Joyce Santos Lages

Prevalência e fatores de risco para insuficiência renal aguda no pós-operatório de revascularização do miocárdio

OBJECTIVE To determine the prevalence, risk factors, and the clinical outcome of patients undergone coronary artery bypass grafting who progressed with Acute Renal Failure (ARF). METHODS A retrospective cohort prospective study was performed from data of 186 patients undergone surgery from January 2003 through June 2006. The stored data were analyzed using the software STATA 9.0. RESULTS The prevalence of ARF was of 30.6% (57/186). In 7.0% (4/57) dialysis therapy was needed. The mean age of patients with and without ARF progression was 62.8 (+/-9.4) years and 61.3 (+/-8.8) years respectively (P=NS). CPB time >115 min (p= 0.011) and cross-clamp time >85 min (p=0.044) were related to ARF by the univariate analysis. The need for intra-aortic balloon (P= 0.049), mechanical ventilation >24h (P = 0.006), Intensive Care Unit (ICU) stay > three days (P< 0.0001), bradycardia (P= 0.002), hypotension (P= 0.045), arrhythmia (P=0.005) and inotropic infusion (P= 0.0001) were higher in the ARF group. Only the ICU stay longer > 3 days showed statistical correlation with ARF by the multivariate analysis (P=0.018). The mortality rate with and without ARF was 8.8% (five cases) and 0.8% (one case) respectively (P=0.016), but it reached 50% (2/4) in dialytic patients. CONCLUSION ARF was a frequent and severe postoperative complication associated with higher mortality and longer ICU stay, which presented as risk factors: longer CPB and cross-clamp times, mechanical ventilation > 24h and hemodynamic instability.

Atypical size and location of a right atrial myxoma: a case report

IntroductionPrimary intracardiac tumors are rare and approximately 50% are myxomas. The majority of myxomas are located in the left atrium and have variable clinical presentation. We report a case of a large myxoma in the right atrium, which is an uncommon location for this type of tumor.Case presentationA 45-year-old Caucasian woman with a history of palpitation had dyspnea on great exertion and discrete weight loss. A cardiac evaluation showed splitting of S1. An echocardiogram showed a large mass in the right atrium, suggesting myxoma; chest computed tomography confirmed the diagnostic hypothesis. Our patient underwent surgical treatment with excision of a 10 cm multilobulated mass. She presented with supraventricular tachycardia during the operation. She was placed in the intensive care unit and her condition improved after the use of amiodarone. The diagnosis of myxoma was confirmed by histopathological study.ConclusionsIn this case report, we emphasize the rarity of large myxomas in the right atrium and the difficulty of differential diagnosis given their dimension and location.

Efeito da perda ponderal induzida pela cirurgia bariátrica sobre a prevalência de síndrome metabólica

