La responsabilidad subjetiva en los derroteros del deseo de hijo / Subjective Responsibility in the Paths of the Desire for a Child

El presente escrito aborda la cuestión del proyecto monomarental, sus derroteros y periplos singulares. Al tiempo que en ellos se vislumbra un camino muchas veces compartido y repetido. La temática reviste una presencia estadística en aumento a nivel mundial que visibiliza cambios sociales, económicos y de derechos en la agenda femenina. El objetivo central del escrito radica en describir en primera persona las circunstancias que llevaron a Helen a recurrir a la ovodonación como método reproductivo y los duelos que dicho recorrido encierra. En síntesis, en la historia de Helen se vislumbra de modo paradigmático el encuentro con la imposibilidad del propio cuerpo reproductivo y la solución que ofrece la medicina; al tiempo que en otra cuerda, se trasluce la dimensión singular y clínica de las decisiones subjetivas por las que ella deberá responder

This paper addresses the question of the singleparent project, its paths and unique journeys. At the same time that in them a path many times shared and repeated is glimpsed. The issue has a growing statistical presence worldwide that makes visible social, economic and rights changes on the women's agenda. The central objective of the writing lies in describing in the first person the circumstances that led Helen to resort to egg donation as a reproductive method and the duels that this journey entails. In short, in Helen's story, the encounter with the impossibility of the reproductive body itself and the solution offered by medicine is glimpsed in a paradigmatic way; while on another string, the singular and clinical dimension of the subjective decisions for which she will have to answer shines through

Interações entre o relógio biológico e a sinalização do estado energético em plantas do complexo Saccharum / Biological clock and energy sensors in plants from Saccharum complex

A cana-de-açúcar e a cana energia são plantas intercruzáveis que compõe o complexo Saccharum. Estas plantas são fonte de biomassa para produção de açúcar, biocombustíveis, eletricidade, entre outros, e utilizam a energia assimilada pela fotossíntese de forma contrastante, ainda que ambas resultem em alta produtividade. O relógio biológico é um mecanismo molecular que gera informações sobre a hora do dia em conjunto com estímulos ambientais, adaptando respostas fisiológicas em prol de otimizar o desenvolvimento dos organismos em um ambiente cíclico, processo que regula cerca de 64% dos genes de cana-deaçúcar no campo. Em organismos sésseis como as plantas, o recorrente processo de produção de energia apenas durante o período luminoso, gera ritmos de metabólitos que influenciam na atividade de enzimas quinases que assim funcionam como sensores do estado energético, em vias conservadas nos eucariotos. Porém, pouco se sabe a respeito de como estes sinais são percebidos a nível transcricional, principalmente em plantas cultiváveis. Para elucidar como estas vias atuam em conjunto em plantas do complexo Saccharum, medimos o nível de transcrição de componentes do relógio biológico, de subunidades que compõe o complexo TOR, e da subunidade catalítica de SnRK1, KIN10. Medimos o desempenho do relógio biológico das variedades através da quantificação de amido em quatro pontos temporais, para obter uma dinâmica de produção e consumo, processo que é regulado pelo relógio biológico e tem genes com perfil de expressão rítmicos em cana de-açúcar. Curiosamente, uma das quatro variedades onde identificamos provável perfil rítmico de consumo de amido é a S.officinarum SP80-3280, cana-de-açúcar utilizada anteriormente para estudos de relógio biológico. Os nove acessos foram divididos em dois grupos com base em sua partição de carbono contrastante. HF (high fiber) com mais fibras e perfilho e grupo HS (high sucrose), com maior armazenamento de açúcares e amido que HF, em todos os horários de coleta, e com baixa produção de fibras. Estes grupos não diferem em expressão dos componentes de relógio biológico, no entanto, HS tem maior transcrição de uma subunidade do complexo TOR, em apenas um dos horários analisados (ZT12). Em conjunto, a expressão dos componentes do relógio biológico divide os acessos entre os que possuem altos níveis de transcrição de ScLHY, no ZT03, e os que possuem maior transcrição dos genes PRR59, 73 e 95, no ZT12, grupos com contrastante partição de carbono. A transcrição dos sensores energéticos se correlaciona no começo da noite em acessos de HS e Krakatau e, no começo da manhã, em acessos de HF e IN84-105, sem agrupar as variedades por espécie ou destino de carbono. Este trabalho sugere que há diferentes níveis de correlação entre a transcrição dos genes mensurados e as contrastantes partições de carbono das plantas do complexo Saccharu

