Cardiac and Liver Fibrosis Assessed by Multiparametric MRI in Patients with Fontan Circulation.

The abnormal hemodynamics in Fontan circulation due to persistently increased systemic venous pressure results in hepatic venous congestion and Fontan-associated liver disease. Combined assessment of cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in this context have not been fully explored. To evaluate cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in patients who have undergone Fontan procedures. Thirty-eight patients and 23 controls underwent cardiac and liver MRI examinations in a 3.0-T scanner. Mann-Whitney, Fisher exact test, and Spearman's correlation were applied to evaluate myocardial volumes, function, native cardiac and liver T1 mapping, ECVs and liver stiffness. The mean native cardiac T1 value (p = 0.018), cardiac ECV (p < 0.001), liver native T1 (p < 0.001), liver ECV (p < 0.001), and liver stiffness (p < 0.001) were higher in patients than controls. The indexed end-diastolic volume (EDVi) correlated with the myocardial ECV (r = 0.356; p = 0.033), native liver T1 (r = 0.571; p < 0.001), and with liver stiffness (r = 0.391; p = 0.015). In addition, liver stiffness correlated with liver ECV (r = 0.361; p = 0.031) and native liver T1 (r = 0.458; p = 0.004). An association between cardiac remodeling and cardiac and liver fibrosis were found in this population. The usefulness of MRI to follow cardiac and liver involvement in these patients is critical to improve treatment strategies and to prevent the need for combined liver and heart transplantation.

How Cardiac Fibrosis Assessed via T1 Mapping Is Associated with Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease.

(1) Background: Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases worldwide. Although cardiovascular and NAFLD risk factors overlap, an independent association between these conditions may exist. Hepatic and cardiac fibrosis are important markers of mortality, but the correlation between these markers in patients with NAFLD has not been well studied. Our main objective was to determine the degree of myocardial fibrosis in patients with NAFLD and its correlation with the severity of liver fibrosis. (2) Methods: In this cross-sectional study, patients with NAFLD were allocated to two groups according to the stage of liver fibrosis assessed using MRI: no or mild fibrosis (F0-F1) and significant fibrosis (F2-F4). Framingham risk scores were calculated to evaluate cardiovascular risk factors, and patients underwent multiparametric cardiac and abdominal MRIs. (3) Results: The sample comprised 44 patients (28 with no or mild liver fibrosis and 16 with significant liver fibrosis). The mean age was 57.9 ± 12 years, and 41% were men. Most patients had high cardiac risk factors and carotid disease. Relative to patients with no or mild liver fibrosis, those with significant fibrosis had a higher median calcium score (p = 0.05) and increased myocardial extracellular volume (ECV; p = 0.02). Liver fibrosis correlated with cardiac fibrosis, represented by the ECV (r = 0.49, p < 0.001). The myocardial ECV differentiated patients with and without significant liver fibrosis (AUC = 0.78). (4) Conclusion: This study showed that diffuse myocardial fibrosis is associated with liver fibrosis in patients with NAFLD.

Importance of 24 h ambulatory blood pressure monitoring in patients with acromegaly and correlation with cardiac magnetic resonance findings.

