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This article reports the rationale for the Brazilian Cardioprotective Nutritional Program (BALANCE Program) Trial. This pragmatic, multicenter, nationwide, randomized, concealed, controlled trial was designed to investigate the effects of the BALANCE Program in reducing cardiovascular events. The BALANCE Program consists of a prescribed diet guided by nutritional content recommendations from Brazilian national guidelines using a unique nutritional education strategy, which includes suggestions of affordable foods. In addition, the Program focuses on intensive follow-up through one-on-one visits, group sessions, and phone calls. In this trial, participants 45 years or older with any evidence of established cardiovascular disease will be randomized to the BALANCE or control groups. Those in the BALANCE group will receive the afore mentioned program interventions, while controls will be given generic advice on how to follow a low-fat, low-energy, low-sodium, and low-cholesterol diet, with a view to achieving Brazilian nutritional guideline recommendations. The primary outcome is a composite of death (any cause), cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, or hospitalization for unstable angina. A total of 2468 patients will be enrolled in 34 sites and followed up for up to 48 months. If the BALANCE Program is found to decrease cardiovascular events and reduce risk factors, this may represent an advance in the care of patients with cardiovascular disease., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The patient-centered medical home is an innovative approach to improve health care outcomes. To address the unique needs of patients with intellectual and developmental disabilities (IDDs), a large health care provider reevaluated the National Committee for Quality Assurance's 6 medical home standards: (a) enhance access and continuity, (b) identify and manage patient populations, (c) plan and manage care, (d) provide self-care and community support, (e) track and coordinate care, and (f) measure and improve performance. This article describes issues to consider when serving patients with IDDs.

Aim of the Study: To demonstrate how, on the basis of the personal experience, the rendezvous technique, in the management of cholelithiasis associated with choledocolithiasis , whenever there is the indication, is better than the sequential treatment., Methods: From January 2008 to May 2011, 48 patients with cholelithiasis and choledocolithiasis combined were treated with endolaparoscopic technique. Of these patients, 23 were treated with the sequential treatment and 25 with the rendezvous method. We attempted to define the indications for endolaparoscopic rendezvous: - cholelithiasis associated with choledocolithiasis or biliary sludge not bigger than 1 cm; - permeability of the colecystic duct; - a clinical picture of medium-low importance., Conclusions: The data of the study confirm the superiority of the rendezvous technique because it resolves cholelithiasis associated with choledocolithiasis in a single surgical act with greater acceptance of the patient who avoids a second invasive surgical act; moreover it requires shorter hospitalization and convalescence, resulting in reduced costs. Finally the data analyzed show a reduction in complications compared to sequential treatment.

A 57-year-old woman underwent an enucleoresection of her right kidney angiomyolipoma. Two weeks later she was admitted to our hospital because of dyspnea at rest with orthopnea. The chest x-ray showed the elevation of both hemidiaphragms and the measurement of the sniff transdiaphragmatic pressure confirmed the diagnosis of bilateral diaphragmatic paralysis. A diaphragm paralysis can be ascribed to several causes, i.e. trauma, compressive events, inflammations, neuropathies, or it can be idiopathic. In this case, it was very likely that the patient suffered from post-surgery neuralgic amyotrophy. To our knowledge, there are only a few reported cases of neuralgic amyotrophy, also known as Parsonage-Turner Syndrome, which affects only the phrenic nerve as a consequence of a surgery in an anatomically distant site.

