Evidence from Cochrane systematic reviews for the dissemination control of the COVID-19 infection

Introduction: The COVID-19 infection has high transmissibility and several measures have been adopted for dissemination control. Objective: To identify and summarize the evidence from the Cochrane systematic reviews (SR) on measures to control the dissemination of the COVID-19 infection. Study design: This review of Cochrane SR has carried out in the Division of Vascular and Endovascular Surgery and in the Division of Emergency Medicine and Evidence-Based Medicine of the Universidade Federal de São Paulo, Brazil. Methods: A comprehensive search in the Cochrane Database of Systematic Reviews retrieved all Cochrane SR directly related to control measures for the COVID-19 dissemination. The main characteristics and results of all included SR were summarized and discussed. Results: Three Cochrane SRs were included in the qualitative synthesis and they evaluated populational and individual measures to control the dissemination of COVID-19. Conclusion: Low-certainty evidence show that quarantine of people exposed to those confirmed or suspected COVID-19 cases prevented 44% - 81% of incident cases and 31% - 63% of deaths compared to no measures and as sooner the quarantine measures are implemented, greater costs are saved. High-confidence evidence showed that clear communication about infection control and prevention guidelines was vital to its implementation. Low-certainty evidence showed that people with a long gown had less contamination than those with a coverall, and the coverall was more difficult to doff. Other SRs are desirable for controlling the dissemination of the COVID-19 infection

Klippel-Trenaunay-Weber Syndrome: association of operative treatment with foam sclerotherapy

The Klippel-Trenaunay-Weber Syndrome is the association of hemangioma, venous ectasia, and hypertrophy of the affected body segment. We report the case of a 39-year-old male followed-up since 1993 due to onset of symptoms in the left lower limb. He was treated only with the use of elastic stockings and general measures. Over the years, he had worsening of venous stasis, of bone hypertrophy, and of skin hyperpigmentation. Color-coded Doppler ultrasonography of the lower limbs showed patency of the deep venous system, venous overflow, segmentar insufficiency of the greater saphenous vein with signs of thrombophlebitis, and insufficient tributary veins. In order to improve venous stasis, ligation of the left sapheno-femoral junction and retrograde foam sclerotherapy (polidocanol 3%) with resection of tributary veins were performed. The patient was discharged in the first postoperative day and has been followed as an outpatient, presenting significant improvement of the symptoms.A Síndrome de Klippel-Trenaunay-Weber representa a associação de hemangiomas planos, ectasias venosas e hipertrofia do segmento corpóreo afetado. Apresenta-se o caso de um paciente de 39 anos, sexo masculino, seguido desde 1993 no serviço da Disciplina de Cirurgia Vascular da Escola Paulista de Medicina (UNIFESP), por quadro inicial da síndrome em membro inferior esquerdo. O paciente foi tratado apenas por elastocompressão e medidas gerais. Neste período, ele evoluiu com piora da estase venosa, da hipertrofia óssea e da hiperpigmentação de pele. Na ultrassonografia Doppler colorida venosa dos membros inferiores havia perviedade do sistema venoso profundo, hiperfluxo venoso, insuficiência segmentar de veia safena magna com sinais de tromboflebite e tributárias insuficientes. Indicou-se, para a melhora da estase venosa, ligadura da junção safeno-femoral esquerda e escleroterapia (polidocanol 3%) retrógrada da mesma, com exérese das ectasias venosas. O paciente recebeu alta hospitalar no primeiro dia pós-operatório e atualmente está em acompanhamento ambulatorial com melhora significativa dos sintomas.Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Estenose de carótida extracraniana: revisão baseada em evidências

RESUMO A doença vascular cerebral extracraniana é uma das mais importantes causas de morte e de incapacidade em todo o mundo e seu tratamento se baseia em estratégias clínica e cirúrgica, sendo que esta última pode ser feita pelas técnicas convencional ou endovascular. O manejo da estenose da bifurcação carotídea visa principalmente a prevenir o acidente vascular cerebral e tem sido objeto de extensa investigação. O papel do tratamento clínico tem sido re-enfatizado, mas a endarterectomia de carótida permanece como o tratamento de primeira linha para pacientes sintomáticos com estenose de 50% a 99% e, para pacientes assintomáticos, com estenose de 60% a 99%. A angioplastia com stent é reservada para pacientes sintomáticos, com estenose de 50% a 99% e com risco elevado para a cirurgia aberta, por motivos anatômicos ou clínicos. Atualmente, o procedimento endovascular não é recomendado para pacientes assintomáticos que tenham condições de serem submetidos ao tratamento cirúrgico convencional. O Brasil apresenta tendência semelhante à de outros países da América do Norte e Europa, observando a manutenção da endarterectomia como a principal indicação para o tratamento da estenose carotídea e reservando o procedimento endovascular para casos em que há contraindicações para a primeira intervenção. Todavia, temos de melhorar os nossos resultados, reduzindo as complicações, notadamente a taxa de mortalidade geral

Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis

ABSTRACT Introduction: Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. Methods: we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. Results: we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. Conclusion: DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases

Angioplasty and stenting for below the knee ulcers in diabetic patients: protocol for a systematic review

Abstract Background The worldwide incidence and prevalence of diabetes mellitus (DM) are increasing. DM has a high social and economic burden due to its complications and associated disorders. Peripheral arterial disease (PAD) is closely related to DM. More than 85% of patients with DM will develop PAD in their lifetime, and between 10 and 25% of patients with DM will have a foot ulcer. In such cases, it is important to determine for each patient whether it is necessary and feasible to revascularise the affected limb as well as the optimal technique. Percutaneous transluminal angioplasty (PTA) is designed to restore blood flow through the vessel lumen by various devices including balloons, drug-coated balloons, bare stents, drug-eluting stents and endovascular atherectomes. This systematic review aims to evaluate the effects of PTA in the treatment of lower limb arterial ulcers in diabetic patients. Methods We will search randomised controlled trials (RCTs) and quasi-RCTs in the following databases (e.g., MEDLINE via PubMed, EMBASE, Lilacs, Cochrane Central Register of Controlled Trials, Ibecs, CINAHL, AMED, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and OpenGrey). Our search strategy will use the following free-text terms and controlled vocabulary (e.g., Emtree, MeSH) for ‘foot ulcer’, ‘leg ulcer’, ‘diabetic foot’, ‘Peripheral Arterial Disease’, ‘Diabetes Complications’, ‘Peripheral Vascular Diseases’, ‘critical limb ischemia’, ‘below the knee ulcer’, ‘angioplasty’, ‘stents’, ‘stenting’, and ‘endovascular procedures’. There will be no limits on date or language of publication. Two authors will, independently, select studies and assess the data from them. Risks of bias (RoB) of included studies will be evaluated using the Cochrane’s RoB tool. If possible, we will perform and report structured summaries of the included studies and meta-analyses. Results are not available as this is a protocol for a systematic review, and we are currently in the phase of building a sensitive search strategy. Discussion While there are several available endovascular techniques for revascularisation, it is unclear which technique has better outcomes for ulcers below the knee in diabetic patients. A systematic review is required to validate and demonstrate these techniques and their outcomes to allow an evidence-based clinical decision. Systematic review registration PROSPERO CRD4201706517