Urgent versus Non-Urgent Transcatheter Aortic Valve Implantation Outcomes.

INTRODUCTION: There are limited data about the outcomes of nonelective transcatheter aortic valve implantation (TAVI). Some studies suggest that these patients (pts) have worst results. Our purpose was to compare outcomes in pts submitted to urgent versus elective TAVI. METHODS: Retrospective analysis of 298 consecutive pts submitted to TAVI between 2018 and 2021 in a single tertiary center. Baseline characteristics and outcomes were collected and compared between elective and nonelective TAVI. RESULTS: Pts submitted to urgent TAVI (79 pts) had worse baseline characteristics, with higher EuroScore risk (9.26 vs. 5.17%, p < 0.0001), STS score (7.09 vs. 4.4%, p < 0.0001), and NT pro-natriuretic peptide B (10,168 vs. 3,241 pg/mL, p = 0.001), lower left ventricle ejection fraction (45 vs. 52%, p = 0.003), more diabetes (46.8 vs. 32.4%, p = 0.0.22), peripheral artery disease (21.5 vs. 6.8%, p < 0.0001), and poor vascular accesses (18.4 vs. 7.4%, p = 0.007). Urgent TAVI was associated with higher mortality (25.3 vs. 15.1%, p = 0.043), 30-day cardiovascular mortality (17.5 vs. 4%, p = 0.001), life-threatening bleeding (11.5 vs. 4.1%, p = 0.018), vascular complications (11.5 vs. 4.6%, p = 0.031), and longer hospital stay (28 vs. 12 days, p < 0.0001), but not with intensive care unit or post-TAVI hospital stay (5 vs. 4 days, p = 0.197 and 11 vs. 10 days, p = 0.572). When adjusted to differences in baseline characteristics, urgent TAVI was only associated with longer hospital stay (p < 0.0001). CONCLUSION: Pts submitted to urgent TAVI have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics instead of the urgent nature of the procedure.

Outcomes and predictors of periprocedural stroke after transcatheter aortic valve implantation.

BACKGROUND: Risk factors for stroke after transcatheter aortic valve implantation (TAVI) are currently incompletely understood. PURPOSE: To identify possible predictors of early post-TAVI stroke and explore its short-term outcomes. METHODS: Retrospective analysis of consecutive patients (pts) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVI were collected. In-hospital and 12 months outcomes were analyzed. RESULTS: A total of 512pts (56,1% female, mean age of 82 ± 6years.) were included. In the first 30 days after TAVI 19pts (3,7%) had a stroke. In univariate analysis stroke was associated with higher body mass index (29 vs 27kg/m2, p=0.035), higher triglyceridemia (> 117,5mg/dL, p=0,002), lower high-density lipoprotein (< 38,5mg/dL, p=0,009) and porcelain aorta (36,8% vs 15,5%, p=0,014) and more frequent use of post-dilatation (58,8% vs 32%, p=0,021). In multivariate analysis, triglycerides > 117,5mg/dL (p=0,032, OR = 3,751) and post-dilatation (p=0,019, OR = 3,694) were the independent predictors. Stroke after TAVI was associated with longer intensive care unit stay (12 vs 4 days, p<0,001) and post-TAVI hospital stay (25 vs 10 days, p<0,0001), higher intra-hospital mortality (21,1% vs 4,3%, p=0,003), cardiovascular 30-day mortality (15,8% vs 4,1%, p=0,026) and 1-year stroke (13,2% vs 1,1%, p=0,003). CONCLUSION: Periprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. In this cohort, 30-day stroke rate after TAVI was 3.7%. Hypertriglyceridemia and post-dilatation were found to be the only independent risk predictors. Outcomes after stroke, including 30-day mortality, were significantly worse.

Effect of continuous positive airway pressure on atrial remodeling and diastolic dysfunction of patients with obstructive sleep apnea and metabolic syndrome: a randomized study.

