Using a mobile application to reduce potentially inappropriate prescribing for older Brazilian adults in primary care: a triple-blind randomised clinical trial

BACKGOUND

Potentially inappropriate prescribing (PIP) has been evaluated in several countries, and several strategies have been devised for deprescribing drugs in older adults. The aim of this study was to evaluate the efficacy of a mobile application in reducing PIP for older adults in primary care facilities in Brazil.

METHODS

This randomised, triple-blind, parallel-group trial was conducted in 22 public primary care facilities in Brazil. During the intervention phase, the general practitioners (GPs) were randomly allocated to the intervention (MPI Brasil app provides information about PIP, therapeutic alternatives and deprescribing) or control (MedSUS app provides general information about medications) group. All GPs were trained on the Clinical Decision-Making Process and how to access an Evidence-Based Health website. The GPs received an Android tablet with an installed mobile application depending on their allocated group, which they used when caring for older patients over at least 3 months. At the end of this period, a sample of older patients aged ≥ 60 years who had been awaiting medical consultation by the participating GPs were interviewed and their prescriptions analysed. The primary outcome was the frequency of PIP in and between the groups.

RESULTS

Among 53 GPs who were administered the baseline survey, 14 were included in the clinical trial. At baseline, 146 prescriptions were analysed: the PIP overall was 37.7% (55/146), in the intervention group was 40.6% (28/69), and in the control group was 35.1% (27/77). After the intervention, 284 prescriptions were analysed: the PIP overall was 31.7% (90/284), in the intervention group was 32.2% (46/143), and in the control group was 31.2% (44/141) (RR: 1.16; 95% CI, 0.76-1.76). In the within-group analysis, the PIP reduced from before to after the intervention in both groups-more significantly in the intervention than in the control group (p < 0.001). In the stratified analysis of PIP frequency by GPs, there was a relative risk reduction in 86% (6/7) of GPs in the intervention group compared to 71% (5/7) in the control group.

CONCLUSION

We found that the MPI Brasil app effectively reduced PIP, suggesting that it may be useful to incorporate this tool into clinical practice.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02918643). First registration on 22/09/2016.

Optimizing Hypertension Treatment in Older Patients Through Home Blood Pressure Monitoring by Pharmacists in Primary Care: The MINOR Clinical Trial

PURPOSE

Incorporating technology such as home blood pressure monitoring (HBPM) into the clinical routine generates opportunities to improve BP monitoring and control in primary health care. It is also important to prevent overtreatment. However, the combination of HBPM with collaborative drug therapy management (CDTM) has not yet been studied. This study aimed to assess the efficacy of combining HBPM with CDTM to optimize hypertension treatment for older patients.

METHODS

This open-label, parallel-group, randomized clinical trial was conducted between June 2021 and August 2022 in a Brazilian community pharmacy and included older patients (aged ≥60 years) with hypertension. Those who were classified as poorly adherent or nonadherent to the prescribed drug treatment or who were unable to perform HBPM were excluded. In the control group, participants received a BP monitor and instructions on how to perform HBPM. A general practitioner, who was provided a report with the obtained BP values, determined any changes to the treatment protocol. In the intervention group, a pharmacist enrolled participants in a drug therapy management protocol and provided the general practitioner with suggestions to optimize the antihypertensive drug therapy, in addition to the report with the BP values. The following outcomes were considered: the proportion of participants receiving deprescriptions of antihypertensive drugs, other treatment adjustments, and the difference in mean BP between the groups 45 days after performing HBPM. The study used a t test combined with Levene's test to calculate mean intergroup differences in BP, the paired t test to calculate mean intragroup differences in BP, and Pearson's χ2 test to determine intergroup differences in changes in drug therapy.

FINDINGS

In each group, 161 participants completed the trial. Antihypertensive agents were deprescribed for 31 (19.3%) participants in the intervention group versus 11 (6.8%) in the control group (P = 0.01). In addition, 14 (8.7%) participants were prescribed antihypertensive drugs in the intervention group versus 11 (6.8%) in the control group (P = 0.52). The mean office systolic BP and HBPM values were lower in the intervention group (P = 0.22 and P = 0.29, respectively).

IMPLICATIONS

Combining HBPM with a CDTM protocol effectively optimized antihypertensive treatment for older patients in a primary health care setting.

CLINICALTRIALS

gov identifier: NCT04861727.

Physicians' and nurses' perspective on chronic disease care practices in Primary Health Care in Brazil: a qualitative study

BACKGROUND

Primary health care-oriented systems provide better healthcare, especially for chronic diseases. This study analyzed the perspectives of physicians and nurses performing care for patients with chronic diseases in Primary Health Care in a Brazilian city.

METHODS

A qualitative study was conducted in Vitória da Conquista, Bahia, Brazil, using semi-structured interviews with five physicians and 18 nurses. The interview included questions from an analytical matrix based on three dimensions of healthcare practices: organizational, technical care, and biopsychosocial, following a deductive approach. The interviews were fully transcribed and analyzed using a thematic categorical approach.

RESULTS

The results indicated that the provision of chronic care occurs in a comprehensive way. Potentialities were identified in the diversification of access, offer of care actions and technologies, integration of teamwork, and bringing together social networks to foster autonomy and self-care. Weaknesses were mostly related to the high number of people in the teams, follow-up of several cases, high turnover of support teams, low integration of Primary Health Care with other levels, difficulties in intersectoral articulation and family participation in care.

CONCLUSION

The multidimensional assessment of health care practices aimed at individuals with chronic noncommunicable diseases was useful to portray the strengths and weaknesses of the services. It also ratifies the need to consider the importance of and investment in primary health care by offering the necessary technical, political, logistical and financial support to the units, to ensure the sustainability of the actions by nurses, doctors and entire team.

