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Predisposing factors for symptoms of anxiety, depression, and insomnia in university students anxiety depression
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Oliveira, Júlia Couto de

; Neves, Vanessa Ribeiro

; Céspedes, Juliana Garcia

; D’Almeida, Vânia

; Okuno, Meiry Fernanda Pinto

; Figueiredo, Laís Lira

; Cerqueira, Ana Rafaela de Brito

; Rosa, Anderson da Silva

Revista Brasileira de Enfermagem

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2024, Volume 77 N. 6 elocation e20230387

Abstract: En Pt Es | Text: En Pt Es | PDF: En | PDF: Pt | PDF: Es

ABSTRACT Objectives: to characterize the sociodemographic and psychological aspects of university students who sought psychiatric care at a Student Support Center of a Federal University and to analyze associations between mental health issues and predisposing factors. Methods: a retrospective analysis of 103 medical records was conducted. The statistical analysis consisted of two steps: a descriptive analysis and a predictive analysis using the Logistic Regression Model. Results: the majority of the students were female. Symptoms of anxiety, depression, and insomnia were the main reasons for seeking care. Students who reported having emotional difficulties that negatively impacted their studies and those who had undergone some form of health treatment showed a higher probability of experiencing anxiety symptoms. Notable correlations were found between anxiety and emotional difficulties, depression and diarrhea, and insomnia and a sedentary lifestyle. Conclusions: symptoms of anxiety, depression, and insomnia led students to seek psychiatric care at the university. Understanding the predisposing factors for mental health issues in university students can inform care strategies and promote academic success. Objectives Methods 10 conducted steps Model Results female diarrhea lifestyle Conclusions success 1

RESUMO Objetivos: caracterizar aspectos sociodemográficos e psicológicos de estudantes universitários que buscaram atendimento psiquiátrico em um Núcleo de Apoio Estudantil de uma Universidade Federal e analisar associações entre alterações de saúde mental e fatores predisponentes. Método: análise retrospectiva de 103 prontuários. A análise estatística consistiu em duas etapas: uma descritiva e uma preditiva pelo Modelo de Regressão Logística. Resultados: a maioria dos estudantes é do gênero feminino. Sintomas de ansiedade, depressão e insônia foram os principais motivos para a procura de atendimento. Estudantes que afirmaram ter dificuldades emocionais prejudiciais aos estudos e os que realizaram algum tratamento para saúde apresentaram maior probabilidade de apresentar sintomas de ansiedade. Destacaram-se correlações entre ansiedade e dificuldades emocionais; depressão e diarreia; e insônia e sedentarismo. Conclusões: sintomas de ansiedade, depressão e insônia levaram estudantes ao atendimento psiquiátrico na universidade. Conhecer fatores predisponentes para adoecimento em saúde mental de universitários pode fundamentar estratégias de cuidado e favorecer o sucesso acadêmico. Objetivos Método 10 prontuários etapas Logística Resultados feminino Destacaramse Destacaram se diarreia sedentarismo Conclusões universidade acadêmico 1

RESUMEN Objetivos: caracterizar los aspectos sociodemográficos y psicológicos de los estudiantes universitarios que buscaron atención psiquiátrica en un Núcleo de Apoyo Estudiantil de una Universidad Federal y analizar las asociaciones entre las alteraciones de salud mental y los factores predisponentes. Métodos: se realizó un análisis retrospectivo de 103 historiales médicos. El análisis estadístico consistió en dos etapas: un análisis descriptivo y un análisis predictivo utilizando el Modelo de Regresión Logística. Resultados: la mayoría de los estudiantes eran mujeres. Los síntomas de ansiedad, depresión e insomnio fueron las principales razones para buscar atención. Los estudiantes que informaron tener dificultades emocionales que afectaron negativamente sus estudios y aquellos que habían recibido algún tipo de tratamiento de salud mostraron una mayor probabilidad de experimentar síntomas de ansiedad. Se encontraron correlaciones significativas entre ansiedad y dificultades emocionales, depresión y diarrea, e insomnio y un estilo de vida sedentario. Conclusiones: los síntomas de ansiedad, depresión e insomnio llevaron a los estudiantes a buscar atención psiquiátrica en la universidad. Conocer los factores predisponentes de los problemas de salud mental en los estudiantes universitarios puede fundamentar estrategias de cuidado y promover el éxito académico. Objetivos Métodos 10 médicos etapas Logística Resultados mujeres diarrea sedentario Conclusiones universidad académico 1

https://doi.org/10.1590/0034-7167-2023-0387

CASE SERIES OF PATIENTS UNDER BIWEEKLY TREATMENT WITH LARONIDASE: A REPORT OF A SINGLE CENTER EXPERIENCE
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Kyosen, Sandra Obikawa

