Scielo RSS <![CDATA[Clinics]]> http://www.scielo.br/rss.php?pid=1807-593220200001&lang=en vol. 75 num. lang. en <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[The mitochondrial calcium uniporter: a new therapeutic target for Parkinson’s disease-related cardiac dysfunctions?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100100&lng=en&nrm=iso&tlng=en <![CDATA[Physical and functional aspects of persons with multiple sclerosis practicing Tai-Geiko: randomized trial]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100200&lng=en&nrm=iso&tlng=en OBJECTIVES: This study aimed to verify the influence of Tai-Geiko on the physical and functional aspects of people with multiple sclerosis (MS). METHODS: This was a parallel-group, randomized trial with two arms. People with MS were allocated to an experimental group (EG) (n=10) and control group (CG) (n=09). The participants received multidisciplinary care supervised by a physiotherapist in the Tai-Geiko exercise. Participants underwent the assessments after the intervention. The Expanded Disability Status Scale (EDSS-maximum score of 6.0), strength test (kgf) using a dynamometer, Timed Up and Go mobility test (TUG), and stabilometric balance test (Platform EMG system®) were evaluated. Demographic data were recorded, including age, sex, comorbidities, lifestyle and classification of MS. Clinical Trials (ReBeC): RBR-4sty47. RESULTS: The EG group improved in 12 variables, and the CG improved in 3 variables. The following values were obtained for pre/postintervention, respectively: EG: lumbar force (38/52 kgf), TUG (11/9 s), locomotion velocity (519/393 ms); double task two (53/39 s); platform stabilometric trajectory: traversed get up (39/26 s) and sit (45/29 s); anteroposterior (AP) amplitude rise (11/8 cm) and sit (12.40/9.94 cm) and anteroposterior frequency rise (1.00/1.56 Hz) and sit (0.8/1.25 Hz) (p&lt;0.05); CG: right-hand grip force (26/29 kgf); TUG (9.8 /8.7 s) and AP (11.84 /9.53 cm) stabilometric amplitude at the sitting moment (p&lt;0.05), (3.2/5.99 Hz, p=0.01) and sit (3.47/5.01 Hz, p=0.04). CONCLUSION: Tai-Geiko practice can be suggested as complementary exercise in the rehabilitation of persons with MS. <![CDATA[Local treatment of colostomy prolapse with the MESH STRIP technique: A novel and highly efficient day hospital technique]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100201&lng=en&nrm=iso&tlng=en OBJECTIVE: Stoma prolapse is an intussusception of the bowel through a mature stoma. It can be caused by increased intra-abdominal pressure, excessively mobile bowel mesentery and/or a large opening in the abdominal wall at the time of stoma formation. It occurs predominantly in loop stomas, and correction methods include conservative modalities, such as local reduction to the prolapsed bowel, or surgical treatment. The purpose of this study was to describe our experience with the treatment of colostomy prolapse using a novel mesh strip technique. METHODS: Between February 2009 and March 2018, ten consecutive male patients underwent correction of colostomy prolapse under local anesthesia by peristomal placement of a polypropylene mesh strip. Operation time, short- and long-term complications, and recurrence rates were recorded and analyzed. RESULTS: No postoperative complications, morbidity or mortality were observed. The median length of the prolapse ranged from 6-20 cm, and the median operative time was 30 minutes. The median duration of follow-up was 25 months (range, 12-89 months). No relapse, mesh strip extrusion, local infection or granuloma formation were found. CONCLUSION: A simple, fast, and low-cost operation under local anesthesia using a mesh strip is a valuable option to treat colostomy prolapse. <![CDATA[Lung Cavities in Chronic Thromboembolic Pulmonary Hypertension]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100202&lng=en&nrm=iso&tlng=en OBJECTIVES: Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension (PH) that arises from obstruction of the pulmonary vessels by recanalized thromboembolic material. CTEPH has a wide range of radiologic presentations. Commonly, it presents as main pulmonary artery enlargement, peripheral vascular obstructions, bronchial artery dilations, and mosaic attenuation patterns. Nevertheless, other uncommon presentations have been described, such as lung cavities. These lesions may be solely related to chronic lung parenchyma ischemia but may also be a consequence of concomitant chronic infectious conditions. The