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Resumo Fundamento Apesar de progresso significativo na melhoria da qualidade do tratamento de doenças cardiovasculares, lacunas persistem em termos de falha na adesão às recomendações de diretrizes. Objetivo Este estudo avalia os efeitos da implementação de um programa de melhoria da qualidade adaptado do Programa Get with the guidelines® da American Heart Association sobre a adesão às diretrizes para síndrome coronária aguda (SCA), fibrilação atrial (FA) e insuficiência cardíaca (IC). Métodos Avaliamos dados demográficos, medidas de qualidade, e desfechos em curto prazo em pacientes com SCA, FA, e IC incluídos no programa Boas Práticas em Cardiologia (BPC) entre 2016 e 2022. Resultados Este estudo incluiu 12167 pacientes em 19 hospitais no Brasil. A idade média foi 62,5 [53,8-71] anos, 61,1% eram do sexo masculino, 68,7% apresentaram hipertensão, 32% diabetes mellitus, e 24,1% dislipidemia. Os escores médios compostos tiveram desempenho sustentável entre o período inicial e o último trimestre do seguimento: 65,8±36,2% a 73± 31,2% para FA (p=0,024); 81,0± 23,6% a 89,9 ± 19,3% para IC (p

Background There are substantial opportunities to improve the quality of cardiovascular care in developing countries through the implementation of a quality program. Objective To evaluate the effect of a Best Practice in Cardiology (BPC) program on performance measures and patient outcomes related to heart failure, atrial fibrillation and acute coronary syndromes in a subset of Brazilian public hospitals. Methods The Boas Práticas em Cardiologia (BPC) program was adapted from the American Heart Association's (AHA) Get With The Guidelines (GWTG) Program for use in Brazil. The program is being started simultaneously in three care domains (acute coronary syndrome, atrial fibrillation and heart failure), which is an approach that has never been tested within the GWTG. There are six axes of interventions borrowed from knowledge translation literature that will address local barriers identified through structured interviews and regular audit and feedback meetings. The intervention is planned to include at least 10 hospitals and 1,500 patients per heart condition. The primary endpoint includes the rates of overall adherence to care measures recommended by the guidelines. Secondary endpoints include the effect of the program on length of stay, overall and specific mortality, readmission rates, quality of life, patients' health perception and patients' adherence to prescribed interventions. Results It is expected that participating hospitals will improve and sustain their overall adherence rates to evidence-based recommendations and patient outcomes. This is the first such cardiovascular quality improvement (QI) program in South America and will provide important information on how successful programs from developed countries like the United States can be adapted to meet the needs of countries with developing economies like Brazil. Also, a successful program will give valuable information for the development of QI programs in other developing countries. Conclusions This real-world study provides information for assessing and increasing adherence to cardiology guidelines in Brazil, as well as improvements in care processes. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Background There are substantial opportunities to improve the quality of cardiovascular care in developing countries through the implementation of a quality program. Objective To evaluate the effect of a Best Practice in Cardiology (BPC) program on performance measures and patient outcomes related to heart failure, atrial fibrillation and acute coronary syndromes in a subset of Brazilian public hospitals. Methods The Boas Práticas em Cardiologia (BPC) program was adapted from the American Heart Association's (AHA) Get With The Guidelines (GWTG) Program for use in Brazil. The program is being started simultaneously in three care domains (acute coronary syndrome, atrial fibrillation and heart failure), which is an approach that has never been tested within the GWTG. There are six axes of interventions borrowed from knowledge translation literature that will address local barriers identified through structured interviews and regular audit and feedback meetings. The intervention is planned to include at least 10 hospitals and 1,500 patients per heart condition. The primary endpoint includes the rates of overall adherence to care measures recommended by the guidelines. Secondary endpoints include the effect of the program on length of stay, overall and specific mortality, readmission rates, quality of life, patients' health perception and patients' adherence to prescribed interventions. Results It is expected that participating hospitals will improve and sustain their overall adherence rates to evidence-based recommendations and patient outcomes. This is the first such cardiovascular quality improvement (QI) program in South America and will provide important information on how successful programs from developed countries like the United States can be adapted to meet the needs of countries with developing economies like Brazil. Also, a successful program will give valuable information for the development of QI programs in other developing countries. Conclusions This real-world study provides information for assessing and increasing adherence to cardiology guidelines in Brazil, as well as improvements in care processes. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Background The neurological manifestations in COVID-19 adversely impact acute illness and post-disease quality of life. Limited data exist regarding the association of neurological symptoms and comorbid individuals. Objective To assess neurological symptoms in hospitalized patients with acute COVID-19 and multicomorbidities. Methods Between June 2020 and July 2020, inpatients aged 18 or older, with laboratory-confirmed COVID-19, admitted to the Hospital São Paulo (Federal University of São Paulo), a tertiary referral center for high complexity cases, were questioned about neurological symptoms. The Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire was used. The data were analyzed as a whole and whether subjective olfactory dysfunction was present or not. Results The mean age of the sample was 55 ± 15.12 years, and 58 patients were male. The neurological symptoms were mostly xerostomia (71%), ageusia/hypogeusia (50%), orthostatic intolerance (49%), anosmia/hyposmia (44%), myalgia (31%), dizziness (24%), xerophthalmia (20%), impaired consciousness (18%), and headache (16%). Furthermore, 91% of the patients had a premorbidity. The 44 patients with subjective olfactory dysfunction were more likely to have hypertension, diabetes, weakness, shortness of breath, ageusia/hypogeusia, dizziness, orthostatic intolerance, and xerophthalmia. The COMPASS-31 score was higher than that of previously published controls (14.85 ± 12.06 vs. 8.9 ± 8.7). The frequency of orthostatic intolerance was 49% in sample and 63.6% in those with subjective olfactory dysfunction (2.9-fold higher risk compared to those without). Conclusion A total of 80% of inpatients with multimorbidity and acute COVID-19 had neurological symptoms. Chemical sense and autonomic symptoms stood out. Orthostatic intolerance occurred in around two-thirds of the patients with anosmia/hyposmia. Hypertension and diabetes were common, mainly in those with anosmia/hyposmia.

