Coronary arterial disease after electroconvulsive therapy: a case report

Objectives Unipolar depression (UPD) is a leading cause of global burden of diseases, particularly among the elderly, whose treatment may be challenging. In such cases, ECT is often recommended due to its safety and efficacy. This report presents a case of a 67-year-old male inpatient that developed a rare cardiac complication during ECT. Methods Clinical case report with patient’s consent and bibliographic review. Results A 67-year-old male inpatient with recurrent severe psychotic depression was hospitalized and ECT was indicated after failure of the pharmacological treatment. A comprehensive clinical pre-evaluation revealed only nonspecific ST-segment changes in electrocardiogram. During the 7th ECT session, it was observed transitory ST-segment depression followed by a discrete increase of plasma troponin I. Severe tri-vessel coronary artery stenosis was found and a percutaneous coronary angioplasty was performed, with satisfactory psychiatric and cardiac outcomes. Conclusions Unipolar depression (UPD) and cardiovascular disease are often coexistent conditions, especially among the elderly. In the current case, myocardial ischemia was detected lately during ECT therapy and its treatment allowed the UPD treatment to be completed adequately.

Treatment of persistent rejection with methotrexate in stable patients submitted to heart transplantation

OBJECTIVE:To evaluate the use of methotrexate for the treatment of recurrent rejection in heart transplant recipients. METHODS: We studied 6 patients submitted to heart transplantation that showed rejection grade > or = 3A (ISHLT) in two consecutives endomyocardial biopsy specimens. The dose was 11.26±3.75mg/week. The evaluated data were: ventricular function, endomyocardial biopsy, white cell count and number of rejection episodes before and after methotrexate administration. RESULTS: There was a reduction in the number of rejection episodes (5.17±1.47 before methotrexate; 2.33±1.75 after 6 months and 3.17±2.99 after 12 months of treatment, p=0.0193). The ventricular function was normal with ejection fraction of 76.5±4.80 before and 75.6±4.59 after methotrexate (p=0.4859). One patient did not finish the treatment because he showed signs of rejection associated with severe pericardial effusion. Five patients had a reduction in the white cell count (8,108±23.72 before and 5650±1350 after methotrexate, p=0.0961). One pulmonary infection with complete resolution after antibiotic treatment was observed. CONCLUSION: Methotrexate in low doses is an effective adjunct therapy in the treatment of recurrent rejection after heart transplantation.

Estimação da função de sobrevivência em dados de eventos recorrentes com censura pela direita

Dissertação de mestrado em Estatística

Prognostic factors of rheumatic mitral stenosis during pregnancy and puerperium

OBJECTIVE: To identifity characteristics associated with complications during pregnancy and puerperium in patients with rheumatic mitral stenosis. METHODS: Forty-one pregnant women (forty-five pregnancies) with mitral stenosis, followed-up from 1991 to 1999 were retrospectively evaluated. Predictor variables: the mitral valve area (MVA), measured by echocardiogram, and functional class (FC) before pregnancy (NYHA criteria).Maternal events: progression of heart failure, need for cardiac surgery or balloon mitral valvulotomy, death, and thromboembolism. Fetal/neonatal events: abortion, fetal or neonatal death, prematurity or low birth weight (<2,500g), and extended stay in the nursery or hospitalization in newborn ICU. RESULTS: The mean ± SD of age of the patients was 28.8±4.6 years. The eventful and uneventful patients were similar in age and percentage of first pregnancies. As compared with the level 1 MVA, the relative risk (RR) of maternal events was 5.5 (95% confidence interval (CI) =0.8-39.7) for level 2 MVA and 11.4 (95% CI=1.7-74.5) for level 3 MVA. The prepregnancy FC (FC > or = II and III versus I) was also associated with a risk for maternal events (RR=2.7; 95% CI=1.4-5.3).MVA and FC were not importantly associated with these events, although a smaller frequency of fetal/neonatal events was observed in patients who had undergone balloon valvulotomy. CONCLUSION: In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but are not associated with fetal/neonatal events. Balloon mitral valvulotomy could have contributed to reducing the risks of fetal/neonatal events in the more symptomatic patients who had to undergo this procedure during pregnancy.

