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Background: Considerable evidence indicates that a signaling crosstalk between the brain and periphery plays important roles in neurological disorders, and that both acute and chronic peripheral inflammation can produce brain changes leading to cognitive impairments. Recent clinical and epidemiological studies have revealed an increased risk of cognitive impairment and dementia in individuals with impaired pulmonary function. However, the mechanistic underpinnings of this association remain unknown. Exposure to SiO 2 (silica) particles triggers lung inflammation, including infiltration by peripheral immune cells and upregulation of pro-inflammatory cytokines. We here utilized a mouse model of lung silicosis to investigate the crosstalk between lung inflammation and memory., Methods: Silicosis was induced by intratracheal administration of a single dose of 2.5 mg SiO 2 /kg in mice . Molecular and behavioral measurements were conducted 24 h and 15 days after silica administration. Lung and hippocampal inflammation were investigated by histological analysis and by determination of pro-inflammatory cytokines. Hippocampal synapse damage, amyloid-β (Aβ) peptide content and phosphorylation of Akt, a proxy of hippocampal insulin signaling, were investigated by Western blotting and ELISA. Memory was assessed using the open field and novel object recognition tests., Results: Administration of silica induced alveolar collapse, lung infiltration by polymorphonuclear (PMN) cells, and increased lung pro-inflammatory cytokines. Lung inflammation was followed by upregulation of hippocampal pro-inflammatory cytokines, synapse damage, accumulation of the Aβ peptide, and memory impairment in mice., Conclusion: The current study identified a crosstalk between lung and brain inflammatory responses leading to hippocampal synapse damage and memory impairment after exposure to a single low dose of silica in mice., (© 2022. The Author(s).)

Early diagnosis is essential for the appropriate management of acute kidney injury (AKI). We evaluated the impact of an electronic AKI alert together with a care bundle on the progression and mortality of AKI. This was a single-center prospective study that included AKI patients aged ≥ 18 years, whereas those in palliative care, nephrology, and transplantation departments were excluded. An AKI alert was issued in electronic medical records and a care bundle was suggested. A series of classes were administered to the multidisciplinary teams by nephrologists, and a clinical pharmacist audited prescriptions. Patients were categorized into pre-alert and post-alert groups. The baseline characteristics were comparable between the pre-alert (n = 1613) and post-alert (n = 1561) groups. The 30-day mortality rate was 33.6% in the entire cohort and was lower in the post-alert group (30.5% vs. 36.7%; p < 0.001). Age, pulmonary disease, malignancy, and ICU admission were associated with an increase in 30-day mortality. The electronic AKI alert together with a care bundle and a multidisciplinary education program was associated with a reduction in 30-day mortality in patients with AKI.

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a powerful predictor of perioperative outcomes. We evaluated the burden of CSA-AKI in patients with preserved baseline renal function., Methods: The data of 2,162 adult patients who underwent cardiac surgery from January 2005 to December 2020 were analyzed. Logistic regression models were used to determine predictors of CSA-AKI and their associations with hospital mortality up to 30 days., Results: The prevalence of acute kidney injury was 43.0%, and 2.0% of patients required renal replacement therapy. Hospital mortality rate was 5.6% (non-acute kidney injury = 2.0% vs. CSA-AKI = 10.4%, P&lt;0.001), and any degree of CSA-AKI was associated with a significant increase in death rates (stage 1 = 4.3%, stage 2 = 23.9%, stage 3 = 59.7%). Multivariable logistic regression analysis identified age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration as predictors of CSA-AKI. Moreover, CSA-AKI was confirmed as independent predictor of hospital mortality for stage 1 (odds ratio, 2.02; 95% confidence interval, 1.16 to 3.51; P=0.013), stage 2 (odds ratio, 9.18; 95% confidence interval, 4.54 to 18.58; P&lt;0.001), and stage 3 (odds ratio, 37.72; 95% confidence interval, 18.87 to 75.40; P&lt;0.001) patients., Conclusion: Age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration are independent predictors of CSA-AKI in patients with preserved baseline renal function. The development of CSA-AKI is significantly associated with worse outcomes, and there is a dose-response relationship between acute kidney injury stages and hospital mortality.