; Toma, Leny

; Nader, Helena Bonciani

; Braga, Marion Coting

; Pereira, Vanessa Gonçalves

; Canossa, Sueli

; Pesquero, João Bosco

; D’Almeida, Vânia

; Martins, Ana Maria

Revista Paulista de Pediatria

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sep 2019, Volume 37 N. 3 Pages 312 - 317

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Objetivo: Descrever a manutenção dos níveis de glicosaminoglicano (GAG) excretados na urina e da estabilização clínica em pacientes com mucopolissacaridose do tipo I (MPS I) com o uso da laronidase num regime de dose alternativo de 1,2 mg/kg a cada duas semanas. Método: Alguns pacientes do nosso serviço participaram de um estudo de otimização de dose da laronidase para o tratamento da MPS I no qual foram comparados quatro esquemas terapêuticos: 0,58 mg/kg/semana, 1,2 mg/kg a cada duas semanas, 1,2 mg/kg/semana e 1,8 mg/kg a cada duas semanas. Após o término do estudo, todos os pacientes passaram a receber a terapia de reposição enzimática (TRE) na dose padrão de bula, que é de 0,58 mg/kg/semana, e nesse regime alguns pais se queixaram da dificuldade em comparecer ao centro todas as semanas, além da dificuldade de se obter acesso para punção venosa. Com base nessas queixas, oito pacientes passaram a receber a TRE no regime alternativo de 1,2 mg/kg a cada duas semanas. Foi feito o estudo retrospectivo de dados de prontuário de pacientes com MPS I que fizeram TRE com laronidase nas doses 0,58 mg/kg/semana e 1,2 mg/kg a cada duas semanas. Resultados: Os pacientes mantiveram-se clinicamente estáveis, não apresentaram aumento dos níveis de GAG urinários nem eventos adversos durante o regime alternativo de dose. Conclusões: A mudança para o esquema de 1,2 mg/kg de laronidase a cada duas semanas foi segura e não acarretou piora clínica nos pacientes que já estavam em TRE na dose padrão.

ABSTRACT Objective: To report the stabilization of urinary glycosaminoglicans (GAG) excretion and clinical improvements in patients with mucopolysaccharidosis type I (MPS I) under an alternative dose regimen of laronidase of 1.2 mg/kg every other week. Methods: We participated in a dose-optimization trial for laronidase in MPS-I patients using four alternative regimens: 0.58 mg/kg every week, 1.2 mg/kg every two weeks, 1.2 mg/kg every week and 1.8 mg/kg every other week (EOW). After the trial ended, the patients resumed the recommended dose and regimen of 0.58 mg/kg every week. Under this regimen, some patients presented difficulties in venous access and were unable to commute weekly to the treatment center. Therefore, we used an alternative regimen that consisted of 1.2 mg/kg EOW in eight patients. A retrospective study of medical records of MPS-I patients who underwent both enzyme replacement therapy (ERT) regimens, of 0.58 mg/kg every week and 1.2 mg/kg EOW, was done. Results: Patients remained clinically stable under the alternative regimen, did not present elevation of urinary GAG nor any adverse event. Conclusions: The switch of dose regimen to 1.2 mg/kg EOW of laronidase was safe, and did not cause any clinical worsening in patients who had been previously under standard dose ERT.

https://doi.org/10.1590/1984-0462/;2019;37;3;00010 890 downloads

Oxidative stress assessment by glutathione peroxidase activity and glutathione levels in response to selenium supplementation in patients with Mucopolysaccharidosis I, II and VI
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Oliveira-Silva, José Araújo de

