Correlation between levels of perceived stress and depressive symptoms in the functional disability of patients with fibromyalgia

SUMMARY OBJECTIVE: The aim of this study was to evaluate the factors that are most correlated with the levels of functional disability in patients with fibromyalgia. METHODS: This is a cross-sectional descriptive study in which 42 patients diagnosed with fibromyalgia according to the criteria of the American College of Rheumatology reported their status using the following questionnaires: the Beck Depression Inventory, the Perceived Stress Scale 14, the Revised Fibromyalgia Impact Questionnaire, the Visual Analog Pain Scale, and the Health Assessment Questionnaire. RESULTS: Moderate to severe levels of depression (Beck Depression Inventory: 22.35±10.39), moderate to severe functional disability (Health Assessment Questionnaire: 1.28±0.58), and high levels of stress (Perceived Stress Scale 14: 31.59±10.02) were found. The correlation adjusted by multiple regression as a function of the Health Assessment Questionnaire indicated a negligible to weak positive correlation with perceived stress (r=0.11), while a moderately strong positive correlation was observed with the Visual Analog Pain Scale (r=0.55). Regarding physical exercise, one of the pillars of the treatment, a moderate negative correlation was found with the Health Assessment Questionnaire (r=-0.4). CONCLUSION: The pain levels were moderately influenced by depression severity. The factors most linked to functional disability are due to the pain levels but not to the perception of stress.

Prevalence of Atrial Fibrillation in Pacemaker Patients

Abstract Background: Current pacemakers allow for the continuous recording of the occurrence of arrhythmic events. One of the most frequent arrhythmias after implantation of a device is atrial fibrillation (AF), an important risk factor for embolic events. The frequency of this arrhythmia in pacemaker patients has not been widely studied. Objectives: This study aimed to evaluate the prevalence, incidence, and predictors of the occurrence of AF in patients with double-chamber pacemakers and without a history of atrial fibrillation prior to implantation. Methods: A dynamic, retrospective, and prospective cohort study was carried out with 186 patients undergoing biannual follow-up of the double-chamber pacemaker, without previous AF, in a single service, between 2016 and 2018. Clinical data were collected from the medical records and the telemetry of the device and the prevalence, incidence rate, relative risk by univariate analysis (by chi-square), and risk ratio were calculated by multivariate analysis (by Cox regression); values of p<0.05 were considered significant. Results: There was a prevalence of 25.3% FA, with an incidence of 5.64 cases / 100 persons-year. The median time for the development of arrhythmia was 27.5 months. Multivariate analysis identified 5 statistically significant predictors: male gender, OR: 2.54 [1.04-6.15]; coronary artery disease, OR: 2.98 [1.20-7.41]; hypothyroidism, OR: 3.63 [1.46-9.07]; prior heart surgery, OR: 2.67 [1.01-7]; and left atrial enlargement, OR: 2.72 [1.25-5.92]. Conclusions: The prevalence and incidence of AF in this population are high. Risk factors for AF were: male gender, coronary artery disease, hypothyroidism, prior heart surgery, and left atrial enlargement.

Association between disease activity and quality of life among patients with rheumatoid arthritis

Abstract The aim of this study is the association between the scores of disease activity, functional capacity and quality of life among patients diagnosed with rheumatoid arthritis, under clinical treatment at the Regional University Hospital of Campos Gerais - Wallace Thadeu de Mello and Silva. The sample was composed by volunteer patients, who freely underwent 3 research questionnaires. With the results of the survey, the disease activity score was correlated to the functional capacity and the quality-of-life scores. A mean of 3.87 and 1.2 was observed for the disease activity and the functional capacity scores, respectively, yet not achieving a correlation between those two variables. A strong correlation between the disease activity and the "functional capacity", "general health status" and "mental health" domains was found. The lowest average observed corresponded to "physical limitation", from the quality-of-life questionnaire. There was no statistically significant correlation between disease activity and functional capacity, although disease activity seems to affect the mental health, general health status and functional capacity of patients.

Comparison between DAS28-ESR and DAS28- CRPus for patients with rheumatoid arthritis: application in a population of southern Brazil

