[Notes on rapid diagnostic tests for chronic Chagas disease]. / Notes sur les tests de diagnostic rapide pour la maladie de Chagas en phase chronique.

A rapid diagnostic test (RDT) is a test that can quickly determine (from minutes up to 2 h) a diagnosis. It is a simple, quick, and inexpensive technique that does not require complex equipment or specialized staff. For this reason, such tests have been proposed for the diagnosis of Chagas Disease (CD), which affects populations difficult to reach, or migrants in nonendemic areas, where there is a low prevalence of the disease. With these notes we take into consideration one of the best RDTs for CD currently available on the market as an example and make some comments on its use in the field on the base of the current evidences.

Serodiscordance in chronic Chagas disease diagnosis: a real problem in non-endemic countries.

According to the WHO, chronic Chagas disease (CD) diagnosis is based on two serological techniques. To establish a definitive diagnosis, the results must be concordant. In cases of discordances, the WHO proposes repeating serology in a new sample, and if results remain inconclusive, a confirmatory test should be performed. This study, conducted at two Tropical Medicine Units in Europe over 4 years, aims to assess the diagnostic yield of TESA- (trypomastigote excreted-secreted antigens) blot as a confirmatory technique in patients with inconclusive and discordant results. Of 4939 individuals screened, 1124 (22.7%) obtained positive results and 165 (3.3%) discordant results. Serology was repeated in 88/165 sera and discrepancies were solved in 25/88 (28.4%) cases. Patients without a definitive diagnosis were classified in two different groups: Group 1, including patients with inconclusive results despite retesting (n = 63), and Group 2, including patients with discordant results not retested (n = 77). TESA-blot was performed for all of Group 1 and 39/77 of Group 2 and was positive for 33/63 (52.4%) and 21/39 (53.8%), respectively. Analysis of Group 1 results showed a moderate agreement between results of the ELISA based on native antigen and TESA-blot (κ 0.53). In contrast, a clear disagreement was observed between the ELISA based on recombinant antigens and TESA-blot (κ <0). A sizeable proportion of patients are suspected to have CD with inconclusive results or in whom re-testing is not feasible. TESA-blot was positive in half of these patients, highlighting the need for a confirmatory assay in European centres caring for exposed individuals.

Prótesis Choostent como método de paliación de la disfagia secundaria a patología maligna / Use of Choostent prosthetic device for palliation of dysphagia secondary to esophageal cancer

Background: Esophageal cancer causes disabling dysphagia and swallowing problems. Aim: To prospectively analyze the outcome of the insertion of a covered self-expanding metallic Choostent type prosthesis as a method of palliation of dysphagia, esophageal fistula or leak secondary to malignant disease of the esophagus or cardia. Material and Methods: A total of 30 consecutive patients aged 75 +/- 8.8 years (63 percent males) with malignant disease of the esophagus or cardia were studied. Results: In 27 patients (90 percent) the stenosis was located in the esophagus, in two (6.7 percent) at the gastroesophageal junction and in one (3.3 percent) at the esophago - jejunal anastomosis due to tumor recurrence. In 24 cases (80 percent), the indication of the prosthesis was dysphagia, in three (10 percent) the presence of a tracheo-esophageal fistula and in the remaining three (10 percent), the suspicion of a perforation. Patients were followed until death. The prosthesis was inserted without incidents in 29 patients (96.6 percent). One patient had a pneumomediastinum, which evolved favorably. Dysphagia subsided in all patients. Early evolution was satisfactory in 12 patients (66.7 percent). The most common early complication was a transient chest pain in 3 cases (10 percent). Four patients (13.3 percent) died within 30 days post procedure. Of the remaining 26 patients, 14 (53.8 percent) had late complications (recurrence of dysphagia in 42 percent and hemorrhage in 11 percent). The mean interval between stent insertion and death was 169 +/- 142.5 days. Conclusions: The Choostent esophageal prosthesis improves dysphagia immediately and safely. However, its use is associated with a high rate of late complications, directly related to prosthetic dysfunction.

