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- Acceptance of Open Preperitoneal Repair in Inguinal Hernia Surgery Delphi-Consensus After an Anonymous International Survey Among European Hernia Society MembersPublication . Lorenz, R; Akkersdijk, W; Paiva De Oliveira, G; Warren, T; Soler, MIntroduction: For years, the Lichtenstein technique was the gold standard for open repair, but several open pre-peritoneal techniques have developed since the fifties of the 20th century that offer some benefits over the Lichtenstein technique in terms of post-surgical incidence of pain. Since the 2023 update of the International HerniaSurge Guidelines, open preperitoneal mesh techniques have been an acceptable alternative, providing available expertise and competence with at least equal results as Lichtenstein repair. Aim: The aim of this project is to understand the views of surgeons regarding the approach to inguinal hernia repair and determine best practice principles for optimal surgical outcomes. Methods: Using a modified Delphi method, a panel of experts developed 43 Likert scale statements across six key domains. These statements were used to develop an online survey distributed to surgeons in Europe involved in inguinal hernia repair. The threshold for consensus was set a priori at 75%. Results: A total of 202 responses were received from surgeons involved in inguinal hernia repair over three rounds of survey. After the initial survey round, seven statements were revised and reissued for a further round. At the conclusion of the survey phase, 31 of the 38 remaining statements achieved consensus (of which 13 achieved ≥90% agreement). From these results, the panellists developed a set of 3 recommendations to help define principles for optimal approach to inguinal hernia repair. Accordingly Open preperitoneal techniques seems to be an alternative to Lichtenstein technique if expertise is available and should be included in a tailored concept. Knowledge of anatomy, Education and Training in open preperitoneal techniques is crucial for the acceptance of these techniques. Conclusion: The proposed set of recommendations provides some principles for surgeons to consider when selecting an approach to inguinal hernia repair, ensuring good patient outcomes in a practical and cost-effective manner.
- Advancing Towards a Targeted Surveillance Strategy in Traumatic Brain InjuryPublication . Moura Gonçalves, V
- Acceptance of Open Preperitoneal Repair in Inguinal Hernia Surgery Delphi-Consensus After an Anonymous International Survey Among European Hernia Society MembersPublication . Lorenz, R; Akkersdijk, W; Paiva De Oliveira, G; Warren, T; Soler, MIntroduction: For years, the Lichtenstein technique was the gold standard for open repair, but several open pre-peritoneal techniques have developed since the fifties of the 20th century that offer some benefits over the Lichtenstein technique in terms of post-surgical incidence of pain. Since the 2023 update of the International HerniaSurge Guidelines, open preperitoneal mesh techniques have been an acceptable alternative, providing available expertise and competence with at least equal results as Lichtenstein repair. Aim: The aim of this project is to understand the views of surgeons regarding the approach to inguinal hernia repair and determine best practice principles for optimal surgical outcomes. Methods: Using a modified Delphi method, a panel of experts developed 43 Likert scale statements across six key domains. These statements were used to develop an online survey distributed to surgeons in Europe involved in inguinal hernia repair. The threshold for consensus was set a priori at 75%. Results: A total of 202 responses were received from surgeons involved in inguinal hernia repair over three rounds of survey. After the initial survey round, seven statements were revised and reissued for a further round. At the conclusion of the survey phase, 31 of the 38 remaining statements achieved consensus (of which 13 achieved ≥90% agreement). From these results, the panellists developed a set of 3 recommendations to help define principles for optimal approach to inguinal hernia repair. Accordingly Open preperitoneal techniques seems to be an alternative to Lichtenstein technique if expertise is available and should be included in a tailored concept. Knowledge of anatomy, Education and Training in open preperitoneal techniques is crucial for the acceptance of these techniques. Conclusion: The proposed set of recommendations provides some principles for surgeons to consider when selecting an approach to inguinal hernia repair, ensuring good patient outcomes in a practical and cost-effective manner.
