Mário de Seixas Rocha

Anti-inflammatory effect of atorvastatin (80 mg) in unstable angina pectoris and non–Q-wave acute myocardial infarction

In this randomized trial, C-reactive protein increased during the first 5 days of an acute coronary syndrome in patients treated with placebo, but this phenomenon was not observed in those randomized to atorvastatin 80 mg/day. This suggests that short-term statin therapy inhibits inflammation in patients with non-ST-elevation acute coronary syndromes.

Subcategorization of Suspicious Breast Lesions (BI-RADS Category 4) According to MRI Criteria: Role of Dynamic Contrast-Enhanced and Diffusion-Weighted Imaging

OBJECTIVE The purposes of this study were to investigate whether dynamic contrast-enhanced MRI is adequate for subcategorization of suspicious lesions (BI-RADS category 4) and to evaluate whether use of DWI improves diagnostic performance. MATERIALS AND METHODS The study group was composed of 103 suspicious lesions found in 83 subjects. Patient ages and lesion sizes were compiled, and two radiologists reanalyzed the images; subcategorized the findings as BI-RADS 4A, 4B, or 4C; and calculated apparent diffusion coefficient (ADC) values. The stratified variables were tested by univariate analysis and inserted in two multivariate predictive models, which were used to generate ROC curves and compare AUCs. Positive predictive values (PPVs) for each subcategory and ADC level were calculated, and interobserver agreement was tested. RESULTS Forty-four (42.7%) suspicious findings proved malignant. Except for age (p = 0.08), all stratified predictor variables were significant in univariate analyses (p < 0.01). Logistic regression models did not differ substantially after comparison of the ROC curves (p = 0.09), but the one including ADC values was slightly better: AUC of 0.89 (95% CI, 0.82-0.95) against AUC of 0.85 (95% CI, 0.78-0.93). PPV increased progressively in each BI-RADS 4 subcategory (4A, 0.15; 4B, 0.37; 4C, 0.84). ADC values of 1.10 × 10(-3) mm(2)/s or less had the second highest PPV (0.77). Interobserver agreement was substantial at a kappa value of 0.80 (95% CI, 0.70-0.90; p < 0.01). CONCLUSION Risk stratification of suspicious lesions (BI-RADS category 4) can be satisfactorily performed with DCE-MRI and slightly improved when DWI is introduced.

HDL-cholesterol level provides additional prognosis in acute coronary syndromes☆

In the setting of acute coronary syndromes, plasma lipids have not been defined as prognostic variables, however little research has been dedicated to this specific issue. In order to test the independent predictive value for in-hospital events of low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides measured at hospital admission, 97 individuals with unstable angina or non-ST-elevation acute myocardial infarction were evaluated. In-hospital events, defined as death, non-fatal myocardial infarction or recurrent unstable angina, were significantly predicted by HDL-cholesterol (C-statistics=0.69; 95% CI=0.55-0.83, P=0.018), contrary to LDL-cholesterol (C-statistics=0.40; 95% CI=0.24-0.56, P=0.23) and triglycerides (C-statistics=0.48; 95% CI=0.31-0.65, P=0.83). The best HDL-cholesterol cut-off point was 32 mg/dl, with a 33% incidence of events in patients with HDL-cholesterol < or =32 mg/dl, compared with only 9% in those with HDL-cholesterol>32 mg/dl (P=0.003). Logistic regression analysis showed HDL-cholesterol< or =32 mg/dl (OR=3.6; 95% CI=1.0-14; P=0.05) and TIMI Risk Score (OR=2.3; 95% CI=1.4-2.9, P=0.001) as the independent predictors of events. Furthermore, the addition of HDL-cholesterol to TIMI Risk Score improved its C-statistic from 0.81 to 0.85. In conclusion, as opposed to LDL-cholesterol and triglycerides, HDL-cholesterol level adds prognostic value to the prediction of in-hospital recurrent events during non-ST-elevation acute coronary syndromes.

