RESUMEN
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , América Latina , Resultado del Tratamiento , Catéteres , Asia , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodosRESUMEN
BACKGROUND: It is estimated that atrial fibrillation (AF) affects approximately 1.5 million people in Brazil; however, epidemiological data are limited. We sought to evaluate the characteristics, treatment patterns, and clinical outcomes in patients with AF in Brazil by creating the first nationwide prospective registry. METHODS: RECALL was a multicenter, prospective registry that included and followed for 1 year 4,585 patients with AF at 89 sites across Brazil from April 2012 to August 2019. Patient characteristics, concomitant medication use, and clinical outcomes were analyzed using descriptive statistics and multivariable models. RESULTS: Of 4,585 patients enrolled, the median age was 70 (61, 78) years, 46% were women, and 53.8% had permanent AF. Only 4.4% of patients had a history of previous AF ablation and 25.2% had a previous cardioversion. The mean (SD) CHA2DS2-VASc score was 3.2 (1.6); median HAS-BLED score was 2 (2, 3). At baseline, 22% were not on anticoagulants. Of those taking anticoagulants, 62.6% were taking vitamin K antagonists and 37.4% were taking direct oral anticoagulants. The primary reasons for not using an oral anticoagulant were physician judgment (24.6%) and difficulty in controlling (14.7%) or performing (9.9%) INR. Mean (SD) TTR for the study period was 49.5% (27.5). During follow-up, the use of anticoagulants and INR in the therapeutic range increased to 87.1% and 59.1%, respectively. The rates/100 patient-years of death, hospitalization due to AF, AF ablation, cardioversion, stroke, systemic embolism, and major bleeding were 5.76 (5.12-6.47), 15.8 (14.6-17.0), 5.0 (4.4-5.7), 1.8 (1.4-2.2), 2.77 (2.32-3.32), 1.01 (0.75-1.36), and 2.21 (1.81-2.70). Older age, permanent AF, New York Heart Association class III/IV, chronic kidney disease, peripheral arterial disease, stroke, chronic obstructive pulmonary disease, and dementia were independently associated with increased mortality while the use of anticoagulant was associated with lower risk of death. CONCLUSIONS: RECALL represents the largest prospective registry of patients with AF in Latin America. Our findings highlight important gaps in treatment, which can inform clinical practice and guide future interventions to improve the care of these patients.
Asunto(s)
Fibrilación Atrial , Accidente Cerebrovascular , Humanos , Femenino , Anciano , Masculino , Fibrilación Atrial/epidemiología , Fibrilación Atrial/terapia , Fibrilación Atrial/complicaciones , Brasil/epidemiología , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Anticoagulantes , Hemorragia/inducido químicamente , Sistema de RegistrosRESUMEN
Aims: Atrial-oesophageal fistula is a serious complication related to ablation of atrial fibrillation. As its occurrence is rare, there is a great lack of information about their mechanisms, incidence, presentations, and treatment. The objective of this manuscript is to present a series of cases of atrial-oesophageal fistula in Brazil, focusing on incidence, clinical presentation, and follow-up. Methods and results: This is a retrospective multicentre registry of atrial-oesophageal fistula cases that occurred in eight Brazilian centres from 2003 to 2015. Ten cases (0.113%) of atrial-oesophageal fistula were reported in 8863 ablation procedures in the period. Most of the subjects were male (70%) with age 59.6 ± 9.3 years. Eight centres were reference units in atrial fibrillation ablation with an experience over than 200 procedures at the time of fistula occurrence. Oesophageal temperature monitoring was performed in eight cases using coated sensors in six. The first atrial-oesophageal fistula clinical manifestation was typically fever (in six patients), with a median onset time of 16.5 (1243) days after ablation. There was a delay of 7.8 ± 3.3 days between the first manifestation and the diagnosis in five patients. The treatment was surgical in six cases, clinical in three and stenting in one. Seven patients died (70%) and two developed permanent neurological sequelae. Conclusion: Atrial-oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.
