[Risk Factors for Delayed Discharge Due to Social Factors: A Retrospective Study]

INTRODUCTION

The hospital setting faces a rate of bed occupation by patients whose discharge is limited by other factors apart from clinical needs. This urges the need for an early identification of the patients at risk of delayed discharge due to social factors in order to reduce expenses and to add value that converts itself into the patient health. The aim of this study was to identify the demographic and clinical factors that may be associated with delayed discharge.

MATERIAL AND METHODS

Demographic and clinical comorbidity data on 582 patients of an internal medicine ward from a tertiary hospital center during the years 2018 and 2019 was analyzed. A binomial logistic regression model was used, adjusted for sex, age, and length of clinical stay, in order to identify potential risk factors associated with delayed discharge.

RESULTS

A total of 473 patients admitted in the internal medicine ward throughout the two years of study were included. Ninety-four (19%) of these patients had their discharge delayed beyond their clinical needs; sixty-four (68%) of these were females. The most representative age was between 75 - 89 years old (45.7%). The characteristics that significantly differed between both non-delayed and delayed discharge were female sex (OR 2.84, 95% CI 1.65 - 4.90, p-value < 0.05), prolonged clinical stay (OR 2.64, 95% CI 1.60 - 4.937, p-value < 0.05) and diabetes mellitus (OR 1.87, 95% CI 1.08 - 3.23, p-value < 0.05). Besides these, the presence of heart failure (OR 0.52, 95% CI 0.27 - 0.99, p-value < 0.05) and chronic kidney disease (OR 0.34, 95% CI 0.14 - 0.86, p-value < 0.05) were associated with a lower risk of delayed discharge.

CONCLUSION

Female sex, a prolonged clinical stay and diabetes mellitus were associated with a higher risk of delayed discharge, while heart failure and chronic kidney disease were associated with a reduced risk. These findings create a basis for a possible future multicentre study aimed at creating a clinical prediction rule to stratify the risk of delayed hospital discharge in the Portuguese population.

Association of skeletal muscle and cardiovascular risk factors in patients with lower extremity arterial disease

BACKGROUND

Sarcopenia is defined as low muscle mass, with low muscle strength or low physical performance. The skeletal muscle mass (or density) and strength are inversely associated with cardiovascular risk factors. We aim to determine the relationship between skeletal muscle characteristics (strength, mass, area), and cardiovascular risk factors in a population with lower extremity artery disease (LEAD) METHODS: : An observational, prospective study including patients with LEAD was conducted from January 2018 to December 2020. The cardiovascular risk factors and anthropometric measurements were prospectively registered. The skeletal muscle characteristics (area, density/mass and strength) were analysed. The skeletal muscle area and density were quantified with a CT scan. The strength was determined with a Jamar® hydraulic hand dynamometer.

RESULTS

96 patients with LEAD with 67.70± 10.11 years-old were enrolled in the study. The most prevalent cardiovascular risk factor was hypertension, followed by dyslipidemia and diabetes. Patients with diabetes had a lower handgrip strength and skeletal muscle density, when compared with patients without diabetes (strength: 19.67± 9.98 kgf versus 26.79 ± 11.80 kgf, p=0.002 and skeletal muscle density: 10.58 ± 17.61 HU versus 18.17 ± 15.33 HU, p=0.032). There was a trend for the association between the presence of cardiovascular risk factors (hypertension and dyslipidemia) and a decrease in skeletal muscle density and strength (density: hypertension: 13.46 ± 16.74 HU versus 20.38 ± 11.63 HU p=0.055; dyslipidemia: 13.57 ± 17.16 HU versus 17.74 ± 13.00 HU p=0.315; strength- hypertension: 22.55 ± 10.08 kgf versus 27.58 ± 15.11 p= 0.073; dyslipidemia: 22.80 ± 10.52 kgf versus 25.28 ± 13.14 kgf p=0.315). Interestingly, we found that smokers had a favorable skeletal muscle characteristic, which could be explained by the higher prevalence of diabetes in non-smokers.

