Persistencia del cavum septum pellucidum y cavum vergae asociado a retraso psicomotor. Informe de caso

Fundamento: Dos de las tres formas en que se presentan los quistes intracraneales de la línea media anterior son: cavum septum pellucidum y cavum vergae; estos normalmente desaparecen después del nacimiento, de persistir suelen ser asintomáticos, pero también pueden estar asociados a manifestaciones obstructivas, trastornos psicóticos o alteraciones del neurodesarrollo que demandan de un seguimiento clínico. Objetivo: Reportar el caso de un paciente de 6 meses con persistencia de estructuras del periodo embrionario en posible asociación con retraso del desarrollo psicomotor. Presentación de caso: Por lo infrecuente que resulta en la práctica, se informa el caso de un paciente de 6 meses con una persistencia del cavum septum pellucidum y cavum vergae en el que se destaca la posible asociación del retraso del neurodesarrollo a la persistencia de estas estructuras. El diagnóstico se realizó de forma precoz y se intervino oportunamente. Conclusiones: La presentación del caso aportó evidencias epidemiológicas que favorecen la posible asociación entre la persistencia de estas estructuras embrionarias y el retraso del desarrollo psicomotor.

Background: Two out of the three forms in which intracranial anterior midline cysts present are: These usually disappear after birth; if they persist, they are often asymptomatic, but may also be associated with obstructive manifestations, psychotic disorders or neurodevelopmental disorders that require clinical follow up. Objective: To report a case of a 6-month-old patient with persistence of embryonic period structures in possible association with psychomotor developmental retardation. Case presentation: Because of how infrequent it is in practice, a case of a 6-month-old patient with a persistent cavum septum pellucidum and cavum vergae is reported in which the possible association of neurodevelopmental delay with the persistence of these structures is pointed out. The diagnosis was made in an early manner and it was timely intervened. Conclusions: The case presentation provided epidemiological evidences that encourage the possible association among the persistence of these embryonic structures and psychomotor developmental retardation.

Implementation of an Acute Coronary Syndrome Simulation Training Strategy for Emergency Healthcare Professionals

The knowledge on the management of patients with acute coronary syndrome (ACS) is essential to reduce the gap between evidence and practice. Objective: To describe a simulation training strategy for emergency healthcare professionals and provide preliminary data on knowledge acquisition, learners' confidence and prescription of medications after training. Methods: The training was part of the implementation of two myocardial infarction systems of care. It comprehended lectures and simulation-based learning using high and low-fidelity mannequins and actors. It was tested in two phases: the first one in Belo Horizonte and the second one in Montes Claros, both in the state of Minas Gerais. A test was applied before and after training to assess knowledge acquisition. Confidence to perform thrombolysis in ST-elevation myocardial infarction (STEMI) patients was assessed using a questionnaire, and the impact on medication prescription analyzed STEMI patients admitted to hospitals in Montes Claros. Results: In the first phase, 156 professionals answered both tests: 70% of them improved their results and the median number of right answers increased (6, interquartile range [IQR] 5-7; vs 7 ([IQR] 6-9; p < 0.05). In the second phase, 242 professionals answered both tests: 58% of the physicians and 83% of the nurses obtained better test scores. Participants referred a positive impact on their clinical practice, 95% reported feeling very secure when perform fibrinolysis after the training, and there was also an impact on medication prescription. Conclusions: There was an impact on the learners' knowledge acquisition and confidence using our two-phase training model, with evidence of impact on performance

Adiponectin in Relation to Coronary Plaque Characteristics on Radiofrequency Intravascular Ultrasound and Cardiovascular Outcome / Relação da Adiponectina com as Características da Placa Aterosclerótica ao Ultrassom Intravascular com Radiofrequência e Desfechos Cardiovasculares

Abstract Background: Prospective data on the associations of adiponectin with in-vivo measurements of degree, phenotype and vulnerability of coronary atherosclerosis are currently lacking. Objective: To investigate the association of plasma adiponectin with virtual histology intravascular ultrasound (VH-IVUS)-derived measures of atherosclerosis and with major adverse cardiac events (MACE) in patients with established coronary artery disease. Methods: In 2008-2011, VH-IVUS of a non-culprit non-stenotic coronary segment was performed in 581 patients undergoing coronary angiography for acute coronary syndrome (ACS, n = 318) or stable angina pectoris (SAP, n = 263) from the atherosclerosis-intravascular ultrasound (ATHEROREMO-IVUS) study. Blood was sampled prior to coronary angiography. Coronary plaque burden, tissue composition, high-risk lesions, including VH-IVUS-derived thin-cap fibroatheroma (TCFA), were assessed. All-cause mortality, ACS, unplanned coronary revascularization were registered during a 1-year-follow-up. All statistical tests were two-tailed and p-values < 0.05 were considered statistically significant. Results: In the full cohort, adiponectin levels were not associated with plaque burden, nor with the various VH-tissue types. In SAP patients, adiponectin levels (median[IQR]: 2.9(1.9-3.9) µg/mL) were positively associated with VH-IVUS derived TCFA lesions, (OR[95%CI]: 1.78[1.06-3.00], p = 0.030), and inversely associated with lesions with minimal luminal area (MLA) ≤ 4.0 mm2 (OR[95%CI]: 0.55[0.32-0.92], p = 0.025). In ACS patients, adiponectin levels (median[IQR]: 2.9 [1.8-4.1] µg/mL)were not associated with plaque burden, nor with tissue components. Positive association of adiponectin with death was present in the full cohort (HR[95%CI]: 2.52[1.02-6.23], p = 0.045) and (borderline) in SAP patients (HR[95%CI]: 8.48[0.92-78.0], p = 0.058). In ACS patients, this association lost statistical significance after multivariable adjustment (HR[95%CI]: 1.87[0.67-5.19], p = 0.23). Conclusion: In the full cohort, adiponectin levels were associated with death but not with VH-IVUS atherosclerosis measures. In SAP patients, adiponectin levels were associated with VH-IVUS-derived TCFA lesions. Altogether, substantial role for adiponectin in plaque vulnerability remains unconfirmed.

