The usefulness of SAGE score in predicting high pulse wave velocity in hypertensive patients: a retrospective cohort study.

Introduction: Aortic stiffness assessed by pulse wave velocity (PWV) is an important predictor to evaluate the risk of hypertensive patients. However, it is underutilized in clinical practice. We aimed to identify the optimal cutoff SAGE score that would indicate a risk PWV ≥ 10 m/s in Brazilian ambulatory hypertensive patients. Materials and methods: A retrospective cohort study. Patients underwent central blood pressure measurement using a validated oscillometric device from August 2020 to December 2021. A ROC curve was constructed using the Youden statistic to define the best score to identify those at high risk for PWV ≥ 10 m/s. Results: A total of 212 hypertensive individuals were selected. The mean age was 64.0 ± 12.4 years and 57.5% were female. The following comorbidities were present: overweight (47.6%), obesity (34.3%), and diabetes (25.0%). Most of the sample (68.9%) had PWV < 10 m/s. According to Youden's statistic, a cutoff point of 6 provided the optimal combination of sensitivity and specificity for identifying patients with a PWV ≥ 10 m/s. This cutoff achieved sensitivity of 97.0%, and specificity of 82.9%. In clinical practice, however, a cutoff point of 7 (where score values of at least 7 were considered to indicate high risk) had a positive likelihood ratio of 8.2 and a negative likelihood ration of 0.346, making this the ideal choice by accurately excluding patients who are less likely to have PWV ≥ 10 m/s. Conclusion: A SAGE score ≥7 identified Brazilian hypertensive patients with a high risk of PWV ≥ 10 m/s.

Demographics and socioeconomic determinants of health predict continued participation in a CT lung cancer screening program.

PURPOSE: We developed machine learning (ML) models to assess demographic and socioeconomic status (SES) variables' value in predicting continued participation in a low-dose CT lung cancer screening (LCS) program. MATERIALS AND METHODS: 480 LCS subjects were retrospectively examined for the following outcomes: (#1) no follow-up (single LCS scan) vs. multiple follow-ups (220 and 260 subjects respectively) and (#2) absent or delayed (>1 month past the due date) follow-up vs timely follow-up (356 and 124 subjects respectively). We quantified the contributions of 14 socioeconomic, demographic, and clinical predictors to LCS adherence, and validated and compared prediction performances of multivariate logistic regression (MLR), support vector machine (SVM) and shallow neural network (NN) models. RESULTS: For outcome #1, age, sex, race, insurance status, personal cancer history, and median household income were found to be associated with returning for follow-ups. For outcome #2, age, sex, race, and insurance status were significant predictor of absent/delayed LCS follow-up. Across 5-fold cross-validation, the MLR model achieved an average AUC of 0.732 (95% CI, 0.661-0.803) for outcome #1 and 0.633 (95% CI, 0.602-0.664) for outcome #2 and is the model with best predictive performance overall, whereas NN and SVM tended to overfit training data and fell short on testing data performance for either outcome. CONCLUSIONS: We identified significant predictors of LCS adherence, and our ML models can predict which subjects are at higher risk of receiving no or delayed LCS follow-ups. Our results could inform data-driven interventions to engage vulnerable populations and extend the benefits of LCS.

EUS- versus ERCP-guided biliary drainage for malignant biliary obstruction: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Increasing evidence support endoscopic ultrasound-guided biliary drainage (EUS-BD) as a potential alternative to endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) in the primary treatment of malignant biliary obstruction (MBO). This systematic review and meta-analysis aimed to compare the efficacy and safety of both techniques as the initial approach for MBO. METHODS: We searched MEDLINE, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing both techniques and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model and I2 statistics were used to evaluate heterogeneity. RESULTS: We included six RCTs (577 patients). There were no significant differences between groups in stent patency (MD 8.18 days; 95% CI -22.55, 38.91), procedure time (MD -6.31 minutes; 95% CI -12.68, 0.06), and survival (MD 4.59 days; 95% CI -34.23, 43.40). Technical success (RR 1.04; 95% CI 0.96, 1.13), clinical success (RR 1.02; 95% CI 0.96, 1.08), overall adverse events (RR 0.58; 95% CI 0.24, 1.43), and cholangitis (RR 1.19; 95% CI 0.39, 3.61) were also similar between groups. However, hospital stay was significantly shorter (MD -1.03 days; 95% CI -1.53, -0.53), and risk of reintervention (RR 0.57; 95% CI 0.37, 0.88), post-procedure pancreatitis (RR 0.15; 95% CI 0.03, 0.66), and tumor in/overgrowth (RR 0.28; 95% CI 0.11, 0.70) were significantly lower with EUS-BD. CONCLUSIONS: EUS-BD and ERCP-BD had similar efficacy and safety as the initial approach for MBO. However, EUS-BD had a significantly lower risk of reintervention, post-procedure pancreatitis, tumor in/overgrowth, and reduced hospital stay.

