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BACKGROUND: Pressure injuries (PIs), especially in the sacral region are frequent, costly, and increase morbidity and mortality of patients in an intensive care unit (ICU). These injuries can occur as a result of prolonged pressure and/or shear forces. Neuromuscular electrical stimulation (NMES) can increase muscle mass and improve local circulation, potentially reducing the incidence of PI. METHODS: We performed a randomized controlled trial to assess the efficacy and safety of NMES in preventing PI in critically ill patients. We included patients with a period of less than 48 h in the ICU, aged ≥ 18 years. Participants were randomly selected (1:1 ratio) to receive NMES and usual care (NMES group) or only usual care (control group-CG) until discharge, death, or onset of a PI. To assess the effectiveness of NMES, we calculated the relative risk (RR) and number needed to treat (NNT). We assessed the muscle thickness of the gluteus maximus by ultrasonography. To assess safety, we analyzed the effects of NMES on vital signs and checked for the presence of skin burns in the stimulated areas. Clinical outcomes were assessed by time on mechanical ventilation, ICU mortality rate, and length of stay in the ICU. RESULTS: We enrolled 149 participants, 76 in the NMES group. PIs were present in 26 (35.6%) patients in the CG and 4 (5.3%) in the NMES group (p ˂ 0.001). The NMES group had an RR = 0.15 (95% CI 0.05-0.40) to develop a PI, NNT = 3.3 (95% CI 2.3-5.9). Moreover, the NMES group presented a shorter length of stay in the ICU: Δ = - 1.8 ± 1.2 days, p = 0.04. There was no significant difference in gluteus maximus thickness between groups (CG: Δ = - 0.37 ± 1.2 cm vs. NMES group: Δ = 0 ± 0.98 cm, p = 0.33). NMES did not promote deleterious changes in vital signs and we did not detect skin burns. CONCLUSIONS: NMES is an effective and safe therapy for the prevention of PI in critically ill patients and may reduce length of stay in the ICU. Trial registration RBR-8nt9m4. Registered prospectively on July 20th, 2018, https://ensaiosclinicos.gov.br/rg/RBR-8nt9m4.

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Based on the knowledge of the social determination of health, the challenge and the strategy of action to promote integrated public policies are posed, focusing on the concept of expanded health in territories where populations with high social exclusion prevail. For this purpose, the dialectic relationship between social classes, territories and health is considered. Based on the founding objectives of primary health care, the family health teams in the municipality of Petrópolis, state of Rio de Janeiro, Brazil, were trained to carry out a participatory rapid assessment related to the goals of the sustainable development objectives, in their areas of operation. This diagnosis guided the action plan for health promotion in eight pilot areas, within which conglomerates of greater social exclusion are defined through participatory mapping. Following criteria for the social control of the health system, established in the country's legislation, the creation of community forums is encouraged, which will elect legitimate community representatives to serve on local health councils, whose main mission is to discuss health and welfare problems on the basis of an intersectoral and expanded vision. The community forums, in conjunction with other local society organizations, discuss the main problems and propose alternative solutions that will collectively transform the reality of the territories. As an initial alternative, agro-ecological urban agriculture projects are established to promote sovereign and resilient transformations.

Con base en los conocimientos sobre la determinación social de la salud, se plantea el desafío y la estrategia de actuación para fomentar políticas públicas integradas, con foco en el concepto de salud ampliada en los territorios donde prevalecen poblaciones de elevada exclusión social. Para ello, se considera la relación dialéctica existente entre las clases sociales, los territorios y la salud. Partiendo de los objetivos fundadores de la atención primaria de la salud, los equipos de salud de la familia en la municipalidad de Petrópolis, estado de Río de Janeiro, Brasil, fueron capacitados para realizar un diagnóstico rápido participativo relacionado con las metas de los objetivos de desarrollo sostenible, en sus áreas de actuación. Dicho diagnóstico orientó el plan de acción para la promoción de salud en ocho áreas piloto, dentro de las cuales se delimitan conglomerados de mayor exclusión social mediante la cartografía participativa. Siguiendo criterios del control social del sistema de salud, establecidos en la legislación del país, se fomenta la creación de foros comunitarios que elegirán representantes legítimos de la comunidad para integrar los consejos locales de salud, cuya principal misión es discutir los problemas de salud y bienestar a partir de una visión intersectorial y ampliada. Los foros comunitarios, en conjunto con otras organizaciones de la sociedad local, debaten los principales problemas y proponen soluciones alternativas que permitan transformar colectivamente la realidad de los territorios. Como alternativa inicial se establecen proyectos de agricultura urbana de carácter agroecológico para promover transformaciones soberanas y resilientes.

