Protocolo Assistencial de Injeções Intravítreas do HCPA: Edema Macular Diabético

O edema macular diabético é uma das principais causas de baixa visual no mundo e a  indicação mais frequente de injeções intravítreas no Hospital de Clínicas de Porto Alegre. O tratamento com injeção intra-vítrea de medicamentos anti-vascular endothelial growth factor, incluindo o bevacizumabe revolucionou o desfecho visual destes pacientes às custas de múltiplas aplicações mensais. Assim como em outros centros, discrepâncias entre condutas da equipe assistencial e dificuldades logísticas acabam comprometendo a efetividade do tratamento. Portanto, desenvolvemos um protocolo de tratamento para a doença embasado na literatura, estabelecendo critérios de inclusão, exclusão, regime de tratamento e seguimento do paciente. Com isto, esperamos otimizar a efetividade e assistência do paciente com edema macular diabético.

Protocolo Assistencial de Injeções Intravítreas do HCPA: Degeneração Macular Relacionada com a Idade na forma neovascular

A degeneração macular relacionada com a idade na forma neovascular é uma das principais causas de cegueira no mundo e a segunda indicação mais frequente de injeções intravítreas no Hospital de Clínicas de Porto Alegre. O tratamento com injeção intra-vítrea de medicamentos anti-vascular endothelial growth factor, incluindo o bevacizumabe revolucionou o desfecho acuidade visual destes pacientes às custas de múltiplas aplicações mensais. Assim como em outros centros, discrepâncias entre condutas da equipe assistencial e dificuldades logísticas acabam comprometendo a efetividade do tratamento. Portanto, desenvolvemos um protocolo de tratamento para a DMRI-n embasado na literatura, estabelecendo critérios de inclusão, exclusão, regime de tratamento e seguimento do paciente. Com isto, esperamos otimizar a efetividade e assistência do paciente com DMRI-n. 

Intravitreal injections for age-related macular degeneration : an HCPA care protocol

A degeneração macular relacionada com a idade na forma neovascular é uma das principais causas de cegueira no mundo e a segunda indicação mais frequente de injeções intravítreas no Hospital de Clínicas de Porto Alegre. O tratamento com injeção intra-vítrea de medicamentos supressores do fator de crescimento endotelial (anti-vascular endothelial growth factor, anti-VEGF), incluindo o bevacizumabe, revolucionou o desfecho visual destes pacientes às custas de múltiplas aplicações mensais. Assim como em outros centros, discrepâncias entre condutas da equipe assistencial e dificuldades logísticas acabam comprometendo a efetividade do tratamento. Portanto, desenvolvemos um protocolo de tratamento para a DMRI-n embasado na literatura, estabelecendo critérios de inclusão, exclusão, regime de tratamento e seguimento do paciente. Com isto, esperamos otimizar a efetividade e assistência do paciente com DMRI-n.Age-related macular degeneration in the neovascular form is one of the main causes of blindness in the world and the second most frequent indication of intravitreal injections at Hospital de Clínicas de Porto Alegre. Treatment with intravitreal injection of antivascular endothelial growth factor agents, including bevacizumab, revolutionized the visual outcome of these patients at the expense of multiple monthly applications. As in other centers, discrepancies in care team’s approaches and logistical difficulties compromise the effectiveness of treatment. Therefore, we developed a treatment protocol for neovascular age-related macular degeneration (nAMD) based on the literature, establishing criteria for inclusion, exclusion, treatment regimen and patient follow-up. We hope to optimize the effectiveness of treatment in patients with nAMD

A new genus of Parastenocarididae (Copepoda, Harpacticoida) from the Tocantins River basin (Goiás, Brazil), and a phylogenetic analysis of the Parastenocaridinae

