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Stroke is the second leading cause of death and disability in Latin America; however, few epidemiological studies have been conducted in South America. An observational study was conducted to analyze trends in stroke mortality in South American (SA) countries. Age-standardized mortality rates and proportional mortality due to stroke in the populations of SA countries between 1990 and 2019 were assessed by extracting data from the Global Burden of Disease 2019 study. Joinpoint regression models were employed to identify trends in the annual percentage change in mortality rates for each segment. Considering the data collected over the 30 years that were studied, the age-standardized stroke mortality trend decreased in Argentina (−1.6%), Uruguay (−0.6%), Brazil (−0.5%), Guyana (−0.5%), and Bolivia (−0.4%), while Venezuela (+1.6%) and Suriname (+1.0%) showed an increasing trend. The proportional stroke mortality trend decreased in Argentina (−1.7%), Paraguay (−0.9%), Uruguay (−0.7%), Guyana (−0.7%), Brazil (−0.5%), and Chile (−0.5%), whereas Bolivia (+1.0%), Suriname (+0.6%), and Peru (+0.4%) exhibited an increasing trend. The trends in stroke mortality between 1990 and 2019 demonstrated considerable variability. While most SA countries experienced significant decreases in stroke mortality trends, Venezuela and Suriname showed increases in age-standardized mortality rates, and Bolivia, Suriname, and Peru exhibited increases in proportional mortality rates. No decreasing stroke mortality trend was observed in the segment after the last joinpoint, highlighting the need for improvement in prevention and treatment.

The disparity between the sexes in stroke mortality has been demonstrated in people from different locations. The objective of this study was to analyze the disparity between sexes in stroke mortality in adults in the metropolitan area of Greater Vitoria between 2000 and 2021. Ecological time series design was conducted with a database of the Brazilian Health System Informatics Department. The annual percentage change and average annual percentage change were calculated through joinpoint regression. Pairwise comparisons using parallelism and coincidence tests were applied to compare temporal trends between men and women. Men had higher mortality rates in most years between 2000 and 2021. In contrast, women had higher proportional mortality values in all years evaluated from 2000 to 2021. The paired comparison revealed a disparity between the sexes in the proportional mortality time series (parallelism test: p = 0.003; coincidence test: p < 0.001). However, the time series of the mortality rates showed no disparity between the sexes (parallelism test: p = 0.114; coincidence test: p = 0.093). From 2000 to 2021, there was a disparity in proportional mortality from stroke between the sexes of the population in the metropolitan area of Greater Vitoria, Brazil. However, the time series of mortality rates between the sexes did not reveal any disparity in the study period.

The climacteric heralds a transition from reproductive to non-reproductive life in women, often accompanied by various clinical manifestations such as dry eye, impacting their quality of life. This study focuses on systematically developing and suitability an educational digital booklet to promote eye health practices and prevent problems among postmenopausal women. The methodological approach encompassed semi-structured interviews with women diagnosed with Dry Eye Syndrome (DES), then constructing the material integrating content, script, illustrations, and layout informed by the interview findings. Subsequent validation involved assessment by 24 health experts for content, appearance, and evaluation by a target audience of 22 women. The booklet attained high suitability scores, with a Global Content Validity Index (CVI) of 0.96, indicating superior suitability as judged by experts. Additionally, it achieved a Global CVI of 0.98 for validation by the target audience. In conclusion, the educational booklet emerges as a suitable and reliable resource for promoting eye heath among DES and non-syndrome women, offering significant potential for broader application in relevant populations.

At the beginning of December 2019, a new type of coronavirus emerged, SARS-CoV-2. This virus causes COVID-19, a highly contagious disease that can initially present asymptomatically and can also lead to death. Our ecological study goal was to evaluate the incidence, mortality, and lethality rates for COVID-19 between the states of Espírito Santo and Minas Gerais, with time series analysis using secondary and public databases on COVID-19 from January 2020 to December 2022. Prais–Winsten linear regression was used for trend analyses. In 2020, the rate in Espírito Santo was 2.19 times greater than in Minas Gerais. This trend continued in 2021, with Espírito Santo’s rate being 1.29 times greater. In 2022, Espírito Santo’s rate remained 2.65 times higher than Minas Gerais. Furthermore, Espírito Santo had the highest mortality, with the exception of 2021. In turn, Minas Gerais had the highest fatality rate throughout the analyzed pandemic period. The state of Espírito Santo had a higher incidence of COVID-19, as well as higher mortality when compared to the state of Minas Gerais. Furthermore, both states showed similar trends for mortality, lethality, and incidence in the years 2020 and 2021.

The north region of Brazil is characterized by significant vulnerabilities, notably surpassing national poverty indicators. These disparities exacerbated the impact of respiratory illnesses on the healthcare system during the COVID-19 pandemic, particularly in areas with limited healthcare resources, inadequate infrastructure, and barriers to healthcare access. The crisis was further influenced by multiple lineages that emerged as significant virus variants associated with increased transmissibility. Within this context, our ecological study focused on analyzing the epidemiological evolution of COVID-19 in the state of Acre. We constructed time-series trends in incidence, lethality, and mortality from March 2020 to December 2022 using the Prais–Winsten regression model. Our findings revealed that in 2020, there was an increasing trend in incidence, while mortality and lethality continued to decrease (p < 0.05). In the following year, both incidence and mortality decreased, while lethality increased at a rate of 1.02% per day. By the end of 2022, trends remained stationary across all rates. These results underscore the importance of ongoing surveillance and adaptive public health measures to bolster the resilience of healthcare systems in remote and vulnerable regions. Indeed, continuous monitoring of the most predominant SARS-CoV-2 lineages and their dynamics is imperative. Such proactive actions are essential for addressing emerging challenges and ensuring effective responses to adverse situations.

Background: A COVID-19 pandemic erupted, causing a global viral pneumonia outbreak, marking the most significant public health crisis of the 21st century. These changes profoundly impacted population health and well-being, leading to shifts in dietary habits. This study aimed to evaluate the consumption of ultra-processed foods in the Brazilian Amazon before, during, and after the COVID-19 pandemic. Methods: This is a secondary data analysis study derived from the Surveillance System of Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel, 2019–2021) of the Brazilian Ministry of Health. All statistical analyses were performed using the Stata 17 statistical program in the survey module (svy). Results: We found an increased frequency in the subgroups of consumption of ultra-processed foods in the capital of the Brazilian Amazon region between the years 2019 and 2021. In the cities of Boa Vista and Macapá, there was a significant increase in the consumption of snacks, salty snacks, cookies, and meat products. Boa Vista and Macapá showed an increase in the percentage difference in the consumption ≥5 of ultra-processed subgroups, being 30.4% (p = 0.014) and 53.7% (p = 0.014), respectively. Conclusions: The study indicated an increase in the consumption of ultra-processed foods in the Brazilian Amazon region during and after social distancing.

