Conocimientos, actitudes y prácticas sobre el test de Papanicolau (PAP) en mujeres embarazadas consultantes de hospitales públicos del Departamento de Alto Paraná, Paraguay / Knowledge, attitudes and practices on the Papanicolau smear test (PAP) in pregnant women attending public hospitals of the Department of Alto Parana, Paraguay

El cáncer de cuello uterino es el más frecuente entre las mujeres en nuestro país y la manera más eficaz para detectar en forma precoz es la realización del test de Papanicolau. El objetivo de este trabajo es identificar conocimientos, actitudes y prácticas sobre el papanicolau en mujeres consultantes de Centros Asistenciales Públicos de Alto Paraná. Estudio descriptivo. Se aplicó un cuestionario estructurado llenado en entrevista a 1049 embarazadas en Hospitales Públicos principales del Dpto. Alto Paraná. Procesamiento utilizando el Paquete Informático para las Ciencias Sociales (SPSS). La participación de las mujeres fue voluntaria y anónima. El 66.3% (695/1049) escuchó hablar del PAP. A las preguntas Que es el PAP? ha respondido correctamente el 15.5% (108), imprecisa el 38.7% (120), errónea el 7.2% (50) y no sabe el 33.7% (383); Para que sirve?, en forma correcta 12.8% (89),errónea 37.3%(258), imprecisa, 37.0% (257) y 11.4% (79) no sabe. Alrededor del 40.0% cree que debe hacerlo cada 6 meses y cada año. El 54.0.5%(372) considera que debe empezar a hacerse "al iniciar las relaciones sexuales y el 41.4% (288) antes de los 20 años. Las principales fuentes de información sobre el PAP son el médico 32.7% (228); familiar 24.3% (169) y enfermera 19.2% (133). El 46.4% (487/1049) del total y el 70.1% (487/ 695) de las que mencionaron conocer se realizó alguna vez. El 16.0% una sola vez. Es alto el porcentaje que no tienen conocimiento sobre el PAP y que dieron respuestas imprecisas y erróneas y que nunca se han realizado el test.

The cervical cancer is the most common among women in our country and the most effective way to early detect it is the PAP. The objective of this work was to identify knowledge, attitudes and practices on the PAP smear test in women attending Public Hospitals of the Department of Alto Paraná. It is a descriptive study which applied structured questionnaires filled in during interviews with 1049 pregnant women in the main public hospitals of Alto Parana. For the processing, it was used the Software Package for Social Sciences (SPSS). The participation of the women was voluntary and anonymous. The 66.3% (695/1049) heard about the PAP. To the question what is the PAP? 15.5% (108) has responded properly, 38.7% (120) imprecisely, 7.2% (50) erroneously 33.7% (383) did not know anything. In relation to the question what is it for? 12.8% (89) answered correctly, 37.3% (258) erroneously, 37.0% (257) imprecisely and 11.4% (79) did not know. Around 40.0% believed they should have it every 6 months and each year, 54.0.5% (372) considered that they should begin to have it at becoming sexually active and 41.4% (288) before 20 years old. The main sources of information about the PAP were: doctor 32.7% (228); family 24.3% (169) and nurse 19.2% (133); The 46.4% (487/1049) of the total and 70.1 % (487/695) of those who said they knew it said they have had it some time; 16.0% only once. There was a high percentage of women that did not have any knowledge about the PAP and that provided imprecise and wrong answers and that have never had the test.

Cumulative effect of complete left bundle-branch block and chronic atrial fibrillation on 1-year mortality and hospitalization in patients with congestive heart failure. A report from the Italian network on congestive heart failure (in-CHF database).

BACKGROUND: Many clinical variables have been proposed as prognostic factors in patients with congestive heart failure. Among these, complete left bundle-branch block and atrial fibrillation are known to impair significantly left ventricular performance in patients with congestive heart failure. However, their combined effect on mortality has been poorly investigated. The aim of this study was to determine whether left bundle-branch block associated with atrial fibrillation had an independent, cumulative effect on mortality for congestive heart failure. METHODS AND RESULTS: We analysed the Italian Network on congestive heart failure (IN-CHF) Registry that was established by the Italian Association of Hospital Cardiologists in 1995. One-year follow-up data were available for 5517 patients. Complete left bundle-branch block and atrial fibrillation were associated in 185 (3.3%) patients. In this population the cause of congestive heart failure was dilated cardiomyopathy (38.4%), ischaemic heart disease (35.1%), hypertensive heart disease (17.3%), and other aetiologies (9.2%). This combination of electrical defects was associated with an increased 1-year mortality from any cause (hazard ratio, HR: 1.88; 95% CI 1.37-2.57) and sudden death (HR: 1.89; 95% CI 1.17-3.03) and 1-year hospitalization rate (HR: 1.83; 95% CI 1.26-2.67). CONCLUSIONS: In patients with congestive heart failure, the contemporary presence of left bundle-branch block and atrial fibrillation was associated with a significant increase in mortality. This synergistic effect remained significant after adjusting for clinical variables usually associated with advanced heart failure. We can conclude that this combination of electrical disturbances identifies a congestive heart failure specific population with a high risk of mortality.