The lipid content and composition of Haematococcuspluvialis exposed to stress conditions were analyzed to assess the potential of this microalga as a biodiesel feedstock. The total lipid content of control cells was 15.61% dw, whereas that of cells exposed to continuous high light intensity with nitrogen-sufficient medium (A-stress condition) or under continuous high light intensity with nitrogen-deprivation medium (B-stress condition) was 34.85% dw and 32.99% dw, respectively. The fatty acid profile was similar under all conditions and indicated that the main components were palmitic, stearic, oleic, linoleic, linolenic and linolelaidic acids. The neutral lipid fraction increased about 2-fold under both stress conditions. The percentage of saturated fatty acids in the neutral lipid fraction was 30.36% and 29.62% in cultures grown under A-stress and B-stress, respectively, and 27.81% under control conditions. The monounsaturated fatty acid content was not significantly different in control and A-stress cultures (20.07% and 19.91%, respectively), but was 18.96% under B-stress. The content of polyunsaturated fatty acids was 47.23% under B-stress and 43.15% under A-stress. Growth-rate was higher under A-stress compared to B-stress. This is the first study of H.pluvialis that provides a detailed characterization of its lipid content in relation to bioenergy. The results indicate the potential of this microalga as a biodiesel feedstock; however, culture conditions still have to be improved in order to achieve an adequate energy balance in mass culture., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Chronic elbow subluxation is uncommon but challenging to treat. Although many treatment methods have been described, few clinical outcome studies have been done because of the infrequency of the condition. Reconstruction has been better defined for radial head deficiencies than for the coronoid. Recognizing and repairing or reconstructing any associated soft-tissue deficiencies are important to a good outcome. For some patients, protecting the reconstruction with a hinged external fixator is recommended to allow early range of motion.

This study compared the conventional parameters of anaerobic cycling power in physically active non-cyclists using the Pro-Race system and a traditional chainring. The force-velocity test was chosen for this purpose because it is the shortest validated cycling laboratory test in which each parameter of maximal anaerobic power can be estimated. The power output (W(max)) and the force at which W(max) is produced (F(opt)) were significantly improved with the eccentric chainring (1100+/-227W versus 1006+/-197W and 1.39+/-0.15N/kg body mass versus 1.13+/-0.16N/kg body mass with the eccentric and round designs, respectively; P<0.006 and P<0.0004, respectively). The power gained (delta power) was significantly correlated with the eccentric chainring F(opt) (r=0.649; P<0.05), the mid-thigh circumference (r=0.685; P<0.05), the estimated lean thigh volume (r=0.765; P<0.01) and the estimated lean lower limb volume (r=0.665; P<0.05). We concluded that the eccentric chainring significantly improved the estimated anaerobic power output during a force-velocity test by increasing the force component, F(opt). Cautious interpretation of our results suggests that the subjects with physical attributes that contribute to developing high forces may have a significant advantage in performing with the eccentric chainring.

Objectives: To compare the distances travelled for inpatient treatment in England between electoral wards prior to the introduction of a policy to extend patient choice and to consider the impact of patients' socio-economic status., Methods: Using Hospital Episode Statistics for 2003-04, the distance from a patient's residence to a National Health Service hospital was calculated for each admission. Distances were summed to electoral ward level to give the distribution of distances travelled at ward level. These were analysed to show the distance travelled for different admission types, ages of patient, rural/urban location, and the socioeconomic deprivation of the population of the ward., Results: There is considerable variation in the distances travelled for hospital admission between electoral wards. Some of this is explained by geographical location: individuals living in more rural areas travel further for elective (median 27.2 versus 15.0 km), emergency (25.3 versus 13.9 km) and maternity (25.0 versus 13.9 km) admissions. But individuals located in highly deprived wards travel less far, and this shorter distance is not explained simply by the closer location of hospitals to these wards., Conclusions: Before the introduction of more patient choice, there were considerable differences between individuals in the distances they travelled for hospital care. An increase in patient choice may disproportionately benefit people from less deprived areas.

This study assessed whether an eccentric chainring that increases crank arm length at the downstroke and decreases it during the upstroke improves performance in a track cycling event: the 1000m time trial. It also determined whether selected physical and physiological variables and the velocity profile are associated with eccentric chainring performance. Twelve cyclists performed an outdoor 1000m time trial on a 333m banked, cement-surfaced track using two different chainrings, round and eccentric, in randomised order. The important findings of this study were that (1) performance did not significantly differ between chainrings; (2) neither the physiological variables (lactate and heart rate) nor the velocity profile (lap times) were affected by use of the eccentric design; (3) when time was saved with the eccentric chainring, it was significantly correlated with estimated lower limb muscle volume (r=-0.605), circumference (r=-0.739), estimated calf muscle volume (r=-0.772) and cross-sectional area (r=-0.745). Moreover, estimated lower limb muscle volume (r=-0.703), estimated calf muscle volume (r=-0.772) and cross-sectional area (r=-0.871) significantly predicted performance with the eccentric chainring. The physical variables associated with eccentric chainring performance were muscle anthropometric parameters. We have interpreted our results cautiously and suggest that the subjects who had greater lower limb muscle volume and greater calf muscle volume, seem to have had a significant advantage in performing with the eccentric chainring. Further testing with track specialists performing at national or international level would be helpful to define the maximal possibilities of this chainring.

Objective: To identify where in England there are likely to be most constraints on choice of hospital for patients waiting longer than six months for elective care., Design: Cross sectional study using routinely collected data., Setting: Population of England and NHS trusts and private sector hospitals in England., Participants: All residents in England., Main Outcome Measures: Availability of beds (available and unoccupied hospital beds), demand (number of people waiting longer than six months), and access (travel time to facilities) to hospital care in England., Results: Most people in England already have an extensive potential choice of hospital. The number of available and unoccupied beds within 60 minutes' travel time was lowest in the Scottish borders, North Yorkshire, and parts of East Anglia, Lincolnshire, Devon, and Cornwall. This pattern was not altered by adding in private facilities. Putting demand with this supply, the number of people in a geographical area waiting longer than six months per bed within 60 minutes' travel time was highest in the south east (except London), parts of the south west (Cornwall, Bristol), East Anglia, and the Welsh border., Conclusion: People in the south east (outside London), East Anglia, and parts of the south west are likely to have to travel further to exercise meaningful choice of hospital for elective care.

The aim of this study was to establish the effect of time of day on maximal anaerobic leg power in a tropical environment (French West Indies). Twenty-three physical education students (15 males and 8 females) who trained 10.5 hours a week (SD 6) volunteered to participate in the study. Their mean age, height and body mass were 22.8 (SD 3) years, 172.6 (SD 8) cm, and 64.6 (SD 7) kg, respectively. The chronotype of all subjects was moderate or intermediate. Tests were scheduled at 08 : 00, 13 : 00 and 17 : 00 hours on separate days in random order and constant conditions (room temperature: 28.1 degrees C [SD 0.6], relative room humidity: 62.6 % [SD 3.4]). On test days, the subjects were first measured at rest for body mass, heart rate and rectal temperature and they then performed vertical jump tests and a force-velocity test. The results showed a time-of-day effect on rectal temperature, which was significantly (p < 0.005) higher by the afternoon (13 : 00 and 17 : 00) than the morning (08 : 00). However, our results failed to show any daytime variation in maximal anaerobic power under the influence of tropical climate, which suggests that a hot and humid environment may have blunted the time-of-day effect by a passive warm-up effect.

Phagocytosis is a receptor-mediated process by which specialized cell types engulf large extracellular particles. Phagosome maturation involves a series of intracellular membrane fusion and budding events resulting in the delivery of particles to compartments enriched in lysosomal hydrolases where they are digested. Substantial amounts of plasma membrane and many phagosomal proteins, such as receptors, rapidly recycle to the plasma membrane following phagosome formation. Despite the importance of this recycling pathway in phagosome maturation and in the retrieval of immunogenic peptides from phagosomes, the molecular machinery involved is largely unknown. To assess the participation of GTPases in phagocytosis and recycling from phagosomes we used aluminum fluoride (AIF(-)(4)), which activates the GDP-bound form of stimulatory and inhibitory trimeric G proteins. AlF(-)(4) inhibited both the uptake to and the recycling from the phagosomal compartment. Cholera toxin, which activates Galphas, and pertussis toxin, which uncouples Gi and Go from receptors, were effective inhibitors of phagocytosis. However, both toxins stimulated recycling from phagosomes. These results suggest that more than one GTP-binding protein participates either directly or indirectly not only in phagocytosis, but also in maturation and recycling from phagosomes, and thereby assign a role for heterotrimeric G proteins in controlling traffic through the phagocytic pathway., (Copyright 2001 Academic Press.)