Sugarcane and Energycane are intercrossable plants that make up the Saccharum complex. These plants are a source of biomass, sugar, biofuels, electricity among others, and even though they use the energy assimilated by photosynthesis in a contrasting way, both results in high productivity. The biological clock is a molecular mechanism that generates information about the time of day in conjunction with environmental stimuli, adapting physiological responses to optimize the development of organisms in a cyclic environment, a process that regulates about 64% of sugarcane genes in field-grown plants. In organisms such as plants, the recurrent process of energy production that happens only during the luminous period generates rhythmicity that may influence the activity of kinase enzymes, thus giving an energy sensor property for then. However, little is known about how these signs are perceived at the transcriptional level, especially in crops and monocots. To elucidate how these pathways act together in plants of the Saccharum complex, we measured the transcription level of the daytime loop of the biological clock, subunits that make up the TOR complex, and the catalytic subunit of SnRK1, KIN10. We measured starch content in four time points, to obtain a dynamic of production and consumption, a process that is regulated by the biological clock and has genes with a rhythmic expression profile in sugarcane. Interestingly, one of the four varieties where we could identify a probable rhythmic profile of starch consumption is a sugarcane SP80-3280 (S. officinarum), that have been used for biological clock studies. The nine genotypes were divided into two groups based on their contrasting carbon partition. HF (high fiber) with more fiber and tiller and group HS (high sucrose), with higher sugar and starch storage than HF, but with lower fiber production. These groups do not differ in expression of biological clock components; however, HS has a higher transcription of a subunit of the TOR complex, in only one of the analyzed times (ZT12). Together, the expression of components of the biological clock divides the genotypes between those with higher levels of ScLHY in ZT03 and those with more transcripts of PRR59, 73 and 95 genes in ZT12, groups that also have contrasting carbon partition. The transcription of TOR complex correlates in the early evening in HS and KRAKATAU, but in the morning, in HF and IN84-105, with no clear correlation with the C destination preferences. This work suggests that there are different levels of correlation between the transcription of biological clock and energy sensors component genes and the contrasting carbon partitions of plants from the Saccharum complex

Relação do cronotipo nos níveis de ansiedade e consumo Máximo de oxigênio em jovens / Relation between chronotype on anxiety levels and maximum oxygen consumption in young people

O presente estudo analisou a relação entre cronotipo, níveis de ansiedade, depressão e estresse, bem como níveis de condicionamento cardiorrespiratório em jovens. Métodos: Foi analisado um total de 36 participantes com idades entre 18 e 28 a nos, saudáveis e que atendessem ao cronotipo matutino e vespertino. Análises de nível de atividade física, consumo máximo de oxigênio, níveis de depressão, ansiedade e estresse foram realizadas com testes específicos. Em todos os cálculos foram utilizados um alfa de p<0.05 para análise estatística. Resultados: O nível de atividade física mostrou que a porcentagem dos matutinos suficientemente ativos foi de 58% comparado com 23.5% dos vespertinos. Mulheres com cronotipo vespertino apresentaram níveis menores de VO2máx quando comparados com as mulheres com cronotipo matutino (p=0.04). Os participantes vespertinos apresentaram níveis maiores de ansiedade (p=0.02) comparados com os matutinos e esses dados foram evidentes nos participantes do sexo feminino onde as mulheres do cronotipo vespertino apresentaram níveis maiores de ansiedade (p=0.03) comparados com mulheres de cronotipo matutino. Conclusão: Portanto, o estudo conclui que indivíduos do cronotipo vespertino apresentaram menores níveis de atividade física e maiores níveis de ansiedade evidenciados principalmente nas mulheres.(AU)

The present study analyzed a relationship between schedule, anxiety, depression and stress levels, as well as cardiorespiratory fitness levels in young people. Methods: A total of 36 healthy participants aged 18 to 28 years who met the criteria for chronotypes morning type and evening type were analyzed. Analyzes of physical activity level, maximal oxygen uptake, depression, anxiety and stress levels were performed. In all calculations, an alpha of p <0.05 was used for statistical analysis. Results: The level of physical activity was higher in morning types 58% compared to 23.5% of evening types. Women with evening chronotype had lower VO2max levels compared with women with a morning chronotype (p= 0.04). Evening types had higher anxiety levels (p= 0.02) compared to morning types and these data were evidenced in female participants with higher anxiety levels (p=0.03) compared to women with a morning chronotype. Conclusion: Therefore, the study concludes that young people with a evening chronotype exhibited lower levels of physical activity and higher anxiety levels, especially in women.(AU)

El nodo sinusal normal: Lo que ahora sabemos / The normal sinus node: What we know now