Abstract The Disease Activity Score 28 (DAS28) shows discrepancies when using erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) scores to assess rheumatoid arthritis (RA). This study aimed to verify the agreement between the DAS28-CRP and DAS28-ESR scores in patients with RA from the south of Brazil. A unicentric cross-sectional study was performed (n = 56). The diagnosis of the patients followed the American College of Rheumatology/ European League Against Rheumatism criteria, and their DAS28 were calculated. The DAS28- ESR score was higher than the DAS28-CRP (DAS28-ESR mean 4.8±1.6; DAS28-CRP mean 4.3±1.4) for 83.9% of the patients. The DAS28-CRP and DAS28-ESR scores showed a very strong correlation (Pearson's coefficient = 0.922; P<0.0001, 95% CI +0.87 to +0.95, statistical power 100%). Spearman's correlation coefficient (0.49; P=0.0001, 95% CI +0.25 to +0.67, statistical power 47.54%) showed a moderate correlation between the unique components of the DAS28 formulas. There was agreement between the tests in only 36 of the patients (64.29%). Among the discordant categories, DAS28-ESR overestimated the classification in 16 patients (28.5%). The Kappa coefficient between the categories was 0.465 (SE 0.084, 95% CI +0.301 to +0.630), showing a moderate degree of agreement between the instruments. Although the DAS28-ESR and DAS28-CRP were highly correlated, they differed significantly in terms of patient categorization and should not be used interchangeably

Relationship between corticotherapy and increased cardiac risk in patients with rheumatoid arthritis

Rheumatoid arthritis is an autoimmune inflammatory joint disease with global prevalence of 0.4% to 1.0%. Extra-articular manifestations increase its morbidity and severity, and cardiovascular diseases present the greatest risk. Therapeutic approaches have been used to treat rheumatoid arthritis, often involving the use of multiple classes of drugs with different mechanisms and forms of action. Corticosteroid therapy is widely used in this therapeutic combination; however, its use has been widely questioned because of its high toxicity and some negative effects, including the possibility of increased cardiovascular risk, depending on the dosage. Some studies have provided important insights into how glucocorticoids have an impact on cardiac complications in patients with rheumatoid arthritis. Most of these studies have concluded that exposure to these drugs at high or cumulative doses is associated with increased risk of death, as well as possibly being associated with the presence of a positive rheumatoid factor.

Coronary endarterectomy: a case control study and evaluation of early patency rate of endarterectomized arteries

Abstract Objective: To compare two groups of patients - the coronary endarterectomy group, with patients undergoing coronary artery bypass grafting (CABG) with coronary endarterectomy (CE), and the control group, with patients undergoing CABG without CE. We analyzed the rate of major outcomes (perioperative acute myocardial infarction [AMI], stroke, and mortality) and minor outcomes (time of cardiopulmonary bypass [CPB], time of aortic clamp, and postoperative length of hospital stay). We also determined the rates of early graft patency in patients undergoing CE. Methods: We reviewed a database of patients submitted to CABG, with or without associated CE, between January 2011 and June 2017. Twenty-five patients submitted to CE were compared with 201 patients submitted only to conventional surgery; the two groups presented similar preoperative characteristics and all the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II variables did not presented statistically significant difference. We considered statistically significant values of P< 0.05. Results: There was no statistically significant difference in relation to time of post-surgical hospitalization (P=0.8139), incidence of perioperative AMI (P=0.2976), stroke (P=0,2976), and mortality rate (P=1.0000), but endarterectomy was associated with longer aortic clamping time (P=0.0004) and CPB time (P=0.0030). The rate of patency evaluated in patients submitted to endarterectomy (78,95%) was compatible with that described in the literature. Conclusion: In this sample, coronary endarterectomy was associated with the rate of early graft patency similar to that of the literature, with morbidity and mortality rates similar to those of conventional surgery.

Prevalence of carotid stenosis and incidence of ischemic stroke in patients undergoing non-coronary cardiac surgery

Abstract Introduction: Many publications on coronary surgery and carotid stenosis (CS) can be found, but we do not have enough information about the relationship between ischemic stroke, CS and non-coronary cardiac surgery. Objectives: To evaluate the incidence and risk factors associated with the stroke and CS ≥50% in patients undergoing non-coronary surgeries. Objectives: We assessed 241 patients, aged 40 years or older, between 2009 and 2016, operated in Santa Casa de Misericórdia de Ponta Grossa-PR, Brazil. We perform carotid Doppler in patients 40 years of age or older before any cardiac surgery as a routine. The incidence and possible risk factors for CS ≥50% and perioperative stroke were analyzed by univariate statistical analysis. Results: 11 patients (4.56%) presented perioperative stroke. The risk factor for stroke was CS ≥50%: OR=5.3750 (1.2909-22.3805), P=0.0208. Eighteen patients (7.46%) had CS ≥50% and their risk factors were extracardiac arteriopathy: OR=18.6607 (6.3644-54.7143), P<0.0001; COPD: OR=3.9040 (1.4491-10.5179), P=0.0071; diabetes mellitus: OR=2.9844 (1.0453-8.5204), P=0.0411; recent myocardial infarction: OR=13.8125 (1.8239-104.6052), P=0.0110; EuroSCORE II higher P=0.0056. Conclusion: The incidences of stroke and CS ≥50% were 4.56% and 7.46%, respectively. The risk factor for stroke was CS ≥50% and for CS ≥50% were extracardiac arteriopathy, COPD, diabetes mellitus, recent myocardial infarction and higher EuroSCORE II.

