Human Immunodeficiency Virus (HIV) 2 Superinfection in a Patient Receiving Antiretroviral Therapy With Longstanding HIV-1 Viral Load Suppression.

Dual human immunodeficiency virus (HIV) 1 and HIV-2 superinfections are rare but challenging. A HIV-1-infected patient receiving effective antiretroviral therapy was investigated for a severe CD4+ cell count decline. HIV-2 superinfection was diagnosed and genotypic test revealed mutations conferring resistance to most drug class, limiting options for treatment.

[Diuretics in the treatment of heart failure]. / Diuréticos no tratamento da insuficiência cardíaca.

Diuretics, together with other drugs and general measures, are of prime importance in the medical treatment of most heart failure patients, namely those with acute pulmonary oedema and overt congestive heart failure. Their beneficial effects result not only from preload and afterload reduction, but also because diuretics are able to improve responses to nitrates and ACE-inhibitors. The appropriate utilisation of diuretics in heart failure therapy frequently involves the use of efficient small doses and drug associations, namely between loop diuretics, thiazides, potassium sparing agents and spirolactone. Physicians must choose the drug carefully, its dosage, time and route of administration, according to the patient's characteristics: heart failure clinical syndrome, age, activity level, systolic or diastolic, left or right ventricular dysfunction, and associated diseases. The role of diuretics in the treatment asymptomatic systolic left ventricular dysfunction and oligosymptomatic diastolic ventricular dysfunction is unclear and should remain under investigation; diuretics may be of benefit in treating those patients with associated diseases, for example arterial hypertension and mild chronic renal failure.

[Guidelines for the therapy of heart failure: importance of the treatment individualization]. / Normas na terapêutica da insuficiência cardíaca: importância da individualização no tratamento.

Heart failure therapy has evolved significantly in recent years, allowing a prolonged survival and better quality of life. However, mortality and morbidity remain high, with enormous costs for the community. The incidence and prevalence of heart failure are increasing in Europe and the United States, predominantly in the elderly. The etiology of heart failure is different nowadays, with about 60% of the patients suffering from coronary artery disease. Modern treatment of heart failure involves general measures common to all patients, regardless of etiology, phase and NYHA class--etiological treatment, correction of precipitating factors, prevention, diet, programmed exercise and angiotensin converting enzyme inhibition. However, the diversity of pathophysiological and etiopathogenic aspects, the symptom intensity and the severity of the disease require individualized therapy, which implies the wise management of a panoply of drugs, mechanical resources and surgery.

[Heart failure: neurohumoral approach to treatment]. / Insuficiência cardíaca: da visão neuro-humoral ao tratamento.

Heart failure is a frequent human disease, partly related to anomalous activation of the defense systems, following a cardiovascular aggression. Increases in the prevalence of heart failure have been observed in the so-called occidental culture countries, probably due to the increased prevalence of cardiovascular risk factors, ageing population, and heart failure patients' survival. During the last two decades, intensive investigation in the human and non-human set have contributed to better knowledge of the patophysiology, the prevention and the therapeutic approach of heart failure. The Authors reviewed on some aspects of the neurohumoral activation in heart failure, with therapeutic implications.

[Heart failure and the clinician at the end of the 20th century]. / A insuficiência cardíaca e o clínico no fim do século vinte.

Congestive heart failure represents a clinical syndrome whose symptoms and signs result from different etiopathogenic and pathophysiological mechanisms. Diagnosing congestive heart failure remains mainly a matter for accurate clinical methodology. Therapeutical approaches to congestive heart failure require a profound knowledge of the behaviour of each system and mechanism involved in the process, namely neurohumoral activation, dysautonomia and endothelial responses, besides renal, skeletal muscle, cardiac and pulmonary participation. So, the treatment of congestive heart failure is always multifactorial. Preventing heart failure requires also an accurate knowledge of those mechanisms, in order to apply the most appropriate measures to stop vascular and cardiac remodeling.

Heart failure treatment in Portuguese hospitals: results of a survey.

The management of heart failure in Europe is largely conducted by primary care physicians in out-patient clinics and by cardiologists and internists in hospitals. Several reports suggest differences among these specialists regarding knowledge and actual practice, and indicate that the application of guidelines is far from optimal. In order to look for differences between cardiologists and internists in terms of implementation of guidelines a survey was carried out among the directors of 83 hospital departments of cardiology and internal medicine in Portugal. The survey included questions about diagnostic and treatment protocols, special areas for management, and suggestions to improve the quality of heart failure patient treatment. The answers suggest that in Portuguese hospitals at least half of the patients with HF are treated by internists. Treatment protocols exist in about 25% of the cardiology departments but are virtually non-existent in internal medicine. The use and availability of echocardiography are high in cardiology but no more than reasonable in internal medicine. There are neither special in-hospital areas nor specialized nurses for the treatment of HF. Cardiologists recognize the need for greater specialization in this field--doctors, nurses and clinics--but this is not a priority for internists. An effort should be made to improve in-hospital HF treatment.

