Outcomes following interval delayed first rib resection for acute axillosubclavian deep venous thrombosis.

BACKGROUND: Current management of axillosubclavian deep venous thrombosis (DVT) often uses thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly used anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique. METHODS: Between September 2012 and April 2021, 27 patients were identified within the institution's electronic medical record as having undergone first rib resection for upper extremity DVT. Seven of these patients had undergone preoperative thrombolysis before referral and were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral limb involvement, presence of documented hypercoagulable state, duration of preoperative and postoperative anticoagulation, and postoperative outcomes. RESULTS: Of the 20 patients (mean age, 26.2 years; 13 males) presenting with acute axillosubclavian DVT, all patients had right (n = 8) or left (n = 12) arm swelling. Five patients had extremity pain and four had extremity discoloration. Ten had axillosubclavian vein involvement, 9 had subclavian vein involvement, and 1 had axillary vein involvement. Two patients were on oral contraceptives and no patients had any other diagnosed hypercoagulable conditions. The mean duration of preoperative and postoperative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months, respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve patients (60%) demonstrated complete DVT resolution by venous duplex examination during the postoperative period and 8 patients (40%) demonstrated partial recanalization/chronic DVT. Complications included one hemothorax and one thoracic duct injury. All 20 patients remain asymptomatic without arm swelling, with a mean follow-up of 55.1 ± 34.7 months. CONCLUSIONS: Among patients presenting with acute axillosubclavian DVT, anticoagulation alone followed by interval first rib resection proved to be successful in providing symptomatic relief in the short to medium term. By eliminating the need for preoperative thrombolysis and postoperative venograms, this potentially cost-saving algorithm simplifies our management for acute venous thoracic outlet syndrome while maintaining good clinical outcomes. Because this study only analyzed our management algorithm's effectiveness in the short to medium term, the long-term effectiveness of this treatment will need to be demonstrated.

Atingimento das Metas de Colesterol LDL em Pacientes com Histórico de Infarto Agudo do Miocárdio: Estudo Transversal do Mundo Real / Attainment of LDL-Cholesterol Goals in Patients with Previous Myocardial Infarction: A Real-World Cross-Sectional Analysis

Resumo Fundamento: As diretrizes da Sociedade Europeia de Cardiologia recomendam um nível de colesterol LDL (LDL-C) < 55 mg/dL para pacientes com doença cardiovascular estabelecida. Embora a fórmula de Friedewald ainda seja amplamente utilizada para estimar o LDL-C, a fórmula mais recente de Martin-Hopkins mostrou maior precisão. Objetivos: Nosso objetivo foi avaliar: A) a proporção de pacientes que atingiram a meta de LDL-C e as terapias utilizadas em um centro terciário; B) o impacto da utilização do método de Martin-Hopkins em vez do método de Friedewald na proporção de pacientes controlados. Métodos: Estudo transversal monocêntrico, incluindo pacientes consecutivos pós-infarto do miocárdio, acompanhados por 20 cardiologistas, em um hospital terciário. Os dados foram coletados retrospectivamente de consultas clínicas realizadas após abril de 2022. Para cada paciente, os níveis de LDL-C e o atingimento das metas foram estimados a partir de um perfil lipídico ambulatorial, utilizando as fórmulas de Friedewald e Martin-Hopkins. Um valor-p bicaudal < 0,05 foi considerado estatisticamente significativo para todos os testes. Resultados: Foram incluídos 400 pacientes (com 67 ± 13 anos, 77% do sexo masculino). Utilizando a fórmula de Friedewald, a mediana de LDL-C sob terapia foi de 64 (50-81) mg/dL, e 31% tinham LDL-C dentro da meta. Estatinas de alta intensidade foram usadas em 64% dos pacientes, 37% estavam em uso de ezetimiba e 0,5% estavam em uso de inibidores de PCSK9. A terapia combinada de estatina de alta intensidade + ezetimiba foi utilizada em 102 pacientes (26%). A aplicação do método de Martin-Hopkins reclassificaria um total de 31 pacientes (7,8%). Entre aqueles considerados controlados pela fórmula de Friedewald, 27 (21,6%) teriam LDL-C estimado por Martin-Hopkins acima da meta. Conclusões: Menos de um terço dos pacientes pós-infarto do miocárdio apresentaram LDL-C dentro da meta. A aplicação da fórmula de Martin-Hopkins reclassificaria um quinto dos pacientes presumivelmente controlados no grupo de pacientes não controlados.