Resumo Fundamento: Faltam dados prospectivos sobre as associações de adiponectina com medidas in-vivo de grau, fenótipo e vulnerabilidade da aterosclerose coronariana. Objetivo: Investigar a associação da adiponectina plasmática com medidas de aterosclerose derivadas de ultrassonografia virtual intravascular (VH-IVUS) e eventos cardíacos adversos importantes (major adverse cardiac events - MACE) em pacientes com doença arterial coronariana estabelecida. Métodos: Em 2008-2011, a VH-IVUS de um segmento coronariano não estenótico não culpado foi realizado em 581 pacientes submetidos à angiografia coronariana para síndrome coronariana aguda (SCA, n = 318) ou angina pectoris estável (APE, n = 263) a partir do estudo de ultrassonografia aterosclerótica-intravascular (ATHEROREMO-IVUS). Sangue foi amostrado antes da angiografia coronária. Foram avaliados a carga de placa coronária, a composição tecidual, as lesões de alto risco, incluindo fibroateroma de capa fina (FCF) derivado de VH-IVUS. Mortalidade por todas as causas, SCA, e revascularização coronária não planejada foram registradas durante um ano de acompanhamento. Todos os testes estatísticos foram bicaudais e os valores de p < 0,05 foram considerados estatisticamente significativos. Resultados: Na coorte completa, os níveis de adiponectina não foram associados à carga de placa, nem a vários tipos de tecido virtual histológico. Entre os pacientes com APE, os níveis de adiponectina (mediana[IIQ]: 2,9(1,9-3,9) µg/mL) foram associados positivamente às lesões FCF derivadas de VH-IVUS, (OR[IC 95%]: 1,78[1,06-3,00], p = 0,030), e inversamente associados a lesões com área luminal mínima (ALM) ≤4,0 mm2 (OR[IC 95%]: 0,55[0,32-0,92], p = 0,025). Em pacientes com SCA, os níveis de adiponectina (mediana[IIQ]: 2,9 [1,8-4,1] µg/mL) não foram associados à carga de placa nem a componentes teciduais. A associação positive de adiponectina ao óbito esteve presente na coorte completa (HR[IC 95%]: 2,52[1,02-6,23], p = 0,045) e (limítrofe) em pacientes com APE (HR[IC 95%]: 8,48[0,92-78,0], p = 0,058). Entre pacientes com SCA, essa associação perdeu significância estatística após ajuste multivariado (HR[IC 95%]: 1,87[0,67-5,19], p = 0,23). Conclusão: Na coorte completa, os níveis de adiponectina foram associados à obito, mas não a medidas de aterosclerose por VH-IVUS. Em pacientes com APE, os níveis de adiponectina foram associados a lesões FCF derivadas de VH-IVUS. Em geral, o papel da adiponectina na vulnerabilidade da placa permanece não confirmado.

Satisfaction of Emergency Physicians with the Care Provided to Patients with Cardiovascular Diseases in the Northern Region of Minas Gerais / Satisfação de Médicos dos Serviços de Urgência com o Cuidado às Doenças Cardiovasculares na Região Ampliada Norte de Minas Gerais

