Unfractionated Heparin in Ruptured Aortic Aneurysms – Narrative Review

INTRODUCTION: Portuguese estimates point out that nearly 20% of aortic aneurysms are treated in a ruptured setting, with in-hospital mortality reaching up to 50%. Although unfractionated heparin (UFH) is routine during elective surgery, this technical point is debatable when treating ruptured aneurysms. The authors aimed to review the literature on the topic of intraoperative heparinization with UFH within the intraoperative period of ruptured aortic aneurysms. METHODS: A MEDLINE and Scopus database search using the terms “unfractionated heparin," “aortic aneurysm," and “ruptured aortic aneurysm” was performed. No time or language limitations were imposed. The last search was run in July 2023. Manuscripts were considered irrespective of study design. Additional articles of scientific interest for the purpose of this non-systematic review were included by cross-referencing. RESULTS: In the rupture setting, UFH usage rates have widely varied throughout time and geographical sites, and they are reported to be as low as 16%. Overall, the evidence of UFH in clinical practice in this scenario is limited. Notwithstanding, there is some evidence from observational studies of an increased pro-coagulant activity in this clinical scenario, favoring a theoretical physiologic benefit. A prospective, non-randomized study of 131 OSR patients found that patients treated with UFH had improved 30-day survival (84% vs 67%, P=0.001). Non-significant differences in blood product usage were noted. Therefore, societal guideline recommendations about intraoperative UFH in ruptured aortic aneurysms are often missing. CONCLUSION: UFH may potentially reduce death after open repair of rAAA. These findings should be carefully interpreted, as the evidence is scarce and heterogeneous and only portrays open repair

Fenestrated Physician-Modified Endografts (PMEGs) - a Viable Option for Urgent Cases

INTRODUCTION: Fenestrated and branched stent graft technology has come a long way over the past few years, enabling the treatment of complex juxtarenal aneurysms, thoracoabdominal aneurysms, and arch pathologies. Many innovations have been developed, namely device and delivery optimization and technical tricks. These concepts have proven to work well when there is sufficient time to plan and manufacture a custom-made device for the patient. However, this is different in urgent or emergent cases. Using parallel graft techniques or off-theshelf stent grafts may be efficient in urgent situations, but it is also associated with selection limitations. Recent publications have demonstrated similar mid-term technical and clinical results between physician-modified endografts (PMEGs) and customized devices. The authors aim to describe their institutional series of PMEGs. METHODS: The clinical files of all patients undergoing PMEGs were consulted, and demographic data as surgery outcomes were collected. Technical success: creating the intended number of fenestrations, target vessel catheterization, and patency. Procedural success: technical success with adequate aneurysm exclusion and without endoleak in the final angiography. 30-day complications and mortality were also evaluated. Technical and procedural success were assessed, as well as morbidity and mortality. RESULTS: Between December 2020 and December 2022, 3 patients underwent PMEGs. The indications were a juxtarenal aortic aneurysm, a type V thoracoabdominal aneurysm and a persistent type 1a endoleak. All patients were symptomatic, with one stable rupture. All cases were performed with technical and procedural success and no morbidity and mortality at 30 days. CONCLUSION: Stent graft modification is a valuable and valid tool in emergencies and should be a vascular surgeon's trump card when dealing with complex aortic pathologies. Nevertheless, due to the absence of longterm evidence, it should be reserved for acute patients unfit for open repair and in aneurysms with unfavorable anatomy for an off-the-shelf device

Contraceção Oral Combinada e sua Associação ao Cancro da Mama: uma Revisão Sistemática

