Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004-2011.

OBJECTIVE: To characterise the trends in the left ventricular assist device (LVAD) implantation rates and outcomes between 2004 and 2011 in the Medicare population. Since the approval of the HeartMate II in 2008, the use of LVADs has steadily climbed. Given the increase in LVAD use, issues around discharge disposition, post-implant hospitalisations and costs require further understanding. METHODS: We examined LVAD implantation rates and short-term and long-term outcomes among Medicare fee-for-service beneficiaries hospitalised for LVAD implantation. We also conducted analyses among survivors 1-year post-discharge to examine rehospitalisation rates. Lastly, we reported Centers for Medicare & Medicaid Services (CMS) payments for both index hospitalisation and rehospitalisations 1 year post-discharge. RESULTS: A total of 2152 LVAD implantations were performed with numbers increasing from 107 in 2004 to 612 in 2011. The 30-day mortality rate decreased from 52% to 9%, and 1-year mortality rate decreased from 69% to 31%. We observed no change in overall length of stay, but post-procedure length of stay increased. We also found an increase in home discharge dispositions from 26% to 53%. Between 2004 and 2010, the rehospitalisation rate increased and the number of hospital days decreased. The adjusted CMS payment for the index hospitalisation increased from $188 789 to $225 697 over time but decreased for rehospitalisation from $60 647 to $53 630. CONCLUSIONS: LVAD implantations increased over time. We found decreasing 30-day and 1-year mortality rates and increasing home discharge disposition. The proportion of patients rehospitalised among 1-year survivors remained high with increasing index hospitalisation cost, but decreasing post-implantation costs over time.

Blood pressure and BMI in adolescents in Aracaju, Brazil.

OBJECTIVE: To assess the prevalence of high blood pressure (BP) and the association of overweight and obesity with high BP among adolescents in Aracaju, Brazil. DESIGN: Cross-sectional study. The main outcome measure was the proportion of adolescents with high BP (sex-, age- and height-specific ≥ 95th percentile). The main predictor variables were overweight and obesity defined according to the criteria of the International Obesity Task Force. Other covariates included age, socio-economic status and leisure-time physical activity. SETTING: Aracaju, Brazil, capital city of Sergipe State, north-eastern Brazil. SUBJECTS: A random sample of 1002 adolescents (442 boys and 560 girls) aged 12-17 years selected from twenty public schools and ten private schools were studied. RESULTS: The prevalence of high BP was 16.9 % (95 % CI 13.1, 21.7) in boys and 12.9 % (95 % CI 9.0, 18.0) in girls. After adjusting for age, socio-economic status and leisure-time physical activity in both boys and girls, overweight (prevalence ratio (PR) = 1.93, 95 % CI 1.08, 3.48; PR = 4.34, 95 % CI 2.58, 7.30, respectively) and obesity (PR = 4.87, 95 % CI 2.35, 10.11; PR = 5.18, 95 % CI 2.67, 10.06, respectively) were found to be associated with high BP. CONCLUSIONS: These findings indicate a high prevalence of high BP in both boys and girls in Aracaju, Brazil. Overweight and obesity were strongly associated with high BP. These findings underscore the urgent need for public health measures to prevent increasing high BP in adolescents in Brazil. Targeting intervention in adolescence may be a critical method for preventing high BP in later life.

Relationship between asthma and high blood pressure among adolescents in Aracaju, Brazil.

BACKGROUND: Asthma has been linked to cardiovascular diseases (CVDs) and related risk factors such as hypertension in adults. It is unclear whether the relationship between asthma and hypertension found among adults is also observed in adolescents. Hence, the authors examined asthma and its association with prehypertension and hypertension among adolescents in Aracaju, Brazil. METHODS: Data on asthma and blood pressure were collected among 1002 adolescents age 12 to 17 years old in 15 public schools, 5 municipal schools, and 10 private schools. Asthma data were ascertained by the International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire. Sex-, age-, and height-specific percentile levels were used to define prehypertension (90-94th percentile) and hypertension (>or=95th percentile). RESULTS: The prevalence of asthma was 20.6% in boys and 27.7% in girls. Among boys, the prevalence rates of prehypertension and hypertension were 26.7% and 17.0%, respectively. Among girls, the rates of prehypertension and hypertension were 14.3% and 12.9%, respectively. There were no statistically significant associations between asthma and prehypertension, and hypertension, even after adjusting for age, social economic status, physical activity, and body mass index (BMI) in both boys (prehypertension: odds ratio [OR] = 1.35, 95% confidence interval [CI]: 0.80-2.27; hypertension: OR = 0.60, 95% CI: 0.29-1.23) and girls (prehypertension: OR = 0.71, 95% CI: 0.40-1.28; hypertension: OR = 1.07, 95% CI: 0.60-1.94). CONCLUSIONS: These results suggest no association between asthma and high blood pressure in adolescents. More prospective studies are needed to establish whether hypertension becomes more pronounced at a specific age in asthmatics, and if so, the possible factors that may contribute to this.

