Cirrhotic cardiomyopathy: Pathogenesis, clinical features, diagnosis, treatment and prognosis.

Cardiac dysfunction among cirrhotic patients has long been recognized in the medical community. While it was originally believed to be a direct result of alcohol toxicity, in the last 30 years cirrhotic cardiomyopathy (CCM) has been described as a syndrome characterized by chronic cardiac dysfunction in cirrhotic patients in the absence of known cardiac disease, regardless of the etiology of cirrhosis. CCM occurs in about 60% of patients with cirrhosis and plays a critical role in disease progression and treatment outcomes. Due to its predominantly asymptomatic course, diagnosing CCM is challenging and requires a high index of suspicion and a multiparametric approach. Patients with CCM usually present with the following triad: impaired myocardial contractile response to exercise, inadequate ventricular relaxation, and electrophysiological abnormalities (notably prolonged QT interval). In recent years, research in this area has grown expeditiously and a new set of diagnostic criteria has been developed by the Cirrhotic Cardiomyopathy Consortium, to properly identify patients with CCM. Nevertheless, CCM is still largely unknown among clinicians, and a major part of its pathophysiology and treatment is yet to be understood. In the present work, we aim to compile and summarize the available data on the pathogenesis, clinical features, diagnosis, treatment, and prognosis of CCM.

Custo-Efetividade de Diferentes Tratamentos Minimamente Invasivos Para Disfunção Temporomandibular de Origem Articular sob a Perspectiva do Sistema Público de Saúde Brasileiro.

OBJECTIVE: This study aimed to evaluate the cost-effectiveness (CE) of minimally invasive interventions for pain associated with articular temporomandibular dysfunction from the Brazilian Public Health System (SUS) perspective. METHODS: This is a CE study with a 1-year time horizon. Effectiveness data were extracted from a network meta-analysis, and 2 treatments with moderate levels of evidence certainty were evaluated: arthrocentesis (ARTRO) plus intra-articular corticosteroid (CO) injection and ARTRO plus intra-articular injection of sodium hyaluronate (SH). For CE analysis, the costs of 2 types of SH (low and high molecular weight) and 4 COs (betamethasone [B], dexamethasone acetate [D], methylprednisolone sodium succinate [M], or triamcinolone hexacetonide [T]) were considered. Modeling was conducted using TreeAge Pro Healthcare software, with the construction of a decision tree representing a hypothetical cohort of adults with articular temporomandibular dysfunction. Deterministic and probabilistic sensitivity analyses were performed. In addition, an acceptability curve was developed. RESULTS: The total costs per joint for ARTRO plus low- and high-molecular-weight SH and ARTRO plus COs B, D, M, and T were, respectively, R$583.32, R$763.85, R$164.39, R$133.93, R$138.57, and R$159.86. ARTRO plus dexamethasone acetate was considered cost-effective, with lower cost and higher net monetary benefit than other technologies. In all sensitivity analysis scenarios, it remained cost-effective. It also showed greater acceptability. CONCLUSION: ARTRO plus dexamethasone acetate was considered the cost-effective technology, exhibiting higher net monetary benefit and higher acceptability from the SUS perspective.

Custo Direto do Tratamento do Acidente Vascular Cerebral Isquêmico na Perspectiva de um Hospital Público Terciário (Direct Cost of Treating Ischemic Stroke From the Perspective of a Tertiary Public Hospital).

