Successful embolization of a clinically significant pulmonary arteriovenous malformation.

The authors present the clinical case of a 59-year-old female patient with a history of peripheral desaturation, which was detected in the perioperative period 4 years earlier. She reported exertional dyspnea, quantified as grade 2 on the Modified Medical Research Council (mMRC) Dyspnea Scale (walks slower than people of the same age because of dyspnea or has to stop for breath when walking at her own pace), and morning cough with mucoid sputum and denied platypnea, epistaxis, telangiectasias and hemoptysis. A computed chest tomography scan revealed a contrast-enhanced lesion on the right upper lobe with an afferent and two efferent vessels compatible with pulmonary arteriovenous malformation. The transesophageal echocardiogram revealed an important right-left shunt compatible with arteriovenous fistula in the pulmonary circulation. An angiography confirmed the diagnosis and a selective embolization of the afferent artery was performed with resolution of symptoms.

The impact of patient and public involvement in chronic respiratory disease research: the ConectAR experience.

ConectAR has demonstrated the feasibility and value of involving patients with chronic respiratory diseases and caregivers as co-researchers, actively considering their perspectives from project inception to implementation and dissemination https://bit.ly/3Oq13se.

Public involvement in chronic respiratory diseases research: A qualitative study of patients', carers' and citizens' perspectives.

INTRODUCTION: Patient and public involvement (PPI) initiatives involving patients with chronic respiratory disease (CRD) are rare. Therefore, this study aimed to explore the perspectives of patients with CRD, carers and interested citizens regarding the relevance and need for a PPI network and suggestions for its implementation. METHODS: A qualitative study based on focus groups was conducted. Recruitment occurred through invitations on social media platforms and to patients who have participated in previous asthma studies of the team. Three focus groups were conducted, via video conference, using a semi-structured guide. Thematic analysis was performed by two independent researchers and discussed with the extended team. RESULTS: Fifteen patients with CRD, one carer and one interested citizen (13 females, median 36 (range: 18-72) years) participated. All participants acknowledged the importance of implementing a collaborative network and demonstrated interest in being integrated. Participants acknowledged the importance of their involvement in several phases of the research cycle. The main aim identified for this network was to facilitate communication between patients and researchers. Participants regarded the integration of patients, carers, researchers and healthcare professionals from different scientific areas as relevant. The use of digital platforms to attract members and support the work, together with group dynamics and regular meetings, were some of the most relevant practical considerations for implementing the network. The identified facilitators for their engagement were sharing experiences, researchers' and healthcare professionals' support and feedback and schedule flexibility. The identified barriers included the amount of time dedicated, low health/digital literacy and the potential detachment of nondiagnosed patients or those with low symptom impact in daily life. CONCLUSION: Patients, carers and citizens acknowledged the relevance of implementing a collaborative network and demonstrated interest in active participation in every stage of the health research cycle. A deeper knowledge of the barriers and facilitators identified in this study could support implementing these initiatives in Portugal. PATIENT OR PUBLIC CONTRIBUTION: This study was designed by a research team that included one patient with asthma and one carer. They were specifically involved in building the study protocol and the interview guide. They also gave feedback regarding the electronic consent form and the short sociodemographic questionnaire created, namely by removing noncontributing words or phrases and rewording expressions. The lay summary was written by another patient with asthma. All participants of this study were invited to implement and integrate the ConectAR network-a collaborative network of research in respiratory health. PUBLIC SUMMARY: In Portugal, chronic respiratory patients do not have an active role as 'coinvestigators'. This study aimed to acknowledge if patients and citizens considered a patient and public involvement network useful, whose main purpose would be to facilitate communication between patients and researchers. A study based on online group interviews was carried out with patients with chronic respiratory diseases and interested citizens, both recruited on social media platforms. Participants considered that bringing together patients, carers, researchers and healthcare professionals is valuable because sharing different experiences and perspectives may help patients to improve their daily lives and increase research quality. In conclusion, patients agree that implementing a collaborative network with researchers and healthcare professionals and participating in the health research cycle is quite preponderant. Acknowledging what can help and deter this network may be beneficial to implementing this type of initiative in Portugal.