Abstract Background: The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. Objective: To assess physicians' satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. Methods: This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. Results: Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. Conclusion: This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Resumo Fundamentos: A insatisfação dos profissionais de saúde dos serviços de urgência tem influência negativa na qualidade do cuidado ao infarto agudo do miocárdio (IAM) e na fixação desses profissionais. Objetivo: Avaliar a satisfação de médicos com a estrutura de atendimento e diagnóstico de serviços públicos de urgência na Região Ampliada Norte de Minas Gerais, previamente à implantação da linha de cuidado ao IAM. Métodos: Estudo transversal, que incluiu médicos das unidades de emergência do SAMU e de hospitais regionais nível II, III e IV. Foi avaliada a satisfação usando a escala CARDIOSATIS-Team. O escore mediano para cada item, a escala global e os domínios foram calculados e então comparados por grupos, utilizando o teste não paramétrico de Mann-Whitney. Foi avaliada a correlação entre tempo de formação e nível de satisfação com o método de Spearman. Um valor-p < 0,05 foi considerado significativo. Resultados: De 137 médicos incluídos, 46% trabalhavam no SAMU. A maior parte dos entrevistados demonstrou insatisfação geral com a estrutura de atendimento, cuja mediana da escala global foi 2,0 (intervalo interquartil [IQ] 2,0-4,0). A maioria dos médicos do SAMU demonstrou-se insatisfeita quanto a atendimento prestado (54%), estrutura para condução das doenças cardiovasculares (52%) e tecnologia disponível para diagnóstico (54%). Na avaliação da satisfação global, evidenciou-se que a insatisfação dos médicos do SAMU foi menor quando comparada à dos médicos de urgência hospitalar. Os médicos de hospitais nível III/IV demonstraram maior satisfação global quando comparados aos de hospitais nível II. Conclusão: Este estudo demonstrou insatisfação geral dos médicos dos serviços de urgência na região em relação à estrutura de atendimento às emergências cardiovasculares.

Primary cardiac angiosarcoma: case report of a rare neoplasia / Angiossarcoma cardíaco primário: relato de caso de uma rara neoplasia

ABSTRACT This article reports a case of primary cardiac angiosarcoma and a brief review is provided. A 44-year-old male patient was suspected of having myxoma in the right atrium. The tumor, on pathology examination, was shown to be a cardiac angiosarcoma. In the postoperative period, the patient developed a cardiac tamponade, requiring reoperation and evolving to death. Angiosarcomas are malignant tumors characterized by a devastating clinical course. They have a predilection for the right atrium, occurring between the third and fifth decades of life, with a male preponderance. Because of its rarity, the ideal treatment has not been identified yet.

RESUMO Este artigo ilustra um caso de angiossarcoma primário cardíaco acompanhado de uma revisão dessa rara neoplasia. Relatamos o caso de um paciente do sexo masculino, 44 anos, com suspeita de mixoma em átrio direito. O tumor, ao exame anatomopatológico, mostrou tratar-se de um angiossarcoma cardíaco. No pós-operatório, o paciente cursou com tamponamento cardíaco, necessitando ser reoperado e evoluindo a óbito. Angiossarcomas são tumores malignos caracterizados por curso clínico devastador. Apresentam predileção pelo átrio direito, e ocorrem entre a terceira e a quinta década de vida, com preponderância no sexo masculino. Devido a sua raridade, o tratamento ideal ainda não está bem estabelecido.

Epidemiological Profile and Quality Indicators in Patients with Acute Coronary Syndrome in Northern Minas Gerais - Minas Telecardio 2 Project / Perfil Epidemiológico e Indicadores de Qualidade em Pacientes com Síndrome Coronariana Aguda na Região Norte de Minas Gerais - Projeto Minas Telecardio 2

Abstract Background: Coronary artery disease is the main cause of death in Brazil. In the Brazilian public health system, the in-hospital mortality associated with acute myocardial infarction is high. The Minas Telecardio 2 Project (Projeto Minas Telecardio 2) aims at implementing a myocardial infarction system of care in the Northern Region of Minas Gerais (MG) to decrease hospital morbidity and mortality. The aim of this study was to describe the profile of the patients with acute coronary syndrome (ACS) cared for in the period that preceded the implementation of the system of care. Methods: Observational, prospective study of patients with ACS admitted between June 2013 and March 2014 to six emergency departments in Montes Claros, MG, and followed up until hospital discharge. Results: During the study period, 593 patients were admitted with a diagnosis of ACS (mean age 63 ± 12 years, 67.6% men), including 306 (51.6%) cases of unstable angina, 214 (36.0%) of ST-elevation myocardial infarction (STEMI), and 73 (12.3%) of non-ST-elevation myocardial infarction (NSTEMI). The total STEMI mortality was 21%, and the in-hospital mortality was 17.2%. In the STEMI patients, 46,0% underwent reperfusion therapy, including primary angioplasty in 88 and thrombolysis in six. Overall, aspirin was administered to 95.1% of the patients within 24 hours and to 93.5% at discharge, a P2Y12 inhibitor was administered to 88.7% participants within 24 hours and to 75.1% at discharge. A total of 73.1% patients received heparin within 24 hours. Conclusion: We observed a low reperfusion rate in patients with STEMI and limited adherence to the recommended ACS treatment in the Northern Region of MG. These observations enable opportunities to improve health care.

