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Objectives The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines. Methods Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine. Results Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000). Conclusions Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.

Summary Background Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS. Methods The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece). Findings Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82–0·90) for high-urgency patients and 0·67 (0·61–0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87–0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81–0·85). Interpretation The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs. Funding Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.

OBJECTIVE To characterize the bulbospongiosus muscle (BSM) in patients with bulbar urethral strictures. MATERIALS AND METHODS We studied 21 patients divided into 2 groups: Stricture Group (n = 14; mean age = 62.00 years) with bulbar stricture submitted to open urethroplasty; and Control Group (n = 7; mean age = 60.14 years) with penile strictures (hypospadias cripples, penile cancer and/or penile infection) who were submitted to perineal urethrostomy. Samples of the BSM were dissected and histologic sections were stained by histochemical and immunohistochemical techniques. Histomorphometric analyzes were performed on photomicrographs. Means were statistically compared using the unpaired Student t test and the Mann-Whitney test (P RESULTS The etiology of bulbar urethral stricture was idiopathic in 2 cases (14.29%), post-TURP in 6 (42.86%), post open radical prostatectomy in 5 (35.71%) and post open prostatectomy in 1 case (7.14%). The average length of the stricture was 2.08 cm. The only parameter analyzed with significant difference between the groups was the vessels (significant difference between the control group: 5.11 ± 1.98% and stricture group: 3.57 ± 1.32%, P = .0460). The quantitative analysis of collagen (Control Group: 10.63 ± 5.37% and Stricture Group: 10.83 ± 4.55%, P = .9296); diameter of BSM muscle fibers (Control Group: 41.71 ± 14.63 µm and Stricture Group: 40.11 ± 8.59 µm, P = .76 and elastic system fibers (Control Group; 3.83 ± 1.54% and Stricture Group: 5.43 ± 2.90%, P = .2601) showed no significant difference. CONCLUSIONS Histologic analysis showed a significant decrease of the BSM vessels in urethral stricture, without changes in elastic fibers, collagen, nerves, and muscle fiber diameter. These findings show that the bulbar urethral stricture causes minimal alterations in the structure of the BSM.

Background To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department. Methods and findings A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk Conclusion We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Forecasting COVID-19 disease severity is key to supporting clinical decision making and assisting resource allocation, particularly in intensive care units (ICUs). Here, we investigated the utility of time- and frequency-related features of the backscattered signal of serum patient samples to predict COVID-19 disease severity immediately after diagnosis. ICU admission was the primary outcome used to define disease severity. We developed a stacking ensemble machine learning model including the backscattered signal features (optical fingerprint), patient comorbidities, and age (AUROC = 0.80), which significantly outperformed the predictive value of clinical and laboratory variables available at hospital admission (AUROC = 0.71). The information derived from patient optical fingerprints was not strongly correlated with any clinical/laboratory variable, suggesting that optical fingerprinting brings unique information for COVID-19 severity risk assessment. Optical fingerprinting is a label-free, real-time, and low-cost technology that can be easily integrated as a front-line tool to facilitate the triage and clinical management of COVID-19 patients. This work has received funding from the Portuguese Foundation for Science and Technology, FCT, through the Research4COVID19 project 156_596835053; and from the European Union’s Horizon 2020 Research and Innovation Programme through the INNO4COV-19 project (Grant Agreement No 101016203). This study is part of an activity that has received funding from EIT Health. EIT Health is supported by the European Institute of Innovation and Technology (EIT), a body of the European Union and receives support from the European Union´s Horizon Europe Research and innovation programme. D.A.C was funded by the NIHR Biomedical Research Centre Programme, Oxford.

Made available in DSpace on 2022-04-28T19:40:44Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-06-01 Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG) Background: The hematology of turtles of the Amazon, such as the Arrau turtle (Podocnemis expansa), has not been well described in the literature. Referencing how to collect and analyze blood samples is fundamental for the medical practice of these exotic animals. Objectives: The aim of this study was to evaluate the hematologic parameters of Arrau turtles of the Amazon to determine the best anticoagulant (EDTA, citrate, or sodium heparin) and cytologic stain (Giemsa, Quick Panoptic, or Rosenfeld) for use with this species. Methods: Blood samples from eight turtles were collected. Three blood smears were made using blood without anticoagulant, and the rest of the sample was distributed in three tubes, containing EDTA, citrate, and sodium heparin, for erythrogram and leukogram analyses. Results: All blood samples anticoagulated with EDTA showed marked hemolysis. Blood collected with citrate showed minimal hemolysis, and blood collected with sodium heparin did not have any hemolysis. Some analyses were not performed on blood containing EDTA because of the intense hemolysis. The erythrocyte variables were obtained and showed better results for blood samples in heparin. Blood smears without anticoagulant were appropriate for differential leukocyte counts with the three stain types, while blood with any of the anticoagulants made it difficult to differentiate leukocytes. Conclusions: Sodium heparin showed the best results and should be the anticoagulant of choice for hematologic studies in P expansa. All cytologic stains were efficient, allowing adequate identification of distinct cell groups. Leukocyte differentiation was assured and had better contrast using blood smears made from blood without an anticoagulant. Mestrado em Sanidade e Produção Animal nos trópicos Curso de Medicina Veterinária Universidade de Uberaba Universidade de Uberaba Escola de Medicina Veterinária Instituto Federal Goiano Faculdade de Ciências Agrárias e Veterinárias de Jaboticabal Universidade Estadual Paulista Júlio de Mesquita Filho Faculdade de Ciências Agrárias e Veterinárias de Jaboticabal Universidade Estadual Paulista Júlio de Mesquita Filho