Cold endoscopic mucosal resection versus cold snare polypectomy for colorectal lesions: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Cold resection of colorectal lesions is widely performed because of its safety and effectiveness; however, it remains uncertain whether adding submucosal injection could improve the efficacy and safety. We aimed to compare cold endoscopic mucosal resection (C-EMR) versus cold snare polypectomy (CSP) for colorectal lesions. METHODS: We performed a systematic review of randomized controlled trials (RCTs) identified from PubMed, Cochrane Library, and Embase. The primary outcome was complete resection. Secondary outcomes were procedure time, en bloc resection, and adverse events (AEs). Prespecified subgroup analyses based on the size and morphology of the polyps were performed. The random-effects model was used to calculate the pooled risk ratio (RR) and mean difference, with corresponding 95%CIs, for dichotomous and continuous variables, respectively. Heterogeneity was assessed using the Cochran Q test and I 2 statistics. RESULTS: 7 RCTs were included, comprising 1556 patients, with 2287 polyps analyzed. C-EMR and CSP had similar risk ratios for complete resection (RR 1.02, 95%CI 0.98-1.07), en bloc resection (RR 1.08, 95%CI 0.82-1.41), and AEs (RR 0.74, 95%CI 0.41-1.32). C-EMR had a longer procedure time (mean difference 42.1 seconds, 95%CI 14.5-69.7 seconds). In stratified subgroup analyses, the risk was not statistically different between C-EMR and CSP for complete resection in polyps<10 mm or ≥10 mm, or for complete resection, en bloc resection, and AEs in the two groups among nonpedunculated polyps. CONCLUSIONS: The findings of this meta-analysis suggest that C-EMR has similar efficacy and safety to CSP, but significantly increases the procedure time. PROSPERO: CRD42023439605.

Socio-Economic Factors and Clinical Context Can Predict Adherence to Incidental Pulmonary Nodule Follow-up via Machine Learning Models.

OBJECTIVE: To quantify the relative importance of demographic, contextual, socio-economic, and nodule-related factors that influence patient adherence to incidental pulmonary nodule (IPN) follow-up visits and evaluate the predictive performance of machine learning models utilizing these features. METHODS: We curated a 1,610-subject patient data set from electronic medical records consisting of 13 clinical and socio-economic predictors and IPN follow-up adherence status (timely, delayed, or never) as the outcome. Univariate analysis and multivariate logistic regression were performed to quantify the predictors' contributions to follow-up adherence. Three additional machine learning models (random forests, neural network, and support vector machine) were fitted and cross-validated to examine prediction performance across different model architectures and evaluate intermodel concordance. RESULTS: On univariate basis, all 13 predictors except comorbidity were found to have a significant association with follow-up. In multiple logistic regression, inpatient or emergency clinical context (odds ratio favoring never following up: 7.28 and 8.56 versus outpatient, respectively) and high nodule risk (odds ratio: 0.25 versus low risk) are the most significant predictors of follow-up, and sex, race, and marital status become additionally significant if clinical context is removed from the model. Clinical context itself is associated with sex, race, insurance, employment, marriage, income, nodule risk, and smoking status, suggesting its role in mediating socio-economic inequities. On cross-validation, all four machine learning models demonstrated comparable and good predictive performances, with mean area under the curve ranging from 0.759 to 0.802, with sensitivity 0.641 to 0.660 and specificity 0.768 to 0.840. CONCLUSION: Socio-economic factors and clinical context are predictive of IPN follow-up adherence, with clinical context being the most significant contributor and likely representing uncaptured socio-economic determinants.

Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis.

BACKGROUND: Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent. Emerging evidence supports remimazolam use in gastrointestinal endoscopy. This systematic review and meta-analysis compares remimazolam and propofol, both combined with a short-acting opioid, for sedation of adults in gastrointestinal endoscopy. METHODS: We searched MEDLINE, Embase, and Cochrane databases for randomised controlled trials comparing efficacy-, safety-, and satisfaction-related outcomes between remimazolam and propofol, both combined with short-acting opioids, for sedation of adults undergoing gastrointestinal endoscopy. We performed sensitivity analyses, subgroup assessments by type of short-acting opioid used and age range, and meta-regression analysis using mean patient age as a covariate. We used R statistical software for statistical analyses. RESULTS: We included 15 trials (4516 subjects). Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984-0.998; high-quality evidence) and a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4-13; moderate-quality evidence), whereas there was no significant difference between the sedatives in other time-related outcomes. Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30-0.56; high-quality evidence), hypotension (RR 0.43; 95% CI 0.35-0.51; moderate-quality evidence), hypotension requiring treatment (RR 0.25; 95% CI 0.12-0.52; high-quality evidence), and bradycardia (RR 0.42; 95% CI 0.30-0.58; high-quality evidence). There was no difference in patient (MD 0.41; 95% CI -0.07 to 0.89; moderate-quality evidence) and endoscopist satisfaction (MD -0.31; 95% CI -0.65 to 0.04; high-quality evidence) between both drugs. CONCLUSIONS: Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.

Evaluation of Salivary Glucose and Salivary Cortisol in Association with Periodontitis in People with Type II Diabetes: A Case-control Study.

BACKGROUND: The relationship between type II diabetes mellitus (DM) and periodontal disease (PD) has been discussed in recent years and may vary according to the patient's location, sex, age and family history. OBJECTIVE: In view of this possible association between periodontitis and DM, this study aimed to evaluate salivary glucose and salivary cortisol levels with periodontitis (staging and degree) in people with type II diabetes compared to non-diabetic individuals. METHODS: This was a case-control study, with 60 participants divided into two groups: DM2- people with type II diabetes (n=30) and NDM- non-diabetic individuals (n=30). For both, a clinical form and periogram were filled out, and blood samples (glycemia, glycated hemoglobin, and cortisol) and saliva (glucose and cortisol) were collected. RESULTS: The diagnosis of periodontitis was 100% in the DM2 group and 80% in the NDM group. As for staging and degree, in the DM2 group, 70% of the participants were in stage IV and 86.67% were in grade C, while in the NDM group, 58.3% of the participants were in stage I and 70.8% were in grade A. Significant differences were observed for the following variables: bleeding to probing and clinical attachment level. The laboratory data presented significant results regarding serum glucose, salivary glucose, and glycated hemoglobin. CONCLUSION: Regarding the influence of salivary glucose and cortisol on periodontal status (staging and degree), these had higher means in the DM2 group when compared to the NDM group. An association of salivary glucose and cortisol levels with the periodontal condition presented by type II diabetic individuals compared to non-diabetic individuals is suggested.

