Identifying subgroups in heart failure patients with multimorbidity by clustering and network analysis.

This study presents a workflow for identifying and characterizing patients with Heart Failure (HF) and multimorbidity utilizing data from Electronic Health Records. Multimorbidity, the co-occurrence of two or more chronic conditions, poses a significant challenge on healthcare systems. Nonetheless, understanding of patients with multimorbidity, including the most common disease interactions, risk factors, and treatment responses, remains limited, particularly for complex and heterogeneous conditions like HF. We conducted a clustering analysis of 3745 HF patients using demographics, comorbidities, laboratory values, and drug prescriptions. Our analysis revealed four distinct clusters with significant differences in multimorbidity profiles showing differential prognostic implications regarding unplanned hospital admissions. These findings underscore the considerable disease heterogeneity within HF patients and emphasize the potential for improved characterization of patient subgroups for clinical risk stratification through the use of EHR data.

Pulmonary arteriovenous malformations in Rendu-Osler-Weber syndrome.

Rendu-Osler-Weber syndrome, also known as hereditary hemorrhagic telangiectasia, is an autosomal dominant hereditary disorder. It is characterized by presence of multiple arteriovenous malformations (AVMs) and telangiectasias. This article reports two cases of patients with Rendu-Osler-Weber syndrome who had pulmonary AVMs and underwent successful endovascular treatment. A brief review of the literature shows that up to 50% of patients with the syndrome have pulmonary AVMs and there is usually a positive family history in these patients. These pulmonary AVMs are multiple in 30% of cases and are associated with the most severe disease complications. Most patients are asymptomatic, even in the presence of AVMs with right-left shunts. When these shunts exceed 25% of the total blood volume, dyspnea, cyanosis, digital clubbing, and extracardiac murmurs may occur. Endovascular treatment is safe and offers control of complications from hereditary hemorrhagic telangiectasia and is currently the treatment of choice for these lesions.

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

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

Malformações arteriovenosas pulmonares na síndrome de Rendu-Osler-Weber / Pulmonary arteriovenous malformations in Rendu-Osler-Weber syndrome

Resumo A síndrome de Rendu-Osler-Weber, também conhecida como telangiectasia hemorrágica hereditária, é uma doença hereditária autossômica dominante. Ela é caracterizada pela presença de múltiplas malformações arteriovenosas e telangiectasias. Este artigo relata dois casos de pacientes com síndrome de Rendu-Osler-Weber que apresentaram malformações arteriovenosas pulmonares e foram submetidos a tratamento endovascular com sucesso. Uma breve revisão da literatura mostra que até 50% dos pacientes com a síndrome têm malformações arteriovenosas pulmonares e geralmente há um histórico familiar positivo nesses pacientes. Em 30% dos casos, elas são múltiplas e estão associadas a complicações mais graves da doença. A maioria dos pacientes é assintomática, mesmo na presença de malformações arteriovenosas com shunt direito-esquerdo. Quando esses shunts excedem 25% do volume total de sangue, podem surgir dispneia, cianose, baqueteamento digital e sopros extracardíacos. O tratamento endovascular oferece segurança e controle das complicações da telangiectasia hemorrágica hereditária, sendo atualmente o tratamento de escolha para essas lesões.

Abstract Rendu-Osler-Weber syndrome, also known as hereditary hemorrhagic telangiectasia, is an autosomal dominant hereditary disorder. It is characterized by presence of multiple arteriovenous malformations (AVMs) and telangiectasias. This article reports two cases of patients with Rendu-Osler-Weber syndrome who had pulmonary AVMs and underwent successful endovascular treatment. A brief review of the literature shows that up to 50% of patients with the syndrome have pulmonary AVMs and there is usually a positive family history in these patients. These pulmonary AVMs are multiple in 30% of cases and are associated with the most severe disease complications. Most patients are asymptomatic, even in the presence of AVMs with right-left shunts. When these shunts exceed 25% of the total blood volume, dyspnea, cyanosis, digital clubbing, and extracardiac murmurs may occur. Endovascular treatment is safe and offers control of complications from hereditary hemorrhagic telangiectasia and is currently the treatment of choice for these lesions.

Epidemiological Impact of Neurodegenerative Diseases in the Rural Spanish-Portuguese Cross-Border Region.

INTRODUCTION: Epidemiological data indicate that neurodegenerative diseases show a high prevalence with a progressive increasing trend, especially in aging populations, as is the case in rural areas. The objective of this study was to assess the quantitative impact of neurodegenerative diseases in rural areas of the Spanish-Portuguese border region and to describe the epidemiological profile of the most prevalent disorders in one of the most depopulated and aged regions of Europe. METHODS: A cross-sectional descriptive study was designed to estimate the prevalence of subjects diagnosed with the most common neurodegenerative disorders: dementia (Alzheimer's disease and other dementias), Parkinson's disease and Parkinsonism, and multiple sclerosis in the Spanish-Portuguese cross-border border region in 2020. It includes Bragança and Guarda Districts (Portugal) and Salamanca (Castilla y León, Spain). RESULTS: Neurodegenerative diseases accounted for 1.85% in the Spanish-Portuguese cross-border region in 2020; a total of 5,819 records were reported: 987 (prevalence, 2.51%) in Salamanca (Spain); 2,332 (prevalence, 1.87%) in Bragança; and 2,500 (prevalence, 1.66%) in Guarda. Female population suffered from them in higher proportion (2.35 vs. 1.32%). Dementia represented 1.19% (3,744), Parkinson's disease and Parkinsonism 0.58% (1,823), and multiple sclerosis 0.08% (252). These disorders impacted older age groups. In the rural border region of Spain, 1 out of 4 cases were institutionalized. CONCLUSION: The findings reveal the health impact of neurodegenerative diseases in the Spanish-Portuguese cross-border region. The epidemiological data emphasize the region's circumstances and highlight research priorities. Intervention strategies must be implemented in the region to ensure quality healthcare in rural areas.

