Fabiana Borba Valiatti

Infecçäo bacteriana no paciente cirrótico

RACIONAL: Em torno de 30% dos pacientes com cirrose hepatica apresentam infeccao bacteriana na admissao hospitalar ou a desenvolvem durante a mesma. As infeccoes bacterianas sao responsaveis por ate 25% das mortes nesta populacao de pacientes. OBJETIVO: Avaliar a prevalencia de infeccao bacteriana em uma populacao de pacientes cirroticos internados em hospital geral, bem como correlacionar sua presenca com a etiologia alcoolica da hepatopatia, com o grau de comprometimento da funcao hepatica e com a presenca de hemorragia digestiva alta. PACIENTES E METODOS: Foram avaliadas retrospectivamente 541 internacoes hospitalares consecutivas em 426 pacientes com cirrose hepatica, internados no periodo de 1992 a 2000. A media de idade destes pacientes foi de 50,5 anos (15-95), sendo 71,2% do sexo masculino. Etiologia alcoolica da hepatopatia esteve presente em 35,4% dos pacientes. Alta ou obito do paciente no periodo da internacao hospitalar foi considerado como principal desfecho. O nivel de significância considerado na analise estatistica foi de 5%. RESULTADOS: As infeccoes bacterianas ocorreram em 25% dos cirroticos (135 episodios). Destas, as mais frequentes foram: a infeccao do trato urinario em 31,1%, a peritonite bacteriana espontânea em 25,9% e a broncopneumonia em 25,2%. Ocorreu associacao de infeccao urinaria e broncopneumonia em 3,7% e infeccao de pele e tecido celular subcutâneo em 11,11%. Bacteremia sem foco definido ocorreu nos quatro casos restantes (2,9%). Houve associacao da presenca de infeccao com a etiologia alcoolica da hepatopatia, com a classificacao de Child-Pugh e com a ocorrencia de hemorragia digestiva alta. A mortalidade hospitalar foi maior nos pacientes infectados (8,9%), estando a mesma associada ao grau de disfuncao hepatocelular. CONCLUSOES: A ocorrencia de infeccao bacteriana no paciente cirrotico hospitalizado e frequente e correlaciona-se com a etiologia alcoolica da hepatopatia, com a reserva funcional hepatica e com a presenca de sangramento digestivo. Alem disso, a presenca de infeccao bacteriana correlaciona-se com mau prognostico.

Is being small for gestational age a risk factor for retinopathy of prematurity? A study with 345 very low birth weight preterm infants

OBJECTIVE To analyze prevalence and risk factors for retinopathy of prematurity (ROP) among preterm infants born small for gestational age (SGA) and appropriate for gestational age (AGA). METHODS A prospective cohort study included preterm infants with birth weight (BW) < or = 1,500 grams and gestational age (GA) < or = 32 weeks, divided into two groups: AGA or SGA. Prevalences and risk factors for ROP were determined in both groups. Logistic regression was used for the significant variables after univariate analysis. RESULTS A total of 345 patients were examined: 199 included in the AGA group and 146 in the SGA. Mean BW and GA in the whole cohort (345 patients) were 1,128.12 grams (+/-239.9) and 29.7 weeks (+/-1.9), respectively. The prevalence of any stage ROP and severe ROP (needing treatment) was 29.6 and 7.0%, respectively. ROP in any evolutive stage developed in 66 AGA (33.2%) and in 36 SGA (24.7%) (p = 0.111). Severe ROP occurred in 15 AGA (7.5%) and in nine SGA (6.2%) (p = 0.779). After adjusted logistic regression, weight gain from birth to sixth week of life and need for blood transfusions were found to be significant risk factors for ROP in both groups. CONCLUSIONS This study has shown that being SGA was not a significant risk factor for any stage ROP or for severe ROP in this cohort and, also, that the risk factors for ROP were similar among SGA and AGA very-low-birth-weight preterm babies.

Papel do fator de crescimento vascular endotelial na angiogênese e na retinopatia diabética

Diabetic retinopathy (DR), a DM microvascular complication, is the leading cause of blindness. Angiogenic factors such as vascular endothelial growth factor (VEGF) are involved in the pathogenesis of DR. VEGF-A is a potent, multifunctional cytokine that acts through the receptors VEGFR-1 and VEGFR-2 expressed in the vascular endothelium and causing increased vascular permeability and neovascularization stimulation in both physiological and pathological processes. The expression of VEGFR-1 is upregulated by hypoxia and is less responsive to VEGF compared to VEGFR-2 which is the main mediator mitogenic, angiogenic, and increased vascular permeability. VEGF polymorphisms have been studied in DR susceptibility and progression. Significant association between the polymorphism 634C / G and the presence of RD is reported mainly in relation to allele C. The homozygous CC is associated to proliferative RD and to increased vitreous and serum levels of VEGF suggesting that the presence of the C allele is an independent risk factor for RD. The knowledge of VEGF lead to the development of anti-VEGF drugs (pegaptanib, ranibizumab and bevacizumab) aiming to prevent pathological neovascularization. The anti-VEGF therapy is a reality in practice medical treatment of DR.