objective of this study was to evaluate the different etiologies that cause lung cavities in CTEPH patients. METHODS: A retrospective data analysis of the medical records of CTEPH patients in a single reference PH center that contained or mentioned lung cavities was conducted between 2013 and 2016. RESULTS: Seven CTEPH patients with lung cavities were identified. The cavities had different sizes, locations, and wall thicknesses. In two patients, the cavities were attributed to pulmonary infarction; in 5 patients, an infectious etiology was identified. CONCLUSION: Despite the possibility of being solely associated with chronic lung parenchyma ischemia, most cases of lung cavities in CTEPH patients were associated with chronic granulomatous diseases, reinforcing the need for active investigation of infectious agents in this setting. <![CDATA[Validity Evidence of an Epidemiological Oropharyngeal Dysphagia Screening Questionnaire for Older Adults]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100203&lng=en&nrm=iso&tlng=en OBJECTIVE: This research aimed to identify evidence of validity of a self-reported Oropharyngeal Dysphagia screening questionnaire for older adults based on test content, response processes, internal structure, relations to other variables, and reliability. METHOD: This is a nonrandomized, cross-sectional study employing the concepts and principles of the Standards for Educational and Psychological Testing. Data were collected from 644 community-dwelling older adults (both genders, age: ≥60 years) who agreed to participate in some steps of the validation process. Statistical methods obtained the content representation of the construct, internal structure validation, discriminant and convergent evidence, and reliability, using a 5% significance level. RESULTS: The screening tool was re-specified in nine questions that provided the best fit and robust reliability, with proper discriminant and convergent evidence. CONCLUSIONS: The screening questionnaire presented valid and reliable results to identify oropharyngeal dysphagia symptoms in older adults, highlighting the importance of the validation process based on the standards to construct an epidemiological instrument. <![CDATA[Permanent education as an inalienable responsibility of health councils: the current scenario in the Unified Health System]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100204&lng=en&nrm=iso&tlng=en OBJECTIVE: To verify whether health councils in Brazil carry out permanent education activities for municipal, state and federal district councilors. METHOD: This was a cross-sectional study with secondary data collection in the Health Council Monitoring System (Sistema de Acompanhamento dos Conselhos de Saúde - Siacs) from May to August 2017. The Siacs is publicly accessible and available on the internet. It provides data from thousands of health councils throughout Brazil. Analysis and interpretation of the data were based on the literature and the enacted legislation, particularly Resolution 453/2012 and the National Policy of Permanent Education for Social Control in the Unified Health System (Política Nacional de Educação Permanente para o Controle Social no Sistema Único de Saúde). RESULTS: Despite the fact that Resolution 453/2012 establishes the deliberation, elaboration, support and promotion of permanent education for social control as functions of the councils (in accordance with the guidelines of the National Policy of Permanent Education), approximately 40% of councils do not carry out permanent education. CONCLUSIONS: It is necessary to strengthen the role of health councils in the elaboration of educational initiatives across the national territory. This includes the allocation of financial resources to increase access to and participation in these initiatives, which would strengthen social control in the Unified Health System. This study emphasizes that the discussion of permanent education is not given sufficient attention in the agendas and routines of health councils. This compromises the effectiveness of councils’ monitoring and deliberation of public health policy. <![CDATA[Transcutaneous tibial nerve stimulation <em>versus</em> parasacral stimulation in the treatment of overactive bladder in elderly people: a triple-blinded randomized controlled trial]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100205&lng=en&nrm=iso&tlng=en OBJECTIVES: To evaluate the effect of transcutaneous tibial nerve stimulation (TTNS) and transcutaneous