The burden of systemic therapy administration route in treating HER2-positive breast cancer (for patients, healthcare professionals, and healthcare system): a systematic literature review.

Introduction: Breast cancer (BC) is one of the leading causes of cancer and is the first cause of death from malignant tumors among women worldwide. New cancer therapies receive regulatory approval yearly and to avoid health disparities in society, the health systems are challenged to adapt their infrastructure, methodologies, and reimbursement policies to allow broad access to these treatments. In addition, listening to patients' voices about their therapy preferences is essential. We aim to investigate the administration route preferences [subcutaneous (SC) or intravenous (IV)] among patients diagnosed with HER2 positive BC and healthcare professionals (HCPs) and to investigate healthcare resources utilization (quality and quantity) for each route of administration (SC or IV) for treating those patients. Methods: We conducted a systematic literature review focused on clinical trials and observational and economic studies, using PubMed (MEDLINE), Cochrane Library, Virtual Health Library (VHL), Scientific Electronic Library Online (SciELO), and Latin American and Caribbean Health Sciences Literature (LILACS) databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Results: The literature review included 25 studies in the analysis. Studies have reported that patients and HCPs prefer the SC route of administration to IV because it saves time in terms of chair time, administration, and preparation and is less painful. In addition, SC administration might be a more cost-saving option when analyzing direct and indirect costs. Discussion: As BC stands as a significant global health concern and the leading cause of cancer-related deaths in women worldwide, understanding and incorporating patient and HCPs preferences in the choice of administration route become paramount. The observed preference for SC administration not only aligns with the imperative of adapting health systems to facilitate broad access to new cancer therapies but also underscores the importance of considering patient experiences and economic implications in shaping treatment strategies. These insights are crucial for healthcare policymakers, clinicians, and stakeholders in optimizing healthcare resources and enhancing the overall quality of BC care.

Estimating Public Economic Gains from Early Breast Cancer and Curative Treatment: A Case Study in Human Epidermal Growth Factor Receptor (HER-2) Positive Targeted Therapies.

INTRODUCTION: Cancer diagnosis influences the choices that patients make regarding current and future labor market activity. These choices have implications for governments based on resulting changes in taxes paid and benefits received. In this analysis we explore how human growth receptor 2 (HER2)-positive residual invasive breast cancer and different treatments influence government accounts excluding health costs. METHODS: HER2-positive early breast cancer (eBC) health states from a published disease model were used to establish likelihood of working and wage impact at different stages of disease. The indirect productivity losses for an average woman aged 49 years were translated into fiscal consequences to government by applying an established government perspective-modeling framework. The fiscal projections (discounted) include gross tax revenue by disease stage, government transfer costs related to time off work and early retirement ,and net fiscal balance (e.g., gross taxes-transfers) in three countries Canada, Portugal, and Brazil. RESULTS: The net fiscal balance in Canada for a healthy woman was C$109,551 compared with a HER2-positive eBC woman treated with trastuzumab emtansine (C$69,767) or trastuzumab (C$62,971). A similar pattern was observed in the three countries but reflecting the overall tax burden in each country, labor force activity, and available public benefits. Age at diagnosis was an important determinant of the likely net fiscal balance, as this influences the remaining working years. DISCUSSION: Women diagnosed with HER2-positive eBC were estimated to pay less lifetime gross taxes and receive more in sickness benefits compared with healthy women. Treatments that improve outcomes are likely to offer fiscal gains for government from improved work force participation.

Fever in a Patient with a Central Venous Catheter Colonized by Pandoraea pnomenusa.

Pandoraea species are a newly described genus of multidrug-resistant, non-fermentative Gram-negative bacilli, mainly isolated from sputum samples of cystic fibrosis patients. In immunocompromised patients or with high antibiotic selective pressure, these pathogens are generally opportunistic and invasive. Although Pandoraea spp. are rare, the true incidence of these infections may be underestimated due to difficulties in microbial identification by phenotypic methods. We present the case of a 51-year-old woman, with new-onset fever after a prolonged hospitalization and multiple courses of antibiotics. Mass spectrometry assays identified Pandoraea pnomenusa in the blood cultures taken from the central venous catheter and in the catheter tip. Fever cessation after catheter removal suggests a catheter-related bloodstream infection. To the best of our knowledge, this is the first isolation of a Pandoraea spp. in Portugal, which should raise awareness to the emergence of these opportunistic and multidrug-resistant microorganisms, and the importance of its prompt identification.