OBJECTIVE: The aim of this study was to evaluate the role of obstructive sleep apnea (OSA) treatment on heart remodeling and diastolic dysfunction in patients with metabolic syndrome (MS). METHODS: This study is a prespecified analysis of a randomized placebo-controlled trial that enrolled patients with a recent diagnosis of MS and moderate-to-severe OSA to undergo continuous positive airway pressure (CPAP) or nasal dilators (placebo) for 6 months. Patients were invited to perform a transthoracic echocardiogram by a single investigator blinded to treatment assignment. RESULTS: A total of 99 (79% men; mean [SD], age: 48 [9] years; BMI: 33 [4] kg/m2 ) completed the study. At follow-up, in the placebo group, patients had a significant increase in atrial diameter: from 39.5 (37.0-43.0) mm to 40.5 (39.0-44.8) mm (p = 0.003). CPAP prevented atrial enlargement: from 40.0 (38.0-44.0) to 40.0 (39.0-45.0) mm (p = 0.194). In patients with diastolic dysfunction at baseline, almost half had diastolic dysfunction reversibility with CPAP (in comparison with only two patients in the placebo group, p = 0.039). In the regression analysis, the chance of diastolic dysfunction reversibility by CPAP was 6.8-fold (95% CI: 1.48-50.26, p = 0.025) compared with placebo. CONCLUSIONS: In patients with MS and OSA, 6 months of CPAP therapy prevented atrial remodeling and increased the chance of diastolic dysfunction reversibility.

Initial single-center experience of a standardized protocol for invasive assessment of ischemia and non-obstructive coronary artery disease.

INTRODUCTION: Coronary vasomotion disorders (CVDs), including microvascular angina (MVA) and vasospastic angina (VSA), account for significant morbidity among patients with non-obstructive coronary artery disease (NOCAD). However, protocols for CVD assessment in clinical practice are seldom standardized and may be difficult to implement. PURPOSE: To assess the safety and feasibility of a comprehensive coronary function test (CFT) protocol for assessment of CVD and the prevalence of different phenotypes of CVD in patients with angina and NOCAD (ANOCA). METHODS: Patients with persistent angina referred for invasive coronary angiogram and found to have NOCAD were prospectively recruited and underwent a CFT. Functional parameters (fractional flow reserve, coronary flow reserve and index of myocardial resistance) and coronary vasoreactivity were assessed in all patients. RESULTS: Of the 20 patients included, the mean age was 63±13 years and 50% were females. Most patients had persistent typical angina and evidence of ischemia in noninvasive tests (75%). The CFT was successfully performed in all subjects without serious complications. Isolated MVA was found in 25%, isolated VSA in 40%, both MVA and VSA in 10% and noncardiac chest pain in 25% of patients. Antianginal therapy was modified after the results of CFT in 70% of patients. CONCLUSION: A coronary function test was feasible and safe in a cohort of patients with ANOCA. CVD were prevalent in this selected group of patients, and some presented mixed CVD phenotypes. CFT may provide a definitive diagnosis in patients with persistent angina and prompt the stratification of pharmacological therapy.

Effect of wither application of an analogue of pig appeasing pheromone on encounters between unfamiliar mini-pigs.

