Readability of medicinal package leaflets: a systematic review

OBJECTIVE To review studies on the readability of package leaflets of medicinal products for human use.METHODS We conducted a systematic literature review between 2008 and 2013 using the keywords “Readability and Package Leaflet” and “Readability and Package Insert” in the academic search engine Biblioteca do Conhecimento Online,comprising different bibliographic resources/databases. The preferred reporting items for systematic reviews and meta-analyses criteria were applied to prepare the draft of the report. Quantitative and qualitative original studies were included. Opinion or review studies not written in English, Portuguese, Italian, French, or Spanish were excluded.RESULTS We identified 202 studies, of which 180 were excluded and 22 were enrolled [two enrolling healthcare professionals, 10 enrolling other type of participants (including patients), three focused on adverse reactions, and 7 descriptive studies]. The package leaflets presented various readability problems, such as complex and difficult to understand texts, small font size, or few illustrations. The main methods to assess the readability of the package leaflet were usability tests or legibility formulae. Limitations with these methods included reduced number of participants; lack of readability formulas specifically validated for specific languages (e.g., Portuguese); and absence of an assessment on patients literacy, health knowledge, cognitive skills, levels of satisfaction, and opinions.CONCLUSIONS Overall, the package leaflets presented various readability problems. In this review, some methodological limitations were identified, including the participation of a limited number of patients and healthcare professionals, the absence of prior assessments of participant literacy, humor or sense of satisfaction, or the predominance of studies not based on role-plays about the use of medicines. These limitations should be avoided in future studies and be considered when interpreting the results.

Biological cycle of Tenuipalpus heveae Baker (Acari, Tenuipalpidae) on leaflets of three rubber tree clones

Life cycle of Tenuipalpus heveae Baker (Acari, Tenuipalpidae) on leaflets from three rubber tree clones. The biological cycle of Tenuipalpus heveae Baker, 1945 (Tenuipalpidae), a potential rubber tree pest mite, was studied by the observation of individuals reared on leaflets of the clones GT 1, PB 235 and RRIM 600, in controlled environmental conditions. Three daily observations were done of 60 eggs on leaflets from each clone in order to verify the development of immature stages and the female oviposition. The fertility life table was constructed based in the collected data. Mites reared on PB 235 had faster rate of development, requiring less time in days, to double its population in number (TD), and had the highest values for egg production, female longevity, net reproductive rate (Ro), intrinsic rate of natural increase (r m) and finite rate of increase (λ). Lower reproductive values and the longest time necessary to reach adult stage were recorded for the mites on GT 1. In all studied clones, the deutonymphal phase had the highest viability, while the larval phase had the lowest, highlighted by the survivorship curve that indicated high mortality during this life stage. The clone PB 235 allowed the most suitable conditions for the development of T. heveae, followed by RRIM 600, while GT 1 was the less suitable substratum to rear this mite species.

Higher glandular trichome density in tomato leaflets and repellence to spider mites

The objective of this work was to evaluate the feasibility of selection for higher glandular trichome densities, as an indirect criterion of selection for increasing repellence to spider mites Tetranychus urticae, in tomato populations derived from an interspecific cross between Lycopersicon esculentum x L. hirsutum var. glabratum PI 134417. Trichome densities were evaluated in 19 genotypes, including 12 from advanced backcross populations, derived from the original cross L. esculentum x L. hirsutum var. glabratum PI 134417. Counts were made both on the adaxial and abaxial leaf surfaces, and trichomes were classified into glandular types IV and VI, other glandular types (types I+VII), and nonglandular types. Mite repellence was measured by distances walked by mites onto the tomato leaf surface after 20, 40 and 60 min. Spider mite repellence biotests indicated that higher densities of glandular trichomes (especially type VI) decreased the distances walked by the mites onto the tomato leaf surface. Selection of plants with higher densities of glandular trichomes can be an efficient criterion to obtain tomato genotypes with higher resistance (repellence) to spider mites.

Uma nova espécie do gênero Cynometra L. (Caesalpiniaceae) para o Estado do Pará, Brasil

Cynometra marleneae is new a taxon discovered after a detailed analysis of the species in the genus. This species differs considerably from the others studied in the shape and thichness of leaflets, shape of petals and number of racemes per axil, among other characters. It is known only from the Trombetas river and tributaries, Pará state.

Mini-sternotomy for the treatment of aortic valve lesions

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous ¼-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided morecomfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.

Mitral Valve Replacement and Remodeling of the Left Ventricle in Dilated Cardiomyopathy with Mitral Regurgitation: Initial Results

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7±3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1± 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

Morphometric and topographic study of coronary ostia

OBJECTIVE: To investigate the morphometric and topographic aspects of coronary ostia, correlating them with the aortic leaflets. METHODS: Fifty-one hearts with the great vessels attached were analyzed in this study. The ascending aorta was transversally sectioned 1 cm above the commissures of the aortic leaflets. The right and left coronary ostia were analyzed, as were the distances from these ostia to the bottom of the aortic sinuses and to the commissures of the aortic leaflets. RESULTS: The left coronary ostium was located below the intercommissural line in 42% of cases, above that line in 40% of cases, and at the level of that line in 18% of cases. The mean distance from the left coronary ostium to the bottom of the corresponding sinus was 12.6±2.61 mm. The right coronary ostium was located below the intercommissural line in 60% of cases, above that line in 28% of cases, and at the level of that line in 12% of cases. The mean distance from the right coronary ostium to the bottom of the corresponding aortic sinus was 13.2±2.64 mm. The mean diameters of the left and right coronary ostia were 4.75±0.93 mm and 3.46±0.94 mm, respectively. The mean diameters of the juxtamural portion of the left and right coronary arteries were 3.75±0.79 mm and 2.9±0.73 mm, respectively. In one case, both ostia were located in the left coronary sinus. CONCLUSION: The left coronary ostium may be located either above or below the intercommissural line. The right coronary ostium is predominantly located below the intercommissural line. The coronary ostia have reduced diameters as compared with the juxtamural diameters of their respective coronary arteries.

Association of Aortic Valve Sclerosis with Previous Coronary Artery Disease and Risk Factors

Background: Aortic valve sclerosis (AVS) is characterized by increased thickness, calcification and stiffness of the aortic leaflets without fusion of the commissures. Several studies show an association between AVS and presence of coronary artery disease. Objective: The aim of this study is to investigate the association between presence of AVS with occurrence of previous coronary artery disease and classical risk factors. Methods: The sample was composed of 2,493 individuals who underwent transthoracic echocardiography between August 2011 and December 2012. The mean age of the cohort was 67.5 ± 15.9 years, and 50.7% were female. Results: The most frequent clinical indication for Doppler echocardiography was the presence of stroke (28.8%), and the most common risk factor was hypertension (60.8%). The most prevalent pathological findings on Doppler echocardiography were mitral valve sclerosis (37.1%) and AVS (36.7%). There was a statistically significant association between AVS with hypertension (p < 0.001), myocardial infarction (p = 0.007), diabetes (p = 0.006) and compromised left ventricular systolic function (p < 0.001). Conclusion: Patients with AVS have higher prevalences of hypertension, stroke, hypercholesterolemia, myocardial infarction, diabetes and compromised left ventricular systolic function when compared with patients without AVS. We conclude that there is an association between presence of AVS with previous coronary artery disease and classical risk factors.

Description of the Immature Stages of Anopheles (Nyssorhynchus) rondoni (Neiva & Pinto) (Diptera: Culicidae)

The larval and pupal stages of Anopheles (Nyssorhynchus) rondoni (Neiva and Pinto) (Albimanus Section) are fully described and illustrated for the first time. The larval stage is similar to An. (Nys.) strodei Root. It can be recognized by the following combination of characters: clypeal index, 1.6-2.9; single, aciculate setae 2,3-C; seta 3-C 0.5-0.7 the length of 2-C; setae 1,2-P rarely sharing a common tubercle; seta 1-P with narrow leaflets. The pupal stage is distinguished from other Nyssorhynchus by having setae 1-IV-VII and 5-V-VII branched. Only minor variation was found in setal counts between specimens from Peixoto de Azevedo, State of Mato Grosso and Bocaina, State of São Paulo, Brazil

Impact of a gall midge Parkiamyia paraensis (Diptera, Cecidomyiidae) on the Amazonian plant Parkia pendula (Fabaceae)

We observed the occurrence of large numbers of galls induced by Parkiamyia paraensis (Diptera, Cecidomyiidae) on the leaflets of Parkia pendula (Fabaceae) in northern Para, Brazil. We addressed two questions in this study: i) what is the proportion of attacked plants in the field, and nursery conditions?; and ii) what is the impact of galls on the host plant? An average of 86% of the plants were galled in the field. Galled P. pendula were distinct from healthy individuals due to their prostrated architecture and death of terminal shoots. Approximately 50% of the total available leaves and 35% leaflets were attacked by P. paraensis on saplings under nursery conditions. Each one-year old plant supported an average of 1,300 galls, and an average of 60g allocated to galled tissue. Otherwise, attacked individuals were taller and heavier than healthy plants. Attacked plants weighed five times more than healthy plants. When the weight of the galls was removed, the total weight (aerial part without galls) of attacked plants was drastically reduced, indicating that most of the biomass of attacked plants was due to the attack by P. paraensis galls. Although the data indicate a paradox, as young plants attacked by the galling herbivore appear to develop more vigorously than unattacked plants, we suggest that P. paraensis negatively affect P. pendula development.

Spatial distribution of a spherical gall (Hymenoptera, Eulophidae) on Caryocar brasiliense (Caryocaraceae)

We obtained the first data on spatial distribution of a spherical galling insect (Hymenoptera, Eulophidae) at the Caryocar brasiliense Camb. (Caryocaraceae) tree level. This work was developed in two pastures in Montes Claros, Minas Gerais State, Brazil. The areas studied were: pasture 1 (in activity) and pasture 2 (abandoned pasture = savanna in recovery). We evaluated the distribution of spherical galls in: foliage orientation (slope), among leaves (border and interior of the tree crown), among leaflets (right, central, left), distal, median, and proximal as well as border, central area, and adjacent to the mid leaf vein of the leaflet, and difference between areas in 10 infested trees per area. The smaller number of spherical gall/leaflet was observed in pasture 1 than in pasture 2. More spherical galls were found on the northern in pasture 1, but in the pasture 2, the lower spherical galls were observed on the northeast than other slopes. The average number of spherical galls did not differ statistically among the three leaflets of C. brasiliense in pasture 2. However, in pasture 1, we observed highest number of spherical galls in the central leaflet. More spherical galls were found in the border than interior of the tree crown. The average number of spherical galls did not differ statistically among the longitudinal region on leaflet of C. brasiliense. The spherical gall insect preferred to colonize the leaf margin than the central portion or near mid vein on transversal regions on a leaflet.

Egg laying site selection by a host plant specialist leaf miner moth at two intra-plant levels in the northern Chilean Atacama Desert

Egg laying site selection by a host plant specialist leaf miner moth at two intra-plant levels in the northern Chilean Atacama Desert. The spatial distribution of the immature stages of the leaf miner Angelabella tecomae Vargas & Parra, 2005 was determined at two intra-plant levels (shoot and leaflet) on the shrub Tecoma fulva fulva (Cav.) D. Don (Bignoniaceae) in the Azapa valley, northern Chilean Atacama Desert. An aggregated spatial pattern was detected for all the immature stages along the shoot, with an age dependent relative position: eggs and first instar larvae were clumped at apex; second, third and fourth instar larvae were mostly found at intermediate positions; meanwhile the spinning larva and pupa were clumped at basis. This pattern suggests that the females select new, actively growing leaflets for egg laying. At the leaflet level, the immature stages were found more frequently at underside. Furthermore, survivorship was higher for larvae from underside mines. All these results highlight the importance of an accurate selection of egg laying site in the life history of this highly specialized leaf miner. By contrast, eventual wrong choices in the egg laying site selection may be associated with diminished larval survivorship. The importance of the continuous availability of new plant tissue in this highly human modified arid environment is discussed in relation with the observed patterns.

