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Objective: To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes., Methods: We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE., Results: We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%)., Conclusion: Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.

Objectives: This study aimed to describe health-related quality of life (HRQoL) 3 months and 1 year after stroke, compare HRQoL between dependent (modified Rankin scale [mRS] 3-5) and independent (mRS 0-2) patients, and identify factors predictive of poor HRQoL., Methods: Patients with a first ischemic stroke or intraparenchymal hemorrhage from the Joinville Stroke Registry were analyzed retrospectively. Using the 5-level version of the EuroQol-5D questionnaire, HRQoL was calculated for all patients 3 months and 1 year after stroke, stratified by mRS score (0-2 or 3-5). One-year HRQoL predictors were examined using univariate and multivariate analyses., Results: Three months after a stroke, data from 884 patients were analyzed; 72.8% were categorized as mRS 0-2 and 27.2% as mRS 3-5, and the mean HRQoL was 0.670 ± 0.256. At 1-year follow-up, 705 patients were evaluated; 75% were classified as mRS 0-2 and 25% as mRS 3-5, and the mean HRQoL was 0.71 ± 0.249. An increase in HRQoL was observed between 3 months and 1 year (mean difference 0.024, P < .0001), both in patients with 3-month mRS 0-2 (0.013, P = .027) and mRS 3-5 (0.052, P < .0001). Increasing age, female sex, hypertension, diabetes, and a high mRS were associated with poor HRQoL at 1 year., Conclusions: This study described the HRQoL after a stroke in a Brazilian population. This analysis shows that the mRS was highly associated with HRQoL after stroke. Age, sex, diabetes, and hypertension were also associated with HRQoL, although not independently of mRS., (Copyright © 2023 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: Randomized controlled trials (RCTs) and observational studies have compared the efficacy and safety of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis., Objectives: Compare TAVR and SAVR in patients with different surgical risks, population characteristics, and different transcatheter prosthetic valves., Methods: An overview of systematic reviews (SRs) was conducted following a structured protocol. Results were grouped by surgical risk, population characteristics, and different valves. RCTs in the SRs were reanalyzed through meta-analyses, and the results were summarized using the GRADE method. The adopted level of statistical significance was 5%., Results: Compared to SAVR, patients with high surgical risk using TAVR had a lower risk of (odds ratio, 95% confidence interval, absolute risk difference) atrial fibrillation (AF) (0.5, 0.29-0.86, -106/1000) and life-threatening bleeding (0.29, 0.2-0.42, -215/1000). Patients with intermediate surgical risk had a lower risk of AF (0.27, 0.23-0.33, -255/1000), life-threatening bleeding (0.15, 0.12-0.19, -330/1000), and acute renal failure (ARF) (0.4, 0.26-0.62, -21/1000). Patients with low surgical risk had a lower risk of death (0.58, 0.34-0.97, -16/1000), stroke (0.51, 0.28-0.94, -15/1000), AF (0.16, 0.12-0.2, -295/1000), life-threatening bleeding (0.17, 0.05-0.55, -76/1000), and ARF (0.27, 0.13-0.55, -21/1000), and had a higher risk of permanent pacemaker implantation (PPI) (4.22, 1.27-14.02, 141/1000). Newer generation devices had a lower risk of AF than older generations, and patients using balloon-expandable devices did not experience higher risks of PPI., Conclusions: This paper provides evidence that patients at low, intermediate, and high surgical risks have better outcomes when treated with TAVR compared with SAVR.

