A systems-based analysis to rethink the European environmental risk assessment of regulated chemicals using pesticides as a pilot case.

A growing body of scientific literature stresses the need to advance current environmental risk assessment (ERA) methodologies and associated regulatory frameworks to better address the landscape-scale and long-term impact of pesticide use on biodiversity and the ecosystem. Moreover, more collaborative and integrative approaches are needed to meet sustainability goals. The One Health approach is increasingly applied by the European Food Safety Authority (EFSA) to support the transition towards safer, healthier and more sustainable food. To this end, EFSA commissioned the development of a roadmap for action to establish a European Partnership for next-generation, systems-based Environmental Risk Assessment (PERA). Here, we summarise the main conclusions and recommendations reported in the 2022 PERA Roadmap. This roadmap highlights that fragmentation of data, knowledge and expertise across regulatory sectors results in suboptimal processes and hinders the implementation of integrative ERA approaches needed to better protect the environment. To advance ERA, we revisited the underlying assumptions of the current ERA paradigm; that chemical risks are generally assessed and managed in isolation with a substance-by-substance, realistic worst-case and tiered approach. We suggest optimising the use of the vast amount of information and expertise available with pesticides as a pilot area. It is recommended to as soon as possible adopt a systems-based approach, i.e. within the current regulatory framework, to spark a step-wise transition towards an ERA framed at a system level of ecological and societal relevance. Tangible systems-based and integrative steps are available. For instance, the rich sources of existing data for prospective and retrospective ERA of pesticides could be used to reality-benchmark existing and new ERA methods. To achieve these goals, collaboration among stakeholders across scientific disciplines and regulatory sectors must be strengthened.

Possible association of urinary incontinence with post-COVID-19: a report of three cases.

INTRODUCTION: The disorder denominated urinary incontinence (UI) has been diagnosed amongst 25-45% of women worldwide. Muscle weakness is one of the more notable symptoms, which is exhibited in the acute form of coronavirus disease 2019 (COVID-19) that compromises the respiratory musculature. Accordingly, this report aims to delineate three cases in women with UI possibly associated with post-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE REPORTS: Three elderly Brazilian women expressed UI symptomology post-COVID-19 recovery. In the investigation reports, there was no documented acute impairment or hospitalization post-COVID-19. Nevertheless, some form of UI derived from muscle weakness was detected and treated by physiotherapy in these patients. The patient 1 (P1) was classified as mixed urinary incontinence (MUI) based on the presented symptomology during the filling phase and urinary leakage on exertion. Intravaginal probing suggested neural integrity. The P2 and P3 were classified as stress urinary incontinence (SUI), related to increased abdominal pressure. In all the three cases, there were benefits from physical therapy treatment. CONCLUSIONS: This case report is relevant in improving our understanding and lead to future research about the possibility of clinical variations as UI after infection by SARS COV 2 contributing to greater awareness in the diagnostic workup and allowing for earlier treatment and management. It is concluded that the surveillance of the distinct symptomologies associated with the SARS-CoV-2 infection is fundamental, because there is no adequate corroboratory evidence in the scientific literature, for the cases of pelvic floor muscles weakness that causes UI.

Effects of a self-care educational program via telerehabilitation on quality of life and caregiver burden in amyotrophic lateral sclerosis: a single-blinded randomized clinical trial protocol.

Introduction: The implementation of a telerehabilitation protocol for self-care in the routine of caregivers of individuals with amyotrophic lateral sclerosis (ALS) has been associated with reduced levels of stress and improved quality of life. Moreover, it may reduce the difficulty of traveling to perform physical or other self-care activities. Thus, this study designed a clinical trial protocol to investigate the effects of a self-care education program via telerehabilitation on the burden and quality of life of caregivers of individuals with ALS. Methods: This single-blinded randomized clinical trial will recruit 26 caregivers and randomly allocate them to the experimental (EG = 13) or control group (CG = 13). The EG will receive an informative booklet and participate in a 6-week synchronous telerehabilitation program with a neuropsychologist, nutritionist, and physiotherapist to discuss physical and mental health. The CG will receive an informative booklet on self-care and physical activity and weekly phone calls for 6 weeks to solve questions about the booklet. Outcomes will include the caregiver burden (Zarit scale), quality of life (World Health Organization Quality of Life BREF), pain (McGill Pain Questionnaire), stress (Perceived Stress Scale), and depression (Beck Depression Inventory), which will be evaluated at the baseline after the six-week program and 30 days after the program. Additionally, we will assess daily the nocturnal awakenings, sleep patterns, level of physical activity, and heart rate variability. Discussion: This study aimed to investigate the effectiveness of telerehabilitation for caregivers of individuals with ALS. If effective, this program could be disseminated among health professionals, increasing the possibility of remotely monitoring individuals with difficulty performing physical activities. Trial registration number: NCT05884034 (clinicaltrials.gov).

