Interventions for thrombosed haemodialysis arteriovenous fistulas and grafts.

BACKGROUND: Patients who present with problems with definitive dialysis access (arteriovenous fistula (AVF) or arteriovenous graft (AVG)) become catheter dependent (temporary access), a condition that often carries a higher risk of infections, central venous occlusions and recurrent hospitalisations. For AVG, primary patency rates are reported to be 30% to 90% in patients undergoing thrombectomy or thrombolysis. According to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines, surgery is preferred when the cause of the thrombosis is a stenosis at the site of the anastomosis in thrombosed AVF. The European Best Practice Guidelines (EBPG) reported that thrombosed AVF may be preferably treated with endovascular techniques, but when the cause of thrombosis is in the anastomosis, surgery provides better results with re-anastomosis. Therefore, there is a need to carry out a systematic review to determine the effectiveness and safety of the intervention for thrombosed fistulae. OBJECTIVES: This review aims to establish the efficacy and safety of interventions for failed AVF and AVG in patients receiving haemodialysis (HD). SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 28 January 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Portal (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: The review included randomised controlled trials (RCTs) and quasi-RCTs in people undergoing HD treatment using AVF or AVG presenting with clinical or haemodynamic evidence of thrombosis. Patients had to have used an AVF or AVG at least once. DATA COLLECTION AND ANALYSIS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Our search strategy identified 14 eligible studies (1176 randomised participants) for inclusion in this review. We included three types of interventions for the treatment of thrombosed AVF and AVG: (1) types of thrombectomy, (2) types of thrombolysis and (3) surgical procedures. Most of the included studies had a high risk of bias due to a poor study design, a low number of patients and industry involvement. Overall, there was insufficient evidence to suggest that a specific intervention was better than another for the outcomes of failure, primary patency at 30 days, technical success and adverse events (both major and minor). Primary patency at 30 days may improve with surgical compared to mechanical thrombectomy (3 studies, 404 participants: RR 1.36, 95% CI 1.07 to 1.67); however, the evidence is very uncertain. Death, access dysfunction, successful dialysis, and SONG (Standards Outcomes in Nephrology) outcomes were rarely reported. The current review is limited by the small number of available studies with a limited number of patients enrolled. Most of the studies included in this review have a high risk of bias and a low or very low certainty of evidence. Further research is required to define the most effective and clinically appropriate technique for access dysfunction. AUTHORS' CONCLUSIONS: It remains unclear whether any intervention therapy affects the patency at 30 days or failure in any thrombosed HD AV access (very low certainty of evidence). Future research will very likely change the evidence base. Based on the importance of HD access to these patients, future studies of these interventions among people receiving HD should be a priority.

Retrograde distal access versus femoral access for below the knee angioplasty.

BACKGROUND: The prevalence of peripheral artery disease (PAD) in the general population is about 12% to 14% and it increases with age. PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two-thirds of people with PAD are based in low- or middle-income countries. Critical limb ischaemia (CLI) occurs in 1% to 2% of people with intermittent claudication over five years. One third of people with CLI have isolated below the knee (BTK) lesions. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease. Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported. People with isolated BTK lesions undergoing angioplasty by conventional femoral access present a high failure rate to cross these lesions. Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion. OBJECTIVES: To evaluate the benefits and harms of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 September 2022. SELECTION CRITERIA: We planned to include randomised or quasi-randomised controlled trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Our primary outcomes were technical success of angioplasty procedure and major procedural complications. Our secondary outcomes were mortality rate, amputation-free survival, primary patency, minor procedural complications and wound healing. We planned to use GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: We identified no randomised or quasi-randomised controlled trials that met the inclusion criteria. AUTHORS' CONCLUSIONS: We identified no randomised or quasi-randomised controlled trials that compared retrograde distal access versus femoral access for BTK angioplasty. High-quality studies that compare retrograde distal access versus conventional femoral access for BTK angioplasty are needed.

