Management of peri-device leak following left atrial appendage closure: A systematic review.

OBJECTIVE: This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure. BACKGROUND: The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. METHODS: A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. RESULTS: We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (<5 mm; 45%), moderate (≥5-9 mm; 25%), and large (≥10 mm; 30%). Endovascular coils and endovascular plugs were used to close both small and moderate sized leaks, and second LAA closure devices were exclusively used for large PDLs. Successful PDL closure occurred in 90%, and was similar between PDL sizes and types of occluder used. Procedural complication rates were uncommon (2.8%). No strokes were reported following PDL closure at 6 months. CONCLUSIONS: In patients with PDL for whom discontinuation of OAC may be considered unsafe, percutaneous closure using a tailored approach with either endovascular coils, plugs, or second occluder represents a safe, and feasible alternative associated with favorable clinical outcomes.

A systematic review on the use of ultrasound enhancing agents with transesophageal echocardiography to assess the left atrial appendage prior to cardioversion.

BACKGROUND: Assessment of the left atrium and atrial appendage (LAA) for thrombus by transesophageal echocardiography (TEE) may be suboptimal due to difficult imaging windows and ultrasound artifacts. The present study analyzed the benefit of using ultrasound enhancing agents (UEAs) with TEE to improve diagnostic accuracy and image quality. METHODS: A systematic review of studies published through December 2020 was performed, and included investigations comparing the number of cases deemed indeterminate for visualization of LAA thrombi on TEE pre- versus post-UEAs prior to cardioversion for atrial fibrillation or flutter (AF). Study results were pooled where the number of indeterminate cases by conventional TEE were re-classified as thrombus present, indeterminate, or thrombus excluded following administration of UEAs. RESULTS: Three studies with a total of 399 patients were identified. Of these, 83 (26%) participants met the inclusion criteria. The mean age of the study population from the three studies was 66 ± 12 years, 29% were female, and prevalence of congestive heart failure or neurologic events was 22% and 5%, respectively. Use of UEAs with TEE re-classified 66% (55/83) of cases initially deemed to be indeterminate for LAA thrombus on conventional TEE. Thrombus was present in 13% (11/83) and excluded in 53% (44/83) of cases; 34% (28/83) of cases remained indeterminate on TEE post-UEAs. There were no complications reported with the administration of UEAs. CONCLUSION: Adjunctive use of UEAs with TEE can facilitate the diagnosis or exclusion of LAA thrombus, and improve the procedural confidence and cost-efficiency of cardioversion for AF.

Long-term clinical outcomes and prognostic indicators for focal impulse and rotor modulation guided ablation: A single-center observational study.

BACKGROUND: Electrophysiologists have developed a computational mapping approach to localize sources that may perpetuate persistent atrial fibrillation (AF). Focal impulse and rotor modulation (FIRM)-guided ablation of these sources have produced variable results. The current study further assesses single-procedure success rates of FIRM-guided ablation for preventing AF or atrial tachyarrhythmia recurrence and analyzes different baseline characteristics as prognostic indicators for individuals experiencing these undesired outcomes. METHODS: Seventy-one consecutive patients (mean age 64.58 ± 9.05 years and 36.6% female) with drug-refractory persistent AF with and without prior history of pulmonary vein antral isolation (PVAI) underwent FIRM-guided ablation. Patients without prior history of PVAI underwent FIRM-guided ablation in addition to de novo PVAI. Patients with prior history of PVAI had the pulmonary veins reassessed at the time of FIRM-guided ablation for reconnection as well as re-isolation, when necessary. These patients were then prospectively followed for AF and atrial tachyarrhythmia recurrence. RESULTS: FIRM analysis revealed rotors in the right atrium in 66.2% (1.77 ± 1.53 mean rotors per patient) and in the left atrium in 85.9% (2.65 ± 1.52 mean rotors per patient) of patients analyzed in the current study. After a single FIRM-guided ablation procedure, AF and atrial tachyarrhythmia recurrence was demonstrated in 21.1% (15/71) and 33.8% (24/71) of patients, respectively. The entire cohort of patients were followed for a mean duration of 23.20 ± 8.38 months with the mean time to AF recurrence found to be 12.35 ± 10.44 months. Furthermore, valvular heart disease (i.e. moderate mitral or tricuspid regurgitation) was found to be a statistically significant independent predictor for AF recurrence following FIRM-guided ablation (p = .033). CONCLUSIONS: FIRM-guided ablation in combination with PVAI is a suitable and effective approach for symptomatic individuals with drug-refractory persistent AF with and without prior history of PVAI. Randomized controlled studies are warranted.

