Use of direct oral anticoagulants for chronic thromboembolic pulmonary hypertension

OBJECTIVES: Chronic thromboembolic pulmonary hypertension is one of the most prevalent forms of pulmonary hypertension and is a major complication of acute pulmonary embolism. One mainstay of chronic thromboembolic pulmonary hypertension treatment is lifelong anticoagulation. The recent advent of direct oral anticoagulants for acute pulmonary embolism treatment has provided a viable and effective alternative for treating this condition. However, little is known about the efficacy of this new class of drugs for treating chronic thromboembolic pulmonary hypertension. We aimed to evaluate the safety and efficacy of direct oral anticoagulants in the treatment of chronic thromboembolic pulmonary hypertension. METHODS: A cohort of chronic thromboembolic pulmonary hypertension patients who initiated treatment with direct oral anticoagulants between June 2015 and November 2016 were enrolled in this study. RESULTS: Sixteen patients used rivaroxaban, three used dabigatran and one used apixaban for a mean follow-up of 20.9 months. The mean age was 51 years, and eighteen patients were classified as functional class II/III. Eight patients underwent a pulmonary endarterectomy and exhibited clinical, hemodynamic and functional improvement and currently continue to use direct oral anticoagulants. No episode of venous thromboembolism recurrence was identified during the follow-up period, but there was one episode of major bleeding after a traumatic fall. CONCLUSIONS: Although direct oral anticoagulants appear to be a safe and effective alternative for treating chronic thromboembolic pulmonary hypertension, larger studies are needed to support their routine use.

Métodos de conservación para actinobacterias con actividad solubilizadora de fósforo / Preservation methods for actinobacterias with phosphate solubilizing activity

El objetivo de esta investigación fue evaluar diferentes métodos de conservación para actinobacterias solubilizadoras de fósforo debido a la poca información de métodos específicos reportados para estos microorganismos. Los métodos de conservación se evaluaron a 3 diferentes periodos de tiempo; largo, mediano y corto plazo, usando métodos de congelación y liofilización; arcilla, sílica, arena y transferencia periódica, respectivamente. Para ello se usaron 15 aislamientos de 3 localidades diferentes (La Vega, Maní y Tota) y un banco de referencia de la Unidad de Investigaciones Agropecuarias de la Pontificia Universidad Javeriana. Se prepararon todos los inóculos en solución salina al 0,85% (p/v) y se ajustaron a una concentración de 10(8) cel/mL, seguido a ello se inocularon los viales de cada método de conservación con sus respectivos crioprotectantes, glicerol 20% (v/v), 30% (v/v) para congelación y skim milk 18% (p/v) para liofilización. Los métodos a mediano plazo se ejecutaron de igual manera, el inóculo se agregó a 10 perlas de arcilla, 10 g de arena y 5 g de sílica, posteriormente se almacenaron a 4 °C. El método de corto plazo se evaluó en agar avena (15 g/L). La evaluación se realizó mediante recuento directo en cámara de Neubauer por la técnica de azul de tripán, además de la caracterización macroscópica y microscópica de cada aislamiento en transferencia periódica. Se estableció que la actividad solubilizadora de fósforo se mantuvo más estable en los métodos de glicerol 30 % (p/v) y liofilización según el análisis estadístico.

The aim of this research was to evaluate different methods of preservation for actinobacteria with phosphate solubilization activity due to there are a few specific methods reported for these organisms. The methods were evaluated at three different time periods; long, medium and short-term and employing methods as cryopreservation and dry-freezing; clay, silica and sand; and periodically plating, respectively. Therefore 15 isolates from 3 different locations (La Vega, Maní and Tota) and a bank reference from Livestock Research Unit of the Pontificia Universidad Javeriana were used. All inocula were prepared in 0.85% saline solution (w/v) which were adjusted to a concentration of 10(8) cells/mL, followed each vial was inoculated with their respective storage cryoprotectants , glycerol 20% (v/v), 30% (v/v) to freeze and 18% skim milk (w/v) for dry-freezing. Medium-term methods were performed similarly; the inoculum was added to 10 clay beads, 10 g of sand and 5 g of silica and then stored at 4 °C. The short-term method was evaluated in oatmeal agar (15 g/L). The evaluation was performed by direct counting in a Neubauer chamberusing trypan blue staining technique, in addition to macroscopic and microscopic characterization of each isolate in periodic plating. It was established that the phosphorus solubilizing activity was more stable in glycerol 30% (w/v) and lyophilization for statistical analysis.

