Improved function and strength in patients with knee osteoarthritis as a result of adding a two-day educational program to usual care. Prospective randomized trial.

Objective: The primary aim was to quantify the improvements on function and pain of patients with knee osteoarthritis (KOA), short education and low income by a two-day self-management program. Secondary aims were verifying if the program improves clinically relevant measures of weight and strength. Design: A prospective randomized clinical trial was conducted in a tertiary hospital in Brazil with 191 patients with Kellgren & Lawrence grades II and III KOA who were allocated to two groups: control (usual care- CG) and intervention (usual care and two days of an OA self-management program with a multiprofessional team - IG). Western Ontario and McMaster Universities Index (WOMAC), weight, body mass index (BMI), Timed up and go (TUG) and five Times Sit to Stand Test (FTSST) were assessed at baseline, six, 12 and 24 months. Results: Groups were similar at baseline (p â€‹> â€‹0.05). Both groups exhibited improved WOMAC total and subsets scores throughout the study (p â€‹< â€‹0.001). However, only IG improved WOMAC total and subsets in all follow-ups above 20% (minimally clinically important difference), with differences in WOMAC pain, function and total scores (p â€‹= â€‹0.001, p â€‹< â€‹0.001, and p â€‹< â€‹0.001, respectively) and best effect sizes at 1 year (0.355, 0.651 and 0.770, respectively). IG group lost weight (p â€‹< â€‹0.001) and BMI (p â€‹< â€‹0.01). Both groups exhibited improvements in TUG and FTSST (p â€‹< â€‹0.001) that remained in all evaluations. FTSST results favored the IG, p â€‹= â€‹0.032. Conclusions: An educational program to patients with KOA, short schooling and low income improves clinically important measures of pain and function.

Severe asthma in obese patients: Improvement of lung function after treatment with omalizumab.

INTRODUCTION: Asthma and obesity have a considerable impact on public health and their prevalence is increasing. Obesity is a known risk factor for asthma and can make it more difficult to control. Omalizumab is recommended in patients with severe allergic persistent asthma. The aim of this study was to assess the impact of omalizumab treatment in obese asthmatic patients with poorly controlled severe persistent asthma. METHODOLOGY: A non-interventional, prospective study was conducted, in an outpatient asthma clinic. All patients with severe asthma who started treatment with omalizumab were included and followed over 12 months. The study population was divided into two groups (obese and non-obese) for statistical analysis (descriptive and comparative analysis). RESULTS: Thirty-two patients (19 obese) were followed. After 12 months of omalizumab treatment, there was a statistically significant improvement in body mass index, number of exacerbations in the previous year, rescue medication, disease control and lung function, in the whole population. At the end of the study obese patients had a significantly better lung function (FEV1) than non-obese. DISCUSSION: As described in the literature, there was a significant reduction in the number of exacerbations in the previous year, rescue medication and better disease control, in the whole population. In relation to lung function, about which published data are inconsistent, treatment with omalizumab significantly improved it in obese patients. CONCLUSION: Our study showed that omalizumab significantly improved asthma control, reduced rescue medication and asthma exacerbations in all the population; and for the first time showed that obese patients achieved significantly improved lung function.

Suckling-induced Fos activation and melanin-concentrating hormone immunoreactivity during late lactation.

AIMS: Melanin-concentrating hormone (MCH) is implicated in the control of food intake, body weight regulation and energy homeostasis. Lactation is an important physiological model to study the hypothalamic integration of peripheral sensory signals, such as suckling stimuli and those related to energy balance. MCH can be detected in the medial preoptic area (MPOA), especially around the 19th day of lactation, when this hormone is described as displaying a peak synthesis followed by a decrease after weaning. The physiological significance of this phenomenon is unclear. Therefore, we aimed to investigate hypothalamic changes associated to sensory stimulation by the litter, in special its influence over MCH synthesis. MAIN METHODS: Female Wistar rats (n=56) were euthanized everyday from lactation days 15-21, with or without suckling stimulus (WS and NS groups, respectively). MCH and Fos immunoreactivity were evaluated in the MPOA and lateral and incerto-hypothalamic areas (LHA and IHy). KEY FINDINGS: Suckling stimulus induced Fos synthesis in all regions studied. An increase on the number of suckling-induced Fos-ir neurons could be detected in the LHA after the 18th day. Conversely, the amount of MCH decreased in the MPOA from days 15-21, independent of suckling stimulation. No colocalization between MCH and Fos could be detected in any region analyzed. SIGNIFICANCE: Suckling stimulus is capable of stimulating hypothalamic regions not linked to maternal behavior, possibly to mediate energy balance aspects of lactation. Although dams are hyperphagic before weaning, this behavioral change does not appear to be mediated by MCH.