Relações Entre Ações de uma Invervenção Educativa na Adesão ao Tratamento e no RNI de Pacientes em Uso de Antagonistas de Vitamina K / Relationship Between Educative Intervention on Treatment Adherence and INR of Patients on Vitamin K Antagonists

Avaliar se uma intervenção educacional interfere na adesão ao tratamento, meta terapêutica e frequência de eventos hemorrágicos de pacientes em uso de antagonistas de vitamina K e se características socioeconômicas/clínicas possuem efeito sobre os resultados encontrados. Método: Estudo analítico intervencionista não controlado qualitativo. Foram incluídos 49 pacientes e aplicados os questionários de medida de adesão ao tratamento (MAT) e socioeconômico. Posteriormente foram realizadas ligações mensais educativas sobre anticoagulação e foram coletadas informações sobre eventos hemorrágicos e valores de RNI. Ao termino da intervenção foi aplicado mais um questionário MAT. Foram comparados os dados antes e após a intervenção. Resultados: Os pacientes foram considerados mais aderentes após a intervenção (p=0,04) e houve diminuição na frequência de eventos hemorrágicos (p=0,01), existindo nenhuma relação com as variáveis socioeconômicas ou clínicas. Não houve melhora significativa em relação à meta de RNI (p=0,06), porém o estado civil desses pacientes teve associação com a estabilidade terapêutica (p=0,04). Conclusões: A intervenção melhorou a aderência e diminuiu os eventos hemorrágicos dos pacientes, não tendo influência sobre a meta terapêutica. Pacientes com cônjuge apresentaram melhores metas terapêuticas se comparados aos solteiros. Não houve interferência de outras variáveis socioeconômicas ou clínicas sobre os desfechos encontrados

Objectives: To evaluate if an educational intervention interfere in treatment adherence, therapeutic ranges and hemorrhagic.events of patients on vitamin K antagonists; and if social, economic and clinical.characteristics are associated with the ending points. Methods: It's an interventionist analytic study. 49 patients were included.and an adherence.and social/economic questionnaires were applied. Then, monthly educative phone calls.were performed about anticoagulation and information about hemorrhagic,events and INR were collected. When intervention,were done, another adherence questionnaire was applied. Data before and after intervention were compared. Results: Patients had their adherence improved (p=0,04) and there was a fall on the prevalence,of hemorrhagic events (p=0,01) with,no,social/clinical variables association. There were no significant,changes,on the therapeutic ranges (p=0,06), although there was a relationship,between marital state and INR,stability (p=0,04). Conclusions: Educational intervention increased adherence,and decreased hemorrhagic events. Marital state has been associated with better therapeutic,ranges. No other social, economic.or clinical.variable has been associated with the ending points

Comparison of Two Central Venous Pressure Control Strategies to Prevent Atrial Fibrillation After Coronary Artery Bypass Grafting / Comparação de Duas Estratégias de Controle de Pressão Venosa Central na Prevenção de Fibrilação Atrial em Pós-Operatório de Revascularização do Miocárdio

Abstract Background: Atrial fibrillation (AF) takes place in 10-40% of patients undergoing coronary artery bypass grafting (CABG), and increases cardiovascular mortality. Enlargement of atrial chambers is associated with increased AF incidence, so patients with higher central venous pressure (CVP) are expected to have larger atrial distension, which increases AF incidence. Objective: To compare post-CABG AF incidence, following two CVP control strategies. Methods: Interventional, randomized, controlled clinical study. The sample comprised 140 patients undergoing CABG between 2011 and 2015. They were randomized into two groups, G15 and G20, with CVP maintained ≤ 15 cmH2O and ≤ 20 cmH2O, respectively. Results: 70 patients were included in each group. The AF incidence in G15 was 8.57%, and in G20, 22.86%, with absolute risk reduction of 14.28%, and number needed to treat (NNT) of 7 (p = 0.03). Mortality (G15 = 5.71%; G20 = 11.42%; p = 0.07), hospital length of stay (G15 = 7.14 days; G20 = 8.21 days; p = 0.36), number of grafts (median: G15 = 3, G2 = 2; p = 0.22) and cardiopulmonary bypass use (G15 = 67.10%; G20 = 55.70%; p = 0.22) were statistically similar. Age (p = 0.04) and hospital length of stay (p = 0.001) were significantly higher in patients who developed AF in both groups. Conclusion: Keeping CVP low in the first 72 post-CABG hours reduces the relative risk of AF, and may be useful to prevent AF after CABG.

Resumo Fundamento: A fibrilação atrial (FA) ocorre em 10-40% dos pacientes submetidos a cirurgia de revascularização miocárdica (RM), e eleva a mortalidade cardiovascular. Como o aumento dos átrios está associado ao aumento da incidência de FA, espera-se que pacientes com pressão venosa central (PVC) mais alta tenham maior distensão atrial, o que eleva a incidência dessa arritmia. Objetivo: Comparar a incidência de FA em pós-operatório de RM, seguindo duas estratégias de controle de PVC. Métodos: Estudo clínico randomizado controlado intervencionista. A amostra foi composta por 140 pacientes submetidos a RM entre 2011 e 2015. Os pacientes foram randomizados em dois grupos, G15 e G20, mantidos com PVC máxima de 15 cmH2O e 20 cmH2O, respectivamente. Resultados: Foram incluídos 70 pacientes em cada grupo. A incidência da arritmia em G15 foi de 8,57% e, no G20, de 22,86%, com redução de risco absoluto de 14,28% e número necessário para tratar (NNT) de 7 (p = 0,03). Mortalidade (G15 = 5,71%; G20 = 11,42%; p = 0,07), tempo de internamento (G15 = 7,14 dias; G20 = 8,21 dias; p = 0,36), número de enxertos (medianas: G15 = 3, G2 = 2; p = 0,22) e uso de circulação extracorpórea (G15 = 67,10%; G20 = 55,70%; p = 0,22) mostraram-se estatisticamente semelhantes. A idade (p = 0,04) e o tempo de internamento (p = 0,001) foram significativamente maiores nos pacientes que desenvolveram FA nos dois grupos. Conclusão: Manter a PVC com valores mais baixos nas primeiras 72h após a cirurgia de RM reduz o risco relativo de FA e pode ser uma ferramenta útil na prevenção da FA após RM.

Anticoagulation quality and complications of using vitamin k antagonists in the cardiac surgery outpatient clinic

ABSTRACT Introduction: In patients with mechanical prosthetic heart valves or atrial fibrillation requiring anticoagulation to prevent thromboembolic events, several factors influence adherence and anticoagulation complications. Objective: To evaluate the factors that interfere with the quality and complications of anticoagulation with vitamin K antagonists. Methods: A retrospective cohort study of 100 patients, in the period from 2011 to 2014, was performed. Anticoagulation conditions in the last year, regarding the presence of complications (embolisms/bleeding) and inadequate treatment were assessed: achievement of less than 8 annual prothrombin times and International Normalized Ratio outside therapeutic target in more than 40% of prothrombin times. Results: There were 31 complications (22 minor bleeding without hospitalization and 9 major complications: 7 bleeding with hospitalization and two emboli); 70 were with International Normalized Ratio outside the target in more than 40% of the tests and 36 with insufficient number of prothrombin times. Socioeconomic factors, anticoagulant type and anticoagulation reason had no relationship with complications or with inadequate treatment. There were more complications in patients with longer duration of anticoagulation (P=0.001). Women had more International Normalized Ratio outside the target range (OR 2.61, CI:1.0-6.5; P=0.04). Patients with lower number of annual prothrombin times had longer times of anticoagulation (P=0.03), less annual consultations (P=0.02) and less dose adjustments (P=0.003). Patients with longer duration of anticoagulation have more complications (P=0.001). Conclusion: There was a high rate of major complications and International Normalized Ratio was outside the goal. Less annual prothrombin times was related to longer duration of anticoagulation, less annual consultations and less dose adjustments. More major complications occurred in patients with longer duration of anticoagulation.

Controle da pressão arterial em idosas hipertensas em uma Unidade de Saúde da Família e fatores associados / Blood pressure control in hypertensive elderly women attended in a Family Health Unit and associated factors

Resumo Introdução A hipertensão arterial sistêmica é uma doença crônica de alta prevalência e com baixas taxas de controle. Este estudo objetivou analisar o controle da pressão arterial em idosas hipertensas acompanhadas em uma Unidade de Saúde da Família e os fatores associados. Métodos Estudo transversal, com análise de dados de prontuários de 190 idosas hipertensas. Foram consideradas controladas as pacientes com nível de pressão arterial menor do que 140/90 mmHg. Para a análise estatística, calcularam-se a razão de prevalência e o intervalo de confiança de 95% para a ocorrência de controle ou não da presão arterial, segundo a associação de alguns fatores. As análises multivariadas foram conduzidas por meio de regressão logística. Resultados Das 190 pacientes em acompanhamento, 108 (56,8%) apresentavam a pressão arterial controlada. Na análise de regressão logística, as variáveis possuir mais de 70 anos (p = 0,033) e residir na área mais afastada da unidade de saúde (p = 0,002) estiveram associadas ao não controle da pressão arterial. Conclusão Embora o percentual de controle da pressão arterial seja elevado na população estudada quando comparado com dados da literatura, medidas devem ser implantadas para o aumento desse percentual, para evitar futuras complicações.

