Treatment of fungal infection on left ventricle assist device driveline exit site: a case report and systematic review.

OBJECTIVE: The use of ventricular assist devices (VAD) is increasing; however, diagnosis and management of device complications, such as the driveline exit site (DES) being the portal of entry for fungal infection, is not well known. METHOD: A systematic review involving searching PubMed (2005 to July 2020) was conducted. The case of a 43-year-old female patient who had a left VAD (LVAD) (HeartMate 3, Abbott, US) is also reported. RESULTS: The patient was successfully treated with ketoconazole cream and oral fluconazole for likely superficial DES fungal infections. We included 36 studies that met our inclusion criteria; however, only one was included in our review. In the literature, five cases of DES fungal infection were reported, with Candida being the only fungal pathogen. CONCLUSION: LVAD fungal infections are uncommon but can be responsible for high mortality rates, require a prolonged period of treatment, and can present a huge problem when surgical alternatives are not available. However, Candida species are most common. Fungal infections can only produce clear discharge, and so the classic definition of driveline infection based on purulent secretion can vary. Negative skin culture does not exclude the diagnosis of infection of the DES, and so empirical diagnosis may only be clinically based.

Cost-Effectiveness Benefits of a Disease Management Program:The REMADHE Trial Results.

BACKGROUND: Published studies have generated mixed, controversial results regarding the cost-effectiveness of heart failure disease management programs (HF-DMPs). This study assessed the cost-effectiveness of an HF-DMP in ambulatory patients compared with usual care (UC). METHODS: In the prospective randomized REMADHE trial, we evaluated incremental costs per quality-adjusted life-year (QALY) and life-year (LY) gained as effectiveness ratios (ICERs) over a study period of 2.47 ± 1.75 years. RESULTS: The REMADHE HF-DMP was more effective and less costly than UC in terms of both QALYs and LYs (95% and 55% chance of dominance, respectively). Average saving was US$7345 (2.5%-97.5% bootstrapped confidence interval -16,573 to +921). The chance of DMP being cost-effective at a willingness to pay US$10,000 per QALY or LY was 99% and 96%, respectively. Cost-effectiveness of HF-DMP was highest in subgroups with left ventricular ejection fraction <35%, age >50 years, male sex, New York Heart Association (NYHA) functional class ≥III, and ischemic etiology. The chance of DMP being cost-effective at a willingness to pay US$10,000 per QALY was ≥90% in all subgroups apart from NYHA functional class I-II, where it was 70%. Even when the intervention costs increased by 500% or when excluding outliers in costs, DMP had a high chance of being cost-effective (87%-99%). CONCLUSIONS: The HF-DMP of the REMADHE trial, which encompasses long-term repeated education alongside telephone monitoring, has a high probability of being cost-effective in ambulatory patients with HF.

Comparative cost-effectiveness of surgery, angioplasty, or medical therapy in patients with multivessel coronary artery disease: MASS II trial.

BACKGROUND: The costs for treating coronary artery disease (CAD) are high worldwide. We performed a prespecified analyses of cost-effectiveness of three therapeutic strategies for multivessel CAD. METHODS: From May 1995 to May 2000, a total of 611 patients were randomly assigned to coronary artery bypass graft (CABG), n = 203; percutaneous coronary intervention (PCI), n = 205; or medical treatment (MT), n = 203. This cost analysis study was based on the perspective of the Public Health Care System. Initial procedural and follow-up costs for medications, cardiology examinations, and hospitalizations for complications were calculated after randomization. Life-years and quality-adjusted life years (QALYs) were used as effectiveness measures. Incremental cost-effectiveness ratios (ICER) were obtained by using nonparametric bootstrapping methods with 5000 resamples. RESULTS: Initial procedural costs were lower for MT. However, the subsequent 5-year cumulative costs were lower for CABG. Compared with baseline, the three treatment options produced significant improvements in QALYs. After 5 years, PCI and CABG had better QALYs results compared with MT. The ICER results favored CABG and PCI, and favored PCI over CABG in 61% of the drawings. On the other hand, sensitivity analysis showed MT as the preferred therapy compared with CABG and PCI, in the analysis considering higher costs. CONCLUSIONS: At 5-year follow-up, the three treatment options yielded improvements in quality of life, with comparable and acceptable costs. However, despite higher initial costs, the comparison of cost-effectiveness after 5 years of follow-up among the three treatments showed both interventions (CABG and PCI) to be cost-effective strategies compared with MT.Trial registration ISRCTN, ISRCTN66068876, Registered 06/10/1994, http://www.controlled-trials.com/ISRCTN66068876.

Risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation: A scoping review.

BACKGROUND: Evidence on infection risk factors is scarce, and precise localization of the site of infection and its treatment remain clinically challenging. OBJECTIVES: This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation. DESIGN: This is a scoping review, registered in the Open Science Framework under DOI10.17605/OSF.IO/Q76B3(https://osf.io/q76b3/). METHOD: This is a scoping review limited to the period between 2015 and 2022.The results of this scoping review are discussed and presented separately in 3 articles. This second paper synthesizes research evidence on the risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation. RESULTS: The initial searches identified 771 studies. Sixty-nine patients met the eligibility criteria and were included in the scoping review. Forty-three articles addressing the risk factors, diagnosis and treatment of infection were included to answer the questions of this review. CONCLUSION: Obesity has been shown to be the most common risk factor for the described process of infection by left ventricular assist devices.18F-fluorodeoxyglucose positron emission tomography showed high sensitivity in detecting cardiac device infection, and labeled leukocyte or gallium citrate-67 scintigraphy showed high specificity for left ventricular assist device infections; therefore, it can help differentiate infection from inflammation, particularly in patients with equivocal fluorodeoxyglucose positron emission tomography. Also, this review brings and discusses the limitations and strengths of diagnostic tests, the knowledge regarding the risk factors for left ventricular assist device infection, the therapeutic heterogeneity, the methodological issues of the studies, and the vast opportunity for future research on left ventricular assist device. IMPLICATIONS FOR CLINICAL PRACTICE: Ventricular assist device professionals should evaluate risk factors prior to device implantation and periodically.18F-fluorodeoxyglucose positron emission tomography should be considered as diagnostic tool in detecting superficial and deep driveline infections. Early treatment, including chronic suppressive therapy and serial surgical debridement, combined with driveline exteriorization and delayed driveline relocation may constitute a potential therapeutic strategy for deep driveline infections.

Perioperative interventions for the prevention of surgical wound infection in adult patients undergoing left ventricular assist devices implantation: A scoping review.

BACKGROUND: Surgical wound infection is the most frequent type of care health associated infection. Lack of knowledge about the prevention of surgical wound infection in patients undergoing left ventricular assist device implantation could significantly undermine the potential benefits of surgical intervention. OBJECTIVES: This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation. DESIGN: This is a scoping review, being registered in the Open Science Framework under DOI https://doi.org/10.17605/OSF.IO/Q76B3 (https://osf.io/q76b3/). METHOD: Left ventricular assist device coordinators and nurse specialists in dermatology and stomatherapy conducted a scoping review in Scopus, The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), limited to the period between 2015 and 2022. The results of this scoping review will be discussed and presented in separate articles. This paper will synthesize research evidence on the perioperative topic. RESULTS: The initial searches resulted in 771 studies. Sixty nine met the eligibility criteria and were included in the scoping review. Eight articles addressing the perioperative topic that answered the question of this article were included. CONCLUSION: Although this scoping review included heterogeneous, and scarce studies with left ventricular assist device patients. As such, there are many promising future research directions for this topic. IMPLICATIONS FOR CLINICAL PRACTICE: Infection surveillance should be an integral part of left ventricular assist device implantation programs in health care institutions. Velvet completely buried in subcutaneous tissues reduces transmission system infection. Triple tunnel method reduces transmission system infection risk.

A review of cost-effectiveness analysis: From theory to clinical practice.

Cost-effectiveness analysis has long been practiced; registries date back to the United States of America War Department in 1886. In addition, everyone does intuitive cost-effectiveness analyses in their daily lives. In routine medical care, health economic assessment becomes increasingly important due to progressively limited resources, rising demands, population increases, and continuous therapeutic innovations. The health economic assessment must analyze the outcomes and costs of actions and technologies as objectively as possible to guarantee efficient assessment of novel interventions for Public Health Policy. In other words, it is necessary to determine how much society or patients are willing to or able to pay for novel interventions compared with existing alternatives, given the available resources. In addition, increased cost may displace other health care services already provided in case of fixed budget health care systems. To conduct such analyses, researchers must use standard methodologies and interpretations in light of regional characteristics according to social and economic determinants as well as clinical practice. Such an approach may be essential for transforming the current healthcare system to a value-based model. In this narrative review, concepts of the importance of and some approaches to health economic evaluation in clinical practice will be discussed.

Plasma biomarkers reflecting high oxidative stress in the prediction of myocardial injury due to anthracycline chemotherapy and the effect of carvedilol: insights from the CECCY Trial.

