Percutaneous Transatrial Access to the Pericardial Space for Epicardial Mapping and Ablation

Background-Puncture of the atrial appendage may provide access to the pericardial space. The aim of this study was to evaluate the feasibility of epicardial mapping and ablation through an endocardial transatrial access in a swine model. Methods and Results-An 8-F Mullins sheath was used to perforate the right (n=16) or left (n=1) atrial appendage in 17 pigs (median weight, 27.5 kg; first and third quartiles [Q1, Q3], 25.2, 30.0 kg). A 7-F ablation catheter was introduced into the pericardial space to perform epicardial mapping and deliver radiofrequency pulses on the atria. The pericardial space was entered in all 17 animals. In 15 (88%) animals, there was no hemodynamic instability (mean blood pressure monitoring, initial median, 80 mm Hg; Q1, Q3, 70, 86 mm Hg; final median, 88 mm Hg; Q1, Q3, 80, 96 mm Hg; P=0.426). In these 15, a mild hemorrhagic pericardial effusion was identified and aspirated (median, 20 mL; Q1, Q3, 15, 30 mL) during the procedure, and postmortem gross analysis revealed that the atrial perforation was closed in these animals. In 2 (12%) of the 17 animals, there was major pericardial bleeding with hemodynamic collapse. On gross examination, it was found that pericardial space was accessed through right ventricular perforation in 1 animal and the tricuspid annulus in the other. After the initial study, we used an occlusion device in 3 other animals to attempt to seal the puncture (2 at the right atrial appendage and 1 at the right ventricle). These 3 animals had no significant pericardial bleeding. Conclusions-Transatrial endovascular right atrial appendage puncture may provide a potential alternative route for pericardial access. Further studies are needed to evaluate its safety with longer and more-complex procedures before being applied in clinical settings. (Circ Arrhythm Electrophysiol. 2011;4:331-336.)

Autologous Hematopoietic Stem Cell Transplantation for Type 1 Diabetes

In this review, we present (1) the scientific basis for the use of high-dose immunosuppression followed by autologous peripheral blood hematopoietic stem cell transplantation for newly diagnosed type 1 diabetes (T1D); (2) an update of the clinical and laboratory outcome of 20 patients transplanted at the University Hospital of the Ribeirao Preto Medical School, University of Sao Paulo, Brazil, and followed up to January/2008, including 4 relapses among 19 patients without previous ketoacidosis; (3) a commentary on criticisms to our article that appeared in four articles from the scientific literature; and (4) a discussion of the prospectives for cellular therapy for T1D.

Temporal evolution of epithelial, vascular and interstitial lung injury in an experimental model of idiopathic pulmonary fibrosis induced by butyl-hydroxytoluene

This study was undertaken to test whether the structural remodelling of pulmonary parenchyma can be sequentially altered in a model and method that demonstrate the progression of the disease and result in remodelling within the lungs that is typical of idiopathic pulmonary fibrosis. Three groups of mice were studied: (i) animals that received 3-5-di-tert-butyl-4-hydroxytoluene (BHT) and were killed after 2 weeks (early BHT = 9); (ii) animals that received BHT and were killed after 4 weeks (late BHT = 11); (iii) animals that received corn oil solution (control = 10). The mice were placed in a ventilated Plexiglas chamber with a mixture of pure humidified oxygen and compressed air. Lung histological sections underwent haematoxylin-eosin, immunohistochemistry (epithelial, endothelial and immune cells) and specific staining (collagen/elastic fibres) methods for morphometric analysis. When compared with the control group, early BHT and late BHT groups showed significant decrease of type II pneumocytes, lower vascular density in both and higher endothelial activity. CD4 was increased in late BHT compared with early and control groups, while CD8, macrophage and neutrophil cells were more prominent only in early BHT. The collagenous fibre density were significantly higher only in late BHT, whereas elastic fibre content in late BHT was lower than that in control group. We conclude that the BHT experimental model is pathologically very similar to human usual interstitial pneumonia. This feature is important in the identification of animal models of idiopathic pulmonary fibrosis that can accurately reflect the pathogenesis and progression of the human disease.

