Plastias de estenoses de intestino delgado na doença de Crohn: resultados imediatos e tardios

BACKGROUND: Strictureplasty is an alternative surgical procedure for Crohn?s disease, particulary in patients with previous resections or many intestinal stenosis. AIM: To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn?s disease. METHODS: Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn?s disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz - 81%, 15 Finney - 13%, seven side-to-side ileocolic strictureplasty - 6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures. RESULTS: Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy. CONCLUSION: Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn?s disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections.

Complicações imediatas e tardias após cirurgia de reservatório ileal na polipose adenomatosa familiar

BACKGROUND: Restorative proctocolectomy is the procedure of choice to treat familial adenomatous polyposis, however it can be associated to short-term and long-term postoperative complications. AIM: To evaluate the occurrence of complications related to the surgical treatment of familial adenomatous polyposis with ileal pouch technique. METHODS: Retrospective study of 69 patients with familial adenomatous polyposis after rectocolectomy with ileal reservoir between 1984 and 2006, operated on Coloproctology Group, Medical Sciences Faculty, State University of Campinas, Campinas, SP, Brazil. The median follow-up period was 82 (2-280) months. Data obtained were surgical techniques and postoperative complications. RESULTS: The morbidity and mortality were 63.8% and 2.9%, respectively. The most frequent complications were small-bowel obstruction (17.4%), anastomotic stricture (15.9%) and pelvic sepsis (10.1%). Acute ischemia of the ileal pouch (4.3%), pouchitis (2.9%) and ileal pouch-related fistula (2.9%) had poorer frequency than others. CONCLUSIONS: The morbid-mortality was similar to the literature?s data and it is acceptable for a complex surgery in two terms like the ileal reservoir-anal anastomosis. The small-bowel obstruction was the most frequent complication. However, ischemia of the reservoir, pouchitis and pelvic sepsis were important complications and was related to the failure of the ileal reservoir.

Resultados da cirurgia de reservatórios ileais em pacientes com doença de Crohn

BACKGROUND: Total rectocolectomy and ileal pouch-anal anastomosis is the choice surgical procedure for patients with ulcerative colitis. In cases of Crohn's disease post-operative diagnosis, it can be followed by pouch failure. AIM: To evaluate ileal pouch-anal anastomosis long-term outcome in patients with Crohn's disease. METHODS: Between February 1983 and March 2007, 151 patients were submitted to ileal pouch-anal anastomosis by Campinas State University Colorectal Unit, Campinas, SP, Brazil, 76 had pre-operative ulcerative colitis diagnosis and 11 had post-operative Crohn's disease diagnosis. Crohn's disease diagnosis was made by histopathological biopsies in nine cases, being one in surgical specimen, two cases in rectal stump, small bowel in two cases, ileal pouch in three and in perianal abscess in one of them. The median age was 30.6 years and eight (72.7%) were female. RESULTS: All patients had previous ulcerative colitis diagnosis and in five cases emergency colectomy was done by toxic megacolon. The mean time until of Crohn's disease diagnosis was 30.6 (6-80) months after ileal pouch-anal anastomosis. Ileostomy closure was possible in 10 cases except in one that had ileal pouch fistula, perianal disease and small bowel involvement. In the long-term follow-up, three patients had perineal fistulas and one had also a pouch-vaginal fistula. All of them were submitted to a new ileostomy and one had the pouch excised. Another patient presented pouch-vaginal fistula which was successfully treated by mucosal flap. Three patients had small bowel involvement and three others, pouch involvement. All improved with medical treatment. Presently, the mean follow-up is 76.5 months and all patients are in clinical remission, and four have fecal diversion. The remaining patients have good functional results with 6-10 bowel movements/day. CONCLUSION: Crohn's disease diagnosis after ileal pouch-anal anastomosis for ulcerative colitis may be usual and later complications such fistulas and stenosis are common. However, when left in situ ileal pouch is associated with good function.

