Sociedade Benef Israelitabras Hospital Albert Einstein

The diagnosis and treatment of hypertension rely on the accuracy of blood pressure (BP) measurements obtained both in and out of the office during awake and sleep periods.

To evaluate whether a home blood pressure monitoring (HBPM) protocol incorporating morning, afternoon, and evening measurements supports the assessment of blood pressure behaviour during sleep and enhances the diagnosis of hypertension.

This cross-sectional study included 40 patients (73% women; age = 62.0 ± 13.2 years) who underwent 24-h ambulatory blood pressure monitoring (ABPM) and (five-day HBPM) with measurements taken across three time periods. The association between the sleep-wake dip recorded by ABPM and the night-day difference measured by HBPM was examined. Additionally, the sensitivity, specificity, predictive values, concordance index, Kappa coefficient, and area under the ROC curve (AUC) of mean BP values obtained from HBPM were compared with those from ABPM.

Mean BP values obtained from HBPM were 126.2 ± 13.3/79.2 ± 9.1 mmHg, (daytime), 125.9 ± 16.4/78.7 ± 10.5 mmHg (evening), and 126.1 ± 14.3/78.9 ± 9.6 mmHg (total). For ABPM, mean values were 120.3 ± 12.5/74.5 ± 8.9 mmHg (awake), 116.5 ± 10.9/69.3 ± 8.0 mmHg (asleep), and 119.4 ± 11.4/73.4 ± 8.0 mmHg (total). Total HBPM outperformed daytime and evening HBPM in detecting abnormalities on ABPM (daytime, night-time, and 24 h), with higher sensitivity, negative predictive value (NPV), AUC, concordance index, and Kappa coefficient. The correlation between the day-night dip in ABPM and the night-day difference in HBPM was weak.

Including night-time measurements in the HBPM protocol improves the accuracy of hypertension diagnosis when compared to ABPM. However, the night-day BP difference captured by HBPM does not correspond to the day-night dip measured by ABPM.

Combining pretest probability (PTP) with computed tomography angiography (CTA) for diagnosing obstructive coronary artery disease (CAD) has not yet been determined.

The purpose of this study was to evaluate the accuracy of PTP calculation alone and with CTA for diagnosing CAD.

A total of 65 prospective diagnostic accuracy studies of patients clinically referred to invasive coronary angiography with stable chest pain were included in this international collaborative individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT) meta-analysis. Mixed-effects logistic regression with a data set-specific random intercept for clustering was applied to 4 models: the traditional Diamond-Forrester models, a PTP model based on the COME-CCT data (termed COME-CCT-PTP calculator), a CTA alone model, and a combined COME-CCT-PTP with CTA model.

Individual patient data from 5,332 patients with clinically indicated invasive coronary angiography from 22 countries were included. The COME-CCT-PTP calculator was more accurate than the original Diamond-Forrester model (AUC: 0.68; 95% CI: 0.66-0.69 vs 0.63; 95% CI: 0.62-0.65). The COME-CCT-PTP with CTA model significantly improved accuracy compared with either model alone (AUC: 0.86; 95% CI: 0.85-0.87 vs 0.81; 95% CI: 0.80-0.82). The improved prediction was consistent in decision curve analysis with an increased net benefit for all chest pain subtypes and was almost equally seen in patients with typical or atypical angina (0.85; 95% CI: 0.84-0.86) and nonanginal or other chest discomfort (0.88; 95% CI: 0.86-0.89).

Combining the COME-CCT-PTP calculator with CTA provides more accurate prediction than the PTP or CTA alone for the diagnosis of obstructive CAD, for all chest pain subtypes.

Esophageal resection, which is the primary treatment of esophageal cancer, is associated with a high risk of morbidity and often leads to significant postoperative pain. This study aimed to evaluate the effect of thoracic epidural analgesia (TEA) on pain management and postoperative outcomes in esophageal cancer surgery.

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (International Prospective Register of Systematic Reviews identification number: CRD42024501967), encompassing studies from the Embase, PubMed, Cochrane, and LILACS databases. Controlled trials and cohort studies comparing TEA with alternative anesthesia strategies, such as patient-controlled analgesia, were considered for inclusion. The outcomes were pain visual score, use of pain rescue medications, hospital stay, intensive care unit (ICU) stay, blood loss, extubation time, operation time, postoperative complications, severe complications, catheter-related complications, opioid-related sedation, mortality, anastomotic leak, pulmonary complications, reintubation, readmission, and vasoactive drug use.

A total of 15 studies with 16,146 patients were selected, consisting of 7 controlled trials, 7 retrospective cohorts, and 1 prospective cohort. TEA was associated with significant reductions in pain scores (mean difference [MD]: -0.83 [95% CI, -1.18 to -0.49]), length of stay (MD, -2.3 days [95% CI, -2.78 to -1.73]), extubation time (MD, -0.13 h [95% CI, -0.17 to -0.08]), severe postoperative complications (risk difference [RD], -0.05 patients [95% CI, -0.08 to -0.03]), anastomotic leakage (RD, -0.03 [95% CI, -0.04 to -0.01]), and pulmonary complications (RD, -0.10 patients [95% CI, -0.19 to -0.02]). The operation times were slightly longer in the TEA group (MD, 7.77 min [95% CI, 0.69-14.85]). TEA was associated with a higher risk of catheter-related complications (RD, 0.09 [95% CI, 0.01-0.17]) and higher use of vasoactive drugs (RD, 0.02 [95% CI, 0.00-0.04]). No significant differences were observed for ICU stay, blood loss, mortality, reintubation, readmission, opioid sedation, or use of rescue medication.

Our findings highlight TEA as an effective strategy for enhancing postoperative recovery in patients with esophageal cancer. TEA not only reduces pain scores but also improves postoperative surgical outcomes, including fewer complications, shorter extubation times, and reduced hospital stays.