Summary Objective The purpose of this study was to investigate the effects of low-intensity strength training with vascular occlusion on specific parameters of neural drive using amplitude and spectral analysis of surface electromyography. Equipment and methods Twenty individuals were assigned to one of two groups (low-intensity strength training with or without vascular occlusion). The first group performed three sets of knee extension exercises until failure, with a 90 seconds interval between sets, while the second group performed three sets of the mean repetitions of the first group. Both groups performed the exercises with the load set at 20% of estimated 1 maximal repetition. To assess electromyographic parameters, sessions 1, 7 and 12 were evaluated, specifically from the first to third repetitions and the 3 final repetitions. One maximal repetition was measured in the same collection times. Results Our findings demonstrated that low-intensity strength training with vascular occlusion improved muscular strength; however, it did not affect the neural drive, since there were no differences in the investigated parameters between sessions. Conclusion Low-intensity strength training with vascular occlusion is effective for producing muscular strength; however, it is not indicated for increases in neural activity.

Objective Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability. Design The TrIAGE project, a prospective observational study based on electronic health record data. Patients and setting Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9–36 months (2012–2014). Main outcome measures We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables. Results In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13–80% in the participating hospitals. Laboratory tests and X-rays were performed in 8–33% of the cases and 21–61% was treated with inhalation medication. Admission rates varied between 8–47% and PICU admission rates varied between 0.1–9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings. Conclusion European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.

Background: Several studies have suggested that preterm births might increase risk for obstructive sleep apnea syndrome (OSAS). The presence of sleep apnea in snoring children based on clinical history alone is often difficult to assess. Aims and objectives: The aim of this study was to determine whether perinatal factors are associated with OSAS in snoring children. Materials and Methods: Retrospective analysis of data from children referred to our department for snoring between March 2016 and March 2020 was performed. Children with orofacial congenital anomalies or non respiratory sleep disorders were excluded. The association between neonatal factors (weight percentile at birth, prematurity, Apgar scores), age at surgery, weight percentile at surgery and adenoid/tonsillar hypertrophy with the presence of obstructive sleep apnea were analyzed. Apneas were considered based on clinical records from relative’s information (filmed respiratory pauses) or Polysomnography reports. Results: 1040 children met the eligibility criteria, 41.8% with OSAS. After correction for potential confounders using a Binary Multivariable Logistic Regression, only tonsillar hypertrophy with need for tonsillectomy significantly associated with obstructive sleep apnea (93.8% versus 66.6% in children without OSAS; pl0.001). Weight at birth, prematurity, Apgar scores, age at surgery, weight at surgery and adenoid hypertrophy did not show an association with OSAS (p g 0,05). Conclusion: Our results fail to show that perinatal risk factors are important for predicting the presence of obstructive sleep apnea in snoring children. Only tonsillar hypertrophy significantly associated with presence of OSAS.

Introduction and objective: To evaluate changes in verumontanum anatomy in patients with benign prostatic hyperplasia (BPH) who used 5-alpha reductase inhibitors (5-ARIs) and to propose an anatomical classification of the verumontanum. Materials and Methods: We studied 86 patients with BPH and 7 patients without the disease (age under 40 years-old who underwent kidney or ureteral lithotripsy). Of the patients with BPH, 34 (mean age=67.26) had 5-ARIs use and 52 (mean age=62.69) did not use the drug. During surgeries, photographs of the seminal colliculus were taken and later, with the aid of software (Image J), the length (longitudinal diameter) and width (transverse diameter) of the verumontanum were measured in all patients. During the procedure, we evaluated the different types of verumontanum. For statistical analysis, the R-Project software was used. Results: In the group of patients with BPH who were taking medication (group 1), the mean measures of length and width of the verumontanum were 4.69mm and 2.94mm respectively. In the group of patients with BPH who did not use the drug (group 2), the mean diameters were 4.54mm and 3.20mm respectively. In the control group (group 3), the average length and width were 5.63mm and 4.11mm respectively. There was an increase in longitudinal and transverse measurements of the control group with an increase in body mass index (BMI) (p=0.0001 and p=0.035 respectively). In addition, there was a reduction in transverse diameter in the group of BPH using 5-ARI with increased prostate volume (p=0.010). We found five different verumontanum types: “volcano” (51.61%), “lighthouse” (24.73%), “whale tail” (12.90%), “hood” (5.38%) and “castle door” (5.38%), which we propose as an anatomical classification. Conclusion: Veromontanum has smaller measurements in patients with BPH regardless of treatment. In the control group, there was an increase in verumontanum diameters with an increase in BMI. The volcano type of verumontanum was the most frequent regardless of groups and BMI.