BACKGROUND Metabolic Syndrome (MS) is often linked to overweight/obesity and can improve after weight loss, such improvement is expected to be proportional to the intensity of weight loss. OBJECTIVE The aim of this study was to evaluate the impact of weight loss induced by bariatric surgery (BS) on the prevalence of MS in a middle-term period. METHODS Thirty-five (35) patients who underwent surgical Rouxs Y gastrojejunal by-pass from October 2001 until October 2005 in our University Hospital were evaluated. 88.5% were female, with a mean age at the time of surgery of 37.8+/-11.1 years and a mean BMI of 45.0+/-6.2 Kg/m(2). During the first stage of our study demographic and clinical-anthropomorphic data were collected prior to the BC procedure, including those criteria needed for the diagnosis of MS, according to the guidelines of the US NCEP. The second stage consisted of reevaluation of those patients in the post-surgical period in order to determine the prevalence of MS in an outpatient setting. RESULTS Prior to surgery, MS was diagnosed in 27 patients (77.1%). When those patients were reevaluated 34.4+/-15 months after surgery, a reduction of mean BMI to 28.3+/-5.0 Kg/m(2) and MS was identified in only two patients (5.7%) (p<0.001). Prevalence of individual criteria such as abdominal circumference, fasting glucose levels, arterial blood pressure, HDL-cholesterol and triglycerides had a reduction of 45.8%, 83%, 87.5%, 57.13% and 94% respectively. CONCLUSION MS is a rather common feature in obese patients enrolled for BS and this procedure has been proved to be extremely efficient reversing the metabolic syndrome, with an expressive reduction of prevalence of each and all of the NCEP criteria.FUNDAMENTO: A sindrome metabolica (SM) esta frequentemente ligada ao excesso de peso e melhora com a perda ponderal, sendo esperado que essa melhora seja proporcional a intensidade dessa perda. OBJETIVO: Avaliar o impacto da perda ponderal induzida pela cirurgia bariatrica (CB) sobre a prevalencia da SM, em medio prazo. METODOS: Foram analisados 35 pacientes submetidos a cirurgia de by-pass gastrojejunal em Y de Roux, no periodo de outubro de 2001 a outubro de 2005, em nosso HU, sendo 88,5% do sexo feminino, com uma media de idade de 37,8±11,1 anos e um IMC medio de 45,0±6,2 kg/m2. Na primeira etapa da pesquisa, foram obtidos dados demograficos e clinico-antropometricos antes da realizacao da CB, incluindo os criterios para o diagnostico da SM, de acordo com as diretrizes do NCEP dos Estados Unidos. Na segunda etapa, os pacientes operados foram reavaliados ambulatorialmente quanto a prevalencia da SM. RESULTADOS:Antes da cirurgia, a SM foi diagnosticada em 27 pacientes (77,1%). Em reavaliacao 34,4±15 meses apos a cirurgia, observou-se uma queda do IMC medio para 28,3±5,0 kg/m2 e a SM foi detectada em apenas dois pacientes (5,7%) (p<0,001). A prevalencia dos criterios cintura abdominal, glicemia, pressao arterial, HDL-colesterol e triglicerideos foi reduzida em, respectivamente, 45,8%, 83%, 87,5%, 57,13% e 94%. CONCLUSAO: A SM e ocorrencia comum em obesos candidatos a CB e esse procedimento se mostrou extremamente eficaz na inducao da regressao da sindrome, verificando-se reducao expressiva da prevalencia de todos os criterios do NCEP.

Is Vitamin D Deficiency a New Risk Factor for Cardiovascular Disease

The role of vitamin D in the regulation of bone metabolism has been well established. However, in recent years, many studies have demonstrated that its role extends far beyond bone health. Growing evidence has shown a strong association between vitamin D deficiency and hypertension, metabolic syndrome, diabetes mellitus and atherosclerosis. The mechanisms by which vitamin D exerts its cardiovascular protective effects are still not completely understood, but there is evidence that it participates in the regulation of renin-angiotensin system and the mechanisms of insulin sensitivity and activity of inflammatory cytokines, besides its direct cardiovascular actions. In this review, several studies linking vitamin D deficiency with cardiometabolic risk as well as small randomized trials that have evaluated the cardiovascular effects of its supplementation are presented. However, large randomized placebo-controlled studies are still needed before we can definitively establish the role of vitamin D supplementation in the prevention and control of cardiovascular disease.

Cystatin C, kidney function, and cardiovascular risk factors in primary hypertension*

OBJECTIVE To investigate the clinical usefulness of serum cystatin C (Scys) and cystatin C-based equations for the screening of chronic kidney disease in primary hypertensive patients, and correlate these markers with risk factors for cardiovascular disease. METHODS A cross-sectional study was performed in 199 middle-aged adults at a basic health unit. Kidney function assessment included measurements of serum creatinine (Scr) and Scys levels, 24-hour microalbuminuria (MA), as well as glomerular filtration rate (GFR) through Larsson and Modification of Diet in Renal Disease (MDRD) study equations. Bland- Altman plot analysis was used to calculate the agreement between equations. RESULTS High levels of Scys were found in 22% of the patients, even with normal values of GFR estimated by MDRD study equation. Systolic blood pressure and MA correlated better with Scys than Scr, but there was no correlation between Scys and diastolic blood pressure. Gender, age > 60 years, MA, and uric acid were significantly associated with high Scys levels. After multivariate analysis, only age > 60 yrs (RR = 6.4; p < 0.001) and male gender (RR = 3.0; p = 0.006) remained associated with high Scys levels. CONCLUSION Cystatin C can be used as a screening marker both for detecting mild declines of renal function and for preventing the risk of cardiovascular events in hypertensive subjects with presumably normal renal function.

