Exercise may cause myocardial ischemia at the anaerobic threshold in cardiac rehabilitation programs

Myocardial ischemia may occur during an exercise session in cardiac rehabilitation programs. However, it has not been established whether it is elicited when exercise prescription is based on heart rate corresponding to the anaerobic threshold as measured by cardiopulmonary exercise testing. Our objective was to determine the incidence of myocardial ischemia in cardiac rehabilitation programs according to myocardial perfusion SPECT in exercise programs based on the anaerobic threshold. Thirty-nine patients (35 men and 4 women) diagnosed with coronary artery disease by coronary angiography and stress technetium-99m-sestamibi gated SPECT associated with a baseline cardiopulmonary exercise test were assessed. Ages ranged from 45 to 75 years. A second cardiopulmonary exercise test determined training intensity at the anaerobic threshold. Repeat gated-SPECT was obtained after a third cardiopulmonary exercise test at the prescribed workload and heart rate. Myocardial perfusion images were analyzed using a score system of 6.4 at rest, 13.9 at peak stress, and 10.7 during the prescribed exercise (P < 0.05). The presence of myocardial ischemia during exercise was defined as a difference ≥2 between the summed stress score and summed rest score. Accordingly, 25 (64 percent) patients were classified as ischemic and 14 (36 percent) as nonischemic. MIBI-SPECT showed myocardial ischemia during exercise within the anaerobic threshold. The 64 percent prevalence of ischemia observed in the study should not be looked on as representative of the whole population of patients undergoing exercise programs. Changes in patient care and exercise programs were implemented as a result of our finding of ischemia during the prescribed exercise.

Association of Alport's syndrome with HDL-DR2 antigen in a group of unrelated patients

A few studies have evaluated HLA antigens in Alport's syndrome; however, there are no large population studies. In the present report, we studied 40 unrelated white patients with Alport's syndrome seen at the Unit of Renal Transplantation, Faculty of Medicine of Ribeirao Preto, Sao Paulo, Brazil. HLA-A, -B, -DR and -DQ antigens were typed using a complement-dependent microlymphocytotoxicity assay. A control white populations (N=403) from the same geographical area was also typed for HLA antigens. Although the frequencies of HLA-A and -B antigens of patients were not statistically different from controls, the frequency of HLA-DR2 antigen observed in patients (65 percent) was significantly increased in relation to controls (26 percent; P<0.001). The relative risk and etiologic fraction for HLA-DR2 antigen were 5.2 and 0.525, respectively. Although few immunological abnormalities have been shown in Alport's syndrome, in this report we emphasize the association of HLA molecules and Alport's syndrome. Besides the well-known inherited molecular defects encoded by tyope IV collagen genes in Alport's syndrome, the major histocompatibility alleles may be in linkage disequilibrium with these defective collagen genes.

Candidíase em pacientes transplantados renais / Candidiasis in kidney transplant patients

O objetivo do trabalho foi verificar a prevalência de candidíase em transplantados renais. Foram avaliados os prontuários dos pacientes transplantados no Hospital das Clínicas de Ribeirão Preto de fevereiro de 1968 a fevereiro de 1995. Nesse período foram transplantados 620 pacientes. Destes, 87 apresentaram 107 episódios de candidíase. Locais mais acometidos: trato urinário com 55 episódios, trato respiratório com 28, e trato gastrointestinal com 16. O agente etiológico mais freqüente foi C. albicans com 65 casos seguido de C. tropicalis com 12 e C. glabrata com 11 casos. As infecções do trato urinário mostraram incidência maior (61,7%) nos primeiros 6 meses. A maioria se apresentou clínicamente como infecção bacteriana. No trato respiratório, as infecções foram caracterizadas por recuperação do agente no escarro. No trato gastrointestinal, 9/16 episódios foram esofágicos, com epigastralgia, dor retroesternal, às vezes acompanhados de candidíase oral ou odinofagia. Nos outros episódios o agente foi recuperado nas fezes com quadro clínico de gastroenterite. Nas infecções dos tratos urinário e respiratório, houve associação da candidíase com antibioticoterapia prévia (76% e 67% respectivamente), além de infecções bacterianas concomitantes (34% e 64% respectivamente). As infecções por Candida sp tiveram prevalência geral em torno de 14,5%. A localização predominante foi no trato urinário e, em seguida, nos tratos respiratório e gastrointestinal, apresentando alto índice de associação com antibioticoterapia prévia e infecções bacterianas.

The medical records of 620 patients submitted to renal transplant from February 1968 to February 1995 were surveyed for Candida infection. Of these, 87 presented 107 episodes of candidiasis. In 42.9% the infection appeared up to 6 months after the transplant. The most frequent involved sites were: urinary tract, respiratory tract, and gastrointestinal tract. The most frequent etiological agents were: C. albicans, C. tropicalis and C. glabrata. Most urinary tract infections occurred in the first 6 months (61.7%) and manifested clinically as a bacterial infection. In the respiratory tract infections were characterized by isolation of the agent in sputum. In the gastrointestinal infections, 9/16 episodes were esophageal. There were 3 deaths directly related to Candidiasis (one pulmonary and 2 disseminated cases). In the urinary tract, and respiratory tract infections there was association of candidiasis with previous antibiotic treatment (76% and 67%, respectively), and with concomitant bacterial infections (34% and 64%, respectively). The overall prevalence of Candida infections was 14.5%. The predominant location was in the urinary tract (51.0%), followed by the respiratory (26.0%) and gastrointestinal tract (15.0%), with a high rate of association with previous antibiotic treatment and bacterial infections.