parasacral stimulation on the treatment of overactive bladder (OAB) in elderly people and to compare the final results between groups. METHODS: Fifty female volunteers, mean age 68.62 (±5.9) years, were randomly allocated into two groups: those receiving TTNS (G1, N=25) and those receiving transcutaneous parasacral stimulation (G2, N=25). The primary outcome was the International Consultation on Incontinence Questionnaire (ICIQ-OAB) score, and secondary outcomes were the International Consultation on Incontinence Questionnaire - short form (ICIQ-SF) score and 3-day bladder diary measurements. Volunteers were assessed before and after the treatment. Clinical Trials (ReBeC): RBR-9Q7J7Y. RESULTS: Both groups’ symptoms improved as measured by the ICIQ-OAB (G1 = &lt;0.001; G2 = &lt;0.001) and ICIQ-SF (G1 = &lt;0.001; G2 = &lt;0.001). In the 3-day bladder diary assessments after treatment, G1 showed a reduced number of nocturia (p&lt;0.001), urgency (p&lt;0.001) and urge urinary incontinence episodes (p&lt;0.001), whereas G2 showed only a reduced number of nocturia episodes (p&lt;0.001). No difference between groups was found. CONCLUSION: Both of the proposed treatments were effective in the improvement of OAB symptoms, but TTNS showed a reduction in a greater number of symptoms as measured by the 3-day bladder diary. No differences were found between groups. <![CDATA[Magnetic resonance angiography and transcranial Doppler ultrasound findings in patients with a clinical diagnosis of vertebrobasilar insufficiency]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100206&lng=en&nrm=iso&tlng=en OBJECTIVE: To evaluate the findings of magnetic resonance angiography (MRA) and transcranial Doppler ultrasound (TCD) in patients with a clinical diagnosis of vertebrobasilar insufficiency (VBI). METHOD: From our outpatient neurotology clinic, we selected patients (using the criteria proposed by Grad and Baloh) with a clinical diagnosis of VBI. We excluded patients with any definite cause for vestibular symptoms, a noncontrolled metabolic disease or any contraindication to MRA or TCD. The patients in the study group were sex- and age-matched with subjects who did not have vestibular symptoms (control group). Our final group of patients included 24 patients (study, n=12; control, n=12). RESULTS: The MRA results did not demonstrate significant differences in the findings between our study and control groups. TCD demonstrated that the systolic pulse velocity of the right middle cerebral artery, end diastolic velocity of the basilar artery, pulsatility index (PI) of the left middle cerebral artery, PI of the right middle cerebral artery, and PI of the basilar artery were significantly higher in the study group than in the control group, suggesting abnormalities affecting the microcirculation of patients with a clinical diagnosis of VBI compared with controls. CONCLUSION: MRA failed to reveal abnormalities in patients with a clinical diagnosis of VBI compared with controls. The PI of the basilar artery, measured using TCD, demonstrated high sensitivity (91%) and specificity (91%) for detecting clinically diagnosed VBI. <![CDATA[Anesthesia upstream of the alcoholic lesion point alleviates the pain of alcohol neurolysis for intercostal neuralgia: a prospective randomized clinical trial]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100207&lng=en&nrm=iso&tlng=en OBJECTIVES: Alcohol for intercostal neuralgia may induce severe injection pain. Although nerve block provided partial pain relief, alcohol might be diluted, and the curative effect decreased when the local anesthetic and alcohol were given at the same point. Therefore, we observed the modified method for intercostal neuralgia, a Two-point method, in which the local anesthetic and alcohol were given at different sites. METHOD: Thirty patients diagnosed with intercostal neuralgia were divided into 2 groups: Single-point group and Two-point group. In the Single-point group, alcohol and local anesthetic were injected at the same point, named the “lesion point”, which was the lower edge of ribs and 5 cm away from the midline of the spinous process. In the Two-point group, alcohol was injected at the lesion point, whereas the local anesthetic was administered at the “anesthesia point”, which was 3 cm away from the midline of spinous process. RESULTS: After alcohol injection, visual analog scale (VAS) in the Two-point group was lower than the Single-point group, and the satisfaction ratio of patients in the