Deprescribing clonazepam in primary care older patients: a feasibility study

Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.

Self-Care in Patients with Non-Optimal Diabetes Management in Brazilian Rural Areas: A Mixed-Methods Study

PURPOSE

This study aims to assess self-care in patients with non-optimal diabetes management (HbA1c >7.0% for adults and >8.0 for those aged 60 or over) and the positive and negative experiences associated with it in the rural communities of a Brazilian municipality.

PATIENT AND METHODS

This is a cross-sectional mixed-methods study. The data were collected from participants with high HbA1c through focus group discussions, subsequently performing thematic analysis, and through structured questionnaires (socioeconomic characteristics and the Summary of Diabetes Self-Care Activities (SDSCA)).

RESULTS

The mean HbA1c of the 156 study participants was 9.94% (95% confidence interval: 9.70-10.19%) and most participants (86.54%) had negative self-care behaviors, with an overall SDSCA mean score of 3.55. This mean was not positive for any of the socioeconomic characteristics. The self-care activities with the most satisfactory performance concerned non-smoking and the use of prescribed medications, and the poorest results were observed for the practice of specific physical activities. The qualitative data indicated that the study participants face many difficulties regarding self-care practices, especially those related to an adequate diet.

CONCLUSION

The self-care assessment revealed unsatisfactory self-care behaviors as well as high HbA1c levels among the study participants and highlighted the various difficulties they encounter. This indicates the need for more attentive health teams to monitor patients, especially regarding actions focused on the non-pharmacological elements of self-care, such as lifestyle changes, which were found to be the dimensions with the most unsatisfactory results.

Older people's knowledge of the purpose of drugs prescribed at primary care appointments

OBJECTIVE

This study aimed to assess older people's knowledge of the purpose of drugs prescribed at medical appointments in primary care units and the possible factors related to their level of knowledge about their medications.

METHODS

This was a cross-sectional study conducted in 22 basic health units in Brazil. Patients aged ≥60 years were included in this study (n=674). Knowledge of prescribed medications was assessed by comparing the responses to the questionnaire and the medication and prescription information. Multivariate analyses were conducted using the Poisson regression with robust variance.

RESULTS

The mean age of the sample was 70.1 (standard deviation: ±7.1) years. Among 674 patients, 272 (40.4%) did not know the indication of at least 1 of their prescribed drugs; among them, 78 (11.6%) did not know the indication of any of their prescribed drugs. In the final multivariate analysis, polypharmacy, illiteracy, and cognitive impairment were found to be associated with misunderstanding the purpose of at least one prescribed drug. Moreover, illiteracy and cognitive impairment were associated with a greater misunderstanding of the purpose of all prescribed drugs.

CONCLUSIONS

In the studied sample, patients demonstrated a high rate of misunderstanding of the purpose of prescribed drugs. Therefore, it is necessary for health services and professionals to implement strategies that increase the quality of the guidance and instructions given to older people in order to promote adherence to treatment.

Improving Access to the Glycated Hemoglobin Test in Rural Communities With Point-of-Care Devices: An Application Study

Background: Living in a rural or remote area is frequently associated with impaired access to health services, which directly affects the possibility of early diagnosis and appropriate monitoring of diseases, mainly non-communicable ones, because of their asymptomatic onset and evolution. Point-of-care devices have emerged as useful technologies for improving access to several laboratory tests closely patients' beds or homes, which makes it possible to eliminate the distance barrier.

Objective: To evaluate the application of point-of-care technology for glycated hemoglobin (HbA1c) estimation in the assessment of glycemic control and identification of new diagnoses of diabetes in primary care among rural communities in a Brazilian municipality.

Materials and Methods: We included individuals aged 18 years or older among rural communities in a Brazilian municipality. From September 2019 to February 2020, participants were assessed for anthropometrics, blood pressure, and capillary glycemia during routine primary care team activities at health fairs and in patient groups. Participants previously diagnosed with diabetes but without recent HbA1c test results or those without a previous diagnosis but with random capillary glycemia higher than 140 mg/dL were considered positive and were tested for HbA1c by using a point-of-care device.

Results: At the end of the study, 913 individuals were accessed. Of these, 600 (65.7%) had no previous diagnosis of diabetes, 58/600 (9.7%) refused capillary glycemia screening and 542/600 (90.7%) were tested. Among tested individuals, 73/542 (13.5%) cases without a previous diagnosis of diabetes, were positive for capillary glycemia. Among positives, 31/73 (42.5%) had HbA1c levels that were considered indicative of prediabetes and 16/73 (21.9%) were newly diagnosed with diabetes. Among the participants, 313/913 (34.3%) were previously diagnosed with diabetes. Recent HbA1c results were unavailable for 210/313 (67.1%). These individuals were tested using point-of-care devices. Among them, 143/210 (68.1%) had HbA1c levels higher than target levels (>7% and >8% for adults and elderly individuals, respectively.

Conclusion: The application of point-of-care devices for HbA1c level measurement improved the access to this test for people living in rural or remote areas. Thus, it was possible to include this technology in the routine activities of primary health care teams, which increased the rates of new diagnoses and identification of patients with uncontrolled glycemia.

Community-Based Interventions to Improve the Control of Non-Communicable Diseases in Underserved Rural Areas in Brazil: A Before-and-After Study

Background: Hypertension and diabetes mellitus are the second and third highest leading causes of disability-adjusted life-years (DALY), respectively, in Brazil. The clinical outcomes of chronic diseases are influenced by various factors. Therefore, there is a need for multifaceted interventions to achieve a decrease in the rate of DALY, with a better control of these diseases.

