Adherence to Guidelines in the Treatment of Acute Coronary Syndromes: Progress Over Time

Introdução: O tratamento das Síndromes Coronárias Agudas (SCA) sofreu várias alterações muito rápidas nos últimos anos, traduzido nas múltiplas propostas de recomendações pelo ACC/AHA/ESC, baseados na evidência clínica. Avaliamos a implementação destas recomendações, comparando uma população de doentes de 2002, com uma população de 2005. Métodos: Estudo retrospectivo de 368 doentes admitidos em 2002 e 420 doentes admitidos em 2005 por SCA (com e sem elevação do segmento ST). Analisaram-se características clínicas e estratégias de tratamento. Resultados: Não se verificaram diferenças em termos de idade, sexo masculino, factores de risco para doença coronária ou história prévia de revascularização miocárdica. Verificou-se uma redução de doentes com antecedentes de enfarte do miocárdico e insuficiência renal e aumento da apresentação como enfarte com elevação do segmento ST. O tratamento com clopidogrel (6% versus 87%), bloqueador-beta(54% versus 79%), inibidores da enzima de conversão da angiotensina (72% versus 84%) e estatinas (78% versus 91%) aumentou (para todos p<0,001). Por outro lado, verificou-se um pequeno decréscimo na utilização de ácido acetilsalicílico (98% versus 95%, p=0,039) (com maior utilização de clopidogrel) e a ticlopidina deixou de ser utilizada (46% versus 0%, p<0,001). Os antagonistas dos receptores da glicoproteína IIb/IIIa não se alteraram significativamente (66% versus 67%, p=NS). Aumentaram as intervenções coronárias percutâneas (53% versus 67%, p<0,001). Não se verificou diferença em termos de mortalidade hospitalar (8,2% versus 6,4%) e aos 30 dias (9,0% versus. 8,6%), com redução ao 1ºano de seguimento (17,1% versus 11,7%, p=0,039). As estatinas e os bloqueadores beta são preditores independentes de mortalidade, com efeito de protecção. Conclusões: Entre 2002 e 2005, o tratamento das SCA melhorou significativamente de acordo com as recomendações existentes, traduzindo-se numa melhoria da mortalidade ao 1º ano de seguimento

Is Chronic Nitrate Therapy Associated with a Different Clinical Presentation of Acute Coronary Syndrome?

A terapêutica com nitratos pode induzir pré-condicionamento isquémico, com consequente aumento da tolerância a isquémia. No contexto de síndromes coronárias agudas (SCA), os nitratos podem condicionar uma diferente forma de apresentação, com maior protecção. Objectivos: Estudar numa população de doentes com SCA se a administração crónica prévia ao evento, de nitratos condiciona a forma de apresentação do SCA. Métodos: Estudo de 287 doentes (65 +- 13 anos, 66% sexo masculino) admitidos no nosso serviço por SCA (com e sem elevação do segmento ST) no primeiro semestre de 2005. Destes, 8% estavam sob terapêutica com nitratos prévia à admissão. Neste grupo 27% apresentaram-se como SCA com elevação do segmento ST e no grupo sem nitratos, este valor foi de 58% (p=0,005). Por análise univariada, a utilização de nitratos foi preditora da ocorrência preferencial de "SCA sem elevação do segmento ST" (OR 0,27, IC 95% 0,10-0,71, p=0,005). Após correcção para variáveis potencialmente influentes (idade, sexo, revascularização prévia, tabagismo) por análise multivariada de regressão logística, a terapêutica com nitratos foi preditora limiar da apresentação clínica "SCA sem elevação do segmento ST" (OR 0,37, IC 95% 0,13-1,04), p=0,059. Conclusão: A utilização prévia à ocorrência de SCA associou-se com um desvio da apresentação para a forma de SCA sem elevação do segmento ST. Este achado pode ser justificado pela hipótese de que os nitratos podem induzir um pré-condicionamento farmacológico, reduzindo a extensão transmural do enfarte

The Prognostic Impact of Renal Failure in Patients with ST-Segment Elevation Acute Myocardial Infarction