Perceção de satisfação dos utentes relativamente aos cuidados de enfermagem numa urgência médico-cirúrgica / Patients' perceived satisfaction with nursing care in a medical-surgical emergency unit / Percepción de la satisfacción de los usuarios respecto a los cuidados de enfermería en un servicio de urgencias médico-quirúrgicas

Resumo Enquadramento: A avaliação da satisfação dos utentes permite obter indicadores importantes para implementar estratégias promotoras de cuidados de saúde, e como tal, de satisfação. Objetivo: Identificar a perceção de satisfação dos utentes relativamente aos cuidados de enfermagem e, avaliar a sua relação com as variáveis sociodemográficas e profissionais. Metodologia: Estudo transversal analítico, exploratório, de cariz quantitativo, a partir da aplicação da Escala de Satisfação do Cidadão face aos Cuidados de Enfermagem (ESCCE), numa amostra de 100 utentes, numa urgência médico-cirúrgica. Resultados: Obteve-se uma pontuação média de perceção de satisfação de 217 ± 57,8. Constatou-se ainda que 41,8% da amostra, apresentou uma perceção elevada de satisfação, 23,2% moderada e 35,3% de baixa satisfação. Verificou-se uma relação estatística significativa com a variável habilitações literárias: os respondentes com menor nível de habilitação, apresentaram uma perceção de satisfação mais elevada (239 ± 60,8). Conclusão: Os resultados sugerem a pertinência em formação de competências técnica, relacional e comunicacional, como estratégias promotoras dos cuidados, e de satisfação, ao nível individual e institucional relativamente aos cuidados de enfermagem.

Abstract Background: Assessing patient satisfaction allows obtaining relevant indicators to implement strategies for improving the quality of care and, consequently, patient satisfaction. Objective: To identify patients' perceived satisfaction with nursing care and assess its association with sociodemographic and professional variables. Methodology: Analytical, cross-sectional, and exploratory study with a quantitative approach. The Escala de Satisfação do Cidadão face aos Cuidados de Enfermagem (Citizen Satisfaction with Nursing Care Scale) was applied to a sample of 100 patients in a medical-surgical emergency unit. Results: The mean perceived satisfaction was 217 ± 57.8. In this sample, 41.8% of participants had high perceived satisfaction, 23.2% had moderate perceived satisfaction, and 35.3% had low perceived satisfaction. A statistically significant correlation was found between satisfaction and education level: participants with lower education levels had higher perceived satisfaction (239 ± 60.8). Conclusion: Technical, relational, and communication skills training is important to improve the quality of care and increase satisfaction with nursing care at an individual and institutional level.

Resumen Marco contextual: La evaluación de la satisfacción de los usuarios permite obtener indicadores importantes para poner en marcha estrategias que promuevan la atención sanitaria y, con ello, la satisfacción. Objetivo: Identificar la percepción de la satisfacción de los usuarios con respecto a los cuidados de enfermería y evaluar su relación con las variables sociodemográficas y profesionales. Metodología: Estudio transversal, analítico, exploratorio y cuantitativo basado en la aplicación de la Escala de Satisfacción del Ciudadano frente a los Cuidados de Enfermería (ESCCE) en una muestra de 100 usuarios de un servicio de urgencias médico-quirúrgicas. Resultados: Se obtuvo una puntuación media de satisfacción percibida de 217 ± 57,8. También se observó que el 41,8% de la muestra tenía una percepción de satisfacción elevada, el 23,2% una satisfacción moderada y el 35,3% una satisfacción baja. Se encontró una relación estadísticamente significativa con la variable nivel de estudios: los encuestados con menor nivel de estudios tenían una mayor percepción de satisfacción (239 ± 60,8). Conclusión: Los resultados sugieren que es relevante la formación en competencias técnicas, relacionales y de comunicación, como estrategias para promover el cuidado y la satisfacción, a nivel individual e institucional, respecto a los cuidados de enfermería.

