Maintenance of Gains, Morbidity, and Mortality at 1 Year Following Cardiac Rehabilitation in a Middle‐Income Country: A Wait‐List Control Crossover Trial

Background-—Despite the epidemic of cardiovascular diseases in middle-income countries, few trials are testing the benefits of cardiac rehabilitation (CR). This trial assessed (1) maintenance of functional capacity, risk factor control, knowledge, and hearthealth behaviors and (2) mortality and morbidity at 6 months following CR in a middle-income country. Methods and Results-—Eligible Brazilian coronary patients were initially randomized (1:1:1 concealed) to 1 of 3 parallel arms (comprehensive CR [exercise plus education], exercise-only CR, or wait-list control). The CR programs were 6 months in duration, at which point follow-up assessments were performed. Mortality and morbidity were ascertained from chart and patient or family report (blinded). Controls were then offered CR (crossover). Outcomes were again assessed 6 months later (blinded). ANCOVA was performed for each outcome at 12 months. Overall, 115 (88.5%) patients were randomized, and 62 (53.9%) were retained at 1 year. At 6 months, 23 (58.9%) of those 39 initially randomized to the wait-list control elected to attend CR. Functional capacity, risk factors, knowledge, and heart-health behaviors were maintained from 6 to 12 months in participants from both CR arms (all P>0.05). At 1 year, knowledge was significantly greater with comprehensive CR at either time point (P<0.001). There were 2 deaths. Hospitalizations (P=0.03), nonfatal myocardial infarctions (P=0.04), and percutaneous coronary interventions (P=0.03) were significantly fewer with CR than control at 6 months. Conclusions-—CR participation is associated with lower morbidity, long-term maintenance of functional capacity, risk factors, and heart-health behaviors, as well as with greater cardiovascular knowledge compared with no CR. Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02575976. (J Am Heart Assoc. 2019;8: e011228. DOI: 10.1161/JAHA.118.011228.) Key Words: cardiac rehabilitation • coronary disease • morbidity/mortality • rehabilitation • risk factorYork University Librarie

A Ética trágica e a prática clínica da psicanalíse

Tese (doutorado) - Universidade Federal de Santa Catarina, Centro de Filosofia e Ciências Humanas. Programa de Pós-Graduação em Psicologia.A valorização do inconsciente e do conflito pulsional, bem como a consideração do homem enquanto produto de forças em combate, aproximam os discursos freudiano e nietzscheano. Entretanto, é a consideração de que o conflito não pode nem deve ser eliminado, mas sim suportado mediante a possibilidade de representações, que os implica em uma mesma ética. Torna-se então possível sustentar a tese de que a prática psicanalítica se orienta a partir dos mesmos pressupostos da ética trágica proposta por Nietzsche de forma que tal orientação ética determina os objetivos e procedimentos da psicanálise. Podemos considerar, então, a psicanálise como uma teoria psicológica e uma prática clínica que possibilita o renascimento do pensamento trágico na contemporaneidad

