2024 updated European Heart Rhythm Association core curriculum for physicians and allied professionals: a statement of the European Heart Rhythm Association of the European Society of Cardiology.

Heart rhythm management is a continuously evolving sub-speciality of cardiology. Every year, many physicians and allied professionals (APs) start and complete their training in cardiac implantable electronic devices (CIEDs) or electrophysiology (EP) across the European Heart Rhythm Association (EHRA) member countries. While this training ideally ends with an EHRA certification, the description of the learning pathway (what, how, when, and where) through an EHRA core curriculum is also a prerequisite for a successful training. The first EHRA core curriculum for physicians was published in 2009. Due to the huge developments in the field of EP and device therapy, this document needed updating. In addition, a certification process for APs has been introduced, as well as a recertification process and accreditation of EHRA recognized training centres. Learning pathways are more individualized now, with Objective Structured Assessment of Technical Skills (OSATS) to monitor learning progression of trainees. The 2024 updated EHRA core curriculum for physicians and APs describes, for both CIED and EP, the syllabus, OSATS, training programme and certification, and recertification for physicians and APs and stresses the importance of continued medical education after certification. In addition, requirements for accreditation of training centres and trainers are given. Finally, suggested reading lists for CIED and EP are attached as online supplements.

Non-invasive three-dimensional electrical activation mapping to predict cardiac resynchronization therapy response: site of latest left ventricular activation relative to pacing site.

AIMS: Pacing remote from the latest electrically activated site (LEAS) in the left ventricle (LV) may diminish response to cardiac resynchronization therapy (CRT). We tested whether proximity of LV pacing site (LVPS) to LEAS, determined by non-invasive three-dimensional electrical activation mapping [electrocardiographic Imaging (ECGI)], increased likelihood of CRT response. METHODS AND RESULTS: Consecutive CRT patients underwent ECGI and chest/heart computed tomography 6-24 months of post-implant. Latest electrically activated site and the distance to LVPS (dp) were assessed. Left ventricular end-systolic volume (LVESV) reduction of ≥15% at clinical follow-up defined response. Logistic regression probabilistically modelled non-response; variables included demographics, heart failure classification, left bundle branch block (LBBB), ischaemic heart disease (IHD), atrial fibrillation, QRS duration, baseline ejection fraction (EF) and LVESV, comorbidities, use of CRT optimization algorithm, angiotensin-converting enzyme inhibitor(ACE)/angiotensin-receptor blocker (ARB), beta-blocker, diuretics, and dp. Of 111 studied patients [64 ± 11 years, EF 28 ± 6%, implant duration 12 ± 5 months (mean ± SD), 98% had LBBB, 38% IHD], 67% responded at 10 ± 3 months post CRT-implant. Latest electrically activated sites were outside the mid-to-basal lateral segments in 35% of the patients. dp was 42 ± 23 mm [31 ± 14 mm for responders vs. 63 ± 24 mm non-responders (P < 0.001)]. Longer dp and the lack of use of CRT optimization algorithm were the only independent predictors of non-response [area under the curve (AUC) 0.906]. dp of 47 mm delineated responders and non-responders (AUC 0.931). CONCLUSION: The distance between LV pacing site and latest electrical activation is a strong independent predictor for CRT response. Non-invasive electrical evaluation to characterize intrinsic activation and guide LV lead deployment may improve CRT efficacy.

Early Bactericidal Activity of Meropenem plus Clavulanate (with or without Rifampin) for Tuberculosis: The COMRADE Randomized, Phase 2A Clinical Trial.

