Intranasal antihistamines in the treatment of idiopathic non-allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

Idiopathic rhinitis (IR), previously known as vasomotor rhinitis (VMR), is the most common type of non-allergic rhinitis (NAR) which affects around 100 million people worldwide. The treatment of patients with IR is not standardized. Intranasal antihistamines (INAH) are potent drugs in the treatment of allergic rhinitis but are frequently prescribed in the treatment of IR. This systematic review of the literature and meta-analysis aims to assess the effects of INAH on IR.

METHODOLOGY

A comprehensive review of the literature was conducted on Medline, Embase and Cochrane library. Randomized, controlled trials and non-randomized comparative parallel group trials comparing INAH to placebo or different INAHs were included. The primary outcome was the change in disease specific quality of life questionnaires, total nasal symptom score (TNSS). The secondary outcomes were other reported nasal symptom scores, individual symptom scores and adverse events.

RESULTS

Six trials out of 987 assessing a total of 675 participants were deemed relevant for inclusion. Compared to placebo, INAH decreased total nasal symptom scores. One study also reported reduction of symptoms recorded on a visual analogue scale. There was no difference between the INAHs in terms of efficacy. Bitter taste sensation was the most frequently reported adverse event.

CONCLUSIONS

INAHs seem to have benefit over placebo on nasal symptoms improvement in the treatment of NAR. No superiority between INAHs was identified.

Echocardiographic strategy for early detection of cardiotoxicity of doxorubicin: a prospective observational study

Background

Cancer chemotherapy using anthracyclines is associated with cardiotoxicity (CTX), and left ventricular ejection fraction (LVEF) analysis is not sensitive to early cardiotoxic changes. Left ventricular global longitudinal strain (LV GLS) monitoring helps screen subclinical CTX; however, the intervals at which it should be performed remain unclear. We aimed to evaluate the incidence of CTX in women with breast cancer and the associated factors and compare two echocardiographic monitoring strategies using two cutoff points for LV GLS variation.

Methods

Patients with breast cancer prescribed doxorubicin underwent serial LVEF and LV GLS assessments using two-dimensional echocardiography every 3 weeks for 6 months.

Results

We included 43 women; none developed a clinical CTX. Considering a relative reduction of LV GLS > 15%, subclinical CTX was present in 12 (27.9%) and six (14%) patients at 3-week and 3-month intervals, respectively (P = 0.28). Additionally, considering a reduction of > 12%, subclinical CTX was present in 17 (39.5%) and 10 (23.3%) patients (P = 0.16), respectively. There were no significant differences in either reference value at 3-week (P = 0.19) and 3-month intervals (P = 0.41). Age ≥ 60 years (P = 0.018) and hypertension (HTN) (P = 0.022) were associated with subclinical CTX in the univariate analysis.

Conclusions

There was no difference in the incidence of subclinical CTX between the two cutoff points and no benefit in performing echocardiography every 3 weeks compared with quarterly monitoring. Advanced age and HTN were associated with the development of subclinical CTX.

Characterization of neuropsychiatric symptoms in a group of individuals with manifest or pre-motor Huntington’s disease in Medellín, Colombia

Introduction

Huntington’s disease (HD) is a rare (1-9/100 000), inherited disease characterized by an elongated CAG repeat on chromosome 4p, leading to a degeneration of neurons. Also, psychiatric symptoms are very common in the early stage and may appear before motor symptoms.

Objectives

To characterize neuropsychiatric symptoms in a group of individuals with manifest or pre-motor Huntington’s disease in Medellín, Colombia.

Methods

Data obtained from clinical records of individuals with HD (motor-manifest or pre-motor with triplets count) evaluated for ENROLL-HD project in the Group of Neuroscience of Antioquia. We explored variables related to substances abuse, neuropsychiatric symptoms, the respective age of onset, sex, and triplet count when available.

Results

Twenty-six (53%) were women, 8% had a familiar history of psychotic illness in a first-degree relative and 88% presented motor symptoms. Also, 59% had a history of depression, 53% irritability, 57% aggressiveness, 34% apathy, 29% perseverative/obsessive behavior, 14% psychosis, and 30% mild cognitive impairment. Ten individuals (20%) had motor without neuropsychiatric symptoms. Also, thirty-seven individuals (76%) presented motor and neuropsychiatric symptoms; of these, 41% had neuropsychiatric symptoms before motor symptoms. No psychiatric symptoms were associated with the use of alcohol, cigarettes, or drugs of abuse.

Conclusions

Neuropsychiatric symptoms are highly prevalent among individuals with HD and studies oriented to create relevant knowledge for the development of advice oriented to people with this disease are necessary.

Disclosure

No significant relationships.

Correlation Between 2D Strain and Classic Echocardiographic Indices in the Diagnosis of Right Ventricular Dysfunction in COPD

Purpose

This study aims to define which of the right ventricular myocardial deformation indices best correlates with the classic echocardiographic measurements and indices of right ventricular (RV) dysfunction in patients with stable chronic obstructive pulmonary disease (COPD).

Patients and Methods

Ninety-one patients with stable COPD underwent clinical evaluation, spirometry, a 6-minute walk test, and echocardiographic examination. Patients were divided into two groups: “with RV dysfunction” (≥1 classic parameter) and “without RV dysfunction”. We used speckle tracking to estimate myocardial deformation. For all analyses, results were considered significant if p < 0.05.

