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Accorsi TAD, Eduardo AA, Moreira FT, Morbeck RA, Köhler KF, Lima KDA, Pedrotti CHS. Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center. Telemed J E Health 2024; 30:1418-1424. [PMID: 38377569 DOI: 10.1089/tmj.2023.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.
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Massaud RM, Accorsi TAD, Massant CG, Silva GS, de Carvalho Leite AV, Franken M, Moreira FT, Köhler KF, De Amicis Lima K, Morbeck RA, Pedrotti CHS. In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study. Front Neurol 2024; 15:1303995. [PMID: 38504799 PMCID: PMC10948599 DOI: 10.3389/fneur.2024.1303995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/15/2024] [Indexed: 03/21/2024] Open
Abstract
Purpose Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Methods Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. Results The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. Conclusion The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.
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Affiliation(s)
| | | | | | - Gisele Sampaio Silva
- Clinical Practices Management, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Marcelo Franken
- Clinical Practices Management, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Flavio Tocci Moreira
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Accorsi TAD, dos Santos GGR, Nemoto RP, Moreira FT, De Amicis K, Köhler KF, Cordioli E, Pedrotti CHS. Telemedicine and patients with heart failure: evidence and unresolved issues. Einstein (Sao Paulo) 2024; 22:eRW0393. [PMID: 38451690 PMCID: PMC10948100 DOI: 10.31744/einstein_journal/2024rw0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/26/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.
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Affiliation(s)
| | | | - Renato Paladino Nemoto
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karen Francine Köhler
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, Nemoto RP, Nunes JT, de Azevedo AFB, Moreira FT, Kohler KF, Lima KDA, Amaral BDR, Morbeck RA, Pedrotti CHS. Clinical Features and Management of Patients Assessed by Cardiology Teleconsultation in the Brazilian Region with the Highest Number of Isolated Cities. Arq Bras Cardiol 2023; 120:e20220467. [PMID: 37162075 PMCID: PMC10263392 DOI: 10.36660/abc.20220467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/23/2023] [Accepted: 02/15/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Cardiovascular diseases are the leading cause of adult mortality. Geographically remote and low-income Brazilian regions lack specialized consultations. The telemedicine management of this population by cardiologists is not fully known. OBJECTIVES To analyze cardiology teleconsultation in the Brazilian region with the highest number of isolated cities. METHODS From February 2020 to October 2021, patients from the North Region of Brazil evaluated by local general practitioners were referred for cardiological evaluation by telemedicine. Referral reasons, demographics, clinical history, physical examinations, tests, medications, and prescriptions pre- and post-telemedicine were analyzed (p<0.05 was considered statistically significant). RESULTS We analyzed 653 patients. The attendance rate was 85.7% (53.1% female, mean age: 54.2±6.5 years). The main reasons for referral were cardiovascular symptoms (58.1%) and risk factors among asymptomatic patients (13.3%). Only 12.6% had a diagnosed disease. Most patients had regular physical examinations and electrocardiograms. Few had recent complementary tests. The prescription of angiotensin receptor blockers (ARBs), calcium channel blockers and statins was significantly increased, while that of digoxin, noncardiac beta-blockers and acetylsalicylic acid (ASA) was decreased at the first teleconsultation. Most of the tests requested were of low complexity and cost: electrocardiogram (28.2%), chest X-ray (14%), echocardiogram (64.5%) and blood tests (71.8%). For 2.1% of patients, interventions were indicated, and 8% were discharged after the first consultation. CONCLUSION On-demand cardiology teleconsultation contributes to heart disease treatment optimization. Most patients were referred with syndromic diagnoses without previous complementary tests. The specialist workup requested was usually available locally and at a low cost but precluded early discharge. Local training could optimize the referral.
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Affiliation(s)
- Tarso Augusto Duenhas Accorsi
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Renato Paladino Nemoto
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Jairo Tavares Nunes
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | | | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Karen Francine Kohler
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Karine de Amicis Lima
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Bruna Dayanne Reges Amaral
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
| | - Renata Albaladejo Morbeck
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein – Telemedicine, São Paulo, SP – Brasil
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Accorsi TAD, Moreira FT, Amicis KD, Köhler KF, Cordioli E, Pedrotti CHS. Tips and tricks for the persistent hiccup management in a Telemedicine encounter. Einstein (Sao Paulo) 2022; 20:eCE0155. [PMID: 36259921 PMCID: PMC9550159 DOI: 10.31744/einstein_journal/2022ce0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karen Francine Köhler
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, Moreira FT, Pedrotti CHS, Amicis KD, Correia RFV, Morbeck RA, Medeiros FF, de Souza JL, Cordioli E. Telemedicine diagnosis of acute respiratory tract infection patients is not inferior to face-to-face consultation: a randomized trial. Einstein (Sao Paulo) 2022; 20:eAO6800. [PMID: 35649057 PMCID: PMC9126601 DOI: 10.31744/einstein_journal/2022ao6800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/05/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. METHODS Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. RESULTS Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). CONCLUSION Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477.
