Cognitive impairment in heart failure

The clinical syndrome of heart failure is one of the leading causes of hospitalisation and mortality in older adults. Due to ageing of the general population and improved survival from cardiac disease the prevalence of heart failure is rising. Despite the fact that the majority of patients with heart failure are aged over 65 years old, many with multiple co-morbidities, the association between cognitive impairment and heart failure has received relatively little research interest compared to other aspects of cardiac disease. The presence of concomitant cognitive impairment has implications for the management of patients with heart failure in the community. There are many evidence based pharmacological therapies used in heart failure management which obviously rely on patient education regarding compliance. Also central to the treatment of heart failure is patient self-monitoring for signs indicative of clinical deterioration which may prompt them to seek medical assistance or initiate a therapeutic intervention e.g. taking additional diuretic. Adherence and self-management may be jeopardised by cognitive impairment. Formal diagnosis of cognitive impairment requires evidence of abnormalities on neuropsychological testing (typically a result ≥1.5 standard deviation below the age-standardised mean) in at least one cognitive domain. Cognitive impairment is associated with an increased risk of dementia and people with mild cognitive impairment develop dementia at a rate of 10-15% per year, compared with a rate of 1-2% per year in healthy controls.1 Cognitive impairment has been reported in a variety of cardiovascular disorders. It is well documented among patients with hypertension, atrial fibrillation and coronary artery disease, especially after coronary artery bypass grafting. This background is relevant to the study of patients with heart failure as many, if not most, have a history of one or more of these co-morbidities. A systematic review of the literature to date has shown a wide variation in the reported prevalence of cognitive impairment in heart failure. This range in variation probably reflects small study sample sizes, differences in the heart failure populations studied (inpatients versus outpatients), neuropsychological tests employed and threshold values used to define cognitive impairment. The main aim of this study was to identify the prevalence of cognitive impairment in a representative sample of heart failure patients and to examine whether this association was due to heart failure per se rather than the common cardiovascular co-morbidities that often accompany it such as atherosclerosis and atrial fibrillation. Of the 817 potential participants screened, 344 were included in this study. The study cohort included 196 patients with HF, 61 patients with ischaemic heart disease and no HF and 87 healthy control participants. The HF cohort consisted of 70 patients with HF and coronary artery disease in sinus rhythm, 51 patients with no coronary artery disease in sinus rhythm and 75 patients with HF and atrial fibrillation. All patients with HF had evidence of HF-REF with a LVEF <45% on transthoracic echocardiography. The majority of the cohort was male and elderly. HF patients with AF were more likely to have multiple co-morbidities. Patients recruited from cardiac rehabilitation clinics had proven coronary artery disease, no clinical HF and a LVEF >55%. The ischaemic heart disease group were relatively well matched to healthy controls who had no previous diagnosis of any chronic illness, prescribed no regular medication and also had a LVEF >55%. All participants underwent the same baseline investigations and there were no obvious differences in baseline demographics between each of the cohorts. All 344 participants attended for 2 study visits. Baseline investigations including physiological measurements, electrocardiography, echocardiography and laboratory testing were all completed at the initial screening visit. Participants were then invited to attend their second study visit within 10 days of the screening visit. 342 participants completed all neuropsychological assessments (2 participants failed to complete 1 questionnaire). A full comprehensive battery of neuropsychological assessment tools were administered in the 90 minute study visit. These included three global cognitive screening assessment tools (mini mental state examination, Montreal cognitive assessment tool and the repeatable battery for the assessment of neuropsychological status) and additional measures of executive function (an area we believe has been understudied to date). In total there were 9 cognitive tests performed. These were generally well tolerated. Data were also collected using quality of life questionnaires and health status measures. In addition to this, carers of the study participant were asked to complete a measure of caregiver strain and an informant questionnaire on cognitive decline. The prevalence of cognitive impairment varied significantly depending on the neuropsychological assessment tool used and cut-off value used to define cognitive impairment. Despite this, all assessment tools showed the same pattern of results with those patients with heart failure and atrial fibrillation having poorer cognitive performance than those with heart failure in sinus rhythm. Cognitive impairment was also more common in patients with cardiac disease (either coronary artery disease or heart failure) than age-, sex- and education-matched healthy controls, even after adjustment for common vascular risk factors.