Objective: To characterize myocardial injury and cardiovascular complications and their predictors in severe and critical COVID-19 patients admitted to the intensive care unit., Methods: This was an observational cohort study of severe and critical COVID-19 patients admitted to the intensive care unit. Myocardial injury was defined as blood levels of cardiac troponin above the 99th percentile upper reference limit. Cardiovascular events considered were the composite of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, heart failure and arrhythmia. Univariate and multivariate logistic regression or Cox proportional hazard models were used to determine predictors of myocardial injury., Results: Of 567 patients with severe and critical COVID-19 admitted to the intensive care unit, 273 (48.1%) had myocardial injury. Of the 374 patients with critical COVID-19, 86.1% had myocardial injury, and also showed more organ dysfunction and higher 28-day mortality (56.6% versus 27.1%, p < 0.001). Advanced age, arterial hypertension and immune modulator use were predictors of myocardial injury. Cardiovascular complications occurred in 19.9% of patients with severe and critical COVID-19 admitted to the intensive care unit, with most events occurring in patients with myocardial injury (28.2% versus 12.2%, p < 0.001). The occurrence of an early cardiovascular event during intensive care unit stay was associated with higher 28-day mortality compared with late or no events (57.1% versus 34% versus 41.8%, p = 0.01)., Conclusion: Myocardial injury and cardiovascular complications were commonly found in patients with severe and critical forms of COVID-19 admitted to the intensive care unit, and both were associated with increased mortality in these patients.

This study aimed to evaluate the COVID-19 hospitalizations in a tertiary hospital by age group and month, considering the introduction and the advance of the vaccination against the disease. The laboratory-confirmed COVID-19-associated hospitalizations among people aged 20 years or older, that occurred between March 2020 and June 2021, were distributed by month of symptom onset and age group. The proportion of hospitalizations by age group was calculated for the year 2021. The proportions were compared using the chi-square test for trends. The marks of vaccination advances among different age groups were taken from the official website LocalizaSUS. In 2020, hospitalizations among people aged 60-80 years old were the most frequent (39.1%). From January-June 2021, when the vaccination commenced, while hospitalizations of patients aged 20 to < 40 and 40 to 60 years old showed an increasing trend, the older age groups and those with vaccination recommendations (from 60 to < 80 and from 80 or over) showed a downward trend. As of June 2021, with widespread vaccination, a drop in hospitalizations was observed in > 60 years old. At 20 to <40 and 40 to < 60, an increase in hospitalizations was observed. It demonstrates the important role of vaccination in combating the COVID-19 pandemic.

Background: The impact of left ventricular reverse remodeling (LVRR) on the prognosis of Chagas cardiomyopathy is unknown. The aim of this study was to determine whether the presence of LVRR can predict mortality in these patients., Methods: From January 2000 to December 2010, the medical charts of 159 patients were reviewed. LVRR was defined as an increase of left ventricular ejection fraction (LVEF) and a decrease of left ventricular end-diastolic diameter (LVDD) by two-dimensional echocardiography. No patient underwent cardiac resynchronization therapy or required mechanical ventricular assistance., Results: At baseline, median (25th-75th) LVDD was 64 mm (59-70), and median LVEF was 33.2% (26.4-40.1). LVRR was detected in 24.5% of patients in a 40-month (26-64) median follow-up. In the LVRR group, LVDD decreased from 64 mm (59-68) to 60 mm (56-65; p < 0.001), and LVEF increased from 31.3% (24.1-39.0) to 42.5% (32.2-47.7; p < 0.001). However, LVRR was not associated with heart failure hospitalization, cardiogenic shock, heart transplantation, or mortality (p > 0.05 for all comparisons). The Cox proportional hazard model analysis identified only cardiogenic shock (hazard ratio [HR]: 2.41; 95% confidence interval [CI]: 1.51-3.85; p < 0.001) and serum sodium level (HR: 0.91; 95% CI: 0.86-0.96; p < 0.001) as independent predictors of all-cause mortality., Conclusions: Left ventricular reverse remodeling occurs in one quarter of patients with Chagas cardiomyopathy and have no impact on the outcomes of patients with this condition.

Background Increased high-sensitivity cardiac troponin T (hs-cTnT) above the upper reference limit (URL) after noncardiac surgery identifies patients at risk for mortality. Prior studies have not analyzed hs-cTnT as a continuous variable or probed age- and sex-specific URLs. This study compared the prediction of 30-day mortality using continuous postoperative hs-cTnT levels to the use of the overall URL and age- and sex-specific URLs. Methods and Results Patients (876) >40 years of age who underwent noncardiac surgery were included. Hs-cTnT was measured on postoperative day 1. Cox proportional hazards models were used to compare associations between 30-day mortality and using hs-cTnT as a continuous variable, or above the overall or age- and sex-specific URLs. Comparisons were performed by the area under the receiver operating characteristic curve analysis. Mortality was 4.2%. For each 1 ng/L increase in postoperative hs-cTnT, there was a 0.3% increase in mortality ( P <0.001). Patients with postoperative hs-cTnT >14 ng/L were 37% of the cohort, while those above age- and sex-specific URLs were 25.3%. Both manifested higher mortality (hazard ratio [HR], 3.19; 95% CI, 1.20-8.49; P =0.020) and (HR, 2.76; P =0.009) than those with normal levels. The area under receiver operating characteristic curve was 0.89 using hs-cTnT as a continuous variable, 0.87 for age- and sex-specific URLs, and 0.86 for the overall URL. Conclusions Hs-cTnT as a continuous variable was independently associated with 30-day mortality and had the highest accuracy. Hs-cTnT elevations using overall and/or age- and sex-specific URLs were also associated with higher mortality.