Support vector machine classification of brain metastasis and radiation necrosis based on texture analysis in MRI.

PURPOSE: To develop a classification model using texture features and support vector machine in contrast-enhanced T1-weighted images to differentiate between brain metastasis and radiation necrosis. METHODS: Texture features were extracted from 115 lesions: 32 of them previously diagnosed as radiation necrosis, 23 as radiation-treated metastasis and 60 untreated metastases; including a total of 179 features derived from six texture analysis methods. A feature selection technique based on support vector machine was used to obtain a subset of features that provide optimal performance. RESULTS: The highest classification accuracy evaluated over test sets was achieved with a subset of ten features when the untreated metastases were not considered; and with a subset of seven features when the classifier was trained with untreated metastases and tested on treated ones. Receiver operating characteristic curves provided area-under-the-curve (mean ± standard deviation) of 0.94 ± 0.07 in the first case, and 0.93 ± 0.02 in the second. CONCLUSION: High classification accuracy (AUC > 0.9) was obtained using texture features and a support vector machine classifier in an approach based on conventional MRI to differentiate between brain metastasis and radiation necrosis.

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial.

Importance: Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output. Objective: To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation. Design, Setting, and Participants: This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold. Interventions: Dual DCCV vs single DCCV. Main Outcomes and Measures: Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure. Results: Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications. Conclusions and Relevance: In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort. Trial Registration: ClinicalTrials.gov Identifier: NCT04539158.

Geospatial investigations in Colombia reveal variations in the distribution of mood and psychotic disorders.

BACKGROUND: Geographical variations in mood and psychotic disorders have been found in upper-income countries. We looked for geographic variation in these disorders in Colombia, a middle-income country. We analyzed electronic health records from the Clínica San Juan de Dios Manizales (CSJDM), which provides comprehensive mental healthcare for the one million inhabitants of Caldas. METHODS: We constructed a friction surface map of Caldas and used it to calculate the travel-time to the CSJDM for 16,295 patients who had received an initial diagnosis of mood or psychotic disorder. Using a zero-inflated negative binomial regression model, we determined the relationship between travel-time and incidence, stratified by disease severity. We employed spatial scan statistics to look for patient clusters. RESULTS: We show that travel-times (for driving) to the CSJDM are less than 1 h for ~50% of the population and more than 4 h for ~10%. We find a distance-decay relationship for outpatients, but not for inpatients: for every hour increase in travel-time, the number of expected outpatient cases decreases by 20% (RR = 0.80, 95% confidence interval [0.71, 0.89], p = 5.67E-05). We find nine clusters/hotspots of inpatients. CONCLUSIONS: Our results reveal inequities in access to healthcare: many individuals requiring only outpatient treatment may live too far from the CSJDM to access healthcare. Targeting of resources to comprehensively identify severely ill individuals living in the observed hotspots could further address treatment inequities and enable investigations to determine factors generating these hotspots.

The frequencies of mental disorders vary by geographic region. Investigating such variations may lead to more equitable access to mental healthcare and to scientific discoveries that reveal specific localized factors that contribute to the causes of mental illness. This study examined the frequency of three disorders with a major impact on public health ­ schizophrenia, bipolar disorder, and major depressive disorder ­ by analyzing electronic health records from a hospital providing comprehensive mental health care for a large region in Colombia. We show that individuals receiving outpatient care mainly live relatively near the facility. Those receiving inpatient care live throughout the region, but cluster in a few scattered locations. Future research could lead to strategies for more equitable provision of mental healthcare in Colombia and identify environmental or genetic factors that affect the likelihood that someone will develop one of these disorders.