A bocha paralímpica no brasil: utilização das estratégias de coping por atletas durante pandemia de Covid-19 / Bocha paralímpica en brasil: uso de estrategias de afrontamiento en el deporte durante la pandemia de Covid-19 / Paralympic boccia in Brazil: use of coping strategies by athletes during the Covid-19 pandemic

A medida adotada de isolamento físico durante pandemia afetou a rotina diária de todo o mundo, inclusive no meio esportivo. Sendo assim, o estudo buscou comparar as estratégias de coping utilizadas por atletas de bocha paralímpica no período da pandemia. A amostra foi composta por 43 atletas (30 homens e 13 mulheres) com 29.9511,76 anos. Para identificar e mensurar as estratégias de coping, foi recorrido o questionário ACSI-28 (athletic coping skills inventory) em sua versão adaptada para o português incrementado em um formulário eletrônico. Na análise dos dados,a normalidade foi verificada pelo teste de shapiro-wilk. Após isto, todas análises inferenciais de comparação foram mensuradas por via de testes estatísticos não paramétricos com testes post-hoc DSCF pareados. Assim, os resultados apontaram que houve diferenças significativas entre comparações no tempo de experiência, “+10 anos”, “5 a 10 anos” e “1 a 3 anos” sobre as subescalas “metas e preparação mental” (6.00±1.75 vs 5±1.50 vs 5±1.50; p<0,05; TE: 0,26) e “treinabilidade” (9.00±3.25 vs 6.00±0.500 vs 8.00±3.00; p<0,05; TE: 0,19). Atletas mais e menos experientes na modalidade da bocha demonstraram superioridade no enfrentamento ao período da pandemia, pois, conseguiram obter melhores índices nas dimensões “metas e preparação mental” e “treinabilidade”, das estratégias de coping quando comparados aos seus pares com menor tempo de experiência. (AU)

La medida de aislamiento físico adoptada durante una pandemia afectó la rutina diaria de todo el mundo, incluso en el ámbito deportivo. Por lo tanto, el estudio buscó comparar las estrategias de afrontamiento utilizadas por los atletas de bocha paralímpico durante el período de pandemia. La muestra estuvo conformada por 43 deportistas (30 hombres y 13 mujeres) con edad 29.95±11,76 años. Para identificar y medir las estrategias de afrontamiento, se utilizó el cuestionario ACSI-28 (inventario de habilidades de afrontamiento atlético) en su versión adaptada al portugués y agregado a un formulario electrónico. En el análisis de datos, la normalidad fue verificada por la prueba de Shapiro-Wilk. Después de eso, todos los análisis de comparación inferencial se midieron mediante pruebas estadísticas no paramétricas con pruebas DSCF post-hoc emparejadas. Así, los resultados mostraron que hubo diferencias significativas entre las comparaciones en términos de experiencia, “+10 años”, “5 a 10 años” y “1 a 3 años” en las subescalas “metas y preparación mental” (6.00±1.75 vs 5±1.50 vs 5±1.50; p<0,05; TE: 0,26) y “entrenabilidad” (9.00±3.25 vs 6.00±0.500 vs 8.00±3.00; p<0,05; TE: 0,19). Los atletas más e menos experimentados en la modalidad de bocha mostraron superioridad para enfrentar el período de la pandemia, ya que pudieron obtener mejores índices en las dimensiones “metas y preparación mental y entrenabilidad” de las estrategias de afrontamiento en comparación con sus pares con menos experiencia. (AU)

The measure of physical isolation adopted during a pandemic affected the daily routine of the whole world, including in the sports environment. Therefore, the study sought to compare the coping strategies used by Paralympic boccia athletes during the pandemic period. The sample consisted of 43 athletes (30 men and 13 women) aged 29.9511,76 years. To identify and measure coping strategies, the ACSI-28 (athletic coping skills inventory) questionnaire was used in its version adapted to Portuguese and added to an electronic form. In data analysis, normality was verified by the Shapiro-Wilk test. After that, all inferential comparison analyzes were measured via nonparametric statistical tests with paired post-hoc DSCF tests. Thus, the results showed that there were significant differencesbetween comparisons in terms of experience, “+10 years”, “5 to 10 years”, and “1 to 3 years” on the subscales “goals and mental preparation” (6.00±1.75 vs 5±1.50 vs 5±1.50; p<0.05; ES: 0.26) and “trainability” (9.00±3.25 vs 6.00±0.500 vs 8.00±3.00; p<0.05; ES: 0.19). More and less experienced athletes in the boccia modality showed superiority in facing the pandemic period, as they obtained better indices in the “goals and mental preparation and trainability” dimensions of coping strategies compared to their peers with less experience (AU)

Impact of physiotherapy with telerehabilitation on caregivers of patients with neurological disorders: A systematic review protocol.

