Hemorragia subaracnóidea - aspectos epidemiológicos, fisiopatológicos e manejo terapêutico

A hemorragia subaracnóidea (HS) é uma doença de elevada morbimortalidade e constitui uma emergência neurológica; as principais etiologias envolvidas são a doença aneurismática e o traumatismo crânio encefálico (TCE). Outras causas menos comuns de HS incluem anormalidades vasculares congênitas, infecções, doenças autoimunes, uso excessivo de drogas ou álcool e uso de anticoagulantes. Outrossim, os sintomas mais comuns da HS incluem dor de cabeça grave, náuseas, vômitos e tontura; em alguns casos, a pode levar à paralisia das extremidades, alterações de comportamento, convulsões ou coma. O exame de tomografia computadorizada (TC) contribui para o diagnóstico da HS, pois possibilita a visualização de características típicas dessa doença, como o edema perilesional, o aumento da incisura de Silvio e a presença de calcificações. Outros fatores que ajudam no diagnóstico são a anamnese e a avaliação clínica. A anamnese pode fornecer dados importantes, como o tempo de duração dos sintomas, a presença de fatores desencadeantes, a presença de outros sintomas e o histórico familiar. A avaliação clínica também é importante, pois a presença de sinais neurológicos focais pode indicar um maior risco de complicações associadas com a HS. Ademais, o tratamento é baseado na causa, mas geralmente envolve o uso de medicamentos, cirurgia ou terapia de reabilitação; em casos de cefaleia secundária a tumores, as principais abordagens são medicamentosas e cirúrgicas. O tratamento medicamentoso pode ser feito com o uso de analgésicos e/ou antidepressivos que aliviam os sintomas. Porém, em caso de tumores malignos, a cirurgia é necessária para remover o tumor, seguida por radioterapia ou quimioterapia. Em suma, a abordagem do paciente com cefaleia depende da etiologia e dos sinais de alarme associados. É importante realizar um diagnóstico preciso para que o tratamento seja adequado e eficaz

PD-L1 may mediate T-cell exhaustion in a case of early diffuse Leishmaniasis caused by Leishmania (L.) amazonensis

Introduction: Diffuse cutaneous leishmaniasis (DCL) is a rare disease form associated with Leishmania (L.) amazonensis in South America. It represents the “anergic” pole of American Tegumentary Leishmaniasis, and the explanation for its resistance to treatment remains elusive. We aimed to study some possible immunological mechanisms involved in the poor DCL treatment response by evaluating some cell surface molecules obtained from a patient with DCL by flow cytometry. Case presentation: A 65-year-old DCL patient who initially failed to respond to the standard treatment for the disease showed vacuolated macrophages filled with amastigotes in lesion biopsy, and L. (L.) amazonensis was identified through ITS1PCR amplification. The Leishmania skin test and indirect immunofluorescence analysis revealed negative results. Peripheral blood from the patient was collected after a few months of treatment, when the patient presented with no lesion. Peripheral blood mononuclear cells were analyzed ex vivo and in vitro after 48 h of stimulation with soluble L. (L.) amazonensis antigen (SLA). Cell death, surface molecules, and intracellular molecules, such as IFN-γ and granzyme B, were analyzed in the cells using flow cytometry. Analysis of the surface markers showed an increased expression of the inhibitory molecule programmed death ligand 1 (PD-L1) in the monocytes restimulated with SLA (approximately 65%), whereas the negative controls were 35% positive for PD-L1. Conversely, compared with the negative controls, we observed a decrease in CD4+IFN-γ+ T cells (8.32 versus 1.7%) and CD8+IFN-γ+ T cells (14% versus 1%). We also observed a relevant decrease in the granzyme B levels in the CD8+ T cells, from 31% in the negative controls to 5% after SLA restimulation. Conclusion: The dysfunctional activation of PD-L1 inhibitory pathway after Leishmania antigen stimulation and reduced levels of IFN-gamma and granzyme B-producing cells could be closely related to unresponssiveness to standard drug treatment of DCL patient

Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017

Objective In Brazil, national estimates of childhood malnutrition have not been updated since 2006. The use of health information systems is an important complementary data source for analysing time trends on health and nutrition. This study aimed to examine temporal trends and socio-demographic inequalities in the prevalence of malnutrition in children attending primary health care services between 2009 and 2017. Design Time trends study based on data from Brazil's Food and Nutrition Surveillance System. Malnutrition prevalence (stunting, wasting, overweight and double burden) was annually estimated by socio-demographic variables. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. Setting Primary health care services, Brazil. Participants Children under 5 years old. Results In total, 15,239,753 children were included. An increase in the prevalence of overweight (APC = 3·4 %; P = 0·015) and a decline in the prevalence of wasting (-6·2 %; P = 0·002) were observed. The prevalence of stunting (-3·2 %, P = 0·359) and double burden (-1·4 %, P = 0·630) had discrete and non-significant reductions. Despite the significant reduction in the prevalence of undernutrition among children in the most vulnerable subgroups (black, conditional cash transfer's recipients and residents of poorest and less developed areas), high prevalence of stunting and wasting persist alongside a disproportionate increase in the prevalence of overweight in these groups. Conclusions The observed pattern in stunting (high and persistent prevalence) and increase in overweight elucidate setbacks in advances already observed in previous periods and stresses the need for social and political strategies to address multiple forms of malnutrition

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Evaluation of the inflammatory response induced by different materials in the treatment of perianal fistulas: experimental study in rats

The medical literature has no study evaluating the effectiveness of different materials used as setons in the treatment of perianal fistulas; therefore, there is no evidence of availability of a more effective material than others for this purpose. Objective: To evaluate the inflammatory response induced by different materials used as seton in perianal fistulas in rats. Method: Thirty Wistar rats, which were initially submitted for the construction of a perianal fistula by passing transfixing steel wire into the anal canal, were used. The rats were kept for 30 days; after this period, and with confirmation of the formation of the perianal fistula, the setons were introduced (10 rats – cotton thread #0; 10 rats – rubber; and 10 rats – silastic); after 30 days the animals were euthanized, and then the area of the fistula repaired by the seton was resected, and the material retrieved was submitted to histological analysis. The results were analyzed statistically. Results: The mean degree of inflammatory process observed by histological analysis after 30 days was 2.3 for the cotton group; 1 for the rubber group; and 1.2 for the silastic group. Conclusion: A greater inflammatory response was observed in the group treated with a cotton seton. In the remaining groups, a lower inflammatory response, with equal intensity for rubber and silastic-treated rats, was noted. Resumo: Não foram encontrados na literatura médica estudos que avaliassem a eficácia dos diferentes materiais utilizados como sedenho no tratamento de fístulas perianais, portanto, não havendo evidências de que haja um material mais eficaz do que outro para esta finalidade. Objetivo: avaliar a resposta inflamatória induzida por diferentes materiais utilizados como sedenhos em fístulas perianais em ratos. Método: foram utilizados 30 ratos Wistar, os quais foram inicialmente submetidos à criação de fístula perianal pela passagem de fio de aço transfixante no canal anal, mantido por 30 dias; após este período, confirmada a formação de fístula perianal, foram introduzidos os sedenhos (10 ratos – fio de algodão zero, 10 ratos – borracha e 10 ratos – silastic); após 30 dias os animais foram submetidos a eutanásia, ressecando-se a área da fístula reparada pelo sedenho, submetendo-se este material à análise histológica. Os resultados foram submetidos a tratamento estatístico. Resultados: a média do grau de processo inflamatório observado pela análise histológica após 30 dias foi de 2,3 para o grupo de sedenho de algodão; de 1 para o grupo de sedenho de borracha e 1,2 para o grupo silastic. Conclusão: Houve maior resposta inflamatória no grupo tratado com sedenho de algodão. Houve resposta inflamatória menor e de igual intensidade nos animais tratados por sedenho de borracha e silastic. Keywords: Fistula, Anal canal, Rats, Seton, Palavras-chave: Fístula, Canal anal, Ratos, Sedenh