The effect of the collateral cerebrovascular circulation on tolerance to carotid artery cross-clamping and on early outcome after carotid endarterectomy.

OBJECTIVE: The Circle of Willis (CoW) serves as the primary source of contralateral blood supply in patients who undergo carotid artery cross-clamping (CC) for carotid endarterectomy (CEA). It has been suggested that the CoW's anatomy influences CEA outcomes. The aim of this study was to evaluate associations between the cerebral collateral circulation, a positive awake test for intraoperative neurologic deficit after carotid CC, and postoperative adverse neurologic events. METHODS: A systematic review was conducted searching MEDLINE, Cochrane, and Web of Science databases for studies that assessed the cerebral circulation, including CoW variations, using neuroimaging techniques in patients who underwent carotid CC. For the metanalytical incidence, the statistical technique used was weight averaging. Otherwise, descriptive analysis was used due to the excessive heterogeneity of the studies. RESULTS: Eight publications, seven cohort and one case-controlled study, involving 1313 patients who underwent carotid artery CC under loco-regional anesthesia, were included in the systematic review. The incidence of positive awake test in the cohort studies ranged from 4.4% to 19.7%. Carotid artery CC resulted in positive awake test in 5% to 91% of patients with alterations in the anterior portion and in 27% to 74% with alterations in the posterior portion of the CoW. A positive awake test in patients with contralateral carotid stenosis or occlusion ranged from 5.8% to 45.7%. Contralateral carotid stenosis >70% or occlusion were associated with a positive awake test (P < .001). Patients with incomplete CoW did not have statistically significant correlation with intraoperative neurological deficits after CC. Data were insufficient to evaluate the effect of the collateral circulation on early outcome after CEA. CONCLUSIONS: In this systematic review, contralateral carotid artery stenosis or occlusion, but not CoW abnormalities, were associated with a positive awake test after carotid artery CC. Further research is needed to evaluate which specific CoW anomaly predicts neurologic deficit after CC and to confirm association between a positive awake test and clinical outcome after CEA.

A multi-national survey to identify clinicians' perspectives concerning Proton Pump inhibitors in patients with systemic sclerosis.

OBJECTIVES: Proton Pump Inhibitors (PPIs) are widely used in SSc for gastroesophageal reflux disease (GERD). However, there is little evidence to support their empirical use and long-term safety has been questioned. Our objective was to better describe clinicians' attitudes toward PPIs prescription and use in SSc patients. METHODS: Clinicians involved in the care of SSc patients were invited through international physician networks and social media to participate in an online survey. RESULTS: Responses from 227 clinicians from 36 countries were evaluable. The majority 'agreed' (41.4 %) or 'strongly agreed' (45.4 %) that GERD is a major cause of morbidity in SSc. Lifestyle modifications are seldom (16 %) considered effective. Only half 'agreed' (43 %) or 'strongly agreed' (11 %) there is solid evidence supporting PPIs efficacy in SSc. The most common reasons for PPIs prescription were symptomatic GERD unresponsive to lifestyle modification (95 %), objective evidence of GERD (82 %), and hoarseness or respiratory symptoms (71 %). There are variable concerns about PPIs long-term safety in SSc. The three highest (mean) reasons (0-10, here 10 is 'very concerned') were: small intestinal bacterial overgrowth (5.5), osteoporosis (5.4), and drug interactions (5.2). There are significant differences in attitudes towards surgery for refractory GERD, and concerns about potential complications. PPIs may have a putative role for disease modification (e.g., ILD and calcinosis), and the role of immunosuppression is uncertain for GI (gastrointestinal) disease in SSc. CONCLUSION: PPIs are frequently prescribed in SSc. Side effects are a recognized concern, especially regarding long-term therapy. There is significant variation in attitudes towards surgical intervention. Future research and practical treatment recommendation for PPIs in SSc are urgently needed.

Patients' unmet needs and treatment preferences concerning digital ulcers in systemic sclerosis.

