Hospital Universitário Onofre Lopes

IntroductionSpeaking valves (SVs) restore phonation and may support airway protection in people with a tracheostomy, yet tolerance varies widely in neurological rehabilitation. We aimed to identify clinical factors associated with SV use and duration in a neurological rehabilitation setting.MethodsWe retrospectively analyzed 117 adults with neurological conditions and tracheostomy admitted to a rehabilitation center. Two internally validated multivariable models were developed: logistic regression for SV use (yes/no) and a quasi-Poisson regression for target daytime SV duration (hours/day), using routinely available bedside clinical variables.ResultsOf 117 patients, 64 (54.7%) used an SV during hospitalization. In the multivariable logistic model, higher level of consciousness (eMCS vs VS/MCS; OR 6.26, 95% CI 1.53-23.14), a positive blue dye test (OR 0.05, 95% CI 0.01-0.30), and endotracheal suction requirement (vs spontaneous cough; OR 0.07, 95% CI 0.003-0.879) were independently associated with SV use. Model performance was strong (AUC 0.856; accuracy 79.5%). Among SV users, longer daytime duration for SV use was associated with younger age, greater inspiratory and expiratory muscle strength, higher consciousness level, mild dysphagia, spontaneous cough, and neuromuscular or spinal cord injury diagnoses. In contrast, moderate-to-abundant secretions were associated with fewer hours.ConclusionIn a single-center neurological rehabilitation cohort, SV adoption and sustained tolerance were associated with bedside indicators of neurological responsiveness, secretion management, swallowing safety, and respiratory muscle strength. Findings should be interpreted as predictive associations and warrant external validation in contemporary multicenter cohorts.

Patient: Female, 40-year-oldFinal Diagnosis: ObesitySymptoms: ObesityClinical Procedure: —Specialty: SurgeryObjective: Unusual clinical courseBackgroundMetabolic and bariatric surgeries (MBS) are effective treatments for obesity and related comorbidities, such as diabetes and hypertension. In patients with morbid obesity and challenges like hepatomegaly, conventional procedures may increase risks. Staged MBS was developed to address these issues, enhancing safety. This report highlights the successful use of isolated intestinal transit bipartition with duodeno-ileal anastomosis, preserving the duodenum, as the first stage of the duodenal switch.Case ReportA 40-year-old woman with a BMI of 40.2 kg/m2 was booked for MBS. Severe hepatomegaly impaired safe access to the esophagogastric junction, leading to the performance of only the intestinal stage of the duodenal switch. A duodeno-ileal anastomosis was created 250 cm from the ileocecal valve, preserving the stomach and partial duodenal function. Without the gastric stage, the patient achieved 50 kg of weight loss (equivalent to 78.7% excess weight loss) over 19 years, without requiring additional surgery. Minor complications included occasional diarrhea, meteorism, and difficulties with vitamin supplementation, all managed effectively through dietary adjustments and nutritional guidance. A benefit was increased satiety.ConclusionsIsolated intestinal transit bipartition with duodeno-ileal anastomosis is an approach that may be used in exceptional cases, such as with this patient. Despite the favorable long-term follow-up results, further studies are necessary to better understand this approach. This method demonstrated sustained weight loss and long-term metabolic control, potentially representing a promising initial treatment option for patients with lower BMIs, including those with type 2 diabetes.