2024 Recommendations for Validation of Noninvasive Arterial Pulse Wave Velocity Measurement Devices.

BACKGROUND: Arterial stiffness, as measured by arterial pulse wave velocity (PWV), is an established biomarker for cardiovascular risk and target-organ damage in individuals with hypertension. With the emergence of new devices for assessing PWV, it has become evident that some of these devices yield results that display significant discrepancies compared with previous devices. This discrepancy underscores the importance of comprehensive validation procedures and the need for international recommendations. METHODS: A stepwise approach utilizing the modified Delphi technique, with the involvement of key scientific societies dedicated to arterial stiffness research worldwide, was adopted to formulate, through a multidisciplinary vision, a shared approach to the validation of noninvasive arterial PWV measurement devices. RESULTS: A set of recommendations has been developed, which aim to provide guidance to clinicians, researchers, and device manufacturers regarding the validation of new PWV measurement devices. The intention behind these recommendations is to ensure that the validation process can be conducted in a rigorous and consistent manner and to promote standardization and harmonization among PWV devices, thereby facilitating their widespread adoption in clinical practice. CONCLUSIONS: It is hoped that these recommendations will encourage both users and developers of PWV measurement devices to critically evaluate and validate their technologies, ultimately leading to improved consistency and comparability of results. This, in turn, will enhance the clinical utility of PWV as a valuable tool for assessing arterial stiffness and informing cardiovascular risk stratification and management in individuals with hypertension.

Therapeutic Adherence According to the Morisky Scale in Patients with Hypertension

Abstract Background In view of the high prevalence of hypertension and the importance of adequate drug therapy in the prevention of complications, it is necessary to know the adherence to drug treatment in this population. Objective To verify adherence to antihypertensive drug treatment in Brazilian patients with hypertension using the Morisky-Green Test (MGT), relating it with demographic data. Methods Prospective, observational, multicenter, national registry study, with 2,578 hypertensive patients participating in study I, the Brazilian Cardiovascular Registry of Arterial Hypertension (I-RBH), recruited in the five regions of Brazil. The analyses carried out on the data were descriptive statistics, qui-square tests, ANOVA, and logistic regression, adopting 5% as the significance level for the tests. Results The research shows that 56.13% of patients in the sample were female; 56.71% were elderly (≥ 65 years); 55.86% were White; 52.37% were from the Southeast Region; and 59.74% were non-adherent. Logistic regression showed an independent relationship between patients' age, ethnicity, and region with medication adherence. Conclusion Adherence to treatment is the key to reducing high rates of cardiovascular complications. The study brings a successful outcome in the relationship between the factors ethnicity, age, and region of patients with hypertension and medication adherence. To this end, it is necessary to understand these factors, considering systematic evaluation in the care of patients with hypertension and other chronic non-communicable diseases. This study is a significant contribution to multidisciplinary teams, as it highlights which risk factors interfere with medication adherence, incorporating better strategies in health education.

Physiological and psychoaffective responses of adults trained in acute hiit protocols / Respuestas fisiológicas y psicoafectivas de adultos entrenados en protocolos agudos de hiit / Respostas fisiológicas e psicoafetivas de adultos treinados em protocolos agudos de hiit

ABSTRACT High Intensity Interval Training (HIIT) promotes similar adaptations and in some cases, superior to continuous aerobic training of moderate intensity, even when performed at all-out intensities. In this condition, it tends to have the greatest physiological disturbance and accumulation of metabolites compared to submaximal intensities, being one of the main factors associated with the negative response of pleasure in training. Objective: To verify the relationship between physiological and psychophysiological responses in order to repeat the training of two HIIT protocols of mesm volume load and different periods of work in trained adults of both sexes. Methods: In a randomized experiment, the sample consisted of 9 individuals aged 28±5 years, body mass 69.6±14.2 kg, height 169±0.1cm, BMI 24.1±2.3 kg/m2 and body fat percentage 20.2±7.9% practitioners of structured aerobic physical exercises for at least six months. Two different HIIT protocols were performed on an exercise bike, being (I) protocol 1:0.5, with prescribed intensity (80-90% of MAX HR), (II) protocol 1:2 with prescribed intensity (all-out) with total duration of effort of 20 minutes and interval of at least 48 hours between each session. Heart rate (HR), systemic blood pressure (SBP), subjective perception of exertion (SPE), visual analog scale (VAS), affective response (AR), fun (PACES) and intention to repeat the session were analyzed. The statistical analysis used was ANOVA with Tukey's post-hoc (p<0.05). Results: The analyses of HR, SBP, VAS, PACES and SPE showed no significant difference between the training protocols. The affective response (AR and intention to repeat) showed a decline in the protocol 1:0.5, but without significance (p>0.05). Conclusion: The data allow us to conclude that the 1:2 protocol caused greater physiological disturbances during exertion and presented greater positive affective response and intention to repeat the exercise session, variables that may contribute to adherence to regular physical exercise. Level of Evidence I; Therapeutic studies - Investigation of treatment results.

