Efeito da implementação de diretriz para profilaxia de tromboembolismo venoso em pacientes cirúrgicos

INTRODUÇÃO: Estratégias efetivas para profilaxia do tromboembolismo venoso (TEV) são amplamente disponíveis, mas são ainda subutilizadas, principalmente no nosso meio. OBJETIVO: Avaliar o efeito da implementação de diretriz para profilaxia do TEV, em pacientes cirúrgicos, sobre a conduta da equipe de saúde na prescrição dessa profilaxia. Método. Estudo retrospectivo pré-intervenção - pós-intervenção. Prontuários de 150 pacientes antes e 150 depois da implementação de uma diretriz para a profilaxia (AID e DID) foram sorteados dentre pacientes de mais de 40 anos internados para cirurgia maior abdominal ou ortopédica. Foram registrados dados demográficos, referência a risco de TEV no prontuário, prescrição de profilaxia para TEV e diagnóstico de TEV durante a internação. RESULTADOS: Não houve diferença entre os dois grupos, AID e DID, quanto aos dados demográficos e ao tempo de profilaxia (5,6 x 6,6 dias). A frequência de profilaxia AID x DID antes da cirurgia foi: profilaxia farmacológica (PF), 6% x 9%; meias de compressão graduada (MCG), 4% x 3%; compressão pneumática intermitente (CPI), 2% x 3%. Após cirurgia: PF 53% x 53%; MCG, 23% x 40% (P<0,05); CPI, 26% x 32% . No total, AP, foi prescrita profilaxia para 60,5% dos pacientes AID e para 66,5% DID, mas a profilaxia foi considerada adequada em 34% dos pacientes AID e em 32% DID. Conclusão. A adoção do protocolo, embora com maior a preocupação com a profilaxia, traduzida pelo aumento na prescrição de MCG, melhorou minimamente sua qualidade, indicando a necessidade de outras intervenções ativas e contínuas para aumentar a aderência ao mesmo.

REVERSIBILITY OF ADENOMATOUS HYPERPLASIA IN THE GASTRIC STUMP AFTER DIVERSION OF BILE REFLUX IN RATS

Morphological and phenotypical patterns of proliferative epithelial lesions induced in the gastric stump mucosa by duodenal content reflux after Billroth II partial gastrectomy (BII) were evaluated in rats. Control animals were either sham-operated or submitted at different times after BII to Roux-en-Y (RY) surgical procedure which prevents duodenal reflux. The lesions were analysed using routine haematoxylin and eosin staining, immunohistochemical staining for pepsinogen isoenzyme 1 and histochemical procedures for mucins (paradoxical Concanavalin A, galactose oxidase Schiff and sialidase galactose oxidase Schiff reactions). Mucosal hyperplasia (H) was observed in the group submitted to BII procedure 6 weeks after surgery. Adenomatous hyperplasia (AH) also appeared 6 weeks after induction of the reflux and its incidence and size increased until the 54th week of the experiment. RY procedure performed in the normal animals at the beginning of the experiment or at the 24th week after BII gastrectomy led to a significantly lower incidence of AH which was related to the moment of surgery. Most of H was due to pyloric mucosal hyperplasia. AH consisted mainly of gastric type glands but in some animals glands of the intestinal type Were present probably originating from the intestinal mucosa. Six mucinous adenocarcinomas were observed, all of them of intestinal type. This study demonstrates that AH induced by BII procedure is a reversible lesion and that the anomalous epithelial proliferation in the stoma may lead to adenocarcinomas.

DEVELOPMENT OF BLOOD-PRESSURE AND CARDIAC REFLEXES IN THE FROG PSEUDIS-PARADOXSUS

Systemic arterial blood pressure and heart rate (f(H)) were measured in unanesthetized, unrestrained larvae and adults of the paradoxical frog, Pseudis paradoxus from São Paulo State in Brazil. Four developmental groups were used, representing the complete transition from aquatic larvae to primarily air-breathing adults. f(H) (49-66 beats/min) was not significantly affected by development, whereas mean arterial blood pressure was strongly affected, being lowest in the stage 37-39 larvae (10 mmHg), intermediate in the stage 44-45 larvae (18 mmHg), and highest in the juveniles and adults (31 and 30 mmHg, respectively). Blood pressure was not significantly correlated with body mass, which was greatest in the youngest larvae and smallest in the juveniles. In the youngest larvae studied (stages 37-39), lung ventilation was infrequent, causing a slight decrease in arterial blood pressure but no change in heart rate. Lung ventilation was more frequent in stages 44-45 larvae and nearly continuous in juveniles and adults floating at the surface. Bradycardia during both forced and voluntary diving was observed in almost every advanced larva, juvenile, and adult but in only one of four young larvae. Developmentally related changes in blood pressure were not complete until metamorphosis, whereas diving bradycardia was present at an earlier stage.

