Introduction New oral anticoagulants (NOACs) are approved for use in nonvalvular atrial fibrillation (AF). Objectives This study aimed to evaluate the efficacy and safety of NOACs compared with warfarin in AF and valvular heart disease (VHD). Methods We identified randomized controlled trials (RCTs) and post-hoc analyses comparing NOACs and warfarin in AF and VHD, including biological and mechanical heart valves (MHV). Through systematic review and meta-analysis, with the aid of the “Rev Man” program 5.3, the primary effectiveness endpoints were stroke and systemic embolism (SE). The primary safety outcome was major bleeding, and the secondary outcome included intracranial hemorrhage. Data were analyzed using risk ratios (RRs) and 95% confidence intervals (CIs), and heterogeneity was assessed using the I 2 statistic. Results Six RCTs were included, involving 13,850 patients with AF and VHD. NOACs significantly reduced the risk of stroke/SE (RR 0.78; 95% CI 0.66–0.91; P = 0.002) and intracranial hemorrhage (RR 0.51; 95% CI 0.33–0.79; P = 0.003) and lowered the risk of major bleeding (RR 0.77; 95% CI 0.58–1.02; P = 0.07) compared with warfarin. Conclusions The efficacy and safety of NOACs as thromboprophylaxis for AF and VHD are similar to those of warfarin. Electronic supplementary material The online version of this article (10.1007/s40268-019-0274-z) contains supplementary material, which is available to authorized users.

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IntroductionMechanical heart valves (MHV) are extremely durable, but they require permanent use of anticoagulation to prevent thromboembolic events. The only approved therapeutic options are vitamin K antagonists (VKAs), such as warfarin. As a drug class, clinical management is difficult, therefore new alternatives need to be evaluated.MethodsRIWA is a phase II/III, prospective, open-label, randomized, pilot study designed to investigate oral rivaroxaban 15 mg twice daily compared with dose-adjusted warfarin for the prevention of stroke (ischemic or hemorrhagic) and systemic embolism in patients with MHV, from August 2018 to December 2019. Patients will undergo transesophageal echocardiography at the beginning and the end of the study (follow-up time 90 days). On an explanatory basis, all events will be analyzed, including stroke, peripheral systemic embolism, valve thrombosis, significant bleeding and death.DiscussionWarfarin and similar VKAs are standard therapy for patients with an MHV. Even with the appropriate use of therapy, the incidence of thromboembolic events is high at 1–4% per year. Furthermore, bleeding risk is significant, ranging from 2 to 9% per year. The new frontier to be overcome in relation to use of the new oral anticoagulants is undoubtedly in patients with MHV. A significant portion of people with MHV worldwide will benefit if noninferiority of these new agents is confirmed.Trial RegistrationClinicalTrials.gov identifier: NCT03566303. Recruitment Status: Recruiting. First Posted: 25 June 2018. Last Update Posted: 25 June 2018.

Patients undergoing hemodialysis are at an increased risk for bloodstream infections (BSIs). Infection usually occurs because of contamination of water supply, water treatment, distribution systems, or reprocessing dialyzers. Here, we report an outbreak of BSIs caused by Stenotrophomonas maltophilia (n = 21) and Burkholderia cepacia (n = 22) among dialyzed patients at a large hemodialysis center in Brazil. Overall, three patients died (7%), two of which had bacteremia caused by S. maltophilia and the other had a B. cepacia infection. We collected water samples from different points of the hemodialysis system for culture and typing. Genetic patterns were identified through PCR-RAPD and pulsed-field gel electrophoresis. The same genotypes of S. maltophilia and B. cepacia recovered from blood cultures were found in dialysis water. Also, multiple genetic profiles were identified among water isolates, suggesting heavy contamination. Bacteremia cases persisted even after implementing standard control measures, which led us to believe that the piping system was contaminated with microbial biofilms. Soon after we changed the entire plumbing system, reported cases dropped back to the number typically expected, and the outbreak came to an end.

Reduction of the BMI allows for an increased interincisor gap, thyromental distance, and reduction in neck circumference. Mallampati classification remains the same.

OBJETIVO: Avaliar prospectivamente a função pulmonar de pacientes submetidas à mastoplastia redutora. MÉTODOS: Doze pacientes femininas portadoras de gigantomastia e sem antecedentes médicos, realizaram mastoplastia redutora no Hospital das Clínicas da UFBA. As pacientes foram submetidas ao teste de função pulmonar e medidas de gases sanguíneos arteriais nos períodos pré-operatório e pós-operatório (três a seis meses). Os dados obtidos foram analisados por meio do teste de Wilcoxon e o nível de significância estatística foi p< 0,05. RESULTADOS: Nos dados obtidos por intermédio dos testes de função pulmonar, a capacidade pulmonar total e o volume residual foram maiores no pós-operatório (p < 0,05). Quanto aos dados de gases arteriais, não houve variações estatisticamente significantes. CONCLUSÃO: O aumento da capacidade pulmonar total e volume residual podem sugerir uma melhor função pulmonar após mastoplastia redutora em gigantomastia, apesar de não alterarem os gases arteriais das pacientes saudáveis.

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