RESUMEN El entrenamiento de intervalos de alta intensidad (HIIT) promueve adaptaciones similares y, en algunos casos, superiores al entrenamiento aeróbico continuo de intensidad moderada. En esta condición, tiende a tener una mayor alteración fisiológica y acumulación de metabolitos en comparación con las intensidades submáximas, siendo uno de los principales factores asociados con la respuesta negativa del placer en el entrenamiento. Objetivo: Verificar la relación entre las respuestas fisiológicas y psicofisiológicas para repetir el entrenamiento de dos protocolos HIIT de carga del mismo volumen y diferentes períodos de trabajo en adultos entrenados de ambos sexos. Métodos: En un experimento aleatorizado, la muestra estuvo constituida por 9 individuos de 28±5 años, masa corporal 69,6±14,2 kg, altura 169±0,1cm, IMC 24,1±2,3 kg/m2 y porcentaje de grasa corporal 20,2±7,9% practicantes de ejercicios físicos aeróbicos estructurados durante al menos seis meses. Se realizaron dos protocolos HIIT diferentes en bicicleta estática, siendo protocolo 1: 0,5, con intensidad prescrita (80-90% de la FC MÁXIMA), protocolo 1: 2 con intensidad prescrita (total) con duración total del esfuerzo de 20 minutos e intervalo de al menos 48 horas entre cada sesión. Se analizaron la frecuencia cardíaca (FC), presión arterial sistémica (PAS), percepción subjetiva de esfuerzo (PSE), escala analógica visual (EVA), respuesta afectiva (FS), diversión (PACES) e intención de repetir la sesión. El análisis estadístico utilizado fue ANOVA con post-hoc de Tukey (p<0,05). Resultados: Los análisis de HR, PAS, EVA, PACES y PSE no mostraron diferencias significativas entre los protocolos de entrenamiento. La respuesta afectiva (FS e intención de repetir) mostró una disminución en el protocolo 1:0,5, pero sin significancia (p>0,05). Conclusión: Los datos permiten concluir que el protocolo 1:2 causó mayores alteraciones fisiológicas durante el esfuerzo y presentó mayor respuesta afectiva positiva e intención de repetir la sesión de ejercicio, variables que pueden contribuir para la adhesión al ejercicio físico. Nivel de Evidencia I; Estudios Terapéuticos - Investigación de los Resultados del Tratamiento.

RESUMO O Treinamento Intervalado de Alta Intensidade (HIIT) promove adaptações semelhantes e em alguns casos, superiores ao treinamento aeróbico contínuo de intensidade moderada, mesmo quando executado em intensidades all out. Nesta condição, tende a maior perturbação fisiológica e acúmulo de metabólitos comparado a intensidades submáximas, sendo um dos principais fatores associados a resposta negativa de prazer no treinamento. Objetivo: Verificar qual relação entre respostas fisiológicas e psicofisiológicas na intenção de repetir o treinamento de dois protocolos HIIT de mesmo volume load e distintos períodos de trabalho, em adultos treinados de ambos os sexos. Métodos: Em experimento randomizado, a amostra foi composta por 9 indivíduos com idade entre 28±5 anos, massa corporal 69,6±14,2 kg, estatura 169±0,1cm, IMC 24,1±2,3 kg/m2 e percentual de gordura corporal 20,2±7,9% praticantes de exercícios físicos aeróbicos estruturados por pelo menos seis meses. Realizaram dois diferentes protocolos de HIIT em bicicleta ergométrica, sendo (I) protocolo 1:0,5, com intensidade prescrita (80-90% da FCmáx), (II) protocolo 1:2 com intensidade prescrita (all-out) com duração total de esforço de 20 minutos e intervalo de pelo menos 48 horas entre cada sessão. Foram analisados frequência cardíaca (FC), pressão arterial sistêmica (PAS), percepção subjetiva de esforço (PSE), escala visual analógica (EVA), resposta afetiva (FS), divertimento (PACES) e intenção de repetir a sessão. A análise estatística usada foi ANOVA com post-hoc de Tukey (p<0,05). Resultados: As análises da FC, PAS, EVA, PACES e PSE não apresentaram diferença significativa entre os protocolos de treinamento. As respostas afetivas (FS e intenção de repetir) apresentaram maior declínio no protocolo 1:0,5, porém sem significância (p>0,05). Conclusão: Os dados permitem concluir que o protocolo 1:2 provocou maiores perturbações fisiológicas durante esforço e apresentou maior resposta afetiva positiva e intenção de repetir a sessão de exercício, variáveis que podem vir a contribuir na aderência à prática regular de exercícios físicos. Nível de Evidência I; Estudos terapêuticos - Investigação dos resultados do tratamento.

Photon-counting detector CT allows significant reduction in radiation dose while maintaining image quality and noise on non-contrast chest CT.

Purpose: To investigate if clinical non-contrast chest CT studies obtained with PCD CT using much lower radiation exposure can achieve the same image quality as with the currently established EID protocol. Materials/methods: A total of seventy-one patients were identified who had a non-contrast chest computed tomography (CT) done on PCD CT and EID CT scanners within a 4-month interval. Five fellowship trained chest radiologists, blinded to the scanner details were asked to review the cases side-by-side and record their preference for images from either the photon-counting-detector (PCD) CT or the energy-integrating detector (EID) CT scanner. Results: The median CTDIvol for PCD-CT system was 4.710 mGy and EID system was 7.80 mGy (p < 0.001). The median DLP with the PCD-CT was 182.0 mGy.cm and EID system was 262.60 mGy.cm (p < 0.001). The contrast to noise ratio (CNR) was superior on the PCD-CT system 59.2 compared to the EID-CT 53.3; (p < 0.001). Kappa-statistic showed that there was poor agreement between the readers over the image quality from the PCD and EID scanners (κ = 0.19; 95 % CI: 0.12 - 0.27; p < 0.001). Chi-square analysis revealed that 3 out of 5 readers showed a significant preference for images from the PCDCT (p ≤ 0.012). There was no significant difference in the preferences of two readers between EID-CT and PCD-CT images. Conclusion: The first clinical PCD-CT system allows a significant reduction in radiation exposure while maintaining image quality and image noise using a standardized non-contrast chest CT protocol.

