Recommendations for starting a grown up congenital heart disease (GUCH) unit

During the last decades, advances in diagnosis and treatment of congenital heart disease have allowed many individuals to reach adulthood. Due mainly to the great diagnostic diversity and to the co-morbidities usually present in this age group, these patients demand assistance in a multidisciplinary facility if an adequate attention is aimed. In this paper we reviewed, based in the international literature and also on the authors’ experience, the structural conditions that should be available for these patients. We highlighted aspects like the facility characteristics, the criteria usually adopted for patient transfer from the paediatric setting, the composition of the medical and para- medical staff taking into account the specific problems, and also the model of outpatient and in-hospital assistance. We also emphasized the importance of patient data storage, the fundamental necessity of institutional support and also the compromise to offer professional training. The crucial relevance of clinical research is also approached, particularly the development of multicenter studies as an appropriate methodology for this heterogeneous patient population.     

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.     

Superior Turbinectomy: Role for a Two-surgeon Technique in Endoscopic Endonasal Transsphenoidal Surgery—Technical Note

We describe a practical technique of superior turbinectomy followed by posterior ethmoidectomy as a less invasive procedure for two-surgeon technique on endoscopic endonasal transsphenoidal surgery. After identification of the superior turbinate and the sphenoid ostium, the inferior third portion of the superior turbinate was coagulated and resected. This partial superior turbinectomy procedure exposed the posterior ethmoidal sinus. Resection of the bony walls between the sphenoid and posterior ethmoid sinuses provided more lateral and superior exposure of the sphenoid sinus. This technique was performed in 56 patients with midline skull base lesions, including 49 pituitary adenomas and 7 other lesions. Meticulous manipulation of instruments was performed in all cases without surgical complications such as permanent hyposmia/anosmia or nasal bleeding. Our findings suggested that the partial superior turbinectomy followed by retrograde posterior ethmoidectomy is a simple and safe technique providing a sufficient surgical corridor for two-surgeon technique to approaching midline skull base regions, mainly involving pituitary adenomas.     

Postpartum depression: A systematic review of the genetics involved

Postpartum depression is one of the most prevalent psychopathologies. Its prevalence is estimated to be between 10% and 15%. Despite its multifactorial etiology, it is known that genetics play an important role in the genesis of this disorder. This paper reviews epidemiological evidence supporting the role of genetics in postpartum depression (PPD). The main objectives of this review are to determine which genes and polymorphisms are associated with PPD and discuss how this association may occur. In addition, this paper explores whether these genes are somehow related to or even the same as those linked to Major Depression (MD). To identify gaps in the current knowledge that require investigation, a systematic review was conducted in the electronic databases PubMed, LILACS and SciELO using the index terms “postpartum depression” and “genetics”. Literature searches for articles in peer-reviewed journals were made until April 2014. PPD was indexed 56 times with genetics. The inclusion criteria were articles in Portuguese, Spanish or English that were available by institutional means or sent by authors upon request; this search resulted in 20 papers. Genes and polymorphisms traditionally related to MD, which are those involved in the serotonin, catecholamine, brain-derived neurotrophic factor and tryptophan metabolism, have been the most studied, and some have been related to PPD. The results are conflicting and some depend on epigenetics, which makes the data incipient. Further studies are required to determine the genes that are involved in PPD and establish the nature of the relationship between these genes and PPD.     

Reproductive Biology of Triatoma brasiliensis (Hemiptera,Triatominae) during the Imaginal Molt

