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BackgroundThe significance of detection of Trypanosoma cruzi DNA in blood of antibody-positive patients for risk of development of Chagas heart disease is not well established. The objective of this study was to compare detection of T. cruzi DNA with known clinical and laboratory markers of Chagas cardiomyopathy (CC) severity.MethodsThis is a case-control study nested within a retrospective cohort developed in Brazil to understand the natural history of Chagas disease. The study enrolled 499 T. cruzi seropositive blood donors (SP-BD) and 488 frequency matched seronegative control donors (SN-BD) who had donated between 1996 and 2002, and 101 patients with clinically diagnosed CC. In 2008-2010 all enrolled subjects underwent a health questionnaire, medical examination, electrocardiograms and echocardiograms and polymerase chain reaction (PCR) analyses. A blinded panel of three cardiologists adjudicated the outcome of CC. Trypanosoma cruzi kinetoplast minicircle sequences were amplified by real-time PCR using an assay with a sensitivity of one parasite per 20 mL of blood. All testing was performed on coded samples.ResultsRates of PCR detection of T. cruzi DNA were significantly (P = 0.003) higher in CC patients and SP-BD diagnosed with CC (79/105 [75.2 %]) compared with SP-BD without CC (143/279 [51.3%]). The presence of parasitaemia was significantly associated with known markers of disease progression such as QRS and QT interval duration, lower left ventricular ejection fraction, higher left ventricular index mass, and elevated troponin and NTpro-BNP levels.ConclusionTrypanosoma cruzi PCR positivity is associated with presence and severity of cardiomyopathy, suggesting a direct role of parasite persistence in disease pathogenesis.

A 36 year-old black female, complaining of headache of one month's duration presented with nausea, vomiting, somnolence, short memory problems, loss of weight, and no fever history. Smoker, intravenous drugs abuser, promiscuous lifestyle. Physical examination: left homonimous hemianopsia, left hemiparesis, no papilledema, diffuse hyperreflexia, slowness of movements. Brain CT scan: tumor-like lesion in the splenium of the corpus calosum, measuring 3.5 x 1.4 cm, with heterogeneous enhancing pattern, sugesting a primary CNS tumor. Due to the possibility of CNS infection, a lumbar puncture disclosed an opening pressure of 380 mmH(2)0; 11 white cells (lymphocytes); glucose 18 mg/dl (serum glucose 73 mg/dl); proteins 139 mg/dl; presence of Trypanosoma parasites. Serum Elisa-HIV tests turned out to be positive. Treatment with benznidazole dramatically improved clinical and radiographic picture, but the patient died 6 weeks later because of respiratory failure. T. cruzi infection of the CNS is a rare disease, but we have an increasing number of cases in HIV immunecompromised patients. Diagnosis by direct observation of CSF is uncommon, and most of the cases are diagnosed by pathological examination. It is a highly lethal disease, even when properly diagnosed and treated. This article intends to include cerebral trypanosomiasis in the differential diagnosis of intracranial space-occupying lesions, especially in immunecompromised patients from endemic regions.

Background Discrepancies in the literature regarding optimal optic nerve sheath diameter (ONSD) cutoffs for intracranial pressure (ICP) necessitate alternative neuroimaging parameters to improve clinical management. Purpose To evaluate the diagnostic accuracy of the dimensions of the perineural subarachnoid space to the optic nerve sheath ratio, measured using US, in predicting increased ICP. Materials and Methods In a prospective cohort study from April 2022 to December 2023, patients with suspected increased ICP underwent optic nerve US to determine the dimensions of arachnoid bulk (DAB) ratio and ONSD before invasive ICP measurement. Correlation between the parameters and ICP, as well as diagnostic accuracy, was assessed using area under the receiver operating characteristic curve (AUC) analysis. Results A total of 30 participants were included (mean age, 39 years ± 14 [SD]; 24 female). The DAB ratio and ONSD were significantly larger in participants with increased ICP (38% [0.16 of 0.42] and 14% [0.82 of 6.04 mm], respectively; P < .001). The DAB ratio showed a stronger correlation with ICP than ONSD ( r s = 0.87 [ P < .001] vs r s = 0.61 [ P < .001]). The DAB ratio and ONSD optimal cutoffs for increased ICP were 0.5 and 6.5 mm, respectively, and the ratio had higher sensitivity (100% vs 92%) and specificity (94% vs 83%) compared with ONSD. Moreover, the DAB ratio better predicted increased ICP than ONSD, with a higher AUC (0.98 [95% CI: 0.95, 1.00] vs 0.86 [95% CI: 0.71, 0.95], P = .047). Conclusion An imaging ratio was proposed to predict ICP based on the relative anatomy of the cerebrospinal fluid space, demonstrating more accurate diagnosis of increased ICP and a strong correlation with ICP values, suggesting its potential utility as a neuroimaging marker in clinical settings. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Shepherd in this issue.