BACKGROUND: Anthracycline (ANT) is often used for breast cancer treatment but its clinical use is limited by cardiotoxicity (CTX). CECCY trial demonstrated that the ß-blocker carvedilol (CVD) could attenuate myocardial injury secondary to ANT. Mieloperoxydase (MPO) is a biomarker of oxidative stress and galectin-3 (Gal-3) is a biomarker of fibrosis and cardiac remodeling. We evaluated the correlation between MPO and Gal-3 behavior with CTX. MATERIALS AND METHODS: A post hoc analysis was performed in the patients who were included in the CECCY trial. A total of 192 women had her blood samples stored during the study at -80°C until the time of assay in a single batch. Stored blood samples were obtained at baseline, 3 and 6 months after randomization. We excluded samples from 18 patients because of hemolysis. MPO and Gal-3 were measured using Luminex xMAP technology through MILLIPLEX MAP KIT (Merck Laboratories). RESULTS: 26 patients (14.9%) had a decrease of at least 10% in LVEF at 6 months after the initiation of chemotherapy. Among these, there was no significant difference in the MPO and Gal-3 when compared to the group without drop in LVEF (p = 0.85 for both MPO and Gal-3). Blood levels of MPO [baseline: 13.2 (7.9, 24.8), 3 months: 17.7 (11.1, 31.1), 6 months: 19.2 (11.1, 37.8) ng/mL] and Gal-3 [baseline: 6.3 (5.2, 9.6), 3 months: 12.3 (9.8, 16.0), 6 months: 10.3 (8.2, 13.1) ng/mL] increased after ANT chemotherapy, and the longitudinal changes were similar between the placebo and CVD groups (p for interaction: 0.28 and 0.32, respectively). In an exploratory analysis, as there is no normal cutoff value established for Gal-3 and MPO in the literature, the MPO and Gal-3 results were splited in two groups: above and below median. In the placebo group, women with high (above median) baseline MPO blood levels demonstrated a greater increase in TnI blood levels than those with low baseline MPO blood levels (p = 0.041). Compared with placebo, CVD significantly reduced TnI blood levels in women with high MPO blood levels (p < 0.001), but did not reduce the TnI levels in women with low baseline MPO blood levels (p = 0.97; p for interaction = 0.009). There was no significant interaction between CVD treatment and baseline Gal-3 blood levels (p for interaction = 0.99). CONCLUSIONS: In this subanalysis of the CECCY trial, MPO and Gal-3 biomarkers did not predict the development of CTX. However, MPO blood levels above median was associated with more severe myocardial injury and identified women who were most likely to benefit from carvedilol for primary prevention (NCT01724450).

Clinical profile of patients enroled in a cell therapy trial for severe coronary artery disease.

AIMS AND OBJECTIVES: To compare the clinical profile of patients included in a clinical trial of autologous bone marrow cells as an adjunctive therapy to coronary artery bypass grafting with that of patients undergoing routine coronary artery bypass grafting. BACKGROUND: The therapeutic potential of autologous bone marrow cells has been explored in the treatment of severe coronary artery disease. There are few data regarding the clinical and socio-economic profile of patients included in clinical trials using bone marrow cell. DESIGN: Case-control study. METHOD: Sixty-seven patients (61 SD 9) years, 82% men) with multivessel coronary artery disease were divided into two groups: patients in the bone marrow cell group (n = 34) underwent incomplete coronary artery bypass grafting + intramyocardial injection of autologous bone marrow cells (lymphomonocytic fraction -2.0 (SD 0.2 x 10(8)) cells/patient) in the ischaemic, non-revascularised myocardium, whereas patients in the coronary artery bypass grafting group (n = 33) underwent routine bypass surgery. Demographics, socio-economic status, clinical and echocardiographic data were collected. Statistical analysis included the Fisher's exact test (categorical variables) and the Student's t-test (continuous variables). RESULTS: There were no significant differences between groups regarding age, gender, BMI, heart rate, blood pressure and echo data. There was a greater prevalence of obesity (65 vs. 33%; OR = 3.7 [1.3-10.1]), of previous myocardial infarction (68 vs. 39%; OR = 3.2 [1.2-8.8]) and prior revascularisation procedures (59 vs. 24%; OR = 4.5 [1.6-12.7]) in the autologous bone marrow cells group and of smokers in the coronary artery bypass grafting group (51 vs. 23%; OR = 3.5 [1.2-10.4]). CONCLUSIONS: Patients included in this clinical trial of autologous bone marrow cells for severe coronary artery disease presented a greater prevalence of myocardial revascularisation procedures, indicating a more severe clinical presentation of the disease. Fewer smokers in this group could be attributable to life style changes after previous cardiovascular events and/or interventions. RELEVANCE TO CLINICAL PRACTICE: The knowledge of the clinical profile of patients included in cell therapy trials may help researchers in the identification of patients that may be enroled in future clinical trials of this new therapeutic strategy.

