Late-Onset Psychogenic Chronic Phonic-Tics.

BACKGROUND: Tics beginning in late adulthood often have an identifiable etiology. Psychogenic tics with onset around 60 years of age are rarely described in the literature. CASE REPORT: A 67-year-old female had experienced phonic tics for 8 years. Episodes occurred without premonitory sensations and precipitant factors, and she could not suppress them. She had no history of childhood tic disorder, and secondary causes of tics were excluded. She was diagnosed with psychogenic tics and treated with quetiapine with mild improvement. DISCUSSION: When physicians are faced with no identifiable cause of tics combined with certain clinical clues, a psychogenic disorder must be suspected.

Clonic Perseveration after Acute Ischemic Stroke: An Insight into the Pathophysiological Mechanisms.

Poststroke movement disorders may manifest as parkinsonism, dystonia, chorea, ballism, athetosis, tremor, myoclonus, stereotypies, and akathisia. In this article, we describe a patient with clonic perseveration 2 days after an acute ischemic stroke. We discuss the phenomenology and provide insights on possible pathophysiological mechanisms involved.

Effect of implementing an acute myocardial infarction guideline on quality indicators.

OBJECTIVE: To evaluate the compliance rates to quality of care indicators along the implementation of an acute myocardial infarction clinical practice guideline. METHODS: A clinical guideline for acute myocardial infarction was introduced on March 1st, 2005. Patients admitted for acute myocardial infarction from March 1st, 2005 to December 31st, 2012 (n=1,431) were compared to patients admitted for acute myocardial infarction before the implementation of the protocol (n=306). Compliance rates to quality of care indicators (ASA prescription on hospital admission and discharge, betablockers on discharge and door-to-balloon time) as well as the length of hospital stay and in-hospital mortality were compared before and after the implementation of the clinical guideline. RESULTS: The rates of ASA prescription on admission, on discharge and of betablockers were higher after guideline implementation: 99.6% versus 95.8% (p<0.001); 99.1% versus 95.8% (p<0.001); and 95.9% versus 81.7% (p<0.001), respectively. ASA prescription rate increased over time, reaching 100% from 2009 to 2012. Door-to-balloon time after versus before implementation was of 86(32) minutes versus 93(51) (p=0.20). The length of hospital stay after the implementation versus before was of 6(6) days versus 6(4) days (p=0.34). In-hospital mortality was 7.6% (before the implementation), 8.7% between 2005 and 2008, and 5.3% between 2009 and 2012, (p=0.04). CONCLUSION: The implementation of an acute myocardial infarction clinical practice guideline was associated with an increase in compliance to quality of care indicators.

Efeito da implementação de um protocolo assistencial de infarto agudo do miocárdio sobre os indicadores de qualidade / Effect of implementing an acute myocardial infarction guideline on quality indicators

OBJETIVO: Avaliar a adesão aos indicadores de qualidade assistencial ao longo da implementação de um protocolo assistencial de infarto agudo do miocárdio. MÉTODOS: Em 1º de março de 2005 foi implementado o protocolo assistencial de infarto agudo do miocárdio. Foram selecionados pacientes admitidos de 1ºde março de 2005 a 31 de dezembro de 2012 (n=1.431). Para comparação, utilizamos os dados de pacientes admitidos por infarto na fase pré-protocolo (n=306). Comparamos a taxa de adesão aos indicadores (taxa de prescrição de AAS na admissão hospitalar e na alta hospitalar, betabloqueador na alta e tempo porta-balão) entre as fases pré e pós-implementação do protocolo, além de tempo de permanência hospitalar e mortalidade intra-hospitalar nas diferentes fases. RESULTADOS: As taxas de prescrição de AAS na admissão e na alta hospitalar, e de betabloqueador foram maiores na fase pós versus a pré-implementação do protocolo: 99,6% versus 95,8% (p<0,001); 99,1% versus 95,8% (p<0,001) e 95,9% versus 81,7% (p<0,001), respectivamente. A taxa de prescrição de AAS aumentou ao longo da implementação do protocolo, atingindo 100% de 2009 a 2012. O tempo porta-balão pós versus pré foi de 86(32) minutos versus 93(51), respectivamente (p=0,20). O tempo de permanência hospitalar foi semelhante na fase pré versus pós-protocolo: 6(6) dias versus 6(4) dias (p=0,34). A mortalidade intra-hospitalar foi de 7,6% no pré-protocolo, 8,7% entre 2005 e 2008 e 5,3% entre 2009 e 2012 (p=0,04). CONCLUSÃO: A implementação do protocolo assistencial refletiu-se na maior adesão aos indicadores de qualidade.