Resumo Fundamento: A doença coronariana é a principal causa de morte no Brasil. No sistema público de saúde brasileiro, a mortalidade hospitalar por infarto agudo do miocárdio é elevada. O Projeto Minas Telecardio 2 tem o objetivo de implantar a linha de cuidado do infarto na Região Ampliada Norte de Minas Gerais (MG), com vistas à redução da morbimortalidade hospitalar. O objetivo deste estudo foi descrever o perfil dos casos de síndrome coronariana aguda (SCA) atendidos no período que precedeu à implantação do programa. Métodos: Estudo prospectivo observacional dos pacientes com SCA admitidos entre junho de 2013 e março de 2014 nas seis portas de entrada de urgência de Montes Claros e acompanhados até a alta hospitalar. Resultados: No período do estudo, 593 pacientes foram admitidos com SCA (idade média 63 ± 12 anos, 67,6% homens), com 306 (51,6%) casos de angina instável, 214 (36,0%) de infarto com supradesnivelamento do ST (IAMCSST) e 73 (12,3%) com infarto sem supradesnivelamento do ST (IAMSSST). A mortalidade total para IAMCSST foi 21% e a intra-hospitalar foi de 17,2%. Nos pacientes com IAMCSST, 46,0% foram submetidos a terapia de reperfusão, com 88 angioplastias primárias e seis trombólises. AAS foi administrado a 95,1% dos pacientes nas primeiras 24 horas e a 93,5% na alta, inibidores do P2Y12 foram administrados a 88,7% dos participantes nas primeiras 24 horas e a 75,1% na alta. Ao todo, 73,1% receberam heparina nas primeiras 24 horas. Conclusão: Foram observadas baixa taxa de reperfusão em pacientes com IAMCSST e adesão limitada aos tratamentos preconizados para abordagem da SCA na Região Ampliada Norte de MG. Estas observações possibilitam oportunidades para melhoria do cuidado em saúde.

One Million Electrocardiograms of Primary Care Patients: A Descriptive Analysis.

In 722 cities of Minas Gerais (Brazil), primary care patients can have their ECGs remotely interpreted by cardiologists of the Telehealth Network of Minas Gerais (TNMG), a public telehealth service. As of December 2014, more than 1.9 million ECGs were interpreted. This study analyzed the database of all ECGs performed by the TNMG on primary care patients from 2009 to 2013 (n=1,101,993). Structured patient data and the results of automated ECG interpretation by the Glasgow Program are described. Mean patient age is 51 years old, 59% of them are women. The average body mass index is 25.9 kg/m2, with an average increase of 0.15 kg/m2 per civil year. Those patients notably have hypertension (33.2%), family history of coronary artery disease (14.5%), smoking (6.9%), diabetes (5.8%), obesity (5.8%) or Chagas Disease (3.0%). Seventy percent of ECGs are normal. This percentage is higher in women (72.3%) and decreases in average by 7.4 every 10 years of life. There are notably 12% of possible myocardial infarction, 10% of possible left ventricular hypertrophy and 8% of possible supraventricular extra systole.

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes / Reestenose Clínica de Stent Coronariano: Seguimento após Tratamento com Análise de Desfechos Clínicos

Background: Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation. Objective: Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment. Methods: We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year. Results: Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44–12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53–44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75–9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35–29.38]; p = 0.019) emerged as predictors of a secondary outcome. Conclusion: Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up. .

Fundamento: A Reestenose Intrastent Clínica (RISC) é a principal limitação da angioplastia coronariana com implante de stent. Objetivo: Descrever as características clínicas e angiográficas da RISC e os desfechos em seguimento de pelo menos doze meses após seu diagnóstico e tratamento. Métodos: Em 110 pacientes consecutivos com RISC, analisaram-se a apresentação clínica, as características angiográficas, o tratamento e os desfechos primário combinado (morte cardiovascular, Infarto Agudo Miocárdio não fatal [IAM]) e secundário combinado (angina instável com internação, revascularização de vaso alvo e lesão alvo) em seguimento mínimo de um ano. Resultados: A média de idade da amostra foi de 61 ± 11 anos (68,2% do sexo masculino). A apresentação clínica foi como Síndrome Coronariana Aguda (SCA) em 62,7%, com RIS proliferativa em 34,5% dos casos. O tratamento realizado foi o implante de Stent Farmacológico (SF) em 36,4%; de Stent Não Farmacológico (SNF) em 23,6%; cirurgia de revascularização em 18,2%; angioplastia por balão em 15,5%; e tratamento clínico em 6,4%. Com seguimento mediano de 19,7 meses, o desfecho primário ocorreu em 18 pacientes, com seis (5,5%) óbitos e 13 (11,8%) IAM, e o secundário em 24 pacientes. Foram preditores de desfecho primário a RISC em SF (HR = 4,36; [1,44 - 12,85], p = 0,009) e o tratamento clínico da RISC (HR = 10,66, [2,53 - 44,87], p = 0,001). O tratamento da RISC com SNF (HR = 4,08 [1,75 - 9,48], p = 0,001) e tratamento clínico (HR = 6,29 [1,35 - 29,38], p = 0,019) foram preditores do desfecho secundário. Conclusão: A RISC se apresenta como SCA na maioria dos casos e os pacientes apresentam elevada frequência de eventos adversos durante o seguimento de médio prazo. .

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes.

BACKGROUND: Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation. OBJECTIVE: Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment. METHODS: We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year. RESULTS: Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44-12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53-44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75-9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35-29.38]; p = 0.019) emerged as predictors of a secondary outcome. CONCLUSION: Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up.