Objective: The hypertensive state is often associated with metabolic abnormalities, including glucose intolerance. Tissue kallikrein, a potent kinin-generating enzyme, is present in the vascular wall and heart tissue. High dietary fructose consumption is reported to induce hyperinsulinemia, hypertriglyceridemia and hypertension. The objective of the present study was to examine the status of kallikrein in vascular and cardiac tissue from highly fructose-fed rats and to delineate the effect of kinins and the angiotensin converting enzyme inhibitor ramipril in this animal model of glucose intolerance., Design and Methods: Male Wistar rats (350 g body weight) were divided into four groups of 10 rats each: (1) controls; (2) oral ramipril at 500 microg/kg per day for the last 2 study weeks; (3) fructose in drinking water as a 10% (w/v) solution for 4 weeks; and (4) fructose + ramipril, with fructose administered as in group 3 plus the administration of ramipril for the last 2 study weeks. Systolic blood pressure (tail-cuff method), glucose tolerance (2 g/kg body weight intraperitoneally) and metabolic parameters were recorded. Kallikrein activity in tail artery and heart tissue homogenates was estimated at the end of the 4th study week from measurements of kininogenase activity and kinins generated by a radioimmunoassay., Results: The area under the curve for the glucose tolerance test increased from 1265 +/- 103 mmol/l after 120 min in the control and 1152 +/- 36 mmol/l in the ramipril group (NS) to 2628 +/- 143 mmol/l in the fructose group (P<0.01). The administration of ramipril to fructose-treated rats in group 4 improved glucose tolerance (2160 +/- 100 mmol/l; P<0.05 versus group 3). Blood pressure increased significantly in fructose-fed rats but fell markedly in fructose-fed rats treated with ramipril (P<0.01). Kallikrein activity measured in the heart and vessels increased as a consequence of fructose administration (P<0.05), but the administration of ramipril increased this parameter to a much greater extent (P<0.01 versus control group), which correlated closely with the decrease in blood pressure and the improvement in glucose tolerance observed in the fructose + ramipril group., Conclusions: The administration of fructose as a solution in the drinking water induced glucose intolerance and increased blood pressure. Treatment with the angiotensin converting enzyme inhibitor ramipril improved glucose tolerance and significantly diminished blood pressure. Cardiovascular kinin-generating capability increased in treated animals and this increase was even higher when rats were treated with ramipril, suggesting that kinins, acting as a paracrine hormonal system, can exert cardiovascular protection and contribute to the beneficial effects of angiotensin converting enzyme inhibitor.

With the aim of implementing an intervention program on physician's prescribing behaviour for diarrhoea in children under five, an ethnoepidemiological study was conducted in Pelotas (Brazil), from February to April 1993. Information on prescription of drugs was obtained through record review of 381 cases of diarrhoea provided by 33 medical doctors from eight health centres. Trained field workers observed a total of 54 clinical consultations due to diarrhoea. Brief exit interviews with the mothers were performed just after the observations. Twenty-seven open-ended home interviews were made with the mothers the day after they had been observed. After all observations had been completed, open-ended interviews were conducted with 21 physicians. The results showed that there is a misunderstanding of the role of ORS in the treatment of diarrhoea: mothers want something to "cut" diarrhoea and they notice that ORS does not act in this way and doctors do not explain the action of ORS in diarrhoea management. Comparing with record reviews, during observations a child had a lower probability of receiving an antibiotic or antidiarrheal drug prescription. This finding indicates that other variables than technical skills are involved in doctor's prescribing behaviour. A lack of ability or of motivation to deal with "anxious or difficult mothers" led some doctors to enhance antibiotic or other non-recommended drugs to manage diarrhoea. Therefore, efforts to improve the quality of case management of diarrhoea, through intervention programmes in the government health sector, are needed in Pelotas.

We describe the design and production of a mitre box that allows magnetic resonance imaging and pathological sectioning of a formalin-fixed brain so that the pathological and radiological slices are coplanar and therefore readily comparable.

