Safety and efficacy of a new covered stent in hemodialysis vascular access outflow stenosis: A Brazilian multicenter retrospective study.

BACKGROUND: Vascular stenosis commonly leads to dysfunction in hemodialysis vascular access. Although percutaneous transluminal angioplasty is an established treatment, stent utilization has increased in the last decade as an alternative solution to extend the access function. This study evaluated the safety and initial results of a new impermeable covered stent for treating vascular access outflow stenosis. METHODS: Investigators retrospectively analyzed 114 hemodialysis patients treated with polytetrafluorethylene-covered stents from September 2018 to September 2022 across four centers. Lesions treated were de novo or restenotic and located in the venous graft anastomosis, outflow segment, cephalic arch, and basilic swing point. Patients were followed by in-person physical examination at 1, 3, and 6 months, and Duplex ultrasound was performed to evaluate the vascular access circuit and in-stent restenosis. The primary efficacy endpoint was target lesion primary patency at 1, 3, and 6 months. Secondary endpoints included access circuit primary patency and secondary patency at 1, 3, and 6 months. The primary safety endpoint was freedom from local or systemic serious adverse events through 30 days post-procedure. RESULTS: Forty-four patients had thrombosed access at the initial presentation, and 41 patients presented with recurrent stenosis. The target lesion primary patency rates at 1, 3, and 6 months were 100%, 89.4%, and 74%, respectively. The access circuit primary patency rates were 100% at 1 month, 85% at 3 months, and 62.7% at 6 months. The secondary patency rates at 1, 3, and 6 months were 100%, 96.4%, and 94.6%, respectively. In the adjusted multivariate Cox regression analysis, only recurrent lesions and female gender were associated with reduced primary patency rates. No serious adverse event was observed through the first 30 days post-procedure. CONCLUSION: In this retrospective analysis, a new covered stent was shown to be safe and effective for treating peripheral outflow stenosis in vascular access.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery.

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

A doença renal crônica é um problema de saúde pública global e em seu estágio terminal está associada à necessidade de terapia dialítica. A grande maioria dos pacientes que necessitam realizar a terapia renal substitutiva, a fazem através da hemodiálise. Portanto, o acesso vascular é de extrema importância para a população dialítica, implicando diretamente na qualidade de vida e na morbimortalidade deste grupo de pacientes. Sendo a confecção, gerenciamento e resgate dos acessos vasculares uma das áreas de atuação do cirurgião vascular, é de grande importância a elaboração de uma diretriz que oriente o especialista no manejo mais adequado do acesso vascular para hemodiálise. Assim, o objetivo desta diretriz é apresentar um conjunto de recomendações para guiar as decisões na referenciação, avaliação, escolha, vigilância e gestão das complicações do acesso vascular para hemodiálise.

Red clays indicate sub-aerial exposure of the Rio Grande Rise during the Eocene volcanic episode.

Autonomous underwater vehicle (AUV) mapping of the western Rio Grande Rise (RGR), South Atlantic, and subsequent exploration and photography of horizontal lava flows exposed in near vertical, faulted escarpments, showed occurrences of red clays/weathered volcanic tops trapped between successive alkaline lava flows. These red clays indicate a hiatus in successive volcanic eruptions. Here, we report detailed mineralogical, geochemical, and rock magnetic characteristics of one such distinct red clay dredged from ~ 650 m water depth in the western RGR. The mineral constituents of the red clay are kaolinite, magnetite, oxidized magnetite (/maghemite), hematite, and goethite, with biogenic calcite and halite occupying voids or precipitated on the surface of the red clay. The chemical index of alteration (CIA) has a value of 93, showing that red clay is a product of extreme chemical weathering of the lava flows. The alkaline volcanic rocks recovered from nearby show an age of ~ 44 Ma, indicating an Eocene age for the volcanism. We show that the red clays are a product of sub-aerial chemical weathering of these Eocene volcanic rocks, in a warm-wet climate, before the thermal subsidence of the RGR to its modern-day bathymetric depth.

Oversized balloon angioplasty for endovascular maturation of arteriovenous fistulae to accelerate cannulation and to decrease the duration of catheter use.

