Distribution of HDL-cholesterol and non-HDL-cholesterol in Brazilian children and adolescents--the Floripa study.

BACKGROUND AND AIMS: HDL-cholesterol (HDL-C) and non-HDL-cholesterol (nHDL-C) are involved in atherosclerosis. The aim of this study was to determine the distribution of HDL-C and nHDL-C and its association with cardiovascular and socio-cultural variables in a pediatric Brazilian sample. METHODS AND RESULTS: Children and adolescents from Florianopolis were randomly selected and a structured questionnaire was administered, a physical examination was performed and a blood sample was collected. Enzymatic and Direct methods in vitro were used to determine the total cholesterol and HDL-cholesterol levels. The associations among HDL-C and nHDL-C and the described variables were tested by odds ratio and logistic regression. A total of 1009 individuals were examined. Based on the Brazilian criteria, 23% were classified with low levels of HDL-C and 25% with high levels of non-HDL-C. After multivariate analysis there were significant associations among low HDL-C and high C-reactive protein (OR, 3.3; 95% CI, 2.1-5.2), paternal tobacco use (OR, 1.5; 95% CI,1.1-2.1), and high triceps-to-subscapular index (OR, 1.5; 95% CI, 1.1-2.2). There were also significant associations among high nHDL-C and high waist circumference (OR, 1.95; 95% CI, 1.16-3.29), black skin color (OR, 1.78; 95% CI, 1.06-3.06), and high income (OR, 1.48; 95% CI, 1.09-2.02). CONCLUSIONS: In this sample, low levels of HDL-C were associated with other clinical variables such as a centripetal fat pattern and C-reactive protein, and n-HDL-C was associated with abdominal obesity, skin color and economic class.

The history of dentistry and medicine relationship: could the mouth finally return to the body?

The relationship between dentistry and medicine has been acknowledged throughout the history of humanity. This relationship was documented in ancient medicine accounts, and has survived until the present day, accompanied by the evolution of molecular technologies. Although we have had very important researchers' contributions in this interdisciplinary area, mainly after the 18th century, the knowledge on oral infections is still ignored by or unknown to the majority of clinical dentists and physicians. These circumstances could be changed through a broader divulgation of this complex relationship, both in the dentistry and in the medicine areas, which in turn would have a significant impact in systemic health worldwide. This movement has already started, as was observed in a World Health Assembly resolution which called for oral health to be integrated into chronic disease prevention programs in 2007. This was a significant indicator of changing perceptions of oral health over the past several decades. This brief review reports the evolution through time of the knowledge on the association between dental infections and systemic diseases, as well as the paths which we could take to consolidate this historical trend.

Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil.

OBJECTIVES: Although effective strategies for the prevention of venous thromboembolism (VTE) are widely available, a significant number of patients still develop VTE because appropriate thromboprophylaxis is not correctly prescribed. We conducted this study to estimate the risk profile for VTE and the employment of adequate thromboprophylaxis procedures in patients admitted to hospitals in the state of São Paulo, Brazil. METHODS: Four hospitals were included in this study. Data on risk factors for VTE and prescription of pharmacological and non-pharmacological thromboprophylaxis were collected from 1454 randomly chosen patients (589 surgical and 865 clinical). Case report forms were filled according to medical and nursing records. Physicians were unaware of the survey. Three risk assessment models were used: American College of Chest Physicians (ACCP) Guidelines, Caprini score, and the International Union of Angiololy Consensus Statement (IUAS). The ACCP score classifies VTE risk in surgical patients and the others classify VTE risk in surgical and clinical patients. Contingency tables were built presenting the joined distribution of the risk score and the prescription of any pharmacological and non-pharmacological thromboprophylaxis (yes or no). RESULTS: According to the Caprini score, 29% of the patients with the highest risk for VTE were not prescribed any thromboprophylaxis. Considering the patients under moderate, high or highest risk who should be receiving prophylaxis, 37% and 29% were not prescribed thromboprophylaxis according to ACCP (surgical patients) and IUAS risk scores, respectively. In contrast, 27% and 42% of the patients at low risk of VTE, according to Caprini and IUAS scores, respectively, had thromboprophylaxis prescribed. CONCLUSION: Despite the existence of several guidelines, this study demonstrates that adequate thromboprophylaxis is not correctly prescribed: high-risk patients are under-treated and low-risk patients are over-treated. This condition must be changed to insure that patients receive adequate treatment for the prevention of thromboembolism.