Introduction: Caregivers are essential during and after rehabilitation but exhibit intense physical and mental burdens due to responsibilities, resulting in stress, irritability, depression, anxiety, pain, and financial distress. Telerehabilitation offers several remote health services that improve time, engagement, and physical and mental health care access. Thus, we outlined a systematic review protocol to evaluate the impact of telerehabilitation on the burden, stress, pain, and quality of life of caregivers of patients with neurological disorders. Methods: Searches will be conducted in Ovid MEDLINE, Pubmed, Scopus, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and PsycINFO databases. Clinical trials evaluating the burden, stress, pain, and quality of life of caregivers of patients with neurological disorders using telerehabilitation will be included without publication date or language restriction. Two reviewers will independently select studies from titles, abstracts, and reference lists. The quality of evidence and risk of bias will be assessed according to Cochrane recommendations. Results: This systematic review to be developed will evaluate the impact of telerehabilitation on the burden, stress, pain, and quality of life of caregivers of patients with neurological disorders. Discussion: Caregivers, especially of patients with neurological disorders, need more attention since the overload, stress, duties with other personal responsibilities, and low remuneration may impact the quality of life. Therefore, they need intervention, especially physical therapy via telehealth, which values the time of caregivers and may change their perception of health and quality of life. PROSPERO registration number: CRD42022278523.

Inclusion of Potentially Inappropriate Medicines for the Older Adults in the Brazilian Consensus in Accordance with International Criteria.

AIM: The use of potentially inappropriate medications (PIM) can impair the safety and effectiveness of pharmacotherapy in the older adults. Thus, several countries have lists and criteria to indicate these drugs, in order to promote the safety of prescription and the rational use of drugs in geriatric practice. OBJECTIVE: This study sought to contribute to the inclusion of PIM for the older adults in the Brazilian criterion (BCPIM/2016) - current list used in Brazil and reference in Latin American countries - through expert approval, comparing convergences with international AGS lists BEERS/2019, STOPP/START/2015, PRISCUS/2010 and EU (7)-PIM List/2015. METHODS: This is a critical analysis of potentially inappropriate medications for use in the older adults present in the list of Brazilian criteria, together with their absence of some drugs that are on international lists (BEERS/2019; Priscus/2010; Stopp/Start/2015; EU7-PIM list/2015). This study was subdivided in 6 stages: selection of national criteria, classification of drugs according to Anatomic Therapeutic Chemical, comparison between BCPIM/2016 with international lists, selection of drugs not included in the Brazilian list, selection of experts for evaluation and suggestions about drugs not included in the Brazilian list and the synthesis of the analysis carried out by the specialists. RESULTS: We cataloged 66 drugs marketed in Brazil that are on international lists, but not in the Brazilian consensus, of which 24 were validated by experts as necessary for inclusion in this consensus, considering the risks and benefits in health care for the older adults. However, the lists have divergences and similarities between them. We observed that eight drugs were common to all criteria studied, mainly related to the nervous system. CONCLUSION: The results suggest the need for periodic validation of PIM against research clinics, new drugs and the inclusion of this agenda by the Ministry of Health in the revision of the National List of Essential Drugs and other Clinical Protocols and Therapeutic Prescription Guidelines for the older adults.

Mercury chloride toxicity in juveniles Prochilodus argenteus a species from southeastern Brazil.

The aim of this study was to determine the 96-h LC50 (lethal concentration for 50% of the test population in 96 h of observation) of mercury chloride (HgCl2) and evaluated its absorption in the gills, liver, and muscle of juvenile "curimatã-pacu," Prochilodus argenteus. The fish were exposed for 4 days to different concentrations of HgCl2: 0.000, 0.0375, 00.075, 0.150, 0.225, 0.300, and 0.400 mg L-1 to get the 96-h LC50, and the concentration of Hg in the tissues. The fish were exposed to different levels of HgCl2 (0.000, 0.0375, 00.075, 0.150, 0.225, and 0.300 mg L-1), for 4 and 7 days, when different tissues (gills, liver, and muscle) were sampled. The mercury concentration values obtained were compared between tissues, days, and concentration of mercury in the water. The 96-h LC50 for P. argenteus was 0.339 mg L-1 of HgCl2, within the range found for other neotropical and tropical species, showing a medium sensitivity. The concentration of Hg in the tissues increased from the muscle to the gills and liver, and according to the increasing concentration of HgCl2 in the water. The fish liver is the most suitable tissue for environmental monitoring and for the evaluation of the consumed fished. Despite being the tissue that least accumulated mercury, the muscle must be evaluated because it is the part consumed by the population.