X ray screening at entry and systematic screening for the control of tuberculosis in a highly endemic prison.

BACKGROUND: Tuberculosis (TB) is a major issue in prisons of low and middle income countries where TB incidence rates are much higher in prison populations as compared with the general population. In the Rio de Janeiro (RJ) State prison system, the TB control program is limited to passive case-finding and supervised short duration treatment. The aim of this study was to measure the impact of X-ray screening at entry associated with systematic screening on the prevalence and incidence of active TB. METHODS: We followed up for 2 years a RJ State prison for adult males (1429 inmates at the beginning of the study) and performed, in addition to passive case-finding, 1) two "cross-sectional" X-ray systematic screenings: the first at the beginning of the study period and the second 13 months later; 2) X-ray screening of inmates entering the prison during the 2 year study period. Bacteriological examinations were performed in inmates presenting any pulmonary, pleural or mediastinal X-ray abnormality or spontaneously attending the prison clinic for symptoms suggestive of TB. RESULTS: Overall, 4326 X-rays were performed and 246 TB cases were identified. Prevalence among entering inmates remained similar during 1st and the 2nd year of the study: 2.8% (21/754) and 2.9% (28/954) respectively, whereas prevalence decreased from 6.0% (83/1374) to 2.8% (35/1244) between 1st and 2nd systematic screenings (p < 0.0001). Incidence rates of cases identified by passive case-finding decreased from 42 to 19 per 1000 person-years between the 1st and the 2nd year (p < 0.0001). Cases identified by screenings were less likely to be bacteriologically confirmed as compared with cases identified by passive-case finding. CONCLUSIONS: The strategy investigated, which seems highly effective, should be considered in highly endemic confined settings such as prisons.

Perception of Race and Sex Diversity in Ophthalmology by Artificial Intelligence: A DALL E-2 Study.

Purpose: In the past few years, there has been remarkable progress in accessibility of open-source artificial intelligence (AI) image generators, developed to help humans understand how AI sees our world. Here, we characterize perception of racial and sex diversity in ophthalmology by AI. Methods: OpenAI's open-source DALL E-2 AI was used for image generation of ophthalmologists with queries that all included "American" and "portrait photo". Factors used for queries contained categories of following: "Positive Characteristic", "Negative Characteristic", "Finances", "Region", "Experience", "Academic Rank", and "Subspecialty". The first 40 faces for each search were categorized on the basis of race and sex by two independent reviewers. If race or sex was not agreed upon, a third reviewer independently provided a classification, or if still indeterminate, the image was labeled as such. Images that did not adequately show facial features were excluded from categorization. Results: A total of 1560 images were included in the analysis. Control search queries specifying solely ophthalmologist sex and/or race outputted (100%) accurate images validating the tool. The query "American ophthalmologist, portrait photo" portrayed the majority of ophthalmologists as White (75%) and male (77.5%). Young/inexperienced/amateur ophthalmologists were perceived to have greater non-White racial diversity (27.5%) and female representation (28.3%) relative to old/experienced/mature ophthalmologists (23.3% non-White and 18.3% female). Ophthalmology department chairs (25%) had slightly more racial diversity compared to residents (22.5%), but residents had greater female representation (30%) compared to chairs (15%). Conclusion: Our results suggest the DALL E-2 AI may perceive a trend of increasing racial and sex diversity in younger, newer ophthalmologists compared to more senior ophthalmologists. Future investigations should attempt to validate how AI may be used as a tool to evaluate ophthalmology's progress towards becoming more inclusive of increasingly diverse ophthalmologists.

Effect of Vancomycin Applied to the Surgical Site on Fracture Healing in a Diabetic Rat Model.