C 60 fullerene (C 60 ) is a nano-pollutant that can damage the respiratory system. Eugenol exhibits significant anti-inflammatory and antioxidant properties. We aimed to investigate the time course of C 60 emulsion-induced pulmonary and spermatic harms, as well as the effect of eugenol on C 60 emulsion toxicity. The first group of mice (protocol 1) received intratracheally C 60 emulsion (1.0 mg/kg BW) or vehicle and were tested at 12, 24, 72 and 96 h (F groups) thereafter. The second group of mice (protocol 2) received intratracheally C 60 emulsion or vehicle, 1 h later were gavaged with eugenol (150 mg/kg) or vehicle, and experiments were done 24 h after instillation. Lung mechanics, morphology, redox markers, cytokines and epididymal spermatozoa were analyzed. Protocol 1: Tissue damping (G) and elastance (H) were significantly higher in F24 than in others groups, except for H in F72. Morphological and inflammatory parameters were worst at 24 h and subsequently declined until 96 h, whereas redox and spermatic parameters worsened over the whole period. Eugenol eliminated the increase in G, H, cellularity, and cytokines, attenuated oxidative stress induced by C60 exposure, but had no effect on sperm. Hence, exposure to C 60 emulsion deteriorated lung morphofunctional, redox and inflammatory characteristics and increased the risk of infertility. Furthermore, eugenol avoided those changes, but did not prevent sperm damage., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Aims: This study aimed to develop and validate a simple method for predicting long-term all-cause mortality in ambulatory patients with chronic heart failure (CHF) residing in an area where Chagas disease is endemic, which will be important not only for patients living in Latin America but also to those living in developed non-endemic countries., Methods and Results: A total of 677 patients with a wide spectrum of aetiologies for left ventricular systolic dysfunction and receiving optimized evidence-based treatment for CHF were prospectively followed for approximately 11 years. We established a risk score using Cox proportional hazard regression models. After multivariable analysis, four variables were independently associated with mortality and included in the CALL Risk Score: Chagas cardiomyopathy aetiology alone [hazard ratio, 3.36; 95% confidence interval (CI), 2.61-4.33; P < 0.001], age ≥60 years (hazard ratio, 1.36; 95% CI, 1.06-1.74; P = 0.016), left anterior fascicular block (hazard ratio, 1.64; 95% CI, 1.27-2.11; P < 0.001), and left ventricular ejection fraction <40% (hazard ratio, 1.73; 95% CI, 1.30-2.28; P < 0.001). The internal validation considered the bootstrapping, a resampling technique recommended for prediction model development. Hence, we established a scoring system attributing weights according to each risk factor: 3 points for Chagas cardiomyopathy alone, 1 point for age ≥60 years, and 2 points each for left anterior fascicular block and left ventricular ejection fraction <40%. Three risk groups were identified: low risk (score ≤2 points), intermediate risk (score of 3 to 5 points), and high risk (score ≥6 points). High-risk patients had more than two-fold increase in mortality (26.9 events/100 patient-years) compared with intermediate-risk patients (10.1 events/100 patient-years) and almost seven-fold increase compared with low-risk patients (4.3 events/100 patient-years). The CALL Risk Score data sets from the development and internal validation cohorts both displayed suitable discrimination c-index of 0.689 (95% CI, 0.688-0.690; P < 0.001) and 0.687 (95% CI, 0.686-0.688; P < 0.001), respectively, and satisfactory calibration [Greenwood-Nam-D'Agostino test (8) = 7.867; P = 0.447] and [Greenwood-Nam-D'Agostino test (8) = 10.08; P = 0.273], respectively., Conclusions: The CALL Risk Score represents a simple and validated method with a limited number of non-invasive variables that successfully predicts long-term all-cause mortality in a real-world cohort of patients with CHF. Patients with CHF stratified as high risk according to the CALL Risk Score should be monitored and aggressively managed, including those with CHF secondary to Chagas disease., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: Few studies regarding chronic kidney disease (CKD) and anemia have been conducted in patients with Chagas cardiomyopathy (CC). We evaluated the risk prediction performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and anemia in CC patients., Methods: From 2000 to 2010, a total of 232 patients were studied in a single-center retrospective study. CKD was defined as creatinine clearance <60 mL/min/1.73 m 2 according to CKD-EPI equation. Anemia was defined as hemoglobin <12 g/dL (women) and <13 g/dL (men). Cox proportional hazards models were used to establish predictors for death., Results: At baseline, 98 individuals (42.2%) had criteria for CKD and 41 (17.7%) for anemia. During follow-up, 136 patients (58.6%) died. Independently, CKD and anemia were not associated with all-cause mortality. However, when they coexisted, an additional risk was attributed for these patients. Cox proportional hazard models analysis identified systolic blood pressure (hazard ratio, 0.99; 95% confidence interval (CI), 0.98 to 1.00; P =0.015), implantable cardioverter-defibrillator (hazard ratio, 0.48; 95% CI, 0.27 to 0.85; P =0.012), left anterior fascicular block (hazard ratio, 1.52; 95% CI, 1.08 to 2.13; P =0.017), left ventricular end-diastolic diameter (hazard ratio, 1.04; 95% CI, 1.02 to 1.06; P < 0.001), and serum sodium (hazard ratio, 0.95; 95% CI, 0.92 to 0.99; P =0.020) as independent predictors for death., Conclusions: CKD and anemia are not independent predictors for long-term mortality in CC patients. However, the prognosis is poorer in individuals with both comorbidities., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2020 Marcelo Arruda Nakazone et al.)