CONCLUSIONS

The indicators of skeletal muscle dysfunction (strength and density) are associated to the presence of diabetes in patients with LEAD. Therapeutic strategies to improve the skeletal muscle characteristics could have a role in improving LEAD risk factors, particularly diabetes.

Electroconvulsive therapy as life-saving in an acute catatonic syndrome associated with bipolar disorder: A case report

Introduction

Catatonia is a neuropsychiatric syndrome characterized by an onset of a dysfunction in psychomotor activity and/or muscle tone, which may be associated with changes in consciousness, affect, and thinking. It is characterized by negativism, wax flexibility, catalepsy, mutism echolalia, ecopraxia, or stupor. It was first described in 1874 by Kahlbaum, who characterized it as specific motor disorder associated with different psychiatric disorders. Kraepelin and Bleuler restricted catatonia to a specific subtype of schizophrenia. However, the association between catatonia and other disorders, notably mood disorders, has been reinstated, including Bipolar Disorder. Its etiology is multiple and there are two severe forms: Neuroleptic Malignant Syndrome (NMS) and Malignant Catatonia (MC). These are syndromes that present high mortality, and the health professional should be aware of its etiology, signs, symptoms, evaluation and treatment.

Objectives

The aim of this work is to present a clinical case of MC, who was sustained by literature included on scientific platforms.

Methods

Case report

Results

It is essential to recognize the different clinical presentations of catatonia, taking into account that these are psychiatric alterations in which urgent intervention is justified. In the presented case, the use of antipsychotic medication has worsened the motor function and its suspension, associated with the introduction of lorazepam, resulted in a slight improvement. The electroconvulsive therapy was the last resort, fully succeeded.

Conclusions

The relationship between SMN and Catatonia/MC remains nuclear from a psychopathological and pathophysiological point of view. Nevertheless, there is general agreement that catatonia represents a very significant risk factor for NMS.

Disclosure

No significant relationships.

First psychotic episode as first manifestation of lyme disease: Case report

Introduction

Lyme disease (LD) is caused by the spirochete Borrelia burgdorferi (Bb) and has been reported to be associated with various psychiatric presentations.

Objectives

To report a case with LD and to highlight the importance of differential diagnosis in a first psychotic episode.

Methods

Case report and non-systematic review of the literature.

Results

A woman aged 31 was admitted to the psychiatric department, after a car accident with a mortal victim, due to a first psychotic episode with visual hallucinations, disorientation in time and space, persecutory and grandiosity delusions. She had a personal psychiatric history of obsessive-compulsive disorder and no previous admission to an inpatient Unit. On psychotropic drugs the condition failed to improve, and subsequently neurological symptoms developed. EEG abnormalities prompted a lumbar puncture. In the CSF a strong plasma cell reaction with atypical cells was observed. The enzyme immunoassay for Borrelia burgdorferi was positive and after treatment with penicillin the psychiatric and neurological signs and symptoms remitted. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient’s complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression.

Conclusions

LD is relatively rare, but awareness of the association between LD and neuropsychiatric presentations can improve understanding of the causes of mental illness and result in more effective prevention, diagnosis and treatment.

Disclosure

No significant relationships.

Clozapine in severe psychotic disorders: Balancing safety with efficacy

Introduction

Clozapine is a member of the dibenazepine class of antipsychotic drugs and has been designated an atypical antipsychotic drug. Clinical studies have shown that clozapine is effective in ameliorating the core symptoms, as well as the negative symptoms, in severe psychotic disorders and is therapeutically effective in treating about 30% of schizophrenic patients who are resistant to standard antipsychotic drugs.

Objectives

The goal is to review pharmacology, efficacy, and clinical use of clozapine, such as its side effects, and the benefit-to-risk ratio of this antipsychotic drug.

Methods

Non-systematic literature review based on scientific databases such as PubMed, using key words such as “clozapine”, “efficacy”, “side effects” and “resistant schizophrenia”.