Objetivo: Analizar en forma prospectiva los resultados de la inserción de una prótesis metálica autoexpandible cubierta tipo Choostent como método de paliación de la disfagia, fístulas o fugas esofágicas secundarias a patología maligna del esófago o cardias. Material y Método: Se estudiaron un total de 30 pacientes consecutivos portadores de patología maligna del esófago o de cardias. La edad promedio fue de 75 +/- 8,8 años. 19 (63,3 por ciento) eran del género masculino. En 27 pacientes (90 por ciento) la estenosis comprometía el esófago, en 2 (6,7 por ciento) la unión gastroesofágica y en 1 (3,3 por ciento) la anastomosis esófago yeyunal por recidiva tumoral. En 24/30 casos (80 por ciento), la indicación de la prótesis fue la disfagia, en 3 (10 por ciento) la presencia de fístula esófago-traqueal y en los 3 restantes (10 por ciento), la sospecha de perforación. Los pacientes fueron controlados hasta su fallecimiento. Resultados: La prótesis se insertó sin incidentes en 29/30 pacientes (96,7 por ciento). Un caso (3 por ciento) presentó neumo-mediastino, que evolucionó favorablemente. La disfagia cedió en la totalidad de los enfermos. La evolución precoz fue satisfactoria en 12/30 pacientes (40 por ciento), siendo la complicación precoz más frecuente el dolor torácico transitorio en 3 casos (10 por ciento). Fallecieron precozmente 4 enfermos (13,3 por ciento). De los 26 restantes, en 14 (53,8 por ciento) se presentaron complicaciones tardías, siendo las más frecuentes la recidiva de la disfagia (42,3 por ciento) y la hemorragia (11,5 por ciento). Conclusión: Las prótesis Choostent mejoran la disfagia en forma inmediata y segura. Son efectivas en el manejo de las fístulas traqueo-esofágicas y perforaciones. Sin embargo, su uso se asocia a una alta tasa de morbilidad tardía directamente relacionada a la disfunción protésica.

Pediatric inflammatory diseases. Part I: multiple sclerosis.

Multiple sclerosis (MS) is an inflammatory CNS disease characterized by multifocal areas of demyelination; usually it arises in young adults, but can also occur in children (under the age of 10) and adolescents (under the age of 18). As in adult, pediatric MS (PMS) diagnosis is based on the demonstration of multiple demyelination episodes separated in time and spaces. Diagnostic criteria realized for childhood are similar to those employed for adults. Although clinical and imaging features of PMS can be similar to those of adults, the disease is often characterized by a more aggressive course and atypical imaging findings, with giant and pseudotumoral plaques. Differential diagnosis between PMS and ADEM could be difficult: clinical findings and MRI are necessary; sometimes MRI follow-up is required for definitive diagnosis.

Chagas disease in Italy: breaking an epidemiological silence.

Chagas disease, a neglected tropical disease that due to population movements is no longer limited to Latin America, threatens a wide spectrum of people(travellers, migrants, blood or organ recipients,newborns, adoptees) also in non-endemic countries where it is generally underdiagnosed. In Italy, the available epidemiological data about Chagas disease have been very limited up to now, although the country is second in Europe only to Spain in the number of residents from Latin American. Among 867 at-risk subjectsscreened between 1998 and 2010, the Centre for Tropical Diseases in Negrar (Verona) and the Infectious and Tropical Diseases Unit, University of Florence found 4.2% patients with positive serology for Chagas disease (83.4% of them migrants, 13.8% adoptees).No cases of Chagas disease were identified in blood donors or HIV-positive patients of Latin American origin. Among 214 Latin American pregnant women,three were infected (resulting in abortion in one case).In 2005 a case of acute Chagas disease was recorded in an Italian traveller. Based on our observations, we believe that a wider assessment of the epidemiological situation is urgently required in our country and public health measures preventing transmission and improving access to diagnosis and treatment should be implemented.