O género Pandoraea é constituído por bacilos Gram-negativo não fermentadores multirresistentes, maioritariamente isolados em amostras respiratórias de doentes com fibrose quística. No entanto, em doentes imunodeprimidos e/ou sujeitos a elevada pressão antibiótica, podem ser agentes invasivos e oportunistas. Apesar de estas infeções serem raras, a incidência pode estar subestimada por dificuldades na sua identificação por métodos fenotípicos. Apresentamos um caso clínico de uma mulher de 51 anos, com febre de novo após um internamento complexo e múltiplos ciclos de antibioterapia. Nas hemoculturas colhidas do cateter venoso central e na ponta do cateter foi identificada, por espectrometria de massa, uma Pandoraea pnomenusa. A resolução da febre após retirada do cateter sugere uma bacteriemia associada a cateter. Tanto quanto é do nosso conhecimento, este é o primeiro caso reportado de Pandoraea spp. em Portugal, pondo em evidência a necessidade de se estar alerta para a emergência de agentes de infeção multirresistentes, bem como a necessidade da sua identificação precoce.

Composition and spatial distribution of floating plastic debris along the estuarine ecocline of a subtropical coastal lagoon in the Western Atlantic.

With the objective of characterizing the composition and spatial distribution of plastic fragments in a subtropical lagoon system, five sample areas affected by various anthropogenic impacts were chosen in the southern part of the Estuarine Lagoon System in Laguna, Santa Catarina, Brazil. The total density of the floating meso- and microplastics encountered was 7.32/m3, with the greatest density in the access channel and external area of the lagoon. Plastic filament was the most abundant and mainly comprised polyester (PET), polypropylene (PP) and polyethylene (PE) from 0.05 to 0.71 mm2. Fishing and urbanization were the main sources of the meso- and microplastics in the environment. This is the first study to evaluate contamination by meso- and microplastics in the southern part of the Estuarine Lagoon System and provides information about the nature and extent of contamination by plastics in this estuarine ecosystem.

A saúde do idoso na graduação em fisioterapia no Brasil: um estudo transversal / La salud del anciano en el grado en fisioterapia en Brasil: un estudio transversal / The health of older people in the physical therapy undergraduate program in Brazil: a cross-sectional study

RESUMO O envelhecimento populacional vem ocorrendo rapidamente em todo o mundo, levando à necessidade de capacitação dos profissionais de saúde envolvidos no cuidado ao idoso, dentre eles o fisioterapeuta. O objetivo deste estudo foi descrever o perfil dos cursos de fisioterapia de instituições do ensino superior (IES) do Brasil quanto ao ensino direcionado à saúde do idoso. Trata-se de um estudo observacional e transversal. Foi realizado um levantamento de informações sobre os cursos de fisioterapia do Brasil através de análise da grade curricular, projetos pedagógicos e formulário específico. Foram analisadas 525 IES, das quais 91,3% oferecem uma disciplina que aborda a saúde do idoso, sendo 98,4% de caráter obrigatório e 91,3% do tipo teórico-prático. Nas práticas, 25,6% são em campo de estágio, sendo 81,9% realizadas com idosos voluntários e 54,9% direcionadas a todos os níveis de atenção. Ao analisar a distribuição da disciplina por região, observou-se que esta está mais presente na região Sudeste (40,2%) (p=0,03). As IES do Brasil abordam, em sua maioria, a saúde do idoso na grade curricular do curso de fisioterapia. No entanto, a distribuição dessa disciplina no país é desigual, podendo trazer divergências na conduta terapêutica e representar prejuízos na qualidade da assistência ao idoso.