Macroreentrant atrial circuits are frequently associated with scarring. Previous reports have shown the possible development of scar tissue that is adjacent to pacemaker (PM) leads. However, reports of PM lead-related reentrant tachycardia are scarce. We report the case of a 63-year-old woman who presented with macroreentrant atrial tachycardia (MAT), related to the atrial trajectory of an old single-lead ventricular PM, that was successfully treated with radiofrequency ablation after a conventional electrophysiological study ruled out isthmus-dependent atrial flutter and provided sufficient data to confirm this diagnosis. This report presents a case of MAT originating around the trajectory of a PM lead, probably because of scar tissue that developed adjacent to the lead. Experimental studies have already shown that interstitial atrial fibrosis may develop adjacent to a ventricular single-lead. This finding suggests that MAT develops in patients with this specific condition. Recognizing this condition is important for managing these arrhythmias and performing safe ablation with the preservation of PM lead integrity.

We study the behaviour, when p→+∞p\to +\infty , of the first p-Laplacian eigenvalues with Robin boundary conditions and the limit of the associated eigenfunctions. We prove that the limit of the eigenfunctions is a viscosity solution to an eigenvalue problem for the so-called ∞\infty -Laplacian. Moreover, in the second part of the article, we focus our attention on the p-Poisson equation when the datum ff belongs to L∞(Ω){L}^{\infty }\left(\Omega ) and we study the behaviour of solutions when p→∞p\to \infty .