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Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Fístula Esofágica/epidemiología , Lesiones Cardíacas/epidemiología , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Fibrilación Atrial/fisiopatología , Brasil/epidemiología , Ablación por Catéter/mortalidad , Fístula Esofágica/diagnóstico , Fístula Esofágica/mortalidad , Fístula Esofágica/terapia , Esofagoscopía , Femenino , Fiebre/epidemiología , Atrios Cardíacos/lesiones , Lesiones Cardíacas/diagnóstico , Lesiones Cardíacas/mortalidad , Lesiones Cardíacas/terapia , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Arritmias Cardíacas , COVID-19 , Servicio de Cardiología en Hospital , Electrocardiografía Ambulatoria , Técnicas Electrofisiológicas Cardíacas/métodos , Telemedicina , Antivirales/farmacología , Arritmias Cardíacas/epidemiología , Arritmias Cardíacas/etiología , Arritmias Cardíacas/terapia , COVID-19/epidemiología , COVID-19/terapia , Servicio de Cardiología en Hospital/organización & administración , Servicio de Cardiología en Hospital/tendencias , Electrocardiografía Ambulatoria/instrumentación , Electrocardiografía Ambulatoria/métodos , Predicción , Humanos , Cooperación Internacional , Innovación Organizacional , SARS-CoV-2 , Sociedades Médicas/tendencias , Telemedicina/métodos , Telemedicina/organización & administración , Telemedicina/tendenciasRESUMEN
Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.
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Cateterismo Cardíaco/normas , Técnicas Electrofisiológicas Cardíacas/normas , Exposición Profesional/normas , Implantación de Prótesis/normas , Dosis de Radiación , Traumatismos por Radiación/prevención & control , Radiografía Intervencional/normas , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Técnicas Electrofisiológicas Cardíacas/efectos adversos , Técnicas Electrofisiológicas Cardíacas/instrumentación , Diseño de Equipo , Fluoroscopía/normas , Humanos , Exposición Profesional/efectos adversos , Exposición Profesional/prevención & control , Salud Laboral/normas , Seguridad del Paciente/normas , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/instrumentación , Traumatismos por Radiación/etiología , Monitoreo de Radiación/normas , Protección Radiológica/normas , Radiografía Intervencional/efectos adversos , Radiografía Intervencional/instrumentación , Medición de Riesgo , Factores de Riesgo , Flujo de TrabajoRESUMEN
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Consenso , Sociedades Médicas , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Humanos , Europa (Continente) , América Latina , AsiaRESUMEN
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
Asunto(s)
Fibrilación Atrial , Fístula Esofágica/cirugía , Ablación por Catéter , Atrios Cardíacos , HumanosAsunto(s)
Fibrilación Atrial/cirugía , Cateterismo Cardíaco/normas , Ablación por Catéter/normas , Criocirugía/normas , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/efectos adversos , Ablación por Catéter/efectos adversos , Consenso , Criocirugía/efectos adversos , Humanos , Factores de Riesgo , Resultado del TratamientoAsunto(s)
Fibrilación Atrial/cirugía , Cateterismo Cardíaco/normas , Ablación por Catéter/normas , Criocirugía/normas , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/efectos adversos , Ablación por Catéter/efectos adversos , Consenso , Criocirugía/efectos adversos , Humanos , Factores de Riesgo , Resultado del TratamientoRESUMEN
The venom of Bothrops jararaca is composed of complex mixture of molecules, mainly lectins, metalloproteinases, serinoproteinases, desintegrins, phospholipases, and peptides. This composition may vary according to the snake's age, gender, and region of origin. The aim of the was to determine individual variation in Bothrops jararaca venom in the Botucatu region, Sao Paulo State, Brazil, by means of enzymatic, biochemical, and pharmacological characterization, utilizing in vitro tests and biological assays. The activities were compared with those of Brazilian Reference Venom (BRV). Protein concentration varied between adult and juvenile groups. The electrophoretic profiles were similar, with molecular masses ranging between 25 and 50 kD, but with intraspecific variations. Reverse-phase high-performance liquid chromatography (RP-HPLC) revealed protein concentration differences. Coagulant activity did not differ significantly among adult groups, but there was a large variation between juvenile venom and BRV, which coagulated more extensively. Venoms from adults displayed greater hemorrhagic activity, especially in males recently obtained from the wild. In contrast, juveniles kept in captivity and adult males showed higher values. Edematogenic activity displayed an increase in edema in all groups. At the mean lethal dose (LD50), toxicity varied significantly between groups, with venom from captive females being threefold more toxic than juvenile venom. Data illustrate the intra- and interspecific complexity that occurs in snake venoms, which may be attributed to ontogenetic, sexual, and environmental factors that affect variability in Bothrops jararaca venom. Further, it is proposed that Brazilian public health authorities document the constitution of pooled venom employed in the immunization of serum-producing animals due to this variability in venom properties. Given the large Brazilian territory, this variability requires regional monitoring and evaluation of the efficacy of bothropic antivenom in treatment of snakebite and consequent permanent sequelae observed.