Assessing clinical reasoning: a method to monitor its development in a PBL curriculum

The aim of this study was to develop and trial a method to monitor the evolution of clinical reasoning in a PBL curriculum that is suitable for use in a large medical school. Termed Clinical Reasoning Problems (CRPs), it is based on the notion that clinical reasoning is dependent on the identification and correct interpretation of certain critical clinical features. Each problem consists of a clinical scenario comprising presentation, history and physical examination. Based on this information, subjects are asked to nominate the two most likely diagnoses and to list the clinical features that they considered in formulating their diagnoses, indicating whether these features supported or opposed the nominated diagnoses. Students at different levels of medical training completed a set of 10 CRPs as well as the Diagnostic Thinking Inventory, a self-reporting questionnaire designed to assess reasoning style. Responses were scored against those of a reference group of general practitioners. Results indicate that the CRPs are an easily administered, reliable and valid assessment of clinical reasoning, able to successfully monitor its development throughout medical training. Consequently, they can be employed to assess clinical reasoning skill in individual students and to evaluate the success of undergraduate medical schools in providing effective tuition in clinical reasoning.

Avaliação dos níveis de atividade física e capacidade aeróbia estimada em estudantes universitários

Mestrado em Fisioterapia

Inquérito sorológico da prevalência de infecção chagásica no Brasil, 1975/1980

A nationwide seroepidemiologic survey of human T. cruzi infection was carried out in Brazil from 1975 to 1980 as a joint programme of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and the Superintendência de Campanhas (SUGAM), Ministry of Health, of Brazil. Due to the marked heterogeneity of urban populations as result of wide migratory movements in the country and since triatomine transmission of the disease occurs mostly in rural areas, the survey was limited to rural populations. The survey was based on a large cluster sampling of complete households, from randomly selected localities comprised of 10 to 500 houses, or up to 200 houses in the Amazon region. Random selection of localities and houses was permitted by a detailed mapping of every locality in the country, as performed and continuously adjusted, by SUCAM. In the selected houses duplicate samples on filter paper were collected from every resistent 1 year or older. Samples were tested in one of 14 laboratories scattered in the country by the indirect anti-IgG immunofluorescence test, with reagents produced and standardized by a central laboratory located at the Instituto de Medicina Tropical de São Paulo. A continuous quality control was performed at this laboratory, which tested duplicates of 10% to 15% of all samples examined by the collaborating laboratories. Data regarding number of sera collected, patients'age, sex, place of residence, place of birth and test result were computerized at the Department of Preventive Medicine, Medical School, University of São Paulo, São Paulo, Brazil. Serologic prevalence indices were estimated for each Municipality and mapped according to States and Territories in Brazil. Since data were already available for the State of São Paulo and the Federal District, these unities were not included in the survey.

Papel do tutor num currículo médico pré-graduado que utilize a aprendizagem por problemas

Educação Médica, 1993; 4(3): 169-173.

Cytomegalovirus and other herpesviruses infections in heart and bone marrow transplant recipients

From January 1988 to January 1989 all the heart transplant and bone marrow recipients at the Instituto do Coração of the Hospital das Clínicas of the University of São Paulo Medical School were studied for the incidence and morbidity associated with herpesviruses infections after transplantation. Five bone marrow and 5 heart transplant recipients were followed for a mean of 4.2 months post-transplantation. All the patients were seropositive for cytomegalovirus (CMV) before admission and 80% experienced one or more recurrences during the observation period. Of the 12 episodes of CMV infection, that were identified in this study, 83% were accompanied by clinical or laboratory abnormalities. However, there was only one case of severe disease. The overall incidence of infection for herpes simplex (HSV) was 50%. Although most of HSV reactivations were oral or genital, one case of HSV hepatitis occurred. One of the 6 episodes of HSV infections that were treated with acyclovir showed an unsatisfactory response and was successfully managed with ganciclovir. All the individuals had anti-varicella zoster virus antibodies, but none of them developed infection. The study emphasizes the importance of active diagnostic surveillance of herpesvirus infections in transplant patients. Both CMV and HSV reactivations showed high incidence and important morbidity and thus, deserve prophylactic therapy.

Evaluation of Helicobacter pylory colonization by serologic test (IgG) and dyspepsia in volunteers from the countryside of Monte Negro, in the Brazilian western Amazon region

The present study intended to analyze the seroprevalence of Helicobacter pylori, IgG, and its relation to dyspepsia in a population from the western Amazon region. During the "Projeto Bandeira Científica", a University of São Paulo Medical School program, in Monte Negro's rural areas, state of Rondônia, 266 blood samples were collected from volunteers. The material was tested for IgG antibodies anti-Helicobacter pylori by ELISA method and the participants were also interviewed on dyspepsia, hygiene and social aspects. Participants aged between five and 81 years old (34 years on average), 149 (56%) were female and 117 (44%) male. We found 210 (78.9%) positive, 50 (18.8%) negative and six (2.3%) undetermined samples. Dyspeptic complaints were found in 226 cases (85.2%). There was no statistical association between dyspepsia and positive serology for H. pylori. We concluded that the seroprevalence in all age categories is similar to results found in other studies conducted in developing countries, including those from Brazil. On the other hand, the seroprevalence found in Monte Negro was higher than that reported in developed countries. As expected, there was a progressive increase in the positivity for H. pylori in older age groups.

HPV : devem os rapazes ser vacinados?

RESUMO - A infecção por Vírus do Papiloma Humano (Human Papillomavirus - HPV) é uma das doenças de transmissão sexual mais frequentes em todo o mundo. A descoberta de que esta infecção é responsável pelo carcinoma do colo do útero impulsionou o desenvolvimento de vacinas contra o HPV. Em Portugal, a vacina tetravalente contra o HPV faz parte do Plano Nacional de Vacinação, sendo administrada apenas a raparigas aos 13 anos de idade como medida profiláctica do carcinoma do colo do útero. Nos Estados Unidos da América, em Dezembro de 2010, a Food and Drugs Administration (FDA) aprovou o uso da vacina tetravalente na prevenção de lesões pré-cancerígenas e cancerígenas do ânus, tanto em rapazes como em raparigas, dos 9 aos 26 anos. A 25 de Outubro de 2011, o Advisory Committee on Immunization Practices (ACIP) recomendou que todos os rapazes de 11 e 12 anos sejam vacinados contra o HPV com a vacina tetravalente. Partindo desta realidade, o que se pretende com o presente trabalho é compilar evidência científica suficiente que permita ponderar mais aprofundadamente acerca das implicações, a partir de dados epidemiológicos e económicos, de se vacinar ou não os rapazes contra o HPV em Portugal. Em primeiro lugar recolheu-se evidência científica acerca da relação entre a infecção por HPV e o desenvolvimento de carcinomas de diversas regiões anatómicas. Em segundo lugar compilaram-se dados epidemiológicos sobre a incidência e sobrevivência associada aos diferentes tipos de tumores potencialmente associados à infecção por HPV, dando especial ênfase à realidade portuguesa. Em terceiro lugar enquadrou-se sucintamente a história da vacinação contra o HPV em Portugal e as vacinas existentes para prevenir esta infecção. Em quarto lugar foram revistos estudos de avaliação económica da vacinação contra o HPV quer em mulheres quer em homens, após uma introdução ao conceito de avaliação económica do medicamento. Em quinto lugar, foi feita uma estimativa dos custos com a vacinação dos rapazes contra o HPV durante os próximos 20 anos. Por último, procurou-se reflectir acerca das implicações de se alargar ou não a vacinação contra o HPV aos rapazes em Portugal.

Africanized honeybee stings: how to treat them

INTRODUCTION: In 1956, Africanized honeybees (AHB) migrated from Brazil to other regions of the Western Hemisphere, including South, Central, and North America, except for Canada. Despite being productive, they are highly aggressive and cause fatal accidents. This study aimed to evaluate patients at the Clinical Hospital of Botucatu Medical School (HC-FMB) and to propose treatment guidelines. METHODS: From 2005 to 2006, the clinical and laboratorial aspects of 11 patients (7 male and 4 female) and the anatomopathological aspects of one patient who had died in 2003 were analyzed. RESULTS: The age of the surviving patients varied from 5 to 87 years, with a mean of 42.5 years. The majority of accidents occurred in the afternoon, and the number of stings ranged from 20 to 500. The principal signs and symptoms were pain and local inflammatory signs, nausea, tachycardia, and vomiting. Biochemical findings presented increased levels of creatine phosphokinase, lactate dehydrogenase, and aspartate/alanine aminotransferase. An 11-year-old male patient died upon entering the attic of a two-storey building where he was attacked by a swarm, receiving more than 1,000 stings. He was sent to HC-FMB where he was treated, but he died 24h later. Observed at the autopsy were erythematous-purpuric skin lesions besides necrosis at the sting locations, rhabdomyolysis, focal myocardial necrosis, tubular hydropic degeneration and focal tubular acute necrosis of the kidneys, myoglobinuria, and centrolobular necrosis in the liver. CONCLUSIONS: Accidents caused by multiple AHB stings always constitute a medical emergency. As there is no specific antivenom, we have developed guidelines, including first aid, drugs, and the proper removal of stingers.

