Cardiomiopatia hipertrófica apical x infarto apical: strain longitudinal ou ressonância magnética? / Apical hypertrophic cardiomyopathy vs. apical infarction: longitudinal strain or MRI?

INTRODUÇÃO: A cardiomiopatia hipertrófica apical (CMHA) ou síndrome de Yamaguchi é uma condição relativamente rara, que apresenta acometimento predominante da região apical do ventrículo esquerdo (VE). O Ecocardiograma com strain nesta condição apresenta uma redução no ápice bem semelhante à imagem obtida no Infarto Apical. Descrevemos um caso onde as duas condições estavam presentes. (Figuras 1 -4) RELATO DE CASO: Masculino, de 78 anos, previamente hipertenso, procurou o pronto socorro por dor precordial teve o diagnóstico de infarto sem supra do segmento ST. Seu eletrocardiograma evidenciava ondas T profundas na parede anterior e lateral. Submetido à estratificação invasiva, sendo evidenciada coronária direita (CD) ocluída no terço proximal (CD), com circulação colateral presente e lesão grave em terço proximal de artéria circunflexa (Cx). Foi submetido à angioplastia com stent farmacológico na CX. Um mês após o evento coronariano agudo, o paciente retorna ao serviço referindo persistência de dor precordial, semelhante ao quadro anterior. Mantinha-se em uso de dupla antiagregação plaquetária, de modo que foi optado por nova estratificação invasiva, que revelou as mesmas lesões previamente citadas, com stent farmacológico em Cx apresentando fluxo TIMI 3. Ao ECO com strain, evidenciou-se aumento isolado da espessura da região apical do VE, medindo 15mm, com contratilidade miocárdica preservada nesta região, redução do strain global de 11.2% e área de redução muito acentuada sugerindo fibrose nessa mesma região poupando as demais paredes. Neste momento, não foi possível a determinação da causa da redução do strain apical, se IAM, Takotsubo ou CMH. A ressonância magnética cardíaca (RMC) com estresse com dipiridamol observou hipertrofia miocárdica assimétrica apical com carga fibrótica de 16% e presença de isquemia miocárdica em segmentos inferosseptal e inferior medioapical, além de realce tardio de padrão não coronariano acometendo a porção apical do VE, com fração de ejeção de 66%. CONCLUSÃO: A identificação da etiologia da fibrose apical só foi possível com a ressonância magnética, que deixou claro ser decorrente da CMHA, já que o padrão de realce era não coronariano. Ao estresse com Dipiridamol, evidenciou isquemia na parede inferior e inferosseptal medioapical determinando que a dor precordial tinha como causa a circulação colateral insuficiente da CD. Concluímos pela necessidade do diagnóstico ser multimodalidades de imagem, com resultados mais conclusivos com RMC.

Miocardio não compactado em esportista ­ um desafio diagnóstico / Uncompressed myocardium in sportsman - a diagnostic challenge

INTRODUÇÃO: Miocárdio não compactado (MNC) é uma cardiopatia congênita rara que teve seu primeiro caso publicado há menos de 40 anos caracterizado pela falta de compactação miocárdica com a formação de trabéculas no ventrículo esquerdo (VE), afetando principalmente a região apical, podendo estar associado à hipertrofia e dilatação do VE. CASO: Masculino, 69 anos, praticante de atividade física (corrida de rua, 10km, 3x/semana). Durante avaliação inicial apresentava-se assintomático e exame físico normal, trazendo resultado de exames de cinco anos atrás, quando ainda era sedentário, apresentando eletrocardiograma (ECG) e ECO normais. Na admissão, apresenta ECG com bloqueio atrioventricular grau I, Teste ergométrico (TE) com boa capacidade funcional, não compatível com resposta isquêmica. O ECO evidenciou hipertrabeculação dominante no ápice do VE com disfunção global do VE (FE 40%). Na RMC mostrou uma relação entre miocárdio não compactado/compactado de 3,0 e confirmou disfunção do VE. Assim, foi realizada a hipótese diagnóstica de MNC, orientada limitação das atividades físicas a leves a moderadas e contraindicado atividades de alta intensidade além de ser iniciado tratamento para disfunção O paciente foi acompanhado com ECOs evidenciando persistência das trabeculações do VE, TE e Holter que não revelaram presença de arritmias ventriculares significativas. Na última avaliação, após um ano de sedentarismo do paciente o ECO evidenciou diminuição da trabeculação no VE e a nova RMC mostrou disfunção do VE (FE 42%) associado a um aumento discreto das trabeculações na porção apical, porém sem fechar critérios para o diagnóstico de MNC com uma relação miocárdio não compactado/compactado <2,3e com ausência de comprometimento septal. Após afastado o diagnóstico inicial, foi levantada a hipótese de miocardiopatia dilatada idiopática, orientando limitação de atividades físicas para leves a moderadas. DISCUSSÃO: Já está bem estabelecido que o treinamento físico pode estar associado a adaptações cardíacas, elétricas e estruturais, e, em casos raros, essas adaptações, tidas como fisiológicas, podem se sobrepor a expressões morfologicamente leves das cardiomiopatias primárias e resolver este dilema diagnóstico pode ser desafiador. O MNC é um distúrbio miocárdico relativamente novo, podendo levar a disfunção sistólica do VE, arritmias ventriculares e até a morte súbita. Eventualmente atletas podem exibir critérios convencionais para MNC destacando a natureza não específica dos critérios diagnósticos atuais se aplicados a populações de atletas.