BACKGROUND: The functional autologous arteriovenous fistula is considered the best vascular access for patients on hemodialysis. Some fistulae exhibit maturation problems after creation and do not reach adequate vessel diameter and flow in dialysis. The aim of this study was to describe our technique of oversized balloon angioplasty for assisted maturation of arteriovenous fistulae to accelerate the cannulation and to decrease the time of catheter use and its outcome. METHODS: A retrospective analysis of balloon-assisted procedures for maturation failure was performed in a single center between October 2011 and January 2019. Patients underwent imaging procedures to identify stenosis, followed by angioplasty using oversized high-pressure balloons from the anastomosis to the deep venous outflow tract. The flow volume, time interval of use of the fistula and removal of the catheter, patency rates, and complications rates were evaluated. RESULTS: Seventy-eight patients underwent 124 balloon angioplasty procedures. Technical and clinical success was achieved in 91% of the cases. In patients in whom maturation was successful, the fistula was cannulated in a mean time of 5 days after the procedure (range, 1-20 days). On average, catheter removal was performed 14 days (range, 5-33 days) after the maturation procedure. The mean flow volume in the fistula before the procedure was 276 ml/min (range, 122-488 ml/min) and 24 h after the maturation was 1014 ml/min (range, 760-1800 ml/min).The primary patency rate at 3, 6, and 12 months was 87.3%, 66.2%, and 50.7%, respectively. Assisted primary patency was 100% at 3 months, 92.9% at 6 months, and 90.0% at 12 months. Minor complications occurred in 18% of cases, and major complications in 4.8%. CONCLUSIONS: The oversized balloon-assisted arteriovenous fistula maturation technique is safe and effective, allowing the cannulation of the fistulae a few hours or days after the procedure and decreasing the time of catheter use.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery / Diretrizes sobre acesso vascular para hemodiálise da Sociedade Brasileira de Angiologia e de Cirurgia Vascular

Abstract Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Resumo A doença renal crônica é um problema de saúde pública global e em seu estágio terminal está associada à necessidade de terapia dialítica. A grande maioria dos pacientes que necessitam realizar a terapia renal substitutiva, a fazem através da hemodiálise. Portanto, o acesso vascular é de extrema importância para a população dialítica, implicando diretamente na qualidade de vida e na morbimortalidade deste grupo de pacientes. Sendo a confecção, gerenciamento e resgate dos acessos vasculares uma das áreas de atuação do cirurgião vascular, é de grande importância a elaboração de uma diretriz que oriente o especialista no manejo mais adequado do acesso vascular para hemodiálise. Assim, o objetivo desta diretriz é apresentar um conjunto de recomendações para guiar as decisões na referenciação, avaliação, escolha, vigilância e gestão das complicações do acesso vascular para hemodiálise.

Effect of Brief Produce Exposure and Unconstrained Grocery Gift Cards on Caregiver Influence on Diet of Elementary Age Children: A Randomized Clinical Trial.