Rationale: Carbapenems are recommended for treatment of drug-resistant tuberculosis. Optimal dosing remains uncertain. Objectives: To evaluate the 14-day bactericidal activity of meropenem, at different doses, with or without rifampin. Methods: Individuals with drug-sensitive pulmonary tuberculosis were randomized to one of four intravenous meropenem-based arms: 2 g every 8 hours (TID) (arm C), 2 g TID plus rifampin at 20 mg/kg once daily (arm D), 1 g TID (arm E), or 3 g once daily (arm F). All participants received amoxicillin/clavulanate with each meropenem dose. Serial overnight sputum samples were collected from baseline and throughout treatment. Median daily fall in colony-forming unit (CFU) counts per milliliter of sputum (solid culture) (EBACFU0-14) and increase in time to positive culture (TTP) in liquid media were estimated with mixed-effects modeling. Serial blood samples were collected for pharmacokinetic analysis on Day 13. Measurements and Main Results: Sixty participants enrolled. Median EBACFU0-14 counts (2.5th-97.5th percentiles) were 0.22 (0.12-0.33), 0.12 (0.057-0.21), 0.059 (0.033-0.097), and 0.053 (0.035-0.081); TTP increased by 0.34 (0.21-0.75), 0.11 (0.052-0.37), 0.094 (0.034-0.23), and 0.12 (0.04-0.41) (log10 h), for arms C-F, respectively. Meropenem pharmacokinetics were not affected by rifampin coadministration. Twelve participants withdrew early, many of whom cited gastrointestinal adverse events. Conclusions: Bactericidal activity was greater with the World Health Organization-recommended total daily dose of 6 g daily than with a lower dose of 3 g daily. This difference was only detectable with solid culture. Tolerability of intravenous meropenem, with amoxicillin/clavulanate, though, was poor at all doses, calling into question the utility of this drug in second-line regimens. Clinical trial registered with www.clinicaltrials.gov (NCT03174184).

Electrocardiographic imaging to guide ablation of ventricular arrhythmias and agreement between two different systems.

BACKGROUND AND AIM: A recent study using an epicardial-only electrocardiographic imaging (ECGI), suggests that the agreement of ECGI activation mapping and that of the contact mapping for ventricular arrhythmias (VA) is poor. The aim of this study was to assess the diagnostic value of two endo-epicardial ECGI systems using different cardiac sources and the agreement between them. METHODS: We performed 69 ECGI procedures in 52 patients referred for ablation of VA at our center. One system based on the extracellular potentials was used in 26 patients, the other based on the equivalent double layer model in 9, and both in 17 patients. The first uses up to 224 leads and the second just the 12­lead ECG. The localization of the VA was done using a segmental model of the ventricles. A perfect match (PM) was defined as a predicted location within the same anatomic segment, whereas a near match (NM) as a predicted location within the same segment or a contiguous one. RESULTS: 44 patients underwent ablation, corresponding to 58 ECGI procedures (37 with the first and 21 with the second system). The percentage of PMs and NMs was not significantly different between the two systems, respectively 76% and 95%, p = 0.077, and 97% and 100%, p = 1.000. In 14 patients that underwent ablation and had the ECGI performed with both systems, raw agreement for PMs was 79%, p = 0.250 for disagreement. CONCLUSIONS: ECGI systems were useful to identify the origin of the VAs, and the results were reproducible regardless the cardiac source.

Assessment of wave front activation duration and speed across the right ventricular outflow tract using electrocardiographic imaging as predictors of the origin of the premature ventricular contractions: A validation study.

AIMS: Evaluate right ventricular outflow tract (RVOT) activation duration (AD) and speed, invasively and with the electrocardiographic imaging (ECGI), as predictors of the origin of the PVCs, validating the ECGI. METHODS: 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of PVCs with inferior axis and had ECGI performed before ablation. Isochronal activation maps of the RVOT in PVC were obtained with the ECGI and invasively. Total RVOT AD was measured as the time between earliest and latest activated region, and propagation speed by measuring the area of the first 10 ms of activation. Cut-off values for AD, activation speed and number of 10 ms isochrones to predict the origin of the PVCs, were obtained with the ROC curve analysis. Agreement between methods was done with Pearson correlation test and Bland-Altman plot. RESULTS: PVCs originated from the RVOT in 11 (61%) patients. The stronger predictor of PVC origin was the AD. The median AD in PVCs from RVOT was significantly longer than from outside the RVOT, both with ECGI and invasively, respectively 62 (58-73) vs 37 (33-40) ms, p < 0.0001 and 68 (60-75) vs 35 (29-41) ms, p < 0.0001. Agreement between the two methods was good (r = 0.864, p < 0.0001). The cut-off value of 43 ms for AD measured with ECGI predicted the origin of the PVCs with a sensitivity and specificity of 100%. CONCLUSIONS: We found good agreement between ECGI and invasive map. The AD measured with ECGI was the best predictor of the origin of the PVCs.