Desmoid tumor in patients with familial adenomatous polyposis

CONTEXT: Desmoid tumors constitute one of the most important extraintestinal manifestations of familial adenomatous polyposis. The development of desmoids is responsible for increasing morbidity and mortality rates in cases of familial adenomatous polyposis. OBJECTIVES: To evaluate the occurrence of desmoid tumors in familial adenomatous polyposis cases following prophylactic colectomy and to present patient outcome. METHODS: Between 1984 and 2008, 68 patients underwent colectomy for familial adenomatous polyposis at the School of Medical Sciences Teaching Hospital, University of Campinas, SP, Brazil. Desmoid tumors were found in nine (13.2%) of these patients, who were studied retrospectively by consulting their medical charts with respect to clinical and surgical data. RESULTS: Of nine patients, seven (77.8%) were submitted to laparotomy for tumor resection. Median age at the time of surgery was 33.9 years (range 22-51 years). Desmoid tumors were found in the abdominal wall in 3/9 cases (33.3%) and in an intra-abdominal site in the remaining six cases (66.7%). Median time elapsed between ileal pouch-anal anastomosis and diagnosis of desmoid tumor was 37.5 months (range 14-60 months), while the median time between colectomy with ileorectal anastomosis and diagnosis was 63.7 months (range 25-116 months). In 6/9 (66.7%) patients with desmoid tumors, the disease was either under control or there was no evidence of tumor recurrence at a follow-up visit made a mean of 63.1 months later (range 12-240 months). CONCLUSIONS: Desmoid tumors were found in 13.2% of cases of familial adenomatous polyposis following colectomy; therefore, familial adenomatous polyposis patients should be followed-up and surveillance should include abdominal examination to detect signs and symptoms. Treatment options include surgery and clinical management with antiestrogens, antiinflammatory drugs or chemotherapy.

PARAFAC: uma ferramenta quimiométrica para tratamento de dados multidimensionais. Aplicações na determinação direta de fármacos em plasma humano por espectrofluorimetria

Since the last decade, the combined use of chemometrics and molecular spectroscopic techniques has become a new alternative for direct drug determination, without the need of physical separation. Among the new methodologies developed, the application of PARAFAC in the decomposition of spectrofluorimetric data should be highlighted. The first objective of this article is to describe the theoretical basis of PARAFAC. For this purpose, a discussion about the order of chemometric methods used in multivariate calibration and the development of multi-dimensional methods is presented first. The other objective of this article is to divulge for the Brazilian chemical community the potential of the combination PARAFAC/spectrofluorimetry for the determination of drugs in complex biological matrices. For this purpose, two applications aiming at determining, respectively, doxorrubicine and salicylate in human plasma are presented.

Avaliação da qualidade de vida em pacientes idosos um ano após o tratamento cirúrgico de fraturas transtrocanterianas do fêmur

OBJECTIVE: Evaluate the impact that trochanteric hip fractures produce on life quality of elderly patients, treated surgically, during one year of monitoring. METHODS: Were selected 73 elderly with transtrochanteric femur fracture, aged equal or over than 65 years and of both sexes. All participants underwent a standardized questionnaire which obtained information on lifestyle habits, functionality, physical activity, ambulation and cognitive state. Were excluded patients who died, not walking, with neurological diseases and pathological fractures. RESULTS: The average age was 80.17 ± 7.2 years and 75% was female. When comparing the summation of activities of daily living (p = 0.04) and instrumental daily living (p = 0.004) obtained before and after fracture, the patients become more dependent after fracture. Activities of daily living that worsened after fracture were bathing (p = 0.04), toileting (p = 0.02) and dressing (p = 0.04). All instrumental activities of daily living showed a significant difference, with functional dependence after fracture, increased need for walking aid (p = 0.00002), aged (p = 0.01) and not doing housework (p = 0.01). The low score on the test Minimental was associated with a greater dependence to perform activities of daily living before (p = 0.00002) and after (p = 0.01) fracture. CONCLUSION: After a year, activities of daily living that depended on the lower limbs worsened significantly, all instrumental activities of daily living were significantly worse in more than 50% of patients and more than half of patients who walked without support lost this ability.

