Tempo de demora intra-hospitalar das síndromes coronárias agudas

TITULO: Tempo de Demora Intra-hospitalar das Síndromes Coronárias Agudas. ENQUADRAMENTO: A doença coronária, por si só, mantém-se no primeiro lugar das causas de morte na União Europeia. O enfarte agudo do miocárdio (EAM) constitui uma importante causa de morbilidade e mortalidade, sobretudo ao nível dos países industrializados, e resulta, habitualmente, de um processo progressivo de aterosclerose coronária. Todos os anos em Portugal ocorrem cerca de 10.000 EAM. Em doentes com enfarte do miocárdio com supradesnivelamento do segmento ST, a reperfusão precoce é o tratamento de eleição. Manter o menor intervalo de tempo desde o início dos sintomas até à reperfusão é realçado nas guidelines atuais como uma prioridade. OBJECTIVOS: Determinar o tempo de demora intra-hospitalar das Síndromes Coronárias Agudas e analisar a influência de determinadas variáveis no tempo de demora intra-hospitalar, como a idade, o sexo, a forma de admissão (proveniência e tipo de transporte), a prioridade do Sistema de Triagem de Manchester (STM), a dor torácica, o tipo de Síndrome Coronária Aguda (SCA) e a Via Verde Coronária (VVC). MÉTODOS: É um estudo quantitativo e transversal. Amostra constituída por 204 indivíduos com diagnóstico médico de SCA, internados na UCIC do CHTV, EPE, no período compreendido de 1 de Janeiro de 2010 a 30 de Setembro de 2010. A recolha de dados teve por base o registo informático do Sistema ALERT®. RESULTADOS: Os doentes são maioritariamente do sexo masculino (70,1%) com uma média de idades de 69,75 anos (dp=12,74). 63,2% são provenientes do domicílio, 34,8% foram referenciados pelo centro de saúde/SUB. A ambulância sem médico e os meios próprios são o tipo de transporte mais utilizado (44,1% e 42,6% respetivamente). 96,1% dos indivíduos apresentaram dor torácica. 49,0% dos indivíduos foi diagnosticado EAM sem Supra-ST, 32,4% dos indivíduos foi diagnosticado EAM com Supra-ST e 18,6% dos indivíduos foi diagnosticado angina instável. O tempo médio de demora pré-hospitalar (DPH) foi de 1043,11 minutos e o tempo médio entre o início da dor torácica e a admissão no Serviço de Urgência (TDH) foi de 1044,13 minutos; o tempo médio entre a admissão e a realização de triagem (DAT) foi de 8,60 minutos; o tempo médio entre a triagem e a realização do eletrocardiograma (DT-ECG) foi de 34,09 minutos; o tempo médio entre a realização do eletrocardiograma e a primeira observação médica (D-ECGMédico) foi de 20,48 minutos; o tempo médio entre a primeira observação médica e a administração da primeira terapêutica (D-Médico-Terapêutica) foi de 20,25 minutos; o tempo médio entre a admissão e a alta/internamento do doente (DIH-SU) foi de 281,91 minutos, com um tempo mínimo de 6 minutos e máximo de 1500 minutos. 64,7% dos indivíduos fizeram o 1.º ECG no SU num tempo superior a 10 minutos e apenas 35,3% dos indivíduos fizeram o 1.º ECG no SU num tempo 10 minutos. 74,5% dos indivíduos foram triados através do fluxograma Dor Torácica, 70,6% dos indivíduos foram triados com a prioridade laranja e 72,7% dos indivíduos do sexo masculino e 70,5% dos indivíduos do sexo feminino entraram pela VVC. Relativamente ao DIH-SU, o tempo médio foi de 126,71 minutos (dp=141,023) nos indivíduos com EAM com Supra-ST, 340,76 minutos (dp=246,71) nos indivíduos com EAM sem Supra-ST e 396,61 minutos (dp=324,50) nos indivíduos com angina instável. CONCLUSÃO: Os indivíduos do sexo masculino têm um tempo de demora intrahospitalar inferior aos indivíduos do sexo feminino (p> 0,05). Os indivíduos do grupo etário <55 anos apresentam melhores valores médios do tempo entre a admissão e a alta/internamento (p> 0,05). Os indivíduos transferidos do domicílio apresentam melhores valores médios no tempo de demora intra-hospitalar que os indivíduos que são referenciados por outra Instituição de Saúde (p> 0,05). Os indivíduos transportados em ambulância com médico apresentam melhores tempos médios de demora intrahospitalar (p< 0,05). Os indivíduos com dor torácica apresentam piores tempos médios de demora intra-hospitalar que os indivíduos sem dor torácica, à exceção do tempo entre a triagem e o ECG (p< 0,05). Os indivíduos com EAM com Supra-ST são os indivíduos que apresentam melhores tempos médios de demora intra-hospitalar (p< 0,001). Os indivíduos que entraram na VVC são os indivíduos que