Objective: To verify whether sustainable long-term interventions, such as health worker training and provision of health education to the patients, contribute to health improvements in patients with hypertension and diabetes from rural communities.

Methods: Over a 6 month period, educational and medical interventions were provided to optimize the treatment of hypertension and diabetes. Furthermore, blood pressure and glycated hemoglobin (HbA1c) measurements were taken at baseline and after the interventions.

Results: The monitored hypertensive patients (n = 276) had a reduction of 13.4 mmHg (p = 0.021) and 5.8 mmHg (p < 0.001) in mean systolic and diastolic blood pressure, respectively. Diabetic patients who were followed-up (n = 71) achieved a 0.55% (p = 0.185) reduction in HbA1c level. The desired blood pressure level (<140/90 mmHg) was achieved in 38.8% of patients with hypertension, whereas the desired level of HbA1c (<7.0% for adults and <8.0% for the elderly) was achieved in 16.9% of patients with diabetes; in addition, 38.0% had a reduction of HbA1c of at least 1%.

Conclusion: The results showed that the interventions improved the blood pressure and HbA1c levels in patients with hypertension and diabetes from rural communities in a municipality in Northeast Brazil.

Unhealthy Food and Psychological Stress: The Association between Ultra-Processed Food Consumption and Perceived Stress in Working-Class Young Adults

BACKGROUND

Ultra-processed foods are industrial formulations made from food extracts or constituents with little or no intact food and often containing additives that confer hyper-palatability. The consumption of these products increases the risk of chronic non-communicable diseases. Stressed people may engage in unhealthy eating as a way to cope. This study aimed to verify whether ultra-processed food consumption was associated with perceived stress levels in industrial and retail workers from Vitoria da Conquista, Brazil.

METHODS

This was a cross-sectional study carried out between July 2017 and August 2018. During the study period, 1270 participants completed a survey administered by an interviewer. Stress levels were assessed using the Perceived Stress Scale. Information regarding weekly ultra-processed food consumption was collected. Ultra-processed foods were classified into four groups: sugary drinks; sugary foods; fast foods; and canned foods, frozen foods, or processed meat. The Student's t-test or one-way analysis of variance was used to assess the differences in stress levels and ultra-processed food consumption. Ordinal regression was used to determine the association between the degrees of stress and ultra-processed food consumption levels.

RESULTS

Factors such as a young age, being unmarried, smoking, high-risk alcohol consumption, negative health perception, and high perceived stress level indicated higher rates of ultra-processed food consumption. Ordinal regression analysis showed that high stress levels were associated with increased odds of higher ultra-processed food consumption (odds ratio: 1.94; 95% CI: 1.54-2.45).

CONCLUSIONS

These findings could help identify appropriate target areas for interventions aimed at mental health promotion and healthier food consumption.

Phytochemical characterization, and antioxidant and antibacterial activities of the hydroethanolic extract of Anadenanthera peregrina stem bark

The Brazilian Cerrado biome consists of a great variety of endemic species with several bioactive compounds, and Anadenanthera peregrina (L.) Speg is a promising species. In this study, we aimed to perform phytochemical characterization and evaluate the antioxidant and antibacterial activities against Staphylococcus aureus and Escherichia coli of the hydroethanolic extract of A. peregrina stem bark. The barks were collected in the Botanical Garden of Goiânia, Brazil. The hydroethanolic extract was obtained by percolation and subjected to physicochemical screening, total phenolic content estimation, high-performance liquid chromatography (HPLC) fingerprinting, and antioxidant (IC50 values were calculated for the 2,2-diphenyl-1-picrylhydrazyl assay - DPPH) and antibacterial activity determination. The pH of the extract was 5.21 and density was 0.956 g/cm3. The phytochemical screening indicated the presence of cardiac glycosides, organic acids, reducing sugars, hemolytic saponins, phenols, coumarins, condensed tannins, flavonoids, catechins, depsides, and depsidones derived from benzoquinones. The extract showed intense hemolytic activity. The total phenolic content was 6.40 g GAE 100 g-1. The HPLC fingerprinting analysis revealed the presence of gallic acid, catechin, and epicatechin. We confirmed the antioxidant activity of the extract. Furthermore, the extract did not inhibit the growth of E. coli colonies at any volume tested, but there were halos around S. aureus colonies at all three volumes tested. These results contribute to a better understanding of the chemical composition of A. peregrina stem bark and further support the medicinal applications of this species.

Cost-Effectiveness of Point-of-Care A1C Tests in a Primary Care Setting

Objective: We evaluated the cost-effectiveness of the point-of-care A1c (POC-A1c) test device vs. the traditional laboratory dosage in a primary care setting for people living with type 2 diabetes. Materials and Methods: The Markov model with a 10-year time horizon was based on data from the HealthRise project, in which a group of interventions was implemented to improve diabetes and hypertension control in the primary care network of the urban area of a Brazilian municipality. A POC-A1c device was provided to be used directly in a primary care unit, and for a period of 18 months, 288 patients were included in the point-of-care group, and 1,102 were included in the comparison group. Sensitivity analysis was performed via Monte Carlo simulation and tornado diagram. Results: The results indicated that the POC-A1c device used in the primary care unit was a cost-effective alternative, which improved access to A1c tests and resulted in an increased rate of early control of blood glucose. In the 10-year period, POC-A1c group presented a mean cost of US$10,503.48 per patient and an effectiveness of 0.35 vs. US$9,992.35 and 0.09 for the traditional laboratory test, respectively. The incremental cost was US$511.13 and the incremental effectiveness was 0.26, resulting in an incremental cost-effectiveness ratio of 1,947.10. In Monte Carlo simulation, costs and effectiveness ranged between $9,663.20-$10,683.53 and 0.33-0.37 for POC-A1c test group, and $9,288.28-$10,413.99 and 0.08-0.10 for traditional laboratory test group, at 2.5 and 97.5 percentiles. The costs for nephropathy, retinopathy, and cardiovascular disease and the probability of being hospitalized due to diabetes presented the greatest impact on the model's result. Conclusion: This study showed that using POC-A1c devices in primary care settings is a cost-effective alternative for monitoring glycated hemoglobin A1c as a marker of blood glucose control in people living with type 2 diabetes. According to our model, the use of POC-A1c device in a healthcare unit increased the early control of type 2 diabetes and, consequently, reduced the costs of diabetes-related outcomes, in comparison with a centralized laboratory test.

