Effect of randomized prophylactic nitroglycerin on radial artery spasm during transradial catheterization: an analysis based on operator experience

One limitation to transradial access (TRA) is the occurrence of spasms (RAS), for which the use of prophylactic medications is recommended. Improvement in TRA material combined with the increase in operators' expertise, might mitigate this benefit. We assess the effect of preventive nitroglycerin on RAS during TRA, evaluating the role of the operator's experience. Patients received 500 µg nitroglycerin or placebo. The operator's expertise was classified as: inexperienced (I), intermediate (M), and experienced (E). 2040 patients were included. Prophylactic use of nitroglycerin did not reduce RAS (10.8% vs. 13.4% (placebo), p = 0.07). RAS incidence was 14.5% in I, 12.5% in M, and 9.7% in E (p = 0.01). In group I, nitroglycerin reduced RAS (17.4% vs. 11.1%, p = 0.04), which was not observed in other groups. Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators. More experienced operators could abolish preventive nitroglycerin use.

Effect of randomized prophylactic nitroglycerin on radial artery spasm during transradial catheterization: An analysis based on operator experience.

One limitation to transradial access (TRA) is the occurrence of spasms (RAS), for which the use of prophylactic medications is recommended. Improvement in TRA material combined with the increase in operators' expertise, might mitigate this benefit. We assess the effect of preventive nitroglycerin on RAS during TRA, evaluating the role of the operator's experience. Patients received 500 µg nitroglycerin or placebo. The operator's expertise was classified as: inexperienced (I), intermediate (M), and experienced (E). 2040 patients were included. Prophylactic use of nitroglycerin did not reduce RAS (10.8% vs. 13.4% (placebo), p = 0.07). RAS incidence was 14.5% in I, 12.5% in M, and 9.7% in E (p = 0.01). In group I, nitroglycerin reduced RAS (17.4% vs. 11.1%, p = 0.04), which was not observed in other groups. Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators. More experienced operators could abolish preventive nitroglycerin use.

Randomized Clinical Trial on Prevention of Radial Occlusion After Transradial Access Using Nitroglycerin: PATENS Trial.

OBJECTIVES: The aim of this study was to evaluate whether administration of nitroglycerin at the beginning or end of a transradial approach (TRA) procedure would preserve radial patency. BACKGROUND: The TRA is becoming the preferred vascular access route in coronary interventions. Radial artery occlusion (RAO) is the most frequent complication. Routine vasodilator treatment aims to reduce spasm and possibly prevent RAO. METHODS: The authors designed a prospective, multicenter, randomized, double-blind, 2-by-2 factorial, placebo-controlled trial encompassing patients undergoing the TRA. Patients were randomized to either 500 µg nitroglycerin or placebo; each arm was also subrandomized to early (upon sheath insertion) or late (right before sheath removal) nitroglycerin administration to evaluate the superiority of nitroglycerin in the prevention of RAO with 24 hours on Doppler ultrasound. RESULTS: A total of 2,040 patients were enrolled. RAO occurred in 49 patients (2.4%). Fifteen of these patients (30.6%) showed re-establishment of flow at 30 days. Nitroglycerin, compared with placebo, did not reduce the risk for RAO at either of the 2 time points (early, 2.5% vs 2.3% [P = 0.66]; late, 2.3% vs 2.5% [P = 0.66]). By multivariable analysis, the presence of spasm (OR: 3.53; 95% CI: 1.87-6.65; P < 0.001) and access achieved with more than 1 puncture attempt (OR: 2.58; 95% CI: 1.43-4.66; P = 0.002) were independent predictors of RAO. CONCLUSIONS: The routine use of nitroglycerin was not associated with a reduction in the rate of RAO, regardless of the time of administration (at the beginning or end of the TRA procedure).

Implementation of an Animal Sporotrichosis Surveillance and Control Program, Southeastern Brazil.

