Video-assisted retroperitoneal debridement for necrotizing pancreatitis: a single center experience in Colombia.

INTRODUCTION: Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10-20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up. METHODS: A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described. RESULTS: A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up. CONCLUSION: According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency.

Towards an update on the antimicrobial use in Adult Care Units in Brazil: insights from multi-hospital prevalence study.

Introduction. Efforts to understand the burden of antibiotic use in low- and middle-income countries such as Brazil are essential for developing strategies that are effective and appropriate in the context of endemic multidrug-resistant organisms.Aim. This study aims to determine antimicrobial-prescribing practices among patients hospitalized in intensive care units (ICUs) for adults in Brazil.Methodology. A 1-day point prevalence multicentre survey was conducted in 58 adult ICUs across the five regions of Brazil. The institutions were categorized according to their type and size. Detailed antimicrobial prescription data were prospectively provided to all patients hospitalized on the day of data collection.Results. A total of 620 patients were included in the study, of whom 63.9% were receiving at least one antimicrobial. Of these, 34.6% were treated for an infection, but only 39.9% of the cases were based on microbiological criteria. Empirical treatment was applied to 72.3% of the patients. Significant differences in antibiotic usage were observed across the different hospitals included in the study. Overall, treatment was most commonly directed towards pneumonia (51.8%) and bloodstream infections (29.6%). Glycopeptides (19.4%) and carbapenems (18.5%) were the most prescribed in teaching hospitals, while in non-teaching hospitals, carbapenems (17.8%) and broad-spectrum cephalosporins (16.8%) were most frequently used.Conclusion. Our study reveals alarming data on antibiotic use in adult ICUs in Brazil, with high frequencies of severe healthcare-associated infections acquired in these units, where patients are frequently subjected to empirical treatment.

Investigation of serum Metrnl levels in pregnant women with gestational diabetes mellitus: a prospective non-interventional cohort study.

OBJECTIVE: The objective of this study was to investigate serum Metrnl levels in pregnant women with gestational diabetes mellitus and compare them with pregnant women without gestational diabetes mellitus. METHODS: The gestational diabetes mellitus group consisted of 87 pregnant women diagnosed with gestational diabetes mellitus, and the control group consisted of 93 healthy pregnant women without gestational diabetes mellitus. Serum Metrnl levels were determined by the enzyme-linked immunosorbent assay method. RESULTS: The two groups were similar in terms of demographic features. The median serum Metrnl level was found to be 1.16 ng/mL in the gestational diabetes mellitus group, while it was determined as 2.2 ng/mL in the control group (p=0.001). The two groups were divided into two subgroups based on participants' body mass index, normal weight and overweight. The lowest median Metrnl level was detected in the normal weight gestational diabetes mellitus group, followed by the overweight gestational diabetes mellitus group, normal weight control group, and overweight control group (1.1, 1.2, 2, and 2.4 ng/mL, respectively). Receiver operating curve analysis was performed to determine the value of the serum Metrnl level in terms of predicting gestational diabetes mellitus. The area under the curve analysis of serum Metrnl for gestational diabetes mellitus estimation was 0.768 (p=0.000, 95%CI 0.698-0.839). The optimal cutoff value for serum Metrnl level was determined as 1.53 ng/mL with 69% sensitivity and 70% specificity. CONCLUSION: Serum Metrnl levels in pregnant women with gestational diabetes mellitus were found to be significantly lower than in pregnant women without gestational diabetes mellitus. The mechanisms underlying the decrease in serum Metrnl levels in gestational diabetes mellitus remain unclear for now, and future studies will reveal the role of Metrnl in the pathophysiology of gestational diabetes mellitus.

Efficacy of convalescent plasma in hospitalized COVID-19 patients: findings from a controlled trial.

The COVID-19 pandemic has driven the search for alternative therapies, including convalescent plasma, historically used in infectious diseases. Despite results in other diseases, its effectiveness against COVID-19 remains uncertain with conflicting results in clinical trials. A pragmatic, single-center, prospective, and open randomized controlled trial was carried out in a hospital in Brazil, with the aim of evaluating the impact of convalescent plasma on the clinical improvement of patients hospitalized with COVID-19. The World Health Organization (WHO) ordinal scale was used to measure clinical improvement, focusing on the reduction in disease severity by up to 2 points, while antibody and C-reactive protein levels were monitored over time. After hospital admission, participants were randomized 1:1 to receive convalescent plasma and standard treatment or to be part of the control group with standard treatment. Follow-up was carried out on days 1, 3, 7, 14 and/or at discharge. From January 14 to April 4, 2022, 38 patients were included, but 3 were excluded due to protocol deviations, resulting in a total of 35 patients: 19 in the control group and 16 in the plasma group. There was no significant difference in clinical improvement between the convalescent plasma group and the control group, nor in secondary outcomes. The study had limitations due to the small number of patients and limited representation of COVID-19 cases. Broader investigations are needed to integrate therapies into medical protocols, both for COVID-19 and other diseases. Conducting randomized studies is challenging due to the complexity of medical conditions and the variety of treatments available.

Does the sonic hedgehog signaling pathway play a role in anti-reflux mechanism of bladder in children?

OBJECTIVE: A hedgehog family ligand, namely, sonic hedgehog (SHH), was reported to be important in the development of bladder and ureter smooth muscle. In this prospective study, we aimed to determine protein expression of SHH in resected ureterovesical junction (UVJ) segments of children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: The study group included 19 children; 12 (63%) girls, 7 (37%) boys, who had ureteroneocystostomy operation; 3 (15.7%) right sided, 7 (36.8%) left sided, 9 (47.3%) bilateral, due to primary VUR between years 2015 and 2018. Totally, 28 UVJ segments were examined for Western Blot analysis to determine related protein expression levels. RESULTS: The mean Western blot band area of SHH gene pathway related protein was 3880.69 (2059.55-13941.61) while the mean area of ß-Actin, the house-keeping gene, was 20180.25 (9530.39-26709.75) (p = 0.001). Correlation analyses between grade of reflux and protein expression of SHH gene pathways revealed no significant relation (p = 0.300). When the UV samples were grouped as low- and high-grade reflux and compared in terms of SHH protein expression levels, no statistically significant difference was found between groups (p = 0.818). CONCLUSION: We concluded that SHH signaling molecule which is effective in development of bladder and ureter smooth musculature might also be effective in etiopathology of reflux.

OBJETIVO: Se ha informado que el ligando sonic hedgehog (SHH) es importante en el desarrollo de los músculos lisos de la vejiga y el uréter. Nuestro objetivo fue determinar la expresión proteica de SHH en los segmentos de la unión ureterovesical de niños con reflujo vesicoureteral (RVU). MATERIALES Y MÉTODOS: El grupo de estudio incluyó a 19 niños; 12 (63%) niñas, 7 (37%) niños, que tuvieron operación de ureteroneocistostomía (UNC); 3 (15.7%) derecho, 7 (36.8%) izquierdo, 9 (47.3%) bilateral, por RVU primario entre los años 2015-2018. Se examinaron un total de 28 segmentos de la unión ureterovesical para análisis de transferencia Western para determinar los niveles de expresión de proteínas relacionadas en las muestras. RESULTADOS: El área media de la banda de transferencia Western de la proteína relacionada con la vía del gen SHH fue de 3880.69 (2059.55-13941.61), mientras que el área media de la ß-actina, el gen de limpieza, fue de 20180.25 (9530.39-26709.75) (p = 0.001). Los análisis de correlación entre el grado de reflujo y la expresión de proteínas de las vías del gen SHH no revelaron una relación significativa (p = 0.300). CONCLUSIÓN: Concluimos que la molécula de señalización SHH también podría ser efectiva en la etiopatología del reflujo vesicoureteral.

[Argentinean registry on the management of Helicobacter pylori infection: effectiveness and safety of first line treatment]. / Registro argentino para el manejo de la infección por Helicobacter pylori: efectividad y seguridad de los esquemas de primera línea de tratamiento.

INTRODUCTION: The optimal management of Helicobacter pylori (H pylori) infection remains unclear. Updated information concerning local data is needed to design the best strategy to treat H. pylori infection to reach high eradication rates. The Argentinean Registry (Hp-ArgReg) on H. pylori management was launched to monitor the eradication practices of gastroenterologists. The objective was to assess the effectiveness and safety of firstline H. pylori treatment in Argentina. MATERIALS AND METHODS: A multicenter prospective registry of the clinical practice of the Argentinean gastroenterologists concerning H. pylori infection (Hp-ArgReg) was developed. Variables included: patient demographic information, previous eradication attempts, prescribed treatment, adverse events, compliance and outcome. RESULTS: Overall, 800 patients were included and 727 patients received first-line empirical treatment. The most frequent treatment indications were dyspepsia (78%) and gastroduodenal ulcer (12%). Among first-line treatments, quadruple therapies (with or without bismuth) achieved eradication rates of 94.9%, while triple therapies achieved eradication rates of 78.9%. Quadruple therapies were significantly more effective than triple therapies (P < 0.01, OR 5, CI 2.95-8.6). Sequential therapy with zinc showed an effectiveness of 95.6%. Adverse events were reported in 29% of the cases (mainly mild) and tolerance was quite similar among therapies. CONCLUSION: in Argentina, Quadruple therapies with or without bismuth and sequential therapy with zinc showed an H. pylori eradication effectiveness of over 90% in real clinical practice. Local Registries for H pylori management could help to control the spread of antibiotic resistance.

Introducción: El óptimo manejo de la infección por Helicobacter pylori (H. pylori) es objeto de debate. Contar con datos locales ayudaría a lograr altas tasas de erradicación. El Registro Argentino H. pylori (RegArg-Hp) se estableció con el objetivo de monitorear el manejo local de la infección. El objetivo fue describir la efectividad y seguridad de las terapias empíricas de primera línea para la erradicación del H. pylori utilizadas en Argentina. Materiales y métodos: Registro prospectivo, multicéntrico, de la práctica clínica de los gastroenterólogos argentinos. Se incluyeron datos demográficos de pacientes con infección por H. pylori, intentos previos de erradicación, tratamiento indicado, eventos adversos, cumplimiento y erradicación. Resultados: De 800 pacientes incluidos, 727 recibieron un tratamiento empírico de primera línea. Las indicaciones de tratamiento más frecuentes fueron dispepsia (78%) y úlcera gastroduodenal (12%). Entre los tratamientos de primera línea, las terapias cuádruples (con o sin bismuto) lograron tasas de erradicación del 94.9% mientras las terapias triples tasas de erradicación del 78.9%. Las terapias cuádruples fueron significativamente más efectivas que las triples (P < 0.01, OR 5, IC 2.95-8.6). La terapia secuencial con zinc mostró una efectividad del 95.6%. Se reportaron eventos adversos en el 29% de los pacientes, generalmente leves y con una tolerancia similar entre las diferentes terapias. Conclusiones: En Argentina, las terapias cuádruples con o sin bismuto y la secuencial con zinc presentaron una efectividad de erradicación de H. pylori superior al 90%. La implementación de registros locales podría contribuir al control de la resistencia a los antibióticos.

Continued Breastfeeding in a Birth Cohort in the Western Amazon of Brazil: Risk of Interruption and Associated Factors.

BACKGROUND: Continued breastfeeding reduces infant mortality and provides nutritional, immunological, and developmental benefits for the child. OBJECTIVES: A prospective cohort study conducted in 2015 followed 608 children who were breastfed between 6 and 24 months. The study assessed the risk of breastfeeding interruption at 12, 18, and 24 months, as well as the factors associated with this outcome, in a cohort of newborns in Rio Branco, using the life table method. METHODS: The factors associated with breastfeeding cessation and their 95% confidence intervals (CI95%) were analyzed using both crude and adjusted Cox proportional hazards regression in a hierarchical model. The risks of breastfeeding cessation at 12, 18, and 24 months were 19%, 65%, and 71%, respectively. RESULTS: Factors positively associated with the risk of breastfeeding cessation include the use of a pacifier before 6 weeks of age (HR = 1.62; CI: 95% 1.24-2.11) and the use of a bottle during the first year of life (HR = 1.41; CI: 95% 1.11-1.78). Maternal return to work after the birth of the baby (HR = 0.78; CI: 95% 0.62-0.97) was found to be negatively associated with the risk of breastfeeding interruption. CONCLUSIONS: Early pacifier use before 6 weeks and the introduction of a bottle in the first year affect continued breastfeeding. Maternal employment was associated with reduced risk of breastfeeding cessation, contrary to most studies.

Acute kidney injury developed in the intensive care unit: a population-based prospective cohort study in the Brazilian Amazon.

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03-1.23), 1.47 (95% CI 1.07-2.03), 1.96 (95% CI 1.40-2.74), 1.05 (95% CI 1.03-1.08) for each unit increase, and 1.62 (95% CI 1.16-2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29-3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14-1.43) for each 10-year increase, 1.64 (95% CI 1.07-2.52), 2.35 (95% CI 1.14-4.83), 1.88 (95% CI 1.03-3.44), 6.73 (95% CI 4.08-11.09), 2.31 (95% CI 1.52-3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31-180 days after ICU discharge were 3.13 (95% CI 1.84-5.31) and 1.69 (95% CI 0.99-2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

Tumor spread through air spaces in lung cancer: prospective analysis of the accuracy of intraoperative frozen section examination.

OBJECTIVE: To establish the accuracy of frozen section examination in identifying tumor spread through air spaces (STAS), as well as to propose a reproducible technical methodology for frozen section analysis. We also aim to propose a method to be incorporated into the decision making about the need for conversion to lobectomy during sublobar resection. METHODS: This was a nonrandomized prospective study of 38 patients with lung cancer who underwent surgical resection. The findings regarding STAS in the frozen section were compared with the definitive histopathological study of paraffin-embedded sections. We calculated a confusion matrix to obtain the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and accuracy. RESULTS: The intraoperative frozen section analysis identified 7 STAS-positive cases that were also positive in the histopathological examination, as well as 3 STAS-negative cases that were positive in the in the histopathological examination. Therefore, frozen section analysis was determined to have a sensitivity of 70%, specificity of 100%, PPV of 100%, NPV of 90.3%, and accuracy of 92% for identifying STAS. CONCLUSIONS: Frozen section analysis is capable of identifying STAS during resection in patients with lung cancer. The PPV, NPV, sensitivity, and specificity showed that the technique proposed could be incorporated at other centers and would allow advances directly linked to prognosis. In addition, given the high accuracy of the technique, it could inform intraoperative decisions regarding sublobar versus lobar resection.

Prognostic value of the duke activity Status Index Questionnaire in predicting mortality in patients with chronic heart failure: 36-month follow-up study.