RESUMEN El envejecimiento de la población ha estado ocurriendo rápidamente en el mundo, lo que resulta necesaria la capacitación de los profesionales de la salud involucrados en el cuidado del anciano, incluido el fisioterapeuta. El presente estudio tuvo el objetivo de describir el perfil de los cursos de fisioterapia en las instituciones de educación superior (IES) en Brasil con respecto a la enseñanza sobre la salud del anciano. Es un estudio observacional y transversal. Se realizó una recopilación de informaciones sobre los cursos de fisioterapia en Brasil mediante el análisis del plan de estudios, los proyectos pedagógicos y un formulario específico. Se analizaron 525 IES, de las cuales el 91,3% ofertan una materia que aborda la salud del anciano, de esta, el 98,4% son obligatorias y el 91,3% del tipo teórico-prácticas. En las del tipo prácticas, el 25,6% están en el ámbito de pasantías, siendo que el 81,9% se realizan con ancianos voluntarios y el 54,9% están dirigidas a todos los niveles de atención. En el análisis de la distribución de la materia por región, se observó una mayor presencia en la región Sudeste (40,2%) (p=0,03). La mayoría de las IES en Brasil abordan la salud de los ancianos en el plan de estudios del curso de fisioterapia. No obstante, la distribución de la materia es desigual en el país, lo que puede resultar en divergencias en la conducta terapéutica e influir negativamente en la calidad de la asistencia a los ancianos.

ABSTRACT Population aging has been occurring rapidly around the world, leading to the need for training for health professionals involved in caring for older adults, including the physical therapist. The aim of this study was to describe the profile of physical therapy courses in higher education institutions (HEIs) in Brazil regarding teaching directed to the health of older adults. This is an observational, cross-sectional study. A survey of information on physical therapy courses in Brazil was carried out through analysis of the curriculum, pedagogical projects and specific form. We analyzed 525 HEIs, of which 91.3% offer a discipline that addresses the health of older people, 98.4% of which is mandatory and 91.3% is the theoretical-practical type. In practice, 25.6% are in the internship field, with 81.9% carried out with older volunteers and 54.9% directed to all levels of care. When analyzing the distribution of the discipline by region, it was observed that it is more present in the Southeast (40.2%) (p=0.03). Most HEIs in Brazil address the health of older adults in the curriculum of the physical therapy course. However, the distribution of this discipline in the country is uneven, which can lead to divergences in therapeutic practice and represent losses in the quality of care for older people.

Changes in employment status up to 5 years after breast cancer diagnosis: A prospective cohort study.

AIM: To assess how sociodemographic, clinical and treatment characteristics impact employment status five-years following a breast cancer diagnosis, and to compare the incidence rate of changes with the general population. METHODS: A total of 462 women with incident breast cancer were evaluated before treatment and three- and five-years later. Adjusted odds ratios (ORs) with 95% confidence intervals (95%CIs) were computed through multinomial logistic regression. Data for comparisons were retrieved from the SHARE Project. Incidence rate ratios (IRRs) with 95%CIs were calculated using Poisson regression. RESULTS: Among the 242 employed women prior to diagnosis, 162 remained employed, 26 became unemployed, 27 entered early retirement, 14 entered normal retirement and 13 were on sick leave at five-years. Unemployment increased with age (≥55 vs < 55 years: OR = 4.49, 95%CI:1.56-12.92; OR = 3.40, 95%CI:1.05-10.97 at three- and five-years, respectively) and decreased with education (>4 vs ≤ 4 years: OR = 0.36, 95%CI:0.13-0.97; OR = 0.27, 95%CI:0.10-0.71 at three- and five-years, respectively). Axillary surgery (unemployment at five-years: OR = 5.13, 95%CI:1.30-20.27), hormonal therapy (unemployment at three-years: OR = 0.28, 95%CI:0.10-0.83) and targeted therapy (sick leave at three-years: OR = 3.79, 95%CI:1.14-12.63) also influenced employment status. Five-years post diagnosis, women with breast cancer had a lower incidence of unemployment (IRR = 0.51, 95%CI:0.30-0.89) than the general population, while, among older women, there was a higher tendency to enter early retirement (IRR = 1.72, 95%CI:0.82-3.61). CONCLUSIONS: Although not all women may want to pursue or continue a professional life following their breast cancer experience; those who do may benefit from social and employer support when returning to work.