Prevalence of retinopathy of prematurity: an institutional cross-sectional study of preterm infants in Brazil

OBJECTIVE Retinopathy of prematurity (ROP) is the leading cause of childhood blindness in most developed countries. This study aimed to verify ROP prevalence among all very low birth weight (VLBW) preterm infants admitted to a level-3 teaching hospital in Porto Alegre, Rio Grande do Sul, Brazil. METHODS Institutional cross-sectional study of 407 premature infants with birth weight < or = 1,500 g or gestational age (GA) < or =32 weeks between 2002 and 2007. All infants screened for ROP were examined after the fourth week of life and followed up until the 45th week of adjusted GA. ROP prevalence was estimated at a 95% confidence level. RESULTS Some degree of ROP in one or both eyes occurred in 25.5% (104) of all screened infants, and severe ROP (threshold stage 3 or higher, requiring treatment to prevent vision loss, as per the criteria of the U.S.-based Multicenter Trial of Cryotherapy for Retinopathy of Prematurity, CRYO-ROP) occurred in 5.8% (24). Based on the criteria of The International Classification for Retinopathy of Prematurity (ICROP, 1984/1987), the disease reached stages 1, 2, and 3 in 11.3% (46), 8.4% (34), and 5.4% (22), respectively. One infant developed the disease up to stage 4 (partial retinal detachment), and one progressed to stage 5 (complete retinal detachment, resulting in 0.2% overall prevalence for ROP-induced blindness). CONCLUSIONS Overall incidence of ROP in this institutional study (25.5%) was comparable to international results from developed countries. A comprehensive countrywide survey on ROP in Brazil is recommended to determine any regional differences in disease prevalence.

Diabetic retinopathy is associated with early autonomic dysfunction assessed by exercise-related heart rate changes

Diabetic retinopathy has been associated with cardiac autonomic dysfunction in both type 1 and type 2 diabetes mellitus (DM) patients. Heart rate (HR) changes during exercise testing indicate early alterations in autonomous tonus. The aim of the present study was to investigate the association of diabetic retinopathy with exercise-related HR changes. A cross-sectional study was performed on 72 type 2 and 40 type 1 DM patients. Autonomic dysfunction was assessed by exercise-related HR changes (Bruce protocol). The maximum HR increase, defined as the difference between the peak exercise rate and the resting rate at baseline, and HR recovery, defined as the reduction in HR from the peak exercise to the HR at 1, 2, and 4 min after the cessation of the exercise, were determined. In type 2 DM patients, lower maximum HR increase (OR = 1.62, 95%CI = 1.03-2.54; P = 0.036), lower HR recovery at 2 (OR = 2.04, 95%CI = 1.16-3.57; P = 0.012) and 4 min (OR = 2.67, 95%CI = 1.37-5.20; P = 0.004) were associated with diabetic retinopathy, adjusted for confounding factors. In type 1 DM, the absence of an increase in HR at intervals of 10 bpm each during exercise added 100% to the odds for diabetic retinopathy (OR = 2.01, 95%CI = 1.1-3.69; P = 0.02) when adjusted for DM duration, A1c test and diastolic blood pressure. In conclusion, early autonomic dysfunction was associated with diabetic retinopathy. The recognition of HR changes during exercise can be used to identify a high-risk group for diabetic retinopathy.

Late afternoon blood pressure increase is associated with diabetic retinopathy in normotensive type 2 diabetes mellitus patients

AIMS To identify if the variability of blood pressure (BP) is associated with diabetic retinopathy (DR) in normotensive type 2 DM patients. METHODS Sixty-five normotensive type 2 DM patients that had 24-h ambulatory BP monitoring (ABPM) were grouped according any degree of DR. RESULTS Fourteen (21%) patients had DR. Office BP and 24-h BP parameters did not differ between groups. At late afternoon period, patients with DR had higher increment in both systolic (11.3+/-12.7mmHg vs. 1.0+/-11.4mmHg, P=0.006) and diastolic (6.7+/-8.6mmHg vs. -0.73+/-10.0mmHg, P=0.017) BP levels than those without. Multivariate logistic analyses were performed with DR as a dependent variable. Each 1mmHg increment in systolic BP at the late afternoon period was associated with a 10.2% increase in DR prevalence [OR 1.102 (CI 95% 1.011-1.202, P=0.027)], after adjustments for A1C test, DM duration, age, albuminuria and current smoking. CONCLUSIONS In conclusion, in normotensive type 2 DM patients, BP increase at late afternoon is associated to DR independently from confounder factors or other ABPM parameters.

