The impact of a physical exercise program on quality of life, fatigue, physical performance, and level of physical activity in patients with cancer.

OBJECTIVE: Increasing evidence suggests that exercise programs are of great value in the rehabilitation and survivorship of patients with cancer. However, challenges remain regarding maintaining patients more physically active. This study aimed to evaluate the impact of a supervised exercise program on quality of life, fatigue, physical performance, and levels of physical activity of patients with cancer. METHODS: An observational longitudinal study, with a 1-year prospective follow-up, was developed. SETTING: This is a university-based outpatient rehabilitation program in a high-complexity cancer care center in Sao Paulo. RESULTS: After the program, patients showed a significant gain in quality of life (p<0.0001), physical performance (p<0.0001), and improvement in fatigue (p<0.0001). After 12 months, 81.1% of the patients remained active, and only 4.5% declared themselves to be sedentary. CONCLUSION: The results of this study confirm that exercise programs are an important tool in the rehabilitation of patients with cancer and that an initial supervised exercise program, in combination with follow-ups, can help increase the levels of physical activity of this population. CLINICAL REHABILITATION IMPACT: This study provides additional information on the outcomes that are expected with the provision of a supervised physical exercise program in the rehabilitation care of patients with cancer and that additional follow-ups could further benefit this population.

The impact of a physical exercise program on quality of life, fatigue, physical performance, and level of physical activity in patients with cancer

SUMMARY OBJECTIVE: Increasing evidence suggests that exercise programs are of great value in the rehabilitation and survivorship of patients with cancer. However, challenges remain regarding maintaining patients more physically active. This study aimed to evaluate the impact of a supervised exercise program on quality of life, fatigue, physical performance, and levels of physical activity of patients with cancer. METHODS: An observational longitudinal study, with a 1-year prospective follow-up, was developed. SETTING: This is a university-based outpatient rehabilitation program in a high-complexity cancer care center in Sao Paulo. RESULTS: After the program, patients showed a significant gain in quality of life (p<0.0001), physical performance (p<0.0001), and improvement in fatigue (p<0.0001). After 12 months, 81.1% of the patients remained active, and only 4.5% declared themselves to be sedentary. CONCLUSION: The results of this study confirm that exercise programs are an important tool in the rehabilitation of patients with cancer and that an initial supervised exercise program, in combination with follow-ups, can help increase the levels of physical activity of this population. CLINICAL REHABILITATION IMPACT: This study provides additional information on the outcomes that are expected with the provision of a supervised physical exercise program in the rehabilitation care of patients with cancer and that additional follow-ups could further benefit this population.

Acupuncture for chemotherapy-induced peripheral neuropathy: a randomised controlled pilot study.

Chemotherapy-induced peripheral neuropathy (CIPN) can cause loss of independence and poor quality of life (QoL) due to severe disabilities, but in spite of its importance there is still a lack of data for the management of CIPN. Acupuncture has showed promising results and may be a cost-effective option for the treatment. OBJECTIVES: To evaluate the effect of acupuncture treatment on neurological symptoms of CIPN and QoL of oncological patients. METHODS: We performed a clinical, single-centre, randomised and controlled pilot study that involved 33 adult patients with cancer and CIPN randomised into two groups (control and acupuncture treated with 10 sessions, two times per week). Both groups were subjected to a complete physical examination and clinical assessment with National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) Scale V.2.0, FIM Scale, European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core (EORTC QLQ-C30) Scale and Visual Analogue Scale for pain before and 5 weeks after treatment. RESULTS: There were no adverse events, and we found statistical differences in groups in physical (p=0.03) and function (p=0.04) domains of EORTC QLQ-C30 when comparing control and acupuncture groups. About NCI CTCAE Scale and neuropathy sensory symptoms, we found better results in acupuncture group, comparing pretreatment and post-treatment analyses (p=0.01). In control group, we have no differences after 5 weeks (p=0.11). CONCLUSION: Although these results suggest an interesting effect of acupuncture on this patient population, the clinical significance has remained unclear. Given the tendency towards benefit and the lack of adverse effects, the authors recommend a follow-up acupuncture trial using higher follow-up time and better sample size. TRIAL REGISTRATION NUMBER: NCT02309164.

