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2.
J Am Soc Echocardiogr ; 34(10): 1046-1055.e3, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34245827

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, with significant clinical and economic burdens, largely driven by adverse cardiovascular outcomes and AF-related hospitalization. Left atrial (LA) parameters have been shown to have prognostic value in cardiovascular disease states. We sought to evaluate the prognostic value of measures of LA size and function, as measured through LA volume index and LA emptying fraction (LAEF), respectively, for AF rehospitalization and long-term adverse outcomes in patients with nonvalvular AF following index hospitalization. METHODS: In this retrospective study, 594 consecutive patients (mean age, 67.8 ± 13.6 years, 53% men) admitted to a tertiary referral center with nonvalvular AF were assessed. Patients who underwent transthoracic echocardiography during their index admission and had complete follow-up data were included and followed for a mean period of 33.18 ± 21.27 months for the primary outcome of AF rehospitalization. The secondary outcome was a composite of all-cause death and major adverse cardiovascular events. RESULTS: The primary outcome occurred in 250 (42%) patients, and the secondary outcome occurred in 219 (37%) patients. On multivariable regression analysis, LAEF had an independent association with AF rehospitalization (hazard ratio [HR] = 0.967; 95% CI, 0.953-0.982; P < .01), and time-dependent receiver operating characteristic curves demonstrated LAEF to have strong diagnostic accuracy in predicting early and intermediate AF rehospitalization. Both LA volume index (HR = 1.014; 95% CI, 1.003-1.026; P = .01) and LAEF (HR = 0.982; 95% CI, 0.970-0.993; P < .01) were associated with all-cause death and major adverse cardiovascular events. CONCLUSIONS: Adverse LA remodeling, as reflected through LA enlargement and reduced LA mechanical function, is associated with AF rehospitalization and long-term adverse cardiovascular outcomes in hospitalized patients with nonvalvular AF.


Assuntos
Fibrilação Atrial , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/diagnóstico por imagem , Benchmarking , Feminino , Átrios do Coração/diagnóstico por imagem , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
Am J Cardiol ; 151: 105-113, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34049674

RESUMO

Left atrial (LA) enlargement predicts adverse cardiovascular events in patients with chronic kidney disease (CKD). The aim of our study was to evaluate the value of LA reservoir strain, a novel measure of LA function, as a prognostic marker for adverse renal outcomes. A total of 280 patients (65.8 ± 12.2years, 63% male) with stable Stage 3 and 4 CKD without prior cardiac history were evaluated with transthoracic echocardiography and prospectively followed for up to 5 years. The primary end point was progressive renal failure, which was the composite of death from renal cause, end-stage renal failure and/or doubling of serum creatinine. Over a mean follow up of 3.9 ± 2.7years, 56 patients reached the composite endpoint. By log rank test, older age, lower baseline eGFR, anemia, diabetes mellitus, higher urinary albumin/creatinine ratio, number of antihypertensive medications, higher indexed left ventricular mass, larger LA volumes, and impaired LA reservoir strain were significant predictors of the composite outcome (p <0.01 for all). Multi-variable Cox regression analysis found LA reservoir strain, eGFR, number of antihypertensive medications and urinary albumin/creatinine ratio were independent predictors for progressive renal failure (p <0.01 for all). Impaired LA reservoir strain was associated with a 2.5-fold higher risk of the composite outcome (HR 2.51, 95% CI 1.19 to 5.30, p = 0.02) and was the only echocardiographic parameter that predicted progressive renal failure independent of established clinical risk factors for end-stage renal failure. Its utility requires validation in high risk CKD patients with cardiac disease.


Assuntos
Função do Átrio Esquerdo , Átrios do Coração/diagnóstico por imagem , Falência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Idoso , Creatinina/sangue , Progressão da Doença , Ecocardiografia , Feminino , Seguimentos , Átrios do Coração/fisiopatologia , Humanos , Falência Renal Crônica/sangue , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/mortalidade
4.
Circ Cardiovasc Qual Outcomes ; 14(3): e007411, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33663224

RESUMO

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.