The Ankle-Brachial Index is Associated With Cardiovascular Complications After Noncardiac Surgery.

BACKGROUND: This study evaluated the association of the ankle-brachial index (ABI) and cardiovascular complications after noncardiac surgery. METHODS: We prospectively evaluated patients referred for noncardiac surgery. The ABI was performed before surgery. Patients with abnormal ABI (≤ 0.9) were included in the peripheral artery disease (PAD) group and the remaining constituted the control group. Cardiac troponin and electrocardiogram were obtained 72 hours after surgery. Patients were followed up to 30 days, and primary end point was the occurrence of any cardiovascular event: cardiovascular death, acute coronary syndrome, isolated troponin elevation (ITE), decompensated heart failure, cardiogenic shock, unstable arrhythmias, nonfatal cardiac arrest, pulmonary edema, stroke, or PAD symptoms increase. RESULTS: We evaluated 124 patients (61.3% male; mean age 65.4 years). During the study, 57.9% of patients in the PAD group had an event versus 25.7% in the control group (P = .011). The ITE was the most observed event (24.2%). After logistic regression, the odds ratio for ITE was 7.4 (95% confidence interval 2.2-25.0, P = .001). CONCLUSIONS: In patients submitted to noncardiac surgery, abnormal ABI is associated with a higher occurrence of a cardiovascular event.

Distress: associated variables of erectile dysfunction post-acute myocardial infarction. A pilot study.

This study aimed to identify the associated variables of erectile dysfunction (ED) in post myocardial infarction (MI) patients without previous sexual dysfunction (SD). Out of the 37 patients, 15 (40%) had ED. Patients significantly reduced the frequency of coitus (P<0.05). Out of nine patients with distress, eight presented ED, and of 28 patients without distress, seven presented ED (89 versus 25%, P=0.001). The two groups (distress versus without distress) were similar regarding confounding variables. We concluded that patients without SD prior the MI had a significant incidence of ED and distress was an associated variable of ED post-infarction.

Effect of niacin and etofibrate association on subjects with coronary artery disease and serum high-density lipoprotein cholesterol <35 mg/dl.

Niacin treatment (alone) was compared with etofibrate and niacin combination to treat patients with high-density lipoprotein <35 mg/dl and without hypertriglyceridemia. The niacin and etofibrate combination proved to be safe and increased high-density lipoprotein cholesterol levels to 48%, which was 3 times higher than that obtained with niacin alone.

Diagonal earlobe crease as a marker of the presence and extent of coronary atherosclerosis.

This study evaluates the association between the presence of diagonal earlobe creases (ELC) and coronary artery disease (CAD). One thousand four hundred twenty-four patients (760 men and 664 women, aged 30 to 80 years) were examined for the presence of ELC and classified into 2 groups: group I control--1,086 consecutive patients who denied symptoms of myocardial ischemia and were admitted to a general hospital for other reasons; group II CAD--338 patients with documented CAD (presence of > or = 70% coronary diameter stenosis at angiography). ELC was present in 304 patients (28%) in group I and 220 (65%) in group II (p < 0.0001). The patients were stratified in age groups to isolate the influence of age because the prevalence of ELC and CAD increased with advancing age (p < 0.0001 for both). This association remained statistically significant in all decades, except for patients aged > 70 years. To further remove the confounding effect of different age and sex distributions between the groups, a direct adjustment of the ELC prevalence was performed. When adjusted for age and sex, the prevalence of creases was still 58% higher in patients with CAD than in control subjects (p < 0.001). The presence of ELC was also related to the extent of CAD as measured by the number of major arteries narrowed (p = 0.015). The observed sensitivity of the sign for the diagnosis of CAD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%.

Usefulness of high-frequency analysis of signal-averaged surface electrocardiograms in acute myocardial infarction before and after coronary thrombolysis for assessing coronary reperfusion.

The incidence of late potentials on the signal-averaged electrocardiogram before and after coronary thrombolysis was studied in 54 patients with an acute myocardial infarction of less than or equal to 5 hours' duration and with an angiographically documented total occlusion of the infarct-related coronary artery on admission. A significant (p = 0.038) 50% relative reduction in the incidence of late potentials was observed in the group of 35 patients who underwent reperfusion: from 16 of 35 (46%) before to 8 of 35 (23%) at 120 minutes after the start of thrombolytic treatment. No significant reduction was seen in the 19 patients in whom thrombolysis was unsuccessful: from 8 of 19 (42%) before to 7 of 19 (37%) afterward. Despite successful recanalization, late potentials persisted or newly developed after thrombolytic therapy in 8 of 54 patients (15%). It is concluded that successful thrombolysis reduces the incidence of late potentials on the signal-averaged electrocardiogram but that the sensitivity and specificity of this finding are not high enough to allow reliable monitoring of coronary reperfusion at the bedside.