INTRODUCTION: Digital ulcers (DUs) significantly impact on quality of life and function in patients with systemic sclerosis (SSc). The aim of our survey was to explore patients' perspectives and their unmet needs concerning SSc-DUs. MATERIALS: SSc patients were invited through international patient associations and social media to participate in an online survey. RESULTS: 358 responses were obtained from 34 countries: US (65.6%), UK (11.5%) and Canada (4.5%). Recurrent DUs are common: >10 DUs (46.1%), 5-10 DUs (21.5%), 1-5 DUs (28.5%), 1 DU (3.9%). Fingertip DUs were most frequent (84.9%), followed by those overlying the interphalangeal joints (50.8%). The impact of DUs in patients is broad, from broad-ranging emotional impacts to impact on activities of daily living, and personal relationships. Half (51.7%) of respondents reported that they received wound/ulcer care, most often provided by non-specialist wound care clinics (63.8%). There was significant variation in local (wound) DU care, in particular the use of debridement and pain management. DU-related education was only provided to one-third of patients. One-quarter (24.6%) were 'very satisfied' or 'satisfied' that the provided DU treatment(s) relieved their DU symptoms. Pain, limited hand function, and ulcer duration/chronicity were the main reasons for patients to consider changing DU treatment. CONCLUSIONS: Our data show that there is a large variation in DU treatment between countries. Patient access to specialist wound-care services is limited and only a small proportion of patients had their DU needs met. Moreover, patient education is often neglected. Evidence-based treatment pathways are urgently needed for DU management.

Subacute Neurotoxicity as an Adverse Reaction to Ceftazidime: A Case Report.

Neurotoxicity associated with cephalosporins is an increasingly recognized complication, although among cephalosporins, ceftazidime is rarely reported for such an adverse reaction. Moreover, subacute, rather than acute, presentation of neurotoxicity associated with cephalosporins is rare. A 77-year-old female patient with stage 4 chronic renal disease was admitted due to cellulitis in her right lower limb, multiorgan dysfunction complicated by oliguric acute kidney injury, and a need for hemodialysis via a central venous catheter. On the 13th day after admission, she became febrile, and bacteremia associated with a central venous catheter was identified, which prompted the initiation of empirical antibiotic therapy with vancomycin and ceftazidime. After 13 days of antibiotic therapy with vancomycin and ceftazidime, the patient became confused, with temporal-spatial disorientation and myoclonus, especially in the upper limbs, with worsening renal function. Ceftazidime was discontinued, and the patient's condition improved with complete remission of symptoms on the 8th day after symptom onset. Neurotoxicity associated with ceftazidime is a rare but probably underdiagnosed adverse reaction. It is more frequent in elderly patients with previous neurological dysfunction and end-stage kidney disease and/or acute kidney injury, and it usually manifests soon after starting treatment. Early identification and monitoring of risk factors and symptoms should lead the physician to a rapid withdrawal of the offending drug.

A Multinational Survey Investigating the Unmet Needs and Patient Perspectives Concerning Proton Pump Inhibitors in Systemic Sclerosis.

OBJECTIVE: Proton pump inhibitors (PPIs) are widely prescribed to treat gastroesophageal reflux disease (GERD) in Systemic Sclerosis (SSc). However, not all patients adequately respond to the treatment, and there are frequent concerns about the safety of long-term use of PPIs. Our aim was to identify the main problems/complaints of SSc patients on PPIs, as well as understand their unmet needs. METHODS: SSc patients treated with PPIs were invited through international patient associations and social media to participate in an online survey. RESULTS: We gathered 301 valid responses from 14 countries (United Kingdom 19.3% and United States 70.4%). Multiple PPIs use (two: 30% and three: 21% in series) was common. The majority (89%) reported improvement in gastrointestinal symptoms from receiving PPIs. Side effects attributed to receiving PPIs were uncommon (19%); however, most (79%) were potentially concerned. Around half (58%) had received lifestyle information, and most (85%) had searched online for information about PPIs. Only in the minority (12%) had a surgical approach been discussed; however, half (46%) indicated that they would be willing to undergo surgery to resolve their GERD symptoms but had important concerns. CONCLUSION: Despite the frequent use of PPIs in patients with SSc, there is significant heterogeneity in prescription, and combination therapy (PPIs plus other medication for acid reflux) is not uncommon (approximately 40%). Patients have significant concerns about PPIs side effects. Education about PPIs is often neglected, and patients very frequently use online sources to obtain information on drug treatment. A surgical approach is infrequently discussed, and patients fear this potential therapeutic approach.