Ocular Surface Disease Related to the Inflammatory and Non-Inflammatory Phases of Thyroid Eye Disease.

Purpose: This study evaluated the ocular surface disease (OSD), especially dry eye disease (DED) parameters by combining qualitative and quantitative tools, including tear matrix metalloproteinase 9 (MMP-9), in patients with Graves' disease (GD) with and without Thyroid eye disease (TED). Patients and Methods: A total of 17 active TED, 16 inactive TED, 16 GD without ophthalmopathy, and 16 healthy controls were included. All patients were assessed with CAS, ophthalmometry, qualitative tear MMP-9, Ocular Surface Disease Index (OSDI), ocular surface staining, Schirmer test, meibography, tear meniscus height, conjunctival hyperemia, and non-invasive tear film break-up time. Patients were classified into three subtypes of DED: aqueous tear deficiency, meibomian gland dysfunction (MGD) and mixed dry eye. Results: Inactive TED was shown to be an associated factor with DED (odds ratio 14, confidence interval 2.24-87.24, p=0.0047), and presented more DED than healthy controls (87.5% versus 33.3%, p=0.0113). MGD was also more prevalent among these subjects than in healthy control (62.5% versus 6.7%; p=0.0273). No significant differences were found in other ophthalmological parameters, except for more intense conjunctival redness among active TED than GD without ophthalmopathy (p=0.0214). Qualitative MMP-9 test was more frequently positive in both eyes among active TED than in other groups (p < 0.0001). Conclusion: Patients with GD were symptomatic and presented a high prevalence of ocular surface changes and DED, particularly the subgroup with inactive TED. Tear MMP-9 detection was associated with active TED suggesting a relationship between ocular surface changes and the initial inflammatory phase of ophthalmopathy.

Seasonal variation in blood pressure: what is still missing?

Seasonal variation of blood pressure (BP) is a topic in cardiology that has gained more attention throughout the years. Although it is extensively documented that BP increases in seasons coupled with lower temperatures, there are still many gaps in this knowledge field that need to be explored. Notably, seasonal variation of BP phenotypes, such as masked and white coat hypertension, and the impact of air pollution, latitude, and altitude on seasonal variation of BP are still poorly described in the literature, and the levels of the existing evidence are low. Therefore, further investigations on these topics are needed to provide robust evidence that can be used in clinical practice.

Brazilian Guidelines for In-office and Out-of-office Blood Pressure Measurement ­ 2023 / Diretrizes Brasileiras de Medidas da Pressão Arterial Dentro e Fora do Consultório ­ 2023

Hypertension is one of the primary modifiable risk factors for morbidity and mortality worldwide, being a major risk factor for coronary artery disease, stroke, and kidney failure. Furthermore, it is highly prevalent, affecting more than one-third of the global population. Blood pressure measurement is a MANDATORY procedure in any medical care setting and is carried out by various healthcare professionals. However, it is still commonly performed without the necessary technical care. Since the diagnosis relies on blood pressure measurement, it is clear how important it is to handle the techniques, methods, and equipment used in its execution with care. It should be emphasized that once the diagnosis is made, all short-term, medium-term, and long-term investigations and treatments are based on the results of blood pressure measurement. Therefore, improper techniques and/or equipment can lead to incorrect diagnoses, either underestimating or overestimating values, resulting in inappropriate actions and significant health and economic losses for individuals and nations. Once the correct diagnosis is made, as knowledge of the importance of proper treatment advances, with the adoption of more detailed normal values and careful treatment objectives towards achieving stricter blood pressure goals, the importance of precision in blood pressure measurement is also reinforced. Blood pressure measurement (described below) is usually performed using the traditional method, the so-called casual or office measurement. Over time, alternatives have been added to it, through the use of semi-automatic or automatic devices by the patients themselves, in waiting rooms or outside the office, in their own homes, or in public spaces. A step further was taken with the use of semi-automatic devices equipped with memory that allow sequential measurements outside the office (ABPM; or HBPM) and other automatic devices that allow programmed measurements over longer periods (HBPM). Some aspects of blood pressure measurement can interfere with obtaining reliable results and, consequently, cause harm in decision-making. These include the importance of using average values, the variation in blood pressure during the day, and short-term variability. These aspects have encouraged the performance of a greater number of measurements in various situations, and different guidelines have advocated the use of equipment that promotes these actions. Devices that perform HBPM or ABPM, which, in addition to allowing greater precision, when used together, detect white coat hypertension (WCH), masked hypertension (MH), sleep blood pressure alterations, and resistant hypertension (RHT) (defined in Chapter 2 of this guideline), are gaining more and more importance. Taking these details into account, we must emphasize that information related to diagnosis, classification, and goal setting is still based on office blood pressure measurement, and for this reason, all attention must be given to the proper execution of this procedure.