Potentially inappropriate medication use in older adults: prevalence and physician knowledge

OBJECTIVE: To analyze the frequency, profile, and additional variables associated with the prescription of potentially inappropriate medications (PIM) to older adults in primary care, and evaluate physicians’ knowledge about these medications. METHODS: A cross-sectional study was conducted based on data from patient records for the period of January 2014 to December 2017 in a city located in the state of Minas Gerais. The frequency of PIM use was evaluated based on the 2019 Beers-Fick criteria. Physician knowledge was evaluated using a validated questionnaire as a primary data source. RESULTS: In a sample of 423 older adults, 75.89% (n = 321) used at least one PIM, the most common of which were medications used to treat central nervous system disorders (48.00%; n = 203). Most participants were female (62.41%; n = 264) and 70 years or older (69.50%; n = 294). When presented with clinical cases illustrating common situations in the management of older patients, 53.33% of physicians (n = 8) answered four or five questions correctly out of a possible seven; 13.33% (n = 2) answered six questions correctly; and 33.33% (n = 5) obtained three correct answers or fewer. CONCLUSIONS: These findings showed a high frequency of PIM use among older adults treated in Primary Health Care settings, with medications used in the treatment of central nervous system disorders. Our results highlight the importance of continuing education for health professionals and improved assessments of the medication available in the Unified Health System (Sistema Único de Saúde; SUS) for use in older adults, especially those taking multiple medications

Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil

BACKGROUND

Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population.

OBJECTIVES

To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors.

DESIGN AND SETTING

This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations.

METHODS

Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription.

RESULTS

In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications.

CONCLUSIONS

High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.

Association between perceived stress and health-risk behaviours in workers

Individuals who experience stress can engage in health-risk behaviours that may decrease work performance. The aim of this study was to determine perceived stress levels in Brazilian workers and verify whether perceived stress was associated with health-risk behaviours. Stress levels of 1,270 workers (1,019 men, 251 women) were assessed using the Perceived Stress Scale. The health-risk behaviours investigated were low intake of vegetables and fruits, daily smoking, high-risk alcohol consumption, physical inactivity, and the presence of obesity. The Student's t-test or one-way analysis of variance was used to assess differences in stress levels. Ordinal regression was used to determine the association between the degrees of stress and health-risk behaviours. Women had higher perceived stress levels than men. In addition, perceived stress levels were higher in those who had low socioeconomic status, were unmarried, had a negative perception of their health, were smokers, or had obesity. Smoking and the presence of two or more health-risk behaviours were associated with 1.84 (95% CI: 1.24-2.73) times and 1.49 (95% CI: 1.18-1.89) times higher odds of experiencing higher degrees of stress, respectively. In women, such an association was observed with the presence of obesity (odds ratio: 2.0; 95% CI: 1.01-3.98).

Evaluation of blood pressure through home monitoring in brazilian primary care: a feasibility study

Blood pressure measurements taken in a clinical setting are subject to errors, therefore there are advantages to monitoring blood pressure at home, especially in in patients diagnosed with hypertension. The study describes the feasibility of home monitoring to assess blood pressure in primary care and compares blood pressure measured at home and during a medical consultation. This cross-sectional study was carried out with patients whose used home blood pressure in the morning and evening, thrice for seven consecutive day sat home. Participants included patients older than 18 years with suspected whitecoat hypertension, taking antihypertensives, or those intolerant of ambulatory blood pressure monitoring, and excluded patients who did not follow the protocol, suffered from an irregular heart rate, and pregnant women. Of the 134 patients who participated in the study, 63.3% had altered blood pressure when measured at health facilities and 48% had higher blood pressure at home. The mean difference between the methods was 10.1 mmHg for systolic and 4.3 mmHg for diastolic. The prevalence of whitecoat hypertension was 19.4%. Blood pressure monitoring at home is a practicable strategy in the Brazilian healthcare system.

Why deprescribing instead of not prescribing?

Prescribing medications involves complex cognitive processes, and mistakes in prescription can cause serious adverse events. Deprescribing is one of the last opportunities to prevent patient harm from the use of drugs that should be avoided, especially among older patients. This viewpoint article aims to discuss the prescription process and some essential concepts, such as polypharmacy, prescription of potentially inappropriate medications, and, particularly, the relevance of deprescribing and its relationship with the appropriate prescription of medications in older people.

