Valores normales de aorta torácica por ecocardiografía. Registro MATEAR (Medición de Aorta Torácica por Ecocardiografía en Argentina) / Normal Values of Thoracic Aorta Dimensions by Echocardiography. The MATEAR (Measurement of Thoracic Aorta by Echocardiography in Argentina) Registry

RESUMEN Introducción: Se han encontrado diferencias en los diámetros de la aorta torácica de acuerdo al sexo, la edad y la superficie corporal. Sin embargo, los resultados son muy heterogéneos. Objetivos: Determinar los diámetros normales de la aorta (DAo) torácica por ecocardiograma transtorácico en nuestra población y analizar la influencia de las variables antropométricas, demográficas y étnicas en los DAo. Material y métodos: Se realizó un registro nacional, prospectivo y multicéntrico que incluyó 1000 adultos sanos (media de edad: 38,3 ± 12,7 años, 553 mujeres, 56,7% de origen caucásico y 38,3% de americanos nativos). Se realizaron mediciones aórticas siguiendo las recomendaciones actuales en 6 niveles: anillo, sinusal, unión sinotubular, ascendente proximal, cayado y descendente proximal. Resultados: El percentilo 95 se encontró por debajo de los 3,80 cm para todos los DAo absolutos, 2,08 cm/m para los indexados por altura y 2,11 cm/m2 para los indexados por superficie corporal (SC). El análisis global mostró correlación positiva y significativa entre todos los diámetros aórticos y la SC y la altura, así como la edad, con la excepción del anillo aórtico, que no presentó modificaciones con el paso del tiempo. En los individuos con índice de masa corporal aumentado, la SC no se correlacionó con los diámetros aórticos. Las mujeres presentaron menores DAo en todos los segmentos y en la raíz aórtica, aun luego de indexar por altura. Los americanos nativos presentaron menores diámetros aórticos absolutos e indexados que los caucásicos en todos los niveles aórticos (p < 0,01), exceptuando la aorta descendente proximal, que no mostró diferencias significativas. Conclusiones: Las variables demográficas, antropométricas y étnicas resultaron ser determinantes significativos de las dimensiones aórticas en todos sus niveles, por lo que deben tenerse en cuenta para la correcta interpretación de estas mediciones.

ABSTRACT Background: Transthoracic echocardiography (TTE) remains the screening tool of choice for thoracic aorta (TA) dilatation. Differences in TA diameters (TAD) according to gender (G), age (A) and body surface area (BSA) have been previously reported. However, these reports are limited by small sample size, different measurement sites or heterogeneous cohorts. There is scarce data on the influence of ethnicitiy on TAD. Objective: We designed a prospective nationwide multicenter registry to determine the normal diameters of the thoracic aorta at all TA segments in healthy adults of both G and their correlations with A, ethnicity and BSA. Methods: A national, prospective and multicenter registry was carried out in 1000 healthy adult people (mean age: 38.3 ± 12.7 years, 553 women, 56.7% of caucasian origin). Aortic measurements were made following the current recommendations at 6 levels: aortic annulus, sinus, sinotubular junction, proximal ascending, arch and proximal descending aorta. Pooled data showed a positive correlation between all TAD and A or BSA (p<0.001), similar in both G. In patients with obesity the correlation was better with height than BSA. Resultados: The 95th percentile was found below 3.80 cm for all absolute aortic diameters, 2.08 cm / m for those indexed by height and 2.11 cm / m2 per body surface. Nomograms were obtained for 3 age categories to predict TAD from BSA with no need of G distinction. Native americans showed significatly lower absolute and indexed TAD than caucasian (p<0.01) from annulus to isthmus. Conclusions: While age and BSA were significant determinants of aortic dimensions at six levels, we have also detected differences in TAD according to ethnicity, suggesting normative values should also be defined for each ethnic group. We propose nomograms of indexed TAD for different age and ethnic groups without G distinction.

Performance analysis of commercial rapid tests for serum troponin detection / Análise do desempenho de testes rápidos comerciais para detecção de troponina I sérica

ABSTRACT Introduction: Rapid tests represent an important diagnostic tool, providing results in a short period of time and eliminating the use of large automated equipment. Objective: To evaluate the performance of five rapid test kits for troponin I detection in serum. Materials and methods: Samples from 100 patients with suspected acute myocardial infarction (AMI) were selected from a hospital in Barbacena, MG, Brazil. They were tested in the five troponin I commercial rapid test kits and the results were compared with the study reference method (quantitative chemiluminescent immunoassay). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and correlation coefficients of the rapid tests against the reference method were defined. Results: The kits from Abon®, Interteck®, Medtest® and Wama® presented the same performance, reaching equal levels of sensitivity (98.08%), specificity (100%), PPV (100%), NPV (97.96%), and correlation coefficient (0.99). The Eco Diagnostica® kit presented lower sensitivity (82.69%), low correlation coefficient (0.91) and NPV (84.21%), not reaching ideal levels even though lying within the confidence interval. Discussion: The results obtained with the Abon®, Interteck®, Medtest® and Wama® test kits corroborate pre-existing literature data on the diagnostic accuracy of rapid tests for troponin detection. These tests are allowed for immediate decision making by physicians and can be used to reduce unnecessary hospitalization time and costs associated with a suspected AMI. Conclusion: The kits from Abon®, Interteck®, Medtest® and Wama® showed excellent diagnostic performance, what makes them an important diagnostic tool in smaller laboratories without automated equipment.