Very early assessment of risk for in-hospital death among 11,483 patients with acute myocardial infarction. GISSI investigators.

BACKGROUND: The efficacy of reperfusion therapy after acute myocardial infarction is time dependent. The risk profile of every patient should be available as soon as possible. Our aim was to determine whether collection of simple clinical markers at hospital admission might allow reliable risk stratification for in-hospital mortality. METHODS: The subjects were 11,483 patients with acute myocardial infarction from the GISSI-2 cohort. The GISSI-1 and GISSI-3 populations were selected to validate the classification. To stratify patients, the tree-growing method called recursive partitioning and amalgamation (RECPAM) was used. This method is used to identify homogeneous and distinct subgroups with respect to outcome. RESULTS: The RECPAM algorithm provided 6 classes. RECPAM class I included Killip class 3 to class 4 patients (516 deaths/1000). RECPAM class II included Killip 2 patients older than 66 years and with anterior infarction or sites of infarction that could not be evaluated (314 deaths/1000). Killip 1 patients older than 75 years and with anterior or multiple sites or sites that could not be evaluated were included in RECPAM class III with Killip class 2 patients younger than 66 years and with systolic blood pressure less than 120 mm Hg or older than 66 years and with any other infarction site (207 deaths/1000). The other classes showed lower mortality rates (91, 32, and 12 deaths/1000 for RECPAM classes IV, V, and VI). In the GISSI 1 and GISSI 3 samples the 6 classes ranked in the same order in terms of mortality rate. With respect to low-risk strata, patients belonging to RECPAM class VI without serious clinical events in the first 4 days had a very low incidence of in-hospital death (0.9%) or morbidity. Cumulative 6-month mortality for the 6 RECPAM classes was 59.6%, 41.2%, 26.4%, 12.9%, 4. 8%, and 2.2%. CONCLUSIONS: Four simple clinical markers readily available at admission of patients with myocardial infarction allow a quick, reliable, and inexpensive prediction of risk for in-hospital and 6-month mortality. The RECPAM classification also helped identify a large subgroup of patients fit for early hospital discharge.

Use of medical resources and quality of life of patients with chronic heart failure: a prospective survey in a large Italian community hospital.

AIMS: To assess the prevalence, clinical characteristics, use of medical resources and quality of life in consecutive patients with chronic heart failure (CHF) hospitalized in a large community hospital during 3 months. METHODS AND RESULTS: The study group included 354 patients with CHF, admitted in the Departments of Internal Medicine (97%) and Cardiology. Median age was 78 years [72;85], 45% were males. CHF was the main diagnosis in 72%; 28% were in NYHA class III and 49% in class IV; 42% had atrial fibrillation. The median hospital stay was 8 days [5;14], in-hospital mortality 9% in those admitted for CHF and 19% in those admitted primarily for other diseases. Patients with CHF occupied 15% of the beds; 1330 ECGs, 389 chest X-rays, 112 echocardiograms and 10 coronary angiograms were performed. A quality of life questionnaire revealed that 82% had problems with mobility, 54% with self-care and 88% with everyday activity. Thirty-nine percent of patients had at least one hospitalization during the previous year. CONCLUSIONS: Ninety-seven percent of hospitalized patients with CHF are admitted in the Internal Medicine wards and occupy 15% of beds. The majority of the patients are 72 years or older, with severe heart failure. The frequency of rehospitalization(s) and mortality rate in this population remains high. Echocardiography is performed only in 27% of patients.

Cardiac magnetic resonance imaging findings in patients with right ventricular outflow tract premature contractions.