Abstract Background: The European Society of Cardiology guidelines recommend an LDL-cholesterol (LDL-C) < 55 mg/dL for patients with established cardiovascular disease. While the Friedewald equation to estimate LDL-C is still widely used, the newer Martin-Hopkins equation has shown greater accuracy. Objectives: We aimed to assess: A) the proportion of patients reaching LDL-C goal and the therapies used in a tertiary center; B) the impact of using the Martin-Hopkins method instead of Friedewald's on the proportion of controlled patients. Methods: A single-center cross-sectional study including consecutive post-myocardial infarction patients followed by 20 cardiologists in a tertiary hospital. Data was collected retrospectively from clinical appointments that took place after April 2022. For each patient, the LDL-C levels and attainment of goals were estimated from an ambulatory lipid profile using both Friedewald and Martin-Hopkins equations. A two-tailed p-value of < 0.05 was considered statistically significant for all tests. Results: Overall, 400 patients were included (aged 67 ± 13 years, 77% male). Using Friedewald's equation, the median LDL-C under therapy was 64 (50-81) mg/dL, and 31% had LDL-C within goals. High-intensity statins were used in 64% of patients, 37% were on ezetimibe, and 0.5% were under PCSK9 inhibitors. Combination therapy of high-intensity statin + ezetimibe was used in 102 patients (26%). Applying the Martin-Hopkins method would reclassify a total of 31 patients (7.8%). Among those deemed controlled by Friedewald's equation, 27 (21.6%) would have a Martin-Hopkins' LDL-C above goals. Conclusions: Less than one-third of post-myocardial infarction patients had LDL-C within the goal. Applying the Martin-Hopkins equation would reclassify one-fifth of presumably controlled patients into the non-controlled group.

Duplex Scans Performed Immediately Following Lower Extremity Angioplasty and Stenting are of Limited Utility.

BACKGROUND: Together with clinical examination, surveillance duplex examination represents the Society of Vascular Surgery recommendations for follow-up after endovascular intervention on the superficial femoral artery (SFA) and popliteal arterial segments. Compliance with postprocedural follow-up remains challenging. To establish a postangioplasty physiologic baseline, our institution began obtaining immediate postprocedural surveillance studies following lower extremity arterial interventions. We reviewed the utility of immediate postprocedural surveillance to determine if these studies enhanced postoperative care. METHODS: Serial patients undergoing SFA and popliteal angioplasty and stenting from January 2014 to December 2020 were identified from our prospectively maintained Vascular Surgery database. Patient demographic information, procedural details, and procedural outcomes were subsequently analyzed from the electronic medical record. RESULTS: Two hundred and sixty-three patients underwent 385 SFA and/or popliteal angioplasty/stenting interventions. Mean patient age was 64.8 ± 10 years. Among these 385 procedures, 350 (90.9%) were followed by immediate (<4 hours) postprocedural lower extremity arterial duplex scans. These 350 procedures included percutaneous transluminal angioplasty and/or stenting of the SFA (n = 236), popliteal artery (n = 34), or both (n = 80). Of these studies, 25 results (7.1%) were abnormal. One asymptomatic patient was admitted to hospital for immediate thrombolysis; however, the remaining 24 patients were followed clinically with no immediate intervention required. Abnormal results included 13 abnormalities appreciated on the final angiogram with 9 patients with known occlusions or stenoses, and 4 patients with mild to moderate CFA stenosis. Abnormal findings not detected on the final angiogram included 7 patients with mild to moderate stenosis and 5 patients with short occlusions (1.4%). All 5 patients with short segmental occlusions not detected on final arteriogram had preprocedural anatomy classified as either TASC C (TransAtlantic Inter-Society Consensus: SFA occlusions > 15 cm in length, n = 1) or TASC D (SFA occlusions > 20 cm in lenth, n = 4). CONCLUSIONS: Immediate postprocedural duplex scans demonstrate significant vessel stenosis or occlusion in approximately 7% of cases but most stenoses and occlusions were noted on final arteriography. Duplex detected short segmental occlusions not noted on final arteriography were rare (1.4%), and occurred among patients with TASC C or TASC D occlusive disease. These duplex detected abnormalities rarely changed the patient's immediate plan of care. The performance of these immediate postprocedural duplex scans demonstrated limited clinical utility.

A comunicação e o cuidado seguro e efetivo de enfermagem em centro cirúrgico e terapia intensiva: revisão integrativa / Communication and safe and effective nursing care in surgical center and intensive care: integrative review