Stenting or angioplasty for the treatment of deep vein thrombosis: Systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Although the cornerstone treatment for deep vein thrombosis (DVT) remains anticoagulation, clinicians perform stenting or angioplasty (SA) in particular patients. To assess the effects of SA in this setting, we performed a systematic review of randomized controlled trials. METHODS: Based on the Cochrane standards, we searched the Cochrane CENTRAL, MEDLINE, Embase, CINAHL, LILACS and IBECS databases, and trial registries. Our primary outcomes were post-thrombotic syndrome (PTS), venous thromboembolism (VTE) and all-cause mortality. RESULTS: We included 7 randomized controlled trial (1485 participants). There was no clinically significant difference between SA and best medical practice (BMP) for the additional treatment of acute DVT regarding PTS (standardized mean difference -7.87, 95% confidence interval [CI] -12.13 to -3.61; very low-certainty) and VTE (risk ratio [RR] 1.19, 95% CI 0.28-5.07, very low-certainty), and no deaths. Compared to BMP, the SA plus BMP and thrombolysis results in little to no difference in PTS (mean difference [MD] -1.07, 95% CI -1.12 to -1.02, moderate-certainty), VTE (RR 1.48, 95% CI 0.95-2.31, low-certainty), and mortality (RR 0.92, 95% CI 0.34-2.52, low-certainty). There was no clinical difference between stenting and BMP for chronic DVT regarding PTS (MD 2.73, 95% CI -2.10 to 7.56, very low certainty) and no VTE and death events. CONCLUSIONS: SA results in little to no difference in PTS, VTE and mortality in acute DVT compared to BMP. The evidence regarding SA in chronic DVT and whether SA, compared to BMP and thrombolysis, decreases PTS and VTE in acute DVT is uncertain. Open Science Framework (osf.io/f2dm6).

Vascular complications in 305 severely ill patients with COVID-19: a cohort study

ABSTRACT BACKGROUND: Although an association has been made between coronavirus disease 2019 (COVID-19) and microvascular disease, data on vascular complications (other than venous thromboembolism) are sparse. OBJECTIVE: To investigate the vascular complications in severely ill patients hospitalized with COVID-19 and their association with all-cause mortality. DESIGN AND SETTING: This cohort study was conducted at the Universidade Federal de São Paulo, Brazil. METHODS: All 305 consecutive patients diagnosed with COVID-19 and hospitalized in the intensive care unit (ICU) of a tertiary university hospital from April 2 to July 17, 2021, were included and followed up for 30 days. RESULTS: Of these, 193 (63.3%) were male, and the mean age was 59.9 years (standard deviation = 14.34). The mortality rate was 56.3% (172 patients), and 72 (23.6%) patients developed at least one vascular complication during the follow-up period. Vascular complications were more prevalent in the non-survivors (28.5%) than in the survivors (17.3%) group and included disseminated intravascular coagulation (DIC, 10.8%), deep vein thrombosis (8.2%), acrocyanosis (7.5%), and necrosis of the extremities (2%). DIC (adjusted odds ratio (aOR) 2.30, 95% confidence interval (CI) 1.01-5.24, P = 0.046) and acrocyanosis (aOR 5.21, 95% CI 1.48-18.27, P = 0.009) were significantly more prevalent in the non-survivors than in the survivors group. CONCLUSION: Vascular complications in critically ill COVID-19 patients are common (23.6%) and can be closely related to the mortality rate (56.3%) until 30 days after ICU admission. Macrovascular complications have direct implications for mortality, which is the main outcome of the management of COVID-19. REGISTRATION: RBR-4qjzh7 (https://ensaiosclinicos.gov.br/rg/RBR-4qjzh7).

Vascular complications in 305 severely ill patients with COVID-19: a cohort study.

