Association of Cognitive Performance with Frailty in Older Individuals with Cognitive Complaints.

OBJECTIVES: Frailty is a risk factor for poor cognitive performance in older adults. However, few studies have evaluated the association of cognitive performance with frailty in a low- to middle-income country (LMIC). This study aimed to investigate an association between cognitive performance and frailty in older adults with memory complaints in Brazil. Secondarily, we aim to assess an association of cognitive performance with gait speed and grip strength. DESIGN: Cross-sectional study. SETTING: Outpatient service from a LMIC. PARTICIPANTS: Older adults with memory complaints reported by the participants, their proxies, or their physicians. MEASUREMENTS: Frailty was evaluated using the Cardiovascular Health Study criteria. A neuropsychological battery evaluated memory, attention, language, visuospatial function, executive function. Linear regression analysis with adjustment for age, sex, and education was used. We also evaluated the interaction of education with frailty, grip strength, and gait speed. RESULTS: Prefrailty was associated with poor performance in the memory domain, as well as slower gait speed was associated with worse performance in memory, attention, language, and executive function. Frailty and grip strength were not associated with cognitive performance. Interactions of education with gait speed were significant for global performance, as well as for attention and visuospatial ability. CONCLUSION: In elderly patients with memory complaints, prefrailty was associated with poor memory performance. Slowness was associated with poorer performance in some cognitive domains, mainly in participants with low education.

Aspectos do uso territorial por onça parda (Puma concolor), através de monitoramento via satélite, na região do Parque Estadual da Serra do Brigadeiro, MG / Aspects of territorial use of the Cougar (Puma concolor), by satelite monitoring, in the Parque Estadual da Serra do Brigadeiro, MG

Objetivou-se com o presente estudo monitorar o comportamento do uso territorial de um macho de onça parda, capturado no Parque Estadual da Serra do Brigadeiro (PESB), por meio da telemetria, usando colar de GPS via Satélite Globalstar. O monitoramento de doze meses resultou na transmissão via satélite de 328 localizações, as quais sugerem que a área utilizada por esse felino seja de aproximadamente 610km2, sendo esta a maior área já descrita para a espécie. Foi possível observar que apenas 20% das localizações ocorreram dentro da área do PESB. O comportamento territorial observado neste trabalho mostra a vulnerabilidade do animal a ações antrópicas, como a caça, atropelamentos e o contato com patógenos entre animais silvestres e domésticos. Observou-se também que duas rodovias configuram barreiras artificiais para o deslocamento do animal, possivelmente impedindo o fluxo gênico entre o PESB e dois outros importantes parques. Com os dados levantados é possível a sugestão de ações de manejo, como a criação de uma conectividade efetiva entre o PESB, o Parque Estadual do Rio Doce e o Parque Nacional do Caparaó, o que poderia contribuir para o intercâmbio genético entre as populações e, dessa forma, favorecer a conservação não somente da onça parda.

We aimed to study the territorial behavior of a male cougar, captured in the Parque Estadual da Serra do Brigadeiro (PESB), using a GPS collar and the Globalstar Satellite. Monitoring the animal for nine months we obtained 328 locations. The data suggest that the area used by this feline is approximately 610km2, the largest area described for this specie. It was also possible to observe that only 20% of the locations of the animal occurred within the PESB area. The territorial behavior observed in this study shows the vulnerability of the animal to human activities such as hunting, road kill and contact with pathogens from domestic animals. It was also observed that two roads constitute artificial barriers for animal movement, possibly preventing gene flow between the PESB and two other parks. The creation of an effective connectivity between the PESB, the Parque Estadual do Rio Doce and the Parque Nacional do Caparaó is critical to ensure genetic exchange between the animal populations and thereby promote their conservation.

Lactoferrin and prevention of late-onset sepsis in the pre-term neonates.

