Showing papers by "Carlos Roberto Ribeiro de Carvalho published in 2015"

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome

Abstract: BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (ΔP = V T /C RS ), in which V T is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than V T or PEEP in patients who are not actively breathing. METHODS Using a statistical tool known as multilevel mediation analysis to analyze individual data from 3562 patients with ARDS enrolled in nine previously reported randomized trials, we examined ΔP as an independent variable associated with survival. In the mediation analysis, we estimated the isolated effects of changes in ΔP resulting from randomized ventilator settings while minimizing confounding due to the baseline severity of lung disease. RESULTS Among ventilation variables, ΔP was most strongly associated with survival. A 1-SD increment in ΔP (approximately 7 cm of water) was associated with increased mortality (relative risk, 1.41; 95% confidence interval [CI], 1.31 to 1.51; P<0.001), even in patients receiving “protective” plateau pressures and V T (relative risk, 1.36; 95% CI, 1.17 to 1.58; P<0.001). Individual changes in V T or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in ΔP (mediation effects of ΔP, P = 0.004 and P = 0.001, respectively). CONCLUSIONS We found that ΔP was the ventilation variable that best stratified risk. Decreases in ΔP owing to changes in ventilator settings were strongly associated with increased survival. (Funded by Fundacao de Amparo e Pesquisa do Estado de Sao Paulo and others.)

Diagnostic methods to assess inspiratory and expiratory muscle strength

Abstract: Impairment of (inspiratory and expiratory) respiratory muscles is a common clinical finding, not only in patients with neuromuscular disease but also in patients with primary disease of the lung parenchyma or airways. Although such impairment is common, its recognition is usually delayed because its signs and symptoms are nonspecific and late. This delayed recognition, or even the lack thereof, occurs because the diagnostic tests used in the assessment of respiratory muscle strength are not widely known and available. There are various methods of assessing respiratory muscle strength during the inspiratory and expiratory phases. These methods are divided into two categories: volitional tests (which require patient understanding and cooperation); and non-volitional tests. Volitional tests, such as those that measure maximal inspiratory and expiratory pressures, are the most commonly used because they are readily available. Non-volitional tests depend on magnetic stimulation of the phrenic nerve accompanied by the measurement of inspiratory mouth pressure, inspiratory esophageal pressure, or inspiratory transdiaphragmatic pressure. Another method that has come to be widely used is ultrasound imaging of the diaphragm. We believe that pulmonologists involved in the care of patients with respiratory diseases should be familiar with the tests used in order to assess respiratory muscle function.Therefore, the aim of the present article is to describe the advantages, disadvantages, procedures, and clinical applicability of the main tests used in the assessment of respiratory muscle strength.

Métodos diagnósticos para avaliação da força muscular inspiratória e expiratória* Diagnostic methods to assess inspiratory and expiratory muscle strength

Abstract: Impairment of (inspiratory and expiratory) respiratory muscles is a common clinical finding, not only in patients with neuromuscular disease but also in patients with primary disease of the lung parenchyma or airways. Although such impairment is common, its recognition is usually delayed because its signs and symptoms are nonspecific and late. This delayed recognition, or even the lack thereof, occurs because the diagnostic tests used in the assessment of respiratory muscle strength are not widely known and available. There are various methods of assessing respiratory muscle strength during the inspiratory and expiratory phases. These methods are divided into two categories: volitional tests (which require patient understanding and cooperation); and non-volitional tests. Volitional tests, such as those that measure maximal inspiratory and expiratory pressures, are the most commonly used because they are readily available. Non-volitional tests depend on magnetic stimulation of the phrenic nerve accompanied by the measurement of inspiratory mouth pressure, inspiratory esophageal pressure, or inspiratory transdiaphragmatic pressure. Another method that has come to be widely used is ultrasound imaging of the diaphragm. We believe that pulmonologists involved in the care of patients with respiratory diseases should be familiar with the tests used in order to assess respiratory muscle function.Therefore, the aim of the present article is to describe the advantages, disadvantages, procedures, and clinical applicability of the main tests used in the assessment of respiratory muscle strength.

