Diathermy Versus Scalpel in Midline Abdominal Incision: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Our study aimed to compare the midline abdominal incision with scalpel and diathermy. METHODS: PubMed, EMBASE, and Cochrane were searched through January 2024 following PRISMA guidelines (PROSPERO, ID: CRD42024516771), and only randomized controlled trials were included. Heterogeneity was assessed using Cochran's Q test and the I2 heterogeneity index. Statistical analysis was performed using Review Manager 5.4 software. RESULTS: Six randomized controlled trials were included, from which 469 patients (51.5%) received diathermy incision and 442 patients (48.5%) underwent the scalpel technique. Patients treated with the electrocautery approach had less incision blood loss (MD -17.57 mL; P < .01). No statistically significant differences were found between groups regarding wound infection incidence, incision time, incision area or first-day postoperative pain. CONCLUSION: Diathermy use in midline abdominal incision may be advocated as it demonstrated a significant reduction in incision-related blood loss, with no differences in wound infection or early postoperative pain incidences compared to the scalpel.

Association of colchicine use with cardiovascular and limb events in peripheral artery disease: Insights from a retrospective cohort study.

BACKGROUND AND AIMS: Colchicine has demonstrated efficacy in treating coronary artery disease, but its efficacy in peripheral artery disease (PAD) remains uncertain. This study aims to address this gap in knowledge. METHODS: A retrospective cohort study was conducted using the TriNetX Network, selecting patients with lower limb PAD between January 1, 2011, and January 1, 2024. Colchicine users were matched 1:1 with non-users through propensity score matching, considering demographics, medical conditions, medications, and psychosocial factors. The primary outcome was a composite of major adverse cardiovascular and limb events (MACLE) - including lower limb amputation, revascularization for lower limb ischemia, acute myocardial infarction, ischemic stroke, and all-cause mortality - over a ten-year follow-up. RESULTS: From 53,568 colchicine-treated and 1,499,969 untreated patients with lower limb PAD, 52,350 pairs were successfully matched. Over ten years, colchicine was associated with a significant reduction in MACLE (hazard ratio, [HR] 0.90, 95% CI 0.88-0.92, p < 0.001), any lower limb amputation (HR 0.84, 95% CI 0.75-0.94, p = 0.002), revascularization for lower limb ischemia (HR 0.85, 95% CI 0.82-0.88, p < 0.001), major adverse cardiovascular events (HR 0.93, 95% CI 0.91-0.95, p < 0.001), and all-cause mortality (HR 0.90, 95% CI 0.87-0.92, p < 0.001). It also result in a reduced risk of ischemic stroke (HR 0.95, 95% CI 0.92-0.98, p = 0.001), but not of acute myocardial infarction (HR 0.98, 95% CI 0.95-1.01, p = 0.24). CONCLUSIONS: Colchicine significantly reduced major adverse cardiovascular and limb events in patients with lower limb PAD, supporting the need for further investigation.

Predictive factors for cranioplasty complications - A decade's experience.

Introduction: Cranioplasty (CP) following craniectomy provides cerebral protection, improves cerebrospinal fluid dynamics, and restores cosmesis. Although often viewed as minor, CP can have major complications. Research question: This study aims to identify the predictive factors for post-operative complications in patients undergoing CP after decompressive craniectomy. Methods: We conducted a retrospective study at a tertiary hospital, analyzing patients who underwent CP after decompressive craniectomy (DC) from 2008 to 2019. Patient demographics, medical history, and surgery details were retrieved from hospital records. Complications included symptomatic intracerebral haemorrhage, extradural or subdural haemorrhage, hydrocephalus, infection, or bone resorption. Results: The study included 168 patients: 139 adults (mean age 47.6 ± 12.68 years) and 29 pediatric patients (mean age 11.8 ± 5.62 years), with a slight male predominance. The overall complication rate was 26.2%, with infection being the most common (8.9%). Predictive factors for CP complications identified by binomial logistic regression, controlling for age and sex, included primary coagulopathy (14.3-fold risk increase, p = 0.034), intraoperative ventricular puncture (7.9-fold risk increase, p = 0.009), and intraoperative dural layer breach (2.8-fold risk increase, p = 0.033). Pre-CP home living was a protective factor. Conclusions: CP requires vigilant management to prevent complications. Primary coagulopathy, intraoperative ventricular puncture, and dural layer breach are significant risk factors for complications.

