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Purple urine bag syndrome (PUBS) is a condition that causes an intense purple discoloration of the urine, predominately in frail, dependent, and bedridden persons who are chronically catheterized and have urinary tract infections. Despite being considered a benign syndrome, PUBS can cause great anxiety, fear, and distress in health professionals, chronically ill persons, and caregivers or family members who provide care.
We report the case of a 98-year-old institutionalized woman with Alzheimer’s dementia with a long-term urinary catheter who developed PUBS.
Although alarming and distressing for the resident and the health-care team, PUBS was resolved by treating the underlying urinary tract infection and applying good genital hygiene and catheter replacement.
Significance of results
Identifying PUBS and its clinical features and management proved to be significantly helpful in ameliorating the anxiety, fear, and distress around the phenomenon.
We present an asymptomatic pregnant patient with congenitally corrected transposition of the great arteries and severe atrioventricular bioprosthesis regurgitation – with increased maternal and fetal risk due to volume overload. She was considered high risk for reintervention and was submitted to an off-label post-partum transcatheter valve-in-valve implantation with a Sapiens 3 valve. The procedure was successful, and she remains asymptomatic 30 months after – and even went through another successful pregnancy.
Behavioral symptoms associated with dementia, such as agitation, are frequent and associated with well-known negative consequences for patients, their carers, and their environment. Pharmacological treatments for agitation using sedatives and antipsychotics are known to have several undesirable side effects and modest efficacy. Non-pharmacological alternatives are recommended as first-line options for agitation in persons with dementia with few side effects, but there is limited evidence of efficacy. We developed a novel and simple non-pharmacological alternative for agitation in dementia residents based on a Brazilian intervention using warm water surgical gloves used in patients with COVID-19 in intensive care units during the pandemic. We coined it “Mãos de Conforto” – Hands of Comfort. We report a series of 7 cases in 3 residents with dementia who whore Hands of Comfort.
We present a case of a 41-year-old patient with an unknown complex cardiac anatomy, who was previously submitted to two cardiac surgeries. Using multimodality imaging, a retrospective diagnosis was established, revealing a heterotaxy syndrome (left isomerism).
Coupled fire–atmosphere feedback is essential for modeling wildland fire spread, especially extreme fire phenomena. In this chapter, the suite of current and emerging tools capable of modeling this complexity is examined; these tools now dominate fundamental wildland fire research and are starting to be applied to fire operations, training, and planning. Some of the barriers to progress and challenges to validating these tools highlighted in this chapter suggest more emphasis on three areas: a scale-dependent and purposeful approach to comparing model results with appropriate observations, recognizing the limitations of each; the quantification of the errors and under-specifications in fuel properties and the impact of each; and assessing large-scale simulations and directing observations to address priority research gaps, from a position informed by the vast catalog of atmospheric scientific research.
We present a case of a patient with dextro-transposition of the great arteries palliated with a Senning procedure and a long-term arrhythmic complication that required an intervention, with an Implantable Cardioverter Defibrillator (ICD) implantation in the sub-pulmonary ventricle (morphologically left). This case highlights the need to perform off-label procedures to deal with the long-term complications of these complex patients.
Healthcare workers (HCWs) not fulfilling the coronavirus disease 2019 (COVID-19) case definition underwent severe acute respiratory coronavirus virus 2 (SARS-CoV-2) screening. Risk of exposure, adherence to personal protective equipment (PPE), and symptoms were assessed. In total, 2,000 HCWs were screened: 5.5% were positive for SARS-CoV-2 by polymerase chain reaction (PCR). There were no differences in PPE use between SARS-CoV-2–positive and –negative HCWs (adherence, >90%). Nursing and kitchen staff were independently associated with positive SARS-CoV-2 results.
The efficacy is measured for a public health intervention related to community-based planning for population protection measures (PPMs; ie, shelter-in-place and evacuation).
This is a mixed (qualitative and quantitative) prospective study of intervention efficacy, measured in terms of usability related to effectiveness, efficiency, satisfaction, and degree of community engagement.
Two municipalities in the Commonwealth of Puerto Rico are included.
Community members consisting of individuals; traditional leaders; federal, territorial, and municipal emergency managers; municipal mayors; National Guard; territorial departments of education, health, housing, public works, and transportation; health care; police; Emergency Medical Services; faith-based organizations; nongovernmental organizations (NGOs); and the private sector.
The intervention included four community convenings: one for risk communication; two for plan-writing; and one tabletop exercise (TTX). This study analyzed data collected from the project work plan; participant rosters; participant surveys; workshop outputs; and focus group interviews.
