Extraskeletal Osteosarcoma in the Duodenum of a Dog

Background: Osteosarcoma is the most observed primary bone tumor in dogs, and may affect the appendicular and axial skeletons. In addition, it may be present in extraskeletal form, accounting for only 1% of cases. As shown by few reports in the literature, the involvement of the intestinal region by is rare. The objective of this study was to report the case of a 13-year-old Yorkshire dog, submitted to an exploratory laparotomy for suspected partial intestinal obstruction, diagnosed with extraskeletal osteosarcoma. Case: A 13-year-old dog, Yorkshire Terrier, male, presented clinical signs of gastrointestinal abnormalities. An ultrasound examination was performed and was found a mass in small intestine region with wall and lumen invasion. Then, was realized exploratory laparotomy and detected intestinal obstruction due to a mass with approximately 5.0 x 6.0 x 4.4 cm localized in duodenum. Surgical removal was performed and the sample sent to the veterinary diagnostic laboratory for histopathological examination. The sample had an irregular surface and firm consistency. In addition, when cut, the mass enveloped the intestinal layers and sometimes obstructed the lumen. Then, the sample were processed routinely for histopathology. After that, in microscopy evaluation was detected cell proliferation, affecting all layers of intestine. In detail, cells were elongated with pleomorphism marked and atypical mitosis. In addition, there was production of cartilage and bone matrix. So, sue the absence of others sites, the neoplasm was considered primary of intestine. After that, to evaluate the expression of KI-67 and COX-2 was performed, and the cell proliferation index was 54.0% and the COX-2 expression was moderate in less than 10% of neoplastic cells. After the surgery, the patient was hospitalized for a week and continue the treatment in home. Afterwards, the tutor received the diagnosis, but even though he was instructed on the severity of the case, he chose not to undergo chemotherapy. After three months, the patient presented abdominal fluid and nodules in your liver, suggesting metastasis, but without diagnosis confirmation. The patient died five months after the diagnosis of extraskeletal osteosarcoma. However, no necropsy was realized, impossibility the diagnosis confirm. Discussion: The frequency of extraskeletal osteosarcoma in dogs remains unknown, with the mammary glands being the most affected site. In the present study, osteosarcoma affects the duodenal region and no reports of this neoplasm in the duodenum of dogs have been found in the literature. The clinical sign of dyschezia was important for the tutor to refer the animal to the veterinarian and perform the ultrasound in an attempt to elucidate the case, as the tumor mass is not always palpable. Histopathological examination and immunohistochemistry were necessary for the differential diagnosis and to establish the prognosis, although after the surgery the tutor chose not to perform chemotherapy. Extraskeletal osteosarcoma are usually highly metastatic, mainly affecting the lymph nodes and liver. In this case, the patient presented a liver nodule three months after the tumor removal surgery, but unfortunately, there was no diagnostic confirmation. Such neoplastic type is rarer and more aggressive than appendicular and axial OS, with an average survival of 1 to 3 months. In this case, as a necropsy was not obtained, we cannot attribute the survival time to the disease. The survival rates of osteosarcomas in dogs are few months, but in the present case, although the patient died five months after surgery, the failure to perform a necropsy compromises the attribution of survival time to extraskeletal osteosarcoma. Keywords: canine, neoplasm, histopathology, immunohistochemistry

Cuidados de enfermagem aplicados à um paciente com úlcera venosa crônica: relato de caso / Nursing care applied to a patient with chronic venous ulcer: a case report

Introdução: As úlceras venosas são consideradas um importante problema de saúde pública mundial que causam alto índice de morbidade nos indivíduos. Objetivo: Relatar o caso de um paciente com úlcera venosa crônica e descrever a importância dos cuidados de enfermagem a serem realizados durante o tratamento de pacientes portadores dessa condição clínica. Relato do caso: No caso relatado o paciente não tem histórico de outras doenças crônicas e é portador de Úlcera Venosa Crônica há 30 anos. Deu entrada no hospital com úlcera venosa em membro inferior direita, dor intensa e odor fétido. A lesão encontrava-se no terço distal da face medial da perna, próximo ao maléolo, tamanho 10 cm e profundidade 1 cm, possuía tecido de fibrina, tecido macerado, tecido de granulação, bordas irregulares e presença de sinais flogísticos. Mesmo após acompanhamento médico e de enfermagem, o paciente optou por amputação do membro e após avaliação médica, a amputação foi realizada na região infrapatelar. Conclusão: As úlceras venosas se constituem como uma condição clínica importante e a aplicação dos cuidados de enfermagem é considerada uma estratégia eficaz no acompanhamento desses pacientes