Adesão ao regime terapêutico medicamentoso da pessoa com doença renal crónica em programa de hemodiálise / Medication adherence in chronic kidney disease patients in haemodialysis programme / Adherencia al régimen terapéutico de medicamentos en personas con enfermedad renal crónica en un programa de hemodiálisis

Resumo Enquadramento: A pessoa com doença renal crónica (DRC) em hemodiálise apresenta um regime terapêutico medicamentoso complexo a seguir, seja no controlo da sintomatologia provocada pela mesma, seja no controlo de comorbilidades. Objetivo: Avaliar o nível de adesão ao regime terapêutico medicamentoso da pessoa com DRC em programa de hemodiálise. Metodologia: Estudo quantitativo, descritivo-correlacional e transversal, com aplicação da Escala de Medida de Adesão aos Tratamentos (MAT) a uma amostra de 101 pessoas com DRC, em programa de hemodiálise. Resultados: A amostra revelou uma pontuação média de adesão ao regime terapêutico medicamentoso de 5,32 ± 0,47, para um valor máximo de 6. O padrão dicotómico da escala, baseada na mediana, classifica 82,18% da amostra (n = 83) como aderente e 17,82% (n = 18) como não aderente. Encontrou-se uma relação estatisticamente significativa da adesão em função de algumas variáveis clínicas: número de patologias e de medicamentos diários. Conclusão: A percentagem de não aderentes ao regime terapêutico medicamentoso reclama ações de melhoria e releva a importância da avaliação continua dos níveis de adesão.

Abstract Background: The person with chronic kidney disease (CKD) on hemodialysis has a complex drug therapy regimen to follow, both in the control of the symptoms caused by the disease and in the control of comorbidities. Objective: To assess the level of adherence to the drug treatment in CKD patients on a hemodialysis program. Methodology: Quantitative, descriptive-correlational and cross-sectional study, based on the application of the Measure of Treatment Adherence scale (MTA), to a sample of 101 people with CKD, undergoing hemodialysis. Results: The sample had a mean score of adherence to the drug treatment regimen of 5.32 ± 0.47, with a maximum value of 6. The dichotomous pattern of the scale, based on the median, classifies 82.18% of the sample (n = 83) as adherent and 17.82% (n = 18) as non-adherent. A statistically significant relationship of adherence was found as a function of some clinical variables: number of pathologies and daily medication. Conclusion: The percentage of non-adherents to the drug therapy regimen calls for improvement actions and highlights the importance of continuous assessment of adherence levels.

Resumen Marco contextual: Una persona con enfermedad renal crónica (ERC) en hemodiálisis tiene que seguir un complejo régimen de terapia farmacológica, tanto en el control de los síntomas causados por la enfermedad como en el control de las comorbilidades. Objetivo Evaluar el nivel de adhesión al régimen terapéutico de medicamentos de la persona con ERC en programa de hemodiálisis. Metodología: Estudio cuantitativo, descriptivo-correlacional y transversal, basado en la aplicación de la Escala de Medición de Adhesión a los Tratamientos (MAT) a una muestra de 101 personas con ERC, en programa de hemodiálisis. Resultados: La muestra reveló una puntuación media de adherencia al régimen terapéutico de medicamentos de 5,32±0,47, para un valor máximo de 6. El patrón dicotómico de la escala, basado en la mediana, clasificó al 82,18% de la muestra (n = 92) como adherente y al 17,82% (n = 18) como no adherente. Se encontró una relación estadísticamente significativa de la adherencia según algunas variables clínicas: número de patologías y medicación diaria. Conclusión: El porcentaje de no adherentes al régimen farmacoterapéutico reclama acciones de mejora y pone de manifiesto la importancia de la evaluación continua de los niveles de adherencia.

Burnout em enfermeiros do serviço de urgência médico-cirúrgica após a pandemia COVID-19 / Medical-surgical emergency nurses' burnout after the COVID-19 pandemic / Burnout en enfermeros del servicio de urgencias médico-quirúrgicas tras la pandemia de COVID-19

Resumo Enquadramento: O burnout consiste numa síndrome de índole tridimensional, decorrente do exercício de uma atividade profissional. Objetivos: Identificar o nível de burnout percecionado pelos enfermeiros do serviço de urgência médico-cirúrgica, após a pandemia COVID-19. Analisar a relação entre as pontuações médias das dimensões do burnout e as variáveis sociodemográficas e profissionais. Metodologia: Estudo quantitativo, descritivo-correlacional, num plano transversal, envolvendo uma amostra de 39 enfermeiros. Resultados: A maioria da amostra (51,3%) enquadra-se no nível sem burnout/burnout reduzido, 28,2% no burnout moderado e 20,5% no burnout elevado. No que concerne à pontuação média por dimensão, a mais elevada surge na exaustão emocional, com 2,60 ± 1,35. Constatou-se uma relação estatisticamente significativa em algumas dimensões, como: o sexo, as horas de trabalho diárias, a satisfação no local de trabalho e a perceção do aumento da exaustão decorrente da pandemia. Conclusão: As percentagens de burnout moderado e burnout elevado relevam a importância da sua monitorização contínua, visando o planeamento/promoção de estratégias de intervenção combativas adequadas, bem como a sua prevenção.

Abstract Background: Burnout is a tridimensional syndrome resulting from professional activities. Objectives: To identify the level of burnout perceived by medical-surgical emergency nurses after the COVID-19 pandemic and to analyze the relationship between the mean scores of the burnout dimensions and the sociodemographic and professional variables. Methodology: Quantitative, descriptive-correlational, and cross-sectional study on a sample of 39 nurses. Results: Most participants (51.3%) have no burnout or a low burnout level, 28.2% have a moderate burnout level, and 20.5% have a high burnout level. Regarding the mean score per dimension, the highest score was emotional exhaustion, with 2.60 ± 1.35. A statistically significant relationship was found in some dimensions, such as gender, working hours per day, workplace satisfaction, and perception of increased fatigue/exhaustion due to the pandemic. Conclusion: The percentages of moderate and high burnout highlight the importance of continuous monitoring, aiming at planning and promoting appropriate prevention and intervention strategies.