Análise dos casos de endocardite infecciosa em um hospital terciário / Analysis of infectious endocarditis cases in a tertiary hospital

Introdução e objetivos: a endocardite infecciosa (EI) é uma doença com alta morbimortalidade, apesar do aprimoramento do diagnóstico e da terapia antimicrobiana. A identificação precoce de pacientes com alto risco de morte ou complicações pode melhorar o desfecho dessa doença. O objetivo foi analisar os casos de EI em um hospital terciário e seus desfechos intra-hospitalares. Pacientes e métodos: analisados retrospectivamente 93 episódios confirmados de EI, em 91 pct, no período de janeiro de 2001 a dezembro de 2008. As variáveis analisadas foram: dados clínicos, infecciosos, modalidade terapêutica e desfechos na evolução hospitalar. A análise estatística utilizou teste do qui-quadrado, Odds Ratio e teste de Mann-Whitney. Resultados: a mortalidade intra-hospitalar ocorreu em 35% (IC 95%; 26-41%), as próteses valvares foram acometidas em 60,23% dos casos, as hemoculturas sem isolamento ocorreram em 36,56%. Nas hemoculturas positivas, o principal agente etiológico isolado foi o Staphylococcus aureus (31,18%), o S. aureus multissensivel em 22,8% e o S. aureus MARSA em 8,6%. A intervenção cirúrgica foi realizada em 48,39% e o principal indicador cirúrgico foi a falha ao tratamento clínico (20,43%). Pacientes que tiveram a ICCcomo desfecho apresentaram mortalidade de 57,14% (p= 0,004 e OR de 3,76, IC 95% ; 1,41- 10,03) e aqueles com marca-passo como sítio de infecção, mortalidade de 66,67%. Conclusões: a EI permanece com elevada morbimortalidade. A mortalidade difere em relação aos agentes etiológicos, estado cardíaco prévio, sítio de infecção e aumento da idade.

Introduction and objective: infectious endocarditis (IE) is a disease with high morbidity and mortality despite improvements in diagnosis and antimicrobial therapy. The early identification of patients at high risk of death or complications can improve the outcome of this disease. The objective was to analyze IE cases in a tertiary hospital and their in-hospital outcomes. Patients and methods: 93 episodes of IE were retrospectively analyzed in 91 patients, between January of 2001 and December of 2008. The analyzed variables were: clinical and infectious data, therapeutic modality, and outcomes during hospital developments. The statisticalanalysis employed the Chi-square, odds ratio, and Mann-Whitney tests. Results: the in-hospital mortality occurred in 35% (IC 95%; 26-41%), valve prostheses were involved in 60.23% of cases, and blood cultures without isolation occurred in 36.56%. In positive blood cultures, the main etiological agent isolated was Staphylococcus aureus in 31.18%, multi sensitive S. aureus in 22.8%, and S. aureus MARSA in 8.6%. Surgical intervention was performed in 48.39% of the patients and the main surgical indicator was failure of clinical treatment (20.43%) Patients who have had ICC as outcome presented 57.14% mortality (p = 0.004 and OR of 3.76, IC 95%;1.41-10.03); mortality rate of 66.67% as observed in those with pacemakers as the site of infection. Conclusions: IE remains with high morbidity and mortality. Mortality rates vary according to the etiological agent, prior cardiac state, site of infection, and increased age.

A combination of faecal tests for the detection of colon cancer: a new strategy for an appropriate selection of referrals to colonoscopy? A prospective multicentre Italian study.

INTRODUCTION: Colonoscopy workload for endoscopy services in Western countries is increasing markedly because of the implementation of faecal occult blood-based mass screening programmes against colorectal cancer (CRC). We therefore explored the possibility of using a combination of faecal tests to prioritize the access to colonoscopy with criteria other than symptoms and/or time of referral. AIMS AND METHODS: We tested a combination of faecal tests [immunochemical faecal occult blood test (i-FOBT), M2-PK, calprotectin] as markers for advanced neoplasia in a selected series of patients requiring colonoscopy for the suspicion of CRC. All the tests were performed in a 1-day stool sample of patients aged 50-80 years, without any dietary restriction, before colonoscopy. RESULTS: A total of 280 patients' stool single samples were analysed. Forty-seven patients had CRC and 85 patients had one or more advanced adenoma(s) at colonoscopy/histology. CRCs were associated with a highly significant increase (P<0.001) in faecal tumour M2-PK (mean 24.2 kU/l), which correlated with Dukes' staging. For CRC detection, i-FOBT was the test with the highest specificity and positive predictive value (0.89 and 0.53), whereas M2-PK had the highest sensitivity and negative predictive value (0.87 and 0.96). Calprotectin showed performance similar to M2-PK in terms of sensitivity and negative predictive value (0.93), but had lower specificity (0.39). The best combination of tests to predict the risk of CRC in this series was i-FOBT+M2-PK, as in patients showing positivity to both markers, the risk of cancer was as high as 79%. CONCLUSION: The combination of i-FOBT and M2-PK is a sensitive tool in clinical practice for the appropriate management of waiting lists for colonoscopy, as it allows the classification of patients into different degrees of priority for investigation, according to their foreseeable risk of CRC.