RESUMEN Introducción: Hoy en día, las pruebas rápidas representan importante herramienta diagnóstica, ofrecen resultados en corto espacio de tempo y dispensan el uso de equipos automatizados. Objetivo: Evaluar el desempeño de cinco kits de pruebas rápidas para detectar troponina I en suero. Material y métodos: Se eligieron 100 especímenes de pacientes sospechosos de infarto agudo de miocardio (IAM) de un hospital en el municipio de Barbacena, Minas Gerais, Brasil. Los especímenes fueron testados en los cinco kits comerciales de prueba rápida de troponina I y el resultado se comparó con el método considerado referencia en el estudio (inmunoensayo quimioluminiscente cuantitativo). Luego, se establecieron los niveles de sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN) y coeficiente de correlación de las pruebas rápidas con respecto al método de referencia. Resultados: Las marcas Abon®, Interteck®, Medtest® y Wama® tuvieron el mismo desempeño, alcanzando niveles iguales de sensibilidad (98,08%), especificidad (100%), VPP (100%), VPN (97,96%) y coeficiente de correlación (0,99), mientras la marca Eco Diagnóstica® presentó 82,69% de sensibilidad, 0,91 de coeficiente de correlación y 84,21% de VPN, no alcanzando los niveles ideales, aunque dentro del intervalo de confianza. Discusión: Los resultados obtenidos con las marcas Abon®, Interteck®, Medtest® e Wama® confirman datos preexistentes en la literatura sobre la precisión diagnóstica de las pruebas rápidas para detectar troponina. Esas pruebas permiten a los médicos adoptar decisiones de forma inmediata y pueden ser usados para reducir tiempo y costos de internaciones innecesarias cuando hay sospecha de IAM. Conclusión: Las marcas Abon®, Interteck®, Medtest® e Wama® presentaron excelente desempeño diagnóstico y representan importante herramienta diagnóstica en laboratorios menores, sin equipos automatizados.

RESUMO Introdução: Atualmente, os testes rápidos representam importante ferramenta diagnóstica, fornecendo resultados em curto espaço de tempo e dispensando a utilização de grandes automações. Objetivo: Avaliar o desempenho de cinco kits de testes rápidos para pesquisa sérica de troponina I. Materiais e métodos: Foram selecionadas 100 amostras de pacientes com suspeita de infarto agudo do miocárdio (IAM) de um hospital do município de Barbacena, Minas Gerais, Brasil. As amostras foram testadas nos cinco kits comerciais de teste rápido de troponina I e o resultado foi comparado com o método considerado referência no estudo (imunoensaio quimioluminescente quantitativo). Em seguida, foram definidos níveis de sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN) e coeficiente de correlação dos testes rápidos em relação ao método de referência. Resultados: Os kits Abon®, Interteck®, Medtest® e Wama® apresentaram o mesmo desempenho, atingindo níveis iguais de sensibilidade (98,08%), especificidade (100%), VPP (100%), VPN (97,96%) e coeficiente de correlação (0,99). O kit Eco Diagnóstica® apresentou 82,69% de sensibilidade, 0,91 de coeficiente de correlação e 84,21% de VPN, não atingindo os níveis ideais, mesmo dentro do intervalo de confiança. Discussão: Os resultados obtidos com os kits Abon®, Interteck®, Medtest® e Wama® confirmam dados preexistentes na literatura sobre a exatidão diagnóstica dos testes rápidos para detecção de troponina. Esses testes permitem a tomada de decisão imediata pelo médico e podem ser usados para reduzir tempo e custos de internações desnecessárias na suspeita de IAM. Conclusão: Os kits Abon®, Interteck®, Medtest® e Wama® apresentaram excelente desempenho diagnóstico e constituem importante ferramenta diagnóstica em laboratórios menores, sem equipamentos automatizados.

Study on the correlation between red cell distribution width and microalbuminuria in patients with chronic heart failure / 天津医药

Objective To observe changes of red blood cell distribution width (RDW) and trace albumin urine (MAU) in patients with chronic heart failure (CHF) and to explore the relationship between them and cardiac function classification. Methods A total of 190 patients with CHF were divided into mild group (NYHA grade II), moderate group (NYHA gradeⅢ) and severe group (NYHA gradeⅣ), according to the grade of cardiac function. A total of 100 subjects with normal physi?cal examination during the same period were selected as the control group. The changes of MAU, urinary creatinine (Scr) ra?tio (UACR), RDW, Scr, hemoglobin (Hb), type B urine sodium titanium (BNP) and left ventricular ejection fraction (LVEF)were compared between four groups. The correlation between UACR, RDW, Scr, Hb, BNP and LVEF were analyzed. Re?sults The levels of RDW, Scr, BNP, hypersensitive C-reactive protein (hsCRP), LVEDd, LVM, LVMI and UACR were sig?nificantly higher in chronic heart failure group than those of control, showing a trend of increase gradually with the rising of heart function classification (P<0.05). The values of Hb and LVEF showed a gradually decreasing trend with the increased heart function classification (P < 0.05). The values of UACR and RDW showed a gradually increasing trend with the in?creased heart function classification (P<0.05). There was a positive correlation between UACR and RDW, and both had a positive correlation with BNP, and a negative correlation with LVEF and Hb(P<0.05). Conclusion RDW and MAU are re?lated to the cardiac function classification, and both can be used for the evaluation of the prognosis in patients with CHF.

