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Introduction: Pediatric ulcerative colitis (CUP), pediatric Crohn's disease (PCD), and pediatric inflammatory bowel disease not classifiable (PIDNCID) have clinical and psychosocial particularities that differentiate them from those of adults and may condition different therapeutic approaches due to possible nutritional, growth and developmental repercussions, representing a challenge for the pediatrician and gastroenterologist. Objective: Develop expert consensus evidence-based recommendations for the timely and safe diagnosis and treatment of Pediatric Inflammatory Bowel Disease (PID) in children under 18 years of age for professionals caring for these patients and healthcare payers. Methodology: Through a panel of experts from the Colombian College of Pediatric Gastroenterology, Hepatology and Nutrition (COLGAHNP) and a multidisciplinary group, 35 questions were asked regarding the clinical picture, diagnosis, and treatment of PID. Through a critical review and analysis of the literature with particular emphasis on the main clinical practice guidelines (CPGs), randomized clinical trials (RCTs), and meta-analyses of the last ten years, from which the experts made 77 recommendations that responded to each of the research questions with their respective practical points. Subsequently, each of the statements was voted on within the developer group, including the statements that achieved > 80%. Results: All statements scored > 80%. PID has greater extension, severity, and evolution towards stenosis, perianal disease, extraintestinal manifestations, and growth retardation compared to adult patients, so its management should be performed by multidisciplinary groups led by pediatric gastroenterologists and prepare them for a transition to adulthood. Porto's criteria allow a practical classification of PID. In CPE, we should use the Paris classification and perform ileocolonoscopy and esophagogastroduodenoscopy, since 50% have upper involvement, using the SES-CD (UCEIS/Mayo in CUP) and taking multiple biopsies. Initial labs should include inflammatory markers and fecal calprotectin and rule out intestinal infections. Treatment, induction, and maintenance of PID should be individualized and decided according to risk stratification. Follow-up should use PCDAI and PUCAI for the last 48 hours. Immunologists and geneticists should evaluate patients with early and infantile PID. Conclusion: A consensus guideline is provided with evidence-based recommendations on timely and safe diagnosis and treatments in patients with ILD.
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BACKGROUND: Accessory pathway (AP)-related arrhythmias are frequent in patients with Ebstein anomaly (EA), and arrhythmia recurrence after catheter ablation remains high despite current technological developments. METHODS: Case series report of patients with EA who were taken to an accessory pathway ablation procedure and where clinical, procedure, and follow-up data are described. In all cases, mapping of the true tricuspid annulus guided by intracardiac ultrasound was used. RESULTS: Six patients with EA underwent an ablation procedure using ICE to delineate the true tricuspid annulus. The duration of the procedure was 253.33 ± 60.92 min, with an acute success of 100%. After a mean follow-up of 16.16 ± 7.7 months, no recurrences of tachycardia were documented, and all patients were free of antiarrhythmic medications. CONCLUSION: Intraprocedural ICE helps to delineate the true tricuspid annulus that contains the APs, facilitating mapping and ablation. We hypothesize that the systematic use of ICE in this scenario improves ablation efficacy while reducing complications, but this must be verified in prospective studies.