Introduction: Due to the complex nature of chronic pain, especially in older adults, a biopsychosocial approach is more effective than an isolated approach for its management. Furthermore, when patients are actively engaged in their pain management, they are more likely to be successful than relying totally on others. Objective: To analyze the self-management strategies currently used by older adults with chronic pain. Method: An integrative review was conducted through seven online databases, searching for scientific studies on this topic published in the last 10 years. Results and conclusion: Fifty-eight studies were included in the final sample. Research on chronic pain self-management for older adults has increased in recent years. Although a diversity of chronic physical painful conditions are being investigated, many conditions are still under-investigated. Online and in-person strategies are currently adopted, demonstrating similar results. Positive results are evidenced by strategies including health promotion, mind control, social participation and take-action fields. Major results come from a combination of strategies focusing on biopsychosocial aspects of pain management. Results include not only the reduction of pain itself, but increased self-efficacy, adoption of health behaviors and improvement of functionality, among others, i.e., improved QoL, despite pain.

Abstract The objectives of this systematic review were to estimate the prevalence of depression and to identify the relationship between depression and quality of life (QOL) among high school and university students. Literature search was performed in the Scopus, Embase, PubMed, Scielo, CINAHL and Web of Science databases, following the PRISMA methodology. The results were presented through descriptive approaches and meta-analysis. Thirty-six studies met the eligibility criteria, and twenty-six were included in the meta-analysis. The prevalence of depressive symptoms was 27% (95% CI 0.21–0.33) among students, being high school and university students was 25% (95% CI 0.14–0.37) and 27% (95% CI 0.20–0.34), respectively, and most studies have shown that depression was associated with low QOL. Among the limitations of the study is the difficulty of generalizing the results found, considering the large sample of health students. New studies should be conducted considering the severity, duration, and patterns of depressive symptoms in high school and university students, to better understand the relationship between depression and QOL.

Abstract This research analyzed the temporal trend of stroke mortality in children aged 0–14 years, from 1990 to 2019, in Brazil and its federative units. This ecological study used data from the Global Burden of Disease, a study led by the Institute for Health Metrics and Evaluation. Stroke definition considered the International Classification of Diseases according to codes G45, G46, and I60–I69. Age-standardized mortality rates and the mean annual percentage change (APC) in mortality rates were estimated. Stroke mortality trends decreased, with an APC of − 3.9% (95% CI − 4.5; − 3.3; p

IntroductionAutism spectrum disorder (ASD) has characteristics that have been observed to develop over time, such as the difficulty of affective, sensory, and emotional processing, which trigger some problems during childhood, limiting children's development. Applied behavior analysis (ABA) is among the therapeutic approaches for ASD, in which treatment can be tailored according to the patient's objectives.ObjectiveBased on ABA, we aimed to analyze the therapeutic strategy for independence in different skill performance tasks of patients diagnosed with ASD.MethodThis is a retrospective observational case series study including 16 children diagnosed with ASD who received ABA-based treatment at a therapeutic clinic in Santo Andre city, São Paulo State, Brazil. Individual task performance of different skill domains was registered in the ABA+ affective intelligence® software throughout the 12 months (from January 2021 to January 2022) of routine treatment.ResultsThe evolution of skills was observed between the T0 and T1 intervals, with improved skills over the observed period.ConclusionThe strategy based on the ABA methodology improved children's skill performance over the observed period.

Northeast Brazil is a region with great international tourist potential. Among the states that make up this region, Paraíba stands out due to the presence of vulnerable groups and factors that contribute to adverse outcomes of COVID-19. Therefore, the aim of this study was to analyze the epidemiological data on the incidence, mortality, and case fatality of COVID-19 in Paraíba. An ecological, population-based study was performed, with data extracted from the Brazilian Ministry of Health database. All cases and deaths from COVID-19 from March 2020 to December 2022 were included. The time series was built by applying the Prais–Winsten regression model, and the daily percent change was calculated to analyze the trends. The highest case fatality of the entire period was in April 2020 (7.8%), but in March 2021, the state broke the dismal record of 1248 deaths and the highest mortality rate (30.5 deaths per 100,000 inhabitants). Stationary mortality and case fatality were better in 2022; however, in February 2022, the mortality rate was at levels similar to the same month of the previous year. These results illustrate that COVID-19 is evolving and needs to be constantly monitored.

Background: Maternal mortality is a significant public health concern, with varying impacts across different regions in Brazil, particularly affecting women from lower-income social classes with limited access to social resources. The aim of this study is to describe the trends in maternal mortality in São Paulo, Brazil, from 2009 to 2019. Materials and Methods: This study employed an ecological approach utilizing a time-series design to examine maternal deaths. Secondary data from the Mortality Information System (SIM) and the Live Births Information System (SINASC) from 2009 to 2019 were utilized. The analysis included all maternal deaths among women aged 10 to 49 years residing in the state of São Paulo. Time-series data for maternal mortality ratios were constructed for the seven regions within São Paulo State. Joinpoint regression analysis was applied to characterize the maternal mortality ratio. The study estimated the annual percentage variation, the average annual percentage variation, and their respective 95% confidence intervals. Results: In São Paulo, a total of 3075 maternal deaths were reported, resulting in a mortality ratio of 45.9 deaths per 100,000 live births. The leading causes of maternal death were eclampsia (7.13%), gestational hypertension (6.09%), and postpartum hemorrhage (5.89%). The analysis of the annual percentage change in the maternal mortality ratio for São Paulo State and its six clusters showed stationarity. Conclusions: The assessment of the maternal mortality ratio in the state of São Paulo, Greater São Paulo, and Baixada Santista revealed an increase in the maternal death ratio over the studied period.

Eating disorders, characterized by abnormal eating behaviors, are among a wide variety of psychiatric conditions that mainly affect children and adolescents. These disorders have a multifactorial origin and can be associated with restrictive diets, negative feelings, harmful family relationships, and post-traumatic stress. Thus, this study’s objective was to evaluate the association between indicators of eating disorders and family and school contexts in Brazilian adolescents who previously experienced sexual abuse and examine the findings based on sex. National School Health Survey data were utilized. Among 102,301 students between 11 and 19 years of age, 4124 reported having experienced sexual abuse and were included in this study. Self-report questionnaires were used to assess participants’ health status and the presence of risk behaviors, which were examined through multivariate analysis using a Poisson regression model. The results indicated positive relationships between self-induced vomiting, laxative misuse, and other purgative methods and infrequent meals with family, hunger, and the presence of violence in students’ daily lives, regardless of sex (p < 0.05). In addition, body dissatisfaction and negative feelings about one’s body were associated with having been bullied or teased by schoolmates for both sexes (p < 0.05). Distant relationships with parents were associated with purgative methods and body dissatisfaction among female students (p < 0.05). In conclusion, body dissatisfaction, negative feelings about one’s body, laxative misuse, self-induced vomiting, and purgative methods were found to be associated with factors in family and school contexts such as hunger, infrequent meals with family, family violence, distant relationships with parents, and bullying at school in adolescents who have previously experienced sexual abuse.

