Risk-Benefit Evaluation for Surgery in a Patient with Psychiatric Complications.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Incidência de trajeto intramiocárdico em grupo populacional / Incidence of intramyocardial bridge in a population sample

Fundamentos: A anomalia causada pelo trajeto intramiocárdico tem sido apontada como diagnóstico diferencialda doença arterial coronariana.Objetivo: Analisar a incidência de trajeto intramiocárdico (TIM) em amostra populacional.Métodos: Estudo observacional, retrospectivo, que analisou prontuários de 200 pacientes diagnosticados comtrajeto intramiocárdico (TIM) ou ponte miocárdica (PM) pela angiotomografia coronariana (angio-TC), no períodode setembro de 2010 a março de 2015, no Hospital Beneficência Portuguesa de São Paulo e MedImagem – serviçode Radiologia do Hospital. Foram analisadas as seguintes variáveis: sexo, idade, altura, peso, cor da pele, históriafamiliar de doença cardiovascular, tabagismo, presença ou não de stent, incidência de dislipidemia, sintomatologia,presença de hipertensão arterial sistêmica (HAS) e diabetes mellitus (DM), e artérias coronárias mais acometidas.Resultados: Dos 200 prontuários analisados, observou-se maior incidência de TIM nos pacientes do sexo masculino(63,7%, n=128); média de idade 57,78±15,0 anos; predomínio da cor branca (85,0%); média de peso 84,5 kg, commais da metade (n=125, 62,5%) dos pacientes abaixo do peso médio; 15 (7,5%) pacientes portavam stent; 81 (40,5%)apresentavam sintomas (dor torácica ou dispneia); 108 (54,0%) tinham história familiar de doença cardiovascular;73 (36,5%) apresentavam dislipidemia; 83 (41,5%) tinham HAS; 28 (14,0%) tinham DM; 98 (49,0%) pacientesapresentavam aterosclerose; e 56 (28,0%) pacientes eram tabagistas. A principal artéria acometida foi a descendenteanterior (n=193, 96,0%)Conclusões: Conclui-se, na população estudada que o TIM é predominante em pacientes masculinos, de corbranca, não obesos, mais idosos, com história familiar de doença cardiovascular. A principal artéria acometidafoi a descendente anterior.

Background: The anomaly caused by intramyocardial bridge has been identified as a differential diagnosis of coronary artery disease.Objective: To analyze the incidence of intramyocardial bridge (IMB) in a population sample.Methods: Retrospective observational study that analyzed medical records of 200 patients diagnosed with intramyocardial bridge (IMB)or myocardial bridge (MB) using coronary computed tomography angiography (CCTA) from September 2010 to March 2015 at HospitalBeneficência Portuguesa de São Paulo and MedImagem — the Radiology service of the Hospital. The following variables were analyzed:sex, age, height, weight, skin color, family history of cardiovascular disease, smoking, presence or absence of stent, incidence of dyslipidemia,symptoms, systemic arterial hypertension (SAH) and diabetes mellitus (DM), and the coronary arteries mostly affected.Results: Of the 200 patient records reviewed, there was a higher incidence of IMB in male patients (63.7%, n=128); mean age 57.78±15.0years; predominance of white color (85.0%); average weight 84.5 kg, with more than half (n=125, 62.5%) of patients below average weight;15 (7.5%) patients were stented; 81 (40.5%) had symptoms (chest pain or dyspnea); 108 (54.0%) had a family history of cardiovasculardisease; 73 (36.5%) presented dyslipidemia; 83 (41.5%) had SAH; 28 (14.0%) had MD; 98 (49.0%) patients had atherosclerosis; and56 (28.0%) patients were smokers. The main affected artery was the left anterior descending artery (n=193, 96.0%).Conclusions: The conclusion is that, in the study population, IMB is prevalent in male patients of white color, non-obese, older,with family history of cardiovascular disease. The main affected artery was the left anterior descending artery.

Informed consent for interventions in stable coronary artery disease: problems, etiologies, and solutions.

The objective of this review was to determine whether patients undergoing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) (1) understand the aims of the proposed intervention, and (2) whether they are offered alternative and potentially more effective therapies, as required for the process of informed consent. We performed a systematic review of Medline for observational studies of patient understanding and perceptions of coronary revascularization and of the consent process. Data extraction was of patient perceptions of expected symptomatic and prognostic benefits of PCI and CABG, and the proportion of patients offered potential alternative treatments. Eight studies were identified, of which seven were relevant to PCI and three to CABG. On average, 55% of patients correctly believed that PCI would improve symptoms, while 78% erroneously believed that PCI would extend life expectancy and 71% erroneously believed PCI would prevent future myocardial infarction. On average, over 80% of patients correctly identified that CABG would improve symptoms, reduce the risk of myocardial infarction and extend life expectancy. In the three studies that examined whether alternative therapies were discussed, 68% of PCI patients and 59% of CABG patients reported no such discussion. In conclusion, a large proportion of patients undergoing coronary interventions do not appear to understand the rationale for treatment and have erroneous perceptions regarding expected benefits. Moreover, patients are frequently not offered potentially more effective alternative therapies. This raises important questions about the adequacy of the current informed consent process. We recommend a multidisciplinary team approach as the most obvious way to remedy current practice.

[Placebo surgery: surprises and ethical questions]. / Chirurgia-placebo: sorprese e problemi etici.

Placebo has a well-known therapeutic potential and this explains why placebo-controlled trials are considered necessary for showing the efficacy (and to a lesser extent the safety) of a new drug treatment. However, there are clear examples of a potent surgical placebo-effect in several pathological fields (cardiology, osteoarthropathy, slipped disk, post-traumatic lesions, abdominal adhesions, Parkinson's disease). The efficacy of the placebo surgery would suggest the advisability of placebo-controlled studies also for some surgical treatments. This type of trials, however, raises a number of reservations and ethical questions. In particular, it is necessary to consider the possible unethical nature of placebo surgery as against the unethical nature of surgical operations lacking any evidence of "specific" efficacy (i.e. being better than placebo).

The ethics of non-intervention in a study of patients awaiting coronary artery bypass surgery.

BACKGROUND: Nurses conducting clinical research frequently encounter ethically challenging situations that require careful analysis if the decisions taken are to be in the best interests of participants, researchers and society. There is a lack of literature which discusses the ethical aspects of the nurse's role in clinical research studies. AIM: The aim of this paper is to discuss the ethical conflicts and decisions taken during a combined qualitative and quantitative study of patients' experiences whilst awaiting coronary bypass surgery. DISCUSSION: Ethical conflict arose because, despite having gained ethics approval for a non-interventional study, the researcher became concerned for the health of some research participants, whose condition was observed to have deteriorated. During the course of the study four of the 70 participants died. As a result, changes to the original research protocol were negotiated and subsequently the researcher intervened in cases where participants' clinical condition had worsened. CONCLUSION: Nurses conducting clinical research studies can face serious ethical dilemmas, particularly if participants' health is at risk. This paper demonstrates the potential for both role conflict and role convergence in nursing research. We contend that since the roles of researcher and clinician are not mutually exclusive, the interface between the two requires further discussion. The paper may to help inform other researchers who struggle with the issue of non-intervention when presented with research participants in need of professional nursing care.

Priority setting in cardiac surgery: a survey of decision making and ethical issues.

OBJECTIVES: The aim of this study was to examine priority setting for coronary artery bypass surgery, and to provide an overview of decisions and rationales used in clinical practice. METHOD: Questionnaires were sent to all permanently employed cardiologists, cardiothoracic surgeons, and anaesthesiologists at nine Swedish hospitals performing adult cardiothoracic surgery. RESULTS: A total of 208 physicians responded (a 44% return rate). There was considerable agreement concerning the criteria that should be used to set priorities for coronary artery bypass interventions (clusters of factors in synthesis). However, there was a lack of accord regarding the use of national guidelines for priority setting and risk indexes. CONCLUSIONS: Basic training and the strong support of ethical principles in priority setting are lacking. The respondents indicated a need for clearer guidelines and an open dialogue or discussion. The lack of generally acknowledged plans and guidelines for priority setting may result in unequal, conditional, and unfair treatment.