Risco de reação adversa ao contraste iodado: validação de conteúdo diagnóstico, resultados e intervenções de enfermagem / Riesgo de reacción adversa a los medios de contraste yodados: validación de contenido diagnóstico, resultados y intervenciones de enfermería / Risk for adverse reaction to iodinated contrast media: diagnosis, outcomes and interventions content validation

O Processo de Enfermagem (PE) vem sendo desenvolvido com a utilização de linguagens padronizadas que incluem a classificação diagnóstica da NANDA International, Inc (NANDA-I) e as classificações de intervenções e resultados de enfermagem segundo a Nursing Interventions Classification (NIC) e a Nursing Outcomes Classification(NOC), respectivamente. Estudos de validação de conteúdo, por meio de consenso entre peritos, vêm sendo realizados para o refinamento dessas taxonomias e qualificação do cuidado de enfermagem nas diferentes especialidades. Recentemente foi inserido na classificação da NANDA-I o diagnóstico de enfermagem (DE) Risco de reação adversa ao contraste iodado, contemplando as áreas de diagnóstico por imagem. Os objetivos desta pesquisa consistiram em: 1) realizar a validação de conteúdo diagnóstico do DE Risco de reação adversa ao contraste iodado (código 00218), incluindo título, definição, fatores de risco e inserção na estrutura da Taxonomia II da NANDA-I; 2) realizar a validação de conteúdo de resultados de enfermagem da NOC e de intervenções de enfermagem da NIC para o DE em estudo, a partir dos fatores de risco validados como principais. Consistiu em objetivo secundário investigar diferenças entre os grupos de peritos médicos e enfermeiros quanto ao julgamento dos elementos propostos. Para isso, foi utilizado o método de validação de conteúdo diagnóstico de Fehring, que consiste na avaliação de peritos quanto à pertinência de cada item proposto. A partir da opinião dos sujeitos, calcula-se um escore correspondente à média ponderada que determinará se o item foi validado como principal (escore maior ou igual a 0,8), secundário (escore menor do que 0,8 e maior que 0,5) ou não validado (escore igual ou menor que 0,5). A coleta de dados foi realizada por meio de survey eletrônico com perguntas fechadas e espaço para comentários...

The Nursing Process (NP) has been developed by using standardized languages including the NANDA International , Inc (NANDA-I) diagnoses classification, the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC). Content validation studies, through expert consensus, has been used to refine these taxonomies and qualify the nursing care in different areas. Recently the nursing diagnosis (ND) Risk for adverse reaction to iodinated contrast media was included in the NANDA-I taxonomyII, involving the diagnostic imaging specialty. The purpose of this study was: 1) to perform the content validation of the ND Risk for adverse reaction to iodinated contrast media (code 00218), including its title, definition, risk factors and insertion in the NANDA-I taxonomy II; 2) to perform the content validation of nursing outcomes (NOC) and nursing interventions (NIC) related to this diagnosis. A secondary purpose was to investigate differences between the groups of experts registered nurses and physicians concerning the judgment of the proposed items. It was utilized the diagnostic content validation model of Fehring that consists in obtaining consensus of experts about each proposed item. The experts opinions results in a weighted ratios (WR) or score that will determine if the item was validated as principal (equal or higher than 0,8), secondary (ranging from less than 0,8 and higher than 0,5) or not validated, which means score equal or minor than 0,5. For data collection, it was utilized an electronic survey containing closed format questions plus space for notes. The expert groups included physicians and registered nurses having at minimal five years in attendance of patients submitted to procedures using iodinated contrast media. The research had two phases...

El Proceso de Enfermería (PE) se ha desarrollado con el uso de lenguajes estandardizados que incluyen la clasificación diagnóstica de la NANDA Internacional, Inc (NANDA-I), la Clasificación de Intervenciones de Enfermería (NIC) y la Clasificación de Resultados de Enfermería (NOC). Los estudios de validación de contenido a través de un consenso entre expertos, se han llevado a cabo para el perfeccionamiento de estas taxonomias y cualificación de los cuidados de enfermería en diferentes especialidades. Recientemente ha incluido en la clasificación de los diagnósticos NANDA-I el diagnóstico de enfermería (DE) Riesgo de reacción adversa al contraste yodado (código 00218), que abarca las áreas de diagnóstico por imágenes. Los objetivos de esta investigación abarco: 1) la validación del contenido del DE Riesgo de reacción adversa al contraste yodado, incluyendo su declaración, definición, los factores de riesgo y la inserción del DE en los Dominios y las Clases de la estructura taxonómica II de NANDA-I; 2) la validación de los resultados de enfermería (NOC) y de las intervenciones de enfermería (NIC) relacionados con el mismo. El objetivo secundario fue investigar las diferencias en las opiniones de expertos médicos y enfermeros en la validación de esta propuesta. Para ello, se utilizó el método de validación de contenido diagnóstico de Fehring, que es la evaluación de expertos sobre la validez de cada tema propuesto. La opinión de los sujetos resultan en un escore que determina si el elemento es validado como principal (mayor o igual a 0,8), secundario (inferior a 0,8 y mayor que 0,5) o no validado (igual o menos de 0,5). La muestra incluyó a los médicos y enfermeros con experiencia de por lo menos cinco años en el cuidado de los pacientes que se someten a procedimientos con contraste yodado. La investigación constó de dos etapas...

Valor del score de Atenas en el diagnóstico de cardiopatía isquémica

Antecedentes: la aparición de ángor y/o infradesnivel del segmento ST durante la prueba ergométrica graduada (PEG) permite hacer el diagnóstico presuntivo de cardiopatía isquémica (CI). Otros cambios electrocardiográficos podrían ser de utilidad. Uno de ellos es el score de Atenas (SDA), que relaciona los cambios de amplitud del complejo QRS en reposo y en el posesfuerzo inmediato (PEI). El propósito de nuestro estudio es determinar la validez del SDA en el diagnóstico de CI; secundariamente, evaluar su correlación con la clase funcional (CF) del paciente y el incremento del doble producto (DP) durante la PEG. Material y método: se realizó un análisis retrospectivo en 75 pacientes remitidos a estudio de perfusión miocárdica (EPM) sensibilizados con PEG. En 25 pacientes se diagnosticó isquemia por la presencia de defectos reversibles de grado moderado a severo. Resultados: en los valores medios del SDA no se hallaron diferencias estadísticamente significativas entre los grupos. En EPM (+) fue -0,16 mm (DS±4,39) y en EPM (-) 1,88 mm (±4,3) (p=0,062). En cambio, existen diferencias significativas en los pacientes con CF I (>7 MET) o un DP>2,5 veces el basal. En los primeros, el SDA fue -3,73 mm (±6,83) en los EPM (+) y 5,2 mm (±4,34) en los EPM (-) (p<0,02). En aquellos con incremento del DP >2,5 veces, el SDA fue -1,57 mm (±6,99) en los EPM (+) y 3,64 mm (±4,72) en los EPM (-) (p<0,03). Conclusiones: el SDA tiene utilidad para predecir isquemia moderada a severa en el EPM en aquellos pacientes en CF I o que incrementen dos veces y media el DP en la PEG.