Sistema MINUS® - técnica minimamente invasiva para o tratamento das fraturas transtrocanterianas do fêmur

The MINUS system was developed as a minimally invasive procedure that uses a diaphyseal cephalic extramedullary implant for the treatment of transtrochanteral fractures of the femur in elderly patients. The implant consists of a sliding screw coupled to a plate adapted to the minimally invasive technique. The surgical access is approximately three centimeters in length located on the lateral surface of the hip, below the projection of the small trochanter. A perfectly adapted instrument was used for the procedure, which also requires the use of an image intensifier, reducing surgery time and rate of bleeding. The objective of this study is to present a new instrument and implant, developed specifically for treatment with the minimally invasive technique, reducing the length of the conventional surgical access from 10 to three centimetres. This new implant was given the commercial name of MINUS System.

O comportamento de crianças em tratamento odontológico: intervenção psicofarmacológica

The present investigation evaluated the effects of diazepam used to manage uncooperative behavior of child dental patients. Six participants received placebo or diazepam (0,3 mg/kg weight) before formal dental treatment at total 54 sessions that were all recorded in videotapes. The analysis of recorded child (crying, body and/or head movements, escape and avoidance) and dentist's behavior management procedures (distraction, explanation, positive reinforcement) indicates no differences by using a double-blind Wilcoxon design (p>0.05). It is suggested the necessity of methodological refinement in studies that combine psychological and pharmacological handling strategies.

Medo, ansiedade e controle relacionados ao tratamento odontológico

The aim of this study was to test fear, anxiety and control related to dental treatment. The subjects were 364 children with ages between 7 and 13 years. Three questionnaires with multiple choice questions were applied in groups of 10 children. The first instrument was the 15-item dental subscale from the Children’s Fear Survey Schedule9. The subjects rated their level of fear on a 5-point scale. The second survey instrument was the 20-item subscale from the State Trait Anxiety Inventory for Children16. This measure was used to capture how anxious the child was, in general. The third instrument was the Child Dental Control Assessment19. It contained 20 items to assess perceived control and 20 items to assess desired control. The results of the survey indicated that dental fear and anxiety were slightly higher for females when compared with male subjects (P < 0.05). Older children (11 to 13 years old) obtained higher fear scores than younger ones (7 to 9 years old). Concerning perceived control, the results indicate that younger children perceive more control than older ones. For desired control, the results indicate that younger children reported higher percentages than older ones. In this study, patients who had undergone anesthesia during treatment revealed higher fear scores when compared with those who had not. Dental fear etiology seems to be related to a procedure that may involve pain or lack of control.

Diabetologia intervencional: uma nova abordagem para o tratamento cirúrgico do diabetes tipo 2

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Consenso brasileiro para a abordagem clínica e tratamento do hipotireoidismo subclínico em adultos: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia

INTRODUCTION: Subclinical hypothyroidism (SCH), defined as elevated concentrations of thyroid stimulating hormone (TSH) despite normal levels of thyroid hormones, is highly prevalent in Brazil, especially among women and the elderly. Although an increasing number of studies have related SCH to an increased risk of coronary artery disease and mortality, there have been no randomized clinical trials verifying the benefit of levothyroxine treatment in reducing these risks, and the treatment remains controversial. OBJECTIVE: This consensus, sponsored by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism and developed by Brazilian experts with extensive clinical experience with thyroid diseases, presents these recommendations based on evidence for the clinical management of SCH patients in Brazil. MATERIALS AND METHODS: After structuring the clinical questions, the search for evidence in the literature was initially performed in the MedLine-PubMed database and later in the Embase and SciELO - Lilacs databases. The strength of evidence was evaluated according to the Oxford classification system and established based on the experimental design used, considering the best available evidence for each question and the Brazilian experience. RESULTS: The topics covered included SCH definition and diagnosis, natural history, clinical significance, treatment and pregnancy, and the consensus issued 29 recommendations for the clinical management of adult patients with SCH. CONCLUSION: Treatment with levothyroxine was recommended for all patients with persistent SCH with serum TSH values > 10 mU/L and for certain patient subgroups.

Politetrafluoroetileno e esclera humana no tratamento cirúrgico de perfuração escleral em coelhos

Purpose: An experimental study to evaluate the behavior of polytetrafluoroethylene (Gore-Tex®) compared with human sclera, in scleral perforations induced in rabbits eyes was performed. Methods: Twenty-two eyes of rabbits were submitted to scleral perforation followed by Gore-Tex® graft in the left eye and human sclera graft in the right eye respectively. During one month the postoperative evolution was analyzed every day: intensity of hyperemia, presence of infection, secretion, rejection and tonicity of the eyes. Results: No cases of secretion, infection or rejection were observed. The histological sections showed fibrosis in the eyes with Gore-Tex®, good adhesion and epithelization. Conclusion: The Gore-Tex® showed to be a plausible material to be used as graft in scleral defects with some advantages such as easy obtention, good handling and durability.

Tratamento da retinopatia diabética: percepções de pacientes em Rio Claro (SP) - Brasil

PURPOSE: To collect information and opinions from a group of diabetic patients regarding diabetic retinopathy and its treatment, in order to get reliable information that can help to improve programs and actions to control and prevent this ocular disease. METHODS: A cross-sectional study was performed. The sample was from 980 diabetic patients seen in a diabetic association. A previous questionnaire was made with general questions about the main subject. Thereafter, an appropriate questionnaire was prepared. RESULTS: The sample showed that among 299 patients with age ranging from 16 to 83 years, with a mean of 57 years, mainly female (67.91%) did not know how severe their disease was (30.8%), or believed that it was not a serious problem (19.7%). The laser technique to solve diabetic retinopathy was known by 60.2% of the patients. It was reported as the only treatment available by 24.1%. Among the reasons for no treatment 59.8% reported that they did not think it was necessary and 29.7% could not afford it. CONCLUSIONS: Patients showed lack of knowledge about how serious is diabetic retinopathy, the possibility of using laser technique for it and the severity of the disease. Some patients believed in the efficacy of the treatment and some patients did not, but all of them reported that they were afraid of submitting to it.

Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia infantil

From December-1965 to November-1969, 95 hydrocephalic infants have been operated upon using ventriculoperitoneal shunt with valve (88 cases with a Spitz-Holter valve, 6 cases with a Hakim valve and one case with a Pudenz-Heyer valve). Up to the present time (December, 1970) a total of 54 children are alive with a compensated hydrocephalus and 9 patients died, being impossible to follow-up the 32 remaining cases. The use of the ventriculoperitoneal shunt has eliminated all cardiovascular-pulmonary complications and reduced the number for surgical revisions. Besides, infections involving the draining system are less severe and more easily controlled than those occurring in the ventriculoatrial shunts. After analysis of the surgical techniques as well as complications and results the following conclusions are stated: 1) the use of a valve in the ventriculoperitoneal shunt difficults the oclusion of the peritoneal end of the draining system; 2) good results can be expected without reoperations in about 42,35% of hydrocephalus cases treated by ventriculoperitoneal shunt with valve; 3) ventriculoperitoneal shunts with valve showed better results when compared to ventriculoatrial shunts. This statement is made comparing two groups of hydrocephalic infants submitted to surgery at the same Service and in the same conditions, with the same follow-up period; 4) the cases presented permit to state that at present time the ventriculoperitoneal shunt with valve is the most suitable surgical procedure for hydrocephalus.

Tratamento dos abscessos intracranianos por trepanopunção

The cases of nine pacients with intracranial abscess operated on by aspiration are reported. Only one patient did not survive. One pacient developed postoperative seizures and, another, hemiparesis. In 5 cases it was necessary a relief of increased intracranial pressure by neurosurgical emergency.