Mielografia em cães sadios com o meio de contraste ioversol 240 mg I/ml: Resultados clínicos e radiológicos

This study aimed to assess the opacification period and diagnostic quality of ioversol 240 mg I/ml in the thoracic and lumbar regions after intracisternally injected, and evaluate its effects on the nervous system by clinical and neurological examinations. Thirty clinically normal non-descript dogs without sex distinction, weighing 9-12 kg were divided into three groups of 10 animals each. All the animals were anaesthetized using diazepam and thiopental sodium. Ioversol was injected at a dose of 0.5ml/kg. Cervical radiographs after 5 minutes to confirm injection of the contrast, and thoracolumbar radiographs after 30, 40, 50 and 60 minutes to evaluate the opacification period were taken. Clinical and neurological examinations were performed daily until 7, 14 and 28 days for groups I, II and III respectively. Adverse reactions such as pedal movements, preconvulsive behavior, muscular spasms, apnea, dyspnea, and vomit anxiety were observed during the myelographic procedure only. Ioversol showed good radiopacity, diffusion and miscibility with the cerebrospinal fluid. Reduction of costs also was possible since it can be autoclaved. Opacification period with diagnostic value was of 60 minutes in 60% of thoracic radiographs and in 80% of lumbar radiographs. Ioversol showed low incidence of clinical and neurological alterations. It is concluded that ioversol 240 mg I/ml is appropriate and safe to be used for myelography in dogs.Este trabalho teve por objetivo avaliar o período de opacificação e a qualidade diagnóstica do ioversol 240 mg I/ml, nas regiões torácica e lombar após sua injeção na cisterna magna, e verificar seus efeitos sobre o sistema nervoso por meio de observações clínicas e neurológicas. Utilizaram-se 30 cães sadios, sem distinção de sexo ou raça, com peso entre 9 e 12 kg, divididos em três grupos de 10 animais cada. Nos animais anestesiados com diazepam e tiopental sódico, o ioversol foi injetado na dose de 0,5 ml/kg. Foram obtidas radiografias cervicais aos cinco minutos para confirmar a injeção do contraste e toracolombares aos 30, 40, 50 e 60 minutos para avaliar o período de opacificação. Exames clínicos e neurológicos foram realizados diariamente até os 7, 14 e 28 dias para os grupos I, II e III respectivamente. Efeitos adversos como movimentos de pedalagem, início de convulsão, espasmos musculares, apnéia, dispnéia e ânsia de vômito foram observados apenas durante o procedimento mielográfico. O ioversol apresentou boas radiopacidade, difusão e miscibilidade com o líquor, oferecendo também a possibilidade de redução de custos, já que pode ser autoclavado. O tempo de opacificação do contraste com valor diagnóstico atingiu 60 minutos em 60% das radiografias torácicas e em 80% das radiografias lombares. Havendo baixa incidência de alterações clínicas e neurológicas, e apropriadas qualidades radiográficas, concluiu-se que o ioversol na concentração de 240 mg I/ml é adequado e seguro para ser utilizado em mielografia de cães

Influence of Male to Female Ratio on Hormone Profiles and Reproductive Performance of Anestrus Postpartum Ewes Subjected to the Male Effect

