Heart failure

A insuficiência cardíaca é síndrome comum, com taxas de prevalência estimadas de 2 a 4%. As duas últimas décadas aumentaram significativamente o conhecimento sobre a doença. Este artigo revisa importantes aspectos fisiopatológicos, semiológicos e da investigação complementar necessários para o manejo clínico. O tratamento, farmacológico e não farmacológico, é detalhado, incluindo suas indicações e contra-indicações.Heart failure is a common syndrome, with prevalence rates around 2 to 4%. Last two decades significantly raised our knowledge about this illness. This article revises important physiopathological, semiological and investigational features, all necessary to clinical management. Pharmacological and non-pharmacological treatments are detailed, including their indications and contra-indications

Efetividade do serviço móvel de urgência (Samu): uso de séries temporais interrompidas

OBJETIVO: Avaliar o desempenho do serviço de atendimento móvel de urgência (Samu) na região do Grande ABC, utilizando como condição traçadora o infarto agudo do miocárdio. MÉTODOS: A análise de séries temporais interrompidas foi a abordagem de escolha para testar efeitos imediatos e graduais da intervenção na população de estudo. A pesquisa compreendeu séries temporais mensais ajustadas da taxa de mortalidade hospitalar por infarto agudo do miocárdio no período entre 2000 e 2011. Os dados foram extraídos do Sistema de Informações sobre Mortalidade, usando a análise de regressão segmentada para avaliar o nível e tendência da intervenção antes e após sua implementação. Para fortalecer a validade interna do estudo, foi incluída uma região controle. RESULTADOS: A análise de séries temporais interrompidas mostrou redução de 0,04 mortes por 100.000 habitantes na taxa de mortalidade em relação à tendência subjacente desde a implantação do serviço de atendimento médico de urgência (p = 0,0040; IC95% -0,0816 – -0,0162) e uma redução no nível de 2,89 mortes por 100.000 habitantes (p = 0,0001; IC95% -4,3293 – -1,4623), ambos com significância estatística. Em relação à região controle, a Baixada Santista, a diferença da tendência do resultado entre desfecho de intervenção e controle pós-intervenção de -0,0639 mortes por 100.000 habitantes mostrou-se estatisticamente significativa (p = 0,0031; IC95% -0,1060 – -0,0219). Não podemos excluir confundimentos, mas limitamos sua presença no estudo incluindo séries de região controle. CONCLUSÕES: Embora a análise de séries temporais interrompidas tenha limitações, essa modelagem pode ser útil para a análise de desempenho de políticas e programas. Apesar de a intervenção estudada não ser uma condição que por si só implica na efetividade, a efetividade não estaria presente sem essa intervenção, que, integrada a outras condições, gera um resultado positivo. O Samu é uma estratégia cuja expansão precisa ser levada em consideração ao formular e consolidar políticas com foco nas urgências e emergências.OBJECTIVE: To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition. METHODS: The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included. RESULTS: The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: −0.0816 – −0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: −4.3293 – −1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of −0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: −0.1060 – −0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series. CONCLUSIONS: Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care

C-reactive protein as an inflammatory marker of acute infections outside intensive care settings: case report and evidence-based literature review

We present the clinical case of a 76-year-old woman with delirium causedby multiple factors, including pneumonia. Although this type of case is quitecommon in clinical practice, it provides us with an opportunity to discusslaboratory testing in this context, with a special focus on the role of C-reactiveprotein (CRP). We present data regarding the requests for determination ofserum CRP levels at the University of São Paulo University Hospital overthe past few years. We also present a review of the medical literature on thetopic, as well as clinical epidemiology concepts related to the impact that CRPtesting has on the medical decision-making process

‘‘Shadow’’ OSCE examiner. A cross-sectional study comparing the ‘‘shadow’’ examiner with the original OSCE examiner format