Use of sirolimus in the treatment of lymphangioleiomyomatosis: favorable responses in patients with different extrapulmonary manifestations

Abstract: OBJECTIVE: Lymphangioleiomyomatosis (LAM) is a rare disease that is currently considered a low-grade neoplasm with metastatic potential and variable progression. Mammalian target of rapamycin (mTOR) inhibitors, such as sirolimus and everolimus, have recently become a treatment option for LAM patients, especially those with extrapulmonary manifestations. The objective of the present study was to describe a case series of four patients with LAM in Brazil who showed significant improvement, particularly in their extrapulmonary manifestations, after treatment with sirolimus (at 1-4 mg/day). METHODS: We describe four cases of LAM patients with different extrapulmonary manifestations who were treated with sirolimus. RESULTS: After treatment with sirolimus for 12 months, one patient presented resolution of severe chylothorax; one had a significant reduction in renal angiomyolipoma volume; and one showed significant regression of retroperitoneal lymphangioleiomyomas and abdominal lymph node enlargement. After treatment with sirolimus for 6 months, the remaining patient had a significant reduction in the volume of a massive retroperitoneal lymphangioleiomyoma. CONCLUSIONS: Our findings confirm that mTOR inhibitors are beneficial for patients with LAM, especially those with extrapulmonary manifestations, such as renal angiomyolipoma, lymphangioleiomyomas, and chylous effusions. However, certain aspects, such as the optimal dose, duration of treatment, and long-term adverse effects, have yet to be sufficiently clarified for mTOR inhibitors to be incorporated into LAM management protocols.

Pulmonary involvement in long-term mixed connective tissue disease: functional trends and image findings after 10 years.

Abstract: OBJECTIVES Interstitial lung disease (ILD) is highly prevalent in patients with mixed connective tissue disease (MCTD). However, little is known about the long-term progression of ILD in MCTD. The aims of this study were to describe pulmonary function test (PFT) and high-resolution computed tomography (HRCT) results in long-term MCTD patients, to measure changes in PFT and HRCT results over a 10-year period, and to ascertain correlations in functional and imaging data. METHODS In this retrospective cohort study, comparison between baseline and follow-up PFT and HRCT data was performed for 39 unselected consecutive MCTD patients. RESULTS At baseline, 51% of the patients had abnormal PFTs. Forced vital capacity (FVC) was slightly reduced at baseline (77% of predicted), but remained stable after 10 years. A relative decrease of 15% in the diffusion capacity for carbon monoxide (DLCO) was detected (from 84% to 71% of predicted, p<0.001). The median lower lobes ILD-HRCT score progressed from 7.5% at baseline to 11.2% at follow-up (p=0.02), and findings of traction bronchiolectasis and honeycombing increased (p<0.05). A moderate negative correlation was observed between functional parameters and quantification of image findings. CONCLUSIONS Functional and radiologic alterations suggestive of ILD in long-term MCTD patients are prevalent, mild, and progressed slightly over time. The most sensitive parameters for detecting subtle progression of ILD in MCTD patients are trends in DLCO, quantification of lower-lobes disease by HRCT (lower-lobes %ILD-HRCT score), and qualitative analysis of HRCT imaging.

Contrasting the Chromosomal Organization of Repetitive DNAs in Two Gryllidae Crickets with Highly Divergent Karyotypes.

Abstract: A large percentage of eukaryotic genomes consist of repetitive DNA that plays an important role in the organization, size and evolution. In the case of crickets, chromosomal variability has been found using classical cytogenetics, but almost no information concerning the organization of their repetitive DNAs is available. To better understand the chromosomal organization and diversification of repetitive DNAs in crickets, we studied the chromosomes of two Gryllidae species with highly divergent karyotypes, i.e., 2n(♂) = 29,X0 (Gryllus assimilis) and 2n = 9, neo-X1X2Y (Eneoptera surinamensis). The analyses were performed using classical cytogenetic techniques, repetitive DNA mapping and genome-size estimation. Conserved characteristics were observed, such as the occurrence of a small number of clusters of rDNAs and U snDNAs, in contrast to the multiple clusters/dispersal of the H3 histone genes. The positions of U2 snDNA and 18S rDNA are also conserved, being intermingled within the largest autosome. The distribution and base-pair composition of the heterochromatin and repetitive DNA pools of these organisms differed, suggesting reorganization. Although the microsatellite arrays had a similar distribution pattern, being dispersed along entire chromosomes, as has been observed in some grasshopper species, a band-like pattern was also observed in the E. surinamensis chromosomes, putatively due to their amplification and clustering. In addition to these differences, the genome of E. surinamensis is approximately 2.5 times larger than that of G. assimilis, which we hypothesize is due to the amplification of repetitive DNAs. Finally, we discuss the possible involvement of repetitive DNAs in the differentiation of the neo-sex chromosomes of E. surinamensis, as has been reported in other eukaryotic groups. This study provided an opportunity to explore the evolutionary dynamics of repetitive DNAs in two non-model species and will contribute to the understanding of chromosomal evolution in a group about which little chromosomal and genomic information is known.