Pathophysiological, cardiovascular and neuroendocrine changes in hypertensive patients during the hemodialysis session.

The pathophysiological mechanisms of arterial hypertension during hemodialysis (HD) in patients with end-stage renal disease (ESRD) are still poorly understood. The aim of this study is to investigate physiological, cardiovascular and neuroendocrine changes in patients with ESRD and its correlation with changes in blood pressure (BP) during the HD session. The present study included 21 patients with ESRD undergoing chronic HD treatment. Group A (study) consisted of patients who had BP increase and group B (control) consisted of those who had BP reduction during HD session. Echocardiograms were performed during the HD session to evaluate cardiac output (CO) and systemic vascular resistance (SVR). Before and after the HD session, blood samples were collected to measure brain natriuretic peptide (BNP), catecholamines, endothelin-1 (ET-1), nitric oxide (NO), electrolytes, hematocrit, albumin and nitrogen substances. The mean age of the studied patients was 43 ± 4.9 years, and 54.6% were males. SVR significantly increased in group A (P<0.001). There were no differences in the values of BNP, NO, adrenalin, dopamin and noradrenalin, before and after dialysis, between the two groups. The mean value of ET-1, post HD, was 25.9 pg ml(-1) in group A and 13.3 pg ml(-1) in group B (P = < 0.001). Patients with ESRD showed different hemodynamic patterns during the HD session, with significant BP increase in group A, caused by an increase in SVR possibly due to endothelial dysfunction, evidenced by an increase in serum ET-1 levels.

Age affects exercise-induced improvements in heart rate response to exercise.

The aim of the present study was to analyze the effects of age on cardiorespiratory fitness (CRF), muscle strength and heart rate (HR) response to exercise adaptation in women in response to a long-term twice-weekly combined aerobic and resistance exercise program. 85 sedentary women, divided into young (YG; n=22, 30.3 ± 6.2 years), early middle-aged (EMG; n=28, 44.1 ± 2.5 years), late middle-aged (LMG; n=20, 56.7 ± 3.5 years) and older (OG; n=15, 71.4 ± 6.9 years) groups, had their CRF, muscle strength (1-repetition maximum test) and HR response to exercise (graded exercise test) measured before and after 12 months of combined exercise training. Exercise training improved CRF and muscle strength in all age groups (P<0.05), and no significant differences were observed between groups. Exercise training also improved resting HR and recovery HR in YG and EMG (P<0.05), but not in LMG and OG. Maximal HR did not change in any group. Combined aerobic and resistance training at a frequency of 2 days/week improves CRF and muscle strength throughout the lifespan. However, exercise-induced improvements in the HR recovery response to exercise may be impaired in late middle-aged and older women.

Genetic relationships of the Portuguese Lidia bovine populations.

To clarify the genetic relationships among the Lidia breed lineages and two main Portuguese Lidia bovine populations, Casta Portuguesa and Brava dos Açores, 24 autosomal microsatellites were analyzed in 120 samples. Brava dos Açores showed the highest observed and expected heterozygosity (0.73 and 0.70, respectively) while Casta Portuguesa showed the lowest observed and expected heterozygosity (0.51 and 0.50, respectively). The results of this study were compared with the previous microsatellites data from the main Lidia bovine lineages. Casta Portuguesa was the most genetically isolated Lidia bovine population as revealed by the average FST genetic distance value with respect to the other lineages (32%). All the populations of Portuguese Lidia had negative FIS values. The Neighbour-joining dendrogram grouped Casta Portuguesa in the same branch with Miura, which was supported by the STRUCTURE software. The results evidenced low levels of genetic diversity and high levels of genetic differentiation in Casta Portuguesa and high levels of genetic diversity in Brava dos Açores populations, probably due to the crossbreeding of different bovine lineages at origin, and genetic flow among herds.

Effect of Saccharomyces strains on the quality of red wines aged on lees.