Results

Clozapine was developed as the first atypical antipsychotic with activity for both the negative and positive symptoms of schizophrenia. The primary indications for clozapine are treatment-resistant psychotic disorder, defined as persistent moderate to severe delusions or hallucinations despite two or more clinical trials with other antipsychotic drugs, and patients who are at high risk for suicide. Concerns over a number of safety considerations are responsible for much of the underutilization of clozapine, such as agranulocytosis, metabolic side effects and myocarditis. These side effects can be detected, prevented, minimized and treated, but there will be a very small number of fatalities.

Conclusions

Awareness of the benefits and risks of clozapine is essential for increasing the use of this lifesaving agent.

Disclosure

No significant relationships.

Tuning the magnetic properties of Sn1-x-y Ce4+x Ce3+y O2 nanoparticles: an experimental and theoretical approach

During the last decade, there was a substantial increase in the research on metal-doped oxide semiconductor nanoparticles due to advances in the engineering of nanomaterials and their potential application in spintronics, biomedicine and photocatalysis fields. In this regard, doping a nanomaterial is a powerful tool to tune its physicochemical properties. The aim of this work is to shine a new light on the role of the neighbouring elements on the oxidation state of the Ce-impurity, from both experimental and theoretical points of view. Herein, we present an accurate study of the mechanisms involved in the oxidation states of the Ce-ions during the doping process of SnO₂ nanoparticles (NPs) prepared by the polymeric precursor method. X-ray diffraction measurements have displayed the tetragonal rutile-type SnO₂ phase in all samples. However, the Bragg's peak (111) and (220) located at 2θ ∼29° and ∼47° evidence the formation of a secondary CeO₂ phase for samples with Ce content up to 10%. X-ray absorption near-edge structure (XANES) measurements, at Ce L3 edge, were performed on the NPs as a function of Ce content. The results show, on one side, the coexistence of Ce³⁺ and Ce⁴⁺ states in all samples; and on the other side, a clear reduction in the Ce³⁺ population driven by the increase of Ce content. It is shown that this is induced by the neighboring cation, and confirmed by magnetic measurements. The monotonic damping of the Ce³⁺/Ce⁴⁺ ratio experimentally, was connected with theoretical calculations via density functional theory by simulating a variety of point defects composed of Ce impurities and surrounding oxygen vacancies. We found that the number of oxygen vacancies around the Ce-ions is the main ingredient to change the Ce oxidation state, and hence the magnetic properties of Ce-doped SnO₂ NPs. The presented results pave the way for handling the magnetic properties of oxides through the control of the oxidation state of impurities.

Boundaries of a systemic disease: a protean presentation of giant cell arteritis

A 60-year-old man was hospitalised with persistent fever, arm pain, dry cough and cholestasis. Diagnostic workup was remarkable for elevated inflammatory markers. Infectious diseases and autoimmune screening were negative. Imaging modalities excluded a neoplastic aetiology. Liver biopsy was negative for granulomatous or lymphomatous infiltrations. Giant cell arteritis (GCA) was suspected, but temporal artery Doppler ultrasound and biopsy were non-diagnostic. A positron emission tomography scan showed intense metabolic uptake in large vessels suggesting the diagnosis of GCA. Prednisolone was initiated with clinical and analytical improvement. At 1-year follow-up, there were no relapses and the patient remains symptom free.

Homeoindex

HOMEOINDEX is a bibliographic database in which everything published in the field of homoeopathy is progressively filed. The methods adopted are those used by major international medical databases (MEDLINE, LILACS), allowing data exchange.

HOMEOINDEX radically changes the situation for dissemination, study, preservation and research of homoeopathic works. It takes homoeopathy out of an archaic phase when work was inaccessible and fragmented and into the modern era.

The development of this work included some unique achievements:

—Introduction of homoeopathy as recognized literature in international institutions

—Adoption of homoeopathic terms (key-words) in official latin-American medical catalogues

—Creation of a Latin American reference centre, for cataloguing and disseminating homoeopathic literature

—The introduction of homoeopathic papers to international medical databases.

