative for learning about potential medication errors when being distracted and interrupted. The simulation scenario had a high degree of fidelity and helped students implement strategies to manage distractions and interruptions. The structured debrief provided an opportunity for meaningful reflection. The impact of the simulation was apparent as students articulated the balance between speed versus safety and new strategies developed to manage distractions and interruptions in clinical practice.This study supports the use of simulation to develop key skills for managing distractions and interruptions during medication preparation in clinical practice.

Background: \ud Few data exist on the comparative safety and immunogenicity of different COVID-19 vaccines given as a third (booster) dose. To generate data to optimise selection of booster vaccines, we investigated the reactogenicity and immunogenicity of seven different COVID-19 vaccines as a third dose after two doses of ChAdOx1 nCov-19 (Oxford–AstraZeneca; hereafter referred to as ChAd) or BNT162b2 (Pfizer–BioNtech, hearafter referred to as BNT).\ud \ud Methods: \ud COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of third dose booster vaccination against COVID-19. Participants were aged older than 30 years, and were at least 70 days post two doses of ChAd or at least 84 days post two doses of BNT primary COVID-19 immunisation course, with no history of laboratory-confirmed SARS-CoV-2 infection. 18 sites were split into three groups (A, B, and C). Within each site group (A, B, or C), participants were randomly assigned to an experimental vaccine or control. Group A received NVX-CoV2373 (Novavax; hereafter referred to as NVX), a half dose of NVX, ChAd, or quadrivalent meningococcal conjugate vaccine (MenACWY) control (1:1:1:1). Group B received BNT, VLA2001 (Valneva; hereafter referred to as VLA), a half dose of VLA, Ad26.COV2.S (Janssen; hereafter referred to as Ad26) or MenACWY (1:1:1:1:1). Group C received mRNA1273 (Moderna; hereafter referred to as m1273), CVnCov (CureVac; hereafter referred to as CVn), a half dose of BNT, or MenACWY (1:1:1:1). Participants and all investigatory staff were blinded to treatment allocation. Coprimary outcomes were safety and reactogenicity and immunogenicity of anti-spike IgG measured by ELISA. The primary analysis for immunogenicity was on a modified intention-to-treat basis; safety and reactogenicity were assessed in the intention-to-treat population. Secondary outcomes included assessment of viral neutralisation and cellular responses. This trial is registered with ISRCTN, number 73765130.\ud \ud Findings: \ud Between June 1 and June 30, 2021, 3498 people were screened. 2878 participants met eligibility criteria and received COVID-19 vaccine or control. The median ages of ChAd/ChAd-primed participants were 53 years (IQR 44–61) in the younger age group and 76 years (73–78) in the older age group. In the BNT/BNT-primed participants, the median ages were 51 years (41–59) in the younger age group and 78 years (75–82) in the older age group. In the ChAd/ChAD-primed group, 676 (46·7%) participants were female and 1380 (95·4%) were White, and in the BNT/BNT-primed group 770 (53·6%) participants were female and 1321 (91·9%) were White. Three vaccines showed overall increased reactogenicity: m1273 after ChAd/ChAd or BNT/BNT; and ChAd and Ad26 after BNT/BNT. For ChAd/ChAd-primed individuals, spike IgG geometric mean ratios (GMRs) between study vaccines and controls ranged from 1·8 (99% CI 1·5–2·3) in the half VLA group to 32·3 (24·8–42·0) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·1 (95% CI 0·7–1·6) for ChAd to 3·6 (2·4–5·5) for m1273. For BNT/BNT-primed individuals, spike IgG GMRs ranged from 1·3 (99% CI 1·0–1·5) in the half VLA group to 11·5 (9·4–14·1) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·0 (95% CI 0·7–1·6) for half VLA to 4·7 (3·1–7·1) for m1273. The results were similar between those aged 30–69 years and those aged 70 years and older. Fatigue and pain were the most common solicited local and systemic adverse events, experienced more in people aged 30–69 years than those aged 70 years or older. Serious adverse events were uncommon, similar in active vaccine and control groups. In total, there were 24 serious adverse events: five in the control group (two in control group A, three in control group B, and zero in control group C), two in Ad26, five in VLA, one in VLA-half, one in BNT, two in BNT-half, two in ChAd, one in CVn, two in NVX, two in NVX-half, and one in m1273.\ud \ud Interpretation: \ud All study vaccines boosted antibody and neutralising responses after ChAd/ChAd initial course and all except one after BNT/BNT, with no safety concerns. Substantial differences in humoral and cellular responses, and vaccine availability will influence policy choices for booster vaccination.\ud \ud Funding: \ud UK Vaccine Taskforce and National Institute for Health Research.

The study aimed to analyze the prevalence of self-reported limitation of functional mobility and associated factors from 2000 to 2015 in elderly residing in the city of São Paulo, Brazil. The analyses used data from the four waves (2000, 2006, 2010, and 2015) in the Health, Well-Being, and Aging Study (SABE). Regression models were conducted to analyze the demographic, socioeconomic, behavioral, and health-related characteristics of individuals associated with limitations of mobility in each wave of the study, and multilevel analysis was performed for comparison between the four waves. The results showed an increase in the prevalence of self-reported limitations in mobility, most evident in the year 2006. There was also an association between chronic health conditions such as history of stroke (PR = 1.43; 95%CI: 1.29; 1.58, in 2000), presence of osteoarticular diseases (PR = 1.35; 95%CI: 1.23; 1.49, in 2015), and complaint of "backache" (PR = 1.33; 95%CI: 1.22; 1.45, in 2006), as well as with socioeconomic aspects such as insufficient income (PR = 1.17; 95%CI: 1.07; 1.28, in 2010). In a context of rapid population aging, these results provide relevant information for promoting public policies to prevent the decline in mobility in the elderly.Este estudo teve como objetivo analisar a prevalência de limitação na mobilidade funcional autorreferida e os fatores associados no período entre os anos 2000 e 2015, em idosos residentes no Município de São Paulo, Brasil. Para as presentes análises foram utilizados os dados das quatro ondas (2000, 2006, 2010 e 2015) do Estudo Saúde, Bem Estar e Envelhecimento (SABE). Foram conduzidos modelos de regressão para analisar as características demográficas, socioeconômicas, comportamentais e relativas à saúde dos indivíduos associadas à limitação da mobilidade em cada onda do estudo, e análise multinível para a comparação entre as quatro ondas. Os resultados indicaram aumento nas prevalências de limitações na mobilidade autorreferida, mais evidente no ano de 2006. Foi observado, ainda, associação com condições crônicas de saúde, como a história de AVC (RP = 1,43; IC95%: 1,29; 1,58, em 2000), a presença de doenças osteoarticulares (RP = 1,35; IC95%: 1,23; 1,49, em 2015), e a queixa de “dor nas costas” (RP = 1,33; IC95%: 1,22; 1,45, em 2006), bem como com aspectos socioeconômicos, como a renda insuficiente (RP = 1,17; IC95%: 1,07; 1,28, em 2010). Em um contexto de envelhecimento populacional acelerado, esses resultados trazem informações relevantes para a promoção de políticas públicas voltadas à prevenção de declínio da mobilidade em pessoas idosas.Este estudio tuvo como objetivo analizar la prevalencia de limitación en la movilidad funcional autoinformada y sus factores asociados durante el período entre los años 2000 y 2015, en ancianos residentes en el Municipio de São Paulo, Brasil. Para los análisis actuales se utilizaron los datos de cuatro oleadas (2000, 2006, 2010 y 2015) del Estudio Salud, Bienestar y Envejecimiento (SABE). Se aplicaron modelos de regresión para analizar las características demográficas, socioeconómicas, comportamentales y relativas a la salud de los individuos, asociadas a la limitación de la movilidad en cada oleada del estudio, y un análisis multinivel para la comparación entre las 4 oleadas. Los resultados indicaron un aumento en las prevalencias de limitaciones respecto a la movilidad autoinformada, pero fue evidente en el año 2006. Se observó, incluso, una asociación con las condiciones crónicas de salud, como un historial de ACV (RP = 1,43; IC95%: 1,29; 1,58, en 2000), la presencia de enfermedades osteoarticulares (RP = 1,35; IC95%: 1,23; 1,49, en 2015), y la queja de “dolor de espalda” (RP = 1,33; IC95%: 1,22; 1,45, en 2006), así como con aspectos socioeconómicos, como la renta insuficiente (RP = 1,17; IC95%: 1,07; 1,28, en 2010). En un contexto de envejecimiento poblacional acelerado, esos resultados presentan información relevante para la promoción de políticas públicas dirigidas a la prevención del declive de la movilidad en personas ancianas.

