Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort.

BACKGROUND AND PURPOSE: Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs. METHODS: This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments. RESULTS: In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication. CONCLUSIONS: Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.

Performance of ultra-low-dose CT for the evaluation of coronary calcification: a direct comparison with coronary calcium score.

AIM: To evaluate the diagnostic performance of ultra-low-dose computed tomography (ULDCT) in comparison to standard coronary calcium score (CCS) acquisition for the evaluation of coronary artery calcification (CAC). MATERIALS AND METHODS: Standard CCS acquisition and ULDCT were performed in patients referred for coronary CT angiography for the evaluation of coronary artery disease. CAC in ULDCT was graded subjectively using a four-point scale (from 0, no calcification, to 3, severe calcification) for the complete study and for each individual coronary segment. The summation of all individual coronary segment scores generated an ULDCT total CAC score. ULDCT results were compared to standard Agatston score and sensitivity and specificity of ULDCT were calculated. RESULTS: CCS and ULDCT were performed in 74 patients, with a mean DLP of 77.7 mGy·cm (±12.1) and 9.3 mGy·cm (±0.6), respectively (p<0.001). Coronary calcification was detected in 47 patients (63.5%) in standard CCS acquisition (median Agatston score of 41; interquartile range [IQR]:0263), in comparison to 42 patients (56.8%) in ULDCT (p<0.001). The sensitivity and specificity of the ULDCT total CAC score ≥1 was 80.9% and 85.2%, respectively, with an accuracy of 82.4%. The area under the receiver operating characteristic curve for the presence of CAC was 0.87. CONCLUSION: ULDCT shows good sensitivity, specificity, and overall accuracy for the detection of coronary calcification with a markedly lower radiation dose in comparison to CCS. ULDCT is unlikely to miss coronary calcification in individuals with at least moderate calcium load (Agatston score >100).

Educational program of organ donation and transplantation at medical school.

A favorable attitude of health professionals to organ donation can positively influence the decision of families of potential donors. By increasing health professionals knowledge about donation and transplantation and qualifying them to disseminate information, education has produced a positive response to increase the insufficient number of donors. Educating students early in their careers may become crucial in this setting. In order to supply the necessary information about the process of donation and transplantation, a medical school in association with the Hospital Transplant Coordination Department created an educational program of organ donation and transplantation. This course is intended for medical, biomedical, and nutrition students. The objective of our program is to supply basic knowledge about organ donation and transplantation to students of medicine, nutrition, and biomedicine and to enhance their commitment to this process. Each semester, 50 to 90 students are enrolled in the course, which involves a total of 25 hours. Various aspects are approached such as brain death, donor management, political and legal aspects of donation, and skin, lung, bone marrow, heart, pancreas, liver, and kidney transplantation. Between March 2006 and June 2007, three courses were carried out and 200 students were trained. The students evaluated the course and rated it as excellent, concluding that it contributed to their education. Their attitude toward organ donation and transplantation was strongly positive at the end of the course. This project aims to educate and stimulate students in the process of organ donation and transplantation and should be implemented in other medical schools.

Late outcome of unsupported annuloplasty for rheumatic mitral regurgitation.

OBJECTIVES: The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty. BACKGROUND: Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up. METHODS: One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support. RESULTS: The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years. CONCLUSIONS: Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.

Off-pump coronary artery bypass grafting does not reduce lymphocyte activation.

OBJECTIVE: In this study, we test the hypothesis that off-pump coronary bypass surgery might result in less lymphocyte activation than on-pump coronary surgery. We also study the behavior of lymphocyte activation markers during and after surgery. BACKGROUND: Coronary artery bypass surgery is known to be associated with changes of inflammatory mediators, immune function, and early phase lymphocyte activation, which could cause postoperative lymphopenia and lymphocyte unresponsiveness. METHODS: We studied lymphocyte activation response in 28 patients randomized to off-pump (n = 13) or on-pump (n = 15) coronary artery bypass surgery. Expression of CD25, CD26, CD69, and DR on T (CD3+) and B (CD19+) lymphocytes on peripheral blood was assessed through flow cytometry. RESULTS: The response of T lymphocytes and their activation markers, as well as B lymphocytes and their activation markers, was similar after on- and off-pump surgery. Overall, T lymphocytes decreased to the lowest level 9 h after surgery and tended to increase later. For B lymphocytes, there was early reduction with increase on the 1st postoperative day. There was early activation of CD69+ and late activation of CD25+ on T lymphocytes. For B lymphocytes, there was early activation of CD69+ and late activation of DR+. CONCLUSIONS: (1) Compared to on-pump cardiopulmonary bypass, off-pump surgery does not reduce lymphocyte activation. (2) Coronary bypass surgery causes the early activation of lymphocytes, as evidenced by the increased expression of lymphocyte activation markers.