Background: the onset of angina and/or ST segment displacement during exercise testing (ET) is useful in the diagnosis of ischemic heart disease (IHD). Other changes in the electrocardiogram also may be of diagnostic value. One of them is the QRS or Athens Score (SDA) based in changes in the amplitude of the QRS complex recorded at rest and immediately post-stress. The purpose of this study is to determine the validity of the SDA in the diagnosis of IHD, secondarily, to evaluate SDA results according the functional class (CF) and the increment in the double product (DP) during the ET. Material and method: we conducted a retrospective study in 75 patients referred to perform myocardial perfusion imaging (EPM) with ET. The diagnosis of ischemia was done in 25 patients with moderate to severe reversible defects. Results: the SDA mean value expressed in mm (±SD) was -0,16 ± 4,39 for EPM (+) and 1,88 ± 4,3 for EPM (-), the difference was non-significant (p=0.062). However, there were significant differences in patients with CF I (> 7 MET) or a DP >2,5 times the baseline. In the first, the SDA was -3,73 ± 6,83 in EPM (+) and 5,2 ± 4,34 in the EPM (-) (p< 0,02). In those with DP increased >2.5 times, the SDA was -1,57 ± 6,99 in the EPM (+) and 3,64 ± 4,72 EPM (-) (p<0,03). Conclusion:the SDA have diagnostic utility for predicting moderate to severe ischemia in the EPM in those patients with CF I or an increment of the DP >2,5 in the ET.

Avaliação do foto-eletrocardiograma como ferramenta de segunda opinião formativa / Evaluation of the photo-electrocardiogram as a tool for formative second opinion

Objetivos: Avaliar o foto-eletrocardiograma (foto-ECG), como uma ferramenta de segunda opinião formativa a distância.Métodos: Cinquenta eletrocardiogramas (ECGs) em papel milimetrado foram fotografados duas vezes, a primeira utilizando-se uma câmera digital Canon, na resolução 0,3 megapixel, e a segunda com um celular Nokia com câmera acoplada, na resolução 2,0 megapixels, gerando 100 foto-ECGs. Por meio de estudos-piloto, definiu-se o método de aquisição das imagens. Os 100 foto-ECGs foram randomizados, criptografados e enviados a um cardiologista remoto por e-mail; enquanto os 50 ECGs em papel milimetrado lhe foram entregues pessoalmente, sem randomização. Sexo e idade foram as únicas informações dos pacientes disponibilizadas ao especialista.Resultados: A análise dos dados demonstrou divergência em 14 dos 50 laudos (28%) na comparação dos ECGs originais com os foto-ECGs adquiridos pela câmera Canon e de 13 dos 50 laudos (26%) entre os laudos dos ECGs originais e dos foto-ECGs capturados pelo celular Nokia. Houve concordância considerável (Kappa=0,356) entre as interpretações de foto-ECGs e ECGs em papel, tanto para o celular Nokia quanto para a câmera Canon.Conclusões: A concordância entre o foto-ECG e os traçados originais demonstrou que o método descrito nesse estudo tem potencial de ser utilizado como uma ferramenta de auxílio à prática clínica, desde que a obtenção dos foto-ECGs seja adaptada de forma a melhorar as imagens dos exames. Apenas com concordância boa a ótima em relação aos ECGs originais, o foto-ECG possibilitará a segunda opinião formativa a distância, conferindo melhores opções diagnósticas e terapêuticas...

Aims: This study aimed to evaluate the photo-electrocardiogram (photo-ECG), as an alternative tool to enable remote formative second opinion in cardiology.Methods: Fifty paper electrocardiograms (ECGs) were photographed two times, the first using a Canon digital camera, 0.3 megapixel resolution, and the second using a Nokia mobile phone integrated camera, 2.0 megapixel resolution, resulting in 100 Photo-ECGs. A pilot study was responsible for determining the acquisition method. The 100 Photo-ECGs were randomized, encrypted and sent by e-mail to a remote cardiologist, while the 50 paper ECGs were delivered to him in person, without randomization. Gender and age were the only patient information made available to the specialist.Results: Data analysis demonstrated a disagreement in 14 of 50 interpretations (28%) when comparing paper ECGs to the Canon camera photo-ECGs and in 13 of 50 interpretations (26%) when comparing paper ECGs to the Nokia camera photo-ECGs. The Kappa test revealed a fair agreement (Kappa=0.356) between interpretations when comparing the original ECGs to their respective photo-ECGs for both camera devices.Conclusion: The concordance between photo-ECGs and original tracings demonstrated that the method described herein has the potential for use as a tool to assist clinical practice, provided that the acquisition of photo-ECGs is adapted so as to improve exam images. Only with good to very good concordance between the original ECGs and photo-ECGs will remote formative second opinion be possible, giving better diagnostic and therapeutic options...