Sedentary behavior and self-harm in adolescents with asthma, rhinitis and eczema.

OBJECTIVE: To investigate the association between allergic diseases and the tendency to self-harm in adolescents, considering the role of sedentary behavior. METHODS: This was a population-based cross-sectional study, carried out in 2022, with 727 adolescents aged 12 to 19 years, from a capital in the Northeast of Brazil. The authors evaluated the association between each allergic disease (asthma, rhinitis and eczema) and self-harm, sedentary behavior and other variables. The authors performed an adjusted analysis of the associations between each allergy disease and the tendency to self-harm and then adjusted to the presence of family members and sedentary behavior. RESULTS: The prevalence of asthma, rhinitis and eczema were 18.76%, 36.21% and 12.86%, respectively. Sedentary behavior and tendency to self-harm were more frequently reported in asthmatics (PR 2.16; 95% CI: 1.55 - 3.00 and PR 1.98; 95% CI: 1.47 - 2.68, for sedentary behavior and self-harm respectively), rhinitis (PR 1.53; 95% CI: 1.25 - 1.88 and PR 1.33; 95% CI: 1.09 - 1.62, respectively) and eczema (PR 2.35; 95% CI: 1.54 - 3.58 and PR 1.55; 95% CI: 1.05 - 2.28, respectively). There was a reduction in the strength of this association in the three conditions, which included a loss of association. CONCLUSION: High rates of sedentary behavior and self-harm in those with asthma, rhinitis and eczema. Physical activity attenuated the risk for self-harm. It warns about the urgency in detecting these factors, whether in the diagnosis or in the implementation of therapy, seeking to reduce their harmful consequences in the short and long term.

Symbolic information approach applied to human intracranial data to characterize and distinguish different congnitive processes.

How the human brain processes information during different cognitive tasks is one of the greatest questions in contemporary neuroscience. Understanding the statistical properties of brain signals during specific activities is one promising way to address this question. Here we analyze freely available data from implanted electrocorticography (ECoG) in five human subjects during two different cognitive tasks in the light of information theory quantifiers ideas. We employ a symbolic information approach to determine the probability distribution function associated with the time series from different cortical areas. Then we utilize these probabilities to calculate the associated Shannon entropy and a statistical complexity measure based on the disequilibrium between the actual time series and one with a uniform probability distribution function. We show that an Euclidian distance in the complexity-entropy plane and an asymmetry index for complexity are useful for comparing the two conditions. We show that our method can distinguish visual search epochs from blank screen intervals in different electrodes and patients. By using a multiscale approach and embedding time delays to downsample the data, we find important timescales in which the relevant information is being processed. We also determine cortical regions and time intervals along the 2-s-long trials that present more pronounced differences between the two cognitive tasks. Finally, we show that the method is useful to distinguish cognitive processes using brain activity on a trial-by-trial basis.

Advancements in understanding the mechanisms of lung-kidney crosstalk.

This narrative review delves into the intricate interplay between the lungs and the kidneys, with a focus on elucidating the pathogenesis of diseases influenced by immunological factors, acid-base regulation, and blood gas disturbances, as well as assessing the effects of various therapeutic modalities on these interactions. Key disorders, such as anti-glomerular basement membrane (anti-GBM) disease, the syndrome of inappropriate antidiuretic hormone secretion (SIADH), and Anti-neutrophil Cytoplasmic Antibodies (ANCA) associated vasculitis (AAV), are also examined to shed light on their underlying mechanisms. This review also explores the relationship between acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), emphasizing how inflammatory mediators can lead to systemic damage and impact multiple organs. In ARDS, fluid overload exacerbates pulmonary edema, while imbalances in blood volume, such as hypovolemia or hypervolemia, can precipitate renal dysfunction. The review highlights how mechanical ventilation strategies can compromise renal blood flow, trigger systemic inflammation, and induce hemodynamic and neurohormonal alterations, all contributing to lung and kidney damage. The impact of extracorporeal membrane oxygenation (ECMO) on lung-kidney interactions is evaluated, highlighting its role in severe respiratory failure and its renal implications. Emerging therapies, such as mesenchymal stem cells and extracellular vesicles, are discussed as promising avenues to mitigate organ damage and enhance outcomes in critically ill patients. Overall, this review offers a nuanced exploration of lung-kidney dynamics, bridging historical insights with contemporary perspectives. It underscores the clinical significance of these interactions in critically ill patients and advocates for integrated management approaches to optimize patient outcomes.