La hipertensión arterial (HTA) es uno de los principales factores de riesgo modificables para la morbilidad y mortalidad en todo el mundo, siendo uno de los mayores factores de riesgo para la enfermedad de las arterias coronarias, el accidente cerebrovascular (ACV) y la insuficiencia renal. Además, es altamente prevalente y afecta a más de un tercio de la población mundial. La medición de la presión arterial (PA) es un procedimiento OBLIGATORIO en cualquier atención médica o realizado por diferentes profesionales de la salud. Sin embargo, todavía se realiza comúnmente sin los cuidados técnicos necesarios. Dado que el diagnóstico se basa en la medición de la PA, es claro el cuidado que debe haber con las técnicas, los métodos y los equipos utilizados en su realización. Debemos enfatizar que una vez realizado el diagnóstico, todas las investigaciones y tratamientos a corto, mediano y largo plazo se basan en los resultados de la medición de la PA. Por lo tanto, las técnicas y/o equipos inadecuados pueden llevar a diagnósticos incorrectos, subestimando o sobreestimando valores y resultando en conductas inadecuadas y pérdidas significativas para la salud y la economía de las personas y las naciones. Una vez realizado el diagnóstico correcto, a medida que avanza el conocimiento sobre la importancia del tratamiento adecuado, con la adopción de valores de normalidad más detallados y objetivos de tratamiento más cuidadosos hacia metas de PA más estrictas, también se refuerza la importancia de la precisión en la medición de la PA. La medición de la PA (descrita a continuación) generalmente se realiza mediante el método tradicional, la llamada medición casual o de consultorio. Con el tiempo, se han agregado alternativas a través del uso de dispositivos semiautomáticos o automáticos por parte del propio paciente, en salas de espera o fuera del consultorio, en su propia residencia o en espacios públicos. Se dio un paso más con el uso de dispositivos semiautomáticos equipados con memoria que permiten mediciones secuenciales fuera del consultorio (AMPA; o MRPA) y otros automáticos que permiten mediciones programadas durante períodos más largos (MAPA). Algunos aspectos en la medición de la PA pueden interferir en la obtención de resultados confiables y, en consecuencia, causar daños en las decisiones a tomar. Estos incluyen la importancia de usar valores promedio, la variación de la PA durante el día y la variabilidad a corto plazo. Estos aspectos han alentado la realización de un mayor número de mediciones en diversas situaciones, y diferentes pautas han abogado por el uso de equipos que promuevan estas acciones. Los dispositivos que realizan MRPA o MAPA, que además de permitir una mayor precisión, cuando se usan juntos, detectan la hipertensión de bata blanca (HBB), la hipertensión enmascarada (HM), las alteraciones de la PA durante el sueño y la hipertensión resistente (HR) (definida en el Capítulo 2 de esta guía), están ganando cada vez más importancia. Teniendo en cuenta estos detalles, debemos enfatizar que la información relacionada con el diagnóstico, la clasificación y el establecimiento de objetivos todavía se basa en la medición de la presión arterial en el consultorio, y por esta razón, se debe prestar toda la atención a la ejecución adecuada de este procedimiento.

A hipertensão arterial (HA) é um dos principais fatores de risco modificáveis para morbidade e mortalidade em todo o mundo, sendo um dos maiores fatores de risco para doença arterial coronária, acidente vascular cerebral (AVC) e insuficiência renal. Além disso, é altamente prevalente e atinge mais de um terço da população mundial. A medida da PA é procedimento OBRIGATÓRIO em qualquer atendimento médico ou realizado por diferentes profissionais de saúde. Contudo, ainda é comumente realizada sem os cuidados técnicos necessários. Como o diagnóstico se baseia na medida da PA, fica claro o cuidado que deve haver com as técnicas, os métodos e os equipamentos utilizados na sua realização. Deve-se reforçar que, feito o diagnóstico, toda a investigação e os tratamentos de curto, médio e longo prazos são feitos com base nos resultados da medida da PA. Assim, técnicas e/ou equipamentos inadequados podem levar a diagnósticos incorretos, tanto subestimando quanto superestimando valores e levando a condutas inadequadas e grandes prejuízos à saúde e à economia das pessoas e das nações. Uma vez feito o diagnóstico correto, na medida em que avança o conhecimento da importância do tratamento adequado, com a adoção de valores de normalidade mais detalhados e com objetivos de tratamento mais cuidadosos no sentido do alcance de metas de PA mais rigorosas, fica também reforçada a importância da precisão na medida da PA. A medida da PA (descrita a seguir) é habitualmente feita pelo método tradicional, a assim chamada medida casual ou de consultório. Ao longo do tempo, foram agregadas alternativas a ela, mediante o uso de equipamentos semiautomáticos ou automáticos pelo próprio paciente, nas salas de espera ou fora do consultório, em sua própria residência ou em espaços públicos. Um passo adiante foi dado com o uso de equipamentos semiautomáticos providos de memória que permitem medidas sequenciais fora do consultório (AMPA; ou MRPA) e outros automáticos que permitem medidas programadas por períodos mais prolongados (MAPA). Alguns aspectos na medida da PA podem interferir na obtenção de resultados fidedignos e, consequentemente, causar prejuízo nas condutas a serem tomadas. Entre eles, estão: a importância de serem utilizados valores médios, a variação da PA durante o dia e a variabilidade a curto prazo. Esses aspectos têm estimulado a realização de maior número de medidas em diversas situações, e as diferentes diretrizes têm preconizado o uso de equipamentos que favoreçam essas ações. Ganham cada vez mais espaço os equipamentos que realizam MRPA ou MAPA, que, além de permitirem maior precisão, se empregados em conjunto, detectam a HA do avental branco (HAB), HA mascarada (HM), alterações da PA no sono e HA resistente (HAR) (definidos no Capítulo 2 desta diretriz). Resguardados esses detalhes, devemos ressaltar que as informações relacionadas a diagnóstico, classificação e estabelecimento de metas ainda são baseadas na medida da PA de consultório e, por esse motivo, toda a atenção deve ser dada à realização desse procedimento.