BACKGROUND: The practice of mixing unfamiliar pigs on farms is common but results in fighting, welfare problems and performance issues. Pigs have different ways of resolving social conflicts, including aggressive and affiliative behaviours. Synthetic appeasing pheromones have demonstrated many positive effects in animal husbandry and are regularly used by breeders to improve animal welfare and performance. The aim of the study was to investigate the effect of a new method of applying pig appeasing-pheromone (PAP) to the withers in an experimental model of pig mixing to determine whether PAP reduced aggression and fighting, increased prosocial behaviours, and improved behavioural and physiological indicators of welfare. RESULTS: PAP reduced fighting between mini-pigs (df = 1; F = 13.47; P = 0.001; mixed logistic regression). Even if not significant, agonistic behaviours tended to be reduced when the treatment was applied (df = 1; F = 4.14; P = 0.058; mixed logistic regression). Likewise, mini-pigs seemed to be scored as not aggressive at all (df = 1; F = 3.61; P = 0.070; GLMM) and to be less aggressive toward the other pig than when placebo was applied. Concerning the latency of the first contact without aggression, a significant effect was found between the PAP and placebo groups (df = 1; χ2 = 4.74; P = 0.0295; Cox model). Moreover, even if not significant, the treated mini-pigs seemed to spent more time looking at each other (df = 1; F = 3.59; P = 0.071; GLMM) and immobile and/or ground sniffing (df = 1; F = 3.18; P = 0.088; GLMM) than those that received placebo. No significant difference was found between groups for salivary cortisol concentration (df = 1; F = 0.10; P = 0.752; GLMM), but variances between groups were heterogeneous at every time. No significant difference was found between groups regarding alpha-amylase activity (df = 1; F = 0.25; P = 0.621; GLMM), but variances between groups were heterogeneous at T0, T1 and T3. These results indicate that the variability (dispersion) within each group was lower when PAP was applied than when the placebo was applied. CONCLUSIONS: The new method of applying PAP improved welfare of mini-pigs (as models of domestic pigs) by reducing fighting, among other interesting results. PAP seems thus a promising biomimetic tool to enhance animal welfare in pig production systems.

Transcatheter aortic valve implantation outcomes in patients with low flow low gradient aortic stenosis.

BACKGROUND: Some studies suggest that patients with low flow low gradient (LF-LG) aortic stenosis (AS) may achieve worse results after undergoing transcatheter aortic valve implantation (TAVI). PURPOSE: To compare outcomes between LF-LG AS and high gradient (HG) AS patients submitted to TAVI. METHODS: Inclusion of 480 consecutive patients who underwent TAVI between 2008 and 2020 at a single tertiary center. Patients were divided into high gradient AS and LF-LG AS; and baseline characteristics and outcomes after the procedure were collected and compared between groups. RESULTS: Patients with LF-LG AS had worse baseline characteristics, with higher Society of Thoracic Surgeons score (p=0.008), New Euroscore II (p<0.0001), and NT pro-natriuretic peptide B (p=0.001), more frequent left ventricular ejection fraction (LVEF) <40% (p<0.0001), coronary artery disease (p<0.0001), including previous myocardial infarction (p=0.002) and coronary artery bypass graft (p<0.0001), poor vascular accesses (p=0.026) and periprocedural angioplasty (p=0.038). In a multivariate analysis, adjusted to differences in baseline characteristics, LF-LG AS was associated with worse functional class at one year (p=0.023) and in the long-term (p=0.004) and with heart failure hospitalizations at one year and in the long-term (p=0.001 and p<0.0001). In a sub-analysis including only patients with LF-LG AS, those with LVEF <40% had the worst outcomes, with more global (p=0.035) and cardiovascular (p=0.038) mortality. CONCLUSION: Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteristic differences. The sub-group of patients with LVEF <40% have the most ominous global outcomes.

Contemporary prevalence of coronary artery disease in patients referred for heart valve surgery.

BACKGROUND: Patients undergoing heart valve surgery are routinely evaluated for the presence of coronary artery disease (CAD). Currently, concomitant valve intervention and surgical revascularization is recommended when there is obstructive CAD. The aim of our study was to evaluate the prevalence of CAD, its treatment strategies, and their prognostic implications in a contemporary population of patients with valvular heart disease (VHD) referred for valve surgery (HVS). METHODS: In a multicenter registry, consecutive patients with formal indication for HVS referred for a preoperative routine invasive coronary angiogram (ICA) were analyzed. Baseline characteristics, CAD prevalence and revascularization patterns, as well as their impact on short and mid-term all-cause mortality, were assessed. RESULTS: Overall, 1133 patients were included; most had aortic stenosis (69%) and obstructive CAD was present in 307 (27.1%). HVS was ultimately performed in 82.3%. In patients with CAD, 53.4% were revascularized. After a mean follow-up time of 29.06±18.46 months, all-cause mortality rate was 12.9%. In multivariate analysis, not having HVS (HR 6.845, 95% CI=4.281-10.947, P<0.001), obstructive CAD (HR 2.762, 95% CI=1.764-4.326, P<0.01), COPD (HR 2.043, 95% CI=1.014-4.197, P=0.022), and age (HR 1.030, 95% CI=1.009-1.063, P=0.047), were independent predictors of all-cause mortality. In patients with obstructive CAD who underwent HVS, revascularization was not significantly associated with survival (HR 2.127, 95% CI=0.0-4.494, P=0.048; log rank P=0.042). CONCLUSIONS: In a contemporary cohort of patients with VHD and surgical indication, overall obstructive CAD prevalence was 27%. CAD presence and severity were associated with higher mortality. However, revascularization was not associated with a survival benefit, except in patients with left anterior descending artery disease.