Results

The mean age across all participants was 65 ± 9 years, with 53% (48/91) being male. Patients in the group with RV dysfunction were able to walk shorter distances and had higher estimated right ventricular systolic pressure (RVSP) and mean pulmonary arterial pressure (mPAP). The RV free wall longitudinal strain (RVFWLS) was the only deformation indices that showed a significant correlation with all classic measurements and indices in the diagnosis of RV dysfunction (Wald test, 10.24; p < 0.01; odds ratio, 1.61). In the ROC curve analysis, the absolute value <20% was the lowest cut-off point of this index for detection of RV dysfunction (AUC = 0.93, S: 95.8%, and E: 88%).

Conclusion

In COPD patients, RVFWLS is the myocardial deformation index that best correlates with classic echocardiographic parameters for the diagnosis of RV dysfunction using <20% as a cut-off point.

Acute Hemodynamic Index Predicts In-Hospital Mortality in Acute Decompensated Heart Failure

Fundamento

O exame físico permite a avaliação prognóstica de pacientes com insuficiência cardíaca (IC) descompensada, porém não é suficientemente confiável e depende da experiência clínica do profissional. Considerando as respostas hemodinâmicas a situações do tipo “luta ou fuga” tais como a admissão no serviço de emergência, foi proposto o índice hemodinâmico agudo (IHA), calculado a partir da frequência cardíaca e pressão de pulso.

Objetivo

avaliar a capacidade prognóstica intra-hospitalar do IHA na IC descompensada.

Métodos

estudo prospectivo, multicêntrico e observacional baseado no registro BREATHE, incluindo dados de hospitais públicos e privados no Brasil. Foram utilizadas análises ROC ( Receiver Operating Characteristic ), de estatística c e de regressão multivariada, assim como o critério de informação de Akaike, para testar a capacidade prognóstica do IHA. O valor-p < 0,05 foi considerado estatisticamente significativo.

Resultados

Foram analisados dados de 463 pacientes com IC com fração de ejeção reduzida a partir do registro BREATHE. A mortalidade intra-hospitalar foi de 9%. A mediana do IHA foi considerada o valor de corte (4 mmHg⋅bpm). Um baixo IHA (≤ 4 mmHg⋅bpm) foi encontrado em 80% dos pacientes falecidos. O risco de mortalidade intra-hospitalar em pacientes com baixo IHA foi 2,5 vezes maior que aquele para pacientes com IHA > 4 mmHg⋅bpm. O IHA foi capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada [sensibilidade: 0,786; especificidade: 0,429; AUC (área sob a curva): 0,607 (0,540-0,674), p = 0,010] mesmo depois dos ajustes para comorbidades e uso de medicamentos [razão de chances (RC): 0,061 (0,007-0,114), p = 0,025].

Conclusões

O IHA é capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada. Esse índice simples e realizado à beira do leito pode se mostrar útil em serviços de emergência. (Arq Bras Cardiol. 2021; 116(1):77-86)

Pediatric hard palate foreign bodies: Case report and Systematic review of the literature

INTRODUCTION

Foreign body impaction in the pediatric hard palate is a rarely described otolaryngologic entity. It is often misdiagnosed as a neoplastic or an inflammatory lesion causing much stress to parents. The aim of this paper is to report a case managed in our department and to present a systematic review of the literature on pediatric hard palate foreign body impaction.

CASE REPORT

We present the case and the management of an impacted plastic screw cap in the hard palate of a 9 month-old boy.

MATERIAL AND METHODS

Following the PRISMA guidelines, a systematic review was conducted in August 2019 using Medline and Embase databases. Included articles were reviewed for mean age at presentation, gender, presumptive diagnosis, time to removal, foreign body type, average size, anesthesia type and complications.

RESULTS

32 reported cases were included. Foreign bodies were mistaken for other diagnoses in 24 cases. Mean duration from first presentation till removal was 56.9 days. Circular plastic covers were found in 20 cases. General anesthesia was used in 68% of the cases. No major complications were reported.

CONCLUSIONS

Foreign body impaction should be kept in the differential diagnosis of hard palate lesions in children. Up to date, this entity is still frequently misdiagnosed.

Impacto dos Modos de Estimulação DDD e VVIR na Capacidade Funcional e Qualidade de Vida de Pacientes Chagásicos

Introdução: A estimulação atrioventricular propicia benefícios hemodinâmicos em relação à ventricular isolada, mas essa vantagem não está completamente estabelecida em pacientes chagásicos com disfunção sistólica. Objetivo:Avaliar a infl uência dos modos de estimulação DDD e VVIR na capacidade funcional, qualidade de vida (QV) e alterações laboratoriais de peptídeo natriurético em pacientes chagásicos com disfunção ventricular submetidos a implante de marcapasso. Métodos: Estudaram-se prospectivamente 20 pacientes (55% do sexo masculino) com média de idade de 62,7(± 9,9 anos) e média da fração de ejeção de 41,8% (± 2,8). Alternadamente, os pacientes receberam a estimulação nos modos DDD e VVIR por um período de três meses sob cada programação. O mínimo percentual de estimulação ventricular admitido foi de 80%. Após cada período, o paciente foi submetido ao teste de caminhada de seis minutos (TC6M), avaliação de QV pelo Minnesota Living with Heart Failure Questionnaire (MLHFQ) e pelo Assesment of QUAlity of life and RELated events (AQUAREL). A avaliação laboratorial foi realizada com a dosagem da fração N-terminal do peptídeo natriurético cerebral (N-terminal pro b-type natriuretic peptide – NT-proBNP). Resultados: A média da distância percorrida no TC6M nos modos DDD e VVIR foram respectivamente 390,60 (± 52,71) e 396,30 (± 52,71) metros (p = 0,160). Verifi caram-se resultados de QV inferiores, considerando o domínio físico do MLHFQ (p = 0,03) e os domínios dispneia de esforço(p = 0,05) e arritmia (p < 0,001) do AQUAREL, com o modo VVIR. Os níveis de NT-proBNP aumentaram signifi cativamente com a estimulação no modoVVIR (p < 0,001). Conclusão: Após três meses de estimulação com omodo VVIR, houve piora da QV dos pacientes chagásicos e aumento dos níveis de NT-proBNP (registro de ensaio clínico: ReBEc RBR-53x476)