Objective: To analyse the factors associated with preventable of infant mortality, in Espirito Santo, Brazil. Methods: Data were collected from records of notifiable of infant death of the Mortality Information System. A total of 5,089 infant deaths were classified as preventable and non-preventable according to the International Collaborative Effort on Infant Mortality (ICE) and the State System of Data Analysis Foundation (SEADE) methods. To investigate the factors associated with preventable of deaths, it was applied the logistic regression. Results: Approximately, 73% of the deaths were preventable according to the ICE, while 76% were preventable according to the SEADE method. Using to both methods, it was observed that preterm birth, postneonatal death and birth weight between 3000 and above 4,000 g represented higher chances for preventable infant deaths. Furthermore, the medical care was more likely to preventable infant death only for ICE method. Conclusions: The factors related to the quality of care offered in the prenatal, prepartum and childbirth periods were more relevant for the occurrence of preventable infant death. Accordingly, it is recommended to strengthen mother-child care to detect risk pregnancies during prenatal care, as well as a hierarchical, regionalized and integrated perinatal network.

ABSTRACT Objective: To assess the trend in motorcyclist mortality rate from traffic accidents in the state of São Paulo, Brazil, from 2015 to 2020. Methods: This is an ecological time series study with secondary data from the Traffic Accident Management Information System of the State of São Paulo (INFOSIGA), referring to motorcyclists’ deaths due to road traffic injuries in the state of São Paulo, Brazil, from 2015 to 2020. The Annual Percent Change was calculated according to the Prais-Winsten regression model, using the Stata 14.0 software. Results: A total of 11,343 deaths of motorcyclists due to road traffic injuries were reported. The highest proportion of deaths occurred among men (88.1%), aged between 18 and 24 years (27.9%), in the two most populous and urbanized regions of the state. The distribution of mortality showed minimal variation in the analyzed period, from 4.22 to 4.42 deaths/100 thousand inhabitants. Among the analyzed sociodemographic variables, the mortality trend of motorcyclists was mostly stationary. Conclusion: The analysis of the mortality of motorcyclists due to road traffic injuries in the state of São Paulo showed a stationary trend.

Background: The COVID-19 pandemic has negative impacts on general health of the population, social isolation can contribute to the emergence of various dysfunctions. Objective: To investigate the association musculoskeletal pain, sleep quality and migraine with the level of physical activity during the COVID-19 pandemic in college students. Method: Data were collected through a sociodemographic questionnaire containing questions regarding sample characterization, the Nordic Musculoskeletal Questionnaire (NMQ), Pittsburgh Sleep Quality Index (PSQI), Migraine Disability Assessment (MIDAS) and the International Physical Activity Questionnaire (IPAQ). Results: In the correlation made between the data at the beginning of the pandemic, there was a direct relationship between PSQI and the number of days with pain (p < 0.001), the Initial MIDAS score (p < 0.001) and the initial pain intensity (p < 0.001). There was a direct relationship between PSQI scores and age (p = 0.044), MIDAS (p < 0.001) and pain intensity (p < 0.001). We identified a direct relationship between MIDAS and the number of days with pain (p < 0.001) and pain intensity (p < 0.001). Conclusion: Social isolation, during the COVID-19 pandemic, probably potentiated painful symptoms in various parts of the body, worsening sleep quality and migraine. In addition, there is a strong evidence that the decrease in physical activity during the pandemic is associated with sleep quality, with the number of days with musculoskeletal pain and migraine.

Abstract Background The transition in the population pyramid is a reality in several locations around the world and projections of an increase in the older population in Brazil demonstrate the relevance of studies on factors that may interfere in the functionality and quality of life in this age group. Thus, the present study aims to assess depression levels and their relationship with sleep quality in institutionalized and community older adults. Methods This cross-sectional study included 220 older people of both sexes, divided into two groups, institutionalized older adults, and community older adults. The older adults were monitored by Community Health Agents (CHA), through identification of everyone in their micro area using a method of random name generation, based on geographic location. Due to the small number of institutionalized older adults, all residents in the institutions were recruited, according to the inclusion and exclusion criteria. The Geriatric Depression Scale (GDS-15) and Pittsburgh Sleep Quality Index (PSQI) were used to assess depression and sleep quality. Results Among the 220 older adults, 175 were community members and 45 were institutionalized. The survey revealed that institutionalized older adults had a higher percentage of severe depression compared to community dwelling older adults (p

Conduction delay in the right ventricular outflow tract as manifested in the electrocardiogram constitutes a high-risk predictor of ventricular arrhythmias in patients with Brugada syndrome. We present a case with a right QRS axis between –90° and ±180°. This feature has never been reported in the context of Brugada syndrome. (Level of Difficulty: Advanced.)

Objective: To analyze the temporal trend of mortality from type 2 Diabetes Mellitus between the years 2008 to 2017. Method: Secondary data from Health Information Systems in Brazil was used. Used all deaths from type 2 Diabetes Mellitus between 30 and 80 years and over, residing in São Paulo, included in the Mortality Information System, from 2008 to 2017. Mortality (per 100,000 inhabitants) by sex and age range was calculated age in the state of São Paulo, Brazil. Analysis of the linear regression model was used to analyze time trends with a 95% confidence level using Stata software version 11.0. Results: The total number of deaths from type 2 Diabetes Mellitus between 2008 and 2017 was 6,899, higher in females with 3,776 deaths (54.73%). Predominant in the elderly over 80 years old with 2,283 deaths (33.09%). Individuals with 1 to 3 years of schooling (education) had a higher occurrence of deaths with 1,917 (27.79%). The most frequent causes of mortality were uncomplicated (3,147; 45.62%), renal complications (1,731; 25.09%) and multiple complications (569; 8.25%). The mortality trend between the years 2008 to 2017 was stationary (β = 0.03; 95% CI: 0.005; 0.11; p = 0.038; r2 = 0.10).Regarding gender, the data demonstrate stability in mortality. Conclusion: Mortality from type 2 Diabetes Mellitus in the state of São Paulo between 2008 and 2017 was stationary. There was stability in mortality from type II DM over the years studied, both in general and by sex.

Objetivo: Analisar o acesso aos medicamentos e fatores associados ao seu uso por usuários hipertensos na Atenção Primária em Saúde. Métodos: Estudo observacional, descritivo e de corte transversal, tendo como instrumento para coleta um questionário validado que abordou o acesso aos medicamentos e os fatores que influenciam seu uso. Utilizaram-se as variáveis: sexo, idade, escolaridade, tempo de tratamento e quantidade de medicamentos anti-hipertensivos utilizada. Avaliou-se o uso dos medicamentos por 250 pacientes hipertensos, maiores de 18 anos, acompanhados pelo Núcleo de Apoio à Saúde da Família em Manhuaçu, Minas Gerais, Brasil. A coleta dos dados ocorreu em abril e maio de 2018. Utilizou-se o programa STATA, versão 15.1, para análise estatística. Apresentaram-se as variáveis em frequência absoluta e relativa, sendo realizado o teste qui-quadrado. Resultados: Identificou-se associação estatística entre o tempo de tratamento e a idade (p=0,006), entre o uso de medicamento no dia anterior e a idade (p=0,030) e entre o esquecimento do medicamento em viagens e o sexo (p=0,007). Em relação aos hábitos racionais, 91,2% (n=228) dos pacientes não pararam de tomar os medicamentos, mesmo sentindo a pressão controlada. Já 84,4% (n=211) dos participantes não sentiram incômodo por seguir corretamente o tratamento e 80,8% (n=202) não apresentaram descuidos na adesão ao tratamento farmacológico. Conclusão: Os usuários apresentaram acesso aos medicamentos e fazem o uso racional do mesmo, seguindo o tratamento apropriadamente, com bons hábitos. O número de fármacos utilizados não influenciou a continuidade do tratamento e o nível de escolaridade não apresentou associação estatística na utilização dos anti-hipertensivos.