"Experiences marked by prejudice(s)?": nurses' representations on 'transvestite' people.

OBJECTIVES: to learn and analyze the structure of nurses' social representations about transvestite people. METHODS: a qualitative research based on the Theory of Social Representations, with 110 nurses enrolled in Graduate Nursing courses, who answered the Free-Association Test, with the stimulus 'transvestite'. Data were processed by the software Ensemble de Programmes Permettant I' Analysedes Évocations. RESULTS: in the central nucleus, the term "prejudice" was the most evoked, followed by "homosexual", "identity" and "female-make-up". Social representation is anchored in the social organization in which transvestite people are still seen and/or associated with homosexuals who make up and assume an identity, without being seen and/or understood as they really are. FINAL CONSIDERATIONS: although prejudice is noteworthy as a central element, terms present in the peripheral system reveal that the group recognizes transvestites as a person with rights, which can translate into health care practices.

Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity: The CECCY Trial.

BACKGROUND: Anthracycline (ANT) chemotherapy is associated with cardiotoxicity. Prevention with ß-blockers remains controversial. OBJECTIVES: This prospective, randomized, double-blind, placebo-controlled study sought to evaluate the role of carvedilol in preventing ANT cardiotoxicity. METHODS: The authors randomized 200 patients with HER2-negative breast cancer tumor status and normal left ventricular ejection fraction (LVEF) referred for ANT (240 mg/m2) to receive carvedilol or placebo until chemotherapy completion. The primary endpoint was prevention of a ≥10% reduction in LVEF at 6 months. Secondary outcomes were effects of carvedilol on troponin I, B-type natriuretic peptide, and diastolic dysfunction. RESULTS: Primary endpoint occurred in 14 patients (14.5%) in the carvedilol group and 13 patients (13.5%) in the placebo group (p = 1.0). No differences in changes of LVEF or B-type natriuretic peptide were noted between groups. A significant difference existed between groups in troponin I levels over time, with lower levels in the carvedilol group (p = 0.003). Additionally, a lower incidence of diastolic dysfunction was noted in the carvedilol group (p = 0.039). A nonsignificant trend toward a less-pronounced increase in LV end-diastolic diameter during the follow-up was noted in the carvedilol group (44.1 ± 3.64 mm to 45.2 ± 3.2 mm vs. 44.9 ± 3.6 mm to 46.4 ± 4.0 mm; p = 0.057). CONCLUSIONS: In this largest clinical trial of ß-blockers for prevention of cardiotoxicity under contemporary ANT dosage, the authors noted a 13.5% to 14.5% incidence of cardiotoxicity. In this scenario, carvedilol had no impact on the incidence of early onset of LVEF reduction. However, the use of carvedilol resulted in a significant reduction in troponin levels and diastolic dysfunction. (Carvedilol Effect in Preventing Chemotherapy-Induced Cardiotoxicity [CECCY]; NCT01724450).

Representações sociais de puérperas sobre as mamas no aleitamento / Representaciones sociales de puérperas sobre la pechos en lactancia / Social representations of puerperals about the breast in breastfeeding

Objetivo: Apreender representações sociais de puérperas sobre as mamas no período do aleitamento. Método: Pesquisa qualitativa, fundamentada na teoria das representações sociais. Utilizou-se o teste de associação livre de palavras, aplicado a 95 puérperas num Centro de Parto Normal de Salvador-Ba, no período de novembro de 2017 a fevereiro de 2018. Realizou-se a análise da estrutura das representações sociais a partir da árvore de similitude das evocações livres. Resultados: As representações sociais das puérperas sobre as mamas são marcantemente a dor e o tamanho, influenciadas por elementos periféricos que envolvem o ato de amamentar e a saúde, estando associadas as suas crenças, conhecimentos e valores afetivos. As participantes reconhecem que as mamas são partes importantes do corpo que requerem cuidado cotidianamente. Conclusão: Os achados corroboram para novos olhares para subjetividades que envolvem o aleitamento, podendo nortear práticas de cuidado em saúde que colaborem para satisfação enquanto nutriz.(AU)