Optic neuropathies include a wide range of disorders from ischemic, toxic, demyelinating, or inflammatory processes with acute/subacute onset to more gradual compressive or genetic etiologies. Accurate clinical history and multimodality optic nerve imaging including MRI and optical coherence tomography have greatly improved the diagnosis of patients with optic neuropathies. We report a case of a woman with severe monocular visual acuity deficit. Optic nerve sheath enhancement seen on MRI led to a broad differential diagnosis including demyelinating causes, optic nerve sheath meningioma (ONSM), tuberculosis, and sarcoid optic neuropathy. Lack of response to treatment with steroids or plasmapheresis led to biopsy, which confirmed the diagnosis of ONSM.

Objective: to elaborate and validate the Instrumento para Avaliação de Modelos metodológicos voltados ao Desenvolvimento de Tecnologias., Methods: a methodological study, developed in three stages: instrument structuring through documentary research and researchers' expertise; instrument validity with a panel of 11 expert judge nurses; and instrument final composition., Results: the instrument, after validity by experts, consisted of 30 items, divided into the content (26 items) and appearance (four items) domains. In the initial instrument validity process, 11 items were modified and seven were withdrawn, as they had a percentage of agreement below 0.80. The instrument showed excellent internal consistency, with values greater than 0.90 in its psychometric criteria., Conclusion: the instrument produced and validated aimed at assessing research methodological models for technological development showed good reliability, and may contribute to the methodological rigor of technological development research in nursing.

Parenting was drastically challenged during the COVID-19 pandemic as families complied with the consequent containment for sanitary and social reasons. The purpose of this study is to explore the relationships among self-report measures (co-parenting, emotional experience and parental support network) and the employment condition (teleworking parents and at-home parents with governmental leave aid) that might be associated with the everyday life change, and their contribution towards family's daily routines during the first COVID-19 lockdown. A sample of 878 parents (90.2% mothers), aged from 21 to 61 years (39.58 ± 6.08), and mainly of Portuguese nationality (97.2%), was gathered through an online survey. Participants completed sociodemographic data and answered questions related to four positive parenting dimensions (Daily routines, Co-parenting, Emotional experience, and Support network) rating on a five-point Likert scale how much their behavior changed during the lockdown. Descriptive statistics and multilinear regression models were tested as well as a mediation model. The results showed that Emotional experience, Co-parenting, and Support network played an important role in family Daily routines, reinforcing that the first COVID-19 lockdown was lived differently by parents according to their employment conditions. Furthermore, the pathways model of factors associated with parental adaptability is suggestive that the direct effect of Emotional experience on Daily routines is partially mediated by Co-parenting and Support network. In line with previous studies on the complexity and dynamic ecology of parenting, the reported indicators showcase the interrelated facets of parenting and its corresponding support needs. Further, clear indicators for the design of family support interventions and family resilience enhancement to stressor events are discussed.

Waste bin monitoring solutions are an essential step towards smart cities. This study presents an exploratory analysis of two waste bin monitoring approaches: (1) ultrasonic sensors installed in the bins and (2) visual observations (VO) of the waste collection truck drivers. Bin fill level data was collected from a Portuguese waste management company. A comparative statistical analysis of the two datasets (VO and sensor observations) was performed and a predictive model based on Gaussian processes was applied to enable a trade-off analysis of the number of collections versus the number of overflows for each monitoring approach. The results demonstrate that the VO are valuable and reveal that significant improvements can be achieved for either of the monitoring approaches in relation to the current situation. A monitoring approach based on VO combined with a predictive model is shown to be viable and leads to a considerable reduction in the number of collections and overflows. This approach can enable waste collection companies to improve their collection operations with minimal investment costs during their transition to fully sensorized bins.

Polycystic Echinococcosis (PE), a neglected life-threatening zoonotic disease caused by the cestode Echinococcus vogeli, is endemic in the Amazon. Despite being treatable, PE reaches a case fatality rate of around 29% due to late or missed diagnosis. PE is sustained in Pan-Amazonia by a complex sylvatic cycle. The hunting of its infected intermediate hosts (especially the lowland paca Cuniculus paca ) enables the disease to further transmit to humans, when their viscera are improperly handled. In this study, we compiled a unique dataset of host occurrences (~86000 records) and disease infections (~400 cases) covering the entire Pan-Amazonia and employed different modeling and statistical tools to unveil the spatial distribution of PE's key animal hosts. Subsequently, we derived a set of ecological, environmental, climatic, and hunting covariates that potentially act as transmission risk factors and used them as predictors of two independent Maximum Entropy models, one for animal infections and one for human infections. Our findings indicate that temperature stability promotes the sylvatic circulation of the disease. Additionally, we show how El Niño-Southern Oscillation (ENSO) extreme events disrupt hunting patterns throughout Pan-Amazonia, ultimately affecting the probability of spillover. In a scenario where climate extremes are projected to intensify, climate change at regional level appears to be indirectly driving the spillover of E. vogeli . These results hold substantial implications for a wide range of zoonoses acquired at the wildlife-human interface for which transmission is related to the manipulation and consumption of wild meat, underscoring the pressing need for enhanced awareness and intervention strategies.