Assuntos
Fibrilação Atrial , Prestação Integrada de Cuidados de Saúde , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Hospitalização , Humanos , Acidente Vascular Cerebral , Telemedicina
5.
J Clin Neurosci ; 85: 27-35, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33581786

RESUMO

Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.


Assuntos
Preconceito , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Adulto Jovem
6.
Eur J Clin Invest ; 51(3): e13395, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32886806

RESUMO

AIMS: The persistence of atrial fibrillation (AF) has been associated with differential clinical outcomes, with studies showing that persistent and permanent AF results in increased morbidity and mortality when compared to the paroxysmal subtype. Given the established prognostic implications of AF subtype, we sought to discern the clinical and structural cardiac parameters associated with persistent/ permanent AF. MATERIALS AND METHODS: Consecutive patients admitted to our institution between January 2013 and January 2018 with a primary diagnosis of non-valvular AF who underwent comprehensive transthoracic echocardiography were retrospectively appraised. Assessment of clinical and echocardiographic parameters was undertaken and compared according to AF subtype. RESULTS: Of 1010 patients, 665 (mean age 66.8 ± 13.5 years, 53% men) had comprehensive transthoracic echocardiography on index admission and were included in the primary analysis. The majority of patients (n = 468; 70%) had paroxysmal AF while 197 (30%) had persistent/ permanent AF. Multivariable logistic regression analysis showed that heart failure (adjusted OR 3.135; 95% CI 2.099 to 4.682, P < .001), right atrial (RA) area ≥18 cm2 (adjusted OR 2.147; 95% CI 1.413 to 3.261, P < .001) and left atrial emptying fraction (LAEF) ≤34% (adjusted OR 2.959; 95% CI 1.991 to 4.398, P < .001) were independent predictors of persistent /permanent AF. CONCLUSIONS: The presence of heart failure, increased RA size and impaired LA function were associated with persistent/ permanent AF. These clinical and cardiac structural risk markers of AF persistence may identify a target population for early intervention to prevent adverse cardiovascular outcomes.

7.
J Am Soc Echocardiogr ; 34(2): 166-175, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33223356

RESUMO

BACKGROUND: Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients. METHODS: Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE. RESULTS: Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores. CONCLUSIONS: LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume.

8.
J Am Heart Assoc ; 10(1): e017840, 2021 01 05.
Artigo em Inglês | MEDLINE | ID: mdl-33372523

RESUMO

Background Left atrial (LA) function plays a pivotal role in modulating left ventricular performance. The aim of our study was to evaluate the relationship between resting LA function by strain analysis and exercise capacity in patients with chronic kidney disease (CKD) and evaluate its utility compared with exercise E/e'. Methods and Results Consecutive patients with stage 3 and 4 CKD without prior cardiac history were prospectively recruited from outpatient nephrology clinics and underwent clinical evaluation and resting and exercise stress echocardiography. Resting echocardiographic parameters including E/e' and phasic LA strain (LA reservoir [LASr], conduit, and contractile strain) were measured and compared with exercise E/e'. A total of 218 (63.9±11.7 years, 64% men) patients with CKD were recruited. Independent clinical parameters associated with exercise capacity were age, estimated glomerular filtration rate, body mass index, and sex (P<0.01 for all), while independent resting echocardiographic parameters included E/e', LASr, and LA contractile strain (P<0.01 for all). Among resting echocardiographic parameters, LASr demonstrated the strongest positive correlation to metabolic equivalents achieved (r=0.70; P<0.01). Receiver operating characteristic curves demonstrated that LASr (area under the curve, 0.83) had similar diagnostic performance as exercise E/e' (area under the curve, 0.79; P=0.20 on DeLong test). A model combining LASr and clinical metrics showed robust association with metabolic equivalents achieved in patients with CKD. Conclusions LASr, a marker of decreased LA compliance is an independent correlate of exercise capacity in patients with stage 3 and 4 CKD, with similar diagnostic value to exercise E/e'. Thus, LASr may serve as a resting biomarker of functional capacity in this population.


