The bussola study. Final results, conclusions and proposals

OBJECTIVE: To evaluate the use of thrombolytic and acetylsalicylic acid therapies in acute myocardial infarct patients as well as the availability of technical and human resources for the care of these patients in the emergency units of the city of Rio de Janeiro. Additional objectives were the evaluation of the use of primary angioplasty and the level of acceptance of SBC /RJ as an entity responsible for programs of continued medical education. METHODS: Interviews with physicians at 46 emergency units in the city of Rio de Janeiro. RESULTS: Of the 46 emergency units inspected, a policy of encouragement to use thrombolytic therapy was only prescribed in 6.5%. In 1/3 of the public wards no thrombolytic agents were available, and in none of them was access to primary angioplasty regularly available; 45.9% did not offer the minimal conditions required for the handling of cases of acute myocardial infarction; 60% of the physicians on-call (at both public and private emergency units), appeared not to know the importance of the use of acetylsalicylic acid in acute myocardial infarct patients; all physicians interviewed would participate in programs of continued medical education organized by the SBC/RJ. CONCLUSION: The study suggests there was: 1) the low probability of the use of thrombolytic therapy in the majority of the emergency units in of the city of Rio de Janeiro due to the inadequate policy of waiting for the transfer of the patient to coronary or intensive care unit; 2) a low awareness to the importance of early use of acetylsalic acid in acute myocardial infarct; 3) half of the emergency units of the public net do not have the minimal conditions required for the handling of cases of acute myocardial infarction; 4) a high level of credibility exists that would enable the SBC/RJ to set up programs for continued medical education to change the mentality regarding the use of thrombolytic therapy and of acetylsalicylic acid.

Hypertension in a female nursing staff-pattern of occurrence, diagnosis, and treatment

OBJECTIVE: To report the pattern of occurrence, diagnosis, and treatment of hypertension in a female nursing staff of an emergency hospital. METHODS: We carried out a cross-sectional study that included interviews and blood pressure measurements of 494 nursing professionals at an emergency hospital in the city of Salvador, in the state of Bahia, Brazil. We considered hypertensive all individual with blood pressure > or = 140/90 mmHg or normal pressure if on regular treatment. RESULTS: We found a prevalence of hypertension of 36.4%. Only 18.3% of the individuals ignored their hypertensive condition, and 64.2% admitted not being having regular treatment. Of those individuals who were having treatment, 69.4% had elevated blood pressure on examination. The major reasons for not being on treatment was the occasional elevation of blood pressure (22.2%) and medical counseling (20.0%). CONCLUSION: The results point to the need to introduce hypertension control measures in this occupational group, because of the magnitude of the disease and the potential impact on diffusion of knowledge and measures to control hypertension.

Postoperative necrotizing fasciitis of the thorax in cardiac surgery

Necrotizing fasciitis is a rare soft tissue infection and a life-threatening emergency, often fatal. Its incidence and management are described plentifully in the medical literature regarding the most common anatomical sites involved like the abdomen, lower and upper limbs, and perineum. However, available data and case reports of chest wall necrotizing fasciitis after thoracic procedures are scarce, mainly after major cardiac operations. We report and discuss a case of necrotizing fasciitis of the chest wall occurring in the immediate postoperative period of a cardiac procedure, and include a brief review of the concepts, pathophysiology, and treatment reported in the medical literature. We emphasize the need for early diagnosis and urgent and effective surgical debridement. Of importance is the fact that we have not found any references in the literature to cases similar or equal to the one we describe here, which occurred in the postoperative period of a cardiac procedure.

Reversibility of ventricular dysfunction: clinical experience in a medical office

OBJECTIVE - To describe clinical observations of marked improvement in ventricular dysfunction in a medical office environment under circumstances differing from those in study protocols and multicenter studies performed in hospital or with outpatient cohorts. METHODS - Eleven cardiac failure patients with marked ventricular dysfunction receiving treatment at a doctors office between 1994 and 1999 were studied. Their ages ranged from 20 and 66 years (mean 39.42±14.05 years); 7 patients were men, 4 were women. Cardiopathic etiologies were arterial hypertension in 5 patients, peripartum cardiomyopathy in 2, nondefined myocarditis in 2, and alcoholic cardiomyopathy in 4. Initial echocardiograms revealed left ventricular dilatation (average diastolic diameter, 69.45±8.15mm), reduced left ventricular ejection fraction (0.38±0.08) and left atrial dilatation (43.36±5.16mm). The therapeutic approach followed consisted of patient orientation, elimination of etiological or causal factors of cardiac failure, and prescription of digitalis, diuretics, and angiotensinconverting enzyme inhibitors. RESULTS - Following treatment, left ventricular ejection fraction changed to 0.63±0.09; left ventricular diameters changed to 57.18±8.13mm, and left atrium diameters changed to 37.27±8.05mm. Maximum improvement was noted after 16.9±8.63 (6 to 36) months. CONCLUSION - Patients with serious cardiac failure and ventricular dysfunction caused by hypertension, alcoholism, or myocarditis can experience marked improvement in ventricular dysfunction after undergoing appropriate therapy within the venue of the doctor's office.