- Operative Treatment of Nonprimary Osteochondral Lesions of the Talus: A Systematic ReviewPublication . Correia Cardoso, R; Andrade, R; Monteiro, I; Machado, C; Malheiro, FS; Serrano, P; Amado, P; Espregueira Mendes, J; Pereira, BSBackground: Nonprimary osteochondral lesions of the talus (OLT) pose a significant challenge in orthopaedics, with no definitive consensus on optimal surgical treatment. Purpose: To consolidate the most recent evidence on operative treatments for nonprimary OLT by assessing patient-reported outcomes (PROs), postoperative complications, and clinical failures. Study design: Systematic review; Level of evidence, 4. Methods: This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and PRISMA in Exercise, Rehabilitation, Sport medicine and Sports science guidelines. Searches were conducted in PubMed, Embase, and Cochrane Library databases through June 2023. Eligible studies evaluated operative outcomes in skeletally mature patients with nonprimary OLT after failed previous surgeries. Primary outcomes included clinical and functional PROs. Secondary outcomes included postoperative complications and clinical failures. Quantitative analyses involved weighted means, mean differences, minimal clinically important differences, success rates (95% binomial proportion confidence interval), and a pre-to-postoperative meta-analysis. Results: Out of 3992 identified records, 50 studies involving 806 ankles from 794 patients were included. All operative treatments significantly improved PROs (P < .05), except osteochondral allograft transplantation (OCA) for American Orthopaedic Foot and Ankle Society and pain (visual analog scale/numeric rating scale [VAS/NRS]) scores and HemiCAP for pain (VAS/NRS) scores. Autologous chondrocyte implantation (ACI) and osteochondral autologous transplantation (OAT) demonstrated the greatest PRO success rates, exceeding 80%. Postoperative complications occurred in 4% of cases, most frequently with HemiCAP. Clinical failures affected 22% of cases, particularly with autologous matrix-induced chondrogenesis, OAT, OCA, and HemiCAP. Conclusion: Our systematic review demonstrated that ACI and OAT are promising treatments for nonprimary OLT, with ACI showing fewer clinical failures than OAT. Conversely, OCA and HemiCAP exhibited lower effectiveness and higher clinical failure rates, suggesting a need for reassessment.
- Chronic Intestinal Failure and Short Bowel Syndrome in Adults: The State of the ArtPublication . Vara-Luiz, F; Glória, L; Mendes, I; Carlos, S; Guerra, P; Nunes, G; Oliveira, CS; Ferreira, A; Santos, AP; Fonseca, JBackground: Short bowel syndrome (SBS) is a devastating malabsorptive condition and the most common cause of chronic intestinal failure (CIF). During the intestinal rehabilitation process, patients may need parenteral support for months or years, parenteral nutrition (PN), or hydration/electrolyte supplementation, as a bridge for the desired enteral autonomy. Summary: Several classification criteria have been highlighted to reflect different perspectives in CIF. The management of CIF-SBS in adults is a multidisciplinary process that aims to reduce gastrointestinal secretions, slow transit, correct/prevent malnutrition, dehydration, and specific nutrient deficiencies, and prevent refeeding syndrome. The nutritional support team should have the expertise to take care of these complex patients: fluid support; oral, enteral, and PN; disease/PN-related complications; pharmacologic treatment; and surgical prevention/treatment. Key messages: CIF-SBS is a complex disease with undesired consequences, if not adequately identified and managed. A comprehensive approach performed by a multidisciplinary team is essential to reduce PN dependence, promote enteral independence, and improve quality of life.
- Cardiovascular risk profile with SCORE2 and SCORE2-OP: comparing Portugal, Spain, Italy, and France using the new European predictive modelsPublication . Fontainhas, M; Gavina, C; Miranda, J; Pereira-Silva, R; Guichard, J; Seixas, D; Araújo, FIntroduction: This study aims to characterize the cardiovascular risk profile in countries with low-to-moderate cardiovascular mortality risk (Italy, Portugal, France, and Spain) using the SCORE2 and SCORE2-OP models. It also examines regional variations and the involvement of healthcare professionals in performing risk assessments. Methods: A retrospective observational study was conducted using data from 24,434 cardiovascular risk assessments performed between December 2022 and July 2023 through a digital application used by physicians. The assessments used the SCORE2 model for individuals aged 40-69 and the SCORE2-OP model for those aged 70 and older. Risk stratification into "low-to-moderate," "high," and "very high" categories was analyzed based on individual risk factors such as age, smoking habits, systolic blood pressure, and cholesterol levels. Results: Approximately 50%-60% of individuals in these countries were classified as having "high" or "very high" cardiovascular risk. The highest proportions were observed in Portugal (62.44%) and Italy (64.05%), while lower proportions were found in Spain (46.65%) and France (52.74%). Regional analysis identified areas with the highest cardiovascular risk, such as Portalegre in Portugal and Apulia in Italy. Key risk factors included older age, smoking, high systolic blood pressure, and high non-HDL cholesterol. General practitioners were the primary healthcare professionals conducting these assessments. Discussion: The study highlights a significant proportion of individuals with "high" or "very high" cardiovascular risk in countries with low-to-moderate mortality risk. These findings underscore the need for targeted cardiovascular disease prevention strategies and the crucial role of general practitioners in managing cardiovascular risk.