Abstract Previous studies have demonstrated that regular avocado consumption presents advantageous effects on cardiovascular system. However, little attention has been paid to the use of avocado as a dietary supplement, in particular, for individuals involved in physical exercise training. Therefore, this study aims to evaluate the effect of acute avocado pulp intake on cardiovascular and autonomic recovery subsequent to moderate exercise. Using a crossover, randomized, double-blind and placebo-controlled trial design, 16 healthy female adults underwent two protocols: Avocado pulp (600 mg in capsule) and placebo (600 mg starch in capsule). After the ingestion of Avocado pulp or placebo, the subjects were seated for 60 min at rest, followed by running on a treadmill at a submaximal level and then remained seated for 60 min during recovery from the exercise. Heart rate (HR), heart rate variability (HRV) [rMSSD, SD1, HF (ms2)] and skin conductance were evaluated before and during exercise, as well as during recovery. HR, systolic blood pressure, HRV and skin conductance recovered faster when subjects were given avocado pulp prior to exercise. In conclusion, avocado pulp improved cardiovascular and autonomic recovery after exercise, suggesting a reduced risk of cardiovascular events after exertion. The current results support the beneficial effects of ingestion of avocado prior to submaximal treadmill running.

Objetivo: Construir e validar um álbum seriado sobre sífilis adquirida a ser utilizado como estratégia educativa para adolescentes. Métodos: Trata-se de um estudo do tipo metodológico realizado em Recife, Pernambuco, no período de novembro de 2018 a abril de 2019. Obtiveram-se dados provenientes de 22 juízes especialistas para validação de aparência e conteúdo do álbum seriado e de 40 adolescentes de uma escola pública, os quais avaliaram o álbum quanto à aparência. Analisou-se a validade de conteúdo considerando: o Item – Level Content Validity Index (I-CVI); a concordância entre os juízes, por meio do coeficiente de correlação intraclasse (ICC); e a validade de aparência, usando o Suitability Assessment of Materials (SAM). Utilizou-se o software Statistical Package for the Social Sciences (SPSS) para análise. Resultados: O álbum seriado possui 20 páginas e contém orientações sobre a sífilis adquirida. A média do I-CVI foi de 0,97 pelos juízes especialistas; constatando-se como excelente nível de concordância entre as respostas. A partir do formulário o SAM, o álbum foi julgado como superior, obtendo uma média de 80,99% entre os juízes, sendo recomendada sua utilização pelo público ao qual se destina. Houve unanimidade pelos adolescentes na aprovação do material, julgando ser claro, de fácil compreensão e relevante. Conclusão: O álbum seriado foi construído e validado em seu conteúdo e aparência por juízes e, quanto à aparência, pelo público-alvo, podendo ser utilizado com adolescentes no ambiente escolar ou em outras realidades.

Abstract Background Cerebral Palsy (CP) is characterised by variable difficulties in muscular action, resulting in inability of the individual to perform functional movement. An option to provide functionality to the individual with CP is the use of computer innovation. The aim of this paper was to verify if there was any performance improvement in a task performed in a virtual environment and if there was transfer to the task performed in the real environment and vice versa in this population. Methods A computer program was developed comprising a motor task, but with two possibilities of user interaction: a) concrete interface (with physical contact): in which the individual touches the computer screen to finish the task and b) abstract interface (no physical contact): in which the individual performs a hand movement in front of the Kinect device. Participants were split into two groups. The experimental group consisted of 28 individuals with CP within the ages of 6 and 15 years old. The control group included 28 typically developing individuals mirroring the age and sex of the experimental group. Results Individuals from both groups were able to improve task performance and retain acquired information. The CP group presented worse performance than the control group in all phases of the study. Further findings showed that the CP group presented better performance in the abstract interface than in the concrete interface, whereas, in the control group, the opposite occurred: their best performance was in the concrete. Conclusions Motor tasks performed by individuals with CP through an interface with a more virtual environment feature (abstract interface: Kinect) provided better performance when compared to an interface with a more real characteristic (concrete interface: Touchscreen). Trial registration ClinicalTrials.gov Identifier - NCT03352440 ; Date of registration - November 17, 2017.

Abstract Background Dyspnea, fatigue, and decline in sleep quality are symptoms of chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation programs have been shown to ameliorate dyspnea and fatigue. However, only a few studies have investigated the effects of pulmonary rehabilitation on the sleep quality of COPD patients. In this study, we analyzed the benefits of a pulmonary rehabilitation program to sleep quality and daytime somnolence in COPD patients. Methods This study was a study of 30 moderate-severe COPD patients. All patients were evaluated by a pulmonologist and underwent polysomnography before participating in the study. For this study, we selected only ex-smokers and patients with sleep apnea were referred to the sleep clinic. These participants were prospectively recruited and not selected based on program completion. Before the start of the program, sleep quality and daytime somnolence of the participants were evaluated using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS), respectively. Rehabilitation program consisted of muscular training sessions conducted at the gym 3 times per week for 12 weeks. After rehabilitation program, the patients were reassessed and their sleep quality and daytime somnolence were reevaluated using the PSQI and the ESS, respectively. Results Before rehabilitation, PSQI evaluation revealed that 73% of the participants had poor sleep quality, and ESS evaluation showed that 86.7% of the participants experienced daytime somnolence. After pulmonary rehabilitation, the PSQI specifically improved in terms of subjective sleep quality and sleep duration (

Background. Transcutaneous electrical nerve stimulation (TENS) has been used as analgesic therapy in many diseases. It is already known that studies that have observed the relationship between pain and cytokines have found that patients who report less severe pain have less production of proinflammatory cytokines. However, one another accepted mechanism is that decreasing proinflammatory cytokines results in decreased pain intensity. Analyzing the literature, the authors describe that, in addition to the analgesic effect, TENS has shown systemic effects, and clinically, the reduction of proinflammatory cytokines could be a protective factor against inflammation. To test the inflammatory effect of TENS, we researched the literature for clinical conditions that suggest that proinflammatory cytokines are one of the main mediators of the disease process. Chronic inflammation is one of the risk factors mentioned for the development of a new cancer; at the same time, it is indicated as an indicator of the worst prognosis. Studies also suggest that the worst prognosis of breast cancer, one of the types with the highest incidence in the world, may be related to increased inflammatory activity. Considering that inflammation is increased in breast cancer and that TENS can reduce proinflammatory cytokines even without blocking the pain pathway, our hypothesis is that the anti-inflammatory effect of TENS can bring benefits to these patients. The aim of this study will be to evaluate the effect of TENS on blood reduction of proinflammatory cytokines in breast cancer patients. Methods. This study will evaluate at least 59 patients, over 18 years of age, diagnosed with breast cancer, but who have not yet started any treatment. All patients will be submitted to TENS intervention (Ibramed, Model Neurodyn III, parameters: VIF—turn on, frequency—2-247 Hz, pulse size—50-500 μs, and intensity (mA)—maximum tolerated by the patient), and the data will be analyzed in the pre- and postintervention of each patient. The application has a total duration of 30 minutes, and 8 ml of blood will be collected before and after the intervention. Proinflammatory (IL-1, IL-2, IL-6, IL-7, and TNF-α) and anti-inflammatory (IL-4, IL-10, IL-13, and FTCβ) cytokines will be analyzed. As a primary endpoint, we will analyze the reduction in blood concentration of proinflammatory cytokines, and as secondary endpoints, we will analyze the size of the effect according to each type of proinflammatory cytokine, describe the effect size of the reduction according to the breast cancer immunohistochemistry, and analyze the effect of TENS on anti-inflammatory cytokines. This study is approved by the Research Ethics Committee (Centro Universitário FMABC, Brazil) and registered in the Brazilian Clinical Trials (Search text: RBR-10jbwh47).