Transient radiation-induced severe obstructive sleep apnea.

Radiotherapy for head and neck cancer can trigger or worsen obstructive sleep apnea (OSA) due to factors such as neurological impairment, muscle atrophy, edema, and xerostomia. We present a case in which a patient developed severe OSA three months after undergoing radiochemotherapy and neck dissection for squamous cell carcinoma of the right lingual tonsil with regional metastasis. Polysomnography confirmed severe OSA. Unfortunately, the patient did not adhere to the recommended treatment. The symptoms persisted for six months but then, unexpectedly, resolved completely. A follow-up polysomnography conducted one year after radiotherapy showed no evidence of OSA. This case suggests that a recent diagnosis of OSA following head and neck radiotherapy may not be permanent and should not necessarily lead to a lifelong prognosis of sleep-related breathing disorders.

Visual Acuity Thresholds in Preterm Newborns: An Experimental Study.

Purpose: Visual acuity plays a role in mediating neurological development in infants by enabling the differentiation of shapes and discriminating objects. Given the rapid structural development of the brain in the first days of life, this aspect is particularly significant for preterm infants, who typically experience this developmental phase while hospitalized in the neonatal intensive care unit (NICU). Therefore, this study aimed to assess visual acuity thresholds in preterm infants during hospitalization and to evaluate possible correlations between visual acuity and clinical parameters. Methods: A cross-sectional study was conducted in an NICU in Northeast Brazil. The visual acuity thresholds were tested using the Teller Acuity Cards II, comprised of 17 gray cards, with one 4 mm diameter peephole at the center and presented with about 35% reflectance. Preterm infants were positioned supine, at 30° elevation on the laps of their caregivers. The evaluator presented both sides of the cards and observed the eye fixation and reactions on both sides. Results: A total of 42 preterm infants with corrected gestational age between 30 to 36 weeks and 6 days were included. Visual acuity ranged from 0.23 to 0.64 cycle per degree. The mean visual acuity threshold was 0.32 cycles per degree for preterm infants at around 32 weeks of corrected gestational age. The visual acuity was not correlated with gestational age (p = 0.18), and neither were birth weight (p = 0.83) or duration of respiratory support (p = 0.98). However, days of phototherapy were inversely correlated with visual acuity (p = 0.04). Conclusions: Despite the challenges of hospitalization, it was possible to carry out a psychophysical test to assess visual acuity in preterm infants. The visual acuity showed no correlation with clinical parameters such as gestational age, birth weight, and duration of respiratory support. However, there was an inverse correlation between the number of days in phototherapy and visual acuity. Understanding the visual acuity levels in preterm infants during their NICU stay can contribute to tailoring interventions and care strategies that specifically address their visual developmental needs. This knowledge may guide healthcare professionals in optimizing the NICU environment to provide appropriate visual stimuli that support neurological development.

Ocular pharmacokinetics of acetazolamide from intravitreal implants by high-performance liquid chromatography coupled to tandem mass spectrometry.

Glaucoma, a leading cause of irreversible blindness, affects about 70 million people globally. Its treatment focuses on reducing intraocular pressure. Acetazolamide, a potent anti-glaucoma drug, is currently used only systemically due to low solubility and permeation, which cause severe side effects. Developing topical medications with acetazolamide requires robust analytical methods for its detection in biological samples. In this context, this study aimed to develop a method to quantify acetazolamide in rabbit vitreous humor samples. The method involved a simple, fast, inexpensive, and environmentally friendly protein precipitation step for sample preparation, needing just 50 µL of sample and 200 µL of organic solvent, with adequate recovery. This was combined with high-performance liquid chromatography coupled to tandem mass spectrometry, enabling highly sensitive (LOQ of 5 ng/mL) quantification within only 5 min. The method proved to be selective, precise, and accurate, with well-fitted analytical curves, with no carryover, and no matrix effect impacting reliability. The method was successfully applied to analyze vitreous humor samples from rabbits in pharmacokinetic studies, monitoring drug release from intravitreal implants. Results showed a controlled release profile, with a maximum drug concentration (Cmax) of 426.01 ± 64.57 ng/mL, time to reach Cmax (Tmax) of 28 days, and area under the curve (AUC0-42 and AUC0-∞) of 7722.66 ± 1125.96 ng days/mL and 8998.11 ± 1311.92 ng days/mL, respectively. The device demonstrated significantly slower elimination, ensuring therapeutic levels for an extended period when compared to intravitreal injection.