The main objective of this study was to determine if the components of the kallikrein-kinin system are released into the venous effluent from isolated perfused rat hearts. To assess the contribution of kinins and the vascular and cardioprotective effects of the ACE inhibitor ramipril, we determined the status of cardiac kallikrein (CKK), potent kinin-generating enzyme, in rats with right ventricular hypertrophy induced by chronic volume overload and left ventricular hypertrophy by aortic banding. CKK was measured as previously described (Nolly, H.L., Carbini, L., Carretero, O.A., Scicli, A.G., 1994). Kininogen by a modification of the technique of Dinitz and Carvalho (1963) and kinins were extracted with a Sep-Pak C18 cartridge and measured by RIA. CKK (169 +/- 9 pg Bk/30 min), kininogen (670 +/- 45 pg Bk/30 min) and immunoreactive kinins (62 +/- 10 pg Bk/30 min) were released into the perfusate. The release was almost constant over a 120 min period. Pretreatment with the protein synthesis inhibitor puromycin (10 mg i.p.) lowered the release of kallikrein (42 +/- 12 pg Bk/30 min, p < 0.001) and kininogen (128 +/- 56 pg Bk/30 min, p < 0.001). Addition of ramiprilat (10 micrograms/ml) increased kinin release from 54 +/- 18 to 204 +/- 76 pg Bk/30 min (p < 0.001). Aortic banding of rats increased their blood pressure (BP) (p < 0.001), relative heart weight (RHW) (p < 0.001) and CKK (p < 0.001). Ramipril treatment induced a reduction in BP (p < 0.05) and RHW (p < 0.005) while CKK remained elevated. Aortocaval shunts increased their ANF plasma levels (p < 0.05), RHW (p < 0.001) and CKK (p < 0.01). Ramipril treatment induced a reduction in RHW (p < 0.05), while CKK and ANF increased significantly (p < 0.05). The present data show that the components of the kallikrein-kinin system are continuously formed in the isolated rat heart and that ramipril reduces bradykinin breakdown with subsequent increase in bradykinin outflow. The experiments with aorta caval shunt and aortic banding show that cardiac tissues increase their kinin-generating activity and this was even higher in ramipril-treated animals. This may suggest that the actual level of kinins is finely tuned to the local metabolic demands. In this experimental model of cardiac hypertrophy. ACE inhibitors potentiate the actions of kinins and probably try to normalise endothelial cell function.

In 1995, 463 patients were admitted in the medical service of Perugia (Sanitary District n. 6). Only 20% of them were enrolled in the TBC programme. Mantoux was: < 10 mm in 35%, 10-15 mm in 25%, > 15 mm in 40%. Chest Rx in 30 subjects demonstrated: normality in 19; old TBC in 7, active TBC in 4 (miliary, bilateral upper lobe pneumonitis, left subapical upper lobe pneumonitis and right lobitis of the upper lobe). All patients were admitted in hospital and showed positive sputum culture for Mycobacterium Tuberculosis. They were treated with isoniazid, rifampin, pyrazinamide, ethambutol/streptomycin for 2 months and with isoniazid, rifampin for other 4-8 months. Two patients showed Mycobacterium tuberculosis with isoniazid resistance. Seven patients were treated with isoniazid chemoprophylaxis without side effects. Migrants should receive information about health care service and be encourage to register themselves with a general practitioner. Skin test screening and chest radiographs for those with positive results should be provided at a convenient location.

The purpose of this study was to evaluate and to compare root canal configuration after preparation with three different hand instruments and techniques: the canal master U preparation technique (Brasseler, Savannah, GA.), using stainless steel or nickel-titanium canal master U instruments, and the step-back technique using precurved conventional stainless steel K-type files. Sixty-three simulated curved canals were divided in three groups of 21 each. Each group was prepared using one of the three instruments. Comparison of root canal configuration was evaluated with pre- and postoperative photographs that measured the difference in canal diameter and the mesial and distal transportation of the canal walls at the canal length and at levels 1, 2, 3, 4, 5, 6, 7, and 8 mm coronal to the canal length. Data obtained were analyzed statistically using an analysis of variance. Instrument breakage was also recorded. Results showed that the final diameter of the prepared canals as well as canal transportation were significantly different between both canal master U instruments and the stainless steel K file. Three stainless steel canal master U instruments separated during instrumentation whereas none in the nickel-titanium canal master U and stainless steel K-type file groups separated. The results of this study show that the canal master U instruments and technique provide a better canal configuration than K files using the step-back technique and that the nickel-titanium canal master U and stainless steel K-type file offers a greater safety factor against breakage than the stainless steel canal master U.

