Myocardial Scintigraphy in the Evaluation of Cardiac Events in Patients without Typical Symptoms / Cintilografia Miocárdica na Avaliação de Eventos Cardíacos em Pacientes sem Sintomas Cardíacos Típicos

AbstractBackground:Cardiovascular disease is a leading cause of death in the world and in Brazil. Myocardial scintigraphy is an important noninvasive method for detecting ischemia in symptomatic patients, but its use in asymptomatic ones or those with atypical symptoms is yet to be defined.Objective:To verify the presence of major cardiac events in asymptomatic patients or those with atypical symptoms (atypical chest pain or dyspnea) that underwent myocardial scintigraphy (MS), over a period of 8 years. Secondary objectives were to identify cardiac risk factors associated with myocardial scintigraphy abnormalities and possible predictors for major cardiac events in this group.Methods:This was a retrospective, observational study using the medical records of 892 patients that underwent myocardial scintigraphy between 2005 and 2011 and who were followed until 2013 for assessment of major cardiac events and risk factors associated with myocardial scintigraphy abnormalities. Statistical analysis was performed by Fisher’s exact test, logistic regression and Kaplan-Meyer survival curves, with statistical significance being set at p ≤ 0.05.Results:Of the total sample, 52.1% were men, 86.9% were hypertensive, 72.4% had hyperlipidemia, 33.6% were diabetic, and 12.2% were smokers; 44.5% had known coronary artery disease; and 70% had high Framingham score, 21.8% had moderate and 8% had low risk. Of the myocardial scintigraphies, 58.6% were normal, 26.1% suggestive of fibrosis and 15.3% suggestive of ischemia. At evolution, 13 patients (1.5%) had non-fatal myocardial infarction and six individuals (0.7%) died. The group with normal myocardial scintigraphy showed longer period of time free of major cardiac events, non-fatal myocardial infarction (p = 0.036) and death. Fibrosis in the myocardial scintigraphy determined a 2.4-fold increased risk of non-fatal myocardial infarction and five-fold higher risk of death (odds ratio: 2.4 and 5.7, respectively; p = 0.043).Conclusion:The occurrence of major cardiac events in 8 years was small. Patients with fibrosis at MS had more major events, whereas patients with normal MS result had fewer major cardiac events, with higher survival.

ResumoFundamento:A doença cardiovascular é uma das principais causas de óbito no Brasil e no mundo. A cintilografia miocárdica tem papel estabelecido na detecção de isquemia de pacientes sintomáticos, mas sua indicação em assintomáticos ou naqueles com sintomas atípicos ainda não está definida.Objetivo:Identificar eventos maiores em pacientes assintomáticos ou com sintomas atípicos (dor torácica atípica ou dispneia) que realizaram cintilografia miocárdica, em até 8 anos. Como objetivos secundários, citamos identificar os fatores de risco associados às alterações na cintilografia miocárdica e os possíveis preditores para eventos maiores nesse grupo.Métodos:Estudo retrospectivo, observacional, por revisão de prontuário, de 892 pacientes que realizaram cintilografia miocárdica entre 2005 e 2011, com seguimento até 2013, para avaliação de eventos maiores e análise dos fatores de risco associados à cintilografia miocárdica alterada. A análise estatística foi realizada por testes de Fisher, regressão logística e curva de sobrevida de Kaplan-Meier, com p significativo se ≤ 0,05.Resultados:Do total dos pacientes da amostra, 52,1% eram homens, 86,9% hipertensos, 72,4% dislipidêmicos, 33,6% diabéticos, e 12,2% tabagistas; 44,5% tinham doença arterial coronária conhecida; e 70% apresentavam escore de Framingham alto, 21,8% moderado e 8% baixo risco. Das cintilografias miocárdicas, 58,6% foram normais; 26,1%, sugestivas de fibrose; e 15,3%, de isquemia. Na evolução, 13 pacientes (1,5%) apresentaram infarto do miocárdio não fatal e 6 pacientes (0,7%) foram a óbito. O grupo com cintilografia miocárdica normal apresentou maior tempo livre de eventos maiores, infarto do miocárdio não fatal (p = 0,036) e morte (p = 0,019). A fibrose determinou risco 2,4 vezes maior de infarto do miocárdio não fatal e cinco vezes maior de morte (odds ratio: 2,4 e 5,7, respectivamente; p = 0,043).Conclusão:A ocorrência de eventos maiores em até 8 anos no grupo estudado foi pequena. Pacientes com fibrose na cintilografia miocárdica apresentaram mais eventos maiores. Pacientes com cintilografia miocárdica normal apresentaram menos eventos maiores, com sobrevida maior.

Atypical Symptoms in Patients With Gastroesophageal Reflux Disease

BACKGROUND/AIMS: Atypical symptoms are common in gastroesophageal reflux disease (GERD). Patients with non-erosive reflux disease (NERD) and erosive reflux disease (ERD) exhibit different clinical characteristics and responses to acid suppression treatment. We aimed to compare atypical characteristics in patients with NERD and ERD. We also investigated the presence of histological esophagitis in patients with NERD and ERD. METHODS: Eligible patients completed a questionnaire regarding reflux symptoms and concomitant atypical symptoms. Endoscopic biopsies with histological examination were performed. RESULTS: Of the 210 patients with GERD, 90 patients with ERD and 120 patients with NERD were studied. ERD patients were characterized by higher prevalence of hiatal hernia (P = 0.001) and smoking (P = 0.047). The prevalence of GERD was greater in the age group between 41 and 60 years regardless of endoscopic finding. There was no difference in the prevalence of atypical symptoms or histological esophagitis between NERD and ERD. In all subjects, heartburn was associated with dysphagia (r = 0.16, P = 0.01), dyspepsia (r = 0.22, P = 0.008) and hiccup (r = 0.19, P = 0.003), whereas acid regurgitation was associated with dyspepsia (r = 0.21, P = 0.014), belching (r = 0.15, P = 0.018) and hiccup (r = 0.19, P = 0.002). CONCLUSIONS: Atypical symptoms did not correlate with the presence of histological esophagitis. Atypical symptoms were equally prevalent in patients with NERD and ERD. The existence of atypical symptoms appears to be associated with the presence of typical reflux symptoms irrespective of endoscopic and histological reflux esophagitis.

Atypical presentation of pediatric bipolar mood disorder : two case reports

Objective: This case reports highlight atypical presentation of pediatric bipolar mood disorder. Pediatric bipolar disorder is said to be a rare condition with some distinct differences from adult bipolar disorder. Despite the ongoing controversy regarding its exact typology, pediatric bipolar mood disorder is being reported in the form of case reports and in systematic research. Pediatric bipolar disorder is difficult to diagnose because its presentation of symptoms overlaps considerably with conduct problems, and ADHD (attention deficit hyperkinetic disorder). Methods: We report two cases which met a diagnosis of pediatric mood disorder where the presentation of symptoms was unique and atypical. Results: The cases are presented so that they help to raise pertinent questions regarding phenomenology, duration, episodic nature of the illness and management of this important group of disorders. Conclusion: Pediatric bipolar disorder should be viewed with seriousness and pediatric mania should be given importance in the assessment of the typology, prognosis and management of this important group of childhood disorder.

Longitud esofágica: estudio prospectivo en pacientes adultos con enfermedad por reflujo gastroesofágico / Esophagus length: Prospective study in adult patients with gastroesophageal reflux disease

Objetivos: Correlacionar la longitud esofágica y de sus esfínteres, en pacientes adultos con enfermedad por reflujo gastroesofágico (ERGE) con síntomas típicos y atípicos. Métodos: Se realizó estudio prospectivo, de corte transversal. Se incluyeron un total de 80 pacientes con diagnóstico clínico, endoscópico y/o pHmétrico de enfermedad por reflujo gastroesofágico referidos al Laboratorio de Motilidad Digestiva del Centro Médico Docente La Trinidad en 2006-7. Se seleccionaron dos grupos: El "A" de pacientes con ERGE y síntomas típicos y el "B" con ERGE y síntomas atípicos. Se les realizó manometría esofágica, determinándose: longitud total y cuerpo esofágico; longitud y presión de los esfínteres esofágicos y presencia de hernia hiatal. Resultados: Del total de pacientes (n=80) que se incluyeron, 58 (72,5%) en el grupo A y 22 (27,5%) en el grupo B. Se encontró un EES de menor longitud en los pacientes del grupo B comparado con el del grupo A con una longitud promedio de 1,91 cm vs 2,71 cm (p= 0,0003). No se encontraron diferencias significativas en cuanto a la longitud del EEI, longitud del cuerpo esofágico. En cuanto a la longitud total esofágica, se encontró que era más corta en el grupo B que en el A, (25,32 cm. vs. 27,34 cm. p= 0,01). La presión del EEI del grupo B fue menor que la presión del mismo en el grupo A. Conclusión: La longitud del esófago total, del EES es menor en pacientes con ERGE y síntomas atípicos que en pacientes con síntomas típicos. Los pacientes con síntomas atípicos presentan una presión disminuida del EEI y una mayor frecuencia de hernia hiatal con respecto a los pacientes con ERGE y síntomas típicos.