Objective: To apprehend social representations of postpartum women about their breasts during the breastfeeding period. Method: Qualitative research, based on the theory of social representations. The free word association test was used, applied to 95 postpartum women in a Normal Delivery Center in Salvador-Ba, from November 2017 to February 2018. The analysis of the structure of social representations was carried out from the tree of similarity of free evocations. Results: The postpartum women's social representations about the breasts are markedly pain and size, influenced by peripheral elements that involve the act of breastfeeding and health, being associated with their beliefs, knowledge and affective values. Participants recognize that the breasts are important parts of the body that require daily care. Conclusion: The findings corroborate new perspectives on subjectivities that involve breastfeeding, which may guide health care practices that contribute to satisfaction as a nursing mother.(AU)

Objetivo: Aprender las representaciones sociales de las mujeres posparto sobre sus senos durante el período de lactancia. Método: Investigación cualitativa, basada en la teoría de las representaciones sociales. Se utilizó la prueba de asociación libre de palabras, aplicada a 95 puérperas en un Centro de Parto Normal en Salvador-Ba, de noviembre de 2017 a febrero de 2018. El análisis de la estructura de las representaciones sociales se realizó a partir del árbol de similitud de evocaciones libres. Resultados: Las representaciones sociales de las mujeres posparto sobre las mamas son marcadamente dolorosas y de tamaño, influenciadas por elementos periféricos que involucran el acto de la lactancia materna y la salud, estando asociadas a sus creencias, conocimientos y valores afectivos. Los participantes reconocen que los senos son partes importantes del cuerpo que requieren cuidados diarios. Conclusión: Los hallazgos corroboran nuevas perspectivas sobre subjetividades que involucran la lactancia materna, las cuales pueden orientar prácticas de cuidado de la salud que contribuyan a la satisfacción como madre lactante.(AU)

Utility and quality-adjusted life-years in coronary artery disease: Five-year follow-up of the MASS II trial.

OBJECTIVES: This study evaluated the utility and quality-of-life year measurements for patients with coronary artery disease who underwent any of 3 therapeutic strategies with a 5-year follow-up. METHODS: Quality-of-life data were obtained from the Medicine, Angioplasty, or Surgery Study II trial. To obtain utilities, the 36-Item Short-Form questionnaire was converted to a 6-Dimensional Health State Classification System. RESULTS: Of the 611 initial patients, 579 completed the questionnaire. In all, 188 patients received the surgical treatment-194 the percutaneous, and the remaining 197 the medical. The median utility scores for the 5 years analyzed were 0.809 (95% confidence interval [CI] 0.794-0.842) for patients assigned to percutaneous coronary intervention, 0.755 (95% CI 0.723-0.774) for medical treatment, and 0.780 (95% CI 0.761-0.809) for coronary artery bypass graft surgery. The difference between percutaneous coronary intervention and medical treatment was statistically significant (P < .05, Dunn test). The median cumulative quality-of-life years across the 5 years were 3.802 (95% CI 3.668-3.936) for percutaneous, 3.540 (95% CI 3.399-3.681) for medical, and 3.764 (95% CI 3.638-3.890) for surgery. Additionally, the median quality-of-life years between percutaneous and medical treatment was 0.262 (95% CI 0.068-0.456), between surgery and medical treatment it was 0.224 (95% CI 0.036-0.413), and between surgery and percutaneous coronary intervention it was -0.038 (95% CI -0.221 to -0.146). CONCLUSION: Coronary artery bypass surgery and percutaneous coronary intervention were similar regarding cumulative quality-of-life years; however, they were both superior to that of medical treatment. The results presented are valuable data for further cost-utility studies.

Circulating miR-1 as a potential biomarker of doxorubicin-induced cardiotoxicity in breast cancer patients.

Cardiotoxicity is associated with the chronic use of doxorubicin leading to cardiomyopathy and heart failure. Identification of cardiotoxicity-specific miRNA biomarkers could provide clinicians with a valuable prognostic tool. The aim of the study was to evaluate circulating levels of miRNAs in breast cancer patients receiving doxorubicin treatment and to correlate with cardiac function. This is an ancillary study from "Carvedilol Effect on Chemotherapy-induced Cardiotoxicity" (CECCY trial), which included 56 female patients (49.9±3.3 years of age) from the placebo arm. Enrolled patients were treated with doxorubicin followed by taxanes. cTnI, LVEF, and miRNAs were measured periodically. Circulating levels of miR-1, -133b, -146a, and -423-5p increased during the treatment whereas miR-208a and -208b were undetectable. cTnI increased from 6.6±0.3 to 46.7±5.5 pg/mL (p<0.001), while overall LVEF tended to decrease from 65.3±0.5 to 63.8±0.9 (p=0.053) over 12 months. Ten patients (17.9%) developed cardiotoxicity showing a decrease in LVEF from 67.2±1.0 to 58.8±2.7 (p=0.005). miR-1 was associated with changes in LVEF (r=-0.531, p<0.001). In a ROC curve analysis miR-1 showed an AUC greater than cTnI to discriminate between patients who did and did not develop cardiotoxicity (AUC = 0.851 and 0.544, p= 0.0016). Our data suggest that circulating miR-1 might be a potential new biomarker of doxorubicin-induced cardiotoxicity in breast cancer patients.