RESUMEN El nodo sinusal constituye el marcapasos fisiológico del corazón. Diferentes estados fisiopatológicos conducen a una reducción de su función, lo que es llamado en la clínica, disfunción sinusal. Sin embargo, para la mejor comprensión de su estado de enfermedad se requiere dilucidar cómo opera en condiciones normales. Las nuevas evidencias señalan que el automatismo del nodo sinusal se produce por la interacción del reloj de membrana y el reloj de calcio, lo que le confiere un fuerte carácter que lo protege contra fallas de funcionamiento. Se presentan las evidencias actuales sobre la sincronía celular dentro del nodo sinusal, así como la forma de propagación eléctrica y el acoplamiento fuente-sumidero. Además, se describen recientes hallazgos anatómicos e histológicos.

ABSTRACT The sinus node is the physiological pacemaker of the heart. Different pathophysiological conditions lead to a reduction of its function, which is clinically called sinus dysfunction. However, for a better understanding of its disease state, it is necessary to elucidate how it works under normal conditions. New evidences indicate that the automatism of the sinus node is produced by the interaction of the membrane clock and the calcium clock, which gives it a strong character that protects it against malfunctions. Current evidences on cell synchrony within the sinus node are presented, as well as the form of electrical propagation and the source-sink coupling. In addition, recent anatomical and histological findings are described.

Unveiling sleep mysteries: Sleep-wake cycle as a biological parameter of the circadian typology (Chronotype) / Revelando mistérios do sono: Ciclo sono-vigília como parâmetro biológico da tipologia circadiana (cronotipo)

The sleep-wake cycle that is circadian rhythm may have different patterns according to sex, environment and genetics determinants. This chronological cycle type, chronotype, may be populational expressed by the extremes, early or later going to bed and waking up, in a continuum. The first, the Morning-type individuals (the lark) and the later, the Evening types (the owl). Between the two extremes, there is the majority of these chronotypes ­ the intermediate ones. These patterns may be classified according to the questionnaires such as Horne and Ostberg Morningness/ Eveningness Questionnaire (MEQ) and the Munich Chrono Type Questionnaire (MCTQ). The rural population tends to be Morning-type, as well as children and younger women, more than men. The Morning person tends to be more healthy than the Evening ones who are more prone to diseases, as depression and metabolic syndrome. This basic knowledge may be helpful to patient's counseling and management: to avoid mismatch of circadian physiology and social duties / sleep. This circadian desynchrony can increase the risk of diseases, consequently there is a need to chrono-medicine into current treatment strategies.

O ciclo sono-vigília, que é um ritmo circadiano, pode ter padrões diferentes de acordo com os determinantes sexuais, ambientais e genéticos. Esse tipo de ciclo cronológico, cronótipo, pode ser expresso em termos populacionais pelos extremos, indo cedo ou mais tarde para a cama ou saindo dela, em um continuum. O primeiro, os indivíduos do tipo Manhã (a cotovia) e o posterior, os tipos da Tarde (a coruja). Entre os dois extremos, há a maioria desses cronotipos - os intermediários. Esses padrões podem ser classificados de acordo com questionários como o Horne e Ostberg Morningness/Eveningness Questionnaire (MEQ) e o Munich Chrono Type Questionnaire (MCTQ). A população rural tende a ser do tipo matutino, assim como crianças e mulheres mais jovens, mais que os homens.A pessoa da manhã tende a ser mais saudável do que as da noite, mais propensa a doenças, como depressão e síndrome metabólica. Esse conhecimento básico pode ser útil para o aconselhamento e tratamento dos pacientes: para evitar incompatibilidade entre a fisiologia circadiana e os deveres sociais / sono. Essa dessincronia circadiana pode aumentar o risco de doenças, consequentemente, é necessário a cronomedicina nas atuais estratégias de tratamento.

Trombosis venosa subclavia asociada a electrodo de marcapasos y síndrome de la plaqueta pegajosa / Subclavian venous thrombosis associated with pacemaker electrode and sticky platelet syndrome

