Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease

AbstractBackground:Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography.Objective:We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD.Methods:We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests.Results:A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27).Conclusions:In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? – Analysis of 568 Patients

Background:Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention.Objective:To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedureMethods:The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated.Results:A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001).Conclusion:Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Carlos Chagas Discoveries as a Drop Back to Scientific Construction of Chronic Chagas Heart Disease

Abstract The scientific construction of chronic Chagas heart disease (CCHD) started in 1910 when Carlos Chagas highlighted the presence of cardiac arrhythmia during physical examination of patients with chronic Chagas disease, and described a case of heart failure associated with myocardial inflammation and nests of parasites at autopsy. He described sudden cardiac death associated with arrhythmias in 1911, and its association with complete AV block detected by Jacquet's polygraph as Chagas reported in 1912. Chagas showed the presence of myocardial fibrosis underlying the clinical picture of CCHD in 1916, he presented a full characterization of the clinical aspects of CCHD in 1922. In 1928, Chagas detected fibrosis of the conductive system, and pointed out the presence of marked cardiomegaly at the chest X-Ray associated with minimal symptomatology. The use of serological reaction to diagnose CCHD was put into clinical practice in 1936, after Chagas' death, which along with the 12-lead ECG, revealed the epidemiological importance of CCHD in 1945. In 1953, the long period between initial infection and appearance of CCHD was established, whereas the annual incidence of CCHD from patients with the indeterminate form of the disease was established in 1956. The use of heart catheterization in 1965, exercise stress testing in 1973, Holter monitoring in 1975, Electrophysiologic testing in 1973, echocardiography in 1975, endomyocardial biopsy in 1981, and Magnetic Resonance Imaging in 1995, added to the fundamental clinical aspects of CCHD as described by Carlos Chagas.

Candida colonization in intensive care unit patients' urine

The objective of this study was to identify possible predisposing factors for candiduria in intensive care unit (ICU) patients from Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, Brazil, during one year. Urine samples from 153 ICU patients were obtained by catheterization on admission day and every seven days. Data such as sex, age, antifungal therapy, and variables as antibiotics, underlying diseases or comorbid conditions and stay in the hospital, were collected from patients who had at least one urine culture that yielded > 10³ yeast colonies/ml. Candiduria was recovered in 68 patients and the commonest predisposing factors were antibiotic therapy (100%) and indwelling urinary catheter (92.6%). The percentage of Candida spp. isolation increased during the extended periods in which patients remained in the ICU. C. albicans was isolated in 69.1%, and the other species non-albicans as C. glabrata, C. kefyr, C. parapsilosis, C. famata, C. guilliermondii, C. krusei, and C. tropicalis were isolated in lower percentage. The high frequency of candiduria and the possible predisposing factors found in ICU patients show that candiduria surveillance should be performed to help reducing nosocomial infections.

Genotyping of two Neisseria gonorrhoeae fluroquinolone-resistant strains in the Brazilian Amazon Region

We report two ciprofloxacin and ofloxacin-resistant Neisseria gonorrhoeae strains that were isolated from the urethral discharge of male patients at the sexually transmitted diseases outpatient clinic of the Alfredo da Matta Foundation (Manaus, state of Amazonas, Brazil). The gonococci displayed minimal inhibitory concentrations (> 32.00 µg/mL) and three mutations in the quinolone resistance-determining region (S91F and D95G in GyrA and S87R in ParC). Both isolates were genotyped using N. gonorrhoeae multi-antigen sequence typing and the analysis showed that the ST225 which represented an emerging widespread multi-resistant clone that has also been associated with reduced susceptibility to ceftriaxone. We recommend continued surveillance of this pathogen to assess the efficacy of anti-gonococcal antibiotics in Brazil.

Effectiveness of heparin versus 0.9% saline solution in maintaining the permeability of central venous catheters: a systematic review

Abstract OBJECTIVE Determining which is the most effective solution (heparin flush compared to 0.9% saline flush) for reducing the risk of occlusions in central venous catheters (CVC) in adults. METHOD The systematic review followed the principles proposed by the Cochrane Handbook; critical analysis, extraction and synthesis of data were performed by two independent researchers; statistical analysis was performed using the RevMan program 5.2.8. RESULTS Eight randomized controlled trials and one cohort study were included and the results of the meta-analysis showed no difference (RR=0.68, 95% CI=0.41-1.10; p=0.12). Analysis by subgroups showed that there was no difference in fully deployed CVC (RR=1.09, CI 95%=0.53-2.22;p=0.82); Multi-Lumen CVC showed beneficial effects in the heparin group (RR=0.53, CI 95%=0.29-0.95; p=0.03); in Double-Lumen CVC for hemodialysis (RR=1.18, CI 95%=0.08-17.82;p=0.90) and Peripherally inserted CVC (RR=0.14, CI 95%=0.01-2.60; p=0.19) also showed no difference. CONCLUSION Saline solution is sufficient for maintaining patency of the central venous catheter, preventing the risks associated with heparin administration.