Continuous erector spinae block for postoperative analgesia in a partial colectomy by subcostal incision / Bloqueo continuo de los erectores espinales para la analgesia postoperatoria en una colectomía parcial por incisión subcostal

Abstract: Erector spinae plane block is an ultrasound-guided technique who has seen a growing role as a perioperative analgesic technique due to its safety profile and versatility. We describe a case of an elderly female with a history of ischemic heart disease and atrial fibrillation, who underwent segmental colectomy by left subcostal laparotomy under general anesthesia, for removal of a colon tumor. An erector spinae plane catheter was placed at the T7 level under ultrasound guidance, and then used for postoperative analgesia. Ropivacaine 0.2% (initial bolus + infusion at 8 mL/h) was used through the catheter, together with intravenous paracetamol and metamizol. This analgesic regimen was maintained for 72 hours, with excellent pain control, after which the catheter was removed. The patient's pain remained controlled and rescue analgesia was not required until her discharge at seven days postoperative. Continuous ESP block was an effective technique for postoperative analgesia in this case, allowing excellent pain control with a low risk of complications and avoiding the use of opioids.

Resumen: El bloqueo del plano del músculo erector espinal es una técnica ecoguiada que ha ganado popularidad como técnica analgésica perioperatoria debido a su perfil de seguridad y versatilidad. Se describe el caso de una anciana con cardiopatía isquémica y fibrilación auricular, a la que se le realizó colectomía segmentaria mediante laparotomía subcostal izquierda bajo anestesia general, para la escisión de un tumor de colon. Se colocó un catéter en el plano del músculo erector espinal al nivel T7 bajo guía ultrasónica y luego se utilizó para analgesia postoperatoria (ropivacaína 0.2% bolo + infusión a 8 mL/h) junto con paracetamol intravenoso y metamizol. Este régimen analgésico se mantuvo durante 72 horas, con excelente control del dolor, tras lo cual se retiró el catéter. La paciente permaneció con adecuada analgesia sin opioides de rescate hasta su alta a los siete días del postoperatorio. El bloqueo del plano del erector espinal torácico continuo fue una técnica eficaz para la analgesia postoperatoria en cirugía abdominal abierta, con bajo riesgo de complicaciones y evitando el uso de opioides.

Série Histórica de Mortalidade por Neoplasias no Estado da Bahia entre os Anos de 2008 e 2018 / Time Series of Mortality from Neoplasms in the State of Bahia between 2008 and 2018 / Serie Histórica de Mortalidad por Neoplasias en el Estado de Bahía entre los Años 2008 y 2018

Introdução: A mortalidade por neoplasias no Brasil se distribui de forma distinta entre as Macrorregiões, sendo a Nordeste responsável pelo segundo maior número de óbitos por neoplasias e, nessa Região, a Bahia ocupa a primeira posição. Objetivo: Analisar a tendência da mortalidade por neoplasias no Estado da Bahia e nas nove Macrorregiões de Saúde, entre 2008 e 2018. Método: Estudo ecológico, a partir dos óbitos por neoplasia (C00-D48) nessas Macrorregiões, registrados no Sistema de Informações sobre Mortalidade entre 2008 e 2018. As tendências de mortalidade por faixa etária foram analisadas pela regressão Joinpoint, tendo como desfecho morte por câncer e ano do óbito como variável independente. Resultados: Ocorreram 115.034 óbitos relacionados à neoplasia, sendo 39,2% registrados na Macrorregião Leste, 53,2% em homens, 65,4% na faixa etária de 60 anos ou mais, 24% com 1 a 3 anos de escolaridade, 68,6% eram negros e 50,9% eram não casados. As tendências das taxas de mortalidade por 100 mil habitantes, ajustadas para as faixas etárias de maiores e menores de 60 anos, indicaram que houve aumento dos óbitos em todas as Macrorregiões, entretanto, o incremento foi maior na Macrorregião Norte para maiores de 60 anos e na Macrorregião Oeste para menores de 60 anos. Conclusão: A mortalidade por câncer nas Macrorregiões baianas aumentou em ambas as faixas etárias, porém há diferenças no perfil de mortalidade por câncer entre as Macrorregiões de um mesmo Estado, indicando a necessidade de criação de políticas que levem em consideração essas peculiaridades regionais