Dispensing of psychotropic drugs in the Brazilian capital city before and during the COVID-19 pandemic (2018-2020).

Objective: Evaluate the data on the psychotropic drugs dispensed by private community pharmacies before and during the SARS-CoV-2 pandemic. Methods: This cross-sectional study compared the quarterly and annual consumption of psychotropic drugs per Defined Daily Dose per 1000 inhabitants-day (DHD). Interrupted time series were also constructed to expose changes in the consumption pattern in the periods before and after March 2020. Results: Among the 20 most consumed psychoactive drugs, 12 were antidepressants, for example, escitalopram (DHD 7.996 and 10.626; p < 0.001), and sertraline (DHD 6.321 and 8.484; p < 0.001), in addition to the hypnotic zolpidem (DHD 6.202 and 8.526; p < 0.001). The time series reveals (R 2 value) a variation in drug dispensing, in DHD values, during the pandemic. Conclusion: Despite the higher variance, a significant increase is clearly seen in the consumption trends of psychoactive drugs, particularly antidepressants, consistent with the pandemic's influence on the general population's mental health.

Effects of Active Upper Limb Orthoses Using Brain-Machine Interfaces for Rehabilitation of Patients With Neurological Disorders: Protocol for a Systematic Review and Meta-Analysis.

Introduction: The field of brain-machine interfaces (BMI) for upper limb (UL) orthoses is growing exponentially due to improvements in motor performance, quality of life, and functionality of people with neurological diseases. Considering this, we planned a systematic review to investigate the effects of BMI-controlled UL orthoses for rehabilitation of patients with neurological disorders. Methods: This systematic review and meta-analysis protocol was elaborated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P 2015) and Cochrane Handbook for Systematic Reviews of Interventions. A search will be conducted on Pubmed, IEEE Xplore Digital Library, Medline, and Web of Science databases without language and year restrictions, and Patents Scope, Patentlens, and Google Patents websites in English, Spanish, French, German, and Portuguese between 2011 and 2021. Two independent reviewers will include randomized controlled trials and quasi-experimental studies using BMI-controlled active UL orthoses to improve human movement. Studies must contain participants aged >18 years, diagnosed with neurological disorders, and with impaired UL movement. Three independent reviewers will conduct the same procedure for patents. Evidence quality and risk of bias will be evaluated following the Cochrane collaboration by two review authors. Meta-analysis will be conducted in case of homogeneity between groups. Otherwise, a narrative synthesis will be performed. Data will be inserted into a table containing physical description, UL orthoses control system, and effect of BMI-controlled orthoses. Discussion: BMI-controlled orthoses can assist individuals in several routine activities and provide functional independence and sense of overcoming limitations imposed by the underlying disease. These benefits will also be associated with orthoses descriptions, safety, portability, adverse events, and tools used to assess UL motor performance in patients with neurological disorders. PROSPERO Registration Number: CRD42020182195.

Are biomechanical strategies to perform functional activities different between individuals with subacute and chronic stroke?

OBJECTIVE: To evaluate if the capacity to perform functional mobility activities change within the first year post-stroke using the Timed "Up and Go" Assessment of Biomechanical Strategies (TUG-ABS). METHODS: A cross-sectional study was conducted with thirty-eight stroke individuals. A motion analysis system was used during the Timed "Up and Go" (TUG) test to evaluate the following activities: sit-to-stand, gait, turn, and stand-to-sit. Kinematic variables related to each activity were obtained in addition to TUG-ABS scores. The ability to perform the activities was compared between subacute (up to 3 months post-stroke, n = 21) and chronic participants (4 to 12 months post-stroke, n = 17) using Mann-Whitney U tests (α= 5%). RESULTS: Results were expressed as median difference (MD) and 95% confidence intervals (95% CI). TUG-ABS scores: Sit-to-stand (MD = 0, 95% CI = 0.0 to 1), gait (MD = 0, 95% CI = 0.0 to 1), stand-to-sit (MD = 0, 95% CI = 0.0 to 1), and total score (MD = 2.0, 95% CI = 0.0 to 6) were not different between groups. Subacute participants presented significant better scores during turn activity (MD = 2.0, 95% CI 0.0 to 2.0). All kinematic variables were not different between participants. CONCLUSIONS: Capacity to perform functional activities was not different within the first year post-stroke, suggesting that biomechanical strategies are developed within the first three months following stroke.