Two-point group was higher (p&lt;0.05). The degree of numbness in the Two-point group was greater than the Single-point group at 1 month and 3 months after operation (p&lt;0.05). However, the long-term effects did not differ. CONCLUSIONS: Local anesthetic was given upstream of the point where alcohol was administered, was a feasible and safe method to relieve pain during the operation, and improved the satisfaction of the patients and curative effect. <![CDATA[Ultrasound <em>Versus</em> Contrast-Enhanced Magnetic Resonance Imaging for Subclinical Synovitis and Tenosynovitis: A Diagnostic Performance Study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100208&lng=en&nrm=iso&tlng=en OBJECTIVES: Radiographic manifestations of synovitis (e.g., erosions) can be observed only in the late stage of rheumatoid arthritis. Ultrasound is a noninvasive, cheap, and widely available technique that enables the evaluation of inflammatory changes in the peripheral joint. In the same way, dynamic contrast-enhanced magnetic resonance imaging (MRI) enables qualitative and quantitative measurements. The objectives of the study were to compare the sensitivity and accuracy of ultrasound in detecting subclinical synovitis and tenosynovitis with those of contrast-enhanced MRI. METHODS: The ultrasonography and contrast-enhanced MRI findings of the wrist, metacarpophalangeal, and proximal interphalangeal joints (n=450) of 75 patients with a history of joint pain and morning stiffness between 6 weeks and 2 years were reviewed. The benefits score was evaluated for each modality. RESULTS: The ultrasonic findings showed inflammation in 346 (77%) joints, while contrast-enhanced MRI found signs of early rheumatoid arthritis in 372 (83%) joints. The sensitivities of ultrasound and contrast-enhanced MRI were 0.795 and 0.855, respectively, and the accuracies were 0.769 and 0.823, respectively. Contrast-enhanced MRI had a likelihood of 0-0.83 and ultrasound had a likelihood of 0-0.77 for detecting synovitis and tenosynovitis at one time. The two imaging modalities were equally competitive for detecting synovitis and tenosynovitis (p=0.055). CONCLUSION: Ultrasound could be as sensitive and specific as contrast-enhanced MRI for the diagnosis of subclinical synovitis and tenosynovitis. <![CDATA[Aberrant expression of calcitonin gene-related peptide and its correlation with prognosis in severe childhood pneumonia]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100209&lng=en&nrm=iso&tlng=en OBJECTIVES: The purpose of this study was to evaluate the relationship between the serum levels of calcitonin gene-related peptide (CGRP) and the prognosis of pediatric patients with severe pneumonia. METHODS: Children diagnosed with severe pneumonia (n=76) were stratified into the survival (n=58) and non-survival groups (n=18) according to their 28-day survival status and into the non-risk (n=51), risk (n=17) and high-risk (n=8) categories based on the pediatric critical illness score (PCIS). Demographic data and laboratory results were collected. Serum CGRP levels were determined by enzyme-linked immunosorbent assay (ELISA). A receiver operating characteristic (ROC) curve was generated to determine the cutoff score for high CGRP levels. RESULTS: Serum CGRP levels were significantly higher in the survival group than in the non-survival group and were significantly higher in the non-risk group than in the risk and high-risk groups. The ROC curve for the prognostic potential of CGRP yielded a significant area under the curve (AUC) value with considerable sensitivity and specificity. CONCLUSION: Our findings show that CGRP downregulation might be a diagnostic marker that predicts the prognosis and survival of children with severe pneumonia. <![CDATA[Usefulness of aqueous and vitreous humor analysis in infectious uveitis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100210&lng=en&nrm=iso&tlng=en OBJECTIVE: To evaluate the role of intraocular fluid analysis as a diagnostic aid for uveitis. METHODS: Twenty-eight samples (27 patients including 3 HIV-infected patients) with active (n=24) or non-active (n=4) uveitis were submitted to aqueous (AH; n=12) or vitreous humor (VH) analysis (n=16). All samples were analyzed by quantitative PCR for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Toxoplasma gondii. RESULTS: The positivity of the PCR in AH was 41.7% (5/12), with 50% (2/4) in immunocompetent and 67% (2/3) in HIV+ patients. The positivity of the PCR in VH was 31.2% (5/16), with 