Lesão renal aguda séptica versus não séptica em pacientes graves: características e desfechos clínicos

Objetivo: Descrever e comparar as caracteristicas e os desfechos clinicos de pacientes com lesao renal aguda septica e nao septica. Metodos: Coorte aberta com 117 pacientes graves com lesao renal aguda consecutivamente admitidos em unidade de terapia intensiva, sendo excluidos aqueles que apresentavam doenca renal cronica em estagio avancado, transplante renal, internacao ou morte em um periodo inferior a 24 horas. Presenca de sepse e obito intra-hospitalar representaram, respectivamente, a exposicao e o desfecho principal. Analise de confundimento foi realizada com a regressao logistica. Resultados: Nao houve diferencas na media de idade entre os grupos com lesao renal aguda septica e nao septica [65,30±(21,27) anos versus 66,35±12,82 anos; p=0,75]. Nos dois grupos, similarmente, observou-se predominio do sexo feminino (57,4% versus 52,4%; p=0,49) e de afrodescendentes (81,5% versus 76,2%; p=0,49). Os pacientes com sepse apresentaram maiores medias de escore Acute Physiology and Chronic Health Evaluation II [21,73±7,26 versus 15,75± (5,98; p 18,5 (OR: 9,77; IC95%: 3,73-25,58) foram associados ao obito. Conclusao: Sepse foi um preditor independente para obito. Existem diferencas entre as caracteristicas e desfechos clinicos dos pacientes com lesao renal aguda septica versus nao septica.Objective This study aimed to describe and compare the characteristics and clinical outcomes of patients with septic and non-septic acute kidney injury. Methods This study evaluated an open cohort of 117 critically ill patients with acute kidney injury who were consecutively admitted to an intensive care unit, excluding patients with a history of advanced-stage chronic kidney disease, kidney transplantation, hospitalization or death in a period shorter than 24 hours. The presence of sepsis and in-hospital death were the exposure and primary variables in this study, respectively. A confounding analysis was performed using logistic regression. Results No significant differences were found between the mean ages of the groups with septic and non-septic acute kidney injury [65.30±21.27 years versus 66.35±12.82 years, respectively; p=0.75]. In the septic and non-septic acute kidney injury groups, a predominance of females (57.4% versus 52.4%, respectively; p=0.49) and Afro-descendants (81.5% versus 76.2%, respectively; p=0.49) was observed. Compared with the non-septic patients, the patients with sepsis had a higher mean Acute Physiology and Chronic Health Evaluation II score [21.73±7.26 versus 15.75±5.98; p<0.001)] and a higher mean water balance (p=0.001). Arterial hypertension (p=0.01) and heart failure (p<0.001) were more common in the non-septic patients. Septic acute kidney injury was associated with a greater number of patients who required dialysis (p=0.001) and a greater number of deaths (p<0.001); however, renal function recovery was more common in this group (p=0.01). Sepsis (OR: 3.88; 95%CI: 1.51-10.00) and an Acute Physiology and Chronic Health Evaluation II score >18.5 (OR: 9.77; 95%CI: 3.73-25.58) were associated with death in the multivariate analysis. Conclusion Sepsis was an independent predictor of death. Significant differences were found between the characteristics and clinical outcomes of patients with septic versus non-septic acute kidney injury.

Predictive performance of BI-RADS magnetic resonance imaging descriptors in the context of suspicious (category 4) findings