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Feixe Acessório Atrioventricular , Ablação por Cateter , Anomalia de Ebstein , Feixe Acessório Atrioventricular/diagnóstico por imagem , Feixe Acessório Atrioventricular/cirurgia , Arritmias Cardíacas/cirurgia , Ablação por Cateter/métodos , Anomalia de Ebstein/complicações , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/cirurgia , Ecocardiografia , Humanos , Estudos ProspectivosRESUMO
CONTEXT: Diabetes has become a global noninfectious pandemic with rates rapidly rising around the globe. The major drivers of this increase in type 2 diabetes are obesity, an increase in processed foods, and a decrease in physical activity. In the United States, the National Diabetes Prevention Program (NDPP) has proven to be an effective lifestyle intervention to delay or prevent new-onset type 2 diabetes. However, there is limited evidence that such a lifestyle program will work in a South American community. OBJECTIVES: This pilot program aims to determine if a modified version of the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP) would be feasible in an Ecuadorian population. The goals of this pilot program were a 7% weight loss, >150 min of physical activity per week, and a reduction of fat calories to yield a reduced risk of type 2 diabetes. This program was led by family medicine physicians and was offered to people with prediabetes in Quito, Ecuador. METHODS: The program was modified to include only the first half of the DPP curriculum, which included a schedule of 16 classes in the first 6 months. Further, the program was provided in Spanish and modified to be more culturally specific to this population. Participants were recruited from the faculty and staff of Pontifical Catholic University of Ecuador (Pontificia Universidad Católica del Ecuador [PUCE]) in Quito. Outcomes measured included A1c reduction, weight loss, increase in physical activity minutes, and progression to type 2 diabetes mellitus (T2DM). RESULTS: The sample included 33 people with prediabetes. The mean age of the participants was 52 years (range, 41-66 years), the mean body mass index (BMI) was 27.6 kg/m2 (range, 21.0-40.3 kg/m2), and the mean HbA1C was 6.2% (range, 5.7-6.4%). The attendance was 97.8% at 6 months. The mean weight loss was 3.4 kg per participant (range, 1.5 kg weight gain to 8.3 kg weight loss); in percentage points, this was a mean weight loss of 3.6% (range, 2.3% gain to 11.8% weight loss). Three-fourths of the participants lost weight (78.3%). The majority of participants (75.8%) met the target physical activity level of 150 min per week, and all participants increased their physical activity levels from baseline. No participants progressed to type 2 diabetes during this study. CONCLUSIONS: The DPP 6 month pilot was effective in this population with prediabetes in Ecuador. The largest changes were made in physical activity time. Holding the program at worksites and providing lunch were key factors in the very high retention rate in this study.
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Diabetes Mellitus Tipo 2 , Estado Pré-Diabético , Adulto , Idoso , Diabetes Mellitus Tipo 2/prevenção & controle , Equador/epidemiologia , Humanos , Estilo de Vida , Pessoa de Meia-Idade , Estado Pré-Diabético/epidemiologia , Estado Pré-Diabético/terapia , Estados Unidos , Redução de PesoRESUMO
COVID-19 is a rapidly evolving public health emergency that has largely impacted the provision of healthcare services around the world. The challenge for electrophysiology teams is double; on one side preventing disease spread by limiting all nonessential face-to-face interactions, but at the same time ensuring continued care for patients who need it. These guidelines contain recommendations regarding triaging in order to define what procedures, device checks and clinic visits can be postponed during the pandemic. We also discuss best practices to protect patients and healthcare workers and provide guidance for the management of COVID-19 patients with arrhythmic conditions.
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Arritmias Cardíacas/cirurgia , Ablação por Cateter/estatística & dados numéricos , Infecções por Coronavirus/prevenção & controle , Atenção à Saúde , Técnicas Eletrofisiológicas Cardíacas/normas , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto , Argentina , Arritmias Cardíacas/diagnóstico , Brasil , COVID-19 , Eletrofisiologia Cardíaca/organização & administração , Ablação por Cateter/normas , Colômbia , Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Técnicas Eletrofisiológicas Cardíacas/estatística & dados numéricos , Feminino , Humanos , Controle de Infecções/organização & administração , América Latina , Masculino , México , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Gestão da Segurança/normas , Sociedades MédicasRESUMO
Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban have at least comparable efficacy as vitamin K antagonists along with a better safety profile, reflected by a lower incidence of intracranial hemorrhage. Specific reversal agents have been developed in recent years. Namely, idarucizumab, a specific antidote for dabigatran, is currently approved in most countries. Andexanet, which reverses factor Xa inhibitors, has been recently approved by the FDA, and ciraparantag, a universal antidote targeted to reverse all DOACs, is still under investigation. In this review we provide an update on the pharmacology of DOACs, the risk of hemorrhagic complications associated with their use, the measurement of their anticoagulant effect and the reversal strategies in case of DOAC-associated bleeding.