INTRODUCTION: Arterial hypertension (AH) is prevalent in acromegaly, but few studies using 24-h ambulatory blood pressure monitoring (24 h-ABPM) suggest that its frequency may be different from office blood pressure (OBP). Left ventricular hypertrophy (LVH) is one of the most frequent cardiac abnormalities. Cardiac magnetic resonance (CMR) is considered the gold standard to evaluate the heart. OBJECTIVES: To compare the frequency of AH when measured by 24 h-ABPM and by OBP and to correlate BP with cardiac mass. METHODS: Patients over 18 years of age with acromegaly underwent OBP evaluation and were later referred to the 24 h-ABPM. Treatment-naïve patients were submitted to CMR. RESULTS: We evaluated 96 patients. From 29 non hypertensive patients by OBP, 9 had AH on 24 h-ABPM. In the group of patients with a previous diagnosis of AH by OBP, 25 had controlled BP and 42 had abnormal BP on 24 h-ABPM, when analyzed by OBP there were 28 with controlled BP. We observed a positive correlation between diastolic BP measured in 24 h-ABPM and IGF-I levels, but we did not observe the same correlation with age, sex, body mass index and GH levels. The CMR was performed in 11 patients. We found a positive correlation of left ventricular mass (LVM) and BP of 24 h-ABPM. In contrast, there was no correlation of OBP with CMR parameters. CONCLUSIONS: We observed, that 24 h-ABPM in acromegaly allows the diagnosis of AH in some patients with normal BP in OBP and also to allow a better treatment. 24 h-ABPM shows a better correlation with VM by CMR.

Evaluation of actions to address acquired syphilis between 2016 and 2019, in a southeast brazilian state capital city / Avaliação das ações de enfrentamento da sífilis adquirida no período de 2016 a 2019, numa capital do sudeste brasileiro

Introdução: as Infecções Sexualmente Transmissíveis (IST) representam um problema de saúde pública global, sendo que são responsáveis por efeitos diretos sobre a saúde reprodutiva e infantil, ocasionando consequências como infertilidade e complicações na gestação e no parto, morte fetal e diversos agravos à saúde da criança.Objetivo: avaliar os indicadores de resultado relacionados à sífilis adquirida no quadriênio 2016-2019, em uma capital do sudeste brasileiro. Método: estudo de avaliação para a gestão, descritivo, de abordagem quantitativa, que avaliou os indicadores de resultado "realização de tratamento adequado para a sífilis na população geral" e "monitoramento da sífilis adquirida". Os dados foram coletados no Sistema de Informação de Agravos de Notificação (SINAN), referentes ao período de 1.º de janeiro de 2016 a 31 de dezembro de 2019. As informações referentes ao tratamento e monitoramento dos casos de sífilis congênita ocorreram mediante busca em prontuário eletrônico, no período de 1.º de agosto de 2020 a 31 de março de 2021. Resultados: o município de Vitória teve 2.647 casos de sífilis adquirida, pelo critério ano de diagnóstico. Quanto à variável sexo, notificaram-se 1.641 homens (61,99%) e 1.006 mulheres (38,01%). A faixa etária predominante foi de 20 a 29 anos, e a raça/cor de maior frequência, f a parda. O nível de escolaridade mais frequente foi médio completo. O teste não treponêmico foi realizado em 84,93% dos casos e o treponêmico 47,22%. Com relação ao indicador "oferta de tratamento adequado para a sífilis", constatou-se que o percentual de tratamento adequado, dentre os casos da rede SEMUS, foi de 90,08%, no total do quadriênio: 87,25% em 2016; 85,27% em 2017; 91,79 em 2018; e 94,23% em 2019. Referente ao indicador "monitoramento dos casos de sífilis na população geral", verificou-se que o percentual de monitoramento adequado, dentre os casos da rede SEMUS, foi de 35,72% no total do quadriênio: 33,33% em 2016; 36,83% em 2017; 34,53% em 2018; e 38,20% em 2019. Conclusão: Os indicadores de resultado avaliados em Vitória, no quadriênio 2016-2019, foram: percentual de tratamento adequado (90,08%) e percentual de monitoramento adequado (35,72%).