Rol de la colangio pancreatografía retrógrada endoscópica en pacientes con pancreatitis aguda biliar leve y vesícula in situ / Endoscopic retrograde colangiopancreatography (ERCP) among patients with biliary pancreatitis and gallbladder in situ

Background: An early decompression of the biliary tract can be useful in biliary pancreatitis. This can be accomplished with an ERCP. Aim: To analyze prospectively the outcomes of ERCP and eventual endoscopic management among patients with mild acute biliary pancreatitis with gallbladder in situ. Material and methods: We studied 90 consecutive patients aged between 15 and 92 years (71 females) with mild acute pancreatitis and gallbladder in situ, that were subjected to an ERCP and eventual sphincterotomy. Forty nine patients (54 percent) had jaundice and 12 (13 percent) had cholangitis. Results: In 67 patients (74 percent), ERCP detected an abnormal ampulla. The bile duct was successfully cannulated in 89 cases (99 percent). Of these, 42 (47 percent) had a dilated bile duct and 36 (40 percent) had choledocholithiasis. In two patients (2 percent) ERCP was only diagnostic. In the remaining patients, it was therapeutic. Endoscopic treatment was successful in 86 patients (99 percent). No complications arising from the endoscopic procedure were recorded. Follow-up was completed in 84 patients (94 percent). Of these, 10 (12 percent) were not subjected to a cholecystectomy, in eight due to a high surgical risk and in two due to refusal. In the remaining 74 patients, a cholecystectomy was performed during the same hospitalization in 57 (77 percent) and on a deferred basis in 17 (23 percent). Conclusions: In patients with mild acute biliary pancreatitis and gallbladder in situ, ERCP is a safe and effective method.

Objetivo: Analizar en forma prospectiva los resultados de la Colangio Pancreatografía Retrógrada Endoscópica (CPRE) y eventual manejo endoscópico en pacientes portadores de pancreatitis aguda biliar (PAB) leve con vesícula in situ. Material y Método: Se estudiaron 90 pacientes consecutivos con PAB leve y vesícula in situ. La edad promedio fue de 49,5 +/- 18,6 años (78,9 por ciento mujeres y 21,1 por ciento hombres). Del total, 49 pacientes (54,4 por ciento) presentaron ictericia y 12 (13,3 por ciento) colangitis. Resultados: La CPRE pesquisó pato-logia de la ampolla en 67/90 pacientes (74,4 por ciento). La canulación selectiva de la vía biliar resultó exitosa en 89/90 casos (98,9 por ciento). En estos, se demostró una vía biliar dilatada en 42 (47,2 por ciento) y coledocolitiasis en 36 (40,4 por ciento). La CPRE fue diagnóstica en 2 enfermos (2,2 por ciento) y hubo indicación de procedimiento terapéutico en los 87 restantes (97,7 por ciento), este resultó exitoso en 86 (98,9 por ciento). No se presentaron complicaciones derivadas de la cirugía endoscópica. Se completó el seguimiento en 84/89 pacientes (94,4 por ciento). De estos, 10 (11,9 por ciento) no fueron colecistectomizados (8 debido al riesgo quirúrgico y 2 por rechazo a la intervención). De los 74 restantes, 57 (77 por ciento) fueron sometidos a una colecistectomía dentro de la misma hospitalización y 17 (23 por ciento en forma diferida. El 91,9 por ciento de ellas (68/74) mediante laparoscopia. Conclusión: En pacientes con PAB leve y vesícula in situ, la CPRE es un método seguro y efectivo. Además, permite efectuar una colecistectomía por vía laparoscópica, durante la misma hospitalización en la gran mayoría de los pacientes y constituye una alternativa a la colecistectomía en pacientes de alto riesgo quirúrgico.

Change in regional cerebral function in l'aquila earthquake survivors with post-traumatic stress disorder: preliminary findings.