Background: Handicap is a patient-centered measure of health status that encompasses the impact of social and physical environment on daily living, having been assessed in advanced and late-stage Parkinson's Disease (PD)., Objective: To characterize the handicap of a broader sample of patients., Methods: A cross-sectional study of 405 PD patients during the MDS-UPDRS Portuguese validation study, using the MDS-UPDRS, Unified Dyskinesias Rating Scale, Nonmotor symptoms questionnaire, PDQ-8 and EQ-5D-3L. Handicap was measured using the London Handicap Scale (LHS)., Results: Mean age was 64.42 (±10.3) years, mean disease duration 11.30 (±6.5) years and median HY 2 (IQR, 2-3). Mean LHS was 0.652 (±0.204); "Mobility," "Occupation" and "Physical Independence" were the most affected domains. LHS was significantly worse in patients with longer disease duration, older age and increased disability. In contrast, PDQ-8 did not differentiate age groups. Handicap was significantly correlated with disease duration ( r  = -0.35), nonmotor experiences of daily living (EDL) (MDS-UPDRS-I) ( r  = -0.51), motor EDL (MDS-UPDRS-II) ( r  = -0.69), motor disability (MDS-UPDRS-III) ( r  = -0.49), axial signs of MDS-UPDRS-III ( r  = -0.55), HY ( r  = -0.44), presence of nonmotor symptoms ( r  = -0.51) and PDQ-8 index ( r  = -0.64) (all P  < 0.05). Motor EDL, MDS-UPDRS-III and PDQ-8 independently predicted Handicap (adjusted R 2  = 0.582; P  = 0.007)., Conclusions: The LHS was easily completed by patients and caregivers. Patients were mild-moderately handicapped, which was strongly determined by motor disability and its impact on EDL, and poor QoL. Despite correlated, handicap and QoL seem to differ in what they measure, and handicap may have an added value to QoL. Handicap seems to be a good measure of perceived-health status in a broad sample of PD., (© 2023 International Parkinson and Movement Disorder Society.)

Many vertebrate species undergo population fluctuations that may be random or regularly cyclic in nature. Vertebrate population cycles in northern latitudes are driven by both endogenous and exogenous factors. Suggested causes of mysterious disappearances documented for populations of the Neotropical, herd-forming, white-lipped peccary (Tayassu pecari, henceforth "WLP") include large-scale movements, overhunting, extreme floods, or disease outbreaks. By analyzing 43 disappearance events across the Neotropics and 88 years of commercial and subsistence harvest data for the Amazon, we show that WLP disappearances are widespread and occur regularly and at large spatiotemporal scales throughout the species' range. We present evidence that the disappearances represent 7-12-year troughs in 20-30-year WLP population cycles occurring synchronously at regional and perhaps continent-wide spatial scales as large as 10,000-5 million km2. This may represent the first documented case of natural population cyclicity in a Neotropical mammal. Because WLP populations often increase dramatically prior to a disappearance, we posit that their population cycles result from over-compensatory, density-dependent mortality. Our data also suggest that the increase phase of a WLP cycle is partly dependent on recolonization from proximal, unfragmented and undisturbed forests. This highlights the importance of very large, continuous natural areas that enable source-sink population dynamics and ensure re-colonization and local population persistence in time and space., Competing Interests: The authors have declared that no competing interests exist.