Neurological assessment of preterm newborns with bronchopulmonary dysplasia

Orientador: Emilio Carlos Elias BaracatDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Recém-nascidos prematuros correspondem de 7 a 10% de todos os nascimentos, mas concentram aproximadamente 85% de todas as complicações perinatais, com alto risco para o desenvolvimento de lesões pulmonares, principalmente a displasia broncopulmonar (DBP), e do sistema nervoso central. O objetivo deste estudo foi descrever e comparar a avaliação neurológica de recém-nascidos pré-termo (RNPT) com e sem DBP. Recém-nascidos pré-termo com peso de nascimento inferior a 1.500g e idade gestacional menor de 32 semanas foram avaliados com 40 semanas de idade gestacional corrigida, no Centro de Atenção Integral a Saúde da Mulher (CAISM) da UNICAMP. Foi utilizada a Avaliação Neurológica de Dubowitz, composta integralmente por 34 itens, dos quais 29 foram avaliados, divididos em 6 categorias: tônus, padrões de tônus, reflexos, movimentos, sinais anormais e comportamento. O estado de consciência do RN no momento do exame foi graduado utilizando-se os 6 graus definidos por BRAZELTON (1973). No período de janeiro de 2005 a setembro de 2007, vinte e quatro recém-nascidos, 12 com DBP e 12 controles sem a doença foram avaliados. A idade média de nascimento foi de 28 semanas (+- 1,38) no grupo com DBP e 31 semanas (+- 1,44) no grupo controle; peso médio no grupo de estudo de 884g (+- 202g) e no grupo controle de 1.156g (+- 216g). Dezoito dos 29 itens avaliados foram homogêneos entre os grupos (p = 1,00) e a pontuação geral dos dois grupos não apresentou diferença (p = 0,30). Na análise dos dados descritivos, observou-se um percentual maior de anormalidade no grupo com DBP em oito itens. A avaliação neurológica de RNPTs com e sem Displasia Broncopulmonar, pelo método Dubowitz, não apresenta diferença às 40 semanas de idade gestacional corrigidaAbstract: Preterm newborns corresponds to 7 to 10% of all births, but concentrates approximately 85% of all perinatal complications, with high risk of pulmonary injuries development, mainly bronchopulmonary dysplasia (BPD), and in the central nervous system. This study objective describes and compares preterm newborns neurological assessment with and without BPD. Preterm newborns with birth weight less than 1.500g and gestational age less than 32 weeks were evaluated by Dubowitz Method, with 40 weeks corrected gestational age, at Centro de Atenção Integral a Saúde da Mulher (CAISM) - UNICAMP. Dubowitz Neurological Assessment was used, consisting of 34 items, which 29 were evaluated, grouped in 6 categories: tone, tone patterns, reflexes, movements, abnormal signs and behavior. Newborn behavioral state was graded in 6 degrees defined by BRAZELTON (1973). From January 2005 to September 2007, twenty four newborns with average birth age of 28 weeks (+- 1,38) from BPD group and 31 weeks (+- 1,44) from control group were evaluated; Study¿s group mean weight was 884g (+- 202g) and control¿s group was 1.156g (+- 216g). Eighteen from 29 checked items were classified as homogeneous among groups (p = 1.00) and general score on two groups were not significantly different (p = 0.30). When analyzed in descriptive manner, the data showed greater abnormality percentage on the BPD group in eight items. The neurological assessment using Dubowitz Neurological method on preterm newborns with and without BPD does not show differences from 40 weeks corrected gestational ageMestradoSaude da Criança e do AdolescenteMestre em Saude da Criança e do Adolescent

Avaliação do efeito mutagênico do herbicida Roundup em bioensaio agudo com o bioindicador Corydoras paleatus (Pisces)

Orientadora: Marta Margarete CestariCoorientador: Marcos Vinícius Mocellin FerraroMonografia (Bacharelado) - Universidade Federal do Paraná. Setor de Ciencias Biológicas. Curso de Graduaçao em Ciencias BiológicasResumo : O Roundup® é um herbicida sistêmico não seletivo a base de glifosato. Descritos pelos fabricantes como pesticidas de "baixa toxicidade e boa compatibilidade ambiental", os herbicidas à base de glifosato representam um bálsamo quando se trata da vegetação indesejada. Além disso, a criação de transgênicos resistentes a Roundup contribui não só para o aumento da produção agrícola, mas também pode resultar em mais resíduos de glifosato que podem ser bioacumulados ao longo da cadeia trófica, podendo afetar animais e, entre eles os humanos. Utilizou-se como bioindicador o peixe Corydoras paleatus, original da Bacia do Rio Amazonas e amplamente distribuído no Sul do Brasil. Seu destaque devese à sua característica ruderal nativa, se distribuindo em regiões com forte interferência humana, como áreas de agricultura intensiva e relacionadas à piscicultura, apresentando valor comercial como peixe ornamental. O objetivo do presente trabalho foi avaliar o efeito genotóxico da exposição de exemplares de Corydoras paleatus ao Roundup®, utilizando-se como biomarcadores as técnicas do Ensaio Cometa de eritrócitos e hepatócitos e o Micronúcleo Písceo de eritrócitos (MNP). Os peixes foram expostos à água contaminada em concentração de Roundup 6,67.10-3l/l (0,00667ml/l) por períodos de 3, 6 e 9 dias, e um grupo controle foi exposto somente a água destilada. O MNP mostrou não haver diferença significante entre os controles e os grupos contaminados; a despeito disso, o ensaio cometa de sangue revelou diferença significante entre o grupo controle quando comparado aos contaminados com cada um dos diferentes tempos de exposição; e Ensaio Cometa com células do fígado também revelou diferença entre o grupo controle e os três tratamentos. O potencial genotóxico do Roundup deveras tem apresentado resultados inconsistentes e muitas vezes controversos, e, apesar de cada método de teste ter suas vantagens, nenhum é universal. Sugere-se afinal que sejam feitos estudos mais aprofundados sobre a biologia de Corydoras paleatus, seu comportamento, sua taxa metabólica e as respostas mais específicas de cada tecido a contaminação. Seria válida também a avaliação de danos diários aos animais, e com no mínimo três concentrações para avaliar a formação de alguma tendência na comparação de dias, danos e concentrações

Avaliação Genotóxica em Rhamdia quelen após contaminação Sub-Crônica com Fipronil