We report the implementation of an animal sporotrichosis surveillance and control program that evaluates strategies to identify suspected and infected cats in a municipality in southeastern Brazil. All adopted measures reinforced the program, although strategies had different abilities to detect the presence of infection.

Metabolic Profile and Body Composition in Twins Concordant and Discordant for Physical Exercise.

The aim of this study was to evaluate the differences in the metabolic profile and body composition of monozygotic (MZ) twins concordant and discordant for the practice of physical exercise. The sample consisted of 92 MZ twins (72.5% female and 27.5% male, mean age 25.4 ± 5.69 years), registered with the Brazilian Registry of Twins, residing in Natal, Brazil. Data collection was carried out between the years 2016 and 2018. On day 1, subjects underwent a whole-body fitness evaluation, including measures of weight, height, body composition by Dual-Energy X-ray Absorptiometry and the Cardiorespiratory Exercise Test. On day 2, 10 ml blood samples were collected (overnight fasting) to determine the lipid profile and fasting glucose. The sample was separated into three groups: Active Concordant twins (Concordant A, n = 44 subjects), Inactive Concordant twins (Concordant I, n = 22 subjects) and Discordant pairs for Physical Exercise (Discordant PE, n = 26 subjects). The results demonstrated a difference between the discordant twins for exercise and also between the active versus sedentary groups, indicating a causal effect of exercise on the fat percentage, maximum oxygen consumption (VO2max) and second ventilatory threshold variables. Between groups, a difference was also observed between the groups in ventilatory threshold, very low-density lipoprotein and triglycerides. We concluded that, regardless of genetics, the practice of physical exercise was sufficient to generate alterations in body composition and VO2max in MZ twins, but not in the lipid profile or fasting glucose.

Comparison of Minimum Pressure and Patent Hemostasis on Radial Artery Occlusion After Transradial Catheterization.

OBJECTIVES: The aim of this study was to compare two hemostatic techniques, minimum pressure technique and patent hemostasis, on radial artery occlusion (RAO) after transradial catheterization. BACKGROUND: RAO is an infrequent complication of transradial procedures. One of the strategies used to reduce this complication is the patent hemostasis technique. Use of minimum pressure in hemostatic wristband, without monitoring patency, might have the same efficacy for preventing RAO. METHODS: This is a multicenter study encompassing patients submitted to transradial catheterization. After pneumatic wristband application, the band was deflated to the lowest allowable volume while preserving hemostasis. Radial artery patency was subsequently evaluated. The group with no return of plethysmographic curve was labeled "minimum pressure," and the group in which the signal returned was labeled "patent hemostasis." RAO was verified by Doppler evaluation within the first 24 hours of the procedure. RESULTS: A total of 1082 patients were enrolled, with mean age of 61.4 ± 10.4 years. The majority (61.0%) were male and 34.5% had diabetes. Patent hemostasis was achieved in only 213 cases (20%). Early RAO occurred in 16 patients (1.8%) in the minimum pressure group and in 4 patients (1.9%) in the patent hemostasis group (P=.97). No major bleeding was observed among the entire cohort. EASY scale for hematoma grade was similar between the cohorts (EASY grades 1-3: 7.0% in the minimum pressure group vs 7.5% in the patent hemostasis group; P=.96). CONCLUSION: Checking radial patency during hemostatic compression may not be necessary after the procedure when adopting a mild and short hemostatic compression.

Embolic protection devices in percutaneous coronary intervention.

Clinical benefit of percutaneous coronary intervention (PCI) depends on both angiographic success at lesion site as well as the restoration of adequate macro and microvascular perfusion. The pathophysiology of embolization from coronary lesions during PCI is multifactorial, being more frequently observed in patients with acute coronary syndrome and in those with lesions at saphenous vein graft (SVG). In this population, despite successful epicardial intervention, distal tissue perfusion may still be absent in up to a quarter of all PCI. Multiple devices and pharmacologic regimens have been developed and refined in an attempt to protect the microvascular circulation during PCI. Among them, embolic protection devices have raised as an attractive adjunctive toll due to their ability to retain debris and potentially prevent distal embolization, reducing major adverse cardiac events. Currently, their use has been validated for the treatment of SVG lesions but failed to show effectiveness in the percutaneous approach of acute coronary syndrome patients, including those with ST elevation myocardial infarction.