Pregnancy complicated by obesity is associated with adverse triggered gestational and neonatal outcomes, with reductions in the subtypes of CD4+ T-lymphocytes representing the modulators of inflammation. It needs to be better established how maternal nutritional statuses impact the neuroendocrine–immune system’s action and affect the immunological mechanisms of the maternal–infant relationship via breastfeeding. This study examined the effects of maternal obesity on human colostrum lymphocytes and the intracellular mechanisms of lymphocyte modulation in the presence of leptin, adiponectin, and melatonin via cell proliferation; the release of intracellular calcium; and apoptosis induction. This cross-sectional study analyzed colostrum samples from 52 puerperal splits and divided them into overweight and eutrophic groups. Colostrum lymphocytes underwent immunophenotyping and cell proliferation by flow cytometry and intracellular calcium release and apoptosis assays by immunofluorescence in the presence or absence of hormones. Significant differences were considered when p < 0.05 by the chi-square or t-test. Maternal obesity reduced the population of T-lymphocytes and TCD4+ in human colostrum and proliferative activities (p < 0.05). These hormones restore lymphocyte proliferation to a level similar to the eutrophic group (p < 0.05). Leptin, adiponectin, melatonin hormones, and biological actions consolidated in the scientific literature also represent maternal and infant protection mechanisms via colostrum and the modulation of human colostrum lymphocytes.

Objetivo: Analisar as internações hospitalares por condições sensíveis à Atenção Primária à Saúde (APS) no estado de Minas Gerais. Métodos: Estudo ecológico com delineamento de série temporal, de base populacional, realizado no estado de Minas Gerais, acerca da internação hospitalar e as principais causas de internações por condições sensíveis à APS. A análise foi baseada na Autorização de Internação Hospitalar, considerando custos, ano, sexo e faixa etária, de acordo com os dados do Sistema de Informação Hospitalar (SIH). Os microdados foram extraídos do serviço de transferência de arquivos no Departamento de Informática do Sistema Único de Saúde (DATASUS) em junho de 2018. Os registros analisados são referentes ao período de janeiro de 2008 a dezembro de 2017, sendo incluídas todas as internações por condições sensíveis à Atenção Primária à Saúde. Resultados: Evidenciou-se que, no período de 2008 a 2017, as internações sensíveis à atenção primária representaram 21,21% (2.506.782) do total de internações no estado de Minas Gerais, com a região Jequitinhonha, seguida das regiões Nordeste e Centro Sul, contribuindo com os maiores percentuais. Com relação às causas, a maior prevalência se concentra em doenças do aparelho circulatório 54,22% (816.617), seguida pelas doenças do aparelho respiratório 43,48% (586.809), doenças endócrinas 85,70% (325.082), doenças geniturinárias 37,13% (309.281) e doenças infecciosas e parasitárias 38,37% (266,294). Conclusão: As internações hospitalares por condições sensíveis à Atenção Primária à Saúde no estado de Minas Gerais seguem o padrão nacional. Embora as internações estejam decrescendo, ainda representam mais de 20% do total de internações realizadas.

The epsilon wave of the electrocardiogram (ECG) together with fragmented QRS (fQRS), the terminal conduction delay, incomplete right bundle branch block (IRBBB) and complete/advanced RBBB (CRBBB) of peripheral origin are part of a spectrum of ventricular depolarization abnormalities of arrhythmogenic cardiomyopathy (AC). Although the epsilon wave is considered a major diagnostic criterion for AC since 2010 (AC Task Force Criteria), its diagnostic value is limited because it is a sign of the later stage of the disease. It would be more appropriate to say that the epsilon wave is a “hallmark” of AC, but is of low diagnostic sensitivity. Although the epsilon wave has high specificity for AC, it can be present in other pathological conditions. In this update we will cover the nomenclature, association with disease states and electrocardiographic aspects of the epsilon wave. Keywords: Epsilon wave, Ventricular post-excitation wave, Fontaine wave

Abstract Background Amyotrophic Lateral Sclerosis (ALS) is a rapid progressive neurodegenerative disease, characterized by a selective loss of motor neurons, brain stem and spinal cord which leads to deterioration of motor abilities. Devices that promote interaction with tasks on computers can enhance performance and lead to greater independence and utilization of technology. Objective To evaluate performance on a computer task in individuals with ALS using three different commonly used non-immersive devices. Method Thirty individuals with ALS (18 men and 12 women, mean age 59 years, range 44–74 years) with a mean score of 26, (minimum score of 14 and maximum 41) on the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) and 30 healthy controls matched for age and gender, participated. All participants were randomly divided into three groups, each using a different device system (motion tracking, finger motion control or touchscreen) to perform three task phases (acquisition, retention and transfer). Results Both the ALS and control group (CG) showed better performance on the computer task when using the touchscreen device, but there was limited transfer of performance onto the task performed on the Finger Motion control or motion tracking. However, we found that using the motion tracking device led to transfer of performance to the touchscreen. Conclusion This study presents novel and important findings when selecting interaction devices for individuals with ALS to access technology by demonstrating immediate performance benefits of using a touchscreen device, such as improvement of motor skills. There were possible transferable skills obtained when using virtual systems which may allow flexibility and enable individuals to maintain performance overtime. Trial registration Registration name: Virtual Task in Amyotrophic Lateral Sclerosis; Registration number: NCT03113630; retrospectively registered on 04/13/2017. Date of enrolment of the first participant to the trial: 02/02/2016.