Impact of DDD and VVIR Stimulation Modes on Functional Capacity and Quality of Life of Chagasic Patients

Introduction: Atrioventricular stimulation provides hemodynamic benefits over the isolated ventricular rate, but this advantage is not completely established in chagasic patients with systolic dysfunction. Objectives: To evaluate the influence of DDD and VVIR stimulation modes on functional capacity, quality of life (QoL) and laboratory abnormalities of a natriuretic peptide in chagasic patients with ventricular dysfunction submitted to pacemaker implantation. Methods: Twenty patients (55% male) with a mean age of 62.7 (± 9.9 years) and a mean ejection fraction of 41.8% (± 2.8) were prospectively studied. Alternately, patients received pacing in the DDD and VVIR modes for a period of three months under each schedule. The minimum percentage of ventricular pacing was 80%. After each period, the patient was submitted to the six-minute walk test (6MWT), QOL assessment by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Assay of QUAlity of life and RELated events (AQUAREL). Laboratory evaluation was performed with the N-terminal fraction of the brain natriuretic peptide (N-terminal pro b-type natriuretic peptide - NT-proBNP). Results: The mean distance walked on the 6MWT in the DDD and VVIR modes were 390.60 (± 52.71) and 396.30 (± 52.71) meters respectively (p = 0.160). Results of lower QOL were found, considering the physical domain of the MLHFQ (p = 0.03) and the domains of effort dyspnea (p = 0.05) and arrhythmia (p <0.001) of the AQUAREL with the VVIR mode. NT-proBNP levels increased significantly with stimulation in VVIR mode (p < 0.001). Conclusion: After three months of stimulation with the VVIR mode, there was worsening of the QoL of the chagasic patients and increase of the levels of NT-proBNP (clinical trial record: ReBEc RBR-53x476).

Safety profile and efficacy of ivabradine in heart failure due to Chagas heart disease: a post hoc analysis of the SHIFT trial

AIMS

The SHIFT trial showed that ivabradine reduced heart rate (HR) and the risk of cardiovascular outcomes. Concerns remain over the efficacy and safety of ivabradine on heart failure (HF) due to Chagas disease (ChD). We therefore conducted a post hoc analysis of the SHIFT trial to investigate the effect of ivabradine in these patients.

METHODS AND RESULTS

SHIFT was a randomized, double-blind, placebo-controlled trial in symptomatic systolic stable HF, HR ≥ 70 b.p.m., and in sinus rhythm. The ChD HF subgroup included 38 patients, 20 on ivabradine, and 18 on placebo. The ChD HF subgroup showed high prevalence of bundle branch right block and, compared with the overall SHIFT population, lower systolic blood pressure; higher use of diuretics, cardiac glycosides, and antialdosterone agents; and lower use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker or target daily dose of beta-blocker. ChD HF presented a poor prognosis (all-cause mortality at 2 years was ~60%). The mean twice-daily dose of ivabradine was 6.26 ± 1.15 mg and placebo 6.43 ± 1.55 mg. Ivabradine reduced HR from 77.9 ± 3.8 to 62.3 ± 10.1 b.p.m. (P = 0.005) and improved functional class (P = 0.02). A trend towards reduction in all-cause death was observed in ivabradine arm vs. placebo (P = 0.07). Ivabradine was not associated with serious bradycardia, atrioventricular block, hypotension, or syncope.

CONCLUSIONS

ChD HF is an advanced form of HF with poor prognosis. Ivabradine was effective in reducing HR in these patients and improving functional class. Although our results are based on a very limited sample and should be interpreted with caution, they suggest that ivabradine may have a favourable benefit-risk profile in ChD HF patients.

Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region

OBJECTIVES

To evaluate the systematic chain of care for patients with acute ST-elevation myocardial infarction (STEMI) referred for primary angioplasty in a capital city in Midwestern Brazil.

BACKGROUND

Acute myocardial infarction is recognized as an important cause of morbidity and mortality and as a public health problem worldwide. Early specialized care is crucial for a good prognosis.

METHODS

All STEMI patients receiving care through the public health system at two tertiary care centers from March 2012 to June 2014 were retrospectively analyzed. Symptom onset-to-balloon time and door-to-balloon time were analyzed and compared with current guideline recommendations.

RESULTS

A total of 835 patients were included. Median symptom onset-to-balloon time was 32 h. A total of 783 (94%) patients had had symptoms for more than 12 h and 507 (61%) for more than 24 h. Only 51 (6%) patients arrived within 12 h of symptom onset and were treated with primary angioplasty. Among these patients, median door-to-balloon time was 37 min, in accordance with guideline recommendations.

CONCLUSION

Treatment of STEMI through the public health system in a capital city in Midwestern Brazil falls short of the recommended guidelines due to failure in the initial links of the chain of care. This potentially reversible failure has an important impact on patient outcomes and on health care burden.

Angiotensin-Converting Enzyme ID Polymorphism in Patients with Heart Failure Secondary to Chagas Disease

Background

Changes in the angiotensin-converting enzyme (ACE) gene may contribute to the increase in blood pressure and consequently to the onset of heart failure (HF). The role of polymorphism is very controversial, and its identification in patients with HF secondary to Chagas disease in the Brazilian population is required.