Outcome after acute incomplete sirolimus-eluting stent apposition as assessed by serial intravascular ultrasound.

We investigated the fate of postprocedural incomplete stent apposition (ISA) after sirolimus-eluting stent (SES) implantation by evaluating long-term intravascular ultrasound findings in 168 consecutive patients (182 de novo lesions). Postprocedural ISA was defined as > or = 1 stent strut that was clearly separated from the vessel wall with evidence of blood speckle behind the strut without overlapping a side branch. After SES implantation, there were 61 ISA sites in 46 stents in 31 patients (23 at the proximal edge, 7 at the distal edge, and 31 within the stent body). There were no clinical, procedural, or intravascular ultrasound measurement differences between patients and lesions with versus without ISA. At follow-up, 15 acute ISA sites (25%) in 11 patients completely resolved and 40 sites (75%) in 20 patients persisted, although 32 of 46 persisting ISA sites (70%) decreased. There was a greater decrease in effective lumen area and a greater increase in peristent plaque area in the complete-resolution group than in the persistent-ISA group. No lesion developed stent thrombosis or in-stent restenosis (angiographic diameter stenosis > 50%). Six acute ISA sites were also associated with new, late acquired ISA, only 1 of which resulted in aneurysm formation. Although most ISAs after SES implantation do not resolve completely, the incidence of restenosis or thrombosis is not affected.

Lopinavir/ritonavir as single-drug therapy for maintenance of HIV-1 viral suppression: 48-week results of a randomized, controlled, open-label, proof-of-concept pilot clinical trial (OK Study).

OBJECTIVE: This study evaluated maintenance with lopinavir/ritonavir monotherapy vs. continuing lopinavir/ritonavir and 2 nucleosides in HIV-infected patients with suppressed HIV replication. DESIGN: Randomized, controlled, open-label, multicenter, pilot clinical trial. METHODS: Adult patients were eligible if they had no history of virologic failure while receiving a protease inhibitor, were receiving 2 nucleosides + lopinavir/ritonavir (400/100 mg b.i.d.) for >1 month and had maintained serum HIV RNA <50 copies/mL for >6 months prior to enrollment. RESULTS: Forty-two patients were randomly assigned 1:1 to continue or stop the nucleosides. At baseline there were no significant differences between groups in median CD4 cells/muL (baseline or nadir), pre-HAART (highly active antiretroviral therapy) HIV log10 viremia, or time with HIV RNA <50 copies/mL prior to enrollment. After 48 weeks of follow-up, percentage of patients remaining at <50 HIV RNA copies/mL (intention to treat, M = F) was 81% for the monotherapy group (95% CI: 64% to 98%) vs. 95% for the triple-therapy group (95% CI: 86% to 100%); P = 0.34. Patients in whom monotherapy failed had significantly worse adherence than patients who remained virally suppressed on monotherapy. Monotherapy failures did not show primary resistance mutations in the protease gene and were successfully reinduced with prerandomization nucleosides. Mean change in CD4 cells/microL: +70 (monotherapy) and +8 (triple) (P = 0.27). Mean serum fasting lipids remained stable in both groups. No serious adverse events were observed. CONCLUSION: Most of the patients maintained with lopinavir/ritonavir monotherapy remain with undetectable viral load after 48 weeks. Failures of lopinavir/ritonavir monotherapy were not associated with the development of primary resistance mutations in the protease gene and could be successfully reinduced adding back prior nucleosides.

Bifurcation coronary lesions treated with the "crush" technique: an intravascular ultrasound analysis.