We conducted a review of the literature regarding epidemiology, clinical, electrocardiographic and vectorcardiographic aspects, classification, and differential diagnosis of left posterior fascicular block.Isolated left posterior fascicular block (LPFB) is an extremely rare finding both in the general population and in specific patient groups. In isolated LPFB 20% of the vectorcardiographic (VCG) QRS loop is located in the right inferior quadrant and when associated with right bundle branch block (RBBB) ≥40%.The diagnosis of LPFB should always consider the clinical aspects, because a definite diagnosis cannot be made in the presence of right ventricular hypertrophy (RVH) (chronic obstructive pulmonary disease (COPD)/emphysema), extensive lateral myocardial infarction (MI) or extremely vertical heart.Intermittent LPFBs are never complete blocks (transient or second degree LPFB) and even in the permanent ones, one cannot be sure that they are complete. When LPFB is associated with RBBB and acute inferior MI, PR interval prolongation is very frequent. Keywords: Left posterior fascicular block, Bifascicular block, Intraventricular conduction disturbances

Introduction: COVID-19 requires governmental measures to protect healthcare system access for people. In this process, the collision of fundamental rights emerges as a crucial challenge for decision-making.Policy Options and Implications: This policy review analyzes selected articles by the PubMed searcher about extreme measures taken in several countries during precedent pandemics and the current pandemic, and selects hard decisions relating to the exceptional measures taken by judicial departments in Brazil, connecting them to the “collision of fundamental rights and law principles.” The collision of rights and principles imposed on decision makers a duty to provide balanced rights, and to adopt the enforcement of some rights prioritization. Ethical concerns were also verified in this field involving rights limitations. During a pandemic, the importance of extreme measures to protect health rights and healthcare systems is instrumental for focused, fast, and correct decision making to avoid loss of life and the collapse of healthcare systems. The main goals of this research are to discuss the implications and guidelines for public health decision making, the indispensable ethical and legal aspects for safeguarding health systems and the lives of people, and the respect of the Justice principle and of fundamental health and dignity rights. We conclude that COVID-19 justifies the prioritization of collective and individual health access rights. Acceptable standards of fundamental rights restrictions are established at the constitutional and international levels and must be enforced by rules and governmental action, to ensure fast and accurate decision making during a pandemic. Freedom rights exercises must be linked to solidarity for the realization of social welfare, for the health rights of all individuals and for health systems to function well during a pandemic.Actionable Recommendations: All individuals are free and equal, therefore social exclusion is prohibited. Institutions must consider social inequalities when discussing public health measures and be guided by ethical standards, by law principles, and rules recognized by constitutional and international law for the benefit of all during a health pandemic.Conclusions: Collective and individual health rights prevail over the collision of rights when facing pandemic occurrences, case by case, in health systems protection, based on the literature, on precedent pandemics and on legitimate Public Health efforts.

Introdução: A fragilidade é uma síndrome multidimensional que aumenta a vulnerabilidade em idosos, causando diminuição das reservas fisiológicas, aumento do declínio funcional e está associada a inúmeras alterações físicas, determinando maiores riscos à saúde do idoso. Objetivo: Analisar a associação entre fragilidade e condições sociodemográficas de idosos atendidos em Unidades Básicas de Saúde da cidade de Cajazeiras, nordeste do Brasil. Métodos: Estudo transversal, realizado em julho de 2015, com 823 idosos, por meio de questionário semiestruturado contendo os critérios de fragilidade propostos por Linda Fried e analisado pelo SPSS versão 21. Utilizou-se o teste qui-quadrado para verificar a associação entre as variáveis, considerando-se estatisticamente significativo p

[This corrects the article DOI: 10.1371/journal.pone.0225866.].

BackgroundLow national immunization coverage (44.64%) requires strengthening the vaccination campaign to improve knowledge about HPV and its vaccine among adolescents and parents/guardians. Our aim is to evaluate factors related to knowledge about HPV, its vaccine, acceptability and divergences among Brazilian adolescents and parents/guardians.MethodsA cross-sectional study was performed at a health unit of Sao Paulo University, Brazil, from 2015 to 2016. The convenience sample comprised 1047 individuals, including 74% (n = 776) adolescents and 26% (n = 271) parents/guardians, who answered a survey (knowledge about HPV, its vaccine, barriers and acceptability).ResultsThe main source of information for adolescents was school (39%, n = 298); for parents/guardians, it was health professionals (55%, n = 153). Parents/guardians were 2.48 times more likely than adolescents to know that HPV caused changes in the Pap smear test [RR 2.48, 95% CI 2.03-3.01 (p < 0.001)], 1.43 times likely to be aware that HPV was a sexually transmitted infection [RR 1.43, 95% CI 1.22-1.68 (p < 0.001)], and 2.77 times likely to be informed that the HPV vaccine decreased the chance of having genital warts [RR 2.77, 95% CI 2.22-2.47 (p < 0.001)]. Girls knew more about the topic than boys (RR 1.67; 95% CI 1.10-2.60); education increased parents' knowledge [(RR 3.38; 95% CI 1.71-6.69)].ConclusionFemale adolescents and parents/guardians with a higher level of education are factors related to suitable knowledge about HPV and its vaccine among Brazilian respondents. There were differences between parents/guardians and adolescents in HPV awareness, clinical implications, vaccine knowledge and vaccine acceptance.

IntroductionWe evaluated trends in hospitalization incidence and mortality due to hemorrhagic and ischemic stroke in young adults, according to gender and developed regions in Brazil.MethodsBetween 2008-2018, we performed a population-based time-series study using official hospitalization and death data due to stroke, in individuals aged 10-49 years, from Southeast and South, Brazil. Data were based on reports from the Unified Health System of Hospital Information System and Mortality Information System. Stroke was defined by the International Classification of Diseases, 10th revision (I60-I63). A Prais-Winsten regression model was performed and the Annual Percentage Change was calculated.ResultsIn total, 78,123 hospitalizations of individuals aged 10-49 years were recorded, of which 59,448 (76%) resulted from hemorrhagic stroke (HS). The hospitalizations for HS was significantly decreased (- 4.37%) among men and women in both regions. The hospitalizations for ischemic stroke (IS) was flat, except between 2011 and 2018, when IS hospitalization rates increased. In the analysis by states, HS hospitalizations declined across all states, except for Espírito Santo, where it remained unchanged (p > 0.05). IS flat hospitalizations were observed in all states, except Espírito Santo, where it increased by 24.93%. In terms of mortality, 28,625 deaths were recorded, of which 26,548 (92.7%) resulted from HS. HS mortality decreased significantly by -3.48%and IS mortality by -3.84%. Decreases also occurred in all Southeast and South states (p < 0.05). IS remained unchanged across all states, except Minas Gerais, where it decreased by -14.95%.ConclusionsWe identified a decline in the hospitalizations and mortality of HS and a flat trend for IS in developed regions of Brazil. The recent period (2011-2018) demonstrated increasing rates in the hospitalizations of IS in both regions and genders. The mortality rates for HS and IS decreased between 2008-2018 in Southeast and South Brazil for both genders.

Abstract Background Precocious puberty (PP) is defined as premature pubertal development. Its consequences surpass the physical evidence of sexual maturity with the premature epiphyseal closure of the long bones and the reduction of adult stature by varied degrees. Central PP is characteristically dependent on GnRH and most of its causes are not completely known. Altered estrogen action is also believed to be involved in the genesis of PP. In fact, estrogen receptor alpha (Rea) gene polymorphisms may be associated with early age at menarche. The objective of this study was to investigate the relationship between Reα gene polymorphisms (PvuII and XbaI) and the occurrence of central PP. Methods A total of 73 girls with central PP and 101 girls with normal pubertal maturation were evaluated. Both groups were genotyped for the PvuII (T/C) and XbaI (A/G) polymorphisms in the Reα gene. Results The frequency distribution of the XbaI (p = 0.28) and of the PvuII (p = 0.12) genotypes, as well as the XbaI and PvuII allelic variants (p = 0.23 and p = 0.86, respectively), did not differ between the groups. Conclusion The PvuII and XbaI Rea gene polymorphisms do not appear to be related to development of central PP.