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Affiliation(s)
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Renata Albaladejo Morbeck
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Fernanda Ferreira Medeiros
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - José Leão de Souza
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Pedrotti CHS, Accorsi TAD, Moreira FT, Lima KDA, Köhler KF, Gaz MVB, Chiamolera M, Cunha GA, Neto AS, Morbeck RA, Cordioli E. Telemedicine medical evaluation of low-risk patients with dengue during an outbreak may be an option in reducing the need for on-site physicians. Int J Infect Dis 2022; 121:106-111. [PMID: 35504552 DOI: 10.1016/j.ijid.2022.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To analyze the effectiveness of telemedicine consultations during an outbreak in reducing the need for face-to-face consultations at a field hospital for patients with dengue. METHODS We performed a retrospective unicentric study between April and May 2015 with 4626 patients (≥15 years old) who spontaneously sought care at an emergency field hospital (Sāo Paulo/Brazil). A nurse initially assessed all patients with dengue through rapid diagnostic testing, automated complete blood count, and risk stratification. During overcrowded situations, a video-based telemedicine consultation was provided as an option to all low-to-moderate risk patients who tested positive. The management was carried out according to current dengue guidelines. The primary end point was a referral to immediate face-to-face medical evaluation. RESULTS Of all patients suspected of dengue infection, 2003 presented positive testing, 1978 were classified as low-moderate risk, and 267 patients with dengue were evaluated by telemedicine. The mean age was 38.17 ± 13.7 years (54.6% female). Oral medications were recommended in 169 (63.3%), intravenous hydration or symptomatic drugs in 96 (36%), 252 (94.4%) were discharged after telemedicine assessment, and only 15 (5.6%) were referred to immediate face-to-face medical evaluation. No adverse events were recorded. CONCLUSION Telemedicine medical assessment of low-to-moderate risk patients with dengue previously screened by nursing triage is effective in replacing the face-to-face evaluation in a field hospital. Telemedicine may be reinforced in epidemiological outbreak scenarios as a cost-effective strategy for the initial assessment of acute patients.
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Affiliation(s)
- Carlos H S Pedrotti
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil.
| | - Tarso A D Accorsi
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | | | | | | | - Marcus V B Gaz
- Emergency Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Murilo Chiamolera
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Gustavo A Cunha
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Ary Serpa Neto
- Intensive Care Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Renata A Morbeck
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
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Bianco HT, Povoa R, Izar MC, Luna Filho B, Moreira FT, Stefanini E, Fonseca HA, Barbosa AHP, Alves CMR, Caixeta AM, Gonçalves I, Moraes PIDM, Lopes RD, Paola AAVD, Almeida D, Moises VA, Fonseca FAH. Accuracy of Post-thrombolysis ST-segment Reduction as an Adequate Reperfusion Predictor in the Pharmaco-Invasive Approach. Arq Bras Cardiol 2021; 117:15-25. [PMID: 34320062 PMCID: PMC8294746 DOI: 10.36660/abc.20200241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
Fundamento A intervenção coronária percutânea primária é considerada o “padrão-ouro” para reperfusão coronária. Entretanto, quando não disponível, a estratégia fármaco-invasiva é método alternativo, e o eletrocardiograma (ECG) tem sido utilizado para identificar sucesso na reperfusão. Objetivos Nosso estudo teve como objetivo examinar alterações no segmento-ST pós-lise e seu poder de prever a recanalização, usando os escores angiográficos TIMI e blush miocárdio (MBG) como critério de reperfusão ideal. Métodos Foram estudados 2.215 pacientes com infarto agudo do miocárdio com supra-ST submetidos à fibrinólise [(Tenecteplase)-TNK] e encaminhados para angiografia coronária em até 24 h pós-fibrinólise ou imediatamente encaminhados à terapia de resgate. O ECG foi realizado pré-TNK e 60 min-pós. Os pacientes foram categorizados em dois grupos: aqueles com reperfusão ideal (TIMI-3 e MBG-3) e aqueles com reperfusão inadequada (fluxo TIMI <3). Foi definido o critério de reperfusão do ECG pela redução do segmento ST >50%. Consideramos p-valor <0,05 para as análises, com testes bicaudais. Resultados O critério de reperfusão pelo ECG apresentou valor preditivo positivo de 56%; valor preditivo negativo de 66%; sensibilidade de 79%; e especificidade de 40%. Houve fraca correlação positiva entre a redução do segmento-ST e os dados angiográficos de reperfusão ideal (r = 0,21; p <0,001) e baixa precisão diagnóstica, com AUC de 0,60 (IC-95%; 0,57-0,62). Conclusão Em nossos resultados, a redução do segmento-ST não conseguiu identificar com precisão os pacientes com reperfusão angiográfica apropriada. Portanto, mesmo pacientes com reperfusão aparentemente bem-sucedida devem ser encaminhados à angiografia brevemente, a fim de garantir fluxo coronário macro e microvascular adequados.