Subjects with post-traumatic stress disorder (PTSD) present a diminished or blunted emotional response, sometimes called "emotional numbing" (EN), that constitutes one of the central symptoms in PTSD. Symptoms of EN include diminished interest in activities, feeling detached or estranged from others, and restricted range of affect (American Psychiatric Association, 2000). The present work studied the emotional components in individuals with PTSD with the principal aim of investigating subjects' functional alteration in the limbic regions, insula and frontal cortex during an emotional task compared with healthy subjects. Ten subjects with PTSD (survivors of the 6.3 magnitude earthquake of April 6, 2009 in L'Aquila) and ten healthy controls underwent fMRI. PTSD was diagnosed according to DSM-IV-R (APA 2000). All subjects underwent fMRI while viewing content-neutral and emotional stimuli. Data analysis revealed that PTSD subjects had significantly greater cerebral activation in particular in the right anterior insula and in bilateral inferior frontal gyrus. Our data suggest that there is a change in the activation of brain areas responsible for emotional processing in patients with PTSD and are consistent with previous findings demonstrating hyperactivation in frontolimbic structures during emotional tasks. Our study suggests that close personal experience may be critical in engaging the neural mechanisms underlying the emotional modulation of memory. Our findings provide evidence that significant alterations in brain function, similar in many ways to those observed in PTSD, can be seen shortly after major traumatic experiences, highlighting the need for early evaluation and intervention for trauma survivors.

Enhanced levels of oxidized low-density lipoprotein prime monocytes to cytokine overproduction via upregulation of CD14 and toll-like receptor 4 in unstable angina.

OBJECTIVES: The purpose of this study was to establish whether oxidized low-density lipoprotein (oxLDL) contributes to cytokine overproduction via upregulation of CD14 and toll-like receptor-4 (TLR-4) expression on circulating monocytes of unstable angina (UA) patients. METHODS AND RESULTS: Expression of CD14 and TLR-4 on circulating monocytes, and the concentration of plasma oxLDL, (interleukin [IL])-6, IL-1 beta, IL-8, tumor necrosis factor (TNF)-alpha, monocyte chemoattractant protein-1 (MCP-1) were measured in 27 control (C) subjects, 29 patients with stable angina (SA), and 27 with UA. CD14 and TLR-4 expression on monocytes and circulating IL-6, IL-1 beta, and oxLDL were higher in UA than in SA and C subjects (P<0.001). In in vitro experiments, oxLDL increased CD14 and TLR-4 expression (P<0.001) in control monocytes as well as IL-6, IL-1 beta, and at a lower extent TNF-alpha and MCP-1 levels in the supernatant (P from <0.05 to <0.001). The preincubation of sera derived from UA patients but with control monocytes also induced a significant increase of CD14 and TLR-4 expression (P<0.001) and of IL-6 and IL-1 beta production (P<0.001) in the supernatant. CONCLUSIONS: In UA patients oxLDL may contribute to monocyte overproduction of some cytokines by upregulating CD14 and TLR-4 expression.

Endoprótesis biliar en el manejo transitorio de la coledocolitiasis / Endoscopic biliary stents for the temporary management of choledocholithiasis

Background: Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a temporary stent can be a solution. Aim: To prospectively analyze the usefulness of endoscopic biliary stents in the temporary management of biliary obstruction due to choledocholithiasis. Material and methods: Analysis of 51 consecutive patients (age range 21-88 years, 34 females) with common bile duct stones that, from January 1999 to December 2001, were subjected to an endoscopic insertion of a biliary stent. Results: The indications for stent placement were a large stone in 40 patients (78%), the insecurity of a complete biliary tract cleaning in eight (16%) and technical difficulties in three (6%). Twenty seven patients (52.9%) were jaundiced and 17 (33.3%) had cholangitis. The prostheses remained in place until definitive resolution of the choledocholithiasis in 47 patients (92%) and migrated in 4 (8%). Bilirubin levels became normal in all cases with jaundice and infection resolved in all those with cholangitis. The definitive treatment of choledocholithiasis was done endoscopically in 28 patients (58%) and surgically in 20 (42%). Three patients were lost from follow up. Of these, one patient (2%) died 14 months later due to a recurrent cholangitis. The remaining two patients were asymptomatic and with the prostheses still in place 522 and 560 days post stent placement. Conclusions: When the immediate endoscopic resolution of choledocholithiasis is not possible, temporary stenting is a simple and safe therapeutic alternative that allows patients to be free of obstructive complications until the definitive treatment is carried out.