Silicosis is an occupational lung disease caused by inhalation of silica particles. It is characterized by intense lung inflammation, with progressive and irreversible fibrosis, leading to impaired lung function. Purinergic signaling modulates silica-induced lung inflammation and fibrosis through P2X7 receptor. In the present study, we investigate the role of P2Y 12 , the G-protein-coupled subfamily prototype of P2 receptor class in silicosis. To that end, BALB/c mice received an intratracheal injection of PBS or silica particles (20 mg), without or with P2Y 12 receptor blockade by clopidogrel (20 mg/kg body weight by gavage every 48 h) - groups CTRL, SIL, and SIL + Clopi, respectively. After 14 days, lung mechanics were determined by the end-inflation occlusion method. Lung histology was analyzed, and lung parenchyma production of nitric oxide and cytokines (IL-1β, IL-6, TNF-α, and TGF-β) were determined. Silica injection reduced animal survival and increased all lung mechanical parameters in relation to CTRL, followed by diffuse lung parenchyma inflammation, increased neutrophil infiltration, collagen deposition and increased pro-inflammatory and pro-fibrogenic cytokine secretion, as well as increased nitrite production. Clopidogrel treatment prevented silica-induced changes in lung function, and significantly reduced lung inflammation, fibrosis, as well as cytokine and nitrite production. These data suggest that inhibition of P2Y 12 signaling improves silica-induced lung inflammation, preventing lung functional changes and mortality. Our results corroborate previous observations of silica-induced lung changes and expand the understanding of purinergic signaling in this process., (Copyright © 2020 Santana, Luna-Gomes, Rangel-Ferreira, Tamura, Da Graça, Machado, Zin, Takiya, Faffe and Coutinho-Silva.)

Objective: To examine the impact of delayed transfer from the emergency room into the intensive care unit on the length of intensive care unit stay and death., Methods: This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay., Results: A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant., Conclusion: Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.

Murine papain-induced emphysema is a model that reproduces many of the features found in patients. Bone marrow-derived mononuclear cells (BMMC) have already been used to repair the alveolar epithelium in respiratory diseases, but not in the papain model. Thus, we hypothesized that BMMC could prevent the pathophysiological processes in papain-induced experimental emphysema. Female BALB/c mice received intratracheal instillation of 50 μL of saline (S groups) or papain (P groups, 10 IU/50 μl of saline) on days 1 and 7 of the experimental protocol. On the 14th day, 2 × 10 6 BMMC of male BALB/c mice (SC21 and PC21) or saline (SS21 and PS21) were injected by the jugular vein. Analyses were done on days 14 (S14 and P14) and 21 (SS21, PS21, SC21, and PC21) of the protocol. qPCR evaluated the presence of the Y chromosome in the lungs of BMMC recipient animals. Functional residual capacity (FRC), alveolar diameter, cellularity, elastic fiber content, concentrations of TNF-α, IL-1β, IL-6, MIP-2, KC, IFN-γ, apoptosis, mRNA expression of the dual oxidase (DUOX1 and DUOX2), production of H 2 O 2 and DUOX activity were evaluated in lung tissue. We did not detect the Y chromosome in recipients' lungs. FRC, alveolar diameter, polymorphonuclear cells (PMN) and levels of KC, MIP-2, and IFN-γ increased in P14 and PS21 groups; the changes in the latter were reverted by BMMC. TNF-α, IL-1β e IL-6 were similar in all groups. The amount of elastic fibers was smaller in P14 and PS21 than in other groups, and BMMC did not increase it in PC21 mice. PS21 animals showed increased DUOX activity and mRNA expression for DUOX1 and 2. Cell therapy reverted the activity of DUOX and mRNA expression of DUOX1. BMMC reduced mRNA expression of DUOX2. Apoptosis index was elevated in PS21 mice, which was reduced by cell therapy in PC21. Static compliance, viscoelastic component of elastance and pressure to overcome viscoelasticity were increased in P14 and PS21 groups. These changes and the high resistive pressure found on day 21 were reverted by BMMC. In conclusion, BMMC showed potent anti-inflammatory, antiapoptotic, antioxidant, and restorative roles in papain-triggered pulmonary emphysema.