Trace metals enrichment and potential ecological risk in sediments of the Sepetiba Bay (Rio de Janeiro, SE Brazil).

The Sepetiba Bay (SB; SE Brazil) has been severely affected by growing of urbanization and industrial activity. This work aims to analyze the evolution of contamination by metals of sediments in SB. The results show a marked increasing trend in the concentrations of potentially toxic elements (PTEs), which is consistent with the rapid populational and industrial growth, mostly since 1970 CE. The remobilization and redistribution of sediments by currents have contributed to the dispersion of metals from the main source of pollutants to relatively distant regions. "Moderately to strongly polluted" sediments are also recorded in some sites in deeper sedimentary layers (namely in preindustrial periods), probably due to lithologic sources of the sediments. The concentrations of PTEs in SB are relatively high when compared with those found globally and in other Brazilian water bodies. Samples of high-resolution sediment cores confirmed that potential ecological risk to the coastal system is influenced not only through human actions but also by natural causes.

From Assessing Risk Factors to Understanding, Preventing, and Treating Cardiovascular Diseases: an Urgent Journey.

Based on the abundant published literature, here we expand the understanding of cardiovascular diseases in a framework already presented in previous articles. In this context, some unique distinguishing features of vascular lesions are explained. A rationale for the role of apolipoprotein apoB100 is presented. It is hypothesized that K⊂ATP⊂ channels and their control by blood pH are behind the development of coronary artery spasm and cardiomyocyte death. Finally, the main cardiovascular risks are explained within the proposed framework.

Cardiovascular Complications of COVID-19 Infection.

INTRODUCTION: Reports of cardiovascular complications related to the COVID-19 infection have been frequent. METHODS: Narrative review for relevant articles on the topic. The classic cardiovascular risk factors, like age, obesity, diabetes, and hypertension are associated with adverse outcomes in COVID-19 patients. Cardiovascular complications can have a diverse clinical presentation including silent myocardial injury, acute coronary syndromes, thromboembolism, cardiac arrhythmias, and heart failure. There are multiple mechanisms of cardiac injury that are not mutually exclusive. The approach to diagnosis and management should be carried out according to usual practice, while considering the particularities of COVID-19 infection. CONCLUSION: The interaction between SARS-CoV-2 and the heart is complex and is manifested in multiple ways. Regardless of the clinical presentation, cardiac complications convey a worse prognosis. Patients should be actively monitored and treated accordingly.

Introdução: As complicações cardiovasculares associadas a infeção por COVID-19 têm sido frequentemente reportadas. Métodos: Revisão da literatura sobre os artigos relevantes neste tópico. Os fatores de risco cardiovasculares clássicos como idade, obesidade, diabetes e hipertensão foram associados a um risco maior de evolução desfavorável. As complicações cardiovasculares podem ter uma apresentação clínica variável incluindo lesão miocárdica, síndrome coronário agudo, trombo-embolismo, arritmias e insuficiência cardíaca. Estão descritos múltiplos mecanismos de lesão cardíaca os quais não são mutualmente exclusivos. A abordagem diagnóstica e terapêutica deve seguir a prática comum tendo, no entanto, em consideração as particularidades da infeção por COVID-19. Conclusão: A interação entre a infeção por COVID-19 e o coração é complexa e manifesta-se de várias formas. Independentemente da apresentação clínica, as complicações cardíacas conferem um prognostico desfavorável pelo que devem ser monitorizadas ativamente e tratadas de forma apropriada.

How Sustained is Roux-en-Y Gastric Bypass Long-term Efficacy? : Roux-en-Y Gastric Bypass efficacy.