Background Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department. Methods and findings The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children 2 0.199 versus 0.204). Conclusions Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS.

Objective To assess the characteristics of suspected coronavirus disease 19 (COVID-19) and the rate of confirmed COVID-19 in a pediatric population at the beginning of the pandemic in Portugal. Study design Suspected COVID-19 pediatric cases that were tested in a Portuguese hospital between March 17 and April 2 2020 were included in this descriptive retrospective study. The analyzed data included socio-demographic parameters, characteristics of the household, underlying medical conditions and symptoms. Results Ninety-four patients were included and all of them were symptomatic and treated without hospitalization. The most common symptoms were cough (80%;n = 75), rhinorrhea (72%;n = 68) and fever (60%;n = 56). There was only one positive for SARS-CoV-2 in a five-year-old child with mild illness without epidemiologic linkage. Conclusion This study showed a low rate of confirmed COVID-19 in children. The causes for this low rate can be multifactorial and illustrates how differently this virus spreads in the pediatric population.

Made available in DSpace on 2020-12-12T01:33:30Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-11-15 Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG) Insular cortex is a brain structure involved in the modulation of autonomic activity and cardiovascular function. The nitric oxide/cyclic guanosine-3′,5′-monophosphate pathway is a prominent signaling mechanism in the central nervous system, controlling behavioral and physiological responses. Nevertheless, despite evidence regarding the presence of nitric oxide-synthesizing neurons in the insular cortex, its role in the control of autonomic and cardiovascular function has never been reported. Thus, the present study aimed to investigate the involvement of nitric oxide/cyclic guanosine-3′,5′-monophosphate pathway mediated by neuronal nitric oxide synthase (nNOS) activation within the insular cortex in the modulation of baroreflex responses in unanesthetized rats. For this, we evaluated the effect of bilateral microinjection of either the nitric oxide scavenger carboxy-PTIO, the selective neuronal nitric oxide synthase inhibitor Nω-Propyl-L-arginine or the soluble guanylate cyclase inhibitor ODQ into the insular cortex on the bradycardia evoked by blood pressure increases in response to intravenous infusion of phenylephrine, and the tachycardia caused by blood pressure decreases evoked by intravenous infusion of sodium nitroprusside. Bilateral microinjection of either NPLA or carboxy-PTIO into the insular cortex increased the reflex bradycardic response, whereas the reflex tachycardia was decreased by these treatments. Bilateral microinjection of the soluble guanylate cyclase inhibitor into the insular cortex did not affect any parameter of baroreflex function evaluated. Overall, our findings provide evidence that insular cortex nitrergic signaling, acting via neuronal nitric oxide synthase, plays a prominent role in control of baroreflex function. However, control of reflex responses seems to be independent of soluble guanylate cyclase activation. Department of Pharmacology School of Medicine of Ribeirão Preto University of São Paulo Laboratory of Pharmacology School of Pharmaceutical Sciences São Paulo State University (UNESP) Department of Health Sciences Faculty of Medicine – Federal University of Lavras Laboratory of Pharmacology School of Pharmaceutical Sciences São Paulo State University (UNESP) CNPq: 141992/2016-6 FAPESP: 2015/05922-9 CNPq: 456405/2014-3 FAPEMIG: APQ-01316-16

ObjectiveTo assess the role of sex in the presentation and management of children attending the emergency department (ED).DesignThe TrIAGE project (TRiage Improvements Across General Emergency departments), a prospective observational study based on curated electronic health record data.SettingFive diverse European hospitals in four countries (Austria, The Netherlands, Portugal, UK).ParticipantsAll consecutive paediatric ED visits of children under the age of 16 during the study period (8–36 months between 2012 and 2015).Main outcome measuresThe association between sex (male of female) and diagnostic tests and disease management in general paediatric ED visits and in subgroups presenting with trauma or musculoskeletal, gastrointestinal and respiratory problems and fever. Results from the different hospitals were pooled in a random effects meta-analysis.Results116 172 ED visits were included of which 63 042 (54%) by boys and 53 715 (46%) by girls. Boys accounted for the majority of ED visits in childhood, and girls in adolescence. After adjusting for age, triage urgency and clinical presentation, girls had more laboratory tests compared with boys (pooled OR 1.10, 95% CI 1.05 to 1.15). Additionally, girls had more laboratory tests in ED visits for respiratory problems (pooled OR 1.15, 95% CI 1.04 to 1.26) and more imaging in visits for trauma or musculoskeletal problems (pooled OR 1.10, 95% CI 1.01 to 1.20) and respiratory conditions (pooled OR 1.14, 95% CI 1.05 to 1.24). Girls with respiratory problems were less often treated with inhalation medication (pooled OR 0.76, 95% CI 0.70 to 0.83). There was no difference in hospital admission between the sexes (pooled OR 0.99, 95% CI 0.95 to 1.04).ConclusionIn childhood, boys represent the majority of ED visits and they receive more inhalation medication. Unexpectedly, girls receive more diagnostic tests compared with boys. Further research is needed to investigate whether this is due to pathophysiological differences and differences in disease course, whether girls present signs and symptoms differently, or whether sociocultural factors are responsible.