AIMS: To assess prospectively the value of cardiac magnetic resonance imaging in patients with apparently idiopathic premature contractions arising from the right ventricular outflow tract. METHODS: We compared magnetic resonance imaging scans in 19 patients (13 males and six females, mean age 44 years) with frequent (> 100 per hour), monomorphic (left bundle branch block and inferior axis morphology) extrasystoles, and in 10 volunteers (four males and six females, mean age 36.7 years) without structural heart disease. Magnetic resonance imaging studies (1 or 1.5 Tesla) included spin-echo and gradient-echo sequences in the standard planes. The presence of structural and dynamic abnormalities of the right and left ventricles, such as reduced wall thickness, systolic bulging, and decreased systolic thickening, were evaluated. In addition, end-diastolic diameters of the right ventricular outflow tract were measured in the transverse plane. RESULTS: The dimensions of the right ventricular outflow tract were wider in patients with extrasystoles compared to the control group. Mean anteroposterior and transverse diameters were 39.6 +/- 4.6 mm vs 29.9 +/- 4.8 mm (P < 0.01) and 27.5 +/- 3.8 mm vs 20.5 +/- 2.5 mm (P < 0.01), respectively. Wall motion and morphological abnormalities were present in 16/19 (84%) patients, and were confined to the anterolateral wall in 15/16 cases. All normal subjects had normal magnetic resonance imaging findings (P = 0.008). CONCLUSIONS: Cardiac magnetic resonance imaging revealed that in patients with idiopathic right ventricular outflow tract premature contractions there was a higher rate of morphological and functional abnormalities of the right ventricular outflow tract than in the normal subjects. Large studies and long follow-up are needed to confirm whether these findings could help identify a localized form of arrhythmogenic cardiomyopathy, and its clinical significance.

Clinical challenge. II. Management of recent onset atrial fibrillation. PAFIT-2 Investigators.

Atrial fibrillation is a very common arrhythmia in patients with structural heart disease, but it also occurs in patients without underlying heart disease. Acute therapy for paroxysmal atrial fibrillation is very dependent on the clinical condition of the patient. Direct current cardioversion is usually the first choice whenever the arrhythmia precipitates heart failure or severe angina, while more stable patients are normally treated with drugs. Most episodes of atrial fibrillation eventually convert to sinus rhythm even in the absence of treatment. Antiarrhythmic drugs can be used to control the ventricular response or to restore sinus rhythm, and several have been tested to assess their ability to convert recent onset atrial fibrillation. The success rate has varied, but generally flecainide and propafenone appear the most effective. Digitalis and calcium channel blockers do not increase the likelihood of reversion but they reduce ventricular rate. Amiodarone has been tested as a possible alternative to flecainide and propafenone. The pros and the cons of these and other drugs in the setting of paroxysmal atrial fibrillation will be discussed. In particular, special emphasis will be given to the differences in the design and in patient selection of the trials that tested antiarrhythmic drugs in paroxysmal atrial fibrillation.

Prognostic value of a history of hypertension in 11,483 patients with acute myocardial infarction treated with thrombolysis. GISSI-2 Investigators. Gruppo Italiano per lo Studio della, Sopravvivena nell'Infarto Miocardico.

OBJECTIVE: To assess the prognostic value of a history of hypertension in patients with acute myocardial infarction (AMI) treated with thrombolysis. DESIGN: Retrospective adjusted analysis of outcome data of patients with AMI randomly allocated to treatment in a controlled study of alteplase versus streptokinase and heparin versus no heparin. SETTING: A highly representative sample (about 90%) of Italian Coronary Care Units. PATIENTS: Patients with (n = 3306) and without (n = 7406) a history of treated hypertension. MAIN OUTCOME MEASURES: Morbidity and mortality during hospital stay and the next 6 months. RESULTS: Patients with a history of hypertension had a significantly higher mortality, both in hospital and during the next 6 months. The difference persisted also after a multivariate analysis including all major prognostic factors for in-hospital and 6-month mortality, respectively. Left ventricular failure and recurrent ischaemic events (angina and re-infarction) were also significantly more frequent in hypertensives both during their hospital stay and during follow-up study. CONCLUSIONS: A history of hypertension is a negative independent prognostic factor after acute myocardial infarction treated with thrombolysis.

Feasibility of simultaneous Tc99m sestamibi and 2D-echo cardiac imaging during dobutamine pharmacologic stress. Preliminary results in a female population.