Embryogenic potential of immature zygotic embryos of Passiflora : a new advance for in vitro propagation without plant growth regulators

Abstract: In vitro strategies for Passiflora have been developed owing to its economic and ecological importance. However, plantlet regeneration through somatic embryogenesis has presented some problems, such as the reproducibility of the protocol and formation of abnormal embryos and plantlets. Thus, this study aimed to establish a protocol exploring the embryogenic potential of immature zygotic embryos (IZE) of the wild species Passiflora miniata Vanderpl. and Passiflora speciosa Gardn. Friable calli, which formed on the abaxial surface of the cotyledons, yielded globular, heart-shaped, torpedo and cotyledonary somatic embryos, characterising the embryogenic response as asynchronous. A high percentage of normal regenerants (90 %) was obtained from IZE in media lacking 2,4-dichlorophenoxyacetic acid (2,4-D) in comparison to the value of normal plantlets (60 %) regenerated from mature zygotic embryos inoculated in media with 2,4-D. This result demonstrates that IZE of P. miniata and P. speciosa possess sufficient levels of endogenous phytohormones to trigger a high rate of indirect somatic embryogenesis. All regenerated plantlets had the same genome size and chromosome number as the explant donor plants. Therefore, the indirect embryogenic pathway, employing IZE inoculated into media free of growth regulators, did not cause changes in the karyotype and morphology. Based on these results, IZE should be considered as explant for the establishment of somatic embryogenesis in other species. Besides, a new, reliable and relatively rapid protocol to recover plantlets of P. miniata and P. speciosa yielded several plants, which were acclimatised and used for ornamental purposes and breeding programs, and for reintroduction into biological reserves.

Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil,

Abstract: Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil. Methods: This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia. Results: Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%. Conclusions: We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.

Lung-dominant connective tissue disease among patients with interstitial lung disease: prevalence, functional stability, and common extrathoracic features.

Abstract: OBJECTIVE: To describe the characteristics of a cohort of patients with lung-dominant connective tissue disease (LD-CTD). METHODS: This was a retrospective study of patients with interstitial lung disease (ILD), positive antinuclear antibody (ANA) results (≥ 1/320), with or without specific autoantibodies, and at least one clinical feature suggestive of connective tissue disease (CTD). RESULTS: Of the 1,998 patients screened, 52 initially met the criteria for a diagnosis of LD-CTD: 37% were male; the mean age at diagnosis was 56 years; and the median follow-up period was 48 months. During follow-up, 8 patients met the criteria for a definitive diagnosis of a CTD. The remaining 44 patients comprised the LD-CTD group, in which the most prevalent extrathoracic features were arthralgia, gastroesophageal reflux disease, and Raynaud's phenomenon. The most prevalent autoantibodies in this group were ANA (89%) and anti-SSA (anti-Ro, 27%). The mean baseline and final FVC was 69.5% and 74.0% of the predicted values, respectively (p > 0.05). Nonspecific interstitial pneumonia and usual interstitial pneumonia patterns were found in 45% and 9% of HRCT scans, respectively; 36% of the scans were unclassifiable. A similar prevalence was noted in histological samples. Diffuse esophageal dilatation was identified in 52% of HRCT scans. Nailfold capillaroscopy was performed in 22 patients; 17 showed a scleroderma pattern. CONCLUSIONS: In our LD-CTD group, there was predominance of females and the patients showed mild spirometric abnormalities at diagnosis, with differing underlying ILD patterns that were mostly unclassifiable on HRCT and by histology. We found functional stability on follow-up. Esophageal dilatation on HRCT and scleroderma pattern on nailfold capillaroscopy were frequent findings and might come to serve as diagnostic criteria.

Effects of the open lung concept following ARDSnet ventilation in patients with early ARDS

Abstract: Ventilation with low tidal volume (V T ) is well recognized as a protective approach to patients with acute respiratory distress syndrome (ARDS), but the optimal level of positive end-expiratory pressure (PEEP) remains uncertain. This study aims to evaluate two protective ventilatory strategies sequentially applied in patients with early ARDS.