Objective

To determine ACE polymorphism in patients with HF secondary to Chagas disease and patients with Chagas disease without systolic dysfunction, and to evaluate the relationship of the ACE polymorphism with different clinical variables.

Methods

This was a comparative clinical study with 193 participants, 103 of them with HF secondary to Chagas disease and 90 with Chagas disease without systolic dysfunction. All patients attended the outpatient department of the General Hospital of the Federal University of Goias general hospital. Alleles I and D of ACE polymorphism were identified by polymerase chain reaction of the respective intron 16 fragments in the ACE gene and visualized by electrophoresis.

Results

In the group of HF patients, 63% were male, whereas 53.6% of patients with Chagas disease without systolic dysfunction were female (p = 0,001). The time from diagnosis varied from 1 to 50 years. Distribution of DD, ID and II genotypes was similar between the two groups, without statistical significance (p = 0,692). There was no difference in clinical characteristics or I/D genotypes between the groups. Age was significantly different between the groups (p = 0,001), and mean age of patients with HF was 62.5 years.

Conclusion

No differences were observed in the distribution of (Insertion/Deletion) genotype frequencies of ACE polymorphism between the studied groups. The use of this genetic biomarker was not useful in detecting a possible relationship between ACE polymorphism and clinical manifestations in HF secondary to Chagas disease.

Prognostic Factors in Severe Chagasic Heart Failure

BACKGROUND

Prognostic factors are extensively studied in heart failure; however, their role in severe Chagasic heart failure have not been established.

OBJECTIVES

To identify the association of clinical and laboratory factors with the prognosis of severe Chagasic heart failure, as well as the association of these factors with mortality and survival in a 7.5-year follow-up.

METHODS

60 patients with severe Chagasic heart failure were evaluated regarding the following variables: age, blood pressure, ejection fraction, serum sodium, creatinine, 6-minute walk test, non-sustained ventricular tachycardia, QRS width, indexed left atrial volume, and functional class.

RESULTS

53 (88.3%) patients died during follow-up, and 7 (11.7%) remained alive. Cumulative overall survival probability was approximately 11%. Non-sustained ventricular tachycardia (HR = 2.11; 95% CI: 1.04 - 4.31; p<0.05) and indexed left atrial volume ≥ 72 mL/m2 (HR = 3.51; 95% CI: 1.63 - 7.52; p<0.05) were the only variables that remained as independent predictors of mortality.

CONCLUSIONS

The presence of non-sustained ventricular tachycardia on Holter and indexed left atrial volume > 72 mL/m2 are independent predictors of mortality in severe Chagasic heart failure, with cumulative survival probability of only 11% in 7.5 years.

Dobutamine Stress Echocardiography Safety in Chagas Disease Patients

BACKGROUND:

A few decades ago, patients with Chagas disease were predominantly rural workers, with a low risk profile for obstructive coronary artery disease (CAD). As urbanization has increased, they became exposed to the same risk factors for CAD of uninfected individuals. Dobutamine stress echocardiography (DSE) has proven to be an important tool in CAD diagnosis. Despite being a potentially arrhythmogenic method, it is safe for coronary patients without Chagas disease. For Chagas disease patients, however, the indication of DSE in clinical practice is uncertain, because of the arrhythmogenic potential of that heart disease.

OBJECTIVES:

To assess DSE safety in Chagas disease patients with clinical suspicion of CAD, as well as the incidence of arrhythmias and adverse events during the exam.

METHODS:

Retrospective analysis of a database of patients referred for DSE from May/2012 to February/2015. This study assessed 205 consecutive patients with Chagas disease suspected of having CAD. All of them had their serology for Chagas disease confirmed.

RESULTS:

Their mean age was 64±10 years and most patients were females (65.4%). No patient had significant adverse events, such as acute myocardial infarction, ventricular fibrillation, asystole, stroke, cardiac rupture and death. Regarding arrhythmias, ventricular extrasystoles occurred in 48% of patients, and non-sustained ventricular tachycardia in 7.3%.

CONCLUSION:

DSE proved to be safe in this population of Chagas disease patients, in which no potentially life-threatening outcome was found.

FUNDAMENTO:

Até poucas décadas atrás, os pacientes chagásicos eram predominantemente trabalhadores rurais, com baixo perfil de risco para doença obstrutiva coronária. Com a crescente urbanização, passaram a ter os mesmos fatores de risco para doença aterosclerótica que indivíduos não infectados. O ecocardiograma sob estresse com dobutamina (EED) é uma importante ferramenta no diagnóstico de coronariopatia. É referido, porém, como um método potencialmente arritmogênico, mas seguro, em pacientes coronarianos não chagásicos. Entretanto, há insegurança na prática clínica de indicá-lo no paciente chagásico, devido ao potencial arritmogênico já intrínseco nesta cardiopatia.

OBJETIVOS:

Analisar a segurança do EED em uma população de chagásicos com suspeita clínica de coronariopatia.

MÉTODOS:

Análise retrospectiva de um banco de dados de pacientes encaminhados para a realização do EED entre maio/2012 e fevereiro/2015. Avaliou-se pacientes consecutivos portadores de doença de Chagas e com suspeita de coronariopatia. Confirmou-se a sorologia para doença de Chagas em todos os pacientes.