BACKGROUND: Although an association has been made between coronavirus disease 2019 (COVID-19) and microvascular disease, data on vascular complications (other than venous thromboembolism) are sparse. OBJECTIVE: To investigate the vascular complications in severely ill patients hospitalized with COVID-19 and their association with all-cause mortality. DESIGN AND SETTING: This cohort study was conducted at the Universidade Federal de São Paulo, Brazil. METHODS: All 305 consecutive patients diagnosed with COVID-19 and hospitalized in the intensive care unit (ICU) of a tertiary university hospital from April 2 to July 17, 2021, were included and followed up for 30 days. RESULTS: Of these, 193 (63.3%) were male, and the mean age was 59.9 years (standard deviation = 14.34). The mortality rate was 56.3% (172 patients), and 72 (23.6%) patients developed at least one vascular complication during the follow-up period. Vascular complications were more prevalent in the non-survivors (28.5%) than in the survivors (17.3%) group and included disseminated intravascular coagulation (DIC, 10.8%), deep vein thrombosis (8.2%), acrocyanosis (7.5%), and necrosis of the extremities (2%). DIC (adjusted odds ratio (aOR) 2.30, 95% confidence interval (CI) 1.01-5.24, P = 0.046) and acrocyanosis (aOR 5.21, 95% CI 1.48-18.27, P = 0.009) were significantly more prevalent in the non-survivors than in the survivors group. CONCLUSION: Vascular complications in critically ill COVID-19 patients are common (23.6%) and can be closely related to the mortality rate (56.3%) until 30 days after ICU admission. Macrovascular complications have direct implications for mortality, which is the main outcome of the management of COVID-19. REGISTRATION: RBR-4qjzh7 (https://ensaiosclinicos.gov.br/rg/RBR-4qjzh7).

Type of anaesthesia for acute ischaemic stroke endovascular treatment.