13% (1/8) in immunocompetent and 50% (4/8) in immunosuppressed HIV negative patients. The analysis was a determinant in the diagnostic definition in 58% of HA and 50% of VH. CONCLUSION: Even in posterior uveitis, initial AH analysis may be helpful. A careful formulation of possible clinical diagnosis seems to increase the chance of intraocular sample analysis being meaningful. <![CDATA[Randomized trial of physiotherapy and hypertonic saline techniques for sputum induction in asthmatic children and adolescents]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100211&lng=en&nrm=iso&tlng=en OBJECTIVES: This study aimed to analyze the efficiency of physiotherapy techniques in sputum induction and in the evaluation of pulmonary inflammation in asthmatic children and adolescents. Although hypertonic saline (HS) is widely used for sputum induction (SI), specific techniques and maneuvers of physiotherapy (P) may facilitate the collection of mucus in some asthmatic children and adolescents. METHODS: A randomized crossover study was performed in patients with well-controlled asthma, and 90 sputum samples were collected. Children and adolescents were assessed using spirometry and randomized at entry into one of three sputum induction techniques: (i) 3% hypertonic saline – HS technique; (ii) physiotherapy (oscillatory positive expiratory pressure, forced expiration, and acceleration of expiratory flow) – P technique; and (iii) hypertonic saline + physiotherapy – HSP technique. ClinicalTrials.gov: NCT03136042. RESULTS: The total cells (mL) and the percentage (%) of differential inflammatory cells were similar in all techniques. The sputum weight (g) in the HSP technique was significantly higher than that in the HS technique. In all techniques, the percentage of viable cells was &gt;50%, and there was no difference between the HS and P techniques. Moreover, sputum induction did not cause any alterations in the pulmonary function of patients. CONCLUSION: The physiotherapy sputum collection technique was effective in obtaining viable cells from mucus samples and yielded the same amount of sputum as the gold standard technique (hypertonic saline). In addition, the physiotherapy maneuvers were both safe and useful for sputum induction in asthmatic children and adolescents with well-controlled asthma. <![CDATA[Prevalence of non-obstructive dysphagia in patients with heartburn and regurgitation]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100212&lng=en&nrm=iso&tlng=en OBJECTIVE: Heartburn and regurgitation are the most common gastroesophageal reflux symptoms, and dysphagia could be a possible symptom. This investigation aimed to evaluate the prevalence of non-obstructive dysphagia in patients with heartburn and regurgitation. METHODS: A total of 147 patients (age, 20-70 years; women, 72%) complaining of heartburn and regurgitation, without esophageal stricture, previous esophageal surgery, or other diseases, were evaluated. Twenty-seven patients had esophagitis. The Eating Assessment Tool (EAT-10) was employed to screen for dysphagia; EAT-10 is composed of 10 items, and the patients rate each item from 0 to 4 (0, no problems; 4, most severe symptom). Results of the 147 patients were compared with those of 417 healthy volunteers (women, 62%; control group) aged 20-68 years. RESULTS: In the control group, only two (0.5%) had an EAT-10 score ≥5, which was chosen as the threshold to define dysphagia. EAT-10 scores ≥5 were found in 71 (48.3%) patients and in 55% of the patients with esophagitis and 47% of the patients without esophagitis. This finding indicates a relatively higher prevalence of perceived dysphagia in patients with heartburn and regurgitation and in patients with esophagitis. We also found a positive correlation between EAT-10 scores and the severity of gastroesophageal reflux symptoms based on the Velanovich scale. CONCLUSION: In patients with heartburn and regurgitation symptoms, the prevalence of dysphagia was at least 48%, and has a positive correlation with the overall symptoms of gastroesophageal reflux. <![CDATA[Type 2 diabetes mellitus-related environmental factors and the gut microbiota: emerging evidence and challenges]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100400&lng=en&nrm=iso&tlng=en The gut microbiota is a group of over 38 trillion bacterial cells in the human microbiota that plays an important role in the regulation of human metabolism through its symbiotic relationship with the host. Changes in the gut microbial