We report the case of a patient with symptoms of myelopathy following acute SARS-CoV-2 infection. MRI documented a longitudinally extensive transverse myelitis and further investigation was unremarkable with the exception of positivity for MOG-IgG in serum. This report extends the spectrum of post-COVID-19 neurological syndromes, and documents a very significant improvement to long-term oral corticosteroid therapy in this setting. Further prospective studies are needed to establish the risk of recurrence in this subset of patients., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The COVID-19 pandemic challenged parental resources pertinent to coping with lockdowns. The main objective of this work was to study parenting during the COVID-19 lockdown. Specifically at focus were parental behaviors concerning key domains for the family (daily routine, co-parenting, emotional experience, and support network) and changes related to the pandemic and associated with the parents' employment statuses. An online survey was carried out through an ad hoc questionnaire where participants completed questions about their sociodemographic data and rated how much their family routines, their co-parenting relationship, their emotional experiences, and the support available in the family network varied on a 5-point scale. The participants included 1384 parents, of which 286 responded to open questions regarding impactful experiences during the lockdown. The results showed differences in daily routine, co-parenting, emotional experience, and support network according to the parents' employment statuses. Between-group comparisons showed that at-home parents caring for children with governmental aids generally revealed more positive parenting behavior changes, while at-home parents who were teleworking reported more difficulties in parent-child activities and co-parenting. Furthermore, the content analysis of the data confirmed how important themes such as family dynamics, professional activities, and the relationship with the school community were throughout the participants' accounts of gains and losses. Overall, parents' employment statuses are associated with diverse experiences during lockdown. The COVID-19 pandemic highlighted the importance of family resources and parental resilience, particularly during circumstances jeopardizing the ever-sensitive work-family balance.

The COVID-19 pandemic has brought humanity's strained relationship with nature into sharp focus, with calls for cessation of wild meat trade and consumption, to protect public health and biodiversity. 1 , 2 However, the importance of wild meat for human nutrition, and its tele-couplings to other food production systems, mean that the complete removal of wild meat from diets and markets would represent a shock to global food systems. 3-6 The negative consequences of this shock deserve consideration in policy responses to COVID-19. We demonstrate that the sudden policy-induced loss of wild meat from food systems could have negative consequences for people and nature. Loss of wild meat from diets could lead to food insecurity, due to reduced protein and nutrition, and/or drive land-use change to replace lost nutrients with animal agriculture, which could increase biodiversity loss and emerging infectious disease risk. We estimate the magnitude of these consequences for 83 countries, and qualitatively explore how prohibitions might play out in 10 case study places. Results indicate that risks are greatest for food-insecure developing nations, where feasible, sustainable, and socially desirable wild meat alternatives are limited. Some developed nations would also face shocks, and while high-capacity food systems could more easily adapt, certain places and people would be disproportionately impacted. We urge decision-makers to consider potential unintended consequences of policy-induced shocks amidst COVID-19; and take holistic approach to wildlife trade interventions, which acknowledge the interconnectivity of global food systems and nature, and include safeguards for vulnerable people., Competing Interests: Declaration of interests The authors declare no competing interests. HB is also affiliated with the Wildlife Conservation Society., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

The understanding and neurological prognostication of hypoxic ischemic encephalopathy (HIE) after hypothermic cardiac arrest (CA) is limited. Recent data suggest that the protein tau ( total tau) might be a useful marker for outcome in patients with HIE. This translational porcine study aimed to analyze brain physiology in relation to total tau protein release during hypothermic CA. Eight domestic pigs were studied as part of a prospective porcine study using cerebral microdialysis (CMD). CMD samples for tau analysis were collected at baseline, after reaching the targeted core temperature of 28°C (hypothermia), after hypoxic hypercapnia (partial asphyxia), and finally 20 minutes after cardiopulmonary resuscitation. CMD-total tau -protein was analyzed using enzyme-linked immunosorbent essay. Cerebral tau protein was slightly elevated at baseline most likely due to an insertion trauma, remained stable during hypercapnic hypoxia, and significantly ( p  = 0.009) increased in 8/8 pigs during resuscitation to 1335 pg/mL (interquartile range: 705-2100). CMD- tau release was associated with lower levels of brain tissue oxygen tension ( p  = 0.011), higher CMD-lactate/pyruvate ratio, higher CMD-lactate, CMD-glutamate, and CMD-glycerol levels ( p  < 0.001, respectively), but not with cerebral perfusion pressure, intracranial pressure, or CMD-glucose levels. This study demonstrates an immediate tau protein release accompanied by deranged cerebral metabolism and decreased brain tissue oxygen tension during mechanical resuscitation in hypothermic CA. Understanding tau physiology and release kinetics is important for the design and interpretation of studies investigating tau as a biomarker of HIE.

As the numbers of SARS-CoV-2 infections increased globally, reports of cutaneous manifestations started to emerge. We describe several patients with COVID-19 who presented with skin changes. We noted such manifestations in four out of 110 patients (3.63%) and describe the clinical situation of each of these patients. Each patient had either a maculopapular or a urticariform rash. These manifestations have a broad differential diagnosis and it was difficult to exclude drug reactions. We hope to raise awareness of this possible manifestation of COVID-19 in order to raise suspicion of this diagnosis among clinicians when they encounter patients with fever and rash. Larger series that also include patients with mild disease and skin biopsies may be useful., Learning Points: Cutaneous manifestations can occur as part of COVID-19, so clinicians should be suspicious of this diagnosis in patients with fever and rash.The differential diagnosis is large and drug reactions are difficult to rule out., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data., (© 2020 The Authors. Ecology © 2020 The Ecological Society of America.)

