Showing papers in "Revista Portuguesa De Pneumologia in 2009"

Effect of Dronedarone on Cardiovascular Events in Atrial Fibrillation

Abstract: Background: Dronedarorie is a new antiarrhythniie drug that is being developed (or the treatment of patients with alnal iihrillalion. Methods: We conducted a multiceuter trial to evaluate the use of dronedarone in 4628 patienls with atrial fibrillation who had additional risk factors for death. Patients wen.' randomly assigned lo receive dronedarone, 400 mg twice a day, or placebo. The primary outcome was the first hospitalization due to cardiovascular e\ents or death. Secondary outcomes were death from any cause, death from cardiovascular causes, and hospilahzalion due to cardiovascular events. Results: The mean follow-up period was 21±5 months, with the study drug discontinued prematurely in 696 of the 2301 patients (30.2%) receiving dronedarone and in 716 of the 2327 patients (30.8%) receiving placebo, mostly because of adverse events. The primary outcome occurred in 734 patients (31 .9%) in the dronedarone group and in 9i7 patients (39.4%) in the placebo group, with a hazard ratio for dronedarone ol 0.76 (95% confidence interval [CIJ. 0.69 to 0.84; P<0.001). There were 1 16 deaths (5.0%) in the dronedarone group and 139 (6.0%) in the placebo group (hazard ratio, 0.84; 95% Cl. 0.66 to 1 .08: P = 0.18). There were 63 deaths from cardiovascular causes (2.7%) in the dronedarone group and 90 (3.9%) in ihe placebo group (hazard ratio. 0.71; 95% CI. 0.51 to 0.98; P = 0.03). largely due to a reduction in (he rale of death from arrhythmia with dronedarone. The dronedarone group had higher rates of bradycardia, QT-interval prolongation, nausea, diarrhea, rash, and an increased serum creatinine level than the placebo group. Hales of ihyroid- and pulmonary-related adverse events were nol significantly different between the two groups. (Conclusion: Dronedarone reduced the incidence of. hospitalization due to cardiovascular events or death in patients with atrial fibrillation. (ChnicalTrials.gov number. NCTOO 174785.).

COPD as a disease of accelerated lung aging(a).

Abstract: Vol XV N.o 4 Julho/Agosto 2009 Resumo A DPOC constitui um problema de saúde global de importância crescente, com enorme impacto nos custos directos e indirectos em recursos de saúde. Apesar do seu impacto, pouco se sabe ainda sobre os mecanismos celulares, moleculares e genéticos desta doença, e as terapêuticas farmacológicas actualmente disponíveis não influenciam a progressão da doença ou a mortalidade. A limitação do débito aéreo avaliada pela redução do volume expiratório máximo no 1.o segundo (FEV1) progride muito lentamente ao longo de várias décadas, condicionando o aparecimento de sintomas em adultos acima dos 40 anos ou já na terceira idade. Desta forma, a prevalência da DPOC é dependente da idade, sugerindo uma relação íntima entre a patogénese da DPOC e a do envelhecimento. A senescência ou processo de envelhecimento define-se como o declínio progressivo da homeostasia que ocorre após estar completa a fase reprodutiva da vida e conduz a um risco aumentado de doença e de morte. Segundo Kirkwood1, o envelhecimento resulta da interacção entre a lesão e a reparação, como resultado da energia produzida pelo indivíduo para manter a integridade orgânica e proteger o ADN da agressão oxidativa. A falência orgânica ou celular na manutenção ou reparação resulta de uma acção integrada entre genes, ambiente e defeitos intrínsecos do organismo. Subjacente ao processo de envelhecimento, existe uma acumulação progressiva de danos a nível molecular. As alterações a nível celular causam reacções inflamatórias, e estas, por sua vez, exacerbam as lesões celulares existentes. Desta forma, os factores inflamatórios e anti-inflamatórios modulam a evolução do envelhecimento. As alterações inflamatórias e estruturais associadas ao envelhecimento resultam da falência em eliminar os radicais de oxigénio (ROS), da falência em reparar o ADN lesado e do encurtamento do telómero. Os telómeros protegem as extremidades dos cromossomas, mas, quando se encontram expostos a elevados níveis de stress oxidativo, vão-se encurtando progressivamente à medida que as células se dividem. Com o envelhecimento, a perda e encurtamento dos telómeros condicionam o declínio da capacidade para as células se dividirem – senescência replicativa. A DPOC como uma doença de envelhecimento acelerado*