RESULTADOS:

A média etária dos 205 pacientes analisados foi de 64 ± 10 anos, sendo a maioria do sexo feminino (65,4%). Nenhum paciente apresentou eventos adversos significativos, como infarto agudo do miocárdio, fibrilação ventricular, assistolia, acidente vascular encefálico, ruptura cardíaca ou morte. Quanto às arritmias, extrassístoles ventriculares frequentes ocorreram em 48% dos pacientes, taquicardia ventricular não sustentada em 7,3%, bigeminismo em 4,4%, taquicardia supraventricular e taquicardia ventricular sustentada em 1% e fibrilação atrial em 0,5%.

CONCLUSÃO:

O EED mostrou ser um exame seguro nessa população de pacientes chagásicos, onde nenhum desfecho grave foi encontrado.

Comparative study between two recombinant human NPH insulin formulations for the treatment of type 2 diabetes mellitus

OBJECTIVE

To compare the effects of the neutral protamine Hagedorn (NPH) recombinant human insulin formulations Gansulin and Humulin N® on the glycemic control of patients with type 2 diabetes mellitus (T2DM).

SUBJECTS AND METHODS

Prospective, double-blind, randomized, parallel, single-center study of 37 individuals with T2DM treated with NPH insulin formulations. The Tukey-Kramer test for multiple comparisons, the Wilcoxon paired comparison test and the Chi-Square test were used for the statistical analyses. The significance level was set at 5% (p < 0.05).

RESULTS

The NPH insulin formulations Humulin and Gansulin similarly reduced the HbA1c levels observed at the end of the study compared with the values obtained at the beginning of the study. In the Humulin group, the initial HbA1c value of 7.91% was reduced to 6.56% (p < 0.001), whereas in the Gansulin group, the reduction was from 8.18% to 6.65% (p < 0.001). At the end of the study, there was no significant difference between the levels of glycated hemoglobin (p = 0.2410), fasting plasma glucose (FG; p = 0.9257) and bedtime plasma glucose (BG; p = 0.3906) between the two insulin formulations. There was no nt difference in the number of hypoglycemic events between the two insulin formulations, and no severe hyp episodes were recorded.

CONCLUSION

This study demonstrated similar glycemic control by NPH insulin Gansulin compared with human insulin Humulin N® in patients with T2DM.

Right ventricular Doppler echocardiographic study of indeterminate form of chagas disease

BACKGROUND

Patients with indeterminate form of Chagas disease/cardiac normality (ICD/CN) exhibited normal electrocardiograms and chest X-rays; however, more sophisticated tests detected some degree of morphological and functional changes in the heart.

OBJECTIVE

To assess the prevalence of systolic and diastolic dysfunction of the right ventricle (RV) in patients with ICD/CN.

METHODS

This was a case-control and prevalence study. Using Doppler two-dimensional echocardiography (2D), 92 patients were assessed and divided into two groups: group I (normal, n = 31) and group II (ICD/CN, n = 61).

RESULTS

The prevalence of RV systolic dysfunction in patients in groups I and II was as follows: fractional area change (0.0% versus 0.6%), mobility of the tricuspid annulus (0.0% versus 0.0%), and S-wave tissue Doppler (6.4% versus 26.0%, p = 0.016). The prevalence of global disorders such as the right myocardial performance index using tissue Doppler (16.1% versus 27.8%, p = 0.099) and pulsed Doppler (61.3% versus 68%, p = 0.141) and diastolic disorders such as abnormal relaxation (0.0% versus 6.0%), pseudonormal pattern (0.0% versus 0.0%), and restrictive pattern (0.0% versus 0.0%) was not statistically different between groups.

CONCLUSION

The prevalence of RV systolic dysfunction was estimated to be 26% (S wave velocity compared with other variables), suggesting incipient changes in RV systolic function in the ICD/CN group.

Incidence of ventricular arrhythmias after stem cell therapy in patients with Chagas cardiomyopathy

Background

Treatment with stem cells in several cardiomyopathies may be related to the increase in arrhythmias.

Objectives

To determine whether intracoronary injection of stem cells in patients with Chagas cardiomyopathy is associated with increased incidence of ventricular arrhythmias, compared to the Control Group.

Methods

A retrospective cohort study that evaluated the medical records of 60 patients who participated in a previous cross-sectional study. The following data were collected: age, gender, drugs used and Holter variables that demonstrated the presence of arrhythmias. Holter was performed in four stages: randomization, 2, 6 and 12 months segments. The Control Group received medical treatment and intracoronary injection of placebo and the Study Group had drug treatment and autologous stem cell implant.

Results

There was no difference between Control Group and Study Group when analyzing the arrhythmia criteria. In the intra-group analysis, significant difference was found between the Holter tests of the Study Group for the variable total ventricular premature beats when compared with baseline, with p = 0.014 between Holter at randomization and Holter at 2 months, p = 0.004 between Holter at randomization and Holter at 6 months, and p = 0.014 between Holter at randomization and Holter at 12 months. The variable non-sustained ventricular tachycardia between Holter at randomization and Holter at 6 months showed p = 0.036.

Conclusion

The intracoronary injection of stem cells did not increase the incidence of ventricular arrhythmias in patients with Chagas cardiomyopathy compared to the Control Group.

Echocardiographic parameters and survival in Chagas heart disease with severe systolic dysfunction

Background

Echocardiography provides important information on the cardiac evaluation of patients with heart failure. The identification of echocardiographic parameters in severe Chagas heart disease would help implement treatment and assess prognosis.

Objective

To correlate echocardiographic parameters with the endpoint cardiovascular mortality in patients with ejection fraction < 35%.