- Analysis of Genes Involved in Oxidative Stress and Iron Metabolism in Heart Failure: A Step Forward in Risk StratificationPublication . Silva, PX; Aguiar, L; Gaspar, M; Faustino, P; Falcão, LM; Barbosa, M; Bicho, M; Inácio, ÂIntroduction: Heart failure (HF) is a clinical syndrome characterized by cardinal symptoms that may be accompanied by signs. It results from structural and/or functional abnormalities of the heart leading to elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise. The prevalence of iron deficiency and anemia justifies the current guidelines recommendation of screening. Genes HP, ACE, MTHFR, HFE, and CYBA are involved in oxidative mechanisms, iron metabolism, and hematologic homeostasis. This study investigates the contribution of variants Hp1/2 (HP), I/D (ACE), C677T (MTHFR), C282Y and H63D (HFE), and C242T (CYBA) to the development of HF, either independently or in epistasis. Methods: We used a database of 389 individuals, 143 HF patients, and 246 healthy controls. Genotypes were characterized through PAGE electrophoresis, PCR, PCR-RFLP, and multiplex-ARMS. Data analysis was performed with the SPSS® 26.0 software (IBM Corp., Armonk, NY). Results: We observed a significant association between the MTHFR gene and HF predisposition. The presence of allele T and genotype CT constituted risk, while genotype CC granted protection. Epistatic interactions revealed risk between genotype II of the ACE gene and genotypes CC (C282Y) or HH (H63D) of the HFE gene. Risk was also observed for interactions between genotype CC (CYBA)and genotypes 2-2 (HP), CT (MTHFR), or HH (HFE-H63D). Conclusion: We concluded that genes HP, ACE, MTHFR, HFE, and CYBA contribute to the susceptibility for HF, individually or in epistasis. This study contributes to the clarification of the role that genes involved in oxidative mechanisms and iron metabolism play in the physiopathology of HF. It is, therefore, a step forward in risk stratification and personalized medicine.
- The impact of methylene blue in colon cancer: a retrospective multicentric studyPublication . Carvalho, A; Limbert, M; Cabral, F; Fareleira, A; Duarte, A; Barroca, R; Goulart, A; Leão, PIntroduction: Discussions about the optimal lymph node (LN) count and its therapeutic consequences have persisted over time. The final LN count in colorectal tissues is affected by a variety of variables (patient, tumor, operation, pathologist, immune response). Methylene blue (MB) intra-arterial injection is a simple and inexpensive procedure that can be used to enhance lymph node count. Aim: Analyze whether there is a statistically significant difference between intra-arterial methylene blue injection and conventional dissection for the quantification of lymph nodes and determine if there is a variation in the quality of lymph node acquisition. Methods and results: Between 2015 and 2022, we conducted a retrospective analysis of colon cancer specimens. Data on the tumor's features, the number of lymph nodes, the number of lymph nodes that were positive, and other factors had been collected. The number of identified lymph nodes was highly significantly improved in the study group (P < 0.05). There is not a significant statistical difference between groups regarding the metastatic lymph node harvest. The group with injection of intra-arterial methylene blue shows a significantly decreased (P < 0.05) of the of cases with less than 12 lymph nodes recovered comparing with the control group. Conclusion: Colon cancer specimens can be easily evaluated concerning lymph nodes using the methylene blue method. Therefore, we strongly advise this approach as a standard procedure in the histological evaluation of colon cancer specimens in order to maximize the identification of lymph nodes. However, the detection of metastatic lymph nodes was unaffected significantly.