The persistent high deforestation rate and fragmentation of the Amazon forests are the main threats to their biodiversity. To anticipate and mitigate these threats, it is important to understand and predict how species respond to the rapidly changing landscape. The short-eared dog Atelocynus microtis is the only Amazon-endemic canid and one of the most understudied wild dogs worldwide. We investigated short-eared dog habitat associations on two spatial scales. First, we used the largest record database ever compiled for short-eared dogs in combination with species distribution models to map species habitat suitability, estimate its distribution range and predict shifts in species distribution in response to predicted deforestation across the entire Amazon (regional scale). Second, we used systematic camera trap surveys and occupancy models to investigate how forest cover and forest fragmentation affect the space use of this species in the Southern Brazilian Amazon (local scale). Species distribution models suggested that the short-eared dog potentially occurs over an extensive and continuous area, through most of the Amazon region south of the Amazon River. However, approximately 30% of the short-eared dog's current distribution is expected to be lost or suffer sharp declines in habitat suitability by 2027 (within three generations) due to forest loss. This proportion might reach 40% of the species distribution in unprotected areas and exceed 60% in some interfluves (i.e. portions of land separated by large rivers) of the Amazon basin. Our local-scale analysis indicated that the presence of forest positively affected short-eared dog space use, while the density of forest edges had a negative effect. Beyond shedding light on the ecology of the short-eared dog and refining its distribution range, our results stress that forest loss poses a serious threat to the conservation of the species in a short time frame. Hence, we propose a re-assessment of the short-eared dog's current IUCN Red List status (Near Threatened) based on findings presented here. Our study exemplifies how data can be integrated across sources and modelling procedures to improve our knowledge of relatively understudied species., Competing Interests: The authors have declared that no competing interests exist., (© 2020 The Authors.)

Amazonia forest plays a major role in providing ecosystem services for human and sanctuaries for wildlife. However, ongoing deforestation and habitat fragmentation in the Brazilian Amazon has threatened both. The ocelot is an ecologically important mesopredator and a potential conservation ambassador species, yet there are no previous studies on its habitat preference and spatial patterns in this biome. From 2010 to 2017, twelve sites were surveyed, totaling 899 camera trap stations, the largest known dataset for this species. Using occupancy modeling incorporating spatial autocorrelation, we assessed habitat use for ocelot populations across the Brazilian Amazon. Our results revealed a positive sigmoidal correlation between remote-sensing derived metrics of forest cover, disjunct core area density, elevation, distance to roads, distance to settlements and habitat use, and that habitat use by ocelots was negatively associated with slope and distance to river/lake. These findings shed light on the regional scale habitat use of ocelots and indicate important species-habitat relationships, thus providing valuable information for conservation management and land-use planning., Competing Interests: None declared.

Background: Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk., Objective: The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele-hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country., Methods: The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews., Results: Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients' treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment., Conclusions: In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices., (©Daniel Vitório Silveira, Milena Soriano Marcolino, Elaine Leandro Machado, Camila Gonçalves Ferreira, Maria Beatriz Moreira Alkmim, Elmiro Santos Resende, Bárbara Couto Carvalho, André Pires Antunes, Antonio Luiz Pinho Ribeiro. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 25.03.2019.)

Introduction: Super-refractory status epilepticus is defined as status epilepticus that persists or recurs 24 hours after anaesthetic therapy onset or after its withdrawal. It is mostly found in intensive care units and carries high mortality but good long-term prognosis for those who survive. In contrast with the initial phases of status epilepticus, treatment lacks strong scientific evidence and is mostly derived from case reports or small case series., Objective: To propose a protocol for the treatment of super-refractory status epilepticus in level III intensive care units, focusing on the treatment strategies to control clinical and/or electroencephalographic epileptic activity., Material and Methods: Narrative review of the literature by PubMed search. Available evidence was discussed in consensus meetings by intensive care and neurology experts' from a level III intensive care unit and one of the Portuguese reference centres for the treatment of refractory epilepsy, respectively., Results: Anaesthetics with the highest level of evidence are propofol, midazolam, thiopental and ketamine. These represent the basis of the treatment of super-refractory status epilepticus and should be used in combination with antiepileptic drugs. The level of evidence for the latter is lower, however, levetiracetam, topiramate, pregabalin, lacosamide, valproic acid, phenytoin and perampanel may be recommended. Alternative therapeutic strategies with very low level of evidence are recommended in cases of total absence of clinical response, such as magnesium sulphate, pyridoxine, ketogenic diet, therapeutic hypothermia and immunosupression., Conclusion: We propose a treatment protocol based on a sequential combination of anaesthetics, anti-epileptic drugs and alternative therapies. Strategies to evaluate treatment response and to wean drugs based on clinical results are also proposed.

