Mid-arm muscle circumference cutoff points in patients with cirrhosis: Low muscle mass related to malnutrition predicts mortality.

OBJECTIVES: Muscle loss is one of the phenotypic criteria of malnutrition, is highly prevalent in patients with cirrhosis, and is associated with adverse outcomes. Mid-arm muscle circumference (MAMC) estimates the skeletal muscle mass and is especially helpful in cases of fluid overload. This study aimed to propose MAMC cutoff points for patients with cirrhosis and demonstrate its association with 1-year mortality. METHODS: This is an analysis of cohort databases from five reference centers in Brazil that included inpatients and outpatients with cirrhosis aged ≥18 y. The nutritional variables obtained were the MAMC (n = 1075) and the subjective global assessment (n = 629). We established the MAMC cutoff points stratified by sex based on the subjective global assessment as a reference standard for malnutrition diagnosis, considering the sensitivity, specificity, and Youden index. An adjusted Cox regression model was used to test the association of MAMC cutoff points and 1-year mortality. RESULTS: We included 1075 patients with cirrhosis, with a mean age of 54.8 ± 11.3 y; 70.4% (n = 757) male. Most patients had alcoholic cirrhosis (47.1%, n = 506) and were classified as Child-Pugh B (44.7%, n = 480). The MAMC cutoff points for moderate and severe depletion were ≤21.5 cm and ≤24.2 cm; ≤20.9 cm and ≤22.9 cm for women and men, respectively. According to these cutoff points, 13.8% (n = 148) and 35.1% (n = 377) of the patients had moderate or severe MAMC depletion, respectively. The 1-year mortality rate was 17.3% (n = 186). In the multivariate analysis adjusted for sex, age, MELD-Na, and Child-Pugh scores, a severe depletion in MAMC was an independent increased risk factor for 1-year mortality (HR: 1.71, 95% CI: 1.24-2.35, P < 0.001). Each increase of 1 cm in MAMC values was associated with an 11% reduction in 1-year mortality risk (HR: 0.89, 95% CI: 0.85-0.94, P < 0.001). CONCLUSIONS: Low MAMC classified according to the new cutoff points predicts mortality risk in patients with cirrhosis and could be used in clinical practice.

Global Leadership Initiative on Malnutrition criteria for the diagnosis of malnutrition and prediction of mortality in patients awaiting liver transplant: A validation study.

OBJECTIVES: The Global Leadership Initiative on Malnutrition (GLIM) is a framework aiming to standardize malnutrition diagnosis. However, it still needs to be validated, in particular for patients with chronic liver disease. This study aimed to validate the GLIM criteria in patients with liver cirrhosis awaiting liver transplant (LTx). METHODS: This was a retrospective observational study carried out with adult patients on the waiting list for LTx, consecutively evaluated between 2006 and 2021. The phenotypic criteria were unintentional weight loss, low body mass index, and reduced muscle mass (midarm muscle circumference [MAMC]). The etiologic criteria were high Model for End-Stage Liver Disease (MELD) and MELD adjusted for serum sodium (MELD-Na) scores, the Child-Pugh score, low serum albumin, and low food intake and/or assimilation. Forty-three GLIM combinations were tested. Sensitivity (SE), specificity (SP), positive and negative predictive values, and machine learning (ML) techniques were used. Survival analysis with Cox regression was carried out. RESULTS: A total of 419 patients with advanced liver cirrhosis were included (median age, 52.0 y [46-59 y]; 69.2% male; 68.8% malnourished according to the Subjective Global Assessment [SGA]). The prevalence of malnutrition by the GLIM criteria ranged from 3.1% to 58.2%, and five combinations had SE or SP >80%. The MAMC as a phenotypic criterion with MELD and MELD-Na as etiologic criteria were predictors of mortality. The MAMC and the presence of any phenotypic criteria associated with liver disease parameters and low food intake or assimilation were associated with malnutrition prediction in ML analysis. CONCLUSIONS: The MAMC and liver disease parameters were associated with malnutrition diagnosis by SGA and were also predictors of 1-y mortality in patients with liver cirrhosis awaiting LTx.

Is arginine supplementation effective in preventing preeclampsia in pregnant women / A suplementação de arginina é efetiva em prevenir pré-eclâmpsia em gestantes?