Resumen Marco contextual: El burnout consiste en un síndrome tridimensional derivado del ejercicio de una actividad profesional. Objetivos: Identificar el nivel de burnout percibido por los enfermeros del servicio de urgencias médico-quirúrgicas tras la pandemia de COVID-19. Analizar la relación entre las puntuaciones medias de las dimensiones del burnout y las variables sociodemográficas y profesionales. Metodología: Estudio cuantitativo, descriptivo-correlacional, en un plano transversal, con una muestra de 39 enfermeros. Resultados: La mayoría de la muestra (51,3%) se encuentra en el nivel de sin burnout/burnout reducido, el 28,2% en el de burnout moderado y el 20,5% en el de burnout alto. En cuanto a la puntuación media por dimensión, la más alta se registró en el agotamiento emocional, con 2,60 ± 1,35. Se observó una relación estadísticamente significativa en algunas dimensiones, como el sexo, las horas de trabajo diarias, la satisfacción en el lugar de trabajo y la percepción de un aumento del agotamiento debido a la pandemia. Conclusión: Los porcentajes de burnout moderado y burnout alto ponen de manifiesto la importancia de su seguimiento continuo, con el fin de planificar/promover estrategias adecuadas de intervención para combatirlo, así como para prevenirlo.

Transporte inter-hospitalar da pessoa em situação crítica: Vivências dos enfermeiros de uma ilha de Cabo Verde / Inter-hospital transport of the critically ill: The experience of nurses from a Cape Verdean Island / Transporte interhospitalario de pacientes en estado crítico: Experiencias del personal de enfermería en una isla de Cabo Verde

Resumo Enquadramento: A transferência inter-hospitalar da pessoa em situação crítica entre ilhas de um país insular decorre da necessidade de acesso a recursos de maior complexidade, cujas condições de transporte/assistência são determinantes para a sobrevivência do doente. Objetivo: Identificar os principais sentimentos e dificuldades vivenciados pelos enfermeiros de uma ilha de Cabo Verde no que concerne ao transporte inter-hospitalar da pessoa em situação crítica. Metodologia: Estudo qualitativo, por entrevista semiestruturada a um grupo focal de enfermeiros. Resultados: Das principais dificuldades apontadas emergiram como subcategorias - Carência/dificuldades ao nível dos meios de transporte; carência de recursos materiais apropriados para assistência durante o transporte; Dificuldades para assegurar o conforto e privacidade do doente; Problemas ao nível da rede referenciação/comunicação inter-hospitalar; Ausência de médico durante o transporte; Problemas relativos ao regresso dos enfermeiros ao hospital de origem. Um leque de sentimentos negativos como a angústia, o medo, as preocupações, entre outros, decorrem das dificuldades vivenciadas. Conclusão: Os relatos dos enfermeiros possibilitam um primeiro diagnóstico da situação, ao nível dos recursos, planeamento e efetivação do transporte.

Abstract Background: Inter-hospital transport of critically ill patients between islands in an island nation is driven by the need for access to more complex health resources. In this context, transport and care delivery conditions are crucial to patient survival. Objective: To identify the main feelings and difficulties of nurses from a Cape Verdean island regarding the inter-hospital transport of critically ill patients. Methodology: This qualitative study was conducted using semi-structured interviews with a focus group of nurses. Results: From the main difficulties identified, the following subcategories emerged: Lack of/difficulties with means of transport; Lack of adequate material resources to assist during transport; Difficulties in ensuring patient comfort and privacy; Problems with inter-hospital referral/communication network; Absence of a physician during transport; and Costs associated with the inability of the nurse to return immediately after delivering the patient. Several negative feelings, such as anguish, fear, and worry, resulted from the difficulties experienced by the nurses. Conclusion: The nurses' statements provide an initial diagnosis of the situation regarding the resources, planning, and execution of inter-hospital transport of critically ill patients.

Resumen Marco contextual: El traslado interhospitalario de un paciente en estado crítico entre islas de un país insular se debe a la necesidad de acceder a recursos más complejos, cuyas condiciones de transporte/asistencia son decisivas para la supervivencia del paciente. Objetivo: Identificar las principales sensaciones y dificultades experimentadas por los enfermeros de una isla de Cabo Verde en relación con el transporte interhospitalario de pacientes en estado crítico. Metodología: Estudio cualitativo, mediante entrevistas semiestructuradas con un grupo focal de enfermeros. Resultados: De las principales dificultades surgieron las siguientes subcategorías - Carencia/dificultades de medios de transporte; Carencia de recursos materiales adecuados para la asistencia durante el transporte; Dificultades para garantizar el confort y la intimidad del paciente; Problemas con la red de derivación/comunicación interhospitalaria; Ausencia de médico durante el transporte; Problemas relacionados con el regreso de los enfermeros al hospital de origen. De las dificultades experimentadas se derivan una serie de sentimientos negativos como angustia, miedo, preocupación, entre otros. Conclusión: Los informes de los enfermeros proporcionan un diagnóstico inicial de la situación, en cuanto a recursos, planificación y ejecución del transporte.