Introduction: sexually Transmitted Infections (STIs) represent a global public health problem, and are responsible for direct effects on reproductive and child health, causing consequences such as infertility and complications during pregnancy and delivery, fetal death, as well as a variety of health problems in affected children.Objective: to evaluate outcome indicators related to acquired syphilis in the period 2016-2019 in a southeast Brazilian state capital.Methods: this is a descriptive management evaluation study with a quantitative approach, which evaluated the outcome indicators "provision of adequate syphilis treatment in the general population" and "monitoring of acquired syphilis". Data were collected on the Notifiable Health Conditions Information System (SINAN), for the period from January 1st 2016 to December 31st 2019. Information regarding treatment and monitoring of cases of acquired syphilis was obtained by searching electronic medical records between August 1st 2020 and March 31st 2021.Results: the municipality of Vitória had 2,647 cases of acquired syphilis, using the criterion of year of diagnosis. The notified cases related to 1,641 men (61.99%) and 1,006 women (38.01%). The predominant age group was 20 to 29 years, while race / skin color was predominantly brown. The most frequent level of education was complete high school. The non-treponemal test was performed in 84.93% of the cases and the treponemal test in 47.22%. Regarding the "provision of adequate syphilis treatment" indicator, we found a total of 90.08% for adequate treatment of cases in Vitória's public health service network for the four-year period: 87.25% in 2016; 85.27% in 2017; 91.79% in 2018; and 94.23% in 2019. Regarding the "monitoring of syphilis cases in the general population" indicator, we found a total of 35.72% for adequate monitoring of cases in Vitória's public health service network for the four-year period: 33.33% in 2016; 36.83% in 2017; 34.53% in 2018; and 38.20% in 2019.Conclusion: the outcome indicators evaluated in Vitória, in the 2016-2019 four-year period, were: adequate treatment 90.08% and adequate monitoring 35.72.

Feasibility and Safety of Ipsilateral Ulnar Access in Cases of Impossibility or Failure of Radial Access for Coronary Angiography or Percutaneous Coronary Intervention.

OBJECTIVES: To evaluate the feasibility and safety of using the ulnar access in coronary angiography and percutaneous coronary intervention, in the failure or contraindication of ipsilateral radial access. METHODS: We prospectively evaluated, in a quaternary hospital, patients undergoing coronary angiography or percutaneous coronary intervention by transulnar approach, in case of failure or contraindication to the ipsilateral radial access. RESULTS: Between August 2018 and March 2020, of the 5,916 invasive coronary procedures performed, 2.2% were by transulnar approach. In the 130 patients evaluated, the indication for use of the transulnar approach was predominantly the low-amplitude or difficult to palpate radial pulse when compared to the ulnar artery (39.2%), followed by occlusion of the ipsilateral radial artery (33.1%). Complications of using the transulnar approach were superficial hematoma or low-degree muscle infiltration with extension ≤10 cm, in 6 patients (4.5%), and in 5 cases (3.8%) hematoma >10 cm. There was a case of transient ischemia of the hand due to forearm hematoma, treated conservatively. No cases of arterial thrombosis, pseudoaneurysm, arteriovenous fistula, symptomatic ulnar artery occlusion or ulnar nerve injury were observed after 30-day follow-up. CONCLUSION: The use of ipsilateral transulnar access is a feasible and safe alternative in cases where radial access would be impossible. This access site is associated with a low incidence of complications, which, when present, are most commonly associated with the occurance of spasm after the attempted radial puncture.

Nutritional status and physical performance using handgrip and SPPB tests in hospitalized older adults.