Neurohormonal Profiles of Assistance Dogs Compared to Pet Dogs: What Is the Impact of Different Lifestyles?

Assistance dogs must manage stress efficiently because they are involved in challenging tasks. Their welfare is currently a fundamental issue. This preliminary study aimed to compare assistance dogs (AD; n = 22) with pet dogs (PD; n = 24), using blood neuromodulator indicators to help find biomarkers that can improve the AD breeding, selection, training, and welfare monitoring. Both populations originated from different breeds, are of different ages, and had different lifestyles. Basal peripheral concentrations of prolactin (PRL), serotonin (5-HT), free (fOT) and total (tOT) oxytocin were measured by immunoassays. Multiple linear regressions were performed to assess the effect of activity, age, sex, and their interactions on these parameters. Correlations between neurohormonal levels were analyzed. No interactions were significant. fOT and tOT concentrations were significantly influenced by age (p < 0.0001 and p = 0.0002, respectively) and dogs' activity (p = 0.0006 and p = 0.0277, respectively). A tendency was observed for age effect on PRL (p = 0.0625) and 5-HT (p = 0.0548), as well as for sex effect on tOT (p = 0.0588). PRL concentrations were heterogenous among AD. fOT and tOT were significantly but weakly correlated (Pearson's r = 0.34; p = 0.04). Blood prolactin, serotonin, and oxytocin may represent biomarkers to assess workload and chronic stress-related responses in ADs and eventually improve their selection and training.

Prevalence and prognostic impact of apical sparing contractility pattern in patients with aortic stenosis referred for transcatheter aortic valve implantation.

INTRODUCTION: Prolonged afterload increase in aortic stenosis (AS) may alter left ventricular (LV) contractility, irrespective of LV ejection fraction (LVEF). The prevalence and morbimortality associated with the apical sparing strain pattern (ASP), a typical finding of cardiac amyloidosis (CA), are not fully understood in patients with AS. We assessed the prevalence of the ASP in patients with severe AS and its clinical impact after transcatheter aortic valve implantation (TAVI). METHODS: Eighty-nine consecutive patients with severe AS and LV hypertrophy referred for TAVI were included. Baseline clinical and echocardiographic data were assessed, including the ASP in bull's eye plots (ASPB), relative apical longitudinal strain (RALS) and EF to global longitudinal strain (EF/GLS) ratio. We analysed all-cause mortality; a composite of all-cause mortality, stroke, and heart failure hospitalizations; and the rate of pacemaker implantation, after TAVI. RESULTS: Mean age was 82 ± 6 years and mean LVEF was 57 ± 10%. ASPB and RALS >1 were present in 43.8% and 24.7% of patients, respectively. Over a median follow-up of 13 months (IQR 6-32), ASPB was associated with higher rates of all-cause mortality (log-rank P=0.001) and was an independent predictor of all-cause mortality in multivariate analysis. Combination of the ASPB and GLS or EF/GLS ratio improved the risk stratification. Patients with RALS >1 were more likely to have new BBB and an indication for pacemaker implantation (P=0.048). CONCLUSION: The ASP, as assessed by the ASPB and RALS, was frequent in patients with AS regardless of the diagnosis of CA. The ASPB may refine risk stratification in patients referred for TAVI.

Three-dimensional speckle-tracking echocardiography for the global and regional assessments of left ventricle myocardial deformation in breast cancer patients treated with anthracyclines.