Asunto(s)
Bothrops/fisiología , Venenos de Crotálidos/toxicidad , Envejecimiento , Animales , Coagulación Sanguínea/efectos de los fármacos , Cromatografía Líquida de Alta Presión/métodos , Venenos de Crotálidos/química , Edema , Electroforesis en Gel de Poliacrilamida , Femenino , Hemorragia , Masculino , RatonesRESUMEN
OPINION STATEMENT: Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide, and it is associated with an elevated risk of thromboembolic events, including ischemic stroke. Evidence suggests that at least 90 % of left atrial thrombi discovered in patients with AF are localized to the left atrial appendage (LAA). Surgical ligation or excision of the LAA is considered the standard of care in patients who undergo mitral valve surgery or as an adjunct to a surgical Maze procedure for treatment of AF. In addition, in selected patients with AF and an elevated risk of thromboembolic events, particularly in those with contraindication to oral anticoagulation (OAC) therapy, it is reasonable to consider LAA exclusion to offer protection against ischemic stroke and other embolic complications. This can be achieved through a number of different strategies, including surgical amputation or ligation of the LAA, percutaneous endocardial occlusion of the LAA by deployment of occlusive devices, and also ligation of the LAA via a closed-chest, percutaneous, epicardial catheter-based approach in select patients. Although results from several recent percutaneous LAA closure and ligation studies are highly promising, the evidence for long-term efficacy and safety is insufficient to presently recommend this approach to all patients other than those in whom long-term OAC is contraindicated. Future randomized studies are required to further address the long-term safety and efficacy of these therapeutic options. Finally, the role for LAA occlusion and ligation seems less clear in patients who undergo successful catheter ablation of AF, since at least in a subgroup of these patients antiplatelet therapy alone has been shown to be sufficient.
RESUMEN
BACKGROUND: The 2017-2018 yellow fever virus (YFV) outbreak in southeastern Brazil marked a reemergence of YFV in urban states that had been YFV-free for nearly a century. Unlike earlier urban YFV transmission, this epidemic was driven by forest mosquitoes. The objective of this study was to evaluate environmental drivers of this outbreak. METHODOLOGY/PRINCIPAL FINDINGS: Using surveillance data from the Brazilian Ministry of Health on human and non-human primate (NHP) cases of YFV, we traced the spatiotemporal progression of the outbreak. We then assessed the epidemic timing in relation to drought using a monthly Standardized Precipitation Evapotranspiration Index (SPEI) and evaluated demographic risk factors for rural or outdoor exposure amongst YFV cases. Finally, we developed a mechanistic framework to map the relationship between drought and YFV. Both human and NHP cases were first identified in a hot, dry, rural area in northern Minas Gerais before spreading southeast into the more cool, wet urban states. Outbreaks coincided with drought in all four southeastern states of Brazil and an extreme drought in Minas Gerais. Confirmed YFV cases had an increased odds of being male (OR 2.6; 95% CI 2.2-3.0), working age (OR: 1.8; 95% CI: 1.5-2.1), and reporting any recent travel (OR: 2.8; 95% CI: 2.3-3.3). Based on this data as well as mosquito and non-human primate biology, we created the "Mono-DrY" mechanistic framework showing how an unusual drought in this region could have amplified YFV transmission at the rural-urban interface and sparked the spread of this epidemic. CONCLUSIONS/SIGNIFICANCE: The 2017-2018 YFV epidemic in Brazil originated in hot, dry rural areas of Minas Gerais before expanding south into urban centers. An unusually severe drought in this region may have created environmental pressures that sparked the reemergence of YFV in Brazil's southeastern cities.