Grassland ecosystem is important for the realization of the global sustainable development goals (e.g. Goal 15) since it provides irreplaceable services for human beings, supporting human health and sustainable development. Most studies have focused on improving grassland restoration techniques, but less attention has been paid to grassland ecosystem stability in succession. Plant community stability of temperate grassland in arid and semi-arid regions is analyzed through 38 sampling sites in Inner Mongolia, China. The degradation succession sequence of grassland is established by principal component analysis, and the species diversity and functional diversity along degradation gradient analyzed by multivariate statistical analysis. The results show that (1) functional diversity has higher explanatory power for community stability than species diversity due to the functional dispersion of plant traits; (2) climate factors rather than grazing or soil control plant community diversity and stability at regional scale; (3) the resistance of plant community does not change in degradation succession, but the trade-off effect of stability components in different plant communities differ, such as the order of trade-off effects (e.g. community resilience (ET)＞community resistance (RT)＞structural variability (St)＞functional variability (Fu) in the community dominated by Stipa grandis, RT＞ET＞St＞Fu in Leymus chinensis community, St＞ET＞Fu＞RT in Stipa capillata community, RT＞St＞Fu＞ET in Artemisia frigida community, St＞Fu＞ET＞RT in Cleistogenes squarrosa community, and Fu＞St＞RT＞ET in Artemisia halodendron community); (4) grassland ecosystem with higher diversity shows greater resilience and lower variability than those with single species, which supports the established diversity hypothesis. Furthermore, sustainable grassland restoration should reduce community variability and improve resilience. These findings highlight the response of diversity to stability in temperate grassland and provide scientific support for grassland ecosystem protection and restoration.

Background COVID-19 vaccine supply shortages are causing concerns about compromised immunity in some countries as the interval between the first and second dose becomes longer. Conversely, countries with no supply constraints are considering administering a third dose. We assessed the persistence of immunogenicity after a single dose of ChAdOx1 nCoV-19 (AZD1222), immunity after an extended interval (44–45 weeks) between the first and second dose, and response to a third dose as a booster given 28–38 weeks after the second dose. Methods In this substudy, volunteers aged 18–55 years who were enrolled in the phase 1/2 (COV001) controlled trial in the UK and had received either a single dose or two doses of 5 × 1010 viral particles were invited back for vaccination. Here we report the reactogenicity and immunogenicity of a delayed second dose (44–45 weeks after first dose) or a third dose of the vaccine (28–38 weeks after second dose). Data from volunteers aged 18–55 years who were enrolled in either the phase 1/2 (COV001) or phase 2/3 (COV002), single-blinded, randomised controlled trials of ChAdOx1 nCoV-19 and who had previously received a single dose or two doses of 5 × 1010 viral particles are used for comparison purposes. COV001 is registered with ClinicalTrials.gov, NCT04324606, and ISRCTN, 15281137, and COV002 is registered with ClinicalTrials.gov, NCT04400838, and ISRCTN, 15281137, and both are continuing but not recruiting. Findings Between March 11 and 21, 2021, 90 participants were enrolled in the third-dose boost substudy, of whom 80 (89%) were assessable for reactogenicity, 75 (83%) were assessable for evaluation of antibodies, and 15 (17%) were assessable for T-cells responses. The two-dose cohort comprised 321 participants who had reactogenicity data (with prime-boost interval of 8–12 weeks: 267 [83%] of 321; 15–25 weeks: 24 [7%]; or 44–45 weeks: 30 [9%]) and 261 who had immunogenicity data (interval of 8–12 weeks: 115 [44%] of 261; 15–25 weeks: 116 [44%]; and 44–45 weeks: 30 [11%]). 480 participants from the single-dose cohort were assessable for immunogenicity up to 44–45 weeks after vaccination. Antibody titres after a single dose measured approximately 320 days after vaccination remained higher than the titres measured at baseline (geometric mean titre of 66·00 ELISA units [EUs; 95% CI 47·83–91·08] vs 1·75 EUs [1·60–1·93]). 32 participants received a late second dose of vaccine 44–45 weeks after the first dose, of whom 30 were included in immunogenicity and reactogenicity analyses. Antibody titres were higher 28 days after vaccination in those with a longer interval between first and second dose than for those with a short interval (median total IgG titre: 923 EUs [IQR 525–1764] with an 8–12 week interval; 1860 EUs [917–4934] with a 15–25 week interval; and 3738 EUs [1824–6625] with a 44–45 week interval). Among participants who received a third dose of vaccine, antibody titres (measured in 73 [81%] participants for whom samples were available) were significantly higher 28 days after a third dose (median total IgG titre: 3746 EUs [IQR 2047–6420]) than 28 days after a second dose (median 1792 EUs [IQR 899–4634]; Wilcoxon signed rank test p=0·0043). T-cell responses were also boosted after a third dose (median response increased from 200 spot forming units [SFUs] per million peripheral blood mononuclear cells [PBMCs; IQR 127–389] immediately before the third dose to 399 SFUs per milion PBMCs [314–662] by day 28 after the third dose; Wilcoxon signed rank test p=0·012). Reactogenicity after a late second dose or a third dose was lower than reactogenicity after a first dose. Interpretation An extended interval before the second dose of ChAdOx1 nCoV-19 leads to increased antibody titres. A third dose of ChAdOx1 nCoV-19 induces antibodies to a level that correlates with high efficacy after second dose and boosts T-cell responses. Funding UK Research and Innovation, Engineering and Physical Sciences Research Council, National Institute for Health Research, Coalition for Epidemic Preparedness Innovations, National Institute for Health Research Oxford Biomedical Research Centre, Chinese Academy of Medical Sciences Innovation Fund for Medical Science, Thames Valley and South Midlands NIHR Clinical Research Network, AstraZeneca, and Wellcome.

Objective: To evaluate knowledge, attitudes and preventive practices on traffic accidents in schoolchildren, before and after the implementation of a health education program. Methods: Experimental study carried out in two public schools in Northeastern Brazil. The sample was composed of 173 children from 3rd to 5th grade and was randomized into Experimental Group (EG; n=0) and Control Group (CG; n=8). The educational program was carried out at EG with the use of the educational therapeutic method (Health Magic Box). The data were obtained through the questionnaire Knowledge, Attitudes and Practices (KAP), applied at the beginning of the study, before any educational actions, and one month after the experimental treatment. Paired Student’s t-test was used to compare the moments before and after the intervention in the EG and initial and final evaluation in the CG. Results: The children in the EG and CG were similar in relation to sociodemographic variables, and no significant difference was observed in the level of knowledge, attitudes and preventive practices on traffic accidents between the groups in the initial evaluation. One month after the experimental treatment, a significant improvement in knowledge was observed in EG (p=0.027). Preventive attitudes and practices were also higher in children in the EG, but without significant differences in relation to CG (p=0.060 and p=0.282, respectively). Conclusions: The educational intervention increased the level of knowledge and maintained the preventive attitudes and practices on traffic accidents at the same level in 3rd-5th grade students. RESUMO Objetivo: Avaliar o conhecimento, as atitudes e as práticas preventivas de acidentes de trânsito entre crianças escolares antes e depois da aplicação de um programa educativo. Métodos: Estudo experimental, com abordagens descritiva e analítica, realizado em duas escolas públicas do nordeste brasileiro. A amostra foi composta de 173 crianças do 3º ao 5º ano do ensino fundamental e aleatorizada em Grupo Experimental (GE), com 90 participantes, e Grupo Controle (GC), com 83 participantes. O programa educativo foi realizado no GE com a utilização do método eduterapêutico (Health Magic Box). Os dados foram obtidos por meio do questionário Conhecimento, Atitudes e Práticas (CAP), aplicado no início da pesquisa, antes de qualquer ação educativa, e após um mês da realização do tratamento experimental. Na análise estatística foi utilizado o teste t de Student pareado para comparação entre os momentos anteriores e posteriores à intervenção no GE e avaliação inicial e final no GC. Resultados: As crianças do GE e GC mostraram-se semelhantes quanto às variáveis sociodemográficas, e não foi observada diferença significativa no nível de conhecimento, atitudes e práticas preventivas de acidentes de trânsito entre os grupos na avaliação inicial. Entretanto, ainda após um mês da realização do experimento, foi evidenciada melhora significativa no conhecimento do GE (p=0,027). As atitudes e práticas preventivas também foram superiores nas crianças do GE, porém sem diferença significativa em relação ao GC (p=0,060 e p=0,282, respectivamente). Conclusões: A intervenção educativa aumentou o nível de conhecimento e manteve as atitudes e práticas preventivas de acidentes de trânsito estabilizadas em estudantes de 3º a 5º ano.

Objectives: The characterization of markers capable of predicting clinically significant hematoma growth (HG) in patients with intracerebral hemorrhage (ICH) may be useful for the selection...

Chronic diseases are often comorbid and present a weighty burden for communities in the 21st century. The present investigation depicted patterns of multimorbidity in the general population and examined its association with the individual- and area-level factors in an urban sample of non-elderly adults of Brazil. Data were from the cross-sectional São Paulo Megacity Mental Health Survey, a stratified multistage area probability sampling investigation. Trained interviewers assessed mental morbidities and asked about physical conditions for 1,571 community-dwelling women and 1,142 men, aged between 18 and 64 years. Principal component analysis depicted patterns of physical-mental multimorbidity, by sex. Following, the patterns of multimorbidity were subjected to multilevel regression analysis, taking into account individual- and area-level variables. Three patterns of clustering were found for women: ‘irritable mood and headache’, ‘chronic diseases and pain’, and ‘substance use disorders’. Among men, the patterns were: ‘chronic pain and respiratory disease’, ‘psychiatric disorders’, and ‘chronic diseases’. Multilevel analyses showed associations between multimorbidity patterns and both individual- and area-level determinants. Our findings call for a reformulation of health-care systems worldwide, especially in low-resource countries. Replacing the single-disease framework by multi-disease patterns in health-care settings can improve the ability of general practitioners in the health-care of person-centred needs.