Perfil e capacidade funcional em sujeitos com Doença de Huntington / Profile and functional capacity in Huntington's disease subjects

Objetivo: traçar o perfil e a capacidade funcional de sujeitos com Doença de Huntington (DH) atendidos em um ambulatório de fisioterapia do Distrito Federal. Método: trata-se de um estudo transversal em que foram aplicados um questionário para coletar informações gerais para traçar o perfil, além do índice de Barthel, escala Lawton para medir grau de independência para as atividades de vida diária, força de preensão palmar por meio do dinamômetro JAMAR®, equilíbrio por meio da escala de equilíbrio de Berg, declínio cognitivo por meio da Montreal Cognitive Assessment (MoCA), e risco de disfagia utilizando a Eating assessment tool (EAT-10). Resultados: foram avaliados sete sujeitos, 58% homens e 42% mulheres com média de idade de 45,8±10,5 anos e tempo médio de diagnóstico de 7,5±4,2 anos. Todos apresentam redução da força de preensão palmar (21,1±7,3 Kg/F) e declínio cognitivo (13,1±4,2 pontos) no MoCA. Sobre o risco de cair, este se fez presente em todos os participantes com o risco de disfagia. Conclusão: os indivíduos com Doença de Huntington apresentaram déficit cognitivo, diminuição da força de preensão palmar e alterações de marcha; porém, ainda mantêm independência para as atividades básicas de vida diária , além de risco para a disfagia.

Objective: to outline the profile and functional capacity of subjects with Huntington's disease (HD) attended at a physiotherapy clinic in the Federal District. Methods: This is a cross-sectional study in which a questionnaire was used to collect general information to profile, besides Barthel index, Lawton scale to measure the degree of independence for the activities of daily life, palmar grip strength using the JAMAR® dynamometer, balance by means of Berg balance scale, cognitive decline by means of the Montreal Cognitive Assessment (MoCA), and risk of dysphagia using the Eating assessment tool (EAT-10). Results: Seven subjects were evaluated, 58% male and 42% female with mean age of 45.8 ± 10.5 years and mean diagnosis time of 7.5 ± 4.2 years. All presented reduced palmar grip strength (21.1 ± 7.3 Kg / F) and cognitive decline (13.1 ± 4.2 points) in MoCA. About the risk of falling this was present in all partcipants as well as the risk of dysphagia. Conclusion: The individuals with Huntington's disease presented cognitive deficit, decreased palmar grip strength and gait alterations, however still maintains independence for the basic activities of daily life, besides risk for dysphagia.

Effect of postoperative goal-directed therapy in cancer patients undergoing high-risk surgery: a randomized clinical trial and meta-analysis.

BACKGROUND: Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. METHODS: A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI ≥ 2.5 L/min/m2 using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. RESULTS: A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, - 7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p < 0.001). A meta-analysis of nine randomized trials showed no differences in postoperative mortality (risk ratio 0.85, 95% CI 0.59-1.23; p = 0.4; p for heterogeneity = 0.7; I2 = 0%) and in the overall complications rate (risk ratio 0.88, 95% CI 0.71-1.08; p = 0.2; p for heterogeneity = 0.07; I2 = 48%), but a reduced hospital length of stay in the GDHT group (mean difference (MD) - 1.6; 95% CI - 2.75 to - 0.46; p = 0.006; p for heterogeneity = 0.002; I2 = 74%). CONCLUSIONS: CI-guided hemodynamic therapy in the first 8 postoperative hours does not reduce 30-day mortality and severe complications during hospital stay when compared to usual care in cancer patients undergoing high-risk surgery. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT01946269 . Registered on 16 September 2013.