Six-month effects of supervised exercise on walking ability and health-related factors in peripheral arterial disease: a pilot study.

BACKGROUND: In peripheral arterial disease (PAD) patients with intermittent claudication (IC), the combination of aerobic and resistance exercises could counteract muscle loss and attenuate disease progression. This study analyzed the effects of six months of a combined exercise program on walking ability, lower limb body composition, cardiovascular risk factors, and Ankle-Brachial Index (ABI). METHODS: Twenty-three patients (age 63.2±1.5 years and ABI 0.58±0.07) with PAD and IC were allocated to a control group (CG) or a supervised exercise group (SUP). Ten patients underwent six months of treadmill walking combined with resistance exercises, three times a week. The CG (N.=13) received a recommendation for walking. All patients were measured at baseline (M0), after three months (M3), and six months (M6). RESULTS: During constant treadmill protocol, the claudication onset time/distance (COT/COD), absolute claudication time/distance (ACT/ACD), and number of pauses of overall patients significantly improved at M3 and M6. Between groups were found significant differences in COT and COD at M6 (P=0.005 and P=0.007, respectively); and in ACT and ACD at M3 (P=0.003 for both) and at M6 (P=0.005 and P=0.005, respectively), with major improvements in the SUP. Over the six months, a significant group effect was found in fat-free mass (P=0.041) and predicted muscle mass (P=0.039) of the lower ABI leg, with greater improvements in the SUP. CONCLUSIONS: A supervised exercise program that combines aerobic and resistance training improves PAD symptoms and has additional benefits for patients. Patients in the program showed improvements in walking ability, lower-limb body composition, perceived exertion, and heart rate during treadmill walking.

Impact of Ultrasound-Guided Foam Sclerotherapy for Pain Control in Patients with Chronic Venous Disease and Great Saphenous Vein Reflux.

Chronic venous disease (CVD) associated with great saphenous vein (GSV) reflux has a higher prevalence of pain in the lower limbs. This study evaluates the impact of ultrasound-guided foam sclerotherapy (UGFS) for GSV and symptom control, accessed by the visual analogue scale (VAS). Patients with CVD who underwent GSV-UGFS were included in this retrospective cohort (417 limbs). The pain was measured before and after the treatment. The scale alteration was assessed as a function of age, sex, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classes, total of sclerotherapy sessions, GSV occlusion patterns, and ulcer healing. Majority of patients were female (59.2%), and the mean age was 56 ± 11.5 years. In the total sample, 78.2% of the GSVs were fully occluded, 19.7% had partial occlusion, 2.2% remained open, and 3.2 ± 1.9 (median = 3.0) sessions were performed. The reduction of symptoms occurred in 88.3% of participants (VAS drop median = 4.8). Patients younger than 50 years and females had the greatest VAS decreases. When comparing the outcomes of complete occlusion versus partial occlusion, there was no significant difference in VAS pain reduction ( p = 0.14). The comparison between CEAP clinical classes also did not show statistically significant differences in delta VAS ( p = 0.71). GSV-UGFS was effective for pain control. However, this improvement does not appear to be related to the pattern of occlusion, indicating that in the short term, the outcomes of total and partial occlusion suggest successful management of symptoms. Other aspects such as gender, age, pretreatment pain intensity, and CEAP classes seem to play a role in the clinical outcome.

Clinical Profile of SARS-CoV-2 Infection: Mechanisms of the Cellular Immune Response and Immunogenetic Markers in Patients from Brazil.

OBJECTIVES: The aim of this study is to evaluate some mechanisms of the immune response of people infected with SARS-CoV-2 in both acute infection and early and late convalescence phases. METHODS: This is a cohort study of 70 cases of COVID-19, confirmed by RT-PCR, followed up to 60 days. Plasma Samples and clinical data were. Viral load, blood count, indicators inflammation were the parameters evaluated. Cellular immune response was evaluated by flow cytometry and Luminex immunoassays. RESULTS: In the severe group, hypertension was the only reported comorbidity. Non severe patients have activated memory naive CD4+ T cells. Critically ill patients have central memory CD4+ T cell activation. Severe COVID-19 patients have both central memory and activated effector CD8+ T cells. Non-severe COVID-19 cases showed an increase in IL1ß, IL-6, IL-10 and TNF and severely ill patients had higher levels of the cytokines IL-6, IL-10 and CXCL8. CONCLUSIONS: The present work showed that different cellular responses are observed according to the COVID-19 severity in patients from Brazil an epicenter the pandemic in South America. Also, we notice that some cytokines can be used as predictive markers for the disease outcome, possibility implementation of strategies effective by health managers.

Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch.