OBJECTIVES: To measure the direct cost of treating acute ischemic stroke (IS) from the perspective of a public hospital in Brazil (HCFMB) and compare it with the reimbursement by the Unified Health System (SUS), through the Procedure Table Management System, Medicines, Orthoses/Prostheses and Special Materials of the Unified Health System (SIGTAP). METHODS: We performed a micro-costing study; four scenarios were evaluated: standard (1); alteplase (2); alteplase and mechanical thrombectomy (3); mechanical thrombectomy (4). Based on the number of patients hospitalized for ischemic stroke in 2019, hospital cost, and SUS billing were calculated for each scenario. Hospital costs were adjusted for inflation using CCEMG-EPPI-Centre Cost Converter. RESULTS: In 2019, 258 patients were hospitalized due to IS, 89.5% in scenario 1, 8% in scenario 2, 1.5% in scenario 3, 1% in scenario 4. From the hospital's perspective, the cost per patient was estimated at R$7780.13, R$15 741.23, R$28 988.49, R$25 739.79, for scenarios 1, 2, 3 and 4, respectively. The reimbursement by SIGTAP was estimated at R$3079.87, R$5417.21, R$10 901.92, R$10 286.28, respectively. If thrombectomy had been included in the SIGTAP, the last two values would be R$25 393.34 and R$24 248.89. CONCLUSIONS: The hospital cost of treating acute IS in 2019 was estimated at R$2 295 209, the SUS reimbursement at R$889 391.54. With the inclusion of thrombectomy at SIGTAP, this reimbursement would be R$975 282.44, and the loss in the cost of HCFMB per patient in relation to reimbursement by the SUS is greater in scenarios without this procedure.

Sex-related differences in ST-segment elevation myocardial infarction: A Portuguese multicenter national registry analysis.

INTRODUCTION AND OBJECTIVES: Sex differences among patients with acute myocardial infarctions remain a matter of debate. Inequalities in presentation, diagnosis, treatment, and prognosis are frequently observed, contributing to a worse prognosis in women. The aim of this study was to investigate sex-related differences in Portuguese ST-segment elevation myocardial infarction (STEMI) patients. METHODS: The authors conducted a retrospective analysis of STEMI patients included in the Portuguese Registry on Acute Coronary Syndromes, between October 2010 and 2022. The two co-primary endpoints were in-hospital and one-year mortality. RESULTS: A total of 14470 STEMI patients were studied. Women were underrepresented with 3721 individuals (25.7%). They were significantly older (70 vs. 62 years, p<0.001), with higher prevalence of cardiovascular risk factors, and underwent less frequently coronary angiography (84.4% vs. 88.5%, p<0.001) and guideline-directed medical therapy (e.g., aspirin 92.5% vs. 95.4%, beta blockers 79.2% vs. 83%, p<0.001). Furthermore, they experienced more complications, such as congestive heart failure (23.4% vs. 14.6%), ischemic stroke (47% vs. 40%), and in-hospital mortality (8.5% vs. 4.1%) (p<0.001 for all comparisons). Similarly, they presented higher one-year mortality (11.5% vs. 6.3%, p<0.001). However, after a multivariate analysis testing significant clinical variables, female sex remained an independent predictor for in-hospital (odds ratio=1.633; 95% CI [1.065-2.504]; p=0.025), but not for one-year mortality. CONCLUSIONS: This analysis reveals sex-related disparities in Portuguese STEMI patients. Despite limitations inherent to registry-based analysis, women were significantly older, with increased cardiovascular risk, less treated, and with higher in-hospital mortality. These disparities should be a concern for clinicians to further improve outcomes and move toward equitable medical care.

The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center.

INTRODUCTION AND OBJECTIVES: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. METHODS: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. RESULTS: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. CONCLUSION: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

Myocardial infarction with non-obstructive coronary arteries: Etiology, diagnosis, treatment and prognosis.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is responsible for 10% of myocardial infarctions. Previously, patients were thought to have good prognosis, but evidence-based management and treatment strategies were scarce. Today, researchers and physicians recognize MINOCA as a condition with non-trivial mortality and morbidity. Therapeutic strategies are highly dependent on the underlying disease mechanism in each patient. However, to reach a diagnosis of MINOCA, a multimodal approach is required and, even with an optimal work-up, the cause remains unknown in 8-25% of patients. Research has been growing and position papers from the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology have been published, and MINOCA has been included in the more recent ESC guidelines on myocardial infarction. Nonetheless, some clinicians still assume that the absence of coronary obstruction excludes the possibility of acute myocardial infarction. Therefore, in the present paper, we aim to compile and present the available data on the etiology, diagnosis, treatment, and prognosis of MINOCA.