Light chain cardiac amyloidosis - a rare cause of heart failure in a young adult

SUMMARY Cardiac amyloidosis is an infiltrative cardiomyopathy, resulting from amyloid deposition within the myocardium. In primary systemic (AL-type) amyloidosis, the amyloid protein is composed of light chains resulting from plasma-cell dyscrasia, and cardiac involvement occurs in up to 50% of the patients We present a case of a 43-year-old man, with complaints of periodical swollen tongue and xerostomia, bleeding gums and haematuria for two months. His blood results showed normocytic anaemia, thrombocytopenia and a high spontaneous INR, therefore he was referred to the Internal Medicine clinic. In the first visit, he showed signs and symptoms of overt congestive heart failure and was referred to the emergency department. The electrocardiogram showed sinus tachycardia and low voltage criteria. Echocardiography showed biventricular hypertrophy with preserved ejection fraction, restrictive physiology with elevated filling pressures, thickened interatrial septum and atrioventricular valves, small pericardial effusion and relative "apical sparing" on 2D longitudinal strain. Cardiac MRI showed diffuse subendocardial late enhancement. Serum protein electrophoresis was inconclusive, however urine analysis revealed nephrotic range proteinuria, positive Bence Jones protein and an immunofixation test with a monoclonal lambda protein band. Abdominal fat biopsy was negative for Congo red stain, nevertheless a bone marrow biopsy was performed, revealing lambda protein monoclonal plasmocytosis, confirming the diagnosis of primary systemic amyloidosis. This case represents a rare cause of heart failure in a young adult. Low-voltage QRS complexes and typical echocardiography features should raise the suspicion for cardiac amyloidosis. Prognosis is dictated by the level of cardiac involvement; therefore, early diagnosis and treatment are crucial.

RESUMO A amiloidose cardíaca corresponde a uma miocardiopatia infiltrativa, resultante do depósito da proteína amiloide no miocárdio. Na amiloidose sistêmica primária (tipo AL), a proteína amiloide é composta por cadeias leves que resultam de discrasia dos plasmócitos, havendo envolvimento cardíaco em até 50% dos doentes. Apresentamos o caso de um homem de 43 anos, com queixas de edema periódico da língua e xerostomia, hemorragia gengival e hematúria há dois meses. Analiticamente havia a destacar anemia normocítica, trombocitopenia e um INR alto espontâneo, pelo que foi referenciado à consulta de Medicina Interna. Na primeira consulta, apresentou-se com sinais de insuficiência cardíaca congestiva franca, pelo que foi referenciado ao Serviço de Urgência. O eletrocardiograma demonstrou taquicardia sinusal e critérios de baixa voltagem. O ecocardiograma revelou hipertrofia biventricular com fração de ejeção preservada, fisiologia restritiva com elevação das pressões de enchimento, espessamento do septo interauricular e das válvulas auriculoventriculares, derrame pericárdico ligeiro e padrão de apical sparing no strain longitudinal 2D. Realizou ainda ressonância magnética cardíaca, que mostrou realce tardio subendocárdico difuso. A eletroforese das proteínas foi inconclusiva, contudo a análise da urina revelou proteinúria no espectro nefrótico, presença de proteína de Bence Jones e um teste de imunofixação com uma banda monoclonal de cadeias lambda. A biópsia da gordura abdominal foi negativa. Não obstante, foi realizada uma biópsia da medula óssea, verificando-se plasmocitose monoclonal lambda, o que confirmou o diagnóstico de amiloidose primária sistêmica. Este caso representa uma causa rara de insuficiência cardíaca no jovem adulto. A baixa voltagem no eletrocardiograma e os achados ecocardiográficos típicos devem fazer suspeitar de amiloidose cardíaca. O prognóstico é ditado pelo nível de envolvimento cardíaco, motivo pelo qual o diagnóstico e o tratamento precoces são essenciais.

Light chain cardiac amyloidosis - a rare cause of heart failure in a young adult.

Cardiac amyloidosis is an infiltrative cardiomyopathy, resulting from amyloid deposition within the myocardium. In primary systemic (AL-type) amyloidosis, the amyloid protein is composed of light chains resulting from plasma-cell dyscrasia, and cardiac involvement occurs in up to 50% of the patients We present a case of a 43-year-old man, with complaints of periodical swollen tongue and xerostomia, bleeding gums and haematuria for two months. His blood results showed normocytic anaemia, thrombocytopenia and a high spontaneous INR, therefore he was referred to the Internal Medicine clinic. In the first visit, he showed signs and symptoms of overt congestive heart failure and was referred to the emergency department. The electrocardiogram showed sinus tachycardia and low voltage criteria. Echocardiography showed biventricular hypertrophy with preserved ejection fraction, restrictive physiology with elevated filling pressures, thickened interatrial septum and atrioventricular valves, small pericardial effusion and relative "apical sparing" on 2D longitudinal strain. Cardiac MRI showed diffuse subendocardial late enhancement. Serum protein electrophoresis was inconclusive, however urine analysis revealed nephrotic range proteinuria, positive Bence Jones protein and an immunofixation test with a monoclonal lambda protein band. Abdominal fat biopsy was negative for Congo red stain, nevertheless a bone marrow biopsy was performed, revealing lambda protein monoclonal plasmocytosis, confirming the diagnosis of primary systemic amyloidosis. This case represents a rare cause of heart failure in a young adult. Low-voltage QRS complexes and typical echocardiography features should raise the suspicion for cardiac amyloidosis. Prognosis is dictated by the level of cardiac involvement; therefore, early diagnosis and treatment are crucial.