Importance: Children's diets affect health trajectories but are difficult to influence, especially for resource-constrained families. Objective: To assess the effectiveness of providing 4 weeks of grocery gift cards and small produce boxes to caregivers on their ability to support healthy shifts in children's diets. Design, Setting, and Participants: This 2-group randomized clinical trial was conducted from May to July 2021, with 4 weeks of intervention and follow-up at 8 weeks. Resources were provided curbside at 3 schools, 3 housing sites, and 1 after-school site for use at home. Participants consisted of 1 index child ages 5 to 11 years with 1 index caregiver from 68 low-income families. Data were analyzed from July 2021 through March 2022. Interventions: During each week for 4 weeks, caregivers were offered 10-lb (4.5 kg) boxes of fruits and vegetables, $10.00 grocery gift cards, an additional $10.00 gift card over the last 3 weeks triggered by a task completion, and a 1-time choice of a $25.00 food preparation tool. Main Outcomes and Measures: Index child and caregiver diets were measured together over the phone at baseline, 4 weeks, and 8 weeks using the 2019 to 2020 Texas School Physical Activity and Nutrition (SPAN) tool, which measures the number of times food items were eaten over the prior day to report a SPAN Healthy Eating Index (SHEI) score and subscores for specific categories of foods (range, 0-57, with higher scores indicating a more healthful diet). Results: Among 68 children (mean [SD] age, 8.2 [1.7] years; 35 [51.5%] girls) and caregivers (mean [SD] age, 37.9 [7.9] years; 63 mothers [92.6%]) from primarily low-income families, 26 caregivers were Hispanic or Latino (38.2%), while 18 caregivers were Black (26.4%), 25 caregivers were White (36.7%), and 24 caregivers had more than 1 race (35.3%). Most families were below the federal poverty level (41 of 60 families that reported income [68.3%]). Per participating caregiver, a mean (SD) 2.7 [1.4] fruit and vegetable boxes and $42.35 ($25.46) worth of gift cards were picked up over 4 weeks. Mean (SE) child SPAN SHEI increased from 32.03 (0.62) times/d to 33.75 (0.69) times/d at 4 weeks (ie, postintervention) and 34.03 (0.69) times/d 4 weeks later (ie, at 8 weeks of follow-up). Mean (SE) child fruit and vegetable intake increased from 5.31 (0.47) times/d to 5.78 (0.51) times/d postintervention and 6.03 (0.51) times/d at follow-up. Children in the control group did not have improved diet (overall mean [SE] SHEI: 31.48 [0.58] times/d at baseline, 31.68 [0.54] times/d postintervention, and 31.81 [0.52] times/d at follow-up; mean [SE] fruit and vegetable intake: 5.21 [0.45] times/d at baseline, 4.77 [0.45] times/d postintervention, and 4.68 [0.41] times/d at follow-up). Compared with children in the control group, mean SHEI was increased for children in the intervention group by 2.07 times/d postintervention and 2.23 times/d at follow-up. Improvements as a function of program dose were statistically significant for child SHEI (P = .01) and fruit and vegetable intake (P = .03). No significant changes in caregiver diets were found. Conclusions and Relevance: This study found that easily accessed fruits and vegetables and unconstrained grocery store cards provided directly to caregivers over 4 weeks resulted in improvements in child diet, which were sustained over 4 additional weeks. Future work may investigate whether diet improvement from a brief intervention optimized for caregiver flexibility reflects a natural maximum or potential for greater improvements on extension. Trial Registration: ClinicalTrials.gov Identifier: NCT04827654.

Letalidade policial e criminalidade violenta / Letalidad policial y criminalidad violenta / Police killings and violent crime

Resumo Entre os operadores da Segurança Pública no Rio de Janeiro, há uma visão recorrente de que o padrão de patrulhamento baseado em incursões, frequentemente associado a episódios de letalidade policial, é necessário e efetivo para redução de crimes. Para investigar essa questão, este artigo apresenta exercícios econométricos que avaliam em que medida um maior número de mortes por intervenção de agentes do Estado está associado a variações subsequentes nos indicadores criminais. A análise cobre o período de 2003 a 2019 e indica que não há uma associação entre o aumento da letalidade policial e a redução dos índices de criminalidade no nível local. Ao contrário, em alguns casos, encontra-se uma correlação significativa e positiva, ou seja, mais mortes estão correlacionadas com maior atividade criminal, embora a magnitude dos efeitos seja bem reduzida. Observa-se, também, que mortes por intervenção de agentes do Estado estão associadas a maiores resultados operacionais, mensurados por apreensão de drogas e de armas. Os resultados são condizentes com um padrão de patrulhamento cuja prioridade é o combate ao varejo do tráfico de drogas.

Resumen Una visión persistente entre los operadores de seguridad pública en Rio de Janeiro es que el patrón de patrullaje basado en redadas policiales, frecuentemente asociado con episodios de letalidad policial, es necesario y efectivo para reducir la criminalidad. Para investigar ese tema, este artículo presenta ejercicios econométricos que evalúan la medida en que un mayor número de muertes por intervenciones de agentes del Estado se asocia con variaciones posteriores en los indicadores criminales. El análisis, que abarca el período comprendido entre 2003 y 2019, indica que no existe una asociación entre el aumento de la letalidad policial y la reducción de las tasas de delincuencia a nivel local. Mientras que, en algunos casos, se encuentra una correlación significativa y positiva, es decir, se correlacionan más muertes con una mayor actividad criminal, aunque la magnitud de los efectos sea bastante reducida. Por otro lado, se observa que las muertes por intervención de agentes del Estado están asociadas con mayores resultados operativos, medidos por la incautación de drogas y de armas. Los resultados son consistentes con un patrón de patrullaje que prioriza la lucha contra el tráfico minorista de drogas.