Abstract Introduction Hypertension is a chronic disease with high prevalence and low control rates. This study aimed to analyze the blood pressure control in hypertensive elderly followed up in a Family Health Unit and its associated factors. Methods Cross-sectional study, with patient records analysis of 190 hypertensive elderly women. Patients’ blood pressure was considered to be under control if lower than 140/90mmHg. For statistical analysis, we calculated the prevalence ratio and 95% confidence interval for controlled and not controled blood pressure, according to the association of some factors. Multivariate analyzes were conducted using logistic regression. Results Of the 190 patients followed up, 108 (56.8%) had controlled blood pressure. In logistic regression analysis, the variables of being older than 70 years (p = 0.03) and reside in the area furthest from the facility (p = 0.002) were associated with uncontrolled blood pressure. Conclusion Although the control rate in this population is high when compared with literature, measurements should be implemented to increase this rate and avoid future complications.

Factors Associated With the Development of Chronic Post-Sternotomy Pain: a Case-Control Study

ABSTRACT OBJECTIVE: The aim of the present study was to investigate the factors associated with chronic post-sternotomy pain in heart surgery patients. METHODS: Between January 2013 and February 2014, we evaluated 453 patients with >6 months post-sternotomy for cardiac surgery at a surgical outpatient clinic. The patients were allocated into a group with chronic post-sternotomy pain (n=178) and a control group without pain (n=275). The groups were compared for potential predictors of chronic post-sternotomy pain. We used Cox proportional hazards regression to determine which independent variables were associated with the development of chronic post-sternotomy pain. RESULTS: In total, 39.29% of the patients had chronic poststernotomy pain. The following factors were significantly associated with chronic post-sternotomy pain: (a) use of the internal thoracic artery in coronary bypass grafting (P =0.009; HR=1.39; 95% CI, 1.08 to 1.80); (b) a history of antidepressant use (P =0.0001; HR=2.40; 95% CI, 1.74 to 3.32); (c) hypothyroidism (P =0.01; HR=1.27; 95% CI, 1.03 to 1.56); (d) surgical wound complication (P =0.01; HR=1.69; 95% CI, 1.08 to 2.63), and (e) patients on disability benefits or scheduled for a consultative medical examination for retirement (P =0.0002; HR=2.05; 95% CI, 1.40 to 3.02). CONCLUSION: The factors associated with chronic poststernotomy pain were: use of the internal thoracic artery; use of antidepressants; hypothyroidism; surgical wound complication, and patients on disability benefits or scheduled for a consultative examination.

Risk factors for perioperative ischemic stroke in cardiac surgery / Fatores de risco para acidente vascular cerebral isquêmico no perioperatório de cirurgia cardíaca

AbstractObjective:The purpose of this study was to evaluate the risk factors for ischemic stroke in patients undergoing cardiac surgery.Methods:From January 2010 to December 2012, 519 consecutive patients undergoing cardiac surgery were analyzed prospectively. The sample was divided into two groups: patients with stroke per and postoperative were allocated in Group GS (n=22) and the other patients in the group CCONTROL (n=497). The following variables were compared between the groups: gender, age, carotid stenosis > 70%, diabetes on insulin, chronic obstructive pulmonary disease, peripheral arteriopathy, unstable angina, kidney function, left ventricular function, acute myocardial infarction, pulmonary arterial hypertension, use of cardiopulmonary bypass. Ischemic stroke was defined as symptoms lasting over 24 hours associated with changes in brain computed tomography scan. The variables were compared using Fisher’s exact test, Chi square, Student’s t-test and logistic regression.Results:Stroke occurred in 4.2% of patients and the risk factors statistically significant were: carotid stenosis of 70% or more (P=0.03; OR 5.07; IC 95%: 1.35 to 19.02), diabetes on insulin (P=0.04; OR 2.61; IC 95%: 1.10 to 6.21) and peripheral arteriopathy (P=0.03; OR 2.61; 95% CI: 1.08 to 6.28).Conclusion:Risk factors for ischemic stroke were carotid stenosis of 70% or more, diabetes on insulin and peripheral arteriopathy.