Long-term histopathologic evaluation of inferior vena cava after modified Greenfield filter implantation - Experimental study in sheep

Aim. The authors assess a modified Greenfield filter (GF) for the long-term patency, filter tilting and histopathologic alterations of the inferior vena cava (IVC).Methods. Adult sheep (n=7) underwent modified GF placement in the IVC. Cavograms were obtained every 3 months and pulmonary angiography at 12 months. Histopathologic and scanning electron microscopy (SEM) analyses were performed on the IVC explanted at 12 months.Results. Cavograms showed that all IVC were patent at the end of the study. Filter tilting occurred in 2/7 animals and extrusion of struts was not observed. Macroscopic examination at explantation showed minimal venous wall thickening. Microscopic examination showed minimal IVC fibrosis and intimal hyperplasia. SEM showed endothelium on the IVC surface at the filter implantation site and a presumed endothelial layer covering partially or totally the struts. The interface filter-IVC was covered by deposits of leucocytes and platelets. No signs of pulmonary embolism were found in all pulmonary angiograms of both groups.Conclusion. The modified filter presented good biocompatibility, stability and absence of thrombogenicity at 12 months. It presented low tendency to tilting and extrusion of struts. The long-term histopathologic alterations in vena caval wall were minimal and the appearance of the studied filters in the IVC was similar to stents placed in the arterial system.

REDUCTION OF CELL PROLIFERATIVE ACTIVITIES OF GASTRIC STUMP ADENOMATOUS HYPERPLASIAS AFTER BILE REFLUX DIVERSION IN RATS

Previously we reported the majority of lesions induced hy bile reflux, in the absence of chemical carcinogens, in the rat remnant stomach to consist primarily of gastric type and secondarily of intestinal type cells, and that they are reversible after diversion of bile reflux. The present study was designed to evaluate changes in proliferative activities in cells of each type under these conditions. The frequency of adenomatous hyperplasia (AH) induced in the gastric stump mucosa by duodenal content reflux after Billroth II partial gastrectomy (BII) increased until the 54th week of the experiment. Roux-en-Y (RY) surgical procedure which prevents duodenal reflux performed at the 24th or 36th week after BII led to a decrease in AH. Cell content of the lesions was analyzed using routine H&E staining, immunohistochemical staining for pepsinogen isoenzyme 1 and histochemical procedures for mucins (paradoxical concanavalin A, galactose oxidase Schiff and sialidase galactose oxidase Schiff reactions) and proliferation in each compartment evaluated by an immunohistochemical method using bromodeoxyuridine (BrdU) and a monoclonal antibody against BrdU. At the 54th week the number of BrdU-labeled cells per normal pyloric column was significantly (P < 0.05) increased to 10.63/pit after the BII operation, while it diminished to 5.23/pit after RY diversion, this being the same level as with the RY procedure alone. AH maintained a high rate of BrdU incorporation at 12.7% after BII operation, which was also significantly reduced (P < 0.01) to 7.0% by the RY surgery. The intestinal type cell showed highest (22.2%), the surface mucous type cell showed the next (16.5%) and the pyloric gland type cell showed lowest (5.2%) BrdU labeling indices after BII operation. All the cell types in AH showed similar proportional decreases in BrdU incorporation after RY diversion. Thus surgical intervention reverses the cell proliferation caused by bile reflux in the gastric stump.