Genetic diversity of standard leaf nutrients in Coffea canephora genotypes during phenological phases

Diagnosing foliar nutritional status is essential for fertilizer recommendations and for the identification of nutrient imbalances. This study aimed to verify genetic diversity and establish mean standards (leaf nutrient contents; LNCs) and relationships among leaf nutrients (LNC relationships; LNCRs) in seven conilon coffee genotypes during both pre-flowering and bean-filling stages. Twenty crops from several cities in the northern region of Espírito Santo State, Brazil, with crop yield either equal to or greater than 100 bags per hectare (during two harvests) were assessed. A total of 140 samples were collected during each evaluation period for quantification of leaf nutrient contents (N, P, K, Ca, Mg, S, Fe, Zn, Cu, Mn, and B). The Ward procedure, a hierarchical genetic clustering method, was used to quantify the genetic diversity among genotypes. To examine differences between the LNCs and LNCRs, F-and Scott-Knott tests were used. LNCs and LNCRs showed significant differences among the conilon coffee genotypes during the evaluation periods. Additionally, the 8V, 10V,and 12V genotypes exhibited the highest values for most of the nutrients, especially for N, P, and Cu. Therefore, the clustering method revealed genetic diversity among genotypes for standard leaf nutrient levels, implying that leaf diagnosis could be specific to each genotype and phenological stage.

Oxidative status of the myocardium in response to different intensities of physical training

The intensity of exercise determines the metabolic pathway and the energetic substrate that is spent. Our study sought to identify the effects of different intensities of swimming on myocardial oxidative status and the blood lipid profile. Eighty Wistar rats (male and female) submitted to different intensities of a swimming regimen (low, LS; moderate, MS; or high, HS) for 16 weeks. Samples of blood and myocardium from the left ventricle were collected to determine lipid profiles and oxidative status. Reactive oxygen species (ROS) and antioxidant capacity against peroxyl radicals (ACAP), lipid profiles and lipid peroxidation was analyzed. ROS levels and ACAP were higher in male rats than in female rats overall (p<0.05). However, ACAP in the myocardium was significantly elevated in LS female rats compared to the MS and HS female rats, which had a significantly lower ACAP compared to all other groups. LS and MS training in both sexes and HS training (in females) led to significant decreases in the heart's lipid peroxidation. Amelioration of the lipid profile and reduction in oxidative damage contributed to a physiological state that benefits cardiovascular function in exercised animals. The results show that low and moderate intensity exercise promotes beneficial adaptations.

Involvement of AOX and UCP pathways in the post-harvest ripening of papaya fruits

Enhanced respiration during ripening in climacteric fruits is sometimes associated with an uncoupling between the ATP synthesis and the mitochondrial electron transport chain. While the participation of two energy-dissipating systems, one of which is mediated by the alternative oxidase (AOX) and the other mediated by the uncoupling protein (UCP), has been linked to fruit ripening, the relation between the activation of both mitochondrial uncoupling systems with the transient increase of ethylene synthesis (ethylene peak) remains unclear. To elucidate this question, ethylene emission and the two uncoupling (AOX and UCP) pathways were monitored in harvested papaya fruit during the ripening, from green to fully yellow skin. The results confirmed the typical climacteric behavior for papaya fruit: an initial increase in endogenous ethylene emission which reaches a maximum (peak) in the intermediate ripening stage, before finally declining to a basal level in ripe fruit. Respiration of intact fruit also increased and achieved higher levels at the end of ripening. On the other hand, in purified mitochondria extracted from fruit pulp the total respiration and respiratory control decrease while an increase in the participation of AOX and UCP pathways was markedly evident during papaya ripening. There was an increase in the AOX capacity during the transition from green fruit to the intermediate stage that accompanied the transient ethylene peak, while the O2 consumption triggered by UCP activation increased by 80% from the beginning to end stage of fruit ripening. Expression analyses of AOX (AOX1 and 2) and UCP (UCP1-5) genes revealed that the increases in the AOX and UCP capacities were linked to a higher expression of AOX1 and UCP (mainly UCP1) genes, respectively. In silico promoter analyses of both genes showed the presence of ethylene-responsive cis-elements in UCP1 and UCP2 genes. Overall, the data suggest a differential activation of AOX and UCP pathways in regulation related to the ethylene peak and induction of specific genes such as AOX1 and UCP1.

Immunoprofiling of oral squamous cell carcinomas reveals high p63 and survivin expression

BACKGROUND

Cancer is a multifactorial disease composed of cells that show somatic mutations and epigenetic changes. The aim of this study was to investigate the expression of proteins involved in the development and maintenance of epithelia, cell cycle regulation, and apoptosis in human oral squamous cell carcinoma (OSCC) tissue samples.

METHODS

A tissue microarray containing 65 primary human OSCC specimens was immunolabeled for bcl-2, survivin, epidermal growth factor receptor (EGFR), p21, p53, p63, and cleaved caspase-3.

RESULTS

Samples were scored for percentage of positively stained tumor cells and staining intensity. A total immunostaining score was also calculated, using the product of percentage and intensity scores. All specimens showed high scores, > 75%, for p63 and survivin, and 75.4% of the specimens also presented high EGFR expression. All cases showed p53-positive cells. p21 showed a diffuse staining pattern. The percentage of cells positive for cleaved caspase-3 and bcl-2 was low.

CONCLUSIONS

The high frequency of tumor cells expressing p63 and survivin highlights the role of these proteins in the malignant transformation of oral epithelium. Collectively, our results suggest that p63 and survivin may constitute attractive targets for cancer therapy in patients with OSCC.