"Valve-In-Valve" aórtico em bioprótese com fratura de folheto / Aortic "Valve-In-Valve" in bioprosthesis with leaflet fracture

INTRODUÇÃO: As biopróteses possuem durabilidade aproximada de 12 a 20 anos. Neste período, complicações relacionadas à degeneração protética podem exigir novas intervenções. Mas o elevado risco de uma reoperação, principalmente se o paciente estiver clinicamente descompensado, tornam a cirurgia convencional muito arriscada ou mesmo proibitiva. Neste cenário, o implante valvar dentro da bioprótese degenerada (valve in valve) se mostrou como opção alternativa e viável. Relatamos um caso de correção de insuficiência aórtica grave por falência estrutural de bioprótese através de valve in valve (ViV) com sucesso em paciente gravemente descompensado. DESCRIÇÃO DO CASO: Homem, 66 anos, hipertenso, implante de bioprótese aórtica e plastia mitral em 2011, devido dupla lesão aórtica e mitral, sem seguimento clínico. Procurou o pronto socorro por dispnéia aos mínimos esforços e anasarca há uma semana. Admitido em IC perfil B. Após tratamento com diuréticos, o ecocardiograma transtorácico (ecoTT) revelou: aumento atrial esquerdo importante (volume indexado de 96 mL/m²); fração de ejeção do VE (FEVE) de 45% - Simpson; bioprótese aórtica apresentava folhetos com hipermobilidade e prolapso, sugestivos de fratura, com refluxo importante, gradiente sistólico (GS) máximo de 69 mmHg, GS médio de 36mmHg e área valvar (AV) de 1,3 cm2. Valva mitral com aspecto de plastia exibindo refluxo de grau importante. Internado para programação cirúrgica a princípio, mas após discussão com Heart Team, e considerando STS de 27 %, indicada a realização de "Valve-in-valve". A angiotomografia com parâmetros anatômicos adequados para o tratamento percutâneo. Procedimento realizado com técnica simplificada e otimizada ("minimalista"), sob sedação. Gradientes pré implante de prótese: VE 120 x 15 mmHg e Aorta 100 x 30 mmHg. Implante de bioprótese Myval 20 e pós dilatação com cateter balão ATLAS GOLD 22 x 40mm com sucesso conforme parâmetros do ecoTT. Após implante valvar, novos gradientes foram adquiridos: VE 130 x 15 mmHg e Aorta 128 x 70 mmHg. Paciente evoluiu com melhora clínica significativa. EcoTT do 1o dia pós procedimento revelou refluxo mitral de grau discreto a moderado e ausência de refluxo aórtico, gradiente GS máximo 21 mmHg, GS médio 11 mmHg, AV 1,4 cm2. O paciente demostrou melhora rápida de sua classe funcional (CF I). CONCLUSÃO: No caso descrito, a realização de "Valve-in-valve" após complicação estrutural de bioprótese constituiu tratamento seguro, efetivo e alternativa à intervenção cirúrgica convencional.