BACKGROUND: A better understanding of performance in functional mobility tasks related to the mortality patterns for the different causes of death for the Brazilian older population is still a challenge. OBJECTIVE: To analyze if gait speed and chair stand test performance are associated with mortality in older adults, and if the overall mobility status changes the effect of other mortality risk factors. METHODS: The data were from SABE (Health, Well-being and Aging Study), a multiple-cohort study conducted in São Paulo, Brazil, with a representative sample of people aged 60 and more. Cox regression models were used to analyze 10-year all-cause and cause-specific mortality with consideration for gait speed and the chair stand test. RESULTS: Of the 1411 participants, 26% died during the follow-up. The performance in the chair stand test had a more consistent association with mortality (hazard ratio (HR)=1.03, 95%CI: 1.00, 1.05) than gait speed. Being unable to perform the test also increased the risk to die by all-cause (HR=1.71, 95%CI: 1.21, 2.42) and by diseases of the circulatory system (HR=2.14, 95%CI: 1.25, 3.65). The stratified analysis of mobility performance changed the effects of some of the mortality risk factors, such as cognitive impairment and multimorbidity. CONCLUSIONS: The chair stand test could be a better choice than 3-meters walking test as a mortality predictor. In addition, the impact of cognitive decline and multimorbidity were greater among those with reduced mobility, supporting the development of preventive interventions and public policies targeted at more vulnerable groups of older adults.

Urban green spaces (UGS) deliver a wide range of regulating, provisioning and cultural ecosystem services (CES), relevant to support the achievement of some United Nations Sustainable Development Goals (e.g., Goal 11: sustainable cities and communities, and Goal 3: good health and well-being). However, knowledge of preferences and uses of UGS by urban dwellers is still lacking. This study assesses the CES perceived by different users in five distinct urban parks located in Coimbra, Portugal: Manuel Braga (secular park), Botanical garden, Choupal national forest, Mondego green park (large area placed next to the river), and Vale das Flores (linear park located in a residential area). A questionnaire survey was performed in each park to investigate the activities performed and their relevance for the users, users' motivations to develop the activities on that specific UGS, the perceived benefits regarding physical and emotional well-being and social interactions, and users' perception about disservices. The results showed that walking, meeting people, practicing and doing activities with children are the activities performed by most users and are perceived as beneficial for physical and emotional well-being. Multifunctionality is a characteristic of all parks and highly appreciated by the users. Significant differences in socio-demographic characteristics of the users and motivations are recorded between parks. The tranquillity of space and landscape beauty are the main motivations to use Manuel Braga Park and the Botanical garden. Distance to the park and transportation means are particularly important for Botanical garden and Vale das Flores park users. Age group and average monthly income were associated in both Choupal national forest, Mondego green park and Vale das Flores park, denoting that older and wealthier users are more able to enjoy these parks. Users' problems or ecosystem disservices were not identified, although plagues (e.g., mosquitoes) and dangerous animals recorded average concerns in the Choupal national forest and in the Vale das Flores and Mondego green parks. This work's findings can help decision-makers better understand users' needs and expectations, thus improving UGS design and management to attract more citizens.

The early identification of individuals at risk of mobility decline can improve targeted strategies of prevention.To evaluate the predictive performance of machine learning (ML) algorithms in identifying older individuals at risk of future mobility decline.We used data from the SABE Study (Health, Well-being and Aging Study), a representative sample of people aged 60 years and more, living in the Municipality of São Paulo, Brazil. Mobility decline was assessed 5 years after admission in the study by self-reported difficulty to walk a block, climb steps, being able to stoop, crouch and kneel, or lifting or carrying weights greater than 5 kg. Popular machine learning algorithms were trained in 70% of the sample with 10-fold cross-validation, and predictive performance metrics were obtained from applying the trained algorithms to the other 30% (test set).Of the 1,615 individuals, 48% developed difficulty in at least one of the four tasks, 32% in stooping, crouching and kneeling, and 30% in carrying weights. The random forest algorithm had the best predictive performance for most outcomes. The tasks that the algorithm was able to predict with better performance were crouching and kneeling (AUC-ROC: 0.81[0.76-0.85]), and lifting or carrying weights (AUC-ROC: 0.80[0.75-0.84]). Age was the most important variable for the algorithms, followed by education and back pain, according to the SHAP (SHapley Additive exPlanations) values.Applications of ML algorithms are a promising tool to identify older patients at risk of mobility decline, with the potential of improving targeted preventive programs.

BACKGROUND: A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials. \ud \ud \ud METHODS: This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674. \ud \ud \ud FINDINGS: Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0-75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4-97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8-80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3-4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation. \ud \ud \ud INTERPRETATION: ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials. \ud \ud \ud FUNDING: UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, Bill & Melinda Gates Foundation, Lemann Foundation, Rede D'Or, Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca.

BACKGROUND: Older adults (aged ≥70 years) are at increased risk of severe disease and death if they develop COVID-19 and are therefore a priority for immunisation should an efficacious vaccine be developed. Immunogenicity of vaccines is often worse in older adults as a result of immunosenescence. We have reported the immunogenicity of a novel chimpanzee adenovirus-vectored vaccine, ChAdOx1 nCoV-19, in young adults, and now describe the safety and immunogenicity of this vaccine in a wider range of participants, including adults aged 70 years and older. METHODS: In this report of the phase 2 component of a single-blind, randomised, controlled, phase 2/3 trial (COV002), healthy adults aged 18 years and older were enrolled at two UK clinical research facilities, in an age-escalation manner, into 18-55 years, 56-69 years, and 70 years and older immunogenicity subgroups. Participants were eligible if they did not have severe or uncontrolled medical comorbidities or a high frailty score (if aged ≥65 years). First, participants were recruited to a low-dose cohort, and within each age group, participants were randomly assigned to receive either intramuscular ChAdOx1 nCoV-19 (2·2 × 1010 virus particles) or a control vaccine, MenACWY, using block randomisation and stratified by age and dose group and study site, using the following ratios: in the 18-55 years group, 1:1 to either two doses of ChAdOx1 nCoV-19 or two doses of MenACWY; in the 56-69 years group, 3:1:3:1 to one dose of ChAdOx1 nCoV-19, one dose of MenACWY, two doses of ChAdOx1 nCoV-19, or two doses of MenACWY; and in the 70 years and older, 5:1:5:1 to one dose of ChAdOx1 nCoV-19, one dose of MenACWY, two doses of ChAdOx1 nCoV-19, or two doses of MenACWY. Prime-booster regimens were given 28 days apart. Participants were then recruited to the standard-dose cohort (3·5-6·5 × 1010 virus particles of ChAdOx1 nCoV-19) and the same randomisation procedures were followed, except the 18-55 years group was assigned in a 5:1 ratio to two doses of ChAdOx1 nCoV-19 or two doses of MenACWY. Participants and investigators, but not staff administering the vaccine, were masked to vaccine allocation. The specific objectives of this report were to assess the safety and humoral and cellular immunogenicity of a single-dose and two-dose schedule in adults older than 55 years. Humoral responses at baseline and after each vaccination until 1 year after the booster were assessed using an in-house standardised ELISA, a multiplex immunoassay, and a live severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) microneutralisation assay (MNA80). Cellular responses were assessed using an ex-vivo IFN-γ enzyme-linked immunospot assay. The coprimary outcomes of the trial were efficacy, as measured by the number of cases of symptomatic, virologically confirmed COVID-19, and safety, as measured by the occurrence of serious adverse events. Analyses were by group allocation in participants who received the vaccine. Here, we report the preliminary findings on safety, reactogenicity, and cellular and humoral immune responses. This study is ongoing and is registered with ClinicalTrials.gov, NCT04400838, and ISRCTN, 15281137. FINDINGS: Between May 30 and Aug 8, 2020, 560 participants were enrolled: 160 aged 18-55 years (100 assigned to ChAdOx1 nCoV-19, 60 assigned to MenACWY), 160 aged 56-69 years (120 assigned to ChAdOx1 nCoV-19: 40 assigned to MenACWY), and 240 aged 70 years and older (200 assigned to ChAdOx1 nCoV-19: 40 assigned to MenACWY). Seven participants did not receive the boost dose of their assigned two-dose regimen, one participant received the incorrect vaccine, and three were excluded from immunogenicity analyses due to incorrectly labelled samples. 280 (50%) of 552 analysable participants were female. Local and systemic reactions were more common in participants given ChAdOx1 nCoV-19 than in those given the control vaccine, and similar in nature to those previously reported (injection-site pain, feeling feverish, muscle ache, headache), but were less common in older adults (aged ≥56 years) than younger adults. In those receiving two standard doses of ChAdOx1 nCoV-19, after the prime vaccination local reactions were reported in 43 (88%) of 49 participants in the 18-55 years group, 22 (73%) of 30 in the 56-69 years group, and 30 (61%) of 49 in the 70 years and older group, and systemic reactions in 42 (86%) participants in the 18-55 years group, 23 (77%) in the 56-69 years group, and 32 (65%) in the 70 years and older group. As of Oct 26, 2020, 13 serious adverse events occurred during the study period, none of which were considered to be related to either study vaccine. In participants who received two doses of vaccine, median anti-spike SARS-CoV-2 IgG responses 28 days after the boost dose were similar across the three age cohorts (standard-dose groups: 18-55 years, 20 713 arbitrary units [AU]/mL [IQR 13 898-33 550], n=39; 56-69 years, 16 170 AU/mL [10 233-40 353], n=26; and ≥70 years 17 561 AU/mL [9705-37 796], n=47; p=0·68). Neutralising antibody titres after a boost dose were similar across all age groups (median MNA80 at day 42 in the standard-dose groups: 18-55 years, 193 [IQR 113-238], n=39; 56-69 years, 144 [119-347], n=20; and ≥70 years, 161 [73-323], n=47; p=0·40). By 14 days after the boost dose, 208 (>99%) of 209 boosted participants had neutralising antibody responses. T-cell responses peaked at day 14 after a single standard dose of ChAdOx1 nCoV-19 (18-55 years: median 1187 spot-forming cells [SFCs] per million peripheral blood mononuclear cells [IQR 841-2428], n=24; 56-69 years: 797 SFCs [383-1817], n=29; and ≥70 years: 977 SFCs [458-1914], n=48). INTERPRETATION: ChAdOx1 nCoV-19 appears to be better tolerated in older adults than in younger adults and has similar immunogenicity across all age groups after a boost dose. Further assessment of the efficacy of this vaccine is warranted in all age groups and individuals with comorbidities. FUNDING: UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midlands NIHR Clinical Research Network, and AstraZeneca.