ABSTRACTAimCollapsing glomerulopathy (CG) is a glomerular disease that progresses rapidly to renal replacement therapy (RRT). Brazil is a conducive site for studies on CG because of its significant burden of infectious diseases and a high frequency of APOL1 risk variants. We described the clinical characteristics, histopathological findings, and outcomes of CG patients.MethodsThis retrospective survey analysed data from 2014 to 2022 from 18 centres of nephrology in all Brazilian regions. CG was diagnosed by kidney biopsy (KB), and the data were collected from medical records: initial symptoms, treatment, evolution to RRT.ResultsA total of 330 patients were included. Most patients were men (61.2%) and of Brown/Black ethnicity (72.7%). The mean age was 32 years. The most common symptoms were loss of renal function (44.2%), nephrotic proteinuria (80.07%), and hematuria (52.31%). KB revealed mild tubular atrophy and interstitial fibrosis (53.3%), moderate‐to‐severe interstitial inflammation (35.9%), and acute tubular necrosis (19.0%). On immunofluorescence, IgM (75.5%) and C3 (81.2%) were found to be most frequently deposited. Secondary etiologies were identified in 94 patients: HIV (13.8%), autoimmune disease (15.9%), and APOL1 high‐risk genotype (48.6%, 35/72). The mean follow‐up period was 13 months. Nephrotic proteinuria persisted in 78.8% of patients, and 30.5% progressed to RRT within 3 months after diagnosis.ConclusionCG affects young patients, leading to RRT in one‐third of cases in approximately 3 months. This multicentre study sets the baselines for risk factors and outcomes in the largest population studies on CG.

BACKGROUND Sleeve gastrectomy (SG) is widely used in obesity treatment, although it is associated with new onset of gastroesophageal reflux disease (de novo GERD) and weight regain. Roux-en-Y gastric bypass (RYGB) is the standard revisional procedure for GERD, though it offers limited additional weight loss. Ileal-based procedures have demonstrated superior outcomes regarding weight loss but have uncertain results in GERD. This study presents preliminary findings on gastric bipartition with functional duodenal exclusion (GBp-FDE) as a revisional approach following SG in this scenario. CASE REPORT A retrospective data analysis was conducted on 10 patients who underwent GBp-FDE due to de novo GERD and obesity recurrence after SG (mean BMI: 37.2±3.2 kg/m²). Nine patients presented with hiatal hernia and 8 with sleeve dilation. GERD was assessed pre- and postoperatively using a validated questionnaire, endoscopy, and contrast radiology. The surgical technique involved a pre-pyloric antroileostomy in Roux-en-Y configuration using a 40% proportion biliopancreatic limb. One-year postoperative findings included pyloric spasm (endoscopy), very preferential contrast flow to the ileum (radiology), and endoscopic access preservation to the duodenum. GERD symptoms resolved in 90% (P=0.0059) and esophagitis healed in 80% (P=0.008), likely due to gastric decompression. Mean percent total weight loss and percent excess weight loss were 35.2±6.6 and 108.0±11.14, respectively. CONCLUSIONS GBp-FDE seems to be a promising surgery for managing de novo GERD and obesity recurrence after SG, through SG pouch decompression and ileal stimuli, promoted by the antroileostomy. Further controlled studies with extended follow-up are necessary to validate these findings.

Introduction: Catheter ablation is a well-established rhythm control strategy for atrial fibrillation (AF), demonstrating superior efficacy compared to antiarrhythmic drug therapy. However, the optimal post-procedural management of oral anticoagulation (OAC) remains uncertain, particularly regarding whether OAC can be safely discontinued in patients without recurrent arrhythmias after the blanking period. Hypothesis: Discontinuing long-term anticoagulation after the blanking period is safe in patients undergoing catheter ablation for AF. Methods: We systematically searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) and observational studies comparing OAC discontinuation versus continuation in patients undergoing catheter ablation for AF. Data were analyzed using Cochrane RevMan (version 9.3.0), with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. Heterogeneity was assessed using the I2 statistic, with p < 0.05 and I2 > 25% indicating significant heterogeneity. The primary outcomes were new thromboembolic events and major bleeding. Results: Our analysis included 23 studies (1 RCT and 22 observational studies) comprising a total of 145,489 patients, of whom 75,585 discontinued anticoagulation. OAC discontinuation did not significantly affect the occurrence of new thromboembolic events (OR 0.76; 95% CI 0.55–1.04; p = 0.08; Figure 1) and was associated with a significant reduction in the risk of major bleeding (OR 0.32; 95% CI 0.19–0.52; p = 0.0001; Figure 2) compared to the continuation of long-term anticoagulation. No significant differences in thromboembolic events were observed in a sensitivity analysis restricted to patients with a CHA2DS2-VASc score ≥ 2 (OR 1.00; 95% CI 0.65–1.53; p = 1.00). Conclusions: OAC discontinuation after the blanking period appears to be safe in patients undergoing catheter ablation for AF, with no increase in thromboembolic risk, even among high-risk individuals. Moreover, it significantly reduces the risk of major bleeding compared to long-term OAC continuation. These findings challenge the conventional practice of indefinite anticoagulation and suggest that discontinuation may be preferable in select patients; however, the limited randomized evidence warrants cautious interpretation.