Objective: The present study refers to a determination of the preoperative B-type natriuretic peptide is a predictor of short-term all-cause mortality in patients undergoing on-pump coronary artery bypass graft surgeries., Methods: Two hundred and twenty-one patients undergoing on-pump coronary artery bypass graft surgeries were evaluated prospectively during a 30-day postoperative follow-up period. Serum B-type natriuretic peptide concentration was measured without a 24-hour period prior to the surgical procedure and the value obtained was correlated with a short-term all-cause mortality., Results: Data analysis showed that all-cause mortality rates were equal to 9.5% in 30 days. Accuracy analysis by the receiver operating characteristic curve found an ideal cut-off value of B-type natriuretic peptide equal to 150 pg/mL in relation to mortality (AUC=0.82, 95% CI=0.71-0.87, P<0.001). Multivariate analysis showed that B-type natriuretic peptide value greater than or equal to 150 pg/mL (P=0.030, HR=3.99, 95% CI=1.14-13.98) was an independent predictor of all-cause mortality in a 30-day follow-up period., Conclusion: Preoperative serum B-type natriuretic peptide concentration is an independent predictor of short-term all-cause mortality in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

Background: The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure., Methods: Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p < 0.05 considered significant., Results: Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p  = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p  = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p  = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p  = 0.004]., Conclusions: Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.

Objective: α-2-agonists cause sympathetic inhibition combined with parasympathetic activation and have other properties that could be beneficial during cardiac anesthesia. We evaluated the effects of dexmedetomidine as an anesthetic adjuvant compared to a control group during cardiac surgery., Methods: We performed a retrospective analysis of prospectively collected data from all adult patients (> 18 years old) undergoing cardiac surgery. Patients were divided into two groups, regarding the use of dexmedetomidine as an adjuvant intraoperatively (DEX group) and a control group who did not receive α-2-agonist (CON group)., Results: A total of 1302 patients who underwent cardiac surgery, either coronary artery bypass graft or valve surgery, were included; 796 in the DEX group and 506 in the CON group. Need for reoperation (2% vs. 2.8%, P=0.001), type 1 neurological injury (2% vs. 4.7%, P=0.005) and prolonged hospitalization (3.1% vs. 7.3%, P=0.001) were significantly less frequent in the DEX group than in the CON group. Thirty-day mortality rates were 3.4% in the DEX group and 9.7% in the CON group (P<0.001). Using multivariable Cox regression analysis with in hospital death as the dependent variable, dexmedetomidine was independently associated with a lower risk of 30-day mortality (odds ratio [OR]=0.39, 95% confidence interval [CI]: 0.24-0.65, P≤0.001). The Logistic EuroSCORE (OR=1.05, 95% CI: 1.02-1.10, P=0.004) and age (OR=1.03, 95% CI: 1.01-1.06, P=0.003) were independently associated with a higher risk of 30-day mortality., Conclusion: Dexmedetomidine used as an anesthetic adjuvant was associated with better outcomes in patients undergoing coronary artery bypass graft and valve surgery. Randomized prospective controlled trials are warranted to confirm our results., Competing Interests: No conflict of interest.

Introduction: In coronary artery bypass (CABG) surgery, the common complications are the need for reintubation, prolonged mechanical ventilation (PMV) and death. Thus, a reliable model for the prognostic evaluation of those particular outcomes is a worthwhile pursuit. The existence of such a system would lead to better resource planning, cost reductions and an increased ability to guide preventive strategies. The aim of this study was to compare different methods - logistic regression (LR) and artificial neural networks (ANNs) - in accomplishing this goal., Material and Methods: Subjects undergoing CABG (n = 1315) were divided into training (n = 1053) and validation (n = 262) groups. The set of independent variables consisted of age, gender, weight, height, body mass index, diabetes, creatinine level, cardiopulmonary bypass, presence of preserved ventricular function, moderate and severe ventricular dysfunction and total number of grafts. The PMV was also an input for the prediction of death. The ability of ANN to discriminate outcomes was assessed using receiver-operating characteristic (ROC) analysis and the results were compared using a multivariate LR., Results: The ROC curve areas for LR and ANN models, respectively, were: for reintubation 0.62 (CI: 0.50-0.75) and 0.65 (CI: 0.53-0.77); for PMV 0.67 (CI: 0.57-0.78) and 0.72 (CI: 0.64-0.81); and for death 0.86 (CI: 0.79-0.93) and 0.85 (CI: 0.80-0.91). No differences were observed between models., Conclusions: The ANN has similar discriminating power in predicting reintubation, PMV and death outcomes. Thus, both models may be applicable as a predictor for these outcomes in subjects undergoing CABG.