Highlights • Cilostazol as adjuvant in the treatment of COVID-19. • Hyperinflammation and coagulability state contribute to COVID-19 severity. • Cilostazol as a multi-target drug for the treatment of COVID-19. • Drug repurposing to address an urgent clinical demand is highlighted. • Cilostazol could play an important role in the treatment of COVID-19., Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) that has emerged and rapidly spread across the world. The COVID-19 severity is associated to viral pneumonia with additional extrapulmonary complications. Hyperinflammation, dysfunctional immune response and hypercoagulability state are associated to poor prognosis. Therefore, the repositioning of multi-target drugs to control the hyperinflammation represents an important challenge for the scientific community. Cilostazol, a selective phosphodiesterase type-3 inhibitor (PDE-3), is an antiplatelet and vasodilator drug, that presents a range of pleiotropic effects, such as antiapoptotic, anti-inflammatory, antioxidant, and cardioprotective activities. Cilostazol also can inhibit the adenosine uptake, which enhances intracellular cAMP levels. In the lungs, elevated cAMP promotes anti-fibrotic, vasodilator, antiproliferative effects, as well as mitigating inflammatory events. Interestingly, a recent study evaluated antiplatelet FDA-approved drugs through molecular docking-based virtual screening on viral target proteins. This study revealed that cilostazol is a promising drug against COVID-19 by inhibiting both main protease (Mpro) and Spike glycoprotein, reinforcing its use as a promising therapeutic approach for COVID-19. Considering the complexity associated to COVID-19 pathophysiology and observing its main mechanisms, this article raises the hypothesis that cilostazol may act on important targets in development of the disease. This review highlights the importance of drug repurposing to address such an urgent clinical demand safely, effectively and at low cost, reinforcing the main pharmacological actions, to support the hypothesis that a multi-target drug such as cilostazol could play an important role in the treatment of COVID-19.

Sibutramine is a serotonin-norepinephrine-dopamine reuptake inhibitor, initially developed as a potential antidepressant and later approved for the management of obesity. Sibutramine use is also associated with psychiatric symptoms, namely mania, panic attacks, and, less frequently, psychosis. We report the case of a 32-year-old man, admitted to our hospital due to a suicide attempt in the context of sibutramine-associated psychosis. The symptoms remitted completely after discontinuation of sibutramine and a brief period of antipsychotic medication. The aim of this manuscript is to highlight the importance of the recognition of sibutramine-associated psychosis, to discuss the possible pathophysiology and the proper clinical and therapeutic management.A sibutramina é um inibidor não seletivo da recaptação de serotonina-noradrenalina-dopamina, inicialmente desenvolvido como potencial antidepressivo e posteriormente aprovado para o tratamento da obesidade. O uso de sibutramina está também associado ao aparecimento de sintomas psiquiátricos como mania, ataques de pânico e, com menor frequência, psicose. Relatamos um caso de um homem de 32 anos, internado no nosso hospital devido a uma tentativa de suicídio no contexto de uma psicose associada à sibutramina. Os sintomas remitiram completamente após a descontinuação da sibutramina e um breve período de terapêutica antipsicótica. O objetivo deste artigo é destacar a importância do reconhecimento da psicose associada à sibutramina, discutir a sua possível fisiopatologia e o seu apropriado manejo clínico e terapêutico.

Different biomarkers are useful in diagnosing infections. The aim of this work was to clarify the relation between different inflammatory biomarkers (white blood cell [WBC] count, C-reactive protein [CRP], procalcitonin [PCT], and C-reactive protein-to-albumin ratio [CAR]) and early infectious complications after colorectal surgery., info:eu-repo/semantics/publishedVersion

In the last decades, the great technological development increased Internet popularity, emerging the concern about its overuse. The objectives of this study were to assess and characterize Internet use in adolescence, determine Internet addiction and clarify its association with sleep disorders and excessive daytime sleepiness.It was performed an observational, cross sectional and community-based study. The target were students attending 7th and 8th grades, to whom was applied an online self-report questionnaire to assess sociodemographic features, Internet use, Internet dependence, sleep characteristics and excessive daytime sleepiness.A total of 727 adolescents were included with a mean age 13 ± 0.9 years. Three-quarters of teenagers use Internet daily and 41% do it for three or more hours/day, mainly at home. The phone and laptop were the main devices used. Online games and social networks use were the main activities performed. Internet dependence was observed in 19% of adolescents, and it was associated with male gender, social networks use, mainly Twitter and Instagram use, self-perceived sleep problems, initial and middle insomnia and excessive daytime sleepiness (p0.05).The results confirm the highlight that Internet has in adolescents routine, who prioritize in their use access to social networks and online games, using single devices, less subject to parental control.The Internet addiction rate observed and its association with sleep alterations and daytime sleepiness emphasizes the importance of this issue.Introdução: A grande evolução tecnológica das últimas décadas tornou a Internet cada vez mais popular, sendo crescente a preocupação com a sua utilização excessiva. Foram objetivos do presente trabalho aferir e caracterizar o uso de Internet na adolescência, determinar a dependência de Internet e estabelecer a sua associação com alterações do sono e sonolência diurna excessiva. Material e Métodos: Foi realizado um estudo de base comunitária, observacional e transversal dirigido a adolescentes a frequentar o sétimo e oitavo ano de escolaridade. Recorreu-se a um questionário de autopreenchimento online, para aferir características sociodemográficas, uso e dependência de Internet, características do sono e sonolência diurna excessiva. Resultados: Foram incluídos 727 adolescentes com idade média de 13 ± 0,9 anos. Três quartos dos adolescentes usa a Internet diariamente e 41% fá-lo durante três ou mais horas/dia, maioritariamente em casa. O telemóvel e o computador portátil são os principais dispositivos utilizados. Os jogos online e o uso das redes sociais são das principais atividades realizadas. A dependência de Internet foi observada em 19% dos adolescentes, associando-se ao género masculino, à utilização de redes sociais, o Twitter e Instagram, à autopercepção de problemas de sono, insónia inicial e intermédia e sonolência diurna excessiva (p0,05). Discussão: Os resultados reiteram o destaque que a Internet tem na rotina dos adolescentes, que priorizam o seu uso no acesso a redes sociais e jogos online, fazendo-o com dispositivos de uso individual, menos passíveis de controlo parental. Conclusão: A dependência de Internet verificada e associação com alterações do sono e sonolência diurna excessiva enfatiza a relevância desta problemática.

Background Until recently, intravenous thrombolysis was the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke. However, this treatment option has low recanalization rates in large-vessel occlusions. The search for additional treatments continued until 5 randomized trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) revealed the superiority of mechanical thrombectomy for anterior circulation large-vessel occlusion. After 1 year of performing thrombectomy with stent retrievers in our tertiary hospital, we intended to answer the question: is it possible to achieve similar results in a "real-world" setting? Methods We analyzed data from our prospective observational registry, compared it with the trials aforementioned, and concluded that the answer is affirmative. Results Our study population of 77 patients, with a mean age of 68,2 years and 48,1% men, is comparable with these trials in much of selection criteria, baseline characteristics, and rate of previous intravenous thrombolysis (72,7%). Recovery of functional independence at 90 days was achieved in almost two thirds of patients, similarly to the referred trials. We devoted special emphasis on fast recanalization, keeping a simple image selection protocol (based on non-enhanced and computed tomography angiography) and not waiting for clinical response to thrombolysis in patients eligible for mechanical thrombectomy. We emphasize a successful recanalization rate of 87% and only 2,6% symptomatic intracranial hemorrhage. Conclusion In summary, mechanical thrombectomy seems to be a safe and effective treatment option in a " real-world " scenario, with results similar to those of the recent randomized controlled trials.