["Severe" congestive heart failure at a medical center]. / A insuficiência cardíaca congestiva "grave" em serviço de medicina.

UNLABELLED: Heart failure (HF) is a dynamic clinical syndrome depending on multiple hemodynamic and neurohormonal factors. This syndrome concerns not only left ventricular systolic dysfunction but also left ventricular diastolic dysfunction and right ventricular dysfunction. Clinical features and therapeutic approaches are different for each of them. NYHA class IV is just one of the various prognostic factors of heart failure; consequently, severe heart failure is not synonymous of NYHA class IV. OBJECTIVE: To study hospitalised patients with heart failure in NYHA class IV, in order to characterise the predominant dysfunction, and analyze evolution and mortality. DESIGN: A retrospective analysis of a prospective study. SETTING: Hundred and eight hospitalised patients (1985-89). Patients with chronic obstructive pulmonary disease and acute myocardial infarction were excluded. PATIENTS: Sixty nine patients: 29 female and 40 male, aged 18 to 81 years old (m = 59 +/- 15.5). METHODS: Patients were clinically examined and had chest radiographs, electrocardiogram and M + 2D mode echocardiogram. Three groups were identified: Group I-patients with predominant left ventricular systolic dysfunction; Group II-patients with predominant left ventricular diastolic dysfunction; Group III-patients with predominant right ventricular dysfunction. RESULTS: 41% of the patients had coronary artery disease; 44%, valvular heart disease; 11.8% dilated cardiomyopathy; 8.7% hypertrophic cardiomyopathy; 8.7% hypertensive cardiomyopathy. Fifty five percent of the patients were in group I and the major aetiology were coronary artery disease and valvular heart disease; 25% of the patients were in group II and the major aetiology were coronary artery disease and hypertrophic cardiomyopathy; 20% of the patients were in group III, all had valvular heart disease. The global mortality during the hospitalisation period was 15.9%, mostly group III (29%) and II (17%). CONCLUSIONS: Heart failure patients in NYHA class IV formed an heterogeneous group, requiring individualised therapeutic approaches. Left ventricular systolic dysfunction was the major pathophysiological mechanism, however, diastolic dysfunction and right ventricular dysfunction were frequent. Coronary artery disease presented as a frequent aetiology of heart failure, resulting in diastolic and/or systolic dysfunction. Valvular heart disease can be present as left ventricular systolic or diastolic dysfunction or as a right ventricular dysfunction, depending on the valvulopathy and the time of evolution. Echocardiography, in association with clinical features, has been very useful for each patient approach, allowing HF aetiology and pathophysiological mechanisms characterisation. The low mortality observed in this study was related certainly to the correction of precipitating factors, together with early etiologic diagnosis and pathophysiological characterisation, and adequate individualised treatment.

[Ibopamine in the treatment of congestive heart failure. Multicenter follow-up study]. / A ibopamina no tratamento da insuficiência cardíaca congestiva. Estudo multicêntrico prolongado.

