Santa Casa de Misericórdia de Marília

Drug-coated balloons are the preferred treatment for in-stent restenosis (ISR), avoiding the need for a second metallic layer. While both paclitaxel-coated balloons (PCB) and limus-coated balloons (LCB, typically sirolimus or biolimus) are used, direct comparative evidence is limited, particularly regarding their long-term angiographic efficacy and clinical safety. We conducted a systematic review and study-level meta-analyzis of studies comparing LCB with PCB for coronary ISR. A comprehensive search was performed across PubMed, Embase, Cochrane, Scopus, Web of science for randomized controlled trials. Outcomes were compared using risk ratios (RR) for categorical data and mean differences for continuous data in a random-effects model. Heterogeneity was assessed using the I2 statistic. Six randomized controlled trials involving 1,038 patients were included (552 in the LCB group and 481 in the PCB group). Compared with PCB, LCB were associated with a significantly higher risk of clinically driven target lesion revascularization (RR: 1.48; 95% CI: 1.02 to 2.14; p = 0.04; I2 = 0%) and target lesion failure (RR: 1.19; 95% CI: 0.87 to 1.62; p = 0.27; I2 = 0%). In contrast, both platforms demonstrated no differences in all-cause mortality (RR: 0.98; p = 0.96), myocardial infarction (RR: 0.73; p = 0.46), stent thrombosis (RR: 0.66; p = 0.57), or MACE (RR: 1.09; p = 0.58). Angiographic outcomes were comparable, including late lumen loss (mean differences: -0.00 mm; p = 0.65; I2 = 74.7%) and minimal lumen diameter (mean differences: -0.12 mm; p = 0.07). In patients with ISR, PCB reduced repeat revascularization compared with LCB. These data suggest a modest advantage for PCB in preventing restenosis following drug-coated balloon angioplasty for ISR.

Reference values for cardiac chamber quantification are essential for clinical decision-making. Brazil is a continental country with marked racial diversity and substantial regional socioeconomic and anthropometric variability, which may not be adequately represented in international echocardiographic standards. To establish reference echocardiographic measurements for healthy Brazilian adults and to investigate geographic and sex-related differences across Brazil's major regions. In this prospective, multicenter study, transthoracic echocardiograms were performed in 496 healthy volunteers (mean age 41 ± 15 years; 55% women) from five Brazilian regions. Left ventricular (LV) and left atrial (LA) dimensions, volumes, mass, ejection fraction, and global longitudinal strain (GLS) were analyzed in accordance with current guidelines. Comparisons were conducted by sex (Student's t test or Mann-Whitney U test) and by region (analysis of variance). Cardiac chamber dimensions and LV mass were greater in men, even after indexing for body surface area. LA volumes were also higher in men, although these differences were attenuated after indexing. Absolute LVGLS and right ventricle (RV) GLS (RVGLS) values were higher in women, whereas LA strain reservoir (LASr) was similar between sexes. Regionally, the Center-West exhibited significantly smaller LV volumes, a difference primarily driven by women, along with lower LVGLS and RVGLS (p < 0.001). In contrast, LA volumes were smaller in the Northeast region. No significant associations were observed between self-reported race and echocardiographic parameters, except for RVGLS and LASr, which were lower in White participants. This study establishes echocardiographic reference values in a nationally representative Brazilian cohort, confirms expected sex-related differences, and identifies previously unrecognized regional variations in cardiac chamber dimensions. These findings underscore the need for population-specific standards to ensure accurate cardiac quantification.

Transcatheter Aortic Valve Implantation (TAVI) or Replacement (TARV) is a widely established treatment for symptomatic severe aortic stenosis (AS) in patients with high or intermediate surgical risk. Diabetes mellitus (DM) is prevalent in TAVR patients and is associated with an increased risk of cardiovascular events, which may elevate procedural risks. A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Web of Science, and Cochrane databases were searched. A random-effects model was applied, with 95% confidence intervals (CIs) and a 5% significance level. Statistical analyses were performed using RStudio version 4.4.1. Twelve studies with 214,444 patients were included, comprising 74,294 diabetic and 140,150 nondiabetic individuals. The analysis revealed no significant differences in all-cause mortality, procedure mortality, 30-day mortality, or complications such as bleeding, myocardial infarction, and major complications. However, 1-year mortality was significantly higher in the diabetic group (RR: 1.51, 95% CI: 1.08-2.13). Diabetic patients were at higher risk for renal injury (RR: 1.46, 95% CI: 1.40-1.51) and lower risk of stroke (RR: 0.91, 95% CI: 0.83-0.99). The length of hospital stay and other major complications showed no significant differences. There was an increased risk of 1-year mortality and renal injury in diabetic patients undergoing TAVI compared to non-diabetics. Surprisingly, the risk for developing stroke in the diabetic group was significantly lower. In any case, the study emphasizes the need for tighter DM control to decrease the risk of such complications in the future.