Resumen El síndrome de la plaqueta pegajosa en un trastorno cualitativo plaquetario en el que bajas concentraciones de epinefrina y adenosina difosfato producen hiperagregabilidad plaquetaria considerable. Se ha especulado mucho sobre la etiología de este trastorno sin que sean claros sus mecanismos fisiopatológicos. Desde el punto de vista clínico, se asocia a trombosis arteriales y venosas recurrentes en pacientes jóvenes, pérdidas gestacionales, otras complicaciones obstétricas y cefalea recurrente.En la literatura se ha descrito su presentación familiar, lo que hace sospechar su comportamiento hereditario autosómico dominante; también se ha reportado un fenotipo adquirido de la enfermedad en algunas poblaciones especiales como pacientes con enfermedad renal crónica en terapia de reemplazo renal o posterior al trasplante renal y en pacientes con cuadros inflamatorios o inmunosupresión. Se expone el caso de una paciente con antecedente de cefalea de difícil manejo, síndrome hipertensivo asociado al embarazo y mortinato, con síndrome del nodo enfermo y disautonomía manejadas con implantación de marcapasos definitivo bicameral con sensor CLS, que desarrolló trombosis de la vena subclavia, asociada al electrodo de marcapasos, recurrente a pesar de anticoagulación con warfarina y rivaroxabán e incluso a pesar de antiagregación con ácido acetilsalicílico, con posterior diagnóstico de síndrome de la plaqueta pegajosa.

Abstract Sticky platelet syndrome is a qualitative platelet disorder in which low concentrations of adrenaline and adenosine diphosphate produce considerable platelet hyperaggregability. There has been much speculation on the origin of this disorder as its pathophysiological mechanisms of action are not yet clear. From a clinical point of view, it is associated with recurrent arterial and venous thrombosis in young patients, miscarriages, other obstetric complications and recurrent headaches.Its familial presentation has been described in the literature, suspecting that it is of a dominant autosomal hereditary nature. An acquired phenotype of the disease has also been reported in some particular patients, such as patients with chronic kidney disease on renal replacement therapy or after a kidney transplant, as well as in patients with inflammatory processes or immunosuppression. The case is presented of a patient with a history of difficult to manage headaches, a hypertensive syndrome associated with the pregnancy, and a foetal death. She also had sick sinus node syndrome and dysautonomia managed with a definitive dual-chamber pacemaker with a CLS sensor. There was then a thrombosis in the subclavian vein associated with the pacemaker electrode, being recurrent despite anticoagulation with warfarin and rivaroxaban, and even despite anti-aggregation treatment with acetyl salicylic acid. She was subsequently diagnosed with sticky platelet syndrome.

Marcapasos con sensor de asa cerrada en disautonomía secundaria a enfermedad de Sandhoff / Closed-loop pacemakers in dysautonomia secondary to Sandhoff disease

Resumen Introducción: en la enfermedad de Sandhoff se ha descrito el compromiso del sistema nervioso autónomo en piel y tracto gastrointestinal; sin embargo, las alteraciones autonómicas del sistema cardiovascular, como la disautonomía, no se han documentado en la literatura revisada. De otro lado, el síncope neuralmente mediado de características cardioinhibitorias, refractario al manejo médico, puede ser tratado con marcapasos con sensor de asa cerrada. Materiales y métodos: se describe el caso de una paciente de 42 años en quien se realizó el diagnóstico de enfermedad de Sandhof. Asociado a esta patología, presentó disautonomía con episodios de síncope diarios sin respuesta al tratamiento médico, que ameritaron el implante de un marcapasos con sensor de asa cerrada. Posteriormente se revisa la literatura existente sobre el tema. Conclusiones: hasta la fecha no se había reportado relación entre la enfermedad de Sandhoff y la disautonomía; en el caso de esta paciente el deterioro de la calidad de vida fue significativo. El uso del algoritmo CLS en síncope neuralmente mediado con características cardioinhibitorias, ha mostrado disminuir la cantidad de síncopes en este tipo de pacientes y mejorar la calidad de vida de los mismos.

Abstract Introduction: Although involvement of the autonomic nervous system in the skin and gastrointestinal tract has been described in Sandhoff disease, no reports of autonomic changes of the cardiovascular system, such as dysautonomia, have been documented in the literature reviewed. On the other hand, the neurally mediated cardioinhibitory syncope that is refractory to medical management can be treated with pacemakers with closed loop sensors. Materials and methods: The case is described of a 42 year-old patient who was diagnosed with Sandhoff disease. Associated to this condition, he presented with dysautonomia with daily episodes of syncope, with no response to medical treatment, which warranted the implant of a pacemaker with a closed loop sensor. The existing literature on this topic was subsequently reviewed. Conclusions: Up until now, there have been no reports on the relationship between Sandhoff disease and dysautonomia. In the case of this patient, the deterioration in the quality of life was significant. The use of the closed loop stimulation (CLS) algorithm in neurally mediated cardioinhibitory syncope has been shown to reduce the number of syncopes in this type of patient and improve their quality of life.

