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1.
Tex Heart Inst J ; 46(3): 222-224, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31708709

RESUMO

Low origin of the coronary arteries, defined as an origin less than 10 mm above the functional aortic annulus, is not usually considered to be a notable anomaly because functional impairment is not intrinsic. We describe a case of severe complications after surgical aortic valve replacement in a 59-year-old woman who had symptomatic aortic valve stenosis, low origin of both main coronary arteries, and a hypoplastic aortic annulus less than 19 mm in diameter. The aortic prosthesis had to be implanted above the hypoplastic anatomic annulus. An inferior-wall myocardial infarction, hypotension, right-sided heart failure, and atrial fibrillation developed during the early perioperative period. Coronary angiograms showed occlusion of the right coronary artery ostium and critical stenosis of the left coronary ostium. During reoperation, posterior aortic patch annuloplasty enabled lower reimplantation of the prosthetic aortic valve, jointly with right coronary artery-venous grafting. To prevent potentially severe complications, we recommend that low origin of the coronary arteries be reported before patients undergo surgical aortic valve replacement. If the ostia are not seen when routine coronary angiography is used, computed tomography should be prospectively performed to characterize this anomaly.


Assuntos
Anormalidades Múltiplas , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Anuloplastia da Valva Cardíaca/métodos , Anomalias dos Vasos Coronários/diagnóstico , Implante de Prótese de Valva Cardíaca/métodos , Complicações Intraoperatórias , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico , Angiografia Coronária , Ponte de Artéria Coronária/métodos , Anomalias dos Vasos Coronários/cirurgia , Ecocardiografia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade
3.
J Am Heart Assoc ; 8(15): e013201, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31311390

RESUMO

See Article Cammann et al.

4.
Clin Rheumatol ; 38(10): 2737-2746, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31161486

RESUMO

OBJECTIVES: To identify baseline predictors of remission and low disease activity (LDA) in early rheumatoid arthritis (RA) from the GLADAR (Grupo Latino Americano De estudio de la Artritis Reumatoide) cohort. METHODS: Patients with 1- and 2-year follow-up visits were included. Remission and LDA were defined by DAS28-ESR (< 2.6 and ≤ 3.2, respectively). Baseline predictors examined were gender, ethnicity, age at diagnosis, socioeconomic status, symptoms' duration, DMARDs, RF, thrombocytosis, anemia, morning stiffness, DAS28-ESR (and its components), HAQ-DI, DMARDs and corticosteroid use, and Sharp-VDH score. Multivariable binary logistic regression models (excluding DAS28-ESR components to avoid over adjustment) were derived using a backward selection method (α-level set at 0.05). RESULTS: Four hundred ninety-eight patients were included. Remission and LDA/remission were met by 19.3% and 32.5% at the 1-year visit, respectively. For the 280 patients followed for 2 years, these outcomes were met by 24.3% and 38.9%, respectively. Predictors of remission at 1 year were a lower DAS28-ESR (OR 1.17; CI 1.07-1.27; p = 0.001) and HAQ-DI (OR 1.48; CI 1.04-2.10; p = 0.028). At 2 years, only DAS28-ESR (OR 1.40; CI 1.17-1.6; p < 0.001) was a predictor. Predictors of LDA/remission at 1 year were DAS28-ESR (OR 1.42; CI 1.26-1.61; p < 0.001), non-use of corticosteroid (OR 1.74; CI 1.11-2.44; p = 0.008), and male gender (OR 1.77; CI 1.2-2.63; p = 0.036). A lower baseline DAS28-ESR (OR 1.45; CI 1.23-1.70; p < 0.001) was the only predictor of LDA/remission at 2 years. CONCLUSIONS: A lower disease activity consistently predicted remission and LDA/remission at 1 and 2 years of follow-up in early RA patients from the GLADAR cohort. Key Points • In patients with early RA, a lower disease activity at first visit is a strong clinical predictor of achieving remission and LDA subsequently. • Other clinical predictors of remission and LDA to keep in mind in these patients are male gender, non-use of corticosteroids and low disability at baseline. • Not using corticosteroids at first visit is associated with a lower disease activity and predicts LDA/remission at 1 year in these patients.