Background: Complete isolation of genders allows intense estrous induction and synchronization once rams are introduced in ewe flocks at the onset of the breeding season (BS). This management practice, defined as the male effect, results from a neuroendocrine process mediated by pheromones. The male effect is a straightforward procedure to induce estrous in noncycling ewes, but conditions for its use have not been fully explored. Thus, this study aimed to evaluate hormone levels and ovarian activity of postpartum ewes in anestrus which are subjected to the male effect under different male to female ratios.Material, Methods & Results: Pospartum females were selected according to body condition score and cyclicity status. Females were kept apart from males during 30 days at a distance of 10 m. Anestrus and ovulation were determined by P4 measures on days 10, 20 and 30 after isolation from males. After P4 concentration diagnosis, anestrus ewe (n = 99) were subjected to male to ewe ratios (MFR) of 1:20 (MFR20), 1:30 (MFR30) and 1:40 (MFR40). Santa Inês rams  (n = 3) of proven fertility were used. Three females of each group were randomly subjected to blood collection for LH concentration analysis. Ovarian activity was performed by ultrasonography after estrus manifestation in six ewe of each group. Estrus events were observed twice a day during the BS of 35 days, and estrus were considered synchronized when it occured within the initial five days of the BS. Pregnancy diagnosis was performed by ultrasonography on days 35 and 60 after the last mating. All ewe were in a non-cycling condition before BS onset, based upon P4 analysis. After initiation of the BS, P4 concentrations increased for all groups. Irrespectively of male to female ratio, male effect induced LH pre-ovulatory peaks within the initial 26 to 86 h of the BS. Synchronization of estrus reached 50% for MFR20, 40% for MFR30 and 20% for MFR40 for all ewe. Moreover, overall estrus incidence was 100% (MFR20), 90% (MFR30) and 65% (MFR40) within the initial 15 days of the BS. However, incidence of ewe that had repeated estrus events was lower for MFR20 than for MFR30. Follicular growth and number of ovulations was similar between groups. Conception rates on first service was higher than that of second service for MFR20 and MFR30, although there was no difference between services for MFR40. In contrast, overall conception rates, delivery type and prolificacy were similar between groups.Discussion: P4 increased to cyclicity levels after contact between genders, demonstrating the potential of the male effect to induce estrus in non-cycling ewes. Most ewe ovulated within three days after the male effect, possibly due to elevated basal LH levels. Moreover, the LH preovulatory peak varied within groups, possibly due to greater interactions between genders, which ultimately may have led to earlier ovulation anticipation under lower MFR. Estrus parameters were similar between groups, suggesting low or negligible effects of MFR. Ovulatory follicle size and growth and the number of ovulations were similar between all groups; previous reports have suggested that this may be due to a strong effect of their genetic background. Conception rates were higher at first than second services, demonstrating the potential of male effect. In conclusion, male to female ratio affects the efficiency of the male effect to induce and synchronize estrus in ewes under postpartum anestrus, but it does not affect conception rates and prolificacy

ATLANTIC EPIPHYTES: a data set of vascular and non-vascular epiphyte plants and lichens from the Atlantic Forest

Epiphytes are hyper-diverse and one of the frequently undervalued life forms in plant surveys and biodiversity inventories. Epiphytes of the Atlantic Forest, one of the most endangered ecosystems in the world, have high endemism and radiated recently in the Pliocene. We aimed to (1) compile an extensive Atlantic Forest data set on vascular, non-vascular plants (including hemiepiphytes), and lichen epiphyte species occurrence and abundance; (2) describe the epiphyte distribution in the Atlantic Forest, in order to indicate future sampling efforts. Our work presents the first epiphyte data set with information on abundance and occurrence of epiphyte phorophyte species. All data compiled here come from three main sources provided by the authors: published sources (comprising peer-reviewed articles, books, and theses), unpublished data, and herbarium data. We compiled a data set composed of 2,095 species, from 89,270 holo/hemiepiphyte records, in the Atlantic Forest of Brazil, Argentina, Paraguay, and Uruguay, recorded from 1824 to early 2018. Most of the records were from qualitative data (occurrence only, 88%), well distributed throughout the Atlantic Forest. For quantitative records, the most common sampling method was individual trees (71%), followed by plot sampling (19%), and transect sampling (10%). Angiosperms (81%) were the most frequently registered group, and Bromeliaceae and Orchidaceae were the families with the greatest number of records (27,272 and 21,945, respectively). Ferns and Lycophytes presented fewer records than Angiosperms, and Polypodiaceae were the most recorded family, and more concentrated in the Southern and Southeastern regions. Data on non-vascular plants and lichens were scarce, with a few disjunct records concentrated in the Northeastern region of the Atlantic Forest. For all non-vascular plant records, Lejeuneaceae, a family of liverworts, was the most recorded family. We hope that our effort to organize scattered epiphyte data help advance the knowledge of epiphyte ecology, as well as our understanding of macroecological and biogeographical patterns in the Atlantic Forest. No copyright restrictions are associated with the data set. Please cite this Ecology Data Paper if the data are used in publication and teaching events. © 2019 The Authors. Ecology © 2019 The Ecological Society of Americ

Male effect associated with management strategies on the reproductive performance of Santa Inês ewes in semi-arid region of Pernambuco State