Effects of Load Addition During Gait Training on Weight-Bearing and Temporal Asymmetry After Stroke: A Randomized Clinical Trial.

OBJECTIVE: The aim of the study was to evaluate the effects of adding load to restrain the nonparetic lower limb during gait training on weight-bearing and temporal asymmetry after stroke. DESIGN: Thirty-eight subjects were randomized into treadmill training with load (5% of body weight) on the nonparetic limb (experimental group) and treadmill training without load (control group). Interventions lasted 30 mins/d for 2 wks (9 sessions). Both groups performed home-based exercises and were instructed to increase the use of paretic limb in daily life situations. Ground reaction force was obtained by a force plate during standing position (static) and gait (dynamic). Temporal gait parameters were assessed by a motion system analysis. Outcome measures were evaluated at baseline, posttraining, and after a 40-day follow-up. RESULTS: The experimental group increased static ground reaction force of the paretic limb at posttraining (P = 0.037) and the control group increased dynamic ground reaction force of the paretic limb at posttraining (P = 0.021), both with maintenance at follow-up. Neither group showed a change in the swing time symmetry ratio after training (P = 0.190). CONCLUSIONS: Treadmill training associated with behavioral strategies/home-based exercises seemed to be useful to minimize weight-bearing asymmetry, but not to improve temporal gait asymmetry. Load addition did not show additional benefits.

Social participation in the health technology incorporation process into Unified Health System.

OBJECTIVE: To describe the current process of social participation in the incorporation of health technologies in Brazil, within the context of the Unified Health System (SUS). METHODS: A descriptive study was conducted based on the analysis of official records of the actions of the National Committee for Health Technology Incorporation into Unified Health System and its website, from the beginning of its activities in January 2012 until December 2017. RESULTS: The findings indicate that, in Brazil, there are legal instruments related to social participation in health, including the health technology assessment (HTA) field. However, its implementation is relatively recent and has been carried out gradually. In addition to the legal instruments (National Health Council representative, public consultation and public hearing forecast), other information and transparency strategies have been shown to be allied to social participation in the incorporation of health technologies. However, activities such as legally provided public hearings have not yet been carried out. CONCLUSIONS: Several actions to foster social participation were developed over the analyzed period, but they need to be evaluated in order to maintain or improve them. In addition, there is a need for more qualified social participation in the various existing spaces, including those prescribed by law.

Avaliação da qualidade de vida do idoso institucionalizado com sinais de demência / Evaluation of the quality of life of institutionalized older adults with signs of dementia

Introdução: A insuficiência cognitiva é um dos principais fatores que podem comprometer a independência e a autonomia dos idosos, especialmente nos que residem em Instituições de Longa Permanência para Idosos (ILPI). Objetivo: Avaliar a qualidade de vida (QV) de idosos com sinais de demência residentes em instituições de longa permanência em Betim, Minas Gerais. Métodos: Trata-se de estudo quantitativo, transversal, de caráter descritivo, em que inicialmente foi conduzida uma triagem com o Miniexame do Estado Mental (MEEM); aqueles participantes que obtiveram triagem positiva, segundo critérios de escolaridade e escore acima de 10, foram submetidos à versão brasileira da Escala de Qualidade de Vida na Doença de Alzheimer (QdV-DA). Dos 106 idosos participantes nas 3 instituições cenário deste estudo, 58 atenderam ao critério de inclusão e, desses, 15 foram inseridos no estudo. Resultados: Foi utilizada a distribuição em quartis para a correção composta (P25 = 26,7; P50 = 31,3; P75 = 36,00). Assim, os resultados permitiram afirmar que 26,7% (n=4) dos idosos avaliados possuem baixa QV, 46,6% média QV (n=7) e 26,7 % foram classificados como tendo alta QV (n=4). Conclusão: A avaliação de constructos subjetivos, como a QV, é um desafio entre idosos com sinais de demência, porém extremamente importante para avaliar o impacto das intervenções propostas. A QV deve ser levada em consideração pelos responsáveis pela gestão dessas instituições, a fim de estruturar suas atividades buscando o bem-estar dos idosos institucionalizados, além de permanecer atentos ao perfil dessa população. (AU)