BACKGROUND: The use of mechanical thrombectomy to restore intracranial blood flow after proximal large artery occlusion by a thrombus has increased over time and led to better outcomes than intravenous thrombolytic therapy alone. Currently, the type of anaesthetic technique during mechanical thrombectomy is under debate as having a relevant impact on neurological outcomes. OBJECTIVES: To assess the effects of different types of anaesthesia for endovascular interventions in people with acute ischaemic stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Specialised Register of Trials on 5 July 2022, and CENTRAL, MEDLINE, and seven other databases on 21 March 2022. We performed searches of reference lists of included trials, grey literature sources, and other systematic reviews.  SELECTION CRITERIA: We included all randomised controlled trials with a parallel design that compared general anaesthesia versus local anaesthesia, conscious sedation anaesthesia, or monitored care anaesthesia for mechanical thrombectomy in acute ischaemic stroke. We also included studies reported as full-text, those published as abstract only, and unpublished data. We excluded quasi-randomised trials, studies without a comparator group, and studies with a retrospective design. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. The outcomes were assessed at different time periods, ranging from the onset of the stroke symptoms to 90 days after the start of the intervention. The main outcomes were functional outcome, neurological impairment, stroke-related mortality, all intracranial haemorrhage, target artery revascularisation status, time to revascularisation, adverse events, and quality of life. All included studies reported data for early (up to 30 days) and long-term (above 30 days) time points. MAIN RESULTS: We included seven trials with 982 participants, which investigated the type of anaesthesia for endovascular treatment in large vessel occlusion in the intracranial circulation. The outcomes were assessed at different time periods, ranging from the onset of stroke symptoms to 90 days after the procedure. Therefore, all included studies reported data for early (up to 30 days) and long-term (above 30 up to 90 days) time points. General anaesthesia versus non-general anaesthesia(early) We are uncertain about the effect of general anaesthesia on functional outcomes compared to non-general anaesthesia (mean difference (MD) 0, 95% confidence interval (CI) -0.31 to 0.31; P = 1.0; 1 study, 90 participants; very low-certainty evidence) and in time to revascularisation from groin puncture until the arterial reperfusion (MD 2.91 minutes, 95% CI -5.11 to 10.92; P = 0.48; I² = 48%; 5 studies, 498 participants; very low-certainty evidence). General anaesthesia may lead to no difference in neurological impairment up to 48 hours after the procedure (MD -0.29, 95% CI -1.18 to 0.59; P = 0.52; I² = 0%; 7 studies, 982 participants; low-certainty evidence), and in stroke-related mortality (risk ratio (RR) 0.98, 95% CI 0.52 to 1.84; P = 0.94; I² = 0%; 3 studies, 330 participants; low-certainty evidence), all intracranial haemorrhages (RR 0.92, 95% CI 0.65 to 1.29; P = 0.63; I² = 0%; 5 studies, 693 participants; low-certainty evidence) compared to non-general anaesthesia. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia (RR 0.21, 95% CI 0.05 to 0.79; P = 0.02; I² = 71%; 2 studies, 229 participants; low-certainty evidence). General anaesthesia improves target artery revascularisation compared to non-general anaesthesia (RR 1.10, 95% CI 1.02 to 1.18; P = 0.02; I² = 29%; 7 studies, 982 participants; moderate-certainty evidence). There were no available data for quality of life. General anaesthesia versus non-general anaesthesia (long-term) There is no difference in general anaesthesia compared to non-general anaesthesia for dichotomous and continuous functional outcomes (dichotomous: RR 1.21, 95% CI 0.93 to 1.58; P = 0.16; I² = 29%; 4 studies, 625 participants; low-certainty evidence; continuous: MD -0.14, 95% CI -0.34 to 0.06; P = 0.17; I² = 0%; 7 studies, 978 participants; low-certainty evidence). General anaesthesia showed no changes in stroke-related mortality compared to non-general anaesthesia (RR 0.88, 95% CI 0.64 to 1.22; P = 0.44; I² = 12%; 6 studies, 843 participants; low-certainty evidence). There were no available data for neurological impairment, all intracranial haemorrhages, target artery revascularisation status, time to revascularisation from groin puncture until the arterial reperfusion, adverse events (haemodynamic instability), or quality of life. Ongoing studies We identified eight ongoing studies. Five studies compared general anaesthesia versus conscious sedation anaesthesia, one study compared general anaesthesia versus conscious sedation anaesthesia plus local anaesthesia, and two studies compared general anaesthesia versus local anaesthesia. Of these studies, seven plan to report data on functional outcomes using the modified Rankin Scale, five studies on neurological impairment, six studies on stroke-related mortality, two studies on all intracranial haemorrhage, five studies on target artery revascularisation status, four studies on time to revascularisation, and four studies on adverse events. One ongoing study plans to report data on quality of life. One study did not plan to report any outcome of interest for this review. AUTHORS' CONCLUSIONS: In early outcomes, general anaesthesia improves target artery revascularisation compared to non-general anaesthesia with moderate-certainty evidence. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia with low-certainty evidence. We found no evidence of a difference in neurological impairment, stroke-related mortality, all intracranial haemorrhage and haemodynamic instability adverse events between groups with low-certainty evidence. We are uncertain whether general anaesthesia improves functional outcomes and time to revascularisation because the certainty of the evidence is very low. However, regarding long-term outcomes, general anaesthesia makes no difference to functional outcomes compared to non-general anaesthesia with low-certainty evidence. General anaesthesia did not change stroke-related mortality when compared to non-general anaesthesia with low-certainty evidence. There were no reported data for other outcomes. In view of the limited evidence of effect, more randomised controlled trials with a large number of participants and good protocol design with a low risk of bias should be performed to reduce our uncertainty and to aid decision-making in the choice of anaesthesia.

External validation of Villalta score in high-middle income country patients with deep vein thrombosis.