Objectives: The objective of this study was to review data from randomized controlled trials to assess whether or not the supplementation of L-Arginine (L-Arg) is effective in reducing the incidence of preeclampsia (PE) in pregnancies at risk of developing the disorder. Methods: We aimed to systematic review randomized controlled trials, including those which compared L-Arg supplementation with placebo in pregnant women at high risk of PE development, analyzing PE incidence as the main outcome. Data were collected from MEDLINE/ Pubmed, EMBASE/ Elsevier, LILACS/ BVS and Cochrane. Results: A total of 46 papers were identified in the primary search. After analysis of eligibility, inclusion and exclusion criteria, two articles (which respected in detail all the stages of evaluation) were included in the present review. A risk of bias assessment was performed. Data analysis revealed that the incidence of PE was significantly lower in both studies, and no major adverse effects were reported. The limitations of this study were the lack of standardization between the trials analyzed and the relative low number of studies included. Conclusions: The supplementation with L-Arg appears to reduce the incidence of PE in pregnant women with high risk for its developmen (AU)

Objetivo: O objetivo deste estudo foi revisar dados de ensaios clínicos randomizados para avaliar se a suplementação de L-Arginina é efetiva para reduzir a incidência de pré-eclâmpsia em gestantes com alto risco de desenvolver a doença. Métodos: Realizamos uma revisão sistemática de ensaios clínicos randomizados, incluindo aqueles que compararam a suplementação de L-Arginina com placebo em gestantes de alto risco de desenvolvimento de pré-eclâmpsia, analisando a incidência de pré-eclâmpsia como desfecho principal. Os estudos foram selecionados do MEDLINE/ Pubmed, EMBASE/ Elsevier, LILACS/ BVS e Cochrane. Resultados: Um total de 46 estudos foram identificados na busca primária. Após análise da elegibilidade, dos critérios de inclusão e de exclusão, dois artigos (que respeitaram em detalhes todas etapas de avaliação) foram incluídos na presente revisão. Foi realizada uma avaliação de risco de viés. A análise dos dados revelou que a incidência de pré-eclâmpsia foi significativamente menor em ambos os estudos, e nenhum efeito adverso importante foi relatado. As limitações deste estudo foram a falta de padronização entre os ensaios clínicos analisados e o número relativamente baixo de estudos incluídos. Conclusão: A suplementação com L-Arginina parece reduzir a incidência de pré-eclâmpsia em gestantes de alto risco para seu desenvolvimento (AU)

Is arginine supplementation effective in preventing preeclampsia in pregnant women? / A suplementação de arginina é efetiva em prevenir pré-eclâmpsia em gestantes?

ABSTRACT: Objectives: The objective of this study was to review data from randomized controlled trials to assess whether or not the supplementation of L-Arginine (L-Arg) is effective in reducing the incidence of preeclampsia (PE) in pregnancies at risk of developing the disorder. Methods: We aimed to systematic review randomized controlled trials, including those which compared L-Arg supplementation with placebo in pregnant women at high risk of PE development, analyzing PE incidence as the main outcome. Data were collected from MEDLINE/ Pubmed, EMBASE/ Elsevier, LILACS/ BVS and Cochrane. Results: A total of 46 papers were identified in the primary search. After analysis of eligibility, inclusion and exclusion criteria, two articles (which respected in detail all the stages of evaluation) were included in the present review. A risk of bias assessment was performed. Data analysis revealed that the incidence of PE was significantly lower in both studies, and no major adverse effects were reported. The limitations of this study were the lack of standardization between the trials analyzed and the relative low number of studies included. Conclusions: The supplementation with L-Arg appears to reduce the incidence of PE in pregnant women with high risk for its development. (AU)

RESUMO: Objetivo: O objetivo deste estudo foi revisar dados de ensaios clínicos randomizados para avaliar se a suplementação de L-Arginina é efetiva para reduzir a incidência de pré-eclâmpsia em gestantes com alto risco de desenvolver a doença. Métodos: Realizamos uma revisão sistemática de ensaios clínicos randomizados, incluindo aqueles que compararam a suplementação de L-Arginina com placebo em gestantes de alto risco de desenvolvimento de pré-eclâmpsia, analisando a incidência de pré-eclâmpsia como desfecho principal. Os estudos foram selecionados do MEDLINE/ Pubmed, EMBASE/ Elsevier, LILACS/ BVS e Cochrane. Resultados: Um total de 46 estudos foram identificados na busca primária. Após análise da elegibilidade, dos critérios de inclusão e de exclusão, dois artigos (que respeitaram em detalhes todas etapas de avaliação) foram incluídos na presente revisão. Foi realizada uma avaliação de risco de viés. A análise dos dados revelou que a incidência de pré-eclâmpsia foi significativamente menor em ambos os estudos, e nenhum efeito adverso importante foi relatado. As limitações deste estudo foram a falta de padronização entre os ensaios clínicos analisados e o número relativamente baixo de estudos incluídos. Conclusão: A suplementação com L-Arginina parece reduzir a incidência de pré-eclâmpsia em gestantes de alto risco para seu desenvolvimento. (AU)

Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool.

BACKGROUND & AIMS: Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA). METHODS: This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively. RESULTS: A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p = 0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle + MELD) (p = 0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA + MELD-Na≥12) (p = 0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA + Child-Pugh) (p = 0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength + Child-Pugh) was independently associated with a longer LOS (p = 0.029; OR:7.21; CI95%:1.22-42.50). CONCLUSION: The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Physicians' quality of life, illness and presenteeism: a cross-sectional epidemiological study.

Introduction: The World Health Organization defines quality of life as " an individuals' perception of their position in life, in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns." physicians, when dealing with illness and exposing themselves to the risks of their profession, must act without compromising their own health status in view of the function performed. Objectives: To evaluate and correlate physicians' quality of life, professional illness, and presenteeism. Methods: This is an epidemiological, cross-sectional, descriptive study with an exploratory quantitative approach. Overall, 309 physicians working in Juiz de Fora, state of Minas Gerais, Brazil were interviewed and answered a questionnaire with sociodemographic and health information and the World Health Organization Quality of Life instrument-Abbreviated version (WHOQOL-BREF). Results: Of physicians in the sample, 57.6% fell ill during their professional activities, 35% took sickness absence, and 82.8% practiced presenteeism. The most prevalent diseases were those involving the respiratory system (29.5%), infectious or parasitic diseases (14.38%), and those involving the circulatory system (9.59%). WHOQOL-BREF scores were boas, and were influenced by sociodemographic characteristics such as sex, age, and time of professional experience. Male sex, professional experience greater than 10 years, and age above 39 years were associated with beter quality of life. Previous illness and presenteeism were negative factors. Conclusions: The participating physicians had a good quality of life in all domains. Sex, age, and time of professional experience were relevant factors. The highest score was observed in the physical health domain, followed by psychological domain, social relationships, and environment, in a descending order.

Introdução: A Organização Mundial da Saúde define qualidade de vida como "a percepção do indivíduo de sua inserção na vida, no contexto da cultura e nos sistemas de valores nos quais ele vive e em relação a seus objetivos, expectativas, padrões e preocupações". Os médicos, ao lidarem com pacientes e se exporem aos riscos da profissão, devem atuar sem comprometer seu estado de saúde frente à função desempenhada. Objetivos: Avaliar e correlacionar a qualidade de vida, o adoecimento profissional e o presenteísmo do médico. Métodos: Estudo epidemiológico de corte transversal, descritivo e exploratório, com características quantitativas. Foram entrevistados 309 médicos atuantes em Juiz de Fora, no estado de Minas Gerais, submetidos a questionário com informações sociodemográficas e de condições de saúde e ao World Health Organization Quality of Life instrument-Abbreviated version (WHOQOL-BREF). Resultados: Na amostra, 57,6% adoeceram durante a atuação profissional, 35% se afastaram do trabalho e 82,8% praticaram presenteísmo. As doenças mais prevalentes foram do sistema respiratório (29,5%), infectoparasitárias (14,38%) e do sistema circulatório (9,59%). As pontuações no WHOQOL-BREF foram boas, afetadas por características sociodemográficas como sexo, idade e tempo de atuação profissional. Sexo masculino, atuação superior a 10 anos e idade maior que 39 anos foram associados a melhor qualidade de vida. Adoecimento prévio e presenteísmo foram fatores negativos. Conclusões: Os médicos participantes do estudo apresentaram boa qualidade de vida em todos os domínios. Sexo, idade e tempo de atuação profissional mostraram-se fatores relevantes. A melhor nota foi observada no domínio físico, com pontuações decrescentes nos domínios psicológico, social e ambiental.