BACKGROUND: The Duke Activity Status Index (DASI) questionnaire has been the focus of numerous investigations - its discriminative and prognostic capacity has been continuously explored, supporting its use in the clinical setting, specifically during rehabilitation in patients with chronic heart failure (CHF).However, studies exploring optimal DASI questionnaire threshold scores are limited. OBJECTIVE: To investigate optimal DASI questionnaire thresholds values in predicting mortality in a CHF cohort and assess mortality rates based on the DASI questionnaire using a thresholds values obtained. METHODOLOGY: This is a prospective cohort study with a 36-month follow-up in patients with CHF. All patients completed a clinical assessment, followed by DASI questionnaire, pulmonary function, and echocardiography. The Receiver Operating Characteristic (ROC) curve analysis was used to discriminate the DASI questionnaire score in determining the risk of mortality. For survival analysis, the Kaplan-Meier model was used to explore the impact of ≤/>23 points on mortality occurring during the 36-month follow-up. RESULTS: One hundred and twenty-four patients were included, the majority being elderly men. Kaplan Meier analysis revealed that ≤/> 23 was a strong predictor of CHF mortality over a 36-month follow-up. CONCLUSION: A score of ≤/>23 presents good discriminatory capacity to predict mortality risk in 36 months in patients with CHF, especially in those with reduced or mildly reduced ejection fraction. Age, ejection fraction, DASI questionnaire score and use of digoxin are risk factors that influence mortality in this population.

Advancing insights in critical COVID-19: unraveling lymphopenia through propensity score matching - Findings from the Multicenter LYMPH-COVID Study.

OBJECTIVE: To elucidate the impact of lymphopenia on critical COVID-19 patient outcomes. METHODS: We conducted a multicenter prospective cohort study across five hospitals in Portugal and Brazil from 2020 to 2021. The study included adult patients admitted to the intensive care unit with SARS-CoV-2 pneumonia. Patients were categorized into two groups based on their lymphocyte counts within 48 hours of intensive care unit admission: the Lymphopenia Group (lymphocyte serum count < 1 × 109/L) and the Nonlymphopenia Group. Multivariate logistic regression, propensity score matching, Kaplan‒Meier survival curve analysis and Cox proportional hazards regression analysis were used. RESULTS: A total of 912 patients were enrolled, with 191 (20.9%) in the Nonlymphopenia Group and 721 (79.1%) in the Lymphopenia Group. Lymphopenia patients displayed significantly elevated disease severity indices, including Sequential Organ Failure Assessment and Simplified Acute Physiology Score 3 scores, at intensive care unit admission (p = 0.001 and p < 0.001, respectively). Additionally, they presented heightened requirements for vasopressor support (p = 0.045) and prolonged intensive care unit and in-hospital stays (both p < 0.001). Multivariate logistic regression analysis after propensity score matching revealed a significant contribution of lymphopenia to mortality, with an odds ratio of 1,621 (95%CI: 1,275 - 2,048; p < 0.001). Interaction models revealed an increase of 8% in mortality for each decade of longevity in patients with concomitant lymphopenia. In the subanalysis utilizing three-group stratification, the Severe Lymphopenia Group had the highest mortality rate, not only in direct comparisons but also in Kaplan‒Meier survival analysis (log-rank test p = 0.0048). CONCLUSION: Lymphopenia in COVID-19 patients is associated with increased disease severity and an increased risk of mortality, underscoring the need for prompt support for critically ill high-risk patients. These findings offer important insights into improving patient care strategies for COVID-19 patients.

Clinical response to nonsurgical periodontal therapy is associated with decreased serum leukocyte count and uric acid levels in kidney transplant recipients.

OBJECTIVE: This study sought to investigate the relationship between clinical response to nonsurgical periodontal therapy (NSPT) and serum changes in leukocyte count, fasting blood glucose, hemoglobin, hematocrit, creatinine, and uric acid in kidney transplant recipients (KTR). METHODOLOGY: A prospective study was performed on 20 KTRs. Periodontal and serum data were collected before and 90 days after NSPT, and delta values (Δ = after NSPT - before) were calculated. Periodontal assessment included periodontal probing depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP). Patients were classified based on the presence of periodontitis and then categorized into stages. RESULTS: Patients showed a reduction in the percentage of sites with PPD≥3mm, PPD≥4 mm and BOP, after NSPT. There was a direct correlation between the deltas of leukocyte count and CAL ≥3 mm (r=0.645, P=0.002) and BOP (r=0.663, P=0.001), and the deltas of uric acid and CAL ≥3 mm (r=0.562, P=0.010). CONCLUSION: A good clinical response to NSPT may affect the reduction of serum levels of leukocyte count and uric acid, suggesting a beneficial effect on systemic health in KTR.

Cesarean birth is associated with lower motor and language development scores during early childhood: a longitudinal analysis of two cohorts.