Co-Orientador: Prof. Marcos Vinicius Mocellin FerraroOrientadora : Marta Margarete CestariDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências Biológicas, Programa de Pós-Graduação em Genética. Defesa: Curitiba, 28/01/2010Bibliografia: fls.62-76Área de concentração: GenéticaA populacao humana mundial em 1950 era de 2,5 bilhoes. Em 2000 ja havia mais de seis bilhoes de pessoas no planeta. O crescimento populacional apresenta-se como um fator negativo frente a disponibilidade dos recursos naturais. A agua se constitui atualmente um fator limitante para o desenvolvimento agricola, urbano e industrial. Rios, lagos e oceanos sao frequentemente usados como esgotos a ceu aberto, sendo os ultimos recipientes de toda a poluicao. Agrotoxicos, derramamento de oleo, metais pesados, detergentes e lixos industriais podem prejudicar e matar organismos que vivem em ambientes aquaticos. Surge assim a necessidade de se avaliar os efeitos que essas substancias podem causar nestes organismos, bem como a necessidade de padronizar as metodologias de avaliacao dos danos causados por tais substancias. Neste trabalho pesquisou-se os efeitos que uma exposicao subcronica de 60 dias ao agrotoxico Fipronil, nas concentracoes de 0,05µg/L, 0,10µg/L e 0,23µg/L, pode causar no peixe Rhamdia quelen atraves do teste do Micronucleo Pisceo, do Ensaio Cometa com branquia e de analise histopatologicas das branquias. Os resultados para o Ensaio Cometa e para lesoes histopatologicas branquiais nao mostraram diferenca entre o controle negativo e os grupos contaminados. Para o teste do Micronucleo Pisceo, a menor concentracao de Fipronil mostrou-se igual ao grupo controle, e as demais concentracoes, acima do controle, com relacao a taxa de dano ao DNA. Esses resultados indicam que as concentracoes testadas de Fipronil nao foram suficientes para se detectar grandes alteracoes no DNA de Rhamdia quelen com os testes escolhidos. Talvez a aplicacao de novos testes, mais precisos podem revelar alguma alteracao. Durante o experimento foram feitas duas padronizacoes de metodologia: uma para o Teste do Micronucleo Pisceo, que concluiu que a contagem de somente mil celulas e suficiente para se obter resultados confiaveis; e outra para o Ensaio Cometa, onde se padronizou o soro bovino fetal como a melhor solucao de estoque para ate 48 horas.In 1950 the human population in the world was around 2.5 billion people. In 2000 there were over six billion on the planet. Population growth is a negative factor against the availability of natural resources. The water is currently an limiting factor for agricultural, urban and industrial development. Rivers, lakes and oceans are often used as sewers, and the ultimate recipient of all pollution. Pesticides, waste and oil spills, metals, urban and industrial waste can harm and kill organisms living in aquatic environments. These situations create the need to evaluate the effects these substances can cause to these organisms. This study therefore investigated, through the Piscine Micronucleus test, the Comet Assay with gill and histopathological analysis of the gills, the effects of the insecticide Fipronil in concentrations of 0.05 µg / L, 0.10µg / L and 0.23µg / L, on fish Rhamdia quelen. The results for the Comet test and histopathological gill lesions showed no difference between the negative control and contaminated groups. For the micronucleus piscine test, the lower concentration of Fipronil was equivalent to the control group and the other concentrations, above the control, when compared with the rate of DNA damage. These results indicate that concentrations of fipronil tested were not sufficient to detect a change in the DNA of Rhamdia quelen with the chosen tests; perhaps more accurate new tests could reveal any changes. During the experiment were done two standardization methods: one for the piscine micronucleus test, which concluded that the counting of only a thousand cells is sufficient to obtain reliable results, and other for the Comet assay, where standardized fetal bovine serum as the best solution for stock up to 48 hours

Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients

Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a lowresource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed. Keywords: Health care services, Cardiac rehabilitation, Cardiac care facilities, Attitude of health personnelYork University Librarie

The impact of cognitive performance on quality of life in individuals with Parkinson's disease