; Yamamoto, Joyce Umbelino Pinto

; Oliveira, Renata Bernardes de

; Monteiro, Vaneisse Cristina Lima

; Frangipani, Beatriz Jurkiewcz

; Kyosen, Sandra Obikawa

; Martins, Ana Maria

; D’Almeida, Vânia

Genetics and Molecular Biology

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mar 2019, Volume 42 N. 1 Pages 1 - 8

Abstract: En | Text: En | PDF: En

Abstract We assessed levels of plasma selenium (Se), selenoproteins and their change after Se supplementation in patients with mucopolysaccharidosis (MPS) types I, II and VI. This was done in a retrospective study of the medical records of 30 patients with MPS I (n=13), MPS II (n=9) and MPS VI (n=8) who were being treated with enzyme replacement therapy. As part of routine nutritional monitoring, Se levels were measured, revealing that 28 patients (93.3%) had values below the normal range. Therefore, they received supplementation for 12 months, and Se was measured after 6 and 12 months. Glutathione peroxidase (GPx) activity, total glutathione (GSHt), oxidized glutathione (GSSG) and reduced glutathione (GSH) were measured at baseline and 6 months after Se supplementation. The mean GSHt at baseline was 7.90 ± 2.36 μmol/g Hb, and after Se supplementation it was 5.76 ± 1.13 μmol/g Hb; GSH/GSSG was 2.3 ± 1.16 at baseline and 0.58 ± 0.38 after supplementation. GPx activity was 16.46 ± 3.31 U/g Hb at baseline and 4.53 ± 4.92 U/g Hb after Se supplementation. The difference was shown to be statistically significant by paired t-test. In conclusion, our study demonstrated that oxidative stress parameters were altered by Se supplementation in patients with MPS I, II and VI who were previously deficient in Se.

https://doi.org/10.1590/1678-4685-gmb-2017-0334 2498 downloads

Diagnosis and Management of Classica Homocystinuria in Brazil: A Summary of 72 Late-Diagnosed Patients
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Poloni, Soraia

; Hoss, Giovana W.

; Sperb-Ludwig, Fernanda

; Borsatto, Taciane

; Doriqui, Maria Juliana R.

; Leão, Emília K.E.A

; Boa-Sorte, Ney

; Lourenço, Charles M.

; Kim, Chong A.

; Souza, Carolina F. M. de

; Rocha, Helio

; Ribeiro, Marcia

; Steiner, Carlos E.

; Moreno, Carolina A.

; Bernardi, Pricila

; Valadares, Eugenia

; Artigalas, Osvaldo

; Carvalho, Gerson

; Wanderley, Hector Y. C.

; D’Almeida, Vânia

; Santana-da-Silva, Luiz C.

; Blom, Henk J.

; Schwartz, Ida V. D.

Journal of Inborn Errors of Metabolism and Screening

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2018, Volume 6 elocation e180007

Abstract: En | Text: En | PDF: En

Abstract This study described a broad clinical characterization of classical homocystinuria (HCU) in Brazil. This was a cross-sectional, observational study including clinical and biochemical data from 72 patients (60 families) from Brazil (South, n = 13; Southeast, n = 37; Northeast, n = 8; North, n = 1; and Midwest, n = 1). Parental consanguinity was reported in 42% of families. Ocular manifestations were the earliest detected symptom (53% of cases), the main reason for diagnostic suspicion (63% of cases), and the most prevalent manifestation at diagnosis (67% of cases). Pyridoxine responsiveness was observed in 14% of patients. Only 22% of nonresponsive patients on treatment had total homocysteine levels <100 mmol/L. Most commonly used treatment strategies were pyridoxine (93% of patients), folic acid (90%), betaine (74%), vitamin B12 (27%), and low-methionine diet + metabolic formula (17%). Most patients diagnosed with HCU in Brazil are late diagnosed, express a severe phenotype, and poor metabolic control. Milder forms of HCU are likely underrepresented due to underdiagnosis.

https://doi.org/10.1177/2326409818788900 1352 downloads

Program of combined physical exercise reduces the perception of pain in a patient with sickle cell anemia. Case report
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Botelho, Renata

; Guerra, Ricardo Luís Fernandes

; D’Almeida, Vânia

; Medeiros, Alessandra

Revista Dor

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sep 2017, Volume 18 N. 3 Pages 270 - 274

