Vari��veis Ecocardiogr��ficas Predizentes de Terap��uticas Apropriadas de Taquidisritmias Ventriculares em Doentes Submetidos a Terap��utica de Ressincroniza����o Card��aca Combinada

INTRODUCTION: The significant risk of sudden arrhythmic death in patients with congestive heart failure and electromechanical ventricular dyssynchrony has led to increased use of combined cardiac resynchronization therapy defibrillator (CRT-D) devices. OBJECTIVES: To evaluate the echocardiographic variables in patients undergoing CRT-D that predict the occurrence of appropriate therapies (AT) for ventricular tachyarrhythmia. METHODS: We analyzed 38 consecutive patients (mean age 60 +/- 12 years, 63% male) with echocardiographic evaluation before and 6 months after CRT-D implantation. Patients with AT were identified in a mean follow-up of 471 +/- 323 days. A standard echocardiographic study was performed including tissue Doppler imaging (TDI). Responders were defined as patients with improvement in NYHA class of < or = 1 in the first six months, and reverse remodeling as a decrease in left ventricular end-systolic volume of < or = 15% and/or an increase in left ventricular ejection fraction of > 25%. RESULTS: The responder rate was 74%, and the reverse remodeling rate was 55%. AT occurred in 21% of patients, who presented with greater left ventricular end-diastolic internal diameter (LVEDD) before implantation (86 +/- 8 vs. 76 +/- 11 mm, p = 0.03) and at 6 months (81 +/- 8 vs. 72 +/- 14 mm, p = 0.08), and increased left ventricular end-systolic internal diameter (66 +/- 14 vs. 56 +/- 14 mm, p = 0.03) and lower ejection fraction (24 +/- 6 vs. 34 +/- 14%, p = 0.08) at 6 months. In the group with AT, the responder rate was lower (38 vs. 83%, p = 0.03), without significant differences in reverse remodeling (38% for the AT group vs. 60%, p = 0.426) or in the other variables. By univariate analysis, predictors of AT were LVEDD before implantation and E' after implantation. Age, gender, ischemic etiology, use of antiarrhythmic drugs, reverse remodeling and the other echocardiographic parameters did not predict AT. In multivariate logistic regression analysis, both LVEDD before implantation (OR 1.24, 95% CI 1.04-1.48, p = 0.019) and postimplantation E' (OR 0.27, 95% CI 0.09-0.76, p = 0.014) remained as independent predictors of AT. CONCLUSIONS: In patients undergoing CRT-D, episodes of ventricular tachyarrhythmia occur with high incidence, independently of echocardiographic response, with LVEDD before implantation and E' after implantation as the only independent predictors of AT in the medium-term. These results highlight the importance of combined devices with defibrillation capability.

Variantes Gen��ticas Pr��-Tromb��ticas como (Improv��veis?) Factores de Risco para as Grandes Crises Vaso-Oclusivas na Drepanocitose

CONTEXTO: A drepanocitose �� uma anemia hemol��tica heredit��ria com caracter��sticas pr��-adesivas, pr��-inflamat��rias e pr��-coagulantes, incluindo altera����es na hemostase e activa����o da cascata da coagula����o. PLANO DO ESTUDO: Neste estudo analisaram-se, em 140 drepanoc��ticos africanos e 126 indiv��duos sem hemoglobina S tamb��m de origem africana, variantes gen��ticas polim��rficas em quatro loci envolvidos na coagula����o (F2 20210G>A e F5 R506Q), na fibrin��lise (PAI-1 5G>4G), ou no metabolismo da homociste��na (MTHFR 677C>T). Estratificaram-se os pacientes em dois grupos de acordo com a ocorr��ncia ou n��o de, pelo menos, uma complica����o vaso-oclusiva (CVO) grave at�� �� data da sua participa����o no estudo. RESULTADOS: N��o se observou uma associa����o estatisticamente significativa entre a ocorr��ncia de uma CVO grave e a heran��a do alelo predisponente �� trombose, 4G no locus PAI-1 ou 677T no locus MTHFR. Nenhum drepanoc��tico apresentava os alelos F2 20210A ou F5 506Q (factor V Leiden). Visando excluir a possibilidade de que genu��nas diferen��as inter-grupos fossem mascaradas pela presen��a de indiv��duos mais jovens no grupo sem-CVO, dividiu-se este num sub-grupo de pacientes mais novos e num sub-grupo de pacientes cuja idade n��o diferia significativamente do grupo com-CVO grave. Mesmo assim, n��o foi encontrada associa����o significativa. No entanto, pode observar-se, no grupo de doentes com o alelo PAI-1 4G (cuja express��o resulta numa diminui����o da actividade fibrinol��tica), uma tend��ncia (OR=1,6) para um risco acrescido de CVO. Esta tend��ncia era ligeiramente maior (OR=2,1) se se considerasse apenas a CVO s��ndrome tor��cica aguda. CONCLUS��ES: O alelo 4G no promotor do PAI-1 poder�� ser um factor de risco para CVO na drepanocitose, uma hip��tese a testar numa s��rie maior de doentes, idealmente oriunda de uma popula����o homog��nea e com alta preval��ncia de drepanocitose.