INTRODUCTION: Renal insufficiency (RI) is associated with higher morbidity and mortality in patients (P) with coronary artery disease and in P submitted to angioplasty. In ST-segment elevation acute myocardial infarction (STEAMI), this impact has not been well demonstrated. AIM: To evaluate the impact of RI in P with STEAMI. METHODS: We evaluated 160 P admitted with STEAMI, mean age of 62+/-14 years, 76% male. We determined creatinine levels on admission. RI was defined as a level >1.5 mg/dl. Analysis of clinical, electrocardiographic and laboratory variables was performed, in relation to the endpoint defined as the occurrence of death at 30-day follow-up. RESULTS: There were 16 deaths (10%) at 30-day follow-up. P with RI (n=21) were older (68+/-11 vs 61+/-14 years, p or =2 (57 vs 12%, p or =75 years, diabetes, Killip class > or =2 on admission, RI, non-use of statins and beta-blockers and use of diuretics. In multivariate analysis, independent predictors of death at 30 days were RI (HR 29.6, 95% CI 6.3-139.9, p<0.001) and non-use of beta-blockers (HR 0.13, 95% CI 0.02-1.01, p=0.01). CONCLUSION: In P admitted for STEAMI, the presence of RI was an independent predictor of death at 30 days whereas the usage of beta-blockers was protective

Investigating the structure and fragmentation of a highly filamentary IRDC

We present 3.7 arcsec (~0.05 pc) resolution 3.2 mm dust continuum observations from the IRAM PdBI, with the aim of studying the structure and fragmentation of the filamentary Infrared Dark Cloud G035.39-00.33. The continuum emission is segmented into a series of 13 quasi-regularly spaced (~0.18pc) cores, following the major axis of the IRDC. We compare the spatial distribution of the cores with that predicted by theoretical work describing the fragmentation of hydrodynamic fluid cylinders, finding a significant (factor of ~8) discrepancy between the two. Our observations are consistent with the picture emerging from kinematic studies of molecular clouds suggesting that the cores are harboured within a complex network of independent sub-filaments. This result emphasises the importance of considering the underlying physical structure, and potentially, dynamically important magnetic fields, in any fragmentation analysis. The identified cores exhibit a range in (peak) beam-averaged column density ($3.6{\rm x}10^{23}{\rm cm}^{-2}<N_{H,c}<8.0{\rm x}10^{23}{\rm cm}^{-2}$), mass ($8.1M_{\odot}<M_{c}<26.1M_{\odot}$), and number density ($6.1{\rm x}10^{5}{\rm cm}^{-3}<n_{H, c, eq}<14.7{\rm x}10^{5}{\rm cm}^{-3}$). Two of these cores, dark in the mid-infrared, centrally-concentrated, monolithic (with no traceable substructure at our PdBI resolution), and with estimated masses of the order ~20-25$M_{\odot}$, are good candidates for the progenitors of intermediate-to-high-mass stars. Virial parameters span a range $0.2<\alpha_{\rm vir}<1.3$. Without additional support, possibly from dynamically important magnetic fields with strengths of the order 230$\mu$G<B<670$\mu$G, the cores are susceptible to gravitational collapse. These results may imply a multi-layered fragmentation process, which incorporates the formation of sub-filaments, embedded cores, and the possibility of further fragmentation

Interstellar Plunging Waves: ALMA Resolves the Physical Structure of Nonstationary MHD Shocks

Magnetohydrodynamic (MHD) shocks are violent events that inject large amounts of energy in the interstellar medium dramatically modifying its physical properties and chemical composition. Indirect evidence for the presence of such shocks has been reported from the especial chemistry detected toward a variety of astrophysical shocked environments. However, the internal physical structure of these shocks remains unresolved since their expected spatial scales are too small to be measured with current instrumentation. Here we report the first detection of a fully spatially resolved, MHD shock toward the infrared dark cloud (IRDC) G034.77-00.55. The shock, probed by silicon monoxide (SiO) and observed with the Atacama Large Millimeter/submillimeter Array (ALMA), is associated with the collision between the dense molecular gas of the cloud and a molecular gas flow pushed toward the IRDC by the nearby supernova remnant (SNR) W44. The interaction is occurring on subparsec spatial scales thanks to the enhanced magnetic field of the SNR, making the dissipation region of the MHD shock large enough to be resolved with ALMA. Our observations suggest that molecular flow–flow collisions can be triggered by stellar feedback, inducing shocked molecular gas densities compatible with those required for massive star formation

Simultaneous wireless and high-resolution detection of nucleus accumbens shell ethanol concentrations and free motion of rats upon voluntary ethanol intake