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Affiliation(s)
- Henrique Tria Bianco
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil
| | - Rui Povoa
- Universidade Federal de Sao Paulo, São Paulo, SP - Brasil
| | | | | | - Flavio Tocci Moreira
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil
| | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil
| | | | | | | | - Adriano Mendes Caixeta
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Iran Gonçalves
- Universidade Federal de Sao Paulo, São Paulo, SP - Brasil
| | | | - Renato Delascio Lopes
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil.,Duke University Hospital, Durham, North Carolina - EUA
| | | | - Dirceu Almeida
- Universidade Federal de Sao Paulo, São Paulo, SP - Brasil
| | - Valdir Ambrosio Moises
- Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil
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Dotta G, Fonseca FAH, Izar MCDO, Souza MTD, Moreira FT, Pinheiro LFM, Barbosa AHP, Caixeta AM, Póvoa RMS, Carvalho AC, Bianco HT. Regional QT Interval Dispersion as an Early Predictor of Reperfusion in Patients with Acute Myocardial Infarction after Fibrinolytic Therapy. Arq Bras Cardiol 2018; 112:20-29. [PMID: 30570061 PMCID: PMC6317627 DOI: 10.5935/abc.20180239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/02/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Patients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial. OBJECTIVE To evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy. METHODS Observational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant. RESULTS We found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified. CONCLUSION Our data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.
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Affiliation(s)
- Gabriel Dotta
- Universidade Federal de São Paulo, São Paulo, SP - Brazil
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Santana MFM, Moreira FT, Turra A. Trophic transference of microplastics under a low exposure scenario: Insights on the likelihood of particle cascading along marine food-webs. Mar Pollut Bull 2017; 121:154-159. [PMID: 28595982 DOI: 10.1016/j.marpolbul.2017.05.061] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 05/22/2023]
Abstract
Microplastics are emergent pollutants in marine environments, whose risks along food-web still need to be understood. Within this knowledge gap, MPs transference and persistence along trophic levels are key processes. We assessed the potential occurrence of these processes considering a less extreme scenario of exposure than used previously, with microplastics present only in the hemolymph of prey (the mussel Perna perna) and absent in the gut cavity. Predators were the crab Callinectes ornatus and the puffer fish Spheoeroides greeleyi. Transference of microplastics occurred from prey to predators but without evidences of particle persistence in their tissues after 10days of exposure. This suggests a reduced likelihood of trophic cascading of particles and, consequently, a reduced risk of direct impacts of microplastics on higher trophic levels. However, the contact with microplastics along food-webs is still concerning, modulated by the concentration of particles in prey and predators' depuration capacity and rate.
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Affiliation(s)
- M F M Santana
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography - Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil.
| | - F T Moreira
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography - Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil
| | - A Turra
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography - Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil
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Santana MFM, Ascer LG, Custódio MR, Moreira FT, Turra A. Microplastic contamination in natural mussel beds from a Brazilian urbanized coastal region: Rapid evaluation through bioassessment. Mar Pollut Bull 2016; 106:183-9. [PMID: 26980138 DOI: 10.1016/j.marpolbul.2016.02.074] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 02/22/2016] [Accepted: 02/26/2016] [Indexed: 05/22/2023]
Abstract
Microplastic pollution (particles <5mm) is a widespread marine threat and a trigger for biological effects, especially if ingested. The mussel Perna perna, an important food resource, was used as bioindicator to investigate the presence of microplastic pollution on Santos estuary, the most urbanized area of the coast of São Paulo State, Brazil. A simple and rapid assessment showed that 75% of sampled mussels had ingested microplastics, an issue of human and environmental concern. All sampling points had contaminated mussels and this contamination had no clear pattern of distribution along the estuary. This was the first time that microplastic bioavailability was assessed in nature for the southern hemisphere and that wild P. perna was found contaminated with this pollutant. This is an important issue that should be better assessed due to an increase in seafood consumption and culture in Brazil and worldwide.