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RESUMEN Con base en los conocimientos sobre la determinación social de la salud, se plantea el desafío y la estrategia de actuación para fomentar políticas públicas integradas, con foco en el concepto de salud ampliada en los territorios donde prevalecen poblaciones de elevada exclusión social. Para ello, se considera la relación dialéctica existente entre las clases sociales, los territorios y la salud. Partiendo de los objetivos fundadores de la atención primaria de la salud, los equipos de salud de la familia en la municipalidad de Petrópolis, estado de Río de Janeiro, Brasil, fueron capacitados para realizar un diagnóstico rápido participativo relacionado con las metas de los objetivos de desarrollo sostenible, en sus áreas de actuación. Dicho diagnóstico orientó el plan de acción para la promoción de salud en ocho áreas piloto, dentro de las cuales se delimitan conglomerados de mayor exclusión social mediante la cartografía participativa. Siguiendo criterios del control social del sistema de salud, establecidos en la legislación del país, se fomenta la creación de foros comunitarios que elegirán representantes legítimos de la comunidad para integrar los consejos locales de salud, cuya principal misión es discutir los problemas de salud y bienestar a partir de una visión intersectorial y ampliada. Los foros comunitarios, en conjunto con otras organizaciones de la sociedad local, debaten los principales problemas y proponen soluciones alternativas que permitan transformar colectivamente la realidad de los territorios. Como alternativa inicial se establecen proyectos de agricultura urbana de carácter agroecológico para promover transformaciones soberanas y resilientes.

ABSTRACT Based on the knowledge of the social determination of health, the challenge and the strategy of action to promote integrated public policies are posed, focusing on the concept of expanded health in territories where populations with high social exclusion prevail. For this purpose, the dialectic relationship between social classes, territories and health is considered. Based on the founding objectives of primary health care, the family health teams in the municipality of Petrópolis, state of Rio de Janeiro, Brazil, were trained to carry out a participatory rapid assessment related to the goals of the sustainable development objectives, in their areas of operation. This diagnosis guided the action plan for health promotion in eight pilot areas, within which conglomerates of greater social exclusion are defined through participatory mapping. Following criteria for the social control of the health system, established in the country's legislation, the creation of community forums is encouraged, which will elect legitimate community representatives to serve on local health councils, whose main mission is to discuss health and welfare problems on the basis of an intersectoral and expanded vision. The community forums, in conjunction with other local society organizations, discuss the main problems and propose alternative solutions that will collectively transform the reality of the territories. As an initial alternative, agro-ecological urban agriculture projects are established to promote sovereign and resilient transformations.

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RESUMO Objetivo: A síndrome de Leigh é uma doença neurodegenerativa com incidência de 1:40.000 nados-vivos. Apresenta ampla heterogeneidade clínica, bioquímica e genética, mas com alterações neuropatorradiológicas homogêneas. Não existe tratamento específico, e o prognóstico é reservado. O objetivo deste estudo foi familiarizar os profissionais de saúde com a doença. Descrição do caso: Menina de 16 meses, com hipotonia axial e atraso do desenvolvimento psicomotor. Dos exames realizados: cariótipo, potenciais auditivos evocados e avaliação oftalmológica normais; presença de hiperlactacidemia e hipocitrulinemia. Após a realização de ressonância magnética cerebral sob anestesia, observou-se agravamento da hipotonia com necessidade de internação por episódios de cianose/apneia. O eletroencefalograma não mostrou atividade epileptiforme. A neuroimagem revelou hipersinal lenticular bilateral com lesão do putâmen e do globo pálido esquerdo. Encontrou-se a mutação 8993T>G (MT-ATP6) no DNA mitocondrial. Comentários: De 10 a 30% dos doentes com síndrome de Leigh apresentam mutações do DNA mitocondrial. A descompensação com agravamento neurológico após intervenção anestésica está descrita e, nesse caso, apoiou o diagnóstico. Importante alertar para casos semelhantes, com diminuição de exames invasivos para diagnóstico.