Ageing on lees involves ageing the wine in contact with yeast cells after fermentation. If combined with the addition of oak chips, it can soften the wood flavour and increase the aromatic complexity of wine. The aim of the present work is to optimise both ageing techniques through selection of an adequate Saccharomyces cerevisiae strain. The study lasted 6 months and content of polysaccharides, anthocyanins, proanthocyanidins, volatile compounds, colour parameters and sensory analysis, were periodically evaluated. Among the strains tested, G37 showed the highest release of polysaccharides (24.4±5.5 mg l(-1)). Vanillin, syringaldehyde and furfuryl alcohol increased with ageing time in 7VA2 treatment. The wine aged with CTPL14 strain presented fewer monomeric and oligomeric proanthocyanidins (12.4±0.6 and 83.4±8.3 mg l(-1), respectively), and showed the lowest astringency and bitterness sensations. Results show an improvement in the sensory profile of the red wine aged with a combination of these two techniques.

Low levels of realized seed and pollen gene flow and strong spatial genetic structure in a small, isolated and fragmented population of the tropical tree Copaifera langsdorffii Desf.

Over the past century, the Brazilian Atlantic forest has been reduced to small, isolated fragments of forest. Reproductive isolation theories predict a loss of genetic diversity and increases in inbreeding and spatial genetic structure (SGS) in such populations. We analysed eight microsatellite loci to investigate the pollen and seed dispersal patterns, genetic diversity, inbreeding and SGS of the tropical tree Copaifera langsdorffii in a small (4.8 ha), isolated population. All 112 adult trees and 128 seedlings found in the stand were sampled, mapped and genotyped. Seedlings had significantly lower levels of genetic diversity (A=16.5±0.45, mean±95% s.e.; H(e)=0.838±0.006) than did adult trees (A=23.2±0.81; H(e)=0.893±0.030). Parentage analysis did not indicate any seed immigration (m(seeds)=0) and the pollen immigration rate was very low (m(pollen)=0.047). The average distance of realized pollen dispersal within the stand was 94 m, with 81% of the pollen travelling <150 m. A significant negative correlation was found between the frequency and distance of pollen dispersal (r=-0.79, P<0.01), indicating that short-distance pollinations were more frequent. A significant SGS for both adults (∼50 m) and seedlings (∼20 m) was also found, indicating that most of the seeds were dispersed over short distances. The results suggested that the spatial isolation of populations by habitat fragmentation can restrict seed and pollen gene flow, increase SGS and affect the genetic diversity of future generations.

Preliminary results on the effects of grape (Vitis vinifera) seed condensed tannins on in vitro intestinal digestibility of the lupin (Lupinus angustifolius) seed protein fraction in small ruminants.

Condensed tannins (CT) from grape seeds (Vitis vinifera L.) were added to complex the protein fraction of Lupinus angustifolius seeds. Three CT/protein ratios were used: 96 mg/g (T(1)), 180 mg/g (T(2)) and 0 mg/g (T(0)). The CP losses in the rumen were assessed by the nylon-bag technique and CP intestinal digestibility (CPID) was estimated using an in vitro assay applying a three-step procedure: samples were subject to rumen degradation (in situ, 16 h) and the remaining residues were subject to the digestive enzymes of the abomasum and pancreas in vitro. A positive effect (p < 0.05) of the level of CT on the immediately soluble faction a and the insoluble degradable fraction b was observed between T(0) and T(2) . In the presence of CT the rumen degradation rate was reduced (p < 0.05) from 0.0763/h (T(0)) to 0.0443/h (T(2)). The application of CT showed a reduction (around 10% for T(1)) of effective rumen CP degradability. The CPID did not seem to be affected (p > 0.05) by the presence of CT. These findings suggest that the use of grape seed CT might have the potential to improve the efficiency of utilisation of the protein fraction from lupin seeds.

Body temperature and diaphoresis disturbances in a patient with arachnoiditis.

IMPLICATIONS: Arachnoiditis, produced by different causes, is an inflammation of the sac containing the spinal cord and nerve roots. Patients with this disease have severe low back and leg pain, sweating and low grade fever. This case had aberrant skin temperature and sweating in different parts of the body.

Postoperative irradiation of primary or recurrent pterygium: results and sequelae.