Methods

Study with retrospective analysis of pre-specified echocardiographic parameters prospectively collected from 60 patients included in the Multicenter Randomized Trial of Cell Therapy in Patients with Heart Diseases (Estudo Multicêntrico Randomizado de Terapia Celular em Cardiopatias) - Chagas heart disease arm. The following parameters were collected: left ventricular systolic and diastolic diameters and volumes; ejection fraction; left atrial diameter; left atrial volume; indexed left atrial volume; systolic pulmonary artery pressure; integral of the aortic flow velocity; myocardial performance index; rate of increase of left ventricular pressure; isovolumic relaxation time; E, A, Em, Am and Sm wave velocities; E wave deceleration time; E/A and E/Em ratios; and mitral regurgitation.

Results

In the mean 24.18-month follow-up, 27 patients died. The mean ejection fraction was 26.6 ± 5.34%. In the multivariate analysis, the parameters ejection fraction (HR = 1.114; p = 0.3704), indexed left atrial volume (HR = 1.033; p < 0.0001) and E/Em ratio (HR = 0.95; p = 0.1261) were excluded. The indexed left atrial volume was an independent predictor in relation to the endpoint, and values > 70.71 mL/m² were associated with a significant increase in mortality (log rank p < 0.0001).

Conclusion

The indexed left atrial volume was the only independent predictor of mortality in this population of Chagasic patients with severe systolic dysfunction.

Is conventional cardiac pacing harmful in patients with normal ventricular function?

BACKGROUND

Right ventricular pacing may be deleterious in patients with left ventricular dysfunction, but in patients with normal function the impact of this stimulation triggering clinically relevant ventricular dysfunction is not fully established.

OBJECTIVES

To evaluate the clinical, echocardiographic findings of patients with previously normal left ventricular function underwent implantation of a pacemaker.

METHODS

Observational, cross-sectional study with 20 patients, who underwent implantation of pacemaker, prospectively followed-up, with the following inclusion criteria: normal left ventricular function defined by echocardiography and ventricular pacing higher than 90%. Were evaluated functional class (FC) (New York Heart Association), 6-minute walk test (6MWT), B-type natriuretic peptide (BNP), echocardiographic assessment (conventional and dyssynchrony parameters), and quality of life questionnaire (QLQ) (SF-36). The assessment was performed at ten days (t1), four months (t2), eight months (t3), 12 months (t4) and 24 months (t5).

RESULTS

Conventional echocardiographic parameters and dyssynchrony parameters showed statistically significant variation over time. The 6MWT, FC, and BNP showed worsening at the end of two years. QLQ showed initial improvement and worsening at the end of two years.

CONCLUSION

The implantation of conventional pacemaker was associated with worsening in functional class, worsening in walk test, increased BNP levels, increased duration of QRS, and worsening in some domains of the QLQ at the end of two years. There were no changes in echocardiography measurements (conventional and asynchrony measures).

IRON-HF study: a randomized trial to assess the effects of iron in heart failure patients with anemia

BACKGROUND

Anemia in heart failure patients and has been associated with increased morbi-mortality. Previous studies have treated anemia in heart failure patients with either erythropoietin alone or combination of erythropoietin and intravenous (i.v.) iron. However, the effect of i.v. or oral (p.o.) iron supplementation alone in heart failure patients with anemia was virtually unknown.

AIM

To compare, in a double-blind design, the effects of i.v. iron versus p.o. iron in anemic heart failure patients.

METHODS

IRON-HF study was a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that enrolled anemic heart failure patients with preserved renal function, low transferrin saturation (TSat) and low-to-moderately elevated ferritin levels. Interventions were Iron Sucrose i.v. 200 mg, once a week, for 5 weeks, ferrous sulfate 200 mg p.o. TID, for 8 weeks, or placebo. Primary endpoint was variation of peak oxygen consumption (peak VO2) assessed by ergospirometry over 3 month follow-up.

RESULTS

Eighteen patients had full follow-up data. There was an increment of 3.5 ml/kg/min in peak VO2 in the i.v. iron group. There was no increment in peak VO2 in the p.o. iron group. Patients' ferritin and TSat increased significantly in both treated groups. Hemoglobin increased similarly in all groups.

CONCLUSION

I.v. iron seems to be superior in improving functional capacity of heart failure patients. However, correction of anemia seems to be at least similar between p.o. iron and i.v. iron supplementation.

Influence of creatine supplementation on the functional capacity of patients with heart failure

BACKGROUND

Heart failure (HF) is a complex syndrome characterized by intolerance to exertion and reduced functional capacity.

OBJECTIVE

To assess the functional capacity of patients with HF and supplemented with creatine.

METHODS

Prospective, randomized, double-blind study. Thirty-three male patients over the age of 18 years with functional class II to IV HF were randomized into two groups as follows: the experimental group (CRE, n = 17), supplemented with 5 g/day of creatine for six months; and the placebo group (PLA, n = 16), receiving 5 g/day of maltodextrin for that same period. Both groups underwent functional capacity assessment by use of cardiopulmonary exercise test and 6-minute walk test (6MWT) before and after the intervention. The Ancova statistical model and Pearson correlation were used to assess the groups and the treatment.

RESULTS

Of the variables assessed on the cardiopulmonary exercise test, peak oxygen consumption (peak VO₂), anaerobic threshold (AT), and oxygen pulse (O₂ pulse) showed no significant differences between the groups (P>0.05). On the 6MWT, no significant difference was observed in the covered distance.

CONCLUSION

Creatine supplementation in patients with HF did not significantly improve functional capacity.

Cell therapy in Chagas cardiomyopathy (Chagas arm of the multicenter randomized trial of cell therapy in cardiopathies study): a multicenter randomized trial

BACKGROUND

Previous studies suggested that transplantation of autologous bone marrow-derived mononuclear cells (BMNCs) improves heart function in chronic chagasic cardiomyopathy. We report the results of the first randomized trial of BMNC therapy in chronic chagasic cardiomyopathy.