Aprotinin in children undergoing correction of congenital heart defects. A double-blind pilot study.

Thirty children undergoing surgical repair for congenital heart defects were randomly selected for a double-blind study on the anti-hemorrhagic and blood-saving properties of aprotinin. The treatment group comprised 14 patients who received aprotinin 7 mg/kg of body weight until the end of perfusion. The placebo group (n = 16) received an infusion of the corresponding volumes of saline. Patients treated with aprotinin bled less during the operation (12.6 ml/kg versus 18.1 ml/kg, p = 0.25) and in the first 24 postoperative hours (chest drainage 12.1 ml/kg versus 17.7 ml/kg, p = 0.07). Hemoglobin loss into chest drainage was reduced in the treated group by half (0.66 versus 1.21 gm in 24 hours, p = 0.07). Fewer blood donors were needed during hospitalization by patients receiving aprotinin (1.07 versus 2.75 donors per patient, p = 0.04). Postoperative transfusion was unnecessary in 64.2% of patients receiving aprotinin compared with only 25% of the placebo group (p = 0.03). Aprotinin increased diuresis significantly during perfusion (4.3 ml/kg versus 1.0 ml/kg, p = 0.005). Other parameters are evaluated, and considerations are made regarding adequacy of the dosage regimen. The drug seems to be safe and easy to handle in children.

A new technique for repair of aortic coarctation. Subclavian flap aortoplasty with preservation of arterial blood flow to the left arm.

From February 1984 to March 1986, 28 patients underwent a new technique of coarctation repair. This technique consists of a complete mobilization of the left subclavian artery extended to the origin of its first branches. The aorta need not be extensively mobilized and the intercostal arteries are individually controlled with snares. After all the proper clamping, the left subclavian artery is detached from the aorta at its origin and is opened longitudinally on its posterior aspect. The anterior wall of the aorta is then incised, beginning with the opening at the origin of the left subclavian artery and extending distally to the descending aorta 12 to 15 mm past the coarctation. The coarctation membrane is excised and the ductus is ligated and divided. The opened left subclavian artery, now forming a flap, is pulled down and sutured to the edges of the aorta, widening the coarctation site and also preserving the blood flow to the left arm. The ages of the patients ranged from 2 months to 25 years (mean 4.24 +/- 4.9 years) and their weights ranged from 2.8 to 52 kg (mean: 14.8 +/- 10.0 kg). There were no hospital deaths and the mean follow-up was 9.6 months (+/- 4.9 months). Recatheterization of four patients from 4 to 12 months postoperatively showed adequate correction and strongly suggested normal growth of the aorta at the site of coarctation, as well as preservation of the blood flow through the left subclavian artery. Doppler measurements showed normal flow to the left arm and no gradients through the isthmic area. Our experience indicates that this technique is not only feasible but is the procedure of choice in most cases of discrete isthmic coarctation and in some cases of long narrowing of the isthmus in patients with a wide range of ages and weights.

Subannular aortic aneurysms in whites. Report of two cases and review of literature.

Subannular aortic aneurysms are a rare entity occurring predominantly in young black men. Five white patients have been reported who underwent surgical correction, but long-term survival occurred in only two. We report two white men, 36 and 45 years old, who survived aortic valve replacement and direct suture of subannular aneurysms, with no symptoms at 29 and 42 postoperative months.

Brain dopamine receptor plasticity: testing a diathesis-stress hypothesis in an animal model.

A wealth of clinical data supports a major role of genetic liability as well as of altered brain dopamine (DA) functioning in different types of behavioural disturbances. Genetic influence on behaviour involves multiple genes, rather than one or two major genes, as well as non-genetic sources of variance. Thus, in recent years, increasing attention has been devoted to the involvement of stressful experiences (life events) in the development and expression of psychopathology. Moreover, a diathesis-stress hypothesis has been proposed, which suggests that the environmental factors (stress) are not specific for a given pathology, whereas genetic factors (diathesis) are. Results obtained in an animal model offer support to this hypothesis. Indeed, mice of the C57BL/6 and DBA/2 inbred strains are equally susceptible to stress but develop different behavioural disturbances related to different alterations of brain DA receptors. Moreover, quantitative trait loci (QTL) associations in the C57 (B) x DBA (D) recombinant inbred (RI) strains indicate a number of provisional QTLs influencing the behavioural effect of stress. Finally, the results of this analysis suggest the involvement of regulatory factors related to stress response and neural or synaptic plasticity in the control of brain DA receptor plasticity.

A new valve retractor for mitral valve procedures.

Optimal exposure greatly facilitates reconstructive mitral valve procedures. We describe an effective method for exposing this valve using a specially designed mitral valve retractor. This technique proved useful in 321 patients who underwent operation on the mitral valve.