Effects of an alternating work shift on air traffic controllers and the relationship with excessive daytime sleepiness and stress / Efeitos do turno de trabalho alternado em controladores de tráfego aéreo e relação com sonolência diurna excessiva e estresse

ABSTRACT Objective: To evaluate symptoms of stress and excessive daytime sleepiness (EDS) in air traffic control (ATC) officers in Brazil. Methods: Fifty-two ATC officers participated, based at three air traffic control units, identified as A, B and C. Stress symptoms were assessed using the Lipp Inventory of Stress Symptoms for Adults, and EDS by the Epworth Sleepiness Scale. Results: The sample mean age was 37 years, 76.9% of whom were male. Excessive daytime sleepiness was identified in 25% of the ATC officers, with 84.6% of these based at air traffic control unit A, which has greater air traffic flow, operating a 24-hour alternating work shift schedule. A total of 16% of the ATC officers had stress symptoms, and of these, 62% showed a predominance of physical symptoms. Conclusion: The high percentage of ATC officers with EDS identified in group A may be related to chronodisruption due to night work and alternating shifts.

RESUMO Objetivo: Avaliar sintomas de estresse e sonolência diurna excessiva (SDE) em controladores de tráfego aéreo (CTA) do Brasil. Métodos: Participaram 52 controladores pertencentes a 3 órgãos de controle de tráfego aéreo, denominados de A, B e C. Os sintomas de estresse, foram avaliados pelo Inventário de Sintomas de Estresse para Adultos, a SDE pela Escala de Sonolência Epworth. Resultados: 76,9% da amostra são do sexo masculino, com média de idade de 37 anos. SDE foi identificada em 25% dos controladores, desses 84,6%, pertencem aos órgãos de controle de tráfego aéreo A, caracterizado por maior movimento de aeronaves, funcionamento 24 horas e escala de serviço em turnos alternantes. Um total de 16% dos controladores apresentam sintomas de estresse, desses, 62% mostraram o predomínio de sintomas físicos. Conclusão: A porcentagem elevada de CTA com SDE identificada no grupo A pode estar relacionada a cronodisrupção devido ao trabalho noturno e alternado.

Cuidado paliativo en falla cardiaca / Palliative care in heart failure

Resumen La falla cardiaca avanzada se caracteriza por un compromiso circulatorio clínicamente significativo que requiere opciones de manejo avanzadas como el trasplante cardiaco, la inotropía intravenosa continua o intermitente, la asistencia ventricular o la terapia paliativa. El paciente con falla cardiaca avanzada no candidato a trasplante o asistencias ventriculares, es terminal y hace parte de un grupo heterogéneo con una condición clínica que fluctúa, con síntomas que condicionan el deterioro de la calidad de vida, y finalmente la muerte. El cuidado paliativo hace parte de las opciones de tratamiento avanzado cuyo objetivo principal es el control de los síntomas en el paciente con enfermedad avanzada, la planificación de los cuidados del final de la vida y los que permiten tener una muerte digna. No es una estrategia reservada para el paciente agónico. Es importante tener una comunicación asertiva con el paciente y su familia, y contar con las herramientas adecuadas para tomar decisiones y comunicarlas. Este documento presenta de forma concreta y práctica la forma de identificar y manejar el paciente con falla cardiaca terminal, con estrategias farmacológicas y no farmacológicas para el control de los síntomas más comunes en esta etapa de la enfermedad, así como de los aspectos relevantes sobre el manejo de dispositivos y conceptos sobre la transición del cuidado y la sedación paliativa.

Abstract Advanced heart failure is characterised by a clinically significant circulatory involvement that requires advances management options such as cardiac transplantation, continuous or intermittent inotropic infusions, ventricular assist devices or palliative therapy. Patients with advanced heart failure who are not candidate for a transplant or ventricular assist devices are terminal and belong to an heterogeneous group with a fluctuating clinical condition, with symptoms that impart their quality of life and eventually cause death. Palliative care is a part of the advanced therapy options whose main goal is to control symptoms in the patient with advanced disease, to plan care in the final stage of life and to allow for a dignified death. It is not a strategy limited to terminal patients. It is important to maintain assertive communication with the patient and their relatives, and to have the necessary tools to make and communicate decisions. This document presents in a concrete and practical manner the way of identifying and managing patients with terminal heart failure, with pharmacological and non-pharmacological strategies to control the most common symptoms at this stage of the disease, as well as therelevant aspects on handling devices and concepts about care transition and palliative sedation.