ABSTRACT: Post-thrombotic syndrome (PTS) is a late complication that does not have a cure yet, with a prevalence estimated between 20 to 75%, associated with previous deep vein thrombosis event. Although the Villalta score (VS) is the gold-standard clinical tool for diagnostic and prognostic evaluation of PTS, there are currently no VS intra-rater agreement established and no validation studies for VS' application into Brazilian Portuguese. We sought to translate and validate VS reliability systematically; and, secondarily, to compare the ultrasound findings with the severity of PTS.We systematically translated the original VS into Brazilian Portuguese (BP). Fifty participants who underwent two outpatient visits were evaluated using the translated VS. We assessed its intra-rater and inter-rater agreement and compared BP VS versus CEAP clinical component (CEAP C), and the clinical PTS severity versus the duplex ultrasound (DUS) findings. The study and its report followed the Guidelines for Reporting Reliability and Agreement Studies.The intra-rater evaluation of VS grades had a simple Kappa coefficient of 0.73, and the simple Kappa coefficient inter-rater for VS grades was 0.67. When VS was compared to CEAP C, it established a remarkably high correlation over 0.9. There was difference among VS values compared to DUS initial deep vein thrombosis territory, with femoropopliteal showing higher values than distal veins. Higher VS values were correlated to DUS venous recanalization and reflux.There was a substantial inter-rater and intra-rater agreement when the BP VS was applied; and when compared to CEAP C, VS showed a high correlation. When VS grading was compared to DUS characteristics, there were significant statistical and clinical correlation, with presence of reflux and recanalization showing higher VS values. This external VS validation also changes the clinical practice allowing the VS use in a different population and establishes the VS intra-rater agreement.

Ventilatory weaning strategies for predicting extubation success in children following cardiac surgery for congenital heart disease: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Congenital heart disease (CHD) comprises the anatomic malformations that jeopardise the structure and function of the heart. It can be extremely complex and serious, corresponding to 30% of all deaths in the first month of life. The surgical approach for adequate treatment requires postoperative mechanical ventilation. The most critical decision related to the postoperative management of patients submitted to cardiac surgery is the right time for extubation, especially because not only abrupt or inadequate discontinuation of ventilatory support can lead to clinical decline and necessity of reintubation but also extended time of mechanical ventilation, which can lead to complications, such as pneumonia, atelectasis, diaphragm hypertrophy, and increasing morbidity and mortality. METHODS AND ANALYSIS: This systematic review plans to include individual parallel, cross-over and cluster randomised controlled trials regarding any breathing trial test to predict extubation success in children submitted to cardiac surgery due to CHD. Studies with paediatric patients submitted to cardiac surgery for congenital cardiopathy repair, attended at a critical care unit, and under mechanical ventilatory support will be included. The main outcomes analysed will be success of extubation, reduction of pulmonary complications and time reduction of mechanical ventilation. ETHICS AND DISSEMINATION: We will not treat patients directly; therefore, ethics committee approval was not necessary because it is not a primary study. We expect that this study may improve healthcare and medical assistance, helping healthcare professionals with routine daily decisions regarding the correct time for extubation. PROSPERO REGISTRATION NUMBER: CRD42021223999.

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review.

BACKGROUND: Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion. OBJECTIVE: To summarize Cochrane systematic review (SR) evidence on treatments for CVAH. DESIGN AND SETTING: Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil. METHODS: A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed. RESULTS: A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs. CONCLUSION: Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

Looking for the Brain Inside the Initial Teacher Training and Outreach Books in Portugal.

The fascination with brain research is widespread, and school teachers are no exception. This growing interest, usually noticed by the increased supply of short-term training or books on how to turn the brain more efficient, leads us to think about their basic training and outreach resources available. Little is known about what the official Initial Teacher Training (ITT) offers concerning the brain literature and if it meets scientific standards. Also, what are the science communication materials that teachers can access to learn about the developing brain remain undiscussed. First, we examined the ITT courses taught in Portuguese Higher Education, both in public and private institutions, to identify the syllabus with updated neuroscientific knowledge. Second, we searched for the neuroscience-related books published in the last 6 years through the National Library of Portugal database. Thirty ITT courses and 35 outreach publications were reviewed through a rapid review methodology. Our results showed an absence of curricular units indicating in their programs that brain research, and its relationship with learning, would be taught in a representative and updated way. In contrast, the number of brain-related books for educators increased in Portugal, corroborating the demand for this field of study by these professionals. Based on the literature that shows how misunderstandings about the brain have increased in school contexts, our discussion recognizes that science outreach could be a way to increase the scientific literacy of school teachers with the research community working more in this direction, but, since a previous problem seems to be unsolved, there is an urgent need for specialized attention to the development of training curricula for future kindergarten and elementary school teachers.