BACKGROUND: Prophylactic vancomycin treatment decreases the prevalence of surgical site and deep infections by >70% in diabetic patients undergoing reconstructive foot and ankle surgery. Thus, determining whether clinically relevant local vancomycin doses affect diabetic fracture healing is of medical interest. We hypothesized that application of vancomycin powder to the fracture site during surgery would not affect healing outcomes, but continuous exposure of vancomycin would inhibit differentiation of osteoblast precursor cells and their osteogenic activity in vitro. METHODS: The vancomycin dose used to treat the diabetic rats was a modest increase to routine surgical site vancomycin application of 1 to 2 g for a 70-kg adult (21 mg/kg). After femur fracture in BB-Wistar type 1 diabetic rats, powdered vancomycin (25 mg/kg) was administered to the fracture site. Bone marrow and periosteal cells isolated from diabetic bones were cultured and treated with increasing levels of vancomycin (0, 5, 50, 500, or 5000 µg/mL). RESULTS: Radiographic scoring, micro-computed tomography (µCT) analysis, and torsion mechanical testing failed to identify any statistical difference between the vancomycin-treated and the untreated fractured femurs 6 weeks postfracture. Low to moderate levels of vancomycin treatment (5 and 50 µg/mL) did not impair cell viability, osteoblast differentiation, or calcium deposition in either the periosteum or bone marrow-derived cell cultures. In contrast, high doses of vancomycin (5000 µg/mL) did impair viability, differentiation, and calcium deposition. CLINICAL RELEVANCE: In this diabetic rodent fracture model, vancomycin powder application at clinically relevant doses did not affect fracture healing or osteogenesis.

Electroconvulsive Therapy Impact on Memory Performance in Patients With Depression.

INTRODUCTION: The safety of electroconvulsive therapy has improved greatly over the last decades, making the potentially adverse effects on memory and other neurocognitive functions the main clinical aspect of concern in the present. In Colombia, the general population and healthcare professionals (even some psychiatrists) seem to have mostly negative opinions towards electroconvulsive therapy treatment, but maybe this could be reconsidered if more information is provided; therefore, the aim of the present study was to evaluate the changes in memory and the severity of the symptoms in a group of patients with severe depression before and after electroconvulsive therapy. METHODS: Twenty-three patients ranging in age from 23 to 70 years from the electroconvulsive therapy service at the San Juan de Dios Clinic (Manizales, Colombia) were recruited in order to assess the effect of electroconvulsive therapy on memory in patients with severe depression. Depressive symptoms and memory were assessed with the Hamilton Depression Scale (HAMD) and Rey Auditory Verbal Learning Test (RAVLT), respectively. The assessment was administered to participants before the initial treatment of electroconvulsive therapy series (0-1 day) and 2 days after their last treatment. RESULTS: Electroconvulsive therapy resulted in significant improvement in the rating of depression. There were no significant differences in the five learning trials, delayed recall, learning and forgetting scores from pre-treatment to post-treatment. Significant pre-treatment/post-treatment differences were found in the delayed recognition trial. CONCLUSIONS: Pre- and post- electroconvulsive therapy cognitive assessment is a feasible and useful procedure. In general, memory performance does not worsen after electroconvulsive therapy in patients with depression. Only delayed recognition is affected a few days following electroconvulsive therapy, particularly in patients with low educational level and bitemporal (BT) electrode placement.

Local zinc treatment enhances fracture callus properties in diabetic rats.

The effects of locally applied zinc chloride (ZnCl2 ) on early and late-stage parameters of fracture healing were evaluated in a diabetic rat model. Type 1 Diabetes has been shown to negatively impact mechanical parameters of bone as well as biologic markers associated with bone healing. Zinc treatments have been shown to reverse those outcomes in tests of nondiabetic and diabetic animals. This study is the first to assess the efficacy of a noncarrier mediated ZnCl2 on bony healing in diabetic animals. This is a promising basic science approach which may lead to benefits for diabetic patients in the future. Treatment and healing were assessed through quantification of callus zinc, radiographic scoring, microcomputed tomography (µCT), histomorphometry, and mechanical testing. Local ZnCl2 treatment increased callus zinc levels at 1 and 3 days after fracture (p ≤ 0.025). Femur fractures treated with ZnCl2 showed increased mechanical properties after 4 and 6 weeks of healing. Histomorphometry of the ZnCl2 -treated fractures found increased callus cartilage area at Day 7 (p = 0.033) and increased callus bone area at Day 10 (p = 0.038). In contrast, callus cartilage area was decreased (p < 0.01) after 14 days in the ZnCl2 -treated rats. µCT analysis showed increased bone volume in the fracture callus of ZnCl2 -treated rats at 6 weeks (p = 0.0012) with an associated increase in the proportion of µCT voxel axial projections (Z-rays) spanning the fracture site. The results suggest that local ZnCl2 administration improves callus chondrogenesis leading to greater callus bone formation and improved fracture healing in diabetic rats.

