Einstein-Sao Paulo最新文献

Background: Iridoschisis is a rare, bilateral condition of unknown etiology, often associated with trauma or surgery, in which the iris stroma splits into layers. It is usually associated with glaucoma and cataract. Facectomy in these patients is challenging owing to the risk of aspirating the iris fibers and limited pupil dilation.

Objective: This systematic review aimed to provide a comprehensive analysis of the clinical features, therapeutic interventions, and outcomes in patients with iridoschisis, to clarify optimal practices and identify areas for future research.

Methods: We described a case of unilateral iridoschisis in a 76-year-old female, diagnosed on imaging examinations without prior ophthalmologic intervention. Preoperative planning for facectomy addressed potential surgical complications. Correct diagnosis facilitated the investigation of glaucomatous optic neuropathy, a common and sight-threatening complication if left untreated. We conducted a systematic search using Medical Subject Headings and Health Science Descriptors combined with Boolean operators.

Sources: PubMed, Cochrane Library, Web of Science, and Embase were searched with no publication restrictions.

Risk of bias: The risk of bias was assessed using the Critical Appraisal Checklist for case reports and case series proposed by The Joanna Briggs Institute.

Synthesis: The reference lists of the retrieved studies were manually checked. A simple descriptive analysis was performed to summarize the results.

Results: The search retrieved data from 234 studies. In the final analysis, 17 references were included, comprising 15 case reports and two case series. Preoperative and postoperative best-corrected visual acuities improved significantly, with cataract surgery being the most common treatment. Common complications included anterior chamber inflammation, corneal edema, and Descemet folds.

Discussion: This case and systematic review provide valuable insights into the management of iridoschisis and its comorbidities, underscoring the importance of careful preoperative planning and ongoing research to refine treatment strategies.Prospero database registration: CRD42024549865.

Objective: To analyze the association of physical disability with medical care and health center infrastructure satisfaction among users of medical offices in Peru in 2016.

Methods: We conducted a cross-sectional analysis of secondary data from the 2016 National Health User Satisfaction Survey (ENSUSALUD). The independent variable was self-reported physical disability and the dependent variables were satisfaction with medical care and health facility infrastructure. Sociodemographic variables and variables related to user satisfaction were included as confounding factors. We conducted multiple linear regression analysis and estimated β coefficients with their corresponding 95% confidence intervals (95%CI). The ENSUSALUD 2016 sample design was accounted for in all calculations.

Results: After adjusting for confounders, individuals with moderate physical disabilities reported an average of 1.96 fewer points (95%CI=-2.95 to -0.97) in satisfaction with medical care compared to that of those without physical disabilities. Similarly, individuals with moderate and severe physical disabilities reported averages of 1.86 (95%CI=-2.75 to -0.96) and 6.40 (95%CI=-9.58 to -3.22) fewer points, respectively, in satisfaction with the healthcare facility infrastructure compared to those of individuals without physical disabilities.

Conclusion: In Peru, people with physical disabilities who use medical offices reported lower satisfaction with medical care and infrastructure of health facilities compared to that of those without physical disabilities.

Valvular heart disease is increasingly prevalent, and bedside confirmation or exclusion of severe disease is needed to enable a rapid and cost-effective diagnostic workup. The physical examination skills of clinicians are insufficient for accurate diagnosis, making complementary tests generally necessary. Despite being commonly requested, electrocardiography and chest radiography present low positive and negative likelihood ratios. Incipient studies involving artificial intelligence have shown promising opportunities to support the diagnosis. In addition, solid current evidence demonstrates that point-of-care ultrasound enhances bedside diagnosis of several cardiovascular conditions. Echocardiographic skills can be acquired after only a few hours of training, which encourages routine bedside use with handling equipment. Despite the routine use of sonography in emergencies, large-scale simplified screening protocols for valvular disease remain lacking. Therefore, improving the accuracy of valvular heart disease diagnosis by integrating all bedside modalities needs to be better understood. We propose a simple, reproducible five-step point-of-care ultrasound protocol for diagnosing valvular heart disease (the ValvUS approach), applicable to all patients. The proposed visual assessment involves evaluating valvular movement, thickness, regurgitant flow, aliasing, and chamber dimensions. This evaluation should be interpreted in the context of traditional clinical probability to ensure the most accurate bedside diagnosis. Typical findings of severe valvular disease on electrocardiography and chest radiography, and particularly on point-of-care ultrasound, may improve the accuracy of bedside diagnosis after clinical assessment in the near future.

■ This paper proposes a contextual and non-reductionist ontology of mental health disorders. ■ It reframes the diathesis-stress model through radical behaviorism and functional contextualism. ■ It emphasizes dynamic interactions between vulnerabilities and environmental stressors. ■ It guides clinical practice toward integrative, personalized, and system-sensitive interventions.