Endoscopic submucosal dissection vs. endoscopic mucosal resection in the treatment of early Barrett's neoplasia: Systematic review and meta-analysis.

OBJECTIVES: Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia. METHODS: An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence. RESULTS: A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04). CONCLUSION: Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.

Impact of an Exercise-Based Cardiac Rehabilitation Program on Cardiopulmonary Test Parameters.

INTRODUCTION: Exercise-based cardiac rehabilitation programs (CRPs) represent a multidisciplinary therapeutic approach tailored to improve cardiorespiratory fitness and overall health-related quality of life, while reducing cardiovascular hospitalizations and mortality. Our aim was to determine changes in exercise capacity and cardiac events according to the left ventricular ejection fraction (LVEF) following a CRP. METHODS: This single-center cohort study included 131 patients who completed a center-based CRP from 2015 to 2022. Cardiopulmonary exercise testing (CPET), transthoracic echocardiography, and laboratory analysis were performed before and after program completion. RESULTS: Of 232 enrolled patients, 131 were included in our cohort analysis, with 36.6% having a reduced LVEF. These patients exhibited higher rates of atrial fibrillation (p = 0.019) and NT-proBNP values (p < 0.001). Patients with reduced LVEF had lower peak VO2 (pVO2) (p = 0.046), percentage of predicted oxygen consumption (ppVO2) (p < 0.001), and VO2 at anaerobic threshold (p = 0.015) during baseline CPET. Completion of the CRP led to comparable improvements in exercise performance between groups, assessed through Δ pVO2 (p = 0.990), Δ ppVO2 (p = 0.610), and Δ VE/VCO2 slope (p = 0.200). In the study population, male gender and hypertension independently predicted variation in VE/VCO2 slope (p = 0.017) and oxygen uptake efficiency slope (p = 0.048), respectively, post-CRP. During follow-up, 9.2% of all patients had hospital admissions for cardiac events, and 3.8% died, with no significant differences between groups. CONCLUSION: Patients with reduced LVEF admitted to our CRP showed lower functional status based on specific CPET parameters. After CRP, both reduced and preserved LVEF groups experienced similar functional improvements. Therefore, strategies to increase participation of patients with reduced LVEF in such programs are warranted.

Brazilian consensus recommendations on the diagnosis and treatment of autoimmune encephalitis in the adult and pediatric populations.

BACKGROUND: Autoimmune encephalitis (AIE) is a group of inflammatory diseases characterized by the presence of antibodies against neuronal and glial antigens, leading to subacute psychiatric symptoms, memory complaints, and movement disorders. The patients are predominantly young, and delays in treatment are associated with worse prognosis. OBJECTIVE: With the support of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, ABN) and the Brazilian Society of Child Neurology (Sociedade Brasileira de Neurologia Infantil, SBNI), a consensus on the diagnosis and treatment of AIE in Brazil was developed using the Delphi method. METHODS: A total of 25 panelists, including adult and child neurologists, participated in the study. RESULTS: The panelists agreed that patients fulfilling criteria for possible AIE should be screened for antineuronal antibodies in the serum and cerebrospinal fluid (CSF) using the tissue-based assay (TBA) and cell-based assay (CBA) techniques. Children should also be screened for anti-myelin oligodendrocyte glucoprotein antibodies (anti-MOG). Treatment should be started within the first 4 weeks of symptoms. The first-line option is methylprednisolone plus intravenous immunoglobulin (IVIG) or plasmapheresis, the second-line includes rituximab and/or cyclophosphamide, while third-line treatment options are bortezomib and tocilizumab. Most seizures in AIE are symptomatic, and antiseizure medications may be weaned after the acute stage. In anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, the panelists have agreed that oral immunosuppressant agents should not be used. Patients should be evaluated at the acute and postacute stages using functional and cognitive scales, such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Modified Rankin Scale (mRS), and the Clinical Assessment Scale in Autoimmune Encephalitis (CASE). CONCLUSION: The present study provides tangible evidence for the effective management of AIE patients within the Brazilian healthcare system.