Reactivation of Chagas' disease in a human immunodeficiency virus-infected patient leading to severe heart disease with a late positive direct microscopic examination of the blood.

We report a human immunodeficiency virus (HIV)-infected man with chronic Chagas' disease who developed a congestive heart failure that could not be clinically controlled. Endomyocardial biopsy revealed severe myocarditis and the xenodiagnosis result was positive, but Trypanosoma cruzi by direct microscopic examination of the blood was found only four months after the symptoms had started. Treatment with benznidazole was effective in reducing parasitemia, stabilizing the clinical status, and controlling tissue damage related to the parasite. Although the finding of T. cruzi trypomastigotes by direct microscopic examination of the blood has been considered the mark of Chagas' reactivation in immunocompromised patients with chronic disease, in this case it was a late finding.

Prognostic significance of ST-T segment alterations in patients with non-Q wave myocardial infarction.

OBJECTIVE: To determine whether, among patients with non-Q wave myocardial infarction, the characteristics of the segment ST-T shifts at presentation in the diagnostic electrocardiogram can identify those with more severe coronary artery disease and predict a poor clinical outcome. DESIGN: Prospective controlled clinical trial. SETTING: Primary referral medical centre. PATIENTS: 93 patients (mean (SD) 62.0 (7.5) years) were studied: 41 with non-Q wave myocardial infarction and T wave inversion and 52 with ST segment depression. Cardiac events and mortality rates were assessed over 42 months. Age, sex, risk factors, creatinine kinase MB isoenzyme peak, and left ventricular function were comparable. RESULTS: 31 patients with T wave inversion myocardial infarction (94.6%) had total occlusion of the infarct related artery, compared with 12 patients with ST segment depression myocardial infarction (26.7%) (P < 0.05). When compared with patients with T wave inversion, patients with ST segment depression had a higher incidence of cardiac events during the first month and in the 41 subsequent months: 9.6% and 30.8% v 0% (P < 0.01) and 9.8% (P < 0.02), respectively. For the same observation periods, the mortality rates in patients with T wave inversion were 4.9% and 7.3%, and in patients with ST segment depression they were 5.8% and 9.6%, respectively. CONCLUSION: These data suggest that during a non-Q wave myocardial infarction the presence of ST segment depression is related to higher rates of short and long term cardiac events when compared with T wave inversion--possibly because of a higher incidence of residual stenosis of the infarct related artery.

Smoking and lipoprotein abnormalities on platelet aggregation in coronary heart disease.

This study aimed to clarify whether smoking had any influence on platelet aggregability in coronary patients with different lipoprotein abnormalities. We studied 297 non-diabetic patients with coronary heart disease, 40 to 85 years of age, 223 (75%) male, 167 smokers and 130 never smokers. After 3 months on Step-One diet, without any regular medication, patients had fasting plasma total cholesterol levels > or = 6.2 mmol/L; low-density lipoprotein > or = 4.14 mmol/L; and different levels of high-density lipoprotein and triglycerides. Platelet aggregation was analyzed by turbidometric method of Born. Patients were classified in groups of smokers and non-smokers. Results showed that platelet hyperaggregability was more prevalent in smokers with lower levels of high-density lipoprotein (47% vs. 20%; P=0.004 for spontaneous platelet aggregation, 56% vs. 33%; P=0.02 for adenosine diphosphate induced platelet aggregation), and in smokers with hypertrygliceridemia (64% vs. 29%; P=0.004 for spontaneous, 81% vs. 43%; P<0.0001 for adenosine diphosphate induced, and 87% vs. 46%; P<0.0001 for adrenaline induced platelet aggregation). Platelet hypoaggregability was greater in non-smokers with normal high-density lipoprotein and triglycerides plasma levels when compared to non-smokers with the same lipid profile (39% vs. 12%; P=0.004). In conclusion, smoking increased platelet reactivity in hypercholesterolemic patients with low high-density lipoprotein levels or high triglycerides levels.

Beta-blocker infusion did not improve left ventricular diastolic function in myocardial infarction: a Doppler echocardiography and cardiac catheterization study.