Objective To determine the positive predictive value (PPV) and likelihood ratio for magnetic resonance imaging (MRI) characteristics of category 4 lesions, as described in the Breast Imaging Reporting and Data System (BI-RADS®) lexicon, as well as to test the predictive performance of the descriptors using multivariate analysis and the area under the curve derived from a receiver operating characteristic (ROC) curve. Materials and Methods This was a double-blind review study of 121 suspicious findings from 98 women examined between 2009 and 2013. The terminology was based on the 2013 edition of the BI-RADS. Results Of the 121 suspicious findings, 53 (43.8%) were proven to be malignant lesions, with no significant difference between mass and non-mass enhancement (p = 0.846). The PPVs were highest for masses with a spiculated margin (71%) and round shape (63%), whereas segmental distribution achieved a high PPV (80%) for non-mass enhancement. Kinetic analyses performed poorly, except for type 3 curves applied to masses (PPV of 73%). Logistic regression models were significant for both patterns, although the results were better for masses, particularly when kinetic assessments were included (p = 0.015; pseudo R2 = 0.48; area under the curve = 90%). Conclusion Some BI-RADS MRI descriptors have high PPV and good predictive performance-as demonstrated by ROC curve and multivariate analysis-when applied to BI-RADS category 4 findings. This may allow future stratification of this category.

Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury

OBJECTIVE: To evaluate the association between extubation failure and outcomes (clinical and functional) in patients with traumatic brain injury (TBI). METHODS: A prospective cohort study involving 311 consecutive patients with TBI. The patients were divided into two groups according to extubation outcome: extubation success; and extubation failure (defined as reintubation within 48 h after extubation). A multivariate model was developed in order to determine whether extubation failure was an independent predictor of in-hospital mortality. RESULTS: The mean age was 35.7 ± 13.8 years. Males accounted for 92.3%. The incidence of extubation failure was 13.8%. In-hospital mortality was 4.5% and 20.9% in successfully extubated patients and in those with extubation failure, respectively (p = 0.001). Tracheostomy was more common in the extubation failure group (55.8% vs. 1.9%; p < 0.001). The median length of hospital stay was significantly greater in the extubation failure group than in the extubation success group (44 days vs. 27 days; p = 0.002). Functional status at discharge was worse among the patients in the extubation failure group. The multivariate analysis showed that extubation failure was an independent predictor of in-hospital mortality (OR = 4.96; 95% CI, 1.86-13.22). CONCLUSIONS: In patients with TBI, extubation failure appears to lengthen hospital stays; to increase the frequency of tracheostomy and of pulmonary complications; to worsen functional outcomes; and to increase mortality.

Does acute hyperglycemia add prognostic value to the GRACE score in individuals with non-ST elevation acute coronary syndromes?

BACKGROUND It is not known in what extent admission glucose improves risk stratification of the GRACE Score in patients with non-ST-segment elevation acute coronary syndromes (ACS). We tested the hypothesis that admission glucose adds relevant prognostic information to the GRACE Score. METHODS Consecutive patients admitted with ACS had plasma glucose measured at admission and cardiovascular events were defined as death, non-fatal myocardial infarction or non-fatal refractory angina during hospitalization. RESULTS Among the 148 patients studied, 11.5% developed cardiovascular events. Patients in the forth quartile of admission glucose (> or =175mg/dl) had a greater incidence of events, compared with those in the first 3 quartiles (22% vs. 8.1%; RR=2.7; 95%CI 1.1-6.4; P=0.03). Plasma glucose remained a predictor of events, after adjustment for diabetes (P=0.03). After adjustment for the GRACE Score, glucose in the forth quartile lost its predictive value (P=0.29). Plasma glucose added to GRACE did not improve the C-statistics (0.82; 95%CI 0.75-0.88), as compared with the original Score (0.81; 95%CI 0.74-0.87). Net reclassification improvement by new score was -0.03 (P=0.86), indicating no useful reclassification. CONCLUSION Despite its association with adverse events, admission plasma glucose does not improve GRACEs accuracy to predict in-hospital events in patients with ACS.