OBJECTIVES: This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch. METHODS: Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed. RESULTS: No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up. CONCLUSIONS: The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

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

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

Qualidade de vida em idosos não institucionalizados / Quality of life of non-institutionalized older people / Calidad de vida en ancianos no institucionalizados

Resumo Enquadramento: A perceção dos idosos acerca da sua qualidade de vida (QdV) é decorrente de uma multiplicidade de fatores, podendo ser avaliada através de escalas genéricas e/ou específicas. Objetivos: Avaliar a QdV de uma amostra de idosos não institucionalizados e analisar a sua relação com variáveis sociodemográficas e clínicas. Metodologia: Estudo descritivo-correlacional, transversal, de cariz quantitativo. Obteve-se uma amostra de 250 idosos. Aplicou-se um instrumento de recolha de dados que integrava duas escalas que avaliavam a QdV, uma genérica (EUROHIS-QOL-8) e outra específica para a população idosa (WHOQOL-OLD). Resultados: Ambas as escalas, numa classificação 0-100, revelaram, para o global, um índice médio de QdV acima do ponto médio (67,19 ±17,95 na EUROHIS-QOL-8 e 67,49±15,46 na WHOQOL-OLD). Revelaram ainda diferenças estatisticamente significativas da perceção da QdV com o sexo, escolaridade e estado civil. A WHOQOL-OLD não revelou a existência de diferenças estatisticamente significativas em função da variável "presença ou não de patologias", contrariamente à EUROHIS-QOL-8. Conclusão: A perceção da QdV dos idosos estava associada às variáveis: sexo, escolaridade e estado civil.

Abstract Background: Older people's perceived quality of life (QoL) is based on several factors and can be assessed through generic and/or specific scales. Objectives: To assess the QoL of a sample of non-institutionalized older people and analyze its association with sociodemographic and clinical variables. Methodology: A descriptive-correlational, cross-sectional, quantitative study was conducted with a sample of 250 older people. Data were collected using two scales for assessing QoL: one generic (EUROHIS-QOL-8) and another specific for older people (WHOQOL-OLD). Results: On a scale from 0 to 100, a mean QoL index above the midpoint was found for the total scales (67.19 +/- 17.95 in EUROHIS-QOL-8 and 67.49+/- 15.46 in WHOQOL-OLD). Statistically significant differences were found between perceived QoL and gender, education level, and marital status. Unlike the EUROHIS-QOL-8, no statistically significant differences were found in the WHOQOL-OLD for the variable "presence of a disease". Conclusion: Older people's perceived QoL was associated with the variables of gender, education level, and marital status.

Resumen Marco contextual: La percepción de los ancianos sobre su calidad de vida (QdV) es el resultado de una multiplicidad de factores y puede ser evaluada a través de escalas genéricas y/o específicas. Objetivos: Evaluar la QdV de una muestra de ancianos no institucionalizados y analizar su relación con variables sociodemográficas y clínicas. Metodología: Estudio descriptivo-correlacional, transversal y cuantitativo. Se obtuvo una muestra de 250 ancianos. Se aplicó un instrumento de recogida de datos que incluía dos escalas que evaluaban la calidad de vida, una genérica (EUROHIS-QOL-8) y otra específica para la población anciana (WHOQOL-OLD). Resultados: Ambas escalas, en una clasificación de 0 a 100, mostraron, para el total, un índice de QdV medio por encima del punto medio (67,19±17,95 en la EUROHIS-QOL-8 y 67,49±15,46 en la WHOQOL-OLD). También mostraron diferencias estadísticamente significativas en la percepción de la QdV según el sexo, la escolaridad y el estado civil. La WHOQOL-OLD no mostró la existencia de diferencias estadísticamente significativas en función de la variable "presencia o ausencia de patologías", al contrario que la EUROHIS-QOL-8. Conclusión: La percepción de la QdV de los ancianos se asoció con las siguientes variables: sexo, escolaridad y estado civil.

Iatrogenias na prestação de cuidados de enfermagem: A perspetiva dos enfermeiros da área médico-cirúrgica / Iatrogenic events in nursing care: The medical-surgical nurses' perspectives / Iatrogenia en los cuidados de enfermería: La perspectiva de los enfermeros del área médico-quirúrgica

Resumo Enquadramento: A prestação de cuidados de saúde aos utentes, deve contemplar como premissas, a qualidade e segurança. No seu desrespeito enquadra-se o evento adverso, entendido como doença ou dano. Objetivo: identificar a perceção dos enfermeiros acerca das iatrogenias na prestação de cuidados de enfermagem na área médico-cirúrgica. Metodologia: Estudo qualitativo, por entrevista semiestruturada a um grupo focal de enfermeiros. Resultados: Os enfermeiros associam ao conceito de iatrogenia em enfermagem o dano que o doente sofre, decorrente das atividades sob sua responsabilidade. Como ocorrências iatrogénicas em enfermagem mais comuns relataram: as quedas/fraturas, os efeitos adversos à administração de terapêutica medicamentosa, o inadequado manuseamento de dispositivos médicos. Como fatores potenciadores emergiram as condições de trabalho inadequadas. Enumeraram-se como estratégias para a minimização destes eventos: a formação contínua, a boa comunicação e liderança, implementação e cumprimento de protocolos. Conclusão: Na perceção da amostra as iatrogenias são uma realidade, cujos fatores potenciadores vão ao encontro aos descritos na literatura científica. A formação contínua nesta área é reconhecida como um pilar para a sua prevenção.