La concentración de calcio iónico se asocia a la presencia de fibrilación auricular post operatoria en pacientes llevados a revascularización miocardica

Objetivo. Determinar en un grupo de pacientes llevados a revascularización miocárdica si existió asociación entre la presencia de niveles de calcio iónico inferiores a 1,1 en las 24 horas del post operatorio y la ocurrencia de fibrilación auricular post operatoria. Metodología. Estudio observacional, analítico de casos y controles, en donde de manera consecutiva se incluyeron 110 sujetos (57 en el grupo de casos con presencia de fibrilación auricular post operatoria y 54 en el grupo de controles sin evidencia de fibrilación auricular) estos sujetos fueron llevados a revascularización miocárdica en la Fundación Cardioinfantil en los años 2010 a 2015. Resultados. Hubo 13 casos de fibrilación auricular post operatoria en pacientes con niveles de calcio iónico inferiores a 1,1 mmol/l en las primeras 24 horas del post operatorio OR: 0,5, IC (0,2-1,2) p: 0,1. Sin determinarse asociación por limitaciones del estudio, sin embargo un 29% de los pacientes con fibrilación auricular tuvieron niveles de calcio inferiores a 1,1 mmol/l en las primeras 24 horas del post operatorio, este valor aumenta a 31% cuando se analizan por separado los valores de calcio obtenidos a las 12 horas. Conclusiones. Aunque no se logró determinar asociación entre la fibrilación auricular post operatoria y las concentraciones de calcio iónico, de manera exploratoria se pudo establecer que un 29% de los pacientes con fibrilación auricular tuvieron concentraciones de calcio iónico inferiores a 1,1 mmol/l, este valor aumenta a 31% cuando se analizan los niveles de calcio iónico por separado.

Cordectomía por sustracción pedicular en la columna dorsal y lumbar en fracturas traumáticas: experiencia en el hospital universitario mayor Mederi y revisión sistemática de la literatura

Objetivo: Presentar la experiencia con la técnica de corpectomia por sustracción pedicular en fracturas traumática a nivel de la columna dorsal y Lumbar en el Hospital Universitario Mayor en Bogotá y hacer una revisión sistemática de la literatura de esta técnica quirúrgica. Material y métodos: Se realizó un análisis retrospectivo de las historias clínicas de pacientes que consultaron al servicio de neurocirugía entre los años 2013 y 2015 con fracturas traumáticas a nivel de la columna dorsal y lumbosacra. Se realizó un análisis de déficit neurológico pre y posoperatorio por medio de la Clasificación neurológica estándar de lesión medular (ASIA), al igual que tiempos de cirugía, sangrado intraoperatorio y complicaciones. A su vez se realiza una revisión sistemática de la literatura sobre esta técnica quirúrgica. Resultados: El total de pacientes que se sometieron a cirugía fue de 32, de los cuales el tiempo quirúrgico promedio fue de 396 min, se obtuvo un ASIA prequirúrgico B: 50% C: 47% y E: 3%. El ASIA post operatorio fue de B: 9% C: 47% D: 38% E: 6%. Se obtuvo una mejoría del déficit neurológico en el 75% los pacientes intervenidos. El promedio de sangrado fue de 1,223 cc. Se tuvieron 4 complicaciones, 2 hematomas en lecho quirúrgico que requirió re intervención y dos fistulas de líquido cefalorraquídeo las cuales se manejaron con vendaje compresivo y reposo absoluto. Conclusiones: La corpectomia por sustracción pedicular requiere de un adecuado entrenamiento y un grupo multidisciplinario dentro de los que se incluye neuroanestesiologo, a su vez de neurocirujanos entrenados en columna. Este abordaje presenta grandes beneficios como disminución de tiempos quirúrgicos, disminución de sangrado intraoperatorio y disminución de morbilidad entre otras.

Simplificação do processo de multiplicação in vitro da oliveira "Olea europaea L."