Assuntos
Função do Átrio Esquerdo/fisiologia , Ecocardiografia/métodos , Tolerância ao Exercício/fisiologia , Átrios do Coração , Insuficiência Renal Crônica , Índice de Massa Corporal , Correlação de Dados , Feminino , Taxa de Filtração Glomerular , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Índice de Gravidade de Doença
9.
Echocardiography ; 37(12): 2018-2028, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33211337

RESUMO

BACKGROUND: Left atrial (LA) deformation during the reservoir phase (LASr) has demonstrated strong prognostic value in different clinical settings. Although determinants of left atrial reservoir strain including left atrial relaxation, left atrial compliance, and left ventricular longitudinal systolic function are fairly well defined, there is incomplete information regarding the effect of left atrial volume on this relationship which is the focus of our study. METHOD: Consecutive patients without prior cardiac disease referred for transthoracic echocardiography were prospectively recruited. All participants underwent clinical assessment, transthoracic echocardiography (TTE), and screening exercise stress test. Only patients with normal left ventricular ejection fraction (LVEF) without left ventricular hypertrophy (LVH) or myocardial ischemia on stress testing were included. RESULTS: A total of 260 patients (57% male, mean age 59 ± 14 years) were included. 70% had hypertension, 33% had diabetes mellitus, and 31% had both HTN and DM. On multivariate analysis, age, e', LAVI, and LV GLS (P < .01 for all) showed an independent association with LASr. Of interest, at lower tertiles of LAVI, a linear decrease in LASr was observed parallel to worsening LV GLS, whilst at higher tertiles of LAVI, the reduction in LASr was non-linear implying that LA enlargement, consequent to LA remodeling, had an incremental effect on LASr. CONCLUSION: Age, e', LV GLS, and LAVI were independently associated with LASr. LA remodeling reflected by larger LAVI had an incremental negative association with LASr independent of LV GLS.


Assuntos
Função do Átrio Esquerdo , Disfunção Ventricular Esquerda , Idoso , Ecocardiografia , Feminino , Átrios do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda
11.
Front Cardiovasc Med ; 7: 590557, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33195479

RESUMO

Cardiac amyloidosis (CA) is a unique disease entity involving an infiltrative process, typically resulting in a restrictive cardiomyopathy with diastolic heart failure that ultimately progresses to systolic heart failure. The two most common subtypes are light-chain and transthyretin amyloidosis. Early diagnosis of this disease entity, especially light-chain CA subtype, is crucial, as it portends a poorer prognosis. This review focuses on the clinical utility of the various imaging modalities in the diagnosis and differentiation of CA subtypes. This review also aims to highlight the key advances in each of the imaging modalities in the diagnosis and prognostication of CA.

13.
J Neurol Sci ; 418: 117115, 2020 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-32916515

RESUMO

BACKGROUND: Strokes in the young and middle-aged are associated with a disproportionately large economic and social impact in addition to their clinical effects. Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes mellitus and smoking) are key drivers of cardiovascular disease including strokes, however recent temporal trends in the younger stroke population have not been well characterised. We aimed to evaluate recent trends of SMuRFs in a cohort of younger patients with ischaemic stroke. METHODS: Consecutive patients aged <65 years with clinical and/or radiological diagnosis of ischaemic stroke or transient ischaemic attack in a tertiary referral centre (2013-2017) were retrospectively appraised. The demographic and clinical comorbidities of these patients were assessed including their SMuRF profile. The prevalence over time and clinical associations of patients with no SMuRFs were studied and compared to patients with SMuRFs. RESULTS: Of 487 patients (53.49 ± 9.13 yrs., 60% men) analysed, 23% did not have SMuRFs. The proportion of "non-SMuRF" patients increased over time (p < 0.01) and this trend was not influenced by age (p = 0.48) or gender (p = 0.68). The presence of SMuRFs was not associated with in-hospital outcomes, however patients without SMuRFs were significantly less likely to be discharged on blood pressure (p < 0.01) and lipid-lowering therapies (p = 0.03). CONCLUSIONS: The proportion of younger stroke patients without SMuRFs is substantial and has increased over time. Our findings highlight the need for further research to better understand the mechanisms underlying stroke development in this population and whether less risk factor treatment in this population could impact longer term outcomes.