Electrocardiographic imaging (ECGI): What is the minimal number of leads needed to obtain a good spatial resolution?

AIMS: Assess the minimal number of ECGI leads needed to obtain a good spatial resolution. METHODS: We enrolled 20 patients that underwent ablation of premature ventricular or atrial contractions using Carto and ECGI with AMYCARD. We evaluated the agreement regarding the site of origin of the arrhythmia between the ECGI and Carto, the area and diameter of the earliest activation site obtained with the ECGI (EASa and EASd). Based on previous studies with pacemapping, we considered a good spatial resolution of the ECGI when the EASd measured on the isopotential map was less than 18 mm. In presence of agreement the ECGI was reprocessed: a) with half the number of electrode bands (8 leads per electrode band) and b) with 6 electrode bands. RESULTS: The initial map was obtained with 23 (22-23) electrode bands per patient, corresponding to 143 (130-170) leads. Agreement rate was 85%, the median EASa and EASd were: 0.7 (0.5-1.3) cm2 and 9 (8-13) mm. With half the number of electrode bands including 73 (60-79) leads, agreement rate was 80%, the EASa and EASd were: 2.1 (1.5-6.2) cm2 and 16 (14 -28) mm. With only six electrode bands using 38 (30-42) leads, agreement rate was 55%, EASa and EASd were: 4.0 (3.3-5.0) cm2 and 23 (21-25) mm. The number of leads was a predictor of agreement with a good spatial resolution, OR (95% CI) of 1.138 (1.050-1.234), p = .002. According to the ROC curve, the minimal number of leads was 74 (AUC 0.981; 95% CI: 0.949-1.00, p < .0001). CONCLUSION: Reducing the number of leads was associated with a lower agreement rate and a significant reduction of spatial resolution. However, the number of leads needed to achieve a good spatial resolution was less than the maximal available.

Changes in bryophyte functional composition during post-fire succession.

Climate and land-use changes are altering fire regimes in many regions around the world. To date, most studies have focused on the effects of altered fire regimes on woody and herbaceous communities, while the mechanisms driving post-fire bryophyte succession remain poorly understood, particularly in Mediterranean-type ecosystems. Here, we examined changes in bryophyte functional composition along a post-fire chronosequence (ranging from 1 to 20+ years) in Pyrenean oak woodlands (northeastern Portugal). To do so, we defined bryophyte functional groups based on seven morphological, reproductive, and life history traits. Then, we fitted linear and structural equation models to disentangle the direct and indirect effects of fire (time since fire and fire intensity), vegetation structure, climate, topography, and edaphic conditions on the abundance of each group. We identified two main functional groups: early colonizers (species with traits associated with strong colonization ability and desiccation tolerance) and perennial stayers (species with high competitive ability, i.e., large perennial mosses). Overall, the abundance of early colonizer species decreased with time since fire and increased with fire intensity, while the opposite was observed for perennial stayers. Thus, successional dynamics reflected a trade-off between species' competitive and colonization abilities, highlighting the role of biotic interactions later in succession. Patterns of functional composition were also consistent with changes in environmental conditions during succession, suggesting that species may experience stressful conditions (i.e., high radiation and low water availability) in early stages of post-fire succession. Our results also indicate that increased fire intensity may alter successional trajectories, leading to long-term changes in bryophyte communities. By understanding the response of bryophyte communities to fire, we were able to identify species with potential use as soil restoration materials.

Quality indicators in atrial fibrillation ablation (RIQAFA). A national registry from the Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE).