Expert perspectives on strategic factors for the management and prevention of heart failure in Portugal.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) has significant morbidity and mortality, and its prevalence will continue to increase in the future. This unfavorable evolution requires reflection as well as recommendations and decisions based on expert critical and strategic appraisal. METHODS: In the Acceleration on Heart Failure Empowerment and Awareness - the Portuguese Challenge (ATHENA-PT) study, a range of strategic factors that represent the strengths, weaknesses, threats, and opportunities (SWOT) of HF in Portugal were established. These factors were assessed quantitatively by experts, to create a final SWOT matrix for the management and prevention of HF in Portugal and to outline recommendations. RESULTS: For HF management, the panel emphasized the following strategic recommendations: (i) reimbursement of natriuretic peptides testing in primary healthcare; (ii) reimbursement of Doppler assessment in echocardiographic studies and promotion of detailed information in reports; (iii) intervention to improve the prognosis of patients with HF with preserved ejection fraction; (iv) ensuring effective healthcare transition between hospital and ambulatory units, using checklists/protocols; and (v) reinforcement and commitment to the training of primary health physicians and to the cardiac rehabilitation of patients. For the prevention of HF, the following recommendations/proposals were proposed: (i) campaigns to raise awareness of cardiovascular disease risk factors; (ii) promotion of physical exercise and healthy eating; and (iii) avoidance of therapeutic inertia in the management of risk factors. CONCLUSIONS: The acknowledgment of various strategic factors and their prioritization by experts made it possible to create and reinforce a range of new strategic recommendations for the management and prevention of HF.

Septic cardiomyopathy: A narrative review.

Sepsis is a systemic inflammatory response syndrome of suspected or documented infectious origin, whose outcome is multiorgan failure. Sepsis-induced myocardial dysfunction (SIMD), present in more than 50% of septic patients, is characterized by (i) left ventricular (LV) dilatation with normal or low filling pressure, (ii) right and/or LV (systolic and/or diastolic) dysfunction and (iii) reversibility. Since the first definition proposed by Parker et al. in 1984, attempts have been made to define SIMD. Many parameters are used to assess cardiac function in septic patients, sometimes making it more difficult to measure due to the intrinsic hemodynamical changes in this condition. Nevertheless, with advanced echocardiographic techniques, such as speckle tracking analysis, it is possible to diagnose and assess systolic and diastolic dysfunction, even in the earliest stages of sepsis. Cardiac magnetic resonance imaging brings new insights into the reversibility of this condition. Many uncertainties still remain regarding the mechanisms, characteristics, treatment and even prognosis of this condition. There are also inconsistent conclusions from studies, therefore this review attempts to summarize our current knowledge of SIMD.

conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT).

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future. METHODS: A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses. RESULTS: Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses. CONCLUSION: This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Blueprint for developing an effective pulmonary embolism response network.

INTRODUCTION: Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in Portugal. It is the third most common cause of cardiovascular death after stroke and myocardial infarction. However, the management of acute PE remains poorly standardized, and there is a lack of access to mechanical reperfusion when indicated. METHODS AND RESULTS: This working group analyzed the current clinical guidelines for the use of percutaneous catheter-directed treatment in this setting and proposed a standardized approach for severe forms of acute PE. This document also proposes a methodology for the coordination of regional resources in order to create an effective PE response network, based on the hub-and-spoke organization design. CONCLUSION: This model can be applied at the regional level, but it is desirable to extend it to the national level.

Aortic annulus rupture with fistula to the right ventricle following aortic valve replacement with a sutureless valve: A surgical complication with a percutaneous solution.