Objetivo: Identificar a importância da comunicação para o cuidado seguro e efetivo de enfermagem em centro cirúrgico e terapia intensiva.Métodos: Revisão integrativa, com levantamento das produções em fevereiro de 2023 nas bases de dados Lilacs, MEDLINE, CINAHL e Scopus. Foram incluídos estudos primários, disponíveis na íntegra, em inglês, português e espanhol.Resultados: Das 1.904 produções inicialmente encontradas, 19 foram incluídos para análise. Os estudos apontaram que a comunicação é fundamental para a garantia da segurança do paciente e inserção da família no processo do cuidado. Essa habilidade vai além da expressão verbal, envolvendo outras formas de se comunicar. Contudo, necessita ser melhorada em algumas situações, evitando principalmente a ocorrência de danos ao cliente. Sugere-se ainda que algumas formas de comunicação requerem ser padronizadas.Conclusão: A comunicação é uma das ações prioritárias e fundamentais para a segurança e efetividade do cuidado de enfermagem, seja nos centros cirúrgicos ou nas unidades de terapia intensiva. Diante desse contexto, se faz necessário que as barreiras de comunicação sejam identificadas e que ações estratégicas organizacionais sejam colocadas em prática, entre elas a educação permanente dos profissionais, bem como a padronização de informações. Ações como essas minimizam os potenciais riscos que permeiam os cuidados críticos e tornam positivas as relações no ambiente de trabalho

Objective: To identify the importance of communication for safe and effective nursing care in the surgical center and intensive care. Methods: An integrative review with a survey of productions in February 2023 in the databases Lilacs, MEDLINE, CINAHL, and Scopus. Primary studies, available in full in English, Portuguese, and Spanish, were included. Results: Of the 1,904 productions initially found, 19 were included for analysis. The studies pointed out that communication is essential to guaranty patient safety and to insert the family in the care process. This skill goes beyond verbal expression and involves other ways of communicating.However, it needs to be improved in some situations, mainly to avoid damage to the customer. It is also suggested that some forms of communication require to be standardized. Conclusion: Communication is one of the priorities and fundamental actions for the safety and effectiveness of nursing care, whether in surgical centers or intensive care units. Given this context, it is necessary that communication barriers are identified and that strategic organizational actions are put into practice, including the permanent education of professionals and the standardization of information. Actions like these minimize the potential risks that permeate critical care and positively impact relationships in the work environment

Effectiveness and Safety of P2Y12 Inhibitor Pretreatment for Primary PCI in STEMI: Systematic Review and Meta-analysis.

ABSTRACT: Dual antiplatelet therapy with aspirin and P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction (STEMI) has been shown to be associated with better outcomes. Yet, there is uncertainty regarding the optimal timing for its initiation. We performed a systematic review and meta-analysis of evidence on pretreatment with P2Y12 inhibitors in combination with aspirin in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). We performed a systematic search of electronic databases PubMed, CENTRAL, and Scopus until April 2022. Studies were eligible if they compared P2Y12 inhibitor upstream administration with downstream use in patients with STEMI submitted to PCI. Studies with patients receiving fibrinolysis or medical therapy only were excluded. Outcomes were assessed at the shortest follow-up available. Of 2491 articles, 3 RCT and 16 non-RCT studies were included, with a total of 79,300 patients (66.1% pretreated, 66.0% treated with clopidogrel). Pretreatment was associated with reduction in definite stent thrombosis (odds ratio [OR] 0.61 [0.38-0.98]), all-cause death (OR 0.77 [0.60-0.97]), and cardiogenic shock (OR 0.60 [0.48-0.75]). It was also associated with a lower incidence of thrombolysis in myocardial infarction flow <3 pre-PCI (OR 0.78 [0.67-0.92]). However, incidence of recurrent MI was not significantly reduced (OR 0.93 [0.57-1.52]). Regarding safety, pretreatment was not associated with a higher risk of major bleeding events (OR 0.83 [0.75-0.92]). Pretreatment with dual antiplatelet therapy, including a P2Y12 inhibitor, was associated with better pre-PCI coronary perfusion, lower incidence of definite stent thrombosis, cardiogenic shock, and, possibly, all-cause mortality with no sign of potential harm encountered.

A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR. METHODS: MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant. RESULTS: Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87). CONCLUSIONS: The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.

Safety of Utilizing Ultrasound as the Sole Modality of Follow-Up after Endovascular Aneurysm Repair.