ANTECEDENTES: Encefalites autoimunes (EAIs) são um grupo de doenças inflamatórias caracterizadas pela presença de anticorpos contra antígenos neuronais e gliais, que ocasionam sintomas psiquiátricos subagudos, queixas de memória e distúrbios anormais do movimento. A maioria dos pacientes é jovem, e o atraso no tratamento está associado a pior prognóstico. OBJETIVO: Com o apoio da Academia Brasileira de Neurologia (ABN) e da Sociedade Brasileira de Neurologia Infantil (SBNI), desenvolvemos um consenso sobre o diagnóstico e o tratamento da EAIs no Brasil utilizando a metodologia Delphi. MéTODOS: Um total de 25 especialistas, incluindo neurologistas e neurologistas infantis, foram convidados a participar. RESULTADOS: Os especialistas concordaram que os pacientes com critérios de possíveis EAIs devem ser submetidos ao rastreio de anticorpos antineuronais no soro e no líquido cefalorraquidiano (LCR) por meio das técnicas de ensaio baseado em tecidos (tissue-based assay, TBA, em inglês) e ensaio baseado em células (cell-based assay, CBA, em inglês). As crianças também devem ser submetidas ao rastreio de de anticorpo contra a glicoproteína da mielina de oligodendrócitos (anti-myelin oligodendrocyte glycoprotein, anti-MOG, em inglês). O tratamento deve ser iniciado dentro das primeiras 4 semanas dos sintomas, sendo as opções de primeira linha metilprednisolona combinada com imunoglobulina intravenosa (IGIV) ou plasmaférese. O tratamento de segunda linha inclui rituximabe e ciclofosfamida. Bortezomib e tocilizumab são opções de tratamento de terceira linha. A maioria das crises epilépticas nas EAIs são sintomáticas, e os fármacos anticrise podem ser desmamadas após a fase aguda. Em relação à encefalite antirreceptor de N-metil-D-aspartato (anti-N-methyl-D-aspartate receptor, anti-NMDAR, em inglês), os especialistas concordaram que agentes imunossupressores orais não devem ser usados. Os pacientes devem ser avaliados na fase aguda e pós-aguda mediante escalas funcionais e cognitivas, como Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Modified Rankin Scale (mRS), e Clinical Assessment Scale in Autoimmune Encephalitis (CASE). CONCLUSãO: Esta pesquisa oferece evidências tangíveis do manejo efetivo de pacientes com EAIs no sistema de saúde Brasileiro.

Diffusion tensor metrics, motor and non-motor symptoms in de novo Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) is a neurodegenerative disorder characterized by dopaminergic neurons' degeneration of the substantia nigra, presenting with motor and non-motor symptoms. We hypothesized that altered diffusion metrics are associated with clinical symptoms in de novo PD patients. METHODS: Fractional Anisotropy (FA) and Mean (MD), Axial (AD), and Radial Diffusivity (RD) were assessed in 55 de novo PD patients (58.62 ± 9.85 years, 37 men) and 55 age-matched healthy controls (59.92 ± 11.25 years, 34 men). Diffusion-weighted images and clinical variables were collected from the Parkinson's Progression Markers Initiative study. Tract-based spatial statistics were used to identify white matter (WM) changes, and fiber tracts were localized using the JHU-WM tractography atlas. Motor and non-motor symptoms were evaluated in patients. RESULTS: We observed higher FA values and lower RD values in patients than controls in various fiber tracts (p-TFCE < 0.05). No significant MD or AD difference was observed between groups. Diffusion metrics of several regions significantly correlated with non-motor (state and trait anxiety and daytime sleepiness) and axial motor symptoms in the de novo PD group. No correlations were observed between diffusion metrics and other clinical symptoms evaluated. CONCLUSION: Our findings suggest microstructural changes in de novo PD fiber tracts; however, limited associations with clinical symptoms reveal the complexity of PD pathology. They may contribute to understanding the neurobiological changes underlying PD and have implications for developing targeted interventions. However, further longitudinal research with larger cohorts and consideration of confounding factors are necessary to elucidate the underlying mechanisms of these diffusion alterations in de novo PD.

Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis.

Background: Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length. Objective: The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD. Methods: All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity). Results: There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]). Conclusions: The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.

Restrictive Versus Liberal Transfusion in Patients with Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the Myocardial Ischemia and Transfusion (MINT) Trial.