Bone marrow-derived mononuclear cell therapy attenuates silica-induced lung fibrosis

This study tests the hypothesis that bone marrow-derived mononuclear cell (BMDMC) therapy may reduce lung inflammation and fibrosis leading to an improvement in respiratory mechanics in a murine model of silicosis. 52 female C57BL/6 mice were randomly assigned into four groups. In the silica group (SIL), silica suspension (20 mg/50 μL in saline) was intratracheally instilled. In the control animals, 50 μL saline was administered intratracheally. At 1 h, the control and SIL groups were further randomised, receiving BMDMC (2×10⁶ i.v. control-cell and SIL-cell) or saline (50 μL i.v. control and SIL). BMDMC were obtained from male donor mice. At day 15, lung mechanics, histology, and the presence of Y chromosome, interleukin (IL)-1β, IL-1α, IL-1 receptor antagonist (IL-1RN), IL-1 receptor type 1, transforming growth factor (TGF)-β and caspase-3 mRNA expressions in lung tissue were analysed. In the SIL-cell group, the fraction area of granuloma, the number of macrophages and the collagen fibre content were reduced, yielding improved lung mechanics. The presence of male donor cells in lung tissue was not confirmed using detection of Y chromosome DNA. Nevertheless, caspase-3, IL-1β, IL-1α, IL-1RN and TGF-β mRNA expression diminished after cell therapy. In conclusion, BMDMC acted on inflammatory and fibrogenic processes improving lung function through paracrine effects.

Motor activity and depression severity in adolescent outpatients

OBJECTIVES

The present study investigated the association between motor activity and severity of depression in 6 depressed adolescent outpatients.

METHOD

Motor activity was assessed by actigraphy and the severity of depression was assessed weekly using the CDRS-R. The levels of motor activity were analyzed by considering activity parameters.

RESULTS

Among the parameters of motor activity studied, the mean total activity, the mean 24-hour activity levels, the mean waking activity, and the mean activity level between 12:00 and 18:00 h were inversely correlated with severity of depression. The means of the 10 most active hours tended toward a negative correlation with the depressive severity score.

CONCLUSION

The results seem to suggest an association between motor activity level and severity of depression in adolescents. Nevertheless, in order to reach a more conclusive understanding, it would be necessary to replicate this study using a larger number of individuals as well as a longer observation period.

Modelling thermal stability and activity of free and immobilized enzymes as a novel tool for enzyme reactor design

In this work, a novel method is proposed to establish the most suitable operational temperature for an enzyme reactor. The method was based on mathematical modelling of the thermal stability and activity of the enzyme and was developed using thermodynamic concepts and experimental data from free and immobilized inulinases (2,1-beta-D fructan frutanohydrolase, EC 3.2.1.7) from Kluyveromyces marxianus, which were used as examples. The model was, therefore, designed to predict the enzyme activity with respect to the temperature and time course of the enzymatic process, as well as its half-life, in a broad temperature range. The knowledge and information provided by the model could be used to design the operational temperature conditions, leading to higher enzyme activities, while preserving acceptable stability levels, which represent the link between higher productivity and lower process costs. For the inulinase used in this study, the optimum temperature conditions leading to higher enzyme activities were shown to be 63 degrees C and 57.5 degrees C for the free and immobilized inulinases, respectively. However, according to the novel method of approach used here, the more appropriate operating temperatures would be 52 degrees C for free and 42 degrees C for immobilized inulinases, showing that the working temperature is not necessarily the same as the maximum reaction rate temperature, but preferably a lower temperature where the enzyme is much more stable.

Quantitative evaluation of intact peripheral nerve structures after utilization of CO2 laser, electrocautery, and scalpel

OBJECTIVE

This study aimed to evaluate quantitatively the integrity of nerve structures near CO2 laser incisions.

BACKGROUND DATA

There are some hypotheses that try to explain the analgesia reported after CO2 laser surgery. One of them is based upon the observation of the destruction of nerve endings after use of this technique.

METHODS

A comparative study was carried out using 25 animals (Rattus norvegicus) divided into five groups of 5 animals each. Standard incisions were carried on the dorsum of the tongue of each animal using the cautery (group 2), scalpel (group 3), CW CO2 laser (group 4), and SPS CO2 (group 5); group I served as control. The animals were killed immediately after the experiment, and specimens were taken and routinely processed to wax. Three-micrometer sections were cut and stained using S-100 protein antibody. The stained sections were analyzed under light microscopy using a calibrated graticule, and the number of intact nerves was counted in five standard areas around the incision.

RESULTS

The results of this study showed that there were no statistically significant differences in the numbers of intact peripheral nerve structures in both laser groups and other groups. No statistically significant difference was found between nonoperated and scalpel groups. The number of intact peripheral structures in cautery wounds was significantly smaller than in non-operated and scalpel wounds.

CONCLUSIONS

Therefore, it is unlikely that immediate destruction of peripheral nerve structures is the cause of post-operative analgesia following CO2 laser surgery.

Effects of the selective M1 muscarinic receptor antagonist dicyclomine on emotional memory

The nonselective muscarinic antagonist scopolamine is known to impair the acquisition of some learning tasks such as inhibitory avoidance. There has been recent research into the effects of this drug in contextual fear conditioning and tone fear conditioning paradigms. The purpose of the present study was to assess the role of the selective M1 muscarinic antagonist dicyclomine in these paradigms and in the inhibitory avoidance test. Rats were administered different doses of dicyclomine or saline 30 min before acquisition training. The animals were tested 24 hr later, and it was observed that 16 mg/kg of dicyclomine impaired both contextual fear conditioning and inhibitory avoidance. However, dicyclomine (up to 64 mg/kg) did not affect tone fear conditioning. These results suggest that the selective M1 muscarinic antagonist dicyclomine differentially affects aversively motivated tasks known to be dependent on hippocampal integrity (such as contextual fear conditioning and inhibitory avoidance) but does not affect similar hippocampus-independent tasks.