Incidence of local complications and risk factors associated with peripheral intravenous catheter in neonates

Abstract OBJECTIVE To evaluate the incidence of complications related to the use of peripheral intravenous catheter in neonates and identify the associated risk factors. METHOD Prospective cohort study conducted in a Neonatal Intensive Care Unit. Participants were the hospitalized neonates undergoing peripheral intravenous puncture in the period from February to June 2013. RESULTS The incidence of complications was 63.15%, being infiltration/extravasation (69.89%), phlebitis (17.84%) and obstruction (12.27%). The risk factors were the presence of infection (p = 0.0192) and weight at the puncture day (p = 0.0093), type of intermittent infusion associated with continuous infusion (p <0.0001), endotracheal intubation (p = 0.0008), infusion of basic plan (p = 0.0027), total parenteral nutrition (P = 0.0002), blood transfusion associated with other infusions (p = 0.0003) and other drugs (p = 0.0004). Higher risk of developing complications in the first 48 hours after puncture. CONCLUSION A high rate of complications related to the use of peripheral intravenous catheter, and risk factors associated with infection, weight, drugs and infused solutions, and type of infusion.

Cardiac tamponade in an infant during contrast infusion through central venous catheter for chest computed tomography

Complications from central venous catheterization include infectious conditions, pneumothorax, hemothorax and venous thrombosis. Pericardial effusion with cardiac tamponade hardly occurs, and in infants is generally caused by umbilical catheterization. The authors describe the case of cardiac tamponade occurred in an infant during chest computed tomography with contrast infusion through a central venous catheter inserted into the right internal jugular vein.

Computed tomography angiography in patients with active gastrointestinal bleeding

Abstract Gastrointestinal bleeding represents a common medical emergency, with considerable morbidity and mortality rates, and a prompt diagnosis is essential for a better prognosis. In such a context, endoscopy is the main diagnostic tool; however, in cases where the gastrointestinal hemorrhage is massive, the exact bleeding site might go undetected. In addition, a trained professional is not always present to perform the procedure. In an emergency setting, optical colonoscopy presents limitations connected with the absence of bowel preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot accurately demonstrate the anatomic location of the bleeding and is not available at emergency settings. The use of capsule endoscopy is inappropriate in the acute setting, particularly in the emergency department at night, and is a highly expensive method. Digital angiography, despite its high sensitivity, is invasive, presents catheterization-related risks, in addition to its low availability at emergency settings. On the other hand, computed tomography angiography is fast, widely available and minimally invasive, emerging as a promising method in the diagnostic algorithm of these patients, being capable of determining the location and cause of bleeding with high accuracy. Based on a critical literature review and on their own experience, the authors propose a computed tomography angiography protocol to assess the patient with gastrointestinal bleeding.

Retenção urinária aguda por extenso hematoma pelvico após herniorrafia inguinal

The authors report a rare case of a patient with urinary retention following an inguinal herniorraphy, due to extrinsic compression of the bladder by an extensive pelvic hematoma, diagnosed by cystourethrogram and pelvic computadorized tomography. A medical treatment was provided by vesical catheterization for seven days. After this period of time, the hematoma had disappeared and the patient recovered to spontaneous miction.

Emprego da submucosa intestinal suína em uretroplastias complexas

We report the use of Porcine Intestinal Submucosa (PIS) in association with Johanson technique for urethroplasty, in the treatment of recurring urethral stenosis. The patient had obliterans xerotica balanitis and had previously undergone 15 internal uretotomies as well as various unsuccessful urethral dilations. As a result of stenotic extension, another surgery was planned using Johanson technique. During the first part of the surgery, intense local fibrosis was observed, which required greater care and protection to avoid fistulae formation. PIS was interposed to reduce the chances of the occurrence of this dreaded complication. During the second part of the surgery, a skin flap obtained from tissue parallel to the urethral plateau was used to prepare a neourethra according to the norms of this technique. PIS was fixed at its extremities, and interposed between the neourethral suture and the skin suture to prevent any contact between them. The procedure was completed with the use of meatoplasty and glandulaplasty. After 6-month follow up, clinical and urodynamic improvement could be seen. If these results can be confirmed by more extensive studies, PIS will provide new perspectives for complex urethroplasties.

Duplicação uretral em homem adulto

Urethral duplication is a rare congenital anomaly. The clinical presentation and treatment varies because of the different anatomical patterns of this abnormality. We report a case of this entity in the adult male patient. The clinical, radiological and endoscopic findings, as well as the treatment are discussed.