Strain longitudinal global como preditor de cardiotoxicidade induzida por quimioterapia / Global longitudinal strain as predictor of chemotherapy-induced cardiotoxicity

Fundamento: A cardiotoxicidade induzida por quimioterapia (CiC) é uma complicação importante entre os pacientes que recebem antraciclinas. Biomarcadores e parâmetros de imagem têm sido estudados por sua capacidade de identificar pacientes com risco de desenvolver essa complicação. O strain longitudinal global do ventrículo esquerdo (SLG-VE) tem sido descrito como um parâmetro sensível para detectar disfunção sistólica, mesmo na presença de fração de ejeção do ventrículo esquerdo (FEVE) preservada. Objetivo: avaliar o papel do SLG-VE como preditor de CiC. Métodos: O presente estudo consiste em uma análise post-hoc do estudo CECCY (Carvedilol for Prevention of ChemotherapyRelated Cardiotoxicity [Carvedilol para Prevenção da Cardiotoxicidade Relacionada à Quimioterapia]), que avaliou a prevenção primária de cardiotoxicidade com carvedilol durante quimioterapia com doxorrubicina em uma população com câncer de mama. Definiu-se cardiotoxicidade como uma redução >10% na FEVE. O SLG-VE foi obtido antes da quimioterapia em pacientes sem doença cardiovascular prévia ou anormalidades no ecocardiograma. Resultados: Trinta e um pacientes submetidos a estudo ecocardiográfico completo incluindo avaliação de SLG-VE antes da quimioterapia foram incluídos nesta análise. Um SLG-VE absoluto <16,9% antes da quimioterapia mostrou 100% de sensibilidade e 73% de especificidade para predizer cardiotoxicidade (AUC=0,85; IC 95% 0,680­0,959, p<0,001). Nesta população, os valores de FEVE antes da quimioterapia não foram preditores de CiC (IC 95% 0,478 a -0,842, p=0,17). A associação de baixos níveis séricos de SLG-VE (<17%) e BNP (>17 pg/mL) dois meses após a quimioterapia aumentou a precisão para detectar CiC de início precoce (100% de sensibilidade, 88% de especificidade, AUC=0,94; IC 95% 0,7810,995, p<0,0001). Conclusões: Nossos dados sugerem que o SLG-VE é um possível preditor de cardiotoxicidade induzida por quimioterapia. São necessários estudos maiores para confirmar a relevância clínica desse parâmetro ecocardiográfico nesse cenário clínico. (AU)

Background: Chemotherapy-induced cardiotoxicity (ChC) is an important complication among patients receiving anthracyclines. Biomarkers and imaging parameters have been studied for their ability to identify patients at risk of developing ChC. Left ventricular global longitudinal strain (LV-GLS) is a sensitive parameter for detecting systolic dysfunction despite the presence of preserved left ventricular ejection fraction (LVEF). Objective: To evaluate the role of the LV-GLS as a predictor of ChC. Methods: This was a post-hoc analysis of the Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity trial, which evaluated the primary prevention of cardiotoxicity with carvedilol during doxorubicin chemotherapy in a population of patients with breast cancer. Cardiotoxicity was defined as a reduction ≥10% in LVEF. LV-GLS was determined before chemotherapy in patients with no prior cardiovascular disease or echocardiogram abnormalities. Results: Thirty-one patients for whom a complete echocardiography study including measurement of LV-GLS was performed before chemotherapy were included in this analysis. An absolute LV-GLS<16.9% before chemotherapy showed 100% sensitivity and 73% specificity for predicting cardiotoxicity (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.680­0.959; p<0.001). In this population, LVEF values before chemotherapy did not predict ChC (95% CI, 0.478 to -0.842; p=0.17). The association of low LV-GLS (<17%) and brain-type natriuretic peptide serum levels (>17 pg/mL) at 2 months after chemotherapy increased the accuracy for detecting early-onset ChC (100% sensitivity, 88% specificity; AUC, 0.94; 95% CI, 0.781­0.995; p<0.0001). Conclusions: Our data suggest that LV-GLS is a potential predictor of ChC. Larger studies are needed to confirm its clinical relevance in this clinical setting. (AU)

Development of Listening Comprehension Tests with Narrative and Expository Texts for Portuguese Students.