Early versus Delayed, Provisional Eptifibatide in Acute Coronary Syndromes

Abstract: Background: Glycoprotein IIb/IIIa inhibitors are indicated in patients with acute coronary syndromes who are undergoing An invasive procedure. The optimal timing of the initiation of such therapy is unknown. Methods: We compared a strategy of early, routine administration of eptifibatide with delayed, provisional administration in 9492 patients who had acute coronary syndromes without ST-segment elevation and who were assigned to an invasive strategy. Patients were randomly assigned to receive either early eptifibatide (two boluses, each containing 180 μg per kilogram of body weight, administered 10 minutes apart, and a standard infusion 12 hours before angiography) or a matching placebo infusion with provisional use of eptifibatide after angiography (delayed eptifibatide). The primary efficacy end point was a composite of death, myocardial infarction, recurrent ischemia requiring urgent revascularization, or the occurrence of a thrombotic complication during percutaneous coronary intervention that required bolus therapy opposite to the initial study-group assignment ("thrombotic bailout") at 96 hours. The key secondary end point was a composite of death or myocardial infarction within the first 30 days. Key safety end points were bleeding and the need for transfusion within the first 120 hours after randomization. Results: The primary end point occurred in 9.3% of patients in the early-eptifibatide group and in 10.0% in the delayed-eptifibatide group (odds ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P=0.23). At 30 days, the rate of death or myocardial infarction was 11.2% in the early-eptifibatide group, as compared with 12.3% in the delayed-eptifibatide group (odds ratio, 0.89; 95% CI, 0.79 to 1.01; P=0.08). Patients in the early-eptifibatide group had significantly higher rates of bleeding and red-cell transfusion. There was no significant difference between the two groups in rates of severe bleeding or nonhemorrhagic serious adverse events. Conclusions: In patients who had acute coronary syndromes without ST-segment elevation, the use of eptifibatide12 hours or more before angiography was not superior to the provisional use of eptifibatide after angiography. The early use of eptifibatide was associated with an increased risk of non-life-threatening bleeding and need for transfusion.

Prevention of disease progression by cardiac resynchronization therapy in patients with asymptomatic or mildly symptomatic left ventricular dysfunction

Abstract: published online Sep 30, 2009; J. Am. Coll. Cardiol. REVERSE Study Group Hassager, Grahame Goode, Tamas Szili-Torok, Cecilia Linde, on behalf of the Claude Daubert, Michael R. Gold, William T. Abraham, Stefano Ghio, Christian Dysfunction) Trial (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction: Insights From the European Cohort of the REVERSE Patients With Asymptomatic or Mildly Symptomatic Left Ventricular Prevention of Disease Progression by Cardiac Resynchronization Therapy in This information is current as of October 1, 2009 http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.08.011v1 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Pathophysiology of chronic heart failure.

Abstract: Heart failure is a medical condition characterized by reduced cardiac output (CO) and increased venous pressure, associated with underlying molecular changes and subsequent damage to and death of cardiac muscle cells. The body has its own ways of increasing lowered CO, which together make up the neurohumoral response. This is composed of three basic elements: (1) a hemodynamic defense reaction which maintains perfusion pressure in the major organs by increasing circulating blood volume, inducing vasoconstriction and stimulating the heart; (2) an inflammatory response (in which the body organs act as if they were facing an exogenous agent), in which inflammatory cytokines and reactive oxygen species play an important role; (3) a hypertrophic response and ventricular remodeling, with structural changes in cardiac muscle cells and in the shape of the ventricular chamber. Neurohumoral mechanisms are classified according to their effects: regulatory (increasing vasoconstriction, sodium retention, inotropism and proliferation); and counter-regulatory (with the opposite effects). Ultimately, they are responsible for the failing heart. Our aim is to bring together data on the mechanisms of progression to heart failure, elucidating the relationships between the biological agents involved, particularly those susceptible to pharmacological modification.

Re-Ly study of stroke prevention in atrial fibrillation Dabigatren versus warfarin in patients with atrial fibrillation N Engl J Med 2009; 361.10: 1056

Abstract: BACKGROUND Warfarin reduces the risk of stroke in patients with atrial fibrillation but increas- es the risk of haemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin inhibitor. In this no inferiority trial, we randomly assigned 18.113 patients who had atrial fibrillation and risk of stroke to receive, in a blinded fashion, fixed doses of dabigatran ―110 mg or 150 mg twice daily ― or, in an unblinded fashion, adjusted-dose warfarin. The median duration of the follow-up period was 2.0 years. The primary outcome was stroke or systemic embolism. RESULTS Rates of the primary outcome were 1.69% per year in the warfarin group, as compared with 1.53% per year in the group that received 110 mg of dabigatran (relative risk with dabigatran, 0.91; 95% confidence interval (CI), 0.74 to 1.11; P < 0.001 for noninferity) and 1.11% per year in the group that received 150 mg of dabigatran (relative risk, 0.66; 95% CI, 0.53 to 0.82; P< 0.001 for superiority). The rate of major bleeding was 3.36& per year in the warfarin group, as compared with 2.71% per year in the 110 mg dabigatran group (P= 0.003) and 3.11% per year in the 150 mg dabigatran group (P=0.31). The rate of hemorrhagic stroke was 0.38% per year in the warfarin group as compared with 0.12% per year with 110 mg of dabigatran (P<0.001) and 0.10% per year with 150m mg of dabigatran (P<0.001). The mortality rate was 4.13% per year in the warfarin group, as compared with 3.75% per year with 110 mg of dabigatran (P=0.13) and 3.64% per year with 150 mg of dabigatran (P=0.051). In patients with atrial fibrillation, dabigatran given at a dose of 1110 mg was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major haemorrhage. Dabigatran administered at a dose of 150 mg, as compared with warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of haemorrhage.

Portuguese Registry of Acute Coronary Syndromes: seven years of activity.