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Affiliation(s)
- M F M Santana
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography, Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil.
| | - L G Ascer
- USP - University of São Paulo, Bioscience Institute (IB), Department of General Physiology, Rua do Matão, 14, 05508-090, Cidade Universitária, São Paulo, São Paulo, Brazil
| | - M R Custódio
- USP - University of São Paulo, Bioscience Institute (IB), Department of General Physiology, Rua do Matão, 14, 05508-090, Cidade Universitária, São Paulo, São Paulo, Brazil
| | - F T Moreira
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography, Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil
| | - A Turra
- USP - University of São Paulo, Oceanographic Institute (IO), Department of Biological Oceanography, Praça do Oceanográfico, 191, 05508-120, Cidade Universitária, São Paulo, São Paulo, Brazil
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Moreira FT, Ramos SC, Monteiro AM, Helfenstein T, Gidlund M, Damasceno NRT, Neto AMF, Izar MC, Fonseca FAH. Effects of two lipid lowering therapies on immune responses in hyperlipidemic subjects. Life Sci 2014; 98:83-7. [PMID: 24447629 DOI: 10.1016/j.lfs.2014.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/23/2013] [Accepted: 01/06/2014] [Indexed: 01/05/2023]
Abstract
AIMS To compare the effects of two of the most effective lipid-lowering therapies with similar LDL-cholesterol reduction capacity on the innate and adaptive immune responses through the evaluation of autoantibodies anti-oxidized LDL (anti-oxLDL Abs) and electronegative LDL [LDL(-)] levels. MAIN METHODS We performed a prospective, randomized, open label study, with parallel arms and blinded endpoints. One hundred and twelve subjects completed the study protocol and received rosuvastatin 40 mg or ezetimibe/simvastatin 10/40 mg for 12 weeks. Lipids, apolipoproteins, LDL(-), and anti-oxLDL Abs (IgG) were assayed at baseline and end of study. KEY FINDINGS Main clinical and laboratory characteristics were comparable at baseline. Lipid modifications were similar in both treatment arms, however, a significant raise in anti-oxLDL Abs levels was observed in subjects treated with rosuvastatin (p=0.026 vs. baseline), but not in those receiving simvastatin/ezetimibe. (p=0.233 vs. baseline), thus suggesting modulation of adaptive immunity by a potent statin. Titers of LDL(-) were not modified by the treatments. SIGNIFICANCE Considering atherosclerosis as an immune disease, this study adds new information, showing that under similar LDL-cholesterol reduction, the choice of lipid-lowering therapy can differently modulate adaptive immune responses.
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Affiliation(s)
| | | | - Andrea Moreira Monteiro
- Complex Fluids Laboratory, Institute of Physics, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Tatiana Helfenstein
- Department of Medicine, Federal University of São Paulo, Sao Paulo, SP, Brazil
| | - Magnus Gidlund
- Department of Immunology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | - Maria Cristina Izar
- Department of Medicine, Federal University of São Paulo, Sao Paulo, SP, Brazil
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Kasmas SH, Izar MC, França CN, Ramos SC, Moreira FT, Helfenstein T, Moreno RA, Borges NC, Figueiredo-Neto AM, Fonseca FA. Differences in synthesis and absorption of cholesterol of two effective lipid-lowering therapies. Braz J Med Biol Res 2012; 45:1095-101. [PMID: 22801416 PMCID: PMC3854149 DOI: 10.1590/s0100-879x2012007500118] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 05/10/2012] [Indexed: 12/13/2022] Open
Abstract
Effective statin therapy is associated with a marked reduction of cardiovascular events. However, the explanation for full benefits obtained for LDL cholesterol targets by combined lipid-lowering therapy is controversial. Our study compared the effects of two equally effective lipid-lowering strategies on markers of cholesterol synthesis and absorption. A prospective, open label, randomized, parallel design study, with blinded endpoints, included 116 subjects. We compared the effects of a 12-week treatment with 40 mg rosuvastatin or the combination of 40 mg simvastatin/10 mg ezetimibe on markers of cholesterol absorption (campesterol and β-sitosterol), synthesis (desmosterol), and their ratios to cholesterol. Both therapies similarly decreased total and LDL cholesterol, triglycerides and apolipoprotein B, and increased apolipoprotein A1 (P < 0.05 vs baseline for all). Simvastatin/ezetimibe increased plasma desmosterol (P = 0.012 vs baseline), and decreased campesterol and β-sitosterol (P < 0.0001 vs baseline for both), with higher desmosterol (P = 0.007) and lower campesterol and β-sitosterol compared to rosuvastatin, (P < 0.0001, for both). In addition, rosuvastatin increased the ratios of these markers to cholesterol (P < 0.002 vs baseline for all), whereas simvastatin/ezetimibe significantly decreased the campesterol/cholesterol ratio (P = 0.008 vs baseline) and tripled the desmosterol/cholesterol ratio (P < 0.0001 vs baseline). The campesterol/cholesterol and β-sitosterol/cholesterol ratios were lower, whereas the desmosterol/cholesterol ratio was higher in patients receiving simvastatin/ezetimibe (P < 0.0001 vs rosuvastatin, for all). Pronounced differences in markers of cholesterol absorption and synthesis were observed between two equally effective lipid-lowering strategies.
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Affiliation(s)
- S H Kasmas
- Divisão de Cardiologia, Departamento de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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