Abstract Background: Healthcare delivered to users must be based on the premises of quality and safety. Failure to comply leads to adverse events understood as illness or harm. Objective: To identify nurses' perspectives on iatrogenic events in medical-surgical nursing care. Methodology: Qualitative study, using semi-structured interviews with a focus group of nurses. Results: Nurses associate iatrogenic events in nursing with patient harm resulting from nursing activities carried out under their responsibility. The most common nursing iatrogenic events reported were falls and fractures, drug therapy-related adverse effects, and inappropriate use of medical devices. Poor working conditions were pointed out as a potentiating factor. The following strategies were listed to minimize iatrogenic events: continuing education, good communication and leadership, implementation and protocols adherence. Conclusion: According to the sample's perspective, iatrogenic events are a reality whose potentiating factors are in line with those described in the literature. Continuing education in this area is recognized as essential for prevention.

Resumen Marco contextual: La prestación de cuidados sanitarios a los usuarios debe contemplar la calidad y la seguridad como premisas. El acontecimiento adverso, entendido como enfermedad o daño, se enmarca en su falta de respeto. Objetivo: Identificar la percepción de los enfermeros sobre la iatrogenia en la prestación de cuidados de enfermería en el área médico-quirúrgica. Metodología: Estudio cualitativo, mediante entrevista semiestructurada, a un grupo focal de enfermeros. Resultados: Los enfermeros asocian el concepto de iatrogenia en enfermería con el daño que sufre el paciente como consecuencia de las actividades de las que son responsables. Los casos de iatrogenia más comunes notificados en enfermería fueron las caídas/fracturas, los acontecimientos adversos a la administración terapéutica medicamentosa y la manipulación inadecuada de dispositivos médicos. Las condiciones de trabajo inadecuadas surgieron como factores potenciadores. Entre las estrategias para minimizar estos acontecimientos, se incluyen: formación continua, buena comunicación y liderazgo, implementación y cumplimiento de los protocolos. Conclusión: En la percepción de la muestra, la iatrogenia es una realidad cuyos factores potenciales coinciden con los descritos en la literatura científica. La formación continua en este ámbito se reconoce como un pilar para su prevención.

Superficial femoral vein transposition as a solution for hemodialysis vascular access.

The significant growth in the number of individuals dependent on hemodialysis for renal replacement therapy and unrestricted use of short and long-term catheters have challenged vascular surgeons in search of solutions for patients whose options for access via the upper limbs have been exhausted and for the increasing rates of central venous stenosis in these patients. When access via the upper limbs is impossible, exceptional techniques can be used and the lower limbs offer feasible alternative vascular access sites for hemodialysis. This article reports a case of superficial femoral vein transposition to make a loop arteriovenous fistula in a patient with no possibility of access via the upper limbs and presents a literature review on this technique that remains little used.

Hydroxychloroquine versus placebo in the treatment of non-hospitalised patients with COVID-19 (COPE - Coalition V): A double-blind, multicentre, randomised, controlled trial.

Background: Previous Randomised controlled trials (RCT) evaluating chloroquine and hydroxychloroquine in non-hospitalised COVID-19 patients have found no significant difference in hospitalisation rates. However, low statistical power precluded definitive answers. Methods: We conducted a multicenter, double-blind, RCT in 56 Brazilian sites. Adults with suspected or confirmed COVID-19 presenting with mild or moderate symptoms with ≤ 07 days prior to enrollment and at least one risk factor for clinical deterioration were randomised (1:1) to receive hydroxychloroquine 400 mg twice a day (BID) in the first day, 400 mg once daily (OD) thereafter for a total of seven days, or matching placebo. The primary outcome was hospitalisation due to COVID-19 at 30 days, which was assessed by an adjudication committee masked to treatment allocation and following the intention-to-treat (ITT) principle. An additional analysis was performed only in participants with SARS-CoV-2 infection confirmed by molecular or serology testing (modified ITT [mITT] analysis). This trial was registered at ClinicalTrials.gov, NCT04466540. Findings: From May 12, 2020 to July 07, 2021, 1372 patients were randomly allocated to hydroxychloroquine or placebo. There was no significant difference in the risk of hospitalisation between hydroxychloroquine and placebo groups (44/689 [6·4%] and 57/683 [8·3%], RR 0·77 [95% CI 0·52-1·12], respectively, p=0·16), and similar results were found in the mITT analysis with 43/478 [9·0%] and 55/471 [11·7%] events, RR 0·77 [95% CI 0·53-1·12)], respectively, p=0·17. To further complement our data, we conducted a meta-analysis which suggested no significant benefit of hydroxychloroquine in reducing hospitalisation among patients with positive testing (69/1222 [5·6%], and 88/1186 [7·4%]; RR 0·77 [95% CI 0·57-1·04]). Interpretation: In outpatients with mild or moderate forms of COVID-19, the use of hydroxychloroquine did not reduce the risk of hospitalisation compared to the placebo control. Our findings do not support the routine use of hydroxychloroquine for treatment of COVID-19 in the outpatient setting. Funding: COALITION COVID-19 Brazil and EMS.

What Leads to a Patient Refusal for Ambulatory Surgery? A Logistic Regression Prediction Model Based on a 5-year Retrospective Analysis of Patients with Abdominal Wall Hernia.