Infarto do miocárdio semsupradesnivelamento do segmento ST:características clínicas, angiográficas eevolução intra-hospitalar dos pacientes / Myocardial infarction without ST segment elevation: clinical and angiographic characteristics, and evolution of inpatients

Fundamento: as características angiográficas dos pacientes com infarto sem supradesnivelamento do segmento ST (IAMSSST) reforçam medidas mais agressivas, independentemente do escore de risco. Objetivo: analisar e descrever as características clínicas basais, dados angiográficos da artéria relacionada ao infarto (ARI) e as complicações clínicas ocorridas na evolução intra-hospitalar em pacientes com IAMSSST submetidos à intervenção coronariana percutânea (ICP). Métodos: estudo de coorte retrospectivo de 81 pacientes com IAMSSST e ARI identificada. Analisados dados clínicos e angiográficos, incluindo localização da ARI, TIMI fluxo pré e pós-procedimento, grau de estenose arterial, ventriculografia e tipo de stent implantado. Resultados: os 81 pacientes analisados realizaram ICP. A média de idade foi de 66,94 anos. Observou-se elevado grau de estenose superior a 90% ou de oclusão total da ARI em 66,7% dos casos e TIMI fluxo de grau reduzido (graus 0,1 e 2) em 53,1%. A lesão da artéria circunflexa (CX) predominou em 42,5%, seguida pela descendente anterior (DA) em 30% e pela coronária direita (CD) em 27,5%. Em 88,23% das vezes em que a CX esteve acometida predominaram as lesões mais graves (superior a 90% ou oclusão). A disfunção ventricular moderada ou grave foi encontrada em 42 pacientes (54,54%); 12 (14,81%) apresentaram complicação intra-hospitalar. A insuficiência cardíaca foi detectada em seis casos (7,40%), seguida por angina IIIC de Braunwald e sangramento com necessidade de hemotransfusão com dois casos cada (2,46%). Um caso evoluiu com óbito (1,23%). Conclusão: na presente análise os pacientes com IAMSSST apresentaram alto número de oclusões e lesões graves, superior a 90% (66,7%), e elevado grau de TIMI fluxo reduzido (graus 0, 1 e 2): 53, 1%. Obteve-se elevado índice de sucesso na recanalização da ARI (96,29%).

Background: The angiographic characteristics of patients with myocardial infarction without ST segment elevation account for the need of aggressive measures irrespective of risk score. Objective: To analyze and describe basic clinical characteristics, angiographic data of infarct-related arteries and clinical complications in the course of inpatients? progress upon percutaneous coronary intervention. Methods: This is a retrospective cohort study of 81 patients whose infarct-related artery had been identified. The study involved the analysis of clinical and angiographic data, including localization of the infarct-related artery, pre- and post-surgery TIMI flow, level of arterial stenosis, ventriculography and type of implanted stent. Results: All the 81 patients analyzed had undergone percutaneous coronary interven-tion. Average age was 66.94 years. The results point to high level of superior stenosis (>90%) or total occlusion of the infarct-related artery (66.7 %), and low TIMI flow grades of 0 1 and 2 (53.1%). Lesion in the circumflex artery prevailed in 42.5 % of the cases, followed by the anterior descending artery (30 %), and the right coronary artery (27.5 %). Cases with affected circumflex artery usually had the mostsevere lesions (above 90 % or occlusion). Mild or serious ventricular dysfunction was found in 42 patients (54.54%); 12 patients (14.81 %) had complications while in hospital. Cardiac insufficiency was detected in 6 cases (7.40%), followed by 2 cases (2.46 %) of angina of type IIC according to Braunwald Classification, and 2 cases of bleeding requiring blood transfusion. One case progressed to death (1.23 %).Conclusion: The analysis pointed to high numbers of occlusions and severe lesions, over 90% (66.7%), and high rate (53.1 %) of reduced TIMI flow (grades 0. 1 and 2). The number of successful recanalization of the infarct-related artery was high (96.29 %).

Factores de riesgo asociados a la hipertensión inducida por el embarazo / Risk factors associated with pregnancy induced hypertension

Se realizó un estudio de 308 gestantes con hipertensión inducida por el embarazo: 77 casos y 231 controles; estas últimas grávidas supuestamente sanas, con vistas a determinar algunos factores de riesgo asociados a la ocurrencia de esa alteración. La investigación se efectuó en el Policlínico Universitario José Martí Pérez de Santiago de Cuba, de enero a diciembre de 2010. Se calculó la razón de productos cruzados y se aplicó la prueba de Ji al cuadrado de independencia. Entre los principales resultados sobresalió que los factores de riesgo biológicos estuvieron vinculados causalmente, exceptuando el precedente de enfermedades asociadas a la gravidez. También se estimó el riesgo atribuible en expuesto porcentual para identificar aquellos factores que al incidir sobre ellos, podría lograrse un mayor impacto, tales como: antecedentes familiares de hipertensión arterial y embarazo, malas condiciones obstétricas e inicio de la gestación malnutridas.