Histopathological changes in the placentas and fetuses of mice infected with Trypanosoma cruzi isolated from the Myotis nigricans nigricans bat.

Histopathological changes and placental transmission were studied in the late stages of pregnancy in mice infected with a strain of Trypanosoma cruzi, isolated from a Myotis nigricans nigricans bat. Large amastigote nests were observed in uterine muscles, as well as in decidual and endothelial placental cells. In addition, persistent coagulative and fibrotic vascular degeneration was observed. Large amastigote burdens were found in giant cells, spongioblasts and endothelial cells within the labyrinthine layer. Transplacental transmission was confirmed in 30% of the fetuses examined, in which amastigote nests were seen only in striated muscle. During the acute phase, intrauterine development was impaired as the result of parasitic invasion of the placenta, and fetal mortality rose to 10%.

Teratogenic effects of the interaction acetylsalicylic acid (ASA) and ethanol: morphologic and morphometric evaluation of the lingual epithelium in rat fetuses.

The objective of the present work was to evaluate the teratogenic effects of the interaction between acetylsalicylic acid (ASA) and ethanol on the epithelium of the lingual mucosa in rat fetuses. On the 10th pregnancy day, a single intraperitoneal ethanol dose (2.96 g/kg body weight) (Group I), ASA (200 mg/kg body weight) (Group II) and ASA plus ethanol, in the same doses (Group III), or saline (Group IV - control), were administrated. The epithelial alterations were assessed by means of histological and morphometric methods, on posterior dorsal, anterior dorsal and ventral regions of the tongue. ASA reduced, in rat fetuses, the ethanol deleterious effects on nuclear size in the epithelial prickle cell of the lingual mucosa. On the other hand, ASA did not influence the effects of ethanol in both epithelial layers of the lingual mucosa, when the nuclear shape, cell volume or epithelial layers thickness were evaluated.

Occupational exposure of Brazilian neonatal intensive care workers to latex antigens.

BACKGROUND: Frequent exposure to latex causes various reactions such as respiratory symptoms and anaphylactic shock. In these cases, proteins found in natural latex are responsible for the serious systemic antilatex-mediated immediate hypersensitive reactions. METHODS: Cross-sectional descriptive survey focusing on 96 Brazilian health care workers (HCW) in the neonatal intensive care unit at CAISM, State University of Campinas UNICAMP, Brazil. All subjects were interviewed, donated blood samples for the latex-specific immunoglobulin E measurement and underwent the skin prick test (SPT) with an antigen extracted from latex gloves. RESULTS: The prevalence of latex positive SPT was 8%. There were eight SPT positive and only one serologic test was in agreement with the SPT. Overall, there was evidence of an association between the latex SPT and reported eczema (P = 0.01); food allergy (P = 0.009) with pineapple (P = 0.01). CONCLUSIONS: These results suggest that the identification of reactions of immediate hypersensitivity mediated by antilatex antibodies in HCW should be encouraged to prevent occupational exposure to latex products.

EMG analysis of the upper and lower fascicles of the orbicularis oris muscle in deaf individuals.

The aim of this study was to analyze electromyographically the upper and lower fascicles of the orbicularis oris muscle in deaf patients comparing them with clinically normal patients. These patients present several disorders in facial muscles, temporomandibular joints disorders and constantly headache in virtue of not the use of the face expression muscles. This was performed in 30 patients from both sexes with a mean age of 18.5 years, divided into 3 groups of 10 patients each: 1. deaf patients with buccal breathing and incompetent lips; 2. in deaf patients with nasal breathing and competent lips; 3. clinically normal patients, in 7 clinical conditions: at rest with and without labial contact, sucking water, blowing, pursing and reciprocal compression of the lips and the emission of the syllabi "PA". It was observed that in the deaf patients group, both fascicles of the orbiculares oris muscles presented hyperactivity in most of the analyzed movements, mainly in buccal breathing with incompetent lips, and the lower fascicle demonstrated the highest electromyographic activity.

Electromyographic evaluation of the adductor pollicis muscle of elderly patients carriers of removable partial prosthesis when using acrylic devices adapted to the handle of toothbrush.