Transcranial doppler in sickle cell anaemia: evaluation of brain blood flow parameters in children of Aracaju, Northeast-Brazil.

BACKGROUND: Environmental factors interfere on sickle cell anaemia (SCA). Transcanial Doppler (TCD) is important to evaluate cerebrovascular disease. OBJECTIVE: To evaluate brain haemodynamic profile of children with SCA in Sergipe. METHODS: Cross sectional study (group1: SCA patients aged 3-18; group2: age and sex matched healthy individuals). Baseline brain flow was evaluated. RESULTS: Group1=34 patients; group 2=81 controls. SCA patients had mean velocity (MV)=125.69 cm/s+/-23.40; pulsatility index (PI)=0.66+/-0.10; middle cerebral artery ratio (MCAr)=14.53+/-15.23; right anterior cerebral artery/right middle cerebral artery=0.77+/-0.20; left anterior cerebral artery/left middle cerebral artery=0.78+/-0.20. Controls had MV=79.44+/-15.54; PI=0.82+/-0.11; MCAr=13.19+/-13.77; right anterior cerebral artery/right middle cerebral artery=0.80+/-0.16; left anterior cerebral artery/left middle cerebral artery=0.84+/-0.18. MV and PI differences were statistically significant between groups. MV was related to age but not to gender. CONCLUSION: MV evaluation using TCD was similar to international standards and possible to be used in our setting.

Transcranial doppler in sickle cell anaemia: evaluation of brain blood flow parameters in children of Aracaju, Northeast - Brazil / Doppler transcraniano em portadores de anemia falciforme: estudo dos parâmetros de fluxo sangüíneo cerebral em crianças de Aracaju, Sergipe

BACKGROUND: Environmental factors interfere on sickle cell anaemia (SCA). Transcanial Doppler (TCD) is important to evaluate cerebrovascular disease. OBJECTIVE: To evaluate brain haemodynamic profile of children with SCA in Sergipe. METHODS: Cross sectional study (group1: SCA patients aged 3-18; group2: age and sex matched healthy individuals). Baseline brain flow was evaluated. RESULTS: Group1=34 patients; group 2=81 controls. SCA patients had mean velocity (MV)=125.69 cm/s±23.40; pulsatility index (PI)=0.66±0.10; middle cerebral artery ratio (MCAr)=14.53±15.23; right anterior cerebral artery/right middle cerebral artery=0.77±0.20; left anterior cerebral artery/left middle cerebral artery=0.78±0.20. Controls had MV=79.44±15.54; PI=0.82±0.11; MCAr=13.19±13.77; right anterior cerebral artery/right middle cerebral artery=0.80±0.16; left anterior cerebral artery/left middle cerebral artery=0.84±0.18. MV and PI differences were statistically significant between groups. MV was related to age but not to gender. CONCLUSION: MV evaluation using TCD was similar to international standards and possible to be used in our setting.