PURPOSE: The rate of weight regain after Roux-en-Y Gastric Bypass (RYGB) can hamper the procedure long-term efficacy for obesity treatment and related comorbidities. To evaluate the rate of weight loss and comorbidity remission failure 10 years or more after RYGB surgery. MATERIALS AND METHODS: Retrospective observational cohort study. Patients submitted to RYGB for obesity treatment at a single centre with 10 years or more after surgery underwent a clinical reassessment. RESULTS: Among the subjects invited for clinical revaluation (n = 585), only those who performed RYGB and attended the hospital visit were included in the study (n = 281). The pre-operative mean body mass index (BMI) was 44.4 ± 6.1 kg/m2. Mean post-operative time was 12.2 ± 1.1 years. After surgery, mean BMI was significantly lower 33.4 ± 5.8 kg/m2 (p < 0.0001), 29.5% with a BMI < 30 kg/m2. Mean Total Weight Lost (%TWL) was 24.3 ± 11.4%, reaching a %TWL ≥ 20% in 70.1% with a mean %TWL of 30.0 ± 7.0%. Co-morbidities remission rate was 54.2% for type 2 diabetes, 34.1% for hypertension, 52.4% for hyperlipidemia and 50% for obstructive sleep apnea. Early complications rate was 13.2% and revision surgery occurred in 2.8% of patients. Four patients died of RYGB complications within the first 90 days after surgery. CONCLUSION: RYGB has a high rate of long-term successful weight loss and obesity-associated comorbidity improvement. Weight loss failure requiring revision surgery occurs in a small proportion of patients. Our data confirms the long-term effectiveness of RYGB as primary bariatric intervention.

Black Bronchoscopy in the Diagnosis of a Lung Mass / Broncoscopia negra en el diagnóstico de una masa pulmonar

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Consensus document on magnetic resonance imaging in patients with cardiac implanted electronic devices. / Documento de Consenso sobre a realização de ressonância magnética em doentes com dispositivos cardíacos electrónicos implantados.

Magnetic resonance imaging (MRI) is currently considered an essential complementary method for diagnosis in many conditions. Exponential growth in its use is expected due to the aging population and a broader spectrum of clinical indications. Growth in its use, coupled with an increasing number of pacemaker implants, implantable cardioverter-defibrillators and cardiac resynchronization therapy, has led to a frequent clinical need for this diagnostic modality in patients with cardiac implantable electronic devices (CIED). This clinical need has fueled the development of devices specifically designed and approved for use in a magnetic resonance (MR) environment under certain safety conditions (MR-conditional devices). More than a decade after the introduction of the first MR-conditional pacemaker, there are now several dozen MR-conditional devices with different safety specifications. In recent years, increasing evidence has indicated there is a low risk to MRI use in conventional (so-called non-MR-conditional) CIED patients in the right circumstances. The increasing number, as well as the greater diversity and complexity of implanted devices, justify the need to standardize procedures, by establishing institutional agreements that require close collaboration between cardiologists and radiologists. This consensus document, prepared jointly by the Portuguese Society of Cardiology and the Portuguese Society of Radiology and Nuclear Medicine, provides general guidelines for MRI in patients with CIED, ensuring the safety of patients, health professionals and equipment. In addition to briefly reviewing the potential risks of MRI in patients with CIED and major changes to MRI-conditional devices, this article provides specific recommendations on risk-benefit analysis, informed consent, scheduling, programming strategies, devices, monitoring and modification of MRI sequences. The main purpose of this document is to optimize patient safety and provide legal support to facilitate easy access by CIED patients to a potentially beneficial and irreplaceable diagnostic technique.

Alpha-1 Antitrypsin Deficiency: Principles of Care.

Alpha-1 antitrypsin deficiency is an autosomal co-dominant inherited disorder that results in decreased circulating levels of alpha-1 antitrypsin (also known as alpha-1 proteinase inhibitor) and predisposes affected individuals to early onset lung and liver disease. There is currently no cure for alpha-1 antitrypsin deficiency. However, appropriate treatment and a high standard of clinical care can prevent patients from being seriously affected and having to undergo major medical interventions, such as organ transplantation. Beyond managing the symptoms associated with alpha-1 antitrypsin deficiency, alpha-1 proteinase inhibitor therapy is the only treatment for the condition's underlying cause. Early diagnosis is important to ensure efficient therapeutic strategies and to minimize further deterioration of lung function. alpha-1 antitrypsin deficiency is under diagnosed globally, partly because the disease has no unique presenting symptoms. This document was prepared by a Portuguese multidisciplinary group and it aims to set out comprehensive principles of care for Alpha-1 antitrypsin deficiency. These include the importance of registries, the need for clinical research, the need for consistent recommendations (regarding diagnosis, treatment and monitoring), the role of reference centres, the requirement for sustained access to treatment, diagnostic and support services, and the role of patient organizations.