The aim of this study was to evaluate the muscular activity of the adductor pollicis muscle, by electromyography, when using a device made of acrylic resin adapted to the handle of toothbrush. 10 patients of both sexes from the Clinic of Removable Partial Dentures of the Dental School--USP, with a mean age of 65 years, were selected. Electromyographic records were obtained with patients in clinical conditions of Initial Rest and under conditions of claw apprehension and dental brushing. The mean results obtained, in mV, were: sat men: 2.97 for rest (R); 11.55 for free closure (FC); 35.80 for strained closure (SC); 29.30 for simulated brushing (SB); 55.00 for brushing (B); 26.87 for simulated brushing with the device (SBA); 69.70 for brushing with the device (BA); 3.72 for post exercise rest (PR). Standing: 2.27 for rest (R); 13.92 for free closure (FC); 45.85 for strained closure (SC); 28.40 for simulated brushing (SB); 72.07 for brushing with the device (BA); 1.42 for postexercise rest (PR). Sat women: 9.78 for rest (R); 22.71 for free closure (FC); 41.48 for strained closure (SC); 26.45 for simulated brushing (SB); 52.78 for brushing (B); 17.00 for simulated brushing with the adapter (SBA); 42.38 for brushing with the adapter (BA); 14.40 for postexercise rest (PR). Standing: 5.26 for rest (R); 17.81 for free closure (FC); 46.55 for strained closure (SC); 40.61 for simulated brushing (SB); 61.71 for brushing (B); 26.08 for simulated brushing with the adapter (SBA); 54.06 for brushing with the adapter (BA); 3.46 for postexercise rest (PR). The adductor pollicis muscle showed a higher electromyographic activity, considered statistically similar to each other, in 3 clinical conditions analyzed: brushing (B), brushing with the adapter (BA) and strained closure (SC). The adductor pollicis muscle showed lower electromyographic activity, considered statistically similar, in 5 clinical conditions analyzed: simulated brushing (SB), simulated brushing with the adapter (SBA), free closure (FC), rest (R) and postexercise rest (PR).

EMG activity of the orbicularis oculi muscle in normal and in individuals indicated to receive eye prosthesis, before and after its placement.

To analyze comparatively through electromyography (EMG) the orbicularis oculi muscle from normal patients and those indicated to receive eye prosthesis (treated patients), it was studied 24 male patients with a mean age of 32.5 years old, who were divided into 2 groups as follows: 12 individuals with absence of the left eyeball and indicated to receive prosthesis (treated); 12 normal individuals (control). The work was performed in 4 different clinical conditions: initial resting; normal opening and closure of the eyelids; forced opening and closure of the eyelids and final resting, before and after placement of eye prosthesis. The exams were made using an Electromyograph K6-I Light Channel and Surface Electrodes. By the results obtained under the work conditions, we can conclude that: the use of eye prosthesis did not interfere in the clinical conditions of opening and closure of the eyelid; the loss of the eyeball increases the EMG activity of the orbicularis oculi muscle; the use of eye prosthesis for a period of 7 days, was not enough to diminish the muscular activity, even its perfect adaptation been evidenced clinically.

Modification of col shape and interproximal area after periodontal surgery associated with the restorative alveolar interface (RAI) technique. Histological study in dogs.

The modification of the col shape and position by the restorative alveolar interface technique (RAI) was studied in the interproximal areas between the mandibular first molars and fourth premolars of 10 dogs. Full thickness flaps were raised to expose the interproximal root surface and alveolar bone crest. The RAI procedure was performed only on the experimental sides and the control areas were the opposite side of the same animal. The animals were sacrificed at zero hour, 7, 14, 21 and 28 days for histological analyses. Approximately 6.0-micron-thick sections were made in buccolingual and mesiodistal directions and stained with hematoxylin-eosin and Mallory for light microscopy analysis. A satisfactory healing process was observed up to the 14th and 21st days which showed a modified col shape. At this time, an inflammatory reaction developed affecting the evolution of the healing. The surgery had probably created conditions for the installation of an inflammatory process resulting from the modified anatomy of the interdental area.

Latex allergy in health care personnel.

This article presents a summary of literature published in recent years about latex allergy. The first article on allergic reactions associated with latex was published in Britain in 1979. Since then, the number of reported cases has increased. A wide variety of allergic reactions that range from contact dermatitis to anaphylactic shock are described in literature. Conclusions support that health care team members must be well informed about the implications of latex allergy to better help allergic individuals.