Main Outcome Measures:
Efficacy was measured in terms of ISO 9241-11, an international standard for usability that includes effectiveness, efficiency, user satisfaction, and “freedom from risk” among users. Degree of engagement was considered an indicator of “freedom from risk,” measurable through workshop attendance.
Two separate communities drafted and exercised ~60-page-long population protection plans, each within 14.5 hours. Plan-writing workshops completed 100% of plan objectives and activities. Efficiency rates were nearly the same in both communities. Interviews and surveys indicated high degrees of community satisfaction. Engagement was consistent among community members and variable among governmental officials.
Frontline communities have successfully demonstrated the ability to understand the environmental health hazards in their own community; rapidly write consensus-based plans for PPMs; participate in an objective-based TTX; and perform these activities in a bi-lingual setting. This intervention appears to be efficacious for public use in the rapid development of community-based PPMs.
We report on what appear to be increasing predation events on nesting Thick-billed Parrots Rhychopsitta pachyrhyncha. Thick-billed Parrots are classified as ‘Endangered’ and their seasonal breeding range is restricted to increasingly fragmented and degraded high elevation mixed conifer forest habitat within the Sierra Madre Occidental region of north-western Mexico. Predation of established breeding pairs has recently contributed to the ongoing decline of Thick-billed Parrot populations by removing mature birds with high reproductive value, which has associated consequences for future recruitment. We observed increasing predation events on nesting Thick-billed Parrots by bobcats Lynx rufus accompanied by kittens throughout the 2018–2019 breeding seasons, and we speculate that recent reductions in bobcat habitat have pushed them into new ranges where they are supplementing their diet with nontraditional prey items.
In Brazil, hospital-based health technology assessment (HB-HTA) units have been implemented countrywide since early 2000 to improve decision-making processes. Multiple-criteria decision analysis (MCDA) can provide a deeper understanding of a given subject. The present study used MCDA to evaluate capacity building among HB-HTA units in Brazil.
This study analyzed preliminary data from a survey developed and sent to all HB-HTA units in Brazil in 2018. The survey comprised 116 questions covering a wide range of aspects. Initially, an expert panel was organized, and 46 objective questions (out of 116) were selected by four experts. Next, these experts classified the selected questions by weighting them according to their relative importance. A Likert scale was used to identify the levels of importance, which were converted to weights ranging from zero to one. The experts then defined a final importance score threshold of 60 percent to classify units as fully operational. Grades below this threshold indicated the need for a more detailed evaluation. Of the 80 survey questionnaires, 23 were evaluated by the proposed method.
Importance weights for each classification were defined as follows: personnel (25%); level of expertise (31%); work production (31%); and infrastructure (13%). The mean final importance score for the HB-HTA units was 68 percent. The maximum and minimum scores achieved were 95 percent and 15 percent, respectively. The HB-HTA units had been established for an average of 6 years, and ten of the 23 units were classified as fully operational.
The multicriteria method presented by this study simplified HB-HTA unit evaluation, reducing the subjectivity of results. Final importance scores for each unit's categories indicated which areas need improvement. Results from the study indicated that infrastructure and personnel could be greatly enhanced, even though the production profile was satisfactory.
Since 2007, 23 Núcleos de Avaliação de Tecnologias em Saúde or hospital-based health technology assessment (HB-HTA) units have been established in teaching hospitals across Brazil. These units aim to promote the development of health technology assessment in hospitals, assisting the decision-making process for implementing new technologies and evaluating and promoting the rational use of widespread technologies.
An online questionnaire was sent by e-mail to all HB-HTA units registered in the Brazilian Network for Evaluation of Health Technologies. Information was acquired to comprehensively assess the activity of the units.
All 23 HB-HTA units answered the questionnaire. Of these, 65 percent had a technology prioritization process. The technologies assessed included drug therapies (73%), equipment (64%), medical devices (64%), clinical protocols (46%), and emerging technologies (27%). The dimensions of health technology assessment (HTA) evaluated by these organizations were: efficacy (76%); effectiveness (67%); safety (67%); costs (52%); cost effectiveness or cost utility (52%); and budget impact (43%). The hospital departments that required more HTA studies were: cardiology (50%); infectious diseases (45%); hospital management (45%); oncology (40%); surgery (40%); and endocrinology (20%). HTA studies supported: incorporation of new technologies (81%); protocol or guideline development (57%); new indications for already approved technologies (38%); and withdrawal of obsolete technologies (29%). Half of the institutions also conducted educational or training activities. The main difficulties reported were a lack of trained professionals (78%), funding (70%), and material resources (48%).