INTRODUCTION AND OBJECTIVES: Atrial fibrillation (AF) is the most common sustained arrhythmia, with significant burden for patients. Catheter ablation is safe and superior for symptom improvement. The purpose of this work was to assess how clinical practice compares with current scientific evidence and quality indicators for AF ablation. METHODS: The Portuguese Association of Arrhythmology, Pacing and Electrophysiology conducted a prospective registry among Portuguese centers to assess clinical practice regarding management of patients referred for ablation and the methodology used in the procedures and related outcomes. RESULTS: A total of 337 patients were referred for ablation, 102 (37.91%) female, age 65 (56-70.8) years. The median CHADS2-VaSC2 thromboembolic risk score was 2 (1-3), and 308 (92.49%) were on anticoagulants. AF was mainly paroxysmal (224, 66.97%) and symptomatic (mEHRA score 3; 2-3). Before ablation most patients (273, 81.49%) underwent cardiac computed tomography and only 24 (7.36%) procedures were performed with uninterrupted anticoagulation. For ablation, Carto® (194; 59.15%) and Ensite® (55; 16.77%) were mainly used, and the preferential strategy was pulmonary vein isolation (316; 94.61%). Acute complications occurred in five (1.49%) patients, while most had symptom improvement at one month (200; 86.21%), sustained at one year. There were 40 (12.6%) relapses within 30 days and 19 (26.39%) at one year. CONCLUSIONS: In a population of patients with AF referred for ablation in Portuguese centers, patient management is provided according to the best scientific evidence and there is a high standard of practice with respect to the quality of AF ablation practice.

Corrigendum: Leaf surfaces and neolithization - the case of Arundo donax L.

[This corrects the article DOI: 10.3389/fpls.2022.999252.].

The compound event that triggered the destructive fires of October 2017 in Portugal.

Portugal is regularly affected by destructive wildfires that have severe social, economic, and ecological impacts. The total burnt area in 2017 (∼540,000 ha) marked the all-time record value since 1980 with a tragic toll of 114 fatalities that occurred in June and October events. The local insurance sector declared it was the costliest natural disaster in Portugal with payouts exceeding USD295 million. Here, the 2017 October event, responsible for more than 200,000 ha of burnt area and 50 fatalities is analyzed from a compound perspective. A prolonged drought led to preconditioned cumulative hydric stress of vegetation in October 2017. In addition, on 15 October 2017, two other major drivers played a critical role: 1) the passage of hurricane Ophelia off the Coast of Portugal, responsible for exceptional meteorological conditions and 2) the human agent, responsible for an extremely elevated number of negligent ignitions. This disastrous combination of natural and anthropogenic drivers led to the uncontrolled wildfires observed on 15 October.

Sympathetic innervation does not contribute to glycerol release in ischemic flaps.

BACKGROUND: Extracellular glycerol as detected by microdialysis has been used as a surrogate marker for (ischemic) tissue damage and cellular membrane breakdown in the monitoring of free microvascular musculocutaneous flaps. One confounding factor for glycerol as a marker of ischemic cell damage is the effect of lipolysis and associated glycerol release as induced by sympathetic signalling alone. We hypothesized that extracellular glycerol concentrations in a microvascular flap with sympathetic innervation would be confounded by intact innervation per se as compared to denervated flap. Clinical relevance is related to the use of both free and pedicled flaps in reconstructive surgery. We tested the hypothesis in an experimental model of microvascular musculocutaneal flaps. METHODS: Twelve pigs were anesthetized and mechanically ventilated. Two identical rectus abdominis musculocutaneal flaps were raised for the investigation. In the A-flaps the adventitia of the artery and accompanying innervation was carefully stripped, while in the B-flaps it was left untouched. Flap ischemia was induced by clamping both vessels for 60 minutes. The ischemia was confirmed by measuring tissue oxygen pressure, while extracellular lactate to pyruvate ratio indicated the accompanying anaerobic metabolism locally. RESULTS: Intramuscular and subcutaneal extracellular glycerol concentrations were measured by microdialysate analyzer. Contrary to our hypothesis, glycerol concentrations were comparable between the two ischemia groups at 60 minutes (p = 0.089, T-test). CONCLUSIONS: In this experimental model of vascular flap ischemia, intact innervation of the flap did not confound ischemia detection by glycerol. Extrapolation of the results to clinical setting warrants further studies.