COVID-19 in prisons: what telejournalism (not) showed - a study on the criteria for newsworthiness during the pandemic. / COVID-19 nas prisões: o que o telejornalismo (não) mostrou - um estudo sobre os critérios de noticiabilidade na pandemia.

To analyze the news coverage of the COVID-19 pandemic in Brazilian prisons and its visibility, 213 articles broadcast between March and December 2020 were examined, found in the search service of the digital streaming video platform Globoplay. Most aired in March, April and July, with the theme almost disappearing in subsequent months. The reports, on numbers of deaths or infections, prevention measures and house arrest or freedom for groups at risk of COVID-19 were mainly published in local telejournals. Health agencies were barely heard. Of the 19 news items presented nationally, 12 address "famous prisoners" and the legibility of house arrest or freedom for groups at risk of COVID-19 unfavorable outcome. The health guidelines and the guarantee of the right to health of persons deprived of liberty were limited to the difficulties in implementing protection measures in prisons and to sustaining the need for restrictive measures to move inside prisons and in exchanges with the outside, to limit the circulation of the virus. In general, the form and visibility given to the topic do not contribute to broadening the viewers' perception of the sanitary conditions in prisons and the fact that health is a right for all, without any distinction.

Para analisar a cobertura telejornalística da pandemia de COVID-19 nas prisões brasileiras e sua visibilidade, foram examinadas 213 matérias veiculadas entre março e dezembro de 2020, encontradas no serviço de buscas da plataforma digital de vídeos por streaming Globoplay. A maior parte foi ao ar em março, abril e julho, com importante redução nos meses subsequentes. As reportagens, sobre números de mortes ou infectados, medidas de prevenção e prisão domiciliar ou liberdade para grupos de risco da COVID-19, foram divulgadas principalmente nos jornais locais. Os órgãos de saúde quase não foram ouvidos. Das 19 notícias apresentadas nacionalmente, 12 abordam os "presos famosos" e a legitimidade da prisão domiciliar ou a liberdade para grupos de risco da COVID-19. As pautas sanitárias e de garantia do direito à saúde das pessoas privadas de liberdade ficaram limitadas às dificuldades para a efetivação nos presídios das medidas de proteção e a sustentar a necessidade de medidas restritivas à movimentação no interior das prisões e nos intercâmbios com o exterior para limitar a circulação do vírus. Em geral, a forma e a visibilidade dadas ao tema não contribuem para ampliar a percepção dos telespectadores sobre as condições sanitárias das prisões e o fato de que a saúde é um direito de todos, sem qualquer distinção.

Analysis of health care in prisons of Pará state, Brazil. / Análise do cuidado em saúde no sistema prisional do Pará, Brasil.

This study aimed to describe Pará's Prison Health. This ecological time series study was based on secondary data with unrestricted access from Institutional Reports of the Penitentiary System and information from the Pará Transparency Web Portal, the National Register of Health Facilities (CNES), and the Notifiable Diseases Information System (SINAN). As a result, we observed a population with a majority of less-educated young black and brown males. In absolute numbers, we observed an increase of health professionals who did not follow the prison population hike. When entered into statistical control charts, the number of medical, dental, and psychological visits varied randomly and outside the limits. The potential coverage of prison health teams linked to the SUS achieved a maximum of 45.77%. Health task forces did not increase the number of visits. The incidence of tuberculosis was much higher than the mean for the state population, and its notification is adequate. Even with restricted secondary data, we could broadly look at the state's prison health, raising issues managers and professionals should consider.