Ruptura gástrica consequente a barotrauma: relato de caso / Gastric rupture consequent to barotrauma: case report / Rotura gástrica por barotrauma: reporte de caso

Introdução: A ruptura gástrica é uma complicação incomum da distensão e aumento da pressão intragástrica, podendo ter diversas etiologias, não sendo necessariamente relacionada a lesões pré-existentes. O quadro clínico pode ser inespecífico, sendo necessário exame de imagem complementar. Objetivos: Identificar as características fisiopatológicas da lesão gástrica por barotrauma, bem como discutir acerca dos diagnósticos diferencias e prognóstico desta condição. Método: Relato de caso realizado através de revisão de prontuário e exames de um paciente com rotura gástrica por barotrauma. Relato de caso: Paciente de 84 anos, com quadro clínico compatível com rotura gástrica por barotrauma após intubação esofágica inadvertida, cujos exames admissionais demonstravam a presença de importante pneumoperitônio. Foi submetido a tratamento cirúrgico, com rafia primária de lesão de 5 cm em parede gástrica, seguido de encaminhamento para UTI. Conclusão: A redução da incidência de lesões iatrogênicas associadas a ventilação mecânica faz-se necessária. Os médicos devem ser treinados corretamente para realização do procedimento, como também para suspeitarem de antemão das complicações ­ particularmente em pacientes com intubação difícil.(AU)

Introduction: Gastric rupture is an uncommon complication of distension and increased intragastric pressure, and may have several etiologies, not necessarily related to pre-existing lesions. The clinical picture may be nonspecific, requiring complementary imaging. Objectives: To identify the pathophysiological characteristics of the gastric lesion by barotrauma, as well as to discuss the differential diagnoses and prognosis of this condition. Method: Case report performed through medical record review and examination of a patient with gastric rupture by barotrauma. Case Report: Patient of 84 years, with clinical picture compatible with gastric rupture by barotrauma after inadvertent esophageal intubation, whose admissional exams demonstrated the presence of important pneumoperitoneum. He was submitted to surgical treatment, with primary raphy of lesion of 5 cm in the gastric wall, followed by referral to ICU. Conclusion: The reduction of incidence of iatrogenic lesions associated with mechanical ventilation is necessary. Physicians should be properly trained to perform the procedure, as well as to suspect in advance of complications - particularly in patients with difficult intubation.(AU)

Introducción: La rotura gástrica es una complicación infrecuente de distensión y aumento de la presión intragástrica, pudiendo tener diferentes etiologías, no necesariamente relacionadas con lesiones preexistentes. El cuadro clínico puede ser inespecífico, requiriendo un examen de imagen complementario. Objetivos: Identificar las características fisiopatológicas de la lesión gástrica por barotrauma, así como discutir los diferentes diagnósticos y pronósticos de esta patología. Método: Reporte de caso realizado mediante la revisión de historias clínicas y exámenes de un paciente con ruptura gástrica por barotrauma. Caso clínico: Paciente de 84 años con cuadro clínico compatible con rotura gástrica por barotrauma tras intubación esofágica inadvertida, cuyos exámenes de ingreso mostraron la presencia de un neumoperitoneo importante. Se sometió a tratamiento quirúrgico, con rafia primaria de una lesión de 5 cm en la pared gástrica, seguida de derivación a UCI. Conclusíon: Es necesario reducir la incidencia de lesiones iatrogénicas asociadas con la ventilación mecánica. Los médicos deben estar debidamente capacitados para realizar el procedimiento, así como para sospechar complicaciones con anticipación, particularmente en pacientes con intubación difícil.(AU)

Uso de Tecnologia Educacional durante a graduação médica / Use of Educational Technology during medical graduation