Sentimentos após cesárea não planejada: estudo de caso / Feelings after unplanned caesarean section: case report

As taxas de cesarianas aumentaram significativamente nas últimas décadas e o Brasil e China lideram os rankings mundiais dessa via de parto. Esse evento está associado a vários desfechos negativos, incluindo sentimentos que podem interferir na aceitação da mulher no momento pós-parto. Esse estudo tem por objetivo compreender os sentimentos de uma mulher submetida à cesárea não planejada. Trata-se de um estudo de caso descritivo, exploratório e qualitativo com análise fenomenológica. A participante do estudo é uma mulher de 38 anos que relata ter sido submetida à uma cesárea baseada em falsas evidências. A entrevista foi realizada no trabalho da participante, em um único dia, sendo este local escolhido pela entrevistada. O instrumento utilizado foi um questionário semiestruturado com perguntas abertas, com auxílio de gravador de voz. A paciente relata estar “tranquila” em relação ao seu corpo, mesmo após ter passado por uma situação conturbadora. Em relação aos profissionais de saúde, os sentimentos relatados foram de medo, frustração e impotência. Os sentimentos relatados como medo, frustração, desânimo, insegurança e impotência podem estar presentes em muitas puérperas que vivenciaram uma cirurgia realizada sem planejamento prévio juntamente com a equipe multiprofissional. A frustração, desânimo e impotência em relação aos profissionais de saúde denotam falta de humanização e demonstram a necessidade de melhoria na relação entre a equipe multiprofissional presente no parto e nascimento e a paciente.

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Extraskeletal Osteosarcoma in the Duodenum of a Dog

Background: Osteosarcoma is the most observed primary bone tumor in dogs, and may affect the appendicular and axial skeletons. In addition, it may be present in extraskeletal form, accounting for only 1% of cases. As shown by few reports in the literature, the involvement of the intestinal region by is rare. The objective of this study was to report the case of a 13-year-old Yorkshire dog, submitted to an exploratory laparotomy for suspected partial intestinal obstruction, diagnosed with extraskeletal osteosarcoma. Case: A 13-year-old dog, Yorkshire Terrier, male, presented clinical signs of gastrointestinal abnormalities. An ultrasound examination was performed and was found a mass in small intestine region with wall and lumen invasion. Then, was realized exploratory laparotomy and detected intestinal obstruction due to a mass with approximately 5.0 x 6.0 x 4.4 cm localized in duodenum. Surgical removal was performed and the sample sent to the veterinary diagnostic laboratory for histopathological examination. The sample had an irregular surface and firm consistency. In addition, when cut, the mass enveloped the intestinal layers and sometimes obstructed the lumen. Then, the sample were processed routinely for histopathology. After that, in microscopy evaluation was detected cell proliferation, affecting all layers of intestine. In detail, cells were elongated with pleomorphism marked and atypical mitosis. In addition, there was production of cartilage and bone matrix. So, sue the absence of others sites, the neoplasm was considered primary of intestine. After that, to evaluate the expression of KI-67 and COX-2 was performed, and the cell proliferation index was 54.0% and the COX-2 expression was moderate in less than 10% of neoplastic cells. After the surgery, the patient was hospitalized for a week and continue the treatment in home. Afterwards, the tutor received the diagnosis, but even though he was instructed on the severity of the case, he chose not to undergo chemotherapy. After three months, the patient presented abdominal fluid and nodules in your liver, suggesting metastasis, but without diagnosis confirmation. The patient died five months after the diagnosis of extraskeletal osteosarcoma. However, no necropsy was realized, impossibility the diagnosis confirm. Discussion: The frequency of extraskeletal osteosarcoma in dogs remains unknown, with the mammary glands being the most affected site. In the present study, osteosarcoma affects the duodenal region and no reports of this neoplasm in the duodenum of dogs have been found in the literature. The clinical sign of dyschezia was important for the tutor to refer the animal to the veterinarian and perform the ultrasound in an attempt to elucidate the case, as the tumor mass is not always palpable. Histopathological examination and immunohistochemistry were necessary for the differential diagnosis and to establish the prognosis, although after the surgery the tutor chose not to perform chemotherapy. Extraskeletal osteosarcoma are usually highly metastatic, mainly affecting the lymph nodes and liver. In this case, the patient presented a liver nodule three months after the tumor removal surgery, but unfortunately, there was no diagnostic confirmation. Such neoplastic type is rarer and more aggressive than appendicular and axial OS, with an average survival of 1 to 3 months. In this case, as a necropsy was not obtained, we cannot attribute the survival time to the disease. The survival rates of osteosarcomas in dogs are few months, but in the present case, although the patient died five months after surgery, the failure to perform a necropsy compromises the attribution of survival time to extraskeletal osteosarcoma. Keywords: canine, neoplasm, histopathology, immunohistochemistry

