Caso Clínico da Semana 1 - by Fábio Soares

Megalacínea Mitral - by Fábio Soares

Drauzio Varela - Médicos x Planos de Saúde

Médicos que vivem da clínica particular são aves raríssimas. Mais de 97% prestam serviços aos planos de saúde e recebem de R$ 8 a R$ 32 por consulta. Em média, R$ 20.

Os responsáveis pelos planos de saúde alegam que os avanços tecnológicos encarecem a assistência médica de tal forma que fica impossível aumentar a remuneração sem repassar os custos para os usuários já sobrecarregados. Os sindicatos e os conselhos de medicina desconfiam seriamente de tal justificativa, uma vez que as empresas não lhes permitem acesso às planilhas de custos.

Tempos atrás, a Fipe realizou um levantamento do custo de um consultório-padrão, alugado por R$ 750 num prédio cujo condomínio custasse apenas R$ 150 e que pagasse os seguintes salários: R$ 650 à atendente, R$ 600 a uma auxiliar de enfermagem, R$ 275 à faxineira e R$ 224 ao contador. Somados os encargos sociais (correspondentes a 65% dos salários), os benefícios, as contas de luz, água, gás e telefone, impostos e taxas da prefeitura, gastos com a conservação do imóvel, material de consumo, custos operacionais e aqueles necessários para a realização da atividade profissional, esse consultório-padrão exigiria R$ 5.179,62 por mês para sua manutenção.

Voltemos às consultas, razão de existirem os consultórios médicos. Em princípio, cada consulta pode gerar de zero a um ou mais retornos para trazer os resultados dos exames pedidos. Os técnicos calculam que 50% a 60% das consultas médicas geram retornos pelos quais os convênios e planos de saúde não desembolsam um centavo sequer.

Façamos a conta: a R$ 20 em média por consulta, para cobrir os R$ 5.179,62 é preciso atender 258 pessoas por mês. Como cerca de metade delas retorna com os resultados, serão necessários: 258 + 129 = 387 atendimentos mensais unicamente para cobrir as despesas obrigatórias. Como o número médio de dias úteis é de 21,5 por mês, entre consultas e retornos deverão ser atendidas 18 pessoas por dia! Se ele pretender ganhar R$ 5.000 por mês (dos quais serão descontados R$ 1.402 de impostos) para compensar os seis anos de curso universitário em tempo integral pago pela maioria que não tem acesso às universidades públicas, os quatro anos de residência e a necessidade de atualização permanente, precisará atender 36 clientes todos os dias, de segunda a sexta-feira. Ou seja, a média de 4,5 por hora, num dia de oito horas ininterruptas.

Por isso, os usuários dos planos de saúde se queixam: "Os médicos não examinam mais a gente"; "O médico nem olhou a minha cara, ficou de cabeça baixa preenchendo o pedido de exames enquanto eu falava”; "Minha consulta durou cinco minutos". É possível exercer a profissão com competência nessa velocidade? Com a experiência de quem atende doentes há quase 40 anos, posso garantir-lhes que não é. O bom exercício da medicina exige, além do exame físico cuidadoso, observação acurada, atenção à história da moléstia, à descrição dos sintomas, aos fatores de melhora e piora, uma análise, ainda que sumária, das condições de vida e da personalidade do paciente. Levando em conta, ainda, que os seres humanos costumam ser pouco objetivos ao relatar seus males, cabe ao profissional orientá-los a fazê-lo com mais precisão para não omitir detalhes fundamentais. A probabilidade de cometer erros graves aumenta perigosamente quando avaliamos quadros clínicos complexos entre dez e 15 minutos.

O que os empresários dos planos de saúde parecem não enxergar é que, embora consigam mão-de-obra barata - graças à proliferação de faculdades de medicina que privilegiou números em detrimento da qualidade -, acabam perdendo dinheiro ao pagar honorários tão insignificantes: médicos que não dispõem de tempo a "perder" com as queixas e o exame físico dos pacientes, pedem exames desnecessários. Tossiu? Raios X de tórax. O resultado veio normal? Tomografia computadorizada. É mais rápido do que considerar as características do quadro, dar explicações detalhadas e observar a evolução. E tem boa chance de deixar o doente com a impressão de que está sendo cuidado.