Silicosis is an occupational lung disease, characterized by irreversible and progressive fibrosis. Silica exposure leads to intense lung inflammation, reactive oxygen production, and extracellular ATP (eATP) release by macrophages. The P2X7 purinergic receptor is thought to be an important immunomodulator that responds to eATP in sites of inflammation and tissue damage. The present study investigates the role of P2X7 receptor in a murine model of silicosis. To that end wild-type (C57BL/6) and P2X7 receptor knockout mice received intratracheal injection of saline or silica particles. After 14 days, changes in lung mechanics were determined by the end-inflation occlusion method. Bronchoalveolar lavage and flow cytometry analyzes were performed. Lungs were harvested for histological and immunochemistry analysis of fibers content, inflammatory infiltration, apoptosis, as well as cytokine and oxidative stress expression. Silica particle effects on lung alveolar macrophages and fibroblasts were also evaluated in cell line cultures. Phagocytosis assay was performed in peritoneal macrophages. Silica exposure increased lung mechanical parameters in wild-type but not in P2X7 knockout mice. Inflammatory cell infiltration and collagen deposition in lung parenchyma, apoptosis, TGF-β and NF-κB activation, as well as nitric oxide, reactive oxygen species (ROS) and IL-1β secretion were higher in wild-type than knockout silica-exposed mice. In vitro studies suggested that P2X7 receptor participates in silica particle phagocytosis, IL-1β secretion, as well as reactive oxygen species and nitric oxide production. In conclusion, our data showed a significant role for P2X7 receptor in silica-induced lung changes, modulating lung inflammatory, fibrotic, and functional changes.

Objectives: The definition of acute renal failure has been recently reviewed, and the term acute kidney injury (AKI) was proposed to cover the entire spectrum of the syndrome, ranging from small changes in renal function markers to dialysis needs. This study was aimed to evaluate the incidence, morbidity and mortality associated with AKI (based on KDIGO criteria) in patients after cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to determine the value of this feature as a predictor of hospital mortality (30 days)., Methods: From January 2003 to June 2013, a total of 2,804 patients underwent cardiac surgery in our service. Cox proportional hazard models were used to determine the association between the development of AKI and 30-day mortality., Results: A total of 1,175 (42%) patients met the diagnostic criteria for AKI based on KDIGO classification during the first 7 postoperative days: 978 (35%) patients met the diagnostic criteria for stage 1 while 100 (4%) patients met the diagnostic criteria for stage 2 and 97 (3%) patients met the diagnostic criteria for stage 3. A total of 63 (2%) patients required dialysis treatment. Overall, the 30-day mortality was 7.1% (2.2%) for patients without AKI and 8.2%, 31% and 55% for patients with AKI at stages 1, 2 and 3, respectively. The KDIGO stage 3 patients who did not require dialysis had a mortality rate of 41%, while the mortality of dialysis patients was 62%. The adjusted Cox regression analysis revealed that AKI based on KDIGO criteria (stages 1-3) was an independent predictor of 30-day mortality (P<0.001 for all. Hazard ratio = 3.35, 11.94 and 24.85)., Conclusion: In the population evaluated in the present study, even slight changes in the renal function based on KDIGO criteria were considered as independent predictors of 30-day mortality after cardiac surgery.

The development of bleomycin-induced pulmonary fibrosis (BLEO-PF) has been associated with differences in genetic background and oxidative stress status. The authors' aim was to investigate the crosstalk between the redox profile, lung histology, and respiratory function in BLEO-PF in C57BL/6, DBA/2, and BALB/c mice. BLEO-PF was induced with a single intratracheal dose of bleomycin (0.1 U/mouse). Twenty-one days after bleomycin administration, the mortality rate was over 50% in C57BL/6 and 20% in DBA/2 mice, and BLEO-PF was not observed in BALB/c. There was an increase in lung static elastance (p < .001), viscoelastic/inhomogeneous pressure (p < .05), total pressure drop after flow interruption (p < .01), and ΔE (p < .05) in C57BL/6 mice. The septa volume increased in C57BL/6 (p < .05) and DBA/2 (p < .001). The levels of IFN-γ were reduced in C57BL/6 mice (p < .01). OH-proline levels were increased in C57BL/6 and DBA/2 mice (p < .05). SOD activity and expression were reduced in C57BL/6 and DBA/2 mice (p < .001 and p < .001, respectively), whereas catalase was reduced in all strains 21 days following bleomycin administration compared with the saline groups (C57BL/6: p < .05; DBA/2: p < .01; BALB/c: p < .01). GPx activity and GPx1/2 expression decreased in C57BL/6 (p < .001). The authors conclude that BLEO-PF resistance may also be related to the activity and expression of SOD in BALB/c mice.