BACKGROUND: Assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for diagnosing cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle-tracking echocardiography (STE) has several advantages, it is not used in this setting. METHODS: 105 breast cancer patients who underwent serial echocardiographic assessment during anthracycline therapy were included. STE was used to estimate 2D GLS, 3D GLS, 3D global circumferential strain (GCS), 3D global radial strain (GRS), and 3D global area strain (GAS). CTRCD was defined as an absolute decrease in 2D/3D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%. RESULTS: 24 patients developed CTRCD. There was a significant worsening of all 3D strain parameters during chemotherapy. 3D strain regional analysis showed impaired contractility in the anterior, inferior, and septal walls. Variations of 3D GRS and 3D GCS were associated with a higher incidence of CTRCD and the variation of 3D GRS was an independent predictor of CTRCD. Variations of 3D GCS and 3D GRS had a good discrimination for predicting CTRCD, with optimal cutoff values of - 34.2% for 3D GCS and - 34.4% for 3D GRS. These variations were observed 45 and 23 days before the diagnosis of CTRCD, respectively. CONCLUSION: Variations of 3D strain parameters were predictive of and preceded CTRCD, and thus have added value over currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered to offer targeted monitoring and timely initiation of cardioprotective treatment.

Working Smarter Not Harder: Oxytocin Increases Domestic Dogs' (Canis familiaris) Accuracy, but Not Attempts, on an Object Choice Task.

The neuropeptide oxytocin (OT) has been shown to enhance dogs' ability to perform an object choice task (OCT) involving the use of human pointing cues, when delivered intranasally. This study aimed at further investigating whether OT enhances task performance by increasing choices made, or by increasing correctness of choices made, and to compare these treatment effects to dog appeasing pheromone (DAP), known to balance emotional activation in dogs. Hence, we compared OCT performance between three groups of dogs: (i) dogs administered OT and a sham collar, (ii) dogs administered a saline placebo and a DAP collar, and (iii) control dogs administered a saline placebo and a sham collar. All three groups consisted of a combination of male and female pet dogs and assistance-dogs-in-training currently living with a volunteer carer. The study also evaluated the effect of intranasal OT and/or DAP on plasma levels of OT, and prolactin; which has previously been linked with anxiety in dogs. The dogs' emotional state was measured using the Emotional Disorders Evaluation in Dogs (EDED) scale. The owners'/carers' degree of anxious- and avoidant-style attachment to their dogs was accessed using the Pet Attachment Questionnaire (PAQ). Interesting descriptive data appeared for both treatment groups. Particularly, in OT group, we obtained significant results demonstrating that intranasal OT enhances OCT performance in dogs compared to control, by increasing the percentage of correct choices, but not the number of choices, made. Results also support that the mode of action of intranasal OT is via direct access to the brain and not via the blood, since no elevation of plasma OT (or prolactin) levels were observed after intranasal administration in this study. Similarly, DAP application did not significantly alter OT or prolactin peripheral concentrations. Several differences were observed between fostered and pet dogs, namely: fostered dogs demonstrated higher levels of serum prolactin, made more choices on the OCT compared to pet dogs but were not more likely to be correct, and were fostered by carers with higher avoidant attachment scores than pet dog owners. These findings implicate consideration of potential carer and training consequences for assistance dogs.

The Impact of Equine-Assisted Therapy on Equine Behavioral and Physiological Responses.

Equine-assisted therapies (EATs) have been widely used in the treatment of patients with mental or physical conditions. However, studies on the influence of equine-assisted therapy (EAT) on equine welfare are very recent, and the need for further research is often highlighted. The aim of this study was to investigate whether EAT creates negative or positive emotions in horses, and the influence of patients' expectations (one group of patients had physical and psychological expectations and one group of patients had only psychological expectations) on horses' emotional responses. Fifty-eight pairs (patient-horse) were involved in this study. Behaviors and heart rate variability (HRV) data were collected during a resting phase, a preparation phase in which the patients brushed and saddled the horse, and a working phase. Behaviors and HRV were compared between phases and among the groups of patients. Our results suggested that the EAT in this study was neither a negative nor a positive event. EATs with patients who had both physical and psychological expectations were more challenging for horses than those with patients who had only psychological expectations. Further research should focus on providing horses with positive stimulation and reinforcement to understand whether a positive association with EAT can be achieved.