An open-label, comparative study of the efficacy and safety of once-daily dose of enoxaparin versus unfractionated heparin in the treatment of proximal lower limb deep-vein thrombosis

Background: Treatment of deep-vein thrombosis (DVT) with a once-daily regimen of enoxaparin, rather than a continuous infusion of unfractionated heparin (UFH) is more convenient and allows for home care in some patients. This study was designed to compare the efficacy and safety of these two regimens for the treatment of patients with proximal lower limb DVT. Methods: 201 patients with proximal lower limb DVT from 13 centers in Brazil were randomized in an open manner to receive either enoxaparin [1.5 mg/kg subcutaneous (s.c.) OD] or intravenous (i.v.) UFH (adjusted to aPTT 1.5-2.5 times control) for 5-10 days. All patients also received warfarin (INR 2-3) for at least 3 months. The primary efficacy endpoint Was recurrent DVT (confirmed by venography or ultrasonography), and safety endpoints included bleeding and serious adverse events. The rate of pulmonary embolism (PE) was also collected. Hospitalization was at the physician's discretion. Results: Baseline patient characteristics were comparable between groups. The duration of hospital stay was significantly shorter with enoxaparin than with UFH (3 versus 7 days). In addition, 36% of patients receiving enoxaparin did not need to be hospitalized, whereas all of the patients receiving UFH were! hospitalized. The treatment duration was slightly longer with enoxaparin (8 versus 7 days). There was a nonsignificant trend toward a reduction in the rate of recurrent DVT with enoxaparin versus UFH, and similar safety. Conclusions: A once-daily regimen of enoxaparin 1.5 mg/kg subcutaneous is at least as effective and safe as conventional treatment with a continuous intravenous infusion of UFH. However, the once daily enoxaparin regimen is easier to administer (subcutaneous versus intravenous), does not require aPTT monitoring, and leads to both a reduced number of hospital admissions and an average 4-day-shorter hospital stay. (C) 2004 Elsevier Ltd. All rights reserved.

Response to Treatment in a Prospective Cohort of Patients with Large Ulcerated Lesions Suspected to Be Buruli Ulcer (Mycobacterium ulcerans Disease)

Background: The World Health Organization (WHO) advises treatment of Mycobacterium ulcerans disease, also called Buruli ulcer'' (BU), with a combination of the antibiotics rifampicin and streptomycin (R+S), whether followed by surgery or not. In endemic areas, a clinical case definition is recommended. We evaluated the effectiveness of this strategy in a series of patients with large ulcers of >= 10 cm in longest diameter in a rural health zone of the Democratic Republic of Congo (DRC).Methods: A cohort of 92 patients with large ulcerated lesions suspected to be BU was enrolled between October 2006 and September 2007 and treated according to WHO recommendations. The following microbiologic data were obtained: Ziehl-Neelsen (ZN) stained smear, culture and PCR. Histopathology was performed on a sub-sample. Directly observed treatment with R+S was administered daily for 12 weeks and surgery was performed after 4 weeks. Patients were followed up for two years after treatment.Findings: Out of 92 treated patients, 61 tested positive for M. ulcerans by PCR. PCR negative patients had better clinical improvement than PCR positive patients after 4 weeks of antibiotics (54.8% versus 14.8%). For PCR positive patients, the outcome after 4 weeks of antibiotic treatment was related to the ZN positivity at the start. Deterioration of the ulcers was observed in 87.8% (36/41) of the ZN positive and in 12.2% (5/41) of the ZN negative patients. Deterioration due to paradoxical reaction seemed unlikely. After surgery and an additional 8 weeks of antibiotics, 98.4% of PCR positive patients and 83.3% of PCR negative patients were considered cured. The overall recurrence rate was very low (1.1%).Interpretation: Positive predictive value of the WHO clinical case definition was low. Low relapse rate confirms the efficacy of antibiotics. However, the need for and the best time for surgery for large Buruli ulcers requires clarification. We recommend confirmation by ZN stain at the rural health centers, since surgical intervention without delay may be necessary on the ZN positive cases to avoid progression of the disease. PCR negative patients were most likely not BU cases. Correct diagnosis and specific management of these non-BU ulcers cases are urgently needed.

Arteriovenous fistula between the right internal mammary artery and the subclavian vein: percutaneous closure with detachable ballooncatheter embolization

A case of iatrogenic fistula from the right internal mammary artery to the subclavian vein following subclavian vein catheterization is reported. The patient had undergone percutaneous Intracath catheterization of the subclavian vein to treat hypovolemic shock during the surgical treatment of ectopic pregnancy. She had remained symptom-free for 7 years and then started to complain of effort dyspnea. The patient was found to have a thrill and a bruit at the subclavian region, and arteriography demonstrated a fistula between the right internal mammary artery and the subclavian vein. The fistula was successfully closed by embolization with a percutaneous detachable balloon catheter. © 1993.