5.
J Clin Rheumatol ; 25(1): 54-58, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29596208

RESUMO

BACKGROUND: By 2015, the World Health Organization reported that 1% of the world population suffered from rheumatoid arthritis (RA) and in Latin America (LA) between 0.5% and 1%. Previously, in May 2014, a consensus meeting was held in Barranquilla, Colombia, where the Project for Implementation and Accreditation of Centers of Excellence (CoE) in RA in LA was established, which then became an official special group of the Pan American League of Associations for Rheumatology (PANLAR). OBJECTIVE: The aim of this study was to define the methodological approach for the accreditation process of CoE in RA in LA. METHODS: A meeting was held in April 2015 with participation of the members of the REAL-PANLAR Steering Committee, and representatives of several LA countries, with the support of 2 experts in accreditation processes and models in Colombia. Then, in November 2015 in San Francisco and in November 2016 in Washington, the REAL-PANLAR Steering Committee met to discuss some final aspects of the project. RESULTS: The following steps for accreditation were defined: application for accreditation, issuance of the concept of assessment of the entity, accreditation decision, and monitoring accreditation. CONCLUSIONS: This is the second REAL-PANLAR consensus paper with the purpose to define the parameters for the accreditation process for future CoE in RA in LA.


Assuntos
Acreditação , Artrite Reumatoide/terapia , Assistência à Saúde , Reumatologia , Consenso , Humanos , América Latina , Sociedades Médicas
7.
J Clin Rheumatol ; 25(2): 101-107, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30028809

RESUMO

BACKGROUND/OBJECTIVE: Although mortality rates related with chikungunya (CHIK) outbreaks in Latin America's (LA's) dengue-endemic rural and new urban regions are low, dealing with symptoms and sequelae can both produce a significant burden of disease and diminish quality of life-from many months to years-after the acute phase of the infection, with a significant impact on public and individual health.The aim of this work was to establish Pan-American League of Associations for Rheumatology-Central American, Caribbean and Andean Rheumatology Association (ACCAR) consensus-conference endorsements and recommendations on the diagnosis and treatment of CHIK-related inflammatory arthropathies transmitted by Aedes aegypti and Aedes albopictus in LA. METHODS: Based on the Consensus Development Conference format, a panel of ACCAR rheumatologist voting members (n = 10) took part in this Pan-American League of Associations for Rheumatology initiative. Experts voted from a previous content analysis of the medical literature on CHIK, 4 subsequent topic conferences, and a workshop. Consensus represents the majority agreement (≥80%) achieved for each recommendation. RESULTS: The experts' panel reached 4 overarching principles: (1) CHIK virus (CHIKV) is a re-emergent virus transmitted by 2 species of mosquitoes: A. aegypti and A. albopictus; (2) CHIKV caused massive outbreaks in LA; (3) chronic CHIKV infection produces an inflammatory joint disease that, in some cases, can last for several months to years, and (4) currently, there are no vaccines or antivirals licensed for CHIKV infections. RECOMMENDATIONS: Pan-American League of Associations for Rheumatology-ACCAR achieved 13 endorsements and recommendations on CHIK categorized in 3 groups: (1) epidemiology and clinical manifestations, (2) diagnosis, and (3) treatment, representing the consensus agreement from the panel's members.