Background: Evidence points to the occurrence of cognitive impairment in all stages of PD, constituting a frequent and debilitating symptom, due to high impact on quality of life and mortality of patients. Objective: To correlate cognitive performance with quality of life in PD. Methods: The sample was drawn from a Movement Disorders Clinic of a reference hospital in Porto Alegre. Inclusion criteria were: PD diagnosis, according to the United Kingdom Parkinson’s Disease Society Brain Bank criteria for idiopathic PD (Hughes et al. 1992) and patient consent to participate. Patients with other neurological pathologies and those submitted to deep brain stimulation were excluded. The evaluation consisted of a cognitive testing battery (composed of eight tests for assessing cognitive performance), and a questionnaire on quality of life (PDQ-39) and depression (BDI). Results: The sample comprised 85 individuals with PD, with a mean age of 62.9 years (±10.7), mean disease duration of 10.4 years (±5.7), and mean educational level of four years (±4.3). There was a significant relationship between total score on the PDQ and all cognitive tests, showing that poor cognitive performance was correlated with poor quality of life. Moreover, a significant correlation was observed between cognitive tests and depression, H&Y, education level, and age. Conclusion: It may be concluded that the individuals with PD in this sample showed a correlation between poorer quality of life and worse cognitive performance. Poor performance was also correlated with more advanced stage, older age, low level of education and depression.Embasamento: As evidências apontam a ocorrência de comprometimento cognitivo em todas as fases da doença de Parkinson (DP), sendo este um sintoma não motor frequente e incapacitante, devido ao alto impacto na qualidade de vida e mortalidade dos pacientes. Objetivo: correlacionar a performance cognitiva com qualidade de vida na DP. Métodos: A amostra foi oriunda de um Ambulatório de Distúrbios do Movimento de um hospital referência de Porto Alegre. Os critérios de inclusão utilizados foram ter diagnóstico de DP e consentir em participar do estudo. Exclui-se pacientes com outras patologias neurológicas ou pacientes com estimulação cerebral profunda. A avaliação foi composta por uma anamnese, bateria de testes cognitivos (composta por oito testes), questionários sobre qualidade de vida (PDQ-39) e depressão (BDI). Resultados: A amostra foi composta por 85 indivíduos com DP, com média de idade de 62,9 anos (±10,7), média do tempo de doença de 10,4 anos (±5,7) e média de escolaridade de 7,4 anos (±4,3). Verificou-se relação significativa entre escore total do PDQ com todos os testes cognitivos, demonstrando que pior performance cognitiva está relacionada com pior qualidade de vida. Além disso, foi observado correlação significativa entre os testes cognitivos com depressão, H&Y, escolaridade e idade. Conclusão: Pode-se concluir que na presente amostra indivíduos com DP apresentaram correlação entre pior qualidade de vida com pior desempenho cognitivo. Isto também foi observado com estágio avançado da doença, idade avançada, baixa escolaridade e depressão

Cardiac Rehabilitation Models around the Globe.

Alternative models of cardiac rehabilitation (CR) delivery, such as home or community-based programs, have been developed to overcome underutilization. However, their availability and characteristics have never been assessed globally. In this cross-sectional study, a piloted survey was administered online to CR programs globally. CR was available in 111/203 (54.7%) countries globally; data were collected in 93 (83.8% country response rate). 1082 surveys (32.1% program response rate) were initiated. Globally, 85 (76.6%) countries with CR offered supervised programs, and 51 (45.9%; or 25.1% of all countries) offered some alternative model. Thirty-eight (34.2%) countries with CR offered home-based programs, with 106 (63.9%) programs offering some form of electronic CR (eCR). Twenty-five (22.5%) countries with CR offered community-based programs. Where available, programs served a mean of 21.4% ± 22.8% of their patients in home-based programs. The median dose for home-based CR was 3 sessions (Q25-Q75 = 1.0⁻4.0) and for community-based programs was 20 (Q25⁻Q75 = 9.6⁻36.0). Seventy-eight (47.0%) respondents did not perceive they had sufficient capacity to meet demand in their home-based program, for reasons including funding and insufficient staff. Where alternative CR models are offered, capacity is insufficient half the time. Home-based CR dose is insufficient to achieve health benefits. Allocation to program model should be evidence-based

The impact of deep brain stimulation on the quality of life and swallowing in individuals with Parkinson's Disease

Introduction Deep brain stimulation (DBS) is an established treatment for Parkinson’s disease (PD). However, there is little evidence regarding the effect of DBS on dysphagia. Objective To assess the swallowing and quality of life of individuals with PD before and after DBS surgery. Methods Our sample consisted of people who had undergone DBS surgery in a referral hospital in the state of Rio Grande do Sul, Brazil. The inclusion criteria were a diagnosis of PD and having undergone DBS surgery. A cognitive screening, through a questionnaire about depression and quality of life, was conducted. Evaluations of each patient’s swallowing were performed before and after surgery. The assessment consisted of anamnesis, clinical assessment, the Functional Oral Intake Scale, clinical evaluation of swallowing, and the Hoehn and Yahr scale. Results The sample included 10 individuals, all male, with a mean age of 57.3 years ( 4.7), a mean disease duration of 13.0 years ( 2.4), and mean level education of 8.1 years ( 4.0). In the clinical evaluation of the swallowing, a significant improvement after DBS was not observed. However, little changes in the signs and symptoms of dysphagia that had a positive impact on the quality of life were observed. Furthermore, there was no relation between the patients’ motor subtype and swallowing pre- and post-DBS. Conclusion There was an improvement in the quality of life of the patients after DBS. However, the improvement in the clinical signs and symptoms of dysphagia did not cause an overall improvement in the swallowing function