Alergia a Medicamentos Reportada em Crian��as que Frequentam Infant��rios

Introdu����o: A preval��ncia de alergia a f��rmacos na popula����o geral n��o se encontra devidamente caraterizada, existindo poucos estudos publicados que tenham abordado esta situa����o em crian��as com idades inferior a seis anos de idade. Este estudo tem como objetivo principal estimar a preval��ncia de alergia a medicamentos reportada pelos pais de crian��as de infant��rios de Lisboa e do Porto. Material e M��todos: No ��mbito da Fase II do projeto ���ENVIRH ��� Ambiente e Sa��de em Creches e Infant��rios��� foi aplicado um question��rio sobre alergia a medicamentos aos pais das crian��as, recrutadas por amostragem aleat��ria estratificada dos infant��rios. Resultados: Foram analisados 1 169 question��rios, 52,5% de rapazes. A idade m��dia foi de 3,5 �� 1,5 anos. A preval��ncia de alergia a medicamentos reportada foi de 4,1% (IC 95%: 3,0 - 5,2%). Os f��rmacos mais referidos foram os antibi��ticos (em 27 rea����es) e os AINEs (em seis rea����es). Na an��lise multivari��vel, a alergia a medicamentos reportada associou-se diretamente com a idade da crian��a (OR 1,19; IC 95% 1,01 - 1,41) e com a refer��ncia a alergia alimentar (OR 3,19; IC95% 1,41 - 7,19) e inversamente com o n��vel de escolaridade dos pais (OR 0,25; IC95% 0,10 - 0,59). Discuss��o: Apesar das limita����es do estudo, os resultados encontram-se de acordo com o reportado por outros autores e sugerem que a preval��ncia reportada de alergia a medicamentos seja elevada no grupo et��rio estudado. Conclus��o: Torna-se necess��rio que situa����es de alergia a medicamentos reportadas pelos pais sejam devidamente estudadas, no sentido de evitar evic����es desnecess��rias que possam condicionar op����es terap��uticas em futuras situa����es de doen��a.

CO2 Concentration in Day Care Centres is Related to Wheezing in Attending Children

Poor ventilation at day care centres (DCCs) was already reported, although its effects on attending children are not clear. This study aimed to evaluate the association between wheezing in children and indoor CO2 (a ventilation surrogate marker) in DCC and to identify behaviours and building characteristics potentially related to CO2. In phase I, 45 DCCs from Lisbon and Oporto (Portugal) were selected through a proportional stratified random sampling. In phase II, 3 months later, 19 DCCs were further reassessed after cluster analysis for the greatest difference comparison. In both phases, children���s respiratory health was assessed by ISAAC-derived questionnaires. Indoor CO2 concentrations and building characteristics of the DCC were evaluated in both phases, using complementary methods. Mixed effect models were used to analyze the data. In phase I, which included 3,186 children (mean age 3.1��1.5 years), indoor CO2 concentration in the DCC rooms was associated with reported wheezing in the past 12months (27.5 %) (adjusted odds ratio (OR) for each increase of 200 ppm 1.04, 95 % CI 1:01 to 1:07). In phase II, the association in the subsample of 1,196 children seen in 19 out of the initial 45 DCCs was not significant (adjusted OR 1.02, 95 % CI 0.96 to 1.08). Indoor CO2 concentration was inversely associated with the practices of opening Windows and internal doors and with higher wind velocity. A positive trend was observed between CO2 and prevalence of reported asthma (4.7 %). Conclusion: Improved ventilation is needed to achieve a healthier indoor environment in DCC.