Introdução: "Tecnologia Educacional" é o conjunto de procedimentos que visa criar um diálogo entre ciência e o processo de ensino-aprendizagem a partir da utilização de tecnologias digitais de informação e comunicação (TDICs) com acesso à internet e das ferramentas digitais para aprendizagem oferecidos por meio da mesma. O presente estudo tem como objetivo investigar quais equipamentos eletrônicos e que tipos de ferramentas digitais são mais utilizadas pelos estudantes da graduação médica no Brasil. Método: Pesquisa transversal, descritiva e quantitativa, com aplicação de questionários pela internet a 1.215 acadêmicos do primeiro ao último período de cursos de medicina das cinco regiões geográficas brasileiras. Resultados: Do total de entrevistados, 94,6% e 98,9% responderam ter acesso a infocentro na instituição de ensino e dispor de internet na própria residência, respectivamente. Os equipamentos mais utilizados são os computadores/notebooks (97,8%) e os smartphones (98,4%). O uso de tablets foi verificado em apenas 33,1% dos alunos. Ferramentas digitais de aprendizagem são utilizadas por 83,0% (n=1008) dos participantes, destes, 91,2% perceberam melhora em seu conhecimento teórico ou prático ao iniciar o uso, sendo a videoaula a mais utilizada (93,2%). Conclusões: O uso das TDICs já está consolidado entre os estudantes de medicina do Brasil e as ferramentas digitais para aprendizagem são utilizadas em larga escala de forma complementar ao ensino médico a fim de otimizar os estudos no dia a dia. A maior parte dos recursos utilizados são gratuitos, apesar de o uso de ferramentas pagas não estar relacionado à renda familiar dos estudantes.

Introduction: "Educational Technology" is the set of procedures that aim to create a dialogue between science and teaching-learning process and is based on the use of Digital Information and Communications Technologies (DICT) by access to the internet and learning digital tools offered through it. The objective of this study is to investigate which types of electronic devices and digital tools are most used by medical students in Brazil. Methods: In this descriptive cross-sectional quantitative research, online questionnaires were applied to 1215 students who attended any medical school year from all five geopolitical Brazilian regions. Results: Out of the total respondents, 94.6% were granted computer laboratories at their educational institution and 98.9% had internet access at home. The most used devices are computers/notebooks (97.8%) and smartphones (98.4%). Tablets use was verified in only 33.1% of the students. Digital learning tools are used by 83.0% (n=1008) of the participants, out of which 91.2% reported improvement in theoretical or practical knowledge after using it. The most used tool is the video lesson (93.2%). Conclusions: DICT have already been consolidated among medical students in Brazil as learning digital tools are widely adopted as complementary educational method. The majority of resources are gratuitous, even though the use of charged tools is not related to students' family income.

Permeability of cork for water and ethanol.

Transport properties of natural (noncompressed) cork were evaluated for water and ethanol in both vapor and liquid phases. The permeability for these permeants has been measured, as well as the sorption and diffusion coefficients. This paper focuses on the differences between the transport of gases' relevant vapors and their liquids (water and ethanol) through cork. A transport mechanism of vapors and liquids is proposed. Experimental evidence shows that both vapors and liquids permeate not only through the small channels across the cells (plasmodesmata), as in the permeation of gases, but also through the walls of cork cells by sorption and diffusion as in dense membranes. The present study also shows that cork permeability for gases was irreversibly and drastically decreased after cork samples were exposed to ethanol or water in liquid phase.

Large mediastinal thoracic duct cyst.

Thoracic duct cysts of the mediastinum are extremely rare. The etiology is related to a congenital or degenerative weakness in the wall of the thoracic duct. Symptoms may arise from compression of adjacent structures. Surgical resection is recommended and allows a definitive histological diagnosis. Postoperative chylothorax is the most frequent complication. We describe a 30-year-old female who presented to us with a history of dry cough and hiccups within the last four months.

Percutaneous endoscopic gastrostomy (PEG) and pulmonary function in patients with amyotrophic lateral sclerosis (ALS). / Gastrostomia endoscópica percutânea (PEG) e função pulmonar em doentes com esclerose lateral amiotrófica (ELA).

UNLABELLED: In ALS PEG tube placement attenuates malnutrition, secondary to bulbar dysphagia, and prevents other frequently fatal complications such as chocking and respiratory arrest. Respiratory insufficiency may be associated to the complications observed in this procedure. PEG tubes were placed in 26 patients (10M/16F) with dysphagia using the Gauderer technique, mild sedatives and local anaesthetics. Results are presented in absolute numbers; average; standard deviation: Age -26, 64,3±11,5; CVF% - 17, 64,5±35,6; PaCO2 - 26, 41,6±7,1; PaO2 - 26, 81,6±14,3. Four of the seventeen patients with spirometric evaluation had FVC inferior to 50%. Nine patients had chronic respiratory failure (CRF). Complications were identified in 2 patients (transient laryngeal spasm) and most likely secondary to bulbar involvement rather than pulmonary function. CONCLUSION: Our experience shows PEG to be a safe procedure even in patients with advanced disease and reduced pulmonary capacity.