Estenosis péptica del esófago: resultados alejados del tratamiento conservador / Peptic stricture of the esophagus: long term outcome of conservative treatment

BACKGROUND: Endoscopic dilatation of esophageal strictures is a simple and safe procedure. AIM: To analyze the long term outcome of conservative treatment for esophageal peptic stricture in patients with high surgical risk. PATIENTS AND METHODS: Twenty consecutive patients, 13 male, whose mean age was 75.2 years, with a peptic stricture of the esophagus and high surgical risk were prospectively studied. All were subjected to endoscopic esophageal dilatation and treated with continuous medical antireflux therapy thereafter. RESULTS: Only five patients complied with antireflux treatment on a regular basis. The remaining 15 were non compliant or abandoned it. A total of 56 dilatations were done (mean 2.8 per patient, range 1-6). No complications were observed after the procedure. With a mean follow up period of 49 months, the outcome of the conservative treatment was classified as excellent or good in all the cases. Eight patients (40 per cent) died of causes unrelated to the treatment. Two patients had an organic foreing body impactation. This situation was solved endoscopically in both. CONCLUSION: In high risk patients, endoscopic dilatation, with or without regular antireflux medical treatment is a simple, safe and effective therapy in the management of peptic oesophagel stenosis.

Prognostic implications of evaluation of contractile reserve in akinetic and hypokinetic segments during low dose dobutamine echocardiography in patients with acute myocardial infarction.

BACKGROUND: Previous studies have reported the prognostic value of myocardial viability (MV) detected using low-dose dobutamine echocardiography (DbE). However, viability was frequently evaluated as improvement in regional wall motion score index, which includes increased function in hypokinetic segments, in which viable myocardium is necessarily present. It is not known whether an evaluation focusing on akinetic segments, in which the possible presence of viable myocardium is unknown, might have more prognostic value. The aim of this study was to compare the prognostic value of the improvement of myocardial function during dobutamine infusion in akinetic and hypokinetic regions in patients with acute myocardial infarction (AMI). METHODS: 191 patients with uncomplicated AMI and at least one akinetic segment were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using DbE. Myocardial viability was evaluated both as an increment in RWMSI (Delta RWMSI), which takes into consideration improvement in both akinetic and hypokinetic regions, and as an improvement of function in akinetic (Delta akinetic) and hypokinetic (Delta hypokinetic), segments considered separately. Follow-up evaluation was performed at 30+/-13 months. RESULTS: On the basis of the Delta RWMSI, 94/191 patients were judged to have myocardial viability, whereas considering myocardial viability in akinetic segments only, 72/191 patients showed viability. At follow-up 18 patients had died (six viable considering Delta RWMSI; three viable considering Delta akinetic). The presence of a previous AMI, the site of AMI, RWMSI and the number of akinetic segments, and Delta RWMSI and Delta akinetic were related to mortality at univariate Cox analysis. At multivariate stepwise Cox regression analysis Delta akinetic, but not Delta hypokinetic proved to be significantly related to mortality. The Kaplan-Meier survival curves were no different in patients with or without viable myocardium evaluated as Delta RWMSI, while they were significantly different considering patients with or without viability in akinetic segments (P=0.04). CONCLUSION: In conclusion our study confirms the prognostic importance of the evaluation of myocardial viability in infarcted patients. However, it points out that it is the presence of viability in akinetic segments that affects long-term survival in these patients. This supports the hypothesis that other mechanisms, above and beyond the effect on regional wall motion, are involved in the beneficial effects of myocardial viability.

[Acute cholangitis caused by choledocholithiasis: traditional surgery or endoscopic biliary drainage]. / Colangitis aguda debida a coledocolitiasis: cirugía tradicional o drenaje biliar endoscópico?

