1000 resultados para tonsilitis [diagnóstico]
Resumo:
Analisou-se o teste de imunofluorescncia indireta com microfilrias de W. bancrofti tratadas pela papana, como antgeno, amplamente utilizado em Recife para o imunodiagnstico da filariose linftica. Foram testados soros de 50 pacientes portadores das diversas formas clnicas da doena, incluindo microfilaremia assintomtica, eosinofilia pulmonar tropical, elefantase de membros inferiores, linfagite aguda e quilria. Para o grupo controle, foram selecionados 50 indivduos vivendo pelo menos h 5 anos em rea endmica, sem nenhuma evidencia clnica e/ou laboratorial da doena, constituindo os chamados endmicos normais. A sensibilidade e especificidade do teste, segundo diferentes pontos de corte, mostraram a impossibilidade de diferenciao entre o grupo controle e o grupo sabidamente infectado. Tambm no foi possvel estabelecer correlao entre os ttulos encontrados e as diferentes formas clnicas. Foi considerada a existncia de reaes cruzadas relacionadas a helmintases intestinais, porm nenhuma relao direta foi encontrada.
Resumo:
Se procesan "a ciegas" 511 muestras de heces por las tcnicas de Kato-Katz, Willis, Ritchie y directo. Al comparar los resultados obtenidos en el diagnstico de Trichuris trichiura, Necator americanus y Ascaris lumbricoides, vimos que la de Kato-Katz fu ms sensible, revelando el mayor nmero de casos, siguindole en orden sucesivo, el Willis, el Ritchie, y el examen directo. Si se tiene en cuenta que el mtodo de Kato-Katz es adems cuantitativo, podemos recomendar-lo como tcnica de eleccin para el diagnstico de las geohelmintiasis intestinales.
Resumo:
Avaliou-se o desempenho da contraimunoeletroforese (CIE) no diagnstico sorolgico da leptospirose humana utilizando trs tipos de antgenos derivados da L. interrogans sorovar icterohaemorrhagiae e do sorovar patoc da L. biflexa. Comparou-se os resultados obtidos na CIE com a prova de referncia a soroaglutinao microscpica (SAM). Soros pareados de 135 pacientes com leptospirose foram subdivididos em 4 grupos de acordo com os resultados da SAM. Como controle coletou-se sangue de 69 indivduos sadios. A concordncia entre as duas tcnicas variou de 92,64 a 94,11%. Os resultados obtidos pela CIE com os antgenos do sorovar icterohaemorrhagiae foram mais favorveis do que aqueles derivados do patoc. Ressaltam-se as caractersticas de elevada sensibilidade detectando anticorpos antileptospiras mais precocemente do que a microaglutinao. As caractersticas encontradas no presente estudo credenciam o emprego da CIE como um mtodo til e prtico para o diagnstico da leptospirose humana na fase aguda da doena.
Resumo:
Uma epidemia de dengue tipo 1 se iniciou em Novembro de 1990 na Regio de Ribeiro Preto, Norte do Estado de So Paulo. Foram confirmados por exames laboratoriais cerca de 3.500 casos at fevereiro de 1991. A Unidade de Pesquisa em Virologia da Faculdade de Medicina de Ribeiro Preto - USP, estudou soros de 502 pessoas suspeitas de apresentarem dengue. Fez-se o diagnstico sorolgico atravs do mtodo da inibio da hemaglutinao (HAI) para dengue tipo 1 em 19% dos analisados. Passou-se a utlilizar um teste imuno-enzimtico para dengue em culturas celulares infectadas (EIA-ICC), que permite identificao simultnea de IgG e IgM. O EIA-ICC embora menos sensvel quando comparado ao HAI (89%), mostrou-se mais eficiente, porque: dispensou a obteno de segundas amostras sricas para o diagnstico; trata-se de tcnica simples, podendo ser efetuada em apenas 5 horas. O vrus dengue tipo 1 foi isolado do sangue de 21 pacientes, por inoculao em clulas de mosquitos C6/36. Fez-se a identificao dos vrus isolados por mtodo de imunofluorescncia indireta, utilizando anti-soro contra todos os flavivirus e anticorpos monoclonais tipo-especficos de dengue. Os sintomas mais freqentemente observados em 71 indivduos com diagnstico de dengue confirmado foram febre (90% dos casos), mialgias (57%) e artralgias (41%)
Resumo:
Foram estudadas 37 amostras de sangue de pacientes com leptospirose, forma icterohemorrgica, com intervalo de tempo de 2 a 12 dias entre o incio dos sintomas e a coleta do material. Isolou-se leptospiras por hemocultura de 5 (13,5%) pacientes e em 4 destes, o agente etiolgico pertencia ao sorogrupo Icterohaemorrhagiae sorovar copenhageni. O teste imunoenzimtico ELISA-IgM apresentou reatividade em 35 (94,6%) pacientes, incluindo os 4 pacientes dos quais o agente etiolgico foi isolado. Este teste demonstrou ser um importante recurso laboratorial para o diagnstico da letospirose humana, mesmo no incio da doena quando ainda na fase de leptospiremia.
Resumo:
As dificuldades para estabelecer diagnstico precoce e de certeza da leptospirose levaram-nos a analisar as alteraes histopatolgicas do msculo gastrocnmio e avaliar, originalmente, a utilidade de mtodo imuno-histoqumico, da peroxidase-antiperoxidase, quando desejada a demonstrao do espiroquetdeo e de seus produtos no referido tecido. O estudo histopatolgico de bipsias da panturrilha configurou quadro de miosite, caracterizado pela correlao entre o infiltrado inflamatrio intersticial e as anormalidades degenerativo-necrticas das fibras musculares. As leses foram consideradas mnimas em 69,45% dos pacientes, moderadas em 19,45% e intensas em 5,55%, estando ausentes nos demais. Por seu turno, o mtodo imuno-histoqumico enzimtico identificou antgeno leptospirtico em 94,45%, configurando resultado muito expressivo.
Resumo:
Dissertao apresentada na Faculdade de Cincias e Tecnologia da Universidade Nova de Lisboa para obteno do grau de Mestre em Engenharia Biomdica
Resumo:
Durante 5 aos se estudiaron 117 pacientes con micosis sistmicas asociadas al SIDA: 74 criptococosis, 39 histoplasmosis y 4 con ambas enfermedades. Para el diagnstico analizamos los siguientes materiales: escarificaciones de lesiones cutneas o mucosas, aspirados de mdula sea, secreciones bronquiales, biopsias de diversos rganos, lquido cefalorraqudeo, hemocultivos y sueros para determinaciones serolgicas. Fueron estudiadas en total 203 muestras de pacientes con histoplasmosis, el 46.3% de las mismas acus la presencia de H. capsulatum. Las escarificaciones cutneas exhibieron la mayor sensibilidad (94.7%), seguidas por las biopsias (80%) y los mielocultivos (42.1%). La demostracin de anticuerpos circulantes por medio de 3 pruebas serolgicas y con de 2 antgenos especficos dio resultados positivos en el 45.4% de los pacientes. Se estudiaron en total 413 especmenes de pacientes con criptococosis, la confirmacin diagnstica fue posible en el 69% de las muestras. El mayor rendimiento se obtuvo con el LCR (89.5%), le seguieron en sensibilidad los hemocultivos (61.2%), las escarificaciones cutneas (42.9%) y los urocultivos (41.7%). La bsqueda de antgeno en los fluidos orgnicos fue positiva en casi todos los casos. La revisin que presentamos permitir una bsqueda ms racional y rpida de los mtodos de diagnstico en las micosis asociadas al SIDA.
Medio dos nveis de referncia de diagnstico em tomografia computorizada para exames de cabea e pescoo
Resumo:
Dissertao apresentada na Faculdade de Cincias e Tecnologia da Universidade Nova de Lisboa para obteno do grau de Mestre em Engenharia Biomdica
Resumo:
Resumo: A insuficincia cardaca, j denominada de epidemia do sculo XXI , de entre as doenas cardiovasculares, a nica cuja incidncia e prevalncia continuam a crescer, apesar dos imensos progressos feitos na rea da teraputica nas ltimas duas dcadas. Caracteriza-se por elevada mortalidade – superior do conjunto das neoplasias malignas -, grande morbilidade, consumo de recursos e custos exuberantes. um dos problemas mais graves de Sade Pblica dos Pases industrializados, cujo manejo dever constituir uma prioridade para os Servios Nacionais de Sade. Todavia, o reconhecimento universal da gravidade desta situao tem originado poucas solues concretas para conter a epidemia, cujo protagonismo no cessa de aumentar. possvel hoje prevenir, tratar de forma a retardar a evoluo da doena ou at revert-la, desde que diagnosticada atempadamente. Qualquer atitude nestas reas pressupe um diagnstico correcto, precoce e completo da situao, sem o qual no haver um tratamento adequado. O diagnstico tem preocupado bem menos os investigadores e os clnicos que a teraputica. , contudo, comprovadamente difcil a todos os nveis dos Cuidados de Sade e constitui certamente a primeira barreira ao controlo da situao. OBJECTIVOS: luz do conhecimento actual e da nossa prpria experincia, propusemo-nos analisar os problemas do diagnstico da insuficincia cardaca e a forma como eles se repercutem no manejo da doena e na sade das populaes. Foram objectivos desta dissertao avaliar como a evoluo dos modelos de insuficincia cardaca e de disfuno ventricular influenciaram a definio e os critrios de diagnstico da doena ao longo do tempo; as consequncias geradas pela falta de consenso quanto definio e aos critrios de diagnstico nas diferentes fases de evoluo desta entidade; discutir o papel da clnica e dos exames complementares no diagnstico da sndrome e nas estratgias de rastreio da disfuno cardaca; apontar alguns caminhos e possveis metodologias para o manejo da doena de forma a que possamos, no futuro, diagnosticar melhor para melhor prevenir, tratar e conter a epidemia. METODOLOGIA: A metodologia utilizada neste trabalho decorre directamente da actividade assistencial diria e da investigao clnica gerada no interesse pelos problemas com que nos deparmos, ao longo dos anos, na rea da insuficincia cardaca. A par com o estudo epidemiolgico da insuficincia cardaca em Portugal, desenvolvemos um protocolo original para a avaliao da qualidade do diagnstico no ambulatrio e do papel da clnica e dos diferentes exames complementares no diagnstico da sndrome. Avalimos os problemas do diagnstico da insuficincia cardaca em meio hospitalar atravs de um inqurito endereado aos Directores de Servio, pelo Grupo de Estudo de Insuficincia Cardaca da Sociedade Portuguesa de Cardiologia. Analismos a qualidade do diagnstico da insuficincia cardaca codificado data da alta hospitalar. Aps a criao de uma rea especfica, vocacionada para o internamento de doentes com insuficincia cardaca, avalimos o seu impacto no diagnstico e tratamento da sndrome. Tambm testmos o desempenho dos peptdeos natriurticos no diagnstico dos diferentes tipos de insuficincia cardaca sintomtica, em meio hospitalar. Os resultados parciais da investigao clnica foram sendo comunicados comunidade cientfica e publicados em revistas da especialidade. Discutimos, nesta dissertao, os artigos publicados e em publicao, luz do estado actual da arte na rea do diagnstico. Reflectimos sobre as consequncias das dificuldades no diagnstico da insuficincia cardaca e apontamos possveis caminhos para implementar o rastreio. RESULTADOS: Em 1982, muito no incio da nossa actividade clnica, cientes da complexidade da insuficincia cardaca e do desafio que a sua abordagem constitua para os clnicos,empenhvamo-nos no desenvolvimento de uma classificao fisiopatolgica original da insuficincia cardaca, que foi tema para a Tese de Doutoramento da Professora Doutora Ftima Ceia em 1989. sistemtico da doena, melhorar os cuidados prestados aos doentes e diminuir os custos envolvidos no manejo da sndrome. No artigo 1 – Insuficincia cardaca: novos conceitos fisiopatolgicos e implicaes teraputicas – publicado em 1984, descrevemos, luz do conhecimento da poca, a insuficincia cardaca como uma doena sistmica, resultado da interaco entre os mltiplos mecanismos de compensao da disfuno cardaca. Desenvolvemos “uma classificao fisiopatolgica com implicaes teraputicas” original, onde delinemos os diferentes tipos de insuficincia cardaca, as suas principais caractersticas clnicas, hemodinmicas, funcionais e anatmicas e propuzemos teraputica individualizada de acordo com a definio e o diagnstico dos diferentes tipos de insuficincia cardaca. Em 1994, no artigo 2 – A insuficincia cardaca e o clnico no fim do sculo vinte – salientamos a forma como os diferentes mecanismos de compensao interagem, influenciam a evoluo da doena no tempo, produzem sndromes diferentes e fundamentam a actuao teraputica. Discutimos a evoluo da definio da doena de acordo com o melhor conhecimento da sua fisiopatologia e etiopatogenia. Sublinhamos a necessidade de desenvolver estratgias para a preveno da doena, o diagnstico precoce e o tratamento atempado. Ainda no primeiro captulo: Insuficincia cardaca: da fisiopatologia clnica – um modelo em constante evoluo – revisitmos os sucessivos modelos fisiopatolgicos da insuficincia cardaca: cardio-renal, hemodinmico, neuro-hormonal e imuno-inflamatrio e a sua influncia na definio da sndrome e nos critrios de diagnstico. Analismos a evoluo do conceito de disfuno cardaca que, dicotomia da sndrome em insuficincia cardaca por disfuno sistlica e com funo sistlica normal, contrape a teoria do contnuo na evoluo da doena. Esta ltima, mais recente, defende que estas duas formas de apresentao no so mais do que fentipos diferentes, extremos, de uma mesma doena que origina vrios cenrios, desde a insuficincia cardaca com fraco de ejeco normal disfuno sistlica ventricular grave No captulo II - O diagnstico da insuficincia cardaca: problemas e consequncias previsveis - analisamos as consequncias da falta de critrios de diagnstico consensuais para a insuficincia cardaca em todo o seu espectro, ao longo do tempo. As dificuldades de diagnstico reflectem-se nos resultados resultados dos estudos epidemiolgicos. Vivemos essa dificuldade quando necessitmos de definir critrios de diagnstico exequveis no ambulatrio, abrangendo todos os tipos de insuficincia cardaca e de acordo com as Recomendaes, para o programa EPICA –EPidemiologia da Insuficincia Cardaca e Aprendizagem – desenhado para os Cuidados Primrios de Sade. No artigo 3 – Epidemiologia da insuficincia cardaca e Aprendizagem – desenhado para os Cuidados Primrios de Sade. No artigo 3 – Epidemiologia da insuficincia cardaca – discutimos as consequncias dos grandes estudos epidemiolgicos terem adoptado ao longo dos anos definies e critrios de diagnstico muito variveis,conduzindo a valores de prevalncia e incidncia da doena por vezes tambm muito diferentes. O problema agudiza-se quando se fala em insuficincia cardaca com fraco de ejeco normal ou com disfuno diastlica, ou ainda em rastreio da disfuno cardaca assintomtica, situaes para as quais tem sido extraordinariamente difcil consensualizar critrios de diagnstico e estratgias. notria a ausncia de grandes estudos de teraputica no contexto da insuficincia cardaca com fraco de ejeco normal ou com disfuno diastlica que, falta de Recomendaes teraputicas baseadas na evidncia, continuamos a tratar de acordo com a fisiopatologia. Assim, discrepncias provavelmente mais relacionadas com os critrios de diagnstico utilizados do que com diferenas reais entre as populaes, dificultam o nosso entendimento quanto ao real peso da insuficincia cardaca e da disfuno ventricular assintomtica. Tambm comprometero certamente a correcta alocao de recursos para necessidades que, na realidade, conhecemos mal. O artigo 4 – Prvalence de l’ insuffisance cardiaque au Portugal – apresenta o desenho dos estudos EPICA e EPICA-RAM. O EPICA foi dos primeiros estudos a avaliar a prevalncia da insuficincia cardaca sintomtica global, na comunidade, de acordo com os critrios da Sociedade Europeia de Cardiologia. Definimos critrios ecocardiogrficos de disfuno cardaca para todos os tipos de insuficincia cardaca, nomeadamente para as situaes com fraco de ejeco normal, numa poca em que ainda no havia na literatura Recomendaes consensuais. No artigo 5 – Prevalence of chronic heart failure in Southwestern Europe: the EPICA study - relatamos a prevalncia da insuficincia cardaca em Portugal con-supra-diagnosticada em 8,3%. A codificao hospitalar falhou uma percentagem significativa de doentes com insuficincia cardaca, minimizando assim o peso da sndrome, com eventual repercusso na alocao dos recursos necessrios ao seu manejo no hospital e para a indispensvel interface com os Cuidados Primrios de Sade. No artigo 8 – Tratamento da insuficincia cardaca em hospitais portugueses: resultados de um inqurito – todos os inquiridos relataram dificuldades no diagnstico atempado da insuficincia cardaca. Os Directores dos Servios de Cardiologia reclamam mais recursos humanos vocacionados e estruturas hospitalares especializadas no diagnstico e tratamento da sndrome, enquanto que os Directores dos Servios de Medicina necessitam de facilidades de acesso aos mtodos complementares de diagnstico como a ecocardiografia e de maior apoio do Cardiologista. As dificuldades no diagnstico da insuficincia cardaca,a todos os nveis de cuidados, acarretam assim consequncias epidemiolgicas, scio-econmicas e financeiras nefastas para o doente individual, a planificao do Sistema Nacional de Sade e para a Sade Pblica No captulo III relembramos a importncia do diagnstico completo da insuficincia cardaca que, para alm do diagnstico sindromtico e anatomo-funcional, dever incluir o diagnstico etiolgico, e das comorbilidades. Muitos destes aspectos podem comprometer a interpretao dos exames complementares de diagnstico e, no raramente, as indicaes dos frmacos que influenciam a sobrevida dos doentes, a estratgia teraputica e o prognstico da sndrome Conscientes das dificuldades no diagnstico da insuficincia cardaca nos Cuidados Primrios de Sade e do papel preponderante dos especialistas em Medicina Familiar na conteno da epidemia, propusemo-nos, como objectivos secundrios do estudo EPICA (artigo 5), investigar a acuidade diagnstica dos instrumentos disposio daqueles colegas, na prtica clnica diria: a clnica e os exames complementares de diagnstico de primeira linha. O artigo 10 – The diagnosis of heart failure in primary care: value of symptoms and signs - documenta o valor limitado dos sinais, sintomas e dados da histria pregressa, quando usados isoladamente, no diagnstico da sndrome. Todos tm baixa sensibilidade para o diagnstico. Tm maior valor preditor os associados s situaes congestivas, mais graves: a dispneia paroxstica nocturna (LR 35,5), a ortopneia (LR 39,1), a dificuldade respiratria para a marcha em plano horizontal (LR 25,8), o ingurgitamento jugular > 6 cm com hepatomegalia e edema dos membros inferiores (LR 130,3), que esto raramente presentes na populao de insuficientes cardacos do ambulatrio (sensibilidade <10%). O galope ventricular (LR 30,0), a taquicardia >110ppm (LR 26,7) e os fervores crepitantes (LR 23,3) tambm esto associados ao diagnstico, mas so tambm pouco frequentes na populao estudada (sensibilidade < 36%). So ainda preditores do diagnstico o tratamento prvio com digitlico (LR 24,9) e/ou com diurtico (LR 10,6), uma histria prvia de edema pulmonar agudo (LR 54,2) ou de doena das artrias coronrias (LR 7,1). No artigo 11- Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy - confirmmos que a hipertenso arterial , de entre os factores de risco e/ou etiolgicos, a causa mais frequente de insuficincia cardaca no ambulatrio, em Portugal (80%). Trinta e nove por cento dos doentes do estudo EPICA tm histria de doena coronria e 15% de fibrilhao auricular. Quantificmos a comorbilidade e analismos a sua potencial influncia no facto da prescrio teraputica estar aqum das Recomendaes internacionais em Portugal, como alis em toda a Europa. No artigo 12 - The value of electrocardiogram and X-ray for confirming or refuting a suspected diagnosis of heart failure in the community – demonstrmos que os dados do ECG e do RX do trax no permitem predizer o diagnstico de insuficincia cardaca na comunidade; 25% dos doentes com insuficincia cardaca objectiva tinham ECG ou RX do trax normais. No artigo 13 - Evaluation of the performance and concordance of clinical questionnaires for heart failure in primary care - comparmos sete questionrios e sistemas de pontuao habitualmente utilizados nos grandes estudos, para o diagnstico da insuficincia cardaca. Mostraram ter, na sua maioria, uma concordncia razovel ou boa entre si. Foram muito especficos (>90%) mas pouco sensveis. Aumentaram a probabilidade do diagnstico de 4,3% pr-teste para 25 a 30% ps-teste. Revelaram-se um melhor instrumento para a excluso da causa cardaca dos sintomas do que para o diagnstico da sndrome O artigo 14 - Epidemiologia da insuficincia cardaca em Portugal continental: novos dados do estudo EPICA – compara as caractersticas dos doentes com suspeita clnica, no comprovada, de insuficincia cardaca (falsos positivos), com os casos de insuficincia cardaca. Os primeiros so mais idosos, mais mulheres, com mais excesso de peso, menos histria de doena das artrias coronrias. Confirma ainda que a clnica, o ECG e o Rx trax no permitem diferenciar os doentes com insuficincia cardaca por disfuno sistlica ventricular daqueles que tm fraco de ejeco normal. Perante o desafio do diagnstico da insuficincia cardaca com fraco de ejeco normal, as dificuldades de acesso ecocardiografia na comunidade e os custos acrescidos do exame, pretendemos averiguar no artigo 15 - The diagnostic challenge of heart failure with preserved systolic function in primary care setting: an EPICA-RAM sub-study - o desempenho do BNP no rastreio dos doentes com a suspeita clnica do diagnstico, a enviar para ecocardiografia. Testmos o desempenho do teste como preditor do diagnstico clnico da insuficincia cardaca com funo sistlica preservada, bem como dos indicadores ecocardiogrficos de disfuno diastlica utilizados no estudo: dilatao da aurcula esquerda e hipertrofia ventricular esquerda. O teste apenas foi bom preditor da dilatao da aurcula esquerda, mas no do diagnstico clnico deste tipo de insuficincia cardaca, nem da presena de hipertrofia ventricular esquerda diagnosticada por ecocardiografia (rea abaixo da curva ROC: 0,89, 0,56 e 0,54 respectivamente). Conclumos que, isoladamente, no ser um bom mtodo de rastreio da doena na comunidade, nem poder substituir o ecocardiograma no doente com a suspeita clnica do diagnstico, pelo menos nas fases precoces, pouco sintomticas da doena. Estudmos e comparmos o desempenho dos peptdeos natriurticos do tipo B - BNP e NT-proBNP - no diagnstico da insuficincia cardaca sintomtica, por disfuno sistlica e com fraco de ejeco preservada, no internamento hospitalar. Avalimos doentes e voluntrios normais, de forma a estabelecermos os cut-off do nosso laboratrio. Relatmos os resultados deste trabalho no artigo 16 – Valor comparativo do BNP e do NT-proBNP no diagnstico da insuficincia carda-ca. Ambos os testes tiveram um excelente desempenho no diagnstico da insuficincia cardaca sintomtica, em meio hospitalar, mas nenhum foi capaz de diferenciar a insuficincia cardaca com disfuno sistlica ventricular da que tem fraco de ejeco normal Revimos, luz do conhecimento actual, o desempenho dos diferentes exames complementares, nomeadamente dos peptdeos natriurticos e da ecocardiografia, no diagnstico da insuficincia cardaca sintomtica global, por disfuno sistlica ventricular e com fraco de ejeco normal e discutimos os critrios mais recentemente propostos e as ltimas Recomendaes internacionais Discutimos as estratgias propostas para o rastreio da disfuno ventricular assintomtica que , na comunidade, pelo menos to frequente quanto a sintomtica. Existe evidncia de que tratar precocemente a disfuno ventricular sistlica assintomtica se traduz em benefcios reais no prognstico e, tal como no caso da disfuno sistlica sintomtica, custo-eficiente. Autilizao do mtodo padro para o rastreio da disfuno cardaca na populao obrigaria realizao de ecocardiograma a todos os indivduos, o que tcnica e economicamente incomportvel. Vrios estudos tm vindo a testar diversas estratgias alternativas, na procura de uma metodologia que seja, tambm ela, custo-eficiente. Os autores so unnimes no aspecto em que nenhum exame, quando avaliado isoladamente, foi til para o rastreio da disfuno cardaca. Contudo apontam para o ECG e/ou os peptdeos natriurticos, integrados ou no em esquemas de pontuao clnica, como testes teis para o pr-rastreio para ecocardiografia. Permitem diminuir os pedidos de ecocardiograma e os custos do rastreio, que se torna to custo-efectivo quanto o do cancro da mama ou do colo do tero. Alguns autores preconizam ainda a avaliao qualitativa da disfuno cardaca por ecocardiograma porttil, no contexto de ECG anmalo ou de peptdeo natriurtico elevado, antes da referenciao para o ecocardiograma completo. Apontam esta estratgia como sendo a mais custo-eficiente para o rastreio da disfuno cardaca. Finalmente, tecemos alguns comentrios finais quanto a perspectivas de futuro para o manejo da insuficincia cardaca. premente estabelecer uma definio precisa e universal da sndrome e critrios de diagnstico consensuais, claros, objectivos, simples e reprodutveis para todo o espectro da insuficincia cardaca, para que possamos num futuro prximo avaliar de forma correcta a extenso do problema, organizar cuidados mdicos eficientes e acessveis a todos e melhorar o prognstico dos doentes, numa poltica imprescindvel e inevitvel de conteno dos custos. Perante os problemas de diagnstico da sndrome no ambulatrio, consideramos ser necessrio implementar programas de formao continuada e facilitar o dilogo e a colaborao entre Cuidados Primrios de Sade e Unidades especializadas no manejo da doena, imagem do que fizemos pontualmente aquando do programa EPICA e do que est a ser desenvolvido em vrios pases europeus e nos Estados Unidos da Amrica, sob a forma de redes alargada de prestao de cuidados, para a insuficincia cardaca. As clnicas de insuficincia cardaca, a laborar sobretudo em meio hospitalar, j deram provas quanto maior conformidade do diagnstico (e tratamento) de acordo com as Recomendaes, assim como na melhoria da qualidade de vida e sobrevida dos doentes. No artigo 17 - Implementar as Recomendaes na prtica clnica: benefcios de uma Unidade de Insuficincia Cardaca Aguda - relatamos a nossa experincia quanto melhoria da qualidade dos cuidados prestados, nas reas do diagnstico e tratamento, numa unidade funcional dedicada ao internamento dos doentes com insuficincia cardaca aguda. Defendemos que estas reas especficas de internamento se devem articular com outras,nomeadamente hospitais de dia de insuficincia cardaca, podendo ou devendo at ser diferentes na sua estrutura e recursos, de acordo com as necessidades das populaes no seio das quais so implementadas. Cabe-lhes um papel determinante na interaco com os Cuidados Primrios de Sade, na formao mdica continuada e de outros profissionais de sade e na recepo e orientao dos doentes referenciados para a especialidade.So ainda necessrios esforos redobrados para a identificao e controlo dos factores de risco e para o estabelecimento de estratgias de rastreio da disfuno ventricular na comunidade. Tal passvel de ser feito e custo-eficiente, mas exige a colaborao de tcnicos de sade, investigadores e poder poltico para avaliar das necessidades reais, implementar e controlar a qualidade destas estratgias, sem as quais no conseguiremos conter a epidemia. SUMMARY: Despite there has been substantial progress in the treatment of heart failure over the last several decades, it is the only cardiovascular disorder that continues to increase in both prevalence and incidence. Characterised by very poor survival and quality of life heart failure is responsible for among the highest healthcare costs for single conditions in developed countries. Heart failure is therefore becoming an increasing concern to healthcare worldwide and must be a priority to National Health Services. It is already called the epidemic of the 21 st century. A correct diagnosis is the cornerstone leading to effective management of the syndrome. An early, accurate and complete diagnosis has become crucial with the identification of therapies that can delay or reverse disease progression and improve both morbidity and mortality. Diagnostic methods may need to encompass screening strategies, as well as symptomatic case identification. Until now, investigation has been over focused on pharmacological treatment; relatively little work has been done on assessing diagnostic tools. This is actually a difficult condition to diagnose at all levels of care, and misdiagnosis must be the first barrier to the control of the epidemic. AIMS Considering current and up-dated knowledge and ourown experience we analyse the problems in diagnosing heart failure and cardiac dysfunction and how they affect patient’s clinical outcome and public health care. It was our aim to analyse how increasing knowledge about cardiac dysfunction influenced the concept of heart failure, its definition and diagnostic criteria; the problems resulting from the use of non consensual definitions and diagnostic criteria; the role of clinical data and diagnostic tests on the diagnosis of the syndrome and on the screening for cardiac dysfunction in the community; to discuss best strategies to enhance diagnostic management of heart failure in all its spectrum, in order to halt the epidemic in the near future. METHODS: The investigation on which the present dissertation is based was developed progressively, along the years, during our every-day clinical practice. Various original clinical investigations and review papers, related to challenges in heart failure management and especially to diagnosis, were presented in scientific meetings and/or published gradually as partial results were obtained. The EPICA Programme (epidemiology of heart failure and awareness), a large-scale epidemiological study on heart failure in Portugal, addressed as secondary endpoints, problems of heart failure misdiagnosis in primary care and the value of clinics and different diagnostic tests to confirme or refute the diagnosis of the syndrome suspected on clinical grounds. But problems on the diagnosis of heart failure are not confined to primary care. Therefore, under the auspices of the Working Group of Heart Failure of the Portuguese Society of Cardiology, a survey on the management of heart failure at hospital was addressed to the heads of Portuguese Cardiology and Internal Medicine Wards. Compliance with Guidelines on diagnosis and treatment of heart failure, perceived difficulties and requests to a better management of the syndrome were ascertained. We have then explored the validity of a coded diagnosis of heart failure at death/discharge from the Department of Medicine of S. Francisco Xavier Hospital, and the rate of misdiagnosis. Gains on compliance with Guidelines on the diagnosis and treatment of heart failure, before and after the implementation of an acute heart failure unit in this Department were assessed. We also compared the performance of type-B natriuretic peptides – BNP and NT-proBNP – on systolic and diastolic heart failure diagnosis, in order to implement the more adequate test. In this thesis we discuss our published papers against the state of the art on heart failure diagnosis, and actual consequences of misdiagnosing. We revisit the accuracy of the different diagnostic testes to a definite diagnosis of the disease. Finally we analyse the different ways of screening for cardiac TESE3 AF 6/9/08 12:25 PM Page 309 310 Summary dysfunction and the more cost-efficient strategies to enhance heart failure diagnosis and management. RESULTS Since 1982, at the very beginning of our clinical activity, already aware of the complexity of the management of heart failure, we were involved in the development of an original pathophysiological heart failure classification, theme of Professor Ftima Ceia Doctoral Thesis discussed in 1989. Paper 1 - Heart Failure. New pathophysiological approach to therapy – published in 1984, described heart failure as a systemic disease resulting from the interaction of the different compensatory mechanisms. We proposed a new dynamic, pathophysiological and aetiological approach to the diagnosis of heart failure syndromes, based on clinics and conventional non-invasive assessment with drug management implications. In 1994, in paper 2 – Heart failure and the physician - towards the XXI century – we discussed the way how the compensatory mechanisms interact, produce the different heart failure syndromes and affect the evolution of the disease. Changing definitions according to the knowledge of the pathophysiology of heart failure at that time were revisited. The need for a universally accepted definition leading to early and accurate diagnosis and treatment of the syndrome was pointed-out. We called for strategies to prevent heart failure. In an up-dated review titled: Heart failure: from pathophysiology to clinics – a model in constant evolution – we revisit the changing pathophysiological models of heart failure – cardio-renal, haemodynamic, neuro-hormonal and imuno-inflamatory models - and their influence on the definition of the syndrome. Traditional dicotomization of heart failure in systolic and diastolic dysfunction is discussed. Rather than being considered as separate diseases with a distinct pathophysiology, systolic and diastolic heart failure may be merely different clinical presentations within a phenotypic spectrum of one and the same disease. Implications for the definition and diagnosis of heart failure are self evident. In chapter II – The diagnosis of heart failure: problems and foreseeable consequences - we analyse epidemiological, clinical and financial consequences of non consensual definition and diagnostic criteria of heart failure for individual patients, Healthcare Systems and Public Health. Problems resulting from the absence of a universally accepted definition of heart failure are clearly illustrated by current epidemiological data and were revisited in paper 3 – Epidemiology of heart failure. In various epidemiological studies measured prevalence and incidence of the syndrome diverge significantly. This worrying variation is certainly more due to different definitions and used diagnostic criteria than true differences between populations. We faced these difficulties when we had to design the EPICA programme, a large population-based study where we had to define simple, effective and easy to obtain diagnostic criteria of heart failure, for the whole spectrum of the disease, in primary care setting. The problem grew when we focused on heart failure with normal ejection function where diagnostic criteria were far from consensual. Therefore large trials on heart failure with normal ejection fraction and consensual evidence-based Guidelines on diagnosis and treatment of diastolic heart failure are still missing. Paper 4 – Prevalence of heart failure in Portugal - presents the design of the EPICA Programme. The EPICA study was one of the first large epidemiological studies addressing the prevalence of global heart failure, in the community, according to the European Guidelines for the diagnosis of the syndrome. We had to define simple, precise echocardiographic criteria to confirm a suspected diagnosis of heart failure on clinical grounds, in all its spectrum. At that time, Guidelines for heart failure with normal ejection fraction where far from consensual and non applicable to the ambulatory. In paper 5 - Prevalence of heart failure in Southwestern Europe: the EPICA study - we reported the prevalence of heart failure in mainland Portugal. From 5434 attendants of primary care centres, representative of the Portuguese population above 25 years, 551 had heart failure, leading to a prevalence of global heart failure of 4.35%, increasing sharply with age in both genders; 1.36% had systolic dysfunction and 1.7% normal ejection fraction. TESE3 AF 6/9/08 12:25 PM Page 310 Summary 311 In paper 6 – Epidemiology of heart failure in primary care in Madeira: the EPICA-RAM study - we report an overall prevalence of heart failure of 4.69%, with systolic dysfunction in 0.76% and with a normal ejection fraction in 2.74% of the cases. Discrepancies in the prevalence of the different types of heart failure between mainland and Madeira are probably related to different Public Health Care organization. Both studies showed that only half of the patients with a suspected diagnosis of heart failure on clinical grounds had the diagnosis confirmed by objective evidence of cardiac dysfunction. It’s therefore probable that unnecessary drugs were prescribed to patients who didn’t need them while others, who would benefit, were not correctly treated for heart failure. Paper 7 – Diagnosis of heart failure in primary care – is a review of the state of the art of the diagnosis of heart failure in primary care setting. It focused on main challenges faced by primary care physicians, namely difficulties on the access to imaging and strategies to screen for cardiac dysfunction. General practitioners awareness and training on the diagnosis and treatment of the syndrome are crucial to halt the epidemic. But problems on the diagnosis of heart failure are not exclusive of primary care. Heart failure is the first cause of hospitalization of patients above 65 years in medical wards, and accounts for more than 70% of the costs with the syndrome. In paper 9 – Validity of a diagnosis of heart failure: implications of misdiagnosing – we reported a prevalence of heart failure in patients hospitalized in our Medicine Department, during a six month period, of 17%. The diagnosis was actually sub-coded at death /discharge. The accuracy of the death / discharge coded diagnosis was 72.2%; the syndrome was under-diagnosed in 21.1% of the cases and over-diagnosed in 8.3%. The discharge codes failed a significant percentage of heart failure cases, biased the actual burden of the syndrome and compromise the allocation of resources to manage in-hospital heart failure and to develop specialised programmes of interaction with primary care. In paper 8 – Treatment of heart failure in Portuguese hospitals: results of a questionnaire – everybody reported difficulties in the management of heart failure. Heads of Cardiology Wards needed more specialised physicians and nurses as well as specific heart failure units for the management of the syndrome, and Heads of Internal Medicine Wards demand more facilities, easier access to echocardiography, and support from heart failure specialised cardiologists. Difficulties in the diagnosis of heart failure at all levels of care, have huge epidemiological, clinical and economic consequences for the individual patient, National Health Services and Public Health. In chapter III, we revisit the relevance of a complete diagnosis of heart failure. An appraisal based on symptoms alone is clearly an incomplete and inaccurate representation of the severity of cardiovascular disease. Determination of cardiac status requires evaluation of composite etiologic, anatomic, and physiologic diagnoses. Functional class and comorbidities must complement the diagnosis, leading to the more appropriate and individualized treatment. Aware of the uncertainty of the diagnosis of heart failure in primary care setting and of the role of General Practitioners in the management of the syndrome, we have evaluated in pre-specified substudies of the EPICA programme, the accuracy of clinics and tests available to the diagnosis of heart failure in the community. Paper 10 – The diagnosis of heart failure in primary care: value of symptoms and signs – confirmed that symptoms and signs and clinical history have limited value in diagnosing heart failure when used alone. The signs and symptoms that best predicted a diagnosis of heart failure were those associated with more severe disease. Among current symptoms, the history of paroxysmal nocturnal dyspnoea (LR 35.5), orthopnea (LR 39.1) and dyspnoea when walking on the flat (LR 25.8) were associated with a diagnosis of heart failure. However, these symptoms were not frequent within this population (sensitivity < 36%). Jugular pressure > 6 cm with hepatic enlargement, and oedema of the lower limbs (LR 130.3), a ventricular gallop (LR 30.0), a heart rate above 110 bpm (LR 26.7), and rales (LR 23.3), were all associated with a diagnosis of heart failure but TESE3 AF 6/9/08 12:25 PM Page 311 312 Summary were infrequent findings (sensitivity < 10%). Prior use of digoxin (LR 24.9) and/or diuretics (LR 10.6), an history of coronary artery disease (LR 7.1) or of pulmonary oedema (LR 54.2) were also associated with a greater likelihood of having heart failure. In paper 11 – Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy – aetiological features and therapy relevant comorbidities were analysed. Hypertension was the more frequent risk factor/aetiology of heart failure in the community in Portugal (about 80%). Thirty nine percent had an history of coronary artery disease, and 15% had atrial fibrillation. In paper 12 – The value of electrocardiogram and X-ray for confirming or refuting a suspected diagnosis of heart failure in the community – we reported that ECG and X-ray features are not sufficient to allow heart failure to be reliably predicted in the community. Twenty five percent of patients with heart failure had a normal ECG or chest X-ray. In paper 13 – Evaluation of the performance and concordance of clinical questionnaires for heart failure in the primary care – we compared the accuracy of seven clinical questionnaires and scores for the diagnosis of heart failure in the community, and their concordance. Concordance was good between most of the questionnaires. Their low sensibility impairs their usefulness as diagnostic instruments, but their high specificity (>90%) makes them useful for the identification of patients with symptoms and signs from non-cardiac cause. In paper 14 – Epidemiology of heart failure in mainland Portugal: new data from the EPICA study -characteristics of patients with a definite diagnosis of heart failure and of those in whom the diagnosis of heart failure suspected on clinical grounds was excluded (false positive) were compared. The laters were older, more frequently women, had excessive weight, and a history of coronary artery disease was less frequent. Clinics, ECG and chest X-ray could not distinguish patients with heart failure due to systolic dysfunction from those with normal ejection fraction. Considering the limited and costly access to echocardiography in the community we address in paper 15 - the diagnostic challenge of heart failure with preserved systolic function in primary care: an EPICA-RAM substudy. The performance of BNP as a predictor of a diagnosis of heart failure with preserved systolic function according to ESC Guidelines, left ventricular hypertrophy and dilated left atria by echocardiography was tested. BNP was a good predictor of a dilated left atria, but not of the diagnosis of heart failure with preserved systolic function or of left ventricular hypertrophy (AUC: 0.89, 0.56, and 0.54 respectively). We conclude that BNP measurement alone was not a suitable screening test for heart failure with normal ejection fraction in the community, at least in patients with no or mild symptoms.In paper 16 – Comparative value of BNP and NTproBNP on the diagnosis of heart failure – we first established normal values and cut-offs for our laboratory.Then we assess the diagnostic accuracy of both peptides for the in-hospital diagnosis of heart failure due to systolic dysfunction and with normal ejection fraction. BNP and NT-proBNP had an excellent and similar accuracy to the diagnosis of both types of symptomatic heart failure, but none could distinguish patients with systolic heart failure from those with normal ejection fraction. We revisited the role of the various tests on the diagnosis of heart failure with systolic dysfunction, and with normal ejection fraction and discussed the more recent International Guidelines. There is a great piece of evidence that early treatment of asymptomatic left ventricular systolic dysfunction is cost-effective. Therefore, several screening strategies were investigated. ECG and type B natriuretic peptides measurements, alone or as part of clinical scores, allowed cost-effective community-based screening for left ventricular systolic dysfunction, especially in high-risk subjects. A programme including hand-held echocardiography, following NT-proBNP or ECG pre-screening prior to traditional echocardiogram was the most cost-effective.Screening strategies for left ventricular dysfunction proved no more costly than existing screening programmes such as those for cervical or breast cancer. Conversely, as far as we know, there is no proven strategy to efficiently screen for diastolic dysfunction in the community.Finally we discuss perspectives for heart failure TESE3 AF 6/9/08 12:25 PM Page 312 Summary 313 management in the near future. Simple, reliable and consensual diagnostic procedures are crucial to evaluate the actual burden of the disease, to comply with Guidelines and to reduce healthcare utilisation and costs. As the management of the syndrome in primary care has been hampered by perceived difficulties in diagnosis, improving diagnostic skills is essential and remains a continuous challenge for primary care clinicians. Moreover, patients may require more investigations and treatments that may not be available or very familiar to General Practitioners. Shared care is therefore necessary. Disease management programmes when available and accessible, are the preferred choice to address this issue. This multidisciplinary model of care delivered in specialized heart failure clinics, heart failure day hospitals and many other heart failure care stru-ctures, have shown success in improving quality of life, and reducing morbi-mortality and costs. In paper 17 - Translating Guidelines into clinical practice: benefits of an acute heart failure unit - we report a better compliance with Guidelines on diagnosis and treatment of heart failure after the implementation of a specialized heart failure unit in our Internal Medicine Department. We defend the implementation of heart failure programme management networks to provide optimal care for both patients and health care providers. They may consist of different structures to better address the needs of the referred patient, the referral physician and the regional health care system, and should have a crucial role in transition between primary and secondary care. Managing heart failure requires resources across the entire spectrum of care. Strategies to prevent heart failure include both primary and secondary prevention, and should encompass risk factors control and screening strategies for cardiac dysfunction in the community. Screening for high risk patients and, at least, for patients with asymptomatic systolic dysfunction is cost effective. Therefore, to improve heart failure outcomes and halt the epidemic, this will require shared efforts from investigators, clinicians and politicians. Health care strategy with adequate funding are imperative for successfull heart failure management. RSUM: L’insuffisance cardiaque, dj appele d’pidmie du XXIeme sicle, est un problme de Sant Publique partout en Europe. Malgr les immenses progrs faits dans le domaine du traitement, dans les deux dernires dcennies, l’insuffisance cardiaque est parmi les maladies cardiovasculaires la seule dont l’incidence et prvalence ne cessent d’augmenter. Ses principales caractristiques sont une mortalit trs leve -suprieure celle de l’ensemble des cancers - et un impact conomique considrable sur les Systmes de Sant. La prise en charge des insuffisants cardiaques doit ainsi tre envisage comme une priorit absolue. Toutefois, et bien que la svrit de la situation soit universellement reconnue, Gouvernements et Systmes de Sant n’ont pris que trs peu de mesures concrtes, visant freiner l’pidmie qui ne cesse de crotre. Nous pouvons aujourd’hui prvenir et, sinon gurir l’insuffisance cardiaque, du moins la traiter de faon freiner la progression de la maladie, ainsi nous soyons capables de faire le diagnostique temps. Toute attitude traputique prsume un diagnostique prcoce et complet de la situation, sans lequel nulle attitude correcte ne pourra tre prise. OBJECTIFS: Nous nous proposons analyser les problmes du diagnostique de l’insuffisance cardiaque, la lumire des connaissances actuelles et de notre propre exprience. Parmi les objectifs de ce travail, nous avons valu la faon d’ont l’volution des concepts d’insuffisance et de dysfonction cardiaque a influenc la dfinition et les critres de diagnostique, au cours des temps, et les consquences du manque de consensus quant la dfinition et aux critres de diagnostique pour les diffrentes phases d’volution de la maladie. Nous avons discut le rle des symptmes, signaux et examens complmentaires dans le diagnostique de l'insuffisance cardiaque et dans les stratgies de screening de la dysfonction cardaque. Finalement nous avons discut quelques chemins et possibles stratgies envisager pour la prise en charge de ces malades pour que, dans un future proche, nous soyons capables de mieux les traiter, mais aussi de mieux prvenir la maladie de faon freiner l’pidmie. MTHODOLOGIE: La mthodologie utilise pour ce travail drive directement de l’exprience acquise dans la prise en charge des malades, et de l’investigation gre par les difficults perues quant au diagnostique de l’insuffisance cardiaque, au long des annes. Quand de l’laboration de l’tude EPICA ne de la ncessit d’obtenir des donnes pidmiologiques nationales en ce qui concerne l’insuffisance cardiaque au Portugal, nous avons conu, selon un dessin original, un protocole d’investigation qui nous a permis d’valuer la qualit du diagnostique de l’insuffisance cardiaque ralis par les mdecins de famille ainsi que le rle des symptmes, des signaux, des donnes de l´histoire clinique, de l’lectrocardiogramme e de la radiographie du thorax, dans le diagnostique de l’ insuffisance dans l’ambulatoire. Nous avons aussi investigu la qualit du diagnostique tabli pendant l’hospitalisation. Nous avons dtermin la relle prvalence de l’insuffisance cardaque hospitalise dans notre service au long de six mois et celle qui a t codifie au moment de la sortie de l´hpital. Nous avons encore compar la qualit do diagnostique avant et aprs l’ouverture d’une unit d’insuffisance cardiaque et la performance des diffrents peptides natriurtiques dans le diagnostique du syndrome. Sous la forme de rponse un questionnaire, qui leur a t adress par le Groupe de Travail d’insuffisance cardiaque de la Socit Portugaise de Cardiologie, sur la prise en charge de l’insuffisance cardiaque, les Directeurs des Services de Cardiologie et Mdicine Interne de tout le Pays se sont prononcs sur leurs difficults, en ce qui concerne le diagnostique et le traitement de l’insuffisance cardiaque. Les rsultats des investigations partielles ont t communiqus la communaut scientifique et publis dans les journaux de la spcialit, au long de ces dernires annes. Cette dissertation est constitue par les papiers publis et en publication auxquels nous avons additionn une rvision de l’tat actuel de l’art du diagnostique de l’insuffisance cardiaque, ainsi q’une rflexion sur les 317 TESE3 AF 6/9/08 12:25 PM Page 317 318 Rsum consquences des difficults prouves au diagnostique de la maladie et sur la manire d’amliorer la prise en charge de l’insuffisance cardiaque.RSULTATS: En 1982, l’hors de notre dbut d’activit, nous avons eu trs tt la perception de la complexit de l’insuffisance cardiaque et du dfi que constituait, pour les cliniciens, la prise en charge de ces malades. Nous avons particip au dveloppement d’une classification physiopathologique originale qui a servi de base pour le doctorat de la Professeur Ftima Ceia en 1989. L’article 1 – Insuffisance cardiaque : nouveaux concepts physiopathologiques et leurs applications thrapeutiques – publi en 1984, nous dcrivons dj l’insuffisance cardiaque comme une maladie systmique, rsultat de l’interaction des diffrents mcanismes de compensation de la dysfonction cardiaque. Nous proposons « une classification physiopathologique avec application thrapeutique » originale, o nous dfinissons les diffrents types d’insuffisance cardiaque et leurs caractristiques cliniques, hmodynamiques, fonctionnelles et anatomiques et proposons un traitement individualis d’accord avec la dfinition et le diagnostique de chacun de ces diffrents types d’insuffisance cardiaque. En 1994, l’article 2 – L’insuffisance cardiaque et le clinicien la fin du XXme sicle – fait une description dtaille de comment les diffrents mcanismes de compensation interagissent, influencent l’volution de la maladie, produisent les diffrents syndromes et justifient le choix du type de traitement. Nous discutons l’volution de la dfinition de la maladie d’accord avec l’volution de l’investigation et une meilleure connaissance de la physiopathologie de la dysfonction cardiaque. Nous soulignons la ncessit du diagnostique et du traitement prcoces et quant urgent il est de dvelopper des stratgies capables de prvenir la maladie. Les investigateurs dfendent aussi l’existence d’un continu entre l’insuffisance cardiaque fraction d’jection normale e celle qui s’accompagne de dysfonction systolique ventriculaire. Ce concept dfend l’existence de plusieurs syndromes d’insuffisance cardiaque qui ne reprsenteront que des phnotypes diffrents d’une mme maladie. Des nouvelles Recommandations pour le diagnostique et exclusion de l’insuffisance cardiaque fraction d’jection normale / dysfonction diastolique surgissent. Nous revisitons ces nouveaux concepts dans le chapitre: L’insuffisance cardiaque: de la physiopathologie la clinique - un modle en constante volution. Au chapitre II – Le diagnostique de l’insuffisance cardiaque: problmes et consquences prvisibles - nous analysons les consquences du manque de critres de diagnostique consensuels pour l’insuffisance cardiaque au long de tout son spectre. Les difficults avec le diagnostique se rpercutent sur les rsultats des grandes tudes pidmiologiques. Nous avons senti cette difficult quand, lors de l’laboration du programme EPICA – Pidmiologie de l’Insuffisance Cardiaque et Apprentissage - nous avons voulu dfinir les critres pour le diagnostique de l’insuffisance cardiaque de tous les types, applicables l’ambulatoire et d’accord avec les Recommandations Internationales. L’article 3 - pidmiologie de l’insuffisance cardiaque – analyse les consquences des diffrentes dfinitions et critres de diagnostique utiliss dans les grandes tudes pidmiologiques qui, au long des annes, ont publi des prvalences et incidences trs variables de l’insuffisance cardiaque. Ce problme s’aggrave encore quand il s’agit de l’pidmiologie de l’insuffisance cardiaque fraction d’jection normale ou dysfonction diastolique, ou des stratgies pour le screening de la dysfonction cardiaque asymptomatique, situations dfinitions et critres encore moins consensuels. L’inexistence de Recommandations appuyes sur l’vidence, pour le traitement de l’insufisance cardiaque fraction d’jection normale ou dysfonction diastolique, est une autre des consquences de ces difficults. C’est ainsi que des diffrences de mthodologie, de dfinitions et de critres de diagnostique, plutt que des diffrences relles entre les populations, difficultent notre connaissance quant la relle surcharge que l’insuffisance cardiaque et la dysfonction cardiaque imposent au Systme National de Sant. Il est ainsi difficile de prvoir les recours ncessaires, attribuer une situation qui est mal connue. L’ article 4 – Prvalence de l’insuffisance cardiaque au Portugal – prsente le dessin des tudes EPICA et EPICA-RAM. EPICA a t l’une des premires tudes TESE3 AF 6/9/08 12:25 PM Page 318 Rsum 319 valuer la prvalence de l’insuffisance cardiaque symptomatique globale, de l’ambulatoire, suivant les Recommandations de la Socit Europenne de Cardiologie pour le diagnostique de l’insuffisance cardiaque. Nous y dfinissons des critres echocardiographiques prcis pour tous les types d’insuffisance cardiaque, notamment celle fraction d’jection normale, alors qu’ l’poque il n’y avait pas encore de Recommandations consensuelles pour le diagnostic de cette situation. L’article 5 – Prevalence of chronic heart failure in Southwestern Europe : the EPICA study - relate la prvalence de l’insuffisance cardiaque au Portugal continental en 1998. Dans une population de 5434 individus gs de plus 25 ans, reprsentative de la population portugaise nous avons identifi 551 cas d’insuffisance cardiaque, correspondant une prvalence de 4,3%, qui augmente avec l´ge, chez les deux genres ; chez 1,3% la dysfonction ventriculaire est systolique, alors que 1,75% ont une fraction d’jection normale. L’article 6 – Epidemiology of chronic heart failure in Primary Care in the Autonomic Region of Madeira: the EPICA-RAM study – a suivi le mme protocole d’investigation et relate une prvalence de l’insuffisance cardiaque globale de 4,69%, 0,76 % dysfonction ventriculaire systolique et 2,74% fraction d’jection normale. Ces deux tudes confirment que quand le diagnostique est suspect par la clinique il ne se confirme objectivement qu’en la moiti des cas, ce qui fait supposer que beaucoup de malades seront sous mdication inapproprie pour l’insuffisance cardiaque alors que d’autres, qui auraient tout intrt la faire, en seront probablement privs. L’article 7 – Diagnosis of chronic heart failure in Primary Care - revoit l’tat de l’art quant au diagnostique de l’insuffisance cardiaque dans la communaut et discute les principaux dfis auxquels les mdecins de famille sont soumis, notamment les difficults d’accs aux examens complmentaires de diagnostique et le screening de la dysfonction cardiaque asymptomatique dans la population en gnral. Mais les problmes de diagnostique de l’insuffisance cardiaque, se posent transversalement tous les niveaux, l’hpital comme chez le mdecin de famille. Bien que l’insuffisance cardiaque soit la premire cause d’hospitalisation aprs les 65 ans, responsable pour la plupart des cots consomms par le syndrome, le diagnostique y est sous-estim. L’article 9 – Validity of a diagnosis of heart failure : implications of misdiagnosing – dmontre que l’insuffisance cardiaque a t la premire cause d’hospitalisation dans notre service, pendant une priode de six mois, ayant une prvalence de 17% et a t largement sous codifie. La sous codification du diagnostique ne fait que diminuer le vrai poids du syndrome, menant l’allocation incorrecte de recours pour la prise en charge de l’insuffisance cardiaque l´hpital et pour l’tablissement de programmes capables de faire l’indispensable interface avec l’ambulatoire. En rponse au questionnaire sur la prise en charge de l’insuffisance cardiaque, que nous rsumons dans l’article 8 – Traitement de l’insuffisance cardiaque dans les hpitaux portugais : rsultats d’un questionnaire - les Directeurs des Services de Mdicine Interne ont relat leurs difficults d’accs l’chocardiographie en temps utile et rclam plus de collaboration du cardiologue; les Directeurs des Services de Cardiologie demandent plus de spcialistes et de structures vocationnes pour le diagnostique et traitement de l’insuffisance cardiaque. Les difficults poses par le diagnostique de l’insuffisance cardiaque tous les niveaux de soins, entranent des consquences pidmiologiques, socioconomiques et financires nfastes pour le patient, la planification du Systme National de Sant et la Sant Publique. Au chapitre III nous rappelons l’importance du diagnostique complet de l’insuffisance cardiaque. Au diagnostique anatomique, fonctionnel et du syndrome, il faut absolument joindre l’tiologie, la classe fonctionnelle e les comorbidits qui conditionnent souvent l’interprtation des testes de diagnostique, le traitement et le pronostique. Conscients des difficults prouves para les mdecins de famille, pour diagnostiquer correctement et en temps utile l’insuffisance cardiaque dans l’ambulatoire, et du rle de ces Spcialistes en ce qui concerne la contention de l’pidmie, nous nous sommes proposs, comme objectifs secondaires de l’tude EPICA,d’investiguer la performance des instruments de diagnostique disponibles et porte de ces cliniciens. L’article 10 – The diagnosis of heart failure in primary TESE3 AF 6/9/08 12:25 PM Page 319 320 Rsum care: value of symptoms and signs – documente les limitations des symptmes, signaux et des donnes cliniques, quand utiliss de forme isole, pour le diagnostique de l’insuffisance cardiaque. Ils sont tous peu sensibles et ceux qui ont la plus grande valeur prdictive sont ceux qui s’associent aux formes congestives, plus graves, de la maladie: la dyspne paroxysmale nocturne (LR 35,5), l’orthopne (LR 39,1), la difficult respiratoire pendant la marche en plan horizontal (LR 25,8), l’ ingurgitation jugulaire > 6 cm accompagne d’ hpatomgalie e d’oedme des membres infrieurs (LR 130,3), le galop ventriculaire (LR 30,0), la tachycardie >110ppm (LR 26,7) et les crpitations pulmonaires (LR 23,3) sont ainsi associs au diagnostique, mais sont trs peu frquents chez les insuffisants cardiaques tout venant de l’ambulatoire. Un traitement antrieur avec du diurtique (LR 10,6) ou de la digoxine (LR 24,9), ou encore un pisode antrieur d’odeme pulmonaire aigu (LR 54,2), sont d’autres prdicteurs du diagnostique. L’article 11 – Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy – confirme que l´hypertension artrielle est, d’entre tous les facteurs de risque, la principale tiologie de l’insuffisance cardiaque dans l’ambulatoire au Portugal (80%). Trente neuf pourcent des malades inclus dans l’tude EPICA avaient une histoire de maladie coronarienne et 15% de fibrillation auriculaire. Nous avons encore analys la comorbidit et son influence sur la prescription, en sachant que la prescription des mdicaments recommands pour l’insuffisance cardiaque est, au Portugal comme d’une forme gnrale en Europe, bien infrieur au dsirable. L’article 12 - The value X- ray for confirming or refuting a suspected diagnosis of heart failure in the community – dmontre que les donnes de l’lectrocardiogramme e de la radiographie du thorax, par sois mme, ne prdisent pas correctement le diagnostique de l’insuffisance cardiaque dans l’ambulatoire; 25% des insuffisants cardiaques inclus dans EPICA avaient un lectrocardiogramme o une radiographie du thorax normal. Al’article 13 - Evaluation of the performance and concordance of clinical questionnaires for heart failure in primary care – nous avons compar sept questionnaires ou scores cliniques habituellement utiliss pour le diagnostique de l’insuffisance cardiaque dans les grandes tudes pidmiologiques et de mdicaments. Ils ont dmontr avoir une concordance peine raisonnable bonne entre eux, et tre trs spcifiques (>90%) pour le diagnostique mais peu sensibles. Ils augmentent la probabilit du diagnostique de 4,3% prtest vers 25 30% post-test et se rvlent ainsi des instruments plus utiles dans l’exclusion d’une cause cardiaque pour les symptmes que pour le diagnostique de l’insuffisance cardiaque. L’article 14 – pidmiologie de l’insuffisance cardiaque au Portugal continental : nouvelles donnes de l’tude EPICA – compare les caractristiques des malades qui, ayant une clinique compatible avec le syndrome, ont t inclus dans EPICA mais n’avaient pas de dysfonction cardiaque objective (faux positifs), avec ceux qui ont eu leur diagnostique objectivement confirm. Les premiers taient plus gs, il y avait plus de femmes, plus de poids excessif, moins de maladie coronarienne. L’investigation confirme encore que les donnes de l’lectrocardiogramme e de la radiographie du torax ne distinguent pas les insuffisants cardiaques qui ont une dysfonction systolique ventriculaire de ceux qui ont une fraction d’jection normale. Face au dfi du diagnostique de l’insuffisance cardiaque fraction d’jection normale, aux difficults d’accs l’chocardiographie dans l’ambulatoire, au prix de l’examen et aux critres encore peu consensuels pour le diagnostique de cette situation, nous avons analys et publi l’article 15 – The diagnostic challenge of heart failure with preserved systolic function in primary care setting: an EPICA-RAM substudy - la valeur des peptides natriurtiques du type B, NTproBNP, comme test de triage des malades qui, parmi ceux qui prsentent une clinique compatible avec le syndrome, devront confirmer objectivement le diagnostique par chocardiographie. Ainsi, nous avons valu la performance du test comme prdicteur : du diagnostique d’insuffisance cardiaque fraction d’jection normale, selon les Recommandations internationales, d’hypertrophie ventriculaire gauche et de dilatation de l’auricule gauche. Le NT-proBNP n’ t bon prdicteur que de ce dernier paramtre, ce qui nous fait conclure que le test ne permet pas de trier les malades de faon diminuer les ncessits d’chocardiographie face une hypothse clinique d’insuffisance cardiaque, du moins en ce qui concerne les cas peu volus, frquemment asymptomatiques, de TESE3 AF 6/9/08 12:25 PM Page 320 Rsum 321 l’ambulatoire. Nous avons aussi compar la performance des peptides natriurtiques du type B - BNP et NT-proBNP – quant au diagnostique de l’insuffisance cardiaque symptomatique dysfonction ventriculaire systolique et fraction d’jection normale, traite l’hpital. Les rsultats de cette investigation sont rvls dans l’article 16 – Comparative value of BNP and NT-proBNP for the diagnosis of heart failure. Les deux tests ont dmontr une performance excelente et comparable dans le diagnostique du syndrome, mais aucun n’a t capable de distinguer les deux types d’insuffisance cardiaque. Nous avons revu et discut l’tat de l’art quant au rle des diffrents examens complmentaires, notamment des peptides natriurtiques et de l’chocardiographie, dans le diagnostique des diffrents types d’insuffisance et de dysfonction cardiaque, ainsi que les toutes dernires Recommandations internationales. Nous avons analys les stratgies proposes pour le screening de la dysfonction ventriculaire asymptomatique, qui est au moins aussi frquente dans l’ambulatoire que l’insuffisance cardiaque symptomatique. Par ailleurs, l’vidence montre que le traitement prcoce de la dysfonction ventriculaire asymptomatique, est efficace et diminue les cots. Le gold standard pour le screening de la dysfonction ventriculaire imposerait la ralisation d’un chocardiogramme toute la population, ce qui est incomportable. Plusieurs stratgies ont t investigues, ces dernires annes, la recherche de celle qui sera la plus efficace tout en pargnant le plus possible. Tous affirment que aucun examen isol ne pourra tre suffisant pour ce screening. Par contre, l’lectrocardiogramme et/ou les peptides natriurtiques, incorpors ou non en scores cliniques, sont souvent voqus comme testes efficaces pour le pr-screening des patients envoyer l’chocardiographie. Son utilisation diminue le nombre ’chocardiogrammes ncessaires et la dpense, tout en tant au moins aussi efficace que le screening du cancer du sein ou du colle de l’utrus, exige un investissement qui n’est en rien suprieur. Quelques auteurs ont dmontr que l'excution d’un chocardiogramme qualitatif, fait avec un chocardiographe portable, aprs l’ECG ou la dtermination du BNP/ NT-proBNP et avant l’chocardiogramme complet, amliore encore la stratgie pour le screening de la dysfonction cardiaque. Finalement nous terminons avec quelques commentaires concernant les perspectives futures pour la prise en charge de l’insuffisanc e cardiaque. Il est absolument urgent et primordial d’tablir d’une dfinition prcise et universelle, ainsi que de critres de diagnostique objectifs, simples et reproductibles, applicables tout le spectre de l’insuffisance cardiaque, de faon ce que, dans un futur proche, nous soyons capables de connatre le vritable poids de l’insuffisance cardiaque, d’organiser une prise en charge le plus efficace possible tout en respectant l’invitable contention des dpenses publiques. Les problmes de diagnostique de l’ambulatoire exigent que les mdecins de famille disposent de programmes de formation continus et que le dialogue avec l’hpital et les spcialistes soit facilit, tel que nous l’avons fait, de forme programme, systmatiquement,pendant le programme EPICA. Les cliniques d’insuffisance cardiaque et les programmes structurs de prise en charge de l’insuffisance cardiaque ont dmontr leur efficacit. Ils permettent une meilleure implmentation des Recommandations de diagnstique et traitement, amliorent la qualit de vie et la survie des insuffisants cardiaques qui y sont suivis. Dans l’article 17 - Translating Guidelines into clinical practice : benefits of an acute heart failure unit - nous rendons compte de notre exprience en ce qui concerne les gains obtenus quant au diagnostic et traitement des insuffisants cardiaques hospitaliss dans notre service avant et aprs l’ouverture d’une unit d’insuffisance cardiaque et qui nous a permi d’amelliorer la qualit des soins prts ces malades. Nous dfendons que ces units spcialement vocationnes pour la prise en charge de l’insuffisance cardiaque doivent se multiplier, s’intgrer en programmes plus vastes d’organisation de soins prter aux insuffisants cardiaques, qui incluent notamment l´hpital de jour et adopter des structures variables d’accord avec les ncessits des populations qu’elles servent. Ces programmes de prise en charge de l’insuffisance cardiaque pourront assumer un rle dterminant dans la formation scientifique des mdecins, spcialement des mdecins de famille, dans l’interface entre les soins primaires et l’hpital et dans la rfrentiation des insuffisants cardiaques. Tous les efforts pour identifier et corriger prcocement les facteurs de risque cardiovasculaire et dvelopper TESE3 AF 6/9/08 12:25 PM Page 321 Rsum des stratgies pour le screening de la dysfonction cardiaque doivent tre multiplis comme stratgies de prvention. Tout cela est possible, efficace un pris semblable celui d’autres programmes dj en cours, mais exige la collaboration de tous, population, professionnels de sant, investigateurs et pouvoir politique qui viabilise l’valuation des ncessits, le montage de ces programmes multidisciplinaires, et en contrle la qualit, de faon ce que trs vite nous puissions contrler cette pidmie.
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Esta apresentao decorre do projecto realizado pela equipa: Helena Rato, Csar Madureira, David Ferraz e Margarida Quintela Martins
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La estrategia bsica para el desarrollo de programas de lucha contra la hidatidosis es en la actualidad la de atencin primaria de la salud. En el presente trabajo, y en ese marco, se instrumenta un sistema de deteccin precoz de la hidatidosis basado en el diagnstico inmunolgico mediante la tcnica de Elisa, a partir de muestras de sangre capilar tomadas en papel de filtro por maestras y agentes sanitarios de los servicios oficiales de la provincia de Rio Negro. Fueron entrenadas 177 maestras y 45 agentes sanitarios correspondientes a 25 escuelas, 3 albergues y 9 hospitales, todos del medio rural. Se obtuvieron 890 muestras de sangre durante el entrenamiento. Posteriormente el personal entrenado instrument el sistema obteniendo 728 muestras al inicio del programa. No hubo diferencias estadsticas en la reactividad de ambas muestras. La prevalencia serolgica hallada fue del 1.32%. La actividad desplegada por maestras y agentes sanitarios permiti detectar 21 casos nuevos, lo cual constituy el 20% de los casos nuevos diagnosticados en el rea en el perodo de trabajo. Se discute la viabilidad y la importancia de la incorporacin de efectores no tradicionales en los Programas de Control de la Hidatidosis.
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Mestre em Engenharia Civil - Especializao em Estruturas
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Mestrado em Engenharia Mecnica – Ramo Energia
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Resumo Onicomicose ou infeco fngica das unhas das mos ou dos ps pode ser provocada por fungos que invadem primariamente a lmina ungueal saudvel. Embora existam outros agentes, como por exemplo bactrias, que podem causar infeces ungueais, as infeces causadas por fungos so mais frequentes e so consideradas uma das principais onicopatias do homem. Os efeitos psicolgicos e emocionais que resultam dos aspectos clnicos da onicomicose podem ser marcantes e ter um impacto significativo na qualidade de vida dos portadores. uma doena com grande potencial crnico associada a uma sria dificuldade teraputica, sendo estes os principais factores agravantes do seu prognstico. Conforme a extenso do comprometimento e a poro da unha envolvida na onicomicose, a infeco causada por fungos pode ser classificada em 5 tipos: onicomicose subungueal distal e lateral, onicomicose superficial leitosa, onicomicose subungueal proximal, onicomicose com distrofia total e onicomicose por candidose. So causadas por diferentes agentes etiolgicos sendo que os mais comuns so os fungos dermatfitos (80 a 90%), seguidos pelas leveduras (5 a 17%) e fungos filamentosos no dermatfitos (2 a 12%). Neste trabalho foram estudadas 54 amostras recolhidas de unhas de doentes com hiptese clnica de onicomicose, das quais 25,93% (14/54) pertenciam a indivduos do sexo masculino e 74,07% (40/54) a indivduos do sexo feminino. As tcnicas convencionais de diagnstico so morosas e muitas vezes de difcil caracterizao a nvel fenotipico, o que condiciona grandemente a implementao da teraputica adequada. O presente trabalho teve como principal objectivo a aquisio de conhecimentos que permitissem um correcto diagnstico micolgico das onicomicoses, atravs do isolamento e identificao das espcies de fungos causadoras de infeco. De uma forma global, consistiu inicialmente no isolamento e posteriormente na identificao dos agentes etiolgicos de onicomicoses, utilizando para tal metodologias convencionais e moleculares. Foi realizado o diagnstico laboratorial baseado no exame directo e na cultura de fragmentos de unhas provenientes de doentes com infeco. Paralelamente, foi extrado o DNA fngico das mesmas amostras clnicas que, aps amplificao da regio ITS dos genes ribossmicos foi utilizado para confirmao e comparao dos resultados. Foi igualmente estudada a ocorrncia de fungos no dermatfitos responsveis por onicomicose. Os mtodos moleculares de diagnstico podem no s constituir uma alternativa mais rpida de diagnstico micolgico como tambm, por serem mais sensveis, permitir a deteco de espcies que, por serem de crescimento fastidioso, no se desenvolvem em cultura.