The triatomines are vectors of the protozoan Trypanosoma cruzi, etiologic agent of Chagas disease. These insects are sexually active after the imaginal molt. Some aspects have been studied in Triatoma brasiliensis during the imaginal molt, such as autogeny in virgin females and the relationship between blood ingestion by fifth instar nymph and the realization of the imaginal molt. Thus, to aid in the understanding of reproductive biology and developmental physiology of these vectors, this article analyzes the spermatogenesis of T. brasiliensis during the imaginal molt. The analysis of the seminiferous tubules from males in the fifth instar during imaginal molt has demonstrated that T. brasiliensis has only a few spermatids and a plentiful quantity of sperm. Thus, we suggest that during imaginal molt the cell division is disrupted aiming to reduce energy costs and the differentiation into sperm is stimulated to ensure the paternity of the adult male.Chagas disease is a potentially life-threatening illness caused by the protozoan parasite Trypanosoma cruzi and transmitted to humans by contact with feces of triatomine bugs, known as “kissing bugs.”¹ These vectors have a typical hemimetabolous life cycle, from eggs through five nymphal instars (N1, N2, N3, N4, and N5) to adult males and females. The transition from the fifth instar nymph to adult is named imaginal molt. During this process it occur some corporal changes, such as the emergence of wings,² exocrine glands (metasternal and Brindley''s glands)^3,4 and development of the reproductive system.^5–8Some aspects have been studied in Triatoma brasiliensis Neiva, 1911 during the imaginal molt, such as autogeny in virgin females⁹ and the relationship between blood ingestion by N5 and the realization of the imaginal molt.¹⁰ This triatomine species is the most important Chagas disease vector in the Brazilian northeast.^11,12 Thus, to aid in the understanding of the reproductive biology and developmental physiology of these vectors, this article analyzes the spermatogenesis of T. brasiliensis during the imaginal molt.Five males in the fifth instar nymphs of T. brasiliensis were isolated and during imaginal molt their testicles were removed and fixed in methanol: acetic acid (3:1). They had been assigned by the “Triatominae Insectarium” within the Department of Biological Sciences, in the College of Pharmaceutical Sciences, at Sao Paulo State University''s “Júlio de Mesquita Filho,” Araraquara campus. The colony was formed from T. brasiliensis collected in intradomiciliary region of the municipality Olho d''Água, State of Paraiba, Brazil in the day April 17, 2008.Seminiferous tubules were first shredded, smashed, and the microscope slides were set in liquid nitrogen. They were then stained with the lacto-acetic orcein cytogenetic technique.^13,14 On the basis of the analysis of slides, it was observed that the N5 nymphs, during imaginal molt, have only one of the phases of spermatogenesis, that is, the spermiogenesis. This is represented by the presence of spermatids (Figure 1A –C) and sperm (Figure 1D).Open in a separate windowFigure 1.Spermiogenesis in Triatoma brasiliensis. Note the elongation of spermatids (A–C) and sperm (D). Bar: 10 μm.Spermatogenesis is the process by which sperms are produced in the seminiferous tubules. It consists of three different phases: spermatocitogenesis, which is a phase of multiplication; meiosis, which is the division phase; and spermiogenesis, which is the differentiation phase.¹⁵Perez and others,¹⁶ reported that in some cases fifth instar nymph have mature gonads. Mello and collaborators,¹⁷ analyzed fifth instar nymph of Triatoma infestans and observed the presence of spermatogonia, spermatocytes (metaphase), spermatids, and sperms. However, during imaginal molt of T. brasiliensis there are only a few spermatids and a plentiful quantity of sperm were observed, and we suggest that during imaginal molt, the cell division is disrupted aiming to reduce energy costs, and the differentiation into sperm is stimulated to ensure the paternity of the adult male.There are some offensive mechanisms that increase the chances to ensure the paternity, such as the characteristics of the genitalia,¹⁸ the seminal fluid,¹⁹ and the courtship behavior.²⁰ Taking it into account, we suggest that the excessive increase of sperms during imaginal molt also increase the chances for the paternity.Thus, we suggest that during the imaginal molt T. brasiliensis showed changes in the reproductive biology of development and physiology to decrease the energy cost, ensuring that the molt occur and mainly to increase the chance of paternity in adults. These results provide important information for understanding the biology of this important vector of the Chagas disease. However, we highlight that new species and a larger number of triatomines should be analyzed to characterize whether this phenomenon occurs in all species of Triatominae subfamily.     

Effect of a 12-week aerobic training program on perceptual and affective responses in obese women

[Purpose] The aim of this study was to observe the effect of self-selected intensity or imposed intensity during aerobic training on perceptual and affective responses in obese women. [Subjects] The study included 26 obese women aged 30–60 years. [Methods] The subjects were randomly divided into two groups, with 13 subjects in each group: self-selected intensity and imposed intensity (10% above ventilatory threshold) groups. All subjects completed an intervention program that lasted 12 weeks, with three exercise sessions a week. The rating of perceived exertion and affective responses (Feeling Scale and Felt Arousal Scale) were monitored in the first, sixth, and twelfth weeks. [Results] Significant differences were observed between groups in heart rate and rating of perceived exertion. The affective responses during exercise were more negative in the imposed intensity group. [Conclusion] Use of a self-selected exercise intensity can promote smaller negative affective responses during exercise and provide a sufficient stimulus for improvement in cardiorespiratory fitness.Key words: Self-selected exercise, Rating of perceived exertion, Affective responses