METHODS AND RESULTS

Patients 18 to 75 years of age with chronic chagasic cardiomyopathy, New York Heart Association class II to IV heart failure, left ventricular ejection fraction (LVEF) <35, and optimized therapy were randomized to intracoronary injection of autologous BMNCs or placebo. The primary end point was the difference in LVEF from baseline to 6 and 12 months after treatment between groups. Analysis was by intention to treat and powered to detect an absolute between-group difference of 5. Between July 2005 and October 2009, 234 patients were enrolled. Two patients abandoned the study and 49 were excluded because of protocol violation. The remaining 183 patients, 93 in the placebo group and 90 in the BMNC group, had a trimmed mean age of 52.4 years (range, 50.8-54.0 years) and LVEF of 26.1 (range, 25.1-27.1) at baseline. Median number of injected BMNCs was 2.20×10(8) (range, 1.40-3.50×10(8)). Change in LVEF did not differ significantly between treatment groups: trimmed mean change in LVEF at 6 months, 3.0 (1.3-4.8) for BMNCs and 2.5 (0.6-4.5) for placebo (P=0.519); change in LVEF at 12 months, 3.5 (1.5-5.5) for BMNCs and 3.7 (1.5-6.0) for placebo (P=0.850). Left ventricular systolic and diastolic volumes, New York Heart Association functional class, Minnesota quality-of-life questionnaire, brain natriuretic peptide concentrations, and 6-minute walking test did also not differ between groups.

CONCLUSION

Intracoronary injection of autologous BMNCs does not improve left ventricular function or quality of life in patients with chronic chagasic cardiomyopathy.

Asymptomatic coronary artery disease in chagasic patients with heart failure: prevalence and risk factors

BACKGROUND

Concomitant asymptomatic coronary artery disease in patients with Chagas cardiomyopathy in heart failure is controversial in the medical literature, as both diseases are prevalent in some regions of Brazil.

OBJECTIVE

To determine the prevalence of coronary artery disease (lesions > 50%) in a specific population of patients with Chagas cardiomyopathy in HF functional class III and IV, who had no previous coronary events.

METHODS

Coronary angiography was performed in 61 consecutive patients with Chagasic cardiomyopathy, in heart failure functional class III and IV, to exclude coronary artery disease. These patients were part of the Cell Therapy Study in Heart Diseases protocol, which required the coronary angiography to be carried out before stem cells were injected. Risk factors for atherosclerosis also analyzed in this population were: age, arterial hypertension, diabetes, dyslipidemia, smoking and overweight.

RESULTS

mean age was 51.6 + 9.6 years and 65.5% (n = 40) of them were males. The prevalence of coronary disease in this population was 1.6% (1). The prevalence of risk factors were: arterial hypertension 18% (11), smoking 59% (36), diabetes 1.6% (1) and dyslipidemia, 6.5% (4).

CONCLUSION

The prevalence of asymptomatic coronary artery disease in patients with severe heart failure due to Chagas disease is low and among the risk factors for coronary heart disease, smoking was the most prevalent.

Foreign body inhalation in the pediatric population: lessons learned from 106 cases

OBJECTIVES

To review the cases encountered in a tertiary care center so as to assess the incidence of foreign body aspiration in the pediatric population and to draw on our experience to improve prevention and early diagnosis.

PATIENTS AND METHODS

Retrospective study of 106 children under the age of 15 years, admitted to the Hôtel-Dieu de France hospital for flexible and/or rigid bronchoscopy between November 1998 and January 2010, for suspected foreign body aspiration (FBA).

RESULTS

Among the children, 56.6% were aged between one and three years. Peanuts or pistachios were found in 48% of cases. In 73% of cases, the FB was bronchial, and slightly more frequently on the right side (60%); 17.8% of cases presented in emergency immediately after inhalation; 12% presented with life-threatening symptoms; 29% presented within 24 hours and 49% were seen later than 72 hours. In 81% of subjects, a typical penetration syndrome was found on interviewing the parents. Physical pulmonary examination was normal in 21% of patients and chest X-ray in 21.8%. Rigid bronchoscopy was preceded by flexible bronchoscopy in 12% of cases. Parental underestimation of the gravity of the situation was a significant factor in delayed diagnosis. Among the patients, 64% examined 24 hours after inhalation were initially treated for another pathology. Delay in diagnosis and organic vs inorganic FB did not significantly correlate with duration of bronchoscopy. The rate of complications did not significantly increase after a 24-hour diagnostic delay threshold.

CONCLUSION

FB aspiration is a serious problem. A high index of suspicion is required in health care providers (ENT, pediatricians and family physicians). Physician and especially parental education are the main guarantors of significantly reduced morbidity and mortality in this pathology.

Epidemiological, clinical e therapeutic profile of heart failure in a tertiary hospital

BACKGROUND

Heart failure is a complex syndrome with multiple risk factors involved in its genesis, making its prevention and management difficult to achieve.

OBJECTIVE

To identify the main etiologies and risk factors in heart failure; to compare clinical and demographic characteristics of patients according to the etiology; analyze whether the treatment is according to that recommended by the Brazilian guidelines.

METHODS

Retrospective, descriptive and observational study, carried out at Hospital das Clínicas of Universidade Federal de Goiás. The patients were divided in four groups, according to the etiology, for comparison: chagasic cardiomyopathy, hypertensive cardiomyopathy, dilated cardiomyopathy and others, ischemic cardiomyopathy. The Chi-square and Fisher's Exact tests, ANOVA and Kruskal-Wallis tests were used in the analysis of the groups and types of treatment.