Background: The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals., Objective: To assess physicians' satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care., Methods: This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant., Results: Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians., Conclusion: This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Commercial hunting for the international trade in animal hides in the 20th century decimated many populations of aquatic wildlife in Amazonia. However, impacts varied significantly between different species and regions, depending upon hunting intensity, accessibility of habitat, and the inherent resilience of various species and their habitats. We investigated the differential responses of two Amazonian Mustelid species, the neotropical otter and giant otter, to commercial hunting pressure along the upper Rio Negro in Brazil, and examined historical factors that influenced spatial and temporal variation in commercial exploitation. We analyzed previously unanalyzed data from historical records of hide shipments to track changes in hide sales and prices for the two species in the late 20th century. We also gathered oral histories from older Baniwa people who had witnessed or participated in commercial otter hunting. These complimentary data sources reveal how intrinsic biological and social characteristics of the two otter species interacted with market forces and regional history. Whereas giant otter populations were driven to local or regional extinction during the late 20th century by commercial hunting, neotropical otters persisted. In recent decades, giant otter populations have returned to some parts of the upper Rio Negro, a development which local people welcome as part of a generalized recovery of the ecosystems in their territory as a result of the banning of animal pelt exports and indigenous land demarcation. This paper expands the scope of the field historical ecology and reflects on the role of local knowledge in biodiversity conservation.

Wastewater systems are of crucial importance to the promotion of sustainable development. Through an integrated planning approach, the costs can be minimized and the resulting benefits maximized. A planning approach at regional level exploits the economies of scale, while achieving a better environmental performance. In this paper we set out a decision support approach for the planning of regional wastewater systems. Optimization models are used, aimed at finding optimal configurations for the location, type and size of the system's infrastructure: sewers, pump stations, and wastewater treatment plants. Solutions are evaluated in terms of the cost of installing, operating and maintaining the infrastructure, and the water quality in the river that receives the treated wastewater. The river water quality varies in accordance with the effluent discharges, and is assessed using environmental parameters. The models are solved with a simulated annealing algorithm complemented by a local improvement procedure. Its application is illustrated through a case study in the Una river basin region, in Brazil.

Introduction:: Chagas disease currently affects 5.7 million people in Latin America and is emerging in non-endemic countries. There is no consensus concerning the efficacy of trypanocidal therapy for patients with the chronic form of the disease. We evaluated cardiac function and sociodemographic, clinical, and serologic characteristics of a group of asymptomatic Trypanosoma cruzi-seropositive former blood donors, and compared the effects of benznidazole treatment applied for different lengths of time., Methods:: Blood donors who screened positive for T. cruzi between 1998 and 2002 were recruited 10 years later for follow-up (n = 244); 46 individuals had received treatment. Three subjects had terminated treatment prematurely. The remaining 43 individuals were divided into two groups: individuals who had received benznidazole therapy for 50-60 days (n = 28; BT ≤60 group) or more than 60 days (n = 15; BT >60). Serologic assays, biochemical tests, electrocardiographic, echocardiographic, and clinical examinations were performed on all participants. Parasite loads were determined by qualitative and quantitative polymerase chain reaction., Results:: Parasitemia was significantly reduced in the BT ≤60 and BT >60 groups compared with the untreated group. There were no differences in epidemiologic profiles or clinical, biochemical, electrocardiographic, or echocardiographic data between any of the groups., Conclusions:: Despite elimination or significant reduction in parasitemia in patients with chronic Chagas disease who received benznidazole, there was no clinical difference between those who were treated for >60 days and those treated for a shorter duration. Furthermore, the adverse effects of benznidazole appear to be less severe than previous reports would suggest.

The Amazon basin is the largest and most species-rich tropical forest and river system in the world, playing a pivotal role in global climate regulation and harboring hundreds of traditional and indigenous cultures. It is a matter of intense debate whether the ecosystem is threatened by hunting practices, whereby an "empty forest" loses critical ecological functions. Strikingly, no previous study has examined Amazonian ecosystem resilience through the perspective of the massive 20th century international trade in furs and skins. We present the first historical account of the scale and impacts of this trade and show that whereas aquatic species suffered basin-wide population collapse, terrestrial species did not. We link this differential resilience to the persistence of adequate spatial refuges for terrestrial species, enabling populations to be sustained through source-sink dynamics, contrasting with unremitting hunting pressure on more accessible aquatic habitats. Our findings attest the high vulnerability of aquatic fauna to unregulated hunting, particularly during years of severe drought. We propose that the relative resilience of terrestrial species suggests a marked opportunity for managing, rather than criminalizing, contemporary traditional subsistence hunting in Amazonia, through both the engagement of local people in community-based comanagement programs and science-led conservation governance.