Highly sensitive detection of ethanol concentrations in discrete brain regions of rats voluntarily accessing ethanol, with high temporal resolution, would represent a source of greatly desirable data in studies devoted to understanding the kinetics of the neurobiological basis of ethanol's ability to impact behavior. In the present study, we present a series of experiments aiming to validate and apply an original high-tech implantable device, consisting of the coupling, for the first time, of an amperometric biosensor for brain ethanol detection, with a sensor for detecting the microvibrations of the animal. This device allows the real-time comparison between the ethanol intake, its cerebral concentrations, and their effect on the motion when the animal is in the condition of voluntary drinking. To this end, we assessed in vitro the efficiency of three different biosensor designs loading diverse alcohol oxidase enzymes (AOx) obtained from three different AOx-donor strains: Hansenula polymorpha, Candida boidinii, and Pichia pastoris. In vitro data disclosed that the devices loading H. polymorpha and C. boidinii were similarly efficient (respectively, linear region slope [LRS]: 1.98 ± 0.07 and 1.38 ± 0.04 nA/mM) but significantly less than the P. pastoris-loaded one (LRS: 7.57 ± 0.12 nA/mM). The in vivo results indicate that this last biosensor design detected the rise of ethanol in the nucleus accumbens shell (AcbSh) after 15 minutes of voluntary 10% ethanol solution intake. At the same time, the microvibration sensor detected a significant increase in the rat's motion signal. Notably, both the biosensor and microvibration sensor described similar and parallel time-dependent U-shaped curves, thus providing a highly sensitive and time-locked high-resolution detection of the neurochemical and behavioral kinetics upon voluntary ethanol intake. The results overall indicate that such a dual telemetry unit represents a powerful device which, implanted in different brain areas, may boost further investigations on the neurobiological mechanisms that underlie ethanol-induced motor activity and reward

Deuterium fractionation across the infrared-dark cloud G034.77−00.55 interacting with the supernova remnant W44

Context. Supernova remnants (SNRs) may regulate star formation in galaxies. For example, SNR-driven shocks may form new molecular gas or compress pre-existing clouds and trigger the formation of new stars. / Aims. To test this scenario, we measured the deuteration of N2H+, DfracN2H+ – a well-studied tracer of pre-stellar cores – across the infrared-dark cloud (IRDC) G034.77-00.55, which is known to be experiencing a shock interaction with the SNR W44. / Methods. We use N2H+ and N2D+J = 1−0 single pointing observations obtained with the 30m antenna at the Instituto de Radioas-tronomia Millimetrica to infer DfracN2H+ towards five positions across the cloud, namely a massive core, different regions across the shock front, a dense clump, an+d ambient gas. / Results. We find DfracN2H+ in the range 0.03−0.1, which is several orders of magnitude larger than the cosmic D/H ratio (~10−5). The DfracN2H+ across the shock front is enhanced by more than a factor of 2 (DfracN2H+ ~ 0.05 - 0.07) with respect to the ambient gas (≤0.03) and simila+r to that measured generally in pre-stellar cores. Indeed, in the massive core and dense clump regions of this IRDC we measure DfracN2H+ ~ 0.01. / Conclusions. We find enhanced deuteration of N2H+ across the region of the shock, that is, at a level that is enhanced with respect to regions of unperturbed gas. It is possible that this has been induced by shock compression, which would then be indirect evidence that the shock is triggering conditions for future star formation. However, since unperturbed dense regions also show elevated levels of deuteration, further, higher-resolution studies are needed to better understand the structure and kinematics of the deuterated material in the shock region; for example, to decipher whether it is still in a relatively diffuse form or is already organised in a population of low-mass pre-stellar cores

Stopping Antiepileptic Drugs: When and Why?

After a patient has initiated an antiepileptic drug (AED) and achieved a sustained period of seizure freedom, the bias towards continuing therapy indefinitely can be substantial. Studies show that the rate of seizure recurrence after AED withdrawal is about two to three times the rate in patients who continue AEDs, but there are many benefits to AED withdrawal that should be evaluated on an individualized basis. AED discontinuation may be considered in patients whose seizures have been completely controlled for a prolonged period, typically 1 to 2 years for children and 2 to 5 years for adults. For children, symptomatic epilepsy, adolescent onset, and a longer time to achieve seizure control are associated with a worse prognosis. In adults, factors such as a longer duration of epilepsy, an abnormal neurologic examination, an abnormal EEG, and certain epilepsy syndromes are known to increase the risk of recurrence. Even in patients with a favorable prognosis, however, the risk of relapse can be as high as 20% to 25%. Before withdrawing AEDs, patients should be counseled about their individual risk for relapse and the potential implications of a recurrent seizure, particularly for safety and driving