Atrial activation during sinus rhythm in patients with rheumatic and non-rheumatic paroxysmal atrial fibrillation. Frequency-domain analysis using signal-averaged electrocardiography

OBJECTIVE: Using P-wave signal-averaged electrocardiography, we assessed the patterns of atrial electrical activation in patients with idiopathic atrial fibrillation as compared with patterns in patients with atrial fibrillation associated with structural heart disease. METHODS: Eighty patients with recurrent paroxysmal atrial fibrillation were divided into 3 groups as follows: group I - 40 patients with atrial fibrillation associated with non-rheumatic heart disease; group II - 25 patients with rheumatic atrial fibrillation; and group III - 15 patients with idiopathic atrial fibrillation. All patients underwent P-wave signal-averaged electrocardiography for frequency-domain analysis using spectrotemporal mapping and statistical techniques for detecting and quantifying intraatrial conduction disturbances. RESULTS: We observed an important fragmentation in atrial electrical conduction in 27% of the patients in group I, 64% of the patients in group II, and 67% of the patients in group III (p=0.003). CONCLUSION: Idiopathic atrial fibrillation has important intraatrial conduction disturbances. These alterations are similar to those observed in individuals with rheumatic atrial fibrillation, suggesting the existence of some degree of structural involvement of the atrial myocardium that cannot be detected with conventional electrocardiography and echocardiography.

Abortamento: enquadramento legal, deontológico e perspectiva ética

A interrupção da gravidez antes do limite gestacional da viabilidade fetal está inerente a uma reflexão multidisciplinar, pelos conflitos que envolve. Do ponto de vista legal, os documentos vigentes em Portugal têm vindo a ser alterados ao longo do tempo no sentido da protecção da saúde da mulher, possibilitando-lhe a informação e apoios necessários a uma tomada de decisão livre, informada e esclarecida. Os determinantes deontológicos acerca dos profissionais de saúde face ao abortamento legitimam a prática em conformidade com a lei, no entanto, salvaguardam o direito de cada um desses profissionais à objecção de consciência. A discussão ética acerca do abortamento nas suas diferentes formas engloba a preocupação com o valor da vida humana intra-uterina, mas também com o respeito pela autonomia individual. Muito embora a discussão acerca do estatuto moral a atribuir à vida humana intra-uterina se perspective em torno de diferentes correntes e opiniões, conclui-se que diversas perspectivas são aceitáveis, numa perspectiva de valorização da diversidade interpessoal.

Useful clinical features for the selection of ideal patients with strial fibrillation for mapping and catheter ablation

OBJECTIVE: To identify useful clinical characteristics for selecting patients eligible for mapping and ablation of atrial fibrillation. METHODS: We studied 9 patients with atrial fibrillation, without structural heart disease, associated with: 1) antiarrhythmic drugs, 2) symptoms of low cardiac output, and 3) intention to treat. Seven patients had paroxysmal atrial fibrillation and 2 had recurrent atrial fibrillation. RESULTS: In the 6 patients who underwent mapping (all had paroxysmal atrial fibrillation), catheter ablation was successfully carried out in superior pulmonary veins in 5 patients (the first 3 in the left superior pulmonary vein and the last 2 in the right superior pulmonary vein). One patient experienced a recurrence of atrial fibrillation after 10 days. We observed that patients who had short episodes of atrial fibrillation on 24-hour Holter monitoring before the procedure were those in whom mapping the focus of tachycardia was possible. Tachycardia was successfully suppressed in 4 of 6 patients. The cause of failure was due to the impossibility of maintaining sinus rhythm long enough for efficient mapping. CONCLUSION: Patients experiencing short episodes of atrial fibrillation during 24-hour Holter monitoring were the most eligible for mapping and ablation, with a final success rate of 66%, versus the global success rate of 44%. Patients with persistent atrial fibrillation were not good candidates for focal ablation.

Does a Role Exist for Tilting-Guided Therapy in the Management of Neurocardiogenic Syncope?

PURPOSE: Upright tilt-table testing (UTT) is an useful method for identifying patients with neurocardiogenic syncope, but its role in the evaluation of therapeutic efficacy is controversial. The aim of this study was to determine the correlation between negative UTT after therapy introduction (acute efficacy) and symptom recurrence during follow-up (chronic efficacy). METHODS: We studied 56 severely symptomatic patients (age 27±19 years) with recurrent (7±12 episodes) neurocardiogenic syncope (positive UTT). Once empirical pharmacological therapy was initiated, all patients underwent another UTT (therapeutic evaluation test - TET). Therapy was not modified after TET results. The probability of symptom recurrence was analyzed with the Kaplan-Meier method and compared by log-rank test in patients with negative and positive TET. RESULTS: Negative UTT after therapy was related to a significantly lower probability of recurrence during follow-up (4.9 versus 52.4% in 12 months, P<0.0001). CONCLUSION: A good correlation exists between acute and long-term efficacy of pharmacological therapy for neurocardiogenic syncope, so that serial UTT may be considered a good method for identifying an effective therapeutic strategy.