ResumoObjetivo:O objetivo do presente trabalho foi avaliar os fatores de risco para acidente vascular encefálico isquêmico em pacientes submetidos à cirurgia cardíaca.Métodos:Entre janeiro de 2010 e dezembro de 2012, foram analisados prospectivamente 519 pacientes consecutivos submetidos à cirurgia cardíaca. A amostra foi dividida em dois grupos: os pacientes com acidente vascular encefálico isquêmico (AVEi) trans e pós-operatório foram alocados no grupo GAVEi (n=22) e os demais pacientes no grupo CControle (n=497). As seguintes variáveis foram comparadas entre os grupos: sexo, idade, estenose carotídea >70%, diabetes em uso de insulina, doença pulmonar obstrutiva crônica, arteriopatia periférica, função renal, angina instável, função do ventrículo esquerdo, infarto agudo do miocárdio recente, hipertensão arterial pulmonar, uso de circulação extracorpórea. Acidente vascular encefálico isquêmico foi definido como presença de sintomas de duração maior que 24 horas associados à alteração em tomografia de crânio. As variáveis foram comparadas, por meio do teste exato de Fisher, Qui quadrado, teste t de Student e regressão logística.Resultados:Verificou-se a ocorrência de acidente vascular encefálico isquêmico em 4,2% dos pacientes e os fatores de risco estatisticamente significativos foram: estenose carotídea de 70% ou mais (P=0,03; OR 5,07; IC 95%: 1,35 a 19,02), diabetes em uso de insulina (P=0,04; OR 2,61; IC 95%: 1,10 a 6,21) e arteriopatia periférica (P=0,03; OR 2,61; IC 95%: 1,08 a 6,28).Conclusão:Foram fatores de risco para acidente vascular encefálico isquêmico: estenose carotídea de 70% ou mais, presença de diabetes em uso de insulina e presença de arteriopatia periférica.

Action of anti-TNF-α drugs on the progression of Alzheimer's disease: A case report / Drogas Anti-TNF-α e sua atuação sobre a progressão da doença de Alzheimer: relato de caso

ABSTRACT. The aim of this study was to describe a clinical case of a patient with Alzheimer's disease (AD) in use of an anti-TNF-α agent for rheumatoid arthritis (RA). The patient reported is an 81-year-old Caucasian man and retired teacher, diagnosed with RA in 2008 and AD in 2011. Treatment with donepezil was started in 2011 and the use of etanercept introduced in 2012. He was previously treated with adalimumab in 2010 for 18 months. In 2013, the subject was engaged in a clinical trial to assess a complementary non-pharmacological approach for AD, presenting significant cognitive improvement during the follow-up period. We propose the hypothesis of a synergistic effect of anti-TNF-α medication used for the treatment of RA as the cause of the improvement in cognitive response observed. These findings could suggest a possible use of this drug class in the therapeutic management of AD.

RESUMO. O objetivo deste estudo foi descrever um caso de um paciente com doença de Alzheimer (DA) simultaneamente sob uso de medicação anti-TNF-α para artrite reumatoide (AR). Paciente masculino, 81 anos, caucasiano, professor aposentado. Diagnosticado com AR em 2008 e DA em 2011. O tratamento com donepezila foi iniciado em 2011, e o uso de etanercept instituído em 2012. O paciente foi tratado anteriormente com adalimumab em 2010 durante 18 meses. Em 2013, participou de um ensaio clínico visando a avaliar uma estratégia não farmacológica complementar para a DA, apresentando melhora cognitiva significativa ao longo do período de seguimento. Sugere-se a hipótese de um efeito sinérgico do agente anti-TNF-α utilizado para tratamento da AR como causa da melhor resposta cognitiva do paciente, indicando possível utilidade dessa classe medicamentosa na abordagem terapêutica da DA.

Acupuntura na fibromialgia: um estudo randomizado-controlado abordando a resposta imediata da dor / Acupuncture in fibromyalgia: a randomized, controlled study addressing the immediate pain response

Objetivo Avaliar a eficácia da acupuntura no tratamento da fibromialgia, considerando-se como desfecho primário a resposta imediata da escala visual analógica (VAS) para avaliação da dor. Material e métodos Estudo randomizado, controlado e duplo-cego incluindo 36 pacientes portadores de fibromialgia (ACR 1990) selecionados no ambulatório de Reumatologia da Santa Casa de Misericórdia de Ponta Grossa, PR. Vinte e um pacientes foram submetidos a uma sessão de acupuntura, nos moldes da Medicina Tradicional Chinesa, e 15 pacientes foram submetidos a um procedimento placebo (acupuntura sham). Para avaliação da dor, os indivíduos preencheram uma Escala Visual Analógica (VAS) antes e imediatamente após o procedimento proposto. As médias na variação da VAS foram comparadas entre os grupos. Resultados A variação entre o valor da EVA final e da EVA inicial foi de –4,36±3,23 (P=0,0001) no grupo de tratamento e de –1,70±1,55 no grupo de controle (P=0,06). A diferença na amplitude de variação da EVA (EVA inicial – final) entre os grupos favoreceu o procedimento verdadeiro (P=0,005). O tamanho de efeito (effect size – ES) para o grupo de tratamento foi de d=1,7, o que é considerado um efeito grande. Embora com uma amostra reduzida, seu poder estatístico para esses resultados foi bastante relevante (94,8%). Conclusão A acupuntura mostrou ser eficaz na redução imediata da dor em pacientes portadores de fibromialgia, com um tamanho de efeito (effect size) bastante significativo. .