Behavioral and Physiological Differences between Working Horses and Chilean Rodeo Horses in a Handling Test.

Non-invasive measures are preferred when assessing animal welfare. Differences in behavioral and physiological responses toward a stressor could be the result of the selection of horses for specific uses. Behavioral and physiological responses of working and Chilean rodeo horses subjected to a handling test were assessed. Five behaviors, number of attempts, and the time to cross a bridge were video recorded and analyzed with the Observer XT software. Heart rate (HR) and heart rate variability (HRV), to assess the physiological response to the novel stimulus, were registered with a Polar Equine V800 heart rate monitor system during rest and the bridge test. Heart rate variability data were obtained with the Kubios software. Differences between working and Chilean rodeo horses were assessed, and within-group differences between rest and the test were also analyzed. Chilean rodeo horses presented more proactive behaviors and required significantly more attempts to cross the bridge than working horses. Physiologically, Chilean rodeo horses presented lower variability of the heart rate than working horses.

Equine Activities Influence Horses' Responses to Different Stimuli: Could This Have an Impact on Equine Welfare?

The learning and cognitive challenges that horses may face differ according to the activities in which they are involved. The aim of this investigation was to study the influence of equine activities on the behavioral responses and autonomic nervous system (ANS) activity of adult horses. Forty-one horses were divided into four groups: dressage (9), jumping (10), eventing (13) and equine-assisted activity/therapy (9). A test was created to compare the horses' behavioral and physiological responses to different stimuli. The goal was always to obtain a treat. To study the ANS activity, heart rate variability was assessed using the standard deviation of the R-R intervals (SDNN), square root of the mean of the sum of the squares of differences between successive interbeat-intervals (RMSSD) and low frequency/high frequency (LF/HF). To assess behavioral responses, video analysis was performed considering the following behaviors: exploration, interactions with another horse, and latency to approach. Significant differences in SDNN (DF = 3; F = 3.36; p = 0.0202), RMSSD (DF = 3; F = 4.09; p = 0.0078), LF/HF (DF = 3; F = 4.79; p = 0.0031), exploration (DF = 3; F = 5.79; p = 0.0013) and latency to approach (DF = 3; F = 8.97; p < 0.0001) were found among horses from different equine activities. The activity that adult horses practice appears to influence behavioral and physiological responses to different stimuli, thus impacting equine welfare.

Cohorting to prevent acquisition of multidrug-resistant bacteria: An interrupted time series study.

BACKGROUND: Grouping patients who acquired resistant microorganisms within a single area (cohorting) has been used to prevent cross-transmission. We aimed to assess cohorting effectiveness in the absence of an outbreak. METHODS: An interrupted time series study was performed in a general hospital considering patients admitted to wards. In the first year, patients who acquired multidrug-resistant (MDR) bacteria were isolated without physical transfer. In the second year, cohorting was implemented, and patients with mixed MDR bacteria were transferred to individual rooms in a specific isolation unit. Cultures were requested upon clinician orders, and surveillance or routine cultures were not performed. The effect of cohorting on the incidence density of MDR bacteria acquisition was assessed using segmented regression analysis. RESULTS: In the first and second years, 2.0 and 2.8 cases per 1,000 patient-days acquired MDR bacteria. The length of hospitalization and mortality rate were similar between phases. There was a linear increase of the monthly incidence densities of MDR bacteria acquisition in the first year (ß1: 0.11; 95% confidence interval [CI]: -0.02 to 0.24), though without an immediate impact of cohorting (ß2: -1.32; 95% CI: -3.81 to 1.16) or a change in the temporal trend (ß3: 0.04; 95% CI: -0.14 to 0.23) from the first to second phase. CONCLUSION: Cohorting may not reduce the incidence density of MDR bacteria acquisition in the absence of an outbreak.