Assuntos
Artrite Infecciosa/diagnóstico , Artrite Infecciosa/terapia , Febre de Chikungunya/complicações , Política de Saúde , Reumatologia , Artrite Infecciosa/virologia , Consenso , Humanos , América Latina , Sociedades Médicas
8.
J Clin Rheumatol ; 25(2): 91-100, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30059414

RESUMO

BACKGROUND/HISTORICAL PERSPECTIVE: Availability of biologic disease-modifying antirheumatic drugs (bDMARDs) has improved clinical outcomes in rheumatoid arthritis, but it also increased the cost of treatment. Biosimilars, the regulated copies of biologic products, have a potential to reduce health care costs and expand access to treatment. However, because of a complex development process, biosimilars can be considered only those noninnovator biologics with satisfactory supporting evidence (ranging from structural to clinical), as outlined in the recommendations by the World Health Organization (WHO). In Latin America, a heterogeneous regulatory landscape and nonconsistent approval practices for biosimilars create decision-making challenges for practicing rheumatologists. SUMMARY OF LITERATURE: Most Latin American countries either have adopted or are in the process of adopting guidelines for the approval of biosimilars. However, among several marketed bDMARDs in the region, currently there are only 2 products that could be considered true biosimilars, based on the WHO criteria. The rest can be considered only intended copies, whose safety and efficacy are not fully established. One such product had to be withdrawn from the market because of safety concerns. CONCLUSIONS AND FUTURE DIRECTIONS: Practicing rheumatologists in Latin America need to understand the regulatory situation for biosimilars in their countries. When considering bDMARDs that are not innovator products, clinicians should use only those that have been approved according to the WHO recommendations. For clarification, local health authorities or professional associations should be contacted.


Assuntos
Antirreumáticos/uso terapêutico , Medicamentos Biossimilares/uso terapêutico , Doenças Reumáticas/tratamento farmacológico , Reumatologia , Humanos , América Latina
9.
Catheter Cardiovasc Interv ; 93(3): 445-447, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30585420

RESUMO

A 52-year-old man was referred for an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva with an intramural course (R-ACAOS-IM), accompanied by progressive angina and dyspnea. He had been initially advised to have surgical treatment. Computerized axial tomographic angiography showed he had an ectopic origin from the left sinus of a small RCA, with a course between the aorta and pulmonary artery. His negative treadmill nuclear stress test was prematurely terminated because of angina and dyspnea. At our institution, intravascular ultrasound imaging indicated an intramural course and critically severe phasically changing proximal stenosis (80%-100%). The stenosis was resolved with stent-angioplasty of the intramural segment. He had no complications and returned quickly to an asymptomatic state with unrestricted physical activity.

11.
Tex Heart Inst J ; 45(4): 205-213, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30374227

RESUMO

Improving preparticipation screening of candidates for sports necessitates establishing the prevalence of high-risk cardiovascular conditions (hr-CVC) that predispose young people to sudden cardiac death (SCD). Our accurate, novel protocol chiefly involved the use of cardiac magnetic resonance (CMR) to estimate this prevalence. Middle and high school students from a general United States population were screened by means of questionnaires, resting electrocardiograms, and CMR to determine the prevalence of 3 types of hr-CVC: electrocardiographic abnormalities, cardiomyopathies, and anomalous coronary artery origin from the opposite sinus with intramural coronary course (ACAOS-IM). We examined the range of normal left ventricular size and function in the main study cohort (schoolchildren 11-14 yr old). We defined diagnostic criteria for hr-CVC and compared the cardiac measurements of these younger participants with those of older children whom we examined (age, 15-18 yr). From 5,169 completed diagnostic studies (mean participant age, 13.06 ± 1.78 yr), CMR results revealed 76 previously undiagnosed cases of hr-CVC (1.47% of the total cohort): 11 of dilated cardiomyopathy (14.5%), 3 of nonobstructive hypertrophic cardiomyopathy (3.9%), 23 ACAOS-IM cases (30.3%; 6 left-ACAOS and 17 right-ACAOS), 4 Wolff-Parkinson-White patterns (5.3%), 34 prolonged QT intervals (44.7%), and 1 Brugada pattern (1.3%). Cardiomyopathies were significantly more prevalent in the older children. Of note, we identified 959 cases (18.5%) of left ventricular noncompaction. If our estimate is accurate, only 1.47% of school-age sports participants will need focused secondary evaluations; the rest can probably be reassured about their cardiac health after one 30-minute screening study.