With global C-section rates rising, understanding potential consequences is imperative. Previous studies suggested links between birth mode and psychological outcomes. This study evaluates the association of birth mode and neurodevelopment in young children across two prospective cohorts, using repeated psychometric assessments. Data from the ELEMENT (Early Life Exposures in Mexico to Environmental Toxicants) and PROGRESS (Programming Research in Obesity, Growth, and Environment and Social Stress) cohorts, comprising 7158 and 2202 observations of 1402 children aged 2 to 36 months, and 726 children aged 5 to 27 months, respectively, were analyzed. Exclusion criteria for the cohorts were maternal diseases such as preeclampsia, renal or heart disease, gestational diabetes, and epilepsy. Neurodevelopment was gauged via Bayley's Scales of Infant Development: 2nd edition for ELEMENT and 3rd edition for PROGRESS. Mixed-effects models longitudinally estimated associations between birth mode and neurodevelopment scores, adjusting for cofounders. In ELEMENT, psychomotor development composite scores were significantly affected by birth mode from ages 2 to 8 months; the largest estimate within this range was at 2 months (ß =-1.93; 95% CI: [-3.64, -0.22], reference: vaginal delivery). For PROGRESS, a negative association was found with motor development composite scores over all the studied age range (ß=-1.91; 95% CI: [-3.01, -0.81]). The association was stronger between ages 6 to 18 months, with the strongest estimate at 11 months (ß=-2.58; 95% CI: [-4.37, -0.74]). A negative impact of C-section on language scores in girls was estimated for the PROGRESS cohort (ß=-1.92; 95% CI: [-3.57, -0.27]), most marked in ages 22 to 25 months (largest ß at 24.5 months=-3.04; 95% CI: [-5.79, -0.30]). Children born by C-section showed lower motor and language development scores during specific age windows in the first three years of life. Further research is necessary to understand the complexities and implications of these findings.

Angiographic description of the superior rectal artery and its anatomical variations in patients undergoing embolization of the superior rectal arteries in hemorrhoidal disease treatment.

BACKGROUND: Angiography of the superior rectal artery showed that its branches were divided into four main branches (two left and two right) in 46.8%; the second most frequent variation was one right and two left branches in 26.6%, followed by two branches to the right and one to the left in 20%; the most uncommon variations were one to the right and one to the left without further subdivision in 6.6%. BACKGROUND: ◼ The superior rectal artery, when it reaches the rectum, divides into two or more branches. BACKGROUND: ◼ Four patterns were observed in the angiographic anatomy of the superior rectal artery. BACKGROUND: ◼ Understanding the angiographic anatomy of the superior rectal artery is important to achieve optimal embolization results. OBJECTIVE: To describe angiographic findings of the superior rectal artery, its branches, and anatomical variations in the hemorrhoidal plexus in patients undergoing rectal artery embolization for hemorrhoidal disease treatment. METHODS: Angiographic findings of 15 patients were obtained from a single-center, prospective clinical study that compared superior rectal artery embolization with the Ferguson technique for hemorrhoidal disease between July 2018 and March 2020. RESULTS: Angiography of the superior rectal artery showed that in seven patients (46.8%), its branches were divided into four main branches (two left and two right), while in four patients (26.6%), the branches divided into one right and two left branches. The most uncommon variation observed in three cases (20%) was the branches divided into two branches to the right and one to the left; no further subdivision into the main branches was observed in one case (6.6%). CONCLUSION: Four patterns were observed in the angiographic anatomy of the superior rectal arteries. Knowledge of the angiographic anatomy of this region and its variations is essential to improve the effectiveness of superior rectal artery embolization. REGISTRY OF CLINICAL TRIALS: NCT03402282.

Acute kidney injury in coronavirus disease: a comparative study of the two waves in Brazil.