Introduction: Cognitive insufficiency is one of the main factors that may compromise the independence and autonomy of the older adults, especially in those living in Homes for the Aged. Objective: To evaluate the Quality of Life (QOL) of older adults with signs of dementia who live in Long-term care facilities in Betim, Minas Gerais State. Methods: This is a quantitative, cross-sectional, descriptive study that initial triage was performed using the Mini-Mental State Examination (MMSE); those who obtained positive screening criteria according to schooling and scores above 10 were submitted to the Brazilian version of the Alzheimer's Disease Quality of Life Scale (QOLAD). The total of 106 older adults in 3 in Long-term care facilities, 58 were able to respond to the cognitive screening performed by the MMSE and, of these, 15 obtained scores to participate in this study. Results: The quartile distribution was used for the composite correction (P25 = 26.7, P50 = 31.3, P75 = 36.00, and the results allowed to state that 26.7% (n=4) had low QOL, 46.6% mean QOL (n=7) and 26.7% were classified as having high QOL (n=4). Conclusion: The evaluation of subjective constructs, as QOL, is a challenge to older adults with signs of dementia, but extremely important to evaluate the impact of the proposed interventions. The QOL should be taken into account by those responsible for the management of these institutions in order to structure their activities seeking the welfare of the institutionalized older adults, attentive to the profile of this population. (AU)

Characterization of the selection of medicines for the Brazilian primary health care.

OBJECTIVE: To characterize the process of selection of medicines for primary health care in the Brazilian regions. METHODS: This article is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos - Serviços, 2015 (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines - Services, 2015), a cross-sectional study that consisted of an information gathering in a sample of cities in the five regions of Brazil. The data used were collected by interviews with those responsible for pharmaceutical services (PS) (n = 506), professionals responsible for the dispensing of medicines (n = 1,139), and physicians (n = 1,558). To evaluate the difference between ratios, we adopted the Chi-square test for complex samples. The differences between the averages were analyzed in generalized linear models with F-test with Bonferroni correction for multiple comparisons. The analyses considered significant had p≤0.05. RESULTS: The professionals responsible for pharmaceutical services reported non-existence of a formally constituted Pharmacy and Therapeutics Committee (PTC) (12.5%). They claimed to have an updated (80.4%) list of Essential Medicines (85.3%) and being active participants of this process (88.2%). However, in the perception of respondents, the list only partially (70.1%) meets the health demands. Of the interviewed professionals responsible for the dispensing of medicines, only 16.6% were pharmacists; even so, 47.8% reported to know the procedures to change the list. From the perspective of most of these professionals (70.9%), the list meets the health demands of the city. Among physicians, only 27.2% reported to know the procedures to change the list, but 76.5% would have some claim to change it. Most of them reported to base their claims in clinical experiences (80.0%). For 13.0% of them, the list meets the health demands. CONCLUSIONS: As this is the first national survey of characterization of the process of selection of medicines within primary health care, it brings unpublished data for the assessment of policies related to medicines in Brazil.

Effects of constraint-induced movement therapy for lower limbs on measurements of functional mobility and postural balance in subjects with stroke: a randomized controlled trial.

Abstrato Background: Constraint-induced movement therapy (CIMT) is suggested to reduce functional asymmetry between the upper limbs after stroke. However, there are few studies about CIMT for lower limbs. OBJECTIVE: To examine the effects of CIMT for lower limbs on functional mobility and postural balance in subjects with stroke. METHODS: A 40-day follow-up, single-blind randomized controlled trial was performed with 38 subacute stroke patients (mean of 4.5 months post-stroke). Participants were randomized into: treadmill training with load to restraint the non-paretic ankle (experimental group) or treadmill training without load (control group). Both groups performing daily training for two consecutive weeks (nine sessions) and performed home-based exercises during this period. As outcome measures, postural balance (Berg Balance Scale - BBS) and functional mobility (Timed Up and Go test - TUG and kinematic parameters of turning - Qualisys System of movement analysis) were obtained at baseline, mid-training, post-training and follow-up. RESULTS: Repeated-measures ANOVA showed improvements after training in postural balance (BBS: F = 39.39, P < .001) and functional mobility, showed by TUG (F = 18.33, P < .001) and by kinematic turning parameters (turn speed: F = 35.13, P < .001; stride length: F = 29.71, P < .001; stride time: F = 13.42, P < .001). All these improvements were observed in both groups and maintained in follow-up. CONCLUSIONS: These results suggest that two weeks of treadmill gait training associated to home-based exercises can be effective to improve postural balance and functional mobility in subacute stroke patients. However, the load addition was not a differential factor in intervention.