Late-onset sepsis (LOS) affects a large proportion of pre-term neonates in neonatal intensive care units (NICUs) worldwide, with high morbidity and related mortality, and frequent occurrence of severe late neurodevelopmental impairment. Due to the frequency, severity and difficulties in early diagnosis and prompt therapy, prevention is crucial for decreasing the burden of infection-related complications in NICUs. It is well known that feeding with fresh maternal milk, hygiene measures and the cautious use of H2-blockers are related with a decreased risk of developing sepsis. However, evidence from randomised clinical trials exists only for fluconazole in the prevention of fungal infections in the NICU. Lactoferrin is the main whey protein in mammalian milk, and is involved in innate immune host defences. Notably, human lactoferrin can be found at increased concentrations in colostrum and in milk from mothers of premature neonates. Human (hLF) and bovine lactoferrin (bLF) share a high (77%) amino-acid homology, and the same N-terminal peptide responsible for antimicrobial activity, called lactoferricin. In vitro, bLF shows potent direct antimicrobial activity against all types of pathogens, which occurs via anti-cell wall actions and leads to disintegration of the micro-organism's membranes. bLF is also synergistic with many antimicrobials and antifungals, and promotes growth and differentiation of the immature gut. Based on this background data, a randomised clinical trial was recently conducted in very low birth weight pre-term neonates given bLF alone or with the probiotic Lactobacillus GG. The aim of the trial was to assess the ability of bLF to prevent late-onset sepsis of any origin in the studied infants during their stay in the NICU. This article discusses the preliminary data from this study, along with the proposed mechanisms of action of bLF in pre-term infants.

[Insulin and glucagon plasma levels in very low birth weight preterm infants of appropriate weight for gestational age]. / Livelli plasmatici di insulina e glucagone in neonati pretermine di peso molto basso appropriato per l'eta gestazionale.

OBJECTIVES: Prematurity is a known risk factor for hypoglycaemia, hyperglycemia, neonatal sepsis and other common neonatal complications, possibly associated with glucoregolatory hormone (insulin and glucagon) alterations. Insulin and glucagon levels change also in relation to gender, mode of delivery and postnatal clinical severity. Because of the lack of reference range in literature, the aim of this study is to assess plasma insulin and glucagon levels in preterm appropriate for gestational age (AGA) infants of birth weight <1500 g (very low birth weight, VLBW) as a function of gestation, birth weight, gender and mode delivery. METHODS: The authors examined 48 preterm AGA infants (mean birth weight 1 163+/-286 g, mean gestational age 28.2+/-2.4 weeks). The infant population was subdivided in relation to gestational age, weight, gender, mode of delivery and assisted ventilation at 5-7(th) days. Plasma glucose, insulin and glucagon levels were assessed in all newborns at birth and at 5-7(th) days of life. Data were analyzed using t-test. RESULTS: A negative correlation between insulin and gestational age was observed (P<0.05). At birth, no significant differences regarding plasma glucose, insulin and glucagon levels were observed as a function of the examined category variables. At the 5-7(th) days of life, insulin levels were significantly higher in newborns with gestational age =or<27 weeks (P<0.02), in the female gender (P<0.02) and in the infants born to emergency Cesarean delivery (P<0.05). CONCLUSIONS: These findings indicate potentially useful reference range values for plasma insulin and glucagon in the VLBW population.

Early activation of the hypothalamic-pituitary-adrenal-axis in very-low-birth-weight infants with small thymus at birth.