Native aortic valve pneumococcal endocarditis--fulminant presentation.

Pneumococcal endocarditis is a rare entity, corresponding to 1 to 3% of native valve endocarditis cases. It has a typically adverse prognosis, with high mortality. There is a reported predilection for the aortic valve; thus, a common presentation is acute left heart failure. We present a case of a 60-year-old woman with a history of sinusitis, who was admitted with the diagnosis of pneumonia. She rapidly deteriorated with signs of septic shock and was transferred to the critical care unit. The transesophageal echocardiogram revealed severe aortic regurgitation due to valve vegetations. Blood cultures were positive for Streptococcus pneumoniae. She underwent cardiac surgery and had multiple postoperative complications. Nonetheless, the patient made a slow and complete recovery. Infectious endocarditis should be ruled out if any suspicion arises, and echocardiography should be performed in an early stage in patients with poor response to vasopressors and inotropes. Patients with pneumococcal endocarditis benefit from an aggressive approach, with performance of early surgery.

Endocardite pneumocócica em válvula aórtica nativa - apresentação fulminante / Native aortic valve pneumococcal endocarditis - fulminant presentation

RESUMO A endocardite pneumocócica é uma entidade rara, cuja incidência se situa entre 1% e 3% dos casos de endocardite de válvula nativa. Esta patologia tem um prognóstico naturalmente adverso, com elevada mortalidade. Relata-se predileção pela válvula aórtica, de forma que é frequente que se apresente com insuficiência cardíaca. Apresentamos o caso de uma paciente do sexo feminino com 60 anos de idade e história pregressa de sinusite, admitida com diagnóstico de pneumonia. Após rápida deterioração, com sinais de choque séptico, ela foi transferida para a unidade de terapia intensiva. O ecocardiograma transesofágico revelou grave refluxo aórtico, devido à presença de vegetações valvares. As hemoculturas foram positivas para Streptococcus pneumoniae. A paciente foi submetida à cirurgia cardíaca e apresentou múltiplas complicações pós-operatórias. Apesar disso, apresentou lenta, porém completa recuperação. A endocardite infecciosa deve ser afastada em caso do surgimento de qualquer suspeita, e a ecocardiografia deve ser realizada precocemente nos pacientes com resposta insuficiente aos vasopressores e inotrópicos. Pacientes com endocardite pneumocócica se beneficiam de uma abordagem agressiva, com realização precoce da intervenção cirúrgica.

ABSTRACT Pneumococcal endocarditis is a rare entity, corresponding to 1 to 3% of native valve endocarditis cases. It has a typically adverse prognosis, with high mortality. There is a reported predilection for the aortic valve; thus, a common presentation is acute left heart failure. We present a case of a 60-year-old woman with a history of sinusitis, who was admitted with the diagnosis of pneumonia. She rapidly deteriorated with signs of septic shock and was transferred to the critical care unit. The transesophageal echocardiogram revealed severe aortic regurgitation due to valve vegetations. Blood cultures were positive for Streptococcus pneumoniae. She underwent cardiac surgery and had multiple postoperative complications. Nonetheless, the patient made a slow and complete recovery. Infectious endocarditis should be ruled out if any suspicion arises, and echocardiography should be performed in an early stage in patients with poor response to vasopressors and inotropes. Patients with pneumococcal endocarditis benefit from an aggressive approach, with performance of early surgery.

Primary cardiac lymphoma in a patient with concomitant renal cancer.

Primary cardiac lymphoma is defined as non-Hodgkin lymphoma involving the heart and/or pericardium. It is a rare cancer that primarily affects the right heart and in particular the right atrium. By contrast, renal cell carcinoma is a relatively common cancer, which in rare circumstances can metastasize to the heart. It is now known that there is an association between non-Hodgkin lymphoma and renal cell carcinoma, although the underlying mechanisms are not fully understood. The authors present a case of primary cardiac non-Hodgkin lymphoma in a patient with concomitant renal cell carcinoma and explore the possible reasons for this association.