Breast cancer is one of the most prevalent and heterogeneous cancers worldwide; however, it remains a complex and enigmatic disease. Advances in targeted therapies combined with increasing knowledge about tumor subtypes and molecular profiling have placed precision medicine on the frontier of oncological treatments. The recent classification of certain HER2 tumors as HER2-low, along with emerging evidence from studies using antibody-drug conjugates to target specific tumor profiles, highlights the relevance of this case study. This report describes the treatment of a 72-year-old woman diagnosed with metastatic triple-negative breast cancer, classified as HER2-low with specific HER2 mutations. The patient showed disease progression despite standard treatments, leading to the use of trastuzumab deruxtecan (T-DXd), an antibody-drug conjugate targeting HER2, as a third-line therapy. Her positive response, which surpassed the median progression-free survival rates seen in clinical trials, highlights the potential of precision medicine, where treatment is customized based on genetic and molecular tumor profiles. These new therapeutic options for difficult-to-treat cancer subtypes expand treatment possibilities, ushering in a new era of personalized and precision-driven oncology.

Patients diagnosed with fibrosing interstitial lung disease are at risk of several complications, some of which may be life-threatening. Computed tomography imaging plays an important role in diagnosing these overlapping conditions. This article summarizes the computed tomography imaging features of the most common conditions associated with fibrosing interstitial lung diseases, categorized by involvement of the lung parenchyma or extra-pulmonary compartments. Some steps may help to recognize such complications, such as having knowledge of the underlying fibrotic lung disease, being aware of potentially immunosuppressive treatments in use, noting new relevant symptoms, checking previous imaging examinations to detect subtle changes, and considering the exam technique, for example, to avoid false perception of ground-glass opacities in exams with insufficient inspiration. Unenhanced computed tomography may be enough to diagnose most situations, but in specific cases, for example, in the clinical suspicion of pulmonary embolism, dedicated computed tomography angiography may be warranted. Careful comparison with previous exams is advised, especially to detect subtle opacities suspicious for lung cancer, underscoring that its detection may be difficult owing to the baseline morphological lung changes. Radiologists must be aware of such possible complications to perform early diagnosis and ensure proper management.

The present study examines the development of medical science during the COVID-19 pandemic in light of Ernst Mayr's critique of Thomas Kuhn's philosophy of scientific revolutions. Kuhn's model, which emphasizes paradigm shifts and disruptive changes in scientific practice, contrasts with the evolutionary and cumulative nature of biological sciences, as argued by Mayr. Revisiting Mayr's critique, we question the applicability of Kuhn's model to the COVID-19 pandemic by using vaccine development as a case study. We argue that the rapid advancements in vaccine technology, particularly mRNA-based vaccines, are better understood as the outcome of multiple independent micro-revolutions in scientific fields, such as genetics, pharmacology, and molecular biology. These disciplines have advanced steadily over decades, facilitating the accelerated response to the pandemic. Consequently, the rapid, effective, and game-changing development and implementation of mRNA vaccines represented a major breakthrough in medical science; their trajectory diverged from Kuhn's concepts of scientific revolution and normal science. Through this analysis, we propose rethinking of medical epistemology - one that acknowledges the asynchronous yet non-disruptive progress of the medical sciences. Such a framework not only provides a more accurate understanding of scientific evolution but also offers a valuable tool for addressing societal challenges, such as vaccine hesitancy and public trust in science.

Background: Non-invasive respiratory support strategies, such as high-flow nasal cannula therapy and non-invasive ventilation, were widely employed during the coronavirus disease 2019 (COVID-19) pandemic, yet their comparative effectiveness remains uncertain.

Objective: To compare the effects of high-flow nasal cannula therapy, non-invasive ventilation, and conventional oxygen therapy on intubation rates and hospital mortality in adults with COVID-19-related acute respiratory failure.

Methods: A systematic review and meta-analysis was conducted following PRISMA and Cochrane guidelines, with searches performed in nine databases for publications up to May 2023. Eligible studies were those on adults (≥18 years) with confirmed severe acute respiratory syndrome coronavirus 2 infection and that included intubation and mortality as primary outcomes. Risk of bias was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohorts and the Cochrane Risk of Bias tool. Pooled results were reported as odds ratios (ORs) with 95% confidence intervals (95%CIs).

Results: Forty-one studies were included in the review and ten in the meta-analysis (2,843 patients). High-flow nasal cannula therapy did not differ from non-invasive ventilation in terms of the intubation rate (OR=1.07, 95%CI=0.89-1.29, p=0.45) but was superior to oxygen therapy (OR=0.79, 95%CI=0.64-0.97, p=0.02). High-flow nasal cannula therapy was also associated with lower mortality than non-invasive ventilation (OR=0.62, 95%CI=0.51-0.76, p<0.0001) but did not differ from oxygen therapy (OR=1.06, 95%CI=0.84-1.33, p=0.64). Substantial heterogeneity was observed in the subgroup analyses (I2=64%-90%).

Interpretation: High-flow nasal cannula therapy may reduce the need for intubation compared with oxygen therapy and may lower the hospital mortality rate compared with non-invasive ventilation. However, heterogeneity in the studies suggests that patient-specific factors and disease severity may influence outcomes.

Conclusion: High-flow nasal cannula therapy shows potential benefits over oxygen therapy and non-invasive ventilation for COVID-19-related acute respiratory failure, particularly in the mortality rate. Clinical use of these therapies should be context-specific, given the need for cautious interpretation of our results and for further high-quality trials.

Prospero database registration: ID CRD 42020226936.