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Sequías , Mosquitos Vectores , Fiebre Amarilla/epidemiología , Fiebre Amarilla/transmisión , Animales , Brasil/epidemiología , Brotes de Enfermedades , Femenino , Humanos , Masculino , Ocupaciones , Enfermedades de los Primates/epidemiología , Enfermedades de los Primates/virología , Primates , Población Urbana , Fiebre Amarilla/veterinaria , Virus de la Fiebre AmarillaRESUMEN
Importance: Contact tracing is a core strategy for preventing the spread of many infectious diseases of public health concern. Better understanding of the outcomes of contact tracing for COVID-19 as well as the operational opportunities and challenges in establishing a program for a jurisdiction as large as New York City (NYC) is important for the evaluation of this strategy. Objective: To describe the establishment, scaling, and maintenance of Trace, NYC's contact tracing program, and share data on outcomes during its first 17 months. Design, Setting, and Participants: This cross-sectional study included people with laboratory test-confirmed and probable COVID-19 and their contacts in NYC between June 1, 2020, and October 31, 2021. Trace launched on June 1, 2020, and had a workforce of 4147 contact tracers, with the majority of the workforce performing their jobs completely remotely. Data were analyzed in March 2022. Main Outcomes and Measures: Number and proportion of persons with COVID-19 and contacts on whom investigations were attempted and completed; timeliness of interviews relative to symptom onset or exposure for symptomatic cases and contacts, respectively. Results: Case investigations were attempted for 941â¯035 persons. Of those, 840â¯922 (89.4%) were reached and 711â¯353 (75.6%) completed an intake interview (women and girls, 358â¯775 [50.4%]; 60â¯178 [8.5%] Asian, 110â¯636 [15.6%] Black, 210â¯489 [28.3%] Hispanic or Latino, 157â¯349 [22.1%] White). Interviews were attempted for 1â¯218â¯650 contacts. Of those, 904â¯927 (74.3%) were reached, and 590â¯333 (48.4%) completed intake (women and girls, 219â¯261 [37.2%]; 47â¯403 [8.0%] Asian, 98â¯916 [16.8%] Black, 177â¯600 [30.1%] Hispanic or Latino, 116â¯559 [19.7%] White). Completion rates were consistent over time and resistant to changes related to vaccination as well as isolation and quarantine guidance. Among symptomatic cases, median time from symptom onset to intake completion was 4.7 days; a median 1.4 contacts were identified per case. Median time from contacts' last date of exposure to intake completion was 2.3 days. Among contacts, 30.1% were tested within 14 days of notification. Among cases, 27.8% were known to Trace as contacts. The overall expense for Trace from May 6, 2020, through October 31, 2021, was approximately $600 million. Conclusions and Relevance: Despite the complexity of developing a contact tracing program in a diverse city with a population of over 8 million people, in this case study we were able to identify 1.4 contacts per case and offer resources to safely isolate and quarantine to over 1 million cases and contacts in this study period.
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COVID-19 , Trazado de Contacto , Femenino , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , Ciudad de Nueva York/epidemiología , Estudios Transversales , CuarentenaRESUMEN
Catheter-based ultrasonography is a widely used tool in cardiac electrophysiology practice, and intracardiac echocardiography is supplanting other forms of imaging to become the dominant imaging modality. Given advances in pericardial access, intrapericardial echocardiography can be performed using ultrasound catheters as well. Intrapericardial echocardiography and echocardiography from the coronary sinus, also an epicardial structure, allows interventionalists to obtain unique views from virtually any vantage point, compared with other forms of echocardiography. Both intrapericardial echocardiography and coronary sinus echocardiography are safe and important alternatives that can be used during complex procedures in the electrophysiology laboratory.
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Seno Coronario/diagnóstico por imagen , Ecocardiografía/métodos , Pericardio/diagnóstico por imagen , Ablación por Catéter , Técnicas Electrofisiológicas Cardíacas/métodos , HumanosRESUMEN
More than 20 years since its initial use, catheter ablation has become a routinely performed procedure for the treatment of patients with atrial fibrillation (AF). Initially based on the electrical isolation of pulmonary veins in patients with paroxysmal AF, subsequent advances in the understanding of pathophysiology led to additional techniques not only to achieve better results, but also to treat patients with persistent forms of arrhythmia, as well as patients with structural heart disease and heart failure.
Após mais de 20 anos desde sua utilização inicial, a ablação por cateter se tornou um procedimento rotineiramente realizado para tratamento de pacientes com fibrilação atrial (FA). Fundamentado inicialmente no isolamento elétrico das veias pulmonares em pacientes com FA paroxística, subsequentes avanços no entendimento da fisiopatologia levaram a técnicas adicionais não só para obter melhores resultados, mas também para tratar pacientes com formas persistentes de arritmia, assim como pacientes com cardiopatia estrutural e insuficiência cardíaca.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/cirugía , Humanos , Venas Pulmonares/cirugía , Recurrencia , Resultado del TratamientoRESUMEN
While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.