Este trabalho buscou descrever a saúde prisional paraense. Trata-se de estudo ecológico, em série temporal, baseado em dados secundários de acesso irrestrito a partir de relatórios institucionais do sistema penitenciário, além de informações provenientes do Portal da Transparência do Pará, do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e do Sistema de Informação de Agravos de Notificação (SINAN). Como resultados, observou-se uma população de maioria jovem, negra e parda, de baixa escolaridade e do sexo masculino. Constatou-se um aumento, em números absolutos, de profissionais de saúde, mas sem acompanhar proporcionalmente o aumento da população carcerária. O número de consultas médicas, odontológicas e psicológicas variou de forma aleatória e fora dos limites quando inseridos em gráficos de controle estatístico. O potencial de cobertura das equipes de saúde prisional vinculadas aos SUS foi de no máximo 45,77%. Mutirões de saúde não aumentaram o número o total de consultas. A incidência de tuberculose mostrou-se muito superior à média para população do estado e sua notificação mostrou-se adequada. Mesmo trabalhando com dados secundários restritos, pôde-se lançar um amplo olhar sobre a saúde prisional do estado, levantando questões que devem ser apreciadas por gestores e profissionais.

[Mortality and causes of deaths in prisons in Rio de Janeiro, Brazil]. / Mortalidade e causas de óbitos nas prisões do Rio de Janeiro, Brasil.

Mortality in prisons, a basic indicator of the right to health for incarcerated persons, has never been studied extensively in Brazil. An assessment of all-cause and cause-specific mortality in prison inmates was conducted in 2016-2017 in the state of Rio de Janeiro, based on data from the Mortality Information System and Prison Administration. Mortality rates were compared between prison population and general population after standardization. The leading causes of death in inmates were infectious diseases (30%), cardiovascular diseases (22%), and external causes (12%). Infectious causes featured HIV/AIDS (43%) and TB (52%, considering all deaths with mention of TB). Only 0.7% of inmates who died had access to extramural health services. All-cause mortality rate was higher among prison inmates than in the state's general population. Among inmates, mortality from infectious diseases was 5 times higher, from TB 15 times higher, and from endocrine diseases (especially diabetes) and cardiovascular diseases 1.5 and 1.3 times higher, respectively, while deaths from external causes were less frequent in prison inmates. The study revealed important potentially avoidable excess deaths in prisons, reflecting lack of care and exclusion of this population from the Brazilian Unified National Health System. This further highlights the need for a precise and sustainable real-time monitoring system for deaths, in addition to restructuring of the prison staff through implementation of the Brazilian National Policy for Comprehensive Healthcare for Persons Deprived of Freedom in the Prison System in order for inmates to fully access their constitutional right to health with the same quality and timeliness as the general population.

A mortalidade nas prisões, indicador fundamental do direito à saúde das pessoas privadas de liberdade (PPL), nunca foi estudada de maneira aprofundada no Brasil. A avaliação da mortalidade global e por causas entre PPL encarceradas em 2016-2017 no Estado do Rio de Janeiro, foi realizada a partir de dados do Sistema de Informações sobre Mortalidade e da Administração Penitenciária. Taxas de mortalidade entre PPL e população geral do estado foram comparadas após padronização. As principais causas de morte entre PPL foram doenças infecciosas (30%), doenças do aparelho circulatório (22%) e causas externas (12%). Dentre as causas infecciosas, destacam-se HIV/aids (43%) e tuberculose (TB) (52% se considerados todos os óbitos com menção de TB). Somente 0,7% das PPL que faleceram tiveram acesso a serviço de saúde extramuros. A taxa global de mortalidade foi maior entre as PPL comparadas à população geral do estado, com mortalidade por doenças infecciosas 5 vezes superior, por TB 15 vezes e por doenças endócrinas, especialmente diabetes, e doenças circulatórias (1,5 e 1,3 vez, respectivamente), enquanto mortes por causa externa foram menos frequentes entre PPL. Este estudo mostra um expressivo excesso de mortes potencialmente evitáveis nas prisões, o que traduz importante desassistência e exclusão dessa população do Sistema Único de Saúde. Evidencia a necessidade de um sistema de monitoramento, em tempo real, dos óbitos, preciso e sustentável, além da reestruturação da saúde prisional por meio da efetivação da Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional para que as PPL usufruam do direito constitucional à saúde em sua integralidade, com a mesma qualidade e tempestividade oferecida à população geral.