With the development of interventional procedures, iatrogenic aorto-right ventricular fistulae are increasingly reported. They may follow surgical aortic valve replacement or percutaneous aortic valve implantation, leading to high morbidity. Traditionally, treatment of fistulae was based on surgical repair, but with advances in endovascular technologies, more emphasis is now placed on percutaneous closure. We report the case of a 78-year-old patient with severe symptomatic aortic stenosis who underwent surgical aortic valve replacement with a Perceval sutureless valve. One month later, he presented with symptoms and signs of heart failure. Transthoracic and transesophageal echocardiography confirmed the presence of a aorto-right ventricular fistula. The fistula was successfully closed percutaneously with an Amplatzer Vascular Plug II, in an intracardiac echocardiography-guided procedure. Aorto-right ventricular fistula is a rare finding after surgical aortic valve replacement and to our knowledge it has never been associated with sutureless aortic valve replacement. A percutaneous procedure with an appropriately selected device may be encouraged because of the high morbidity and mortality of redo open-heart surgery. To minimize the risk of a second general anesthesia, the use of intracardiac echocardiography to guide the percutaneous procedure is feasible and safe.

Continuous Aspiration Mechanical Thrombectomy for the management of intermediate- and high-risk pulmonary embolism: Data from the first cohort in Portugal.

INTRODUCTION: This study describes the experience of a reference center using continuous aspiration mechanical thrombectomy for acute high- and intermediate-high-risk pulmonary embolism (PE). METHODS: Twenty-nine consecutive patients with acute central PE (48.3% high-risk PE; 82.8% in class >III from the original Pulmonary Embolism Severity Index score; median Charlson Comorbidity Index of 4) were treated with the Indigo® Mechanical Thrombectomy System between March 2018 and March 2020. Technical success was defined as successful placement of the device and initiation of aspiration thrombectomy. Clinical success was defined as any improvement in hemodynamic and/or oxygenation parameters, pulmonary hypertension or right heart strain at 48 hours, and survival to hospital discharge. Safety was defined as freedom from severe adverse events potentially related to the procedure. Three-month follow-up results were collected. RESULTS: Technical success was 96.6%. Miller index and systolic pulmonary arterial pressure were significantly reduced after the procedure (-5.5±3.0, and -10.2±11.5 mmHg, respectively, both p<0.001). There was a significant improvement in mean paO2/FiO2 ratio (+77.1±103.2; p=0.001), shock index (-0.4±0.4; p<0.001), need for aminergic support at 48 h after the procedure (-75.0%, p=0.006) and improvement in right ventricular function in 66.6% (p=0.008). Clinical success was 75.9%. Severe adverse event rate was 10.3%: two deaths during the procedure and one pulmonary macroembolization during device progression. In-hospital and three-month survival rates were 82.8% and 72.4%, respectively. CONCLUSIONS: Aspiration thrombectomy for acute high- and intermediate-high-risk PE is feasible with a high technical and clinical success rate. Nevertheless, all-cause mortality is still high, probably related to the baseline high-risk features of the studied population and associated comorbidities.

Antiplatelet therapy at discharge and long-term prognosis in Takotsubo syndrome: Insights from the Spanish National Registry (RETAKO).

INTRODUCTION: Endothelial dysfunction and platelet activation have been highlighted as possible mediators in Takotsubo syndrome (TTS). Nevertheless, to date, evidence on the usefulness of antiplatelet therapy in TTS remains controversial. The aim of our study is to evaluate long-term prognosis in TTS patients treated with antiplatelet therapy (APT) at hospitalization discharge. MATERIAL AND METHODS: An ambispective cohort study from the Spanish National Takotsubo Registry database was performed (June 2002 to March 2017). Patients were divided into two groups: those who received APT at hospital discharge (APT cohort) and those who did not (non-APT cohort). Primary endpoint was all-cause death. Secondary endpoints included the composite of recurrence or readmission and a composite of death, recurrence or readmission. RESULTS: From a total of 741 patients, 728 patients were alive at discharge. Follow-up was performed in 544 patients, who were included in the final analysis: 321 patients (59.0%) in the APT cohort and 223 patients (41.0%) in the non-APT cohort. The APT cohort had a better clinical presentation and received more heart failure and acute coronary syndrome-like therapies (angiotensin converting enzyme inhibitors/angiotensin receptor blockers: 75.1% vs. 51.1%; p<0.001, betablockers: 71.3% vs. 50.7%; p<0.001, statins: 67.9% vs. 33.2%; p<0.001). After adjusting for confounder factors, APT at discharge was a protective factor for all-cause death (adjusted hazard ratio (HR) 0.315, 95% confidence interval (CI): 0.106-0.943; p=0.039) and the composite endpoint of all-cause death, recurrence or readmission (adjusted HR 0.318, 95% CI: 0.164-0.619; p=0.001) at month 25 of follow-up. CONCLUSION: Patients with TTS receiving APT at discharge presented better prognosis up to two-years of follow-up compared with their counterparts not receiving APT.