Prognostic impact of bundle branch block after acute coronary syndrome. Does it matter if it is left of right?

BACKGROUND: In previous guidelines, acute coronary syndromes (ACS) with new or presumably new left bundle branch block (LBBB) were an indication for reperfusion treatment, preferably with primary angioplasty. Recent guidelines also included the presence of right bundle branch block (RBBB) in this recommendation. It was our objective to evaluate in a population of patients with ACS the differential impact of RBBB and LBBB in prognosis. METHODS: Consecutive patients included prospectively in a single-centre registry of ACS were included in the study. Patients were analyzed according to baseline ECG characteristics (normal QRS, LBBB or RBBB). Primary outcome was all-cause mortality at one-year follow-up. We used Cox-proportional hazards models to assess the predictive value for the primary outcome. RESULTS: A total of 3990 patients were included in, with a mean age of 64 (13) years, 72% males, 3.4% with LBBB and 4.3% with RBBB. Patients with BBB were older, with more previous history of myocardial infarction and coronary revascularization and higher prevalence of cardiovascular risk factors (except smoking). Medical treatment was similar but they were less often submitted to angioplasty. In univariate analysis, BBB patients had worst outcome (Log-rank, p < 0.001), but similar in LBBB and RBBB (Log-rank, p = 0.597). In multivariate analysis, only RBBB (HR 1.66, 95%CI 1.14-2.40, p = 0.007) is an independent predictor of all-cause mortality. CONCLUSIONS: Patients with BBB have worst outcome after an ACS, particularly with RBBB. For that reason, we should pay special attention and treat these patients as aggressively as patients with normal QRS duration or LBBB.

A Prospective Randomized Trial Comparing the Vienna Nomogram and a Ten-Core Prostate Biopsy Protocol: Effect on Cancer Detection Rate.

BACKGROUND: We evaluated whether the Vienna nomogram increases the detection rate of transrectal ultrasound-guided prostate biopsy compared with a 10-core biopsy protocol. PATIENTS AND METHODS: In the present prospective randomized study, men eligible for prostate biopsy were randomized to a Vienna nomogram protocol (group A) or a 10-core protocol (group B). They were further stratified according to age (≤ 65, > 65 but ≤ 70, and > 70 years) and prostate volume (≤ 30, > 30 but ≤ 50, > 50 but ≤ 70, and > 70 cm3). The cancer detection rate (CDR) was compared between the groups by logistic regression analysis, with adjustment for age as necessary, overall and with age and prostate volume stratification. Additional statistical analysis was performed with Fisher's exact test for contingency tables and the Mann-Whitney U test for 2 independent samples. P < .05 was considered statistically significant. A subgroup analysis was performed for patients with serum prostate-specific antigen levels of 2 to 10 ng/mL. RESULTS: From January 2009 to July 2010, 456 patients were enrolled, 237 to the Vienna nomogram group and 219 to the 10-core group. No significant differences were found in serum prostate-specific antigen or prostate volume between the 2 groups. Multivariate analysis with adjustment for age revealed no significant differences in CDR, with 42.6% in group A and 38.4% in group B (P = .705). When stratified by age and prostate volume, no statistically significant differences were found in the CDR between the groups in all subclasses. Also, in the subgroup analysis, CDR was not significantly different, 37.9% versus 34.7% for groups A and B, respectively (P = .891). CONCLUSION: These results study suggest that the use of the Vienna nomogram does not significantly increase the overall CDR compared with a 10-core biopsy scheme. Further prospective randomized studies, with adequate sample sizes, are needed to definitively determine the best prostate biopsy protocol.