apresentam melhores tempos médios de demora intra-hospitalar (p< 0,001). PALAVRAS-CHAVE: Síndrome coronária aguda, Tempo de demora intra-hospitalar, Triagem de Manchester, Dor torácica, Tipo de SCA, Via Verde Coronária, ECG.ABSTRACT TITLE: In-hospital delay time in Acute Coronary Syndrome FRAMEWORK: Coronary heart disease alone remains in the first cause of death in the European Union. The acute myocardial infarction (AMI) is an important cause of morbidity and mortality, especially at the level of industrialized countries, and usually results of a progressive process of coronary atherosclerosis. Every year in Portugal occur, about 10000 AMI. In patients with ST-segment elevation myocardial infarction, the early reperfusion therapy is the treatment of choice. Keep the shortest time interval from symptom onset to reperfusion is emphasized in current guidelines as a priority. OBJECTIVES: Determining the time delay of thein-hospital management of Acute Coronary Syndromes and analyze the influence of certain variables in the in-hospital delay time, such as age, sex, the form of admission (provenance and type of transport), the priority of the Manchester Triage System, chest pain, the type of Acute Coronary Syndrome (ACS) and VVC. METHODS: It is a quantitative cross-sectional, retrospective study. Sample of 204individuals, with diagnosis of acute coronary syndrome (ACS), hospitalized in the Coronary Care Unit of CHTV, EPE from the period 1 January 2010 to 30 September 2010. Data collection was based on the computer record ALERT ®System. RESULTS: Patients are mostly male (70.1%) with average age of 69,75. 63.2% came from home, 34.8% were referred by a health center. The type of transport used were, ambulance without doctor and by own means (44.1% and 42.6% respectively). 96.1%ofindividuals had chest pain. 49.0% of individuals were diagnosed with Non-STsegment elevation myocardial infarction, 32.4% of individuals were diagnosed with STsegment elevation myocardial infarction and 18.6%of individuals diagnosed unstable angina. The pre-hospital delay time average was 1043.11 minutes and the time of the beginning of chest pain and admission to hospital average was 1044.13 minutes; time average between admission and triage was 8.60 minutes; time between triage and application of ECG averaged 34.09 minutes; time between execution of ECG and the first medical observation averaged 20.48 minutes; time between the first observation and the first medical therapeutic averaged 20.25 minutes. The average time between admission and discharge/hospitalization was 281.91 minutes, with a minimum time of 6 minutes and a maximum of 1500 minutes. 64.7%of individual shad the first ECG in the emergency room at a time over 10 minutes and only 35.3% of individual shad the first ECG in the emergency room at a time 10 minutes. 74.5% of individuals were triaged through the flowchart chest pain, 70.6% of individuals were triaged with the priority orange and 72.7% of males and 70.5% of females entered the VVC. For the time between admission and discharge/hospitalization, the average time was 126.71 minutes (sd = 141.03) in individuals with ST-segment elevation myocardial infarction, 340.76 minutes (sd = 246.71) in individuals with Non-ST-segment elevation myocardial infarction and 396.61 minutes (sd = 324.50) in patients with unstable angina. CONCLUSION: The males have a lower in-hospital delay time than females (p>0.05). Individuals in the age group <55 year shave better average time between admission and discharge/hospitalization (p>0.05). Individuals transferred from home show better average in-hospital delay time than individuals that are referenced by other Health Institutions (p>0.05). Individuals transported by ambulance with a doctor have better average in-hospital delay time (p<0.05). Individuals with chest pain have worse average in-hospital delay time than individuals without chest pain, except for the time between triage and ECG (p <0.05). Individuals with ST-segment elevation myocardial infarction are the individuals with the best average in-hospital delay time (p <0.001). Individuals who entered the VVC are individuals who have better average in-hospital delay time (p <0.001). KEY WORDS: Acute coronary syndrome, in- hospital delay time, Manchester Triage system, chest pain, type of ACS, via verde coronária. Sd= standard deviation