INTRODUÇÃO: Aspectos ambientais interferem na apresentação da anemia falciforme (AF). Doppler transcraniano (DTC) é útil na avaliação do risco para doença cerebrovascular em pacientes com AF. OBJETIVO: Avaliar o perfil hemodinâmico cerebral de crianças com AF em Sergipe. MÉTODO: Estudo transversal (grupo1: portadores de AF 3-18 anos; grupo2: indivíduos saudáveis, pareados por idade e gênero). Foram avaliadas medidas de fluxo sangüíneo cerebral basal. RESULTADOS: Grupo1 (n=34): velocidade média (Vm)=125,69 cm/s ±23,40; índice de pulsatilidade (Ip)=0,66±0,10; relação entre artéria cerebral média (ACMs)=14,53±15,23; artéria cerebral anterior (ACA)/ACM direita=0,77±0,20; ACA/ACM esquerda=0,78±0,20. Grupo 2 (n=81): Vm=79,44 cm/s ±15,54; Ip=0,82±0,11, relação entre ACMs=13,19±13,77, ACA/ACM direita=0,80±0,16; ACA/ACM esquerda=0,84± 0,18. Vm foi maior e Ip menor no grupo1. Vm se correlacionou com idade mas não com gênero. CONCLUSÃO: O perfil hemodinâmico cerebral de crianças com AF em Sergipe assemelha-se às referências internacionais. Não se observou interferência de fatores ambientais sobre os resultados.

Papel do eixo GH/IGF-1 na fisiopatologia da síndrome metabólica: resistência insulínica e lesão de órgãos-alvo / GH/IGF-1 axis and the pathogenesis of metabolic syndrome: focus on insulin resistance and target organ damage

Síndrome metabólica é definida como um agrupamento de fatores lipídicos e não-lipídicos, de origem metabólica, tendo como marcador fisiopatológico comum a resistência insulínica. É uma entidade extremamente heterogênea, apresentando-se com 16 fenótipos possíveis. A busca do conhecimento de marcadores moleculares, de novos fenótipos intermediários e o entendimento da complexa interação genética/meio-ambiente (por exemplo, interação no micro-ambiente uterino) pode promover o aparecimento de novas terapias que visem facilitar o controle dos fatores hemodinâmicos e metabólicos definidores de síndrome metabólica e, conseqüentemente, amortizar a elevada morbimortalidade dos portadores desta síndrome epidêmica. Dentre estes mecanismos, emerge o eixo GH/IGF-1 como sistema candidato para explicar parte da sua expressão fenotípica. Destacam-se, neste artigo, as evidências que apontam para: (1) associação entre síndrome metabólica e desregulação (hipofunção) do eixo GH/IGF-1; (2) associação entre deficiência de GH e expressão fenotípica da síndrome metabólica; e (3) perspectiva terapêutica da reposição de GH corrigindo as múltiplas alterações características da síndrome metabólica, quando da presença de deficiência relativa do GH

Endothelial function is preserved in Chagas' heart disease patients without heart failure.

Endothelium may be damaged, especially at the coronary microcirculation, in animal models of Chagas' disease by several mechanisms. Endothelial dysfunction has been reported in chronic Chagas' heart disease patients with heart failure. Nevertheless, peripheral endothelial function has never been studied in patients with Chagas' heart disease without heart failure and other conditions that could per se alter the endothelial function. Endothelial function was evaluated in 9 patients with Chagas' heart disease (44.8 +/- 1.5 years, 5 females, left ventricular ejection fraction > or = 60%) and 10 healthy matched controls (38.6 +/- 5.5 years, 5 females). Extreme caution was exercised to select patients with no other conditions that could per se alter the endothelial function. Forearm blood flow was measured at baseline and during intra-brachial artery infusion of crescent doses of acetylcholine (0.75, 5, and 15 microg/100 mL tissue/min) and nitroprusside (1, 2, and 4 microg/ 100 mL tissue/min), an endothelium-dependent and an endothelium-independent vasoactive drug, respectively. At baseline, blood pressure and heart rate (continuously recorded with Finapress) and the forearm blood flow were similar in both groups. Acetylcholine (ACh) and sodium nitroprusside (SNP) caused significant and similar dose-dependent increases in forearm blood flow of all subjects: maximum ACh response of 24.8 versus 23.7, and maximum SNP response 24.4 versus 23.7 mL/100 mL tissue/min, respectively, for control and chagasic Groups. No significant systemic hemodynamic changes were observed during the intra-arterial infusion of the drugs. The authors conclude that the peripheral endothelial function is preserved in Chagas' heart disease patients without heart failure.

Hypercholesterolemia blunts forearm vasorelaxation and enhances the pressor response during acute systemic hypoxia.