Prevalência de verdadeiras crises hipertensivas e adequação da conduta médica em pacientes atendidos em um pronto-socorro geral com pressão arterial elevada

BACKGROUND High blood pressure is a common reason for patients to seek an emergency room, and many of them may possibly be wrongly diagnosed with hypertensive crisis and, consequently, be inappropriately treated. OBJECTIVE To analyze the cases of patients seen in a general emergency room because of high blood pressure as for meeting the criteria for the diagnosis of hypertensive crisis and the appropriateness of medical management. METHODS Of the 1012 patients consecutively seen in a private referral general emergency room in the city of São Luís, State of Maranhão, between August and November 2003, 198 (19.56%) had a main diagnosis of high blood pressure in that visit. Of these, proper information could only be obtained from the patient charts of 169 patients; 54.4% of them were females with a mean age of 53.3 +/- 15.2 years. Data regarding patients and the attendant physicians were collected, and each case was classified as an urgency, emergency or pseudohypertensive crisis; the medical management was classified as appropriate or inappropriate. We also sought to identify the factors associated with the medical management and with the use of antihypertensive medication. RESULTS Criteria for the characterization of a hypertensive crisis were present in only 27 patients (16%), and all were classified as urgencies. Medical management was considered appropriate in 72 cases (42.6%), and was neither influenced by specialty (p=0.5) nor by the physicians experience (p=0.9). Blood pressure levels, but not the presence or absence of symptoms, were predictive of the use of antihypertensive medication (p<0.001). CONCLUSION In the population analyzed, less than one fifth of the patients seen in an emergency room with a presumed hypertensive crisis met defined criteria for this diagnosis. Medical management was considered appropriate in less than half of the occurrences.

Effects of weight loss induced by bariatric surgery on the prevalence of metabolic syndrome

BACKGROUND Metabolic Syndrome (MS) is often linked to overweight/obesity and can improve after weight loss, such improvement is expected to be proportional to the intensity of weight loss. OBJECTIVE The aim of this study was to evaluate the impact of weight loss induced by bariatric surgery (BS) on the prevalence of MS in a middle-term period. METHODS Thirty-five (35) patients who underwent surgical Rouxs Y gastrojejunal by-pass from October 2001 until October 2005 in our University Hospital were evaluated. 88.5% were female, with a mean age at the time of surgery of 37.8+/-11.1 years and a mean BMI of 45.0+/-6.2 Kg/m(2). During the first stage of our study demographic and clinical-anthropomorphic data were collected prior to the BC procedure, including those criteria needed for the diagnosis of MS, according to the guidelines of the US NCEP. The second stage consisted of reevaluation of those patients in the post-surgical period in order to determine the prevalence of MS in an outpatient setting. RESULTS Prior to surgery, MS was diagnosed in 27 patients (77.1%). When those patients were reevaluated 34.4+/-15 months after surgery, a reduction of mean BMI to 28.3+/-5.0 Kg/m(2) and MS was identified in only two patients (5.7%) (p<0.001). Prevalence of individual criteria such as abdominal circumference, fasting glucose levels, arterial blood pressure, HDL-cholesterol and triglycerides had a reduction of 45.8%, 83%, 87.5%, 57.13% and 94% respectively. CONCLUSION MS is a rather common feature in obese patients enrolled for BS and this procedure has been proved to be extremely efficient reversing the metabolic syndrome, with an expressive reduction of prevalence of each and all of the NCEP criteria.FUNDAMENTO: A sindrome metabolica (SM) esta frequentemente ligada ao excesso de peso e melhora com a perda ponderal, sendo esperado que essa melhora seja proporcional a intensidade dessa perda. OBJETIVO: Avaliar o impacto da perda ponderal induzida pela cirurgia bariatrica (CB) sobre a prevalencia da SM, em medio prazo. METODOS: Foram analisados 35 pacientes submetidos a cirurgia de by-pass gastrojejunal em Y de Roux, no periodo de outubro de 2001 a outubro de 2005, em nosso HU, sendo 88,5% do sexo feminino, com uma media de idade de 37,8±11,1 anos e um IMC medio de 45,0±6,2 kg/m2. Na primeira etapa da pesquisa, foram obtidos dados demograficos e clinico-antropometricos antes da realizacao da CB, incluindo os criterios para o diagnostico da SM, de acordo com as diretrizes do NCEP dos Estados Unidos. Na segunda etapa, os pacientes operados foram reavaliados ambulatorialmente quanto a prevalencia da SM. RESULTADOS:Antes da cirurgia, a SM foi diagnosticada em 27 pacientes (77,1%). Em reavaliacao 34,4±15 meses apos a cirurgia, observou-se uma queda do IMC medio para 28,3±5,0 kg/m2 e a SM foi detectada em apenas dois pacientes (5,7%) (p<0,001). A prevalencia dos criterios cintura abdominal, glicemia, pressao arterial, HDL-colesterol e triglicerideos foi reduzida em, respectivamente, 45,8%, 83%, 87,5%, 57,13% e 94%. CONCLUSAO: A SM e ocorrencia comum em obesos candidatos a CB e esse procedimento se mostrou extremamente eficaz na inducao da regressao da sindrome, verificando-se reducao expressiva da prevalencia de todos os criterios do NCEP.