Side-to-side carotid-subclavian anastomosis for interrupted aortic arch.

A simple technique is proposed for restoring aortic flow in an interrupted aortic arch simulating a type B interruption that does not require aortic cross-clamping, circulatory arrest, or the ligation of major aortic branches. Side-to-side anastomosis between the left carotid and subclavian arteries together with division of the ductus arteriosus and pulmonary artery banding proved effective for relieving aortic arch stricture in that location.

Surgical treatment of annuloaortic ectasia with composite grafts including homologous dura mater valves.

We describe 3 patients in whom a composite dura mater valve-Dacron tube graft was used for replacement of the entire ascending aorta and aortic valve. Two patients had Marfan's syndrome and 1, a chronic aortic dissection, type II. All had severe aortic regurgitation. There were no early or late deaths in a follow-up period of 2, 7, and 12 months, respectively. All 3 patients were asymptomatic when last seen. Two underwent postoperative aortography that disclosed well-functioning valves and good filling of the coronary arteries. It is concluded that annuloaortic ectasia is best treated by the technique of total replacement of the ascending aorta and aortic valve by a composite valve-tube graft, and that the homologous dura mater valve, for its characteristics of central flow, lack of need for anticoagulants, and durability, represents a reasonable alternative for use in this situation.

New needle for catheter introduction in left atrium.

We describe a new needle for left atrial catheter introduction. It allows catheter introduction through the right superior pulmonary vein or through the interatrial septum. Used in 32 patients (adults and children), the device proved to be highly efficient, simple, and safe.

Technical considerations for partial left ventriculectomy (Batista operation).

The surgical technique for partial left ventriculectomy (Batista operation) as performed in two surgical centers is described. This surgical remodeling of the left ventricle restores the abnormal geometric configuration produced by the dilated failing heart. It accomplishes a reduction of the left ventricular end-diastolic diameter and end-diastolic volume with consequent increase in left ventricular function. This procedure represents the newest surgical approach in the management of patients with end-stage cardiomyopathy; it can be used as a bridge to transplantation or perhaps as a definitive form of therapy, particularly in those patients in whom heart transplantation is contraindicated. This report describes technical guidelines to avoid serious intraoperative and postoperative complications directly associated with this technique.

Surgical repair of ventricular aneurysms. Early results with Cooley's technique.

Using bovine pericardium instead of Dacron for grafting, we performed ventricular endoaneurysmorrhaphy (Cooley's technique) in 13 patients with postmyocardial infarction left ventricular aneurysm. Twelve patients were men and 1 was a woman; their ages ranged from 38 to 67 years (mean, 51.2 +/- 11.4 years). Eight patients had large anterolateral aneurysms, 4 had apical aneurysms, and 1 had a false inferior aneurysm. Postoperatively, the mean cardiac index increased from 2.07 +/- 0.50 to 3.09 +/- 0.99 L/min/m2 (p < 0.05), with a mean percentage increase of 50.17% +/- 37.03%. No patient required postoperative mechanical circulatory assistance, and pharmacologic support could be withdrawn soon after surgery. All patients had uncomplicated recoveries and were asymptomatic upon discharge, at a mean time of 9.0 +/- 2.3 days after surgery. We conclude that ventricular endoaneurysmorrhaphy provides excellent initial results, and we believe, through subjective analysis of ventriculograms, that the use of bovine pericardium for grafting produces better functional results than does the use of Dacron.

[Technology and algorithms for implantable dual chamber defibrillators]. / Technologie und Algorithmen für implantierbare Zweikammer-Defibrillatoren.

The next generation of implantable cardioverter/defibrillators (ICDs) will have the capability for sensing and defibrillating in both chambers of the heart. These devices, which are presently being developed, will thus be able to differentiate between ventricular and supraventricular tachycardias, and to respond accordingly. The burden of stress on the patient will therefore also be further reduced by avoiding unnecessary shock treatment of supraventricular tachycardias. In addition, the new generation of ICDs can also be used for the treatment of chronic atrial tachyarrhythmias. With the dual-chamber IEGM-recording capability, these ICDs will also provide the physician with an important diagnostic tool. The present article describes such an ICD.

[Evaluation of an indirect hemagglutination test for the serodiagnosis of amebiasis]. / Evaluation d'un test d'hémagglutination indirecte amibiase (HAI) pour le serodiagnostic de l'amibiase.