Impact of Physical Activity Interventions on Blood Pressure in Brazilian Populations

Background: High blood pressure is associated with cardiovascular disease, which is the leading cause of mortality in the Brazilian population. Lifestyle changes, including physical activity, are important for lowering blood pressure levels and decreasing the costs associated with outcomes. Objective: Assess the impact of physical activity interventions on blood pressure in Brazilian individuals. Methods: Meta-analysis and systematic review of studies published until May 2014, retrieved from several health sciences databases. Seven studies with 493 participants were included. The analysis included parallel studies of physical activity interventions in adult populations in Brazil with a description of blood pressure (mmHg) before and after the intervention in the control and intervention groups. Results: Of 390 retrieved studies, eight matched the proposed inclusion criteria for the systematic review and seven randomized clinical trials were included in the meta-analysis. Physical activity interventions included aerobic and resistance exercises. There was a reduction of -10.09 (95% CI: -18.76 to -1.43 mmHg) in the systolic and -7.47 (95% CI: -11.30 to -3.63 mmHg) in the diastolic blood pressure. Conclusions: Available evidence on the effects of physical activity on blood pressure in the Brazilian population shows a homogeneous and significant effect at both systolic and diastolic blood pressures. However, the strength of the included studies was low and the methodological quality was also low and/or regular. Larger studies with more rigorous methodology are necessary to build robust evidence

Dopamine signaling regulates fat content through β-oxidation in Caenorhabditis elegans.

The regulation of energy balance involves an intricate interplay between neural mechanisms that respond to internal and external cues of energy demand and food availability. Compelling data have implicated the neurotransmitter dopamine as an important part of body weight regulation. However, the precise mechanisms through which dopamine regulates energy homeostasis remain poorly understood. Here, we investigate mechanisms through which dopamine modulates energy storage. We showed that dopamine signaling regulates fat reservoirs in Caenorhabditis elegans. We found that the fat reducing effects of dopamine were dependent on dopaminergic receptors and a set of fat oxidation enzymes. Our findings reveal an ancient role for dopaminergic regulation of fat and suggest that dopamine signaling elicits this outcome through cascades that ultimately mobilize peripheral fat depots

Dopamine induced fat reduction requires β-oxidation machinery.

<p>(A–B) Dopamine induced fat reduction is reduced by RNAi mediated knockdown of β-oxidation enzymes. (A) Representative images and (B) quantification of wild type animals fed with the indicated RNAi clones. Black and white bars represent vehicle and 5 mM dopamine treated animals, respectively. (C) Fluorescence quantification of 5 mM dopamine treated mutant worms available to corresponding RNAi gene clones. Data are showed as percentage of “No dopamine” control average ± SEM. (n = 8–10 animals per condition) (B) ** p<0.01 and *** p<0.001 compared to dopamine-treated animals fed on empty vector. (C) ** p<0.01 compared to “No dopamine” control animals of the same genotype. (D) Change in transcriptional levels of indicated metabolic genes upon 5 mM dopamine exposure quantified by qPCR. Dopamine increased kat-1 transcriptional level. Data are presented as average of three independent populations ± SD. Ctd – Ct dopamine exposed worms/Ctc – Ct No dopamine worms. * p<0.05 compared to “No dopamine” control animals. (E) Dopamine-treated animals exhibit an increase in β-oxidation rate. Data are presented as average of 12 independent populations ± SEM. * p<0.05 compared to “No dopamine” control animals.</p

Dopamine signaling effects on fat depends on dopamine receptors.

<p>(A–B) Fat levels of various mutants with or without exposure to dopamine. Black and white bars represent vehicle and 5 mM dopamine treated animals, respectively. Data are shown as percentage of wild type vehicle-treated average ± SEM. (n = 10–20 animals per condition per genotype). *** p<0.001 compared to vehicle-treated animals of the same genotype, ### p<0.001 compared to vehicle-treated wild type animals, +++ p<0.001 compared to dopamine-treated wild type animals.</p