BACKGROUND: The MINT trial raised concern for harm from a restrictive versus liberal transfusion strategy in patients with acute myocardial infarction (MI) and anemia. Type 1 and type 2 MI are distinct pathophysiological entities that may respond differently to blood transfusion. This analysis sought to determine if the effects of transfusion varied among patients with a type 1 or a type 2 MI and anemia. We hypothesized that the liberal transfusion strategy would be of greater benefit in type 2 than in type 1 MI. METHODS: We compared rates of death or MI at 30 days in patients with type 1 (n=1460) and type 2 (n=1955) MI and anemia who were randomly allocated to a restrictive (threshold of 7 to 8 g/dL) or a liberal (threshold of 10 g/dL) transfusion strategy. RESULTS: The primary outcome of death or MI was observed in 16% of type 1 MI and 15.4% of type 2 MI patients. The rate of death or MI was higher in patients with type 1 MI randomized to a restrictive (18.2%) versus liberal (13.2%) transfusion strategy (RR 1.32, 95% CI 1.04 - 1.67) with no difference observed between the restrictive (15.8% ) and liberal (15.1% ) transfusion strategies in patients with type 2 MI (RR 1.05 95% CI 0.85-1.29). The test for a differential effect of transfusion strategy by MI type was not statistically significant (P-interaction = 0.16). CONCLUSIONS: The concern for harm with a restrictive transfusion strategy in patients with acute MI and anemia raised in the MINT primary outcome manuscript may be more apparent in patients with type 1 than type 2 MI. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov number, NCT02981407.

Baseline brain volume predicts home-based transcranial direct current stimulation effects on inattention in adults with attention-deficit/hyperactivity disorder.

BACKGROUND: Home-based transcranial direct current stimulation (Hb-tDCS) is a non-invasive brain stimulation technique that utilizes low-intensity electric currents delivered via scalp electrodes to modulate brain activity. It holds significant promise for addressing inattention in adults with attention-deficit/hyperactivity disorder (ADHD). However, its effectiveness varies among individuals, and predicting outcomes remains uncertain, partially due to the influence of individual differences in ADHD-related brain anatomy. METHODS: We analyzed data from a subsample, composed by twenty-nine adult patients with ADHD, of the Treatment of Inattention Symptoms in Adult Patients with ADHD (TUNED) trial. Fourteen patients underwent active anodal right cathodal left dorsolateral prefrontal cortex (DLPFC) Hb-tDCS for 4 weeks and fifteen received sham-related tDCS intervention. Inattention outcome was evaluated at both baseline and endpoint (4th week). Baseline structural measures of the DLPFC, anterior cingulate cortex (ACC) and subcortical structures, previously associated with ADHD, were quantified. Several linear mixed models, with a three-way interaction between the fixed predictors brain volume or thickness, time, and treatment were calculated. Multiple comparison corrections were applied using the Benjamini-Hochberg method. RESULTS: Baseline volume of the left DLPFC regions middle frontal gyrus (t (25) = 3.33, p-adjusted = 0.045, Cohen's d = 1.33, 95% CI = [0.45, 2.19]), inferior frontal gyrus (orbital part) (t (25) = 3.10, p-adjusted = 0.045, Cohen's d = 1.24, 95% CI = [0.37, 2.08]), and of the left ACC supragenual (t (25) = 3.15, p-adjusted = 0.045, Cohen's d = 1.26, 95% CI = [0.39, 2.11]) presented significant association with the inattentive score improvement only in the active tDCS group. More specifically, the smaller these regions were, the more the symptoms improved following anodal right cathodal left DLPFC Hb-tDCS. CONCLUSION: Hb-tDCS was associated with greater improvement in brain areas related to attention regulation. Brain MRI can be potentially used to predict clinical response to tDCS in ADHD adults.