Abstract Background The use of technology to assist in the communication, socialization, language, and motor skills of children with Down’s syndrome (DS) is required. The aim of this study was to analyse research findings regarding the different instruments of ‘augmentative and alternative communication’ used in children with Down’s syndrome. Methods This is a systematic review of published articles available on PubMed, Web of Science, PsycInfo, and BVS using the following descriptors: assistive technology AND syndrome, assistive technology AND down syndrome, down syndrome AND augmentative and alternative communication. Studies published in English were selected if they met the following inclusion criteria: (1) study of children with a diagnosis of DS, and (2) assistive technology and/or augmentative and alternative communication analysis in this population. Results A total of 1087 articles were identified. Thirteen articles met the inclusion criteria. The instruments most used by the studies were speech-generating devices (SGDs) and the Picture Exchange Communication System (PECS). Conclusion Twelve instruments that provided significant aid to the process of communication and socialization of children with DS were identified. These instruments increase the interaction between individuals among this population and their peers, contributing to their quality of life and self-esteem.

Congenital long QT syndrome type 3 (LQT3) is the third in frequency compared to the 15 forms known currently of congenital long QT syndrome (LQTS). Cardiac events are less frequent in LQT3 when compared with LQT1 and LQT2, but more likely to be lethal; the likelihood of dying during a cardiac event is 20% in families with an LQT3 mutation and 4% with either an LQT1 or an LQT2 mutation. LQT3 is consequence of mutation of gene SCN5A which codes for the Nav1.5 Na+ channel α-subunit and electrocardiographically characterized by a tendency to bradycardia related to age, prolonged QT/QTc interval (mean QTc value 478 ± 52 ms), accentuated QT dispersion consequence of prolonged ST segment, late onset of T wave and frequent prominent U wave because of longer repolarization of the M cell across left ventricular wall.

Abstract Background The association between gynecological diagnoses and their distribution in the health sectors provides benefits in the field of women’s health promotion and in medical and interdisciplinary education, along with rationalization according to level of care complexity. Thus, the objective is analyze the clinical-demographic characteristics, main diagnoses in gynecological ambulatory care, and their distribution in health services. Method This is a research project of retrospective audit study design with a chart review of data from 428 women treated at University Ambulatory Clinic of Women’s Health, the facility in gynecology and training for Family and Community Medical Residents, São Paulo, Brazil, from 2012 to 2014. Clinical and demographic information, gynecological diagnoses (International Classification of Diseases), and distribution of health services (primary, secondary, and tertiary) were described. Results The female patients present non-inflammatory disorders of the female genital tract (81.07%, n = 347) and diseases of the urinary system (22.66%, n = 97) among the gynecological diagnoses. The chances of having benign breast disease and non-inflammatory disorders of the female genital tract during the reproductive period corresponds to being 3.61 (CI 1.00–16.29) and 2.56 times (CI 1.58–4.16) higher, respectively, than during the non-reproductive period. The non-inflammatory disorders of the female genital tract (93.33%, n = 28) are most related to the tertiary sector. The distribution in health services was the following: 71.30% (n = 305) in the primary sector, 21.70% (n = 93) in the secondary sector and 7% (n = 30) in the tertiary sector. Conclusion The studied women presented non-inflammatory disorders of the female genital tract and diseases of the urinary system as determined by gynecological diagnoses. Low-assistance complexity followed in most cases.

Introduction: The elderly population grows globally every day, and along with it the incidence of high blood pressure also grows, following these data scientists seek tools to improve the health of this population, a widely used tool for assessing cardiovascular function is the heart rate variability(HRV), that is a mecanism that allows the investigation of oscillations in the intervals between consecutive heart beats (RR intervals). There are already studies on the autonomic nervous system in the elderly population, however, these studies investigated normotensive patients and there is little research in hypertensive patients. Aim: To compare the cardiac autonomic modulation between healthy elderly and hypertensive elderly. Method: The total sample was 80 elderly people- 40 healthy elderly and 40 elderly (HBP). Anthropometric data, HRV analysis and IPAQ questionnaire were collected. For the analysis of cardiac modulation data in the time domain (pNN50, SDNN and RMSSD) and frequency domain (LF and HF). The geometric analysis (RRtri, TINN, SD1, SD2 and SD1/SD2 ratios). Results: In the time domain the MeanRR index presented a HAS increase 832.35 ± 104.46 ms vs control 782.73 ± 112.78 ms (p = 0.040). In the SDNN, there was a 58.35ms decrease vs the SAH 43.15 ms (p = 0.030). In the frequency domain, HF decreased control 247.00 ms2 vs HAS 157.00 ms2 (p = 0.002). In the geometric, the TINN and SD2 in the HAS group decreased in relation to the control from 203.38 ± 80.26 ms to 161.83 ± 53.25 ms (p = 0.018) and from 71.95 ms to 59.40 ms (p = 0.051). The mean SD1/SD2 ratio showed an increase between the Control and SAH groups from 0.22 ± 0.10 to 4.09 ± 1.18 and there was a statistical difference (p = 0.001). Conclusion: Hypertensive elderly patients present decreased heart rate variability and decreased parasympathetic modulation when compared to normotensive elderly.

Abstract Background Pain reduction can be achieved by lowering proinflammatory cytokine levels in the blood. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive physiotherapeutic resource for pain management, but evidence on the effectiveness of this device at reducing proinflammatory cytokines in the blood is unclear. This study systematically reviews the literature on the effect of TENS on proinflammatory cytokines. Methods A systematic review protocol was developed based on searches of articles in six electronic databases and references of retrieved articles, contact with authors, and repositories of clinical trials. Eligibility criteria: publication in peer-reviewed journals, randomized clinical trials, use of TENS in the experimental group, and pre- and post-measurements of proinflammatory cytokines in the blood. Selection of the studies and extraction of the data will be carried out by two reviewers independently. Characteristics of the study, participants, interventions and outcomes were extracted and described. Assessments were performed on the risk of bias, level of evidence and the size of the intervention effect in the studies, according to GRADE guidelines and the Cochrane Handbook for Systematic Reviews. Clinical and statistical assessments compared the effects of the interventions (meta-analysis), taking into consideration any influencing characteristics of the studies (e.g., methods and application sites). Discussion We anticipate that this review will strengthen evidence-based knowledge of the effect of TENS on proinflammatory cytokines and, as a result, direct new studies to benefit patients with specific pathologies. Systematic review registration PROSPERO, CRD42017060379 .