A deficiência de alfa-1 antitripsina é uma doença hereditária autossómica co-dominante que resulta numa diminuição dos níveis plasmáticos de alfa-1 antitripsina (também conhecida por inibidor da alfa-1 proteinase) e predispõe os indivíduos afetados ao desenvolvimento de doença pulmonar e hepática precoce. Atualmente não existe cura para a deficiência de alfa-1 antitripsina. No entanto, o tratamento adequado e um elevado padrão de cuidados clínicos podem prevenir que os doentes sejam gravemente afetados e terem que se submeter a intervenções médicas major, como o transplante de órgão. Para além de atuar nos sintomas associados à deficiência de alfa-1 antitripsina, a terapêutica com o inibidor da alfa-1 proteinase é o único tratamento disponível que atua na causa subjacente desta patologia. O diagnostico precoce é importante para assegurar a implementação de estratégias terapêuticas eficientes e para minimizar a destruição adicional da função pulmonar. A deficiência de alfa-1 antitripsina está globalmente sub diagnosticada, em parte devido ao fato desta doença não apresentar sintomas únicos. Este documento foi preparado por um grupo multidisciplinar e visa estabelecer princípios de cuidados abrangentes para a deficiência de alfa-1 antitripsina. Estes incluem a importância dos registros, a necessidade de investigação clinica, a necessidade de recomendações consistentes (no que diz respeito ao diagnostico, tratamento e monitorização), o papel dos centros de referência, a necessidade de acesso sustentado ao tratamento, diagnostico e serviços de suporte, e o papel das associações de doentes.

Towards a new understanding of the molecular mechanisms of cardiovascular disease.

In this article, we review a process put forward in former publications by which fatty acid micelles and vesicles with an acidic core can develop, and the physiological manifestations of such process in the human body. The process allows the understanding of arterial calcification, why coronary arteries, aorta, and carotids are the most affected vessels, and the preferential distribution of plaques on the areas of the endothelium where shear stress is lower. Also reviewed are the role of systemic buffers in the control of blood pH, and the effects of pollutants, namely heavy metals, diet, and ethanol intake, on cardiovascular risks. The most important cardiovascular risk factors are explained based on their effect on either lowering blood pH or increasing blood FFA concentration, or both. Cardiovascular risk protection factors also find an explanation within the proposed framework. As a final point, the importance of knowing blood pH and concentrations of free fatty acids and albumin concentrations in the blood is emphasized in developing a strategy of prevention of cardiovascular disease.

[Clinical manifestations and late diagnosis of common variable immunodeficiency]. / Manifestaciones clínicas y diagnóstico tardío de la inmunodeficiencia común variable.

BACKGROUND: Common Variable Immunodeficiency (CVID) is the most frequent type of severe primary immunodeficiency (PID). Clinical manifestations of CVID occur at any age; nevertheless, they are more frequent between the age of 6 and 10 years, and between the age of 20 and 40 years. In medical literature, there are hardly any diagnostic reports on CVID after 50 years of age. CLINICAL CASE: A 58-year-old man with a clinical history of repeated infections since the age of 35. The tests showed a decrease in IgG, IgA, and specific antibodies, without any other causes of hypogammaglobulinemia. The CVID diagnosis was made and the patient received treatment with human immunoglobulin replacement and a reinforcement of personal and environmental hygiene. The patient stopped presenting repeated infections. CONCLUSION: Diagnoses made after the age of 50, although they're late, they are fundamental to the recovery of the patient. In the referred case, replacement with human immunoglobulin allowed an improvement in the quality of life.

Antecedentes: La inmunodeficiencia común variable (IDCV) es la inmunodeficiencia primaria (IDP) grave más frecuente. Las manifestaciones clínicas surgen en cualquier edad, pero son más frecuentes entre los seis y 10 años y entre los 20 y 40 años. En la literatura, casi no hay informes de diagnóstico de IDCV después de los 50 años.Caso clínico: Hombre, 58 años de edad, con historia clínica de infecciones de repetición desde los 35 años. Los exámenes mostraron disminución de IgG, IgA, anticuerpos específicos, sin otras causas de hipogammaglobulinemia. Se realizó el diagnóstico de IDCV y recibió reposición de inmunoglobulina humana, así como refuerzo de la higiene personal y ambiental. El paciente dejó de presentar infecciones de repetición.Conclusión: Los diagnósticos después de los 50 años, a pesar de ser tardíos, son fundamentales para la recuperación de los pacientes. En el caso referido, la reposición con inmunoglobulina humana permitió mejorar la calidad de vida.