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review

ABSTRACT BACKGROUND: Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion. OBJECTIVE: To summarize Cochrane systematic review (SR) evidence on treatments for CVAH. DESIGN AND SETTING: Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil. METHODS: A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed. RESULTS: A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs. CONCLUSION: Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

Recommendations for use of personal protective equipment (PPE) in surgical procedures during the SARS-Cov pandemic.

Since the Coronavirus Disease 2019 was classified as a pandemic by the World Health Organization in 2019, many measures have been proposed to reduce the risks and the chances of contamination by the new coronavirus. In this context, wearing personal protective equipment is very important, especially in hospital environments and situations involving healthcare, since the degree of exposure is notably higher among the subgroup of healthcare professionals. The aim of this article is to propose a roadmap for the sequence of personal protective equipment use for surgical procedures during the coronavirus pandemic. The recommendations were based on Brazil's public health policy and World Health Organization guidelines. Five roadmaps for PPE sequences are presented for the most commonly performed procedures: fitting central venous catheters; fitting catheters requiring radioscopy; open surgeries; diagnostic and therapeutic angiography, and dressings.

Two New ßN-Alkanoyl-5-Hydroxytryptamides with Relevant Antinociceptive Activity.

In this work, we describe a new route for the synthesis and the antinociceptive effects of two new ßN-alkanoyl-5-hydroxytryptamides (named C20:0-5HT and C22:0-5HT). The antinociceptive activities were evaluated using well-known models of thermal-induced (reaction to a heated plate, the hot plate model) or chemical-induced (licking response to paw injection of formalin, capsaicin, or glutamate) nociception. The mechanism of action for C20:0-5HT and C22:0-5HT was evaluated using naloxone (opioid receptor antagonist, 1 mg/kg), atropine (muscarinic receptor antagonist, 1 mg/kg), AM251 (cannabinoid CB1 receptor antagonist, 1 mg/kg), or ondansetron (5-HT3 serotoninergic receptor antagonist, 0.5 mg/kg) 30 min prior to C20:0-5HT or C22:0-5HT. The substances both presented significant effects by reducing licking behavior induced by formalin, capsaicin, and glutamate and increasing the latency time in the hot plate model. Opioidergic, muscarinic, cannabinoid, and serotoninergic pathways seem to be involved in the antinociceptive activity since their antagonists reversed the observed effect. Opioid receptors are partially involved due to tolerant mice demonstrating less antinociception when treated with both compounds. Our data showed a quicker and simpler route for the synthesis of the new ßN-alkanoyl-5-hydroxytryptamides. Both compounds demonstrated significant antinociceptive effects. These new compounds could be used as a scaffold for the synthesis of analogues with promising antinociceptive effects.

Regulating and Cultural Ecosystem Services of Urban Green Infrastructure in the Nordic Countries: A Systematic Review.

In the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden), the Urban Green Infrastructure (UGI) has been traditionally targeted at reducing flood risk. However, other Ecosystem Services (ES) became increasingly relevant in response to the challenges of urbanization and climate change. In total, 90 scientific articles addressing ES considered crucial contributions to the quality of life in cities are reviewed. These are classified as (1) regulating ES that minimize hazards such as heat, floods, air pollution and noise, and (2) cultural ES that promote well-being and health. We conclude that the planning and design of UGI should balance both the provision of ES and their side effects and disservices, aspects that seem to have been only marginally investigated. Climate-sensitive planning practices are critical to guarantee that seasonal climate variability is accounted for at high-latitude regions. Nevertheless, diverging and seemingly inconsistent findings, together with gaps in the understanding of long-term effects, create obstacles for practitioners. Additionally, the limited involvement of end users points to a need of better engagement and communication, which in overall call for more collaborative research. Close relationships and interactions among different ES provided by urban greenery were found, yet few studies attempted an integrated evaluation. We argue that promoting interdisciplinary studies is fundamental to attain a holistic understanding of how plant traits affect the resulting ES; of the synergies between biophysical, physiological and psychological processes; and of the potential disservices of UGI, specifically in Nordic cities.