Abstract: BACKGROUND The Portuguese Registry of Acute Coronary Syndromes was established in 2002, with the goal of gathering data on the clinical characteristics, treatment and prognosis of Portuguese patients with acute coronary syndromes (ACS). OBJECTIVE To report the information collected during the seven years of activity of the Portuguese Registry of ACS (from January 1, 2002 to December 31, 2008). METHODS The Portuguese Registry of ACS is an observational, prospective and continuous registry, which started on January 1, 2002 and involved 45 Portuguese hospitals. Patients with ST-segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) were included. Information was collected on 188 variables, including data on clinical presentation, treatment and prognosis of patients with ACS. RESULTS The registry included 22,482 patients (mean age 66 +/- 13 years, 70% male), distributed as follows: 45.4% STEMI, 41.4% NSTEMI and 13.1% UA. Reperfusion therapy was used in 63% of STEMI patients, ris- ing from 60% in 2002 to 75% in 2008, with an increasing proportion of primary angioplasty relative to fibrinolysis. Aspirin, low molecular weight heparin and glycoprotein IIb/IIIa inhibitors were used in respectively 97%, 88% and 26% of the patient population. A combination of dual antiplatelets, beta-blockers, angiotensin-converting enzyme inhibitors and statins was used in 32% of patients during hospitalization, in 26% on discharge and in 16% six months after the acute event. Coronary angiography was performed in the majority of patients (62%), followed by a coronary revascularization procedure in about a third (38%). Coronary angiography was increasingly used during the period under analysis, with a concomitant increase in revascularization procedures. In-hospital mortality was 5.2% in the overall population (7.7% in STEMI, 3.9% in NSTE-MI and 0.7% in UA), declining significantly over time. Cumulative mortality six months after the acute event was 7.5% (10.2% in STEMI, 6.6% in NSTEMI and 1.5% in UA). CONCLUSION The Portuguese Registry of ACS has collected crucial information on the clinical characteristics, treatment and prognosis of ACS in Portugal. The reported results reveal discrepancies between the guidelines for ACS treatment and their application in clinical practice. Analysis of the results has identified several issues that require particular attention and future intervention in order to improve ACS treatment and prognosis.

Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol 2009; 54: 1099-106

Abstract: Objectives The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function. Background Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear. Methods We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivatin cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up. Results The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded and optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis. Conclusions Among patients with severe asymptomatic organic mitral regurgitation, BNP $105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine worhup for risk stratification.

Efeito do envelhecimento cronológico na função pulmonar. Comparação da função respiratória entre adultos e idosos saudáveis

Abstract: Introduction: The respiratory system changes with age and understanding these changes helps detect and prevent respiratory dysfunctions in the elderly Aims: This study compares the respiratory pattern in healthy non-smoker adults and the elderly, using lung function testing and expansion of the chest to confirm the effects of aging on lung function Methodology: We used lung function testing to measure forced vital capacity, forced expiratory volume in one second, peak expiratory flow rate and maximum voluntary ventilation We also measured expansion of the chest Measurements were taken with subjects resting in the dorsal recumbent position with upper body elevated to 45o Statistical analysis consisted of the Student T test for independent samples, the non-parametric Mann-Whitney test with a p < 005 level, and linear regression analysis, also with a p < 005 level, to assess correlation between variables studied and age Our population consisted of 35 elderly subjects and 35 adults 15 of the elderly subjects were male (43%) and 20 female (57%) 16 of the adult group were male (46%) and 19 female (54%) The sample was mapped in terms of age, weight, height, abdominal girth and clinical data, to exclude factors which could distort the results Results: The difference between the two study groups attained statistical significance for all parameters measured The linear relationship was also significant between age and all parameters and a negative and significant correlation was seen Expansion of the chest in females was the parameter most inversely correlated with age (6037%) The lung function testing variable with the greatest difference between the groups was peak expiratory flow rate (3577% in females and 3617% in males) Conclusions: Our results show differences in the respiratory patterns of healthy adults and the elderly, suggesting that age impacts on lung function Both male and female elderly subjects had lower lung function testing scores than the adult subjects, with this difference more marked in females Rev Port Pneumol 2009; XV (4): 629-653

Prevalence and management of hypertension in primary care in Portugal. Insights from the VALSIM study.

Abstract: Introduction: Hypertension (HT) is the most common modifiable risk factor of cardiovascular disease, and HT management and controle is of major importance in preventive strategies. However, patterns of antihypertensive (AHT) treatment have never been evaluated in Portugal. Objective: To estimate the prevalence of HT and to characterize its management in a primary care setting, identifying the most frequently used drugs and evaluating regional variations in treatment patterns. Methods: The VALSIM study is a descriptive cross-sectional study performed in a primary care setting, involving 719 general practioners (GPs) and representative of all regions of Portugal. The first two patients aged ≥18 years consulting their GP on each day were asked to participate, irrespective of the reason for consultation. After informed consent was obtained, a questionnaire was used to collect sociodemographic, clinical and laboratory data. Two blood pressure (BP) measurements were taken after a 5-minute rest period in a seated position. HT was defined as BP higher than 140/90 mmHg or use of antihypertensive medication. Results: A total of 16,856 subjects were evaluated (mean age 58.1±15.1 years; 61.3% women). The prevalence of HT adjusted for age and gender was 42.62% (males: 43.09% age and gender was 42.62% (males: 42.09% females: 42.19%). Of the 9,189 hypertensive patients under treatment, the proportion receiving one, two or three or more drug classes was 47.62%, 36.16% and 16.22% respectively. The classes most frequently used in monotherapy were angiotensin receptor blockers (ARBs, 16.9%), angiotensin-converting enzyme inhibitors (ACEIs, 14.41%) and diuretics (5.85%). The most common associations of two classes were ARB-diuretic (11.82%), ACEI-diuretic (11.79%), ACEI-calcium channel blocker (CCB, 2%), CCB-diuretic (1.81%) and ARB-CCB (1.53%). The most frequently used AHT drugs were diuretics (47.4%), ARBs (43%) and ACEIs (39,2%). CCBs were used in 18.9% and betablockers in 16.2% only. Different patterns of treatment were identified according to gender, age and region of residence. Diuretics were used more in the elderly, women, and in the Azores (61.9%) and the Alentejo (58.3%). ARBs were used preferentially in middle aged patients, men and in the Northern region (48.6%). Conclusions: There is considerable regional variation in treatment patterns. The proportion of hypertensive patients under monotherapy is still very high. Increasing the use of combination antihypertensive therapy would probably improve HT control in the population. Furthermore, increased use of CCBs would probably also be useful, as they are used than would be expected, compared to other European countries.