Eirinicaris antonioi gen. et sp. n. (Parastenocaridinae) is described from the Brazilian rocky savannas, an ecosystem under heavy anthropogenic pressure. The subfamily is distributed worldwide, with representatives in Africa, Asia, Australia, Europe, and North America. This is the first time a non-Remaneicaris Parastenocaridinae is described from a Neotropical region indicating that Parastenocaridinae species were already present in a vast geographical area, before the split of the Gondwana. The new taxon is included within the subfamily Parastenocaridinae based on the following characters: 1) segments 5, 6, and 7 of the male antennules forming a functional unit for clasping the female; 2) segment 7 with small process at the inner margin, forming an incipient "pocket-knife" structure with segment 6; 3) last segment pointing medially when closed; 4) the endopod of female leg 3 one-segmented and spiniform, without distal seta; 5) the apophysis and terminal seta of the exopod of male leg 3 are fused; 6) the genital field is rectangular and much broader than the height in the female; 7) the group of three lateral setae I, II, and III of the furca and the dorsal seta are situated at the same level in the female; and 8) the basis of leg 1 has an inner seta. The new taxon can be distinguished from all other Parastenocaridinae genera by the unique sexually dimorphic telson and furca. In the male, the dorsal seta is inserted at the midlength of the furca and setae I, II, and III are displaced anteroventrally. A phylogenetic analysis of the subfamily Parastenocaridinae is given based on the description of the type species of each genus and available descriptions of all Parastenocaridinae species. Eirinicaris gen. n. is the sister taxon of a clade formed by Kinnecaris and Monodicaris, sharing with them the long male and female leg 5 with a long spiniform process, and with Kinnecaris, a distal pore on the spiniform process. © Paulo H.C. Corgosinho et al

Amiodarone for arrhythmia in patients with Chagas disease : a systematic review and individual patient data meta-analysis

Background Chagas disease is a neglected chronic condition caused by Trypanosoma cruzi, with high prevalence and burden in Latin America. Ventricular arrhythmias are common in patients with Chagas cardiomyopathy, and amiodarone has been widely used for this purpose. The aim of our study was to assess the effect of amiodarone in patients with Chagas cardiomyopathy. Methodology We searched MEDLINE, Embase and LILACS up to January 2018. Data from randomized and observational studies evaluating amiodarone use in Chagas cardiomyopathy were included. Two reviewers selected the studies, extracted data and assessed risk of bias. Overall quality of evidence was accessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Principal findings We included 9 studies (3 before-after studies, 5 case series and 1 randomized controlled trial). Two studies with a total of 38 patients had the full dataset, allowing individual patient data (IPD) analysis. In 24-hour Holter, amiodarone reduced the number of ventricular tachycardia episodes in 99.9% (95%CI 99.8%-100%), ventricular premature beats in 93.1% (95%CI 82%-97.4%) and the incidence of ventricular couplets in 79% (RR 0.21, 95%CI 0.11–0.39). Studies not included in the IPD analysis showed a reduction of ventricular premature beats (5 studies), ventricular tachycardia (6 studies) and ventricular couplets (1 study). We pooled the incidence of adverse side effects with random effects meta-analysis; amiodarone was associated with corneal microdeposits (61.1%, 95%CI 19.0–91.3, 5 studies), gastrointestinal events (16.1%, 95%CI 6.61–34.2, 3 studies), sinus bradycardia (12.7%, 95%CI 3.71–35.5, 6 studies), dermatological events (10.6%, 95%CI 4.77–21.9, 3 studies) and drug discontinuation (7.68%, 95%CI 4.17–13.7, 5 studies). Quality of evidence ranged from moderate to very low. Conclusions Amiodarone is effective in reducing ventricular arrhythmias, but there is no evidence for hard endpoints (sudden death, hospitalization). Although our findings support the use of amiodarone, it is important to balance the potential benefits and harms at the individual level for decision-making

Clinical practice guidelines in Brazil : developing a national programme

In Brazil, governmental and non-governmental organisations develop practice guidelines (PGs) in order to optimise patient care. Although important improvements have been made over the past years, many of these documents still lack transparency and methodological rigour. In order to conduct a critical analysis and define future steps in PG development in Brazil, we carried out a structured assessment of strengths, weaknesses, opportunities and threats (SWOT analysis) for the development of a national guideline programme. Participants consisted of academia, methodologists, medical societies and healthcare system representatives. In summary, the PG development process has improved in Brazil and current investments in methodological research and capacity-building are ongoing. Despite the centralised processes for public PGs, standardised procedures for their development are not well established and human resources are insufficient in number and capacity to develop the amount of trustworthy documents needed. Brazil’s capacity could be strengthened and initial efforts have been made such as the adoption of standards proposed by world-renowned institutions in PG development and enhancement of the involvement of key stakeholders. Further steps involve the alignment between health technology assessment and PG processes for synergy and the development of a national network to promote the interaction between groups involved in the development of PGs. The lessons learned from this paper could be used to foster debate on guideline development, especially for countries facing similar threats on this topic

Priorities for Emergency Department Syncope Research

Study objectives There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. Methods We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. Results There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. Conclusion We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED