Evaluation of the Medical Care of Patients with Hypertension in an Emergency Department and in Ambulatory Hypertension Unit

OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeirão Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.

Clinical Profile, Predictors of Mortality, and Treatment of Patients after Myocardial Infarction, in an Academic Medical Center Hospital

OBJECTIVE: To evaluate clinical profiles, predictors of 30-day mortality, and the adherence to international recommendations for the treatment of myocardial infarction in an academic medical center hospital. METHODS: We retrospectively studied 172 patients with acute myocardial infarction, admitted in the intensive care unit from January 1992 to December 1997. RESULTS: Most patients were male (68%), white (97%), and over 60 years old (59%). The main risk factor for coronary atherosclerotic disease was systemic blood hypertension (63%). Among all the variables studied, reperfusion therapy, smoking, hypertension, cardiogenic shock, and age were the predictors of 30-day mortality. Most commonly used medications were: acetylsalicylic acid (71%), nitrates (61%), diuretics (51%), angiotensin-converting enzyme inhibitors (46%), thrombolytic therapy (39%), and beta-blockers (35%). CONCLUSION: The absence of reperfusion therapy, smoking status, hypertension, cardiogenic shock, and advanced age are predictors of 30-day mortality in patients with acute myocardial infarction. In addition, some medications that are undoubtedly beneficial have been under-used after acute myocardial infarction.

Assessment of the DIXTAL DX-2710 Automated Oscillometric Device for Blood Pressure Measurement with the Validation Protocols of the British Hypertension Society (BHS) and the Association for the Advancement of Medical Instrumentation (AAMI)

OBJECTIVE: To assess the Dixtal DX2710 automated oscillometric device used for blood pressure measurement according to the protocols of the BHS and the AAMI. METHODS: Three blood pressure measurements were taken in 94 patients (53 females 15 to 80 years). The measurements were taken randomly by 2 observers trained to measure blood pressure with a mercury column device connected with an automated device. The device was classified according to the protocols of the BHS and AAMI. RESULT: The mean of blood pressure levels obtained by the observers was 148±38/93±25 mmHg and that obtained with the device was 148±37/89±26 mmHg. Considering the differences between the measurements obtained by the observer and those obtained with the automated device according to the criteria of the BHS, the following classification was adopted: "A" for systolic pressure (69% of the differences < 5; 90% < 10; and 97% < 15 mmHg); and "B" for diastolic pressure (63% of the differences < 5; 83% < 10; and 93% < 15 mmHg). The mean and standard deviation of the differences were 0±6.27 mmHg for systolic pressure and 3.82±6.21 mmHg for diastolic pressure. CONCLUSION: The Dixtal DX2710 device was approved according to the international recommendations.

Demographic characteristics of the population undergoing cine coronary angiography at the Instituto do Coração of the Medical School of USP from 1986 to 1995

OBJECTIVE: To obtain information about the profile and behavior of a population with ischemic heart disease undergoing cine coronary angiography and to determine disease severity. METHODS: Retrospective study assessing patients hospitalized at InCor from 1986 to 1995, in which the variables age, sex, and number of major coronary arteries with obstruction degree > 40% were analyzed. RESULTS: We studied 18,221 patients and observed a significant increase in the number of females (22.8% to 25.2%, P=0.001) and an increase in age (57.1±29.3 to 60.4±10.7 years, P=0.0001). A significant increase in the incidence of multivessel disease was observed, which was more frequent among males (69.2% and 64.5%) and among the older patients (59.8±9.8 and 56.8±10.7 years, P=0.0001). A reduction in the incidence of single-vessel disease was also observed (66.2% vs 69.2% and 33.8% vs 30.5%, respectively, P<0.0001). CONCLUSION: A change in the profile of the population studied was observed as follows: patients undergoing cine coronary angiography at InCor were older, had a greater number of impaired major coronary arteries, and the number of females affected increased, leading to indices suggestive of a poorer prognosis.