Association between red blood cell distribution width and outcomes at six months in patients with acute coronary syndromes.

Abstract: Background: Higher values of red cell distribution width (RDW) may be associated with adverse outcomes in patients with heart failure and in those with stable coronary artery disease. We assessed the hypothesis that higher RDW values are associated with adverse cardiovascular outcomes in patients with acute coronary syndromes (ACS). Methods : We studied 1796 patients with ACS admitted to a coronary care unit. We analyzed clinical and laboratory characteristics, management, and outcomes of patients according to tertiles of baseline RDW. The primary outcome was death or myocardial infarction (MI) during six-month follow-up. Results : Patients with higher RDW values tended to be older, were more likely to be female and have a history of MI, and more often had renal dysfunction, anemia, and Killip class >I on admission (p<0.05). Higher RDW values were associated with increased 6-month mortality (tertile 1: 8.2%; tertile 2: 10.9%; tertile 3: 15.5%; p=0.001 for trend) and increased 6-month death/MI rates (tertile 1, 13.0%; tertile 2, 17.2%; tertile 3, 22.9%; p<0.0001 for trend). An association between higher RDW and increased 6-month death/MI rates was found in patients with non-ST-elevation ACS (10.5% vs. 15.3% vs. 22.7%; p<0.001 for trend), with a tendency in

Definition of hypertension: the impact of number of visits for blood pressure measurement.

Abstract: Introduction: A diagnosis of hypertension should be based on multiple blood pressure (BP) measurements, taken on at least two separate occasions We aimed to assess the impact of considering different criteria for a definition of hypertension, based on number of visits for blood pressure measurement, on estimates of hypertension prevalence, awareness, treatment and control, and on its association with two variables definitely related to hypertension: body mass index and left ventricular hypertrophy Methods: We used data from a cross-sectional study of 739 participants, aged ≥45 years, randomly selected from a non-institutionalized Portuguese population, from January 2001 to December 2003 Main outcome measures were prevalence of hypertension (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or current antihypertensive drug therapy) based on BP measurements on one visit, on BP measurements on a second visit or on fulfilling the same criteria on the two different visits Results: Estimated hypertension prevalence was 634% (95% CI:598-669) using BP measurements from the first visit (HTN 1 ) and 602% (95% CI: 566-638) using BP measurements from the second visit (HTN 2 ) If both visits are used as criteria the estimated hypertension prevalence (HTN Final ) was 563% (95% CI: 527-600), p (McNemar test) <0001, between HTN 1 and HTN Fina and between HTN 2 and HTN Final Awareness, treatment and control changed from 602% to 644%, 531% to 598% and 249% to 220%, respectively, when using information from the first or both visits All three different estimates of hypertension prevalence have a similar strong and independent association with body mass index (OR=271 for body mass index ≥30 with HTN Final ) and with left ventricular hypertrophy (OR=321 for HTN Final with left ventricular hypertrophy) Discussion and Conclusions: In many individuals labeled as hypertensive on a single evaluation, hypertension was not confirmed on reassessment, leading to a significant overestimation of 126% of the true prevalence For this reason BP should be measured on at least two office visits both for clinical purposes and in epidemiological studies On the other hand, this did not reflect on the association between hypertension and body mass index or left ventricular hypertrophy, suggesting that unconfirmed cases do not necessarily imply misclassification

Air pollution and cardiovascular disease.

Abstract: Air pollution is associated with increased cardiovascular morbidity and mortality. Recent experimental and epidemiologic studies show that particulate matter (PM) air pollution with PM10 or inhalable (thoracic) particles (mean aerodynamic diameter < 10 microm) is most consistently linked with acute and chronic cardiovascular effects. Fine (PM2.5) and ultrafine (PM0.1) particles (aerodynamic diameter < 2.5 and < 0.1 microm) are able to reach the small airways and terminal alveoli, and PM0.1 can also be translocated directly into the systemic circulation. PM2.5 and PM0.1 are mainly formed by fossil fuel combustion and are the main components of exhaust emissions from motor vehicles. A variety of biological mechanisms responsible for adverse cardiovascular outcomes associated with PM have been described, including the release of pro-oxidative and pro-inflammatory mediators from the lungs into the circulation, autonomic nervous system imbalance, and the direct actions on the heart and vasculature of ultrafine particles translocated into the systemic circulation. The induction of oxidative stress by these particles may be central to all of these putative pathways that trigger coagulation and thrombosis, increased heart rate and reduced heart rate variability, endothelial dysfunction, arterial vasoconstriction, apoptosis, and hypertension. In chronic exposures these alterations favor the development and progression of atherosclerosis and possibly of hypertension in the long term, and in the short term acute exposures contribute to plaque instability, affect various traditional risk factors and trigger acute cardiovascular events (myocardial ischemia and infarction, stroke, heart failure, arrhythmias, and sudden death), particularly in high-risk subjects. There are currently also significant concerns with the risks of engineered nanoparticles.