Effects of reprocessing on chemical and morphological properties of guide wires used in angioplasty / Efeitos do reprocessamento nas propriedades químicas e morfológicas de fios-guia usados em angioplastia

OBJECTIVE: To investigate the influence of the reprocessing technique of enzymatic bath with ultrasonic cleaning and ethylene oxide sterilization on the chemical properties and morphological structure of polymeric coatings of guide wire for regular guiding catheter. METHODS: These techniques simulated the routine of guide wire reprocessing in many hemodynamic services in Brazil and other countries. Samples from three different manufacturers were verified by scanning electron microscopy and X-ray photoelectron spectroscopy. RESULTS: A single or double sterilization of the catheters with ethylene oxide was not associated with morphological or chemical changes. However, scanning electron microscopy images showed that the washing method was associated with rough morphological changes, including superficial holes and bubbles, in addition to chemical changes of external atomic layers of polymeric coating surfaces, as detected by the X-ray photoelectron spectroscopy method, which is compatible with extended chemical changes on catheter surfaces. CONCLUSION: The reprocessing of the catheters with ethylene oxide was not associated with morphological or chemical changes, and it seemed appropriate to maintain guide wire coating integrity. However, the method combining chemical cleaning with mechanical vibration resulted in rough anatomical and chemical surface deterioration, suggesting that this reprocessing method should be discouraged.

OBJETIVO: Investigar a influência das técnicas de reprocessamento de banho enzimático com limpeza ultrassônica e a esterilização com óxido de etileno nas propriedades químicas e estruturas morfológicas de revestimentos poliméricos de fios-guia usados como guias em cateteres regulares. MÉTODOS: Estas técnicas simulam a rotina de processamento de fios-guia em muitos serviços de hemodinâmica do Brasil e de outros países. Amostras de três diferentes fabricantes foram verificadas por microscopia eletrônica de varredura e espectroscopia de fotoelétrons de raios-X. RESULTADOS: Uma única ou dupla esterilização dos cateteres com óxido de etileno não foi associada a mudanças químicas ou morfológicas. Contudo, imagens de microscopia eletrônica de varredura mostraram que o método de lavagem foi associado a intensas modificações morfológicas, incluindo bolhas e buracos superficiais, assim como mudanças nas ligações químicas das camadas atômicas externas do revestimento polimérico, conforme demonstrado por resultados de espectroscopia de fotoelétrons de raios-X, compatível com extensas modificações químicas induzidas por esse processo de lavagem. CONCLUSÃO: O reprocessamento dos fios-guia de cateteres com óxido de etileno não está associado a mudanças químicas e morfológicas dos mesmos e pode ser considerado adequado para manter a integridade destes materiais. Entretanto, o método que combina lavagem química com vibração mecânica resulta em intensas deteriorações anatômicas e químicas, sugerindo que esse método de processamento deve ser desencorajado.

Desafios a implantacao do centro de leitura de eletrocardiografia no ELSA-Brasil / Desafios en la implantacion del centro de lectura de electrocardiografia en el ELSA-Brasil / Challenges to implementation of the ECG reading center in ELSA-Brasil

O eletrocardiograma é um método estabelecido de avaliação cardiovascular de baixo custo utilizado há décadas em estudos epidemiológicos de grande porte. Apesar disso, sua utilização em estudos desse tipo se constitui em desafio, especialmente quando se pretende implantar Centro de Leitura próprio. Este artigo descreve o processo, dificuldades e desafios de implantação do Centro de Leitura em eletrocardiograma no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Dentre os aspectos discutidos, ressaltam-se: os critérios para escolha dos eletrocardiógrafos e da central de armazenamento e manejo dos aparelhos; o pessoal necessário; os procedimentos de aquisição e de transmissão dos eletrocardiogramas para o Centro de Leitura; os sistemas de codificação dos traçados, com ênfase para o código de Minnesota; os aspectos éticos e práticos relacionados à entrega dos laudos aos participantes do estudo; e os aspectos relacionados ao controle de qualidade.

Electrocardiography is an established low-cost method of cardiovascular assessment, utilized for decades large epidemiological studies. Nonetheless, its use in large epidemiological studies presents challenges, especially when seeking to develop a reading center. This article describes the process, difficulties and challenges of implementing an electrocardiogram reading center in Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). Among the issues discussed, we have emphasized: the criteria for selection of the electrocardiography machine and the central for storage and management of the machines; the required personnel; the procedures for acquisition and transmission of electrocardiographs to the Reading Center; coding systems, with emphasis on the Minnesota code; ethical and practical issues regarding the delivery of reports to study participants; and aspects related to quality control.

Afericoes e exames clinicos realizados nos participantes do ELSA-Brasil / Medical assessments and measurements in ELSA-Brasil

Este artigo descreve os exames clínicos realizados no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Alguns deles (antropometria, pressão arterial e índice tornozelo-braquial) já têm uso clínico consolidado. Outros, como a velocidade de onda de pulso, variabilidade da frequência cardíaca e medida da espessura médio-intimal de carótidas, carecem de valor de referência na população brasileira não doente e podem constituir preditores importantes de desfechos cardiovasculares. A medida da pressão arterial após manobra postural foi incluída no ELSA-Brasil porque foi pouco testada em estudos epidemiológicos. O ELSA-Brasil inovou na realização do índice tornozelo-braquial, ao usar um aparelho automático em substituição à coluna de mercúrio na medida da pressão arterial, e também na medida do diâmetro ântero-posterior do lobo direito do fígado pela ultrassonografia, proposta para avaliação quantitativa da doença hepática gordurosa não-alcoólica. Os participantes são indivíduos mais jovens (a partir dos 35 anos) do que em outras coortes focadas no estudo da aterosclerose subclínica. A inclusão de indivíduos mais jovens e a diversidade dos exames realizados tornam o ELSA-Brasil um estudo relevante no contexto da epidemiologia brasileira e internacional.