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO JUSTIFICATIVA E OBJETIVOS: A anemia falciforme é uma das doenças hematológicas hereditárias mais frequentes no mundo. Dentre as diversas manifestações clínicas, a principal característica dessa doença são as crises dolorosas. Considerando o crescente número de indivíduos com anemia falciforme no Brasil, o aumento da expectativa de vida desses indivíduos, e que ainda recebem orientação para restringirem práticas de esforços físicos, investigações sobre o tema se tornam relevantes, uma vez que o exercício físico tem sido elencado como estratégia na promoção da saúde. O objetivo deste estudo foi analisar a percepção da dor, algumas respostas fisiológicas e a qualidade de vida de uma portadora de anemia falciforme submetida a um programa de exercício físico combinado (aeróbio e resistido). RELATO DO CASO: Paciente do sexo feminino, 56 anos de idade, diagnosticada com anemia falciforme quando criança, e no decorrer desta pesquisa não fez uso rotineiro de fármacos para o controle da doença. No exame físico e ergoespirométrico, e durante o período de intervenção de quatro meses de exercício físico combinado, não apresentou quadro clínico crítico, apenas algumas dificuldades características, como: dores osteomusculares, baixa resistência cardiorrespiratória e fadiga precoce. CONCLUSÃO: Os resultados sugeriram que um programa de exercício físico combinado e regular produziu alterações importantes para a paciente, em diferentes aspectos relacionados à sua saúde, dentre elas destacam-se a diminuição da dor osteomuscular e aumento da aptidão física geral, contribuindo para a melhora da percepção da qualidade de vida.

ABSTRACT BACKGROUND AND OBJECTIVES: Sickle cell anemia is one of the most common hereditary hematological disease in the world. Among many clinical manifestations, the main characteristic of this disease is the painful crises. Considering the increasing number of individuals with sickle cell anemia in Brazil, the increase in life expectancy of these individuals, who are advised to restrict physical activity, it is important to investigate this subject since exercises have been listed as relevant in health promotion. The objective of this study was to analyze the perception of pain, some physiological responses and the quality of life of a patient with sickle cell anemia undergoing a program of physical exercises (aerobic and resistance). CASE REPORT: Female patient, 56 years old, diagnosed with sickle cell anemia as a child, and in the course of this research did not make routine use of drugs in the control of the disease. On physical and ergo-spirometric examination, and during four-month of combined exercise, she did not present critic clinical condition, only some characteristic difficulties such as musculoskeletal pain, low cardiorespiratory resistance, and early fatigue. CONCLUSION: The results suggested that a program of combined and regular exercises produced important changes in the patient, in several aspects related to her health, including the reduction of musculoskeletal pain and increased general physical fitness, contributing to the improvement of the perception of quality of life.

https://doi.org/10.5935/1806-0013.20170114 8607 downloads

Tryptophan overloading activates brain regions involved with cognition, mood and anxiety
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SILVA, LUANA C.A.

; VIANA, MILENA B.

; ANDRADE, JOSÉ S.

; SOUZA, MELYSSA A.

; CÉSPEDES, ISABEL C.

; D’ALMEIDA, VÂNIA

Anais da Academia Brasileira de Ciências

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mar 2017, Volume 89 N. 1 Pages 273 - 283

Abstract: En | Text: En | PDF: En

ABSTRACT Tryptophan is the only precursor of serotonin and mediates serotonergic activity in the brain. Previous studies have shown that the administration of tryptophan or tryptophan depletion significantly alters cognition, mood and anxiety. Nevertheless, the neurobiological alterations that follow these changes have not yet been fully investigated. The aim of this study was to verify the effects of a tryptophan-enriched diet on immunoreactivity to Fos-protein in the rat brain. Sixteen male Wistar rats were distributed into two groups that either received standard chow diet or a tryptophan-enriched diet for a period of thirty days. On the morning of the 31st day, animals were euthanized and subsequently analyzed for Fos-immunoreactivity (Fos-ir) in the dorsal and median raphe nuclei and in regions that receive serotonin innervation from these two brain areas. Treatment with a tryptophan-enriched diet increased Fos-ir in the prefrontal cortex, nucleus accumbens, paraventricular hypothalamus, arcuate and ventromedial hypothalamus, dorsolateral and dorsomedial periaqueductal grey and dorsal and median raphe nucleus. These observations suggest that the physiological and behavioral alterations that follow the administration of tryptophan are associated with the activation of brain regions that regulate cognition and mood/anxiety-related responses.