A economia no preço da consulta resulta em contas astronômicas pagas aos hospitais, onde vão parar os pacientes por falta de diagnóstico precoce, aos laboratórios e serviços de radiologia, cujas redes se expandem a olhos vistos pelas cidades brasileiras. Por essa razão, os concursos para residência de especialidades que realizam procedimentos e exames subsidiários estão cada vez mais concorridos, enquanto os de clínica e cirurgia são desprestigiados.

Aos médicos, que atendem a troco de tão pouco, só resta a alternativa de explicar à população que é tarefa impossível trabalhar nessas condições e pedir descredenciamento em massa dos planos que oferecem remuneração vil. É mais respeitoso com a medicina procurar outros meios de ganhar a vida do que universalizar o cinismo injustificável do "eles fingem que pagam, a gente finge que atende".

O usuário, ao contratar um plano de saúde, deve sempre perguntar quanto receberão por consulta os profissionais cujos nomes constam da lista de conveniados. Longe de mim desmerecer qualquer tipo de trabalho, mas eu teria medo de ser atendido por um médico que vai receber bem menos do que um encanador cobra para desentupir o banheiro da minha casa. Sinceramente.

Fonte: site do Drauzio Varella

Médicos versus planos de saúde
www.drauziovarella.com.br
Dr. Drauzio Varella - Site Oficial

Blog de Eletrocardiografia - DR. NESTOR RODRIGUES DE OLIVEIRA NETO

Para os interessados nos mistérios do ECG, recomendo o excelente Blog de Eletrocardiografia do Dr. Netor Rodrigues de Oliveira Neto.

http://tracadosdeecg.blogspot.com/

ATUALIZAÇÃO: REPOLARIZAÇÃO PRECOCE

A repolarização precoce é uma alteração presente em indivíduos com coração estruturalmente normal, sendo mais comum em homens jovens, principalmente nos predipostos à vagotonia. Se apresenta como elevação rápida do segmento ST, com pequena concavidade superior, geralmente associado a ondas T proeminentes, e assimétricas. Pode existir um entalhe característico no final do QRS, chamado ondas J (semelhantes às ondas J vistas na hipotermia).

Embora considerada tradicionalmente como uma alteração benigna, estudos recentes têm pontuado que a repolarização precoce nem sempre é uma condição benigna e, pelo menos em alguns casos, está associado com morte súbita por fibrilação ventricular primária. A presença de repolarização precoce nas derivações inferolaterais estariam associados a maior risco. Um estudo mostrou que a elevação do ponto J é mais frequente em indivíduos com FV idiopática quando comparado com controles (N Engl J Med. 2008 May 8;358(19):2016-23; J Am Coll Cardiol. 2008 Oct 7;52(15):1231-8).

O estudo de maior impacto sobre o risco de morte súbita associado a repolarização precoce é o de Haissaguerre et al, publicado em 2008: Haïssaguerre M et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med. 2008 May 8;358(19):2016-23).

O editorial seguinte:

"ECG Phenomena of the Early Ventricular Repolarization in the 21 Century" (Indian Pacing and Electrophisiology 2008) está disponível no link abaixo:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2490813/pdf/ipej080149-00.pdf

Caso da semana 1- CIV pós IAM - by Fábio Soares

- Ruptura septal ventricular (VSR) é uma complicação rara mas fatal de infarto do miocárdio (IM). O evento costuma ocorrer 2 a 8 dias após um infarto e precipita frequentemente o choque cardiogênico.

- Embora os estudos de autópsia revelem uma taxa de incidência de 11% de ruptura da parede livre do miocárdio após IAM, a perfuração da parede do septo é muito menos comum, ocorrendo a uma taxa de cerca de 1-2%.

- Fatores de risco para ruptura septal incluem idade avançada (> 65 anos), sexo feminino, doença uniarterial, IAM extenso, e pobre circulação colateral septal. [18, 19]

- Antes do advento dos trombolíticos, hipertensão e ausência de história de angina eram fatores de risco para o CIV. Comprometimento do VD também é considerado fator de risco para a ruptura do septo.

Birnbaum Y, Wagner GS, Gates KB, Thompson TD, Barbash GI, Siegel RJ, et al. Clinical and electrocardiographic variables associated with increased risk of ventricular septal defect in acute anterior myocardial infarction. Am J Cardiol. Oct 15 2000;86(8):830-4.