La mortalidad en las prisiones, indicador fundamental del derecho a la salud de personas privadas de libertad (PPL), nunca se estudió profundamente en Brasil. La evaluación de la mortalidad global y por causas entre PPL, encarceladas en 2016-2017 en el estado de Rio de Janeiro, se realizó a partir de datos del Sistema de Información de Mortalidad y la Administración Penitenciaria. Se compararon las tasas de mortalidad entre PPL y población general del estado tras la estandarización. Las principales causas de muerte entre PPL fueron: enfermedades infecciosas (30%), enfermedades del aparato circulatorio (22%) y causas externas (12%). Entre las causas infecciosas, se destacan VIH/sida (43%) y tuberculosis (TB) (52%, si se consideran todos los óbitos con mención TB). Solamente un 0,7% de las PPL que fallecieron tuvieron acceso a un servicio de salud extramuros. La tasa global de mortalidad fue mayor entre las PPL, comparada con la población general del estado. Entre las PPL, la mortalidad por enfermedades infecciosas fue 5 veces superior, por TB 15 veces, y por enfermedades endocrinas, especialmente diabetes, y enfermedades circulatorias (1,5 y 1,3 veces respectivamente), mientras que las muertes por causa externa fueron menos frecuentes entre PPLs. Este estudio muestra un expresivo exceso de muertes potencialmente evitables en las prisiones, lo que se traduce en una importante desasistencia y la exclusión de esta población del Sistema Único de Salud. Pone en evidencia la necesidad de un sistema de supervisión en tiempo real de los óbitos, preciso y sostenible, además de la reestructuración de la salud en las prisiones, mediante la efectivización de la Política Nacional de Atención Integral a la Salud de las Personas Privadas de Libertad en el Sistema Penitenciario para que las PPLs disfruten del derecho constitucional a la salud en su integridad, con la misma calidad y oportunidad ofrecida a la población general.

Electroconvulsive Therapy Impact on Memory Performance in Patients With Depression.

INTRODUCTION: The safety of electroconvulsive therapy has improved greatly over the last decades, making the potentially adverse effects on memory and other neurocognitive functions the main clinical aspect of concern in the present. In Colombia, the general population and healthcare professionals (even some psychiatrists) seem to have mostly negative opinions towards electroconvulsive therapy treatment, but maybe this could be reconsidered if more information is provided; therefore, the aim of the present study was to evaluate the changes in memory and the severity of the symptoms in a group of patients with severe depression before and after electroconvulsive therapy. METHODS: Twenty-three patients ranging in age from 23 to 70 years from the electroconvulsive therapy service at the San Juan de Dios Clinic (Manizales, Colombia) were recruited in order to assess the effect of electroconvulsive therapy on memory in patients with severe depression. Depressive symptoms and memory were assessed with the Hamilton Depression Scale (HAMD) and Rey Auditory Verbal Learning Test (RAVLT), respectively. The assessment was administered to participants before the initial treatment of electroconvulsive therapy series (0-1 day) and 2 days after their last treatment. RESULTS: Electroconvulsive therapy resulted in significant improvement in the rating of depression. There were no significant differences in the five learning trials, delayed recall, learning and forgetting scores from pre-treatment to post-treatment. Significant pre-treatment/post-treatment differences were found in the delayed recognition trial. CONCLUSIONS: Pre- and post- electroconvulsive therapy cognitive assessment is a feasible and useful procedure. In general, memory performance does not worsen after electroconvulsive therapy in patients with depression. Only delayed recognition is affected a few days following electroconvulsive therapy, particularly in patients with low educational level and bitemporal (BT) electrode placement.