The Importance of MTHFR C677T/A1298C Combined Polymorphism in Deep Vein Thrombosis: A Case Report.

A 37-year-old woman presented in the emergency room with abdominal pain and nausea for about three weeks. She had no known risk factors for venous thromboembolism beyond taking oral contraceptives as a regular medication. Computed tomography (CT) scan revealed portal, superior mesenteric and splenic vein thrombosis. Thrombophilia tests were negative, except for the presence of heterozygosity for mutation of the methylenetetrahydrofolate reductase (MTHFR) gene. Homocysteine levels and folic acid were normal. Anticoagulation was started. Follow-up CT after eight months showed cavernous transformation of the portal vein.

Leaf surfaces and neolithization - the case of Arundo donax L.

Arundo donax L. (Arundinoideae subfamily, Poaceae family) is a sub-tropical and temperate climate reed that grows in arid and semi-arid environmental conditions, from eastern China to the Mediterranean basin, suggesting potential adaptations at the epicuticular level. A thorough physical-chemical examination of the adaxial and abaxial surfaces of A. donax leaf was performed herein in an attempt to track such chemophenetic adaptations. This sort of approach is of the utmost importance for the current debate about the hypothetical invasiveness of this species in the Mediterranean basin versus its natural colonization along the Plio-Pleistocene period. We concluded that the leaf surfaces contain, apart from stomata, prickles, and long, thin trichomes, and silicon-rich tetralobate phytolits. Chemically, the dominating elements in the leaf ashes are oxygen and potassium; minor amounts of calcium, silicon, magnesium, phosphorous, sulphur, and chlorine were also detected. In both surfaces the epicuticular waxes (whose density is higher in the adaxial surface than in the abaxial surface) form randomly orientated platelets, with irregular shape and variable size, and aggregated rodlets with variable diameter around the stomata. In the case of green mature leaves, the dominating organic compounds of the epicuticular waxes of both surfaces are triterpenoids. Both surfaces feature identical hydrophobic behaviour, and exhibit the same total transmittance, total reflectance, and absorption of incident light. The above findings suggest easy growth of the plant, remarkable epidermic robustness of the leaf, and control of water loss. These chemophenetic characteristics and human influence support a neolithization process of this species along the Mediterranean basin.

Aerobic exercise, alone or combined with an anti-inflammatory drug, reduces the severity of epileptic seizures and levels of central pro-inflammatory cytokines in an animal model of epileptic seizures.

Epilepsy is a chronic neurological disorder and there is increasing evidence about the role of inflammation in epileptogenesis. These findings have spurred the search for new immunomodulatory approaches that can improve prognosis. Using an animal model of chemically-induced epileptic seizures, we tested exercise alone as non-pharmacological therapy, and exercise combined with an anti-inflammatory drug. Five groups were used: sedentary, diazepam, aerobic exercise alone, aerobic exercise combined with an anti-inflammatory drug, and naive control. Our goal was to compare the severity of the epileptic seizures between groups as well as seizure latency in a pentylenetetrazole-induced paradigm. Cytokine levels (IL-1ß, TNF-α, and IL-10) were measured. Both exercise groups showed a reduction in seizure severity and lower levels of pro-inflammatory cytokines in the cortex, while the levels of cytokines in the hippocampus remained unaffected.

Effect of customized healing abutments on the peri-implant linear and volumetric tissue changes at maxillary immediate implant sites: A 1-year prospective randomized clinical trial.