Introduction: Mortality by neoplasms in Brazil is distributed differently among the Macroregions, with the Northeast responsible for the second highest number of deaths and, within this Macroregion, Bahia is ranked first. Objective: To analyze the trend of mortality by neoplasms in the State of Bahia and in the nine health Macroregions, between 2008 and 2018. Method: Ecological study based on deaths by neoplasia (C00-D48) in these Macroregions and registered in the Mortality Information System between 2008 and 2018. Mortality trends by age group were analyzed using the Joinpoint regression, with cancer death as an outcome and year of death as an independent variable. Results: There were 115,034 deaths related to neoplasia, 39.2% of which were recorded in the East Macroregion, 53.2% in men, 65.4% in the age group of 60 years or more, 24% with 1 to 3 years of education, 68.6% were black and 50.9% were not married. Trends in mortality rates per 100,000 inhabitants adjusted for the age groups of older and younger than 60 years indicated that the number of deaths grew in all Macroregions, however the increase was greater in the North Macroregion for over 60 and in the West Macroregion for under 60 years old. Conclusion: Cancer mortality in Bahia Macroregions has increased for both age groups, but there are differences in the profile of cancer mortality among Macroregions in the same state, indicating the need to create policies that address these regional peculiarities

Introducción: La mortalidad por neoplasias en Brasil se distribuye de manera diferente entre las Macrorregiones, siendo la Nordeste responsable del segundo mayor número de muertes por neoplasias y, dentro de esta Macrorregión, Bahía ocupa el primer lugar. Objetivo: Analizar la tendencia de la mortalidad por neoplasias en el Estado de Bahía y en las nueve Macrorregiones de salud, entre 2008 y 2018. Método: Estudio ecológico con base en las muertes por neoplasias (C00-D48) ocurridas en las Macrorregiones de Bahía y registrados en el Sistema de Información de Mortalidad entre 2008 y 2018. Las tendencias de mortalidad por grupo de edad se analizaron mediante la regresión de Joinpoint, con muerte por cáncer como resultado y año de muerte como variable independiente. Resultados: Se registraron 115.034 defunciones relacionadas con neoplasias, de las cuales 39,2% se registraron en la Macrorregión Este, 53,2% en hombres, 65,4% en el grupo de edad de 60 años o más, 24% con 1 a 3 años de escolaridad, 68,6% eran negros y 50,9% no estaban casados. Las tendencias en las tasas de mortalidad por 100.000 habitantes ajustadas por los grupos de edad mayores y menores de 60 años indicaron que todas las Macrorregiones experimentaron un aumento en el número de muertes, sin embargo, el aumento fue mayor en la Macrorregión Norte para los mayores de 60 años y en la Macrorregión Oeste para menores de 60 años. Conclusión: La mortalidad por cáncer en las Macrorregiones de Bahía ha aumentado para ambos grupos de edad, pero existen diferencias en el perfil de mortalidad por cáncer entre las Macrorregiones de un mismo Estado, lo que indica la necesidad de crear políticas que tomen en cuenta estas peculiaridades regionales

Global Longitudinal Strain Predicts Poor Functional Capacity in Patients with Systolic Heart Failure / Strain Longitudinal Global é Preditor de Baixa Capacidade Funcional em Pacientes com Insuficiência Cardíaca Sistólica