PURPOSE: To evaluate the efficacy of postoperative beta irradiation and to analyze treatment sequelae in patients with primary and recurrent pterygium. METHODS AND MATERIALS: From June 1986 to June 1998, 94 patients corresponding to 100 eyes received postoperative beta irradiation. Two groups of patients were treated: 37 eyes with primary pterygium (Group I) and 63 eyes with recurrent pterygium (Group II). Terson technique surgery was used in the majority of patients. Time between surgery and beta irradiation ranged from 2 to 48 h. Radiation doses and fractionation consisted of 30 Gy/3 fractions/5 days in 17 cases, 60 Gy/6 fractions/6 weeks in 80 cases, and 20 Gy/1 fraction in 3 patients. RESULTS: Fourteen of the 100 cases (14%) treated with surgery and adjuvant irradiation recurred. The overall crude local recurrence rates were 5.4% for Group I and 19% for Group II patients. The 5-year probability of local tumor control was 83.5% for the whole group of patients, 94% for Group I, and 76.9% for Group II (p = 0.04). The early sequelae related to surgery or irradiation were self limited and disappeared by 6 months after the end of the treatment: ocular irritation (14 cases), scleral atrophy (5 cases), and neovascularization (7 cases). A greater incidence of sequelae was observed in Group II patients, but the difference between the groups was not statistically significant (p = 0.15). No significant correlation between treatment sequelae and treatment dose was noted: 29% sequelae with 30 Gy vs. 18.7% sequelae with 60 Gy (p = 0.32). No late complications have been observed. CONCLUSION: Adjuvant beta irradiation provides effective therapy for primary pterygium, is somewhate less effective in patients with recurrent pterygium, and is associated with a moderate rate of early and transient sequelae.

Tree species impoverishment and the future flora of the Atlantic forest of northeast Brazil.

Estimates of species extinction due to human impact on tropical forests have previously been based on the relationship between species number and area. Here we use a different approach to estimate loss of tree species in the Atlantic forest of northeast Brazil. We evaluate the characteristics of plant species, their avian dispersers and the distribution of the forest remnants on the landscape to estimate that about 33.9% of tree species in this region will become extinct on a regional scale. Because northeast Brazil is the most threatened sector of South American Atlantic forest, our results highlight the need to change the current conservation paradigm for this region. Rather than focus on the creation of isolated reserves in any medium-to-large forest remnant, a bioregional planning approach is urgently required to rescue this unique biota from extinction.

Squamous cell carcinoma of the breast.

Squamous carcinoma of the breast (SCB) is a rare entity. For its diagnosis, the exclusion of squamous cell carcinoma of local cutaneous structures and metastasis of distant squamous carcinoma are mandatory. The aim was to retrospectively evaluate the prevalence, epidemiological and clinical characteristics of the cases of SCB, studied in our institution, between January 1985 and December 1996. The diagnosis was histopathological. We studied the patients' demographic data and tumour characteristics. In the 11-year study period, 5791 patients with breast carcinoma were admitted to our Institution, seven (0.1%) of which were SCB. All seven patients were female and Caucasian. Their average age was 63 years (range 24-82). The presentation was always a breast lump. Five patients were in Stage II-A and two in Stage II-B. All tumours were hormone-receptor negative. The initial treatment was surgery and four patients received adjuvant radiotherapy. The median follow-up was 64 months. No relapses were diagnosed. SCB is a rare entity. The initial therapeutic approach should be surgical. There is still no consensus regarding adjuvant therapy. The prognosis of this type of breast cancer is still the subject of controversy with some series, including the present study, suggesting an indolent clinical course and a relatively good prognosis.

[Distribution of Aedes aegypti and dengue in the State of Maranhão, Brazil]. / Distribuição do Aedes aegypti e do dengue no Estado do Maranhão - Brasil.

Dengue and Aedes aegypti are widespread in the State of Maranhão. During 1995, 87 of the 136 of the State's counties, including 176 towns and 480,687 households, were studied, of which 30 counties (34. 4%), 118 towns (67.0%) and 10,357 households (2.1%) were positive for Aedes aegypti. The positive counties are distributed as follow: 3 on São Luís Island, 7 in the Amazonia of Maranhão, 12 in the southern zone of the cerrados or savannas, and 5 in the mixed forest/savanna/palm grove zone. One positive county for Ae. aegypti was located in each of the following: alluvial fields, forest/palm grove, and sand dune/shoals areas. The Ae. aegypti-positive household rates were higher in the Amazonia of Maranhão (3.5%) and on São Luís Island (2.5%), because they are the most heavily traveled migratory and trade routes between Maranhão and neighboring states and are also the State's main economic centers. Household infestation rates for Ae. aegypti and reported dengue case rates were higher during the rainy season, showing the importance of rain in forming prime breeding sites for Aedes and spreading dengue.