BACKGROUND & AIMS: Malnutrition and poor physical performance are highly prevalent within hospitalized older adults, and both have in common the loss of muscle mass. Likewise, there is growing interest in identifying markers of physical performance, other than just measuring muscle mass, that might be useful for managing malnutrition. This study aimed to (i) characterize the physical condition of hospitalized older adults in comparison to previously published reference percentile values of same age adults and (ii) to examine the association between the nutritional status and physical performance of older inpatients. METHODS: A total of 604 inpatients (age 84.3 ± 6.8 years, 50.3% women) participated in this cross-sectional study. Patients were assessed for nutritional status (Mini Nutritional Assessment-Short Form (MNA-SF)) and physical performance (handgrip strength and the Short Physical Performance Battery (SPPB)). RESULTS: During hospitalization, 65.7% of the inpatients were at risk of malnutrition or malnourished. More than a half of the older inpatients were unfit (≤P25) for handgrip strength (52.0%) and SPPB total score (86.3%) as well as for two of its subtests, gait speed (86.7%) and 5 times sit-to-stand (91.1%) tests. Patients' nutritional status was significantly associated with better physical performance within all tests (all p < 0.001), as their nutritional status improved so did their physical performance (all p for trend <0.001). Hence, being at risk of malnutrition or malnourished significantly increased the likelihood for being classified as unfit according to handgrip strength (OR: 1.466, 95% CI: 1.045-2.056), SPPB total score (OR: 2.553, 95% CI: 1.592-4.094) and 4-m walking test (OR: 4.049, 95% CI: 2.469-6.640) (all p < 0.05), and as frail (OR: 4.675, 95% CI: 2.812-7.772) according to the SPPB frailty threshold (p < 0.001). CONCLUSIONS: This study reinforces the use of handgrip strength and SPPB, as well as its subtests (gait speed and 5 times sit-to-stand tests), in hospitalized older adults as alternative measures of muscle mass for malnutrition management. Hence, it seems that risk of malnutrition or malnutrition assessed by MNA-SF might help to predict poor physical performance in older inpatients.

Identification of frailty and sarcopenia in hospitalised older people.

BACKGROUND: People with frailty and/or sarcopenia have an increased risk of negative health outcomes. However, their diagnosis is often difficult. Considering the potential value of myostatin and follistatin as biomarkers of these conditions, we aimed to compare the association between both myokines and frailty and/or sarcopenia in post-hospitalised older people. In addition, the capability of myostatin and follistatin for identifying frailty and sarcopenia was compared with physical tests. MATERIALS AND METHODS: Participants in this cross-sectional study consisted of 84 post-hospitalised patients immediately after discharge. Participants met the following inclusion criteria: aged ≥ 70 years, score of ≥20 on the Mini-Mental State Examination, and able to stand up and walk independently for at least 4 m. Serum myostatin and follistatin concentrations were measured by enzyme-linked immunosorbent assay. Body measures and results from 4 physical tests (hand grip, chair stand, 8-foot timed Up and Go (8TUG) and gait speed (GS)) were also recorded. Frailty was evaluated by the Fried index, and sarcopenia by the criteria of the European Working Group on Sarcopenia in Older People. RESULTS: Myostatin concentration was lower and follistatin concentration higher in people with frailty or sarcopenia. Receiver operating characteristic curves indicated that GS and 8TUG tests had the greatest capability for identifying frailty. Myostatin was the only variable capable of identifying sarcopenia. CONCLUSION: Myostatin may be a useful biomarker for sarcopenia in post-hospitalised older adults. However, it has a lower capability for identifying frailty than physical tests. Further studies using larger samples and these myokines together with other biomarkers are warranted.

Determinants of participation in a post-hospitalization physical exercise program for older adults.

BACKGROUND: Older patients often experience a decline in physical function and cognitive status after hospitalization. Although interventions involving physical exercise are effective in improving functional performance, participation in physical exercise interventions among older individuals is low. We aimed to identify factors that contribute to exercise refusal among post-hospitalized older patients. METHODS: A cross-sectional study of recruitment data from a randomized controlled trial was conducted involving 495 hospitalized people ≥70 years old. Sociodemographic and clinical data were obtained from the Basque Public Health System database. We determined physical function with the Short Physical Performance Battery (SPPB), nutritional status with the Mini-Nutritional Assessment, frailty according to the Fried phenotype criteria, and cognitive function with the Short Portable Mental Status Questionnaire (SPMSQ). Student's t, Mann-Whitney U, or chi-squared tests were applied for bivariate analysis. Parameters significantly associated with participation were introduced in a logistic multivariate regression model. RESULTS: Among the analyzed patients, 88.8% declined participation in the physical exercise program. Multivariate regression revealed that older age (OR: 1.13; 95% CI: 1.07-1.19), poor nutritional status (OR: 0.81; 95% CI: 0.69-0.95), and reduced home accessibility (OR: 0.27; 95% CI: 0.08-0.94) were predictors of participation refusal. Moreover, patients who declined participation had worse performance on the SPPB (P < 0.05) and its tests of balance, leg strength, and walking speed (P < 0.05). No differences were found between groups in other variables. CONCLUSIONS: This study confirms low participation of older adults in a post-hospitalization physical exercise program. Non-participation was associated with increased age, poor nutritional status, and reduced home accessibility. Our findings support the need for intervention design that accounts for these factors to increase older patient participation in beneficial exercise programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12619000093189 , (date: January 22, 2019, retrospectively registered).