Endothelial function and atherosclerosis: circulatory markers with clinical usefulness.

Abstract: The healthy endothelium secretes and expresses at the surface various molecules which help maintain vascular wall structure and vascular homeostasis, as well as regulating vascular tone and leukocyte traffic. In response to various aggressive stimuli, the endothelial cell modulates its properties to restore vascular homeostasis. Usually, changes in the endothelial cell phenotype are transient and do not compromise the subsequent re-establishment of endothelial function. However, in certain pathological conditions, such as atherosclerosis, endothelial function is chronically disturbed, and this alteration is a critical step in the progression of the disease. In recent years, advances in knowledge have improved our understanding of the physiopathology of atherosclerosis, which is now known to be a dynamic and progressive process proceeding from endothelial dysfunction and inflammation of the vascular wall. The evolution and prognosis of atherosclerosis, along with the efficacy of therapeutic modalities, can be assessed by measuring the circulating levels of various biomarkers expressed or released by the endothelium. The purpose of this review is to reappraise the evidene concerning endothelial function under physiological conditions and in atherosclerosis, and to analyze markers of endothelial function with clinical applicability.

Redes de colaboración científica internacional en tabaquismo: análisis de coautorías mediante el Science Citation Index durante el periodo 1999-2003

Abstract: Objetivo: El objetivo de este trabajo fue establecer los patrones de colaboracion cientifica internacional y la visibilidad que genera la coautoria de articulos sobre tabaquismo en relacion a paises, a traves del Science Citation Index-Expanded (SCI-Expanded) en el periodo de 1999 a 2003. Material y metodos: Se seleccionaron los articulos de colaboracion sobre tabaquismo entre paises en SCI-Expanded (1999-2003). Se analizaron las redes de colaboracion subyacente entre paises, comparando su productividad (numero de articulos producidos), su visibilidad (numero de citas recibidas) y centralidad (grado nodal, intermediacion y proximidad). Resultados: Se recuperaron 3.484 articulos en los que habian participado 5.008 instituciones de 79 paises. Reino Unido fue el mas productivo, seguido de Alemania y Francia. Reino Unido fue, asimismo, el pais que publico mas articulos (570) de colaboracion interinstitucional, seguido de Estados Unidos y Alemania. Sin embargo, Estados Unidos fue el que publico mas articulos en colaboracion internacional, seguido de Reino Unido y Francia. Todos los paises recibieron mas citas por sus articulos de colaboracion interinstitucional o internacional que por los publicados sin ningun tipo de colaboracion. Las redes de colaboracion se encuentran completamente conectadas en un unico componente, y el aumento que experimenta anualmente el tamano de estas redes entre paises se realiza a expensas de paises nuevos en la periferia de la red. Conclusion: Existe una correlacion positiva entre la colaboracion internacional e interinstitucional y el numero de citas que recibe un articulo. La citacion de articulos se mantiene constante a lo largo del periodo analizado.

Effects of aging on lung function. A comparison of lung function in healthy adults and the elderly.

Abstract: Introduction The respiratory system changes with age and understanding these changes helps detect and prevent respiratory dysfunctions in the elderly. Aims This study compares the respiratory pattern in healthy non-smoker adults and the elderly, using lung function testing and expansion of the chest to confirm the effects of aging on lung function. Methodology We used lung function testing to measure forced vital capacity, forced expiratory volume in one second, peak expiratory flow rate and maximum voluntary ventilation. We also measured expansion of the chest. Measurements were taken with subjects resting in the dorsal recumbent position with upper body elevated to 45°. Statistical analysis consisted of the Student T test for independent samples, the non-parametric Mann-Whitney test with a p Our population consisted of 35 elderly subjects and 35 adults. 15 of the elderly subjects were male (43%) and 20 female (57%). 16 of the adult group were male (46%) and 19 female (54%). The sample was mapped in terms of age, weight, height, abdominal girth and clinical data, to exclude factors which could distort the results. Results The difference between the two study groups attained statistical significance for all parameters measured. The linear relationship was also significant between age and all parameters and a negative and significant correlation was seen. Expansion of the chest in females was the parameter most inversely correlated with age (60.37%). The lung function testing variable with the greatest difference between the groups was peak expiratory flow rate (35.77% in females and 36.17% in males). Conclusions Our results show differences in the respiratory patterns of healthy adults and the elderly, suggesting that age impacts on lung function. Both male and female elderly subjects had lower lung function testing scores than the adult subjects, with this difference more marked in females.

Blood pressure distribution of a sample of healthy Portuguese children and adolescents: the AVELEIRA registry.