Assuntos
Doenças Cardiovasculares/diagnóstico , Morte Súbita Cardíaca/epidemiologia , Imagem Cinética por Ressonância Magnética/métodos , Programas de Rastreamento/métodos , Instituições Acadêmicas , Esportes , Estudantes/estatística & dados numéricos , Adolescente , Doenças Cardiovasculares/mortalidade , Criança , Morte Súbita Cardíaca/etiologia , Eletrocardiografia , Feminino , Humanos , Masculino , Prevalência , Estudos Retrospectivos , Fatores de Risco , Inquéritos e Questionários , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
12.
Catheter Cardiovasc Interv ; 92(2): 313-321, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30051621

RESUMO

This is a novel re-appraisal of an understudied and misunderstood group of important coronary anomalies. The general name of the group is "anomalous origin of the left coronary artery," but several additional details should be included in this group of anomalies and the explanation of their pathophysiology. The most lethal form in young athletes or military recruits features intramural aortic proximal course. This comprehensive review is based on a large experience at a dedicated center for coronary artery anomalies, using evolving knowledge (over 20 years) while employing prospective and disciplined programs of evaluation and treatment, according to the nature and severity of each anomaly. The most common pathogenic mechanism of coronary dysfunction relates to intramural coronary course, with or without ectopic origin, leading to variable lateral compression and stenosis inside the aortic tunica media; this compression is present at rest and worsens with exertion. We propose that such variable and dynamic stenoses can be best studied by examining their specific anatomy and clinical presentation, stress testing, and, most importantly, in vivo evaluation by intravascular ultrasonography. Such methods should be used to support individual risk evaluation and selection among treatment options.


Assuntos
Angiografia Coronária , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Morte Súbita Cardíaca/etiologia , Isquemia Miocárdica/etiologia , Ultrassonografia de Intervenção , Idoso , Circulação Coronária , Anomalias dos Vasos Coronários/mortalidade , Anomalias dos Vasos Coronários/fisiopatologia , Vasos Coronários/fisiopatologia , Teste de Esforço , Feminino , Humanos , Masculino , Microcirculação , Pessoa de Meia-Idade , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Vasodilatadores/administração & dosagem , Adulto Jovem
14.
Clin Rheumatol ; 36(12): 2789-2797, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29098475

RESUMO

Health education is fundamental in the management of RA patients. This study explored patient needs for educational material appropriate for RA patients in our region through a website. This study includes seven focus groups and semi-structured interviews across 4 countries (Argentina, Chile, Colombia, and Mexico) with 71 RA patients. Transcripts were analyzed by anthropologists using qualitative analysis (QA), resulting in themes and subthemes to be developed. Five themes and over 50 subthemes of interest were identified by patients. Grouped into categories as follows: (1) knowing the disease, (2) living with arthritis, (3) treatment and therapies for RA, (4) psychosocial support, and (5) information for families. A response was written by the team in plain Spanish on patient subthemes of interest including additional areas that the team considered relevant. Three videos for YouTube were produced: on patient-doctor relationships, patients at work, and home and at the clinic. Illustrations in a comic book format on RA diagnosis were created. The educational site on RA of PANLAR can be found at htpp://artritisreumatoide.cl. This project accomplished a comprehensive list of RA patient interests, revealing the complex relationship between the information on the disease, the experience of a chronic disease, and the way in which patients approach, conceive, and manage their disease. We expect to gather information on how the website will be used in the future for patients and their families and maintain and improve the website as well as adapt its content to different socioeconomic realities.