Uso de los sistemas de presión negativa en el tratamiento de infecciones asociadas a dispositivos: ''una vieja terapia con un uso novedoso'' / Use of negative pressure systems for the management of infections associated to devices: ''an old therapy with a new use''

Resumen Introducción: El cuidado de los pacientes con infecciones asociadas al dispositivo sin endocarditis, incluye: la extracción completa y la realización de capsulectomía para evitar la reinfección. El uso de nuevos elementos como el sistema de la presión negativa es una terapia novedosa que ha demostrado disminuir: los tiempos de recuperación, el tiempo de estancia intrahospitalaria, la necesidad de nuevas intervenciones por sangrado o lavado y el tiempo de espera para un nuevo implante. Nuestro objetivo es describir la experiencia de un centro de cuarto nivel, en el manejo de las infecciones asociadas a los dispositivos sin endocarditis, con el uso de la terapia de presión negativa como parte del manejo. Metodología: Se realizó una descripción retrospectiva de la experiencia en el manejo de la terapia de presión negativa en pacientes con infecciones asociadas a dispositivo, en un centro de cuarto nivel. Se exponen cinco casos, a los que se les realizó: la extracción completa del dispositivo, la capsulectomía anterior y posterior, el lavado quirúrgico y el implante de la terapia con presión negativa. Conclusión: La experiencia presentada demuestra que el uso de la terapia de presión negativa es un protocolo de tratamiento novedoso, que en nuestros pacientes con infección asociada a dispositivo sin endocarditis, es segura y de fácil utilización.

Abstract Introduction: Care for patients with infections associated to the device without endocarditis include complete extraction and performing a capsulectomy to avoid reinfection. The use of new elements, such as the negative pressure system, is a new therapy that has shown to reduce recovery time, inpatient stay, need of new interventions due to bleeding or washing and waiting time for a new implant. The goal is to describe the experience of a fourth level centre for managing infections associated with devices without endocarditis using a negative pressure system as part of the therapy. Methods: Descriptive retrospective study of the experience of negative pressure therapy for managing patients with device-related infections at a fourth level centre. Five cases are exposed where complete removal of the device, anterior and posterior capsulectomy, surgical washing and negative pressure therapy were performed. Conclusion: Presented experience shows that the use of negative pressure therapy is a new therapy protocol that is safe and easy for managing our patients with an infection associated to the device without endocarditis.

Spanish translation of the mood rhythm instrument: a novel approach to mood evaluation

Introduction: The Mood Rhythm Instrument (MRI) is a questionnaire developed to assess the circadian rhythm of mood-related behaviors. The aim of this study was to translate this instrument from Brazilian Portuguese into Spanish. Methods: The translation process consisted of forward translation, adjustment, back translation, back translation review and harmonization. Results: Comparing the initial Spanish translation and the final Spanish version, there were no semantic differences and the items were not changed. Conclusions: The Spanish version of the MRI is ready to be tested in a Spanish population. In the future, assessing and comparing mood-related behaviors in transcultural studies will be possible(AU)

Hallazgos electrocardiográficos en pacientes con marcapasos definitivos: revisión de la literatura / Electrocardiographic findings in permanent pacemaker patients: A literature review

Los marcapasos cardíacos han sido parte del arsenal terapéutico para el manejo de una variedad de bradiarritmias durante muchas décadas y con la evolución de los generadores de estimulación se ha reducido su tamaño, incrementado la longevidad, así como su complejidad. Los más recientes ofrecen diagnósticos del ritmo y estado de la enfermedad, con varios algoritmos diseñados para ofrecer un tiempo de entrega de la estimulación de impulsos y aun los más recientes presentan diagnósticos indicativos de la fisiopatología. El uso de la estimulación ha aumentado en forma significativa de 46,7/100.000 en 1993 a 61,6/100.000 en 2009, con el porcentaje de dispositivos de cámara doble, pasando del 62% al 82% durante este período, con alrededor de 20.000 reemplazos al año en los Estados Unidos. El trazado en el electrocardiograma varía de acuerdo con el tipo de dispositivo, número y colocación de electrodos, así como su configuración. Es importante que el médico se encuentre familiarizado con estos hallazgos, así como las principales causas del mal funcionamiento, por ello se presenta esta revisión donde se muestran las características principales de función de los marcapasos, así como su normal interpretación en el electrocardiograma y las principales causas de mal funcionamiento.