Background: heart rate variability (HRV) is a noninvasive diagnostic method used in the assessment of the autonomic modulation of the heart. The assessment of HRV using nonlinear dynamics methods in the preoperative period of surgical myocardial revascularization could be predictive of morbidity such as pulmonary infections in the postoperative period., Objective: to evaluate the behavior of HRV using nonlinear dynamics in the preoperative period of surgical myocardial revascularization and its relation to the occurrence of pulmonary infections in the in-hospital postoperative period., Methods: a total of 69 patients with coronary artery disease (mean age of 58.6 ± 10.4 years) and indication for elective surgical myocardial revascularization were studied. In order to quantify the nonlinear dynamics of HRV, the following procedures were performed: detrended fluctuation analysis (DFA); analysis of the short (α1) and long-term (α2) components of DFA; approximate entropy (ApEn); Lyapunov exponent (LE); and Hurst exponent (HE) of time series of RR intervals of the ECG, as captured by the Polar S810i instrument on the day before surgery., Results: at the cut-off levels set by the ROC curve, there was a significant difference between the groups with and without pulmonary infections in the postoperative period of myocardial revascularization for total DFA, approximate entropy and Lyapunov exponent with p = 0. 0309, p = 0.0307 and p = 0.0006, respectively., Conclusion: the nonlinear dynamics methods, at their respective cut-off levels, allowed for the identification of patients developing pulmonary infection in the postoperative period of surgical myocardial revascularization, thus suggesting that these methods may have a prognostic value for this group of patients.

Background: The acute kidney injury (AKI) is a complex disease for which there is no accepted standard definition nowadays. The Acute Kidney Injury Network (AKIN) represents an attempt to standardize the criteria for diagnosis and staging of acute renal dysfunction based on recently published RIFLE criteria, that means, (Risk, Injury, Failure, Loss, and End-stage kidney disease)., Objectives: To evaluate the incidence and associated mortality of AKI in patients submitted to on-pump coronary artery bypass graft surgery (on-pump CABG)., Methods: A total of 817 patients were divided into two groups: negative AKI (-), with 421 patients (51.5%), and positive AKI (+), with 396 patients (48.5%). Increase of 0.3 mg/dL in creatinine or of 50% in creatinine's basal value was considered as AKI., Results: The rate of patient's mortality with or without AKI within 30 days after cardiac surgery was 12.6% and 1.4%, respectively (p<0.0001). In a multivariate logistic regression model, AKI after on-pump CABG was an independent predictor of death within 30 days (OR=6.7; p=0.0002). This group of patients presented a longer period of permanency in intensive care unit (ICU) [median 2 days (2 to 3) versus 3 days (2 to 5); p=0.0001] and a bigger proportion of patients with prolonged permanence in intensive care (>14 days) (14 versus 2%; p=0.0001)., Conclusion: In the studied population, even a discrete alteration in renal function, based on AKIN criteria, was an independent predictor of death in 30 days after on-pump CABG.

We report a rare case of extramedullary plasmocytoma associated with a massive deposit of amyloid in the duodenum. A 72-year-old Japanese man was admitted to our hospital presenting with a 3-mo history of epigastric pain, vomiting and weight loss. On computed tomography (CT) a wall thickening of the fourth part of the duodenum was observed. Multiple biopsies obtained from the lesion showed infiltration of plasma cells and lymphocytes, but they were not conclusive. The patient underwent resection of the lesion and, on histopathological examination, the lesion consisted of a dense and diffuse infiltrate of plasma cells and a few admixed lymphocytes with reactive follicles extending to the muscular propria. An extensive deposition of amyloid was also observed. Immunohistochemical stains revealed that a few plasmacytoid cells showed lambda light chain staining, though most were kappa light chain positive. These cells also were positive for CD138 and CD56 but negative for CD20 and CD79. The findings were consistent with extramedullary plasmocytoma associated with a massive deposit of amyloid in duodenum. A subsequent workup for multiple myeloma was completely negative. The patient showed no signs of local recurrence or dissemination of the disease after 12 mo follow-up. Because of the association of plasmocytoma and amyloidosis, the patient must be followed up because of the possible systemic involvement of the neoplasm and amyloidosis in future.