Predictors of major complications after elective abdominal surgery in cancer patients.

BACKGROUND: Patients undergoing abdominal surgery for solid tumours frequently develop major postoperative complications, which negatively affect quality of life, costs of care and survival. Few studies have identified the determinants of perioperative complications in this group. METHODS: We performed a prospective observational study including all patients (age > 18) undergoing abdominal surgery for cancer at a single institution between June 2011 and August 2013. Patients undergoing emergency surgery, palliative procedures, or participating in other studies were excluded. Primary outcome was a composite of 30-day all-cause mortality and infectious, cardiovascular, respiratory, neurologic, renal and surgical complications. Univariate and multiple logistic regression analyses were performed to identify predictive factors for major perioperative adverse events. RESULTS: Of a total 308 included patients, 106 (34.4%) developed a major complication during the 30-day follow-up period. Independent predictors of postoperative major complications were: age (odds ratio [OR] 1.03 [95% CI 1.01-1.06], p = 0.012 per year), ASA (American Society of Anesthesiologists) physical status greater than or equal to 3 (OR 2.61 [95% CI 1.33-5.17], p = 0.003), a preoperative haemoglobin level lower than 12 g/dL (OR 2.13 [95% CI 1.21-4.07], p = 0.014), intraoperative use of colloids (OR 1.89, [95% CI 1.03-4.07], p = 0.047), total amount of intravenous fluids (OR 1.22 [95% CI 0.98-1.59], p = 0.106 per litre), intraoperative blood losses greater than 500 mL (2.07 [95% CI 1.00-4.31], p = 0.043), and hypotension needing vasopressor support (OR 4.68 [95% CI 1.55-27.72], p = 0.004). The model had good discrimination with the area under the ROC curve being 0.80 (95% CI 0.75-0.84, p < 0.001). CONCLUSIONS: Our findings suggest that a perioperative strategy aimed at reducing perioperative complications in cancer surgery should include treatment of preoperative anaemia and an optimal fluid strategy, avoiding fluid overload and intraoperative use of colloids.

Liberal Versus Restrictive Transfusion Strategy in Critically Ill Oncologic Patients: The Transfusion Requirements in Critically Ill Oncologic Patients Randomized Controlled Trial.

OBJECTIVE: To assess whether a restrictive strategy of RBC transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock. DESIGN: Single center, randomized, double-blind controlled trial. SETTING: Teaching hospital. PATIENTS: Adult cancer patients with septic shock in the first 6 hours of ICU admission. INTERVENTIONS: Patients were randomized to the liberal (hemoglobin threshold, < 9 g/dL) or to the restrictive strategy (hemoglobin threshold, < 7 g/dL) of RBC transfusion during ICU stay. MEASUREMENTS AND MAIN RESULTS: Patients were randomized to the liberal (n = 149) or to the restrictive transfusion strategy (n = 151) group. Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0-3] vs 0 [0-2] unit; p < 0.001). At 28 days after randomization, mortality rate in the liberal group (primary endpoint of the study) was 45% (67 patients) versus 56% (84 patients) in the restrictive group (hazard ratio, 0.74; 95% CI, 0.53-1.04; p = 0.08) with no differences in ICU and hospital length of stay. At 90 days after randomization, mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95% CI, 0.53-0.97; p = 0.03). CONCLUSIONS: We observed a survival trend favoring a liberal transfusion strategy in patients with septic shock when compared with the restrictive strategy. These results went in the opposite direction of the a priori hypothesis and of other trials in the field and need to be confirmed.

Transfusion requirements in surgical oncology patients: a prospective, randomized controlled trial.