National Registry of Hypertension Control Evaluated by Office and Home Measurements: The LHAR National Registry. / Registro Nacional do Controle da Hipertensão Arterial Avaliado pela Medida de Consultório e Residencial no Brasil: Registro LHAR.

BACKGROUND: It is known that around 30% of patients have higher blood pressure (BP) values when examined at the office than at home. Worldwide, only 35% of patients with hypertension undergoing treatment have reached their BP targets. OBJECTIVE: To provide epidemiological data on BP control in the offices of a sample of Brazilian cardiologists, considering office and home BP measurement. METHODS: This is a cross-sectional analysis of patients with a hypertension diagnosis and undergoing antihypertensive treatment, with controlled BP or not. BP was assayed in the office by a medical professional and at home using home BP monitoring (HBPM). The association between categorical variables was verified using the chi-square test (p<0.05). RESULTS: The study included 2540 patients, with a mean age of 59.7 ± 15.2 years. Most patients were women (62%; n=1575). Prevalence rates of 15% (n=382) for uncontrolled white coat hypertension and 10% (n=253) for uncontrolled masked hypertension were observed. The rate of BP control in the office was 56.3% and at home, 61%. Meanwhile, 46.4% of the patients had controlled BP in and outside of the office. Greater control was observed in women and in the 49-61 years age group. Considering the new DBHA 2020 threshold for home BP control, the control rate was 42.4%. CONCLUSION: BP control in the offices of a sample of Brazilian cardiologists was 56.3%; this rate was 61% when BP was measured at home and 46.4% when considering both the office and home.

FUNDAMENTO: Sabe-se que em torno de 30% dos pacientes apresentam valores de pressão arterial (PA) mais elevados quando examinados no consultório do que em suas residências. No mundo, admite-se que apenas 35% dos hipertensos já tratados tenham alcançado meta pressórica. OBJETIVO: Fornecer dados epidemiológicos sobre o controle da PA nos consultórios, em uma amostra de cardiologistas brasileiros, avaliado pela medida de consultório e monitorização residencial da pressão arterial (MRPA). MÉTODOS: Análise transversal. Observou-se pacientes com diagnóstico de hipertensão arterial, em tratamento anti-hipertensivo, podendo ou não estar com a PA controlada. A PA foi verificada no consultório por profissional médico, e no domicílio através da MRPA. A associação entre variáveis categóricas se deu por meio do teste do qui-quadrado (p < 0,05). RESULTADOS: Foram incluídos 2.540 pacientes, com idade média 59,7 ± 15,2 anos. A maioria dos pacientes eram mulheres (62%; n = 1.575). O estudo mostrou uma prevalência de 15% (n = 382) de hipertensão do avental branco não controlada, e 10% (n = 253) de hipertensão mascarada não controlada. A taxa de controle da PA no consultório foi 56,3%, e no domicílio, de 61%; 46,4% dos pacientes tiveram PA controlada no consultório e fora dele. Observou-se maior controle no sexo feminino e na faixa etária 49-61 anos. Observando o controle domiciliar com o novo ponto de corte das Diretrizes Brasileiras de Hipertensão Arterial de 2020, a taxa de controle foi de 42,4%. CONCLUSÃO: O controle pressórico nos consultórios em uma amostra de cardiologistas brasileiros foi de 56,3%; 61% quando a PA foi obtida no domicílio, e 46,4% quando o controle foi observado tanto no consultório como no domicílio.

Characterization of meibomian gland dysfunction in patients with rosacea / Caracterização da disfunção das glândulas de Meibomio em pacientes com rosácea

ABSTRACT Purpose: To compare ocular surface parameters in rosacea patients with those of controls. Methods: Ninety-three participants took part in this cross-sectional, observational, non-interventional study. These consisted of a rosacea group (n=40) and a control group (n=53). We compared objective parameters of the ocular surface, including conjunctival hyperemia, tear film stability and volume, meibomian gland dysfunction, dry eye disease, and ocular surface staining, between the two groups. Results: In the rosacea group, 69.23% were female. The mean age was 47.34 ± 12.62 years old. No statistically significant differences between groups were found in visual acuity (p=0.987), tear film parameters (tear meniscus height (p=0.338), noninvasive tear film rupture time (p=0.228), invasive rupture time (p=0.471), Schirmer's test scores (p=0.244), conjunctival hyperemia (p=0.106), and fluorescein staining (p=0.489). Significant differences were found in meibography evaluations (p=0.026), mucous layer integrity (p=0.015), and ocular surface symptoms (p<0.0001). Rosacea patients also showed important eyelid differences in glandular expressibility (p<0.001), glandular secretion pattern (p<0.001), and telangiectasia (p<0.001) compared to controls. Conclusion: Meibomian gland dysfunction is frequently associated with dermatological conditions. It can be observed in morphological findings from meibography as well as lipid secretion impairment, leading to evaporative dry eye, ocular surface dysfunction, and inflammation.