BACKGROUND: An acute thymic involution in human fetuses and newborns has been described in very-low-birth-weight (VLBW) infants with histological chorioamnionitis. However, the mechanisms of thymic involution remain to be clarified. Here, we tested the hypothesis that an activation of the hypothalamic-pituitary-adrenal (HPA) axis occurs in VLBW infants with acute thymic involution at birth. METHODS: A total of 180 randomly selected VLBW newborns (28.8 +/- 3.15 wk gestation; 1093 +/- 305 g) entered the study. Thymic size was measured on standard chest radiographs at birth, and expressed as the ratio between the transverse diameter of the cardiothymic image at the level of the carina (CT) and that of the thorax (T). CT/T < 0.28 was considered to indicate a small thymic size. Plasma cortisol and adrenocorticotropic hormone (ACTH) concentrations were determined on days 1 (d-1) and 7 (d-7), and at 1 month (mo-1). Results. A total of 66 (36.7%) newborns had CT/T < 0.28. Infants with small thymus had significantly increased cortisol on d-1 ( approximately 5.2-folds) [median: 18.95 (95% CI: 11.20-39.4) microg/dl vs. 3.66 (1.94-6.82) microg/dl, p < 0.0001)] and d-7( approximately 1.7-folds) [12.0 (4.39-22.97) microg/dl vs. 7.8 (3.63-12.8) microg/dl, p = 0.0384)], as compared with those with normal thymic size, together with higher adrenocorticotropic hormone (ACTH) concentrations on d-1 ( approximately 1.9-folds) [28 (15.6-61.07) pg/ml vs. 14.9 (9.0-23.42) pg/ml, p = 0.0005)], while no significant differences for cortisol at mo-1 or ACTH concentrations on d-7 and mo-1 were evidenced (p > 0.50). From a multivariate logistic regression analysis, a small thymus at birth was a significant independent predictor of plasma cortisol concentrations in the top-quartile (OR = 14.4; 95% CI: 6.079-34.11), and plasma ACTH concentrations in the top-quartile (OR = 4.40 (95% CI: 1.99-9.74) on d-1 (results adjusted for variables significant at univariate analysis). CONCLUSIONS: Our data indicated the presence of a previously unrecognized, early activation of the HPA axis in VLBW newborns with a small thymus at birth.

Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome.

BACKGROUND: In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. METHODS: We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure-volume curve, a tidal volume of less than 6 ml per kilogram, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes. RESULTS: After 28 days, 11 of 29 patients (38 percent) in the protective-ventilation group had died, as compared with 17 of 24 (71 percent) in the conventional-ventilation group (P<0.001). The rates of weaning from mechanical ventilation were 66 percent in the protective-ventilation group and 29 percent in the conventional-ventilation group (P=0.005): the rates of clinical barotrauma were 7 percent and 42 percent, respectively (P=0.02), despite the use of higher PEEP and mean airway pressures in the protective-ventilation group. The difference in survival to hospital discharge was not significant; 13 of 29 patients (45 percent) in the protective-ventilation group died in the hospital, as compared with 17 of 24 in the conventional-ventilation group (71 percent, P=0.37). CONCLUSIONS: As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge.

Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS.

The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. Twenty-five patients were submitted to LPA--with the combined use of permissive hypercapnia (PHY), VT < 6 ml/kg, distending pressures above PEEP < 20 cm H2O, and PEEP 2 cm H2O above the lower inflection point on the static inspiratory P-V curve (P(FLEX))- and 23 control patients were submitted to conventional mechanical ventilation. LPA was initiated at once, resulting in an immediate increase in heart rate (p = 0.0002), cardiac output (p = 0.0002), oxygen delivery (DO2l, p = 0.0003), and mixed venous Po2 (p = 0.0006), with a maintained systemic oxygen consumption (p = 0.52). The mean pulmonary arterial pressure markedly increased (mean increment 8.8 mm Hg; p < 0.0001), but the pulmonary vascular resistance did not change (p = 0.32). Cardiac filling pressures increased (p < 0.001) and the systemic vascular resistance fell (p = 0.003). All these alterations were progressively attenuated in the course of the first 36 h, despite persisting hypercapnia. Plasma lactate suffered a progressive decrement along the early period in LPA but not in control patients (p < 0.0001). No hemodynamic consequences of LPA were noticed in the late period and renal function was preserved. A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.

[Factory noise]. / Il rumore nelle fabbriche.

Regulations dealing with noise and vibration are examined in the light of general precepts on safeguarding the physical health of workers to be found in the Civil Code, the workers' charter and, i.e. those included in the prevention of accidents at work legislation, that dealing with health in the work environment, and the recent national health service law. A brief account is also given of the approach taken by the courts to the disputed question of the evaluation of damage to the hearing, and maximum noise acceptability levels. Reference is also made to a personal study of the risks imposed by occupational exposure to noise. Lastly, an explanation is proffered of the criminal and tortious liability of manufacturers and sellers of machines and equipment whose noise levels are harmful to those who use them.