Cardiac [artificial] pacemakers have been part of the therapeutic arsenal for the treatment of a variety of bradyarrhythmias during many decades. With the development of pulse generators, pacemakers are now smaller in size and have increased device longevity and complexity. The latest pacemakers have the ability to detect rhythm and provide cardiovascular disease states. Several algorithms were designed to offer a time to deliver a stimulus pulse. Even more modern pacemakers are capable to provide diagnoses which indicate cardiovascular physiopathology. The use of stimulation has increased significantly from 46.7/100.000 in 1993 to 61.6/100.000 in 2009, showed by the dual chamber device use rate which has increased from 62 to 82% during this period, with around 20.000 upgrades performed yearly in the United States. The electrocardiographic traces vary according to the type of device, number and location of electrodes, as well as their configuration. Doctors must be familiar with these findings and have an understanding of the main causes of malfunction. This review was undertaken for that purpose showing the main features of pacemaker functioning, as well as, the correct interpretation of electrocardiographic traces and the main causes of malfunction.

Association between shift work and microalbuminuria: data from KNHANES(2012–2014)

BACKGROUND: Shift work disturbs workers' biological clocks and this condition can cause various health problems including cardiovascular disease. The elevated albuminuria level has been significantly associated with the risk of the cardiovascular disease even within a normal reference range. Therefore, this study aimed to investigate the association between shift work and microalbuminuria. METHODS: Workers aged over 20 years from the fifth and sixth Korea National Health and Nutrition Examination Survey(KNHANES 2012–2014; n = 3000) were included in this analysis. The multiple logistic regression analysis was performed to determine the association between shift work and microalbuminuria stratified by gender. RESULTS: The prevalence of microalbuminuria in male subjects was higher among day workers, but the difference was not significant. However, the prevalence of microalbuminuria among females was higher in shift workers with statistical significance. For female, the Odds ratio of microalbuminuria in shift workers was significantly higher with 1.86 (95% CI 1.02–3.39) compared with day workers. After dividing into 5 subgroups of the shift work pattern, the odds ratio of microalbuminuria for fixed night shift was significantly higher at 4.68 (95% CI 1.29–17.00) compared with day workers. CONCLUSIONS: This study showed that shift work was associated with microalbuminuria in female workers. Especially we found out the association between fixed night shift and microalbuminuria in female workers.

Infección relacionada con los dispositivos cardiovasculares / Cardiovascular device-related infections

Resumen Objetivo: Describir las características demográficas y clínicas de los pacientes que presentaron infecciones relacionadas con los dispositivos cardiovasculares electrónicos implantables. Métodos: Se revisaron las historias clínicas de los pacientes que ingresaron por infecciones de los dispositivos cardiovasculares implantables entre enero de 2006 y septiembre de 2015. Se describieron las características relacionadas con el paciente, el procedimiento, el dispositivo y el microorganismo aislado. Resultados: 22 pacientes fueron admitidos por infecciones relacionadas con los dispositivos electrónicos cardiovasculares implantables. El promedio de edad fue 63 años (DE 13,7) y 86% fueron del sexo masculino. La mitad de los pacientes tenían enfermedad renal crónica y solo el 27% diabetes mellitus. Todos los casos tenían al menos 2 electrodos intracardiacos y el 40,91% refirieron el antecedente de recambio del dispositivo. El germen más frecuentemente aislado fue el Staphylococcus epidermidis. La mortalidad fue del 22,73%. Conclusiones: Las infecciones por los dispositivos cardiovasculares son cada vez más frecuentes. Se debe identificar la presencia de infección local o sistémica con o sin compromiso intracardiaco. Los objetivos del tratamiento van dirigidos a la remoción del dispositivo cardiovascular y el tratamiento antibiótico dirigido.

Abstract Motivation: To describe demographic and clinical characteristics of patients who developed infections related to cardiovascular implantable electronic devices. Methods: Medical records of patients who were admitted for infections of cardiovascular implantable devices between January 2006 and September 2015 were reviewed. Characteristics related to the patient, the procedure, the device and the isolated microorganism were described. Results: 22 patients were admitted for infections related to cardiovascular implantable Electronic devices Average age was 63 years (SD 13.7) and 86% were male. Half of the patients suffered from chronic renal disease and only 27% diabetes mellitus. All cases had at least 2 intracardiac electrodes and 40.91% had required a previous replacement of the device. The most frequently isolated germ was Staphylococcus epidermidis. Mortality rate was 22.73%. Conclusions: Cardiovascular device-related infections are more and more frequent. The presence of a local or systemic infection with or without intracardiac involvement must be identified. The goals of the treatment are oriented towards the removal of the cardiovascular device and empirical antibiotic therapy.