Elevated factor VIII in a patient with acute coronary syndrome.

Factor VIII is a clotting factor that plays a crucial role in the coagulation cascade. Above-normal levels are found in 11% of the general adult population. Various studies have established a causal association between elevated factor VIII and venous thrombosis; some studies also suggest a relation with arterial thrombosis, particularly myocardial infarction and stroke. We report the case of a 36-year-old man with obesity, smoking and dyslipidemia as cardiovascular risk factors and a history of acute myocardial infarction at age 26. He was admitted to the coronary care unit with a diagnosis of ST-elevation myocardial infarction. Coronary angiography showed a thrombus in the distal segment of the first obtuse marginal artery, which was causing the obstruction. The thrombus was aspirated but there was no reflow. A coagulation study revealed elevated factor VIII; other parameters were normal. Even though this patient presented several cardiovascular risk factors, we highlight the need for more studies on the effect of elevated factor VIII on thrombus formation leading to acute coronary syndrome. Another important question is the use of oral anticoagulation in these patients as an integral part of the management of acute coronary syndrome.

[Cost-effectiveness of trastuzumab in the treatment of early stages breast cancer patients, in Portugal]. / Custo-efectividade de trastuzumab no tratamento de doentes com cancro da mama em estádios iniciais em Portugal.

INTRODUCTION: Despite the important advances observed in the last 25 years in the comprehension of the clinical and biological nature of breast cancer and its treatment, this disease remains a significant cause of cancer morbidity and mortality worldwide. The clinical trial Hera has demonstrated the safety and efficacy of trastuzumab in the treatment of HER2 positive (HER2+) breast cancer patients, in early stages, subsequent to surgery, chemotherapy (neoadjuvante or adjuvant) and radiotherapy, if applied. OBJECTIVES: To evaluate the cost-effectiveness of 1-year trastuzumab treatment versus standard care (observation following standard adjuvant chemotherapy), in patients with HER2+ breast cancer in early stages from the societal and the Portuguese National Health Service (NHS) perspectives. METHODS: A 5-state Markov model with annual transition cycles was developed to estimate the long term health and economic outcomes of HER2+ early breast cáncer patients based on HERA clinical trial results. Portuguese NHS resource use and costs were estimated from a consensus expert panel and published unit costs, respectively. Clinical and economic outcomes were discounted at 3% per annum. The incremental cost-effectiveness ratios per life year gained (LYG) and per quality adjusted life year (QALY) gained were estimated. One-way sensitivity analysis was performed. RESULTS: Considering a 45 year time horizon, treatment with trastuzumab was estimated to increase discounted life expectancy by 2,114 life years and quality-adjusted life expectancy by 2,009 QALYs compared to standard care. Direct and indirect costs were projected to be 61.839 euro and 19.759 euro with trastuzumab and 40.559 euro and 25.392 euro with standard of care. These results corresponded to incremental cost-effectiveness ratios of 10.067 euro and 10.595 euro assuming direct costs only, and of 7.400 euro and 7.789 euro including indirect costs, per life year gained and per QALY gained, respectively. CONCLUSIONS: The 1-year trastuzumab use as adjuvant therapy in HER-2+ early breast cancer patients improves survival and can be considered a cost effective therapy with a high degree of certainty in the Portuguese setting.

Myocardial infarction as the first probable manifestation of caseous calcification of the mitral annulus.

Calcification of the mitral annulus is a common echocardiographic finding during routine evaluation of patients. Caseous calcification of the mitral annulus (CCMA) on the other hand is a rare variant, occurring in about 0.06-0.07% of echocardiographic studies. The authors present the case of a 73-year-old woman admitted to hospital with an anterior wall acute coronary syndrome, in whom transthoracic echocardiography showed a well-defined echogenic rounded mass measuring 27 x 22 mm in diameter attached to the posterior mitral annulus. After transesophageal echocardiography and magnetic nuclear imaging, which confirmed the characteristics of the mass, the patient underwent surgical resection of the mass and mitral replacement with a mechanical prosthetic valve. Histological examination confirmed the diagnosis. Systemic embolism associated with CCMA is a rare but possible complication and was probably the cause of the acute coronary syndrome in this patient.