Anormalidade pupilar rara na sinusopatia maxilar

Sinusitis can affect adjacent tissues, including those of the nervous system. In this report we describe a case of maxillary sinusopathy causing a rare pupillary abnormality with paradoxical reaction to light. As far as we know, this is the first time that this association has been described.

Lesões intestinais decorrentes de isquemia e reperfusão: Fisiopatologia e modelos experimentais

The intestinal ischemia is unusual in vascular surgery emergency. Its main causes are embolisms and arterial thrombosis. In addition to severe ischemia, reperfusion of the ischemic tissues can lead to several complications that may worsen the ischemic lesion and produce a life threatening situation caused by systemic alterations. Intestinal tissue injuries due to ischemia and reperfusion have been demonstrated in clinical and experimental studies, in which pathophysiology and adequate treatment were also studied. The great variety of experimental models used and results achieved reflect the need for an intestinal ischemia and reperfusion experimental model that is simple, reproducible and consistent, in order to search for treatments that can reduce the damage caused by this situation. In this review, the main pathophysiologic aspects and the most used experimental models will be reviewed. Copyright © 2005 by Sociedade Brasileira de Angiologia e Cirurgia Vascular.

Abordagem diagnóstica dos pacientes com suspeita de trombose venosa profunda dos membros inferiores

Deep venous thrombosis is a relatively common disease, which can present pulmonary embolism as a complication in its acute phase, and later the post-thrombotic syndrome. Thus, diagnosis should be made as soon as possible, in order to prevent or minimize such complications. Several studies have shown that the symptoms and the clinical signs are inaccurate for the deep venous thrombosis diagnosis and that complementary exams are necessary. As an attempt to simplify the patients' assessment, Well et al., in 1997, developed a clinical prediction index that combines symptoms, signs and risk factors for deep venous thrombosis and managed to make a simpler approach through an association of this index with the complementary exams. Phlebography has been considered the gold standard of complementary exams. However, since it is an invasive exam and thus subject to complications, other diagnostic methods were introduced aiming at making the diagnostic approach simpler and less invasive. Doppler ultrasound, duplex scan, impedance plethysmography, computed tomography, and blood tests such as the D-dimer are some of the available methods for assessing the patient with suspicion of deep venous thrombosis. Among them, duplex scan has shown excellent accuracy and it is currently widely accepted as the first choice test for approaching the patient with deep venous thrombosis. Several authors have suggested an association of diagnostic methods to simplify and make the assessment of such patients more cost-effective, leading to the introduction of a wide range of diagnostic strategies. The different diagnostic methods used for assessing deep venous thrombosis are discussed, as well as a review of the literature on the accuracy, advantages and disadvantages of these methods. Copyright © 2005 by Sociedade Brasileira de Angiologia e Cirurgia Vascular.

Ftalato de di-(2-etilexila) (DEHP) em bolsas de PVC para soluções parenterais de grandes volumes

Large volume parenteral solutions (LVPS) are widely used as vehicles for intravenous administration of drugs and polyvinyl chloride (PVC) flexible bags are, nowadays, the plastic containers most commonly used to pack and drip-feed LVPS. An advantage of using bags is that they collapse flat and thus reduce the risk of airborne contamination and embolism caused by air in the bloodstream. They are mainly used in hospitals. This review deals with some important aspects of the PVC packaging containing the plasticizer DEHP, generally used to pack LVPS. The interaction between drug and package is discussed, with an emphasis on the migration of DEHP from the PVC bag to LVPS containing the immunosuppressant cyclosporin, and toxicological aspects are considered.

Prosthetic rehabilitation of a bone defect with a teeth-implant supported, removable partial denture

The use of teeth-implant, mucosa-supported removable dentures for rehabilitation of partially edentulous patients involves highly complex biomechanical aspects. This type of prosthesis associates 3 kinds of support that react differently to the functional and parafunctional forces developed in the oral cavity. Although the construction of removable partial dentures may seem paradoxical when osseointegrated implants are placed, in some cases, this option is an excellent alternative to solve difficulties related to the anatomic, biologic, psychomotor, and financial conditions of the patient. This article reports on a case in which a teeth-implant, mucosa-supported removable partial denture was the option of choice for a patient with financial and anatomic limitations, having a large structural loss of the residual alveolar ridge caused by trauma by a gunshot injury at the mandible. The 5-year follow-up did not reveal any type of biomechanical or functional problem. Copyright © 2006 by Lippincott Williams and Wilkins.