Abstract: INTRODUCTION The distribution of blood pressure in Portuguese children and adolescents remains relatively unknown. Given the prevalence of hypertension in Portugal and the epidemiological trends for most cardiovascular diseases, it is important to ascertain blood pressure distribution at young ages, which constitutes the main objective of this registry. METHODS A sample of 1618 children and adolescents from the Central region of Portugal was included in this survey. The sample's mean age was 12.98 +/- 3.12 years (range: 5-18 years), body mass index 19.85 +/- 3.55 (range: 12.71-38.46); 1438 were male, mean age 12.39 +/- 3.35 years, and 180 female, mean age 13.05 +/- 3.07 years. Blood pressure and heart rate were measured three times after a 10-minute resting period. The measurements were performed with a validated automatic blood pressure monitor (Colson MAM BP 3AA1-2; Colson, Paris) and with an appropriately sized cuff over the brachial artery. All subjects were involved in amateur sports, with 80% of the sample beginning their activity at the time of evaluation. RESULTS The overall prevalence of hypertension was 9.8%, and high-normal blood pressure was found in 18.2%. Hypertension prevalence was higher in females (15.0% vs. 9.1% in males; p < 0.05). Comparison between registered athletes and subjects beginning their sports activity revealed similar hypertension prevalence (9.1% vs. 9.9% respectively; p = NS). Obesity was found in 5.3%, 3.9% in females and 5.5% in males. The prevalence of hypertension was greater in obese subjects (23%) than in overweight (14%) and normal weight (8%) subjects, clearly suggesting a relation between weight profile and blood pressure levels. CONCLUSIONS Our results reveal that a significant proportion of the children studied have blood pressure levels above the 90th percentile, with an overall prevalence of hypertension of 9.8%, more pronounced in females and related to overweight. The implications of these observations are even more important when we consider the epidemiology of hypertension in Portugal and its link with stroke as the leading cause of death and disability.

Consumo de tabaco na população portuguesa retratado pelo Inquérito Nacional de Saúde (2005/2006)

Abstract: Resumo O presente estudo visa contribuir para o conhecimento da epidemiologia da exposicao ao tabaco na populacao portuguesa, atraves da analise de dados do Inquerito Nacional de Saude realizado entre 2005 e 2006. Neste trabalho, a populacao portuguesa e caracterizada quanto a prevalencia de fumadores, ex-fumadores e nao fumadores e quanto a exposicao e atitudes face ao fumo do tabaco. Algumas destas caracteristicas sao desagregadas por variaveis sociodemograficas, como o sexo, a idade e a regiao de residencia. As frequencias apresentadas expressam valores estimados para a populacao residente em Portugal no ano de 2005. Atraves de regressao logistica binaria construiram-se perfis dos fumadores. Os resultados revelaram que 20,9% da populacao com 15 e mais anos de idade, residente em Portugal (incluindo as regioes autonomas), era fumadora a data da entrevista (sexo masculino: 30,9%; sexo feminino: 11,8%) e que 18,7% fumava diariamente. Mais de metade dos homens fumava, ou ja tinha fumado (56,9%), ao contrario das mulheres que, na grande maioria, nunca tinha fumado (81,3%). Apos remocao do efeito ocasionado pela diferente estrutura etaria, as prevalencias mais elevadas de homens que fumavam diariamente foram observadas nos Acores (31,0%) e no Alentejo (29,9%). Ja entre as mulheres, a prevalencia mais elevada de consumo diario de tabaco ocorreu na regiao de Lisboa e Vale do Tejo (15,4%), seguida do Algarve (12,8%). Em media, os homens fumavam mais cigarros por dia (20 cigarros) do que as mulheres (13 cigarros). A populacao acoriana evidenciou os consumos medios diarios mais elevados (homens: 23 cigarros; mulheres: 16 cigarros). Rev Port Pneumol 2009; XV (6): 1005-1027

Effectiveness and safety of levosimendan in clinical practice.

Abstract: Background In previous randomized studies levosimendan improved hemodynamics and clinical course, with a still unclear effect on prognosis. There are, however, few data regarding its effects when used in daily practice. Aims We evaluated the clinical effectiveness and safety of levosimendan in the treatment of acute systolic heart failure (SHF) in daily practice conditions. Methods In this prospective, multicenter, nonrandomized trial, a continuous infusion of levosimendan (0.05 microg/kg/min-0.2 microg/kg/min) was administered for 24 hours. An optional loading dose of 12 microg/kg over 10 minutes was used. The primary combined endpoint of clinical effectiveness (as defined by a eight-variable clinical score) and safety (defined by the absence of serious adverse events) was assessed at 24 hours after the beginning of treatment; a second similar primary combined endpoint was assessed at 5 days. Results One hundred and twenty-nine consecutive patients requiring inotropes despite optimal oral background heart failure therapy were recruited. The primary endpoint was reached in 80.6% at 24 hours and in 79.7% at 5 days. During the six months before levosimendan the number of patient days of hospitalization for heart failure was 14.9 +/- 14.6 versus 3.1 +/- 7.6 during the six months following levosimendan (p Conclusions In daily practice, levosimendan was clinically effective and safe in 80.6% and 79.7% of patients with acute SHF at 24 hours and 5 days respectively after the beginning of treatment. A marked reduction in the number of days of hospitalization for heart failure was also seen during the subsequent six months.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Abstract: Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modem approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECC of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and ardiovascular management of the athlete are briefly addressed.