New anticoagulants for the treatment of venous thromboembolism / Os novos anticoagulantes no tratamento do tromboembolismo venoso

Worldwide, venous thromboembolism (VTE) is among the leading causes of death from cardiovascular disease, surpassed only by acute myocardial infarction and stroke. The spectrum of VTE presentations ranges, by degree of severity, from deep vein thrombosis to acute pulmonary thromboembolism. Treatment is based on full anticoagulation of the patients. For many decades, it has been known that anticoagulation directly affects the mortality associated with VTE. Until the beginning of this century, anticoagulant therapy was based on the use of unfractionated or low-molecular-weight heparin and vitamin K antagonists, warfarin in particular. Over the past decades, new classes of anticoagulants have been developed, such as factor Xa inhibitors and direct thrombin inhibitors, which significantly changed the therapeutic arsenal against VTE, due to their efficacy and safety when compared with the conventional treatment. The focus of this review was on evaluating the role of these new anticoagulants in this clinical context.

O tromboembolismo venoso (TEV) está entre as principais causas de morte por doenças cardiovasculares no mundo, atrás apenas do infarto agudo do miocárdio e do acidente vascular cerebral. O TEV possui espectro de apresentação que vai desde a trombose venosa profunda até o tromboembolismo pulmonar agudo, de acordo com gravidade crescente de acometimento, sendo seu tratamento baseado na anticoagulação plena dos pacientes. Há muitas décadas, sabe-se que a anticoagulação interfere diretamente na mortalidade associada ao TEV. Até o início deste século a terapia anticoagulante se baseava no uso de heparina, em suas formas não fracionada ou de baixo peso molecular, e de antagonistas da vitamina K, principalmente a varfarina. Ao longo das últimas décadas, foram desenvolvidos novas classes de medicamentos anticoagulantes, inibidores do fator Xa e inibidores diretos da trombina, que mudaram significativamente o arsenal terapêutico do TEV, em função de suas características de eficácia e segurança em relação ao tratamento convencional, sendo o foco principal de esta revisão avaliar seu papel neste contexto clínico.

Definição e classificação da hipertensão pulmonar / Pulmonary hipertension: definition and classification

A hipertensão pulmonar apresentou desenvolvimento bastante significativo nas últimas duas décadas, devido ao maior conhecimento fisiopatológico de suas mais diversas formas. Espelhando esse desenvolvimento, houve evolução da definição assim como do sistema de classificação da hipertensão pulmonar que divide os pacientes em 5 grupos distintos: hipertensão arterial pulmonar (HAP); Hipertensão pulmonar causada por doenças do coração esquerdo; Hipertensão pulmonar causada por doença pulmonar e/ou hipóxia; Hipertensão pulmonar tromboembólica crônica e Hipertensão pulmonar com mecanismos multifatoriais ou não esclarecidos. A classificação adequada dos pacientes é a base para a instituição terapêutica apropriada, particularmente considerando que a evidência atual que sustenta o uso das medicações disponíveis principalmente na doença arterial pulmonar. Sua adoção reforça a necessidade de avaliação diagnóstica abrangente em todos os casos de hipertensão pulmonar...

Pulmonary hypertension showed significant development in the last two decades due to higher pathophysiological knowledge of its various forms. Mirroring these developments, there was evolution of the definition as well as pulmonary hypertension classification system that divides patients into five groups: pulmonary arterial hypertension (PAH); Pulmonary hypertension caused by left heart diseases; Pulmonary hypertension caused by pulmonary disease and / or hypoxia; Chronic thromboembolic pulmonary hypertension and pulmonary hypertension with multifactorial mechanisms or unclear. The appropriate classification of patients is the basis for appropriate therapeutic institution particularly since the current evidence supporting the use of drugs available mainly in the lung artery disease. Its adoption reinforces the need for comprehensive diagnostic evaluation in all cases of pulmonary hypertension...

Left ventricular dysfunction in patients with suspected pulmonary arterial hypertension / Disfunção ventricular esquerda em pacientes com suspeita de hipertensão arterial pulmonar

OBJECTIVE: To evaluate the role of right heart catheterization in the diagnosis of pulmonary arterial hypertension (PAH). METHODS: We evaluated clinical, functional, and hemodynamic data from all patients who underwent right heart catheterization because of diagnostic suspicion of PAH-in the absence of severe left ventricular dysfunction (LVD), significant changes in pulmonary function tests, and ventilation/perfusion lung scintigraphy findings consistent with chronic pulmonary thromboembolism-between 2008 and 2013 at our facility. RESULTS: During the study period, 384 patients underwent diagnostic cardiac catheterization at our facility. Pulmonary hypertension (PH) was confirmed in 302 patients (78.6%). The mean age of those patients was 48.7 years. The patients without PH showed better hemodynamic profiles and lower levels of B-type natriuretic peptide. Nevertheless, 13.8% of the patients without PH were categorized as New York Heart Association functional class III or IV. Of the 218 patients who met the inclusion criteria, 40 (18.3%) and 178 (81.7%) were diagnosed with PH associated with LVD (PH-LVD) and with PAH, respectively. The patients in the HP-LVD group were significantly older than were those in the PAH group (p < 0.0001). CONCLUSIONS: The proportional difference between the PAH and PH-LVD groups was quite significant, considering the absence of echocardiographic signs suggestive of severe LVD during the pre-catheterization investigation. Our results highlight the fundamental role of cardiac catheterization in the diagnosis of PAH, especially in older patients, in whom the prevalence of LVD that has gone undiagnosed by non-invasive tests is particularly relevant. .

OBJETIVO: Avaliar o papel do cateterismo de câmaras cardíacas direitas no diagnóstico de hipertensão arterial pulmonar (HAP). MÉTODOS: Entre 2008 e 2013, foram avaliadas as características clínicas, funcionais e hemodinâmicas de todos os pacientes que realizaram cateterismo cardíaco direito por suspeita de HAP em nosso laboratório, depois de afastada a presença de disfunção ventricular esquerda (DVE) grave, de alterações significativas nos testes de função pulmonar ou de resultados de cintilografia pulmonar de inalação/perfusão compatíveis com tromboembolismo pulmonar crônico. RESULTADOS: Durante o período de estudo, 384 pacientes foram submetidos a cateterismo cardíaco diagnóstico. A hipertensão pulmonar (HP) foi confirmada em 302 pacientes (78,6%). A média de idade desses pacientes foi de 48,7 anos. Os pacientes sem HP apresentaram melhor perfil hemodinâmico e menores níveis de peptídio natriurético do tipo B que aqueles diagnosticados com HP. No entanto, 13,8% dos pacientes sem HP apresentavam-se em classe funcional III/IV do New York Heart Association. Dos 218 pacientes que cumpriam os critérios de inclusão, 40 (18,3%) e 178 (81,7%) foram diagnosticados como portadores de HP associada à DVE (HP-DVE) e HAP, respectivamente. O grupo HP-DVE tinha idade significativamente mais avançada que aqueles com HAP (p < 0,0001). CONCLUSÕES: A diferença proporcional entre os grupos HAP e HP-DVE foi bastante significativa, considerando a inexistência de sinais ecocardiográficos sugestivos de DVE importante como parte da investigação que antecedeu ...

Impact of a program to promote health and quality of life of elderly / Impacto de um programa de promoção da saúde na qualidade de vida do idoso