BACKGROUND: Endoscopic drainage of the biliary tree for acute cholangitis is a therapeutic modality with a lower mortality and complication rates. AIM: To compare endoscopic drainage with surgical treatment in the emergency management of acute cholangitis. PATIENTS AND METHODS: Between 1995 and 1998, sixty five patients with acute cholangitis were subjected to an endoscopic drainage of the biliary tree. In the same period, 40 patients were treated with traditional surgical procedures. The evolution of both groups of patients were compared. RESULTS: Sixty two patients (95.4%) subjected to endoscopic treatment had a satisfactory evolution, compared with 23 (58%) of those operated (p < 0.001). Five operated patients and no individual subjected to endoscopic drainage died (p < 0.01). Mean postoperative hospital stay of operated patients was 15.5 +/- 19.6 days compared to 5.8 +/- 4.2 days in those subjected to endoscopic drainage (p < 0.001). Definitive resolution of biliary obstruction was achieved in 83% of patients subjected to endoscopic drainage or traditional surgery. CONCLUSIONS: Endoscopic drainage has a lower rate of complications and mortality than traditional surgery, in the treatment of acute cholangitis.

Mitral regurgitation and left ventricular diastolic dysfunction similarly affect mitral and pulmonary vein flow Doppler parameters: the advantage of end-diastolic markers.

Enhanced early mitral flow and reduced systolic pulmonary vein flow may be caused both by increased left ventricular pressure as the result of diastolic dysfunction and by increased transmitral flow as the result of mitral regurgitation. Nevertheless, Doppler parameters are widely used to predict left ventricular filling pressure. We aimed to analyze the interference of mitral regurgitation with Doppler parameters usually used to estimate left ventricular filling pressure and to identify markers independent of mitral regurgitation, which could reliably estimate increased left ventricular filling pressure. Eighty-four patients (age, 62 +/- 9 years; 82% men) had a complete echocardiographic Doppler examination. Transmitral E- and A-wave velocity, E deceleration time and A duration, pulmonary vein systolic and diastolic velocities, and reversal flow duration and maximal and minimal left atrial volumes were measured. The difference between the duration of pulmonary vein and mitral A waves was calculated (A'-A). Mitral regurgitant volume was quantitatively assessed by echocardiography. Left ventricular end-diastolic pressure was measured invasively. Patients had a wide range of left ventricular ejection fraction (14% to 70%), mitral regurgitant volume (0 to 94 mL), and left ventricular end-diastolic pressure (3 to 37 mm Hg). E velocity, E/A, pulmonary vein systolic and diastolic, and systo-diastolic ratios were significantly and independently correlated with both left ventricular end-diastolic pressure and mitral regurgitant volume. A'-A showed a strong correlation with left ventricular end-diastolic pressure (r = 0.70; P <.0001), but the relation with mitral regurgitant volume was not significant (r = 0.19; P =.08). Mitral regurgitation affects the majority of Doppler parameters widely used to predict filling pressure but does not influence Ad'-Ad, which proved to be the strongest predictor of left ventricular end-diastolic pressure.

Relationship between mitral regurgitation and myocardial viability after acute myocardial infarction: their impact on prognosis.