Atomic pair distribution function at the Brazilian Synchrotron Light Laboratory: application to the Pb1-xLaxZr0.40Ti0.60O3 ferroelectric system

This work reports the setting up of the X-ray diffraction and spectroscopy beamline at the Brazilian Synchrotron Light Laboratory for performing total scattering experiments to be analyzed by atomic pair distribution function (PDF) studies. The results of a PDF refinement for Al₂O₃ standard are presented and compared with data acquired at a beamline of the Advanced Photon Source, where it is common to perform this type of experiment. A preliminary characterization of the Pb_1-xLa_xZr_0.40Ti_0.60O₃ ferroelectric system, with x = 0.11, 0.12 and 0.15, is also shown.

Preparation and structural-optical characterization of dip-coated nanostructured Co-doped ZnO dilute magnetic oxide thin films

We demonstrate the feasibility to prepare Co-doped ZnO thin films (Zn_1−xCoxO, x = 0; 0.01; 0.03 and 0.05) via the dip-coating technique, a very simple and a low-cost process. We focus the structural and the optical analyses in the context of the DMOs.

The role of oxygen vacancies and their location in the magnetic properties of Ce1−xCuxO2−δ nanorods

Ceria (CeO₂) is a promising dilute magnetic semiconductor. The ferromagnetic order has proven to be an surface effect.

β-Lapachone activity in synergy with conventional antimicrobials against methicillin resistant Staphylococcus aureus strains

The aim of this study was to evaluate the antimicrobial activity of lapachol, α-lapachone, β-lapachone and six antimicrobials (ampicillin, amoxicillin/clavulanic acid, cefoxitin, gentamicin, ciprofloxacin and meropenem) against twelve strains of Staphylococcus aureus from which resistance phenotypes were previously determined by the disk diffusion method. Five S. aureus strains (LFBM 01, LFBM 26, LFBM 28, LFBM 31 and LFBM 33) showed resistance to all antimicrobial agents tested and were selected for the study of the interaction between β-lapachone and antimicrobial agents, busing checkerboard method. The criteria used to evaluate the synergistic activity were defined by the Fractional Inhibitory Concentration Index (FICI). Among the naphthoquinones, β-lapachone was the most effective against S. aureus strains. FICI values ranged from 0.07 to 0.5, suggesting a synergistic interaction against multidrug resistant S. aureus (MRSA) strains. An additive effect was observed with the combination β-lapachone/ciprofloxacin against the LFBM 33 strain. The combination of β-lapachone with cefoxitin showed no added benefit against LFBM 31 and LFBM 33 strains. This study demonstrated that, in general, β-lapachone combined with beta lactams antimicrobials, fluoroquinolones and carbapenems acts synergistically inhibiting MRSA strains.

Factors controlling physico-chemical characteristics in the coastal waters off Mangalore--a multivariate approach