Gestational malaria associated to Plasmodium vivax and Plasmodium falciparum placental mixed-infection followed by foetal loss: a case report from an unstable transmission area in Brazil

Gestational malaria is a multi-factorial syndrome leading to poor outcomes for both the mother and foetus. Although an unusual increasing in the number of hospitalizations caused by Plasmodium vivax has been reported in Brazil, mortality is rarely observed. This is a report of a gestational malaria case that occurred in the city of Manaus (Amazonas State, Brazil) and resulted in foetal loss. The patient presented placental mixed-infection by Plasmodium vivax and Plasmodium falciparum after diagnosis by nested-PCR, however microscopic analysis failed to detect P. falciparum in the peripheral blood. Furthermore, as the patient did not receive proper treatment for P. falciparum and hospitalization occurred soon after drug treatment, it seems that P. falciparum pathology was modulated by the concurrent presence of P. vivax. Collectively, this case confirms the tropism towards the placenta by both of these species of parasites, reinforces the notion that co-existence of distinct malaria parasites interferes on diseases' outcomes, and opens discussions regarding diagnostic methods, malaria treatment during pregnancy and prenatal care for women living in unstable transmission areas of malaria, such as the Brazilian Amazon

Immunization With The Maebl M2 Domain Protects Against Lethal Plasmodium Yoelii Infection.

Malaria remains a world-threatening disease largely because of the lack of a long-lasting and fully effective vaccine. MAEBL is a type 1 transmembrane molecule with a chimeric cysteine-rich ectodomain homologous to regions of the Duffy binding-like erythrocyte binding protein and apical membrane antigen 1 (AMA1) antigens. Although MAEBL does not appear to be essential for the survival of blood-stage forms, ectodomains M1 and M2, homologous to AMA1, seem to be involved in parasite attachment to erythrocytes, especially M2. MAEBL is necessary for sporozoite infection of mosquito salivary glands and is expressed in liver stages. Here, the Plasmodium yoelii MAEBL-M2 domain was expressed in a prokaryotic vector. C57BL/6J mice were immunized with doses of P. yoelii recombinant protein rPyM2-MAEBL. High levels of antibodies, with balanced IgG1 and IgG2c subclasses, were achieved. rPyM2-MAEBL antisera were capable of recognizing the native antigen. Anti-MAEBL antibodies recognized different MAEBL fragments expressed in CHO cells, showing stronger IgM and IgG responses to the M2 domain and repeat region, respectively. After a challenge with P. yoelii YM (lethal strain)-infected erythrocytes (IE), up to 90% of the immunized animals survived and a reduction of parasitemia was observed. Moreover, splenocytes harvested from immunized animals proliferated in a dose-dependent manner in the presence of rPyM2-MAEBL. Protection was highly dependent on CD4(+), but not CD8(+), T cells toward Th1. rPyM2-MAEBL antisera were also able to significantly inhibit parasite development, as observed in ex vivo P. yoelii erythrocyte invasion assays. Collectively, these findings support the use of MAEBL as a vaccine candidate and open perspectives to understand the mechanisms involved in protection.833781-379

Structural Changes of the Paraflagellar Rod during Flagellar Beating in Trypanosoma cruzi

, the agent of Chagas disease, is a protozoan member of the Kinetoplastidae family characterized for the presence of specific and unique structures that are involved in different cell activities. One of them is the paraflagellar rod (PFR), a complex array of filaments connected to the flagellar axoneme. Although the function played by the PFR is not well established, it has been shown that silencing of the synthesis of its major proteins by either knockout of RNAi impairs and/or modifies the flagellar motility.Here, we present results obtained by atomic force microscopy (AFM) and transmission electron microscopy (TEM) of replicas of quick-frozen, freeze-fractured, deep-etched and rotary-replicated cells to obtain detailed information of the PFR structures in regions of the flagellum in straight and in bent state. The images obtained show that the PFR is not a fixed and static structure. The pattern of organization of the PFR filament network differs between regions of the flagellum in a straight state and those in a bent state. Measurements of the distances between the PFR filaments and the filaments that connect the PFR to the axoneme as well as of the angles between the intercrossed filaments supported this idea.Graphic computation based on the information obtained allowed the proposal of an animated model for the PFR structure during flagellar beating and provided a new way of observing PFR filaments during flagellar beating

Association of the DNMT3B -579G>T polymorphism with risk of thymomas in patients with myasthenia gravis

Increasing evidence suggests a contribution of epigenetic processes in promoting cancer and autoimmunity. Myasthenia gravis (MG) is an autoimmune disease mediated, in approximately 80% of the patients, by antibodies against the nicotinic acetylcholine receptor (AChR+). Moreover, epithelial tumours (thymomas) are present in about 10-20% of the patients, and there is indication that changes in DNA methylation might contribute to the risk and progression of thymomas. However, the role of epigenetics in MG is still not completely clarified. In the present study we investigated if a common polymorphism (-579G&gt;T: rs1569686) in the promoter of the DNMT3B gene coding for the DNA methyltransferase 3B, an enzyme that mediates DNA methylation, increases the risk to develop MG or MG-associated thymomas. The study polymorphism was selected based on recent reports and a literature meta-analysis suggesting association with increased risk of various types of cancer. We screened 324 AChR+ MG patients (140 males and 184 females, mean age 56.0 \ub1 16.5 years) and 735 healthy matched controls (294 males and 441 females, mean age 57.3 \ub1 15.6 years). 94 of the total MG patients had a thymoma. While there was no association with the whole cohort of MG patients, we found a statistically significant association of the DNMT3B-579T allele (OR = 1.51; 95% CI=1.1-2.1, P = 0.01) and the TT homozygous genotype (OR = 2.59; 95% CI=1.4-4.9, P = 0.006) with the risk of thymoma. No association was observed in MG patients without thymoma, even after stratification into clinical subtypes. Present results suggest that the DNMT3B-579T allele might contribute to the risk of developing thymoma in MG patients, particularly in homozygous TT subjects

Photography-based taxonomy is inadequate, unnecessary, and potentially harmful for biological sciences

The question whether taxonomic descriptions naming new animal species without type specimen(s) deposited in collections should be accepted for publication by scientific journals and allowed by the Code has already been discussed in Zootaxa (Dubois & Nemésio 2007; Donegan 2008, 2009; Nemésio 2009a–b; Dubois 2009; Gentile & Snell 2009; Minelli 2009; Cianferoni & Bartolozzi 2016; Amorim et al. 2016). This question was again raised in a letter supported by 35 signatories published in the journal Nature (Pape et al. 2016) on 15 September 2016. On 25 September 2016, the following rebuttal (strictly limited to 300 words as per the editorial rules of Nature) was submitted to Nature, which on 18 October 2016 refused to publish it. As we think this problem is a very important one for zoological taxonomy, this text is published here exactly as submitted to Nature, followed by the list of the 493 taxonomists and collection-based researchers who signed it in the short time span from 20 September to 6 October 2016

Renal replacement therapy in acute kidney injury: controversy and consensus

Renal replacement therapies (RRTs) represent a cornerstone in the management of severe acute kidney injury. This area of intensive care and nephrology has undergone significant improvement and evolution in recent years. Continuous RRTs have been a major focus of new technological and treatment strategies. RRT is being used increasingly in the intensive care unit, not only for renal indications but also for other organ-supportive strategies. Several aspects related to RRT are now well established, but others remain controversial. In this review, we review the available RRT modalities, covering technical and clinical aspects. We discuss several controversial issues, provide some practical recommendations, and where possible suggest a research agenda for the future