Symptoms in different severity degrees of bruxism: a cross-sectional study

Objective: The aim of the present study was to evaluate symptoms of the muscle pain, sleep quality, oral health, anxiety, stress and depression in individuals with different severity degrees of bruxism. Methods: Seventy-two individuals with bruxism were enrolled in the study, classified into: moderate (n=25) and severe (n=47) bruxism. Pain intensity was assessed using the Visual Analogical Scale, pain threshold with algometer, sleep quality by the Pittsburgh Sleep Quality Index, oral health by the Oral Health Impact Profile, anxiety by the State-Trait Anxiety Inventory, stress by the Perceived Stress Scale and depression using the Beck Depression Inventory. The significance level considered was 5%. Results: The results showed that individuals with severe bruxism presented greater muscle pain intensity, sleep disorder, worse oral health, high anxiety level and dysphoria with statistically significant differences (pObjetivo: Avaliar sintomas de dor muscular, qualidade de sono, saúde bucal, ansiedade, estresse e depressão em indivíduos com diferentes graus de severidade do bruxismo. Métodos: Setenta e dois indivíduos com bruxismo participaram do estudo e foram classificados com bruxismo moderado (n=25) e severo (n=47). A intensidade da dor foi avaliada pela Escala Visual Analógica, limiar de dor com o algômetro, qualidade de sono pelo Índice de Qualidade de Sono de Pittsburgh, saúde bucal pelo Perfil de Impacto de Saúde Bucal, ansiedade pelo Inventário de Ansiedade Traço-Estado, estresse pela Escala de Estresse Percebido e depressão pelo Inventário de Depressão de Beck. O nível de significância considerado foi 5%. Resultados: Os resultados demonstraram que indivíduos com bruxismo severo apresentaram maior intensidade de dor muscular, distúrbio do sono, pior qualidade de saúde bucal, elevado grau de ansiedade e disforia, com diferenças estatisticamente significantes (p;0,05). Conclusão: Os dados sugerem que indivíduos com bruxismo severo tem sintomas mais intensos. Eles apresentam maior intensidade de dor muscular, alterações na qualidade do sono e saúde bucal, ansiedade e depressão do que indivíduos com bruxismo moderado. Porém, ambos apresentam similaridade no estresse.Objetivo: Evaluar los síntomas dolor muscular, calidad de sueño, salud bucal, ansiedad, estrés y depresión en sujetos con diferentes niveles de gravedad del bruxismo. Método: Participaron del estudio 72 personas con bruxismo, clasificado según los niveles moderado (n=25) y grave (n=47). Se evaluaron la intensidad del dolor mediante la Escala Visual Analógica, umbral de dolor con algómetro, la calidad de sueño por el Índice de Calidad de Sueño de Pittsburgh, la salud bucal mediante el Perfil del Impacto de Salud Bucal, la ansiedad por el Inventario de Ansiedad Rasgo-Estado, el estrés mediante la Escala de Estrés Percibido y la depresión por el Inventario de Depresión de Beck. Se consideró el nivel de significación de 5%. Resultados: Los sujetos con bruxismo grave presentaron más intensamente dolor muscular, trastorno de sueño, peor calidad de salud bucal, alto grado de ansiedad y disforia, con diferencias estadísticamente significativas (p;0,05). Conclusión: Los datos mostraron que los sujetos con bruxismo grave sufren síntomas más intensos. A pesar de sufrir síntomas más intensos de dolor muscular, calidad de sueño y salud bucal alterada, ansiedad y depresión que los sujetos con bruxismo moderado, el estrés está presente en los dos niveles de bruxismo

15N Fractionation in Infrared-Dark Cloud Cores

Nitrogen is one of the most abundant elements in the Universe and its 14N/15N isotopic ratio has the potential to provide information about the initial environment in which our Sun formed. Recent findings suggest that the Solar System may have formed in a massive cluster since the presence of short-lived radioisotopes in meteorites can only be explained by the influence of a supernova. The aim of this project is to determine the 14N/15N ratio towards a sample of cold, massive dense cores at the initial stages in their evolution. We have observed the J=1-0 transitions of HCN, H13CN, HC15N, HN13C and H15NC toward a sample of 22 cores in 4 Infrared-Dark Clouds (IRDCs). IRDCs are believed to be the precursors of high-mass stars and star clusters. Assuming LTE and a temperature of 15K, the column densities of HCN, H13CN, HC15N, HN13C and H15NC are calculated and their 14N/15N ratio is determined for each core. The 14N/15N ratio measured in our sample of IRDC cores range between ~70 and >763 in HCN and between ~161 and ~541 in HNC. They are consistent with the terrestrial atmosphere (TA) and protosolar nebula (PSN) values, and with the ratios measured in low-mass pre-stellar cores. However, the 14N/15N ratios measured in cores C1, C3, F1, F2 and G2 do not agree with the results from similar studies toward the same massive cores using nitrogen bearing molecules with nitrile functional group (-CN) and nitrogen hydrides (-NH) although the ratio spread covers a similar range. Amongst the 4 IRDCs we measured relatively low 14N/15N ratios towards IRDC G which are comparable to those measured in small cosmomaterials and protoplanetary disks. The low average gas density of this cloud suggests that the gas density, rather than the gas temperature, may be the dominant parameter influencing the initial nitrogen isotopic composition in young PSN