Background: Coronary artery disease is the main cause of death in Brazil. In the Brazilian public health system, the in-hospital mortality associated with acute myocardial infarction is high. The Minas Telecardio 2 Project (Projeto Minas Telecardio 2) aims at implementing a myocardial infarction system of care in the Northern Region of Minas Gerais (MG) to decrease hospital morbidity and mortality. The aim of this study was to describe the profile of the patients with acute coronary syndrome (ACS) cared for in the period that preceded the implementation of the system of care., Methods: Observational, prospective study of patients with ACS admitted between June 2013 and March 2014 to six emergency departments in Montes Claros, MG, and followed up until hospital discharge., Results: During the study period, 593 patients were admitted with a diagnosis of ACS (mean age 63 ± 12 years, 67.6% men), including 306 (51.6%) cases of unstable angina, 214 (36.0%) of ST-elevation myocardial infarction (STEMI), and 73 (12.3%) of non-ST-elevation myocardial infarction (NSTEMI). The total STEMI mortality was 21%, and the in-hospital mortality was 17.2%. In the STEMI patients, 46,0% underwent reperfusion therapy, including primary angioplasty in 88 and thrombolysis in six. Overall, aspirin was administered to 95.1% of the patients within 24 hours and to 93.5% at discharge, a P2Y12 inhibitor was administered to 88.7% participants within 24 hours and to 75.1% at discharge. A total of 73.1% patients received heparin within 24 hours., Conclusion: We observed a low reperfusion rate in patients with STEMI and limited adherence to the recommended ACS treatment in the Northern Region of MG. These observations enable opportunities to improve health care., Competing Interests: Potential Conflict of Interest No potential conflict of interest relevant to this article was reported.

Low emission zones (LEZ) are areas where the most polluting vehicles are restricted or deterred from entering. In recent years, LEZ became a popular option to reduce traffic-related air pollution and have been implemented in many cities worldwide, notably in Europe. However, the evidence about their effectiveness is inconsistent. This calls for the development of tools to evaluate ex-ante the air quality impacts of a LEZ. The integrated modelling approach we propose in this paper aims to respond to this call. It links a transportation model with an emissions model and an air quality model operating over a GIS-based platform. Through the application of the approach, it is possible to estimate the changes induced by the creation of a LEZ applied to private cars with respect to air pollution levels not only inside the LEZ, but also, more generally, in the city where it is located. The usefulness of the proposed approach was demonstrated for a case study involving the city of Coimbra (Portugal), where the creation of a LEZ is being sought to mitigate the air quality problems that its historic centre currently faces. The main result of this study was that PM10 and NO2 emissions from private cars would decrease significantly inside the LEZ (63% and 52%, respectively) but the improvement in air quality would be small and exceedances to the air pollution limits adopted in the European Union would not be fully avoided. In contrast, at city level, total emissions increase and a deterioration of air quality is expected to occur., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aims: In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities., Methods and Results: The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]., Conclusion: The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.

In this study porous gelatin scaffolds were prepared using in-situ gas foaming, and four crosslinking agents were used to determine a biocompatible and effective crosslinker that is suitable for such a method. Crosslinkers used in this study included: hexamethylene diisocyanate (HMDI), poly(ethylene glycol) diglycidyl ether (epoxy), glutaraldehyde (GTA), and genipin. The prepared porous structures were analyzed using Fourier Transform Infrared Spectroscopy (FT-IR), thermal and mechanical analysis as well as water absorption analysis. The microstructures of the prepared samples were analyzed using Scanning Electron Microscopy (SEM). The effects of the crosslinking agents were studied on the cytotoxicity of the porous structure indirectly using MTT analysis. The affinity of L929 mouse fibroblast cells for attachment on the scaffold surfaces was investigated by direct cell seeding and DAPI-staining technique. It was shown that while all of the studied crosslinking agents were capable of stabilizing prepared gelatin scaffolds, there are noticeable differences among physical and mechanical properties of samples based on the crosslinker type. Epoxy-crosslinked scaffolds showed a higher capacity for water absorption and more uniform microstructures than the rest of crosslinked samples, whereas genipin and GTA-crosslinked scaffolds demonstrated higher mechanical strength. Cytotoxicity analysis showed the superior biocompatibility of the naturally occurring genipin in comparison with other synthetic crosslinking agents, in particular relative to GTA-crosslinked samples., (Copyright © 2016 Elsevier B.V. All rights reserved.)