Purpose of the study To analyze a representative sample of older individuals of Sao Paulo, Brazil, according to outdoor fallers, indoor fallers and non-fallers, and to identify biological and socioeconomic (individual and contextual) factors associated with the occurrence and place of falls. Materials and methods A cross-sectional study was conducted using data (n = 1345) from the 2010 wave of the Health, Wellbeing and Aging (SABE) Study, a representative sample of older residents (60 years and older) of Sao Paulo, Brazil. Multinomial logistic analysis was performed to identify individual factors associated with the occurrence and place of falls, and multilevel multinomial analysis to identify contextual effects (green areas, violence, presence of slums and income inequality). Results 29% had a fall in the last 12 months, with 59% occurring in indoor spaces. Individuals who had outdoor falls were overall not statistically different from non-fallers; on the other hand, those who had the last fall indoor had worse health status. Moderate homicide rate was a factor associated with increased presence of indoor falls, compared with non-fallers. Implications Our results describe the importance of falls, a common problem in active and community-dwelling older adults of Sao Paulo, Brazil. Transforming outdoor spaces into walk-friendly areas is essential to allow socialization and autonomy with safety. Creating strategies that take into account the most vulnerable populations, as those who live in violent areas and the oldest older adults, will be a growing challenge among developing countries.

In obsessive-compulsive disorder, pedophilia-themed obsessions-distressing intrusive thoughts about being sexually attracted to, or sexually abusing, children-are the most distressing for patients and the most misdiagnosed among healthcare professionals. Our aim is to present a case report highlighting the role stigma plays in delaying treatment, the clinical challenges in the diagnosis, and in the treatment of pedophilia-themed obsessive-compulsive disorder, in order to address the lack of literature on the subject. The case concerns a 33-year-old man with suicidal thoughts associated with the unbearable suffering caused by pedophilia-themed obsessions he had been having over the previous decade, without ever asking for help. This situation was highly disabling, leaving him mostly isolated in his bedroom. After the differential diagnosis was made, a treatment plan combining pharmacological and cognitive-behavioural therapy was implemented. After 18 months he showed a degree of remission that made it possible for him to apply for a job.Na perturbação obsessivo-compulsiva as obsessões pedofílicas - pensamentos intrusivos sobre ser sexualmente excitado, ou abusar sexualmente, de crianças - estão entre os mais angustiantes para os doentes e os mais incorretamente diagnosticados pelos profissionais de saúde. O nosso objetivo é apresentar um caso clínico destacando o papel que o estigma tem no atraso do início do tratamento e os desafios clínicos que se verificam em relação ao diagnóstico e ao tratamento desta perturbação, de modo a colmatar a falta de literatura sobre o assunto. O caso é relativo a um homem de 33 anos, com ideação suicida associada ao sofrimento insuportável causado pelas obsessões sexuais pedofílicas que tinha desde há uma década, sem nunca ter recorrido a um profissional de saúde. Esta situação teve muito impacto no seu funcionamento deixando-o maioritariamente isolado no seu quarto. Após o diagnóstico diferencial, implementou-se o projeto terapêutico combinando tratamento farmacológico e psicoterapia cognitivo-comportamental. Após 18 meses o doente apresentou uma melhoria significativa permitindo-o concorrer a um emprego.

Human-induced urban growth and sprawl have implications for greenhouse gas (GHG) emissions that may not be included in conventional GHG accounting methods. Improved understanding of this issue requires use of interactive, spatial-explicit social–ecological systems modeling. This paper develops a comprehensive approach to modeling GHG emissions from urban developments, considering Stockholm County, Sweden as a case study. GHG projections to 2040 with a social–ecological system model yield overall greater emissions than simple extrapolations in official climate action planning. The most pronounced difference in emissions (39% higher) from energy use single-residence buildings resulting from urban sprawl. And this difference is not accounted for in the simple extrapolations. Scenario results indicate that a zoning policy, restricting urban development in certain areas, can mitigate 72% of the total emission effects of the model-projected urban sprawl. The study outcomes include a decision support interface for communicating results and policy implications with policymakers. Electronic supplementary material The online version of this article (10.1007/s13280-019-01290-y) contains supplementary material, which is available to authorized users.

In forensic toxicology, drugs of abuse are routinely analyzed due to legal statute in medical or legal investigation, such as death cases, poisoning cases, and drug misuse, determining potential exposure to controlled substances. Despite the widespread use of blood and urine as matrices for forensic toxicological analysis, the use of hair samples has grown as the limitations associated with this matrix are overcome and new areas of application emerge. Hair provides several advantages over urine and blood, such as the easiness of sample collection and the ability to provide a retrospective analysis of drug consumption. Drug analysis in hair is following a path where less amount of sample has been needed to detect drugs of abuse. Improvement in sample preparation methods and lowering detection limits in instrumental analysis is providing forensic scientists with the tools to use drug analysis with hair as a routine approach in the forensic laboratory. Actually, besides the chronological exposition to a drug, hair may provide information about the day a chemical was used. This should become part of the standard information sent by forensic scientists to criminal investigators and courts. The aim of this review is to summon the extraction procedures used to perform forensic toxicological analysis in hair as well as the major advances in this field once a sample preparation step is critical and takes up most of the total analysis time.

We explored the adherence to a home-delivered, computer-based, cognitive remediation protocol in a first-episode psychosis outpatient cohort. Seventeen patients underwent a cognitive training protocol for 6 months using an online platform accessible from their home under the supervision of a qualified neuropsychologist. Neuropsychological, psychopathological, and functional data were collected at baseline and postintervention, whereas qualitative appraisal of the intervention was assessed monthly. Overall, participants' evaluation of the program was positive. This was reflected in a good adherence rate with 12 (70%) of 17 patients completing 80% of the prescribed sessions. Exploratory analysis revealed significant improvements in sustained attention (p = 0.020) and verbal memory (p = 0.018). A decrease in negative symptoms and an improvement on the Clinical Global Impression were also found (p = 0.009). We believe these are encouraging results to further explore the adopted delivery approach, which could facilitate access to cognitive training earlier and to a larger group of patients.

Gaze deviation (GD) in acute ischemic stroke patients has been suggested to be associated with poor outcome and with the presence of large vessel occlusion. Our aim was to study the prognostic significance of GD in ischemic stroke patients submitted to acute revascularization treatments. Retrospective single-center study of consecutive anterior circulation ischemic stroke patients submitted to thrombolysis and/or endovascular revascularization between 2007 and 2017. The groups of patients with and without GD were compared concerning baseline clinical and imagiological variables, functional outcome at 3 months, and survival at 1 year. Among a study population of 711 patients, 332 (46.7%) presented GD. Patients with GD were more frequently of female sex (p = 0.048), had higher baseline NIHSS scores (p < 0.001), had lower ASPECTS on baseline CT (p < 0.001), more frequently had ischemia of the right hemisphere (p < 0.001), presented higher NIHSS 24 hours after treatment (p < 0.001), and more frequently presented cardioembolic stroke (p = 0.003). In the unadjusted analyses, GD was associated with decreased 3-month functional independence and increased 1-month and 1 year mortality (p < 0.001). After adjustment for variables of interest, namely, for NIHSS 24 hours after treatment, GD was no longer associated with functional outcome or survival. GD in patients with acute ischemic stroke is associated with increased clinical and imagiological severity at baseline. However, in patients submitted to acute revascularization treatments, this does not appear to be independent predictor of functional outcome or survival.

To analyze the agreement between self-reported race and race reported on death certificates for older (≥ 60 years) residents of Sao Paulo, Brazil (from 2000 to 2016) and to estimate weights to correct mortality data by race. We used data from the Health, Well-Being and Aging Study (SABE) and from Brazil’s Mortality Information System. Misclassification was identified by comparing individual self-reported race with the corresponding race on the death certificate (n = 1012). Racial agreement was analyzed by performing sensitivity and Cohen’s Kappa tests. Multinomial logistic regressions were adjusted to identify characteristics associated with misclassification. Correction weights were applied to race-specific mortality rates. Total racial misclassification was 17.3% (13.1% corresponded to whitening, and 4.2% to blackening). Racial misclassification was higher for self-reported pardos/mixed (63.5%), followed by blacks (42.6%). Official vital statistics suggest highest elderly mortality rates for whites, but after applying correction weights, black individuals had the highest rate (45.85/1000 population), followed by pardos/mixed (42.30/1000 population) and whites (37.91/1000 population). Official Brazilian data on race-specific mortality rates may be severely misclassified, resulting in biased estimates of racial inequalities.