BACKGROUND: Immediate implant placement (IIP) associated with the use of bone substitutes and collagen matrices (CM) seems to reduce the amount of resorption at peri-implant areas. Recently, customized healing abutments (CA) appeared as another solution in order to seal the socket and preserve the original soft tissue contour. PURPOSE: To evaluate peri-implant tissues dimensional changes after using customized healing abutments compared with the use of xenogeneic collagen matrices as socket sealing options in flapless maxillary immediate implant placement. MATERIAL AND METHODS: The present study was designed as a prospective, randomized, controlled clinical trial. Patients were allocated into two groups depending on the socket sealing option: in the CM group a collagen matrix was used and in the CA group a customized abutment. Digital impressions were taken prior to extraction, 1, 4, and 12 months after implant insertion and the digital files allowed to evaluate linear buccal changes (MBC) and the buccal volumetric variation (BVv) between the different time points at peri-implant tissue areas. Additionally, mucosa variation was computed assessing the papilla presence and the midfacial mucosa height. Statistical significance was set at 0.05. RESULTS: Twenty-eight patients were observed during a 12-month period. Significant differences between mean values of BVv at the first month were observed at the CM and CA group (-9.75 ± 6.65% and -4.76 ± 5.29%, respectively) (p = 0.043). At the 1-year follow-up, no significant differences were found in terms of BVv between the two groups, although the thin bone phenotype (≤1 mm) significantly influenced the volumetric variations that occurred in each group. No significant differences were noticed in midfacial mucosa and papillae alteration between groups, after 1 year of treatment. CONCLUSION: Both treatment options are predictable solutions for socket sealing in IIP, although a higher volumetric variation can be expected in the presence of thin bone phenotypes.

Effect of Sedation Regimen on Weaning from Mechanical Ventilation in the Intensive Care Unit.

BACKGROUND: Intensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay. OBJECTIVE: The aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process. PATIENTS AND METHODS: Intubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24 h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as 'fit for weaning' until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53). RESULTS: Patients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder. CONCLUSION: Dexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.

Ionic Liquid-Assisted Synthesis of Mesoporous Silk Fibroin/Silica Hybrids for Biomedical Applications.

New mesoporous silk fibroin (SF)/silica hybrids were processed via a one-pot soft and energy-efficient sol-gel chemistry and self-assembly from a silica precursor, an acidic or basic catalyst, and the ionic liquid 1-butyl-3-methylimidazolium chloride, acting as both solvent and mesoporosity-inducer. The as-prepared materials were obtained as slightly transparent-opaque, amorphous monoliths, easily transformed into powders, and stable up to ca. 300 °C. Structural data suggest the formation of a hexagonal mesostructure with low range order and apparent surface areas, pore volumes, and pore radii of 205-263 m2 g-1, 0.16-0.19 cm3 g-1, and 1.2-1.6 nm, respectively. In all samples, the dominating conformation of the SF chains is the ß-sheet. Cytotoxicity/bioactivity resazurin assays and fluorescence microscopy demonstrate the high viability of MC3T3 pre-osteoblasts to indirect (≥99 ± 9%) and direct (78 ± 2 to 99 ± 13%) contact with the SF/silica materials. Considering their properties and further improvements, these systems are promising candidates to be explored in bone tissue engineering. They also offer excellent prospects as electrolytes for solid-state electrochemical devices, in particular for fuel cells.

Deep sedation with dexmedetomidine in a porcine model does not compromise the viability of free microvascular flap as depicted by microdialysis and tissue oxygen tension.

BACKGROUND: Deep sedation is often necessary after major reconstructive plastic surgery in the face and neck regions to prevent sudden spontaneous movements capable of inflicting mechanical injury to the transplanted musculocutaneous flap(s). An adequate positioning may help to optimize oxygenation and perfusion of the transplanted tissues. We hypothesized that dexmedetomidine, a central alpha2-agonist and otherwise potentially ideal postoperative sedative drug, may induce vasoconstriction in denervated flaps, and thus increase the risk of tissue deterioration. METHODS: Two symmetrical myocutaneous flaps were raised on each side of the upper abdomen in 12 anesthetized pigs. The sympathetic nerve fibers were stripped from the arteries in one of the flaps (denervated flap), while nerve fibers were kept untouched in the other (innervated flap). After simulation of ischemia and reperfusion periods, the animals were randomized to deep postoperative sedation with either propofol (n = 6) or dexmedetomidine (n = 6). Flap tissue metabolism was monitored by microdialysis and tissue-oxygen partial pressure. Glucose, lactate, and pyruvate concentrations were analyzed from the dialysate every 30 min for 4 h. RESULTS: Mean arterial blood pressure was higher in the dexmedetomidine group (P = 0.036). Flap tissue metabolism remained stable throughout the experiment as measured by lactate-pyruvate and lactate-glucose ratios (median ranges 14.3-24.5 for lactate-pyruvate and 0.3-0.6 for lactate-glucose) and by tissue-oxygen partial pressure, and no differences were found between groups. CONCLUSIONS: Our data suggest that dexmedetomidine, even if used for deep sedation, does not have deleterious effects on local perfusion or tissue metabolism in denervated musculocutaneous flaps.