Intermittent left bundle branch block - reversal to normal conduction during general anesthesia / Bloqueio intermitente de ramo esquerdo - reversão para condução normal durante anestesia geral

Abstract Background and objectives: Transient changes in intraoperative cardiac conduction are uncommon. Rare cases of the development or remission of complete left bundle branch block under general and locoregional anesthesia associated with myocardial ischemia, hypertension, tachycardia, and drugs have been reported. Complete left bundle branch block is an important clinical manifestation in some chronic hypertensive patients, which may also be a sign of coronary artery disease, aortic valve disease, or underlying cardiomyopathy. Although usually permanent, it can occur intermittently depending on heart rate (when heart rate exceeds a certain critical value). Case report: This is a case of complete left bundle branch block recorded in the preoperative period of urgent surgery that reverted to normal intraoperative conduction under general anesthesia after a decrease in heart rate. It resurfaced, intermittently and in a heart-rate-dependent manner, in the early postoperative period, eventually reverting to normal conduction in a sustained manner during semi-intensive unit monitoring. The test to identify markers of cardiac muscle necrosis was negative. Pain due to the emergency surgical condition and in the early postoperative period may have been the cause of the increase in heart rate up to the critical value, causing blockage. Conclusions: Although the development or remission of this blockade under anesthesia is uncommon, the anesthesiologist should be alert to the possibility of its occurrence. It may be benign; however, the correct diagnosis is very important. The electrocardiographic manifestations may mask or be confused with myocardial ischemia, factors that are especially important in a patient under general anesthesia unable to report the characteristic symptoms of ischemia.

Resumo Justificativa e objetivos: Alterações transitórias da condução cardíaca no intraoperatório são pouco frequentes. Foram reportados raros casos de desenvolvimento ou remissão de bloqueio completo de ramo esquerdo sob anestesia (geral e locorregional), associados a isquemia do miocárdio, hipertensão, taquicardia e fármacos. O bloqueio completo de ramo esquerdo é uma manifestação clínica importante em alguns hipertensos crônicos, pode também significar doença arterial coronária, doença valvular aórtica ou cardiomiopatia subjacentes. Embora habitualmente permanente, pode ocorrer na forma intermitente dependente da frequência cardíaca (quando a frequência cardíaca excede determinado valor crítico). Relato de caso: Este é um caso de bloqueio completo de ramo esquerdo registrado no pré-operatório de cirurgia urgente que reverteu para condução normal no intraoperatório sob anestesia geral após diminuição da frequência cardíaca. Ressurgiu, de forma intermitente e dependente da frequência cardíaca, no pós-operatório imediato, acabou por reverter novamente à condução normal de forma sustentada durante vigilância em unidade semi-intensiva. O estudo com marcadores de necrose muscular cardíacos foi negativo. A dor do quadro cirúrgico urgente e pós-operatório imediato pode ter estado na origem da subida da frequência cardíaca até ao valor crítico e causado bloqueio. Conclusões: Embora o desenvolvimento ou a remissão desse bloqueio sob anestesia sejam incomuns, o anestesiologista deverá estar alertado para a possibilidade da sua ocorrência. Pode ter caráter benigno, contudo o diagnóstico correto é muito importante. As manifestações eletrocardiográficas podem ser confundidas com ou encobrir isquemia miocárdica, fatos de especial importância num paciente sob anestesia geral incapaz de referir sintomatologia característica de isquemia.

Efficacy and safety of a four-drug fixed-dose combination regimen versus separate drugs for treatment of pulmonary tuberculosis: a systematic review and meta-analysis

Abstract Introduction: Tuberculosis, particularly multi-drug-resistant tuberculosis, is a major cause of morbidity and mortality worldwide. To the best of our knowledge, however, no study to date has assessed the combined use of the four available drugs for tuberculosis treatment, which is an issue of great clinical relevance. Objective: To determine whether the four-drug fixed-dose combination is safer or more effective than separate drugs for treatment of pulmonary tuberculosis. Methods: A systematic review of the literature was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: In pooled results from five randomized controlled trials with 3502 patients across Africa, Asia, and Latin America, four-drug fixed-dose combination therapy was no better than separate drugs therapy in terms of culture conversion after 2 and 6 months of treatment. There were no significant differences between the groups in overall incidence of adverse effects. However, the meta-analytic measure (log odds ratio) revealed that separate drugs treatment had a 1.65 [exp (0.5) = 1.65] increased chance of gastrointestinal adverse effects compared to four-drug fixed-dose combination treatment. Conclusions: The reviewed studies showed that four-drug fixed-dose combination therapy provides greater patient comfort by reducing the number of pills and the incidence of gastrointestinal adverse effects, as well as simplifying pharmaceutical management at all levels.