The aim of this study was to determine the prevalence of suicidal ideation and explore associated factors among travestis and transsexuals. A cross-sectional study was conducted between 2015 and 2016 with 22 travestis and 36 transsexuals who were members of the four transgender organizations operating in the state of Rio Grande do Norte, Brazil. Associations between suicidal ideation and the categorical variables were measured using the chi-squared test, Fisher's exact test, and likelihood ratios. Multivariate analysis was performed using robust Poisson regression. The suicidal ideation prevalence rate was 41.4% (95%CI 41.3-54.51%): 13.79% among travestis (95%CI 4.91-22.66%) and 27.61% in transsexuals (95%CI 16.08-39.08%). The prevalence of suicidal ideation was higher among respondents who reported suffering violence at school (PR = 2.05; 95%CI 1.08-3.87) and those experiencing moderate/severe depression (PR = 3.86; 95%CI 1.51-9.83). The findings suggest that unfavorable school contexts and the presence of depression compromise mental health and contribute to suicidal ideation among travestis and transsexuals.Objetivou-se analisar a prevalência e os fatores associados à ideação suicida em travestis e transexuais. Estudo transversal, realizado entre 2015 e 2016 com travestis (n = 22) e transexuais (n = 36) associadas a quatro organizações civis do Rio Grande do Norte. Avaliou-se a diferença entre as categorias por meio dos testes qui-quadrado, exato de Fisher e de razão de verossimilhança. Realizou-se a análise múltipla por meio da regressão de Poisson com variância robusta. A prevalência de ideação suicida foi de 41,4% (IC 95%: 41,3-54,51%), sendo de 13,79% entre travestis (IC 95%: 4,91-22,66%) e 27,61% entre transexuais (IC 95%: 16,08-39,08%). Observou-se que apresentaram maior prevalência de ideação suicida os participantes com histórico de violência na escola (RP = 2,05; IC 95%: 1,08-3,87) e classificados com níveis depressivos moderado/grave (RP = 3,86; IC 95%: 1,51-9,83). Contexto escolar desfavorável e presença de sintomatologia depressiva parecem prejudicar a saúde mental e colaborar com a ideação suicida de pessoas transexuais e travestis.

Objective: To identify socioeconomic and contextual factors associated with functional mobility and falls in elderly residents of São Paulo, Brazil. Method: We used data from the Health, Well-Being, and Aging ( Saúde, Bem-estare Envelhecimento [SABE]) Study. The dependent variables were falling in the last year and functional mobility impairment. Individual (marital status, race, education, and perception of income sufficiency) and contextual (green area and violence) factors were analyzed by multilevel logistic models. Results: Having 8 or more years of schooling was a protective factor for mobility impairment. Neighborhoods with moderate homicide rate were associated with higher odds of falling. Moderate green spaces were associated with higher odds of falling and lower odds to have mobility impairment for individuals 80 years and older. Discussion: Our findings support the concern that neighborhood characteristics are associated with falls and mobility impairment. Strategies to prevent these outcomes should consider contextual aspects.

Made available in DSpace on 2020-12-12T02:44:24Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-10-01 Shelters are places that receive certain species of domestic animals, mostly dogs and cats, that are normally abandoned. These animals are easy to handle because they are crowded and have limited movement. Dogs, due to the close relationship with humans, are considered the main domestic reservoirs in the peridomiciliary cycle of American trypanosomiasis infection in humans. Therefore, in several countries studies are carried out to assess the occurrence of infection in these animals. This work evaluated the occurrence of Trypanosoma cruzi in dogs from shelters in the city of Aracaju, Sergipe. This was an observational and cross-sectional study to detect the occurrence of T. cruzi in blood samples from shelter dogs using polymerase chain reaction (PCR) with the TcZ1/TcZ2 primers. A total of 168 blood samples from dogs (104 females and 64 males) were collected and subjected to DNA and PCR extraction, and seventeen (10.1%) samples showed amplification of the product of the expected size. The TcZ1/TcZ2 primer pair used is considered specific for T. cruzi, and it is capable of amplifying all strains without amplifying other Trypanosoma species. The shelters evaluated had different physical infrastructure; animals positive for T. cruzi were found in all of them, as confirmed by sequencing. It is concluded that shelter dogs, as well as other domestic animals, can function as indicators of the occurrence of T. cruzi in Aracaju-SE, providing relevant epidemiological information for health surveillance and monitoring of Trypanosomatid infections. Postgraduate Program in Health and Environment Tiradentes University-UNIT, Av. Murilo Dantas, 300 Biological Sciences Course Tiradentes University-UNIT, Av. Murilo Dantas, 300 Institute of Technology and Research – ITP, Av. Murilo Dantas, 300 Postgraduate Program in Bioscience and Biotechnology Apllied to Pharmacy São Paulo State University-UNESP School of Pharmaceutical Sciences Rodovia Araraquara-Jaú, km 1, Campos Ville Postgraduate Program in Bioscience and Biotechnology Apllied to Pharmacy São Paulo State University-UNESP School of Pharmaceutical Sciences Rodovia Araraquara-Jaú, km 1, Campos Ville

Atherosclerosis is a multifactorial chronic disease, initiated by an endothelial dysfunction. Adenosine and its analogs can change a variety of inflammatory diseases and has shown important effects at different disease models. Inosine is a stable analogous of adenosine, but its effects in inflammatory diseases, like atherosclerosis, have not yet been studied. The aim of this study was to evaluate the pharmacological properties of inosine, administered sub chronically in a hypercholesterolemic model. Male Wistar rats were divided into four groups: control group (C) and control + inosine (C + INO) received standard chow, hypercholesterolemic diet group (HCD) and HCD + inosine (HCD + INO) were fed a hypercholesterolemic diet. At 31st experimentation day, the treatment with inosine was performed for C + INO and HCD + INO groups once daily in the last 15 days. We observed that the hypercholesterolemic diet promoted an increase in lipid levels and inflammatory cytokines production, while inosine treatment strongly decreased these effects. Additionally, HCD group presented a decrease in maximum relaxation acetylcholine induced and an increase in contractile response phenylephrine induced when compared to the control group, as well as it has presented an enhancement in collagen and ADP-induced platelet aggregation. On the other hand, inosine treatment promoted a decrease in contractile response to phenylephrine, evoked an improvement in endothelium-dependent vasorelaxant response and presented antiplatelet properties. Moreover, inosine activated eNOS and reduced p38 MAPK/NF-κB pathway in aortic tissues. Taken together, the present results indicate inosine as a potential drug for the treatment of cardiovascular disorders such as atherosclerosis.

Objective To validate the defining characteristics of the nursing diagnosis "labile emotional control" in traumatic brain injury (TBI) outpatients. Design This was a descriptive, cross-sectional, quantitative study. Methods Thirty-one Brazilian nurses who were experts in the area of TBI answered a semistructured questionnaire on the diagnosis "labile emotional control" based on NANDA-International (NANDA-I) Taxonomy II (2015-2017) using a Likert-type scale to rate the 13 defining characteristics. Based on Fehring's model, the weighted average of ≥80 was used to define the main characteristic and the mean of ≥0.50 was considered for total content validation. Results Out of the 13 defining characteristics of the nursing diagnosis studied, "leaving a social situation" (0.80) and "expression of emotions inconsistent with the triggering factor" (0.81) were classified as principal characteristics, while the 11 others were classified as secondary characteristics. The diagnosis "labile emotional control" obtained a total score of 0.69, which was considered valid according to NANDA-I Taxonomy II. Conclusions Because this is a new diagnosis with subjective characteristics, there is a need to train nurses to recognize the defining characteristics for the diagnosis. Clinical relevance The validation of this diagnosis helps nurses understand and identify the subjective characteristics of the emotional impressions expressed by patients with TBI. These defining characteristics will help improve TBI nurses' clinical practice.

Current trend of novel psychoactive substances (NPS) among teenagers is posing new clinical, scientific and forensic societal questions. Synthetic cathinones are among the most consumed groups of NPS appearing on the street market and internet on a regular basis. The properties of these substances change regularly, due to structural modification to circumvent legislation. This practice makes almost impossible to characterize its toxicological profiles on an acceptable time scale, mostly due to the time-consuming experiments that must be held in animal models or human cells by standard methods. Such an issue demands the development of a rapid and inexpensive methodology to be used as a high-throughput screening of cathinones’ toxicity. The yeast Saccharomyces cerevisiae shares highly conserved molecular and cellular mechanisms with human cells and has been used before for pharmacological drugs. In the present work it is proposed to use S. cerevisiae growth curves as a high throughput screening method to profile synthetic cathinones toxicity in a short time scale. The results obtained by S. cerevisiae growth curves analysis were compared to differentiated SH-SY5Y human neuronal cells and similar responses were found. The screening tool methodology has shown able to prioritize the most toxics NPS and can be useful for early warning programs on NPS.

Non-traumatic intracerebral hemorrhage (ICH) is associated with a significant global burden of disease, and despite being proportionally less frequent than ischemic stroke, in 2010 it was associated with greater worldwide disability-adjusted life years lost. The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time of the event. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health-related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH and subsequent thromboembolic events. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken together with the patient and next of kin.