Objective: To evaluate the effect on quality of life of elderly people enrolled in the Grupo de Assistência Multidisciplinar ao Idoso Ambulatorial (GAMIA) of the Geriatric Service of the Hospital das Clínicas of the Faculdade de Medicina of Universidade de São Paulo. Methods: In 83 elderly participants of group between 2000 and 2002 the quality of life was assessed by the World Health Organization Quality of Life (WHOQOL-bref) at the beginning and the end of the program. Functionality was assessed by the Katz and Lawton scales and socio-demographic data were obtained from medical charts. Results: Females predominated (79.5%) and overall mean age was 69.30 years. Data analysis showed a reduction in the physical domain of WHOQOL-bref (p = 0.014) and increased psychological health and environment domains (p = 0.029 and p = 0.007 respectively), detecting a trend of increase in social relationships and in general domains (p = 0.062 and p = 0.052 respectively). Conclusions: The clinical evaluation of elderly may have the predominant factor for the deterioration of their perception in the physical domain because of the detection of previously unknown diseases and determination of the use of new drugs. Improvement in psychological health and the environment can be related to psychological and social support that the elderly received from peers and professionals and the benefits of group activities, as well as the upward trend observed in the social relationships and general domains. Participation in a program to promote healthy aging was effective in improving the quality of life of the elderly.

Objetivo: Avaliar os efeitos na qualidade de vida de idosos matriculados no Grupo de Assistência Multidisciplinar ao Idoso Ambulatorial (GAMIA) do Serviço de Geriatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Métodos: Nos 83 idosos participantes do grupo entre 2000 e 2002, a qualidade de vida foi avaliada pelo World Health Organization Quality of Life (WHOQOL-bref) no início e no fim do programa. A funcionalidade foi avaliada pelas Escalas de Katz e Lawton e os dados sociodemográficos foram obtidos nos prontuários. Resultados: Houve predomínio do sexo feminino (79,5%) e a média geral de idade foi de 69,30 anos. A análise dos dados mostraram uma redução no domínio físico do WHOQOL-bref (p = 0,014) e a elevação dos domínios psicológico e meio ambiente (p = 0,029 e p = 0,007, respectivamente), detectando-se tendência de elevação nos domínios relações sociais e geral (p = 0,062 e p = 0,052, respectivamente). Conclusões: Como a avaliação clínica desses idosos revelou doenças desconhecidas previamente e determinou a utilização de novos medicamentos, a percepção que os idosos tinham, em relação à sua saúde, pode ter sido o fator preponderante para a piora no domínio físico. A melhora dos domínios psicológico e meio ambiente pode estar relacionada ao suporte psicológico e social que o idoso recebeu dos colegas e profissionais e dos benefícios das atividades em grupo, bem como às tendência de elevação observada nos domínios relações sociais e geral. A participação em um programa de promoção do envelhecimento saudável mostrou-se eficaz na melhora da qualidade de vida do idoso.

Evaluación de la presencia del gen mer A implicado en la detoxificación de mercurio a partir de actinomicetos nativos del humedal de La Conejera / Evaluation of the presence of mer A gen implied in the mercury detoxification from native actinomycetes of La Conejera wetland

Se aislaron diez cepas de actinomicetos nativos del humedal La Conejera a partir de muestras de sedimento y agua, con el fin de determinar la capacidad de resistencia y detoxificación de mercurio, evaluando la presencia del gen mer A involucrado en el proceso. La prueba de resistencia fue realizada mediante un test de sensibilidad tomando concentraciones desde 3,68x10-3 mM hasta 10 mM de HgCl2. Se realizaron curvas de crecimiento de 192 h para las cepas resistentes al mercurio, en un medio suplementado con 0,01 mM y 0,05 mM de HgCl2, realizando una fermentación discontinua y midiendo el crecimiento por la técnica de peso seco. A partir de estos resultados se determinó un tiempo de adaptación de 24 h y una producción máxima de biomasa de 2,72 g·L-1 a la hora 72. Paralelamente, se realizó la secuenciación de los genes de resistencia al mercurio de Streptomyces lividans 1326, por medio del diseño de los oligonucleótidos capaces de amplificar el extremos 3’ del gen mer A, codificador de la enzima mercurio reductasa. Se optimizaron las condiciones de amplificación por PCR para obtener un producto amplificado de 686 pb aproximadamente. Finalmente, se realizó una electroforesis en campo pulsado comprobando la presencia de plásmidos en la cepa KH7 con tamaños aproximados de 50, 90 y 300 Kb, no integrados al cromosoma y posiblemente asociados a la resistencia presentada frente al metal.