https://doi.org/10.1590/0001-3765201720160177 2778 downloads

Homocysteine and Psychiatric Disorders
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Silva, Vanessa Cavalcante da

; Oliveira, Allan Chiaratti de

; D’Almeida, Vânia

Journal of Inborn Errors of Metabolism and Screening

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2017, Volume 5 elocation e160031

Abstract: En | Text: En | PDF: En

Abstract Psychiatric disorders are highly prevalent all over the world with a great impact on public health. Altered homocysteine metabolism is implicated in the pathogenesis of many of these disorders, as it can interfere in normal methylation of subcellular components, promote neuroexcitotoxicity, and induce oxidative stress and inflammation. There are cumulative data implicating these mechanisms in the development of autism, schizophrenia, depression, bipolar disorder, and Alzheimer disease. Altered homocysteine metabolism is multifactorial in its origin. On one hand, genetic factors act as predisposing factors through brain development and function, and on the other hand, environmental factors give the opportunity for nutritional interventions improving metabolic status and possibly also clinical parameters. This article provides a review on the association of 1-carbon metabolism and autism, schizophrenia, depression, bipolar disorder, and dementia and goes through studies on the role of different cofactors and metabolites involved in this pathway.

https://doi.org/10.1177/2326409817701471 1388 downloads

Avaliação da relação entre o polimorfismo C677T no gene para MTHFR e a concentração plasmática de homocisteína na doença arterial coronariana
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Muniz, Maria Tereza C.

; Siqueira, Erika R.F.

; Fonseca, Rosana A.

; D’Almeida, Vânia

; Hotta, Júlia K.

; Santos, José E. dos

; Cavalcanti, Maria do S.M.

; Sampaio, Cláudio A.M.

Arquivos Brasileiros de Endocrinologia & Metabologia

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dec 2006, Volume 50 N. 6 Pages 1059 - 1065

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

OBJETIVO: O objetivo deste trabalho é determinar a prevalência do polimorfismo C677T do gene metilenotetraidrofolato redutase (MTHFR) e associá-la com a concentração plasmática de homocisteína plasmática na doença arterial coronariana (DAC). MÉTODOS: Foram avaliados 93 pacientes com DAC documentada, atendidos no Hospital Universitário Oswaldo Cruz (Recife, PE, Brasil), e 108 controles sem a doença. Foram determinados os perfis lipídicos de pacientes e controles. As concentrações plasmáticas de homocisteína e folato foram determinadas por HPLC e quimioluminescência, respectivamente. A genotipagem foi realizada por RFLP/PCR. RESULTADOS: Os grupos de pacientes e controles foram homogêneos quanto aos perfis genéticos do polimorfismo investigado. Nos pacientes, as concentrações plasmáticas médias de homocisteina (11,7 ± 4,4 µmol/L) e de folato (6,22 ± 3,0 ng/dL) foram estatisticamente diferentes daquelas observadas nos controles (8,84 ± 3,2 µmol/L e 7,69 ± 3,1 ng/dL, respectivamente), ao nível de significância de 0,05. Entretanto, não houve correlação entre concentração plasmática de homocisteína e folato nos pacientes (r= -0,202). Não foi observada associação entre a homozigosidade 677TT para MTHFR e a concentração plasmática de homocisteína sérica (p= 0,634). A comparação dos casos e controles que apresentaram simultaneamente alta concentração plasmática de homocisteína e baixa concentração de folato, resultou numa razão de chance superior à de cada variável analisada independentemente (RC= 11,9; IC 95%= 4,16-34,42, p< 0,01). CONCLUSÕES: A mutação C677T não parece ser um fator genético importante capaz de explicar a hiperhomocisteinemia moderada observada nos pacientes com DAC. Outros fatores, ambientais e genéticos, devem ser investigados.