Water quality parameters (temperature, pH, salinity, DO, BOD, suspended solids, nutrients, PHc, phenols, trace metals--Pb, Cd and Hg, chlorophyll-a (chl-a) and phaeopigments) and the sediment quality parameters (total phosphorous, total nitrogen, organic carbon and trace metals) were analysed from samples collected at 15 stations along 3 transects off Karnataka coast (Mangalore harbour in the south to Suratkal in the north), west coast of India during 2007. The analyses showed high ammonia off Suratkal, high nitrite (NO(2)-N) and nitrate (NO(3)-N) in the nearshore waters off Kulai and high nitrite (NO(2)-N) and ammonia (NH(3)-N) in the harbour area. Similarly, high petroleum hydrocarbon (PHc) values were observed near the harbour, while phenols remained high in the nearshore waters of Kulai and Suratkal. Significantly, high concentrations of cadmium and mercury with respect to the earlier studies were observed off Kulai and harbour regions, respectively. R-mode varimax factor analyses were applied separately to surface and bottom water data sets due to existing stratification in the water column caused by riverine inflow and to sediment data. This helped to understand the interrelationships between the variables and to identify probable source components for explaining the environmental status of the area. Six factors (each for surface and bottom waters) were found responsible for variance (86.9% in surface and 82.4% in bottom) in the coastal waters between Mangalore and Suratkal. In sediments, 4 factors explained 86.8% of the observed total variance. The variances indicated addition of nutrients and suspended solids to the coastal waters due to weathering and riverine transport and are categorized as natural sources. The observed contamination of coastal waters indicated anthropogenic inputs of Cd and phenol from industrial effluent sources at Kulai and Suratkal, ammonia from wastewater discharges off Kulai and harbour, PHc and Hg from boat traffic and harbour activities of New Mangalore harbour. However, the strong seasonal currents and the seasonal winds keep the coastal waters well mixed and aerated, which help to disperse the contaminants, without significantly affecting chlorophyll-a concentrations. The interrelationship between the stations as shown by cluster analyses and depicted in dendograms, categorize the contamination levels sector-wise.

Drug-induced apoptosis in yeast

In order to alter the impact of diseases on human society, drug development has been one of the most invested research fields. Nowadays, cancer and infectious diseases are leading targets for the design of effective drugs, in which the primary mechanism of action relies on the modulation of programmed cell death (PCD). Due to the high degree of conservation of basic cellular processes between yeast and higher eukaryotes, and to the existence of an ancestral PCD machinery in yeast, yeasts are an attractive tool for the study of affected pathways that give insights into the mode of action of both antitumour and antifungal drugs. Therefore, we covered some of the leading reports on drug-induced apoptosis in yeast, revealing that in common with mammalian cells, antitumour drugs induce apoptosis through reactive oxygen species (ROS) generation and altered mitochondrial functions. The evidence presented suggests that yeasts may be a powerful model for the screening/development of PCD-directed drugs, overcoming the problem of cellular specificity in the design of antitumour drugs, but also enabling the design of efficient antifungal drugs, targeted to fungal-specific apoptotic regulators that do not have major consequences for human cells.

[Reconstruction of velopharyngeal sphincter in secondary Cleft Palate: surgical alternative]

There are numerous surgical procedures for the repair of Cleft Palate (CP). Since 1998, in children with CP we use a modified Wardill-Kilner technique, with a large section of the nasal mucous layer at the level of the muscular insertion on the hard palate and lateral nasopharingeal wall, obtaining a push-back and reorientation of the muscular fibres without dissection, diminishing this way the risks of haemorrhages and fibrosis, simplifying the intervention. It allows a lower operative time and a short internment. The aim of our study was to evaluate the results of this operative procedure specially in the development of the speech in 73 children operated on from 1998 until 2000 in our hospital. We verify a competence of the velopharingeal sphincter with ideal results in speech in 88,8% of the cases.

Tolerance to various toxicants by marine bacteria highly resistant to mercury

Bacteria highly resistant to mercury isolated from seawater and sediment samples were tested for growth in the presence of different heavy metals, pesticides, phenol, formaldehyde, formic acid, and trichloroethane to investigate their potential for growth in the presence of a variety of toxic xenobiotics. We hypothesized that bacteria resistant to high concentrations of mercury would have potential capacities to tolerate or possibly degrade a variety of toxic materials and thus would be important in environmental pollution bioremediation. The mercury-resistant bacteria were found to belong to Pseudomonas, Proteus, Xanthomonas, Alteromonas, Aeromonas, and Enterobacteriaceae. All these environmental bacterial strains tolerant to mercury used in this study were capable of growth at a far higher concentration (50 ppm) of mercury than previously reported. Likewise, their ability to grow in the presence of toxic xenobiotics, either singly or in combination, was superior to that of bacteria incapable of growth in media containing 5 ppm mercury. Plasmid-curing assays done in this study ascertained that resistance to mercury antibiotics, and toxic xenobiotics is mediated by chromosomally borne genes and/or transposable elements rather than by plasmids.

The glycoprotein IIb/IIIa receptor inhibitor (abciximab) in ST-segment elevation myocardial infarction

A successful therapy is presented using the antiplatelet agent abciximab, alone, in an ST-segment elevation acute myocardial infarction. The patient was treated in a center with permanent catheterization facilities. Clinical trials are necessary to validate the efficacy and the cost-effectiveness of this clinical decision and therapeutic option.

[Peripheral revascularization by cardiologists]

OBJECTIVE

To analyse the initial experience in peripheral arterial revascularization, using percutaneous techniques, by interventional cardiologists.

DESIGN

Retrospective clinical study.

SETTING

Cardiology department of a specialised public non-university hospital.

PATIENTS

Twenty patients, 18 male and 2 female, with ages between 37 and 84 years, who underwent peripheral interventions between May 5 1989 and February 20 1998.

INTERVENTIONS

Patients were subdivided into two groups: Group I, 9 patients, 8 male, average age of 56 +/- 13 years, undergoing renal artery angioplasty; Group II, 11 patients, 10 male, average age of 63 +/- 10 years, undergoing angioplasty of the distal aorta (1), of the right subclavian artery (1), of the iliac arteries (6) and of the femoral arteries (3). In Group I, 11 arteries were dilated, 6 by balloon angioplasty and 5 with stent implantation (Palmaz-Schatz--4 and Symphony--1). In Group II, 12 arteries were dilated, 5 by balloon angioplasty and 7 with 12 stent implantations (Palmaz-Schatz--6, Symphony--5 and NIRTM--1). In 8 patients, 1 of Group I and 7 of Group II, coronary angioplasty was also performed in 14 arteries and 18 segments, exclusively by balloon (3 patients) or with 10 stent implantations (5 patients).

RESULTS

There was angiographic success in all patients (100%) and clinical success in 85% (17/20) of patients. All clinical complications occurred in Group I patients: retroperitoneal bleeding in one; right femoral artery pseudoaneurysm requiring surgery in one patient: acute renal failure in one patient. There were no cardiac complications in patients undergoing peripheral and cardiac angioplasties at the same stage. In the mean follow-up period of 26 months, one patient required reangioplasty of a right iliac artery and another underwent iliac-femoral bypass, both of Group II and before peripheral stents were available.

CONCLUSIONS

Percutaneous peripheral arterial revascularization performed by experienced interventional cardiologists seems safe and efficient, being perfectly justified in patients requiring simultaneous coronary angioplasty.

[Total occlusion of the left common coronary artery--a case report]

Total chronic occlusion of the left main coronary artery is an unusual finding. After a review of the literature, the authors present a case report of a patient with stable angina and total occlusion of the left main coronary artery, right coronary with atherosclerotic lesions and normal ventricular function.

[Value of exercise test for risk stratification acute myocardial infarction]

OBJECTIVES

To assess the prognostic value of predischarge exercise testing (ET) in patients hospitalized for acute myocardial infarction (AMI).

CONTEXT

Department of Cardiology in a reference hospital for Interventional Cardiology

METHODS

Between January 1990 and December 1994, 178 patients hospitalized for AMI were discharged and referred to the outpatient clinic (mean follow up, 1049 +/- 612 days). Eighty-two percent of these patients were men, mean age--56 +/- 12 years. Patients that did not perform predischarge ET (Group A, n 77) were retrospectively compared with those who did (Group B, n = 101). In relation to demographic and clinical characteristics; we analysed cardiac events (CE) and death during the first 18 months after discharge in both groups. In group B patients, we studied the relation of ET parameters (duration of exercise, occurrence of exercise-induced ischaemia and arrhythmias, maximum heart rate, blood pressure response, rate pressure product and severity score) to CE and death during the first 18 months after AMI.