Assuntos
Artrite Reumatoide/terapia , Gerenciamento Clínico , Educação em Saúde , Internet , Educação de Pacientes como Assunto , Antirreumáticos/uso terapêutico , Artrite Reumatoide/diagnóstico , Região do Caribe , Humanos , América Latina
15.
Clin Rheumatol ; 36(12): 2855-2858, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28840387

RESUMO

The implementation of excellence centers in specific diseases has been gaining recognition in the field of health; specifically in rheumatoid arthritis, where the prognosis of the disease is related to an early diagnosis and a timely intervention, it is necessary that the provision of health services is developed in an environment of quality, opportunity, and safety with the highest standards of care. A methodology that allows this implementation in such a way that is achievable by the most of the care centers is a priority to achieve a better attention to populations with this disease. In this paper, we propose a systematic and progressive methodology that will help all the institutions to develop successful models without faltering in the process. The expected impact on public health is defined by a better effective coverage of high-quality treatments, obtaining better health outcomes with safety and accessibility that reduces the budgetary impact for the health systems of our countries.


Assuntos
Artrite Reumatoide/terapia , Qualidade da Assistência à Saúde , Reumatologia/normas , Artrite Reumatoide/diagnóstico , Humanos
16.
J Clin Rheumatol ; 22(8): 405-410, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27870762

RESUMO

BACKGROUND: With the increases in and aging of the populations of the Americas, monitoring the number of rheumatologists is critical to address and focus on areas of greatest need. OBJECTIVES: The aim of this study was to gather data on the rheumatology workforce from 21 national societies in the Pan American League of Associations for Rheumatology (PANLAR). METHODS: In September and October 2012 and again in October and November 2015, the heads of the 21 rheumatology national societies were contacted in the 2012 survey; all national societies responded except Cuba. In the 2015 survey, all responded except Nicaragua, for which information was provided by national society presidents in adjacent countries. RESULTS: The data from 21 societies contained in PANLAR consist of 10,166 adult and 678 pediatric rheumatologists serving 961 million people. The number of rheumatologists per 100,000 population varies greatly from 3.9 per 100,000 people (Uruguay) to 0.11 per 100,000 people (Nicaragua). The number of training programs also varies widely, with some countries having no indigenous programs. The distribution of rheumatologists is mainly in the large cities, particularly in the smaller countries. Pediatric rheumatologists have dramatically increased in number in 2012, but 96% reside in 6 countries. This remains an underserved area in most countries. CONCLUSIONS: The rheumatology workforce in the Americas has improved between 2012 and 2015, especially in the number of pediatric rheumatologists. However, numerically and in the perception of the 21 member societies of PANLAR, the number is still inadequate to meet the increasing demands for rheumatologic care, especially in the care of children with rheumatic disease and in rural areas.


Assuntos
Reumatologistas/provisão & distribução , Reumatologia , Américas , Criança , Humanos , Doenças Reumáticas , Inquéritos e Questionários , Recursos Humanos
17.
Clin Rheumatol ; 35(10): 2381-5, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27553387

RESUMO

At the end of 2013, the Pan American Health Organization issued an epidemiological alert due to the detection of the first local cases of Chikungunya in the Americas. By August 2015, autochthonous transmissions were detected in 33 countries and territories of the Americas. Latin America has reported nearly one million cases; only Colombia has issued a report of >200,000 cases during the first 4 months of 2015. In some Latin American and Caribbean countries, Chikungunya becomes a major public health problem. The disease commonly exhibits a self-limited course of arthritis, usually lasting for a few days or that may be prolonged to weeks; however, in 10-60 % of cases, joint pain may become chronic and persist for up to 3-5 years. Human-caused environmental changes, such as climate change, the globalization of international exchange, and disordered urban growth, are some factors that aid in its emergence and dissemination. Outbreaks of Chikungunya comprise a challenge for health care systems and rheumatologists because of the high attack rate on the population and the anticipated development of post-Chikungunya chronic rheumatism. This review emphasizes the rheumatologic clinical manifestations reported in the American continent and highlights the challenges that health care systems face in the absence of an effective vaccine and specific treatment to fight Chikungunya.