Ten native actinomycete strains were isolated from water and sediment samples collected in La Conejera wet-lands to assess mercury resistance and detoxification ability for evaluating the presence of the mer A gene involved in that process. Sensitivity assays were performed using 3.68 x 10-3 mM to 10 mM HgCl2 concentrations. Growth curves were generated for each resistant strain after 192 h in discontinuous fermentation in medium supplemented with 0.01 mM and 0.05 mM HgCl2. Biomass growth was then measured by dry weight, maximum value (2.37 g·L-1) being obtained after 72 h. Primer pairs were designed based on the sequence encoding the mercury-reductase enzyme in Streptomyces lividans 1326. PCR conditions for amplifying that region were standardised. The mer A gene was identified in the KH7 strain, resulting in an amplified product of around 686 bp. The KH7 strain electrophoresis profile obtained by pulsed field gel electrophoresis showed 50, 90 and 300 Kb plasmid DNA which could be related to metal resistance in this strain.

Factores asociados a la estancia hospitalaria en instituciones de segundo y tercer nivel de Santa Fe de Bogotá en 1998 / Factors associated with hospital stay in second and third level institutions in Santa Fe de Bogotá in 1998

Introducción El tiempo de estancia hospitalaria es un indicador de la eficiencia en la utilización de los recuros y últimamente se ha utilizado como una estrategia de contención en los hospitales de Santafé de Bogotá. Existe la duda de si pertenecerá la red de la Secretaría Distrital de Salud (SDS) conlleva a diferencias en el tiempo de hospitalización con relación a los hospitales no adscritos con los cuales hay contratación externa de servicios, o de si existen diferencias dependiendo del organismo fuente de pago de los costos de hospitalización. Materiales y metodología Este estudio, ensamblado sobre una cohorte histórica, compara la estancia hospitalaria dependiendo de la adscripción y de la fuente de pago de los cotos de hospitalización, en 2,084 historias de pacientes atendidos entre enero y junio de 1998, en Santa Fe de Bogotá, en segundo y en tercer nivel de atención, controlando por otros factores que se asocian al tiempo de estancia hospitalaria. Se utilizó un análisis univariado de sobrevida, y un análisis multivariado con el método de riesgos proporcionales de Cox (método Stepwise), para explicar la relación entre las variables con la estancia, para cada nivel de atención. Resultados y conclusiones Se encuentra que para el segundo nivel de atención no hay diferencias en la estancia entre la red adscrita y la red no adscrita. La fuente de pago no explica la estancia cuando se ajusta por otras variables. Para el tercer nivel de atención la estancia es mayor en la red no adscrita y está relacionada con la fuente de pago, efecto que persiste al ajustar por otras variables de confusión.

Introduction Hospital length of stay is an indicator of efficiency in the use of resources and has recently been used as a containment strategy in the hospitals of Santafé de Bogotá. There is some doubt as to whether belonging to the network of the District Health Secretariat (SDS) leads to differences in the length of hospital stay in relation to non-affiliated hospitals with which there is outsourcing of services, or whether there are differences depending on the source of payment of hospitalization costs. Materials and methodology This study, assembled on a historical cohort, compares the hospital stay depending on the affiliation and the source of payment of hospitalization costs, in 2,084 histories of patients attended between January and June 1998, in Santa Fe de Bogotá, at the second and third level of care, controlling for other factors associated with the length of hospital stay. A univariate analysis of survival and a multivariate analysis with the Cox proportional hazards method (Stepwise method) were used to explain the relationship between variables and length of stay for each level of care. Results and conclusions It is found that for the second level of care there are no differences in the length of stay between the affiliated network and the non-affiliated network. The source of payment does not explain the length of stay when adjusted for other variables. For the third level of care, the length of stay is greater in the non-affiliated network and is related to the source of payment, an effect that persists when adjusting for other confounding variables.

Calcio iónico en el paciente crítico / Ionic calcium in the critical patient

La concentración de calcio sérico ionizado es indispensable para el control del metabolismo celular y otros procesos biológicos. Diferentes factores tales como control hormonal, concentración de albúmina sérica y alteraciones hidro-electrolíticas pueden alterar las concentraciones del calcio sérico ionizado, que representa la forma libre y activa de este ión. En diferentes estados patológicos se puede observar una disminución del calcio sérico y es importante detectar y manejar tempranamente la hipocalcemia en el paciente críticamente enfermo.