Abstract A common view among policy makers in Public Security in Rio de Janeiro is that the patrolling pattern based on police raids, regularly associated with the use of lethal force, is both necessary and effective to reduce crime. In order to examine this issue, this article presents econometric exercises to assess in what extent a greater number of police killings is correlated with subsequent variations in criminal indicators. The analysis covers the period from 2003 to 2019 and indicates no correlation between increases in the use of lethal force by the police and reductions in crime rates at the local level. On the contrary, in some cases, a significant and positive correlation is observed, which means more police killings are correlated with greater criminal activity, although the magnitudes of the effects are rather reduced. On the other hand, we show that police killings are associated with greater operational results, as measured by drugs and weapons seizure. The results are consistent with a patrolling pattern that prioritizes the combat of retail markets for illicit drugs.

Thoracoabdominal mobility evaluation by photogrammetry in newborns after expiratory flow increase technique / Avaliação da mobilidade toracoabdominal por fotogrametria em recém-nascidos após a técnica de aumento do fluxo expiratório

Abstract Introduction: Expiratory flow increase is a maneuver of respiratory physical therapy that promotes flow direction to the upper airways however, when applied in newborns, it may result in changes of thoracoabdominal mobility. Objective: To evaluate the thoracoabdominal mobility by photogrammetry in newborns after expiratory flow increase technique. Methods: Experimental blind study performed with newborns in supine position on a support table with upper limbs flexed, abducted and externally rotated and hip flexed at 110°. Adhesive markers were allocated for geometric delimitation of the thoracoabdominal compartment and expiratory flow increase technique was performed for 5 minutes with the therapist's hands on the thorax and abdomen. Newborns were filmed before and after the maneuver and the frames were analyzed in AutoCAD® software by a blinded investigator at the time of the procedure. The largest and the smallest thoracoabdominal area were expressed in cm2 and the mean values were compared between two moments (pre and post maneuver) by paired t test. Results: Twenty newborns with a mean age of 39 weeks were included. Before the maneuver, thoracoabdominal area was 56.1 cm2 during expiration and 59.7 cm2 during inspiration, and after the maneuver the value was 56.2 cm2 during expiration and 59.8 cm2 during inspiration, with no statistical difference between before and after (p = 0.97, p = 0.92, respectively). Conclusion: Results demonstrate that expiratory flow increase technique does not seem to change thoracoabdominal mobility of healthy newborns.

Resumo Introdução: O aumento do fluxo expiratório é uma manobra da fisioterapia respiratória que promove um direcionamento do fluxo para as vias aéreas superiores, entretanto, quando aplicada em recém-nascidos, pode resultar em uma variação da mobilidade toracoabdominal. Objetivo: Avaliar a mobilidade toracoabdominal pela fotogrametria em recém-nascidos após a manobra de aumento do fluxo expiratório. Métodos: Estudo experimental, cego, realizado com os recém-nascidos posicionados em supino sobre uma bancada de apoio com o membro superior em flexão, abdução e rotação externa e quadril flexionado a 110°. Foram alocados marcadores adesivos para a delimitação geométrica do compartimento toracoabdominal e o aumento do fluxo expiratório foi realizado por 5 minutos com as mãos do terapeuta sobre o tórax e abdome. Os recém-nascidos foram filmados pré e pós-manobra e os fotogramas foram analisados no software AutoCAD por um pesquisador cego ao momento do experimento. A maior e a menor área toracoabdominal foram expressas em cm 2 e os valores médios foram comparados entre os dois momentos (pré e pós manobra) pelo Teste t pareado. Resultados: Foram incluídos 20 recém-nascidos com idade média de 39 semanas. Antes da manobra a área toracoabdominal foi 56,1 cm2 durante a expiração e 59,7 cm 2 na inspiração e após a manobra o valor foi 56,2 cm 2 durante a expiração e 59,8 cm 2 durante a inspiração, sem diferença estatística entre o antes e o depois (p = 0,97, p = 0,92, respectivamente). Conclusão: Os resultados deste estudo demonstram que a técnica de aumento do fluxo expiratório parece não alterar a mobilidade toracoabdominal de recém-nascidos saudáveis.

Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease.