Feasibility of simultaneous 2D-Echo and SPECT Tc99m Sestamibi imaging during dobutamine infusion was evaluated in a female population with suspected coronary artery disease and scheduled for diagnostic coronary angiography. A total of 49 consecutive subjects were studied. Patients under continuous ECG and 2D-Echo monitoring underwent standard dobutamine infusion at increasing doses to a diagnostic end-point. Tc99m Sestamibi was administered at the peak of the dobutamine effect. With this approach, 35 patients were identified correctly by 2D-Echo (Sensitivity = 60.1%; Specificity = 83.3%; Agreement = 71.4%; k = 0.43). Perfusion imaging with Tc99m Sestamibi resulted in correctly identifying 41 patients (Sensitivity = 83%; Specificity = 84%; Agreement = 83.6%; k = 0.67). Combining information obtained from the two tests resulted in increased specificity (92%) and decreased sensitivity (64%). Simultaneous assessment of perfusion and function with Tc99m Sestamibi and 2D-Echo imaging during dobutamine administration is easily performed without added risk or discomfort to the patient. Tc99m Sestamibi appeared to be slightly superior to 2D-Echo for the detection of CAD in this population, but the difference does not reach conventional statistical significance. The combined use of the two independent tests did not substantially improve the diagnostic accuracy of each method.

Intravenous propafenone in paroxysmal atrial fibrillation: a randomized, placebo-controlled, double-blind, multicenter clinical trial. Paroxysmal Atrial Fibrillation Italian Trial (PAFIT)-2 Investigators.

BACKGROUND: Pharmacological conversion of paroxysmal atrial fibrillation is frequently necessary. The aim of this study was to compare intravenous propafenone, a class Ic antiarrhythmic agent, with placebo in paroxysmal atrial fibrillation (AF) of recent onset (< 72 h). PATIENTS AND METHODS: We randomly allocated 75 patients, aged 18 to 70 years, with paroxysmal AF to receive intravenous propafenone (2 mg/kg in 15 min followed by 1 mg/kg in 2 h) or the matching placebo. Patients were followed for 3 h. Exclusion criteria were the presence of one of the following: clinical heart failure, recent acute myocardial infarction, hypotension, atrioventricular block, Wolff-Parkinson-White syndrome, or current treatment with antiarrhythmic agents or digitalis. RESULTS: No sign of heart disease was found in 74.7% of the patients. Echocardiographically determined left atrium diameter was similar in the two groups. Conversion to sinus rhythm occurred in 24 of 41 patients allocated to propafenone and in 10 of 34 patients allocated to placebo (odds ratio 3.2, 95% confidence intervals 1.3-7.9; p < 0.01). Mean conversion time was 34 +/- 29 and 71 +/- 55 min, respectively, for propafenone and placebo. Mean heart rate in nonconverters decreased from 146 to 109 beats/min in patients treated with propafenone while it remained virtually unchanged in those treated with placebo. Only minor side effects were noted. CONCLUSIONS: Intravenous propafenone is an effective therapeutic option for restoring sinus rhythm in patients with paroxysmal AF of recent onset.

Conventional risk factors reconsidered in patients with acute myocardial infarction.

Large-scale randomized clinical trials have allowed an exploration of the interactions between conventional risk factors and prognosis in patients who have already suffered acute myocardial infarction. The exposure to risk factors not only increases the probability of developing the disease but also affects the subsequent prognosis. Elderly, hypertensive and diabetic patients are at increased risk both during the in-hospital phase and afterwards. Nevertheless, secondary analyses sometimes produce unexpected results; the surprising finding of a protective effect of cigarette smoking with respect to death and re-infarction is probably the best example and illustrates how carefully secondary analyses should be performed.

Cytokines in acute myocardial infarction: selective increase in circulating tumor necrosis factor, its soluble receptor, and interleukin-1 receptor antagonist.

Cytokines play a pathogenetic role in a variety of infective and inflammatory diseases. In the present study, we had two objectives: (a) to define the kinetics of tumor necrosis factor (TNF) in plasma after acute myocardial infarction (AMI) in patients treated with early thrombolysis, and (b) to measure other cytokines, interleukin-1 (IL-1) and TNF receptor antagonists, in plasma. TNF-alpha, but not IL-1 beta or IL-8, was present in plasma of 6 of 7 patients with severe AMI (Killip class 3 or 4). No TNF (< 50 pg/ml) was detected in a group of 11 patients with uncomplicated myocardial infarction (Killip class 1) or in control patients without AMI. Soluble TNF receptor type I and IL-1 receptor antagonist (IL-1Ra) were also significantly increased in the group with severe AMI compared with those with uncomplicated AMI. Circulating TNF is increased only in AMI complicated by heart failure at hospital admission. This finding may have diagnostic and therapeutic relevance.

Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2).

BACKGROUND: The overall rate of mortality due to ischemic heart disease is known to increase progressively with age. We evaluated the relation between the mortality rate and age in patients with first myocardial infarctions treated with thrombolytic therapy. METHODS: We studied 9720 patients with first infarctions who had been enrolled in the GISSI-2 trial. (This trial compared the efficacy of tissue plasminogen activator with that of streptokinase in patients with myocardial infarction.) Of these, only 35 percent had a history of angina. The relation between age and mortality during hospitalization and during the six months after discharge was determined by unadjusted and adjusted analyses. RESULTS: The in-hospital mortality rate was 1.9 percent among patients 40 years old or younger, but it increased to 31.9 percent among those more than 80 years old; however, values for indicators of infarct size did not increase with age. Autopsies were performed in 20 percent of the 772 patients who died in the hospital; the findings showed that the frequency of cardiac rupture increased from 19 percent among patients 60 years old or younger to 86 percent among those more than 70 years old. The mortality rate for the first six months after hospital discharge also increased significantly with age. After adjustment for confounding variables, older age continued to be significantly associated with a higher risk of in-hospital and post-discharge death. When age was introduced into a multivariate model as a continuous variable, the risk of death was estimated to increase by about 6 percent per year for both in-hospital and six-month mortality rates. CONCLUSIONS: In patients with first myocardial infarctions who received thrombolytic therapy, age was a powerful independent predictor of both in-hospital and post-discharge mortality rates. The exponential, age-related increase in the mortality rate did not appear to be explained by larger infarcts.

[Morphofunctional changes in the left ventricle of the elderly person and the vulnerability to myocardial necrosis]. / Alterazioni morfofunzionali del ventricolo sinistro nell'anziano e vulnerabilità alla necrosi miocardica.

In the Western world the percentage of subjects over the age of 60 years is rapidly increasing. Therefore, elderly individuals represent a progressively increasing proportion of patients with ischemic heart disease (IHD), which is the most prevalent disease in this age range. In the elderly both the clinical presentation and the outcome of IHD have some peculiar features which may have important therapeutic implications. The prevalence of both coronary atherosclerosis and uncomplicated angina pectoris increases up to the sixth decade when it reaches a plateau. Conversely, the prevalence of myocardial infarction increases progressively at increasing ages without reaching any plateau at all. These findings indicate that the higher prevalence of myocardial infarction in the elderly is not caused by a worsening of the atherosclerotic background, but rather by a greater prevalence and/or severity of the functional factors such as local smooth muscle hyperreactivity, local thrombotic stimuli and alterations of the systemic thrombosis-thrombolysis equilibrium which are more directly responsible for the irreversible occlusion of a coronary artery branch. Therefore, the prevention of IHD in the elderly should focus mainly on the ischemic stimuli leading to coronary thrombosis rather than on the atherosclerotic background. Another important feature of IHD in the elderly is the high short and medium-term mortality of acute myocardial infarction. This excess of mortality is caused mainly by a much higher incidence of cardiac rupture, which does not appear to be related to the severity of coronary atherosclerosis nor to the infarct size.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolysis in acute myocardial infarction.

The 1980s has been a critical decade for the management of acute myocardial infarction (MI) because of the concentration in a very short time span of innovative results produced by a new generation of trials, in which thrombolysis has been the preeminent topic. The message coming from the results in the more than 50,000 patients included in the five key trials is simple and clear: thrombolysis, of any type, is the cornerstone of acute treatment of MI, and it works well to produce a very favorable epidemiologic picture. In the GISSI-2 trial, the nationwide adoption of a package of recommended treatments centered on thrombolysis for the overall population of patients with an acute MI has produced a relevant modification of the natural history of the disease, reducing the in-hospital mortality by about 40% in few years (from 13% to 8.8%). In particular, in the great majority of cases (patients aged less than 70 years in Killip class I with a first acute MI), the mortality has gone down to 3%, making a further reduction very hard to obtain with new drugs or strategies. In this context, we will discuss the concept of the relevance for clinical practice of obtaining even greater patency rates with new thrombolytic agents (hopefully more efficient and safe) or with new combinations of traditional agents.