Mais Complicações em Mulheres após Revascularização do Miocárdio Mesmo com Tempos Cirúrgicos Reduzidos: Atenção por Equidade e Melhoria da Qualidade / More Hospital Complications in Women after Cabg Even for Reduced Surgical Times: Call to Action for Equity in Quality Improvement

Resumo Fundamento Análises em grandes registros apontam desfechos desfavoráveis para mulheres submetidas à cirurgia de revascularização do miocárdio (CRM), enquanto estudos randomizados sofrem com a falta de representatividade. Objetivo Comparar os resultados hospitalares ajustados entre homens e mulheres submetidos à CRM. Métodos Entre julho de 2017 e junho de 2019, 3991 pacientes foram submetidos à CRM primária isolada, tanto de forma eletiva como de urgência, em 5 hospitais de estado de São Paulo, Brasil. Para equilibrar as diferenças entre homens e mulheres, as populações foram ajustadas utilizando o Propensity Score Matching. Os desfechos considerados para análise foram os utilizados pelo STS Adult Database. As análises foram conduzidas no software R, considerando significância valores de p < 0,05. Resultados Após o Propensity Score Matching (1:1), cada grupo incluiu 1089 pacientes. Em relação às variáveis intraoperatórias os homens apresentaram maior tempo de CEC (p<0,001), tempo cirúrgico (p<0,001), número de anastomoses distais (p<0,001) e uso de enxertos arteriais. Em relação aos desfechos as mulheres apresentaram maior incidência de infecção de ferida profunda (p=0,006), tempo prolongado na Unidade de Terapia Intensiva (p=0,002), maior necessidade do uso de balão intraórtico (p=0,04), maior taxa de transfusão sanguínea (p<0,001), maior readmissão hospitalar em até 30 dias após a cirurgia (p=0,002) e maior taxa de óbitos (p=0,03). Conclusões Apesar dos homens terem apresentado um maior tempo de CEC, maior número de enxertos arteriais e maior número de anastomoses distais, os resultados imediatos após CRM foram piores em mulheres.

Abstract Background Analyses of extensive registries indicate adverse outcomes for women undergoing coronary artery bypass grafting (CABG) surgery, while randomized studies often lack representativeness. Objective To compare adjusted hospital outcomes between men and women undergoing CABG. Methods From July 2017 to June 2019, 3991 patients underwent primary isolated CABG, both electively and urgently, in 5 hospitals in the state of São Paulo, Brazil. To mitigate demographic differences between men and women, populations were adjusted using propensity score matching (PSM). The outcomes considered for analysis were those used by the STS Adult Database. The analyses were performed using R software, with a significance set at p<0.05. Results After PSM (1:1), each group included 1089 patients. Regarding intraoperative variables, men exhibited longer cardiopulmonary bypass (CPB) time (p<0.001), surgical time (p<0.001), a higher number of distal anastomoses (p<0.001), and increased use of arterial grafts. Regarding outcomes, women had a higher incidence of deep sternal wound infection (p=0.006), prolonged Intensive Care Unit stay (p=0.002), increased need for an intra-aortic balloon pump (p=0.04), higher blood transfusion rates (p<0.001), higher 30-day hospital readmission rates after surgery (p=0.002) and higher mortality rate (p=0.03). Conclusions Although men had longer CPB times, a greater number of arterial grafts, and a greater number of distal anastomoses, immediate results after CABG were poorer in women.

Invisibilidades das Práticas Integrativas e Complementares na Atenção Primária à Saúde / The Invisibility of Integrative and Complementary Practices in Primary Healthcare

Resumo A invisibilidade é uma questão que necessita de maior atenção entre os profissionais de saúde, pois algumas atividades na Atenção Primária passam despercebidas. Um exemplo é a oferta de terapias complementares, cuja implementação tem sido frágil e, consequentemente, pode ser invisibilizada no Sistema Único de Saúde. Este estudo visa compreender os fatores que contribuem para a invisibilidade pública das Práticas Integrativas e Complementares na Atenção Primária. Trata-se de uma pesquisa descritiva, exploratória e qualitativa, envolvendo entrevistas semiestruturadas com 20 profissionais na Região Metropolitana de Goiânia. A análise de conteúdo temática foi aplicada às entrevistas, revelando elementos que indicam a invisibilidade pública dessas práticas, como a falta de discussão nas reuniões de equipe, a desuniformidade no registro nos prontuários dos usuários e a baixa priorização na implementação. Nas entrevistas, a humilhação social, produto da invisibilidade pública, também pode ser percebida devido à sobrecarga, constrangimentos e falta de espaço físico para a oferta das práticas aos usuários. Conclui-se que as Práticas Integrativas e Complementares são frequentemente invisibilizadas na Atenção Primária.