Evidências de revisões sistemáticas Cochrane para o controle da disseminação da infecção pela COVID-19* / Evidence of revisions systematic Cochrane for the controlling the dissemination of COVID-19 infection

Introdução: A infecção pela COVID-19 tem alta transmissibilidade e várias medidas foram adotadas para controle da disseminação. Objetivo: Identificar e sumarizar as evidências das revisões sistemáticas (RS) Cochrane sobre medidas de controle da disseminação da infecção pela COVID-19. Desenho do estudo: Esta revisão das RS Cochrane foi realizada na Disciplina de Cirurgia Vascular e Endovascular e na Disciplina de Medicina de Urgência e Medicina Baseada em Evidências da Universidade Federal de São Paulo, Brasil. Métodos: Uma busca ampla na Cochrane Database of Systematic Reviews recuperou todas as RS Cochrane que avaliam as evidências diretamente relacionadas às medidas para controle da disseminação da COVID-19. As principais características e resultados de todas as análises incluídas foram sumarizadas e discutidas. Resultados: Três RS Cochrane foram incluídas na síntese qualitativa e versaram sobre medidas populacionais e medidas individuais para controle de disseminação da COVID-19. Conclusão: Evidências de certeza baixa mostram que quarentena de pessoas expostas a casos confirmados ou suspeitos evitou 44%-81% de casos incidentes e 31%-63% de mortes em comparação com nenhuma medida e quanto antes as medidas de quarentena são implementadas, maior a economia de custos. Evidências de confiança alta mostraram que uma comunicação clara sobre as diretrizes de controle e prevenção de infecção foi vital para sua implementação. Evidência de certeza baixa mostrou que as pessoas com um avental longo tiveram menos contaminação

Peripherally inserted central catheter versus central venous catheter for intravenous access: A protocol for systematic review and meta-analysis.

BACKGROUND: Since the first description of the central venous catheter (CVC) in 1952, it has been used for the rapid administration of drugs, chemotherapy, as a route for nutritional support, blood components, monitoring patients, or combinations of these. When CVC is used in the traditional routes (eg, subclavian, jugular, and femoral veins), the complication rates range up to 15% and are mainly due to mechanical dysfunction, infection, and thrombosis. The peripherally inserted central catheter (PICC) is an alternative option for CVC access. However, the clinical evidence for PICC compared to CVC is still under discussion. In this setting, this systematic review (SR) aims to assess the effects of PICC compared to CVC for intravenous access. METHODS: We will perform a comprehensive search for randomised controlled trials (RCTs), which compare PICC and traditional CVC for intravenous access. The search strategy will consider free text terms and controlled vocabulary (eg, MeSH and Entree) related to "peripherally inserted central venous catheter," "central venous access," "central venous catheter," "catheterisation, peripheral," "vascular access devices," "infusions, intravenous," "administration, intravenous," and "injections, intravenous." Searches will be carried out in these databases: MEDLINE (via PubMed), EMBASE (via Elsevier), Cochrane CENTRAL (via Wiley), IBECS, and LILACS (both via Virtual Health Library). We will consider catheter-related deep venous thrombosis and overall successful insertion rates as primary outcomes and haematoma, venous thromboembolism, reintervention derived from catheter dysfunction, catheter-related infections, and quality of life as secondary outcomes. Where results are not appropriate for a meta-analysis using RevMan 5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. RESULTS: Our SR will be conducted according to the Cochrane Handbook of Systematic Reviews of Interventions and the findings will be reported in compliance with PRISMA. CONCLUSION: Our study will provide evidence for the effects of PICC versus CVC for venous access. ETHICS AND DISSEMINATION: This SR has obtained formal ethical approval and was prospectively registered in Open Science Framework. The findings of this SR will be disseminated through peer-reviewed publications or conference presentations. REGISTRATION:: osf.io/xvhzf. ETHICAL APPROVAL: 69003717.2.0000.5505.