Post-stroke hemiparesis: Does chronicity, etiology, and lesion side are associated with gait pattern?

BACKGROUND: Studies that evaluate gait rehabilitation programs for individuals with stroke often consider time since stroke of more than six months. In addition, most of these studies do not use lesion etiology or affected cerebral hemisphere as study factors. However, it is unknown whether these factors are associated with post-stroke motor performance after the spontaneous recovery period. OBJECTIVE: To investigate whether time since stroke onset, etiology, and lesion side is associated with spatiotemporal and angular gait parameters of individuals with chronic stroke. METHODS: Fifty individuals with chronic hemiparesis (20 women) were evaluated. The sample was stratified according to time since stroke (between 6 and 12 months, between 13 and 36 months, and over 36 months), affected cerebral hemisphere (left or right) and lesion etiology (ischemic and hemorrhagic). The participants were evaluated during overground walking at self-selected gait speed, and spatiotemporal and angular gait parameters were calculated. Results Differences between gait speed, stride length, hip flexion, and knee flexion were observed in subgroups stratified based on lesion etiology. Survivors of a hemorrhagic stroke exhibited more severe gait impairment. Subgroups stratified based on time since stroke only showed intergroup differences for stride length, and subgroups stratified based on affected cerebral hemisphere displayed between-group differences for swing time symmetry ratio. CONCLUSION: In order to recruit a more homogeneous sample, more accurate results were obtained and an appropriate rehabilitation program was offered, researchers and clinicians should consider that gait pattern might be associated with time since stroke, affected cerebral hemisphere and lesion etiology.

Effects of treadmill training with load addition on non-paretic lower limb on gait parameters after stroke: A randomized controlled clinical trial.

The addition of load on the non-paretic lower limb for the purpose of restraining this limb and stimulating the use of the paretic limb has been suggested to improve hemiparetic gait. However, the results are conflicting and only short-term effects have been observed. This study aims to investigate the effects of adding load on non-paretic lower limb during treadmill gait training as a multisession intervention on kinematic gait parameters after stroke. With this aim, 38 subacute stroke patients (mean time since stroke: 4.5 months) were randomly divided into two groups: treadmill training with load (equivalent to 5% of body weight) on the non-paretic ankle (experimental group) and treadmill training without load (control group). Both groups performed treadmill training during 30min per day, for two consecutive weeks (nine sessions). Spatiotemporal and angular gait parameters were assessed by a motion system analysis at baseline, post-training (at the end of 9days of interventions) and follow-up (40days after the end of interventions). Several post-training effects were demonstrated: patients walked faster and with longer paretic and non-paretic steps compared to baseline, and maintained these gains at follow-up. In addition, patients exhibited greater hip and knee joint excursion in both limbs at post-training, while maintaining most of these benefits at follow-up. All these improvements were observed in both groups. Although the proposal gait training program has provided better gait parameters for these subacute stroke patients, our data indicate that load addition used as a restraint may not provide additional benefits to gait training.

Is there influence of the load addition during treadmill training on cardiovascular parameters and gait performance in patients with stroke? A randomized clinical trial.

BACKGROUND: Although exercises involving both lower limbs are indicated for aerobic training, stroke patients have shown expressive asymmetry between the paretic and non-paretic lower limb (NPLL). Performing activities that stimulate the paretic limb during aerobic exercise may optimize training results. OBJECTIVE: To evaluate if there is influence of load addition on NPLL during treadmill training on cardiovascular parameters and gait performance of subacute stroke patients. METHODS: Thirty-eight stroke subjects with gait deficits were randomized into experimental group, which underwent treadmill training with a mass attached on NPLL, and control group, which underwent only treadmill training. Interventions lasted 2 weeks (9 sessions). Main outcomes were heart rate, arterial blood pressure, gait speed and distance covered. Assessments occurred at rest, 10th and 20th minutes of the session and immediately after each session. RESULTS: There was improvement in speed and walking distance in both groups. All cardiovascular parameters had showed no changes compared to 1st and 9th sessions and there were no differences between groups within each session. CONCLUSIONS: Load addition on NPLL did not alter cardiovascular parameters and gait training provide better gait performance of subacute stroke patients, which indicates this therapy can be considered useful and safe for these patients.