RESULTS

A total of 144 patients' files were analyzed; the patients' mean age was 61 ± 15 years and 54.2% of them were males. Chagasic cardiomyopathy was the main etiology (41%). Arterial hypertension (48.6%), anemia (22.9%), coronary disease (19.4%), dyslipidemia (17.3%) and diabetes (16.6%) were the main risk factors. There was a higher prevalence of female individuals among the hypertensive patients (p=0.044) as well as a higher frequency of pulmonary rales (p < 0.01). Heart rate was lower among chagasic patients (p < 0.001). The most often prescribed medications were diuretics (81.2%), angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (77.7%), beta-blockers (45.8%), spironolactone (35.4%), digitalis (30.5%) and vasodilators (8.3%).

CONCLUSION

Chagasic cardiomyopathy was the main cause of heart failure. No significant clinical differences were observed among patients from the four etiologic groups.

Study on the major maternal risk factors in hypertensive syndromes

BACKGROUND

There are several risk factors for hypertensive syndromes in pregnancy (HSP), and these can be related to regional and ethnic factors. Studies on this issue are scarce in the State of Goiás.

OBJECTIVE

To investigate maternal risk factors for HSP.

METHODS

Case-control study based on the analysis of medical records of parturients from the Maternity Service of Hospital das Clínicas da Universidade Federal de Goiás (HC-UFG) in 2005. Risk factors were analyzed using Logistic Regression Analysis and Fisher's Exact Test.

RESULTS

In 2005, there were 890 deliveries in the Maternity Service of HC-UFG, and 129 pregnant women were diagnosed with HSP (14.5%). The multivariate analysis identified obesity as a risk factor both for gestational hypertension--GH (OR: 17.636; 95% CI: 2.859 to 108.774) and for preeclampsia superimposed on chronic hypertension--PESCH (OR: 27.307; 95% CI: 4.453 to 167.440). Primiparity was a risk factor for GH (OR: 5.435; 95% CI: 1.923 to 15.385). Age above 30 years was a risk factor for PESCH (OR: 5.218; 95% CI: 1.873 to 14.536) and a protective factor against preeclampsia--PE (OR: 0.035; 95% CI: 0.003 to 0.364). Non-white race was an independent risk for PE (OR: 13.158; 95% CI: 1.672 to 100.000) and previous PE for PESCH (OR: 4.757; 95% CI: 1.261 to 17.938). Of the pregnant women with chronic hypertension (CH), 73.5% developed PESCH (p < 0.001).

CONCLUSION

The factors identified--obesity, non-white race, previous PE, age above 30 years and CH, were similar to those found in the majority of studies in the literature.

Levosimendan in decompensated heart failure patients: efficacy in a Brazilian cohort. Results of the BELIEF study

BACKGROUND

Levosimendan is a new inodilatory agent that enhances cardiac contractility via Ca(2+) sensitization and induces vasodilation through the activation of KATP/BKCa.

OBJECTIVE

To study the efficacy and safety of levosimendan in a decompensated heart failure (DHF) Brazilian cohort, and in b-adrenergic agonist resistant patients.

METHODS

The Brazilian Evaluation of Levosimendan Infusion Efficacy (BELIEF) study was prospective, multicenter, observational and included 182 high-risk DHF patients, all of which received open-label levosimendan. Primary end point was hospital discharge without additional inotropic therapy (responder). Secondary end points were changes in hemodynamics, clinical parameters, and brain natriuretic peptide (BNP).

RESULTS

Mortality rate was 14.8%, and 139 of 182 patients were responders. In non responders it was 62.8%. Systolic blood pressure was a predictor of response. In b-adrenergic agonist resistant group, 55.8% were responders. Overall, 54 patients experienced at least one adverse event; most of them resolved either spontaneously or after levosimendan dose reduction. A significant improvement in quality of life was verified at 2-6 months of follow-up (p<0.0001).

CONCLUSION

Our results suggest levosimendan infusion as an alternative therapy in the short term management of DHF patients. HF severity can influence the response to levosimendan treatment. Prospective studies are warranted in a Brazilian cohort including Chagas heart disease.

Rationale and Design of the IRON-HF Study: A Randomized Trial to Assess the Effects of Iron Supplementation in Heart Failure Patients With Anemia

BACKGROUND

Anemia is a common finding in heart failure (HF) patients and has been associated with increased morbidity and mortality. It is generally denominated as anemia of chronic disease (ACD), but the association with true ferropenic anemia is common. Many studies have investigated the effects of treating anemia in HF patients with either erythropoietin alone or combination of erythropoietin and intravenous iron. However, the effect of iron supplementation alone in HF patients with ACD, ferropenic anemia, or both is unknown.

METHODS AND RESULTS

IRON-HF study is a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that will enroll anemic HF patients with relatively preserved renal function, low transferrin saturation, low iron levels, and low to moderately elevated ferritin levels. Interventions are iron sucrose intravenously 200 mg once per week for 5 weeks, ferrous sulfate 200 mg by mouth 3 times per day for 8 weeks, or placebo. The primary objective is to assess the impact of iron supplementation (intravenously or by mouth) compared with placebo in HF patients with anemia from deficient iron availability. The primary end point is variation of peak oxygen consumption assessed by ergospirometry over 3-month follow-up. Secondary end points include functional class, brain natriuretic peptide levels, quality of life scores, left ventricular ejection fraction, adverse events, HF hospitalization, and death.

CONCLUSIONS

The results of IRON-HF should help to clarify the potential clinical impact of mild to moderate anemia correction in HF patients.