Evidence from Cochrane systematic reviews for controlling the dissemination of COVID-19 infection. A narrative review.

BACKGROUND: COVID-19 infection has high transmissibility and several measures have been adopted for controlling its dissemination. OBJECTIVE: To identify and summarize the evidence from Cochrane systematic reviews (SRs) regarding measures for controlling the dissemination of COVID-19 infection. DESIGN AND SETTING: This review of Cochrane SRs was carried out in the Division of Vascular and Endovascular Surgery and in the Division of Emergency Medicine and Evidence-Based Medicine of Universidade Federal de São Paulo, Brazil. METHODS: A comprehensive search in the Cochrane Database of Systematic Reviews retrieved all Cochrane SRs directly related to measures for controlling COVID-19 dissemination. The main characteristics and results of all the SRs included were summarized and discussed. RESULTS: Three Cochrane SRs were included in the qualitative synthesis. These evaluated population-based and individual measures for controlling the dissemination of COVID-19. CONCLUSION: Low-certainty evidence shows that quarantine for people exposed to confirmed or suspected COVID-19 cases prevented 44% to 81% of incident cases and 31% to 63% of deaths, compared with situations of no measures. Moreover, the sooner the quarantine measures were implemented, the greater the cost savings were. High-confidence evidence showed that clear communication about infection control and prevention guidelines was vital for successful implementation. Low-certainty evidence showed that healthcare professionals with long gowns were less exposed to contamination than were those using coveralls. In addition, coveralls were more difficult to doff. Further SRs on controlling the dissemination of COVID-19 infection are desirable.

Evidence from Cochrane systematic reviews for the dissemination control of the COVID-19 infection

Introduction: The COVID-19 infection has high transmissibility and several measures have been adopted for dissemination control. Objective: To identify and summarize the evidence from the Cochrane systematic reviews (SR) on measures to control the dissemination of the COVID-19 infection. Study design: This review of Cochrane SR has carried out in the Division of Vascular and Endovascular Surgery and in the Division of Emergency Medicine and Evidence-Based Medicine of the Universidade Federal de São Paulo, Brazil. Methods: A comprehensive search in the Cochrane Database of Systematic Reviews retrieved all Cochrane SR directly related to control measures for the COVID-19 dissemination. The main characteristics and results of all included SR were summarized and discussed. Results: Three Cochrane SRs were included in the qualitative synthesis and they evaluated populational and individual measures to control the dissemination of COVID-19. Conclusion: Low-certainty evidence show that quarantine of people exposed to those confirmed or suspected COVID-19 cases prevented 44% - 81% of incident cases and 31% - 63% of deaths compared to no measures and as sooner the quarantine measures are implemented, greater costs are saved. High-confidence evidence showed that clear communication about infection control and prevention guidelines was vital to its implementation. Low-certainty evidence showed that people with a long gown had less contamination than those with a coverall, and the coverall was more difficult to doff. Other SRs are desirable for controlling the dissemination of the COVID-19 infection.

Anterior Communicating Artery Aneurysm Uncommon Hemorrhagic Presentation: Case Report

Intracranial aneurysm rupture causes subarachnoid hemorrhage in 80% of the cases, and it may be associated with intracerebral hemorrhage and/or intraventricular hemorrhage (IVH) in 34% and 17% of the patients, respectively. However, on rare occasions, aneurysm rupturemay be present causing isolate intracerebral hemorrhage or IVH without subarachnoid hemorrhage. We describe an unusual case of an anterior communicating aneurysm rupture presented with IVH, without subarachnoid hemorrhage. Although isolated IVH is rare, aneurysm rupture is a possible condition. Patients presenting with head computed tomography revealing IVH without subarachnoid hemorrhage should be promptly investigated with contrasted image exam to identify and treat possible causes, even in the absence of subarachnoid hemorrhage.