[Dietary fat and ischemic stroke risk in Northern Portugal]. / Gordura alimentar e risco de acidente vascular cerebral isquémico no norte de Portugal.

INTRODUCTION: A few international studies suggest an inverse association of the intake of fat with risk of ischemic stroke. On the contrary of coronary heart disease, only 10% a 15% of ischemic strokes are associated to large vessels atherosclerosis. This suggests different mechanisms for these two pathologies. So, we design a study whose aim is to quantify the ischemic stroke risk associated to dietary fat. PARTICIPANTS AND METHODS: A case-control study, that included two hundred ninety seven individuals of both sexes, hospitalized in the S. João Hospital in Oporto, with a first episode of ischemic stroke. Six hundred and seventy one controls of both sexes were also evaluated, selected by random digit dialing. The target population was Caucasian adults aged 44 years or older, living in the area served by the above named hospital, without cognitive abnormalities and who had not changed their dietary habits in the past year. The information was obtained by a structured questionnaire, by interview that included socio-demographic, medical and behavioural aspects (physical activity, tobacco use, food habits). Food intake in the past year was evaluated by a validated, semi-quantitative food frequency questionnaire. Logistic regression was used to evaluate the relative risk (odds ratio) and their 95% confidence intervals, with separate models fitted for men and women. RESULTS: Lipids accounted for less than 30% of the total energy and less than 10% were saturated fatty acids and polyunsaturated fatty acids but the cholesterol ingestion in men were higher than 300 mg. The increasing quartiles of total lipids, monounsaturated, polyunsaturated and saturated fatty acids and cholesterol were independent protective risk factors. However, the intake of trans fatty acids increases the risk. Intake of oleic and linolenic fatty acids only had significant protection in women while intake of all n-3 fatty acids, dodecohexanoic acid in particular, had a significant protective effect in both sexes. All the n-6 fatty acids and arachidonic fatty acids also had an inverse association in women but they showed a tendency to be directly associated with ischemic stroke in men. CONCLUSION: The total intakes of fat, saturated fat, monounsaturated fat and polyunsaturated fat were associated with reduced risk of ischemic stroke of both sexes.

Pulmonary embolism associated with a large tricuspid-related mass.

The case of a 43-year-old man with diabetes and alcoholism admitted to the emergency room with shock, fever, pleuritic chest pain and systemic symptoms is presented. Laboratory tests revealed anemia, leukocytosis, thrombocytopenia, high sedimentation rate and D-dimers, hypoxemia and hypocapnea. He also had sinus tachycardia, rSR' in V1 and an opacity on the periphery of the right pulmonary field. Blood and urine cultures were negative, as were serological markers. The echocardiogram showed a large mass adhering to the tricuspid valve, suggestive of myxoma. The patient underwent surgery, and anatomopathological examination of the mass showed it to be a bacterial vegetation, with no agent isolated. It is pointed out that differential diagnosis is difficult between a myxoma with systemic symptomatology associated with a possible pulmonary embolism, and tricuspid endocarditis with negative blood culture associated with a septic pulmonary embolism, which turned out to be the diagnosis in this patient.

Granulomas cardíacos a ovos de schistosoma e fibrose endomiocárdica / Cardiac Granulomas due to Schistosoma Eggs and Endomyocardial Fibrosis

Evidences of a possible association between endomyocardial fibrosis and schistosomiasis have been recently investigated. We describe the finding of cardiac schistosomal granulomas in a 14 year-old-girl presenting symptoms and signals of right side endomyocardial fibrosis. Refractory ascistis and progressive atrioventricular block were observed during follow-up. Endomyocardial biopsy and post mortem specimens showed inflammatory infiltrates, schistosomal granuloma and fibrosis.

Evidências da possível correlação entre fibrose endomiocárdica e esquistossomose mansônica têm sido recentemente suspeitadas. Relatamos a presença de um granuloma esquistossomótico, em jovem de 14 anos, com quadro clínico de endomiocardiofibrose do coração direito, evoluindo com ascite refratária e bloqueio atrioventricular do 1º grau que progrediu para bloqueio atrioventricular total. As amostras de tecido cardíaco, obtidas durante biopsia transoperatória e análise histopatológica do coração postmortem, revelaram presença de infiltrado inflamatório, granuloma esquistossomótico e fibrose