Primary cardiac tumors in children: a 16-year experience

Abstract: Introduction Primary cardiac tumors are rare in children. The majority are benign and noninvasive, although they may have significant hemodynamic consequences depending on their location. The most frequent type in children is rhabdomyoma, usually multiple and intraventricular. Objectives To assess the presentation and outcome of patients with cardiac tumors followed by the Department of Pediatric Cardiology of Hospital de Santa Cruz. Methods A retrospective analysis was performed of the clinical records of patients diagnosed with primary cardiac tumors between January 1992 and March 2008. Results Eleven children with a diagnosis of primary cardiac tumor were identified, three of them detected antenatally. In the remaining cases, median age at diagnosis was 27.5 months, ranging from two days to 13 years. Seven (64%) were male. In three cases diagnosis was made during fetal echocardiography, and in the others by transthoracic echocardiogram. In six patients magnetic resonance imaging was used to confirm the diagnosis. All were benign (eight rhabdomyomas, one papillary fibroelastoma, one myxoma and one pericardial tumor with histological features of Castleman disease). Six patients were asymptomatic at the time of diagnosis; two cases presented with arrhythmias; one with heart failure; and two were diagnosed following stroke, one with right hemiparesis, and the other with paresthesias of the lip and fingers of the right hand. In four cases there was total or partial tumor regression. Surgery was performed in four patients, due to tumor location and/ or significant left ventricular outflow tract obstruction. One of these patients died following surgery due to multiorgan system failure. Final remarks Primary cardiac tumors are uncommon in children. Their treatment depends mainly on location and histological type. The most serious complications are ventricular outflow tract obstruction and thromboembolic events, which are associated with a poor prognosis even when surgery is attempted.

Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain

Abstract: Objectives: This study was designed to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain. Background: Triage of chest pain patients in the emergency department remains challenging. Methods: We used an observational cohort study in chest pain patients with normal initial troponin and nonischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up. Results: Among 368 patients (mean age 53 ± 12 years, 61% men), 31 had ACS (8%). By coronary CTA, 50% of these patients were free of coronary artery disease (CAD), 31% had nonobstructive disease, and 19% had inconclusive or positive computed tomography for significant stenosis. Sensitivity and negative predictive value for ACS were 100% (n = 183 of 368; 95% confidence interval [CI]: 98% to 100%) and 100% (95% CI: 89% to 100%), respectively, with the absence of CAD and 77% (95% CI: 59% to 90%) and 98% (n = 300 of 368, 95% CI: 95% to 99%), respectively, with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95% CI: 49% to 60%) and 87% (95% CI: 83% to 90%), respectively. Only 1 ACS occurred in the absence of calcified plaque. Both the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to Thrombolysis In Myocardial Infarction risk score (area under curve: 0.88, 0.82, vs. 0.63, respectively; all p < 0.0001). Conclusions: Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.

Carga da doença atribuível ao tabagismo em Portugal

Abstract: Resumo A Organizacao Mundial de Saude (OMS) estimou no seu relatorio de 2002 que cerca de 14% da carga da doenca nos paises mais ricos seja atribuivel ao consumo de produtos de tabaco. As doencas mais relacionadas com o consumo de tabaco incluem um conjunto de doencas cardiovasculares, neoplasias e doencas respiratorias. Este artigo estima a carga da doenca atribuivel ao tabaco em Portugal, tomando como base os dados das estatisticas demograficas e de saude disponiveis para Portugal em 2005. A conclusao final da analise e que 11,7% das mortes em Portugal se podem atribuir ao consumo de tabaco. Se medirmos a carga da doenca atraves dos anos de vida ajustados por incapacidade – disability adjusted life years (DALY) gerados pela mortalidade, as proporcao da carga da doenca atribuivel ao tabaco e 11,2%. A divisao entre sexos e muito desigual, ja que 15,4% da carga da doenca masculina e 17,7% das mortes sao atribuiveis ao tabaco, mas apenas 4,9% da carga da doenca feminina e 5,2% das mortes. Estes numeros para a mortalidade atribuivel sao mais elevados do que as estimativas anteriormente disponiveis para Portugal (Peto et al. 2006), as quais apontavam para 14% das mortes masculinas e apenas 0,9% das femininas. O artigo apresenta estimativas sobre a carga da doenca redutivel, ou seja, as reducoes de mortalidade e DALY que ocorreriam se os fumadores abandonassem o tabagismo e passassem a experimentar o risco medio das populacoes de ex-fumadores, o qual e superior ao dos nunca fumadores mas inferior ao dos fumadores. As estimativas sao que a carga da doenca medida pelos DALY se reduziria em 5,8% (7,8% dos homens e 2,8% das mulheres) e que as mortes se reduziriam em 5,8% (8,5% homens e 2,9% mulheres). O artigo inclui igualmente estimativas dos DALY perdidos por incapacidade. As doencas relacionadas com o tabagismo geraram 121 643 DALY, dos quais 72 126 (59%) sao atribuiveis ao tabagismo e 12 417 (10%) sao redutiveis. Rev Port Pneumol 2009; XV (6): 951-1004

Cardiac troponin I levels in acute pulmonary embolism.