Pressure sores among malnourished necropsied adults - preliminary data

Pressure sores are common among bedridden, elderly, or malnourished patients, and may occur in terminal ill patients because of impaired mobility, fecal or urinary incontinence, and decreased healing capacity. The aim of this study was to compare frequency of pressure sores between malnourished and non-malnourished necropsied adults. METHOD: All (n = 201) adults (age ³ 18 years) autopsied between 1986 and 1996 at the Teaching Hospital of Triangulo Mineiro Medical School (Uberaba) were eligible for the study. Gender, race, weight, height and main diagnoses were recorded. Ninety-six cases were excluded because of probable body water retention (congestive heart failure, hepatic insufficiency, nephrotic syndrome) or pressure sores secondary to peripheral vascular ischemia. Body mass index (BMI) was used to define malnourished (BMI < 18.5 kg/m²) and non-malnourished (BMI > 18.5kg/m²) groups. RESULTS: Except for weight (42.5kg; range: 28-57 vs. 60; 36-134.5kg) and BMI (16.9; range: 12.4-18.5 vs. 22.7; range: 18.5-54.6kg/m²), respectively, there were no statistical differences among 43 malnourished and 62 non-malnourished cases in relation to age (54.9 ± 20.4 vs. 52.9 ± 17.9 years), percentage of white persons (74.4 vs. 64.5%), male gender (76.7 vs. 69.3%) and main diagnoses. Five malnourished (11.6%) and 7 (11.5%) non-malnourished cases had pressure sores (p=0.89). CONCLUSION: Pressure sores were equally common findings in necropsied persons with protein-energy malnutrition, as assessed by body mass index.

Pediatric cardiac postoperative care

The Heart Institute of the University of São Paulo, Medical School is a referral center for the treatment of congenital heart diseases of neonates and infants. In the recent years, the excellent surgical results obtained in our institution may be in part due to modern anesthetic care and to postoperative care based on well-structured protocols. The purpose of this article is to review unique aspects of neonate cardiovascular physiology, the impact of extracorporeal circulation on postoperative evolution, and the prescription for pharmacological support of acute cardiac dysfunction based on our cardiac unit protocols. The main causes of low cardiac output after surgical correction of heart congenital disease are reviewed, and methods of treatment and support are proposed as derived from the relevant literature and our protocols.

Dura mater mitral and tricuspid bioprostheses: 30 years of follow-up

PURPOSE: The dura mater bioprosthesis was developed in the Department of Cardiopneumology of the Hospital das Clínicas of the University of São Paulo Medical School in 1971. Here, we present the clinical results of the dura mater bioprosthesis over 30 years of follow-up. METHODS: We studied 70 consecutive patients who underwent mitral or tricuspid valve replacement with a dura mater bioprosthesis between January 1971 and August 1972. RESULTS: The early mortality was 10% (7 patients). The follow-up was 87% complete (9 patients were lost to follow-up). Two patients were alive and asymptomatic 30 years after valve replacement; 33 patients underwent reoperations due to valve dysfunction, and 19 died during the follow-up period. At 30 years, the actuarial survival was 49.2 ± 8.6%; freedom from rupture, 27.0 ± 10.2%; freedom from calcification, 78.8 ± 8.6%; and freedom from reoperation, 18.8 ± 7.5%. CONCLUSIONS: The dura mater bioprosthesis played an important role in the treatment of patients with mitral and tricuspid valve disease. The low rate of thromboembolism and the long period of follow-up without evidence of valve dysfunction, which occurred for several of our patients, are important characteristics of these bioprosthesis.

Transmyocardial laser revascularization. Early clinical experience

OBJECTIVE: To analyze the initial clinical experience of transmyocardial laser revascularization (TMLR) in patients with severe diffuse coronary artery disease. METHODS: Between February, 1998 and February, 1999, 20 patients were submitted to TMLR at the Heart Institute (InCor), University of São Paulo Medical School, Brazil, isolated or in association with conventional coronary artery bypass graft (CABG). All patients had severe diffuse coronary artery disease, with angina functional class III/IV (Canadian Cardiovascular Society score) unresponsive to medical therapy. Fourteen patients were submitted to TMLR as the sole therapy, whereas 6 underwent concomitant CABG. Fifty per cent of the patients had either been previously submitted to a CABG or to a percutaneous transluminal coronary angioplasty (PTCA). Mean age was 60 years, ranging from 45 to 74 years. RESULTS: All patients had three-vessel disease, with normal or mildly impaired left ventricular global function. Follow-up ranged from 1 to 13 months (mean 6.6 months), with no postoperative short or long term mortality. There was significant symptom improvement after the procedure, with 85% of the patients free of angina, and the remaining 15 % of the patients showing improvement in functional class, as well as in exercise tolerance. CONCLUSION: This novel technique can be considered a low risk alternative for a highly selected group of patients not suitable for conventional revascularization procedures.