Multiploidy occurrence in tomato calli from anther culture

Abstract: Anther culture has long been used for the production of fully homozygous lines in order to produce, mainly, doubled haploid plants, which are of great interest in plant breeding. For tomato, a recalcitrant species for androgenesis production protocols have not been standardized. It is known that the genotype, anther size, the developmental stage of the microspore, and the medium composition are some factors that can influence the calli production. The present study aimed to adapt flow cytometry methodology to verify the microsporogenesis phases of anthers in order to assess the anther responsiveness of different tomato genotypes in an androgenesis-induction culture medium and to analyze the DNA ploidy level of calli produced by flow cytometry. Anthers from flower buds of length 1.0 to 5.9 mm, corresponding to the size range as analyzed by flow cytometry and cytogenetic methods, were inoculated into Murashige and Skoog (MS) basal medium containing the growth regulators 6-(y,y-dimethylallylamino) purine and indole-3-acetic acid. The obtained calli were subsequently analyzed by flow cytometry to determine the DNA ploidy level. Surprisingly, despite no pretreatment with microtubule-depolymerizing agents, five classes of multiploid calli were observed, as follows: class I (2C-4C-8C-16C), class II (2C-4C-8C-16C-32C), class III (4C-8C), class IV (4C-8C-16C) and class V (8C-16C-32C). Multiploid calli were identified in short-term (two month) culturing, suggesting that the variable culture duration did not directly influence the occurrence of endoreduplication. In this work, this type of somaclonal variation has been reported for the first time in tomato anther culture, and their possible origin has been discussed. Key words: Callogenesis, flow cytometry, polyploidy, Solanum lycopersicum, somaclonal variation.

Doença pulmonar em pacientes com artrite reumatoide: avaliação radiográfica e espirométrica

Abstract: Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA).Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry.Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure.Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

Early sex discrimination in Carica papaya by nuclei FISH

Abstract: Carica papaya L. is a polygamous species with three sex types: male, female and hermaphrodite. However, the sex identification is only possible after flowering, by inspection of the flowers, which takes time, labor and financial resources. Molecular biology researchers have developed a number of genetic markers in an attempt to distinguish the papaya sex before reaching reproductive maturity. In the present study, we aimed to provide a molecular diagnosis of early sexing for the female and hermaphrodite plants of two commercially important Brazilian varieties of C. papaya (‘Golden’ and ‘Rubi’). For this, it was investigated seven sequence characterized amplified region markers previously described in the literature by the polymerase chain reaction technique, and then, it was developed a probe for fluorescence in situ hybridization (FISH) protocol by using a chosen marker as probe. This molecular marker was selected based on its consistently polymorphic banding pattern, which was also demonstrated by FISH analyses: fluorescent signals in hermaphrodite nuclei isolated from leaves of both cultivars, but no detectable intensity fluorescence signal in female nuclei from both cultivars. Once the probe was constructed, this new and reliable technique, based on FISH in nuclei, could be a valuable tool for sexing the papaya seedlings with commercial application in large scale and open the possibility towards automatized diagnostic assay.

Diagnostic methods to assess inspiratory and expiratory muscle strength* Métodos diagnósticos para avaliação da força muscular inspiratória e expiratória

Abstract: Impairment of (inspiratory and expiratory) respiratory muscles is a common clinical finding, not only in patients with neuromuscular disease but also in patients with primary disease of the lung parenchyma or airways. Although such impairment is common, its recognition is usually delayed because its signs and symptoms are nonspecific and late. This delayed recognition, or even the lack thereof, occurs because the diagnostic tests used in the assessment of respiratory muscle strength are not widely known and available. There are various methods of assessing respiratory muscle strength during the inspiratory and expiratory phases. These methods are divided into two categories: volitional tests (which require patient understanding and cooperation); and non-volitional tests. Volitional tests, such as those that measure maximal inspiratory and expiratory pressures, are the most commonly used because they are readily available. Non-volitional tests depend on magnetic stimulation of the phrenic nerve accompanied by the measurement of inspiratory mouth pressure, inspiratory esophageal pressure, or inspiratory transdiaphragmatic pressure. Another method that has come to be widely used is ultrasound imaging of the diaphragm. We believe that pulmonologists involved in the care of patients with respiratory diseases should be familiar with the tests used in order to assess respiratory muscle function.Therefore, the aim of the present article is to describe the advantages, disadvantages, procedures, and clinical applicability of the main tests used in the assessment of respiratory muscle strength.