O objetivo neste estudo, dividido em dois experimentos, foi avaliar o efeito macho associado a estratégias de manejo sobre o desempenho reprodutivo de ovelhas da raça Santa Inês criadas em regime semi-extensivo. No primeiro experimento, constituído de três tratamentos (T1, T2 e T3), foi avaliado a influência da distância do afastamento entre macho e fêmea, antes da estação de monta de 45 dias, sobre o desempenho reprodutivo de fêmeas pluríparas (n = 60). As ovelhas foram afastadas por 3.000 m (T1), 3 m (T2) e 300 m (T3) de distância dos reprodutores (n = 3) 60 dias antes dos experimentos durante os períodos climáticos de seca e chuva. No período seco, o valor médio da primeira manifestação de estro foi de 15,45 ± 10,36 (T1), 9,25 ± 6,41 (T2) e de 13,05 ± 10,24 (T3) dias e no período chuvoso foi de 8,73 ± 5,84 (T1), 9,30 ± 5,62 (T2) e de 6,10 ± 5,66 (T3) dias, não havendo diferença (P > 0,05) dentro e entre tratamentos, bem como entre os diferentes períodos climáticos. A indução do estro ocorreu em 100% das fêmeas no T1, T2 e T3 em ambos os períodos climáticos. A sincronização dos estros nos primeiros cinco dias da estação de monta do período seco ocorreu somente em 20% das fêmeas, sendo de 30% (T1), 15% (T2) e de 15% (T3), não havendo diferença (P > 0,05) entre os tratamentos. No período chuvoso ocorreu em 40% das fêmeas, sendo de 30% (T1), 35% (T2) e de 45% (T3), não existindo diferença (P > 0,05) entre os tratamentos. A porcentagens de prenhez nos períodos seco e chuvoso foram de 85% (T1), 80% (T2) e de 75% (T3), não havendo diferença (P > 0,05) dentro e entre os tratamentos. A prolificidade no período seco foi de 1,29 (T1), 1,38 (T2) e de 1,13 (T3) e no período chuvoso foi de 1,12 (T1), 1,25 (T2) e de 1,26 (T3), não havendo diferença (P > 0,05) entre os tratamentos de ambos períodos climáticos. No segundo experimento, constituído de três tratamentos (DT0, DT24, DT48), foi avaliado o efeito do desaleitamento temporário associado ao efeito macho sobre o desempenho reprodutivo de ovelhas pluríparas (n = 60), com cria ao pé. No DT0 (n = 20), não houve interrupção do aleitamento, no DT24 (n = 20), o aleitamento foi interrompido por 24 horas e no DT48 (n = 20) foi interrompido por 48 horas. As ovelhas (n = 60) foram afastadas dos reprodutores (n = 3) sem contato visual, olfativo e auditivo 60 dias antes do início da estação de monta de 45 dias durante o período de seca. As porcentagens de estro foram de 90% no DT0 e de 100% no DT24 e DT48, não diferindo (P > 0,05) entre os tratamentos. A sincronização dos estros até o 5o dia da estação de monta foi de 15% (DT0), 30% (DT24) e de 25% (DT48), não havendo diferença entre os tratamentos. As porcentagens de prenhez foram de 38,4% (DT0), 60,0% (DT24) e de 45,0% (DT48), não se constatando diferença (P > 0,05) entre os tratamentos. A prolificidade foi de 1,43 (DT0), 1,17 (DT24) e de 1,22 (DT48), não havendo diferença (P > 0,05) entre os tratamentos. Os resultados do primeiro experimento permitem concluir que o efeito macho pode ser obtido evitando-se apenas o contato táctil entre reprodutor e fêmea, bem como que a estação de monta de 45 dias pode ser realizada tanto no período seco quanto no chuvoso. Com os dados do segundo experimento conclui-se que o desaleitamento temporário é eficiente para induzir o estro, mas não para sincronizá-lo e tampouco para elevar o índice de prenhez e a prolificidade das ovelhas da raça Santa Inês na estação de monta de 45 dias durante o período de seca.The aim of this study, divided into two trials, was to evaluate the male effect associated with management strategies on the reproductive performance of Santa Inês ewes raised in a semi-extensive regime. In the first experiment, consisting of three treatments (T1, T2 and T3), was evaluate the effect of the separation distance between male and female, before the breeding season of 45 days, on the reproductive activity of pluriparous ewes (n = 60). They were kept at distances of 3.000 m (T1), 3 m (T2) and 300 m (T3) from the breeders (n = 3) 60 days before of the experiments during both the dry season and the rainy season. In dry season, the first manifestation of estrus averaged at 15.45 ± 10.36 (T1), 9.25 ± 6.41 (T2) and 13.05 ± 10.24 (T3) days. In rainy season, the average was 8.73 ± 5.84 (T1), 9.30 ± 5.62 (T2) and 6.10 ± 5.66 (T3) days. There was no difference in treatment (P > 0.05) during these different climatic conditions. Estrus induction occured in 100% of the females in T1, T2 and T3 in both climatic periods. Estrus synchronization on the first five days of mating season only occured in 20% of the females during dry season, being 30% (T1), 15% (T2) and 15% (T3). In rainy season, synchronisation occured in 40% of females, being 30% (T1), 35% (T2) and 45% (T3), with no differential treatment (P > 0.05) between both climatic periods. The pregnancy percentages in dry and rainy seasons were 85% (T1), 80% (T2) and 75% (T3), with no differential treatment (P > 0.05) between both climatic periods. Prolificacy in dry season was 1.29 (T1), 1.38 (T2) and 1.13 (T3) and in rainy season it was 1.12 (T1), 1.25 (T2) and 1.26 (T3) with no differential treatment (P > 0.05) between rainy and dry seasons. In the second experiment, consisting of three treatments (DT0, DT24, DT48), was evaluate the effect of temporary interrupt of sucking on the reproductive performance of pluriparous ewes (n = 60) with offspring. At DT0 (n = 20), there was no interruption of sucking while at DT24 (n = 20), interrupted of sucking for 24 hours and at DT48 (n = 20), interruption of sucking for 48 hours. Breeders were kept away from the females (n= 60), without visual, odor or hearing contact for 60 days before the breeding season of 45 days during the dry season. Estrous percentages were 90% (DT0), 100% (DT24) and 100% (DT48), with no difference (P > 0.05) among treatments. Estrous synchronization up to the 5th day of mating season was 15% (DT0), 30% (DT24) and 25% (DT48), with no difference among treatments. Pregnancy percentages were 38.4% (DT0), 60.0% (DT24) and 45.0%(DT48) with no difference (P > 0.05) among treatments. Prolificness was 1.43 (DT0), 1.17 (DT24) and 1.22 (DT48), with no difference (P > 0.05) among treatments. The results of the first experiment allow us to conclude that the ram effect can be obtained simply by avoiding physical contact between the breeder and the female as well as that the 45 day mating season can take place in both the rainy and dry season. The data from the second experiment allow us to conclude that temporary weaning is efficient to induce estrous, however is not to synchronize estrous as well as to increase the pregnancy rate and prolificacy of Santa Inês ewes in the breeding season of 45 days during dry period