Prevalence and variables associated with physical inactivity in individuals with high and low socioeconomic status

BACKGROUND: Studies that considered only the leisure physical activity found that the physical inactivity is higher among lower-income individuals. There is a possibility that this association shows modifications, when considering transportation, work and domestic activities. OBJECTIVE: To determine whether there is a difference between the prevalence of physical inactivity between individuals of high and low socioeconomic levels. METHODS: The sample consisted of individuals of both sexes, aged 18 or older, from two groups of different socioeconomic levels. The low socioeconomic level (LSEL) group consisted of the parents of students from a public school. The high socioeconomic level (HSEL) group consisted of the parents of students from a private College. The International Physical Activity Questionnaire (IPAQ) was used to determine the level of physical activity. RESULTS: A total of 91 individuals were evaluated in the LSEL group and 59 in the HSEL group. In the LSEL group, 42.9% (39) of the individuals were classified as insufficiently active, compared to 57.6% (34) of individuals in the HSEL group. Taking as a parameter of physical inactivity the time of weekly physical activity < 150 minutes, there was a decrease in the classification of inactivity in both groups, although with the maintenance of higher inactivity among individuals of HSEL (49.2% vs 28.6%; p= 0.01). CONCLUSION: The individuals of HSEL are more sedentary than the individuals of LSEL.BACKGROUND Studies that considered only the leisure physical activity found that the physical inactivity is higher among lower-income individuals. There is a possibility that this association shows modifications, when considering transportation, work and domestic activities. OBJECTIVE To determine whether there is a difference between the prevalence of physical inactivity between individuals of high and low socioeconomic levels. METHODS The sample consisted of individuals of both sexes, aged 18 or older, from two groups of different socioeconomic levels. The low socioeconomic level (LSEL) group consisted of the parents of students from a public school. The high socioeconomic level (HSEL) group consisted of the parents of students from a private College. The International Physical Activity Questionnaire (IPAQ) was used to determine the level of physical activity. RESULTS A total of 91 individuals were evaluated in the LSEL group and 59 in the HSEL group. In the LSEL group, 42.9% (39) of the individuals were classified as insufficiently active, compared to 57.6% (34) of individuals in the HSEL group. Taking as a parameter of physical inactivity the time of weekly physical activity < 150 minutes, there was a decrease in the classification of inactivity in both groups, although with the maintenance of higher inactivity among individuals of HSEL (49.2% vs 28.6%; p= 0.01). CONCLUSION The individuals of HSEL are more sedentary than the individuals of LSEL.

Effect of atorvastatin (80 mg) on recurrent ischemia in unstable angina pectoris or Non–ST-Elevation acute myocardial infarction