O cancro da mama é a doença maligna mais frequentemente diagnosticada nas mulheres em todo o mundo, com incidência e mortalidade crescentes, pelo que o conhecimento dos seus fatores de risco é de grande importância para se poder investir em medidas de prevenção primária eficazes. O contracetivo oral combinado (COC) é o método contracetivo mais utilizado em mulheres em idade fértil, com utilização média de 5 anos. Esta revisão sistemática pretende avaliar se existe maior incidência de cancro da mama em mulheres em idade fértil com exposição a COC superior a 5 anos, comparativamente a exposição inferior a 5 anos.Breast cancer is the most frequently diagnosed malignant disease in women worldwide, with increasing incidence and mortality, therefore the knowledge of its risk factors is of great importance to be able to invest in effective primary prevention measures. The combined oral contraceptive (COC) is the most widely used contraceptive method in women of childbearing age, with an average use of 5 years. This systematic review aims to assess whether there is a higher incidence of breast cancer in women of childbearing age with exposure to COC for more than 5 years, compared to less than 5 years of exposur

The Impact of Digital CBT-I on the Treatment of Insomnia Disorder, an Evidence Based Practice

Introdução: Em Portugal, a insónia tem uma prevalência estimada de 10%. O tratamento de primeira linha é a terapia cognitivo-comportamental dirigida à insónia (TCC-I), no entanto há escassez de terapeutas disponíveis. O objetivo desta revisão baseada na evidência foi averiguar a eficácia das TCC-I através de meios digitais (TCC-ID) em adultos. Métodos: Foi realizada pesquisa de metanálises, metanálises em rede (MAR), revisões sistemáticas, ensaios clínicos randomizados (ECR) e normas de orientação clínica, publicados entre janeiro de 2018 e dezembro de 2022. Termos MeSH: “cognitive behavioural therapy”, “insomnia disorder”, “telemedicine” e “digital technology”. Fontes de dados: Cochrane Library, DARE, NICE, Direção-Geral de Saúde, Google Scholar e PubMed. Resultados: Foram obtidos 101 artigos e selecionados uma MAR e três ECR. A TCC-ID (Somryst®) apresenta uma probabilidade de 56% de ser o tratamento mais eficaz na insónia e uma probabilidade de 64% de ser o tratamento mais eficaz na sua remissão às 6 a 12 semanas. Em grávidas com insónia, a TCC-ID (Sleepio®) apresenta uma redução superior do score Índice de Severidade da Insónia (ISI) comparativamente com as terapias convencionais (p = 0,08). As taxas de remissão de insónia aos seis meses pós-parto foram superiores no grupo da TCC-ID (p = 0,02). Verificou-se uma melhoria no score ISI às 4 semanas (p = 0,063) após TCC-ID (StudiCare Sleep-e®) e às 12 semanas a diferença tornou-se estatisticamente significativa (p < 0,001). Tanto a TCC-I como TCC-ID apresentam impacto positivo na gravidade dos sintomas de insónia. No grupo que recebeu TCC-ID (WeChat®), houve uma melhoria estatisticamente significativa do score Pittsburgh Sleep Quality Index (p < 0,001). Discussão: A evidência demonstra não inferioridade entre TCC-ID e TCC-I convencional em adultos. A presente revisão apresenta limitações: amostra pouco heterogénea e inclusão de aplicações em língua estrangeira. Conclusão: A TCC-ID pode ser recomendada como alternativa à TCC-I convencional (Strength of Recommendation Taxonomy A).Introduction: The estimated prevalence of insomnia disorder in Portugal is 10%. The first line treatment is cognitive behavioral therapy for insomnia (CBT-I), nevertheless there is a lack of available therapists. The aim of this evidence-based practice is to verify the efficacy of CBT-I through digital media (CBT-ID) in adults. Methods: A search of meta-analyses, network meta-analyses (NMA), systematic reviews, randomized clinical trials (RCT) and clinical guidelines published between january 2018 and december 2022 was carried out. MeSH terms: “cognitive behavioral therapy”, “insomnia disorder”, “telemedicine” and “digital technology”. Data sources: Cochrane Library, DARE, NICE, Directorate-General for Health, Google Scholar and PubMed. Results: 101 articles were obtained and one MAR and three RCT were selected. CBT-ID (Somryst®) has a probability greater than 56% of being the most effective treatment in insomnia and greater than 64% of being the most effective treatment in insomnia remission (6 to 12 weeks). In pregnant women with insomnia, there is a higher reduction of the Insomnia Severity Index (ISI) score with CBT-ID (Sleepio®) in comparison with conventional therapies (p = 0.08). Remission rates at six months postpartum were higher in the group receiving CBT-ID (p = 0.02). There was an improvement in the ISI score at four weeks (p = 0.063) after CBT-ID (StudiCare Sleep-e®) and at 12 weeks the difference was more evident, becoming statistically significant (p < 0.001). Both CBT-I and CBT-ID show a positive impact in severity of insomnia symptoms. In the group that received CBT-ID (WeChat®), there was a statistically significant improvement in the Pittsburgh Sleep Quality Index score (p < 0.001). Discussion: The evidence demonstrates non-inferiority between CBT-ID and conventional CBT-I in adults. This review has limitations: a sample with low heterogeneity and the inclusion of applications in a foreign language. Conclusion: CBT-ID can be recommended as an alternative to conventional CBT-I (Strength of Recommendation Taxonomy A)