BACKGROUND: Post endovascular aneurysm repair (EVAR), surveillance with computed tomography-aortography (CTA) remains the most common practice, per Society for Vascular Surgery (SVS) guidelines. Chronic exposure to both radiation and intravenous (IV) contrast has raised concerns about long-term CTA follow-up (FU). As we have selectively used ultrasound (US) as a sole modality for post-EVAR surveillance, we sought to review our outcomes in this subset of patients. METHODS: Retrospective review of our institution's vascular database identified 213 EVAR patients from 2013 to 2021. Fenestrated-EVAR and snorkel reconstructions were excluded. Patient demographics/outcomes, abdominal aortic aneurysm (AAA) characteristics, and FU modalities and outcomes were analyzed. Unpaired Student's t-test, ANOVA, and chi-squared test were used to assess group differences. RESULTS: Eighty-five of the 213 EVAR patients (39.9%) were lost to FU within 3 months. Among the 128 remaining patients, 91 underwent FU using initial US, while 37 patients underwent post-EVAR FU initially using CTA. There were no significant differences (P > 0.05) between patient age (75.5 ± 9.4 vs. 75.3 ± 8.5), body mass index (BMI) (27.7 ± 5.4 vs. 28.9 ± 7.4), or mean AAA size (5.6 ± 1.1 vs. 5.9 ± 1.2) in US-surveilled and computed tomography (CT)-surveilled groups, respectively. Of the 91 patients, initially surveilled with US, 15 patients demonstrated endoleak and/or AAA growth (>5 mm). The 15 patients with US-demonstrated endoleak and/or growth underwent confirmatory CTA, with 3 patients eventually requiring EVAR revision. Among 37 patients initially surveilled with CT, 10 demonstrated significant growth and 2 patients eventually required EVAR revision. There were no patients with AAA rupture during post-EVAR surveillance. FU data were analyzed among a select lower-risk group of patients (preoperative AAA diameter ≤5.5 cm, BMI ≤30, and no endoleak at completion of EVAR). Among this group, there were no surveilled patients who required EVAR reintervention, regardless of surveillance modality (US n = 32; CT n = 4). The average FU was 29.5 ± 26.4 months in the US group and 26.4 ± 22.3 months in the CT group (P > 0.05). CONCLUSIONS: Although initial CT surveillance following EVAR remains ideal, in select lower-risk patients, US is a viable alternative even for the initial post-procedure study. Advantages include decreased radiation exposure and cost. Our data suggest that US is a safe sole modality for surveillance following EVAR in selective patients.

Predicting obstructive coronary artery disease in heart failure with reduced ejection fraction: A practical clinical score.

INTRODUCTION AND OBJECTIVES: Obstructive coronary artery disease (CAD) remains the most common etiology of heart failure with reduced ejection fraction (HFrEF). However, there is controversy whether invasive coronary angiography (ICA) should be used initially to exclude CAD in patients presenting with new-onset HFrEF of unknown etiology. Our study aimed to develop a clinical score to quantify the risk of obstructive CAD in these patients. METHODS: We performed a cross-sectional observational study of 452 consecutive patients presenting with new-onset HFrEF of unknown etiology undergoing elective ICA in one academic center, between January 2005 and December 2019. Independent predictors for obstructive CAD were identified. A risk score was developed using multivariate logistic regression of designated variables. The accuracy and discriminative power of the predictive model were assessed. RESULTS: A total of 109 patients (24.1%) presented obstructive CAD. Six independent predictors were identified and included in the score: male gender (2 points), diabetes (1 point), dyslipidemia (1 point), smoking (1 point), peripheral arterial disease (1 point), and regional wall motion abnormalities (3 points). Patients with a score ≤3 had less than 15% predicted probability of obstructive CAD. Our score showed good discriminative power (C-statistic 0.872; 95% CI 0.834-0.909: p<0.001) and calibration (p=0.333 from the goodness-of-fit test). CONCLUSIONS: A simple clinical score showed the ability to predict the risk of obstructive CAD in patients presenting with new-onset HFrEF of unknown etiology and may guide the clinician in selecting the most appropriate diagnostic modality for the assessment of obstructive CAD.

Masson's Lesion: A Very Rare Cardiac Mass.

Masson lesion is a rare type of vascular tumour usually found in the skin and soft tissues. Histologic examination remains the gold standard for diagnosis. Treatment involves complete surgical excision, and correct diagnosis is essential to avoid unnecessary aggressive therapy. A unique case of Masson lesion presenting as an asymptomatic pericardial mass is reported for the first time. Multimodality imaging was used for a comprehensive noninvasive mass characterization. Relevant imagiologic and pathologic findings for differential diagnosis are discussed. The importance of close coordination among different medical specialties for optimal care of this unusual clinical condition is highlighted.

Analysis of a Novel Inpatient Acute Limb Ischemia Alert System.