The main objective of this study was to examine the effect of continuous aerobic training (CAT) in hypertensive, obese people. Seven patients of average age (45.3±3.9 years), height (1.63±0.1 m), body weight (89.09±22.0 kg), and body mass index (33.44±8.6 kg/m2) were subjected to the training. CAT was performed in thrice-weekly nonconsecutive sessions (90 min per week) with intervals of 48 hr between each session. The training sessions entailed 30 min of walking at an intensity of 70%-80% of the maximum heart rate (MHR) on a treadmill over a period of eight weeks, giving a total of 24 sessions. Through correlation analyses, we found significant improvement in the systolic pressure (R=0.5675, P=0.0253) and diastolic pressure (R=0.7083, P=0.0088) when the last session was compared to the first session of training. We found no differences in the diastolic pressure and systolic pressure before, during and after 15 min of the protocol exercise. The program showed a large effect size (ES) for systolic pressure (ES=0.85) and a small ES for diastolic pressure (ES=0.33). We found no differences in the blood pressure (BP) and heart rate (HR) during and after the training of obese hypertensive humans, but we found a positively significant correlation between HR and BP in the last session and a large ES, suggesting that this protocol exercise might have significance effect in the long term.

The medial preoptic area (mPOA) participates in the temperature and cardiovascular control. The mPOA receives inputs from limbic structures and sends projections to hypothalamus and brainstem. Moreover, stress elicits pronounced neuronal activation in mPOA, suggesting its involvement in central neural pathway mediating stress responses. In the present study, we report the effect of acute mPOA neurotransmission inhibition using cobalt chloride (CoCl2-nonselective synapse blocker) on the mean arterial pressure (MAP), heart rate (HR), body and tail temperature (Tbody and Ttail, respectively), as well as on the HR component of baroreflex. We also verified the participation of mPOA in the autonomic changes evoked by acute restraint stress (RS). Our results demonstrated that microinjection of CoCl2 into mPOA caused tachycardia, hyperthermia and a Ttail decrease, without altering MAP. The inhibition of mPOA with CoCl2 increased the sympathetic component of cardiac baroreflex when assessed 10min after its administration. In addition, pretreatment of mPOA with CoCl2 increased RS-evoked tachycardic and hyperthermic responses evoked by RS when compared with aCSF-treated animals, without affecting the RS-evoked pressor response and the fall in Ttail. In summary, our results suggest that mPOA exerts a tonic inhibitory influence on the sympathetic cardiac tone under both rest and stress conditions, modulating negatively the sympathetic component of baroreflex. Results also confirm the mPOA involvement in the control of body temperature because its inhibition was followed by a sustained increase in body temperature and vasoconstriction in the tail artery territory.

BackgroundThe aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.MethodsWe analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.ResultsPatients presenting at night were younger (median (IQR) age: 3.7 (1.4–8.2) years vs 4.8 (1.8–9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78–0.86 and aOR: 0.64, 95% CI 0.60–0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49–1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24–1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.ConclusionsChildren visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

BACKGROUND Transforming growth factor β1 (TGF-β1) and tumour necrosis factor (TNF) have been implicated in Chagas disease pathophysiology and may correlate with left ventricular (LV) function. OBJECTIVES We determined whether TGF-β1 and TNF serum levels correlate with LV systolic and diastolic functions and brain natriuretic peptide (BNP) serum levels in chronic Chagas disease. METHODS This cross-sectional study included 152 patients with Chagas disease (43% men; 57 ± 12 years old), classified as 53 patients with indeterminate form and 99 patients with cardiac form (stage A: 24, stage B: 25, stage C: 44, stage D: 6). TGF-β1, TNF, and BNP were determined by enzyme-linked immunosorbent assay ELISA. Echocardiogram was used to determine left atrial and LV diameters, as well as LV ejection fraction and diastolic function. FINDINGS TGF-b1 serum levels were lower in stages B, C, and D, while TNF serum levels were higher in stages C and D of the cardiac form. TGF-β1 presented a weak correlation with LV diastolic function and LV ejection fraction. TNF presented a weak correlation with left atrial and LV diameters and LV ejection fraction. CONCLUSIONS TNF is increased, while TGF-β1 is decreased in the cardiac form of chronic Chagas disease. TNF and TGF-β1 serum levels present a weak correlation with LV systolic and diastolic function in Chagas disease patients.