A Efetividade de um Programa de Reabilitação na Melhoria de Sintomas da Pessoa com Hipertensão Pulmonar: Protocolo de Revisão Sistemática da Literatura

Introdução: A Hipertensão Arterial Pulmonar (HAP) é uma condição fisiopatológica que pode estar associada a várias doenças cardiorrespiratórias, pelo que a sua complexidade exige uma abordagem multidisciplinar, incluindo intervenções como treino de exercício, apoio psicológico, educação e programas de reabilitação pulmonar, melhorando sintomas e qualidade de vida (Humbert et al., 2022). Objetivos: Avaliar a efetividade de programas de reabilitação na melhoria sintomática em pessoas com HAP. Material e Métodos: Definiu-se como pergunta de investigação “Qual a efetividade (O) de programas de reabilitação (I) na melhoria sintomática em pessoas com HAP (P)?”. Consideraram se critérios de inclusão: adultos com HAP (participantes), submetidos a programas de reabilitação (intervenção), com avaliação do impacto na melhoria sintomática (resultados), em qualquer contexto. Incluem-se artigos integrais de estudos quantitativos experimentais (ensaios controlados randomizados), quasi-experimentais, analíticos/descritivos observacionais. Sem limite temporal ou linguístico. A revisão baseia-se na Metodologia JBI para Revisões Sistemáticas de Efetividade, com uma estratégia em três fases: pesquisa preliminar de revisões (PROSPERO, JBI Evidence Synthesis, Cochrane Database, Medline), pesquisa nos cabeçalhos da PubMed e CINAHL (identificação de termos) e pesquisa completa na B-On, CINAHL e PubMed (Tufanaru et al., 2020). Definiu-se como expressão booleana [AB]'effectiveness' OR [AB]'efficacy' OR [AB]'outcome*' OR [AB]'effect*' AND [AB]'rehabilitation*' AND [AB]'pulmonary arterial hypertension'). As referências introduzir-se-ão no Zotero®. Títulos e resumos serão selecionados por 2 revisores, incoporados no JBI SUMARI, seguido da avaliação da qualidade metodológica (incluindo-se limiares superiores a 70%), da síntese narrativa e da avaliação do nível de evidência (abordagem GRADE e criação de Resumo das Conclusões/SoF) (McMaster University and Evidence Prime, 2023; Schünemann et al., 2013). Resultados: Os resultados incluirão impacto na qualidade de vida, dispneia, fadiga, capacidade/tolerância ao exercício, hemodinâmica cardiopulmonar ou consumo máximo de oxigénio (Tufanaru et al., 2020).Conclusões: É essencial pensar nas implicações clínicas do estabelecimento de programas de reabilitação especializados e efetivos.info:eu-repo/semantics/publishedVersio

Prognostic Factors Associated with Disability in a Cohort of Neuromyelitis Optica Spectrum Disorder and MOG-Associated Disease from a Nationwide Portuguese Registry.