Assuntos
Isquemia Encefálica , Doenças Cardiovasculares , Ataque Isquêmico Transitório , AVC Isquêmico , Acidente Vascular Cerebral , Idoso , Isquemia Encefálica/complicações , Isquemia Encefálica/epidemiologia , Doenças Cardiovasculares/epidemiologia , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia
14.
JACC Cardiovasc Imaging ; 13(12): 2485-2494, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32861659

RESUMO

OBJECTIVES: This study sought to assess the relationship between E/e' and exercise capacity in patients with chronic kidney disease (CKD) and evaluate its prognostic role. BACKGROUND: Patients with CKD have diastolic dysfunction, reduced physical fitness, and elevated risk of cardiovascular disease. METHODS: Patients with stage 3 and 4 CKD without previous cardiac disease underwent resting and exercise stress echocardiograms with assessment of exercise E/e'. Patients were compared to age-, sex-, and risk factor-matched control individuals and were followed annually for 5 years for cardiovascular death and major adverse cardiovascular event(s) (MACE). Exercise capacity was assessed as metabolic equivalents (METs), with reduced exercise capacity defined as METs of ≤7. Raised exercise E/e' was defined as >13. RESULTS: A total of 156 patients with CKD (age 62.8 ± 10.6 years; male: 62%) were compared to 156 matched control individuals. Patients with CKD were more likely to be anemic (p < 0.01) and had increased left ventricular mass (p < 0.01), larger left atrial volumes (p < 0.01), and higher resting (p < 0.01) and exercise E/e' (p < 0.01). Patients with CKD achieved lower exercise METs (p < 0.01), and more patients with CKD had METs of ≤7 (p < 0.01). Receiver-operating characteristic curves showed exercise E/e' (area under the curve [AUC]: 0.89; 95% CI: 0.84 to 0.95; p < 0.01) as the strongest predictor of reduced exercise capacity in patients with CKD. Over a follow-up period of 41.4 months, a raised exercise E/e' of >13 was an independent predictor of cardiovascular death and MACE on unadjusted and adjusted hazard models. CONCLUSION: E/e' is a strong predictor of exercise capacity and METs achieved by patients with CKD. Exercise capacity was reduced in patients with CKD, presumably consequent to diastolic dysfunction. Elevated exercise E/e' in patients with CKD is an independent predictor of cardiovascular death and MACE.

15.
Int J Cardiol Heart Vasc ; 29: 100547, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32514426

RESUMO

•TS and AMI are separate cardiac conditions with similar clinical presentations.•TS have a higher LVSI than AMI, indicating a more spherical left ventricle.•LVSI may be utilised acutely to assist differentiation of acute phase TS and AMI.

16.
Heart Rhythm ; 17(11): 1991-1999, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32565194

RESUMO

Atrial fibrillation (AF)-related hospitalization has risen over the last 2 decades and is the most influential determinant of total disease-related expenditure. In this review article, we describe several identified drivers of hospitalization from several registries and large-scale clinical trials, including key cardiovascular and non-traditional risk factors. We also discuss available assessment tools for discerning overall risk of hospitalization, including AF symptom scores, thrombosis and bleeding disposition, and non-invasive cardiac structural assessment. Finally, we highlight the different treatment paradigms that have been proven to reduce AF burden, progression, and hospitalization in the literature.