Myelography in healthy dogs using ioversol 240 mg I/ml contrast medium: Clinical and radiological results

Este trabalho teve por objetivo avaliar o período de opacificação e a qualidade diagnóstica do ioversol 240 mg I/ml, nas regiões torácica e lombar após sua injeção na cisterna magna, e verificar seus efeitos sobre o sistema nervoso por meio de observações clínicas e neurológicas. Utilizaram-se 30 cães sadios, sem distinção de sexo ou raça, com peso entre 9 e 12 kg, divididos em três grupos de 10 animais cada. Nos animais anestesiados com diazepam e tiopental sódico, o ioversol foi injetado na dose de 0,5 ml/kg. Foram obtidas radiografias cervicais aos cinco minutos para confirmar a injeção do contraste e toracolombares aos 30, 40, 50 e 60 minutos para avaliar o período de opacificação. Exames clínicos e neurológicos foram realizados diariamente até os 7, 14 e 28 dias para os grupos I, II e III respectivamente. Efeitos adversos como movimentos de pedalagem, início de convulsão, espasmos musculares, apnéia, dispnéia e ânsia de vômito foram observados apenas durante o procedimento mielográfico. O ioversol apresentou boas radiopacidade, difusão e miscibilidade com o líquor, oferecendo também a possibilidade de redução de custos, já que pode ser autoclavado. O tempo de opacificação do contraste com valor diagnóstico atingiu 60 minutos em 60% das radiografias torácicas e em 80% das radiografias lombares. Havendo baixa incidência de alterações clínicas e neurológicas, e apropriadas qualidades radiográficas, concluiu-se que o ioversol na concentração de 240 mg I/ml é adequado e seguro para ser utilizado em mielografia de cães