Background and purpose Post-stroke dysphagia occurs in up to three quarters of patients with acute stroke and is associated with a higher risk of respiratory infections and poor outcome. Systematic screening of dysphagia in the acute stroke unit is essential to identify patients at risk of aspiration and to provide dietary recommendations. Our study aimed to assess the impact of the systematic application of the Gugging Swallowing Screen (GUSS) in patients with acute ischaemic stroke. Methods This was a retrospective study of consecutive patients with acute ischaemic stroke admitted to an acute stroke unit in two time periods: pre-GUSS (February 2014-July 2015), when the 10-mL water-swallowing test was systematically administered, and GUSS (August 2015-October 2016), when the GUSS test was systematically administered. Groups were compared with regard to baseline and stroke characteristics, and the occurrence of stroke-associated pneumonia (SAP), in-hospital death and 3-month outcome. Results Of the 344 patients who were included in the study (median age 71 years), 51.7% were male with a median National Institutes of Health Stroke Scale score of 11. A total of 204 patients were included during the pre-GUSS period and 140 during the GUSS period. Patients in the GUSS period more frequently had diabetes and partial anterior circulation syndromes, and were more frequently treated with thrombectomy. There was no difference in the occurrence of SAP between the two groups (pre-GUSS, 12.5%; GUSS, 15.1%; P = 0.490) and no differences were found concerning in-hospital mortality (P = 0.996), 3-month functional independence (P = 0.647) or 3-month mortality (P = 0.598). Conclusions The systematic administration of GUSS in a population of patients with acute ischaemic stroke did not reduce the occurrence of SAP, mortality or 3-month functional dependence when compared with the systematic administration of the 10-mL water-swallowing test.

This study aims to present the stages related to the use of machine learning algorithms for predictive analyses in health. An application was performed in a database of elderly residents in the city of São Paulo, Brazil, who participated in the Health, Well-Being, and Aging Study (SABE) (n = 2,808). The outcome variable was the occurrence of death within five years of the elder's entry into the study (n = 423), and the predictors were 37 variables related to the elder's demographic, socioeconomic, and health profile. The application was organized according to the following stages: division of data in training (70%) and testing (30%), pre-processing of the predictors, learning, and assessment of the models. The learning stage used 5 algorithms to adjust the models: logistic regression with and without penalization, neural networks, gradient boosted trees, and random forest. The algorithms' hyperparameters were optimized by 10-fold cross-validation to select those corresponding to the best models. For each algorithm, the best model was assessed in test data via area under the ROC curve (AUC) and related measures. All the models presented AUC ROC greater than 0.70. For the three models with the highest AUC ROC (neural networks and logistic regression with LASSO penalization and without penalization, respectively), quality measures of the predicted probability were also assessed. The expectation is that with the increased availability of data and trained human capital, it will be possible to develop predictive machine learning models with the potential to help health professionals make the best decisions.Este estudo objetiva apresentar as etapas relacionadas à utilização de algoritmos de machine learning para análises preditivas em saúde. Para isso, foi realizada uma aplicação com base em dados de idosos residentes no Município de São Paulo, Brasil, participantes do estudo Saúde Bem-estar e Envelhecimento (SABE) (n = 2.808). A variável resposta foi representada pela ocorrência de óbito em até cinco anos após o ingresso do idoso no estudo (n = 423), e os preditores, por 37 variáveis relacionadas ao perfil demográfico, socioeconômico e de saúde do idoso. A aplicação foi organizada de acordo com as seguintes etapas: divisão dos dados em treinamento (70%) e teste (30%), pré-processamento dos preditores, aprendizado e avaliação de modelos. Na etapa de aprendizado, foram utilizados cinco algoritmos para o ajuste de modelos: regressão logística com e sem penalização, redes neurais, gradient boosted trees e random forest. Os hiperparâmetros dos algoritmos foram otimizados por validação cruzada 10-fold, para selecionar aqueles correspondentes aos melhores modelos. Para cada algoritmo, o melhor modelo foi avaliado em dados de teste por meio da área abaixo da curva (AUC) ROC e medidas relacionadas. Todos os modelos apresentaram AUC ROC superior a 0,70. Para os três modelos com maior AUC ROC (redes neurais e regressão logística com penalização de lasso e sem penalização, respectivamente), foram também avaliadas medidas de qualidade da probabilidade predita. Espera-se que, com o aumento da disponibilidade de dados e de capital humano capacitado, seja possível desenvolver modelos preditivos de machine learning com potencial para auxiliar profissionais de saúde na tomada de melhores decisões.El objetivo de este estudio fue presentar las etapas relacionadas con la utilización de algoritmos de machine learning para análisis predictivos en salud. Para tal fin, se realizó una aplicación en base a datos de ancianos residentes en el Municipio de São Paulo, Brasil, participantes en el estudio Salud Bienestar y Envejecimiento (SABE) (n = 2.808). La variable respuesta se representó mediante la ocurrencia de óbito en hasta 5 años tras la inclusión del anciano en el estudio (n = 423), y los predictores fueron representados por 37 variables relacionadas con el perfil demográfico, socioeconómico y de salud del anciano. El aplicación se organizó según las siguientes etapas: división de los datos en formación (70%) y test (30%), pre-procesamiento de los predictores, aprendizaje y evaluación de modelos. En la etapa de aprendizaje, se utilizaron cinco algoritmos para el ajuste de modelos: regresión logística con y sin penalización, redes neuronales, gradient boosted trees y random forest. Los hiperparámetros de los algoritmos se optimizaron mediante una validación cruzada 10-fold, para seleccionar aquellos correspondientes a los mejores modelos. Para cada algoritmo, el mejor modelo se evaluó con datos de la prueba del área debajo de la curva (AUC) ROC y medidas relacionadas. Todos los modelos presentaron AUC ROC superior a 0,70. Para los tres modelos con mayor AUC ROC (redes neuronales y regresión logística con penalización de Lasso y sin penalización, respectivamente) también se evaluaron medidas de calidad de la probabilidad pronosticada. Se espera que, con el aumento de la disponibilidad de datos y de capital humano capacitado, sea posible desarrollar modelos predictivos de machine learning con potencial para ayudar a profesionales de salud en la toma de mejores decisiones.

Objective To conduct a survival analysis according to age at natural menopause (NM) in a representative sample of elderly women from the municipality of Sao Paulo, Brazil. Study design We analyzed data from the Health, Well-Being and Aging study (SABE), a cohort that started in 2000. Mortality data up to September 2016 were obtained by linkage from the Program for Mortality Information of Sao Paulo (PRO-AIM). Main outcome measures We used Cox regression to analyze all-cause and cause-specific mortality rates for cardiovascular diseases, respiratory diseases and cancer, according to age at menopause, categorized as Results After 16 years of follow-up, there were 444 deaths, of which 199 were from cardiovascular diseases, 73 from respiratory diseases and 65 from cancer. After adjustment for socioeconomic, reproductive and lifestyle factors, having an early menopause (at age 41–44) was associated with an increased risk of all-cause mortality (HR = 1.48, 95% IC: 1.03, 2.14) relative to NM at 50–54 years. Women aged 41–44 and 45–49 at NM had twice the risk of cancer mortality of the reference group. We did not find significant associations between age at NM and cause-specific mortality for respiratory and cardiovascular diseases. Conclusions Our findings suggest that early menopause is associated with all-cause mortality in the largest city of Latin America. In addition, earlier age at NM was associated with cancer mortality. These results suggest that age at NM may be a biomarker for mortality, irrespective of country of residence.

Introduction Pathophysiology of cervical artery dissection is complex and poorly understood. In addition to well-known causative and predisposing factors, including major trauma and monogenic connective tissue disorders, morphological characteristics of the styloid process have been recently recognized as a possible risk factor for cervical internal carotid artery dissection. Aims To study the association of the anatomical characteristics of styloid process with internal carotid artery dissection. Methods Retrospective, multicenter, case–control study of patients with internal carotid artery dissection and age- and sex-matched controls. Consecutive patients with internal carotid artery dissection and controls with ischemic stroke or transient ischemic attack of any etiology excluding internal carotid artery dissection, who had performed computed tomography angiography, diagnosed between January 2010 and September 2016. Two independent observers measured styloid process length and styloid process distance to internal carotid artery. Results Sixty-two patients with internal carotid artery dissection and 70 controls were included. Interobserver agreement was good for styloid process length and styloid process–internal carotid artery distance (interclass correlation coefficient = 0.89 and 0.76, respectively). Styloid process ipsilateral to dissection was longer than left and right styloid process in controls (35.8 ± 14.4 mm versus 30.4 ± 8.9 mm and 30.3 ± 8.2 mm, p = 0.011 and p = 0.008, respectively). Styloid process–internal carotid artery distance ipsilateral to dissection was shorter than left and right distance in controls (6.3 ± 1.9 mm versus 7.2 ± 2.1 mm and 7.0 ± 2.3 mm, p = 0.003 and p = 0.026, respectively). Internal carotid artery dissection was associated with styloid process length (odds ratio = 1.04 mm−1, 95% confidence interval = 1.01–1.08, p = 0.015) and styloid process–internal carotid artery distance (OR = 0.77 mm−1, 95% confidence interval = 0.64–0.92, p = 0.004). Conclusion Longer styloid process and shorter distance between styloid process and cervical internal carotid artery are associated with cervical internal carotid artery dissection.