For low- and middle-income countries, the process of implementing HB-HTA units remains a challenge. Even though human resources and funding are scarce, HB-HTA units continue to develop. Given their importance in the decision-making process, it is imperative that every effort is made to ensure their activities continue.
What are the factors behind citizen support for the use of extralegal violence in Latin America? The prevailing argument is that, in countries overwhelmed by skyrocketing levels of criminal violence, people endorse the use of extralegal violence as a way to cope with insecurity. Other scholars believe that support for extralegal violence is the result of state withdrawal and failure. Few empirical studies, however, have tested any of these arguments. In this article, using regional data from the 2012 AmericasBarometer, we examine different explanations regarding citizen support for the utilization of extralegal violence in Latin America and the Caribbean. We developed a multi-item scale that gauges support for different forms of extralegal violence across the Americas, and we hypothesize that support for extralegal violence is higher not only in countries with extreme levels of violence but especially in countries in which people distrust the political system. Results indicate that support for extralegal violence is significantly higher in societies characterized by little support for the existing political system.
Chagas disease (ChD), also known as American trypanosomiasis, is a neglected tropical disease caused by the protozoan parasite Trypanosoma cruzi. About 6 to 7 million people worldwide are estimated to be infected, most in Latin America. Health-related quality of life (HRQoL) and utility measures are still poorly employed for assessment of ChD lifetime impairments. Brazilian HRQoL published data showed that the cardiac subgroup of patients have worse scores than other ChD chronic groups. For the time being, utility scores are not available yet for the ChD population. The present study aims to assess quality of life (QoL), as utility scores, of patients with chronic Chagas Disease.
This is a cross-sectional study. Data were collected from 183 outpatients with chronic ChD in a reference center in Brazil. Information pertaining to sociodemographics, clinical status, and quality of life were collected using self-administered questionnaires. Utilities were obtained by the European Quality of Life – 5 Dimensions (EQ-5D) questionnaire. Comparisons were made between clinical subtypes and population normative values. Continuous variables were compared using t-test or ANOVA, and categorical variables were compared using Chi-square test. Associations between QoL and patient characteristics stratified by demographics, clinical status were identified by linear regression models.
Most subjects were female (61 percent). The average age of men was 53.3 years and women 56.6. When analyzing the EQ-5D utility scores, it was observed that the results were lower for cardiac patients (0.610–95% CI 0.582–0.638) in comparison to indeterminate form patients (0.659–0.632–0.687). When comparing patients with the general population of the same age and sex, patients with ChD showed lower utility scores than normative values (0.624–95% CI 0.596–0.652).
Chronic ChD causes a negative impact on quality of life, physical functioning, as well as psychosocial function, with the impairment becoming worse in cardiac patients.
The aim of this study was to develop and to assess a specific Multi-Criteria Decision Analysis (MCDA) framework to evaluate new drugs in an hospital pharmacy and therapeutics committee (P&TC) setting.
A pilot criteria framework was developed based on the EVIDEM (Evidence and Value: Impact on DEcisionMaking) framework, together with other relevant criteria, and assessed by a group of P&TC's members. The weighting of included criteria was done using a 5-point weighting technique. Two drugs were chosen by evaluation: an orphan-drug for Gaucher disease, and a nonorphan drug for the treatment of inflammatory bowel disease. Evidence matrices were developed, and value contribution of each drug was evaluated by P&TC's members. An agreed final framework was obtained through a discussion between the P&TC's members.
After criteria assessment, the pilot framework included eight quantitative criteria: “disease severity,” “unmet needs,” “comparative efficacy/effectiveness,” “comparative safety/tolerability,” “comparative patient-reported outcomes,” “comparative cost consequences-cost of treatment,” “comparative cost consequences-other medical costs,” and “quality of evidence”; and one contextual criterion: “opportunity costs and affordability.” The most valued criteria were: “comparative safety/tolerability,” “disease severity,” and “comparative efficacy/effectiveness.” When assessing the drugs most valued characteristics of the MCDA were the possibility that all team may contribute to drug assessment by means of scoring the matrices and the discussion to reach a consensus in drug positioning and value decision making.
The reflective MCDA would integrate quantitative and qualitative criteria relevant for a P&TC setting, allowing reflective discussions based on the criteria weighting score.