ABSTRACT Objective: Leigh syndrome is a neurodegenerative disorder with an incidence of 1:40,000 live births. It presents wide clinical, biochemical, and genetic heterogeneity, but with homogenous neuropatoradiological alterations. There is no specific treatment, and the prognosis is reserved. This case report aimed familiarize health professionals with the disease. Case Description: A 16-month-hold girl who was followed in outpatient clinic due to axial hypotonia and delayed psychomotor development. Karyotype, auditory evoked potentials and ophthalmologic evaluation were normal. Evidence of hyperlactacidemia and hypocitrullinemia was detected in the patient. After performing brain magnetic resonance under anesthesia, hypotonia got worse, and the patient was hospitalized after an episode of cyanosis and apnea. The electroencephalogram showed no epileptiform activity. Neuroimaging revealed bilateral lenticular hyperintensity, especially in the putamen and in the left globus pallidus regions. Molecular analysis revealed an 8993T>G (MT-ATP6) mutation in the mitochondrial DNA. Comments: Between 10 and 30% of individuals with Leigh syndrome have mitochondrial DNA mutations. The decompensation after anesthetic intercurrences is typically associated with neurological deterioration and, in this case, increased the diagnosis suspicion. It is important to alert for similar cases and to reduce invasive diagnostic tests if the diagnosis is suspected.

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OBJECTIVE: Leigh syndrome is a neurodegenerative disorder with an incidence of 1:40,000 live births. It presents wide clinical, biochemical, and genetic heterogeneity, but with homogenous neuropatoradiological alterations. There is no specific treatment, and the prognosis is reserved. This case report aimed familiarize health professionals with the disease. CASE DESCRIPTION: A 16-month-hold girl who was followed in outpatient clinic due to axial hypotonia and delayed psychomotor development. Karyotype, auditory evoked potentials and ophthalmologic evaluation were normal. Evidence of hyperlactacidemia and hypocitrullinemia was detected in the patient. After performing brain magnetic resonance under anesthesia, hypotonia got worse, and the patient was hospitalized after an episode of cyanosis and apnea. The electroencephalogram showed no epileptiform activity. Neuroimaging revealed bilateral lenticular hyperintensity, especially in the putamen and in the left globus pallidus regions. Molecular analysis revealed an 8993T>G (MT-ATP6) mutation in the mitochondrial DNA. COMMENTS: Between 10 and 30% of individuals with Leigh syndrome have mitochondrial DNA mutations. The decompensation after anesthetic intercurrences is typically associated with neurological deterioration and, in this case, increased the diagnosis suspicion. It is important to alert for similar cases and to reduce invasive diagnostic tests if the diagnosis is suspected.

OBJETIVO: A síndrome de Leigh é uma doença neurodegenerativa com incidência de 1:40.000 nados-vivos. Apresenta ampla heterogeneidade clínica, bioquímica e genética, mas com alterações neuropatorradiológicas homogêneas. Não existe tratamento específico, e o prognóstico é reservado. O objetivo deste estudo foi familiarizar os profissionais de saúde com a doença. DESCRIÇÃO DO CASO: Menina de 16 meses, com hipotonia axial e atraso do desenvolvimento psicomotor. Dos exames realizados: cariótipo, potenciais auditivos evocados e avaliação oftalmológica normais; presença de hiperlactacidemia e hipocitrulinemia. Após a realização de ressonância magnética cerebral sob anestesia, observou-se agravamento da hipotonia com necessidade de internação por episódios de cianose/apneia. O eletroencefalograma não mostrou atividade epileptiforme. A neuroimagem revelou hipersinal lenticular bilateral com lesão do putâmen e do globo pálido esquerdo. Encontrou-se a mutação 8993T>G (MT-ATP6) no DNA mitocondrial. COMENTÁRIOS: De 10 a 30% dos doentes com síndrome de Leigh apresentam mutações do DNA mitocondrial. A descompensação com agravamento neurológico após intervenção anestésica está descrita e, nesse caso, apoiou o diagnóstico. Importante alertar para casos semelhantes, com diminuição de exames invasivos para diagnóstico.

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Objective The aim of this study was to obtain data on phrenic neuroconduction and electromyography of the diaphragm muscle in difficult-to-treat asthmatic patients and compare the results to those obtained in controls. Methods The study consisted of 20 difficult-to-treat asthmatic patients compared with 27 controls. Spirometry, maximal inspiratory and expiratory pressure, chest X-ray, phrenic neuroconduction and diaphragm electromyography data were obtained. Results The phrenic compound motor action potential area was reduced, compared with controls, and all the patients had normal diaphragm electromyography. Conclusion It is possible that a reduced phrenic compound motor action potential area, without electromyography abnormalities, could be related to diaphragm muscle fiber abnormalities due to overload activity.