Abstract: OBJECTIVE Estimation of individual risk and choice of initial therapeutic approach for patients with pulmonary embolism (PE) remains controversial. The three key components for risk stratification in PE are clinical evaluation, cardiac biomarkers and assessment of right ventricular size and function. The aim of this study was to assess the ability of admission troponin I (TnI) levels to predict short-term mortality and complicated clinical course in patients with PE. METHODS We performed a retrospective analysis of 100 consecutive patients admitted with a diagnosis of PE between January 2004 and November 2007. Patients in whom the diagnosis was confirmed by spiral computed tomography, ventilation perfusion scan, pulmonary angiography or echocardiography and with serum TnI measurement in the first 24 hours of hospital stay were selected. The study population (n = 62) was divided into two groups according to the presence or absence of elevated TnI levels (TnI > or = 0.10 ng/ml). Clinical characteristics, electrocardiographic and echocardiographic signs of right ventricular dysfunction (RVD), brain natriuretic peptide (BNP) levels, in-hospital mortality and the composite endpoint of complicated PE (defined as the presence of at least one of the following: in-hospital death, cardiogenic shock, need for mechanical ventilation or inotropic support) were compared between groups. RESULTS Thirty-seven patients (59.7%) had elevated TnI levels (Tpos) and 25 (40.3%) had normal levels (Tneg). The two groups were not significantly different (p = NS) in age (66.2 vs. 71 years), gender (female 70.3 vs. 60.0%), clinical presentation or length of hospital stay (14.7 vs. 18.1 days). Tpos patients had a higher prevalence of electrocardiographic signs of RVD (78.4 vs. 40.0%, p < 0.01). Echocardiographic RVD was also more common in the Tpos group but the difference did not reach statistical significance (56.0% vs. 27.3%, p = NS). Elevated serum TnI was significantly associated with complicated in-hospital clinical course (complicated PE: 29.7% in the Tpos group vs. 4.0% in the Tneg group (adjusted OR = 9.08; 95% CI 1.07-77.4; p = 0.044). In-hospital mortality was 8.1%, with a strong trend for higher mortality in the Tpos group (13.5% vs. 0%, p = 0.055). CONCLUSIONS Elevated TnI levels are associated with higher risk for in-hospital mortality and complicated clinical course. Additional studies are needed to assess whether troponin levels, alone or in conjunction with other tests, can be used to guide therapeutic strategy and improve the prognosis of patients with PE.

The methylenetetrahydrofolate reductase gene variant (C677T) as a susceptibility gene for tetralogy of Fallot.

Abstract: The aim of this study was to evaluate whether the cytosine-to-thymine mutation at base 677 of the methylenetetrahydrofolate reductase gene (MTHFR C677T), which has been associated with neural tube defects and congenital oral cleft, is also associated with tetralogy of Fallot (TF), a congenital heart disease. The MTHFR C677T genotype was investigated in a sample of 38 children born with TF who underwent surgical repair in early life. Two hundred and fifty-one healthy individuals were included as controls for allele and genotype frequencies. We found a higher prevalence of the T allele in TF compared to the control group (OR = 1.675; 95% CI [1.022-2.743]; p = 0.05). The TT genotype increased by 4.856 the risk for this congenital disease (95% CI 1.308 12.448; p = 0.028). Our results suggest that MTHFR polymorphism can be considered a susceptibility gene for this congenital heart disease.

Lower lung field tuberculosis

Abstract: Lower lung lobe tuberculosis is less common than the classical radiological forms of pulmonary tuberculosis. However this radiological presentation has a particular relevance in patients with some associated pathological conditions, such as diabetes mellitus, HIV infection and chronic alcoholism. We make a review of this entity in reference to an illustrative clinical case.

Reclassifying bronchial-pulmonary carcinoma: Differentiating histological type in biopsies by immunohistochemistry

Abstract: The current state of molecular knowledge on lung cancer demands a histological classification which goes beyond small-cell and non-small-cell carcinoma to provide support for tailored therapy in aiding in understanding of the drugs currently available. As diagnosis and follow-up in the vast majority of lung cancer cases is based on biopsies and cytology samples, Immunohistochemical Bronchial Pulmonary Carcinoma Classification (IBPCC) is necessary to reveal the raft of characteristics available. This provides morphological support for the WHO's 1999/2004 classification, in addition to an understanding of carcinogenesis. The immunohistochemical panel clarifies the main morphology and cytology characteristics to maintain the leading histological types as squamous cell carcinoma (high weight molecular cytokeratins/HWMC), adenosquamous carcinoma (CK7, TTF1, HWMA), neuroendocrine carcinoma (Chrg, Syn, CD56, TTF1, Ki67), adenocarcinoma (CK7, CK20, TTF1) and bring the polymorphic and pleomorphic carcinomas under a single banner of pleomorphic carcinoma (Ck7, TTF1, HWMC, VMT, Desmin, Actin) which shelters large cell carcinomas and sarcomatoid carcinomas. Lung cancer chemotherapy will still be based on platinum and gemcitabine for the near future and the IBPCC is a simple and efficient tool for streamlining the registration of lung cancer histological characteristics in biopsies and other reduced samples to support clinical evidence and trials.

Liver transplantation for neurologic Wilson´s Disease: reflections on two cases within a Mexican cohort

Abstract: 1Zepeda-Gomez S, 1 Garcia-Leiva J, 1 Remes-Troche JM, 1 Angeles-Angeles A, 2 Torre-Delgadillo A, 2

A 4-year trial of tiotropium in chronic obstructive pulmonary disease (UPLIFT trial).

Abstract: N Engl J Med 2008; 359:1543-54. Introducao Nestes dois ultimos anos foram publicados os resultados dos dois maiores estudos na area da DPOC, o TORCH e o UPLIFT. Ambos com cerca de 6000 doentes e com a duracao, respectivamente, de tres e quatro anos. Os objectivos eram muito altos: reducao da mortalidade e reducao/modificacao da taxa de declinio do FEV1 na DPOC. Se em ambos o objectivo primario nao foi atingido, e certo que, apos estes resultados, outras e muito importantes informacoes clinicas se obtiveram (objectivos secundarios) e muito da nossa pratica clinica, e dos paradigmas como encaramos a DPOC, irao mudar.