During the nineteenth century, scientific expeditions travelled across Brazil investigating its fauna, flora and natural geological resources. By examining letters, reports, travelogues and illustrations of that time, it is possible to picture those expeditions, the naturalists themselves and the assistants who accompanied them, as well as something of society in nineteenth century Brazil. Our research focuses on the iconography of these travelers. These images help us to understand the way these traveling naturalists viewed nature, the men living in the interior and the indigenous peoples. By comparing eight images selected to illustrate the travelers' campsites we sought to observe their similarities and differences, revealing what they tell us about these travelers, their expeditions and the context in which they worked.

Objective: The aim of this study was to systematically review the literature for validity of palpatory procedures for evaluating anatomical bone landmarks in the cervical spine., Methods: A systematic search of electronic databases identified observational studies assessing validity and/or accuracy regarding evaluation of anatomical bone landmarks of cervical spine palpatory procedures. The databases used in the search included the US National Library of Medicine of the National Institutes of Health (MEDLINE/PubMed), the Regional Library of Medicine (Bireme), the Scientific Electronic Library Online (SciELO), the Physiotherapy Evidence Database (PEDro), the Latin American and Caribbean Health Sciences Literature database (LILACS), the Cochrane Library, and Coordination of Personnel Improvement of Higher Education (CAPES/Brazil). Data were extracted by a primary reviewer, and 2 independent reviewers used a critical appraisal tool to estimate the quality of the retrieved studies. The results were synthesized qualitatively within the Quality Assessment of Diagnostic Accuracy Studies criteria. After completing the synthesis and scoring, the reviewers applied classifications such as "low," "fair," and "good.", Results: The initial search yielded 69860 articles. After selection criteria were applied, 5 studies satisfied the eligibility criteria. Three studies verified the validity of the manual palpatory procedure, and 2 studies correlated the findings of the palpatory procedures with other measured results. According to Quality Assessment of Diagnostic Accuracy Studies criteria, 3 studies presented good methodological quality, and 2 presented fair methodological quality. Studies demonstrated an accuracy range from 51% to 87.8%., Conclusion: There are few studies that evaluate the validity of manual palpatory procedures for examining boney landmarks of the cervical spine. The 5 that were found showed fair to good methodological quality. However, we note that there may be poor external validity due to the sampling heterogeneity of these studies., (Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.)

Introduction: There is a substantial amount of evidence from animal models that early brain injury (EBI) may play an important role for secondary brain injury after aneurysmal subarachnoid hemorrhage (aSAH). Cerebral microdialysis (CMD) allows online measurement of brain metabolites, including the pro-inflammatory cytokine interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9), which is indicative for disruption of the blood-brain barrier., Methods: Twenty-six consecutive poor-grade aSAH patients with multimodal neuromonitoring were analyzed for brain hemodynamic and metabolic changes, including CMD-IL-6 and CMD-MMP-9 levels. Statistical analysis was performed by using a generalized estimating equation with an autoregressive function., Results: The baseline cerebral metabolic profile revealed brain metabolic distress and an excitatory response which improved over the following 5 days (P <0.001). Brain tissue hypoxia (brain tissue oxygen tension of less than 20 mm Hg) was common (more than 60% of patients) in the first 24 hours of neuromonitoring and improved thereafter (P <0.05). Baseline CMD-IL-6 and CMD-MMP-9 levels were elevated in all patients (median = 4,059 pg/mL, interquartile range (IQR) = 1,316 to 12,456 pg/mL and median = 851 pg/mL, IQR = 98 to 25,860 pg/mL) and significantly decreased over days (P <0.05). A higher pro-inflammatory response was associated with the development of delayed cerebral ischemia (P = 0.04), whereas admission disease severity and early brain tissue hypoxia were associated with higher CMD-MMP-9 levels (P <0.03). Brain metabolic distress and increased IL-6 levels were associated with poor functional outcome (modified Rankin Scale of more than 3, P ≤0.01). All models were adjusted for probe location, aneurysm securing procedure, and disease severity as appropriate., Conclusions: Multimodal neuromonitoring techniques allow insight into pathophysiologic changes in the early phase after aSAH. The results may be used as endpoints for future interventions targeting EBI in poor-grade aSAH patients.

The current study presents an effective and simple strategy to obtain stable porous scaffolds from gelatin via a gas foaming method. The technique exploits the intrinsic foaming ability of gelatin in the presence of CO2 to obtain a porous structure stabilised with glutaraldehyde. The produced scaffolds were characterised using physical and mechanical characterisation methods. The results showed that gas foaming may allow the tailoring of the 3-dimensional structure of the scaffolds with an interconnected porous structure. To assess the effectiveness of the preparation method in mitigating the potential cytotoxicity risk of using glutaraldehyde as a crosslinker, direct and in-direct cytotoxicity assays were performed at different concentrations of glutaraldehyde. The results indicate the potential of the gas foaming method, in the preparation of viable tissue engineering scaffolds., (Copyright © 2014 Elsevier B.V. All rights reserved.)