RESULTS

The proportion of patients aged 70 years or older was greater in group A (23% vs 3%, P < 0.001). In this group, there was a greater prevalence of recurrent ischaemia (51% vs 29%, P < 0.001) and left ventricular dysfunction (42% vs 25%, P < 0.05). Group A patients were also submitted to less thrombolysis (45% vs 62%, P < 0.05) and to revascularization procedures (25% vs 41%, P < 0.05). In group B patients, the incidence of CE did not differ with respect to duration of ET, rate pressure product or maximum heart rate. Incidence of CE was greater in patients with exercise-induced ischaemia (38% vs 15%, P < 0.05), severity score > 2 (45% vs 18%, P < 0.02) and inadequate rise (< 30 mmHg) in systolic blood pressure (39% vs 13%, P < 0.02). The total incidence of CE and revascularization was also greater in patients with exercise-induced ischaemia (88% vs 49%, P < 0.001), severity score > 2 (95% vs 56%, P < 0.02) and inadequate rise in systolic blood pressure (93% vs 45%, P < 0.001).

CONCLUSIONS

In patients without indication for ET as part of risk stratification after AMI, clinical characteristics were more severe as defined by age greater than 70 years, residual ischaemia and left ventricular dysfunction. Patients that performed ET had smaller risk, except when presenting exercise-induced ischaemia, severity score > 2 and inadequate rise in systolic blood pressure.

[Revascularization in patients with prior coronary bypass surgery]

Increasingly over the past several years, patients have returned after coronary surgery for reintervention procedures. This reflects immediate postsurgical complications and the relentless progression of coronary artery disease in the native circulation and in the bypass grafts. Although there are randomized comparative data for coronary bypass surgery (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) and medical therapy, these trials have always excluded patients with previous (GABG).

OBJECTIVES

We attempted to compare the risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG).

METHODS AND RESULTS

This study examines follow up data (15.4 +/- 11.0 months) from 130 patients with previous CABG, who required either PTCA (Group A, n = 73) or re-CABG (Group B; n = 57) at a single center from 1994 to 1997. Follow up data were obtained from subsequent office visits and telephone calls. The PTCA and re-CABG groups were similar with respect to gender (86% vs 94% males), mean age (62 +/- 9 vs 59 +/- 10 years), angina CCS classes 3 and 4 (73% vs 69%), diminished left ventricular function (23% vs 26%), risk factors such as diabetes (19% vs 17%), hypercolesterolemia (49% vs 45%) and smoking (48% vs 39%) and three-vessel native coronary artery disease (67% vs 72%). The symptomatic status prior to the revascularization procedure was similar in both groups. Complete and functional revascularization was achieved in 85% of the PTCA group and in 92% of those with re-CABG (p = NS). During the hospital stay the complication rates were lower in the PTCA group. Actuarial survival was different at follow up (p = 0.04). Both PTCA and re-CABG groups resulted in equivalent event-free survival (freedom from death, myocardial infarction, unstable angina and urgent revascularization). The need for repeat revascularization at follow up was significantly higher in the PTCA group (PTCA 28% vs re-CABG 10%, p < 0.01).

CONCLUSIONS

In this non-randomized study of patients with previous CABG requiring revascularization procedures, PTCA resulted in lower procedural morbidity and mortality risks. At follow up, both PTCA or CABG were similar for event-free survival; PTCA offered lower overall mortality, although it is associated to a greater need for subsequent revascularization procedures.

[Treatment acute myocardial infarct in the pre-hospital phase]

The authors review and discuss the medical treatment in the prehospital phase of acute myocardial infarction while working at the Referral Centre for Emergency Patients of the National Institute for Medical Emergencies (CODU-INEM). The diagnosis of myocardial infarction should be suspected immediately by the doctor on duty at CODU-INEM in all patients with acute thoracic pain. Then it is essential to send a medical team to the scene as soon as possible after the onset of symptoms in order to treat and to prevent acute fatal complications.