Medical care and deaths due to coronary artery disease in Brazil, 1980-1999

OBJECTIVE: To estimate the frequency of medical care preceding deaths due to coronary artery diseases (CAD) in different Brazilian regions and capitals and to describe trends in medical care from 1980 to 1999. METHODS: Information on medical care preceding deaths due to coronary artery diseases/acute myocardial infarction in adults > 20 years from 1980 to 1999 was collected in the DATASUS, the databank of the Brazilian Health Ministry. Sex, states, and capitals selected for 1999 were analyzed in the study. Medical care was stratified as follows: with, without, and ignored medical care. The descriptive analysis comprised frequencies, ratios of frequency, test for proportions, and increments or reductions in frequencies. RESULTS: Acute myocardial infarction (AMI) represented 75 to 85% of the CAD in the period; the frequency of deaths with medical care ranged from 48.9 to 63%, and that of ignored medical care ranged from 27.2 to 41.5%. The frequency of other CAD with medical care ranged from 56 to 76%. The frequency of deaths preceded by medical care decreased by 17.8%, and that with ignored medical care increased by 36.5% (RF=2). The values for the other CAD were -20.2% and +64.6% (RF=44.4). Deaths preceded by medical care were more frequent in females at all ages and in all Brazilian regions. CONCLUSION: The results show a high frequency of sudden death and suggest errors in diagnosis or codification and overestimation of the statistics about mortality. Validation of the death certificate diagnosis and frequent surveillance are required.

Substituição valvar isolada com próteses metálicas St. Jude Medical em posição aórtica ou mitral: seguimento de médio prazo

FUNDAMENTO: Em nosso meio as próteses valvares biológicas predominam, considerando-se as dificuldades relacionadas à anticoagulação, mesmo em pacientes jovens, a despeito da necessidade de repetidas operações devido à degeneração das próteses biológicas. OBJETIVO: Apresentar a evolução em médio prazo de pacientes submetidos à substituição da valva mitral ou aórtica por prótese valvar mecânica St. Jude. MÉTODOS: Foi analisada retrospectivamente a evolução dos pacientes operados entre janeiro de 1995 e dezembro de 2003 e seguidos até dezembro de 2006. RESULTADOS: Cento e sessenta e oito pacientes receberam prótese valvar mitral e 117, aórtica. A idade média de ambos os grupos foi de 45 anos. Entre os mitrais, 75% tinham até 55 anos e 65% eram mulheres. Entre os aórticos, 66% tinham até 55 anos e 69% eram homens. Considerando-se apenas mortes relacionadas às próteses valvares, a sobrevida foi de 85,6% para os mitrais e de 88,7% para os aórticos (p=0,698). Entre os mitrais, 97% estavam livres de reoperação, e entre os aórticos 99% (p=0,335). Quanto aos eventos tromboembólicos, a porcentagem de pacientes livres foi de 82% entre os mitrais e de 98% entre os aórticos (p=0,049), e para os eventos hemorrágicos foi de 71% e 86% respectivamente (0,579). Quanto à ocorrência de endocardite, 98 % entre os mitrais e 99% entre os aórticos estavam livres ao final de 10 anos (p=0,534). CONCLUSÃO: Nossa experiência com próteses metálicas St. Jude em uma população predominantemente jovem confirma o bom desempenho desta prótese, em acordo com outras experiências publicadas.

Comparison of Cardiovascular Risk Factors in Different Areas of Health Care Over a 20-Year Period

Background:Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Knowledge about cardiovascular risk factors (CVRFs) in young adults and their modification over time are measures that change the risks and prevent CVDs.Objectives:To determine the presence of CVRFs and their changes in different health care professionals over a period of 20 years.Methods:All students of medicine, nursing, nutrition, odontology, and pharmacy departments of Federal University of Goiás who agreed to participate in this study were evaluated when they started their degree courses and 20 years afterward. Questionnaires on CVRFs [systemic arterial hypertension (SAH), diabetes mellitus, dyslipidemia, and family history of early CVD, smoking, alcohol consumption, and sedentarism] were administered. Cholesterol levels, blood sugar levels, blood pressure, weight, height, and body mass index were determined. The Kolmogorov-Smirnov test was used to evaluate distribution, the chi-square test was used to compare different courses and sexes, and the McNemar test was used for comparing CVRFs. The significance level was set at a p value of < 0.05.Results:The first stage of the study included 281 individuals (91% of all the students), of which 62.9% were women; the mean age was 19.7 years. In the second stage, 215 subjects were reassessed (76% of the initial sample), of which 59.07% were women; the mean age was 39.8 years. The sample mostly consisted of medical students (with a predominance of men), followed by nursing, nutrition, and pharmacy students, with a predominance of women (p < 0.05). Excessive weight gain, SAH, and dyslipidemia were observed among physicians and dentists (p < 0.05). Excessive weight gain and SAH and a reduction in sedentarism (p < 0.05) were observed among pharmacists. Among nurses there was an increase in excessive weight and alcohol consumption (p < 0.05). Finally, nutritionists showed an increase in dyslipidemia (p < 0.05).Conclusion:In general, there was an unfavorable progression of CVRFs in the population under study, despite it having adequate specialized knowledge about these risk factors.