167 sera have been tested to appreciate the value of an indirect hemagglutination test (Amibiase HAI FUMOUZE) comparatively to an agglutination test of sensibilized particles of latex (Bichro latex Amibe Fumouze BLA) Amibiase HAI test comes out as sensitive and specific for the detection of antibodies in patients suffering from visceral amoebiasis. But some antibodies are also detected in patients with an antecedent of amoebiasis, as it is usually the case with some other techniques. A high positivity of the indirect hemagglutination test, and the concordance between the test HAI and the BLA one are in favour of a visceral amoebiasis. While lower rates or discrepancy between the two tests may evoke an hidden infestation in patients coming out or originated from endemic zones.

[Involvement of pulmonary function in patients treated with rotated chest muscle flap surgery for the treatment of sternal wound complications after heart surgery]. / Comprometimento da função pulmonar em pacientes submetidos à cirurgia de rotação de retalho do músculo peitoral para correção de complicações do esterno pós-cirurgia cardíaca.

PURPOSE: To evaluate pulmonary function of patients submitted to muscle flap for treatment of mediastinitis. METHODS: Fifteen patients operated with the muscle flap technique were compared with 26 consecutive patients submitted to heart surgery with extracorporeal circulation, that did not present wound complications. Both groups were evaluated for age, sex, body weight, height, surgery, forced vital capacity (FVC), forced expiratory volume in first second (FEV1) and the relation (FEV1/FVC) in absolute and percentual values, espirometry conclusions and clinical evidences of lung disease. RESULTS: There was no statistical difference between preoperative and postoperative period for FVC (p = 0.98), FEV1 (p = 0.68) and FEV1/FVC (p = 0.30) in the group with no sternal complications. In the control group, the median of FVC was 3907 +/- 1053.25 and in the study group was 2818 +/- 766.86 in absolute values (p = 0.0015). The median of FEV1, in the control group, was 2995 +/- 855.68 and in the study group was 2232 +/- 617.68 in absolute values (p = 0.0046). There was statistical difference, between groups, in FVC (104.78 +/- 21.73 and 82.04 +/- 21.16) and FEV1 (99 +/- 22.67 and 79.04 +/- 19.17) in percentual (p = 0.0026 and 0.0067) values. There was no statistical difference for the ratio FEV1/FVC. The study group had five patients diagnosed as having restrictive ventilatory insufficiency by espirometry against none in the control group (p = 0.0031). CONCLUSION: Patients with infectious complications of sternum and mediastinum, treated surgically with muscle flap rotation may present restrictive pulmonary insufficiency in moderate degree, that must be considered in this situation.

[The use of a rate-responsive pacemaker after heart transplantation]. / Uso de marcapasso com resposta de freqüência após transplante cardíaco.

PURPOSE: The indications and the results of pacemaker implant following orthotopic cardiac transplantation. METHODS: Four patients implanted a cardiac pacemaker (PM) in the early post-operative period (PO) of orthotopic cardiac transplantation (from 10th to 16th PO day). The patients were 33 to 55 year-old and the indications to PM were supraventricular arrhythmia (atrial fibrillation or flutter) associated with atrioventricular block in three, and complete atrioventricular block in one patient. Previous to PM implant, patients were submitted to endomyocardial biopsy, which was normal in two patients, evidenced mild rejection in one and moderate rejection in the remaining. A ventricular rate responsive pacemaker was implanted in all patients, with sensors responsive to muscular activity in one patient, and to minute ventilation in three. RESULTS: One patient died in the 20th PO due to acute allograft rejection not controlled by immunosuppressive drugs. Three other patients had satisfactory evolution and the pacemakers were programmed during exercise testing, previous to hospital discharge. Recent evaluation revealed that these patients are in good clinical condition at the 6th, 14th and 24th PO months. Adequate pacemaker function was insured by exercise testing and ambulatory electrocardiographic recording. CONCLUSION: A ventricular rate responsive pacemaker represented a satisfactory mode of pacing, in patients with severe bradycardia, following heart transplantation.

[Hospital risk factors in subclavian-pulmonary anastomosis with polytetrafluoroethylene graft]. / Fatores de risco hospitalar na anastomose subclávia-pulmonar com enxerto de politetrafluoretileno.

PURPOSE: Identification of risk factors for mortality in subclavian-pulmonary anastomosis using polytetrafluorethylene (PTFE). PATIENT AND METHODS: Immediate surgical results (30 days) were analyzed in 180 cyanotic patients consecutively operated on from september 1979 to march 1989. RESULTS: The hospital mortality was 12.7% (23 patients) and age at surgery, low weight (less than 3 kg) and preoperative diagnosis were considered risk factors for mortality. Pulmonary artery diameter at echocardiography, date of surgery and diameter of the conduits were associated with increased risk, but this association lacked statistical significance. Sex and previous palliative surgery have not increased hospital mortality. CONCLUSION: We believe that identification of risk factors to PTFE conduit implant plays an important role in the preoperative management of those patients in order to obtain better results in this life saving procedure.