The article describes assessments and measurements performed in the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). Some assessments including anthropometric assessment, casual blood pressure measurement, and ankle-brachial index have an established clinical application while others including pulse wave velocity, heart rate variability, and carotid intima-media thickness have no established application and do not have reference values for healthy Brazilian population but may be important predictors of cardiovascular outcomes. Blood pressure measurement following postural change maneuver was included in the ELSA-Brasil because it has not been much tested in epidemiological studies. Innovative approaches were developed for assessing the ankle-brachial index using an automatic device instead of the mercury column to measure blood pressure and for assessing the anterior-posterior diameter of the right lobe of the liver by ultrasound for quantitative assessment of nonalcoholic fatty liver disease. All ELSA-Brasil subjects were younger (35 years or more) than those included in other cohorts studying subclinical atherosclerosis. The inclusion of younger individuals and a variety of assessments make the ELSA-Brasil a relevant epidemiology study nationwide and worldwide.

Estrategias de identificacao, investigacao e classificacao de desfechos incidentes no ELSA-Brasil / ELSA-Brasil strategies for outcome identification, investigation and ascertainment

OBJETIVO: O artigo descreve as estratégias do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) para a manutenção da adesão dos participantes ao longo do tempo e seu seguimento adequado. Isto é fundamental para garantir a validade interna de estudos longitudinais e identificar, investigar e classificar os desfechos incidentes de interesse. MÉTODOS: A metodologia de seguimento da coorte combina contatos telefônicos anuais com re-exames e entrevistas a cada três ou quatro anos. O objetivo é identificar desfechos incidentes de natureza transitória, reversíveis ou não; desfechos finais, de natureza irreversível; bem como complicações relacionadas à evolução das doenças cardiovasculares e diabetes, principais doenças estudadas. RESULTADOS: As entrevistas telefônicas visam monitorar a saúde dos participantes e identificar possíveis eventos ocorridos, como internações hospitalares, exames ou procedimentos especializados definidos previamente. O participante também é incentivado a comunicar a ocorrência de algum evento de saúde ao Centro de Pesquisa. A partir da identificação de um potencial evento, é iniciado um processo de investigação, que inclui acesso a prontuários médicos para verificação de datas e informações detalhadas sobre aquele evento. Os documentos obtidos são analisados sem identificação do paciente, profissional ou serviço de saúde e classificados por um comitê de especialistas médicos. A classificação de desfechos incidentes adotada baseia-se em critérios internacionais consagrados, garantindo comparabilidade e reduzindo o erro de classificação deles. Além dessas estratégias, a ocorrência de desfechos ...

OBJECTIVE: The article describes the strategies adopted by the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil) for participation and retention of subjects. This is key to ensure internal validity of longitudinal studies, and to identify, investigate, and ascertain outcomes of interest. METHODS: The follow-up strategies include annual telephone contacts with new assessments and interviews every three to four years this approach aims to identify transient outcomes (reversible or not), permanent outcomes as well as complications related to the progression of major diseases - cardiovascular diseases and diabetes - to be studied. RESULTS: Telephone interviews are designed to monitor subjects' health status and to identify potential health-related events such as hospital admissions, medical visits or pre-selected medical procedures. Subjects are also encouraged to report to the ELSA-Brasil team any new health-related events. When a potential event is identified, a thorough investigation is carried out to collect relevant information about that event from medical records. All data are blinded and reviewed and analyzed by a medical expert committee. Incident outcome ascertainment follows well-established international criteria to ensure data comparability and avoid misclassification. In addition to these strategies, the occurrence of health-related events is also investigated through linkage of secondary databases, such as national mortality and hospital admission databases. CONCLUSIONS: Accurate identification of outcomes will allow to estimating their incidence in the study cohort and to investigate the effect of the exposures studied in the ELSA-Brasil at baseline and at its subsequent waves. .

Controvérsias no diagnóstico e tratamento da trombose venosa profunda pela ecografia vascular / Controversies in the diagnosis and treatment of deep vein thrombosis for vascular ultrasound

A trombose venosa profunda é uma entidade clínica potencialmente grave, responsável por elevada morbimortalidade. A ecografia vascular representa o método propedêutico de escolha no diagnóstico e acompanhamento dos pacientes com essa doença. Entretanto, várias questões permanecem controversas, tais como a abordagem inicial do paciente com suspeita de trombose venosa profunda, os tipos de protocolo a serem usados, o tempo para a realização do exame e a trombose no plexo de panturrilha. O objetivo dessa revisão é discutir esses assuntos à luz dos conhecimentos atuais.

Deep vein thrombosis is a potentially serious clinical entity, responsible for high morbidity and mortality. The vascular ultrasound is the diagnostic methods of choice in the diagnosis and monitoring of patients with this disease. However, several issues remain controversial, such as the initial approach of patients with suspected deep vein thrombosis, protocols to be used, the time for the exam and thrombosis in the calf plexus. The objective of this review is to discuss these issues in light of current knowledge.

Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados / Assesment of arterial damage by noninvasive peripheral arterial tonometry in non-diabetic hemodialysis patients

Background: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. Aim: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. Material and Methods: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. Results: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7± 0.4 and2.7 ± 0.4 respectively p < 0.01). Conclusions: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.

Is there a need to redo many of the diagnoses of hypertension? / Há a necessidade de refazer muitos dos diagnósticos de hipertensão?