Princípios gerais e aplicaçöes de reabilitaçäo / Rehabilitation: principles and applications

A reabilitaçäo cardíaca é o processo de desenvolvimento e manutençäo de nível desejável de atividade física, social e psicológica após o início da doença coronária sintomática. Trata-se de terapêutica multidisciplinar para patologia multifatorial. Os maiores objetivos säo: melhora da capacidade funcional e da qualidade de vida, mudança de hábitos após evento coronário, com modificaçäo dos fatores de risco e reduçäo dos índices de mortalidade. Säo discutidos os vários efeitos do treinamento físico, clusive sobre a qualidade de vida de homens e mulheres, os tipos de exercício apropriados, conforme o tipo de doença cardiovascular, bem como a estratificaçäo quanto ao risco para atividade física após evento coronário. finalmente, säo apresentadas as indicaçöes e contra-indicaçöes atuais da reabilitaçäo cardíaca.

Atividade física e qualidade de vida após transplante cardíaco / Physical activity and quality of life after heart transplantation

O crescente número de transplantes cardíacos em nosso país e as limitaçöes funcionais, psicológicas e sociais após a cirurgia justificam a inclusäo desse grupo especial de pacientes em programa de reabilitaçäo cardiovascular, com abrangência multidisciplinar. Idealmente, o programa deve iniciar no período pré-transplante, pois estudos recentes demonstram que o tratamento farmacológico da insuficiência cardíaca avançada, isoladamente, näo reduz os sintomas como fadiga e dispnéia ao exercício. Váriosutores têm reportado melhora das respostas hemodinâmicas e respiratórias ao esforço com programas supervisionados de exercícios regulares e de moderada intensidade. Particularidades como a denervaçäo do coraçäo do doador, que resulta em taquicardia de repouso e insuficiência cronotrópica, assim como a disfunçäo diastólica säo fatores presentes e que limitam as adaptaçöes periféricas ao treinamento físico. Os benefícios descritos ocorrem a partir de oito semanas, destacando-se os aumentos entre 30 por cet e 40 por cento do consumo máximo de oxigênio e entre 30 por cento e 35 por cento na capacidade de exercício. Melhora da qualidade de vida e estabilidade psicológica também säo relatadas após período de 3 a 6 meses e o apoio e o envolvimento familiar säo imprescindíveis. A terapia imunossupressora, particularemente os corticosteróides, os episódios de rejeiçäo aguda e infecçöes säo fatores que interferem negativamente nos resultados funcionais e psicológicos, daí a necessidade de seguimento clínico coníno e frequente durante todo o processo de reabilitaçäo.

Transmission of Chagas' disease through transplanted kidney: occurrence of the acute form of the disease in two recipients from the same donor

Two cases of acute Chagas' disease acquired after renal transplantation are reported. The two patients received the kidney from the same donor. The present paper confirms this form of transmission of Chagas' disease and reinforces the need to exclude kidney donors with Trypanosoma cruzi infection.

Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77 (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Sucesso terapêutico com uso de esteróide em um caso de nefrite intersticial aguda secundária à rifampicina / Therapeutic success with use of steroid in a case of acute interstitial nephritis secondary to rifampin

O uso de corticosteróides e/ou outras drogas imunossupressoras no tratamento de nefrite intersticial aguda (NIA) permanece controverso. Os autores relatam um caso de NIA, secundária ao uso de rifampicina, tratado com prednisona, no qual se obteve excelente resposta: paciente feminina com diagnóstico de tuberculose pulmonar, que se apresentava com funçäo renal normal, foi submetida a terapêutica tríplice (rifampicina e pirazinamida). No quadragésimo dia de tratamento, mostrou creatinina de 2,4mg/dl e BUN de 27mg/dl; após três dias, foi submetida a exames que mostraram: creatinina plasmática, 5,5mg/dl; nitrogênio uréico plasmático, 74mg/dl; sódio urinário, 78mEq/1; osmolalidade urinária, 416mOsm/Kg de H2O e fraçäo de excreçäo de sódio de 4,3%; exame do sedimento urinário com leucocitúria, hematúria e eosinofilúria; proteinúria de 24 horas de 900mg; ultra-som renal normal. A biopsia renal revelou tratar-se de NIA, sendo suspensa a rifampicina e, como a funçäo renal continuava a piorar, iniciou-se prednisona. Houve estabilizaçäo dos níveis de escórias nitrogenadas e queda a partir do quarto dia de tratamento, recebendo alta hospitalar com funçäo renal normal

Influencia da glicose no liquido de dialise sobre os niveis sericos de colesterol, HDL colesterol e triglicerides em pacientes submetido a hemodialise. / Influence of glucose in the dialysis fluid on serum cholesterol, HDL cholesterol and triglycerides levels in patients subjected to hemodialysis

O trabalho avalia o efeito da glicose no liquido de dialese, na lipemia de 6 pacientes submetidos a hemodialise.Esses pacientes foram seguidos em um periodo de 6 meses, sem adicao de glicose no banho e em um 2o. periodo, tambem de 6 meses, com liquido contendo glicose numa concentracao de 200mg%. Nos dois periodos foram dosados colesterol, triglicerides e HDL colesterol A analise dos dados mostrou que nao houve diferenca significativa da lipemia no segundo periodo em relacao ao primeiro, indicando que a glicose no liquido de dialise nao influenciou os niveis da lipemia nesses pacientes