- Immunomodulatory Effects and Protection in Sepsis by the Antibiotic MoxifloxacinPublication . Velho, TR; Raquel, H; Figueiredo, N; Neves-Costa, A; Pedroso, D; Santos, I; Willmann, K; Moita, LFSepsis is a leading cause of death in Intensive Care Units. Despite its prevalence, sepsis remains insufficiently understood, with no substantial qualitative improvements in its treatment in the past decades. Immunomodulatory agents may hold promise, given the significance of TNF-α and IL-1β as sepsis mediators. This study examines the immunomodulatory effects of moxifloxacin, a fluoroquinolone utilized in clinical practice. THP1 cells were treated in vitro with either PBS or moxifloxacin and subsequently challenged with lipopolysaccharide (LPS) or E. coli. C57BL/6 mice received intraperitoneal injections of LPS or underwent cecal ligation and puncture (CLP), followed by treatment with PBS, moxifloxacin, meropenem or epirubicin. Atm-/- mice underwent CLP and were treated with either PBS or moxifloxacin. Cytokine and organ lesion markers were quantified via ELISA, colony-forming units were assessed from mouse blood samples, and DNA damage was evaluated using a comet assay. Moxifloxacin inhibits the secretion of TNF-α and IL-1β in THP1 cells stimulated with LPS or E. coli. Intraperitoneal administration of moxifloxacin significantly increased the survival rate of mice with severe sepsis by 80% (p < 0.001), significantly reducing the plasma levels of cytokines and organ lesion markers. Notably, moxifloxacin exhibited no DNA damage in the comet assay, and Atm-/- mice were similarly protected following CLP, boasting an overall survival rate of 60% compared to their PBS-treated counterparts (p = 0.003). Moxifloxacin is an immunomodulatory agent, reducing TNF-α and IL-1β levels in immune cells stimulated with LPS and E. coli. Furthermore, moxifloxacin is also protective in an animal model of sepsis, leading to a significant reduction in cytokines and organ lesion markers. These effects appear unrelated to its antimicrobial activity or induction of DNA damage.
- World Heart Federation Cholesterol Roadmap: The Portuguese casePublication . Abreu, A; Dores, H; Gonçalves, L; Franco, F; Silveira, C; Proença, G; Teresa Timóteo, A; Cardim, N; Pedro, M; Fiuza, M; Ferreira, D; Bento, L; Patrício, L; Caldeira, D; Bravo Baptista, S; Santos, J; Rocha, E; Raimundo, A; Catarino, C; Carrageta, M; Mexia, R; Araújo, F; Pereira, H; Santos, R; Pinto, FJAtherosclerotic cardiovascular disease (ASCVD) remains the major cause of premature death and disability; effective cardiovascular (CV) risk prevention is fundamental. The World Heart Federation (WHF) Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention. At the invitation of the WHF, a group of experts from the Portuguese Society of Cardiology (SPC), addressed the cholesterol burden at nationally and discussed possible strategies to include in a Portuguese cholesterol roadmap. The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk. An infographic scorecard was built to include in the WHF collection, for a clear idea about CV risk and cholesterol burden in Portugal, which would also be useful for health policy advocacy. The expert discussion and preventive strategies proposal followed the five pillars of the WHF document: awareness improvement; population-based approaches for CV risk and cholesterol; risk assessment/population screening; system-level approaches; surveillance of cholesterol and ASCVD outcomes. These strategies were debated by all the expert participants, with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention. Several key recommendations were outlined: include all stakeholders in a multidisciplinary national program; create a structured activities plan to increase awareness in the population; improve the quality of continuous CV health education; increase the interaction between different health professionals and non-health professionals; increment the referral of patients to cardiac rehabilitation; screen cholesterol levels in the general population, especially high-risk groups; promote patient self-care, engage with patients' associations; use specific social networks to spread information widely; create a national database of cholesterol levels with systematic registry of CV events; redefine strategies based on the evaluation of results; create and involve more patients' associations - invert the pyramid order. In conclusion, ASCVD and the cholesterol burden remain a strong global issue in Portugal, requiring the involvement of multiple stakeholders in prevention. The Portuguese cholesterol roadmap can provide some solutions to help urgently mitigate the problem. Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change. A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden.