Variabilidade e reprodutibilidade da análise das medições ecocardiográficas na estenose valvular aórtica

Background: Doppler echocardiography is the most frequent method for detecting and evaluating the severity of valvular aortic stenosis. The aim of this study was to assess the variability and reproducibility of echocardiographic parameters including aortic valve area (AVA), peak aortic jet velocity (Vmax), velocity ratio (VLVOT/Vmax), peak gradient (Gmax) and mean gradient (Gmean) in aortic stenosis (AS) patients. Methods: Doppler echocardiograms were obtained from 150 randomly selected patients (56.7% male; mean age 73±9 years) with asymptomatic moderate aortic valve stenosis. The echocardiographic measurements were performed by two independent level III (expert) blinded observers. To assess intra-observer variability, we evaluated parameters of AS progression at two different times (mean of two weeks after the first examination). Results: For intra-observer variability (observer 1), the variation and reproducibility coefficients were, respectively, 1.88% and 0.16 m/s for Vmax, 2.08% and 0.14 for VLVOT/Vmax, 2.05% and 0.18 cm2 for AVA, 3.89% and 5.18 mmHg for Gmax and 7.87% and 6.30 mmHg for Gmean. For inter-observer variability, the variation and reproducibility coefficients were, respectively, 2.00% and 0.14 m/s for Vmax, 2.91% and 0.14 for VLVOT/Vmax, 7.67% and 0.16 cm2 for AVA, 8.53% and 7.06 mmHg for Gmean and 3.90% and 5.58 mmHg for Gmax. Both intra- and inter-observer studies showed excellent intraclass correlation coefficients (ICC) for all echocardiographic parameters (ICC ranged from 0.943 to 0.990 for intra-observer variability and from 0.955 to 0.992 for interobserver variability). Conclusion: Doppler echocardiographic measurements of AVA, Vmax, Gmax and Gmean are highly reproducible when performed by expert observers. Of all echocardiographic parameters, Vmax and VLVOT/Vmax showed the best variability and reproducibility, and thus constitute reliable tools for clinical and research purposes in aortic stenosis diagnosis and follow-up.Introdução: A ecocardiografia Doppler é o método mais frequente de detecção e avaliação da gravidade da estenose valvular aórtica. O objectivo deste estudo foi avaliar a variabilidade e reprodutibilidade dos parâmetros ecocardiográficos como a área valvular aórtica (AVA), velocidade pico (Vmax), relação de velovidades (VLVOT/Vmax), gradiente pico (Gmax) e gradiente médio (Gmédio) nos doentes com estenose aórtica. Métodos: Um ecocardiograma Doppler foi realizado em 60 doentes consecutivos seleccionados aleatoriamente (da população do estudo RAAVE) com estenose aórtica moderada a grave assintomática (56.7% sexo masculino; idade média 73 ± 9 anos). As medidas ecocardiográficas foram efectuadas por dois ecocardiografistas de nível III numa estratégia de dupla ocultação. Para o estudo da variabilidade intra-observador, avaliamos os prâmetros de progressão da estenose aórtica em dois momentos diferentes (média de duas semanas após o 1.º exame). Resultados: No que respeita à variabilidade intra-observador (observador 1), os coeficientes de variação e reprodutibilidade foram, respectivamente, 1.88% e 0.16 m.s-1 para a Vmax, 2.08% e 0.14 cm2 para a VLVOT/Vmax, 2.05% e 0.18 ms-1 para a AVA, 3.89% e 5.18 mmHg para Gmax and 7.87% e 6.30 mmHg para o Gmédio. No que respeita à variabilidade inter- -observador, os coeficientes de variação e reprodutibilidade foram, respectivamente, 2.00% e 0.14 m.s-1 para a Vmax, 2.91% e 0.14 m.s-1 para a relação VLVOT/Vmax, 7.67% e 0.16 cm2 para a AVA, 8.53% e 7.06 mmHg para o Gmédio e 3.90% e 5.58 mmHg para o Gmax. Os estudos intra-observador e inter-observador mostraram ter excelentes coeficientes de correlação intra-classe (CCI), para todos os parâmetros ecocardiográficos (CCI varia de 0.943 até 0.990 para a variabilidade intra- -observador e de 0.955 até 0.992 para a variabilidade inter-observador). Conclusões: As medições ecocardiográficas da AVA, Vmax, Gmax and Gmédio são altamente reprodutíveis quando realizadas por ecocardiografistas experientes. De todos os parâmetros ecocardiográficos a Vmax e a relação VLVOT/Vmax apresentam os melhores valores de variabilidade e reprodutibilidade e assim constituem provavelmente a melhor ferramenta no diagnóstico e seguimento criterioso dos doentes com estenose valvular aórtica.info:eu-repo/semantics/publishedVersio

Avoidable mortality in acute myocardial infarction at hospital level : where to look for answers?

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017Background: Outcomes assessment is very important for improving health care outcomes and control spending. Acute myocardial infarction (AMI) was chosen for its prevalence, high morbidity and mortality, relevant mortality variability and high treatment costs. Purpose: To study the differences between hospitals in AMI mortality and the associated waste from unjustified variation. Methods: Patients with AMI discharged from public hospitals in our country in 2011–13 were selected and anonymized administrative data was utilized. The relevant variables to explain the differences in mortality were: patient characteristics (demographics, AMI type, comorbidities, and procedures), hospital characteristics (hospital with “coronary green way”, volume, and university hospital), and travel time to hospital. Generalized linear mixed models (1st level: patient, 2nd level: hospital) were used and specifically binary logistic regression was applied. The differences in mortality explained by each group of variables were evaluated with a percentual rate of Pseudo-r2. We considered as waste the number of additional deaths in each hospital compared to patients with the same characteristics, through the hospital random effect variance (difference of each hospital to the global odds). Results: 22.380 patients treated in 17 hospitals were included. Mortality rate was 9.5%. The mortality rate varied between 5.4% (H11) and 14.1% (H3). Our model explained 29.8% of the differences in mortality. Comorbidities explained 23.2% of mortality differences, demographic variables 7.8%, procedures 6.6%, and type of AMI 2.8%. Angioplasty and primary angioplasty procedures were protective factors, since all other procedures showed a comparatively increased risk of death, particularly fibrinolysis without angioplasty (OR 5.9; CI 3.2–10.9). Across all hospitals, there were 137 avoidable deaths, with a variation between -81 deaths (hospital with lower mortality) and +133 deaths (hospital with higher mortality). As shown in Fig. 1, there was a risk of death 3.5 times higher at H8 than at H7. The model showed excellent discrimination (area under the ROC curve: 0.871). Conclusion: We observed significant differences in mortality in acute myocardial infarction between hospitals, therefore indicating variability of practices. The scale of avoidable deaths justifies an investigation of its causes, mainly in the hospitals with worse performance. The hospital characteristics had little impact on the detected differences, so the inefficiencies are probably more related with the internal organization of hospitals and the way care is provided. These results raise relevant concerns at the health system and hospitals levels, in particular about the compliance with AMI guidelines.info:eu-repo/semantics/publishedVersio

Avaliação antropométrica longitudinal de lactentes nascidos de mães infectadas pelo HIV-1

OBJETIVO: Evaluar los parámetros de crecimiento en lactantes nacidos de madres infectadas con el VIH-1. MÉTODOS: Evaluación longitudinal de los z-escores peso-edad (PI), estatura-edad (EI), peso-estatura (PE) fue realizada en una cohorte. Fueran estudiados 97 lactantes no infectados y 33 lactantes infectados nacidos de madres infectadas con el VIH-1 en Belo Horizonte, Sureste de Brasil, de 1995 a 2003. El tiempo medio de seguimiento para los lactantes infectados y no infectados fue de 15,8 meses (variación: 6,8 a 18,0 meses) y 14,3 meses (variación: 6,3 a 18,6 meses), respectivamente. Se utilizó el modelo de regresión linear de efectos mixtos ajustado por máxima verosimilitud restringida para construir las curvas de crecimiento. RESULTADOS: Los z-escores PI, EI y PE de los lactantes infectados con el VIH-1 presentaron decrecimiento. A los seis meses, la diferencia promedio en los z-escores PI, EI y PE entre lactantes infectados y no infectados con el VIH era, respectivamente, 1,02, 0,59 y 0,63 desviaciones-estándares. A los 12 meses, la diferencia promedio en los z-escores PI, EI y PE entre lactantes infectados y no infectados era, respectivamente, 1,15, 1,01 y 0,87 desviaciones-estándares. CONCLUSIONES: El comprometimiento precoz y creciente de los indicadores antropométricos de niños infectados con el VIH-1 muestra la importancia de identificar precozmente niños infectados con el VIH que están en riesgo nutricional y la necesidad de evaluarse continuamente las intervenciones nutricionales adoptadas.OBJECTIVE: To evaluate the growth parameters in infants who were born to HIV-1-infected mothers. METHODS: The study was a longitudinal evaluation of the z-scores for the weight-for-age (WAZ), weight-for-length (WLZ) and length-for-age (LAZ) data collected from a cohort. A total of 97 non-infected and 33 HIV-infected infants born to HIV-1-infected mothers in Belo Horizonte, Southeastern Brazil, between 1995 and 2003 was studied. The average follow-up period for the infected and non-infected children was 15.8 months (variation: 6.8 to 18.0 months) and 14.3 months (variation: 6.3 to 18.6 months), respectively. A mixed-effects linear regression model was used and was fitted using a restricted maximum likelihood. RESULTS: There was an observed decrease over time in the WAZ, LAZ and WLZ among the infected infants. At six months of age, the mean differences in the WAZ, LAZ and WLZ between the HIV-infected and non-infected infants were 1.02, 0.59, and 0.63 standard deviations, respectively. At 12 months, the mean differences in the WAZ, LAZ and WLZ between the HIV-infected and non-infected infants were 1.15, 1.01, and 0.87 standard deviations, respectively. CONCLUSIONS: The precocious and increasing deterioration of the HIV-infected infants' anthropometric indicators demonstrates the importance of the early identification of HIV-infected infants who are at nutritional risk and the importance of the continuous assessment of nutritional interventions for these infants.OBJETIVO: Avaliar os parâmetros de crescimento em lactentes nascidos de mães infectadas com o HIV-1. MÉTODOS: Avaliação longitudinal dos z-escores peso-idade (PI), estatura-idade (EI), peso-estatura (PE) foi realizada em uma coorte. Foram estudados 97 lactentes não-infectados e 33 lactentes infectados nascidos de mães infectadas com o HIV-1 em Belo Horizonte, MG, de 1995 a 2003. O tempo mediano de seguimento para os lactentes infectados e não-infectados foi de 15,8 meses (variação: 6,8 a 18,0 meses) e 14,3 meses (variação: 6,3 a 18,6 meses), respectivamente. Utilizou-se o modelo de regressão linear de efeitos mistos ajustado por máxima verossimilhança restrita para construir as curvas de crescimento. RESULTADOS: Os z-escores PI, EI e PE dos lactentes infectados com o HIV-1 apresentaram decréscimo. Aos seis meses, a diferença média nos z-escores PI, EI e PE entre lactentes infectados e não-infectados com o HIV era, respectivamente, 1,02, 0,59 e 0,63 desvios-padrão. Aos 12 meses, a diferença média nos z-escores PI, EI e PE entre lactentes infectados e não-infectados era, respectivamente, 1,15, 1,01 e 0,87 desvios-padrão. CONCLUSÕES: O comprometimento precoce e crescente dos indicadores antropométricos de crianças infectadas com o HIV-1 mostra a importância de identificar precocemente crianças infectadas com o HIV que estão em risco nutricional e a necessidade de se avaliarem continuamente as intervenções nutricionais adotadas

Sirolimus-eluting stent for the treatment of in-stent restenosis: a quantitative coronary angiography and three-dimensional intravascular ultrasound study

BACKGROUND: We have previously reported the safety and effectiveness of sirolimus-eluting stents for the treatment of de novo coronary lesions. The present investigation explored the potential of this technology to treat in-stent restenosis. METHODS AND RESULTS: Twenty-five patients with in-stent restenosis were successfully treated with the implantation of 1 or 2 sirolimus-eluting Bx VELOCITY stents in Sao Paulo, Brazil. Nine patients received 2 stents (1.4 stents per lesion). Angiographic and volumetric intravascular ultrasound (IVUS) images were obtained after the procedure and at 4 and 12 months. All vessels were patent at the time of 12-month angiography. Angiographic late loss averaged 0.07+/-0.2 mm in-stent and -0.05+/-0.3 mm in-lesion at 4 months, and 0.36+/-0.46 mm in-stent and 0.16+/-0.42 mm in-lesion after 12 months. No patient had in-stent or stent margin restenosis at 4 months, and only one patient developed in-stent restenosis at 1-year follow-up. Intimal hyperplasia by 3-dimensional IVUS was 0.92+/-1.9 mm(3) at 4 months and 2.55+/-4.9 mm(3) after 1 year. Percent volume obstruction was 0.81+/-1.7% and 1.76+/-3.4% at the 4- and 12-month follow-up, respectively. There was no evidence of stent malapposition either acutely or in the follow-up IVUS images, and there were no deaths, stent thromboses, or repeat revascularizations. CONCLUSION: This study demonstrates the safety and the potential utility of sirolimus-eluting Bx VELOCITY stents for the treatment of in-stent restenosis

Healthy lifestyle interventions to combat noncommunicable disease : a novel nonhierarchical connectivity model for key stakeholders : a policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine

© 2015 Mayo Foundation for Medical Education and Research, and the European Society of Cardiology. This article is being published concurrently in Mayo Clinic Proceedings [1]. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. [1] Arena R, Guazzi M, Lianov L, Whitsel L, Berra K, Lavie CJ, Kaminsky L, Williams M, Hivert M-F, Franklin NC, Myers J, Dengel D, Lloyd-Jones DM, Pinto FJ, Cosentino F, Halle M, Gielen S, Dendale P, Niebauer J, Pelliccia A, Giannuzzi P, Corra U, Piepoli MF, Guthrie G, Shurney D. Healthy Lifestyle Interventions to Combat Noncommunicable Diseased - A Novel Nonhierarchical Connectivity Model for Key Stakeholders: A Policy Statement From the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine. Mayo Clinic Proceedings 2015; DOI: 10.1016/j.mayocp.2015.05.001 [In Press]Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to$13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.info:eu-repo/semantics/publishedVersio

Brazil in the Era of Fascism: The “New State” of Getúlio Vargas

The New State established in Brazil by Getúlio Vargas (1937–1945) is the most important case of the institutionalisation of a dictatorship of the fascism era in Latin America. During this time, an impressive spectrum of authoritarian regimes was established, some of which were very instable and poorly institutionalised, while others were more consolidated. Roger Griffin coined the concept of para-fascism for some of them, and the “New State” of Getúlio Vargas in Brazil is a paradigmatic case. In this essay, we analyse the processes of institutional reform in 1930s Brazil paying particular attention to how domestic political actors look at institutional models of fascism and corporatism.info:eu-repo/semantics/publishedVersio