Comparison between tilt-table testing results performed during different periods of the day

OBJECTIVE: To evaluate the influences of circadian variations on tilt-table testing (TTT) results by comparing the positivity rate of the test performed during the morning with that of the test performed in the afternoon and to evaluate the reproducibility of the results in different periods of the day. METHODS: One hundred twenty-three patients with recurrent unexplained syncope or near-syncope referred for TTT were randomized into 2 groups. In group I, 68 patients, TTT was performed first in the afternoon and then in the morning. In group II, 55 patients, the test was performed first in the morning and then in the afternoon. RESULTS: The TTT protocol was the prolonged passive test, without drug sensitization. Twenty-nine (23.5%) patients had a positive result in at least one of the periods. The positivity rate for each period was similar: 20 (16.2%) patients in the afternoon and 19 (15.4%) in the morning (p=1.000). Total reproducibility (positive/positive and negative/negative) was observed in 49 (89%) patients in group I and in 55 (81%) in group II. Reproducibility of the results was obtained in 94 (90.4%) patients with first negative tests but in 10 (34%) patients with first positive tests. CONCLUSION: TTT could be performed during any period of the day, and even in the 2 periods to enhance positivity. Considering the low reproducibility rate of the positive tests, serial TTT to evaluate therapeutic efficacy should be performed during the same period of the day.

As dinâmicas de tradução nos mercados da edição: uma análise da tradução especializada em contexto académico

Relatório de estágio de mestrado em Tradução e Comunicação Multilingue

Acute myocardial infarction: clinical and epidemiological profile and factors associated with in-hospital death in the municipality of Rio de Janeiro

OBJECTIVE: To study the factors associated with the risk of in-hospital death in acute myocardial infarction in the Brazilian public health system in Rio de Janeiro, Brazil. METHODS: Sectional study of a sample with 391 randomly drawn medical records of the hospitalizations due to acute myocardial infarction recorded in the hospital information system in 1997. RESULTS: The diagnosis was confirmed in 91.7% of the cases; 61.5% males; age = 60.2 ± 2.4 years; delta time until hospitalization of 11 hours; 25.3% were diabetic; 58.1% were hypertensive; 82.6% were in Killip I class. In-hospital mortality was 20.6%. Thrombolysis was used in 19.5%; acetylsalicylic acid (ASA) 86.5%; beta-blockers 49%; angiotensin-converting enzyme (ACE) inhibitors 63.3%; calcium channel blockers 30.5%. Factors associated with increased death: age (61-80 years: OR=2.5; > 80 years: OR=9.6); Killip class (II: OR=1.9; III: OR=6; IV: OR=26.5); diabetes (OR=2.4); ventricular tachycardia (OR=8.5); ventricular fibrillation (OR=34); recurrent ischemia (OR=2.7). The use of ASA (OR=0.3), beta-blockers (OR=0.3), and ACE inhibitors (OR=0.4) was associated with a reduction in the chance of death. CONCLUSION: General lethality was high and some interventions of confirmed efficacy were underutilizated. The logistic model showed the beneficial effect of beta-blockers, and ACE inhibitors on the risk of in-hospital death.

Left atrial myxoma as the cause of syncope in an adolescent

A case of left atrial myxoma is reported in a 14-year-old female patient with recurrent episodes of syncope. The patient was immediately referred to the cardiologist after an inconclusive neurological investigation. Syncope is a symptom thoroughly described as being associated with heart myxomas, but its specific association with adolescence is extremely rare. The authors discuss the clinical manifestations of the disease, emphasizing the diagnostic difficulties on the basis of the unspecific symptoms. As part of the analysis a Brazilian literature review was carried out. Also, the authors experience in the surgical treatment of the heart tumors is briefly presented.