OBJECTIVE: To evaluate the compliance rates to quality of care indicators along the implementation of an acute myocardial infarction clinical practice guideline. METHODS: A clinical guideline for acute myocardial infarction was introduced on March 1st, 2005. Patients admitted for acute myocardial infarction from March 1st, 2005 to December 31st, 2012 (n=1,431) were compared to patients admitted for acute myocardial infarction before the implementation of the protocol (n=306). Compliance rates to quality of care indicators (ASA prescription on hospital admission and discharge, betablockers on discharge and door-to-balloon time) as well as the length of hospital stay and in-hospital mortality were compared before and after the implementation of the clinical guideline. RESULTS: The rates of ASA prescription on admission, on discharge and of betablockers were higher after guideline implementation: 99.6% versus 95.8% (p<0.001); 99.1% versus 95.8% (p<0.001); and 95.9% versus 81.7% (p<0.001), respectively. ASA prescription rate increased over time, reaching 100% from 2009 to 2012. Door-to-balloon time after versus before implementation was of 86(32) minutes versus 93(51) (p=0.20). The length of hospital stay after the implementation versus before was of 6(6) days versus 6(4) days (p=0.34). In-hospital mortality was 7.6% (before the implementation), 8.7% between 2005 and 2008, and 5.3% between 2009 and 2012, (p=0.04). CONCLUSION: The implementation of an acute myocardial infarction clinical practice guideline was associated with an increase in compliance to quality of care indicators.

Comportamento da síndrome coronariana aguda: resultados de um registro brasileiro / Acute coronary syndrome behavior: results of a Brazilian registry

FUNDAMENTO: O Brasil carece de registros multicêntricos publicados de síndrome coronariana aguda. OBJETIVO: O Registro Brasileiro de Síndrome Coronariana Aguda é um estudo multicêntrico nacional com objetivo de apresentar dados representativos das características clínicas, e manejo e evolução hospitalares dessa síndrome. MÉTODOS: Participaram 23 hospitais de 14 cidades. Foram elegíveis pacientes que se apresentaram com suspeita de síndrome coronariana aguda nas primeiras 24 horas, com quadro clínico sugestivo, associado a alterações eletrocardiográficas compatíveis e/ou marcadores de necrose. O seguimento foi realizado até o óbito ou a alta hospitalar. RESULTADOS: Entre os anos de 2003 e 2008, foram incluídos 2.693 pacientes com diagnóstico de síndrome coronariana aguda, sendo 864 (32,1%) mulheres. O diagnóstico final foi de angina instável para 1.141 (42,4%) pacientes, com mortalidade de 3,06% deles; de infarto agudo do miocárdio sem supradesnível de ST para 529 (19,6%) pacientes, com mortalidade de 6,8% deles; e de infarto agudo do miocárdio com supradesnível de ST para 950 (35,3%) pacientes, com mortalidade de 8,1% deles; tiveram diagnóstico não confirmado 73 (2,7%) pacientes, com mortalidade de 1,36% deles. A mortalidade global foi de 5,53%. O modelo de regressão logística múltipla identificou o gênero feminino (OR=1,45), o diabetes melito (OR=1,59), o índice de massa corporal (OR=1,27) e a intervenção coronariana percutânea (OR=0,70) como fatores de risco de óbito, para demografia e intervenções. Um modelo para óbito por complicações maiores identificou choque cardiogênico/Edema Agudo de Pulmão (OR=4,57), reinfarto (OR=3,48), acidente vascular cerebral (OR=21,56), sangramento grave (OR=3,33), parada cardiorrespiratória (OR=40,27) e classe funcional de Killip (OR=3,37). CONCLUSÃO: Os dados do Registro Brasileiro de Síndrome Coronariana Aguda não diferem de outros coletados fora do país. Seus achados poderão ajudar a promover um melhor planejamento e manejo do atendimento da síndrome coronariana aguda a nível público e privado.