This investigation aimed to develop and collect psychometric data for two tests assessing listening comprehension of Portuguese students in primary school: the Test of Listening Comprehension of Narrative Texts (TLC-n) and the Test of Listening Comprehension of Expository Texts (TLC-e). Two studies were conducted. The purpose of study 1 was to construct four test forms for each of the two tests to assess first, second, third and fourth grade students of the primary school. The TLC-n was administered to 1042 students, and the TLC-e was administered to 848 students. The purpose of study 2 was to test the psychometric properties of new items for the TLC-n form for fourth graders, given that the results in study 1 indicated a severe lack of difficult items. The participants were 260 fourth graders. The data were analysed using the Rasch model. Thirty items were selected for each test form. The results provided support for the model assumptions: Unidimensionality and local independence of the items. The reliability coefficients were higher than .70 for all test forms. The TLC-n and the TLC-e present good psychometric properties and represent an important contribution to the learning disabilities assessment field.

"Experiences marked by prejudice(s)?": nurses' representations on 'transvestite' people / "¿Experiencias prejuiciosas?": representaciones de enfermeras en personas de 'travestis' / "Vivências marcadas por preconceito(s)?": representações de enfermeiras(os) sobre pessoas 'travestis'

ABSTRACT Objectives: to learn and analyze the structure of nurses' social representations about transvestite people. Methods: a qualitative research based on the Theory of Social Representations, with 110 nurses enrolled in Graduate Nursing courses, who answered the Free-Association Test, with the stimulus 'transvestite'. Data were processed by the software Ensemble de Programmes Permettant I' Analysedes Évocations. Results: in the central nucleus, the term "prejudice" was the most evoked, followed by "homosexual", "identity" and "female-make-up". Social representation is anchored in the social organization in which transvestite people are still seen and/or associated with homosexuals who make up and assume an identity, without being seen and/or understood as they really are. Final Considerations: although prejudice is noteworthy as a central element, terms present in the peripheral system reveal that the group recognizes transvestites as a person with rights, which can translate into health care practices.

RESUMEN Objetivos: aprehender y analizar la estructura de las representaciones sociales de las enfermeras sobre la persona travesti. Métodos: investigación cualitativa, basada en la teoría de las representaciones sociales, con 110 enfermeras matriculadas en cursos de posgrado de enfermería, que respondieron a la prueba de asociación de la palabra libre, con el estímulo 'travesti'. Los datos se procesaron utilizando el software Ensemble de Programmes Permettant I' Analysedes Évocations. Resultados: en el núcleo central, el término "prejuicio" fue el más evocado, seguido de "homosexual", "identidad" y "maquillaje-femenino". La representación social está anclada en la organización social en la que las personas travestis todavía son vistas y/o asociadas con el homosexual que se maquilla y asume una identidad, sin embargo, sin ser visto y/o entendido como realmente es. Consideraciones finales: aunque el prejuicio se destaca como un elemento central, los términos presentes en el sistema periférico revelan que el grupo reconoce a los travestis como una persona con derechos, lo que puede traducirse en prácticas de atención médica.

RESUMO Objetivos: apreender e analisar a estrutura das representações sociais de enfermeiras(os) sobre a pessoa travesti. Métodos: pesquisa qualitativa, fundamentada na Teoria das Representações Sociais, com 110 enfermeiras(os) matriculadas(os) em cursos de Pós-Graduação em Enfermagem, que responderam ao Teste de Associação Livre de Palavras, com o estímulo 'travesti'. Os dados foram processados pelo softwareEnsemble de Programmes Permettant I' Analysedes Évocations. Resultados: no núcleo central, o termo "preconceito" foi o mais evocado, seguido por "homossexual", "identidade" e "maquiagem-feminino". A representação social está ancorada na organização social em que as pessoas travestis ainda são vistas e/ou associadas ao homossexual que se maquia e assume uma identidade, sem, no entanto, serem vistas e/ou compreendidas como realmente são/estão. Considerações Finais: embora o preconceito se notabilize como elemento central, termos presentes no sistema periférico revelam que o grupo reconhece a travesti enquanto pessoa de direitos, o que pode traduzir-se nas práticas de cuidado em saúde.