O papel das Comissões de Integração Ensino-Serviço CIES em questão: revisão de literatura / The role of the CIES Teaching-Service Integration Commissions in question: literature review

O estudo objetiva fazer uma revisão integrativa sobre a atuação das Comissões de Integração-Ensino Serviço em diferentes contextos, aspectos de funcionamento, desafios e estratégias para superação de dificuldades como instrumento da Prática Baseada em Evidências, seguindo parâmetros metodológicos pré-estabelecidos. Para tanto, realizou-se diálogos a partir das informações extraídas das produções selecionadas, seguindo uma análise descritiva e reflexiva de acordo com a categorização com as questões: compreendendo o papel das Comissões de Integração-Ensino Serviço na condução da Política de Educação Permanente; desafios para o funcionamento e desenvolvimento das Comissões de Integração-Ensino Serviço; avanços e estratégias para desenvolver as potencialidades das Comissões de Integração-Ensino Serviço. Observou-se a capacidade das CIES em fomentar a participação ativa e democrática dos entes representantes do Quadrilátero do Sistema Único de Saúde (SUS), destacou-se a necessidades de outros estudos para fortalecer as estratégias em andamento, bem como, disseminar o que está dando certo e buscar ferramentas metodológicas, dialógicas, avaliativas que dê conta de forma crítica a compreensão sobre o movimento na junção de esforços para a consolidação do SUS

The study aims to make an integrative review on the performance of the Integration ­Teaching Service Commissions in different contexts, aspects of functioning, challenges and strategies to overcome difficulties as an instrument of Evidence-Based Practice, following pre-established methodological parameters. For this purpose, dialogues were carried out based on the information extracted from the selected productions, following a descriptive and reflective analysis according to the categorization with the questions: understanding the role of CIES in the conduct of the Permanent Education Policy; challenges for the functioning and strategies to develop of Integration ­Teaching Service Commissions. The capacity of the Integration ­Teaching Service Commissions to promote the active and democratic participation of the entities representing the Quadrilateral of the Unified Health System (SUS) was observed. The need for further studies was highlighted to strengthen the strategies in progress, as well as to disseminate what is working and to seek methodological tools, dialogical, evaluative that critically account for the understanding of the understanding of the joining of efforts for the consolidation of SUS

O papel das Comissões de Integração Ensino-Serviço CIES em questão: revisão de literatura / The role of the CIES Teaching-Service Integration Commissions in question: literature review

O estudo objetiva fazer uma revisão integrativa sobre a atuação das Comissões de Integração-Ensino Serviço em diferentes contextos, aspectos de funcionamento, desafios e estratégias para superação de dificuldades como instrumento da Prática Baseada em Evidências, seguindo parâmetros metodológicos pré-estabelecidos. Para tanto, realizou-se diálogos a partir das informações extraídas das produções selecionadas, seguindo uma análise descritiva e reflexiva de acordo com a categorização com as questões: compreendendo o papel das Comissões de Integração-Ensino Serviço na condução da Política de Educação Permanente; desafios para o funcionamento e desenvolvimento das Comissões de Integração-Ensino Serviço; avanços e estratégias para desenvolver as potencialidades das Comissões de Integração-Ensino Serviço. Observou-se a capacidade das CIES em fomentar a participação ativa e democrática dos entes representantes do Quadrilátero do Sistema Único de Saúde (SUS), destacou-se a necessidades de outros estudos para fortalecer as estratégias em andamento, bem como, disseminar o que está dando certo e buscar ferramentas metodológicas, dialógicas, avaliativas que dê conta de forma crítica a compreensão sobre o movimento na junção de esforços para a consolidação do SUS.