OBJECTIVE: The aim of this study is to determine the prevalence of C677T methylenetetrahydrofolate reductase (MTHFR) polymorphism and correlate it with plasma homocysteine levels in coronary artery disease (CAD). METHODS: Ninety-three patients with documented CAD from Hospital Universitário Oswaldo Cruz (Recife, PE, Brazil) and 108 healthy controls were evaluated. Homocysteine and folate levels were determined by HPLC and chemoluminescence, respectively, and lipid profile was considered. Genotyping was done by RFLP/PCR. RESULTS: The groups were homogeneous for the C677T polymorphisms. The homocysteine level in cases (11.7 µmol/L) was statistically different from that observed in controls (8.84 µmol/L, p< 0.05). It was also observed that 72% of the patients had homocysteine values above12 µmol/L while the control group presented only 32% in this range. There was no relationship between homozigosity for the C677T polymorphism and the homocysteine level (p= 0.634). We noticed statistical differences between folate levels from patients and controls (6.22 and 7.69 ng/dL, p< 0.05, respectively). However, there was no correlation between homocysteine and folate concentrations in the entire group (r= -0.202). Comparing cases and controls, the odds ratio (OR) when homocysteine is high and folate is low was OR= 11.9; CI 95%= 4.16-34.42, p< 0.01. CONCLUSION: A lack of correlation between C677T mutation and homocysteine level suggests that environmental factors and others genetic factors seem to exert more influence on homocysteine level in this population.

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Alzheimer's disease in Brazilian elderly has a relation with homocysteine but not with MTHFR polymorphisms
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Silva, Vanessa Cavalcante da

; Ramos, Flávio José da Costa

; Freitas, Elizabete Malaquias

; Brito-Marques, Paulo Roberto de

; Cavalcanti, Márcia Nery de Holanda

; D’Almeida, Vânia

; Cabral-Filho, José Eulálio

; Muniz, Maria Tereza Cartaxo

Arquivos de Neuro-Psiquiatria

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dec 2006, Volume 64 N. 4 Pages 941 - 945

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

OBJETIVO: Investigar a associação entre a concentração plasmática total de homocisteína (Hcy), os polimorfismos C677T e A1298C do gene MTHFR e o desenvolvimento da Doença de Alzheimer (AD). MÉTODO: Foram avaliados 43 pacientes com doença de Alzheimer possível (37%) e provável (63%) e 50 controles não dementes, não divergentes quanto ao sexo, idade, anos de escolaridade, diabetes, consumo de álcool e de café e vida sedentária. Os níveis plasmáticos de homocisteína foram determinados por HPLC e a genotipagem para MTHFR por PCR/RFLP. A comparação dos níveis de homocisteína foi realizada pelo teste "U" Mann-Whitney, a comparação das proporções dos genótipos e alelos pelo teste de Fisher-Freeman-Halton e as demais variáveis qualitativas, pelo teste do qui-quadrado. RESULTADOS: Os pacientes AD apresentaram níveis mais elevados de Hcy plamática total do que os controles e a diferença entre os grupos foi estatisticamente significante. Não houve diferença nas distribuições genotípicas C677T e A1298C entre pacientes e controles. A concentração de Hcy não variou com os genótipos. CONCLUSÃO: Nossos dados confirmam a associação de concentração elevada de Hcy plasmática com DA e sugerem que os polimorfismos C677T e A1209C não contribuem para a susceptibilidade genética a DA em idosos do Nordeste do Brasil.

OBJECTIVE: To investigate the association between total plasma homocysteine concentration, C677T and A1298C polymorphisms in MTHFR gene and Alzheimer's disease (AD) development. METHOD: Forty-three patients with probable (63%) and possible (37%) AD and 50 non-demented controls were evaluated. Groups did not differ as to gender, age, scholar years, diabetes, alcohol and coffee intake and physical activity. Total plasma homocysteine (Hcy) levels were determined by HPLC and genotyping for MTHFR by PCR/RFLP. Mann-Whitney "U" test was used to compare quantitative variable, Fisher-Freeman-Halton test to compare genotypes and allele proportions and Chi-square test to other qualitative variables. RESULTS: AD patients presented higher total plasma Hcy levels than controls and the difference was statistically significant. No differences in the C677T and A1298C MTHFR polymorphisms distributions were found between patients and controls. Plasma homocysteine concentration did not change with MTHFR genotypes. CONCLUSION: Our data confirms the association between increased plasma Hcy concentration and AD and suggests that neither C677T nor A1298C MTHFR polymorphisms contributed to genetic susceptibility for AD in elderly individuals in the Northeast of Brazil.

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