Factores de Risco Social, Comportamental e Biol��gico de Gravidez na Adolesc��ncia: Estudo de Caso-Controlo

Introdu����o: O melhor conhecimento dos factores de risco da gravidez na adolesc��ncia, especialmente a n��o desejada, pode ser uma forma de contribuir para a sua preven����o. Objectivo: Determinar poss��veis factores de risco sociais, comportamentais e biol��gicos de gravidez na adolesc��ncia. M��todos: Estudo de caso-controlo comparando adolescentes gr��vidas (casos) com adolescentes que nunca estiveram gr��vidas (controlos). Foram analisados factores de risco (a) social: ��ndice de Graffar, tipo de fam��lia, rendimento escolar e abandono escolar; (b) comportamental: h��bitos de depend��ncia, coitarca, contracep����o e n��mero de parceiros sexuais; e (c) biol��gico: idade, menarca, regularidade dos ciclos menstruais, ��ndice de massa corporal e perturba����es da sa��de mental. Resultados: Foram inclu��das 50 jovens em cada grupo, emparelhadas por idade. Os factores de risco de gravidez encontrados com significado estat��stico foram (a) sociais: ��ndice de Graffar ���4 (OR: 4,96; IC 95%: 1,96-12,74), fam��lia n��o nuclear (OR: 4,64; IC 95%: 1,83-11,98), reprova����es pr��vias (OR: 8,84; IC 95%: 3,20-25,16) e abandono escolar (OR: 9,01; IC 95%: 3,34-24,96); (b) comportamentais: h��bitos de depend��ncia (OR: 8,43; IC 95%: 1,65-57,87) e n��o utiliza����o de contracep����o (OR: 44,33; IC 95%: 5,05-100,92); e (c) biol��gicos: idade de menarca <12 anos (OR: 5,25; IC 95%: 1,89-15,02), irregularidade dos ciclos menstruais (OR: 4,51; IC 95%: 1,74-11,91) e ��ndice de massa corporal >percentil 85 (OR: 2,95; IC 95%: 1,04-8,55). N��o se revelaram factores de risco de gravidez a exist��ncia de mais de um parceiro sexual (OR: 4,42; IC: 0,5-99,31), idade de coitarca <15 anos (OR: 5,11; IC 95%: 0,93-36,71) e as perturba����es da sa��de mental (OR=1; IC 95%=0,15-6,63). Conclus��o: Na promo����o da sa��de sexual e reprodutiva sugere-se que se d�� aten����o privilegiada ��s jovens de meio desfavorecido, de fam��lias n��o nucleares, com insucesso escolar, h��bitos de depend��ncia, idade menor de menarca, aus��ncia de contracep����o, irregularidade menstrual e excesso de peso.

Compliance with ESPGHAN Position on Complementary Feeding in a Multicultural European Community. Does Ethnicity Matter?

Introduction: In 2008, ESPGHAN published a position paper on complementary feeding providing recommendations to health care professionals. Cultural and socio-economic factors might affect the compliance to these orientations. Aim: To estimate the prevalence of inadequacies during complementary feeding (ESPGHAN, 2008) and its association with different ethnic backgrounds. Methods: Cross-sectional survey of a convenience sample of caretakers of children up to 24 months of age in a single community health centre in Greater Lisbon, through a volunteer, self-applied questionnaire. Results: From a sample of children with wide cultural diversity, 161 valid questionnaires were obtained (median child���s age 9 months, median mother���s age 32 years). The prevalence rate of at least one complementary feeding inadequacy was 46% (95%CI: 38.45-53.66). The commonest inadequacies were: avoiding lumpy solid foods after 10 months of age (66.7%), avoidance or delayed introduction of foods beyond 12 months (35.4%), introduction of gluten beyond 7 months (15.9%) or salt before 12 months (6.7%). For each increase of 1 month in the age of the child, the odds of inadequacies raised 36.7% (OR = 1.37; 95%CI: 1.20-1.56; p < 0.001). The odds for inadequacies in children of African or Brazilian offspring was three times higher that of Portuguese ancestry (OR = 3.31; 95%CI: 0.87-12.61; p = 0.079). The influence of grandparents was related to an increase in the odds of inadequacies (OR = 3.69; 95%CI: 0.96-14.18; p = 0.058).Conclusion: Inadequacies during complementary feeding are frequent and may be influenced by the cultural background.