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ABSTRACT Objective The aim of this study was to obtain data on phrenic neuroconduction and electromyography of the diaphragm muscle in difficult-to-treat asthmatic patients and compare the results to those obtained in controls. Methods The study consisted of 20 difficult-to-treat asthmatic patients compared with 27 controls. Spirometry, maximal inspiratory and expiratory pressure, chest X-ray, phrenic neuroconduction and diaphragm electromyography data were obtained. Results The phrenic compound motor action potential area was reduced, compared with controls, and all the patients had normal diaphragm electromyography. Conclusion It is possible that a reduced phrenic compound motor action potential area, without electromyography abnormalities, could be related to diaphragm muscle fiber abnormalities due to overload activity.

RESUMO Objetivo O objetivo do presente estudo foi obter dados da neurocondução do frênico e exame com agulha do diafragma em pacientes com asma de difícil controlee comparar com um grupo normal. Métodos O estudo consiste em realizar radiografia de tórax, espirometria, pressão máxima inspiratória e expiratória, neurocondução do nervo frênico e eletromiografia do músculo diafragma em 20 pacientes asmáticos de difícil controle e comparar com 27 controles. Resultados Encontramos redução da área do potencial de ação muscular composto do nervo frênico e a eletromiografia do musculo diafragma estava normal em todos os pacientes. Conclusão É possível que a redução da área do potencial de ação muscular composto do nervo frênico nos pacientes com asma de difícil controle associado a eletromiografia normal do músculo diafragma esteja relacionada as alterações da fibra muscular do mesmo devido à sobrecarga de atividade.

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OBJECTIVE: The aim of the present study was to define normative data of phrenic nerve conduction parameters of a healthy population. METHODS: Phrenic nerve conduction studies were performed in 27 healthy volunteers. RESULTS: The normative limits for expiratory phrenic nerve compound muscle action potential were: amplitude (0.47 mv - 0.83 mv), latency (5.74 ms - 7.10 ms), area (6.20 ms/mv - 7.20 ms/mv) and duration (18.30 ms - 20.96 ms). Inspiratory normative limits were: amplitude (0.67 mv - 1.11 mv), latency (5.90 ms - 6.34 ms), area (5.62 ms/mv - 6.72 ms/mv) and duration (13.77 ms - 15.37 ms). CONCLUSION: The best point of phrenic nerve stimulus in the neck varies among individuals between the medial and lateral border of the clavicular head of the sternocleidomastoid muscle and stimulation of both sites, then choosing the best phrenic nerve response, seems to be the appropriate procedure.

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ABSTRACT Objective: The aim of the present study was to define normative data of phrenic nerve conduction parameters of a healthy population. Methods: Phrenic nerve conduction studies were performed in 27 healthy volunteers. Results: The normative limits for expiratory phrenic nerve compound muscle action potential were: amplitude (0.47 mv - 0.83 mv), latency (5.74 ms - 7.10 ms), area (6.20 ms/mv - 7.20 ms/mv) and duration (18.30 ms - 20.96 ms). Inspiratory normative limits were: amplitude (0.67 mv - 1.11 mv), latency (5.90 ms - 6.34 ms), area (5.62 ms/mv - 6.72 ms/mv) and duration (13.77 ms - 15.37 ms). Conclusion: The best point of phrenic nerve stimulus in the neck varies among individuals between the medial and lateral border of the clavicular head of the sternocleidomastoid muscle and stimulation of both sites, then choosing the best phrenic nerve response, seems to be the appropriate procedure.

RESUMO Objetivo: O objetivo do presente estudo foi definir os dados normativos de condução do nervo frênico de uma população saudável. Métodos: Foram realizados estudos de condução do nervo frênico em 27 voluntários saudáveis. Resultados: Os limites normais do potencial de ação muscular composto do nervo frênico durante a expiração foram: amplitude (0.47 mv - 0.83 mv), latência (5.74 ms - 7.10 ms), área (6.20 ms/mv - 7.20 ms/mv) e duração (18.30 ms - 20.96 ms). E durante a inspiração os limites normais foram: amplitude (0.67 mv - 1.11 mv), latência (5.90 ms - 6.34 ms), área (5.62 ms/mv - 6.72 ms/mv) e duração (13.77 ms - 15.37 ms). Conclusão: O melhor ponto de estímulo do nervo frênico no pescoço varia entre a borda medial e lateral da cabeça clavicular do músculo esternocleidomastóideo. Estimular ambos os locais e escolher a melhor resposta do nervo frênico parece ser o procedimento mais adequado.

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