BACKGROUND McNeal divided the human prostate into three major anatomical areas: the peripheral zone (PZ), the central zone (CZ), and the transition zone (TZ). Each of these areas is biologically and histologically distinct. The PZ and TZ have clinical significance and are associated with prostate cancer (PC) and benign prostatic hyperplasia (BPH), respectively. Therefore, the objective of the present study was to quantitatively and qualitatively analyze the parenchymal and stromal components that constitute the different prostate zones. METHODS We assessed 19 samples from each prostate zone. The samples were obtained from necropsies of young people between 18 and 32 years of age with intact urogenital tracts. The samples were fixed in 4% buffered formalin and processed for paraffin embedding. Sections with a thickness of five micrometres were obtained from each sample. The sections were stained using histochemical and immunohistochemical techniques to identify the acinar and stromal components of each zone. Photomicrographs were obtained for morphometric analysis using an algorithm based on color segmentation. Data were analyzed using one-way analysis of variance (ANOVA) with the Bonferroni post-test. Differences with P

Introduction: Ureteropelvic junction obstruction (UPJO) is the most common congenital cause of upper urinary tract obstruction in children. Our objective is to report our experience concerning the first 20 laparoscopic pyeloplasties. Material and methods: Retrospective study including twenty children with diagnosis of UPJO that underwent laparoscopic pyeloplasty by a single surgeon, at our Hospital, between November 2010 and December 2014, with at least one year of follow-up. Success was defined as absence of conversion, resolution of symptoms and radiologic criteria improvement. Results: Median age at surgery was 9.5 years (range between 10 months and 17 years-old). Intrinsic obstruction was found in 7 cases, extrinsic obstruction in 12 cases and one case with both situations. Median operative time was 235 minutes (range between 165-275 minutes), with need for conversion in 2 cases (10%). Median hospital stay was 2 days (range between 2-5 days. Four patients (20%) had early postoperative complications and two cases (10%) needed surgical revision during follow-up. Median follow-up time was 33 months (range between 12-60 months). In follow-up, all but two patients were asymptomatic. There was radiologic improvement of hydronephrosis in all patients but one, although he had non-obstructive pattern in renographic drainage. Conclusion: Our results are similar to those found in literature, with success rates comparable to open pyeloplasty with advantages of minimally invasive surgery.

Background The International Pharmacists for Anticoagulation Care Taskforce (iPACT) is an expert group committed to enhancing the key role that pharmacists play in anticoagulation management. Pharmacists are ideally suited to monitor patients in this therapeutic area, but an assessment of their knowledge in providing consultations has not been formally evaluated. Purpose The purpose of this needs assessment survey was to identify self-reported gaps in competences and confidence among practising pharmacists in the area of anticoagulation; to identify variances in confidence levels between community and hospital pharmacists; and to examine areas of anticoagulation with varying needs. Material and methods An electronic link to the needs assessment survey was distributed to the pharmacists in the participating countries via their respective professional organisations or colleges. Countries with adequate response rates included in the preliminary statistical analysis were Canada, France, Portugal, Croatia, Brazil, Ireland, Hungary, New Zealand and the UK. Results 1692 pharmacists completed the survey. The distribution of respondents were Canada 357 (21.1%), France 304 (18.0%), New Zealand 237 (14.0%), Portugal 180 (10.6%), Croatia 180 (10.6%), Hungary 171 (10.1%), Brazil 76 (4.5%), Ireland 68 (4.0%) and the UK 60 (3.5%). Community pharmacists had the highest participation 759 (44.9%) while outpatient hospital pharmacists, inpatient hospital pharmacists working on wards and other practice sites represented 133 (7.9%), 339 (20.0%) and 461 (27.2%) of the population, respectively. Overall, pharmacists were less confident in providing information on DOACs compared with VKA (83.4% vs 55.5%; p 0.005) but significantly higher when comparing those pharmacists working on inpatient hospital wards (mean score=24.0 vs 26.0; p 0.005). More than 90% of pharmacists reported they would like additional education in anticoagulation with personalised e-learning as the preferred source. Conclusion These results highlight the apparent lack of confidence by both community and hospital pharmacists when discussing anticoagulation, particularly DOACs. Future continuing education programmes should be developed on electronic platforms focusing on practical clinical themes that apply across all settings. No conflict of interest

This study focused on cognitive representations of low back pain patients receiving chiropractic (n = 213) versus physiotherapy treatment (n = 125). Variables assessed included satisfaction with care, illness perceptions, beliefs about pain and medicines, attitudes towards doctors and medicine, suffering, adherence and functional incapacity. In the chiropractic treatment, functional incapacity was predicted by painful symptoms, suffering and personal control, and in the physiotherapy treatment by age, pain intensity, positive suffering, care satisfaction, illness identity and medication adherence. The groups differed on all cognitive variables assessed. Interventions should take into consideration cognitive dimensions, across treatment modalities., info:eu-repo/semantics/submittedVersion