 

- Aproximadamente 60% das rupturas do septo ocorrem no infarto da parede anterior, 40% ocorrem no infarto da parede posterior ou inferior. CIV posterior pode ser acompanhada de insuficiência mitral secundária a infarto do músculo papilar ou disfunção do músculo subjascente.

- Rupturas septais são mais comuns em pacientes com grandes infartos anteriores devido à oclusão da artéria DA. Estes infartos estão associados com elevação do segmento ST e ondas Q nas derivações inferiores (II, III, aVF) e essas são, portanto, as alterações no ECG mais comumente encontradas. Essas rupturas são geralmente apicais e simples.

Hayashi T, Hirano Y, Takai H, Kimura A, Taniguchi M, Kurooka A. Usefulness of ST-segment elevation in the inferior leads in predicting ventricular septal rupture in patients with anterior wall acute myocardial infarction. Am J Cardiol. Oct 15 2005;96(8):1037-41

- Rupturas septais em pacientes com infarto inferior ocorrem masi raramente. Essas rupturas envolvem o porção basal da parede ínfero-septal e são frequentemente complexas.

Skehan JD, Carey C, Norrell MS, de Belder M, Balcon R, Mills PG. Patterns of coronary artery disease in post-infarction ventricular septal rupture. Br Heart J. Oct 1989;62(4):268-72.

Educação... Saúde... Respeito...

Cardiomiopatia Hipertrófica - by Fábio Soares

Anatomic and clinical correlates of septal morphology in hypertrophic cardiomyopathy

 

Aslan T. Turer1*, Zainab Samad2, Anne Marie Valente3, Michele A. Parker2, Brenda Hayes2, Raymond J. Kim2, Joseph Kisslo 2, and Andrew Wang2

1Division of Cardiology, Department of Medicine, University of Texas-Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390-9047 USA; 2Division of Cardiovascular Medicine, Duke University Medical Center, Durham, NC, USA; and 3Children’s Hospital Boston, Department of Cardiology, Harvard Medical School, Boston, MA, USA

Received 8 February 2010; revised 10 August 2010; accepted after revision 10 September 2010; online publish-ahead-of-print 1 November 2010

Aim: The presence of septal hypertrophy in hypertrophic cardiomyopathy (HCM) is common. To date, there has been no accepted classification of septal morphology in HCM. Furthermore, the possible relationship between septal morphology and clinical features of HCM is undefined.

Methods and results: Seventy-five consecutive adult patients with HCM were enrolled. Septal morphologies were retrospectively categorized into one of four patterns of hypertrophy based on transthoracic echocardiography. Left ventricular diastolic function by Doppler echocardiography and late gadolinium enhancement (LGE) by magnetic resonance imaging were assessed in all patients. Patients were followed for a mean of 45+32 months. Catenoid septum was the most common morphologic subtype (46 of 75, 61%), followed by simple sigmoid (22 of 75, 29%), neutral (4 of 75, 5%), and apical (3 of 75, 4%). Inter-observer reproducibility of septal classifications was high (k ¼ 0.95). Patients with the catenoid subtype presented at a younger age, had worse diastolic function, and high rates of LGE. The presence of catenoid septal morphology was independently associated with LGE in multivariable logistic regression analysis. Implantable cardioverter-defibrillator implantation for prevention of sudden cardiac death occurred only in patients with this septal morphology.

Conclusion: We propose a simple, reproducible classification system of patterns of septal hypertrophy in HCM. These patterns of hypertrophy are associated with significant differences in clinical, haemodynamic, and myocardial characteristics. Further studies are needed to evaluate the relationship between septal morphology and outcome or response to therapies in HCM.

 

O papel do Ecocardiograma na Hipertensão Pulmonar - by Fábio Soares

Falando em limitações do ecocardiograma... recomendo a leitura deste artigo, o qual enviei por e-mail a todos do grupo Ecobahia. E não deixem de ler o editorial, muito bem escrito em anexo.