Health care cost analysis of enhanced pacing modalities in bradycardia patients: Portuguese case study on the results of the MINERVA trial.

INTRODUCTION: The MINERVA trial established that atrial preventive pacing and atrial antitachycardia pacing (DDDRP) in combination with managed ventricular pacing (MVP) reduces progression to permanent atrial fibrillation (AF) in patients with paroxysmal or persistent AF and bradycardia who need cardiac pacing, compared to standard dual-chamber pacing (DDDR). It was shown that AF-related health care utilization was significantly lower in the DDDRP + MVP group than in the control group. Cost analysis demonstrated significant savings related to this new algorithm, based on health care costs from the USA, Italy, Spain and the UK. OBJECTIVE: To calculate the savings associated with reduced health care utilization due to enhanced pacing modalities in the Portuguese setting. METHODS: The impact on costs was estimated based on tariffs for AF-related hospitalizations and costs for emergency department and outpatient visits in Portugal. RESULTS: The MINERVA trial showed a 42% reduction in AF-related health care utilization thanks to the new algorithm. In Portugal, this represents a potential cost saving of 2323 euros per 100 patients in the first year and 17118 euros over a 10-year period. Considering the number of patients who could benefit from this new algorithm, Portugal could save a total of 75369 euros per year and 555410 euros over 10 years. Additional savings could accrue if heart failure and stroke hospitalizations were considered. CONCLUSION: The combination of atrial preventive pacing, atrial antitachycardia pacing and an algorithm to minimize the detrimental effect of right ventricular pacing reduces recurrent and permanent AF. The new DDDRP + MVP pacing mode could contribute to significant costs savings in the Portuguese health care setting.

Acidemia and blood free fatty acids: analysis of cardiovascular risk factors in a new context.

Following a hypothesis developed in an earlier paper, here it is discussed how deviations of blood pH from the normal range (namely states of acidemia) together with high blood levels of free fatty acids (FFA) may offer a rationale for many important risk factors for cardiovascular diseases (CVD) by shaping a context for formation of fatty acid micelles and vesicles with an acidic core, which fuse with the endothelia, disrupt vital cell processes, and thereby may initiate atherosclerotic plaque formation. Acidemia may arise primarily from dysregulation of the systemic buffers that control blood pH, chronic diseases of kidneys and lungs, inappropriate diet, or may be induced by some common drugs. The level of free fatty acids may be increased and maintained high by chronic stress, and adrenergic shocks. Elevated concentrations of blood FFA in a context of acidemia allow to understand important cardiovascular aspects: the increased risk of menopausal women, the protective effects of physical exercise, the changes in vascular behavior characteristic of metabolic acidosis/acidemia, the role of diet in the pH balance, on how some known medicines like metformin, steroids, NSAIDS, proton pump inhibitors, and calcium supplements may influence CVD risk, and an explanation is offered for the role of statins.

Secular Trends in Anthropometrics and Physical Fitness of Young Portuguese School-Aged Children.

INTRODUCTION: The purpose of this study was to analyze secular trends in anthropometrics and physical fitness of Portuguese children. MATERIAL AND METHODS: A group of 1819 students (881 boys and 938 girls) between 10 and 11 years old was assessed in their 5th and 6th scholar grade throughout a 20 years' time-frame. ANCOVA models were used to analyze variations in anthropometrics (height, weight and body mass index) and physical fitness (sit and reach, curl-up, horizontal jump and sprint time) across four quinquennials (1993 - 1998; 1998 - 2003; 2003 - 2008; 2008 - 2013). RESULTS: Secular trends showed the presence of heavier boys and girls with higher body mass index in the 5th and 6th grade throughout the last 20 years. There was also a presence of taller girls but just until the 3rd quinquennial. Both boys and girls were able to perform better on the core strength test and sprint time but become less flexible over the years. Mean jumping performance remained unchanged for both genders. DISCUSSION: The present study provides novel data on anthropometrics and physical fitness trends over the last two decades in young Portuguese children, consistent with the results reported in other developed countries. CONCLUSION: Evidence for the start of a positive secular trend in body mass index and in some physical fitness components over the last two decades among the Portuguese youth.