RESUMO Objetivo: Avaliar as alterações da superfície ocular em pacientes com Rosácea, e comparar com grupo controle. Métodos: Noventa e três indivíduos foram selecionados para este estudo transversal, observacional e não intervencionista, dividido em dois grupos: rosácea (n=40) e controles (n=53). Foram avaliados parâmetros objetivos da superfície ocular (hiperemia conjuntival, estabilidade e volume do filme lacrimal, disfunção da glândula meibomiana, doença do olho seco, coloração da superfície ocular) e comparado indivíduos saudáveis com pacientes com rosácea. Resultados: 69,23% dos indivíduos com rosácea eram mulheres, com média de idade de 47,34 ± 12,62 anos. Em comparação com controles pareados, não foram evidenciadas diferenças estatisticamente significativas em relação à acuidade visual (p=0,987) e parâmetros do filme lacrimal (altura do menisco lacrimal (p=0,338), tempo de ruptura do filme lacrimal não invasivo (p=0,228), tempo invasivo de ruptura (p=0,471) e teste de Schirmer (p=0,244), bem como hiperemia conjuntival (p=0,106) e coloração com fluoresceína (p=0,489). Associação significativa foi encontrada na avaliação da meibografia (p=0,026), integridade da camada mucosa (p=0,015) e sintomas de superfície ocular (p<0,0001). Pacientes com rosácea também apresentaram alterações importantes na borda palpebral: expressibilidade glandular (p<0,001), padrão de secreção glandular (p<0,001) e telangiectasia (p<0,001). Conclusão: A disfunção da glândula de Meibômio está frequentemente associada a condições dermatológicas e é caracterizada por achados morfológicos na meibografia, bem como comprometimento da secreção lipídica que leva ao olho seco evaporativo e alterações da superfície ocular e inflamação.

Reassessment of the type locality of Euptychiastigmatica Godman, 1905, with the description of two new sibling species from Amazonia (Lepidoptera, Nymphalidae, Satyrinae, Satyrini).

A brief historical review regarding the type locality of Euptychiastigmatica Godman, 1905 was conducted, which suggests that its type locality is actually Rio de Janeiro, Brazil, rather than northeastern Argentina, as previously purported. Consequently, E.stigmatica and its senior synonym E.cyanites Butler, 1871, are regarded to be two species-group names representing a taxon in the euptychiine genus Caeruleuptychia Forster, 1964 known from the Brazilian Atlantic Forest. A lectotype is designated for E.cyanites. Additionally, two closely related species are named and described using an integrative approach with morphological and molecular evidence. Caeruleuptychiaharrisi Nakahara & Freitas, sp. nov. and C.aemulatio Nakahara & Willmott, sp. nov. both occur in Amazonia and COI barcode data recovered these taxa as part of the caerulea clade of Caeruleuptychia.

Fecal microbiota transplantation and its repercussions in patients with melanoma refractory to anti-PD-1 therapy: scope review.

INTRODUCTION: despite being extremely effective in some cases, up to 70% of patients with melanoma do not respond to anti-PD-1/PD-L1 (primary resistance) and many of the responders eventually progress (secondary resistance). Extensive efforts are being made to overcome this resistance through new strategies, especially aimed at modulating the intestinal microbiota. OBJECTIVE: to assess whether fecal microbiota transplantation (FMT), associated with immunotherapy, is beneficial in the clinical course of patients with refractory melanoma. METHODS: this is a scope review, based on studies collected on the MEDLINE, ScienceDirect, The Cochrane Library, Embase and BMJ Journals; using the terms: "Antibodies, Monoclonal"; "Drug Resistance, Neoplasm"; "Fecal Microbiota Transplantation"; "Host Microbial Interactions"; "Immunotherapy"; "Melanoma"; and "Microbiota". Clinical trials, in English, with relevant data on the subject and fully available were included. A cut-off period was not determined, due to the limited amount of evidence on the topic. RESULTS: crossing the descriptors allowed the identification of 342 publications and, after applying the eligibility criteria, allowed the selection of 4 studies. From the analyses, it was observed that a considerable part of those studied overcame resistance to immune checkpoint inhibitors after FMT, with better response to treatment, less tumor growth and increased beneficial immune response. CONCLUSION: it is noted that FMT favors the response of melanoma to immunotherapy, translated into significant clinical benefit. However, further studies are necessary for the complete elucidation of the bacteria and the mechanisms involved, as well as for the translation of new evidence to oncological care practice.

Competition for water and rapid exclusion of an island endemic by a pantropical species in a tropical climate.

Water availability has major effects on community structure and dynamics globally, yet our understanding of competition for water in the tropics is limited. On the tropical Trindade Island, we explored competition for water in the context of the rapid exclusion of an endemic sedge, Cyperus atlanticus (Cyperaceae), by a pantropical, N-fixing shrub, Guilandina bonduc (Fabaceae). Guilandina patches were generally surrounded by rings of bare soil, and dead Cyperus halos commonly surrounded these bare zones. With geo-referenced measurements, we showed that Guilandina patches and bare soil zones rapidly expanded and replaced adjacent Cyperus populations. We found that soil water potentials were much lower in bare soils than soils under Guilandina or Cyperus, and that leaf water potentials of Cyperus plants were lower when co-occurring with Guilandina than when alone. When Guilandina was removed experimentally, Cyperus populations expanded and largely covered the bare soil zones. Our results indicate that when Guilandina establishes, its root systems expand beyond its canopies and these roots pull water from soils beneath Cyperus and kill it, creating bare zone halos, and then Guilandina expands and repeats the process. This scenario indicates rapid competitive exclusion and displacement of an endemic by a common pantropical species, at least in part through competition for water.