OBJECTIVES: Acute limb ischemia (ALI) is a surgical emergency that generally develops in the outpatient setting. Hospitalized patients are also at risk for acute limb ischemia, but their presentation may be atypical or altered by medical therapy. Our institution developed an alert system to facilitate the prompt recognition and treatment of ALI that occurs in the inpatient population. We aimed to evaluate the usage of the system after the first 2 years of operation. METHODS: All ALI alerts from October 2017 to December 2019 were collected from paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours) or delayed (after 8 hr). Time and location data were evaluated to determine patterns of usage and true-positive rate of the system. RESULTS: From October 2017 to December 2019, there were 237 ALI alerts obtained from paging records containing time and location information for the alert. More alerts originated from ICUs relative to non-ICU floors (68% vs. 33%, P< 0.001), however a greater proportion of non-ICU floor alerts required intervention compared to ICU alerts (32.0% vs. 5.1%, P < .0001). The highest number of ALI alerts were from the Medical ICU (MRICU) (45.9%) and medical/surgical floors (33.3%), followed by Surgical ICU (20.2%). Alerts were more common within 3 hr of morning and evening nursing shift changes (47.3%, P < 0.001). From the 237 total alerts, the patient was able to be identified retrospectively in 186 cases, and of these 27 resulted in operative interventions (14.5%, positive predictive value), with 11 patients (40.7%) requiring urgent intervention with a median time to intervention of 3.5 hr (range 2.2-4.8), and 16 (59%) alerts undergoing a delayed intervention at a mean of 3 days (range 2-4). A total of 73 (39.2%) alert patients died during their admission, of which 65 (89.0%) were in an ICU, and no deaths were directly related to ALI. The median time to death was 2 days (range 0-95 days), and in 22 cases death occurred <24 hr from time of alert. CONCLUSION: Our novel hospital-wide ALI alert system demonstrates a 14.5% positive predictive value for ischemia that resulted in an intervention. Alerts were more likely to originate from the ICU setting and during nursing shift changes. Alerts originating from non-ICU floors were 5 times more likely to undergo surgical intervention for ALI. Further analysis is required to assess the effect of this system on patient safety, outcome, and allocation of institutional resources.

Syncope Caused by a Head and Neck Cancer Controlled by a Permanent Pacemaker.

Syncope caused by carotid sinus syndrome due to head and neck cancer is rare. We report a case of recurrent syncope as a result of extreme bradycardia requiring pacemaker implantation. The patient began chemotherapy and radiation therapy to treat the underlying cause. When diagnosed early, a positive outcome is expected in these situations. LEARNING POINTS: The differential diagnosis of transient loss of consciousness is frequently evident at clinical examination but may prove to be a challenge.The invasion and direct compression of the carotid sinus is a rare cause of carotid sinus syndrome and presents clinically as syncope.

Experience with Eversion Endarterectomy of the Common Femoral Artery with Comparison to Standard Endarterectomy with Patch.

In this retrospective study, we review the outcome of femoral eversion endarterectomy (EE) and standard endarterectomy with patch angioplasty (SEP) over a 10-year period. EE technique involves transection of common femoral artery (CFA), eversion endarterectomy of the distal CFA, and primary end-to-end reconstruction. One hundred forty-two patients underwent femoral endarterectomy, among which 38 (26.8%) endarterectomies were performed using the eversion technique. The cumulative 2-year primary patency of EE with or without a concurrent procedure was greater than 86% and did not statistically differ from SEP. EE is a feasible technique when the use of a patch needs to be avoided.

Lipoabdominoplastia em âncora / Anchor lipoabdominoplasty

A obesidade mórbida se caracteriza por acúmulo de tecido adiposo que se distribui de maneira heterogênea em todo o organismo, tendo a gastroplastia como o mais recente método de tratamento cirúrgico. Após perda considerável de peso, o doente apresenta sobras cutâneas, sob essas sobras acumulam-se secreções que favorecem a instalação de infecções cutâneas que podem ser minimizadas com a execução de dermolipectomias. Os autores descrevem a técnica de lipoabdominoplastia em âncora, adaptando os princípios de descolamento reduzido do retalho, lipoaspiração de abdome e flancos, e preservação da fáscia de Scarpa infraumbilical associado à marcação pré-cirúrgica em "Fleur-de-Lis". A técnica foi realizada em 17 pacientes em pós-operatório tardio de gastroplastia, entre janeiro de 2018 e junho de 2019, com idade entre 35 a 66 anos, sendo 16 pacientes do sexo feminino e 1 do sexo masculino. Todos os pacientes foram operados com exames pré-operatórios dentro da normalidade, condições clínicas satisfatórias e IMC<30. Na presente série de casos, um paciente apresentou epidermólise de coto umbilical; todos os pacientes apresentaram edema e equimoses, e um paciente apresentou seroma no 13º dia de pós-operatório. Hematoma, necrose, infecção, deiscência de ferida operatória ou eventos tromboembólicos não foram observados em nenhum paciente. A técnica demostrou ser segura e eficaz no tratamento de pacientes com excedente cutâneo abdominal, com melhora do contorno corporal, porém há necessidade de maior tempo de acompanhamento pós-operatório e maior número de casos operados para melhor mensurar os resultados, bem como a incidência de complicações.

Morbid obesity is characterized by the accumulation of adipose tissues distributed heterogeneously throughout the body, and gastroplasty is the latest method of surgical treatment. After considerable weight loss, patients present with excess skin under which secretions accumulate, increasing susceptibility for skin infections, which can be minimized with dermolipectomy. Herein, we describe the anchor lipoabdominoplasty technique, adapting the principles of reduced flap detachment, abdominal and flank liposuctions, and preservation of the infraumbilical Scarpa's fascia associated with the preoperative fleurde- lis marking. The technique was used for seventeen patients, including sixteen women and one man, with late postoperative gastroplasty, aged 35­66 years in the period from January 2018 to June 2019. The patients presented with normal preoperative testing, satisfactory clinical conditions, and body mass index scores less than 30 kg/m2. In the present case series, one patient had umbilical cord remnant epidermolysis; all patients had edema and ecchymosis; and one patient had seroma on postoperative day 13. Hematoma, necrosis, infection, wound dehiscence, or thromboembolic events were not observed in any patient. The technique is safe and effective in the treatment of patients with abdominal excess skin, improving their body contour. However, longer postoperative follow-up periods and more cases are necessary to better measure the results and incidence of complications.