Aneurysmal dilation of the reimplant segment of the visceral vessels after thoracoabdominal aneurysm correction

We present a case of aneurysmal dilation of the aortic residual segment, involving abdominal vessels in corrective surgeries for thoracoabdominal aortic aneurysm, through the identification of risk groups for recurrent dilation, aiming at using a specific operative technique with a branched graft, to prevent aneurysm relapse.

Ligation of the thoracic duct for the treatment of chylothorax in heart diseases

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

Prácticas comunicativas forenses: Las relaciones intertextuales en el examen de testigos. Forensic communicative practices: intertextual relations in examination of witnesses.

Inscripto en el análisis del discurso interaccional de tradición angloamericana y optando por un abordaje metodológico etnográfico, este proyecto plantea investigar las relaciones entre textos orales y entre textos orales y escritos vinculados en cadenas textuales en un acontecimiento comunicativo institucional en el que tales relaciones tienen consecuencias directas en la confiabilidad de la información e intervienen en la construcción del conocimiento oficial. La situación comunicativa elegida es el examen y el contraexamen de testigos comunes durante procesos penales orales, de formato común no abreviado, en la jurisdicción de Córdoba capital. En las interacciones verbales con litigantes y jueces en las que emerge el testimonio se ponen en juego otros textos orales (en forma de citas de lo dicho antes por el mismo testigo u otras personas, referencias a rumores u opiniones colectivas, etc.) y textos escritos (actas de secuestro, informes periciales, actas de las declaraciones testimoniales en la etapa de instrucción, etc.). El foco de atención son las prácticas asociadas a la intertextualidad puesto que condicionan el carácter de la prueba testimonial producida ante el juzgador. Postulamos que los litigantes despliegan tácticas locales y estrategias globales reconocibles y recurrentes vinculadas al tratamiento de diversas categorías de textos previos. Además, planteamos averiguar si la participación de los jueces en interacción con los testigos es de suficiente injerencia como para ser un modo importante de generación de prueba testimonial. El enfoque metodológico general es etnográfico y analíticodiscursivo. Se seleccionará una causa por delito grave, se presenciará el debate en la cámara y se registrará el audio de todas las audiencias. Los datos a analizar serán los segmentos en las interacciones en los que se incorpora la lectura o se cita las actas de las declaraciones indagatorias o testimoniales anteriores, y los segmentos en los que se requiere, en calidad de prueba testimonial, la reproducción de dichos. Se procederá a partir de los detalles de la superficie textual y la pragmática de los intercambios y aprovechando el valor heurístico del concepto de voz, buscando identificar patrones recurrentes y los mecanismos generales que los rigen. Sobre esa base, se considerarán los intercambios verbales como interacción social que emerge moldeada por condiciones situacionales e institucionales y otros factores, tales como la incidencia de la pertenencia a grupos sociales o profesionales. Con el estudio se obtendrá una visión de prácticas cotidianas asociadas a la intertextualidad que son de crucial importancia para el carácter de la prueba testimonial producida ante el juzgador. Este paso nos acercará a conocer cómo se lleva a cabo efectivamente la administración de justicia penal y permitirá valorar los patrones de conducta a la luz de las normas procesales. In line with the Anglo-American tradition of situated discourse analysis, this project aims at tracing the links between oral texts and between oral and written texts related in textual chains which are present in an institutional event in which such relations have a direct consequence on the reliability of the information given and have an impact on the construction of what counts as official knowledge. The communicative situation under study is that of the direct and cross-examination of lay witnesses during a criminal trial in the city of Córdoba. During the face-to-face interactions between trial lawyers and judges in which the testimony takes place, other oral texts and written texts get incorporated. The focus of this research is centered on practices of intertextuality as they condition the nature of the oral evidence produced. It is argued that trial lawyers use recurrent local tactics and global strategies that are related to the treatment given to different categories of previous texts. Another aim of this study is to examine if judge’s interventions have an impact on the generation of the oral evidence. The data will come from a criminal trial that will be audio-taped in its entirety. Ethnographic observations of a criminal trial will be made. The focus of analysis will be on segments of interactions in which previous texts are read aloud or incorporated as quotes. After carrying out a detailed analysis of the surface of texts and the pragmatics of the exchanges, recurrent patterns and the general mechanisms that condition their emergence will be described. In this way, verbal exchanges will be considered social interactions that unfold conditioned by situational, institutional and social factors. This study will examine the relationship between intertextuality and the institutional practice of providing oral evidence. This will help understand how justice is actually administered and how patterns of behavior are valued according to institutional norms.