We aims to analyze the effects of full-spectrum cannabis oil extract and THC on EMG of respiratory muscles, NIRS, cardiovascular hemodynamics, and peripheral tissue perfusion. It is a randomized, controlled, crossover, double-blind clinical trial with 18 healthy participants (25 [22–30] years old). Each participant underwent three interventions: Full-Spectrum (I-FS), THC (I-THC), and Placebo (I-P), assessed at baseline (A1), one hour (A2), and two hours post-intervention (A3). During each intervention, subjects performed 2 minutes of quiet breathing (qb), 2 minutes with inspiratory and expiratory threshold load resistor (val), followed by 4 minutes of recovery (rec) against inspiratory and expiratory loads of 30% of PImax and 10% of PEmax. For respiratory muscle activity, I-THC increased %RMS of the sternocleidomastoid and parasternal muscles (p<0.05), while I-FS enhanced scalene and parasternal activation (p≤0.021). Regarding oxygenation, NIRS on the vastus medialis showed that HHb levels decreased in both I-FS and I-THC groups, with a significant difference at qb (p=0.003) and val (p=0.020) compared to baseline. O2Hb showed an increasing pattern, with a significant rise in the I-THC group during the val time point (p=0.029). Both oils increased heart rate (HR), with a stronger effect in I-THC (p=0.002). The cardiac index rose in I-THC at A2 and A3 (p<0.05) and in I-FS at A2 and A3 (p<0.05). Vascular resistance was lower in I-THC than in I-P (p=0.017) and I-FS (p=0.003). These findings suggest that cannabis oil compounds enhance respiratory muscle activation, oxygenation and cardiovascular responses, under respiratory load.

Objective: To investigate the relationship between respiratory function, functionality, and mortality in amyotrophic lateral sclerosis (ALS) patients and to determine which respiratory parameters show the strongest correlation with functionality and mortality. Methods: The study was conducted in Rio Grande do Norte, Northeast Brazil, between January 2018 and December 2023. This was a retrospective cohort, following individuals with ALS who were evaluated at the University Laboratory. Results: A total of 74 ALS patients were included in the analysis, with a mean age of 55.7 ± 13.5 years. Most were male (66.2%) and predominantly presented with spinal-onset ALS (51.3%). Respiratory variables (except peak expiratory flow (PEF)) showed a weak but significant inverse correlation with mortality (FVC% predicted (rpb = −0.260; p < 0.001), SNIP (rpb = −0.235; p = 0.001), MEP (rpb = −0.207; p = 0.007), MIP (rpb = −0.198; p = 0.009), and PEF% predicted (rpb = −0.156; p = 0.013)). When analyzing their correlation with ALSFRS-R, all variables showed a significant positive correlation (ranging from weak to moderate) with functionality. A reduction of one unit in the respiratory variables PEF% of predicted, maximal inspiratory pressure (MIP), and sniff nasal inspiratory pressure (SNIP) increased the risk of death by an average of 300% (OR = 2.99; 95% CI: 2.05–4.35), 2% (OR = 1.02; 95% CI: 1.01–1.03), and 1% (OR = 1.01; 95% CI: 1.00–1.02), respectively. Conclusions: Our findings suggest that direct measurements of respiratory function and muscle strength, particularly PEF and SNIP, may serve as more useful markers to guide early interventions such as non-invasive ventilation, thereby improving quality of life and potentially prolonging survival.