Identification of a 30 kDa antigen from leishmania (L.) chagasi amastigotes implicated in protective cellular reponses in a murine model.

An antigen of apparent molecular mass of 30 kDa, termed p30, was purified from Leishmania (L.) chagasi amastigotes after separation of parasite extracts by sodium dodecyl sulfate-polyacrylamide gel eletroctrophoresis followed by electroelution. The use of the purified antigen in lymphocyte cultures from BALB/c mice previously immunised with L. (L.) chagasi amastigotes led to high levels of proliferation. Animal immunisation with p30 plus complete Freund's adjuvant either by subcutaneous or intraperitoneal route led to comparable antigenic stimulation. Similar stimulation indices induced by p30 were also obtained when animals were immunised with Corynebacterium parvum as adjuvant by the intraperitoneal route. Detection of IL-2 and IFN-gamma in the supernatants from lymphocytes stimulated by p30 and inhibition of the production of these lymphokines in the presence of anti-CD4 strongly indicated the involvement of the Th1 subset in the responses elicited by p30 antigen. Immunisation of BALB/c mice with p30 provided partial protection against challenge with L. (L.) chagasi amastigotes, indicating a protective role for p30 and that Th1 can be related to accquired resistance to visceral leishmaniasis in a murine model. Further characterisation studies were performed by the use of a monoclonal antibody directed to a cysteine proteinase of 30 kDa from L. (L.) amazonensis amastigotes. Despite the cross-reactivity presented by p30 from both Leishmania species, the p30 from L. (L.) chagasi amastigotes lacks proteolytic activity.

Denture-induced fibrous inflammatory hyperplasia: a retrospective study in a school of dentistry.

PURPOSE: The aim of this study was to investigate the denture-induced fibrous inflammatory hyperplasia (FIH) that occurs around the borders of an ill-fitting denture, in relation to frequency of the lesion, age and sex distribution, length of denture use, and frequency of dysplasia. MATERIALS AND METHODS: A comprehensive review of FIH diagnosed in patients wearing dentures by the oral pathology diagnostic service at the University of São Paulo over 26 years (1971 to 1996) was undertaken, based on retrospective analysis of the oral histopathologic files. RESULTS: The frequency of FIH was 15% of the total number of pathologies diagnosed at the service of oral pathology in that period. The disorder occurred predominantly in the fifth and sixth decades of life and more often among females, at a proportion of 5:1. The frequency of FIH was higher for a length of denture use of between 1 and 10 years. Dysplasia was found in 4% of cases. CONCLUSION: The knowledge of some aspects of FIH, especially the possible histologic alteration of dysplasia, supports the importance of the diagnosis and treatment of the lesion and suggests that any excised tissue should be submitted to histopathologic evaluation. Education and regular review of patients who have worn dentures are essential if the development of FIH is to be prevented.

Angioarchitectural arrangements in corrosion cast of the nasal septum of the Mongolian gerbil.

The three-dimensional architecture of the vascular network of the nasal septum of the gerbil rat was studied using the corrosive resin cast technique. The angioarchitecture of the nasal septum observed with scanning electron microscopy (SEM) showed that a vascular network is disposed in the lamina propria. The capillaries, arterioles, venules and arteries were closely observed in different areas of the nasal septum mucosa.

Scanning electron microscopy of the rat tongue mucosa with special attention to the bacteria on epithelial cell membranes.

The authors examined the filiform and fungiform papillae surfaces of rat tongue by scanning electron microscopy showing the numerous groupings of bacteria on the epithelial cell membranes. The fungiform papillae were round in shape and present few bacteria. The epithelial cell of filiform papillae revealed numerous streptococci. The grouping of the bacteria are attached on the epithelial cell membrane, demonstrating three-dimensional SEM images.

[Allergic reactions caused by latex: warning to health workers]. / Reações de alergia provocadas pelo látex: um alerta aos trabalhadores da área da saúde.