A oliveira tem sido multiplicada ao longo dos tempos por métodos convencionais de propagação vegetativa como a enxertia e a estacaria lenhosa e semilenhosa. No entanto, estes métodos revelam-se lentos ou ineficientes para determinadas cultivares. No caso da cv. ‘Galega Vulgar’, ainda com grande expressão no olival português, e de difícil enraizamento por estacaria semilenhosa, tem sido usada a micropropagação de modo a contornar essas limitações e assim obter um elevado número de plantas em curto período de tempo. O custo final de produção por este processo ainda é elevado, podendo comprometer a sua aplicação a nível comercial. Grande parte dos custos estão relacionados com a fase de enraizamento in vitro que carece de ambiente estéril e condições de assépsia para a sua execução. Com vista a uma redução de custos associados a esta fase de produção, pretendeu-se com este trabalho testar a viabilidade do enraizamento ex vitro, na ausência de condições de assépsia. Este método poderá permitir uma significativa redução da mão-de-obra, ao mesmo tempo que facilitará a aclimatização das plantas e a obtenção de um sistema radicular de melhor qualidade. Compararam-se as taxas de enraizamento in vitro (controlo), com as obtidas ex vitro. Foram utilizados explantes provenientes de dois clones da cv. ‘Galega Vulgar’, (cl. 1441 e cl. 2022) cultivados e mantidos in vitro há vários anos no Laboratório de Melhoramento e Biotecnologia da Universidade de Évora. Para além do clone foi avaliada a influência do tipo de estaca (basal e apical), da hormona de enraizamento (AIB e ANA), da sua concentração (540 e 3000 ppm) e ainda de dois substratos, Preformas Jiffy® e pastilhas de fibra coco. Os melhores resultados foram obtidos com o clone 1441 em pastilhas de fibra de coco prensada, com o uso de estacas basais. Quanto à auxina, não se observaram diferenças significativas entre a utilização de ANA na concentração de 540 ppm e AIB na concentração de 3000 ppm. A aclimatização das plantas foi conseguida com taxas elevadas de sucesso, independentemente do tratamento utilizado. Conclui-se que a aplicação do método de enraizamento ex vitro simplifica procedimentos e mantém taxas de enraizamento elevadas, conduzindo assim a uma efetiva redução de tempo e custos associados; Simplifying procedures for in vitro propagation of olive “Olea europaea L.” Abstract: The olive tree has been multiplied throughout the ages by conventional methods of vegetative propagation such as grafting and wood or softwood cuttings. These propagation methods are somehow inefficient for certain cultivars. For the CV. ‘Galega Vulgar‘, still with great expression in Portuguese olive orchards, propagation has been attempted by in vitro culture in order to circumvent these limitations and so obtain a large number of plants in short time period. The final production fees associated to this process are still high which may compromise its application to a commercial level. Most of this process fees are related to the in vitro rooting phase which lacks sterile and aseptic conditions for its implementation. Aiming to reduce the costs associated with this production phase, this work tested the feasibility of the ex vitro rooting in the absence of aseptic conditions, which can allow a significant reduction of the manpower involved and an easier plant acclimatization due to its transplant with a balled-root system. In vitro rooting rates (control) were compared with those obtained with the ex vitro experiments. Explants from two clones of the cv. ‘Galega Vulgar‘ (cl. 1441 and cl. 2022), grown and maintained in vitro for several years in the Laboratory of Biotechnology and Plant Breeding of the University of Évora, were used in the trials. In addition to the clone, the effect of the cutting type (basal and apical), the rooting hormone (AIB and ANA), their concentration (540 and 3000 ppm) and two substrates, Preformas Jiffy ® and pressed coco fiber pellets, were also evaluated. The best results were obtained with the clone 1441, when rooted in pressed coco fiber pellets, using basal cuttings. Under this conditions no significant differences were observed between the use of ANA at 540 ppm or AIB in the 3000 ppm. Acclimatization of plants was achieved with high rates of success, regardless of the treatment used. It can be concluded that the application of the ex vitro rooting method allows to maintain high rooting rates, contributing for an effective reduction of time and fees of the rooting process.