Mitral regurgitation (MR) after acute myocardial infarction (AMI) is an important prognostic factor. Although its mechanisms are still debated, ventricular remodeling probably plays an important role. Because myocardial viability (MV) in the infarct zone reduces infarct expansion and ventricular remodeling, it is also possible that its presence counteracts the development of mitral regurgitation in infarcted patients. To evaluate this issue 191 patients with uncomplicated AMI, wall motion abnormalities (akinesis) and semiquantitative evaluation of MR were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using low-dose dobutamine echocardiography (DbE). Follow-up evaluation was performed at 30+/-13 months. Seventy-nine patients had no MR; 86 patients had grade 1 MR, 11 patients had grade 2 MR, nine patients had grade 3 MR, and six patients had grade 4 MR. Patients with significant MR (>grade 1) were older (63+/-7 vs. 59+/-10 years, P=0.03), had lower reduction of RWMSI (DeltaRWMSI) during DbE (0.08+/-0.11 vs. 0.22+/-0.28, P=0.01), more stenotic vessels at coronary angiography (2.35+/-0.93 vs. 1.67+/-1.12, P=0.01), and more frequently had anterior-inferior AMI (P<0.0001); they also had a non-significant tendency to higher RWMSI (2.04+/-0.38 vs. 1.92+/-0.28, P=0.06). In a multivariate regression analysis, DeltaRWMSI proved to be significantly related to the grade of MR (P=0.02). Eighteen patients died during follow-up. Death was more frequent in patients with MR (10/165 vs. 8/26, P=0.0003). At multivariate stepwise Cox regression analysis both the extent of ventricular dysfunction and the presence of MR were significantly related to mortality (P<0.0001 and P=0.01, respectively); DeltaRWMSI showed a non-significant tendency to influence mortality (P=0.09). When MR was excluded from the multivariate analysis, DeltaRWMSI remained significantly related to mortality (P=0.05). In conclusion our study suggests that the presence of MV in infarcted patients influences the development of MR. This reduction of MR may be one of the mechanisms by which MV affects mortality after AMI and should be considered in all studies that evaluate MV after myocardial infarction.

Left atrial overload can be used to estimate mitral regurgitant volume.

This study was conducted to assess the accuracy of the estimated mitral regurgitant volume using both the left atrial filling volume and the systolic component of pulmonary vein flow expressed as the percent of its total. Since mitral regurgitation fills the left atrial chamber, the variation in atrial volume during ventricular systole has been proposed as a means to evaluate the severity of regurgitation. Although the correlation with invasive grading of mitral regurgitation is good, there is an unacceptable overlap among grades caused by the absence of information concerning pulmonary vein flow, which enters the left atrium while regurgitation occurs. The Doppler regurgitant volume, or Dp-RVol (mitral stroke volume minus aortic stroke volume) was quantified in 74 patients with any degree and etiology of mitral regurgitation. Atrial volumes were measured from the four-chamber apical view (biplane area-length method). The systolic time-velocity integral of pulmonary vein flow was expressed as the percent of the total (PVs%) (systolic-diastolic) time-velocity integral. These parameters were subjected to multivariate analysis and a regression equation was obtained. The equation was subsequently applied to a group of 31 patients without mitral regurgitation, as evaluated by color Doppler or continuous-wave Doppler and to the overall population (105 patients) in order to estimate the mitral regurgitant volume. In 74 patients with mitral regurgitation, the Doppler regurgitant volume was univariately correlated with the left atrial filling volume (r= 0.74; p<0.0001) and the systolic pulmonary vein velocity integral expressed as the percent of the total (r=0.67; p<0.0001). In multiple regression analysis, the combination of atrial filling and the pulmonary vein velocity integral provided the more accurate estimation of the regurgitant volume (R2=0.84; standard error of the estimate [SEE], 13.9 mL; p<0.0001; Dp-RVol equals 7.84+[1.08*left atrial filling volume] 2 [0.839*PVs%]). In 31 patients with no mitral regurgitation detected by color Doppler or continuous wave Doppler the estimated regurgitant volume was 4.3±6.6 mL. In the overall population the estimated regurgitant volume and the Doppler regurgitant volume correlated well with each other (R2=0.85; SEE, 11.5 mL; p<0.0001). The equation was 100% sensitive and 98% specific in detecting a regurgitant volume higher than 55 mL. The combination of the atrial filling volume and the systolic pulmonary vein time-velocity integral expressed as the percent of the total allows reliable estimation of the regurgitant volume in patients with mitral regurgitation. (c)2001 CHF, Inc.

[Employment "survival" among nursing workers at a public hospital]. / "Sobrevivência" no emprego dos trabalhadores de enfermagem em uma instituição hospitalar pública.

This study aimed at estimating the employment "survival" time of nursing workers after their admission to a public hospital as a turnover index. The Life Table method was used in order to calculate the employment survival probability by X years for each one of the categories of workers. The results showed an accentuated turnover of the work force in the studied period. The categories nursing auxiliary and nurse presented low stability in employment while the category nursing technician was more stable.