CONTEXT AND OBJECTIVE: Most hypertensive subjects undergoing treatment were diagnosed solely through measurements made in the consultation office. The objective of this study was to redo the diagnosis of treated patients after new clinical measurements and ambulatory blood pressure monitoring (ABPM). DESIGN AND SETTING: Cross-sectional study conducted in an outpatient specialty clinic. METHODS: Patients with mild-to-moderate hypertension or undergoing anti-hypertensive treatment, without target organ damage or diabetes, were included. After drug withdrawal lasting 2-3 weeks, new blood pressure (BP) measurements were made during two separate visits. ABPM was performed blindly, in relation to clinical measurements. The BP thresholds used for diagnosing hypertension, white-coat hypertension, normotension and masked hypertension were: 140 (systolic) and 90 (diastolic) mmHg for office measurements and 135 (systolic) and 85 (diastolic) mmHg for mean awake ABPM (MAA). RESULTS: Evaluations were done on 101 subjects (70% women); mean age 51 ± 10 years. The clinical BP was 155 ± 18/97 ± 10 mmHg (first visit) and 150 ± 16/94 ± 11 mmHg (second visit); MAA was 137 ± 13/ 86 ± 10 mmHg. Sixty-four patients (63%) were confirmed as hypertensive, 28 (28%) as white-coat hypertensive, nine (9%) as normotensive and none as masked hypertensive. After ABPM, 37% of the presumed hypertensive patients did not fit into this category. CONCLUSION: This study showed that hypertension was overdiagnosed among hypertensive subjects undergoing treatment. New diagnostic procedures should be performed after drug withdrawal, with the aid of BP monitoring.

CONTEXTO E OBJETIVO: A maioria dos hipertensos em tratamento teve seu diagnóstico feito somente com medidas no consultório. O objetivo deste estudo é refazer o diagnóstico em pacientes tratados após novas medidas clínicas e monitorização ambulatorial da pressão arterial (MAPA). TIPO DE ESTUDO E LOCAL: Estudo transversal realizado em clínica de especialidade. MÉTODOS: Foram incluídos pacientes com hipertensão leve a moderada ou em tratamento anti-hipertensivo, sem lesões de órgão-alvo ou diabetes. Após suspensão do tratamento por duas a três semanas, novas medidas da pressão arterial (PA) foram feitas em duas visitas distintas. A MAPA foi feita às cegas em relação às medidas clínicas. Os limites pressóricos utilizados para o diagnóstico da hipertensão, hipertensão do avental branco, normotensão e hipertensão mascarada foram: 140 (sistólica) e 90 (diastólica) mmHg para as medidas de consultório e 135 (sistólica) e 85 (diastólica) mmHg para as médias de vigília da MAPA (MVM). RESULTADOS: Foram avaliados 101 indivíduos (70% mulheres), idade 51 ± 10 anos. PA clínica: 155 ± 18/97 ± 10 mmHg (primeira visita) e 150 ± 16/94 ± 11 mmHg (segunda visita), MVM de 137 ± 13/86 ± 10 mmHg. Sessenta e quatro (63%) pacientes foram confirmados como hipertensos, 28 (28%) como portadores de hipertensão do "avental branco", 9 (9%) como normotensos e nenhum como tendo hipertensão mascarada. Após a MAPA, 37% de presumíveis hipertensos não se enquadravam como tal. CONCLUSÃO: Este estudo revela um excesso de diagnósticos de hipertensão em hipertensos tratados. Novos procedimentos diagnósticos devem ser realizados após suspensão da medicação, com auxílio das monitorizações da PA.

Bedside noninvasive scoring system in diagnosis of coronary heart disease / 中华全科医师杂志

Objectives To evaluate the effectiveness of bedside noninvasive scoring system in diagnosis of coronary heart disease (CAD).MethodsSix hundred and twelve patients with suspected CAD in our hospital were enrolled (343 males and 269 females) from September 2008 to October 2010,with an average age of 55 ± 7 y.The detailed history was taken; physical examination,resting electrocardiogram,blood biochemistry,treadmill exercise test and/or 12 lead Holter monitoring,64 or 256 rows CT coronary artery imaging and coronary artery angiography were performed in all patients.The risk factors for CAD were screened by multiple questionnaire surveys with Delphi method.The risk factors were stratified according to the results of expert survey: heavy smoking,diabetes mellitus,typical angina,positive treadmill exercise test and positive Holter monitoring electrocardiogram were included in the highest risk factors with an integrated scores of 8 ; dyslipidemia of 3 items,hypertension complicated with left ventricular hypertrophy were high risk factors with an integrated scores of 6; males≥40 y,medium smoking,dyslipidemia of 2 items,pathoglycemia,heavy drinking,positive ECG and post-menopause females were moderate risk factors with integrated scores of 4; Low risk factors contain moderate drinking and dyslipidemia of item,were classified as low risk factors with an integrated scores of 2. The bedside noninvasive scoring system was evaluated in all patients and the results were compared with those from multi-slice spiral CT or coronary angiography.ResultsWhen integrated score ≥ 24 was set as the cut-off level for diagnosis of CAD,thesensitivity,specificity,positive predictive value and accuracy were 89.95％,85.63％,94.03％and 88.73％ respectively.When integrated score≤ 14 was set as the exclusion criteria of CAD,the sensitivity,specificity,positive predictive value and accuracy were of 93.10％,82.86％,98.09％ and 84.80％ respectively.The accuracy was lower than that of multi-slice spiral CT or coronary angiography( P ＜0.05 ).ConclusionsThe bedside noninvasive scoring system is effective for preliminary diagnose of CAD,but need to be further improved.