Advances in hypertrophic cardiomyopathy: What the cardiologist needs to know.

Hypertrophic cardiomyopathy (HCM) is known as the most common genetic heart disease, characterized by otherwise unexplained left ventricular (LV) hypertrophy. In spite of major advances in whole genome sequence techniques, it is still not possible to identify the causal mutation in approximately half of HCM patients. Consequently, a new HCM concept, "beyond the sarcomere" is being developed, supported by data from recent HCM registries which reveal two distinct HCM subgroups: sarcomere positive HCM subgroup and nonfamilial HCM subgroup. Sarcomere positive HCM patients tend to be younger age at diagnosis, have fewer co-morbidities, present more often with reverse septal morphology, more myocardial fibrosis, less LV outflow tract obstruction, and a worse prognosis when compared to nonfamilial HCM patients. These subgroups, with different molecular basis, phenotypes and clinical profiles, will likely require specific management strategies. Important research advances have also been made concerning diagnosis, sudden cardiac death stratification and therapy. In this article, we seek to review recent relevant knowledge, summarizing the advances in this complex and heterogeneous disease.

Transgressions of innate moral codes - transgressions in service of the Self.

Beginning with a discussion of transgressions against innate, archetypal moral codes, I also present those transgressions carried out in service of the Self. While both represent an affront to a universal moral code, the latter often furthers an individual's relationship to the Self. These themes are illustrated through the stories of Pontius Pilate, Jephthah, Il Padrino - the Godfather, then coupled with clinical vignettes. An important theme throughout this paper concerns humanity's ongoing hunger to expiate guilt through the practices of scapegoating, sin-eating and confession. While these practices promise redemption, each seriously fails through their reluctance to address the unconscious recognition and consequences of transgressions.

Commençant par une discussion sur les transgressions des codes moraux innés et archétypaux, je présente aussi les transgressions effectuées au service du Soi. Alors que ces deux formes représentent une offense au code moral universel, la deuxième forme fait souvent avancer la relation d'un individu avec le Soi. Ces thèmes sont illustrés par les histoires de Ponce Pilate, de Jephté, d'Il Padrino - le Parrain, puis couplés à des vignettes cliniques. Un thème important tout au long de cet article concerne l'appétit constant de l'humanité pour expier sa culpabilité à travers l'utilisation du bouc-émissaire, du mangeur de péchés, ou de la confession. Alors que ces pratiques promettent la rédemption, chacune d'elle est sérieusement défaillante de par sa répugnance à s'occuper de la reconnaissance inconsciente et des conséquences des transgressions.

Comienzo con una discusión acerca de las transgresiones de los códigos morales, innatos, arquetípales. También presento aquellas transgresiones realizadas al servicio del Self. Mientras ambas representan una afrenta a un código moral universal, la última a menudo favorece la relación individual con el Self. Estos temas son ilustrados a través de historias de Poncio Pilato, Jephthah, el Padrino II, articulándolas con viñetas clínicas. Un tema importante a través del artículo concierne el constante anhelo de la humanidad de expiar la culpa a través de prácticas del chivo expiatorio, el pecado y la confesión. Mientras estas prácticas prometen la redención, cada una fracasa seriamente debido a la reluctancia a reconocer el inconsciente y las consecuencias de las transgresiones.