The Application of Virtual Reality in Patient Education.

BACKGROUND: Virtual reality (VR) provides an immersive image-viewing experience that has recently been expanding in use in clinical medicine. We developed a three-dimensional (3D) model of an abdominal aortic aneurysm (AAA) for patients with a diagnosis of an AAA to view in VR to assess the use of VR in patient education. METHODS: This was a cross-sectional study using an educational intervention. A standardized 3D model of an AAA was generated from a computed tomography scan and uploaded onto a 3D image-hosting website. Patients with an AAA who participated in the study wore a Google Cardboard VR headset, with a mobile device displaying the digital 3D AAA image in VR. Patients completed a survey afterward for assessing satisfaction with VR on a 5-point agreement Likert scale. RESULTS: Between September 2017 and January 2018, 19 patients participated in our study (90% participation rate). Most participants had no prior experience with VR (n = 15; 79%), and the mean age was 69 ± 8 years. Seventeen (89%) participants agreed or strongly agreed that they felt better informed about their health status after using VR and would like to see VR used more in their health care, while sixteen (84%) agreed or strongly agreed that they felt more engaged in their health care because of using VR. Almost all participants felt comfortable using VR (n = 17; 90%) and enjoyed using the technology (n = 16; 84%). CONCLUSIONS: VR proved to be an engaging learning tool that patients perceived as beneficial in understanding their health status. Further efforts to investigate the role of VR in education and health care should be explored.

Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos / Accessibility to Basic Family Health Units from the perspective of the elderly

Resumo O objetivo deste artigo é avaliar a acessibilidade às Unidades Básicas de Saúde da Família na perspectiva dos idosos em um município do Nordeste brasileiro. Foram coletadas informações socioeconômicas e demográficas dos idosos e sua avaliação acerca da acessibilidade (organizacional, sociocultural e econômica) aos serviços oferecidos pela Estratégia Saúde da Família (ESF). Utilizou-se instrumento validado para avaliar a ESF pelos usuários em municípios paraibanos, o qual foi adaptado à população de idosos. Foi analisada a associação das variáveis socioeconômicas e demográficas com a avaliação da acessibilidade. Para a acessibilidade organizacional, idosos das classes econômicas inferiores apresentaram maior chance de emitir avaliação positiva aos horários de atendimento, e menor chance de avaliação positiva em relação à quantidade de atendimentos por dia e à facilidade em receber medicamentos. As mulheres apresentaram maior chance de avaliar positivamente a consulta com especialistas (acessibilidade econômica). A avaliação dos idosos mostra a existência de barreiras, principalmente na acessibilidade organizacional, que ainda persistem para a procura e a utilização dos serviços.

Abstract This article aims to evaluate accessibility to health services from the perspective of the elderly in a city of Northeast Brazil. Socioeconomic and demographic data were collected, and the organizational, socio-cultural and economic accessibility to services offered by the Family Health Strategy (FHS) was assessed. A validated instrument adapted for the elderly population was used to assess the FHS by users in cities in Paraíba. The association of socioeconomic and demographic variables with accessibility was assessed. For organizational accessibility, the elderly of lower economic classes were more likely to give a positive evaluation regarding the opening hours for care, and less likely to give a positive assessment in relation to the amount of people attended per day and the ease to obtain medication. Women were more likely to positively evaluate the consultation with experts (economic accessibility). The evaluation of the elderly shows the existence of barriers, especially in organizational accessibility, which still persist regarding the demand and use of health services.

Severe fat embolism in perioperative abdominal liposuction and fat grafting / Embolia gordurosa grave no peroperatório de lipoaspiração abdominal e lipoenxertia

ABSTRACT BACKGROUND AND OBJECTIVES: Fat embolism syndrome may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe fat embolism syndrome after liposuction and fat grafting. CASE REPORT: SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45 min of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH = 7.21; PCO2 = 51 mmHg; PO2 = 52 mmHg; BE = -8; HCO3 = 18 mEq L-1, and lactate = 6.0 mmol L-1. Transthoracic echocardiogram showed PASP = 55 mmHg, hypocontractile VD and LVEF = 60%. Diagnosis of pulmonary embolism. After 24 h of intensive treatment, the patient developed anisocoria and coma (Glasgow coma scale = 3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72 h of evolution, the patient progressed to brain death. CONCLUSION: Fat embolism syndrome usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis.