The vascular wall itself, through a complex interplay of endocrine, neurocrine and autoparacrine mechanisms, plays an active role in vascular homeostasis. The endothelial cell senses humoral and hemodynamic changes and responds by secreting a variety of metabolically active substances that act locally causing either vasodilatation or vasoconstriction. Kallikrein (KK) and the mRNA for KK are present in arteries and veins. Vascular KK releases kinins from kininogen which circulate in plasma and is also present in vascular tissue. Vascular-derived kinins induce vasodilatation through the release of endothelial compounds (prostacyclin, EDRFs and cytochrome P-450). Disturbance in the delicate balance between vasodilators and vasoconstrictors may play a role in the development of hypertension. Vascular kallikrein (VKK) was significantly (P < 0.05) elevated after 2 weeks of development of renovascular and mineralocorticoid hypertension, and blood pressure was only slightly elevated. However, VKK decreased in both experimental models when blood pressure was increased. It is possible that the increase in VKK in the early stages resulted in increased local vasodilatory activity, thus counteracting the rise in blood pressure. As hypertension developed, KK was significantly decreased in arteries. The decrease in arterial KK during established hypertension is most likely secondary to high blood pressure. When the endothelium is damaged by high blood pressure, diabetes, excessive LDL cholesterol or cigarette smoking, a net imbalance favoring vasoconstriction, proliferation and migration of cells and increased lipid deposition predisposes to specific vascular diseases. Converting enzyme inhibitors (CEI) blunt the proliferative response of vascular smooth muscle cells after endothelial injury. The cardiovascular protective effects of CEI are mediated in part by the antihypertrophic, antihyperplastic and antithrombotic effects of kinins. The vascular kallikrein-kinin system has a promising role in the regulation of vascular homeostasis and some of the CEI effects may be explained by potentiation of the vascular-derived kinins.

A series of 37 anthraquinones were evaluated for their ability to inhibit the induction of cytolytic T-lymphocytes in a mixed lymphocyte culture system, useful as a preliminary screen for immunosuppressive agents. These compounds were also tested for their ability to prevent the production of antibody in mice. It was demonstrated that 1,4-bis [(2-aminoethyl)amino]-5, 8-dihydroxy-9,10-anthracenedione dihydrochloride (AEAD, 2) derived from mitoxantrone (MX, 1) by removing hydroxyethyl groups from both side chains was extremely active in depressing immune responses in vitro and in vivo. Four additional anthraquinones related to AEAD were also identified to share similar suppressive activity. They include a Schiff base, 1,4-dihydroxy-5,8-bis[[2-[(3-pyridinylmethylene)amino]ethyl]amino] -9,10-anthracenedione; a dimer with N-terminals methylated, 1,1-[ethylenebis (iminoethyleneimino)]-bis [5,8-dihydroxy-4-[(2-methylamino-ethyl)amino] anthraquinone tetrahydrochloride; an oxazolidine, 1,4-dihydroxy-5,8-bis [[2-(2-propyl-3-oxazolidinyl)ethyl]amino] anthraquinone; and its polymeric oxazolidine, poly [5,8-dihydroxy-1,4-anthraquinonyleneiminoethylene-3,2-oxazolidine- diyltrimethylene-2,3-oxazolidinediylethyleneimino]. These compounds may warrant further consideration as candidates for the treatment of refractory autoimmune diseases and in organ transplantation.

A series of 3,6-bis(aminoalkoxy)acridines (2) was prepared and shown to have a protective antiviral effect against an interferon-sensitive virus (Columbia SK) and to partially restore an antibody response to a T-cell-dependent antigen in leukemic immunosuppressed mice. The presence of circulating interferon and the stimulation of natural killer cell activity in mice was observed for 21.

A 31-year-old white man presented with a 30-day history of dysphagia without weight loss. Esophagogram revealed a lobulated mass at the junction of the middle and lower third of the esophagus. Esophagoscopy showed the presence of a pigmented tumor at that level. Histological examination indicated that the tumor was a primary malignant melanoma. Partial esophagectomy was performed through a right thoracotomy incision, revealing hilar lymph nodes invaded by tumor. One month postoperatively, the patient died from extensive brain metastases.

Fifty-three patients were operated on with the transsphenoidal approach and a biologic tissue adhesive was used, in order to fix the mucoperiosteal flap. Results and advantages of the technique are discussed.