Hypolipidaemic effects of naringenin, rutin, nicotinic acid and their associations

Atherosclerosis can be defined as being a disease of coronary circulation. The present work evaluates the action of the naringenin, rutin, nicotinic acid, isolated and in association, on the metabolism of lipids. Cholesterol, cholesterol HDL, and triacylglycerols have been dosed after retreat of blood, following the administration of the compounds dissolved in propylene glycol by intraperitoneal route in doses of 5 mg kg-1 body wt. Results evidence that naringenin and nicotinic acid, isolated as well as their association with naringenin and nicotinic acid-rutin, present the largest percentual reduction of cholesterol. On the other hand, the best results for cholesterol-HDL have been obtained with naringenin, while rutin has shown the best triacylglycerols levels.

Sensitization to ethanol's stimulant effect is associated with region-specific increases in brain D2 receptor binding

RATIONALE

Stimulation of locomotor activity by low doses of ethanol (EtOH) and the potentiation of this response after repeated administration (sensitization) have been related to EtOH's rewarding and addictive properties and to altered dopaminergic activity in brain. In mice, behavioral sensitization to EtOH occurs only in a subset of treated animals, and this provides an opportunity for distinguishing general drug effects from sensitization-specific brain effects.

OBJECTIVES

In view of evidence suggesting a role for dopamine D2 receptors in EtOH preference and abuse liability, the present study addressed the hypothesis that D2 binding would be altered in specific brain regions in mice showing differential sensitization responses to chronic EtOH administration.

METHODS

Male albino Swiss mice received 2.4 g/kg EtOH i.p. daily for 21 days and were then separated into sensitized or non-sensitized subgroups on the basis of weekly locomotor activity tests.

RESULTS

Autoradiographic analyses of [(3)H]raclopride binding to D2 sites revealed significant increases in the anterior caudate-putamen of mice in the EtOH-sensitized group when compared with either saline controls (+40%, P<0.00009) or to mice in the EtOH non-sensitized group (+32%; P<0.0003). Smaller increases were seen in the ventrolateral caudate-putamen of sensitized animals (+18% vs. control, P<0.02; and 12% vs. non-sensitized mice, P<0.07). No differences were found in other brain regions, including the nucleus accumbens, olfactory bulb and substantia nigra.

CONCLUSIONS

The observed increases in D2-receptor binding in circumscribed targets of nigrostriatal projections may reflect either a pre-existing condition in sensitization-prone animals or a selective vulnerability of D2 receptors to chronic EtOH in these animals. In either case, it may be a marker for differential susceptibility to EtOH sensitization.

Cognitive profile of patients with relapsing remitting multiple sclerosis

Multiple sclerosis (MS) is a common disease in Western countries of temperate/cold climate, but in tropical countries an increasing number of cases have been diagnosticated. Moved by the lack of information about cognitive dysfunction of Brazilian MS patients, the present study attempted to describe features of neuropsychological alterations in patients with relapsing remitting MS living in the city of São Paulo. They were compared to healthy volunteers, matched for age and education. In the absence of global intellectual deterioration, the patients had a deficit: a) in learning and verbal long-term memory tasks and in visual long-term memory of complex figure; b) in timed tasks, accounted for by a slowness of mental processes; c) in tasks with a motor component. Tendency to depression was observed; anxiety levels were normal.

Differences in central and peripheral responses to oxotremorine in young and aged rats

Few studies have investigated the pharmacological response of agents that act on the cholinergic system from the point of view of age. The present article investigated central responses (tremor) and peripheral responses (chromodacryorrhea) subsequent to the administration of oxotremorine to young (3-6 months of age) and aged rats (24-30 months of age). The aged rats presented greater duration and intensity of tremor in three doses utilized (0.25, 0.5, and 1.0 mg/kg) compared to young rats. These two groups of animals did differ in latency for the onset of the tremor. The aged rats presented more intense chromodacryorrhea than the young rats in all utilized doses. These data are indicative that both responses--central and peripheral--are affected by aging, possibly as a result of pharmacokinetic alterations and/or alterations in functionality of the cholinergic system in aged rats.

Anterograde effects of a single electroconvulsive shock on inhibitory avoidance and on cued fear conditioning

A single electroconvulsive shock (ECS) or a sham ECS was administered to male 3-4-month-old Wistar rats 1, 2, and 4 h before training in an inhibitory avoidance test and in cued classical fear conditioning (measured by means of freezing time in a new environment). ECS impaired inhibitory avoidance at all times and, at 1 or 2 h before training, reduced freezing time before and after re-presentation of the ECS. These results are interpreted as a transient conditioned stimulus (CS)-induced anxiolytic or analgesic effect lasting about 2 h after a single treatment, in addition to the known amnesic effect of the stimulus. This suggests that the effect of anterograde learning impairment is demonstrated unequivocally only when the analgesic/anxiolytic effect is over (about 4 h after ECS administration) and that this impairment of learning is selective, affecting inhibitory avoidance but not classical fear conditioning to a discrete stimulus.

A case of neonatal haemochromatosis

We describe a case of neonatal haemochromatosis, pointing out the difficulties in diagnosing this fatal disease, which here involved the early occurrence of hepatic carcinoma.

Strategies used by hippocampal- and caudate-putamen-lesioned rats in a learning task

In rats, hippocampal lesions result in impairment of spatial navigation, although other learning abilities remain unaltered. When learning a left/right discrimination task, rats can use a spatial strategy (with external maze landmarks-Situation 1) or are forced to use an egocentric strategy (without external or internal maze cues-Situation 2). Little is known about the extrahippocampal systems involved in the utilization of egocentric strategy. It is suggested that striatum could play an important role in the learning abilities that are spared after hippocampal lesion. The aim of our study was to investigate which strategy is used by rats bearing hippocampal or caudate-putamen lesions in the acquisition of a left/right discrimination task in an elevated T-maze in both Situations 1 and 2. We also investigated the effect of each lesion on the reversal of discrimination in both situations. Acquisition was not altered in any of the situations; however, a transfer test showed that hippocampal-lesioned rats used a different strategy (egocentric) from control animals (spatial) in Situation 1. In addition, reversal of the discrimination was impaired in Situation 2. Caudate-putamen lesion produced a transient effect on reversal of discrimination only in the egocentric task (Situation 2), but did not impair acquisition of the task in either situation, thus suggesting that the animals were able to use either strategy.