In this study, a bibliographic survey is made of all articles, published during the last few years, dealing with allergic reactions to latex. The first article on allergic reactions associated with latex was published in Britain, in 1979. Since then, the number of cases reported have increased (Barton, 1993). Type I allergic reaction (immediate reaction) and Type IV (delayed reaction) are part of the latex allergic process (Steelman, 1995). Contact allergy is due to inadequate washing during manufacture, which results in the retention of water-soluble proteins that cause allergic reactions in susceptible people. A wide variety of allergic reactions that vary from contact dermatitis to anaphylatic shock are described in literature. These finding show that a health team must know the probable implications of latex allergy.

The annual testicular cycle of the domestic quail (Coturnix coturnix japonica).

A morphometric study was conducted on the testis of the domestic quail Coturnix coturnix japonica to determine testicular kinetics. We investigated the variability along the year of testicular parameters such as seminiferous tubule diameter, germinal epithelium height and amount of meiotic figures of maturing spermatids in the seminiferous epithelium and of sperm in the tubular lumen. The results of morphometric analysis showed the occurrence of an annual testicular cycle defined by four distinct phases: a resting phase (at the end of summer), a recrudescence phase (in the fall), a proliferative phase (at the end of winter and beginning of spring), and a regression phase (spring and summer). We also observed that the testes of adult quails present elevated and maximal spermatogenic activity in fall-winter (short-day period) and at the beginning of spring, respectively, and lower values in spring and summer (long-day periods), with minimum values at the end of summer.

Biochemical and histopathological alterations induced in rats by Tityus serrulatus scorpion venom and its major neurotoxin tityustoxin-I.

Intravenous injection into the rat of sublethal doses of Tityus serrulatus scorpion venom (100 micrograms protein/kg) or its major neurotoxin tityustoxin-I (TsTX-I, 20 micrograms/kg) caused, 30-180 min after injection, statistically significant increases in the serum levels of aspartate aminotransferase, amylase, creatine kinase and lactate dehydrogenase, as well as hyperglycemia, a high level of plasma free fatty acids and a low level of liver glycogen. The in vitro serum levels of the above enzymes did not change. For alanine aminotransferase, gamma-glutamyl transferase and alkaline phosphatase, neither in vitro nor in vivo alterations were observed. The whole venom and TsTX-I caused hepatic congestion with hemolysis and hydropic degeneration. Other histological lesions included edema and congestion with subpleural hemorrhage in the lungs, hypertrophy of fibers with degeneration areas in the heart, and congestion and hemorrhage in the kidneys. In the salivary glands, alterations to the acini and ductules were visible. In the adrenal glands no morphological alterations could be detected at the studied doses. The results suggest that the in vivo enzymatic and histopathological alterations are due to tissue lesions evoked by the whole venom and TsTX-I. An indirect effect, however, induced by stimulation of acetylcholine and catecholamine release in the postganglionic nerve terminals, cannot be excluded.

Scanning electron microscopy study of the interface epithelium-connective tissue surface of the lingual mucosa in Calomys callosus.

The characteristics of the interface epithelium-connective tissue of the lingual mucosa of Calomys callosus was studied by employing scanning electron microscopy after removal of the epithelial cells. In the anterior part, the connective tissue papillae of filiform papillae are distributed at random in their original configuration, and the round-shaped fungiform papillae are scattered among the filiform papillae. In the middle part, the filiform papillae present several rod-shaped projections. In the posterior part, the vallate papilla are oval in shape, and the connective tissue reveals a large ridge separated by deep lateral grooves. The posterior adjacent area is a flat surface and shows several openings of salivary gland ducts. The foliate papillae are formed by several small ridges separated by grooves. In the areas adjacent to the foliate papilla, small pointed and laminar papillae were observed.

[The most frequent nursing diagnoses in an oncology admission unit]. / Diagnósticos de enfermagem mais freqüentes em uma unidade de internação de oncologia.

The aim of this paper was to survey the most frequent nursing diagnoses by means of the nursing history and medical procedure in order to help the care provided at the Oncology Nursing Service of Women Health Whole Care (Centro de Atenção Integral à Saúde da Mulher-CAISM). The five most common diagnoses were: risk for infection, risk for altered body temperature, risk for aspiration and colonic constipation of the exchanging pattern, and risk for activity intolerance of the moving pattern. Data collection was based on these patterns. Data predominantly involving social, cultural, psychological and spiritual aspects were hardly interpreted, because they were poorly registered or omitted.