Recurrent seizures have such a negative impact upon the lives of persons with epilepsy that their prevention is a constant preoccupation of neurologists. Despite the large number of antiseizure medications (ASMs) currently available and of publications on their putative efficacy, adverse effects, and order of preference to start treatment, there is very little information on how to manage treatment over time. Here, we propose the analogy of a chess game to encourage neurologists to develop strategic decisions at each point in time to correctly manage ASMs toward the best possible degree of seizure control. We leverage that the strategy of the chess player must be adapted to each move of the opponent, to emphasize the need to individualize the treatment of epileptic seizures according to variations in response to ASMs that occur over time. The chess player calculates the best move at each point in the chess game just as the neurologist draws upon their knowledge and experience to select the best ASM regimen for a given patient and adjust it based on their "gestalt" of the patient's response to each treatment change. This gestalt, however, is firmly grounded in rational, flexible adaptations to ASM treatment protocols. Strategic decision-making in several epilepsy scenarios is given to illustrate the utility of the chess analogy.

A Educação Permanente em Saúde, enquanto uma estratégia de aprendizagem, se configura como aprendizagem-trabalho de acordo com as demandas nos serviços de saúde e da população. O presente estudo tem por objetivo relatar a experiência da organização da Educação Permanente em Saúde em um Hospital de Ensino. Trata-se de um relato de experiência vivenciado na Santa Casa de Misericórdia de Sobral, um hospital do interior do Estado do Ceará onde a Educação Permanente em Saúde (EPS) é gerenciada pelo Departamento de Ensino, Pesquisa e Extensão. O processo de organização das EPS é realizado por meio de estratégias e fluxos previamente definidos, incluindo a construção e o acompanhamento do Plano de Educação Permanente, sendo realizado o levantamento das necessidades de treinamento vivenciadas pelos gestores do hospital. Além disso, são realizadas as avaliações de reação das EPS pelos colaboradores e a avaliação de impacto pelo líder do serviço. A EPS contribui significativamente com o aprimoramento da qualidade assistencial, com as atualizações de protocolos e com a execução dos procedimentos adequadamente. Percebe-se que as EPS realizadas in loco nos setores, a adesão dos líderes aos treinamentos e a participação das residências em saúde são essenciais para o fortalecimento da cultura da educação permanente no hospital.

Objective: To identify and describe the factors related to the knowledge, perceptions, and practices regarding emergency care for stroke among patients with risk factors such as diabetes and hypertension. Background: Health literacy in stroke implies the ability of non-medical individuals to recognize stroke symptoms and make timely decisions, which is a key factor influencing outcomes in patients with this condition. No previous study has evaluated the knowledge and perceptions of the general population about stroke in Bogotá. Methods: A cross-sectional study was conducted between October 2023 and April 2024. A validated questionnaire surveyed 5402 individuals in Bogotá. Results: Lower stroke symptom knowledge was associated with male sex (OR = 1.26, 95% CI (1.12, 1.42); p &lt; 0.001), low socio-economic strata (OR = 2.20, 95% CI (1.85, 2.60); p &lt; 0.001), and lower educational level (OR = 1.59, 95% CI (1.38, 1.82); p &lt; 0.001). Furthermore, a low educational level was correlated with a higher risk of choosing inadequate courses of action in the event of having an acute stroke. This included taking home remedies (OR = 1.52, 95% CI (1.30, 1.79); p &lt; 0.001) or going to the pharmacy (OR = 1.66, 95% CI (1.36, 1.93); p &lt; 0.001). Conclusions: Factors such as poor recognition of stroke symptoms, failure to identify it as an emergency, and socioeconomic disparities contribute to delays in seeking timely treatment. Addressing knowledge gaps and socioeconomic disparities is crucial for improving outcomes in stroke patients.