Objective To evaluate the efficacy of acupuncture in the treatment of fibromyalgia, considering the immediate response of the visual analogue pain scale (VAS) as its primary outcome. Methods Randomized, controlled, double-blind study including 36 patients with fibromyalgia (ACR 1990) selected from the outpatient rheumatology clinic, Santa Casa de Misericórdia, Ponta Grossa, PR. Twenty-one patients underwent an acupuncture session, under the principles of the traditional Chinese medicine, and 15 patients underwent a placebo procedure (sham acupuncture). For pain assessment, the subjects completed a Visual Analogue Scale (VAS) before and immediately after the proposed procedure. The mean change in VAS was compared among groups. Results The variation between the final and initial VAS values was -4.36±3.23 (P=0.0001) in the treatment group and -1.70±1.55 in the control group (P=0.06). The difference in terms of amplitude of variation of VAS (initial – final VAS) among groups favored the actual procedure (P=0.005). The effect size (ES) for the treatment group was d=1.7, which is considered a large effect. Although small, the statistical power of the sample for these results was very relevant (94.8%). Conclusion Acupuncture has proven effective in the immediate pain reduction in patients with fibromyalgia, with a quite significant effect size. .

Efeito do controle da pressão venosa central na ocorrência de fibrilação atrial após revascularização do miocárdio: estudo caso-controle / Effect of central venous pressure control on the occurrence of atrial fibrillation after coronary artery bypass grafting: case-control study

Introdução: Este estudo teve como objetivo comparar a incidência de fibrilação atrial apósrevascularização do miocárdio entre pacientes que tiveram a pressão venosa central rigorosamente controladanas primeiras 48-72 horas de pós-operatório e pacientes que não tiveram controle rigoroso. Método: Estudoobservacional, do tipo caso-controle, realizado na Santa Casa de Misericórdia de Ponta Grossa. O caso foicomposto por 80 pacientes avaliados prospectivamente submetidos a revascularização miocárdica entre 2012e 2014, os quais tiveram a pressão venosa central avaliada de duas em duas horas, nas primeiras 72 horas depós-operatório, sendo administrada uma ampola de furosemida cada vez que a pressão atingiu o ponto de cortepreestabelecido de forma randomizada em 15 cmH2O ou 20 cmH2O. Já o controle foi composto por 184 pacientesavaliados retrospectivamente submetidos a revascularização miocárdica entre 2009 e 2012, antes do início darandomização, nos quais o controle da pressão venosa central foi menos rigoroso, ficando a necessidade de usode diurético a critério dos intensivistas. Avaliou-se a incidência de fibrilação atrial nas primeiras 72 horas depós-operatório nos dois grupos. Resultados: A incidência de fibrilação atrial foi menor no grupo caso (11,25%, 9em 80), comparativamente ao grupo controle (23,35%, 43 em 184) (P = 0,03). Outras variáveis estudadas foramsemelhantes entre os grupos, exceto o clearance de creatinina, que foi maior no grupo controle. Conclusão: Opresente estudo demonstra que o controle da pressão venosa central nas primeiras 72 horas de pós-operatório écapaz de reduzir a incidência de fibrilação atrial após revascularização do miocárdio.

Background: This study was aimed at comparing the incidence of atrial fibrillation after coronaryartery bypass grafting among patients who have had central venous pressure strictly controlled within thefirst 48-72 hours after surgery and patients who did not have a strict control. Method: Observational, casecontrolstudy, performed at Santa Casa de Misericórdia de Ponta Grossa. The case included 80 prospectivelyevaluated patients submitted to myocardial revascularization between 2012 and 2014, who had central venouspressure evaluated every two hours, in the first 72 hours after surgery. Patients received a vial of furosemide everytime the pressure reached the pre-established cutoff randomly set as 15 or 20 cmH2O. The control included 184retrospectively evaluated patients undergoing myocardial revascularization between 2009 and 2011 prior to thebeginning of randomization; in this group central venous pressure control was less rigorous, requiring use ofdiuretics at the discretion of the intensivists. The incidence of atrial fibrillation in the first 72 hours after surgerywas evaluated in both groups. Results: The incidence of atrial fibrillation was lower in the case group (11.25%,9 in 80) than in the control group, (23.35%, 43 in 184) (P = 0.03). Other studied variables were similar betweenthe groups except for the creatinine clearance, which was higher in the control group. Conclusion: The presentstudy demonstrates that the central venous pressure control within the first 72 hours after surgery reduces theincidence of atrial fibrillation after coronary artery bypass grafting.