Começando com uma discussão sobre transgressões contra códigos morais inatos e arquetípicos, também apresento essas transgressões realizadas a serviço do Si Mesmo. Embora ambos representem uma afronta a um código moral universal, este último muitas vezes promove a relação de um indivíduo com o Si Mesmo. Esses temas são ilustrados através das histórias de Pôncio Pilatos, Jefté, Il Padrino - o Poderoso Chefão, então juntamente com vinhetas clínicas. Um tema importante ao longo deste artigo diz respeito à fome contínua da humanidade de expiar culpa através das práticas de bode expiatório, pecado e confissão. Embora essas práticas prometam redenção, cada uma falha seriamente por sua relutância em abordar o reconhecimento do inconsciente e as consequências das transgressões.

[Consensus on HPV of the Portuguese Society of Andrology, Sexual Medicine and Reproduction: Treatment]. / Consensos em HPV Masculino da Sociedade Portuguesa de Andrologia, Medicina Sexual e Reprodução: Tratamento.

The treatment of condyloma is generally a challenge in clinical practice. Although the spontaneous resolution rate is high, a significant proportion of patients seek treatment, not because of symptomatology, but mainly for aesthetic issues and concerns related to the transmission or worsening of existing lesions. The available treatments should be applied only for clinically evident macroscopic lesions. Ideally, available therapies should have rapid action onset and clearance, resolve symptoms, reduce recurrence rate and viral load, be effective in treating small lesions, and be well tolerated. However, none of the currently available treatments is clearly more effective than the others and there is no ideal treatment for all patients or for all condyloma. Therefore, the therapeutic decision should be based on the clinician's experience, available resources, lesion morphology, size, number and location, primary or recurrent lesions, disease severity, patient preference and expectations, patient's immune competence, convenience, tolerance, cost of treatment and results of previous therapies. The available treatments are divided into three groups: applied by the patient himself (imiquimod 3.75 or 5%, podophyllotoxin .5%, synecatekines 10% or 15%), applied by the health care provider (bi- and tricloacetic acids 80%-90%, intralesional interferon alpha, cryotherapy, surgical removal, electrofulguration, laser ablation) and experimental or alternative therapies (topical cidofovir, intralesional bleomycin, photodynamic therapy). Treatment methodologies can be further divided into their action - ablative or destructive treatment (cryotherapy, electrofulguration, laser ablation, surgical excision), cytotoxic or proapoptotic treatments (podophyllotoxin .5%, 5-fluoruracil, bleomycin) and immunomodulatory treatments (imiquimod 3.75% or 5%, synecatekines 10% or 15%, intralesional interferon alpha). The overall success rate of the various treatments available ranges from 23% to 94%. Only treatments that include cryotherapy or surgical excision are suitable in condyloma with any anatomical location and that have the highest success rate in monotherapy. Recurrences are common regardless of the treatment received. In contrast, immunomodulatory therapies despite having lower initial clearance rates appear to have higher probabilities of cure in the medium term, with low recurrence rates. Some treatments may be combined with each other and the effectiveness of combined therapies appears to be superior to monotherapy (proactive sequential treatment). The consensuses for the treatment of HPV also consider special situations: immunocompromised patients, meatus and intraurethral lesions and treatment of the partner.

Optimization of heart failure with reduced ejection fraction prognosis-modifying drugs: A 2021 heart failure expert consensus paper.

Heart failure (HF) with reduced ejection fraction (HFrEF) is associated with high rates of hospitalization and death. It also has a negative impact on patients' functional capacity and quality of life, as well as on healthcare costs. In recent years, new HFrEF prognosis-modifying drugs have emerged, leading to intense debate within the international scientific community toward a paradigm shift for the management of HFrEF. In this article, we report the contribution of a Portuguese HF expert panel to the ongoing debate. Based on the most recently published clinical evidence, and the panel members' clinical judgment, three key principles are highlighted: (i) sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; (ii) the four foundation HFrEF drugs are the angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, regardless of the presence of type-2 diabetes mellitus; (iii) these four HFrEF drug classes should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks.