ecosystem are associated with increased susceptibility to metabolic disease in humans. However, the composition of the gut microbiota in those with type 2 diabetes mellitus and in the pathogenesis of metabolic diseases is not well understood. This article reviews the relationship between environmental factors and the gut microbiota in individuals with type 2 diabetes mellitus. Finally, we discuss the goal of treating type 2 diabetes mellitus by modifying the gut microbiota and the challenges that remain in this area. <![CDATA[Mobility impact and methods of diaphragm monitoring in patients with chronic obstructive pulmonary disease: a systematic review]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100401&lng=en&nrm=iso&tlng=en The objectives of the study were to identify the factors that limit diaphragmatic mobility and evaluate the therapeutic results of the monitoring methods previously used in patients with chronic obstructive pulmonary disease. The PubMed, Web of Science, Scopus, and LILACS databases were used. A gray literature search was conducted with Google scholar. PRISMA was used, and the bias risk analysis adapted from the Cochrane Handbook for clinical trials and, for other studies, the Downs and Black checklist were used. Twenty-five articles were included in the qualitative synthesis analysis on physiotherapeutic techniques and diaphragmatic mobility. Eight clinical trials indicated satisfactory domains, and on the Downs and Black scale, 17 cohort studies were evaluated to have an acceptable score. Different conditions must be observed; for example, for postoperative assessments the supine position is suggested to be the most appropriate position to verify diaphragm excursion, although it has been shown to be associated with difficulty of restriction and matching in samples. Therefore, we identified the need for contemporary adjustments and strategies that used imaging instruments, preferably in the dorsal position. Therapeutic evidence on the association between the instrumental method and diaphragmatic mobility can be controversial. The ultrasound measurements indicated some relevance for different analyses, for pulmonary hyperinflation as well as diaphragm thickness and mobilization, in COPD patients. In particular, the study suggests that the ultrasound technique with B-mode for analysis and M-mode for diaphragmatic excursion be used with a 2 - 5 MHz with the patient in the supine position. However, the methods used to monitor diaphragm excursion should be adapted to the conditions of the patients, and additional investigations of their characteristics should be performed. More selective inclusion criteria and better matching in the samples are very important. In addition, more narrow age, sex and weight categories are important, especially in patients with chronic obstructive pulmonary disease. <![CDATA[Prior exercise training and experimental myocardial infarction: A systematic review and meta-analysis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322020000100402&lng=en&nrm=iso&tlng=en Exercising prior to experimental infarction may have beneficial effects on the heart. The objective of this study was to analyze studies on animals that had exercised prior to myocardial infarction and to examine any benefits through a systematic review and meta-analysis. The databases MEDLINE, Google Scholar, and Cochrane were consulted. We analyzed articles published between January 1978 and November 2018. From a total of 858 articles, 13 manuscripts were selected in this review. When animals exercised before experimental infarction, there was a reduction in mortality, a reduction in infarct size, improvements in cardiac function, and a better molecular balance between genes and proteins that exhibit cardiac protective effects. Analyzing heart weight/body weight, we observed the following results - Mean difference 95% CI - -0.02 [-0.61,0.57]. Meta-analysis of the infarct size (% of the left ventricle) revealed a statistically significant decrease in the size of the infarction in animals that exercised before myocardial infarction, in comparison with the sedentary animals -5.05 [-7.68, -2.40]. Analysis of the ejection fraction, measured by echo (%), revealed that animals that exercised before myocardial infarction exhibited higher and statistically significant measures, compared with sedentary animals 8.77 [3.87,13.66]. We conclude that exercise performed prior to experimental myocardial infarction confers cardiac benefits to animals.