INTRODUCTION: Ambulatory surgery has proven benefits in patient wellbeing and cost reduction in healthcare systems. However, some patients referred for ambulatory surgery are refused and directed instead towards inpatient care, which generates several drawbacks. The reasons for this refusal have not been yet studied. The aim of this study is to identify, retrospectively, significant variables associated with patient refusal for ambulatory surgery and develop a mathematical tool able to predict with strong accuracy those who will be rejected. MATERIAL AND METHODS: Over a 5-year period (2014 - 2018), all patients that underwent abdominal hernia repair in our hospital in an inpatient setting, and that had been previously refused for ambulatory surgery, were analysed for a total of 94 variables. A multivariate logistic regression model was developed to identify risk factors associated with refusal using data from 136 patients (65 refused vs 71 accepted). A prediction index for refusal in ambulatory surgery - IRAS - was derived and tested (n = 62 patients). RESULTS: The risk index included five significant risk factors: type 2 diabetes mellitus [OR 14.669 (2.982; 72.154)], physical status [OR 49.155 (15.532; 155.555)], prior malignancy [OR 14.518 (2.653; 79.441)], prior abdominal surgery [OR 3.455 (1.006; 11.866)] and usage of antiplatelet agents [OR 25.600 (4.309; 152.066)]. All risk factors were associated with a high risk of refusal (OR between 3.455 for history of prior abdominal surgery and 49.155 according to the American Society of Anaesthesiologists physical status classification). Defining five points as the maximum IRAS score that predicts suitability for ambulatory surgery resulted in a positive predictive value of 93.55% and negative predictive value of 87.10%. DISCUSSION: Significant patient variables for refusal of an ambulatory procedure were determined and an easy to use risk index - IRAS - was built that is able to predict with good accuracy which patients will be refused. CONCLUSION: IRAS is a useful tool that can contribute to reduce time to surgery and improve patients' quality of life.

Introdução: A cirurgia de ambulatório tem benefícios comprovados no bem-estar dos doentes e na redução de custos dos sistemas de saúde. Porém, alguns doentes referenciados para cirurgia de ambulatório são recusados e encaminhados para internamento. Os motivos desta recusa ainda não foram estudados. Neste trabalho identificámos, retrospectivamente, variáveis significativas na recusa dos doentes e fornecemos uma ferramenta matemática capaz de prever de forma precisa aqueles que serão rejeitados. Material e Métodos: Ao longo de cinco anos (2014 - 2018), todos os doentes submetidos a correção cirúrgica de hérnia abdominal em regime de internamento no nosso centro hospitalar previamente recusados para cirurgia de ambulatório foram analisados para um total de 94 variáveis. Um modelo de regressão logística multivariada foi desenvolvido para identificar os fatores de risco para recusa usando dados de 136 doentes (65 recusados vs 71 aceites). Um índice preditivo para recusa de cirurgia em ambulatório, IRAS, foi criado e testado (n = 62 doentes). Resultados: O IRAS incluiu cinco fatores de risco significativos: diabetes mellitus tipo 2 [OR 14,669 (2,982; 72,154)], estado físico [OR 49,155 (15,532; 155,555)], neoplasia maligna prévia [OR 14,518 (2,653; 79,441)], cirurgia abdominal prévia [OR 3,455 (1,006; 11,866)] e uso de agentes antiplaquetários [OR 25,600 (4,309; 152,066)]. Todos os fatores de risco foram associados a elevado risco de recusa (OR entre 3,455 para história de cirurgia abdominal prévia e 49,155 de acordo com a classificação do estado físico segundo a American Society of Anaesthesiologists). A definição de cinco pontos como a pontuação máxima do IRAS que prevê adequação para cirurgia de ambulatório resultou num valor preditivo positivo de 93,55% e um valor preditivo negativo de 87,10%. Discussão: Foram determinadas variáveis significativas para recusa de um doente para cirurgia de ambulatório e construído um índice de risco de fácil utilização, IRAS, capaz de predizer que doentes serão recusados com boa precisão. Conclusão: O índice IRAS é uma ferramenta útil que pode contribuir para a redução dos tempos de espera e melhorar a qualidade de vida dos doentes.

Transposição de veia femoral superficial como solução de acesso vascular para hemodiálise / Superficial femoral vein transposition as a solution for hemodialysis vascular access

Resumo O crescimento significativo do número de indivíduos dependentes de hemodiálise para terapia renal substitutiva e o uso irrestrito de cateteres de curta e longa permanência têm desafiado os cirurgiões vasculares em busca de soluções para a exaustão de acessos nos membros superiores e taxas crescentes de estenose venosa central nesses pacientes. Na impossibilidade do acesso em membros superiores, técnicas excepcionais podem ser utilizadas, e os membros inferiores são uma alternativa factível como sítio de acesso vascular para hemodiálise. Este artigo relata um caso de transposição de veia femoral superficial para confecção de uma fístula arteriovenosa em alça em um paciente sem possibilidade de acessos nos membros superiores, além de fazer uma revisão da literatura sobre essa técnica ainda pouco utilizada.

Abstract The significant growth in the number of individuals dependent on hemodialysis for renal replacement therapy and unrestricted use of short and long-term catheters have challenged vascular surgeons in search of solutions for patients whose options for access via the upper limbs have been exhausted and for the increasing rates of central venous stenosis in these patients. When access via the upper limbs is impossible, exceptional techniques can be used and the lower limbs offer feasible alternative vascular access sites for hemodialysis. This article reports a case of superficial femoral vein transposition to make a loop arteriovenous fistula in a patient with no possibility of access via the upper limbs and presents a literature review on this technique that remains little used.