17.
Int J Cardiol Heart Vasc ; 26: 100454, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31909178

RESUMO

Background: Stroke is one of the leading causes of morbidity and mortality with a significant percentage classified as cryptogenic. Left atrial (LA) remodelling, a substrate for atrial fibrillation (AF) and stroke development, may play a role in identification of the aetiology of cryptogenic stroke. We aimed to examine LA function to gain mechanistic insights into the pathophysiology of cryptogenic stroke in young patients otherwise at low risk for cardiovascular disease. Methods: Patients aged <60 years without traditional cardiovascular risk factors and who were diagnosed with ischaemic cryptogenic stroke or TIA were evaluated and compared to healthy controls and patients with paroxysmal AF with a CHA2DS2-VA score of 0. Conventional and novel left ventricular (LV) and LA echocardiographic parameters between the three groups were assessed. Results: Each group consisted of thirty patients. There were no significant differences in LV parameters (LVEF, LV endoGLS) between groups. LA strain in stroke patients was significantly lower compared to the controls (median 33%; interquartile range (IQ) [32/39] vs 31 [27/34]; p = 0.008). LA strain was significantly lower in AF patients compared to stroke patients (median 21% [19/22] vs 31% [27/34]; p < 0.0001). Conclusion: A stepwise reduction in measures of LA function was appreciated between controls, young stroke and paroxysmal AF groups. This may indicate dynamic LA remodelling occurring in the young stroke population and suggest a shared causal mechanism for stroke development in this group. LA strain may further refine the risk for cardioembolic stroke.

19.
Cardiol Res Pract ; 2016: 1020818, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27313943

RESUMO

Ischaemic left ventricular (LV) dysfunction can arise from myocardial stunning, hibernation, or necrosis. Imaging modalities have become front-line methods in the assessment of viable myocardial tissue, with the aim to stratify patients into optimal treatment pathways. Initial studies, although favorable, lacked sufficient power and sample size to provide conclusive outcomes of viability assessment. Recent trials, including the STICH and HEART studies, have failed to confer prognostic benefits of revascularisation therapy over standard medical management in ischaemic cardiomyopathy. In lieu of these recent findings, assessment of myocardial viability therefore should not be the sole factor for therapy choice. Optimization of medical therapy is paramount, and physicians should feel comfortable in deferring coronary revascularisation in patients with coronary artery disease with reduced LV systolic function. Newer trials are currently underway and will hopefully provide a more complete understanding of the pathos and management of ischaemic cardiomyopathy.

20.
Vaccine ; 34(15): 1816-22, 2016 Apr 04.
Artigo em Inglês | MEDLINE | ID: mdl-26902546

RESUMO

OBJECTIVE: This study was designed with objective to study pain response of infants to change in sequence of administration of Hepatitis B and DTwP vaccines. METHODS: This was a randomized parallel control trial. The study was carried out in the immunization clinic of the Department of Pediatrics, LLRM Medical College, Meerut. One hundred and thirty healthy term infants up to 4 months of age were injected either DTwP vaccine first or Hepatitis B vaccine first, followed one minute later by the other vaccine. RESULT: Baseline characteristics did not differ between the groups. The mean (SD) of AUC of MFCS and NIPS was significantly more in DF group as compared to HF group (for MFCS 25.5 ± 5.4 versus 22.5 ± 5.5, p<0.01; for NIPS 31.77 ± 5.5 versus 27.64 ± 6.9, p < 0.01). Similarly mean (SD) of AUC of Heart rate and saturation of oxygen showed significant variation in DF group as compared to HF group (for heart rate 591.6 ± 55 versus 559.6 ± 49, p< 0.01; for SpO2 326.4 ± 12 versus 335 ± 8, p < 0.01). CONCLUSION: These results showed that infant experienced lesser pain when Hepatitis B was administered first than when DTwP vaccine was given first.


Assuntos
Vacina contra Difteria, Tétano e Coqueluche/administração & dosagem , Vacinas contra Hepatite B/administração & dosagem , Dor/prevenção & controle , Vacinação/métodos , Método Duplo-Cego , Feminino , Humanos , Lactente , Masculino , Medição da Dor
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