Background: Several infectious agents have been investigated since the association between atherosclerosis and infection was demonstrated; however, the results of these studies are contradictory., Objective: To test the association between serum titers of anti-Chlamydia and anti-Mycoplasma antibodies in different forms of acute coronary syndromes (ACS)., Methods: One hundred and twenty-six patients were divided in 4 groups: ACS with ST-segment elevation (32 patients), ACS without ST-segment elevation (30 patients), chronic coronary artery disease (30 patients) and blood donors without known coronary disease (34 patients--control group). In the two first groups, serum samples were collected at hospital admission (first 24 hours of hospitalization) and after a 6-month follow-up. In the other two groups, only a basal sample was collected. Anti-Chlamydia and anti-Mycoplasma antibodies were measured by indirect immunofluorescence in all samples., Results: Significant differences were observed between the basal sample and the one measured after a 6-month follow-up in patients with myocardial infarction with ST-segment elevation for Chlamydia (650+/-115.7 versus 307+/-47.5, p=0.0001) as well as Mycoplasma (36.5+/-5.0 versus 21.5+/-3.5, p=0.0004). The groups with ACS had higher anti-Chlamydia and anti-Mycoplasma serum antibody levels in the basal measurement, when compared to the patients with chronic coronary disease and the control group, but the differences were not statistically significant., Conclusion: The present study showed an association between the serum titers of anti-Chlamydia and anti-Mycoplasma antibodies in the acute phase of patients with unstable angina or myocardial infarction.

Background: The aim was to demonstrate that a reduction in the nonlinear behavior of heart rate variability (HRV) in the preoperative period in patients undergoing coronary artery bypass graft (CABG) triggers higher morbidity and mortality rates in the postoperative stay., Material/method: Seventy patients (59+/-10.3 years) were included. HRV was captured by a Polar Advanced S810 heart rate monitor and analyzed using the nonlinear variables detrended fluctuation analysis (DFA), autocorrelation (tau), Lyapunov exponent (LE), and the Poincaré plot (PP). Based on two scenarios, death vs. non-death (scenario 1) and events vs. their absence (scenario 2), the occurrence of neurological complications, infections, kidney failure, arrhythmia, and death were evaluated. Sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio (95% CI) were recorded., Results: In scenario 1, significant differences were found for DFA, alpha-2, LE, PP[SD1], and PP[SD2], with p-values of 0.0172, 0.0343, 0.0159, 0.0069, and 0.0287, respectively. In scenario 2, differences were found for alpha-1, alfa-2, tau, LE, PP[SD1], and PP[SD2], with p-values of 0.0066, 0.0426, 0.0188, 0.0108, 0.0005, and 0.0158, respectively. The best areas under ROC curve were seen in scenario 1, with values of 0.72 (tau), 0.77 (LE), and 0.78 (PP[SD1])., Conclusions: Analysis of HRV in the nonlinear domain in the preoperative period in patients undergoing elective CABG surgery may detect subgroups with a high risk for postoperative complications, at least with the assistance of some of the variables, and it can become a new prognostic tool for assessing patients scheduled to undergo other major surgeries.

Penetrating aortic ulcer is a variant of classic aortic dissection having distinct histopathological characteristics. If not appropriately treated, it evolves to combined morbidity and mortality rates as high as those of classic dissection. This condition, therefore, warrants special attention with accurate diagnosis and treatment. Percutaneous management using endoprosthesis is the method of choice, since the patients are usually elderly and have comorbidities that would increase the complication rates of traditional surgery. A 78-year-old woman complaining of thoracic pain was admitted to the hospital; her pain had been radiating to the interscapular and left lumbar regions for four months. Upon diagnostic investigation, a penetrating aortic ulcer was found, and after being successfully treated percutaneously with stent implantation, the patient became asymptomatic and is under outpatient follow-up.

The assessment and stratification of patients with chest pain in the emergency unit may indicate the appropriate therapy for each patient based on the probability of the presence of acute coronary artery disease and on the risk of its major cardiac events. That assessment is based on the triplet: clinical setting, electrocardiographic findings, and markers of myocardial lesion. We report the case of a 58-year-old male chagasic patient admitted to the emergency unit due to chest pain and palpitations, with an electrocardiogram showing sustained ventricular tachycardia and positive troponin measurement (0.99 ng/mL). The patient underwent cine coronary angiography, which evidenced no obstructive coronary artery disease.

Background: In lipoplasty, the ease of fat removal and appearance of aspirated fat may vary considerably, depending on which area of the body is being treated., Goal: Fat samples from areas of the body in which lipoplasty is commonly performed were subjected to morphohistologic analysis to gain a better understanding of the fat structure and its clinical implications., Methods: Subcutaneous cellular tissue from the back, promontory, love handles, buttocks, upper abdomen, lower abdomen, lateral thigh skin ("saddle bags"), anterior thigh, and inner thigh was removed from 10 fresh cadavers for macroscopic and microscopic analysis., Results: No differences were found in the deep layer of the subcutaneous cellular tissue from different areas with respect to the characteristics and size of fat globules. At the superficial layer, differences were found with respect to the size, shape, and alignment of the fat globules and the density of the surrounding collagen., Conclusion: When lipoplasty is performed, the morphohistologic characteristics of fat tissue in different body areas should be taken into consideration in determining the surgical approach that will achieve the most aesthetic result. (Aesthetic Surg J 2002;22:513-518.).