Systemic administration of cannabidiol (CBD) is able to attenuate cardiovascular responses to acute restraint stress through activation of 5-HT1A receptors. Previous results from our group suggest that the bed nucleus of the stria terminalis (BNST) is involved in the antiaversive effects of the CBD. Moreover, it has been proposed that synapses within the BNST influence restraint-evoked cardiovascular changes, in particular by an inhibitory influence on the tachycardiac response associated to restraint stress. Thus, the present work investigated the effects of CBD injected into the BNST on cardiovascular changes induced by acute restraint stress and if these effects would involve the local activation of 5-HT1A receptors. The exposition to restraint stress increased both blood pressure and heart rate (HR). The microinjection of CBD (30 and 60 nmol) into the BNST enhanced the restraint-evoked HR increase, in a dose-dependent manner, without affecting the pressor response. The selective 5-HT1A receptor antagonist WAY100635 by itself did not change the cardiovascular responses to restraint stress, but blocked the effects of CBD. These results showed that CBD microinjected into the BNST enhanced the HR increase associated with acute restraint stress without affecting the blood pressure response. Although these results are not in agreement with those observed after systemic administration of CBD, they are similar to effects observed after reversible inactivation of the BNST. Moreover, similar to the effects observed after systemic administration, CBD effects in the BNST seem to depend on activation of 5-HT1A receptors.

Neural reflex mechanisms, such as the baroreflex, are involved in regulating cardiovascular system activity. Previous results showed that the ventral portion of the medial prefrontal cortex (vMPFC) is involved in modulation only of the cardiac baroreflex bradycardic component. Moreover, vMPFC N-methyl-D-aspartate (NMDA) receptors modulate the bradycardia baroreflex, but the baroreflex tachycardic component has not been investigated. Furthermore, glutamatergic neurotransmission into the vMPFC is involved in activation of the cardiac sympathetic and parasympathetic nervous system. Finally, it has been demonstrated that glutamatergic neurotransmission into the vMPFC can be modulated by the endocannabinoid system and that activation of the CB1 cannabinoid receptor by anandamide, an endocannabinoid, can decrease both cardiac baroreflex bradycardic and tachycardic responses. Thus, there is the possibility that glutamatergic neurotransmission into the vMPFC does not modulate only the cardiac bradycardic component of the baroreflex. Therefore, the present study investigated whether glutamatergic neurotransmission into the vMPFC modulates both cardiac baroreflex bradycardic and tachycardic responses. We found that vMPFC bilateral microinjection of the NMDA receptor antagonist AP7 (4 nmol/200 nl), of a selective inhibitor of neuronal nitric oxide (NO) synthase N-propyl (0.08 nmol/200 nl), of the NO scavenger carboxy-PTIO (2 nmol/200 nl), or of the NO-sensitive guanylate cyclase ODQ (2 nmol/200 nl) decreased the baroreflex activity in unanesthetized rats. Therefore, our results demonstrate the participation of NMDA receptors, production of NO, and activation of guanylate cyclase in the vMPFC in the modulation of both cardiac baroreflex bradycardic and tachycardic responses. © 2013 Wiley Periodicals, Inc.

Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-27T11:29:38Z No. of bitstreams: 0 Made available in DSpace on 2014-05-27T11:29:38Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-06-03 Dynamic exercise evokes sustained cardiovascular responses, which are characterized by arterial pressure and heart rate increases. Although it is well accepted that there is central nervous system mediation of cardiovascular adjustments during exercise, information on the role of neural pathways and signaling mechanisms is limited. It has been reported that glutamate, by acting on NMDA receptors, evokes the release of nitric oxide through activation of neuronal nitric oxide synthase (nNOS) in the brain. In the present study, we tested the hypothesis that NMDA receptors and nNOS are involved in cardiovascular responses evoked by an acute bout of exercise on a rodent treadmill. Moreover, we investigated possible central sites mediating control of responses to exercise through the NMDA receptor-nitric oxide pathway. Intraperitoneal administration of the selective NMDA glutamate receptor antagonist dizocilpine maleate (MK-801) reduced both the arterial pressure and heart rate increase evoked by dynamic exercise. Intraperitoneal treatment with the preferential nNOS inhibitor 7-nitroindazole reduced exercise-evoked tachycardiac response without affecting the pressor response. Moreover, treadmill running increased NO formation in the medial prefrontal cortex (MPFC), bed nucleus of the stria teminalis (BNST) and periaqueductal gray (PAG), and this effect was inhibited by systemic pretreatment with MK-801. Our findings demonstrate that NMDA receptors and nNOS mediate the tachycardiac response to dynamic exercise, possibly through an NMDA receptor-NO signaling mechanism. However, NMDA receptors, but not nNOS, mediate the exercise-evoked pressor response. The present results also provide evidence that MPFC, BNST and PAG may modulate physiological adjustments during dynamic exercise through NMDA receptor-NO signaling. © 2013 Elsevier B.V. Department of Natural Active Principles and Toxicology School of Pharmaceutical Sciences São Paulo State University, Rodovia Araraquara-Jau Km 01, Caixa Postal 502, Araraquara, SP, 14801-902 Department of Pharmacology School of Medicine of Ribeirão Preto University of São Paulo, Ribeirão Preto, SP, 14049-900 Department of Natural Active Principles and Toxicology School of Pharmaceutical Sciences São Paulo State University, Rodovia Araraquara-Jau Km 01, Caixa Postal 502, Araraquara, SP, 14801-902

Aims To evaluate the effectiveness of gestational diabetes (GDM) treatment compared to usual antenatal care, in the prevention of adverse pregnancy outcomes. Additionally, to assess the quality of the evidence to support GDM treatment according to GRADE guidelines. Methods Fourteen electronic databases and reference lists of relevant literature were searched for articles published from inception to February, 2012. Controlled clinical trials comparing GDM treatment to usual antenatal care were included. Independent extraction of articles was done by two authors using predefined data fields. Results Seven trials involving 3157 women were included. We found high quality evidence that treatment of GDM reduces macrosomia (RR = 0.47; 95% CI, 0.34–0.65; NNT = 11.4) and large for gestational age birth (RR = 0.57; 95% CI, 0.47–0.71; NNT = 12.2); moderate quality evidence that treatment reduces preeclampsia (RR = 0.61; 95% CI, 0.46–0.81; NNT = 21.0) and hypertensive disorders in pregnancy (RR = 0.64; 95% CI, 0.51–0.81; NNT = 18.1); and low quality evidence that treatment reduces shoulder dystocia (RR = 0.41; 95% CI, 0.22–0.76; NNT = 48.8). No statistically significant reduction was seen for caesarean section. No increase in small for gestational age or preterm birth was found. Conclusions Treatment of GDM is effective in reducing macrosomia (high quality evidence), preeclampsia and shoulder dystocia.

In several patients, intellectual disability and/or congenital malformation may be attributed to chromosomal changes. In this study, we conducted an array-CGH test of 200 patients from the Northeast of Brazil with intellectual disability and/or congenital malformation. Blood samples were collected from the proband and from their parents when possible. DNA was extracted and investigated using the array-CGH test. Findings were evaluated for the pathogenicity in databases of benign and pathogenic changes (ISCA, UCSC, DGV, and DECIPHER). Forty-seven copy number variations (CNVs) were identified in 43/200 (21.5%) patients, including 25/98 (25.5%) in males and 22/102 (21.57%) in females. We considered 33 of these to be clinically significant, reaching a diagnosis rate of 16.5%. The sizes of the CNVs varied from 102 kb to 24 Mb in deletions and from 115 kb to 140 Mb in duplications. In 10/47 (21.3%) patients, the rearrangement involved a sex chromosome. Thirty-nine patients had one chromosomal aberration, while 2 concomitant abnormalities were detected in 4 patients. Ten of 47 CNVs (21.3%) were > 5Mb in size. Fifteen patients had CNVs related to known syndromes. This research highlights the contribution of submicroscopic chromosomal changes to the etiology of intellectual disability and/or congenital malformation, particularly the implication of chromosomal abnormalities detected using an array-CGH test, with a high rate of 16.5%. Thus, our results support the use of array-CGH replacing standard karyotype as the first-tier cytogenetic diagnostic test for patients with multiple congenital anomalies and/or intellectual disability.

AIM: To investigate the expression profiles of hsa-miR-29c and hsa-miR-135b in gastric mucosal samples and their values as gastric carcinogenesis biomarkers. METHODS: The expression levels of hsa-miR-29c and hsa-miR-135b in normal gastric mucosa, non-atrophic chronic gastritis, intestinal metaplasia and intestinal-type gastric adenocarcinoma were analysed using quantitative real-time PCR. The difference between hsa-miR-29c and hsa-miR-135b expression profiles in the grouped samples was evaluated by ANOVA and Student’s t-test tests. The results were adjusted for multiple testing by using Bonferroni’s correction. P values ≤ 0.05 were considered statistically significant. To evaluate hsa-miR-29c and hsa-miR-135b expressions as potential biomarkers of gastric carcinogenesis, we performed a receiver operating characteristic curve analysis and the derived area under the curve, and a Categorical Principal Components Analysis. In silico identification of the genetic targets of hsa-miR-29c and hsa-miR-135b was performed using different prediction tools, in order to identify possible genes involved in gastric carcinogenesis. RESULTS: The expression levels of hsa-miR-29c were higher in normal gastric mucosal samples, and decreased progressively in non-atrophic chronic gastritis samples, intestinal metaplasia samples and intestinal-type gastric adenocarcinoma samples. The expression of hsa-miR-29c in the gastric lesions showed that non-atrophic gastritis have an intermediate profile to gastric normal mucosa and intestinal-type gastric adenocarcinoma, and that intestinal metaplasia samples presented an expression pattern similar to that in intestinal-type gastric adenocarcinoma. This microRNA (miRNA) has a good discriminatory accuracy between normal gastric samples and (1) intestinal-type gastric adenocarcinoma; and (2) intestinal metaplasia, and regulates the DMNT3A oncogene. hsa-miR-135b is up-regulated in non-atrophic chronic gastritis and intestinal metaplasia samples and down-regulated in normal gastric mucosa and intestinal-type gastric adenocarcinoma samples. Non-atrophic chronic gastritis and intestinal metaplasia are significantly different from normal gastric mucosa samples. hsa-miR-135b expression presented a greater discriminatory accuracy between normal samples and gastric lesions. This miRNA was associated with Helicobacter pylori presence in non-atrophic chronic gastritis samples and regulates the APC and KLF4 tumour suppressor genes. CONCLUSION: Our results provide evidence of epigenetic alterations in non-atrophic chronic gastritis and intestinal metaplasia and suggest that hsa-miR-29c and hsa-miR-135b are promising biomarkers of gastric carcinogenesis.