Introdução: Analisar as tendências seculares ao nível da antropometria e aptidão física das crianças portuguesas. Material e Métodos: Um grupo de 1819 crianças (881 rapazes e 938 raparigas) entre os 10 e os 11 anos de idade, foi avaliado no 5º e 6º ano de escolaridade durante 20 anos. A ANCOVA foi usada para analisar as variações de antropometria (índice de massa corporal, peso e altura) e aptidão física (sentar e alcançar, força abdominal, salto horizontal e corrida de velocidade) durante quatro quinquénios (1993 - 1998; 1998 - 2003; 2003 - 2008 e 2008 - 2013). Resultados: As tendências seculares mostraram a presença de crianças mais pesadas e com um índice de massa corporal mais elevado ao longo dos últimos 20 anos. Verificou-se também a presença de raparigas mais altas, mas só até ao terceiro quinquénio. Ambos os géneros melhoraram o desempenho nos testes de força abdominal e corrida de velocidade mas pioram a sua capacidade de flexibilidade ao longo dos anos. O desempenho no salto horizontal permaneceu inalterado em ambos os géneros. Discussão: Este estudo fornece novos dados sobre a tendência dos registos antropométricos e de aptidão física nos últimos 20 anos em crianças Portuguesas, sendo consistente com as tendências reportadas sobre outros países desenvolvidos. Conclusão: Os resultados sugerem uma tendência positiva nos últimos 20 anos no índice de massa corporal e em alguns componentes da aptidão física em crianças Portuguesas.

Efficacy And Safety Of Implantable Loop Recorder: Experience Of A Center.

Introduction: Symptoms like syncope or palpitations frequently present a diagnostic challenge. An implantable loop recorder (ILR) is an important aid in the management of these patients. Methods: A retrospective study of patients that underwent ILR implantation from November 2007 to 2014. For each patient the indication for implantation, baseline characteristics, previous study, complications, recorded tracing and interventions were evaluated. Results: A total of 62 patients were included, 50% men, with a mean age of 62.5±18.8 years old. Previously to ILR implantation 88.7% of patients had performed Holter, 17.7% external events recorder, 33.9% Tilt test and 29% an electrophysiological study. The implantation indications were recurrent syncope in 90.3%, palpitations 8.1% and ischemic stroke in one patient. Mean follow-up time was 17.1±16.3 months. Symptoms were reported in 66.1% of the patients, 46.8% of those yielding a diagnostic finding. In all cases of palpitation complaints with diagnosis we found atrial fibrillation (AF). In patients with syncope atrioventricular conduction disturbance was demonstrated in 19.6%, sinus node dysfunction in 16.1%, paroxysmal supra-ventricular tachycardia 7.1% and AF in 1.8%. These finding resulted in 19 pacemaker and one CRT-D implantation, introduction of anticoagulation in five patients and one ablation of accessory pathway. There were no major complications. Conclusion: ILR proved to be safe and efficient. It has enabled the identification or exclusion of serious rhythm disturbances in more than half of patients and provided a targeted therapeutic intervention.

On the etiology of cardiovascular diseases: A new framework for understanding literature results.

The interpretative framework presented here provides a rationale for many well-known features of cardiovascular diseases. Prolonged acidemia with high blood levels of free fatty acids is proposed to shape the basic context for formation of fatty acid micelles and vesicles with an acidic core that fuse with the endothelia, disrupt vital cell processes, and initiate atherosclerotic plaque formation. It offers an explanation for the distributed localization of atherosclerotic lesions, and how mild cases of occurrence of fatty acids vesicles formed within the heart and the arteries close to the heart may cause such lesions. It provides a rationale for how acute events, namely heart attacks and strokes, may arise from stormy development of fatty acid vesicles within the heart. Additionally, a process is proposed for clot development from the existing fatty acid vesicles.