Inaccuracy of Doppler Echocardiographic Estimates of Pulmonary Artery Pressures in Patients With Pulmonary Hypertension Implications for Clinical Practice

Jonathan D. Rich , MD ; Sanjiv J. Shah , MD ; Rajiv S. Swamy , MD ; Anna Kamp , MD ; and Stuart Rich , MD , FCCP

Background: Recent studies suggest that Doppler echocardiography (DE)-based estimates of pulmonary artery systolic pressure (PASP) may not be as accurate as previously believed. We sought to determine the accuracy of PASP measurements using DE compared with right-sided heart catheterization (RHC) in patients with pulmonary hypertension (PH). 

Methods: We compared DE estimates of PASP to invasively measure PASP during RHC in 160 consecutive patients with PH (part one). To account for possible changes in hemodynamics between DE and RHC, we then prospectively determined PASP in an additional 23 consecutive patients undergoing simultaneous RHC and DE (part two). Bland-Altman analyses were performed to evaluate the agreement between RHC and DE measurements of PASP. Accuracy was predefi ned as 95% limits of agreement within 6 10 mm Hg for PASP estimates.

Results: In part one, there was moderate correlation between DE and RHC measurements of  PASP ( r 5 0.68, P , .001). However, using Bland-Altman analysis, the bias for DE estimates of PASP was 2.2 mm Hg with 95% limits of agreement ranging from 2 34.2 to 38.6 mm Hg. DE estimates of PASP were determined to be inaccurate in 50.6% of patients. In part two, there was moderate correlation between DE and RHC measurements of PASP ( r 5 0.71, P , .01). However, despite simultaneous DE and RHC measurements, the bias for DE estimates of PASP was 8.0 mm Hg  with 95% limits of agreement ranging from 2 28.4 to 44.4 mm Hg.

Conclusions: DE estimates of PASP are inaccurate in patients with PH and should not be relied on to make the diagnosis of PH or to follow the effi cacy of therapy. CHEST 2011; 139(5):988–993

Trecho do editorial: O papel do Ecocardiograma na Hipertensão Pulmonar - O óbvio precisa ser provado

In Greek mythology, Echo (Greek, x ώ ; Ēkhō ; Sound ) is a mountain nymph who loves her own voice. Although it is indeed beautiful, the voice of echocardiography is insuffi cient as a solo instrument used in the diagnosis of PAH. Common sense and the obvious, as defi ned by Aristotle 2,300 years ago, still deserve our respect, particularly in the current era of rapidly increasing complexity in medicine and science.

Ian Paterson , MD ; Evangelos D. Michelakis , MD Edmonton, AB, Canada

Musculatura Pectínea exuberante em AAE - by Fábio Soares

Os músculos pectíbeos são colunas musculares localizadas na superfície interna da aurícula direita e esquerda. Eles também percorrem a parede anterior do átrio adjacente. São chamados de músculos pectíneos por causa de sua suposta semelhança com um pente.

Placa aterosclerótica em aorta torácica descendente - by Fábio Soares

Prolapso da Valva Mitral e Aneurisma Mamilar Chagásico - by Fábio Soares

Associação rara de se ver...

Paródia do dia... Call Day (Rebecca Black Friday Parody)

"A melhor banda de todos os tempos da última semana", é assim que surgem e desaparecem os grandes hits da internet. Baseado em um "grande clássico" no mundo virtual, apresento-lhes Call Day!
Boa semana a todos

Luto pela saúde

Qual o diagnóstico? - by Fábio Soares

Paciente masculino, 57 anos, sem comorbidades previamente diagnosticadas. Qual o diagnóstico?

ECG e Terapia de Ressincronização Ventricular - by Fábio Soares

From Journal of Cardiovascular Electrophysiology

Reliability and Reproducibility of QRS Duration in the Selection of Candidates for Cardiac Resynchronization Therapy

Maxime De Guillebon, M.D.; Jean-Benoit Thambo, M.D.; Sylvain Ploux, M.D.; Antoine Deplagne, M.D.; Frederic Sacher, M.D.; Pierre Jais, M.D.; Michel Haissaguerre, M.D.; Philippe Ritter, M.D.; Jacques Clementy, M.D.; Pierre Bordachar, M.D

Background: A QRS >120 ms remains the recommended criterion for the selection of cardiac resynchronization therapy (CRT) candidates. However, the reproducibility of this measurement has not been studied thoroughly.