320 slice CT electrocardiograph-gating double phase cardiac function angiography scan mode:a preliminary investigation of one-stop-shop exam / 中华放射学杂志

Objective To explore the feasibility of evaluating cardiac structure, coronary artery,pulmonary artery and cardiac function in one single scan by 320-row CT ECG-gated double phase cardiac function scan mode. MethodsForty patients underwent the 320-detector row CT double phase cardiovascular angiography. The pulmonary phase and aortic phase were reconstructed in order to evaluate the pulmonary and coronary artery. MPR reconstructions of both pulmonary and aortic phase were used to analyze the function of the two ventricles. And the results of the cardiac function were compared with those of transthoracic echocardiography. Thirty-five cases could be analyzed and diagnosed, while the other 5 cases had to be given up because of the poor imaging quality. The mean heart rate was (71.2 ± 11.2) beat per min (bpm). No arrhythmia case included. Results ( 1 ) Pulmonary embolism were diagnosed in 11 cases,coronary artery disease (CAD) were found in 5 cases, while post-stent implantation were observed in 7 cases. Six cases of congenital heart disease were diagnosed with 3 ASD and 3 primary pulmonary hypertension. Another one was diagnosed with left atrial myxoma, and 5 cases were pulmonary embolism associated with CAD. All of above cases were verified by final clinical diagnosis. (2) The heart function parameters including LVEDd , RVEDd, LVESd, RVESd and LVEF were (36.7 ±3.3), (43.3 ± 3.4) mm,(31.6±5.1), (41.3 ±5.1) mm and (47.1 ±15.1) for CT, while those were (40.3 ±3.1), (47.3 ±4.2) mm,(37.3 ±5.6), (45.3 ±3.3) mm,and (46.0 ± 14.8) for ultrasound, respectively. The CT results were correlated with the ultrasound ( n = 35, r = 0.886-0.988, P ＜ 0.01 ). (3) The average radiation exposure was ( 5.4 ± 0.5 ) mSv. Conclusions 320-row CT ECG-gated double phase cardiac function scan mode is feasible for the "one-stop-shop" examination of the cardiovascular disease. This noninvasive method is recommended for the diagnosis, differential diagnosis, treatment and prognosis of cardiovascular disease.

Analysis of the liver function and myocardial enzymes in 80 critically ill children / 中国基层医药

Objective To investigate the clinical significance of liver function and myocardial enzyme indexes in critically ill children, by the determination of liver function and myocardial enzymes in critically ill children. Methods Select children,with the application of pediatric critical illness scoring system to rate and decided 80 cases of critically ill children as a critical group,of which 18 cases were very critically ill children. And chose 80 cases of non-critically ill children as a control group. Determine liver function and myocardial enzymes of the cases given the appropriate treatment within the first hour of being hospitalized. Results The most critical group in children with the changes of liver function and myocardial enzyme in children above the critical group, while the critical group above the non-critical group, the greater the change, statistically significant (all P ＜ 0.05). Conclusion The liver function and myocardial enzymes not only could be used as indicators of the liver and myocardial injury,but also auxiliary diagnostic index in critically ill children,and had important clinical significance in judging the severity and prognosis of the disease.

Breve história da eletrocardiografia / Brief history of the electrocardiography

A eletrocardiografia nasceu e desenvolveu-se graças a pesquisadores ilustres que souberam captar o desenvolvimento da eletrofisiologia e de novas tecnologias na elaboração de uma ferramenta diagnóstica sem precedentes. Einthoven pode ser considerado o pai da eletrocardiografia, já que seu galvanômetro de corda permitiu registros fidedignos e com padronização empregada até hoje. Thomas Lewis foi grande estudioso das arritmias, sucessor de Einthoven, e professor de Frank N. Wilson. As derivações unipolares de Wilson permitiram o registro dos potenciais elétricos em qualquer parte do corpo. A eletrocardiografia também propiciou o estabelecimento da teoria coronariana das síndromes anginosas e, mais recentemente, novas aplicações clínicas, tais como ostestes ergométricos, eletrofisiológicos, holter e a eletrocardiografia de alta resolução.

Electrocardiography was born and developed thanks to distinguished researchers that knew how to capture the development of electrophysiology and new technologies in developing an unprecedented diagnostic tool. Einthoven can be considered the father of electrocardiography, as his string galvanometer allowed reliable recordings with standardization still applied today. Thomas Lewis has studied greatly the arritmias, successor of Einthoven, and teacher of Frank N. Wilson. Wilsonïs unipolar leads allowed the electrical potentials recording wherever on the body. Electrocardiography (ECG) also facilitated the establishment of the theory of angina coronary syndromes and, more recently, new clinical applications, such as exercise stress testing, electrophysiological, Holter and ECG with high resolution.

Magnetocardiography in Coronary Artery Disease with Nonspecific Electrocardiographic Finding

BACKGROUND AND OBJECTIVE: Magnetocardiography (MCG) is a noninvasive method for the registration of the magnetic component of electromagnetic fields in the heart that arise from electrical activity during the cardiac cycle. It has a theoretical advantage, over ECG, for the detection of coronary artery disease (CAD), mainly due to its higher sensitivity for local currents and better spatial resolution. However, its clinical value in the diagnosis of CAD, compared to other diagnostic tools, remains untested. The feasibility of MCG for detecting myocardial ischemia was studied. SUBJECTS AND METHODS: Ninety three patients (54 male, 39 female) with chest pain were enrolled in this study. Patients with a pacemaker or other metal implants, as well as those in unstable conditions, were excluded. Coronary angiography was performed on all the patients, following ECG and MCG measurements, on the same day. Coronary artery disease was diagnosed when intraluminal narrowing was greater than 70%. The ECG and MCG findings were compared to those of the coronary angiography, which was used as the gold standard. RESULTS: Forty two patients were diagnosed with CAD by the coronary angiography. The sensitivities and specificities of MCG and ECG for detecting a CAD were 76.2 and 47.1%, and 38.1 and 86.3%, respectively. Seventy patients showed non-diagnostic ECG for CAD. The sensitivity and specificity of MCG for detecting a CAD in this group of patients were 69.2 and 52.3%, respectively. CONCLUSION: MCG is a novel noninvasive technique for the diagnosis of coronary artery disease, but further investigation for the optimization of the efficacy of this technology will be required.