OBJECTIVES: We report intravascular ultrasound (IVUS) findings after crush-stenting of bifurcation lesions. BACKGROUND: Preliminary results with the crush-stent technique are encouraging; however, isolated reports suggest that restenosis at the side branch (SB) ostium continues to be a problem. METHODS: Forty patients with bifurcation lesions underwent crush-stenting with the sirolimus-eluting stent. Postintervention IVUS was performed in both branches in 25 lesions and only the main vessel (MV) in 15 lesions; IVUS analysis included five distinct locations: MV proximal stent, crush area, distal stent, SB ostium, and SB distal stent. RESULTS: Overall, the MV minimum stent area was larger than the SB (6.7 +/- 1.7 mm2 vs. 4.4 +/- 1.4 mm2, p < 0.0001, respectively). When only the MV was considered, the minimum stent area was found in the crush area (rather than the proximal or MV distal stent) in 56%. When both the MV and the SB were considered, the minimum stent area was found at the SB ostium in 68%. The MV minimum stent area measured <4 mm2 in 8% of lesions and <5 mm2 in 20%. For the SB, a minimum stent area <4 mm2 was found in 44%, and a minimum stent area <5 mm2 in 76%, typically at the ostium. "Incomplete crushing"--incomplete apposition of SB or MV stent struts against the MV wall proximal to the carina--was seen in >60% of non-left main lesions. CONCLUSIONS: In the majority of bifurcation lesions treated with the crush technique, the smallest minimum stent area appeared at the SB ostium. This may contribute to a higher restenosis rate at this location.

Fast track endoscopic thoracic sympathicotomy.

The length of hospital stay is an important factor of cost and psychological discomfort in the treatment of hyperhidrosis by endoscopic thoracic sympathicotomy (ETS). Our experience enrolls 1587 patients operated on an outpatient basis in the last 10 years and seven months. This study aimed to confirm that ETS can be performed on an outpatient basis. Fifty-two consecutive patients (30 males and 22 females) were submitted to ETS under general anesthesia using a single lumen endotracheal tube, with lung collapse by intrapleural injection of CO(2). The sympathetic chain and the communicating rami were severed at different levels according to hyperhidrosis location. Patients were physical state American Society of Anesthesiologists 1 and 2. Age varied between 13 and 55 years (27.3 +/- 10.2 years). They were monitored with ECG, SPO2, NIBP, expired CO(2), sevoflurane analyzer, and airway pressure. Normal saline (40.0 +/- 2.7 ml/kg) was infused intravenously. The drugs used were propofol, alfentanil, rocuronium, ondansetron, dexamethasone, dipyrone, cetoprofene and sevoflurane. Anesthesia and post-operative data were analyzed. Post-operative thoracic X-rays were taken in 20 patients before discharge. Anesthesia lasted 67.2 +/- 20.8 minutes, and the surgical procedure took 46.3 +/- 20.9 minutes. The patients stayed 18.0 +/- 11.0 minutes in the post-anaesthetic care unit and were discharged from hospital after 150.3 +/- 43.1 minutes. The only abnormal post-operative event observed was insignificant residual carbothorax, found in 2 (10%) of the thoracic X-rays taken. In conclusion, this study confirmed that ETS can be performed safely on an outpatient basis.

Estudio morfológico y morfométrico de la epidermis de fetos de ratas intoxicadas con plomo durante la preñez / Morphologic and morphometric study of the fetal epidermis after lead intoxication of rats during pregnancy

Fueron estudiados los efectos que la intoxicación prenatal con plomo produce en la histología y en los parámetros morfométricos de la epidermis de la región occipitofrontal de la bóveda del cráneo fetal. El plomo, administrado intraperitonealmente en forma de acetato en el 10º día de preñez en ratas Wistar, en dosis de 25 mg por kg de peso corporal, causó retardo del crecimiento intrauterino en fetos y placentas. Se demostró que la epidermis de la bóveda del cráneo es más delgada en los fetos intoxicados por plomo. Los resultados del análisis morfométrico sugieren que el plomo induce retardo en el crecimiento y en la diferenciación de las células epidérmicas de la bóveda craneal de los fetos