BACKGROUND: It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches. METHODS: We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed. RESULTS: From our data, LATP (n=24) took significantly longer than CTP (n=12; 3.9±1.1 vs. 2.6±0.6h, p=0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21-1.96, p<0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76-4.04, p=0.19) or length of stay (OR 0.33, 95% CI -0.41 to 1.08, p=0.38). CONCLUSION: Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

Educación estratégica en el hospital III Congreso / Strategical education at the III Congress Hospital

La educación estratégica la iniciamos en el hospital "III Congreso", de Pinar del Río, en el mes de enero de 1996. El equipo multidisciplinario del CEPROPER "Simón Bolívar" se reunió con el Consejo de Dirección del centro y seleccionaron 3 servicios (Dermatología, Retinosis pigmentaria y Oncología) para comenzar a introducir este estilo de trabajo. Los miembros del equipo realizaron 67 visitas de familiarización en distintos turnos para identificarse con los trabajadores y conocer el algoritmo de trabajo utilizado. El centro cuenta con 20 facilitadores distribuidos en distintas especialidades, entre ellos 7 en enfermería. Se problematizaron los servicios, detectándose dificultades con algunos procederes de enfermería y en los métodos de limpieza utilizados por las auxiliares generales. Aplicamos evaluaciones de desempeño y técnicas de identificación de necesidades de aprendizaje, para detectar las dificultades de conocimientos que presentaron los enfermeros. Confeccionamos un plan para desarrollar los procesos educativos que se le impartieron a los 9 compañeros que presentaron dificultades de aprendizaje, monitoreamos los procesos impartidos y se comprueba su efectividad. Según la encuesta aplicada pudimos conocer sus criterios en relación con la educación estratégica, pues todos responden que la conocen, que han recibido la información por distintas vías y que se sienten motivados con el estilo que ella propone(AU)

The strategic education begins it in the hospital III Congress", of Pinegrove of the River, in the month of January of 1996. The team multidisciplinario of the CEPROPER Simón Bolivar met with the Council of Address of the center and they selected 3 services (Dermatology, Retinosis pigmentaria and Oncología) to begin to introduce this work style. The members of the team carried out 67 familiarización visits in different shifts to be identified with the workers and to know the algorithm of used work. The center has 20 facilitators distributed in different specialties, among them 7 in infirmary. You problematizaron the services, being detected difficulties with some infirmary procederes and in the methods of cleaning used by the general assistants. We apply acting evaluations and technical of identification of learning necessities, to detect the difficulties of knowledge that the male nurses presented. We make a plan to develop the educational processes that were imparted the 9 partners that presented learning difficulties, monitoreamos the imparted processes and he/she is proven their effectiveness. According to the applied survey we could meet their approaches in connection with the strategic education, because all respond that they know it that have received the information for different roads and that they are motivated with the style that she proposes(AU)

Educación estratégica en el hospital III Congreso / Strategical education at the III Congress Hospital

La educación estratégica la iniciamos en el hospital "III Congreso", de Pinar del Río, en el mes de enero de 1996. El equipo multidisciplinario del CEPROPER "Simón Bolívar" se reunió con el Consejo de Dirección del centro y seleccionaron 3 servicios (Dermatología, Retinosis pigmentaria y Oncología) para comenzar a introducir este estilo de trabajo. Los miembros del equipo realizaron 67 visitas de familiarización en distintos turnos para identificarse con los trabajadores y conocer el algoritmo de trabajo utilizado. El centro cuenta con 20 facilitadores distribuidos en distintas especialidades, entre ellos 7 en enfermería. Se problematizaron los servicios, detectándose dificultades con algunos procederes de enfermería y en los métodos de limpieza utilizados por las auxiliares generales. Aplicamos evaluaciones de desempeño y técnicas de identificación de necesidades de aprendizaje, para detectar las dificultades de conocimientos que presentaron los enfermeros. Confeccionamos un plan para desarrollar los procesos educativos que se le impartieron a los 9 compañeros que presentaron dificultades de aprendizaje, monitoreamos los procesos impartidos y se comprueba su efectividad. Según la encuesta aplicada pudimos conocer sus criterios en relación con la educación estratégica, pues todos responden que la conocen, que han recibido la información por distintas vías y que se sienten motivados con el estilo que ella propone(AU)