Abstract Invisibility is an issue that requires more attention among healthcare professionals, as some activities in Primary Care go unnoticed. One example is the offer of complementary therapies, whose implementation has been frail and, consequently, can be overlooked in the Unified Health System. This study aims to understand the factors contributing to the public invisibility of Integrative and Complementary Practices in Primary Care. It is a descriptive, exploratory, and qualitative research involving semi-structured interviews with 20 professionals in the Metropolitan Region of Goiânia. Thematic content analysis was applied to the interviews, revealing elements indicating the public invisibility of these practices, such as insufficient discussion in team meetings, inconsistency in the recording in user files, and low prioritization in implementation. In the interviews, social humiliation, a product of public invisibility, can also be perceived due to overload, embarrassments, and lack of physical space for the provision of practices to the users. It is concluded that Integrative and Complementary Practices are often overlooked in Primary Care.

Derivation and external validation of predictive models for invasive mechanical ventilation in intensive care unit patients with COVID-19.

BACKGROUND: This study aimed to develop prognostic models for predicting the need for invasive mechanical ventilation (IMV) in intensive care unit (ICU) patients with COVID-19 and compare their performance with the Respiratory rate-OXygenation (ROX) index. METHODS: A retrospective cohort study was conducted using data collected between March 2020 and August 2021 at three hospitals in Rio de Janeiro, Brazil. ICU patients aged 18 years and older with a diagnosis of COVID-19 were screened. The exclusion criteria were patients who received IMV within the first 24 h of ICU admission, pregnancy, clinical decision for minimal end-of-life care and missing primary outcome data. Clinical and laboratory variables were collected. Multiple logistic regression analysis was performed to select predictor variables. Models were based on the lowest Akaike Information Criteria (AIC) and lowest AIC with significant p values. Assessment of predictive performance was done for discrimination and calibration. Areas under the curves (AUC)s were compared using DeLong's algorithm. Models were validated externally using an international database. RESULTS: Of 656 patients screened, 346 patients were included; 155 required IMV (44.8%), 191 did not (55.2%), and 207 patients were male (59.8%). According to the lowest AIC, arterial hypertension, diabetes mellitus, obesity, Sequential Organ Failure Assessment (SOFA) score, heart rate, respiratory rate, peripheral oxygen saturation (SpO2), temperature, respiratory effort signals, and leukocytes were identified as predictors of IMV at hospital admission. According to AIC with significant p values, SOFA score, SpO2, and respiratory effort signals were the best predictors of IMV; odds ratios (95% confidence interval): 1.46 (1.07-2.05), 0.81 (0.72-0.90), 9.13 (3.29-28.67), respectively. The ROX index at admission was lower in the IMV group than in the non-IMV group (7.3 [5.2-9.8] versus 9.6 [6.8-12.9], p < 0.001, respectively). In the external validation population, the area under the curve (AUC) of the ROX index was 0.683 (accuracy 63%), the AIC model showed an AUC of 0.703 (accuracy 69%), and the lowest AIC model with significant p values had an AUC of 0.725 (accuracy 79%). CONCLUSIONS: In the development population of ICU patients with COVID-19, SOFA score, SpO2, and respiratory effort signals predicted the need for IMV better than the ROX index. In the external validation population, although the AUCs did not differ significantly, the accuracy was higher when using SOFA score, SpO2, and respiratory effort signals compared to the ROX index. This suggests that these variables may be more useful in predicting the need for IMV in ICU patients with COVID-19. GOV IDENTIFIER: NCT05663528.

Combined effects of high hydrostatic pressure and pulsed electric fields on quinoa starch: Analysis of microstructure, morphology, thermal, and pasting properties.

The aim of this study was to evaluate the impact of non-thermal methods, using high hydrostatic pressure (HHP) and pulsed electric field (PEF), on the dual modification of quinoa starch and to analyze the microstructural, morphological, thermal, pasting, and texture properties. Starch was treated with HHP at 400 MPa for 10 min, while PEF was applied using voltages of 10 and 30 kV cm-1 for a total time of 90s. The modification techniques were effective in breaking down amylose molecules and amylopectin branches, where for the dual treatment, higher values of DP6-12 were found. The average diameter and gelatinization temperatures were elevated after HHP, thus forming clusters that require more energy for paste formation. The use of 30 kV cm-1 and 400 MPa (HP30) in starch facilitates the creation of new food products with better texture, stability and nutritional value, making them suitable for use in food emulsions and the cosmetics industry.