Methods: QRS duration was measured by 3 experienced cardiologists and by automatic measurement on 228 electrocardiograms (ECGs) randomly collected from 188 subjects, including neonates, healthy adults, patients with complete and incomplete bundle branch block, and CRT candidates. All ECGs were recorded at a 25 mm/s sweep speed. Forty recordings were duplicated and 50 ECGs were recorded at both 25 and 50 mm/s.

Results: Significant interobserver differences (P < 0.001) were found between each combination of paired observers, with an up to 50-ms absolute variability between cardiologists and low concordance with computerized measurements. Intraobserver absolute variability was also significant (P < 0.01) for the 3 observers. These significant differences persisted (P < 0.01) when focusing our interest on the ECGs in the 100–140 ms range (defined as at least one out of the 4 measures in this range). Considering the 120 ms limit, 22 (27.5%) ECGs were differently classified by at least one of the cardiologists. We observed similar interobserver differences between each combination of paired observers with a 50 mm/s sweep speed.

Conclusion: Manual QRS duration measurements were associated with significant inter- and intraobserver variability and low concordance with computerized measurements. The measurement of QRS is, therefore, operator-dependent and a reevaluation of the measurement methods may be essential to develop clinical and investigative standards.

New England Journal of Medicine - Clinical Practice Companion

O NEJM disponibilizou uma coletânea de artigos dos mais diversos campos da medicina, distribuídos em Prática Clínica, Terapêutica Clínica, Conceitos Atuais e Outros recursos. Encontra-se em formato e-book e pode ser baixado gratuitamente. Basta clicar no link abaixo e se cadastrar gratuitamente no site e baixar o arquivo.

Clinical Ptactice Companion

Boa leitura a todos. Abraço.
Fábio Soares

Para descontrair...

Anestesista x Ortopedista

Caso enviado por Dr. Leandro Serafim

Paciente masculino, 45 anos, sem comorbidades. Na falta de bebida gaseificada, foi água mesmo...



Estenose aórtica grave? - by Fábio Soares

SEAS data question definition of "severe" aortic stenosis when LVEF is normal

February 24, 2011 | Steve Stiles

Dallas, TX - A retrospective look at a prospective trial has raised questions about the echocardiographic criteria by which aortic-valve stenoses should classified as "severe," with all the implications for management, including surgery, the term implies [1].

Typically, either a small aortic-valve area (AVA) or a high transvalvular pressure gradient might point to severe stenosis; but what if AVA suggests severe stenosis while the gradient is low, especially in an asymptomatic patient with normal LV systolic function?

Such patients with "low-gradient 'severe' aortic-valve stenosis" aren't all that rare and have a prognosis similar to patients with aortic disease considered only moderate by echo criteria, Dr Nikolaus Jander (Herz-Zentrum Bad Krozingen, Germany) and colleagues observed based on their analysis of patients from the prospective Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study.

The findings are reassuring, given concerns that such low-pressure gradients may derive from reduced stroke volume and may therefore be a dire prognostic sign, as some reports have suggested, according to the group in their report published online February 14, 2011 in Circulation.

On the contrary, they conclude, low-gradient "severe" aortic stenosis, which they defined per guidelines as AVA <1.0 cm² with a mean transvalvular gradient <40 mm Hg, "in general does not indicate advanced aortic-valve disease. [The] indication for valve replacement may safely be restricted to those in whom symptoms can clearly be attributed to aortic stenosis."

In an accompanying editorial [2], Dr William A Zoghbi (Methodist DeBakey Heart and Vascular Center, Houston, TX) argues that—consistent with the SEAS analysis and unpublished data from his center—the 1.0-cm² AVA threshold should be lowered to more realistically reflect prognosis in such low-gradient, normal-LVEF patients.

"An overestimation of aortic-stenosis severity by [the] current AVA cutoff can have significant implications for management and possibly lead to earlier surgery than is optimal in patients with questionable symptoms," he writes.

"We know from the Jander study that if you don't have comorbidities, you're asymptomatic, and have this low-gradient 'severe' aortic stenosis and a normal ejection fraction, then the prognosis is similar to patients with moderate aortic stenosis," Zoghbi commented to heartwire.

The guidelines' 1.0-cm² AVA cutoff for severe disease, he said, comes from studies that were generally much smaller and less reliable than the current one. Based on the latter's stronger data, the guidelines for low-gradient, normal-LVEF patients with aortic stenosis should be "refined."