Predicting pre-triage waiting time in a maternity emergency room through data mining

An unsuitable patient flow as well as prolonged waiting lists in the emergency room of a maternity unit, regarding gynecology and obstetrics care, can affect the mother and child’s health, leading to adverse events and consequences regarding their safety and satisfaction. Predicting the patients’ waiting time in the emergency room is a means to avoid this problem. This study aims to predict the pre-triage waiting time in the emergency care of gynecology and obstetrics of Centro Materno Infantil do Norte (CMIN), the maternal and perinatal care unit of Centro Hospitalar of Oporto, situated in the north of Portugal. Data mining techniques were induced using information collected from the information systems and technologies available in CMIN. The models developed presented good results reaching accuracy and specificity values of approximately 74% and 94%, respectively. Additionally, the number of patients and triage professionals working in the emergency room, as well as some temporal variables were identified as direct enhancers to the pre-triage waiting time. The imp lementation of the attained knowledge in the decision support system and business intelligence platform, deployed in CMIN, leads to the optimization of the patient flow through the emergency room and improving the quality of services.

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

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

Chest Pain Units: A Modern Way of Managing Patients with Chest Pain in the Emergency Department

It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of acute myocardial infarction (AMI), and just about the same number have unstable angina. Therefore, about one half to two thirds of these patients with chest pain do not have a cardiac cause for their symptoms 2,3. Thus, the emergency physician is faced with the difficult challenge of identifying those with ACS - a life-threatening disease - to treat them properly, and to discharge the others to suitable outpatient investigation and management.

The Role of B-Type Natriuretic Peptide in the Diagnosis of Congestive Heart Failure in Patients Presenting to an Emergency Department with Dyspnea

OBJECTIVE: To determine the utility of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure (CHF) in patients presenting with dyspnea to an emergency department (ED). METHODS: Seventy patients presenting with dyspnea to an ED from April to July 2001 were included in the study. Mean age was 72&plusmn;16 years and 33 (47%) were male. BNP was measured in all patients at the moment of admission to the ED. Emergency-care physicians, blinded to BNP values, were required to assign a probable initial diagnosis. A cardiologist retrospectively reviewed the data (blinded to BNP measurements) and assigned a definite diagnosis, which was considered the gold standard for assessing the diagnostic performance of BNP. RESULTS: The mean BNP concentration was higher in patients with CHF (n=36) than in those with other diagnoses (990&plusmn;550 vs 80&plusmn;67 pg/mL, p<0.0001). Patients with systolic dysfunction had higher BNP levels than those with preserved systolic function (1,180&plusmn;641 vs 753&plusmn;437 pg/mL, p=0.03). At a blood concentration of 200 pg/mL, BNP showed a sensitivity of 100%, specificity of 97.1%, positive predictive value of 97.3%, and negative predictive value of 100%. The application of BNP could have potentially corrected all 16 cases in which the diagnosis was missed by the emergency department physician. CONCLUSION: BNP measurement is a useful tool in the diagnosis of CHF in patients presenting to the ED with dyspnea.

Stress During ACLS Courses: Is it Important for Learning Skills?

OBJECTIVE: To determine the influence of stress on teaching medical emergencies in an Advanced Cardiac Life Support (ACLS) course and to verify this influence on learning, and the efficiency of emergency care training. METHODS: Seventeen physicians signed up for an ACLS course. Their pulses were taken and blood pressure (BP) verified on the first day, before the beginning of the course, and on the second day, during the theoretical and practical test (TPT). Variations in pulse rates and BP were compared with students' test grades. Then, students answered a questionnaire of variables (QV) about the amount of sleep they had during the course, the quantity of study material and the time spent studying for the course, and a stress scale graphic. RESULTS: Seven students had a pulse variation less than 10% between the 2 periods and 10 had a 10% or more variation. Grades on TPT were, respectively, 91.4&plusmn;2.4 and 87.3&plusmn;5.2 (p<0.05). Six students had a BP variation less than 20 mmHg, and in 11 it varied more than 21 mmHg. Grades on the TPT were 92.3&plusmn;3.3 and 86.2&plusmn; 8.1, respectively (p<0.05). The QV dates did not significantly influence grades. CONCLUSION: Stress, as an isolated variable, had a negative influence on the learning process and on the efficiency of emergency training in this situation.

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

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

Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room

OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. RESULTS: The mean age of the patients studied was 51.7±12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated.

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

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

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

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

Medical botany containing systematic and general descriptions, with plates, of all the medicinal plants, indigenous and exotic, comprehended in the catalogues of the materia medica, as published by the Royal Colleges of Physicians of London and Edinburgh : accompanied with a circumstantial detail of their medicinal effects, and of the diseases in which they have been most successfully employed /

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