[Oropharyngeal dysphagia and aspiration]. / Disfagia orofaríngea y broncoaspiración.

Oropharyngeal dysphagia, or inability to swallow liquids and/or solids, is one of the less well known geriatric syndromes, despite its enormous impact on functional ability, quality of life and health in affected individuals. The origin of oropharyngeal dysphagia can be structural or functional. Patients with neurodegenerative or cerebrovascular diseases and the frail elderly are the most vulnerable. The complications of oropharyngeal dysphagia are malnutrition, dehydration and aspiration, all of which are serious and provoke high morbidity and mortality. Oropharyngeal aspiration causes frequent respiratory infections and aspiration pneumonias. Antibiotic therapy must cover the usual microorganisms of the oropharyngeal flora. Oropharyngeal dysphagia should be identified early in risk groups through the use of screening methods involving clinical examination of swallowing and diagnostic confirmation methods. The simplest and most effective therapeutic intervention is adaptation of the texture of the solid and the viscosity of the liquid.

Disfagia orofaríngea y broncoaspiración / Oropharyngeal dysphagia and aspiration

La disfagia orofaríngea o la imposibilidad para deglutir los elementos líquidos y/o sólidos es uno de los síndromes geriátricos menos conocido, a pesar de su enorme impacto en la capacidad funcional, calidad de vida y salud de los pacientes que la padecen. Su origen puede ser estructural o funcional. Los pacientes con enfermedades neurodegenerativas, cerebrovasculares y los ancianos frágiles son los colectivos más vulnerables. Las complicaciones de la disfagia orofaríngea son la desnutrición, la deshidratación y la broncoaspiración, todas ellas graves y con elevada morbimortalidad. La broncoaspiración ocasiona frecuentes infecciones respiratorias y neumonías aspirativas. El tratamiento antibiótico deberá cubrir los gérmenes habituales de la flora orofaríngea. Debemos identificar de forma precoz la disfagia orofaríngea en los grupos de riesgo mediante la utilización de métodos de cribado de exploración clínica de la deglución y métodos diagnósticos de confirmación. La intervención más sencilla y con mayor eficacia terapéutica es la adaptación de la textura de los sólidos y la viscosidad de los líquidos (AU)

Oropharyngeal dysphagia, or inability to swallow liquids and/or solids, is one of the less well known geriatric syndromes, despite its enormous impact on functional ability, quality of life and health in affected individuals. The origin of oropharyngeal dysphagia can be structural or functional. Patients with neurodegenerative or cerebrovascular diseases and the frail elderly are the most vulnerable. The complications of oropharyngeal dysphagia are malnutrition, dehydration and aspiration, all of which are serious and provoke high morbidity and mortality. Oropharyngeal aspiration causes frequent respiratory infections and aspiration pneumonias. Antibiotic therapy must cover the usual microorganisms of the oropharyngeal flora. Oropharyngeal dysphagia should be identified early in risk groups through the use of screening methods involving clinical examination of swallowing and diagnostic confirmation methods. The simplest and most effective therapeutic intervention is adaptation of the texture of the solid and the viscosity of the liquid (AU)