BACKGROUND: Magalhães et al. demonstrated that the incidence of acute kidney injury was high in hospitalized patients with COVID-19 and that the second wave was associated with greater severity; however, the mortality rates were similar between the two periods. This may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients. BACKGROUND: ◼ Renal involvement was frequent in patients with COVID-19 and related to worse outcomes. BACKGROUND: ◼ Diuretic use, mechanical ventilation, proteinuria, hematuria, age, and creatine phosphokinase and D-dimer levels were risk factors for acute kidney injury. BACKGROUND: ◼ Acute kidney injury, mechanical ventilation, elevated SOFA Score, and elevated ATN-ISS were associated with mortality. BACKGROUND: ◼ The second wave was associated with greater severity; however, the mortality rates were similar between the two periods. BACKGROUND: ◼ This may reflect the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic. OBJECTIVE: This study aimed to evaluate the incidence of acute kidney injury in hospitalized Brazilian patients with COVID-19 and identify the risk factors associated with its development and prognosis during the two waves of the disease. METHODS: We performed a prospective cohort study of hospitalized patients with COVID-19 at a public university hospital in São Paulo from March 2020 to May 2021. RESULTS: Of 887 patients hospitalized with COVID-19, 54.6% were admitted to the intensive care unit. The incidence of acute kidney injury was 48.1%, and the overall mortality rate was 38.9%. Acute kidney replacement therapy was indicated for 58.8% of the patients. The factors associated with acute kidney injury were diuretic use (odds ratio [OR] 2.2, 95%CI= 1.2-4.1, p=0.01), mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001), hematuria(OR= 2.02, 95%CI= 1.1-3.5, p<0.0001), chronic kidney disease (OR= 2.6, 95%CI= 1.2-5.5, p=0.009), age (OR= 1.03, 95%CI= 1.01-1.07, p=0.02), and elevated creatine phosphokinase (OR= 1.02, 95%CI= 1.01-1.07, p=0.02) and D-dimer levels (OR= 1.01, 95%CI= 1.01-1.09, p<0.0001). Mortality was higher among those with acute kidney injury (OR= 1.12, 95%CI= 1.02-2.05, p=0.01), elevated Sequential Organ Failure Assessment Scores (OR= 1.35, 95%CI= 1.1-1.6, p=0.007), elevated Acute Tubular Necrosis-Injury Severity Score (ATN-ISS; (OR= 96.4, 95%CI= 4.8-203.1, p<0.0001), and who received mechanical ventilation (OR= 12.9, 95%CI= 4.3-38.2, p<0.0001). During the second wave, the number of cases requiring mechanical ventilation (OR= 1.57, 95%CI= 1.01-2.3, p=0.026), with proteinuria (OR= 1.44, 95%CI= 1.01-2.1, p=0.04), and with higher ATN-ISS Scores (OR= 40.9, 95%CI= 1.7-48.1, p=0.04) was higher than that during the first wave. CONCLUSION: Acute kidney injury was frequent in hospitalized patients with COVID-19, and the second wave was associated with greater severity. However, mortality rates were similar between the two periods, which may reflect both the effectiveness of vaccines and the constant learning that frontline professionals gained throughout the pandemic to provide greater support to their patients. REGISTRY OF CLINICAL TRIALS: RBR-62y3h7.

Cost-effectiveness of radiofrequency ablation versus percutaneous ethanol injection for early hepatocellular carcinoma in a resource-poor setting: a randomized trial.

OBJECTIVE: This study assessed the cost-effectiveness of radiofrequency ablation compared with percutaneous ethanol injection in patients with early hepatocellular carcinoma in relation to the objective response rate and costs related to the procedure. METHODS: This was a prospective single-center randomized trial. The primary outcome was cost-effectiveness. Secondary outcomes were the complete response rate according to the modified response evaluation criteria in solid tumors 60 days after randomization and the complication rate within 180 60 days. RESULTS: Fifty patients were placed into the following groups: percutaneous ethanol injection (n=23) and radiofrequency ablation (n=27). Fifty-four nodules were randomized (mean follow-up: 205.37 days). The estimated mean hospital cost was US$ 1854.11 and US$ 2770.96 for the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups, respectively. The incremental cost-effectiveness ratio was US$ -2674.59, which is advantageous for radiofrequency ablation. After 60 d, 28 of 29 nodules in the Radiofrequency Ablation Group achieved complete response versus 12 of 22 in the Percutaneous Ethanol Injection Group (RD, 42.01 [95%CI= 20.55-63.24]; p<0.001). Only four early complications were observed among patients treated by percutaneous ethanol injection (p<0.05). Late complications occurred in two and one patient(s) in the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups (p>0.05), respectively. CONCLUSION: Radiofrequency ablation was more cost-effective and achieved higher complete response and lower complication rates than the Percutaneous Ethanol Injection Group within this cohort. REGISTRY OF CLINICAL TRIALS: NCT06450613.

Serum progesterone measurement on the day of fresh embryo transfer and its correlation with pregnancy success rates: A prospective analysis.

Studies regarding serum Progesterone (P4) concentration and Clinical Pregnancy Rates (CPR) in fresh Embryo Transfer (ET) after Controlled Ovarian Stimulation Cycles (COS) remain inconclusive. To find a P4 cutoff point on fresh ET day associated with higher CPR, and to identify predictive factors of CPR and P4, the authors conducted a prospective cohort of 106 patients who underwent COS at a public IVF center. The luteal phase was supported with vaginal micronized progesterone (200 mg, 8/8h), beginning on oocyte retrieval day. The primary outcome was CPR beyond the 8th week of pregnancy. A ROC curve was constructed to identify the best cutoff point correlated with higher CPR. Multivariate analysis evaluated predictive variables of CPR and P4 concentration. P4 levels showed no significant differences between pregnant and non-pregnant patients (67.12 ± 31.1 ng/mL vs. 64.17 ± 61.76, p = 0.7465). The cutoff point correlated with higher CPR was P4 ≥ 28.9 ng/mL (AUC 0.5654). Women's age (OR = 0.878; 95 % CI 0.774-0.995) and top-quality embryo transfer (OR = 2.89; 95 % CI 1.148-7.316) were associated with CPR. Women's age ≥ 40 years (OR = 0.0956; 95 % CI 0.0156-0.5851), poor response to COS (OR = 0.0964; 95 % CI 0.0155-0.5966), and follicles ≥ 10 mm (OR = 1.465; 95 % CI 1.013-2.117) were associated with the cutoff point. As the ROC curve was unsatisfactory, P4 ≥ 28.9 ng/mL should not be used to infer gestational success. In fresh ET, P4 concentration may merely reflect a woman's age and individual response to COS rather than being a reliable CPR predictor.