Determining the spatial thickness (z) of in situ and reworked fallout pyroclastic deposits plays a key role in volcanological studies and in shedding light on geomorphological and hydrogeological processes in peri-volcanic areas. However, this is a challenging line of research because (1) field-based measurements are expensive and time-consuming, (2) the ash might have been dispersed in the atmosphere by several volcanic eruptions, and (3) wind characteristics during an eruptive event and soil-forming and/or denudation processes after ash deposition on the ground surface affect the expected spatial distribution of these deposits. This article tries to bridge this knowledge gap by applying statistical techniques for making representative spatial thickness predictions to be used for the analysis of geomorphic processes at the catchment and sub-catchment scales. First, we compiled a field-based thickness measurement dataset (https://doi.org/10.5281/zenodo.8399487 ; Matano et al., 2023) of fallout pyroclastic deposits in the territories of several municipalities in Campania, southern Italy. Second, 18 predictor variables were derived mainly from digital elevation models and satellite images and were assigned to each measurement point. Third, the stepwise regression (STPW) model and random forest (RF) machine learning technique are used for thickness modeling. Fourth, the estimations are compared with those of three models that already exist in the literature. Finally, the statistical combination of different predictions is implemented to develop a less biased model for estimating pyroclastic thickness. The results show that the prediction accuracy of RF (RMSE <82.46 and MAE <48.36) is better than that of existing models in the literature. Moreover, statistical combination of the predictions obtained from the above-mentioned models through a least absolute deviation (LAD) combination approach leads to the most representative thickness estimation (MAE <45.12) in the study area. The maps for the values estimated by RF and LAD (as the best single model and combination approach, respectively) illustrate that the spatial patterns did not change significantly, but the estimations by LAD are smaller. This combined approach can help in estimating the thickness of fallout pyroclastic deposits in other volcanic regions and in managing geohazards in areas covered with loose pyroclastic materials. [ABSTRACT FROM AUTHOR]

Abstract Background Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. Method This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. Results During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. Conclusion Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.

Resumo Fundamento: A fibrilação atrial é um problema de saúde pública associado com um risco cinco vezes maior de acidente vascular cerebral e mortalidade. A análise de custos é importante para a introdução de novas terapias, e deve ser reconsiderada em situações especiais, tais como a pandemia do coronavírus em 2020. Objetivo: Avaliar os custos (em um período de um ano) relacionados à terapia anticoagulante e a qualidade de vida de pacientes com fibrilação atrial tratados em um hospital público universitário. Métodos: Os custos do paciente foram aqueles relacionados à anticoagulação e calculados pela média de custos mensais da varfarina ou de anticoagulantes orais diretos (DOACs). As despesas não médicas, como alimentação e transporte, foram calculadas a partir de dados obtidos de questionários. O questionário brasileiro SF-6D foi usado para medir a qualidade de vida. Valores p

Resumo 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 50%. Consideramos p-valor

A multidisciplinary study, including geomorphological, stratigraphic, paleontological and archaeological methods and techniques, allowed for a detailed exploration of coastal landforms and environments in front of the ancient city of Pompeii (southern Italy). The famous site of Pompeii sits on a small volcanic hill in the alluvial-coastal plain of the Sarno River, very close to the ancient paleoshoreline. When the Roman city was buried during the eruption of Vesuvius in 79 CE, pyroclastic fall and flow deposits covered the urban centres and ancient coastal landforms. In this study, 83 new boreholes were carried out up to a depth of 10 m. Some of them (15) were analysed for their sedimentological, stratigraphical and paleontological characterisation, in order to reconstruct the sedimentary environments in 79 CE. The data collected allow for new hypotheses to be formulated regarding the paleoshorelines, as well as the 79 CE coastal landforms and environments. In particular, litho-stratigraphic and fossil assemblages highlight the presence of shallow marine environments in a large back-ridge depression, named Masseria Curati, that is located just outside the city walls. This hypothesis opens new insights on the unknown location of the harbour of the Roman city. [ABSTRACT FROM AUTHOR]