Introduction: The COVID-19 pandemic has wrought negative consequences concerning quality of care for stroke patients since its onset. Prospective population-based data about stroke care in the pandemic are limited. This study aims to investigate the impact of COVID-19 pandemic on stroke profile and care in Joinville, Brazil., Methods: A prospective population-based cohort enrolled the first-ever cerebrovascular events in Joinville, Brazil, and a comparative analyzes was conducted between the first 12 months following COVID-19 restrictions (starting March 2020) and the 12 months just before. Patients with transient ischemic attack (TIA) or stroke had their profiles, incidences, subtypes, severity, access to reperfusion therapy, in-hospital stay, complementary investigation, and mortality compared., Results: The profiles of TIA/stroke patients in both periods were similar, with no differences in gender, age, severity, or comorbidities. There was a reduction in incidence of TIA (32.8%; p = 0.003). In both periods, intravenous thrombolysis (IV) and mechanical thrombectomy (MT) rates and intervals from door to IV/MT were similar. Patients with cardioembolic stroke and atrial fibrillation had their in-hospital stay abbreviated. The etiologic investigation was similar before and during the pandemic, but there were increases in cranial tomographies ( p = 0.02), transthoracic echocardiograms ( p = 0.001), chest X-rays ( p < 0.001) and transcranial Doppler ultrasounds ( p < 0.001). The number of cranial magnetic resonance imaging decreased in the pandemic. In-hospital mortality did not change., Discussion: The COVID-19 pandemic is associated with a reduction in TIA, without any influence on stroke profile, the quality of stroke care, in-hospital investigation or mortality. Our findings show an effective response by the local stroke care system and offer convincing evidence that interdisciplinary efforts are the ideal approach to avoiding the COVID-19 pandemic's negative effects, even with scarce resources., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 dos Reis, de Magalhães, Diegoli, Longo, Moro, Safanelli, Nagel, Lange and Zétola.)

Background: Brazil's Universal Health System is the world's largest and covers every citizen without out-of-pocket costs. Nonetheless, healthcare inequities across regions have never been systematically evaluated., Methods: We used government databases to compare healthcare resource utilization, outcomes, expenditure, and years of life lost between 2016 and 2019. The maps used patients' residences as reference and adjusted for age and private health insurance coverage., Results: The Atlas shows that for several comparisons, there were no procedures in some regions, including primary coronary angioplasty, thrombolysis for stroke, bariatric surgery, and kidney transplant. Colonoscopy varied 1481.2-fold, asthma hospitalizations varied 257.5-fold, and mammograms varied 133.9-fold. Cesarean births ranged from 19.5% to 84.0%, and myocardial infarction and stroke case-fatalities were 1.1% to 33.7% and 5.0% to 39.0%, respectively. Higher private health insurance coverage in each region was associated with increased resource utilization in the public system in most comparisons., Conclusion: These findings demonstrate that the SUS does not fulfill the Brazilian constitutional rights due to underutilization, overutilization, and access disparities. The Atlas outlines multiple opportunities to generate value in the SUS., (© 2023. The Author(s).)

The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based healthcare requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicentre study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischaemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischaemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2210 (interquartile range: I$1163-4504). Fifty percent of the patients registered a favourable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome-adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The RESILIENT trial demonstrated the clinical benefit of mechanical thrombectomy in patients presenting acute ischemic stroke secondary to anterior circulation large vessel occlusion in Brazil., Aims: This economic evaluation aims to assess the cost-utility of mechanical thrombectomy in the RESILIENT trial from a public healthcare perspective., Methods: A cost-utility analysis was applied to compare mechanical thrombectomy plus standard medical care (n = 78) vs. standard medical care alone (n = 73), from a subset sample of the RESILIENT trial (151 of 221 patients). Real-world direct costs were considered, and utilities were imputed according to the Utility-Weighted modified Rankin Score. A Markov model was structured, and probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of results., Results: The incremental costs and quality-adjusted life years gained with mechanical thrombectomy plus standard medical care were estimated at Int$ 7440 and 1.04, respectively, compared to standard medical care alone, yielding an incremental cost-effectiveness ratio of Int$ 7153 per quality-adjusted life year. The deterministic sensitivity analysis demonstrated that mRS-6 costs of the first year most affected the incremental cost-effectiveness ratio. After 1000 simulations, most of results were below the cost-effective threshold., Conclusions: The intervention's clear long-term benefits offset the initially higher costs of mechanical thrombectomy in the Brazilian public healthcare system. Such therapy is likely to be cost-effective and these results were crucial to incorporate mechanical thrombectomy in the Brazilian public stroke centers.