Terapia de la resincronización cardiaca transvenosa en la población pediátrica / Transvenous cardiac resynchronization therapy in pediatric population

Resumen La disfunción ventricular izquierda y la cardiopatía dilatada (CD), debidas a la estimulación crónica ventricular derecha son complicaciones reconocidas en adultos y niños. La terapia de la resincronización cardiaca (TRC), ha demostrado beneficios en los adultos con disfunción ventricular izquierda (FEVI < 35%), deterioro de la clase funcional y bloqueo de la rama izquierda (intrínseco o inducido por estimulación). En los niños la incidencia de cardiomiopatía dilatada es desconocida y no existen guías o grandes estudios sobre la resincronización cardiaca, por lo que no es posible extrapolar las recomendaciones de los pacientes adultos. Se presenta la experiencia en una paciente con bloqueo A-V completo postquirúrgico tras corrección de cardiopatía congénita, portadora de un marcapaso quien desarrolló la falla cardiaca, esta fue tratada exitosamente mediante la resincronización biventricular en dos oportunidades, con recuperación de la clase funcional y los parámetros hemodinámicos.

Abstract Left ventricular dysfunction and dilated cardiomyopathy (DC) caused by right ventricular chronic stimulation are recognised complications in adults and children. Cardiac resynchronization therapy (CRT) has shown benefits in adults with left ventricular dysfunction (LVEF < 35%), deterioration of functional class and left bundle-branch block (instrinsic or induced by stimulation). Incidence of dilated cardiomyopathy in children is unknown, and there are no guides or big studies about cardiac resynchronization therapy, so recommendations for adult patients cannot be extrapolated. The experience of a female patient with a pacemaker and postoperative complete AV block after correction of a congenital heart disease is presented; she developed heart failure that was successfully treated with biventricular resynchronization in two opportunities, with recovery of functional class and hemodynamic parametres.

Masa en cuello secundaria a electrodo de estimulación cardiaca abandonado / Neck mass secondary to an abandoned pacing lead

Mujer de 70 años de edad, con historia de un electrodo de estimulación cardiaca abandonado, que genera: un trastorno de la deglución y una deformidad estética que la hacen consultar en múltiples oportunidades. A pesar de que se planteó la opción del retiro quirúrgico, se logró una extracción endovascular por la tracción de un electrodo. Describimos la utilidad del eco intracardiaco y el catéter ENSnare®, para la extracción de los electrodos en este tipo de casos.

70-year-old woman with a history of an abandoned pacing lead who developed a deglutition disorder and an aesthetic deformity that made her consult in multiple specialties. Even though surgical removal was considered, endovascular extraction was accomplished with the traction of the lead. We describe the usefulness of the intracardiac echocardiography and the ENSnare® catheter for this type of lead extractions.

Ruptura de electrodo ventricular por síndrome de "twiddler" / Ventricular electrode rupture due to twiddler's syndrome

El síndrome de "twiddler" se caracteriza por el enrollamiento y desplazamiento de los electrodos de un dispositivo de estimulación cardíaca debido a rotación a lo largo de su eje mayor, ya sea de manera espontánea o por manipulación del dispositivo. En la mayoría de los casos, dicho desplazamiento se acompaña de daño del electrodo; no obstante, no se ha descrito la ruptura total del electrodo. A continuación se describe el caso de un paciente con marcapasos unicameral implantado por fibrilación auricular lenta, en quien se documentó disfunción del mismo con falla en la detección y la captura; al interrogatorio el paciente manifestó astenia, adinamia, intolerancia al ejercicio y presíncope. La evaluación radiológica documentó enrollamiento del electrodo formando asas apretadas, con ruptura completa del electrodo y desplazamiento del generador del marcapasos en un bolsillo amplio. Según criterio de los autores, este es el primer caso de síndrome de twiddler en el que se documenta ruptura completa del electrodo.

Twiddler's syndrome is characterised by a twist and displacement of the electrodes of a cardiac stimulation device due to a rotation on its main axis, either spontaneously or when manipulating the pacemaker. In most cases this movement is accompanied by damage of the electrode; however, complete rupture of the lead has not been described. A case of a patient carrying a unicameral pacemaker required due to slow atrial fibrillation is now described, where a dysfunction of the device was documented as a failure to detect and capture. Upon interrogation the patient manifested asthenia, adynamia, exercise intolerance and pre-syncope. Radiological assessment documented a twisted electrode with the shape of tight handles, with complete electrode rupture and displacement of the pacemaker generator in a wide pocket. According to the authors’ criteria, this is the first Twiddler's syndrome case where total rupture of an electrode has been documented.