[Role of auxiliary diagnostic tests in the clarification of the etiology of syncope: experience at an arrhythmia center]

Syncope is a syndrome caused by a reversible reduction of blood to the brain. Three hemodynamic abnormalities can cause syncope: an acute decrease in cardiac output, an acute increase in cerebrovascular resistance and a fall in systemic blood pressure due to ineffective control of peripheral vascular resistance. We made a retrospective study of 121 patients with syncope history, 67 males, and 57 females, with mean age 48 +/- 14 years, and at least six months of clinical follow-up. Twelve patients had valvular disease, two patients had hypertrophic cardiomyopathy, eight patients had dilated cardiomyopathy, 14 patients had ischemic disease, three patients had congenital disease; 82 patients did not have cardiac disease. Syncope etiology was arrhythmic in 69 patients: 47 patients had tachyarrhythmia (supraventricular--in 27 patients and ventricular in 20 patients) and 15 patients had bradyarrhythmia (seven patients had sinus node disease and eight patients had atrioventricular block). Non arrhythmic etiology of syncope was identified in 29 patients (neurologic disease--ten patients, metabolic disease--one patient and iatrogenic--two patients; vasodepressor syncope--14 patients, and hypertrophic cardiomyopathy--two patients). It was not possible to determine the syncope etiology in 30 patients. The assessment of patients who present syncope depends on establishing the basis for the symptoms. The initial step is differentiating patients with normal cardiovascular systems from those with heart disease. In the former, tilt-table testing proved to be the most productive from a diagnostic perspective; in the latter group, electrophysiologic evaluation was the most elucidative from a diagnostic perspective. The ultimate goal is to obtain a sufficiently strong correlation between syncopal symptoms and detected abnormalities to permit an accurate assessment of prognosis and to develop an effective treatment plan.

CONCLUSIONS

It is very important to establish the etiology of syncope for optimal management of patients and it is therefore possible to control the symptoms in the majority of them. The patients who present syncope require a complete history and a physical examination for an appropriate workup to be initiated. Tilt-table testing was the most accurate for the diagnosis of vasodepressor syncope while electrophysiologic testing provides an accurate method for assessing the etiology of tachyarrhythmic syncope.

Blood flow velocity measurements in the optic nerve of glaucomatous patients by elaboration of a constant to evaluate the evolutive risk

METHODS

We performed Echo color Doppler examinations on 100 glaucomatous patients (197 eyes). Ophthalmic artery and central retinal artery were particularly considered. The study included eyes in every level and type of glaucoma, and in various types of treatment (topical therapy, Argon laser trabeculoplasty, Argon/YAG/surgical iridectomy, trabeculectomy). The parameters we considered were: ocular tension, anterior chamber angle, optic disc excavation, visual field, refraction and vascular risk factors. We measured the flow values of the ophthalmic artery and of the central retinal artery, i.e. maximal systolic velocity, diastolic velocity and vascular resistance index.

RESULTS

We observed that if we divide the value of ocular tension by the systolic velocity and multiply the result by the resistance index, we obtain a number which may be considered as a prognostic factor of evolutive risk. We compared our cases with a population free from glaucomatous and cardiovascular problems.

[Acute myocardial infarct in a young cocaine user]

In patients less than 40 years of age, acute myocardial infarction (AMI) has special clinical and pathophysiologic characteristics. Its prevalence varies between 5 and 10%. In such patients, AMI associated with chronic cocaine abuse has a non-negligible prevalence of 6%. The purpose of this report is to describe the case of a 24-year old male patient with smoking habits and chronic abuse of cocaine and hallucinogenic drugs. This patient developed clinical, enzymatic and electrocardiographic criteria of anterior AMI, two hours after the ingestion of an LSD-like hallucinogenic drug. The coronary angiography revealed a critical stenosis of the medium segment of the left anterior descendent artery, and a pre-stenotic aneurysmatic dilatation. In order to determine the etiology of the aneurysm, various laboratory and histologic tests were performed. The results of these were normal. We review the pathophysiology, clinical manifestations and prognosis of cocaine-associated AMI.