Neural reflex mechanisms, such as the baroreflex, are involved in the regulation of cardiovascular system activity. Previous results from our group (Resstel LB, Correa FM. Medial prefrontal cortex NMDA receptors and nitric oxide modulate the parasympathetic component of the baroreflex. Eur J Neurosci 23: 481–488, 2006) have shown that glutamatergic synapses in the ventral portion of the medial prefrontal cortex (vMPFC) modulate baroreflex activity. Moreover, glutamatergic neurotransmission in the vMPFC can be modulated by the endocannabinoids system (eCBs), particularly the endocannabinoid anandamide, through presynaptic CB1receptor activation. Therefore, in the present study, we investigated eCBs receptors that are present in the vMPFC, and more specifically whether CB1receptors modulate baroreflex activity. We found that bilateral microinjection of the CB1receptor antagonist AM251 (100 or 300 pmol/200 nl) into the vMPFC increased baroreflex activity in unanesthetized rats. Moreover, bilateral microinjection of either the anandamide transporter inhibitor AM404 (100 pmol/200 nl) or the inhibitor of the enzyme fatty acid amide hydrolase that degrades anandamide, URB597 (100 pmol/200 nl), into the MPFC decreased baroreflex activity. Finally, pretreatment of the vMPFC with an ineffective dose of AM251 (10 pmol/200 nl) was able to block baroreflex effects of both AM404 and URB597. Taken together, our results support the view that the eCBs in the vMPFC is involved in the modulation of baroreflex activity through the activation of CB1receptors, which modulate local glutamate release.

The lateral septal area (LSA) is a limbic structure involved in autonomic, neuroendocrine and behavioural responses. An inhibitory influence of the LSA on baroreflex activity has been reported; however, the local neurotransmitter involved in this modulation is still unclear. In the present study, we verified the involvement of local LSA adrenoceptors in modulating cardiac baroreflex activity in unanaesthetized rats. Bilateral microinjection of the selective α1-adrenoceptor antagonist WB4101 (10 nmol in a volume of 100 nl) into the LSA decreased baroreflex bradycardia evoked by blood pressure increases, but had no effect on reflex tachycardia evoked by blood pressure decreases. Nevertheless, bilateral administration of the selective α2-adrenoceptor antagonist RX821002 (10 nmol in 100 nl) increased baroreflex tachycardia without affecting reflex bradycardia. Treatment of the LSA with a cocktail containing WB4101 and RX821002 decreased baroreflex bradycardia and increased reflex tachycardia. The non-selective β-adrenoceptor antagonist propranolol (10 nmol in 100 nl) did not affect either reflex bradycardia or tachycardia. Microinjection of noradrenaline into the LSA increased reflex bradycardia and decreased the baroreflex tachycardic response, an opposite effect compared with those observed after double blockade of α1- and α2-adrenoceptors, and this effect of noradrenaline was blocked by local LSA pretreatment with the cocktail containing WB4101 and RX821002. The present results provide advances in our understanding of the baroreflex neural circuitry. Taken together, data suggest that local LSA α1- and α2-adrenoceptors modulate baroreflex control of heart rate differently. Data indicate that LSA α1-adrenoceptors exert a facilitatory modulation on baroreflex bradycardia, whereas local α2-adrenoceptors exert an inhibitory modulation on reflex tachycardia.

In the present study, we investigated the role played by the hypothalamic paraventricular nucleus (PVN) in the modulation of cardiac baroreflex activity in unanesthetized rats. Bilateral microinjections of the nonselective neurotransmission blocker CoCl(2) into the PVN decreased the reflex bradycardic response evoked by blood pressure increases, but had no effect on reflex tachycardia evoked by blood pressure decreases. Bilateral microinjections of the selective NMDA glutamate receptor antagonist LY235959 into the PVN caused effects that were similar to those observed after microinjections of CoCl(2), decreasing reflex bradycardia without affecting tachycardic response. The microinjection of the selective non-NMDA glutamate receptor antagonist NBQX into the PVN did not affect the baroreflex activity. Also, the microinjection of L-glutamate into the PVN increased the reflex bradycardia, an effect opposed to that observed after PVN treatment with CoCl(2) or LY235959, and this effect of L-glutamate was blocked by PVN pretreatment with LY235959. LY235959 injected into the PVN after i.v. treatment with the selective beta(1)-adrenoceptor antagonist atenolol still decreased the reflex bradycardia. Taken together, our results suggest a facilitatory influence of the PVN on the bradycardic response of the baroreflex through activation of local NMDA glutamate receptors and a modulation of the cardiac parasympathetic activity.

The authors report one case of late cutaneous Schistosomiasis mansoni in a biopsy of a skin lesion in the sacral region in a 51-year-old female living in Contagem, Minas Gerais. The patient was treated successfully with oxamniquine (Mansil®).