OBJECTIVE: To assess safety and efficacy of ibopamine, 200 mg TID, added to conventional treatment of congestive heart failure. DESIGN: A prospective, longterm, open study over two years (1986-88). A multicenter trial. SETTING: Outpatients of Departments of Internal Medicine of S. Francisco Xavier Hospital and Sta. Maria Hospital, and Departments of Cardiology of Sta. Cruz Hospital and Hospital Militar Principal, Lisbon. PATIENTS AND METHODOLOGY: 63 patients, 49 males from 34 to 80 years (m = 55.6 +/- 11.36) and 14 females from 41 to 80 years (m = 63 +/- 10.2), with congestive heart failure, NYHA class II in 52 patients (82.5%) and NYHA class III in 11 patients (17.5%) with a mean disease duration of 47.9 months entered into the study. Digoxin, diuretics, nitrates and antiarrhythmic drugs were allowed as concomitant therapy. Patients carried out clinical examination, ECG and laboratory tests monthly and X-Ray at the beginning and at the end of each year of the study. RESULTS: 42 patients completed one year of treatment and 20/42 continued for an additional year, 17 patients completed this second year of follow-up. From the 42 patients who completed the first year period, the NYHA class changed from II to I in 17/38 from II to III in 2/38 patients from III to II in 3/4 patients, and from III to IV in one patient. Twenty patients dropped during the first year of treatment. Six for non-compliance (less than 80% of the treatment). Two were submitted to cardiac valve surgery. Seven had cardiovascular clinical events: one ventricular tachycardia, one atrial fibrillation, one pulmonary edema, one patient had no therapeutic effect, two patients had anxiety and fatigue and one patient died suddenly. One diabetic patient had uncontrolled hyperglycemia. One patient had gastric ulcer. Two had nausea and vomiting. Dysrhythmia and nausea and vomiting were the only clinical events, considered, respectively, possibly related and related, to ibopamine. During the second year of treatment 9/11 patients were stabilized in NYHA class I and 6/9 in NYHA class II, one patient changed from class II to class I, and one patient changed from class I to class II of the NYHA. Three patients did not complete the second year of treatment; one due to abnormal creatininemia; one for probable pulmonary embolism with CHF worsening; the third died suddenly. None of these events was considered related to ibopamine. Heart rate, arterial pressure, laboratory values and cardiothoracic index did not vary over the two years of the study. CONCLUSIONS: This has been the first study with data from patients treated with 200 mg TID of ibopamine during two years. Ibopamine has been shown to be a safe and useful drug added to conventional treatment of cardiac heart failure. Clinical events were few and well controlled after ibopamine interruption.

Tissue Doppler imaging in different locations of the mitral annulus: all different or all the same?

BACKGROUND: The assessment of the mitral annulus motion with tissue Doppler imaging is claimed to be an accurate method to quantify global left ventricular systolic and diastolic function. However, it is not yet perfectly defined which site of the annulus must be selected. Familial amyloidotic polyneuropathy of the Portuguese type (FAP) is an hereditary systemic disease in which diastolic dysfunction may occur. AIM: 1--To determine if in FAP patients the mitral annulus motion is independent of the selected site. 2--To compare pulsed wave Doppler parameters with tissue Doppler parameters in the different annular sites. METHODS: Of 24 FAP patients studied, 14 were included. In each patient we performed conventional transmitral pulsed wave Doppler and tissue Doppler in the 4 sites of the mitral annulus and measured the velocities of the rapid filling wave e, of the atrial contraction wave a and calculated e/a ratio. RESULTS: According to the transmitral inflow profile, patients were divided in 2 groups: Group I--normal global diastolic function and Group II--abnormal relaxation. Group I--33% of these patients showed e/a > 1 in the four sites and 67% showed e/a > 1 in at least 1, but not in all the sites. The rate of normal sites per patient was 3.1. Group II--25% of these patients showed e/a < 1 in the 4 sites of the annulus and 75% had e/a < 1 in at least 1, but not in all the sites analysed. The rate of abnormal sites/patient was 3.1. in this group. When conventional and tissue Doppler data were compared (bland and altman) the septal portion of the annulus was the one with the best correlation. CONCLUSIONS: 1--The assessment of the mitral annulus motion with tissue Doppler imaging is dependent on the site selected for study. 2--The septal site was the one that showed the highest correlation and concordance between pulsed wave Doppler and tissue Doppler. 3--The relative number of normal versus abnormal sites was determinant of the transmitral pattern. 4--Tissue Doppler imaging identified: a) among patients until now classified as normal diastolic function, a subgroup of patients with abnormal function in some sites of the annulus and b) among patients with abnormal relaxation, a subgroup with normal diastolic function in some sites of the annulus.

[Diastolic dysfunction and left ventricular hypertrophy in familial amyloidotic polyneuropathy: a cause-effect relationship?]. / Disfunção diastólica e hipertrofia ventricular esquerda na polineuropatia amiloidótica familiar: relação causa-efeito?