Assuntos
Febre de Chikungunya/epidemiologia , Surtos de Doenças , Humanos , Incidência , América Latina/epidemiologia , Reumatologia
19.
J Clin Rheumatol ; 21(8): 435-9, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26513305

RESUMO

The First PANLAR Rheumatology Review Course was held in Barranquilla, Colombia, in April 2015. Researchers, rheumatologists, epidemiologists, and a variety of allied professionals and patients attended the meeting. The scientific program included plenary sessions and symposia delivered by renowned experts in the field, followed by an interactive forum of discussion during 2 days.A broad spectrum of topics was discussed, reflecting the current challenges and opportunities for diagnosis and treatment of rheumatoid arthritis (RA) in Latin America. The scientific program included not only traditional disease aspects, but also social implications, research projects, and educational characteristics, patient perspectives, and novel care models, emphasizing the need for training human resources and proposing unique approaches to RA health care in Latin America, therefore helping us to increase and improve the knowledge and understanding of the characteristics of this health condition in the region, thus promoting and encouraging equity, quality, and efficiency of RA health care.


Assuntos
Artrite Reumatoide , Assistência à Saúde , Educação de Pacientes como Assunto , Reumatologia , Desenvolvimento de Pessoal , Antirreumáticos/uso terapêutico , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/terapia , Assistência à Saúde/métodos , Assistência à Saúde/organização & administração , Gerenciamento Clínico , Humanos , América Latina , Melhoria de Qualidade , Reumatologia/educação , Reumatologia/métodos , Fatores Socioeconômicos
20.
Catheter Cardiovasc Interv ; 86(2): 199-208, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26178792

RESUMO

OBJECTIVES: We attempted to characterize the anatomy, function, clinical consequences, and treatment of right-sided anomalous coronary artery origin from the opposite side (R-ACAOS). BACKGROUND: Anomalous aortic origin of a coronary artery is a source of great uncertainty in cardiology. A recent study by our group found that ACAOS had a high prevalence (0.48%) in a general population of adolescents. METHODS: Sixty-seven consecutive patients were diagnosed with R-ACAOS according to a new definition: ectopic right coronary artery (RCA) with an intramural proximal course. We used intravascular ultrasonograms of the RCA to quantify congenital stenosis (in patients with potentially serious clinical presentations), and we correlated these measurements with clinical manifestations. RESULTS: All patients had some proximal intramural stenosis (mean 50%, range 16-83% of the cross-sectional area). Forty-two patients (62%) underwent stent-percutaneous coronary intervention (PCI) of R-ACAOS because of significant symptoms, positive stress tests, and/or significant stenosis. Stent-PCI was successful in all cases and correlated with improved symptoms at >1-year follow-up in 30 patients (71%) who were available for clinical follow-up. No ACAOS-related deaths occurred. The instent restenosis rate was 4/30 (13%) at a mean follow-up time of 5.0 years. CONCLUSIONS: This preliminary, but large and unprecedented observational study shows that cases angiographically identified as R-ACAOS universally feature an intramural aortic course but only occasionally severe stenosis on resting IVUS imaging. Our data suggest that stent-PCI with IVUS monitoring ameliorates patients' presenting symptoms.


Assuntos
Angioplastia Coronária com Balão/instrumentação , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/terapia , Seio Aórtico/diagnóstico por imagem , Stents , Ultrassonografia de Intervenção , Malformações Vasculares/diagnóstico por imagem , Adolescente , Adulto , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Criança , Angiografia Coronária , Reestenose Coronária/etiologia , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Índice de Gravidade de Doença , Seio Aórtico/anormalidades , Seio Aórtico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Malformações Vasculares/fisiopatologia , Adulto Jovem
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