BACKGROUND: Brazil lacks published multicenter registries of acute coronary syndrome. OBJECTIVE: The Brazilian Registry of Acute Coronary Syndrome is a multicenter national study aiming at providing data on clinical aspects, management and hospital outcomes of acute coronary syndrome in our country. METHODS: A total of 23 hospitals from 14 cities, participated in this study. Eligible patients were those who came to the emergency wards with suspected acute coronary syndrome within the first 24 hours of symptom onset, associated with compatible electrocardiographic alterations and/or altered necrosis biomarkers. Follow-up lasted until hospital discharge or death, whichever occurred first. RESULTS: Between 2003 and 2008, 2,693 ACS patients were enrolled, of which 864 (32.1%) were females. T he final diagnosis was unstable angina in 1,141 patients, (42.4%), with a mortality rate of 3.06%, non-ST elevation acute myocardial infarction (AMI) in 529 (19.6%), with mortality of 6.8%, ST-elevation AMI 950 (35.3%), with mortality of 8.1% and non-confirmed diagnosis 73 (2.7%), with mortality of 1.36%. The overall mortality was 5.53%. The multiple logistic regression model identified the following as risk factors for death regarding demographic factors and interventions: female gender (OR=1.45), diabetes mellitus (OR=1.59), body mass index (OR=1.27) and percutaneous coronary intervention (OR=0.70). A second model for death due to major complications identified: cardiogenic shock/acute pulmonary edema (OR=4.57), reinfarction (OR=3.48), stroke (OR=21.56), major bleeding (OR=3.33), cardiopulmonary arrest (OR=40.27) and Killip functional class (OR=3.37). CONCLUSION: The Brazilian Registry of Acute Coronary Syndrome data do not differ from other data collected abroad. The understanding of their findings may help promote better planning and management of acute coronary syndrome care in public and private health services.

Acute coronary syndrome behavior: results of a Brazilian registry.

BACKGROUND: Brazil lacks published multicenter registries of acute coronary syndrome. OBJECTIVE: The Brazilian Registry of Acute Coronary Syndrome is a multicenter national study aiming at providing data on clinical aspects, management and hospital outcomes of acute coronary syndrome in our country. METHODS: A total of 23 hospitals from 14 cities, participated in this study. Eligible patients were those who came to the emergency wards with suspected acute coronary syndrome within the first 24 hours of symptom onset, associated with compatible electrocardiographic alterations and/or altered necrosis biomarkers. Follow-up lasted until hospital discharge or death, whichever occurred first. RESULTS: Between 2003 and 2008, 2,693 ACS patients were enrolled, of which 864 (32.1%) were females. T he final diagnosis was unstable angina in 1,141 patients, (42.4%), with a mortality rate of 3.06%, non-ST elevation acute myocardial infarction (AMI) in 529 (19.6%), with mortality of 6.8%, ST-elevation AMI 950 (35.3%), with mortality of 8.1% and non-confirmed diagnosis 73 (2.7%), with mortality of 1.36%. The overall mortality was 5.53%. The multiple logistic regression model identified the following as risk factors for death regarding demographic factors and interventions: female gender (OR=1.45), diabetes mellitus (OR=1.59), body mass index (OR=1.27) and percutaneous coronary intervention (OR=0.70). A second model for death due to major complications identified: cardiogenic shock/acute pulmonary edema (OR=4.57), reinfarction (OR=3.48), stroke (OR=21.56), major bleeding (OR=3.33), cardiopulmonary arrest (OR=40.27) and Killip functional class (OR=3.37). CONCLUSION: The Brazilian Registry of Acute Coronary Syndrome data do not differ from other data collected abroad. The understanding of their findings may help promote better planning and management of acute coronary syndrome care in public and private health services.