Reverse auction: a potential strategy for reduction of pharmacological therapy cost.

BACKGROUND: Polypharmacy is a significant economic burden. OBJECTIVE: We tested whether using reverse auction (RA) as compared with commercial pharmacy (CP) to purchase medicine results in lower pharmaceutical costs for heart failure (HF) and heart transplantation (HT) outpatients. METHODS: We compared the costs via RA versus CP in 808 HF and 147 HT patients followed from 2009 through 2011, and evaluated the influence of clinical and demographic variables on cost. RESULTS: The monthly cost per patient for HF drugs acquired via RA was $10.15 (IQ 3.51-40.22) versus $161.76 (IQ 86.05­340.15) via CP; for HT, those costs were $393.08 (IQ 124.74-774.76) and $1,207.70 (IQ 604.48-2,499.97), respectively. CONCLUSION: RA may reduce the cost of prescription drugs for HF and HT, potentially making HF treatment more accessible. Clinical characteristics can influence the cost and benefits of RA. RA may be a new health policy strategy to reduce costs of prescribed medications for HF and HT patients, reducing the economic burden of treatment.

Defining characteristics of decreased cardiac output: a literature review.

OBJECTIVE: The study aims to proceed a literature review of defining characteristics (DCs) of decreased cardiac output (DCO). METHODS: Medline database was used to perform this study. The descriptors used were "low cardiac output" and "nursing diagnosis." RESULTS: Seventy-nine DCs were identified. Among them, 28 have already been approved by NANDA-I. Some data from microcirculation assessment such as high levels of serum lactate and decreased oxygen venous saturation were identified as indicators of this nursing diagnosis. CONCLUSIONS: Some of the approved DCs were identified through literature review but others seem to be new as they have not been cited in the NANDA-I classification. PRACTICAL IMPLICATIONS: Further content and clinical validations are needed to confirm if data from microcirculation might be considered as DCs of DCO.

Reverse Auction: A Potential Strategy for Reduction of Pharmacological Therapy Cost / Pregão: Estratégia para Redução do Custo da Terapia Farmacológica em Insuficiência Cardíaca e Transplante Cardíaco

Background:Polypharmacy is a significant economic burden.Objective:We tested whether using reverse auction (RA) as compared with commercial pharmacy (CP) to purchase medicine results in lower pharmaceutical costs for heart failure (HF) and heart transplantation (HT) outpatients.Methods:We compared the costs via RA versus CP in 808 HF and 147 HT patients followed from 2009 through 2011, and evaluated the influence of clinical and demographic variables on cost.Results:The monthly cost per patient for HF drugs acquired via RA was $10.15 (IQ 3.51-40.22) versus $161.76 (IQ 86.05‑340.15) via CP; for HT, those costs were $393.08 (IQ 124.74-774.76) and $1,207.70 (IQ 604.48-2,499.97), respectively.Conclusion:RA may reduce the cost of prescription drugs for HF and HT, potentially making HF treatment more accessible. Clinical characteristics can influence the cost and benefits of RA. RA may be a new health policy strategy to reduce costs of prescribed medications for HF and HT patients, reducing the economic burden of treatment.

Fundamento:A polifarmácia tem um significativo peso econômico.Objetivo:Testar se o uso de pregão em comparação ao de farmácias comerciais (FC) para a compra de medicamentos reduz o custo do tratamento de pacientes ambulatoriais de insuficiência cardíaca (IC) e transplante cardíaco (TC).Métodos:Comparação dos custos do tratamento através de pregão versus FC em pacientes de IC (808) e TC (147) acompanhados de 2009 a 2011, avaliando-se a influência de variáveis clínicas e demográficas no custo.Resultados:Os custos mensais por paciente para medicamentos de IC adquiridos através de pregão e através de FC foram $10,15 (IQ 3,51-40,22) e $161,76 (IQ 86,05-340,15), respectivamente. Para TC, aqueles custos foram $393,08 (IQ 124,74-774,76) e $1.207,70 (IQ 604,48-2.499,97), respectivamente.Conclusão:O pregão pode reduzir o custo dos medicamentos prescritos para IC e TC, podendo tornar o tratamento de IC mais acessível. As características clínicas podem influenciar o custo e os benefícios do pregão, que pode ser uma nova estratégia de política de saúde para baixar os custos dos medicamentos prescritos para IC e TC, diminuindo o peso econômico do tratamento. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0).