UNLABELLED: TTR Met30 Familial Amyloidotic Polyneuropathy of the Portuguese type (FAP) is an incapacitating and lethal hereditary disorder that affects predominantly young adults of both genders. Portuguese type FAP patients have sensory, motor and autonomic polyneuropathy. The generalised systemic amyloid infiltration involves the heart, leading to the characteristic granular bright sparkling echocardiographic pattern. LV wall thickening occurs in the late phases of the disease. LV diastolic dysfunction has been reported in the absence of systolic dysfunction; an abnormal diastolic transmitral flow pattern assessed by pulsed wave Doppler (PW) was described. PW is very much dependent on load conditions. Tissue Doppler imaging (TDI) has been used as a more reliable method to assess long axis diastolic function. OBJECTIVE: 1--To identify the incremental value of TDI in the assessment of diastolic function in FAP. 2--To correlate diastolic pattern abnormalities and left ventricular mass index (LVMI) in FAP patients. METHODS: We performed a prospective evaluation of 24 consecutive FAP patients and selected 14 (sinus rhythm, age < 45 years). Diastolic function was assessed by PW and classified as normal (GI-E/A > 1) or abnormal (GII-E/A < 1). TDI was performed in 4 sites of the mitral annulus (septum, lateral, inferior, anterior). Velocities of the rapid filling wave (E') and atrial contraction wave (A') were measured and E'/A' calculated. In each site we considered the TDI as normal (E'/A' > 1) or abnormal (E'/A' < 1). The LVMI was calculated by Devereux's formula. RESULTS: Age, gender and heart rate were similar in both groups. TDI at the septal mitral annulus was normal in all of the GI patients (E'/A': 1.29 +/- 0.19) and suggestive of abnormal LV relaxation in all of the GII patients (E'/A': 0.82 +/- 0.11, p < 0.0001). TDI revealed abnormal diastolic pattern when a restricted number of sites of the mitral annulus were assessed, even in GI patients and before PW abnormalities occurred. Fractional shortening (FS) and LVMI were similar in GI and GII (FS-GI: 45.5 +/- 5.3, GII 43.5 +/- 8.1%, p: NS; LVMI--GI: 66 +/- 9.3, GII: 67 +/- 3.0 g/m2 p: NS). CONCLUSION: The assessment of mitral annulus motion has introduced new data in the study of diastolic function of FAP patients. An abnormal LV relaxation pattern occurred early in the evolution of the disease in patients with normal LVMI and systolic function.

[Myocardiopathy caused by Portuguese-type familial amyloidotic polyneuropathy. Sequential morphologic and functional study of 60 patients]. / A miocardiopatia da polineuropatia amiloidótica familiar de tipo português. Estudo sequencial morfológico e funcional de 60 doentes.

AIM OF THE STUDY: To assess the cardiac involvement of familial amyloidotic polyneuropathy--Portuguese type (FAP) in a prospective study. INTRODUCTION: FAP is a sensitive, motor and autonomic familial polyneuropathy, due to amyloid deposits on nerve and vascular structures, related to abnormal transthyretin synthesis. FAP is a progressive systemic disease. The associated cardiomyopathy is well characterized in the Japanese form, but studies on FAP--Portuguese type cardiomyopathy remains controversial, regarding its occurrence and clinical and morphofunctional aspects. POPULATION: The Authors studied 60 Portuguese caucasoid patients, belonging to 55 different families: 23 women from 27 to 67 years old (m = 40.78 +/- 18.4) and 37 men, from 31 to 60 years old (m = 40.8 +/- 12.8). The diagnosis was established by characteristic clinical aspects, electromyograms and nerve or gut biopsies, positive for amyloid. Patients were classified in phases from I to VI according to the severity of neurological involvement and disability. METHODS: All the patients carried out clinical evaluation, thorax X-Ray, conventional EKG, Holter EKG (20-24 hours), M + 2D echocardiography and phonocardiography. Morphological and functional data were obtained from 85 echocardiographic recordings; special attention was paid to the evidence of structural abnormalities, evaluation of internal chamber dimension, left ventricular mass and systolic function indexes (left ventricular fractional shortening, left ventricular ejection fraction, left ventricular end-systolic stress index and Vcf). CONCLUSIONS: Suggestive aspects of pericardial and myocardial amyloid infiltration were found even in the earliest phases of the disease; all the records of patients in advanced phases (III to VI) were abnormal. The most frequent abnormalities founded were: a bright sparkling pericardial and myocardial echo pattern and increased ventricular wall thickness, with increased left ventricular mass index in 85% of patients in phases III to VI. Vcf was abnormally increased when plotted together with left ventricular end-systolic stress index, which was normal or decreased, probably reflecting "excessive" inotropism, in 1/3 of patients in phases III to VI. Systolic function was never depressed; no cardiac chamber enlarged. So, this study points out the presence of an infiltrative and/or hypertrophic cardiomyopathy in FAP--Portuguese type; suggestive aspects of diastolic dysfunction and decrease in systolic function were recorded. However, in the clinical setting of FAP, symptoms and signs like dyspnea, fatigue, oedema, may not be diagnosis of congestive heart disease.

