Baseline Prolonged PR Interval and Outcome of Cardiac Resynchronization Therapy: A Systematic Review and Meta-analysis / Intervalo PR Basal Prolongado e Desfecho da Terapia de Ressincronização Cardíaca: Revisão Sistemática e Meta-Análise

Abstract Background: Recent studies suggest that baseline prolonged PR interval is associated with worse outcome in cardiac resynchronization therapy (CRT). However, a systematic review and meta-analysis of the literature have not been made. Objective: To assess the association between baseline prolonged PR interval and adverse outcomes of CRT by a systematic review of the literature and a meta-analysis. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2017. The included studies were published prospective or retrospective cohort studies that compared all-cause mortality, HF hospitalization, and composite outcome of CRT with baseline prolonged PR (> 200 msec) versus normal PR interval. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals. Results: Six studies from January 1991 to May 2017 were included in this meta-analysis. All-cause mortality rate is available in four studies involving 17,432 normal PR and 4,278 prolonged PR. Heart failure hospitalization is available in two studies involving 16,152 normal PR and 3,031 prolonged PR. Composite outcome is available in four studies involving 17,001 normal PR and 3,866 prolonged PR. Prolonged PR interval was associated with increased risk of all-cause mortality (pooled risk ratio = 1.34, 95 % confidence interval: 1.08-1.67, p < 0.01, I2= 57.0%), heart failure hospitalization (pooled risk ratio = 1.30, 95 % confidence interval: 1.16-1.45, p < 0.01, I2= 6.6%) and composite outcome (pooled risk ratio = 1.21, 95% confidence interval: 1.13-1.30, p < 0.01, I2= 0%). Conclusions: Our systematic review and meta-analysis support the hypothesis that baseline prolonged PR interval is a predictor of all-cause mortality, heart failure hospitalization, and composite outcome in CRT patients.

Resumo Fundamento: Estudos recentes sugerem que intervalo PR basal prolongado está associado a prognóstico ruim para a terapia de ressincronização cardíaca (TRC). No entanto, nunca foram feitas uma revisão sistemática e meta-análise da literatura. Objetivo: Avaliar a associação entre intervalo PR basal prolongado e resultados adversos da TRC por meio de uma revisão sistemática e meta-análise da literatura. Métodos: Pesquisamos de forma abrangente os bancos de dados MEDLINE e EMBASE, desde o início até março de 2017. Os estudos incluídos eram de coorte prospectivos ou retrospectivos que comparavam mortalidade por todas as causas, hospitalização por insuficiência cardíaca e desfecho composto por TRC com PR basal prolongado (> 200 ms) versus intervalo PR normal. Os dados de cada estudo foram combinados pelo modelo de efeitos aleatórios, variância genérica inversa de DerSimonian e Laird para calcular as razões de risco e os intervalos de confiança de 95% (IC95%). Resultados: Foram incluídos seis estudos de janeiro de 1991 a maio de 2017 nesta metanálise. A taxa de mortalidade por todas as causas foi mencionada em quatro estudos envolvendo 17.432 intervalos PR normais e 4.278 prolongados. Hospitalização por insuficiência cardíaca foi abordada em dois estudos envolvendo 16.152 PR normais e 3.031 prolongados. Desfecho composto esteve presente em quatro estudos com 17.001 PR normais e 3.866 prolongadas. Intervalo PR prolongado foi associado a risco aumentado de mortalidade por todas as causas (razão de risco agrupado = 1,34, IC95%: 1,08-1,67, p < 0,01, I2= 57,0%), hospitalização por insuficiência cardíaca (razão de risco agrupado = 1,30, 95 % de IC95%: 1,16-1,45, p < 0,01, I2= 6,6%) e desfecho composto (razão de risco agrupado = 1,21, IC95%: 1,13-1,30, p < 0,01, I2= 0%). Conclusões: Nossa revisão sistemática e metanálise suportam a hipótese de que o intervalo PR basal prolongado é um preditor de mortalidade por todas as causas, hospitalização por insuficiência cardíaca e desfecho composto em pacientes submetidos à TRC.

Rol de la ecografía en la evaluación de la cortical ósea / Role of ultrasound in the evaluation of the bone cortex

La ecografía es el método de elección para la evaluación inicial de las partes blandas y el sistema muscular, siendo una técnica accesible, portátil y de bajo costo. Sin embargo, ha sido excluida de la exploración y evaluación de las patologías óseas debido a la idea de que es incapaz de penetrar la superficie del hueso. De hecho, muchos radiólogos admiten que esta es una de las pocas localizaciones donde la ecografía no resulta efectiva. Si bien algunos de estos conceptos son ciertos, este método puede aportar valiosa información diagnóstica sobre el estado del hueso, principalmente sobre la cortical ósea, en variadas circunstancias. La ecografía de la cortical ósea es posible por el artefacto de reflexión hiperecogénico lineal y regular que esta genera. En manos experimentadas, el reconocimiento y exploración de la superficie ósea permiten obtener datos muy útiles. Los tumores óseos generan reacciones periósticas fácilmente observables y caracterizables por ultrasonido, con la ventaja adicional de que el Doppler color identifica la vascularización del tumor. Las fracturas se observan como disrupciones de la cortical y la patología degenerativa se puede sospechar ante irregularidades corticales. Asimismo, es posible reconocer patologías como avulsiones, callos óseos de procesos previos e incluso fracturas por estrés. En este ensayo iconográfico mostramos diferentes casos de ecografías de partes blandas que evidenciaron hallazgos patológicos en la cortical ósea, permitiendo arribar a un diagnóstico o guiando en la elección de un estudio adicional.

