What Are the Barriers to Telerehabilitation in the Treatment of Musculoskeletal Diseases?

Introduction: Musculoskeletal-related chronic pain is one of the most disabling in the world, with knee osteoarthrosis (OA) being one of the main causes of functional limitation and chronic pain among people over 45 years of age. In view of this, the expansion of telehealth services, including telerehabilitation, allows less restricted access to health services, reducing expenses and saving time. Purpose: The aim of the study was to verify the barriers to the implementation of telerehabilitation in the treatment of chronic musculoskeletal diseases compared to face-to-face rehabilitation. Data Source: The data were obtained from PubMed, Scopus, the Virtual Health Library (VHL), Cochrane, and the Web of Science databases. Methods: This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to answer the PICOT question, “What are the barriers to implementing a telerehabilitation program for older people with knee osteoarthritis?”. The risk of bias was analyzed using the Review Manager program (RevMan). A search for articles was conducted and included only randomized clinical trials with older people with knee OA, selected by two blinded authors, according to inclusion and exclusion criteria, without publication time restriction, in the PROSPERO registry CRD42022316488. Results: The barriers to telerehabilitation have been overcome with the diversification of means of communication, the various possible ways of monitoring these patients from a distance, and the scheduling of face-to-face assessments and reassessments. The results presented in this review indicate that the barriers to implementing treatment protocols have been overcome, leading to clinical results which showed that there were no differences between the telerehabilitation and face-to-face groups for the clinical condition investigated. Conclusion: The barriers to telerehabilitation, which were more related to Internet access, telecommunication devices, personal relationships, and adequate monitoring of the exercise protocol, were overcome by diversifying the means of communication and delivering the exercise protocol for the implementation of telerehabilitation

ANÁLISE DO PERFIL E DA CONDIÇÃO BUCAL DO PACIENTE DOMICILIAR ASSISTIDO POR EQUIPE INTERDISCIPLINAR DE HOSPITAL TERCIÁRIO

INTRODUÇÃO: A assistência domiciliar é definida como um conjunto de medidas desenvolvidas para uma estratégia assistencial de saúde, com objetivo preventivo, curativo e/ou paliativo, apresentando abordagem interdisciplinar. É de grande relevância para a desospitalização, redução de custos hospitalares, reinserção social e familiar, e promoção de qualidade de vida ao paciente. OBJETIVO: Determinar o perfil, condição bucal dos pacientes e os procedimentos odontológicos realizados no domicílio. MÉTODOS: Estudo retrospectivo de 94 prontuários odontológicos de pacientes assistidos pela Divisão de Odontologia do ICHCFMUSP inserida no Núcleo de Assistência Domiciliar Interdisciplinar (NADI), do período de maio de 2014 a dezembro de 2015. RESULTADOS: Predominância do sexo feminino (60,64%), com média de idade de 81,11 anos, sendo que 49,01% dos pacientes apresentavam patologias neurológicas, e 77,05% tinham o diagnóstico de doenças crônicas como hipertensão arterial sistêmica, dislipidemia ou diabetes mellitus. Foi avaliado índice CPOD médio de 22,59. As queixas odontológicas mais frequentes foram relacionadas a desadaptação das próteses dentárias, boca seca e dificuldade de higiene bucal. Foram realizados 70 procedimentos dentários como raspagem corono radicular, exodontias, reembasamento de prótese dentária e restaurações. CONCLUSÃO: O acesso a assistência odontológica domiciliar proporciona remoção de focos bucais e resolução da queixa odontológica, proporcionando conforto e menor estresse ao paciente que necessita deste tipo de assistência, assim como o treinamento e orientação do cuidador sobre higiene bucal, o qual é fundamental para controle das infecções bucais, conforto bucal e qualidade de vida

USO DE INFUSÃO DE PLAQUETAS E SELANTE DE FIBRINA PARA EXODONTIA EM PACIENTE COM ANEMIA APLÁSTICA: DESCRIÇÃO DE PROTOCOLO.

A aplasia medular é uma desordem rara e grave caracterizada pela deficiência de produção de células sanguíneas e plaquetas, ocasionando pancitopenia, o que predispõe a sangramentos, petéquias, equimose e/ou hematomas em pele e mucosas, além do risco de infecção. Os principais tratamentos propostos são imunossupressão, transfusões sanguíneas e transplante de células tronco hematopoiéticas. Diante deste fato é de extrema importância manter a cavidade bucal sem focos infecciosos, porém a remoção dos mesmos pode provocar consequências graves, como sangramento intenso. O presente estudo tem como objetivo relatar o caso clínico de uma paciente portadora de aplasia medular com necessidade de tratamento odontológico cruento, bem como destacar as principais condutas interdisciplinares para a assistência odontológica segura. Paciente LLA, 18 anos, em preparo para transplante de células tronco hematopoiéticas, com necessidade de exodontia do dente 36 devido à grande destruição coronária e sintomatologia dolorosa. Devido ao número reduzido de plaquetas (5,2 mil/mm³), optou-se pela infusão de plaquetas prévias ao procedimento e utilização de selante de fibrina, intra alveolar, após exodontia. O selante de fibrina é derivado de sangue ou plasma humano e reproduz a última fase da coagulação fisiológica do sangue. Diversos estudos publicados revelam a eficácia do selante de fibrina, uma vez que o mesmo auxilia na coaptação dos tecidos, vedamento de feridas e no estabelecimento da hemostasia. Com base na literatura apresentada neste estudo, conclui-se que pacientes portadores de aplasia medular podem ser submetidos a tratamentos odontológicos cruentos com segurança, utilizando um bom planejamento interdisciplinar que garantam medidas hemostáticas sistêmicas e locais