Meningoencephalic herniation into the middle ear.

Meningoencephalic herniation into the middle ear (MHME) is a rare condition. It can result from ear surgery, infection, head trauma or can be spontaneous. Diagnosis requires a high degree of clinical suspicion. The presentation may suggest the condition, but sometimes the intraoperative discovery of an occult meningoencephalic herniation may be a frightening situation. Treatment planning must avoid intra-cranial complications. Transmastoid (TM) and middle cranial fossa (MCF) are alternative or complementary approaches, determined by several factors, including the size and the site of the bony defect and the presence or absence of middle ear infection. Three case reports are presented and a review of the literature is performed, to explain some aspects related to MHME, including aetiopathogenesis, clinical presentation, histopathology, diagnosis and treatment.

Non-Boltzmann thermodynamic integration (NBTI) for macromolecular systems: relative free energy of binding of trypsin to benzamidine and benzylamine.

The relative free energies of binding of trypsin to two amine inhibitors, benzamidine (BZD) and benzylamine (BZA), were calculated using non-Boltzmann thermodynamic integration (NBTI). Comparison of the simulations with the crystal structures of both complexes, trypsin-BZD and trypsin-BZA, shows that NBTI simulations better sample conformational space relative to thermodynamic integration (TI) simulations. The relative binding free energy calculated using NBTI was much closer to the experimentally determined value than that obtained using TI. The error in the TI simulation was found to be primarily due to incorrect sampling of BZA's conformation in the binding pocket. In contrast, NBTI produces a smooth mutation from BZD to BZA using a surrogate potential, resulting in a much closer agreement between the inhibitors' conformations and the omit electron density maps. This superior agreement between experiment and simulation, of both relative binding free energy differences and conformational sampling, demonstrates NBTI's usefulness for free energy calculations in macromolecular simulations.

Overcoming prejudice.

PIP: People of African descent comprise a large proportion of Brazil's population. While racism exists in the country, it is commonly denied. Most Afro-Brazilians live in poor areas, with poor health care services, sanitation, schools, and transport. Since HIV is linked to poverty, Afro-Brazilians are more affected by HIV than is the overall population. Although Afro-Brazilians contribute to Brazil's culture, they do not benefit from that contribution. Recognizing this considerable social problem, Project Araye was created in 1996 to address issues of race and HIV. Building upon religious and cultural traditions, the project is staffed by Afro-Brazilians who are knowledgeable in both health issues and Afro-Brazilian culture. Project Araye supports a wide range of diverse community leaders in linking sexual health and HIV with other health concerns which affect Afro-Brazilians such as sickle-cell anemia, diabetes, and leprosy. One important challenge has been overcoming the target population's denial of HIV and encouraging Afro-Brazilians to accept that HIV also affects them. Community leaders include religious leaders, rap musicians, artists, and other people respected by various communities. Activities include visits to samba dance schools, Umbanda and Candomble temples, and street youth groups to provide HIV-related information.^ieng

Quantitative study of Lowe's square-root-of-time method of closed-system anaesthesia.

Intermittent injection of liquid anaesthetic into a closed breathing system is particularly suitable in countries with limited resources. A method of calculating appropriate times and magnitudes of the injected doses was described by Lowe but the method has never been assessed rigorously. Such an assessment was the purpose of this study. The technique was used in a double-blind, randomized comparison of halothane, enflurane and isoflurane in oxygen-air, with 20 ASA I or II patients in each group, undergoing superficial or abdominal surgery. The prescribed times of injection were adhered to, but the doses, after the first two, were adjusted to maintain systolic arterial pressure within 20% of the reference preoperative value. Partial pressures of the anaesthetics were monitored but concealed from the investigator-anaesthetist. The mean doses found necessary for each anaesthetic were within 33% of those calculated to produce 1.3 MAC. However, end-tidal partial pressure (just before each dose) stabilized at a steady level of only 0.97, 0.42 and 0.77 MAC for halothane, enflurane and isoflurane, respectively. Recovery from enflurane was much more rapid than that from the other agents but no patient admitted to any dreams. We conclude that the rate of uptake of anaesthetic declines more slowly than predicted and that the patients receiving enflurane were less deeply anaesthetized because the greater hypotensive effect of enflurane led to the use of smaller doses.