OSCEOBJECTIVES: Feedback is a powerful learning tool, but a lack of appropriate feedback is a very common complaint from learners to teachers. To improve opportunities for feedback on objective structured clinical examinations (OSCEs), a modified examiner role, termed the ‘‘shadow’’ examiner, was tested. This study aims to present and analyze comparisons between the ‘‘shadow’’ examiner and the original OSCE examiner format. METHODS: In 2011, experiments were carried out with modifications to the examiner’s role to define the ‘‘shadow’’ examiner format. From February 2012 to May 2014, research was conducted with 415 6th-year medical students. Of these students, 316 were randomly assigned to assessments by both ‘‘shadow’’ and ‘‘fixed’’ examiners. Pearson correlation analysis with linear regression, Student’s t-tests and Bland-Altman plots were the statistical methods used to compare the assessment modes. To strengthen the analysis, checklist items were classified by domain. RESULTS: High correlations between the ‘‘shadow’’ and ‘‘fixed’’ examiners’ global scores were observed. The results of the analysis of specific domains demonstrated higher correlations for cognitive scores and lower correlations for affective scores. No statistically significant differences between the mean examiner global scores were found. The Bland-Altman analysis showed that the ‘‘shadow’’ examiners’ affective scores were significantly higher than those of the ‘‘fixed’’ examiners, but the magnitude of this difference was small. CONCLUSION: The modified examiner role did not lead to any important bias in the students’ scores compared with the original OSCE examiner format. This new strategy may provide important insights for formative assessments of clinical performance

Effects of Pentoxifylline on TNF-Alpha and Lung Histopathology in HCl-Induced Lung Injury

OBJECTIVE: To evaluate the effects of pentoxifylline on hydrochloric acid-induced lung lesions in rats subjected to mechanical ventilation. METHODS: Twenty male, adult Wistar-EPM-1 rats were anesthetized and randomly grouped (n=5 animals per group) as follows: control-MV (mechanical ventilation, MV group); bilateral instillation of HCl (HCl group); bilateral instillation of HCl followed by pentoxifylline (50 mg/kg bw) infusion (HCl+PTX group) and pentoxifylline infusion followed by bilateral instillation of HCl (PTX+HCl group). At 20, 30, 90 and 180 min after treatments, the blood partial pressures of CO2 and O2 were measured. The animals were euthanized, and bronchoalveolar lavages were taken to determine the contents of total proteins, corticosterone and TNF-alpha. Samples of lung tissue were used for histomorphometric studies and determining the wet-to-dry (W/D) lung weight ratio. RESULTS: In the MV group, rats had alveolar septal congestion, and, in the HCl group, a remarkable recruitment of neutrophils and macrophages into the alveoli was noticed; these events were reduced in the animals with PTX+HCl. The partial pressure of oxygen increased in PTX+HCl animals (121±5 mmHg) as compared with the HCl (62±6 mmHg) and HCl+PTX (67±3 mmHg) groups within 30 minutes. TNF-alpha levels in bronchoalveolar lavage were significantly higher in the HCl group (458±50 pg/mL), reduced in the HCl+PTX group (329±45 pg/mL) and lowest in the PTX+HCl group (229±41 pg/mL). The levels of corticosterone in bronchoalveolar lavage were significantly lower in the HCl (8±1.3 ng/mL) and HCl+PTX group (16±2 ng/mL) and were highest in the PTX+HCl (27±1.9 ng/mL). CONCLUSION: Pretreatment with PTX improves oxygenation, reduces TNF-alpha concentration and increases the concentration of corticosterone in bronchoalveolar lavage upon lung lesion induced by HCl

Neck circumference is associated with carotid intimal-media thickness but not with coronary artery calcium : results from the ELSA-Brasil

Abstract Background and aims: It is uncertain whether neck circumference can be a risk indicator for subclinical atherosclerosis. We aimed to investigate their relationships measured by coronary artery calcium (CAC) and common carotid intima-media thickness (cc-IMT) with neck circumference in ELSA-Brasil. Methods and results: In cross-sectional and sex-specific analyses of 2266 women (50.6 8.4 yrs) and 1886 men (50.7 9.0 yrs) with both cc-IMT and CAC, free from previous cardiovascular disease at baseline, we built logistic models using diverse cut-off points for CAC score (0 vs >0, 0.05 for all). Conclusion: Neck circumference was significantly and independently associated with cc-IMT but not with CAC in women and men, indicating a possible effect of perivascular fat tissue on atherosclerosis

Adherence to the EAT-Lancet sustainable reference diet and cardiometabolic risk profile: cross-sectional results from the ELSA-Brasil cohort study