BACKGROUND: Several studies have indicated that a restrictive erythrocyte transfusion strategy is as safe as a liberal one in critically ill patients, but there is no clear evidence to support the superiority of any perioperative transfusion strategy in patients with cancer. METHODS: In a randomized, controlled, parallel-group, double-blind (patients and outcome assessors) superiority trial in the intensive care unit of a tertiary oncology hospital, the authors evaluated whether a restrictive strategy of erythrocyte transfusion (transfusion when hemoglobin concentration <7 g/dl) was superior to a liberal one (transfusion when hemoglobin concentration <9 g/dl) for reducing mortality and severe clinical complications among patients having major cancer surgery. All adult patients with cancer having major abdominal surgery who required postoperative intensive care were included and randomly allocated to treatment with the liberal or the restrictive erythrocyte transfusion strategy. The primary outcome was a composite endpoint of mortality and morbidity. RESULTS: A total of 198 patients were included as follows: 101 in the restrictive group and 97 in the liberal group. The primary composite endpoint occurred in 19.6% (95% CI, 12.9 to 28.6%) of patients in the liberal-strategy group and in 35.6% (27.0 to 45.4%) of patients in the restrictive-strategy group (P = 0.012). Compared with the restrictive strategy, the liberal transfusion strategy was associated with an absolute risk reduction for the composite outcome of 16% (3.8 to 28.2%) and a number needed to treat of 6.2 (3.5 to 26.5). CONCLUSION: A liberal erythrocyte transfusion strategy with a hemoglobin trigger of 9 g/dl was associated with fewer major postoperative complications in patients having major cancer surgery compared with a restrictive strategy.

Blood transfusion in cardiac surgery is a risk factor for increased hospital length of stay in adult patients.

BACKGROUND: Allogeneic red blood cell (RBC) transfusion has been proposed as a negative indicator of quality in cardiac surgery. Hospital length of stay (LOS) may be a surrogate of poor outcome in transfused patients. METHODS: Data from 502 patients included in Transfusion Requirements After Cardiac Surgery (TRACS) study were analyzed to assess the relationship between RBC transfusion and hospital LOS in patients undergoing cardiac surgery and enrolled in the TRACS study. RESULTS: According to the status of RBC transfusion, patients were categorized into the following three groups: 1) 199 patients (40%) who did not receive RBC, 2) 241 patients (48%) who received 3 RBC units or fewer (low transfusion requirement group), and 3) 62 patients (12%) who received more than 3 RBC units (high transfusion requirement group). In a multivariable Cox proportional hazards model, the following factors were predictive of a prolonged hospital length of stay: age higher than 65 years, EuroSCORE, valvular surgery, combined procedure, LVEF lower than 40% and RBC transfusion of > 3 units. CONCLUSION: RBC transfusion is an independent risk factor for increased LOS in patients undergoing cardiac surgery. This finding highlights the adequacy of a restrictive transfusion therapy in patients undergoing cardiac surgery. TRIAL REGISTRATION: Clinicaltrials.gov identifier: http://NCT01021631.

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery.

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

Pharmacological mechanisms underlying the anti-ulcer activity of methanol extract and canthin-6-one of Simaba ferruginea A. St-Hil. in animal models.