Background To characterize atrial ectopic activity in patients with cryptogenic ischemic stroke (CIS) or transient ischemic attack (TIA) and determine its prognostic significance. Methods Retrospective cohort study, in which 184 patients with CIS or TIA who had performed 24-hour Holter electrocardiogram were included. The median follow-up was 27.5 months. Baseline clinical and imagiologic characteristics, etiologic investigation results, and ischemic stroke and TIA recurrences information were collected. Number of atrial premature complexes (APCs) per hour was categorized as less than 10 APCs/hour, 10-30 APCs/hour, and more than 30 APCs/hour. Results Most of the patients had less than 10 APCs/hour (82.6%), 8.2% had 10-30 APCs/hour, and 9.2% had more than 30 APCs/hour. Patients with more than 30 APCs/hour had a greater median left atrium diameter than patients with 30 APCs/hour or less (42 mm vs. 38 mm; 95% confidence interval [CI], .50-7.00; P = .003). Annual recurrence rate of CIS or TIA was 2.9% in patients with less than 10 APCs/hour, 11.0% in 10-30 APCs/hour, and 22.6% in more than 30 APCs/hour ( P = .001). More than 30 APCs/hour were independently associated with recurrence risk in multivariate survival analysis (hazard ratio, 3.40; 95% CI, 1.12-10.32; P = .030). Conclusions In patients with CIS or TIA, frequent atrial ectopic activity (>30 APCs/h) was independently associated with increased risk of stroke or TIA recurrence. Further studies need to validate frequent atrial ectopic activity as a risk factor for recurrence in cryptogenic stroke and confirm its role as a predictor of occult atrial fibrillation.

OBJECTIVE To evaluate the effects of instrumental sacred music and sacred music with vocals on the spiritual well-being of bereaved relatives. METHOD This is a randomized clinical trial carried out with family members bereaving the death of loved ones to cancer. Participants were allocated into three groups: Group 1 (control), Group 2 (experimental using sacred music with vocals) or Group 3 (experimental using instrumental sacred music). Spiritual well-being was assessed through the Spiritual Well-Being Scale. RESULTS Sixty-nine (69) family members participated. Mean scores before and after the intervention indicated high levels of spiritual well-being (106.4 and 105.5 in Group 1; 103.2 and 105.2 in Group 2; 107.4 and 108.7 in Group 3) and religious well-being (57.9 and 56.9 in Group 1; 56.3 and 56.4 in Group 2; 57.4 and 58.1 in Group 3), and moderate levels of existential well-being (48.5 and 48.6 in Group 1; 46.9 and 48.9 in Group 2; 49.9 and 50.7 in Group 3), with the exception of Group 3 which presented a high level of existential well-being after the intervention. CONCLUSION The results show that there were no statistically significant differences in the spiritual well-being scores between the experimental groups and the control group. We evidence the need for further studies that use music therapy as a Nursing intervention for bereaved families. Brazilian Registry of Clinical Trials: RBR-2wtwjz. Resumen OBJETIVO Evaluar los efectos de la música sacra, instrumental y cantada en el bienestar espiritual de familiares enlutados. MÉTODO Se trata de un ensayo clínico randomizado, realizado con familiares enlutados por la muerte, por cáncer, de entes queridos. Los participantes fueron distribuidos en tres grupos: Grupo 1 (control), Grupo 2 (experimental con música sacra cantada) o Grupo 3 (experimental con música sacra instrumental). El bienestar espiritual fue valorado mediante la Escala de Bienestar Espiritual. RESULTADOS Participaron 69 familiares. Los puntajes medios, antes y después de la intervención, señalaron altos niveles de bienestar espiritual (106,4 y 105,5 en el Grupo 1; 103,2 y 105,2 en el Grupo 2; 107,4 y 108,7 en el Grupo 3) y bienestar religioso (57,9 y 56,9 en el Grupo 1; 56,3 y 56,4 en el Grupo 2; 57,4 y 58,1 en el Grupo 3), y moderados niveles de bienestar existencial (48,5 y 48,6 en el Grupo 1; 46,9 y 48,9 en el Grupo 2; 49,9 y 50,7 en el Grupo 3), con excepción del Grupo 3, el que previa intervención presentó alto nivel. CONCLUSIÓN Los resultados demuestran que no hubo diferencia estadísticamente significativa en los puntajes de bienestar espiritual entre los grupos experimentales y el grupo control. Se evidencia la necesidad de nuevas investigaciones que utilicen la musicoterapia como intervención de Enfermería a la familia enlutada. Registro Brasileño de Ensayos Clínicos: RBR-2wtwjz. Resumo OBJETIVO Avaliar os efeitos da música sacra, instrumental e cantada, no bem-estar espiritual de familiares enlutados. MÉTODO Trata-se de um ensaio clínico randomizado, realizado com familiares enlutados pela morte, por câncer, de entes queridos. Os participantes foram alocados em três grupos: Grupo 1 (controle), Grupo 2 (experimental com música sacra cantada) ou Grupo 3 (experimental com música sacra instrumental). O bem-estar espiritual foi avaliado por meio da Escala de Bem-Estar Espiritual. RESULTADOS Participaram 69 familiares. Os escores médios, antes e após a intervenção, indicaram altos níveis de bem-estar espiritual (106,4 e 105,5 no Grupo 1; 103,2 e 105,2 no Grupo 2; 107,4 e 108,7 no Grupo 3) e bem-estar religioso (57,9 e 56,9 no Grupo 1; 56,3 e 56,4 no Grupo 2; 57,4 e 58,1 no Grupo 3), e moderados níveis de bem-estar existencial (48,5 e 48,6 no Grupo 1; 46,9 e 48,9 no Grupo 2; 49,9 e 50,7 no Grupo 3), com exceção do Grupo 3 que, após a intervenção, apresentou alto nível. CONCLUSÃO Os resultados demonstram que não houve diferença estatisticamente significativa nos escores de bem-estar espiritual entre os grupos experimentais e o grupo controle. Evidencia-se a necessidade de novas pesquisas que utilizem a musicoterapia como intervenção de Enfermagem à família enlutada. Registro Brasileiro de Ensaios Clínicos: RBR-2wtwjz.

INTRODUCTION Red cell distribution width (RDW) has been found to be a prognostic marker in vascular diseases. Increased RDW predicted mortality and outcome after ischemic stroke however, the underlying mechanisms are unclear. Our study aimed to clarify the relation of RDW with stroke severity and 1-year survival. MATERIAL AND METHODS Single-centre retrospective cohort study based on a prospective database of consecutive patients with acute anterior circulation ischemic stroke treated with intravenous thrombolysis (IVT) in a 9-year period. Clinical characteristics were collected from the registry. Additional information, namely pre-IVT RDW, was retrieved from individual patient records. Information concerning survival during the first year after stroke was collected from the national Health Data Platform. RESULTS 602 patients were included. Patients in the higher RDW quartiles were older, and more frequently presented hypertension and cardioembolic etiology. RDW was higher in patients who presented early infection and a positive correlation was found between RDW and C-reactive protein. RDW was not associated with admission severity of stroke, neurological status 24 h after stroke or occurrence of symptomatic intracranial hemorrhage (sICH). Patients in the higher quartiles of RDW presented a lower 1-year survival (p

An otherwise healthy girl aged 4 years was observed because of a 6-month history of tachycardia, polyphagia, chronic cough and agitation. Physical examination revealed hiperhydrosis, exuberant exophthalmia (figure 1) and a palpable, elastic and painless goitre. Laboratory work up showed an increased FT4, low thyroid-stimulating hormone (TSH) and positive thyrotropin receptor antibodies (TRABs) (figure 2), and thyroid ultrasonography demonstrated a diffusely heterogeneous, enlarged gland with no nodules, compatible with Graves' disease. The girl was initiated immediately to treatment with tiamazole (MTZ) and propranolol, and after few months, an euthyroid state was achieved and maintained until 2 years (figure 2). After this period, MTZ treatment was suspended and …

To the Editor: In an interesting subanalysis of the important IST-3 (Third International Stroke Trial),1 the authors studied the impact of insular cortex infarct, visualized in follow-up scans, on functional outcome and death at 6 months. In this analysis, only patients with documented ischemic lesions in follow-up scans were included. Patients with insular involvement more frequently had admission National Institutes of Health Stroke Scale (NIHSS) score of ≥15 (59.3% versus 25.0%) and atrial fibrillation (35.3% versus 28.1%), and there was a marginal statistical difference concerning treatment allocation, with more patients with insular involvement having received alteplase (52.0% versus 47.4%). Unadjusted death at 6 months was strikingly higher for patients with right or left insular involvement; however, this association persisted only for right insular infarct after adjustment for …