RESUMO JUSTIFICATIVA E OBJETIVOS: A Síndrome da Embolia Gordurosa (SEG) pode acontecer em pacientes vítimas de politrauma (fratura de ossos longos) ou operações plásticas (lipoaspiração), comprometendo circulação, respiração e/ou sistema nervoso central. O presente relato mostra evolução de SEG grave após lipoaspiração e lipoenxertia. RELATO DO CASO: SSS, 42 anos, ASA 1, sem fatores de risco para trombose, candidata a lipoaspiração abdominal e implante de prótese mamária. Submetida à anestesia geral balanceada com monitorização básica e ventilação controlada. Após 45 minutos de procedimento, houve queda súbita e progressiva da capnometria, hipoxemia e hipotensão grave. Imediatamente foi monitorizada com PAM e cateter central, tratada com vasopressores, inotrópicos e infusão de cristaloides, obtendo estabilização do quadro. Amostra sanguínea arterial mostrou pH = 7,21; PCO2 = 51 mmHg; PO2 = 52 mmHg; BE = -8; HCO3 = 18 mEQ/l e lactato = 6,0 mmol/l. Ecocardiograma transtorácico mostrou PSAP = 55 mmHg, VD hipocontrátil e FEVE = 60%. Diagnóstico de embolia pulmonar. Após24 h de tratamento intensivo, a paciente evoluiu com anisocoria e coma com escala de glasgow 3. Realizada TC de encéfalo que evidenciou isquemia cerebral grave, hemisférica, com sinais de êmbolos de gordura em A. cerebral média D; o ecocardiograma transesofágico mostrou forame oval patente. Finalmente, após 72 h de evolução, a paciente evoluiu para morte encefálica. CONCLUSÃO: A SEG ocorre geralmente em jovens. O tratamento baseia-se principalmente na infusão de líquidos e drogas vasoativas, ventilação mecânica e correção do fator desencadeante (fixação precoce de fraturas ou suspensão da lipoaspiração). O comprometimento multiorgânico indica pior prognóstico.

Severe fat embolism in perioperative abdominal liposuction and fat grafting.

BACKGROUND AND OBJECTIVES: Fat embolism syndrome may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe fat embolism syndrome after liposuction and fat grafting. CASE REPORT: SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45min of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH=7.21; PCO2=51mmHg; PO2=52mmHg; BE=-8; HCO3=18mEqL(-1), and lactate=6.0mmolL(-1). Transthoracic echocardiogram showed PASP=55mmHg, hypocontractile VD and LVEF=60%. Diagnosis of pulmonary embolism. After 24h of intensive treatment, the patient developed anisocoria and coma (Glasgow coma scale=3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72h of evolution, the patient progressed to brain death. CONCLUSION: Fat embolism syndrome usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis.

[Severe fat embolism in perioperative abdominal liposuction and fat grafting]. / Embolia gordurosa grave no peroperatório de lipoaspiração abdominal e lipoenxertia.

BACKGROUND AND OBJECTIVES: Fat embolism syndrome (FES) may occur in patients suffering from multiple trauma (long bone fractures) or plastic surgery (liposuction), compromising the circulatory, respiratory and/or central nervous systems. This report shows the evolution of severe FES after liposuction and fat grafting. CASE REPORT: SSS, 42 years old, ASA 1, no risk factors for thrombosis, candidate for abdominal liposuction and breast implant prosthesis. Subjected to balanced general anesthesia with basic monitoring and controlled ventilation. After 45minutes of procedure, there was a sudden and gradual decrease of capnometry, severe hypoxemia and hypotension. The patient was immediately monitored for MAP and central catheter, treated with vasopressors, inotropes, and crystalloid infusion, stabilizing her condition. Arterial blood sample showed pH = 7.21; PCO2 = 51mmHg; PO2 = 52mmHg; BE = -8; HCO3 = 18 mEq/L, and lactate = 6.0 mmol/L. Transthoracic echocardiogram showed PASP = 55mmHg, hypocontractile VD and LVEF = 60%. Diagnosis of pulmonary embolism. After 24h of intensive treatment, the patient developed anisocoria and coma (glasgow coma scale = 3). A brain CT was performed which showed severe cerebral hemispheric ischemia with signs of fat emboli in right middle cerebral artery; transesophageal echocardiography showed a patent foramen ovale. Finally, after 72h of evolution, the patient progressed to brain death. CONCLUSION: FES usually occurs in young people. Treatment is based mainly on the infusion of fluids and vasoactive drugs, mechanical ventilation, and triggering factor correction (early fixation of fractures or suspension of liposuction). The multiorgânico involvement indicates a worse prognosis.

Central aortic wire confirmation for emergent endovascular procedures: As fast as surgeon-performed ultrasound.