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Anticorpos Monoclonais Humanizados/uso terapêutico , Antitrombinas/administração & dosagem , Antitrombinas/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/terapia , Administração Oral , Antídotos/uso terapêutico , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Humanos , Pirazóis/administração & dosagem , Pirazóis/efeitos adversos , Piridinas/administração & dosagem , Piridinas/efeitos adversos , Piridonas/administração & dosagem , Piridonas/efeitos adversos , Fatores de Risco , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Tiazóis/administração & dosagem , Tiazóis/efeitos adversosRESUMO
Catheter ablation of atrial fibrillation may predispose patients to the development of atypical atrial flutters (AFL). We describe two cases of roof dependent AFLs that failed to terminate despite posterior wall isolation. An epicardial breakthrough involving the septopulmonary bundle is proposed. The correlation between the electrophysiological findings and the anatomical substrate is described.
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Fibrilação Atrial/cirurgia , Flutter Atrial/etiologia , Ablação por Cateter/efeitos adversos , Pericárdio/fisiopatologia , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Pericárdio/cirurgia , Resultado do TratamentoRESUMO
Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban have at least comparable efficacy as vitamin K antagonists along with a better safety profile, reflected by a lower incidence of intracranial hemorrhage. Specific reversal agents have been developed in recent years. Namely, idarucizumab, a specific antidote for dabigatran, is currently approved in most countries. Andexanet, which reverses factor Xa inhibitors, has been recently approved by the FDA, and ciraparantag, a universal antidote targeted to reverse all DOACs, is still under investigation. In this review we provide an update on the pharmacology of DOACs, the risk of hemorrhagic complications associated with their use, the measurement of their anticoagulant effect and the reversal strategies in case of DOAC-associated bleeding.
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Humanos , Fatores de Coagulação Sanguínea/uso terapêutico , Antitrombinas/administração & dosagem , Antitrombinas/efeitos adversos , Anticorpos Monoclonais Humanizados/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/terapia , Pirazóis/administração & dosagem , Pirazóis/efeitos adversos , Piridinas/administração & dosagem , Piridinas/efeitos adversos , Piridonas/administração & dosagem , Piridonas/efeitos adversos , Tiazóis/administração & dosagem , Tiazóis/efeitos adversos , Administração Oral , Fatores de Risco , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Antídotos/uso terapêuticoRESUMO
BACKGROUND: Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) often terminate spontaneously, presumably due to changes in the electrophysiological properties of the reentrant circuit. However, the mechanism of spontaneous termination of these arrhythmias is incompletely understood. METHODS: We included 70 consecutive patients with reentrant supraventricular tachycardias (35 AVNRT, 35 AVRT) in whom the arrhythmia ended spontaneously during the electrophysiologic study. We determined in each patient the duration of the induced arrhythmia, site of block, beat-to-beat oscillations in tachycardia cycle-length (CL), A-H, H-V, H-A and V-A intervals. RESULTS: In 21/34 (62%) patients with AVNRT and 19/30 (63%) with orthodromic AVRT, tachycardia termination was preceded by progressive increase in tachycardia CL due to prolongation of the A-H interval (Mobitz type-I pattern). In 13/34 patients with AVNRT (38%) and 11/30 with orthodromic AVRT (37%), termination occurred suddenly without a preceding change in CL, with block ensuing retrogradely either in the fast AV nodal pathway or the accessory pathway (Mobitz type-II pattern). In 4/5 patients with antidromic AVRT the tachycardia ended at the retrograde limb with previous prolongation of the VA interval. CONCLUSION: Spontaneous termination of AVNRT and AVRT is a time-related phenomenon. Despite different pathways being involved in these two reentrant tachycardias, termination can follow antegrade or retrograde block in similar ratio (60% antegradely and 40% retrogradely). Antegrade block is preceded by prolongation of the AH interval (Mobitz type-I), whereas retrograde block occurs unexpectedly in the retrograde limb (Mobitz type-II). Fatigue of conduction appears to be involved in this phenomenon.