Ultrasound is the best choice to evaluate soft tissues and the muscular system because of its accessibility, low cost and portability. Historically, the assumption has been that because ultrasound waves cannot penetrate bone, it is not useful in the evaluation of the skeletal system and its diseases. Radiologists admit that one of the very few tissue types which ultrasound cannot evaluate is bone. There is, of course, much truth in this, but recent studies suggest that ultrasound can provide valuable diagnostic information regarding the state of bone in some circumstances. The high reflectivity of sound at the bone-soft tissue interface is what allows the bone surface to be visualised. Valuable diagnostic information can be obtained by exploring bone surface in detail. The fact that bone tumours manifest themselves as periosteal reactions makes them easily recognisable by ultrasound, with the additional advantage if using Doppler colour. Bone fractures could be seen as interruptions of the bone continuity, and degenerative diseases should be suspected when an irregular surface is observed. Likewise, other pathologies such as avulsion fractures, bone callus stemming from previous processes, and even stress fractures can be identified. In this pictorial essay different cases are presented of musculoskeletal ultrasound in which bone surface was evaluated and abnormalities discovered, making a diagnosis or suggesting an additional test.

Use of preoperative embolization prior to transplant nephrectomy

ABSTRACT Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Lithium in Psychiatry / Litio en Psiquiatría

Background: Lithium is a light, metallic element and minerals containing it are most abundant in the Andes. John Cade introduced lithium carbonate for the treatment of mania in 1949, opening the era of modern clinical psychopharmacology. Lithium remains the most extensively studied mood-stabilizing agent. It has had a revolutionary impact in supporting bipolar manic-depressive disorder as a discrete diagnosis, and on psychiatric therapeutics. Methods: We survey the development of lithium treatment in psychiatry, including findings concerning effects on suicide. Results: Lithium is the most extensively studied treatment for bipolar disorder and the prototypical mood-stabilizing agent, despite emergence of anticonvulsants and modern antipsychotics. In addition to limiting recurrences of mania, and some reduction of recurrences of bipolar depression, lithium has demonstrated protective effects against suicide. All treatments for bipolar disorder have notable limitations, including sometimes serious adverse effects, incomplete prevention of recurrences of mania and limited prevention of depression, which accounts for three-quarters of the approximately 50% time-ill in long-term follow-up with standard treatments. Lithium can be toxic in untreated overdoses; safe dosing requires monitoring of serum concentrations. Lithium also may have mild teratogenic effects, but far less than those of anticonvulsants used for bipolar disorder. Conclusions: Lithium opened the era of modern psychopharmacology and continues as the best-established mood-stabilizing treatment for bipolar disorder as well as having strong evidence of suicide-preventing effects.

Antecedentes: Litio es un elemento metálico ligero y los minerales que lo contienen abundan predominantementeen la región andina. John Cade introdujo el uso de carbonato de litio para el tratamiento de manía en 1949, iniciando con ello la era de la moderna psicofarmacología clínica. Litio se mantiene como el más extensamente estudiando agente estabilizador del ánimo. Ha tenido un impacto revolucionario en la preservación del trastorno maniaco-depresivo o bipolar como un diagnóstico discreto y en el campo de la terapéutica psiquiátrica.Métodos: Se examina el desarrollo histórico del tratamiento con litio en psiquiatría, incluyendo hallazgos en relación a su efecto sobreconducta suicida. Hallazgos:Litio es el tipo de tratamiento más extensamente estudiado en el manejo de trastorno bipolar disorder, constituido como el prototipo de agente estabilizador del ánimo, a pesar de la emergencia de agentes anticonvulsivantes y de los antipsicóticos modernos. Además de limitar la recurrencia de episodios maniacos y reducir en algo las recurrencias de depresión bipolar, litio ha demostrado efectos protectores en relación a suicidio y conducta suicida. Todos los tipos de tratamiento de trastorno bipolar tienen limitaciones notables, incluyendo algunas veces serios efectos adversos, prevención incompleta de recurrencias de manía y prevención limitada de depresión, todo lo cual constituye las tres cuartas partes de aproximadamente el 50 % de tiempo con enfermedad en estudios de seguimiento a largo plazo con tratamientos estándar.