Purpose The EAT-Lancet Commission released a reference sustainable diet to improve human health and respect the planetary boundaries. The Planetary Health Diet Index (PHDI) was developed with the purpose of evaluate the adherence to this reference diet. The aim of the present study was to evaluate the association between adherence to the EAT-Lancet diet with cardiometabolic risk profile. Methods We used the cross-sectional baseline data from 14,155 participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multicenter ongoing cohort study. Dietary data were collected using a 114-item validated food frequency questionnaire. The PHDI was used to assess the adherence to the EAT-Lancet diet. It consists of 16 components and the total score can range from 0 to 150 points. Linear, logistic and quasi-Poisson regression models were built to evaluate the associations between PHDI and the outcomes. Results Individuals with higher adherence to EAT-Lancet diet (PHDI, 5th quintile) had lower values for systolic blood pressure (β − 0.84; 95% CI − 1.66: − 0.01), diastolic blood pressure (β − 0.70; 95% CI − 1.24: − 0.15), total cholesterol (β − 3.15; 95% CI − 5.30: − 1.01), LDL-c (β − 4.10; 95% CI − 5.97: − 2.23), and non-HDL-cholesterol (β − 2.57; 95% CI − 4.62: − 0.52). No association was observed for HDL-c, triglycerides and HOMA-IR. Conclusions Our results indicate that higher adherence to the EAT-Lancet diet is associated with lower levels of blood pressure, total cholesterol, LDL-c, and non-HDL-c

The association of diabetes, subclinical hypothyroidism and carotid intima-media thickness: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brazil)

Introduction: The association of diabetes with subclinical thyroid diseases may increase the risk of cardiovascular diseases. We analyzed the association of subclinical hypothyroidism, diabetes, and both diseases with carotid Intima-Media Thickness (cIMT) as a surrogate maker for early cardiovascular disease in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods: Cross-sectional analysis with data from the 3rd visit (2017‒2019). Linear regression models were used to evaluate the association of subclinical hypothyroidism, diabetes and of both diseases with a cIMT presented as Beta (95% Confidence Interval ‒ 95% CI) without adjustment, with adjustment for sociodemographic variables (Model 1) and multivariable adjustment (Model 1 more cardiovascular risk factors). We also used logistic regression models to analyze the Odds Ratio (OR) and 95% CI for the association of both diseases using cIMT > P75%. Results: After the exclusion of patients with previous cardiovascular disease, 5,077 participants with no diseases, 1578 with diabetes, 662 with subclinical hypothyroidism, and 234 with both diseases were included in the analysis. Linear regression models showed an association of cIMT with only diabetes (β = 0.019; 95% CI 0.012 to 0.027; p < 0.0001) and subclinical hypothyroidism more diabetes (β = 0.03; 95% CI 0.010‒0.047, p < 0.0001). The logistic regression model reported an association between diabetes and CIMT higher than P75% (OR = 1.49, 95% CI 1.30‒1.71). No interaction between diabetes and subclinical hypothyroidism was detected using cIMT respectively as a continuous (p = 0.29) or as a categorical variable (p = 0.92). Discussion: Diabetes was associated with higher cIMT values. However, no additive effect of subclinical hypothyroidism associated with diabetes over cIMT was detected

ELSA-Brasil: a 4-year incidence of hearing loss in adults with and without hypertension

OBJECTIVE To compare the incidence of hearing loss among adults stratified by the occurrence of hypertension, and to investigate the association between hypertension and hearing loss. METHODS Longitudinal observational study, part of the Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil, Longitudinal Study on Adult’s Health). Data from the first and second waves were analyzed, including information from audiological assessment and general health of the subjects. As outcome, we considered the presence of hearing loss (hearing thresholds above 25 dBHL at frequencies from 500 Hz to 8 kHz) and, as exposure variable, hypertension (report of medical diagnosis of hypertension; and/or use of drugs to treat hypertension; and/or pressure systolic blood pressure ≥ 140 mmHg; or diastolic blood pressure ≥ 90 mmHg). As covariables for adjustment were considered: sex, age, education, race / ethnicity, income, smoking, diabetes, and occupational exposure to noise. Poisson regression analysis was conducted, estimating the crude and adjusted relative risks, with 95% confidence intervals, in order to assess the factors associated with hearing loss. RESULTS In crude analyses, the incidence of hearing loss was higher for subjects with hypertension (9.7% versus 5.4%). The crude relative risks for hearing loss was almost double (1.93; 95%CI: 1.10–3.39) for subjects with hypertension in the right ear. In the adjusted analyses, the relative risks was not significant for the hypertension variable (1.42; 95%CI: 0.75–2.67). Being 60 years or older (RR: 5.41; 95%CI: 2.79–10.50) showed a statistically significant association with hearing loss, indicating that older adults have higher relative risks for hearing loss. CONCLUSION In the adjusted analyses controlled for multiple risk factors there was no association between hypertension and hearing loss. The dichotomous variable age (being 60 years or older), on the other hand, has shown a significant association with hearing loss