Biotypes, serovars and antimicrobial resistance patterns of Acinetobacter baumannii clinical isolates

255 Acinetobacter strains, from clinical specimens of inpatients and outpatients, were identified phenotypically according to the new taxonomy proposed by Bouvet and Grimont. A. baumannii was the most frequent species (80.8%). This species underwent biotyping and serotyping according to the scheme of Bouvet and Grimont, and that of Traub, respectively, 81.2% of samples belonged to biotypes 2, 6 and 9 with a predominance of biotype 2. 86.6% of the strains could be serotyped; 2 new serotypes were encountered. The new serotype 29, being the most frequently isolated, was related to biotype 2 (86.6%), whereas serotype 13 was related to biotype 6 (84.8%). These clones presented marked multiple resistance patterns and were widespread in different wards. No outbreak was reported during the period studied. These phenotypical methods proved to be useful in differentiating strains of A. baumannii and, if used together, they showed a high discriminatory power.

Dissociated paradoxical sleep deprivation effects on inhibitory avoidance and conditioned fear

Rats were submitted to paradoxical sleep deprivation (PSD) for 24, 72, or 96 h and were trained on a double aversively motivated task, encompassing a step-through inhibitory avoidance and a classical conditioning of fear to a brief tone serving as conditional stimulus. Retention test of the inhibitory avoidance was performed at the same apparatus of training (without tone presentation). Retention of conditioned fear was assessed in an open field apparatus, where the freezing reaction to the tone was measured. PSD for 24 and 72 h preceding the training session had no effect on either task. However, PSD during the 96 h preceding the training session impaired acquisition of inhibitory avoidance, but had no effect on classically conditioned fear. It is concluded that PSD had differential effects on the two tasks, both aversively motivated and trained at the same time and conditions.

Long-lasting effects of chronic ethanol administration on the activity of antioxidant enzymes

The aim of this study was to investigate the long-lasting effects of prolonged administration of ethanol doses on oxidative processes of aged rats. We determined the activity of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) in erythrocytes of rats 15, 20, and 24 months old treated with an average daily dose of 1.5 g/Kg of ethanol or saline administered intraperitoneally for 13 weeks and after a 2 month period of withdrawal from treatment. The activity of all three enzymes decreased significantly with aging in the controls, while no age-related changes were found among treated rats. These findings are important since they are the first to show a long-lasting toxic effect of low ethanol doses observed in association with the aging process.

Tyrosine 151 is part of the substrate activation binding site of bovine trypsin. Identification by covalent labeling with p-diazoniumbenzamidine and kinetic characterization of Tyr-151-(p-benzamidino)-azo-beta-trypsin

Identification of the substrate activation site of beta-trypsin by a 1:1 reaction with p-diazoniumbenzamidine chloride was confirmed by spectral analysis. Proteolysis of Cm-p-benzamidino-azo-beta-trypsin provided peptides containing modified tyrosine residues. The major product, Ser-146 to Lys-156, which corresponded to labeling at Tyr-151, was recovered in 35% yield, and its structure was demonstrated by amino acid analysis, Edman degradation, and mass spectrometry. Yields of labeled Tyr-151, Tyr-39, and Tyr-172, identified by peptide analysis, were in the proportion of 100:7:3. Tyr-151-(p-benzamidino)-azo-beta-trypsin is permanently activated, but can be further activated by substrates. Values of kcat, Ks', and kcat' vary from two to three times the equivalent values for trypsin. Berenil (4,4'-diazoamino-bis-benzamidine), a parabolic competitive inhibitor of beta-trypsin, was a hyperbolic competitive inhibitor of azo-beta-trypsin. Thus, Tyr-151, part of subsite S'2, affects the catalytic process and, when modified covalently, permanently activates trypsin. Equilibrium binding with berenil supported the kinetic data obtained with substrates. This permits the integration of protein modification, kinetics, equilibrium binding, and crystallographic data to demonstrate a fine interaction between subsites S1-S3 and S'2 in trypsin and azo-beta-trypsin, resulting in subtle structural changes when the native enzyme is covalently modified at Tyr-151.

A dissociation between the proactive ECS effects on inhibitory avoidance learning and on classical fear conditioning

This study investigated if the nature of the task is a determinant factor of whether or not a series of electroconvulsive shock (ECS) will proactively affect learning in animals. Rats were administered one daily ECS for 7 days. A day after the last administration they were concomitantly trained on an inhibitory avoidance task and on classical conditioning of fear response to a brief tone. Twenty-four hours later they were exposed for 8 min to an open-field arena and the freezing reaction was measured both before and after tone presentation (classical fear conditioning test). On the subsequent day the step-through latency (without presentation of the tone) was measured on the avoidance apparatus (inhibitory avoidance test). Impairment of inhibitory avoidance was seen in ECS-administered animals in comparison to controls, but the freezing reaction to the tone was equally high in both groups. Additional groups of rats were trained in order to control for ECS alone-induced freezing and pseudoconditioning. Also, it was demonstrated that the differential ECS effects on the two tasks were not due to the order of testing since similar dissociation was obtained when inhibitory avoidance test was conducted before the open-field test.