It would make greater sense, according to Zoghbi, to tighten the severe-stenosis AVA threshold to 0.8 cm², which would make AVA criteria consistent with hemodynamic definitions of severe stenosis.

SEAS had randomized >1800 patients with aortic stenosis to receive daily therapy with simvastatin 40 mg/ezetimibe 10 mg (Vytorin, Merck/Schering-Plough Pharmaceuticals) or placebo. As covered by heartwire, the combination drug significantly lowered LDL-cholesterol levels without significantly cutting the rate of major cardiovascular/aortic-valve events, the primary end point. The finding helped dash hopes that LDL-lowering therapy, especially with statins, might attenuate the progression of aortic stenosis. But the trial was at least as noteworthy for a public debate over whether ezetimibe may have increased the risk of cancer, which the FDA eventually concluded was unlikely.

The current analysis looked at the trial's 1525 asymptomatic patients with an LVEF >55% and either low-gradient "severe" or moderate (AVA 1.0-1.5 cm² and mean gradient 25-40 mm Hg) aortic stenosis at baseline echocardiography.

The patients with low-gradient "severe" aortic stenosis had greater LV mass at baseline, but the two groups were comparable in LV wall thickness. Clinical outcomes over the mean follow-up of nearly four years, especially for the primary end point of aortic-valve events (CV death, aortic-valve replacement, and heart failure due to aortic stenosis) were also comparable.

Baseline echocardiographic and follow-up (mean, 46 months) clinical outcomes, low-gradient "severe" vs moderate stenosis

Parameter	Low-gradient "severe" stenosisa, n=435	Moderate stenosisb, n=184	p
LV wall mass at baseline (g)	182.3	211.6	<0.01
LV wall thickness (relative to size) at baseline (%)	36.5	37.3	0.30
Aortic valve eventsc (%)	48.5	44.6	0.37
Major CV events (%)	50.9	48.5	0.58
CV death (%)	7.8	4.9	0.19

a. AVA <1.0 cm² and mean transvalvular pressure gradient <40 mm Hg

b. AVA 1.0-1.5 cm² and mean transvalvular pressure gradient 25-40 mm Hg

c. Primary end point; includes death from CV causes, aortic-valve replacement, and heart failure due to aortic stenosis

The primary-end-point rates were similar whether the stroke volume index was above or below 35 mL/m².

The rates of aortic-valve events and major CV events were significantly greater (74.3%, p<0.01, for both end points) in the 35 patients who met both criteria for severe aortic stenosis—that is, mean transvalvular pressure gradient >40 mm Hg and AVA <1.0 cm²—compared with those with low-gradient "severe" stenosis. Rates of CV death were similar.

According to Zoghbi, the findings suggest that asymptomatic, normal-LVEF patients with aortic stenosis, a low transvalvular gradient, and AVA between 0.8 cm² and 1.0 cm² can be managed as conservatively as patients with "moderate" disease.

For surgery to be considered, even for normal-LVEF patients with AVA <0.8 cm², there would generally have to be symptoms, he noted.

"Where it becomes problematic is when they have comorbidities that can bring about symptoms that may be similar to [those caused by] severe aortic stenosis." For example, if the patient has renal dysfunction and dyspnea, "the difficulty would be in teasing out how much [dyspnea] is due to the aortic stenosis."

 

Infecção relacionada a dispositivos eletrônicos implantáveis - by Fábio Soares

Cardiovascular implantable electrophysiological device-related infections: a review

Gould, Paul A; Gula, Lorne J; Yee, Raymond; Skanes, Allan C; Klein, George J; Krahn, Andrew D

Purpose of review: The use of cardiac implantable electrophysiological device (CIED) therapy in the management of cardiac disease is increasing with the improvements in technology of permanent pacemaker and implantable cardioverter defibrillators. Accordingly CIED-related infections are increasing and have become an important clinical problem. The purpose of this review is to summarize current literature on the epidemiology, risk factors, pathophysiology, diagnosis and management of CIED-related infections.