UTILIZAÇÃO DA TERAPIA FOTODINÂMICA NO TRATAMENTO DA OSTEORRADIONECROSE DOS MAXILARES: DESCRIÇÃO DE PROTOCOLO CLÍNICO.

A osteorradionecrose (ORN) é a complicação mais severa da radioterapia (RT) de cabeça e pescoço, sendo definida por uma exposição de osso necrótico que persiste por período superior a 3 meses. A ORN pode estar associada a dor, sequestro ósseo, fratura patológica, fístula orocutânea e deformidades. Atualmente, a teoria mais aceita afirma que após a realização da RT os tecidos tornam-se hipovascularizados, hipocelulares e hipóxicos dificultando sua cicatrização. O tratamento da ORN é realizado através da limpeza cirúrgica associada a antibiótico terapia, higiene oral e ao uso de clorexidina 0,12%. A terapia fotodinâmica (PDT), técnica que associa o uso de um corante fotossensibilizador a uma fonte de luz como um comprimento de onda específico do LASER, pode ser usada objetivando-se a desinfecção da ORN. Será relatado um protocolo clínico de PDT aplicado em 2 pacientes com ORN em mandíbula. Ambos do sexo masculino, submetidos a RT de cabeça e pescoço devido a CEC em cavidade oral, com exposição de osso necrótico após 4 meses da exodontia do 36 (±0,4cm por lingual, no 1º paciente; ±2,0cm em rebordo, no 2º). Foi realizada limpeza local com clorexidina 0,12%, aplicação do corante azul de metileno 0,01% por 5 minutos e aplicação de LASER de baixa potência (660nm, 120J/cm2, 3,6J, 100mW, 36s) recobrindo toda a área comprometida. As aplicações foram realizadas semanalmente, por 4 semanas consecutivas. Observou-se proliferação epitelial sobre o osso tratado com a PDT, com resolução completa no 1º caso e parcial no 2º, mas com melhora da dor. O uso da PDT no tratamento da ORN mostrou-se importante por promover a desinfecção do osso necrótico favorecendo a reparação tecidual que permitiu menor deformidade quando comparada ao tratamento cirúrgico convencional

Epidemiology and clinical course of severe acute respiratory syndrome coronavirus 2 infection in cancer patients in the Veneto Oncology Network: The Rete Oncologica Veneta covID19 study

Introduction: Coronavirus disease 2019 (COVID-19) pandemic started in Italy with clusters identified in Northern Italy. The Veneto Oncology Network (Rete Oncologica Veneta) licenced dedicated guidelines to ensure proper care minimising the risk of infection in patients with cancer. Rete Oncologica Veneta covID19 (ROVID) is a regional registry aimed at describing epidemiology and clinical course of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with cancer. Materials and methods: Patients with cancer diagnosis and documented SARS-CoV-2 infection are eligible. Data on cancer diagnosis, comorbidities, anticancer treatments, as well as details on SARS-CoV-2 infection (hospitalisation, treatments, fate of the infection), have been recorded. Logistic regression analysis was applied to calculate the association between clinical/laboratory variables and death from any cause. Results: One hundred seventy patients have been enrolled. The median age at time of the SARS-CoV infection was 70 years (25-92). The most common cancer type was breast cancer (n = 40). The majority of the patients had stage IV disease. Half of the patients had two or more comorbidities. The majority of the patients (78%) presented with COVID-19 symptoms. More than 77% of the patients were hospitalized and 6% were admitted to intensive care units. Overall, 104 patients have documented resolution of the infection. Fifty-seven patients (33%) have died. In 29 cases (17%), the cause of death was directly correlated to SARS-CoV-2 infection. Factors significantly correlated with the risk of death were the following: Eastern Cooperative Oncology Group performance status (PS), age, presence of two or more comorbidities, presence of dyspnoea, COVID-19 phenotype ≥ 3, hospitalisation, intensive care unit admission, neutrophil/lymphocyte ratio and thrombocytopenia. Conclusions: The mortality rate reported in this confirms the frailty of this population. These data reinforce the need to protect patients with cancer from SARS-CoV-2 infection

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030