OBJECTIVE: During hypoxia, active substances released by the endothelium play a key role in the cardiovascular and respiratory responses elicited to optimize oxygen delivery. As hypercholesterolemia is a major cause of endothelial dysfunction, it may interfere with these responses. METHODS AND RESULTS: We studied cardiovascular and ventilatory responses to acute systemic hypoxia in 14 patients with hypercholesterolemia (HC) and 13 control (CO) subjects. Oxygen saturation decreased similarly in both groups. Diastolic blood pressure increased only in the HC group (P=0.0002) and, despite systolic blood pressure increases both in the HC group, 140+/-4 (95% confidence interval [CI],131 to 149 mm Hg) to 154+/-4 mm Hg (95% CI,145 to 164 mm Hg), and in the CO group, 133+/-3 (95% CI,126 to 140 mm Hg) to 140+/-4 mm Hg (95% CI,132 to 148 mm Hg), the HC group showed an enhanced pressor response (P=0.03, group comparison). Both groups had increased forearm blood flow, but the decrease in forearm vascular resistance in the CO group, 40+/-5 (95% CI, 30 to 51 UR) to 31+/-4 UR (95% CI,23 to 39 UR) (P=0.0001) was not seen in the HC group, 29+/-3 (95% CI, 22 to 37 UR) to 26+/-3 UR (95% CI, 20 to 33 UR), (P=0.03, group comparison). CONCLUSIONS: Hypercholesterolemic patients demonstrate a hyperreactive pressor response and absence of forearm vasodilation during acute systemic hypoxia.

Tratamento não-medicamentoso da hipertensão arterial / Non-pharmacological treatmet of hypertension

O tratamento não-medicamentoso pode controlar a hipertensão leve; quando associado com o tratamento farmacológico, pode melhorar o controle do paciente com hipertensão moderada/grave. A boa adesão ao tratamento não-farmacológico e ao tratamento farmacológico da hipertensão constitui tarefa difícil para médico e paciente. Existem várias medidas não-farmacológicas que, quando praticadas, resultam em grande benefício em relação ao controle da pressão arterial e co-morbidades comumente encontradas no paciente hipertenso. Dentre as medidas com eficácia comprovada e de melhor impacto na pressão arterial, merecem destaque a redução do peso, a redução do sódio da dieta e a prática regular de atividade física. Em relação à perda de peso, já foi demonstrado que pequena perda (~5 por cento do peso total) resulta em melhor controle da pressão arterial e das alterações metabólicas associadas e em regressão da hipertrofia cardíaca. A redução moderada do sal da dieta (~6 g/dia) resulta em queda significativa da pressão arterial no paciente hipertenso. O benefício da atividade física no tratamento da hipertensão arterial até recentemente ainda não estava bem estabelecido; porém, novos estudos têm demonstrado que a prática de exercícios do tipo isotônico de carga moderada resulta na redução sustentada da pressão arterial. Outras medidas, tais como suplementação de potássio e aumento do consumo do ácido graxo ômega 3, também resultam em queda da pressão arterial. Finalmente, a perda de peso, principalmente nos pacientes hipertensos com obesidade central, pode resultar em grande benefício para esses pacientes, pelo fato de não só reduzir a pressão arterial mas também facilitar o controle de co-morbidades (diabete, dislipidemia). A nosso ver, o esforço conjunto de equipe multidisciplinar no sentido de entender melhor os pacientes e o empenho no sentido da mudança de estilo de vida podem resultar em melhor controle da hipertensão e em redução do risco cardiovascular global...

Defeito do septo interventricular adquirido no curso de endocardite infecciosa / Acquired ventricular septal defect during infective endocarditis

We studied five patients with acquired ventricular septal defect during the course of an infective endocarditis. All patients were male and had a previous aortic valve disease associated with an aortic ring abscess. Clinical examination was useful for the diagnosis of 4 cases, emphasizing the following findings: systolic murmur and/or left paraesternal thrill and right-heart failure. Incidence of congestive heart failure was 60//, while 40//of all patients died during the in-hospital course. No specific etiologic agent was detected. Therefore, acquired ventricular septal defect should be suspected in patients with infective endocarditis of the aortic valve that evolve with a systolic murmur and/or paraesternal thrill and right-heart failure. Immediate surgical treatment is mandatory in these cases