Background and Purpose: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, doctors and public authorities have demonstrated concern about the reduction in quality of care for other health conditions due to social restrictions and lack of resources. Using a population-based stroke registry, we investigated the impact of the onset of the COVID-19 pandemic in stroke admissions in Joinville, Brazil., Methods: Patients admitted after the onset of COVID-19 restrictions in the city (defined as March 17, 2020) were compared with those admitted in 2019. We analyzed differences between stroke incidence, types, severity, reperfusion therapies, and time from stroke onset to admission. Statistical tests were also performed to compare the 30 days before and after COVID-19 to the same period in 2019., Results: We observed a decrease in total stroke admissions from an average of 12.9/100 000 per month in 2019 to 8.3 after COVID-19 ( P =0.0029). When compared with the same period in 2019, there was a 36.4% reduction in stroke admissions. There was no difference in admissions for severe stroke (National Institutes of Health Stroke Scale score >8), intraparenchymal hemorrhage, and subarachnoid hemorrhage., Conclusions: The onset of COVID-19 was correlated with a reduction in admissions for transient, mild, and moderate strokes. Given the need to prevent the worsening of symptoms and the occurrence of medical complications in these groups, a reorganization of the stroke-care networks is necessary to reduce collateral damage caused by COVID-19.

Background: It is unknown if improvements in ischemic stroke (IS) outcomes reported after cerebral reperfusion therapies (CRT) in developed countries are also applicable to the "real world" scenario of low and middle-income countries. We aimed to measure the long-term outcomes of severe IS treated or not with CRT in Brazil., Methods: Patients from a stroke center of a state-run hospital were included. We compared the survival probability and functional status at 3 and 12 months in patients with severe IS treated or not with CRT. From 2010 to 2011, we performed intravenous reperfusion when patients arrived within 4.5 h time-window (IVT group) and after 2011, mechanical thrombectomy (MT) combined or not with intravenous alteplase (IAT group). Those who arrived >4.5 h in 2010-2011 and >6 h in 2012-2017 did not undergo CRT (NCRT group)., Results: From 2010 to 2017, we registered 917 patients: 74% (677/917) in the NCRT group, 19% (178/917) in the IVT group and 7% (62/917) in the IAT group. Compared to the NCRT group, IVT patients had a 28% higher (HR: 0.72; 95% CI 0.53-0.96) 3-month adjusted probability of survival and risk of functional dependence was 19% lower (adjusted RR: 0.81; 95% CI 0.73-0.91). For those who underwent MT, the adjusted probability of survival was 59 % higher (HR: 0.41; 95% CI 0.21-0.77) and the risk of functional dependence was 21% lower (adjusted RR: 0.79; 95% CI 0.66-094). These outcomes remained significantly better throughout the first year., Conclusion: CRT led to better outcomes in patients with severe IS in Brazil., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Chronic kidney disease is defined by the progressive loss of renal function. Interventions in early stages significantly improve the prognosis of patients with chronic kidney disease, reducing the mortality, and many studies show that early nephrologist referral reduces the mortality rate., Objective: To analyze the characteristics of the patients in dialysis and the time between the first consultation in the dialysis clinic and the beginning of the dialytic program., Methods: It was made a cohort retrospective study with two analysis axis: the social and epidemiological characteristics of the patients in hemodialysis and the time between the first consultation in the clinic and the beginning of the dialytic program. Analytical and descriptive methods where used to compare these data with the early referral and the mortality 12 months after the dialysis onset., Results: One hundred and one patients were analyzed. The mortality rate of the early and lately referred patients was 47.8% and 20.5%, respectively (HR = 2.38; IC = 1.06-5.36; p = 0.035). Concerning the patients which initiated the dialysis with catheter and arteriovenous fistula, the mortality was respectively 51.4% and 10.3% (HR = 4.61; IC = 1,54-13,75; p = 0.006)., Conclusion: The referral timing was predominantly late. The late referral was associated with a greater mortality. Other variables associated with a greater mortality were age of 70 or more, presence of diabetes and the use of catheter by the dialysis onset.