Introduction: Neuromyelitis optica spectrum disorders (NMOSD) and MOG-associated disease (MOGAD) are an increasingly recognized group of demyelinating disorders of the central nervous system. Previous studies suggest that prognosis is predicted by older age at onset, number of relapses, the severity of the first attack and autoantibody status. Objective: To study prognostic factors associated with disability progression and additional relapses in the 3-year follow-up of a national NMOSD/MOGAD cohort. Results: Out of 180 of the initial Portuguese cohort, data on 82 patients was available at the end of the follow-up period (2019-2022). Two patients died. Twenty (24.4%) patients had one or more attack in this period (25 attacks in total), mostly transverse myelitis (TM) (56.0%) or optic neuritis (32.0%). MOGAD was significantly associated with a monophasic disease course (p = 0.03), with milder attacks (p = 0.01), while AQP4 + NMOSD was associated with relapses (p = 0.03). The most common treatment modalities were azathioprine (38.8%) and rituximab (18.8%). AQP4 + NMOSD more frequently required chronic immunosuppressive treatment, particularly rituximab (p = 0.01). Eighteen (22.5%) had an EDSS ≥6 at the end of the follow-up. AQP4 + NMOSD (p 6 were significantly older (64.0 ± 2.8 versus 31.0 ± 17.1, p = 0.017). A bivariate logistic regression model including the serostatus and TM attacks during disease history successfully predicted 72.2% of patients that progressed to an EDSS≥6. Conclusion: This study highlights that myelitis predict increased disability (EDSS≥6) in NMOSD/MOGAG and AQP4 positivity is associated with increased disability.This study highlights that myelitis predict increased disability (EDSS≥6) in NMOSD/MOGAG and AQP4 positivity is associated with increased disability

Suplementos Multivitamínicos na Gravidez: Qual a Evidência?

O período da gravidez constitui uma etapa chave na qual se deve apostar na promoção de estilos de vida saudáveis. Durante esta fase, as necessidades energéticas e de alguns nutrientes estão aumentadas para dar resposta às alterações metabólicas que ocorrem. Apesar de só haver indicação por parte da Organização Mundial da Saúde e Direção-Geral da Saúde para suplementar a mulher grávida com ácido fólico, ferro e iodo, a utilização de suplementos alimentares com vitaminas e minerais destinados para mulheres grávidas, é muitas vezes recomendada. Pretende-se neste artigo, apresentar a evidência que existe relativamente à toma destes suplementos na gravidez.info:eu-repo/semantics/publishedVersio

Organ Crosstalk and Dysfunction in Sepsis.

Sepsis is a dysregulated immune response to an infection that leads to organ dysfunction. Sepsis-associated organ dysfunction involves multiple inflammatory mechanisms and complex metabolic reprogramming of cellular function. These mechanisms cooperate through multiple organs and systems according to a complex set of long-distance communications mediated by cellular pathways, solutes, and neurohormonal actions. In sepsis, the concept of organ crosstalk involves the dysregulation of one system, which triggers compensatory mechanisms in other systems that can induce further damage. Despite the abundance of studies published on ​​organ crosstalk in the last decade, there is a need to formulate a more comprehensive framework involving all organs to create a more detailed picture of sepsis. In this paper, we review the literature published on organ crosstalk in the last 10 years and explore how these relationships affect the progression of organ failure in patients with septic shock. We explored these relationships in terms of the heart-kidney-lung, gut-microbiome-liver-brain, and adipose tissue-muscle-bone crosstalk in sepsis patients. A deep connection exists among these organs based on crosstalk. We also review how multiple therapeutic interventions administered in intensive care units, such as mechanical ventilation, antibiotics, anesthesia, nutrition, and proton pump inhibitors, affect these systems and must be carefully considered when managing septic patients. The progression to multiple organ dysfunction syndrome in sepsis patients is still one of the most frequent causes of death in critically ill patients. A better understanding and monitoring of the mechanics of organ crosstalk will enable the anticipation of organ damage and the development of individualized therapeutic strategies