Morbimortality study of infection in patients undergoing different types of dialysis in a renal replacement therapy center

INTRODUCTION: Renal replacement therapy is the treatment of end-stage chronic kidney disease and can be performed through dialysis catheters, arteriovenous fistulas/grafts, and peritoneal dialysis. Patients are usually immunocompromised and exposed to invasive procedures, leading to high rates of infection and increased mortality. OBJECTIVES: To compare the prevalence of infection and related deaths, as well as the sensitivity profile of the putative bacteria in patients treated with peritoneal dialysis, arteriovenous fistula hemodialysis and catheter hemodialysis. METHODS: This is case-control study. Six hundred forty-four patients undergoing renal replacement therapy were selected. Patients were divided into three groups according to the modality of dialysis treatment: peritoneal dialysis (126 patients), arteriovenous fistula hemodialysis (326 patients), and catheter hemodialysis (192 patients). RESULTS: One hundred sixteen patients (18.01%) developed infection. There was a higher incidence of infection in the peritoneal dialysis group (44 patients; 34.92%; OR: 3.32; CI 95% = 2.13-5.17; p = 0.0001). In the catheter hemodialysis group, 48 patients (25%) had infection (OR: 1.88; CI 95%: 1.24-2.85; p = 0.0035). In the arteriovenous fistula hemodialysis group, 24 patients (7.36%) developed infection (OR: 0.19; CI 95%: 0.12-0.31; p = 0.0001). Five patients (4.31%) died due to infection (four in the peritoneal dialysis group and one in the catheter hemodialysis group). There were no deaths due to infection in the arteriovenous fistula hemodialysis group. CONCLUSIONS: Peritoneal dialysis is the treatment with greater risk of infection and mortality, followed by catheter hemodialysis. The lowest risk of infection and mortality was observed in arteriovenous fistula hemodialysis group. .

Benefícios tardios do uso de marcapasso no tratamento da miocardiopatia hipertrófica obstrutiva / Long-term benefits of pacemaker use in obstructive hypertrophic cardiomyopathy treatment

OBJETIVO: Avaliar os resultados tardios do uso de marcapasso (MP) em pacientes portadores de miocardiopatia hipertrófica obstrutiva (MHO), sintomáticos e refratários ao tratamento medicamentoso.MÉTODO: Foram avaliados 10 pacientes portadores de MHO, refratários ao tratamento com betabloqueador e/ou verapamil, submetidos a implante de MP de dupla-câmara (DDD). Os pacientes foram acompanhados por um período médio de 4,5 anos após o implante. Foram comparados os dados clínicos (classe funcional, presença de síncope ou tontura e dor precordial) e os gradientes de pressão máximos na via de saída do VE pelo ecocardiograma, no pré-implante, na consulta entre três e seis meses e na consulta atual. Os dados clínicos foram confirmados por teste ergométrico realizado na última avaliação clínica.RESULTADOS: Não houve mortalidade e sim melhora significativa (p=0,0233) da classe funcional após o implante, que persistiu até a última avaliação, bem como desaparecimento de dor precordial e tontura, estatisticamente significativo para tontura (p=0,0412). O gradiente máximo na via de saída do VE foi 90,6 mmHg no pré-implante, 19 com três e seis meses e 13 no exame atual (p=0,00001). Houve correlação entre a classe funcional avaliada clinicamente e pelo teste ergométrico.CONCLUSÃO: Ocorreu melhora significativa da classe funcional e desaparecimento dos sintomas de dor precordial e tontura, bem como redução significativa do gradiente na via de saída do VE, que persistiu no seguimento tardio, mostrando que o uso de MP DDD foi uma opção terapêutica segura e resolutiva em longo prazo na amostra estudada.

Trombocitopenia induzida por heparina e necrose cutânea por varfarina: relato de caso / Heparin-induced thrombocytopenia and warfarin-induced skin necrosis: case report

É relatado um caso de trombocitopenia induzida por heparina complicada, com necrose cutânea induzida por varfarina em paciente de 74 anos, sexo feminino, internada com diagnóstico de fratura do colo do fêmur, trombose venosa profunda e tromboembolismo pulmonar. A necrose cutânea induzida por varfarina é uma complicação rara da terapia anticoagulante, com alta morbidade e mortalidade, que pode estar associada à trombocitopenia induzida por heparina.

This paper describes a case of heparin-induced thrombocytopenia complicated by warfarin-induced skin necrosis in a 74-year old female patient hospitalized with diagnoses of a hip fracture, deep vein thrombosis and pulmonary thromboembolism. Warfarin-induced skin necrosis is a rare complication of anticoagulant therapy, with high morbidity and mortality that may be associated with heparin-induced thrombocytopenia.

Sinovite hipertrófica familiar / Sinovite hipertrófica familiar

A sinovite hipertrófica familiar é uma condição rara, de origem familiar, que deve ser lembrada no diagnóstico das artrites da infância. Os autores apresentam o caso de um menino de 7 anos, portador de deformidades dos artelhos em flexão e múltiplos derrames articulares indolores acometendo grandes articulações, desde o nascimento e sem sintomas sistêmicos. O paciente possui uma prima com quadro semelhante.