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Infecciones por VIH/epidemiología , VIH/aislamiento & purificación , Exposición Materna/estadística & datos numéricos , Sífilis/epidemiología , Adulto , Brasil/epidemiología , Femenino , Infecciones por VIH/virología , Humanos , Embarazo , Sífilis/microbiología , Adulto JovenRESUMEN
OBJECTIVES: Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil. METHODS: Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment. RESULTS: We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care. CONCLUSIONS: Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally.
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Antibacterianos/uso terapéutico , Penicilinas/uso terapéutico , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Sífilis/tratamiento farmacológico , Adulto , Brasil/epidemiología , Estudios de Cohortes , Femenino , Humanos , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/epidemiología , Mujeres Embarazadas , Atención Prenatal , Sífilis/diagnóstico , Sífilis/epidemiología , Adulto JovenRESUMEN
COVID-19 infection has shown rapid growth worldwide, and different therapies have been proposed for treatment, in particular, the combination of immune response modulating drugs such as chloroquine and hydroxychloroquine (antimalarials) alone or in combination with azithromycin. Although the clinical evidence supporting their use is scarce, the off label use of these drugs has spread very quickly in face of the progression of the epidemic and the high mortality rate in susceptible populations. However, these medications can pathologically prolong the QT interval and lead to malignant ventricular arrhythmias such that organized guidance on QT evaluation and management strategies are important to reduce morbidity associated with the potential large-scale use.
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Antimaláricos/efectos adversos , Infecciones por Coronavirus/tratamiento farmacológico , Electrocardiografía , Síndrome de QT Prolongado/inducido químicamente , Síndrome de QT Prolongado/diagnóstico por imagen , Neumonía Viral/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Adulto , Anciano , Antimaláricos/administración & dosificación , Arritmias Cardíacas/inducido químicamente , Arritmias Cardíacas/epidemiología , Azitromicina/administración & dosificación , Azitromicina/efectos adversos , COVID-19 , Cloroquina/administración & dosificación , Cloroquina/efectos adversos , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Hidroxicloroquina/administración & dosificación , Hidroxicloroquina/efectos adversos , Incidencia , Masculino , Persona de Mediana Edad , Pandemias/prevención & control , Pandemias/estadística & datos numéricos , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , Pronóstico , Medición de Riesgo , Tratamiento Farmacológico de COVID-19RESUMEN
Background The use of ionizing radiation in medical procedures is associated with significant health risks for patients and the health care team. Objectives Evaluate the safety and acute efficacy of ablation for atrial fibrillation (AF) and supraventricular arrhythmias (SVTs) using an exclusively non-fluoroscopic approach guided by intracardiac echo (ICE) and 3D-mapping. Methods 95 pts (mean age 60 ± 18 years, 61% male) scheduled for AF Ablation (69 pts, 45 paroxysmal AF and 24 persistent AF) or non-AF SVT (26 pts - 14 AV node reentry, 6 WPW, 5 right atrial (RA) flutters, 1 atrial tachycardia) underwent zero fluoro procedures. Nine patients (9.5%) had permanent pacemakers or defibrillator resynchronization (CRT-D) devices. Both CARTO (65%) and NAVx (35%) mapping systems were used, as well as Acunav and ViewFlex ICE catheters. Results Pulmonary vein isolation (PVI), as well as all other targets that needed ablation in both atria were reached and adequately visualized. No pericardial effusions, thrombotic complications or other difficulties were seen in these series. Difficult transseptal puncture (19 patients - 20%) was managed without fluoroscopy in all cases. No backup fluoroscopy was used, and no lead apparel was needed. Pacemaker interrogations after the procedure did not show any lead damage, dislocation, or threshold changes. Conclusions A radiation-free (fluoroless) catheter ablation strategy for AF and other atrial arrhythmias is acutely safe and effective when guided by adequate ICE and 3D-mapping utilization. Multiple different bi-atrial sites were reached and adequately ablated without the need for backup fluoroscopy. No complications were seen. (Arq Bras Cardiol. 2020; 114(6):1015-1026).