Left ventricular (LV) diastolic function changes after myocardial infarction. It has been suggested that beta blockers may improve diastolic function in hypertensive and heart failure patients. Doppler echocardiographic filling patterns and invasive hemodynamic indices have been used to analyze LV diastolic function. To determine the effect of beta blockers on LV diastolic function, we studied 32 patients with anterior wall myocardial infarction with a mean age of 53 years. Peak early and late flow velocities, peak early-to-late flow velocities ratio, pressure half time, diastolic filling period, isovolumic relaxation time, cardiac index, mean arterial pressure, wedge pressure, and systemic and pulmonary vascular resistance indices were obtained simultaneously before and after an intravenous infusion of 10 mg of atenolol. Cardiac index decreased from 4.27 +/- 0.97 to 3.19 +/- 0.91 l/min/m2 (p = 0.0001); mean arterial pressure decreased from 85 +/- 10 to 80 +/- 11 mmHg (p = 0.004); wedge pressure increased from 11 +/- 5 to 13 +/- 4 mmHg (p = 0.002); systemic vascular resistance index increased from 1586 +/- 409 to 1980 +/- 634 dyn.m2.s/cm5 (p = 0.0002); pulmonary vascular resistance index increased from 115 +/- 58 to 163 +/- 72 dyn.m2.s/cm5 (p = 0.0004); peak late flow velocity decreased from 64 +/- 15 to 49 +/- 14 cm/s (p = 0.0001); early-to-late ratio increased from 0.95 +/- 0.35 to 1.29 +/- 0.36 (p = 0.0001); diastolic filling period increased from 300 +/- 108 to 400 +/- 110 ms (p = 0.0001) and isovolumic relaxation time increased from 133 +/- 29 to 143 +/- 29 ms (p = 0.009). No significant changes were observed for peak early flow velocity and pressure half-time.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperlipidemia related to the use of HIV-protease inhibitors: natural history and results of treatment with fenofibrate.

Hyperlipidemia has been frequently recorded as a side effect of treating HIV patients with protease inhibitors (PI). This study was initiated to analyze the modifications on blood lipids in HIV-patients receiving PI and the safety and efficacy of the treatment with fenofibrate. Total (TC) and HDL-cholesterol, triglycerides (TG), and CD(4)(+) T-cell counts were measured in 30 HAART-naive patients (Group I) before and after PI introduction. In a second phase of the study, the effects of fenofibrate on lipids, CPK, CD(4)(+), and viral load were determined in 13 patients (Group II) with elevated TC or TG. In Group I, 60% of the patients showed TC or TG elevations. Average increments of 31% and 146% in TC and TG respectively (p<0.0006 and p<0.0001) were observed. In Group II, fenofibrate treatment was associated with decrements of 6.6% (TC) and 45.7% (TG) (p=0.07 and 0.0002) and no modifications on CPK, CD(4)(+), and viral load. In conclusion, hyperlipidemia is common during the treatment of HIV with protease inhibitors, and fenofibrate appears to be an effective and safe choice for its treatment.

[Psychological factors influencing smoking persistence in coronary patients]. / Fatores psicológicos intervenientes na manutenção do tabagismo em portadores de doença arterial coronária.

PURPOSE: To study the psychological factors influence on the maintenance of smoking in coronary patients. METHODS: Questionnaire was applied in 40 smoking coronary patients, to investigate the tobacco's dependence type and degree, resistance degree, readiness level to abstinence and attitudes/emotions that favors tobacco's use. Male sex was predominant (75%) with age ranging from 25 to 80 (mean 52) years. RESULTS: Regarding the tobacco psychological type dependence, 75% of patients smoke to lower tension, 47.5% presenting a moderate resistance to quit smoking. Concerning the readiness to abstinence, 42.5% of patients were found to be in the contemplative stage. CONCLUSION: The coronary patient quit smoking treatment must include interventions aimed to provide instruments to cope with stressful situations and to increase the motivation to reach an action and maintenance abstinence smoking stage.

[Salvage coronary angioplasty in a young patient with Takayasu arteritis and myocardial infarction]. / Angioplastia coronária de salvamento em jovem com arterite de Takayasu e infarto do miocárdio.

A 16 year old boy with Takayasu's disease was admitted with myocardial infarction. Thrombolytic therapy with intravenous streptokinase showed no signs of reperfusion. Rescue angioplasty of the left descending coronary artery was performed with success.