Disfunção cardíaca na sepse / Cardiac dysfunction in sepsis

A ligação entre depressão miocárdica clínica e efeitos de substâncias depressoras do miocárdio, circulantes no soro de pacientes sépticos, já é conhecida desde meados de 1970. Mediadores inflamatórios têm participação nessa patogênese, tais como fator de necrose tumoral e interleucina...

[Transient ventricular dysfunction (Takotsubo cardiomyopathy)]. / Síndrome da disfunção apical reversível (Takotsubo).

The patient was a male with myasthenia gravis, hospitalized with acute respiratory failure due to decompensation of the underlying disease. He evolved with findings suggestive of acute myocardial infarction, with electrocardiographic and enzymatic alterations compatible with that diagnosis. The patient underwent emergency coronary angiography, which showed no severe coronary obstruction, although his left ventricle had significant systolic dysfunction with characteristic alterations, on ventriculography, of the syndrome described as transient ventricular dysfunction or Takotsubo syndrome. On evolution, complete recovery of the electrocardiographic alterations and systolic ventricular function assessed on echocardiography occurred, confirming the syndrome.

Síndrome da disfunção apical reversível (Takotsubo) / Transient ventricular dysfunction (Takotsubo cardiomyopathy)

Homem portador de miastenia gravis, internado por descompensação da doença de base, em insuficiência respiratória aguda. Na evolução, apresentou quadro sugestivo de infarto agudo do miocárdio, com alterações eletrocardiográficas e enzimáticas compatíveis com o diagnóstico. Submetido a coronariografia de urgência, não evidenciou obstrução coronariana grave, entretanto o ventrículo esquerdo apresentava disfunção sistólica importante, com alteração característica pela ventriculografia da síndrome descrita como disfunção ventricular transitória ou síndrome de Takotsubo. Na evolução, houve completa recuperação das alterações eletrocardiográficas e da função ventricular sistólica avaliada pelo ecocardiograma, confirmando a síndrome.

Vasoplegic syndrome after off-pump coronary artery bypass surgery.

OBJECTIVE: The vasoplegic syndrome (VS) has been implicated in life-threatening complications after open heart surgery, where the whole-body inflammatory reaction is attributed to the cardiopulmonary bypass (CPB). Off-pump coronary artery bypass grafting (OPCAB) has been recently achieving growing enthusiasm mainly due avoiding the side effects of CPB. However herein the occurrence of VS in OPCAB is reported. METHODS: The vasoplegic syndrome usual findings occurring in the early postoperative period include severe hypotension, tachycardia, normal or elevated cardiac output and low systemic vascular resistance. Four patients underwent to OPCAB presented all the signs of VS intraoperatively or within the first 6 postoperative h. RESULTS: The patients needed aggressive vasoactive drug support for hemodynamic stabilization and all of them developed complications. These patients also had tendency to require administration of blood and blood derivatives due to diffuse and oozing type bleeding. Mean intensive care unit stay of surviving patients was 70 h and mean period of postoperative hospitalization was 9 days. Tumor necrosis factor-alpha blood levels in one patient were elevated postoperatively though no signs of infection were observed. One patient died. CONCLUSIONS: Although vasoplegic syndrome can complicate OPCAB surgery, the rationale for avoiding CPB remains valid considering the benefits provided by OPCAB.

Tratamento clínico das dissecções de aorta / Clinical treatment of the aortic dissections

A dissecção aórtica é, talvez, uma das doenças de maior morbidade e mortalidade que acometem o sistema cardiovascular. A abordagem clínica eficaz seguida de complementação diagnóstica por imagem (radiografia de tórax, ecocardiograma transesofágico, ressonância magnética, tomografia computadorizada e aortografia) é fundamental para o rápido reconhecimento da doença e pronto tratamento. Antes de um possível tratamento cirúrgico definitivo, o tratamento clínico é necessário, visando à redução do estresse hemodinâmico no segmento dissecado do vaso, por meio do controle da pressão arterial e diminuição da atividade inotrópica do coração. Essa conduta pode ser definitiva quando se opta pelo tratamento clínico em casos de dissecções crônicas ou dissecções agudas do tipo B.