Resumo Fundamento Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes. Objetivos Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular. Métodos Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética. Conclusões Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Resumo Fundamento Existem grandes oportunidades de melhoria da qualidade do cuidado cardiovascular em países em desenvolvimento por meio da implementação de um programa de qualidade. Objetivo Avaliar o efeito de um programa de Boas Práticas em Cardiologia (BPC) nos indicadores de desempenho e desfechos clínicos dos pacientes relacionados à insuficiência cardíaca, fibrilação atrial e síndromes coronarianas agudas em um subconjunto de hospitais públicos brasileiros. Métodos O programa Boas Práticas em Cardiologia (BPC) foi adaptado do programa Get With The Guidelines (GWTG) da American Heart Association (AHA) para ser utilizado no Brasil. O programa está sendo iniciado em três domínios de cuidado simultaneamente (síndrome coronariana aguda, fibrilação atrial e insuficiência cardíaca), o que consiste em uma abordagem nunca testada no GWTG. Existem seis eixos de intervenções utilizadas pela literatura sobre tradução do conhecimento que abordará barreiras locais identificadas por meio de entrevistas estruturadas e reuniões regulares para auditoria e feedback. Planeja-se incluir no mínimo 10 hospitais e 1500 pacientes por doença cardíaca. O desfecho primário inclui as taxas de adesão às medidas de cuidado recomendadas pelas diretrizes. Desfechos secundários incluem o efeito do programa sobre o tempo de internação, mortalidade global e específica, taxas de readmissão, qualidade de vida, percepção do paciente sobre saúde e adesão dos pacientes às intervenções prescritas. Resultados Espera-se, nos hospitais participantes, uma melhoria e a manutenção das taxas de adesão as recomendações baseadas em evidência e dos desfechos dos pacientes. Este é o primeiro programa em melhoria da qualidade a ser realizado na América do Sul, que fornecerá informações importantes de como programas de sucesso originados em países desenvolvidos como os Estados Unidos podem ser adaptados às necessidades de países com economias em desenvolvimento como o Brasil. Um programa bem sucedido dará informações valiosas para o desenvolvimento de programas de melhoria da qualidade em outros países em desenvolvimento. Conclusões Este estudo de mundo real proverá informações para a avaliação e aumento da adesão às diretrizes de cardiologia no Brasil, bem como a melhora dos processos assistenciais. (Arq Bras Cardiol. 2020; 115(1):92-99)

There are algorithms to estimate the location of an accessory pathway (AP), but they tend to present low accuracy in right-sided APs. This paper presents a new electrocardiographic criterium to estimate the location of a right-sided AP. Rest ECGs from patients with manifest preexcitation of right-sided APs were evaluated and the SV2/RV3 ratio was calculated, considering values < 1 for lateral (anterior or posterior) and ≥ 1 for septal (anterior or posterior) APs. This ratio was compared with other signs already described in literature. In 175 consecutive patients, 60 met the inclusion criteria. For APs located in superior portions of the tricuspid ring, the SV2/RV3 ratio < 1 was 80% accurate for anteroseptal location (specificity: 75%), where His electrograms were recorded. For APs located in inferior portions of the tricuspid ring a SV2/RV3 < 1 was 82,86% accurate for mid and posteroseptal location (specificity: 95.38%). This work reports a new and simple criterium that can accurately distinguish right-sided lateral and septal APs with good specificity: SV2/RV3 ratio.

Background Ventricular tachycardia (VT) in patients with chronic chagasic cardiomyopathy (CCC) is associated with considerable morbidity and mortality. Catheter ablation of VT in patients with CCC is very complex and challenging. The main goal of this work was to assess the efficacy of VT catheter ablation guided by late potentials (LPs) in patients with CCC. Methods and Results Seventeen consecutive patients with refractory VT and CCC were prospectively included in the study. Combined endo‐epicardial voltage and late activation mapping were obtained during baseline rhythm to define scarred and LP areas, respectively. The end point of the ablation procedure was the elimination of all identified LPs. Epicardial and endocardial dense scars (