[Thrombolytic treatment in pulmonary thromboembolism in the postoperative period following heart surgery complicated by ischemic cerebrovascular attack]. / Tratamento trombolítico no tromboembolismo pulmonar em pós-operatório de cirurgia cardíaca complicado por acidente vascular cerebral isquêmico.

A 69 years old man with pulmonary embolism early after coronary bypass surgery complicated by ischemic stroke received thrombolytic therapy. Reperfusion of the pulmonary artery was achieved. Conversion of the ischemic stroke to hemorrhagic infarction was observed at the CT-Scan without neurological impairment.

[Late potentials in patients with myocardial infarction subjected to coronary thrombolysis]. / Comportamento dos potenciais tardios em portadores de infarto do miocárdio submetidos à trombólise coronária.

PURPOSE: Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis with success. MATERIAL AND METHODS: Thirty-five patients with acute myocardial infarction, 32 (91.4%) male with ages varying from 33 to 68 (mean 52.6). Thrombolysis was obtained during cinecoronarography with intravenous infusion "in bolus" of doses of 50 mg, 60 mg and 70 mg of rt-PA, with a new bolus of 30 mg at 60 minutes after the procedure. A new angiographic study was performed 12-48 hours late. The high resolution ECG was taken with the ART system model 1200 EPX, before, after and 72 hours later. The presence of electrical activity in the last 40 ms of the QRS complex with less than 20 mu volts in amplitude and more than 35 ms in duration characterized the LP. RESULTS: LP was observed in 16 (46%) patients during the phase of arterial occlusion. LP was recorded only in 23% after recanalization and in 26% when the infarcted related artery (IRA) remain opened. The reduction in the LP was 43.5%. Only one patient with LP had threatening arrhythmia. CONCLUSION: In patients with demonstrated thrombotic occlusion of the IRA, the recanalization diminished the incidence of LP in 43.5% of the patients. Further studies are necessary to achieve the exact clinical importance of these findings.

[The influence of lipoprotein (a) in thrombolysis with r-TPA for myocardial infarction]. / Influência da lipoproteína (a) na trombólise com rt-PA no infarto do miocárdio.

PURPOSE: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA for myocardial infarction (MI). METHODS: Thirty-eight MI patients, 28 male, mean age 51 +/- 9 years, submitted to thrombolysis with rt-PA, divided in two groups according the result of the thrombolysis: A) Successful, B) Failure. Serum fibrinogen (SF) was assessed before and 90 minutes after treatment. Lp (a) levels were determined six months later. These parameters were analyzed in both groups. RESULTS: Lp (a) levels were similar in groups A and B (p = 0.45). The SF levels were not different in the groups. CONCLUSION: Lp (a) seems to have no influence in thrombolysis with rt-PA for MI.

[ST segment as an arterial recanalization indicator after thrombolytic therapy in myocardial infarction]. / Segmento ST como indicador de recanalização arterial após terapêutica trombolítica no infarto do miocárdio.

PURPOSE: To evaluate the importance of the segment ST in the identification of coronary recanalization in patients submitted to intravenous thrombolysis during acute myocardial infarction (MI). PATIENTS AND METHODS: Seventy four patients with MI, 62 male with mean age of 52.6 +/- 10 years. All patients had angiographically demonstrated occlusion of the infarct-related artery (IRA) before the thrombolytic treatment with intravenous "in bolus" infusion of 50 mg, 60 mg and 70 mg of rt-PA. The recanalization of the IRA was assessed 90 minutes later. The real status of the IRA in the angiograms was compared with the ST segment changes between the ECGs obtained before and after the thrombolytic therapy. RESULTS: Fifty six (75.6%) patients presented a significant reduction in the ST segment elevation (groups I and II). Of these, 47 possessed an opened IRA. From the 18 patients who did not show ST segment decrement (group III), 13 had an occluded IRA, and 5 an opened one. The method presented sensitivity of 90.3% and a specificity of 59.1%, positive predictive value of 83.9% and negative predictive value of 72.2%. CONCLUSIONS: The ST segment is an important marker of coronary recanalization or not following intravenous thrombolytic therapy.

[Doppler echocardiographic diagnosis of atherosclerotic aneurysm of the coronary artery]. / Diagnóstico ecodopplercardiográfico de aneurisma aterosclerótico de artéria coronária.

A 74 year-old man with acute myocardial infarction submitted to thrombolytic therapy had the diagnosis of atherosclerotic aneurysm of the coronary artery attained with Doppler echocardiography. Subsequently diagnosis was confirmed by angiography and the atherosclerotic etiology identified in pathology.