Understanding the consequences of environmental fluctuations for parasite dynamics requires a long-term view stretching over many transmission cycles. Here we studied the dynamics of three malaria parasites (Plasmodium azurophilum, P. leucocytica and P. floridense) infecting the lizard Anolis gundlachi, in the rainforest of Puerto Rico. In this malaria–anole system we evaluated temporal fluctuations in individual probability of infection, the environmental drivers of observed variation and consequences for host body condition and Plasmodium parasites assemblage. We conducted a total of 15 surveys including 10 from 1990 to 2002 and five from 2015 to 2017. During the early years, a lizard's probability of infection by all Plasmodium species appeared stable despite disturbances ranging from two hurricanes to short droughts. Over a longer timescale, probability of infection and overall prevalence varied significantly, following non-linear relationships with temperature and rainfall such that highest prevalence is expected at intermediate climate measures. A perplexing result was that host body condition was maximized at intermediate levels of rainfall and/or temperature (when risk of infection was highest), yet we found no significant decreases in body condition due to infection. Plasmodium parasite species composition varied through time with a reduction and near local extinction of P. floridense. Our results emphasize the need for long-term studies to reveal host–parasite dynamics, their drivers and consequences.
Chagas disease, caused by the protozoan parasite Trypanosoma cruzi, is a neglected chronic condition with a high burden of morbidity and mortality. It affects about 6 million people in twenty-one countries of Latin America, and has recently become a global health concern (1), especially due to immigration from endemic areas into the developed world. Cardiac arrhythmias are common in patients with Chagas cardiomyopathy and amiodarone has been widely used as an antiarrhythmic drug. Amiodarone has been recommended as the treatment of choice for all patients with sustained ventricular tachycardia (2). The objective of this systematic review is to evaluate the effect of amiodarone in arrhythmia patients with the cardiac form of chronic Chagas disease.
Searches was conducted in MEDLINE (PubMed), EMBASE and LILACS from the inception to December 2016. Studies regarding the use of amiodarone to treat arrhythmia in patients affected by Chagas disease were included, and the outcomes were arrhythmia, adverse effects and sudden death. Selection of articles and data extraction were made by two independent reviewers.
The database search found 378 articles but only 9 studies with 373 subjects fulfilled the eligibility criteria. The nine studies selected were composed of case series (two), crossover clinical trials (two), and clinical trials (five). Results showed that amiodarone reduced ventricular extrasystoles in all studies and ventricular tachycardia in eight studies. During treatment with amiodarone, patients in eight studies had side effects. Corneal microdeposits and gastric discomfort were the most common adverse effects present in studies. Three studies reported sudden death during follow-up.
Amiodarone seems to be an effective antiarrhythmic drug for Chagasic patients, reducing uncomfortable symptoms such as tachycardia. This information can be useful in the primary care context, supporting general practitioners to manage Chagas cardiopathy, mainly when specialized cardiologic consultants are not available.
Chagas disease, caused by the parasite Trypanosoma cruzi, affects more than seven million people worldwide and it is considered by the World Health Organization (WHO) a neglected tropical disease (1). About one third of Chagas patients develop gastrointestinal disorders, such as dysphagia and achalasia. Management of the disease focuses on symptom improvement and drugs that relax the lower esophageal sphincter pressure (LESP), such as isosorbide and nifedipine. However, the use of these therapies is doubtful because of their side effects and palliative approach (2). The objective of this systematic review is to assess the effectiveness of isosorbide and nifedipine on gastrointestinal manifestation of Chagas disease.
We searched MEDLINE, EMBASE and LILACS databases to retrieve potentially relevant articles from inception to December 2016. Inclusion criteria: clinical trials, cohorts or cross-sectional design; adults (>18 years old); assessment of effects of isosorbide or nifedipine on gastrointestinal symptoms in Chagas patients. Two reviewers independently screened titles and abstracts, selected eligible studies and extracted data from each study. PROSPERO registration number: CRD42017055143.
Eight studies were included (two case series, two clinical trials and four crossovers). Three studies evaluated the effect of isosorbide in LESP and three in esophageal emptying. All of them found that isosorbide rapidly reduces LESP and increases esophageal emptying rates, improving dysphagia. However, several patients reported collateral effects, such as gastroesophageal reflux, headaches and dizziness. One study evaluated the effect of nifedipine on LESP and one on esophageal emptying. Nifedipine decreased LESP, but there was no effect on esophageal emptying.
The available evidence shows isosorbide is effective in the management of gastrointestinal symptoms. Frequently health care of Chagas disease patients is delivered by primary care physicians. So, information on effectiveness of interventions can be aggregated to clinical guidelines, having an important value to inform general practitioners on the decision-making process regarding treatment of this group of patients, avoiding referencing to a specialized care.