Leadless and Wireless Cardiac Devices: The Next Frontier in Remote Patient Monitoring.

In the last decade, advances in wireless and sensor technologies, and the implementation of telemedicine, have led to innovative digital health care for cardiac patients. Continuous monitoring of patients' biomedical signals, and acute changes in these signals, may result in timely, accurate diagnoses and implementation of early interventions. In this review, we discuss commonly used wireless and leadless cardiac devices including pulmonary artery pressure sensors, implantable loop recorders, leadless pacemakers and subcutaneous implantable cardioverter-defibrillators. We discuss the concept and function of each device, indications, methods of delivery, potential complications, consideration for implantation, and cost-effectiveness.

Inflammatory bowel disease and the risk for cardiovascular disease: Does all inflammation lead to heart disease?

Inflammation has a strong role in the development of atherosclerotic cardiovascular disease (ASCVD). Several systemic inflammatory conditions have been linked to an increased risk of ASCVD; however, this has not been well established in Inflammatory Bowel Disease (IBD). IBD is comprised of Ulcerative Colitis and Crohn's disease, both of which involve chronic inflammation of the intestinal tract, often with evidence of systemic involvement. Several ASCVD risk factors such as smoking, diabetes, poor diet and the presence of obesity may increase the risk of ASCVD in patients suffering from IBD, despite a lower prevalence of hypertension and hypercholesterolemia. Medications used to treat IBD and target inflammation, such as steroids, may also accelerate the risk of the risk for ASCVD heart failure while exacerbating ASCVD risk factors. Several studies have demonstrated an elevated risk of acute myocardial infarction and stroke in these patients, most notably in women and in younger patients. Some cohort studies have also suggested a link between IBD and both atrial fibrillation and heart failure, particularly during periods of active flares. All IBD patients, particularly younger individuals, should be screened for ASCVD risk factors with aggressive risk factor modification to reduce the risk of cardiovascular events. Further research is needed to identify how to prevent and treat cardiovascular events that occur in patients with IBD, particularly during active flares.

Central sleep apnea and atrial fibrillation: A review on pathophysiological mechanisms and therapeutic implications.

Precipitating factors and chronic diseases associated with atrial fibrillation (AF) are detailed in the literature. Emerging evidence over the last several decades suggests a potential causal relationship between central sleep apnea (CSA) and AF. Mechanisms including apnea-induced hypoxia with intermittent arousal, fluctuating levels of carbon dioxide, enhanced sympathetic/neurohormonal activation and oxidative stress causing inflammation have been implicated as etiologic causes of AF within this subpopulation. CSA affects the efficacy of pharmacologic and catheter-based antiarrhythmic treatments, which is why treating CSA prior to these interventions may lead to lower rates of AF. Subsequently, a reduction in the AF burden with transvenous phrenic nerve stimulation (TPNS) has become a topic of interest. The present review describes the relationship between these conditions, pathophysiologic mechanisms implicating the role of CSA in development of AF, and emerging therapeutic interventions.

First Experience Using a Nonfenestrated Cardioform Septal Occluder for Closure of Giant Mitral Paravalvular Leak.

A variety of fenestrated vascular plugs have been used to seal paravalvular leaks with meaningful success; however, incomplete closure and refractory hemolysis remains a common problem. We describe the feasibility and rationale of their first experience using a nonfenestrated Cardioform Septal Occluder (Gore Medical, Flagstaff, Arizona) to treat a giant mitral paravalvular leak. (Level of Difficulty: Advanced.).

When "Blue Babies" Grow Up: Complications After Surgical Repair of Tetralogy of Fallot.

Tetralogy of Fallot (TOF) is a complex congenital cardiac defect. Surgical correction is well established as the treatment of choice and has resulted in a rapidly growing group of adults living with TOF. We describe potential complications of patients who have undergone TOF repair and were lost to follow-up. (Level of Difficulty: Intermediate.).