A body of evidence has suggested that many cellular actions of statin therapy may acutely improve endothelial function even before affecting the lipid profile.1 Statins can acutely enhance nitric oxide bioavailability via their lipid-independent actions by upregulating endothelial nitric oxide synthase.2 In this randomized clinical trial, we evaluated the effect of high-dose atorvastatin on myocardial ischemia measured by ST-segment monitoring during the first 2 days after an episode of unstable angina pectoris (UAP) or non–Q-wave acute myocardial infarction (AMI). • • • Patients admitted to the coronary care unit of Portuguese Hospital, Salvador, Brazil, due to UAP or non–Q-wave AMI from December 2000 to March 2002 were considered candidates for the study. Inclusion criteria were defined as onset of chest discomfort in the previous 48 hours in patients with electrocardiographic changes consisting of transient ST-segment depression ( 0.05 mV), T-wave inversion ( 0.1 mV) and/or positive troponin I ( 1.0 ng/dl). Patients with positive troponin results were defined as having AMI, otherwise they were characterized as UAP. Patients were excluded if they had left bundle branch block, any liver disease, history of statin intolerance, pregnancy, or lactation. The study was approved by the local ethic committee and all participants provided written informed consent. A first blood sample to measure plasma lipids was drawn before initiation of therapy. The enrolled patients were submitted to a randomized, double-blind, placebo-controlled program with either 80 mg of atorvastatin or placebo administered once a day. ST-segment recording (Holter) was performed during the first 2 days of therapy and treatment efficacy was primarily assessed by comparing the amount of ischemia measured by Holter in the 2 groups. After 5 days, experimental therapy was withdrawn and another blood sample was taken for evaluation of the drug effect on plasma lipids. Cardiovascular events during hospitalization, defined as the composite of death, nonfatal AMI, and recurrent UAP, were also recorded. No other type of lipid-lowering therapy was offered to the patients during the first 5 days. Continuous 2-channel electrocardiographic recordings was performed by a calibrated amplitude-modulated cassette recorder (Dynamis 3000, Sao Paulo, Brazil) to detect reversible ST-segment shifts compatible with ischemia, which was defined as a 0.1 mV ST-segment depression or elevation measured 80 ms after the J point, lasting 1 minute and separated by the last episode by 1 minute. Number of ischemic episodes and total ischemia duration was measured in each patient. Ischemic burden was defined as the product of ischemic duration in minutes by the ST-segment depression in millimeters.3 The time from the first episode of ischemia was also recorded. Commercial enzymatic methods were used for the determination of total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (Dimension Clinical Chemistry System; Dade-Behring, Newark, Delaware).4 HDL cholesterol was determined by the same method used for total cholesterol after precipitation of apolipoprotein B containing lipoproteins with magnesium phosphotungstate. Low-density lipoprotein (LDL) cholesterol was calculated by Friedewald’s formula. Duration of ischemia, number of ischemic epidodes, ischemic burden, and time to the first ischemic episode in each patient were compared between the 2 groups by Wilcoxon’s rank-sum test. The prevalence of patients with ischemia and of patients with 60 minutes of ischemia were compared between the 2 groups by Fisher’s exact test. Baseline characteristics were compared by unpaired Student’s t test for continuous variables and by chi-square or Fisher’s exact tests for categorical variables. Wilcoxon’s sign-rank test was utilized for the paired analysis of plasma lipid changes after therapy in each group. Cardiovascular events were compared between the 2 groups by the chi-square test. Nonparametric tests were applied in most situations because Holter variables were not normally distributed. Analysis of variance and logistic regression were utilized to adjust Holter variables to baseline differences between the groups. We calculated a sample size of 50 patients per group, based on a 2-sided of 5% and a statistical power of 85%, assuming that a 50% reduction in duration of ischemia with atorvastatin would be clinically significant. We based this calculation on the previously described 11 9 minutes of ischemia per patient with UAP per 24 hours.5 One hundred patients were randomized (64 12 years; 51 men); 55 had AMI and 45 had UAP. Fifty From the School of Medicine, Federal University of Bahia, Salvador; Cardiology Division, Portuguese Hospital, Salvador; and Heart Institute (InCor), University of Sao Paulo Medicine School, Sao Paulo, Brazil. Dr. Correia’s address is: Rua do Taruma 90/1002, Salvador BA, Brazil 41.810-440. E-mail: lucorrei@terra.com.br. Manuscript received November 22, 2002; revised manuscript received and accepted February 24, 2003.

Associacao entre o indice de respiracao rapida e superficial e o sucesso da extubacao em pacientes com traumatismo cranioencefalico

Objective To investigate the association between the rapid shallow breathing index and successful extubation in patients with traumatic brain injury. Methods This study was a prospective study conducted in patients with traumatic brain injury of both genders who underwent mechanical ventilation for at least two days and who passed a spontaneous breathing trial. The minute volume and respiratory rate were measured using a ventilometer, and the data were used to calculate the rapid shallow breathing index (respiratory rate/tidal volume). The dependent variable was the extubation outcome: reintubation after up to 48 hours (extubation failure) or not (extubation success). The independent variable was the rapid shallow breathing index measured after a successful spontaneous breathing trial. Results The sample comprised 119 individuals, including 111 (93.3%) males. The average age of the sample was 35.0±12.9 years old. The average duration of mechanical ventilation was 8.1±3.6 days. A total of 104 (87.4%) participants achieved successful extubation. No association was found between the rapid shallow breathing index and extubation success. Conclusion The rapid shallow breathing index was not associated with successful extubation in patients with traumatic brain injury.