Changes in Medical Management after Coronary CT Angiography

AbstractIntroduction:Coronary computed tomography angiography (CCTA) allows for non-invasive coronary artery disease (CAD) phenotyping. There are still some uncertainties regarding the impact this knowledge has on the clinical care of patients.Objective:To determine whether CAD phenotyping by CCTA influences clinical decision making by the prescription of cardiovascular drugs and their impact on non-LDL cholesterol (NLDLC) levels.Methods:We analysed consecutive patients from 2008 to 2011 submitted to CCTA without previous diagnosis of CAD that had two serial measures of NLDLC, one up to 3 months before CCTA and the second from 3 to 6 months after.Results:A total of 97 patients were included, of which 69% were men, mean age 64 ± 12 years. CCTA revealed that 18 (18%) patients had no CAD, 38 (39%) had non-obstructive (< 50%) lesions and 41 (42%) had at least one obstructive ≥ 50% lesion. NLDLC was similar at baseline between the grups (138 ± 52 mg/dL vs. 135 ± 42 mg/dL vs. 131 ± 44 mg/dL, respectively, p = 0.32). We found significative reduction in NLDLC among patients with obstrctive lesions (-18%, p = 0.001). We also found a positive relationship between clinical treatment intensification with aspirin and cholesterol reducing drugs and the severity of CAD.Conclusion:Our data suggest that CCTA results were used for cardiovascular clinical treatment titration, with especial intensification seen in patients with obstructive ≥50% CAD.

Observations on the dipteran fauna in a focus of dermal leishmaniasis in the State of Minas Gerais: II. The distribution of families in relation to their medical, veterinary and economic importance

Miniature light traps used to collect Phlebotominae in a focus of dermal leishmaniasis in the eastern part of the State of Minas Gerais, Brazil. Over a period of seven months, the other Diptera captured in 179 light trap samples were identified to family level. The traps were placed in eight localities which constituted three different biotopes: three woodland aresas, cultivated land, and a peridomestic site. A comparison is made between the totals of Dipeterans collected in each biotope, the total numbers of families collected in each biotope and the estimated indices of diversity. Dendograms representing the degrees of association between families of Diptera in different biotopes are presented. Some families of Diptera are uniformly distributed throughout the study area; a few families seem to have become adapted to areas where human activity has induced the greatest ecological changes. The impact between Dipterans and human well-being is discussed. The availabel evidence indicates that transmission of dermal leishmaniasis does not occur in areas where sand flies can be captured in greatest densities.

The yellow fever 17D vaccine virus as a vector for the expression of foreign proteins: development of new live flavivirus vaccines

The Flaviviridae is a family of about 70 mostly arthropod-borne viruses many of which are major public health problems with members being present in most continents. Among the most important are yellow fever (YF), dengue with its four serotypes and Japanese encephalitis virus. A live attenuated virus is used as a cost effective, safe and efficacious vaccine against YF but no other live flavivirus vaccines have been licensed. The rise of recombinant DNA technology and its application to study flavivirus genome structure and expression has opened new possibilities for flavivirus vaccine development. One new approach is the use of cDNAs encopassing the whole viral genome to generate infectious RNA after in vitro transcription. This methodology allows the genetic mapping of specific viral functions and the design of viral mutants with considerable potential as new live attenuated viruses. The use of infectious cDNA as a carrier for heterologous antigens is gaining importance as chimeric viruses are shown to be viable, immunogenic and less virulent as compared to the parental viruses. The use of DNA to overcome mutation rates intrinsic of RNA virus populations in conjunction with vaccine production in cell culture should improve the reliability and lower the cost for production of live attenuated vaccines. The YF virus despite a long period ignored by researchers probably due to the effectiveness of the vaccine has made a come back, both in nature as human populations grow and reach endemic areas as well as in the laboratory being a suitable model to understand the biology of flaviviruses in general and providing new alternatives for vaccine development through the use of the 17D vaccine strain.

Ancient medical texts, modern reading problems

The word tradition has a very specific meaning in linguistics: the passing down of a text, which may have been completed or corrected by different copyists at different times, when the concept of authorship was not the same as it is today. When reading an ancient text the word tradition must be in the reader's mind. To discuss one of the problems an ancient text poses to its modern readers, this work deals with one of the first printed medical texts in Portuguese, the Regimento proueytoso contra ha pestenença, and draws a parallel between it and two related texts, A moche profitable treatise against the pestilence, and the Recopilaçam das cousas que conuem guardar se no modo de preseruar à Cidade de Lixboa E os sãos, & curar os que esteuerem enfermos de Peste. The problems which arise out of the textual structure of those books show how difficult is to establish a tradition of another type, the medical tradition. The linguistic study of the innumerable medieval plague treatises may throw light on the continuities and on the disruptions of the so-called hippocratic-galenical medical tradition.