Abstract Background Individuals with Cerebral Palsy (CP) present with sensorimotor dysfunction which make the control and execution of movements difficult. This study aimed to verify the speed-accuracy trade-off in individuals with CP. Methods Forty eight individuals with CP and 48 with typical development (TD) were evaluated (32 females and 64 males with a mean age of 15.02 ± 6.37 years: minimum 7 and maximum 30 years). Participants performed the “Fitts’ Reciprocal Aiming Task v.1.0 (Horizontal)” on a computer with different sizes and distance targets, composed by progressive indices of difficulty (IDs): ID2, ID4a and ID4b. Results There were no statistical differences between the groups in relation to the slope of the curve (b1) and dispersion of the movement time (r2). However, the intercept (b0) values presented significant differences (F(1.95) = 11.3; p = .001]), with greater movement time in the CP group compared to the TD group. It means that for individuals with CP, regardless of index difficulty, found the task more difficult than for TD participants. Considering CP and TD groups, speed-accuracy trade-off was found when using different indices of difficulty (ID2 and ID4). However, when the same index of difficulty was used with a larger target and longer distance (ID4a) or with a narrow target and shorter distance (ID4b), only individuals with CP had more difficulty performing the tasks involving smaller targets. Marginally significant inverse correlations were identified between the values of b1 and age (r = −0.119, p = .052) and between r2 and Gross Motor Function Classification System (r = −0.280, p = .054), which did not occur with the Manual Ability Classification System. Conclusion We conclude that the individuals with CP presented greater difficulty when the target was smaller and demanded more accuracy, and less difficulty when the task demanded speed. It is suggested that treatments should target tasks with accuracy demands, that could help in daily life tasks, since it is an element that is generally not considered by professionals during therapy. Trial registration ClinicalTrials.gov, NCT03002285 , retrospectively registered on 20 Dec 2016.

Abstract Background Down syndrome (DS) has unique physical, motor and cognitive characteristics. Despite cognitive and motor difficulties, there is a possibility of intervention based on the knowledge of motor learning. However, it is important to study the motor learning process in individuals with DS during a virtual reality task to justify the use of virtual reality to organize intervention programs. The aim of this study was to analyze the motor learning process in individuals with DS during a virtual reality task. Methods A total of 40 individuals participated in this study, 20 of whom had DS (24 males and 8 females, mean age of 19 years, ranging between 14 and 30 yrs.) and 20 typically developing individuals (TD) who were matched by age and gender to the individuals with DS. To examine this issue, we used software that uses 3D images and reproduced a coincidence-timing task. Results The results showed that all individuals improved performance in the virtual task, but the individuals with DS that started the task with worse performance showed higher difference from the beginning. Besides that, they were able to retain and transfer the performance with increase of speed of the task. Conclusion Individuals with DS are able to learn movements from virtual tasks, even though the movement time was higher compared to the TD individuals. The results showed that individuals with DS who started with low performance improved coincidence- timing task with virtual objects, but were less accurate than typically developing individuals. Trial registration ClinicalTrials.gov Identifier: NCT02719600 .

Exhaustive exercise in a hot environment can impair performance. Higher epinephrine plasma levels occur during exercise in heat, indicating greater sympathetic activity. This study examined the influence of exercise in the heat on stress levels. Nine young healthy men performed a maximal progressive test on a cycle ergometer at two different environmental conditions: hot (40°C) and normal (22°C), both between 40% and 50% relative humidity. Venous blood and saliva samples were collected pre-test and post-test. Before exercise there were no significant changes in salivary biomarkers (salivary IgA: p = 0.12; α-amylase: p = 0.66; cortisol: p = 0.95; nitric oxide: p = 0.13; total proteins: p = 0.07) or blood lactate (p = 0.14) between the two thermal environments. Following exercise, there were significant increases in all variables (salivary IgA 22°C: p = 0.04, 40°C: p = 0.0002; α-amylase 22°C: p = 0.0002, 40°C: p = 0.0002; cortisol 22°C: p = 0.02, 40°C: p = 0.0002; nitric oxide 22°C: p = 0.0005, 40°C: p = 0.0003, total proteins 22°C: p

INTRODUCTION:Chronic kidney disease (CKD) has a set of clinical and laboratory abnormalities where renal function loss is noted. The high prevalence of comorbidity of people living with CKD, its economic impact and its prognosis have made it a public health problem, justifying the need to implement preventive measures. OBJECTIVE:To analyse the mortality and incidence of hospital admissions for CKD. METHODS:Ecological study with a time series design using secondary microdata of deaths and hospital admissions from patients with CKD from 1996 to 2017 in the State of Espírito Santo, Brazil. RESULTS:The average mortality rate of CKD during the studied years was 2.92 per 100,000 inhabitants per year. During this period global mortality was a stationary phenomenon. In women, the trend of mortality from 2005 on increased 7,87% per year. Between 2008 and 2017, the average incidence hospital admissions due to CKD per year was 45.76 per 100,000 inhabitants. It was observed that the overall hospital admission increased by the equivalent of 6.23% per year. More than a half of mortality and hospitalisations correspond to male patients over 50 years of age. In terms of mortality, 32.99% corresponded to Caucasian patients, while 35.13% of hospitalisations were mixed race. CONCLUSION:We found that age and gender are factors associated with deaths and hospitalisations for chronic kidney disease. While hospitalisation increases 6.23% per year, global mortality remains stationary. However, from 2005 onwards a trend towards increasing of 7.87%/annual in mortality was observed in women.

IntroductionProviding safety culture is the first and undoubtedly most important feature that patient care should have, as it is the basis for other measures. There are associations between Burnout Syndrome and lower perceptions of safety culture and greater risks in patient safety.ObjectiveTo analyze the relationship between patient safety culture and burnout in pediatric hospitals.MethodThis is a cross-sectional study with a quantitative approach performed with health professionals who work in pediatric hospitals located in the Metropolitan Region of Cariri, Northeastern Brazil. The study enrolled 148 professionals who performed direct health care for the child in three different hospitals. For the evaluation of the Patient Safety Culture, the version, translated and validated for Brazil, of the Survey on Patient Safety Culture (HSOPSC) questionnaire was applied and to evaluate the occurrence of Burnout, we chose the Maslach Burnout Inventory (MBI).ResultsAmong the dimensions of burnout that presented the most moderate to high, depersonalization and low professional achievement stand out. When considering the syndrome with the professional who presented a "high" score in only one of the three dimensions, it was identified that 44.6% presented the disease. All patient safety dimensions studied correlated with some dimension of burnout.ConclusionThe study evidenced the influence of all patient safety domains for the development of burnout syndrome in pediatric professionals. Also, it was identified that the organizational climate is the main determinant of burnout, especially in what refers to "teamwork between units".

[This corrects the article DOI: 10.1371/journal.pone.0209510.].

New technologies designed to improve the communication of autistic children can also help to promote interaction processes and cognitive and social development. The aim of this study was to analyze the instruments used to improve the communication skills of children with autism spectrum disorder. We searched the PubMed and Web of Science databases using the descriptors “autism”, “Asperger”, “education”, “children” and “assistive technology” and selected articles that met the following inclusion criteria: (i) original research; (ii) written in English; (iii) based on participants with a primary diagnosis of autism spectrum disorder; and (iv) tested an instrument designed to promote communication in children with autism spectrum disorder. Our search retrieved 811 articles, of which 34 met the inclusion criteria. Data on 26 instruments were extracted, and the measurement properties of the instruments were combined with information about their outcomes and presentation. The most commonly used interventions were the Treatment and Education of Autistic and Related Communication Handicapped Children program and the Picture Exchange Communication System. The Treatment and Education of Autistic and Related Communication Handicapped Children program was shown to produce improvements in the communication skills, socialization and self-care skills of children with autism spectrum disorder. The Picture Exchange Communication System produced inconsistent results. The results of the identified studies confirm the significant importance of these instruments in improving the communicative process of autistic children.