[Etiologic diagnosis of pleural effusions in the adult. A solved problem?]. / Diagnóstico etiológico dos derrames pleurais do adulto. Um problema resolvido?

Pleural effusion in adults is a common syndrome due to various local and systemic diseases. A careful clinical approach is very important for etiological diagnosis; pleural fluid examination and pleural biopsy are needed in almost all cases. Other techniques, like ultrasonography, computed tomography and thoracoscopy, may also be required. In this review article, the Author presents some diagnostic strategies, emphasizing the role of accurate clinical examination and the need to interpret the conventional tests precisely.

[Acute pulmonary edema. The therapeutic approach]. / Edema pulmonar agudo. Abordagem terapêutica.

The management of acute pulmonary edema remains an interesting challenge to the clinician. The early recognition of this frequent condition, based on clinical features, must lead to the institution of general measures of therapy that can save most patients; a delay or mistake in this early treatment is lethal. The subsequent treatment depends on the characterization of the etiology and the pathophysiological characteristics of each case. The authors present a review of the management of acute pulmonary edema for the general practitioner, which includes the general first line measures and also mention some therapeutic approaches, related to different etiologies, namely those requiring intensive care units.

[Cefoxitin: its role in the therapy of anaerobic infections]. / Cefoxitina: papel na terapêutica das infecções por anaeróbios.

Cefoxitin is a second generation cephalosporin commonly used to treat anaerobic and mixed infections. The authors reviewed the recently published data about the efficacy of cefoxitin; its utility in different clinical entities, patterns of resistance and resistance mechanisms, indications and reliability of in vitro susceptibility testing. These data indicate the need for determining susceptibility patterns of anaerobics at each hospital and point out to the essential close communication between the microbiologist and clinician to the rational treatment of anaerobic infections.

[Individualized monitoring of the therapy with gentamycin using pharmacokinetic methods. Which method to choose?]. / Monitorização individualizada da terapêutica com gentamicina por métodos farmacocinéticos. Que Método escolher?

Gentamicin has an excellent cost/efficacy ratio for gram negative infections treatment. Its use is often limited in clinical practice by its narrow safety margins and a high incidence of toxicity. Gentamicin related nephrotoxicity is a major adverse effect, mostly in patients with other concomitant potential risk factors. As many other Authors we have found in our Internal Medicine Service during 1992 a gentamicin related nephrotoxicity incidence of 22.5%. Various empiric methods and nomograms have shown a significant incidence of error in predicting individualized gentamicin dosage regimens. Pharmacokinetics methods have demonstrated much better results regarding efficacy and toxicity. The aim of this prospective study carried out during 1993-1994 was to individualize by pharmacokinetics methods dosage regimens of gentamicin in patients with one or more concomitant risk factors of nephrotoxicity. The purpose of pharmacokinetics dosage regimens has been to achieve trough serum concentrations of gentamicin in therapeutics range-0.5 to 2 micrograms/ml-on the first 24 to 48 hours of treatment, and the maintenance in this range during all the treatment, avoiding both toxic and under therapeutic levels. The incidence of gentamicin related nephrotoxicity has been evaluated in this population. Twenty patients were studied: 18 males and 2 females aged 59.6 years (19 to 85). All had one or more potential risk factors for nephrotoxicity-65 years or more: 13, previous renal failure: 6, other nephrotoxic drugs: 10, diuretics: 4, dehydration: 5, congestive heart failure: 5, diabetes: 3, hypertension: 3. For the first 10 patients gentamicin dosage regimens have been determined by Sawchuk-Zaske pharmacokinetics method and for the subsequent 10 patients by Bayesian method. The two subpopulations had no significant differences regarding mean age, sex and potential risk factors for nephrotoxicity. Results of Sawchuk-Zaske method: 53 trough gentamicin serum concentration were obtained; 86.8% were within the therapeutic range, 7.5% were toxic and 5.7% were under therapeutic. Results of Bayesian method: 44 determinations of gentamicin through concentrations were obtained; 86.3% within therapeutic range, 2.4% were toxic and 11.3% were under therapeutic. A great variability in pharmacokinetic patient's profile has been found and explains the great variability of individualized dosage regimens of gentamicin (30 to 320 mg/day). No patients had gentamicin related nephrotoxicity. Both pharmacokinetics methods lead to a efficient and save employment of gentamicin in patients with previous renal failure and other potential risk factors for nephrotoxicity.