[Prevalence of transthyretin cardiac amyloidosis in patients hospitalized for heart failure with preserved ejection fraction and septal thickness]. / Prevalencia de amiloidosis cardíaca por transtiretina en pacientes internados por insuficiencia cardíaca con fracción de eyección preservada y engrosamiento septal.

INTRODUCTION: Transthyretin cardiac amyloidosis (ATTR-CM) usually presents as heart failure with preserved ejection fraction. Its diagnosis has a significant clinical impact, as specific treatment is currently available. The aim of this study is to assess the prevalence of ATTR-CM in patients hospitalized for heart failure with preserved ejection fraction and septal thickness in our region. METHODS: Cross-sectional study. Patients over 18 years old hospitalized for heart failure with preserved ejection fraction (greater than 50%) and septal thickness greater than or equal to 12 mm during the period from 8/2019 to 1/2023 were prospectively included. A pyrophosphate bone scintigraphy (PYP) was planned to assess cardiac involvement. The prevalence of ATTR-CM and its 95% confidence interval were calculated. RESULTS: A PYP was performed in 59/82 patients. The median age was 85 [IQR 78-88] years old, 54% women. On admission, 61% had atrial fibrillation/flutter rhythm and the median NT-Pro-Bnp was 3536 [IQR 1700-7748] pg/nl. The mean ejection fraction was 57% (± 5). The prevalence of ATTR-CM diagnosed by bone scintigraphy with PYP was 19% (95%CI 9.7-30.1). No differences were found compared with those patients who did not perform a PYP. CONCLUSION: In patients admitted for heart failure with preserved ejection fraction and septal thickness, the diagnosis of ATTR-CM was relatively common (1/5). We believe that it should be routinely explored.

Introducción: La amiloidosis cardíaca por transtiretina (TTR) se suele presentar como insuficiencia cardiaca (IC) con fracción de eyección preservada. Diagnosticarla tiene impacto clínico, ya que actualmente se dispone de tratamiento específico. El objetivo de este estudio fue evaluar la prevalencia en nuestro medio de TTR en pacientes hospitalizados por IC con función sistólica preservada e hipertrofia septal. Métodos: Estudio de corte transversal. Se incluyeron de forma prospectiva pacientes mayores a 18 años internados por IC con función sistólica conservada (fracción de eyección mayor a 50%) y espesor septal mayor o igual a 12 mm durante el periodo del 8/2019 a 1/2023. El compromiso cardiaco se evaluó mediante un centellograma óseo con pirofosfato (PYP) Se calculó la prevalencia de amiloidosis por TTR y su IC95%. Resultados: Se efectuó un centellograma en 59/82 pacientes. La edad fue de 85 [RIC 78-88] años, el 54% mujeres. Al ingreso, el 61% presentó ritmo de fibrilación/aleteo auricular y una mediana de NT-Pro-Bnp de 3536 pg/ml [RIC 1700-7748 pg/nl]. La media de fracción de eyección fue de 57 (± 5) %. La prevalencia de amiloidosis cardiaca por TTR diagnosticada por centellograma óseo con PYP fue del 19% (IC95% 9,7-30,1). No se detectaron diferencias con los 23 pacientes que no efectuaron centellograma. Conclusiones: En pacientes internados por IC con fracción de eyección preservada y engrosamiento septal el diagnóstico de amiloidosis cardiaca por TTR fue relativamente frecuente (1/5), por lo que consideramos que debería explorarse en forma rutinaria.

Impact of different blood pressure targets on cerebral hemodynamics in septic shock: A prospective pilot study protocol-SEPSIS-BRAIN.