Postconceptional age at the treatment of retinopathy of prematurity in inborn and referred preterm infants from the same institution

PURPOSE The outcomes of the treatment of retinopathy of prematurity (ROP) seem to be better in inborn patients than in those patients who were referred for ROP treatment. This study aims to investigate the timing of treatment and the outcomes in inborn patients and in patients referred for treatment to the Hospital de Clínicas de Porto Alegre, Brazil. METHODS An institutional prospective cohort study was conducted from 2002 to 2010 and included in group 1 all inborn preterm neonates treated for retinopathy of prematurity and in group 2 all babies referred for treatment to the same institution. All of the included patients presented birth weight (BW) ≤1,500 g and/or gestational age (GA) ≤32 weeks. Main outcomes were postconceptional age at the treatment and one year follow-up outcomes in both groups. The considered variables were: BW, GA, stage and location of retinopathy of prematurity at treatment. RESULTS Group 1 comprised 24 inborn patients. Mean BW and GA at birth were 918 ± 232 g and 28.2 ± 2.1 weeks, respectively, and median post-conceptional postconceptional age at treatment was 37 weeks. Group 2 comprised 14 infants transferred for treatment. Mean BW and GA at birth were 885 ± 188 g and 28.2 ± 2.4 weeks, respectively, and median postconceptional age at treatment was 39 weeks. Mean BW and GA were similar in both groups (P=0.654 and P=0.949, respectively), but the difference among the postconceptional age was significant (P=0.029). CONCLUSIONS Inborn patients were treated for retinopathy of prematurity during the 37(th) week of postconceptional age while transferred patients were treated, usually, after the 39(th) week postconceptional age. The worst outcomes observed among referred patients could be partially explained by the delayed time for treatment.

Ser pequeno para a idade gestacional é um fator de risco para a retinopatia da prematuridade? Estudo com 345 pré-termos de muito baixo peso

OBJETIVO: Comparar a prevalencia e os fatores de risco para a retinopatia da prematuridade entre pre-termos pequenos para a idade gestacional e pre-termos apropriados para a idade gestacional. METODOS: Estudo de coorte, prospectivo, incluindo pre-termos com peso de nascimento ≤ 1.500 g e idade gestacional ≤ 32 semanas divididos em dois grupos: apropriados para a idade gestacional ou pequenos para a idade gestacional. As prevalencias da retinopatia da prematuridade e os fatores de risco foram estudados nos dois grupos. Regressao logistica foi utilizada apos analise univariada. RESULTADOS: Foram examinados um total de 345 pacientes: 199 no grupo apropriados para a idade gestacional e 146 no grupo pequenos para a idade gestacional. As medias do peso de nascimento e da idade gestacional na coorte de 345 pacientes foram 1.128,12 g (±239,9) e 29,7 semanas (±1,9), respectivamente. A prevalencia da retinopatia da prematuridade em qualquer estadiamento e da retinopatia da prematuridade severa (necessitando tratamento) foi 29,6 e 7%, respectivamente. A retinopatia da prematuridade em qualquer estadiamento ocorreu em 66 apropriados para a idade gestacional (33,2%) e em 36 pequenos para a idade gestacional (24,7%) (p = 0,111). A retinopatia da prematuridade severa ocorreu em 15 apropriados para a idade gestacional (7,5%) e em nove pequenos para a idade gestacional (6,2%) (p = 0,779). Apos regressao logistica ajustada, o ganho ponderal do nascimento ate a sexta semana de vida e a necessidade de transfusoes sanguineas foram fatores de risco significativos para a retinopatia da prematuridade nos dois grupos. CONCLUSOES: Este estudo mostrou que ser pequenos para a idade gestacional nao foi um fator de risco significativo para o surgimento da retinopatia da prematuridade e que os fatores de risco para a retinopatia da prematuridade sao semelhantes em pre-termos pequenos para a idade gestacional e apropriados para a idade gestacional.

Incidence of retinopathy and neonatal nurse practioner’s role in prevention of blindness due to retinopathy of prematurity at Hospital de Clínicas de Porto Alegre, Brazil – prospective observational descriptive study

Introduction: Retinopathy of prematurity is a leading cause of blindness in children in middle-income countries. Recent improvements in the intensive neonatal cares allied with better personal qualification for assistance to the pre-term neonate increased survival rates among very low birth weight infants. This study aims to evaluate the incidence of the disease in premature children born at Hospital de Clinicas de Porto Alegre - Brazil, and also to describe the neonatal nurse practioner’s in prevention of blindness at this institution. Methods: A prospective observational descriptive study was conducted on 329 premature children born with birth weight ≤ 1.500 grams and/or ≤ 32 weeks of gestational age between October of 2002 and October of 2006. All of the children were examined by indirect binocular ophthalmoscopy after pupil dilation with association of Tropicamide 0.5% and Phenylephrine 2.5%, eye drops. The ophthalmological examination was first conducted between the 4th and the 6th weeks of life and repeated according the findings based in the international classification. Results: Retinopathy was diagnosed in 84 of the neonates with an incidence rate of 25.5% (84/329). Eighteen of the 329 screened children (5.5%) reached threshold disease and 17 of them needed diode laser treatment to prevent the disease progression. One patient missed the treatment. Conclusions: The incidence of retinopathy was similar to other international results as well as the occurrence of 5.2% of treatable disease. Only one of the infants developed the disease up to the most serious stage (ROP 5), resulting in a 0.3% of blindness due to the retinopathy at the institution since 2002.