Abstract Background: Left ventricular global longitudinal strain value (GLS) can predict functional capacity in patients with preserved left ventricular ejection fraction (LVEF) heart failure (HF) and to assess prognosis in reduced LVEF HF. Objetive: Correlate GLS with parameters of Cardiopulmonary Exercise Test (CPET) and to assess if they could predict systolic HF patients that are more appropriated to be referred to heart transplantation according to CPET criteria. Methods: Systolic HF patients with LVEF < 45%, NYHA functional class II and III, underwent prospectively CPET and echocardiography with strain analysis. LVEF and GLS were correlated with the following CPET variables: maxVO2, VE/VCO2 slope, heart rate reduction during the first minute of recovery (HRR) and time needed to reduce maxVO2 in 50% after physical exercise (T1/2VO2). ROC curve analysis of GLS to predict VO2 < 14 mL/kg/min and VE/VCO2 slope > 35 (heart transplantation's criteria) was performed. Results: Twenty six patients were selected (age, 47 ± 12 years, 58% men, mean LVEF = 28 ± 8%). LVEF correlated only with maxVO2 and T1/2VO2. GLS correlated to all CPET variables (maxVO2: r = 0.671, p = 0.001; VE/VCO2 slope: r = -0.513, p = 0.007; HRR: r = 0.466, p = 0.016, and T1/2VO2: r = -0.696, p = 0.001). GLS area under the ROC curve to predict heart transplantation's criteria was 0.88 (sensitivity 75%, specificity 83%) for a cut-off value of -5.7%, p = 0.03. Conclusion: GLS was significantly associated with all functional CPET parameters. It could classify HF patients according to the functional capacity and may stratify which patients have a poor prognosis and therefore to deserve more differentiated treatment, such as heart transplantation.

Resumo Fundamento: O strain longitudinal global (SLG) é capaz de predizer a capacidade funcional dos pacientes com insuficiência cardíaca (IC) e fração de ejeção do ventrículo esquerdo (FEVE) preservada, e avaliar o prognóstico na IC com FEVE reduzida. Objetivo: Correlacionar o SLG com parâmetros do teste de exercício cardiopulmonar (TECP), e avaliar se o SLG seria capaz de predizer quais pacientes com IC sistólica deveriam ser encaminhados ao transplante cardíaco de acordo com os critérios do TECP. Métodos: Os pacientes com IC sistólica com FEVE <45%, classe funcional NYHA II e III, submeteram-se prospectivamente ao TECP e à ecocardiografia com análise do strain. A FEVE e o SLG foram correlacionados com as seguintes variáveis do TECP: maxVO2, inclinação de VE/VCO2, redução da frequência cardíaca durante o primeiro minuto de recuperação (RFC), e tempo necessário para a redução do maxVO2 em 50% após o exercício físico (T1/2VO2). Foi realizada análise da curva ROC do SLG em predizer um VO2 < 14 mL/kg/min e uma inclinação de VE/VCO2 > 35 (critérios para transplante cardíaco). O nível de significância adotado na análise estatística foi de p < 0,05. Resultados: Vinte e seis pacientes foram selecionados para o estudo (idade, 47±12 anos, 58% homens, FEVE média LVEF = 28 ± 8%). A FEVE correlacionou-se somente com o maxVO2 e o T1/2VO2. O SLG correlacionou-se com todas as variáveis do TECP (maxVO2: r = 0,671; p = 0,001; inclinação de VE/VCO2: r = -0,513; p = 0,007; RFC: r = 0,466; p = 0,016; e T1/2VO2: r = -0,696, p = 0,001). A área sob a curva ROC para o SLG para predizer os critérios para transplante cardíaco foi de 0,88 (sensibilidade 75%, especificidade 83%) para um ponto de corte de -5,7%, p = 0,03. Conclusão: O SLG apresentou associação significativa com todos os parâmetros funcionais do TECP. O SLG foi capaz de classificar os pacientes com IC segundo capacidade funcional e possivelmente pode identificar quais pacientes têm um prognóstico ruim e, portanto, se beneficiariam de um tratamento diferenciado, tal como o transplante cardíaco.