RELEVANCE: Simaba ferruginea A. St-Hil. (Simaroubaceae) is a subshrub typical of the Brazilian Cerrado, whose rhizomes are popularly used as infusion or decoction for the treatment of gastric ulcers, diarrhea and fever. AIM OF THE STUDY: To evaluate the pharmacological mechanism(s) of action of the antiulcer effects of the methanol extract of Simaba ferruginea and its alkaloid canthin-6-one. MATERIALS AND METHODS: Rhizome of Simaba ferruginea was macerated with methanol to obtain the methanol extract (MESf) from which was obtained, the chloroform fraction. Canthin-6-one alkaloid (Cant) was purified and then isolated from the chloroform fraction (CFSf). The isolated Cant was identified by HPLC. Anti-ulcer assays were determined using ethanol and indomethacin-induced ulcer models in mice and rats respectively. In order to determine the probable mechanisms of actions of MESf and Cant animals were pretreated with l-NAME prior to anti-ulcer agent treatments and ulcer induction and nitric oxide (NO) level determined in order to assess NO involvement in the gastroprotective effects. Assays of malondialdehyde (MDA), myeloperoxidase (MPO), pro-inflammatory cytokines: interleukin 8 (IL-8) and tumor necrosis factor-alpha (TNF-α) and prostaglandin E(2) (PGE(2)) were also carried out according to previously described methods. RESULTS: The results indicate that the antiulcerogenic effects of MESf and Cant in ethanol-induced ulcer is mediated in part through increase in the production of protective endogenous NO as the antiulcerogenic activity of MESf and Cant was reduced in animals pre-treated with l-NAME. In indomethacin-induced ulcer pre-treatment with MESf and Cant showed reduction in the levels of MPO and MDA in the gastric tissue, thus indicating the participation of the antioxidant mechanisms on the gastroprotective effects. The plasma levels of IL-8 in ulcerated rats with indomethacin were also reduced by Cant, but not by MESf, indicating that inhibition of this cytokine contributes to the gastroprotective effect of Cant. However MESf and Cant had no effect on the mucosal membrane levels of PGE(2), indicating that the gastroprotective effects of these agents is independent of PGE(2) modulation. CONCLUSION: The results obtained in this study with MESf and Cant added insights into the pharmacological mechanisms involved in their mode of antiulcer action. The results indicate that Cant is one of the compounds responsible for these effects. Such findings are of extreme importance in the strive for future development of potent, safer and effective antiulcer agent. The efficacy of MESf and Cant in gastroprotection shows that Simaba ferruginea might be a promising antiulcer herbal medicine, in addition to confirming the popular use of this plant against gastric ulcer models utilised in this study.

Comportamento de aves nectarivoras em Erythrina speciosa Andrews (Leguminosae-Papilionoideae) em uma área de Floresta Atlântica, Ilha Grande, Rio de Janeiro / Behavior of nectar-feeding birds on Erythrina speciosa Andrews (Leguminosae-Papilionoideae) in an Atlantic Forest area, Ilha Grande, RJ

Entre junho e agosto de 2001, foram observadas as aves visitantes florais de Erythrina speciosa (Leguminosae-Papilionoideae) em uma área de Floresta Atlântica da Ilha Grande, RJ. Os visitantes observados foram Amazilia fimbriata, Thalurania glaucopis, Eupetomena macroura (Trochilidae), Coereba flaveola e fêmeas de Ramphocelus bresilius (Emberizidae). Os machos de T. glaucopis visitaram as flores principalmente após às 10h, sendo 73,5

das visitas consideradas legítimas. Visitaram um maior numero de flores com a diminuição do volume de néctar, mas não houve relação significativa para as outras espécies de beija-flores. As fêmeas de T. glaucopis realizaram 97,5

de visitas legítimas, visitando as flores principalmente durante a tarde. Amazilia fimbriata visitou as flores com frequência ao longo do dia sendo 99

From June to August of 2001, we studied the floral visitation by birds in Erythrina. speciosa, in an area of Atlantic Forest at Ilha Grande, RJ. The visitors observed were Amazilia fimbriata, Thalurania glaucopis and Eupetomena macroura (Trochilidae), Coereba flaveola and females of Ramphocelus bresilius (Emberizidae). Males of T. glaucopis visited the flowers mostly after l 0h and 73,5

das visitas de modo legítimas. Eupetomena macroura registrada apenas as 9h utilizou as flores de maneira esporádica, não realizando visitas legítimas. Tanto C. flaveola quarto R. bresilius, cujos bicos são muito curtos em relação ao comprimento das corolas, realizaram apenas visitas ilegítimas(AU)

of their visits were legitimate. They visited significantly more flowers when nectar volume decreased but the visits/nectar volume relationship was not found in other hummingbird species. Females of T. glaucopis visited the flowers mostly in the afternoon with 97,5 visits legitimate. Eupetomtena macroura, recorded only once, visited flowers in an illegitimate way as did C. flaveola and R. bresilius the beaks of which are short relatively to the flowers corollas(AU)