INTRODUCTION: Septic shock, a life-threatening condition, can result in cerebral dysfunction and heightened mortality rates. In these patients, disturbances in cerebral hemodynamics, as reflected by impairment of myogenic cerebral autoregulation (CA), metabolic regulation, expressed by critical closing pressure (CrCP) and reductions in intracranial compliance (ICC), can adversely impact septic shock outcomes. The general recommendation is to maintain a target mean arterial pressure (MAP) of 65 mmHg but the effect of different MAP targets on cerebral hemodynamics in these patients is not clear and optimal targets might be dependent on the status of CA. This protocol aims to assess the cerebral hemodynamics profile at different pressure targets in septic shock patients. METHODS: Prospective, non-randomized, single-center trial, which will study cerebral hemodynamics in patients with septic shock within 48 hours of its onset. Patients will be studied at their baseline MAP and at three MAP targets (T1: 65, T2: 75, T3: 85 mmHg). Cerebral hemodynamics will be assessed by transcranial Doppler (TCD) and a skull micro-deformation sensor (B4C). Dynamic CA will be expressed by the autoregulation index (ARI), calculated by transfer function analysis, using fluctuations of MAP as input and corresponding oscillations in cerebral blood velocity (CBv). The instantaneous relationship between arterial blood pressure and CBv will be used to estimate CrCP and resistance-area product (RAP) for each cardiac cycle using the first harmonic method. The B4C will access ICC by intracranial pressure waveforms (P2/P1). The primary aim is to assess cerebral hemodynamics (ARI, CrCP, RAP, and P2/P1) at different targets of MAP in septic shock patients. Our secondary objective is to assess cerebral hemodynamics at 65mmHg (target recommended by guidelines). In addition, we will assess the correlation between markers of organ dysfunction (such as lactate levels, vasoactive drugs usage, SOFA score, and delirium) and CA. ETHICS AND DISSEMINATION: The results of this study may help to understand the effect of the recommended MAP and variations in blood pressure in patients with septic shock and impaired CA and ICC. Furthermore, the results can assist large trials in establishing new hypotheses about neurological management in this group of patients. Approval was obtained from the local Ethics Committee (28134720.1.0000.0048). It is anticipated that the results of this study will be presented at national and international conferences and will be published in peer-reviewed journals in 2024 and 2025. TRIAL REGISTRATION: Trial registration number: NCT05833607. https://clinicaltrials.gov/study/NCT05833607.

Lack of Anticoagulant Use in Patients with Atrial Fibrillation and Increased Risk of Thromboembolic Events According to Sex: Insights from a Multicentric Brazilian Study. / Falta de Uso de Anticoagulantes em Pacientes com Fibrilação Atrial e Risco Aumentado de Eventos Tromboembólicos de Acordo com o Sexo: Insights de um Estudo Multicêntrico Brasileiro.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and its presentation differs according to age and sex. Recent studies have revealed differences in AF among various demographic groups, including the Latin American population. OBJECTIVES: To better understand potential disparities in AF prevalence and treatment strategies in the Brazilian population through data from a large multicentric prospective registry. METHODS: The Rede D'Or AF registry is a multicenter prospective observational study including patients aged ≥ 18 years with AF who were seen in the emergency department of 32 tertiary hospitals in Brazil. Patients were characterized according to sex and other baseline characteristics and were classified according to previous anticoagulant use. The lack of anticoagulant use in patients with previous indications was analyzed. Statistical significance was set at 5%. RESULTS: The study data were from a total of 1955 patients enrolled. Male sex was more prevalent, and men were younger than the women. Due to an increased prevalence of previous AF episode and a higher CHA2DS2-VASc score, more women had indications for anticoagulant therapy; however, a significant proportion was not receiving this treatment. From 29 in-hospital deaths, 15 patients had previous indication for anticoagulation, but only 3 were using anticoagulants. CONCLUSION: This study revealed sex-related differences in the Brazilian population of patients with AF that are consistent with trends in high-income countries. The promotion of better implementation of anticoagulant and antithrombotic therapies to reduce the risk of death and thromboembolic events among women with AF in Brazil is crucial.

FUNDAMENTO: A fibrilação atrial (FA) é a arritmia cardíaca mais prevalente e sua apresentação difere de acordo com a idade e o sexo. Estudos recentes revelaram diferenças na FA entre vários grupos demográficos, incluindo a população latino-americana. OBJETIVOS: Melhor compreender as possíveis disparidades na prevalência da FA e nas estratégias de tratamento na população brasileira por meio de dados de um registro prospectivo multicêntrico de grande escala. MÉTODOS: O registro de FA da Rede D'Or é um estudo observacional prospectivo multicêntrico que incluiu pacientes com idade ≥ 18 anos com FA atendidos no pronto-socorro de 32 hospitais terciários no Brasil. Os pacientes foram caracterizados de acordo com o sexo e outras características basais e classificados de acordo com o uso prévio de anticoagulantes. Foi analisada a falta de uso de anticoagulantes em pacientes com indicações prévias. A significância estatística foi estabelecida em 5%. RESULTADOS: Os dados do estudo foram provenientes de um total de 1.955 pacientes inscritos. O sexo masculino foi mais prevalente e os homens eram mais jovens que as mulheres. Devido ao aumento da prevalência de episódios anteriores de FA e a um escore CHA2DS2-VASc mais elevado, mais mulheres tiveram indicação de terapia anticoagulante; no entanto, uma proporção significativa não estava recebendo esse tratamento. Dos 29 óbitos intra-hospitalares, 15 pacientes tinham indicação prévia para anticoagulação, mas apenas 3 estavam em uso de anticoagulantes. CONCLUSÃO: O presente estudo revelou diferenças relacionadas ao sexo na população brasileira de pacientes com FA que são consistentes com tendências em países de alta renda. A promoção de uma melhor implementação de terapias anticoagulantes e antitrombóticas para reduzir o risco de óbito e eventos tromboembólicos entre mulheres com FA no Brasil é crucial.