Optimization of heart failure with reduced ejection fraction prognosis-modifying drugs: A 2021 heart failure expert consensus paper.

Heart failure (HF) with reduced ejection fraction (HFrEF) is associated with high rates of hospitalization and death. It also has a negative impact on patients' functional capacity and quality of life, as well as on healthcare costs. In recent years, new HFrEF prognosis-modifying drugs have emerged, leading to intense debate within the international scientific community toward a paradigm shift for the management of HFrEF. In this article, we report the contribution of a Portuguese HF expert panel to the ongoing debate. Based on the most recently published clinical evidence, and the panel members' clinical judgment, three key principles are highlighted: (i) sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; (ii) the four foundation HFrEF drugs are the angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, regardless of the presence of type-2 diabetes mellitus; (iii) these four HFrEF drug classes should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks.

Tuberculosis in childhood and adolescence: a view from different perspectives.

OBJECTIVE: To describe the epidemiological situation of tuberculosis in children under 19 years of age in Brazil and to review the latest publications on disease risk, diagnosis, treatment, and prevention. SOURCE OF DATA: Notifiable Diseases Information System (2018), World Health Organization estimates, and PubMed articles selected using the descriptor "Tuberculosis," delimited by type of study, period, age, and language. SYNTHESIS OF DATA: In 2018, in Brazil, 9.4% of notifications were in children under 19 years. The pulmonary form predominated in 80.1% of the cases. The cure rate was 76.8%, lethality was 0.8%, and abandonment was 10.4%. The prevalence of drug-resistant tuberculosis (2011-2016) was 0.5%. It has been found that the risk of disease can reach up to 56% in children under 5 years, influenced by helminth co-infections, malaria, chronic viral infections, live attenuated virus vaccines, and hypovitaminosis D. Exposure to a bacilliferous patient for periods shorter than 30minutes is sufficient for the development of infection and/or disease. In Brazil, microbiological screening is recommended, but the use of the scoring system, modified in 2019, has been maintained. Studies on infection detection have supported the use of the tuberculin skin test. In the treatment, the great advance was the introduction of dispersible formulations, adjustment of the recommended doses, and shortened regimens for latent infection. Several vaccine studies (stages 1-3) are ongoing, but no BCG-licensed substitute has been implemented yet. CONCLUSIONS: There has been progress in treatment, but major challenges need to be overcome to improve diagnosis, monitoring, and outcome of cases, aiming to eliminate tuberculosis.

Viral encephalitis: a practical review on diagnostic approach and treatment.

OBJECTIVES: To review the diagnostic criteria for encephalitis and encephalopathy of presumed infectious etiology, as well as the diagnostic workup for viral encephalitis and its treatment approaches. The authors also intended to summarize relevant information on specific viruses frequently found in Brazil. SOURCE OF DATA: Literature search on Pubmed/MEDLINE using the following keywords: "viral", "encephalitis", "child", or "adolescents", filtering for articles on humans and in English. SUMMARY OF DATA: Viral encephalitis is the most common cause of encephalitis and is responsible for high rates of morbidity, permanent neurologic sequelae, and according to the virus, may have high mortality rates. The most common etiologies are herpesviruses 1 and 2 (HSV-1 and HSV-2), non-polio enterovirus, and arboviruses (in Brazil, dengue, Zika, and chikungunya). Other relevant etiologies are seasonal influenza, cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), and the re-emergent measles. CONCLUSION: Clinical data, laboratory results, and neuroimaging findings support the diagnosis of encephalitis and the specific viral etiology. To increase the likelihood of etiologic confirmation, it is important to know the best approach to collecting samples and to choose the best identification technique for each virus. The differential diagnosis of viral encephalitis includes other infections and immune-mediated inflammatory central nervous system disorders.