POSTPARTUM BOVINE ENDOMETRITIS TREATMENT BY INTRAUTERINE AND INTRAMUSCULAR ADMINISTRATION OF OXITETRACYCLINE TRATAMENTO DE ENDOMETRITE BOVINA PÓS PUERPERAL PELAS VIAS INTRAMUSCULAR E INTRA-UTERINA

The aim of this study was to evaluate the efficiency of the postpartum bovine endometritis treatment by intrauterine and intramuscular administration of tetracycline. Forty six cross bred cows diagnosed by gynecological exam with postpartum endometritis were assigned randomly in two treatments: G1 (n=21) - animals were treated with one intramuscular (IM) dose of tetracycline (20 mg/Kg of body weight), while in G2 (n=25) animals were treated with one intrauterine (IU) dose of tetracycline (30 mg/Kg of body weight). No difference (p>0.05) was observed in the recovery rate between the two treatments (61.9 X 76.0%, G1 and G2, respectively). The interval from treatment until first estrous was 33.9±22.6 versus 14.8 ±10.9 days (P<0.05) and until first service was 54.7 ± 33.9 versus 27.2 ± 20.3 days (P<0.05;) for G1 and G2, respectively. No difference (p>0.05) was observed in the number of services per conception between G1 (1.54) and G2 (1.3). The treatment cost was lower for the G1 (U$3.51 versus U$ 5.00). Although not to have had differences in the clinical recovery rate, the use of the oxitetracycline managed for way IU in the postpuerperal treatment of endometrites in cows revealed more efficient in the reduction of the interval between the treatment and first heat and first insemination, beyond presenting lower cost that the treatment with oxitetracycline managed for way IM<br /><br />KEY WORDS: Bovine, postpartum endometritis, intrauterine, intramuscular, oxitetracicline.<br /> Este trabalho teve por objetivo comparar a eficiência do uso da oxitetracilina, administrada pelas vias intramuscular (IM) e intrauterina (IU), no tratamento de endometrites em vacas no período pós-puerperal. Foram utilizados 46 animais mestiços que apresentaram quadro clínico de endometrite, distribuídos aleatoriamente em dois tratamentos: G1 (n=21) – tratado com uma dose de 30 mg/Kg PV de oxitetraciclina por via IM, e G2 (n=25)  – uma infusão de 20 mg/Kg PV de oxitetraciclina por via IU. Não houve diferença (p>0,05) na taxa de recuperação dos animais, 61,9% e 76,0% para G1 e G2, respectivamente. O intervalo entre o tratamento e o primeiro estro (P<0,05) foi de 33,9 ± 22,6 versus 14,8 ± 10,9 dias, e do tratamento à primeira inseminação artificial (P<0,05) foi de 54,7 ± 33,9 versus 27,2 ± 20,3 dias para G1 e G2, respectivamente. Não houve diferença entre o número de serviços por concepção entre G1 (1,54) e G2 (1,30). O tratamento pela via IU apresentou menor custo, quando comparado ao IM (P<0,05; R$6,54 e R$ 9,3, respectivamente). Apesar de não ter havido diferenças na taxa de recuperação clínica, o uso da oxitetracilina administrada pela via IU no tratamento de endometrites pós-puerperal em vacas mostrou-se mais eficiente na redução do intervalo entre o tratamento e o primeiro estro e a primeira inseminação, além de apresentar menor custo que o tratamento com oxitetracilina administrada pela via IM. <br /><br />PALAVRAS-CHAVES: Bovinos, endometrite pós-puerperal, intramuscular, intrauterina, oxitetraciclina

Influence of Male to Female Ratio on Hormone Profiles and Reproductive Performance of Anestrus Postpartum Ewes Subjected to the Male Effect