Can patients maintain their use of everolimus until lung transplantation

Abstract: L transplantation is the standard of care for selected patients with advanced lung diseases, with more than 45,000 procedures performed until 2013. The median survival time after procedure is markedly increasing; therefore, caregivers seek to reduce long-term complications by developing maintenance immunosuppressive regimens that minimize use of calcineurin inhibitors (CNIs) because these drugs increase the risk of chronic renal failure, diabetes, hyperlipidemia, and hypertension. The introduction of mechanistic target of rapamycin (mTOR) inhibitors provided an opportunity for limiting CNI exposurewithout loss of efficacy.However, these drugs are antiproliferative, and their early use is not recommended because of the risk of bronchial dehiscence. Moreover, because lung retransplantation remains a therapeutic option in patients with chronic lung allograft dysfunction (CLAD), there is concern that the preoperative use of mTOR inhibitors may increase the risk of bronchial dehiscence after retransplantation. It is suggested that mTOR inhibitors should be used after bronchial anastomosis has healed; however, limited information is available on their preoperative use. Here, we describe 2 patients who recently underwent lung retransplantation after receiving everolimus as adjunctive immunosuppressant for decreasing the dose of CNIs. Patient 1 was a 27-year-old woman with cystic fibrosis who underwent bilateral lung transplantation. She was prescribed cyclosporine (10 mg/kg per day, therapeutic drug monitoring [TDM], 250 ng/mL), sodium mycophenolate (1080 mg/day), and prednisone (0.25 mg/kg per day). She developed rapidly progressive bronchiolitis obliterans associated

What if my lung-dominant connective tissue disease (LD-CTD) patient eventually met criteria for a definite CTD: The role of prognosis!

Abstract: Objectives: Evaluate the characteristics of patients with lung-dominant connective tissue disease (LD-CTD) that eventually met criteria for a definite CTD. Methods: Patients with interstitial lung disease and positive antinuclear antibody results (≥1/320) and/or specific autoantibodies with at least one clinical extrathoracic feature suggesting a CTD were retrospectively evaluated. Results: Of the 1998 patients screened, 63 initially met the LD-CTD criteria. Eleven (18%) patients eventually met a definitive CTD criteria during follow-up [4 scleroderma(SSc), 3 polimyositis(PM), 3 Sjogren9s and 1 Rheumatoid Arthritis], after a median of 40 months, comprising the CTD group. Comparison between the CTD and the LD-CTD groups showed no statistically difference in age at diagnosis (53 vs 58 months), extrathoracic features of a CTD, autoantibody profile, ILD pattern (NSIP in 54% and 40%) or PFTs behavior over time. However, CTD group had a longer follow-up (median 84 vs. 52 months, p=0.003) and no death registered, opposed to 21% mortality rate in the LD-CTD group (p=0.09). Comparison between the deceased and survived groups showed significant differences in smoking (91% vs 42%, p=0.003) and follow-up length (median 58 vs 23 months, p= 0.0002). Conclusions: Our LD-CTD cohort showed a minority of patients who eventually met a definite CTD, mostly SSc, only after a long follow-up period. The persistent LD-CTD group had a shorter follow-up length and higher mortality with marginal statistical significance. No deaths were noticed in the CTD group, despite been followed more longer than the LD-CTD group, suggesting that LD-CTD might have a worse prognosis.

My time at the JBP

Abstract: 403 It has been a few months since I completed my term as Editor-in-Chief of the Brazilian Journal of Pulmonology (BJP), and it is great to be able to write about those four years, especially as our Journal completes its 40th year in publication. In Brazil, being the editor of a scientific journal is an additional task to juggle, along with academic or health care activities. I remember the conversations I had, before my editorship, with the President of the Brazilian Thoracic Association (BTA)—Roberto Stirbulov—and with the Editor who preceded me—José Baddini Martinez. I was reluctant, because I was well aware of the huge workload and, especially, of the enormous responsibility that I would have going forward. In my first Editorial, I emphasized the fundamental work of those who had preceded me, who had succeeded in getting the BJP indexed for the major international databases. I also emphasized how important it was that we (university professors and other health professionals in the field of respiratory medicine), work together to improve the scientific quality of our Journal, in order to gain more respect at the national and international level. I committed myself to leading this mission. received its first impact factor from Journal Citation Reports (JCR), an Institute for Scientific Information (ISI) Web of Knowledge database, and this was greatly celebrated. We had been monitoring the performance of the BJP in other databases, especially Scopus, which has its own metric (SCImago Journal Rank), and we expected to fare well in the ranking. In fact, the result was highly positive, placing us in a prominent position among Brazilian scientific journals (the BJP ranked third among medical journals) and in an admirable intermediate position among all respiratory journals worldwide. In 2013, however, the BJP was excluded from the JCR list. The argument was that we had received an anomalously large number of citations in an article published in another Brazilian journal, which could artificially inflate our impact factor. That was a time of great tension. Our (temporary) exclusion led to a series of measures being taken by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, Office for the Advancement of Higher Education), the agency that evaluates graduate programs in Brazil, and this negatively impacted its tri-annual evaluation of several of our programs. What discomforted me greatly, and even made me a little angry, was that CAPES did not allow any of …