Aspects of leaf anatomy of kudzu (Pueraria lobata, Leguminosae-Faboideae) related to water and energy balance

Kudzu is a cover crop that has escaped cultivation in some subtropical and warm temperate regions. Kudzu has previously demonstrated broad intraspecific physiological plasticity while colonizing new environments. The objective of this paper was to investigate characteristics of kudzu leaflet anatomy that might contribute to its successful growth in climatically distinct environments, and to escape cultivation as well. Fresh and fixed leaflet strips of field-grown plants were analyzed. The lower epidermis of kudzu showed a higher frequency of stomata (147 ± 19 stomata mm-2) than the upper epidermis (26 ± 17 stomata mm-2). The average number of trichomes per square milimeter was 8 for both the upper and the lower epidermis. The average trichome length was 410 ± 200 mum for the upper epidermis and 460 ± 190 mum for the lower epidermis. Cuticle thickness was not considerably different between lower and upper epidermis. The leaflet blade consisted basically of two layers (upper and lower) of unicellular epidermis, two layers of palisade parenchyma and one layer of spongy parenchyma. One layer of paraveinal mesophyll was found between palisade and spongy parenchyma. In conclusion, leaflets of kudzu present anatomical characteristics that might contribute to the broad physiological plasticity shown by kudzu.

Bacterial spot and early blight biocontrol by epiphytic bacteria in tomato plants

The objective of this work was to evaluate in vitro and in vivo biocontrol of bacterial spot (Xanthomonas vesicatoria) and early blight (Alternaria solani) by the epiphytic bacteria Paenibacillus macerans and Bacillus pumilus. Tomato plants were previously sprayed with epiphytic bacteria, benzalkonium chloride and PBS buffer and, after four days, they were inoculated with A. solani and X. vesicatoria. To determine the phytopathogenic bacteria population, leaflet samples were collected from each treatment every 24 hours, for seven days, and plated on semi-selective medium. The effect of epiphytic bacteria over phytopathogens was performed by the antibiosis test and antagonistic activity measured by inhibition zone diameter. The epiphytic and benzalkonium chloride drastically reduced the severity of early blight and bacterial spot in comparison to the control (PBS). In detached leaflets, the epiphytic bacteria reduced in 70% the number of phytopathogenic bacteria cells in the phylloplane. The antibiosis test showed that the epiphytic bacteria efficiently inhibit the phytopathogens growth. In all the bioassays, the epiphytic bacteria protect tomato plants against the phytopathogens

Gas exchanges in peach palms as a function of the spad chlorophyll meter readings

The close relationship between the chlorophyll-meters readings and the total chlorophyll and nitrogen contents in leaves, has allowed their evaluation both in annual and perennial species. Besides, some physiological events such as the CO2 assimilation have also been estimated by chlorophyll meters. This work was carried out aiming to evaluate the gas exchanges of peach palms as a function of the chlorophyll SPAD-Meter readings. Three year-old peach palms from Yurimaguas, Peru were studied in Ubatuba, SP, Brazil, spaced 2 x 1 m in area under a natural gradient of organic matter which allowed four plots to be considered, according to the peach palms leaves colors, from light yellow to dark green. The SPAD readings and the stomatal frequency of leaflets were evaluated. The photosynthetic photon flux density (PPFD, μmol m-2 s-1), the leaf temperature (Tleaf, ºC), the CO2 assimilation (A, μmol m-2 s-1), the stomatal conductance (g s, mol m-2 s-1), the transpiration (E, mmol m-2 s-1) and the intercellular CO2 concentration (Ci, μmol mol-1) were evaluated with a portable infrared gas analyzer (LCA-4, ADC BioScientific Ltd., Great Amwell, U.K.). A linear increase in the CO2 assimilation as a function of the SPAD readings (y = -0.34 + 0.19x, R² = 0.99), indicates that they can be a rapid and cheap complementary method to evaluate in peach palms some important physiological events, such as CO2 assimilation.