Reconstruction of the chest wall with external metal brace: alternative technique in poststernotomy mediastinitis

OBJECTIVE To demonstrate the experience with the reconstruction of the chest wall utilizing metal brace to reduce the tension in the suture lines of myocutaneous flap in cases of mediastinitis. METHODS From July 2001 to February 2006, 1389 heart surgeries were performed in our institution of which eight (0.6%) developed mediastinitis. Seven were male and the mean age was 56.7 years. The risk factors for infection were diabetes and obesity in seven and malnutrition in one case. Seven patients had been undergone CABG and one repair of a congenital heart disease. The chest wall reconstruction consisted of percutaneous insertion of Kirshner wires parallel to the edges of the wound for anchoring of sutures to the muscular plane in order to allow the reduction of tension in the free edges of the wound and subsequent closure of the subcutaneous tissue and skin. RESULTS There was one death in the immediate postoperative due to arrhythmia and one late death secondary to sepsis. The remaining patients presented satisfactory postoperative course with good healing of the wound after the removal of the metal braces on the 21st postoperative day and in the follow-up of 6 to 54 months. CONCLUSION The reconstruction of the chest wall utilizing temporary metal braces showed to be a safe and effective procedure with good aesthetic and functional outcomes in this group of patients.

Rhinosporidiosis: the largest case series in Brazil

INTRODUCTION Rhinosporidiosis is a chronic infection of the mucous membrane and is caused by Rhinosporidium seeberi, an aquatic mesomycetozoan. The mode of infection is probably transepithelial penetration. The large number of rivers and lakes and the strong presence of riparian populations in the State of Maranhão are strong predisposing factors for rhinosporidiosis. METHODS A 5-year retrospective study was conducted in a tertiary medical center situated in Maranhão, Northeast Brazil. Twenty-five Maranhense patients diagnosed with rhinosporidiosis were analyzed. RESULTS Most of the patients were children, adolescents and young adults (age range: 7-24 years, mean age: 14 years). The majority of the participants were male (84%), brown (76%), and students (92%). All lesions involved the entire nasal cavity and presented with a vascular polypoid mass. All patients were treated by surgical excision of the lesions. CONCLUSIONS Rhinosporidiosis affects younger age groups, especially students from the countryside and the outskirts of urban areas. This study will aid and guide physicians in diagnosing and treating this infection in endemic areas.

Abdominal obesity and reduction of glomerular filtration

The objective was to evaluate the association between nutritional status and the glomerular filtration rate (GFR) in remaining quilombolas. Cross-sectional study carried out on 32 remaining quilombola communities in the municipality of Alcântara-MA. The nutritional indicators (IN) used were: body mass index (BMI); Waist circumference (WC); Waist-to-hip ratio (WHR); Waist-to-height ratio (WHtR); conicity index (CI) and estimated visceral adipose tissue (VAT). GFR was estimated from the CKD-EPI creatinine-cystatin C formula. The Shapiro Wilk test was used to evaluate the normality of the quantitative variables. In order to compare the second IN sex, the chi-square test was applied. The Anova or Kruskal-Wallis tests were used to verify the association between IN and GFR. Of the 1,526 remaining quilombolas studied, 89.5% were black or brown, 51.2% were women, 88.6% belonged to economic classes D and E and 61.2% were farmers or fishermen. Clinical investigation revealed 29.2% of hypertensive patients, 8.5% of diabetics and 3.1% with reduced GFR. The BMI revealed 45.6% of the remaining quilombolas with excess weight. When compared to men, women presented a higher prevalence of overweight by BMI (56.6% vs 33.8%, p <0.001) and abdominal obesity CC (52.3% vs 4.3%), WHR (76,5% vs 5.8%), WHtR (82.3% vs 48.9%) and VAT (27.1% vs 14.5%) (p <0.001). Comparing the means of IN according to the GFR, it was observed that the higher the mean value of the IN lower the GFR (p <0.05). The GFR reduced with increasing mean values of nutritional indicators of abdominal obesity, regardless of sex.