A study of 308 pregnant women with pregnancy induced hypertension (77 cases and 231 controls; the latter were supposedly healthy) was carried out from January to December, 2010 in order to determine some risk factors associated with the occurrence of this disorder. Research was performed at José Martí Pérez University Polyclinic from Santiago de Cuba. Odds ratio was estimated and chi square test was applied. Among the main results prevailed that biological risk factors were causally related, except for the precedent of diseases associated with pregnancy. Risk difference was also estimated in the exposed percentage to identify those factors, such as pregnancy hypertension family history, poor obstetrical conditions, and initial malnourished pregnancy that, when influencing on them, a major impact would be achieved.

Impact of a population-based colorectal cancer screening program on local health services demand in Italy: a 7-year survey in a northern province.

OBJECTIVES: In 2005, the National Health Service recommended a population-based colorectal cancer (CRC) screening program using biennial fecal occult blood testing (FOBT), followed by total colonoscopy in positive patients. So far, no studies have been performed to evaluate the impact of a mass-screening CRC campaign on the health system services at the community level in Italy. We have therefore assessed the workload generated by the first two biennial rounds of screening program on the activity of hospital services involved in CRC diagnosis in the Lecco province. METHODS: Routine data from all hospital services of our province were collected on activity levels related to CRC diagnosis from January 2003 to December 2009. This time span covered the 2 years prior to, as well as the two biennial rounds of the CRC screening program. In particular, we focused on the volume of outpatient FOBTs and colonoscopies (both diagnostic and interventional) performed among subjects outside the screening program. Joinpoint models were used to test whether an apparent change in trend of examination over time was statistically significant in different age cohorts of the population (<50 years, 50-69 years, and ≥70 years). RESULTS: The volume of "extra-screening" per-patient/FOBTs and colonoscopies increased significantly over the evaluated periods in all ages, until year 2008, when a steady trend was beginning; the AAPCs (average of the annual percent changes) values were 5.7, 3.1, and 8.4 for FOBT and 14.6, 13.4, and 16.7 for colonoscopy in the three age cohorts, respectively. However, the increase in both FOBT and colonoscopy demand was maximal in the cohort ≥70 years, where three statistically significant annual percent changes (APCs) were identified (in 2003-2005, 2005-2006, and 2006-2007 APCs were 12.3, 14.9, and 15.9 for FOBT, and 18.7, 36.8, and 25.4 for colonoscopy, respectively). CONCLUSIONS: After the implementation of a FOBT-based mass-screening program for CRC, careful consideration must be given to the significant increase in the workload of hospital services involved in CRC diagnosis, outside the screening campaign. The extra-work mainly involves gastroenterologists performing colonoscopy, whose activity increased over the 5-year period by 118%, as well as laboratory services, where the demand of FOBTs rose by 40%. This phenomenon, mainly attributable to a profound change in the attitude toward CRC screening by those age cohorts outside the program, covers a time span of two full rounds of screening, whereupon a steady trend for colonoscopy is apparent.

Diagnóstico tardío de cáncer de colon recurrente en la atención primaria de salud / Late diagnosis of the colon recurrent cancer in the primary health care

Se realizó un estudio descriptivo, longitudinal y retrospectivo de 68 pacientes con cáncer de colon recurrente, que acudieron a consulta de seguimiento por esta causa en el Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora de Santiago de Cuba, desde enero de 1990 hasta diciembre de 2005. Se obtuvo que esa neoplasia fue generalmente diagnosticada en etapas avanzadas de la enfermedad y que los 2 primeros años de seguimiento resultaron decisivos para el diagnóstico de la recurrencia, el cual suele establecerse de forma tardía, de manera que el tratamiento debe ser paliativo en la mayoría de los afectados.

A descriptive, cross-sectional and retrospective study of 68 patients with recurrent colon cancer who attended their follow-up visits due to this cause was carried out in the Saturnino Lora Teaching Provincial Hospital in Santiago de Cuba, from January, 1990 to December, 2005. It was obtained that this neoplasia was generally diagnosed in advanced stages of the disease and that the first 2 years of follow up were decisive for the diagnosis of the recurrence, which may usually be reached in a late stage, so that the treatment should be palliative in most of those affected.

Modificación de conocimientos en adolescentes sobre maltrato infantil intrafamiliar / Modification to knowledge of family child abuse among adolescents

Se realizó una intervención educativa en adolescentes, pertenecientes al Equipo Básico de Trabajo A del Policlínico Universitario José Martí Pérez de Santiago de Cuba, desde enero hasta junio del 2007, a fin de modificar algunos conocimientos sobre maltrato infantil intrafamiliar en estos. La muestra se tomó por el método aleatorio simple y se impartió un programa de actividades donde se expusieron aspectos importantes sobre el tema tratado y finalmente se evaluó la eficacia del programa de actividades desarrollado. Se utilizaron el porcentaje como medida de resumen y la prueba de McNemar como validación estadística, con una diferencia significativa de p<0,05. Se logró elevar el nivel de conocimientos sobre el tema en la mayoría de los integrantes de la casuística

An educational intervention was carried out in adolescents, belonging to the Basic Working Team A of the José Martí Pérez Teaching Polyclinic in Santiago de Cuba, from January to June 2007, in order to modify some knowledge of family child abuse in them. The sample was selected by the simple random method and a program of activities was conducted where important aspects on the matter were stated, and finally the effectiveness of the developed program of activities was evaluated. Percentage as summary measure and the McNemar test as statistical validation were used, with a significant difference of p 0,05. It was achieved to increase the level of knowledge on the matter in most people of the case material

Intervención educativa en pacientes con enfermedades cerebrovasculares isquémicas e hipertensión arterial / Educational intervention in patients with ischemic stroke and high blood pressure

Se efectuó una intervención comunitaria en 30 pacientes con hipertensión arterial, atendidos en el consultorio médico nr 40, perteneciente al área de salud del Policlínico Docente José Martí de Santiago de Cuba, desde junio de 2007 hasta enero de 2008, para modificar algunos conocimientos sobre las enfermedades cerebrovasculares isquémicas. La mayoría de los afectados tenían nociones inadecuadas al respecto antes de la acción educativa y después de esta lograron modificarlas positivamente, por lo cual se demostró la efectividad del programa de actividades aplicado en esa parte del centro urbano.

A communitary intervention was carried out in 30 patients with high blood pressure assisted in the family physician office # 40 belonging to the health area of José Martí teaching polyclinic in Santiago de Cuba, from June, 2007 to January, 2008, to modify some knowledge about the ischemic stroke. Most of the affected ones had inadequate notions in this regard before the teaching action and after this they could modify them positively, so the effectiveness of the activities program applied to this part of the urban center was demonstrated.

Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study.

OBJECTIVES: Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC. METHODS: A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0-3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months. RESULTS: A variable concordance was found over time between endoscopic and clinical score (weighted kappa between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted kappa between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6-17.6 and OR: 9.1; 95% CI: 2.5-33.5, respectively). CONCLUSIONS: Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Factores de riesgo asociados al maltrato infantil intrafamiliar en alumnos del Seminternado Roberto Rodríguez Sarmiento / Risk factors associated with family child abuse in schoolchildren from the Roberto Rodríguez Sarmiento day boarding school

Se realizó un estudio de tipo caso- control, basado en 50 menores que sufrieron cualquiera de las categorías de maltrato infantil, cometido por sus padres o cuidadores (casos), y 100 niños seleccionados mediante un muestreo aleatorio simple (controles), pertenecientes al seminternado Roberto Rodríguez Sarmiento del área de salud José Martí, de Santiago de Cuba, de enero a diciembre del 2007, para identificar aquellos factores relacionados con la aparición de violencia intrafamiliar en edades comprendidas entre 8 y 11 años. Se utilizaron como técnicas estadísticas la razón de productos cruzados y el intervalo de confianza. Las modalidades más frecuentes de maltrato infantil resultaron ser la violencia física y la psicológica, en infantes con factores favorecedores como el aprovechamiento académico deficiente y la hiperactividad, unidos a la baja per capita familiar y el divorcio; la madre fue la principal persona que maltrataba a sus hijos.

Case-control study was carried out in 50 children that suffered any of the categories of child abuse made by their parents or caretakers (cases), and 100 children selected by means of a simple random sampling (control) belonging to the Roberto Rodríguez Sarmiento day boarding school from the José Martí health area in Santiago de Cuba, from January to December, 2007, to identify those factors related to the occurrence of domestic violence in ages between 8 and 11 years. Odds ratio and interval of confidence were used as statistical techniques. The most frequent modalities of child abuse were physical and psychological violence in children with helping factors such as a deficiency in academic performance and hiperactiviy along with low family income and divorce. The mother was the main person that mistreated her childre.

Chemotherapy error reduction: a multidisciplinary approach to create templated order sets.

More than 48,000 newly diagnosed cancer patients can expect to have some adverse events related to their care each year. Historically, 20% of these adverse events have been medication related, and two thirds have been thought to be preventable. Since the majority of these errors occurred during the order writing process, the prioritized changes made at the joint pediatric program for Children's Hospital, Boston, and Dana-Farber Cancer Institute have been the initiation of templated orders and the development of a computerized order entry system. The goal of this initiative was to decrease errors related to chemotherapy administration by creating legible, complete, clearly defined order sets, and at the same time, to make order writing and reviewing more efficient. Chemotherapy templates were created using a consistent format and a rigorous multidisciplinary review process. Each order set includes the following: identification of the patient and cycle of chemotherapy to be given, criteria necessary to receive chemotherapy, chemotherapy orders with modifications if appropriate, and supportive care orders. Templated order sets have reduced the duplication of work efforts by significantly reducing the number of changes made during the order verification process; orders are more complete, and standardization has occurred.