BACKGROUND: Uncontrolled hemorrhage is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an evolving technique for controlling noncompressible torso hemorrhage. A challenge limiting REBOA use is the dependence on fluoroscopy for confirmation of intra-aortic positioning of a guide wire, a necessary component for safe and accurate balloon deployment. The current study evaluates using surgeon-performed sonography alone, without fluoroscopy, in identifying the aorta and the presence of an intra-aortic guide wire. We postulate that with the use of the subxiphoid Focused Abdominal Sonography for Trauma (FAST) view, both the aorta and an intra-aortic guide wire can be reliably identified. METHODS: One hundred angiography patients underwent femoral arterial cannulation and guide wire advancement to the supraceliac aorta. From the subxiphoid FAST view, the aorta was identified in both sagittal and transverse planes. Intra-aortic wire identification was subsequently recorded. The rate of preferential central aortic wire positioning from unaided guide wire advancement was also observed. RESULTS: The mean patient age and body mass index were 61.8 years and 27.0 kg/m, respectively. Eighty-eight percent of the studies were performed using portable point-of-care ultrasound machines. Identification of the aorta via the subxiphoid FAST was successful in 97 (97%) of 100 patients in the sagittal and 98 (98%) of 100 patients in the transverse orientation. Among visualized aortas, an intra-aortic wire was identifiable in 94 (97%) of 97 patients in the sagittal and 91 (93%) of 98 patients in the transverse orientation. Unaided wire advancement achieved preferential central aortic positioning in 97 (97%) of 100 patients. Fluoroscopy-free ultrasound identification of an advancing intra-aortic guide wire was successful in 56 (98%) of 57 patients. CONCLUSION: The subxiphoid FAST view can reliably identify a central aortic guide wire in both transverse and sagittal orientations. Unaided guide wire advancement has a high likelihood of both preferential central aortic positioning and subsequent ultrasound identification. These findings eliminate the need for routine fluoroscopy for this important initial maneuver during emergency endovascular procedures. LEVEL OF EVIDENCE: Diagnostic study, level V.

Previous hemodialysis access improves functional outcomes of the proximal radial artery fistula in males.

BACKGROUND: The proximal radial artery fistula (PRA) has been established as an early viable surgical option for arteriovenous fistula creation. The overall assisted primary patency reported in the literature approaches 100% at 1 year. We hypothesize that this excellent patency does not represent a functional result when seen in light of successful cannulation and fistula utilization. METHODS: We retrospectively queried our Veterans Administration Hospital operative database to identify 284 male patients who had 571 access procedures performed by a senior vascular surgeon attending (R.K.D.) from January 1, 2003, to December 31, 2008. Operative details, patient comorbidities, fistula maturation time (time to first cannulation), functional patency (date of access to abandonment, revision to another fistula type, conversion to a prosthetic graft, thrombosis of the fistula, conversion to peritoneal dialysis, renal transplant, or patient death), and total duration (creation of the fistula to the end of its functional patency) were collected and analyzed. RESULTS: A total of 144 PRAs were placed during the study period. In all, 87 patients underwent primary proximal radial artery fistula (P-PRA) placement in a limb without previous access; 57 patients had a secondary proximal radial artery fistula (S-PRA) after a failed previous fistula or graft in the same limb. There were no differences between the 2 groups in terms of age, comorbidities, and operative details. A total of 91 patients (63.2%) were receiving hemodialysis at the time of P-PRA or S-PRA placement. Outcomes of P-PRA and S-PRA populations on hemodialysis were examined. There was increased cannulation success (33% vs. 55%; P = 0.00354, Fisher's exact test), functional patency (755.2 ± 661.2 days vs. 405.4 ± 531.9 days; P = 0.0220, Wilcoxon two-sample test), and total duration (859.5 ± 650.7 days vs. 516.8 ± 547.2 days; P = 0.0361, Wilcoxon two-sample test) of S-PRA over P-PRA. There was no difference in endovascular interventions between the 2 groups (1.6 ± 1.0 interventions per access versus 1.1 ± 0.7 interventions per access; P = 0.2109, Wilcoxon two-sample test). Subgroup analysis (analysis of variance) of the S-PRA group indicated that a patent but failing previous access in the same arm was not superior in terms of successful cannulation, functional patency, or total duration when compared with a thrombosed previous access. CONCLUSIONS: The PRA remains a viable first access procedure undertaken at our institution. Compared with the reported 12-month assisted primary patency of this fistula type, we found a small percentage of PRAs actually being accessed for successful hemodialysis treatment. The S-PRA appears to have a significantly higher successful cannulation rate, functional patency, and total duration time when compared with the P-PRA in patients receiving hemodialysis treatments. The mechanism of these improved outcomes is not known; considering patency or thrombosis of a previous access in the S-PRA group did not predict future access success in the same extremity.