Recent findings: The diagnosis and management of CIED-related infections can be difficult. Recent research would suggest extraction of all CIED components, and concomitant appropriate antibiotic therapy is the principal management modality of CIED component and pocket infection. The exact duration of antibiotic therapy and timing of re-implantation still require further delineation in the absence of comparative evidence; however, improvements in technologies such as the excimer laser have enabled percutaneous extraction to be performed effectively and safely in the vast majority of patients. Differentiating CIED-related infection from noninfected mechanical issues that may not require extraction or antibiotics can be very difficult. Research is continuing into better methods to diagnose and treat infection.

Summary: CIED-related infections are an important clinical problem with ongoing research to improve diagnosis and treatment. Currently, percutaneous CIED extraction and antibiotic therapy are the mainstay of treatment.

Current Opinion in Cardiology:

January 2011 - Volume 26 - Issue 1 - p 6–11

Prevençao primária: Crianças e vídeogame, se não pode vencê-los... - by Fábio Soares

AHA-Nintendo summit asks: Will video games battle obesity?

April 28, 2011 | Reed Miller

San Francisco, CA - Researchers at a summit cohosted by the American Heart Association (AHA) and Nintendo are optimistic that video games, once a hallmark of sedentary lifestyles, can be transformed into a force for cardiovascular health. But even as so-called "active games" receive positive responses from cardiologists, some point to the dollars behind the partnership and call for an emphasis on transparency.

In January, 75 experts from the fields of game design, medicine, public health, education, communications, psychology, and fitness gathered at the University of California, San Francisco. According to a summary of the meeting proceedings by Dr Debra Lieberman (University of California, Santa Barbara) and colleagues, now published online April 25, 2011 in Circulation [1], the AHA-Nintendo relationship is an "important effort in the AHA's 2020 impact goal," and this conference was "a fundamental first step . . . to begin examining the potential opportunities and benefits of the use of active-play video games to help children and adults avoid sedentary behavior."

"We are so delighted to be in a prestigious medical journal to get to an audience that really needs to see some credible research before they're going to embrace our field," Lieberman told heartwire. "This conference showed that we have a good body of research now done by really good researchers and we can really start making claims about the value of these games."

One of the other authors of the summit proceedings, Dr Barry Franklin (Beaumont Hospital, Royal Oak, MI), told heartwire that the meeting "fulfilled AHA's goal of saying, Let's begin to look at things beyond the structured exercise programs—that is, contemporary technologies—to try to get more people off the chair and physically active."

In the AHA's 2009 annual report, Nintendo is listed as a donor within the $10 000-to-$24 999 range. In 2010, Nintendo of America and the AHA announced a more formal partnership and revealed that Nintendo has given the AHA $1.5 million. The AHA granted the company the right to put the organization's AHA "heart check" logo on all Wii virtual exercise and active game systems—a move that prompted one forum contributor on theheart.org to ask if the AHA would also be offering its checkmark for bicycles and basketballs. At the time, AHA president Dr Clyde Yancy (Northwestern University, Chicago, IL) defended AHA's deal with Nintendo, citing the company's pioneering development of games that require the player to do more than just push buttons.

Franklin agrees. "After reviewing the research, I came to the sobering realization that these games may have a profound impact on public health and that's why I got behind it," he said. "I work with a number of scientists who are naysayers who say 'show me the data.' . . . I'm not saying that the Nintendo Wii prevents heart attacks or has major effects on risk factors, but the data clearly show that, depending on the game played and the population, it can increase energy expenditure two- to fivefold. . . . So researchers look at this and say, 'This has the potential to replace a walk, which we know is therapeutic and beneficial.' "

Comentário completo no link abaixo:

http://www.theheart.org/article/1217531.do

Um exemplo do que foi dito no post anterior... by Fábio Soares

Até aqui, apenas uma estenose aórtica, com VE hipertrófico e AE com aumento grave, até que na janela subcostal...

Análise do arco aórtico para todos? - by Fábio Soares

A janela supraestenal e subcostal são sempre renegados... Não é infreqüente "esquecermos" de utilizar essas janelas para conclusão diagnóstica ao término do exame. Mas será que depois de realizado todo o exame, alguma informação pode ser adcionada? Óbvio que sim, são inúmeras as possibilidades que podem ser consideradas com a adição destas insonações, sem com isto aumentar muito a duração de um exame. Segue abaixo um estudo interessante sobre a análise do arco aórtico em exame de rotina.