Objective: To correlate the length of their esophageal sphincter and, in adult patients with gastroesophageal reflux disease (GERD) with symptoms typical and atypical. Methods: We conducted prospective study, cross-sectional. We included a total of 80 patients with clinical diagnosis, endoscopic and / or pHmétrico of gastroesophageal reflux disease related to laboratory Motility Digestive Centro Medico Docente La Trinidad in 2006-7. Were selected two groups: The "A" and GERD patients with typical symptoms and the "B" with atypical symptoms and GERD. They were conducted esophageal manometry, determined: total length and esophageal body; pressure and length of the esophagus and sphincters presence of hiatal hernia. Results: Of the total patients (n = 80) that were included, 58 (72.5%) in group A and 22 (27.5%) in group B. There was a minor ESS length of patients in group B compared with Group A with an average length of 1.91 cm vs. 2.71 cm (p = 0.0003) No significant differences were found on the length ERA, esophageal body length. As for the total length esophageal, was found to be shorter in group B compared with A (25.32 cm. Vs. 27.34 cms. P = 0.01). The pressure of the ERA group B was lower than the same pressure in group A. Conclusion: The total length of the esophagus, the ESS is lower in patients with atypical symptoms and GERD in patients with typical symptoms. Patients with atypical symptoms have diminished pressure ERA and a higher frequency of hiatal hernia regarding patients with typical symptoms and GERD.

Síntomas respiratorios asociados a la enfermedad por reflujo gastroesofágico: diagnóstico y tratamiento / GERD related respiratory symptoms: diagnosis and treatment

La enfermedad por reflujo gastroesofágico puede generarsíntomas respiratorios. Éstos se desencadenan cuandoel contenido esofágico refluye a la vía aérea, generandouna microaspiracion; o a través de un reflejo vago-vagal. Los síntomas respiratorios pueden ser vagos ycoexistir con la enfermedad por reflujo, sin una verdaderarelación causa-efecto. Para tratar estos pacientes,es fundamental realizar un diagnóstico preciso que asocielas dos entidades. El algoritmo debe incluir estudiosque detecten reflujo gastroesofágico, microaspiración y,de corresponder, lesión laríngea. A continuación, se debeaplicar la terapéutica más efectiva. El tratamientomédico posee menor tasa de éxito si lo comparamos conla obtenida en pacientes con síntomas típicos. Esto puededeberse a que episodios de reflujo no-ácido son losgeneradores de síntomas, a la existencia de un dañoirreversible en la vía aérea o a dosis insuficientes demedicación para neutralizar el ácido. La fundoplicaturaes un tratamiento efectivo que frena todo tipo dereflujo patológico (ácido y no-ácido). Este artículo describela utilidad de los tests diagnósticos y menciona losresultados obtenidos con las diversas formas de tratamiento.Adicionalmente, comenta acerca de la potencialaplicación de la impedancia esófago-faringea enesta población.

Gastroesophageal reflux disease can cause respiratory symptoms. These symptoms are triggered by reflux events that reach the pharynx, causing microaspiration or through vagal reflex. Respiratory symptoms can be vague and coexist with gastroesophageal reflux disease, without a real link between the two entities. To effectively treat these patients, it is important tofind an association between the two diseases. Work up should include the diagnosis of reflux disease, the diagnosis of pharyngeal reflux events -microaspiration - and, if possible, of laryngeal injury. Once the diagnosis has been established, an effective therapy must be offered to the patient. In these patients, medical treatment is less effective when compared to the results in the population with typical symptoms. This may be due to the fact that non-acid reflux episodes are causing the respiratory symptoms or as a result of an irreversible damage generated in the airway. Antireflux surgery is an effective therapy that reduces both acid and non-acid reflux events. This article describes the different diagnostic tests as well as the results obtained with surgical treatment in this population. Additionally, it describes potential applications of esophageal and pharyngeal impedance monitoring in these patients.

Diagnosis and treatment of renal tuberculosis(report of 52 cases) / 中华泌尿外科杂志

Objective To investigate the clinical manifestations,diagnosis and treatment of renal tuberculosis(TB). Methods This series included 52 patients with renal TB.Of them 36 cases (69%) presented with irritative symptoms.10 cases (19%) had lumbago accompanied by hematuria.6 cases (11%) had renal angina and 6(11%) painless hematuria.B-ultrasonography suggested renal TB in 20 cases and unilateral hydronephrosis in 22 cases;renogram showed that the diseased kidneys had no function in 31 cases.Urinal AFB and tuberculosis PCR(Tb-PCR) were performed in 38 cases,the results were positive in 13(34%)and 21(55%),respectively.27 cases were misdiagnosed to have calculi or inflammation.Treatments consisted of antituberculous chemotherapy in 12 cases (23%)and surgery in 40(77%). Results All of the 12 cases who received medications recovered completely.40 cases undergoing surgery were pathologically diagnosed to have renal TB;of them 5 cases developed ureteral stump syndrome. Conclusions Urine AFB and Tb-PCR remain the primary diagnostic methods before operation.When the non-functioning kidney is resected,the involved ureter should be concomitantly resected as much as possible.