Psychiatric and clinical correlates of rapid cycling bipolar disorder: a cross-sectional study

Objective: Rapid cycling (RC) is a feature of bipolar disorder (BD) that has been associated with worse outcome and more severe disability. Our goal was to investigate the association of demographic and clinical factors with RC. Methods: We compared RC and non-rapid cycling (NRC) BD patients from the Brazilian Research Network in Bipolar Disorder (BRN-BD) regarding age at onset of BD; total number of episodes; previous number of manic, depressive, mixed, and hypomanic episodes; polarity of the first episode; gender; number of suicide attempts; number of lifetime hospitalizations and lifetime history of at least one hospitalization; family history of mood disorder; clinical comorbidities such as hypothyroidism, hyperthyroidism, seizures; and current use of medications such as lithium, anticonvulsants, antipsychotics, and antidepressants. Results: We studied 577 patients and found that 100 (17.3%) met the criteria for RC in the year before the investigation. RC patients had earlier age at onset, longer duration of disease, more lifetime depressive and manic episodes, higher number of suicide attempts, and higher rate antidepressant use. Conclusion: The presence of RC in the previous year was associated with specific clinical characteristics closely related to worse outcome in the course of BD.

Urolithiasis and crohn's disease.

OBJECTIVE: To present an updated description of the relation between Crohn's disease (CD) and Urolithiasis. PATIENTS AND METHODS: A literature search for English-language original and review articles was conducted in Medline, Embase, and Cochrane databases in the month of December 2014 for papers either published or e-published up to that date, addressing the association between CD and urolithiasis as its consequence. All articles published in English language were selected for screening based on the following search terms: "CD," "renal calculus," "IBD," and "urolithiasis." We restricted the publication dates to the last 15 years (2000-2014). RESULTS: In total, 901 patients were included in this review of which 95 were identified as having CD and urolithiasis simultaneously, for a total of 10.5%. Average age was 45.07 years old, irrespective of gender. 28.6% of patients received some kind of medical intervention without any kind of surgical technique involved, 50% of patients were submitted to a surgical treatment, and the remaining 21.4% were submitted to a combination of surgical and medical treatment. Urolithiasis and pyelonephritis incidence ranged from 4% to 23% with a risk 10-100 times greater than the risk for general population or for patients with UC, being frequent in patients with ileostomy and multiple bowel resections. We found that urolithiasis occurred in 95 patients from a total of 901 patients with CD (10.5%); 61.81% in men and 38.19% in women. Stone disease seems to present approximately 4-7 years after the diagnosis of bowel disease and CaOx seems to be the main culprit. CONCLUSIONS: CD is a chronic, granulomatous bowel disease, with urolithiasis as the most common extraintestinal manifestation (EIM), particularly frequent in patients submitted to bowel surgery. This complication needs to be recognized and addressed appropriately, especially in patients with unexplained renal dysfunction, abdominal pain, or recurrent urinary tract infection. We believe this study to be an updated valuable review as most data related to this kind of EIM refers to articles published before 2000, most of them before 1990. These patients need to be followed up with a specific prevention plan to eliminate or mitigate the risk factors for stone disease, aiming at preventing its formation and its complications, preserving renal function, reducing morbidity, and ultimately improving their quality of life.

Psychiatric and clinical correlates of rapid cycling bipolar disorder: a cross-sectional study.

OBJECTIVE:: Rapid cycling (RC) is a feature of bipolar disorder (BD) that has been associated with worse outcome and more severe disability. Our goal was to investigate the association of demographic and clinical factors with RC. METHODS:: We compared RC and non-rapid cycling (NRC) BD patients from the Brazilian Research Network in Bipolar Disorder (BRN-BD) regarding age at onset of BD; total number of episodes; previous number of manic, depressive, mixed, and hypomanic episodes; polarity of the first episode; gender; number of suicide attempts; number of lifetime hospitalizations and lifetime history of at least one hospitalization; family history of mood disorder; clinical comorbidities such as hypothyroidism, hyperthyroidism, seizures; and current use of medications such as lithium, anticonvulsants, antipsychotics, and antidepressants. RESULTS:: We studied 577 patients and found that 100 (17.3%) met the criteria for RC in the year before the investigation. RC patients had earlier age at onset, longer duration of disease, more lifetime depressive and manic episodes, higher number of suicide attempts, and higher rate antidepressant use. CONCLUSION:: The presence of RC in the previous year was associated with specific clinical characteristics closely related to worse outcome in the course of BD.