Background: Complete isolation of genders allows intense estrous induction and synchronization once rams are introduced in ewe flocks at the onset of the breeding season (BS). This management practice, defined as the male effect, results from a neuroendocrine process mediated by pheromones. The male effect is a straightforward procedure to induce estrous in noncycling ewes, but conditions for its use have not been fully explored. Thus, this study aimed to evaluate hormone levels and ovarian activity of postpartum ewes in anestrus which are subjected to the male effect under different male to female ratios.Material, Methods & Results: Pospartum females were selected according to body condition score and cyclicity status. Females were kept apart from males during 30 days at a distance of 10 m. Anestrus and ovulation were determined by P4 measures on days 10, 20 and 30 after isolation from males. After P4 concentration diagnosis, anestrus ewe (n = 99) were subjected to male to ewe ratios (MFR) of 1:20 (MFR20), 1:30 (MFR30) and 1:40 (MFR40). Santa Inês rams  (n = 3) of proven fertility were used. Three females of each group were randomly subjected to blood collection for LH concentration analysis. Ovarian activity was performed by ultrasonography after estrus manifestation in six ewe of each group. Estrus events were observed twice a day during the BS of 35 days, and estrus were considered synchronized when it occured within the initial five days of the BS. Pregnancy diagnosis was performed by ultrasonography on days 35 and 60 after the last mating. All ewe were in a non-cycling condition before BS onset, based upon P4 analysis. After initiation of the BS, P4 concentrations increased for all groups. Irrespectively of male to female ratio, male effect induced LH pre-ovulatory peaks within the initial 26 to 86 h of the BS. Synchronization of estrus reached 50% for MFR20, 40% for MFR30 and 20% for MFR40 for all ewe. Moreover, overall estrus incidence was 100% (MFR20), 90% (MFR30) and 65% (MFR40) within the initial 15 days of the BS. However, incidence of ewe that had repeated estrus events was lower for MFR20 than for MFR30. Follicular growth and number of ovulations was similar between groups. Conception rates on first service was higher than that of second service for MFR20 and MFR30, although there was no difference between services for MFR40. In contrast, overall conception rates, delivery type and prolificacy were similar between groups.Discussion: P4 increased to cyclicity levels after contact between genders, demonstrating the potential of the male effect to induce estrus in non-cycling ewes. Most ewe ovulated within three days after the male effect, possibly due to elevated basal LH levels. Moreover, the LH preovulatory peak varied within groups, possibly due to greater interactions between genders, which ultimately may have led to earlier ovulation anticipation under lower MFR. Estrus parameters were similar between groups, suggesting low or negligible effects of MFR. Ovulatory follicle size and growth and the number of ovulations were similar between all groups; previous reports have suggested that this may be due to a strong effect of their genetic background. Conception rates were higher at first than second services, demonstrating the potential of male effect. In conclusion, male to female ratio affects the efficiency of the male effect to induce and synchronize estrus in ewes under postpartum anestrus, but it does not affect conception rates and prolificacy

Implementation of a Brazilian Cardioprotective Nutritional (BALANCE) Program for improvement on quality of diet and secondary prevention of cardiovascular events: A randomized, multicenter trial

Background: Appropriate dietary recommendations represent a key part of secondary prevention in cardiovascular disease (CVD). We evaluated the effectiveness of the implementation of a nutritional program on quality of diet, cardiovascular events, and death in patients with established CVD. Methods: In this open-label, multicenter trial conducted in 35 sites in Brazil, we randomly assigned (1:1) patients aged 45 years or older to receive either the BALANCE Program (experimental group) or conventional nutrition advice (control group). The BALANCE Program included a unique nutritional education strategy to implement recommendations from guidelines, adapted to the use of affordable and regional foods. Adherence to diet was evaluated by the modified Alternative Healthy Eating Index. The primary end point was a composite of all-cause mortality, cardiovascular death, cardiac arrest, myocardial infarction, stroke, myocardial revascularization, amputation, or hospitalization for unstable angina. Secondary end points included biochemical and anthropometric data, and blood pressure levels. Results: From March 5, 2013, to Abril 7, 2015, a total of 2534 eligible patients were randomly assigned to either the BALANCE Program group (n = 1,266) or the control group (n = 1,268) and were followed up for a median of 3.5 years. In total, 235 (9.3%) participants had been lost to follow-up. After 3 years of follow-up, mean modified Alternative Healthy Eating Index (scale 0-70) was only slightly higher in the BALANCE group versus the control group (26.2 ± 8.4 vs 24.7 ± 8.6, P <.01), mainly due to a 0.5-serving/d greater intake of fruits and of vegetables in the BALANCE group. Primary end point events occurred in 236 participants (18.8%) in the BALANCE group and in 207 participants (16.4%) in the control group (hazard ratio, 1.15; 95% CI 0.95-1.38; P =.15). Secondary end points did not differ between groups after follow-up. Conclusions: The BALANCE Program only slightly improved adherence to a healthy diet in patients with established CVD and had no significant effect on the incidence of cardiovascular events or death. © 2019 The Author