Natalino Salgado Filho

Envolvimento da função renal em pacientes com leishmaniose visceral (calazar)

Evaluation of the renal involvement of visceral leishmaniasis (kala-azar) aiming at verifying clinical and laboratorial repercussions of the renal implication on VL. Laboratory analysis was performed of blood and urine samples collected immediately after confirming diagnosis through the finding of Leishmania in bone marrow. Two (18.1%) patient presented complications associated with kala-azar. Five patients (45.4%) presented macroscopic hematuria and one case (No 9) clinical manifestations compatible with an acute nephritis syndrome. Laboratorial data of urine exam showed: proteinuria in 10 (90.9%) patients, hematuria in 7 (63.6%) and leukocyturia in 6 (54.5%) cases. Nine (81.8%) patients presented high levels of microalbuminuria, characterizing glomerular lesion. The presence of proximal tubulopathy, measured through retinol binding protein observed in 5 (45.4%) cases. Conclusion: renal involvement was manifested in most subjects, contributing to the severity of the disease.

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.

Cisto pericárdico gigante: relato de caso

Pericardial cysts are uncommon congenital abnormalities. Most are asymptomatic and are found incidentally on chest roentgenograms. Giant cysts are an even more uncommon finding, and reports of their natural history, presentation and management are few. In this report the authors describe a case of a giant pericardial cyst with symptoms of mediastinal compression for which the surgical excision guaranteed a 12-month follow-up of complete remission of the symptomatology.

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.

Dietary approach to hypertension based on low glycaemic index and principles of DASH (Dietary Approaches to Stop Hypertension): a randomised trial in a primary care service

Hypertension is one of the leading causes of morbidity and mortality in Brazil. Diet may play an important role in reducing blood pressure (BP), as has been shown for diets high in fruits, vegetables and low-fat dairy products and low in salt (Dietary Approaches to Stop Hypertension (DASH)-Na). A low-glycaemic index Brazilian diet combined with the principles of the DASH-Na diet was evaluated in a randomised study of 206 individuals who were followed for 6 months. In the control group (CG), counselling was based on standard care and mainly focused on salt intake reduction. An intention-to-treat analysis showed that, after 6 months, systolic BP was reduced by 14·4 mmHg and diastolic BP by 9·7 mmHg in the experimental group (EG), compared with 6·7 and 4·6 mmHg, respectively, in the CG. After adjusting for body weight, BP at baseline and age, these changes were 12·1 and 7·9 mmHg, respectively. Urinary Na excretion was also reduced by 43·4 mEq/24 h in the EG. Food intake was modified accordingly during the intervention with an increase in the consumption of vegetables (2·97-5·85 frequency of consumption measured in three non-consecutive days), fruits (4·09-7·18), beans (1·94-3·13) and fish (1·80-2·74) by the EG. The present study showed the feasibility of a Brazilian dietary approach to treating hypertension by reducing urinary Na excretion and BP, changes that may have a great impact on public health and promote the benefits of controlling hypertension.

Estimated Visceral Adipose Tissue, but Not Body Mass Index, Is Associated with Reductions in Glomerular Filtration Rate Based on Cystatin C in the Early Stages of Chronic Kidney Disease

Information on the association between obesity and initial phases of chronic kidney disease (CKD) is still limited, principally those regarding the influence of visceral adipose tissue. We investigated whether the visceral adipose tissue is more associated with reductions in glomerular filtration rate (GFR) than total and abdominal obesity in hypertensive individuals with stage 1-2 CKD. A cross-sectional study was implemented which involved 241 hypertensive patients undergoing treatment at a primary health care facility. GFR was estimated using equations based on creatinine and cystatin C levels. Explanatory variables included body mass index (BMI), waist circumference (WC), and estimated visceral adipose tissue (eVAT). The mean age was 59.6 ± 9.2 years old and 75.9% were female. According to BMI, 28.2% of subjects were obese. Prevalence of increased WC and eVAT was 63.9% and 58.5%, respectively. Results from the assessment of GFR by BMI, WC, and eVAT categories showed that only women with increased eVAT (≥150 cm2) had a lower mean GFR by Larsson (P = 0.016), Levey 2 (P = 0.005), and Levey 3 (P = 0.008) equations. The same result was not observed when the MDRD equation was employed. No association was found between BMI, WC, eVAT, and GFR using only serum creatinine. In the early stages of CKD, increased eVAT in hypertensive women was associated with decreased GFR based on cystatin C.

Cintura hipertrigliceridêmica e risco cardiometabólico em mulheres hipertensas

OBJECTIVE: To evaluate the association between hypertriglyceridemic waist (HW) and cardiometabolic risk factors in women with hypertension. METHODS: A cross-sectional study was performed in 218 patients monitored by HiperDia (Enrollment and Monitoring Program for Hypertensive and Diabetic Individuals) in two health units in Sao Luis, MA, Brazil. The dependent variable was HW and the independent variables were sociodemographics, lifestyle, anthropometrics, and health problems. RESULTS: HW was present in 33% of the sample and was predominant in women aged > 60 years (56.4%), non-whites (81.7%), those with eight or fewer years of schooling (57.3%), and those belonging to socioeconomic class C (49%). Excess weight (68.8%) and hypercholesterolemia (68.8%) were observed. HW was associated with: smoking (PR: 2.08; p = 0.017), overweight (PR: 2.46; p = 0.010), obesity (PR: 4.13; p 100 mg/dL or being diabetic (PR: 1.86; p = 0.006). After adjustment, total cholesterol (PR = 1.78; p = 0.012), HDL-cholesterol (PR: 3.03; p 25 to 30 kg/m2 (PR = 3.61; p < 0.001) remained associated. CONCLUSION: A high prevalence of HW and its association with altered lipid profile and excess body weight was observed. HW showed to be an important diagnostic tool for the monitoring of hypertensive women with metabolic risk, which is low cost, easily accessible, and useful in clinical practice, especially in primary health care in the Brazilian Unified Health System (Sistema Unico de Saude - SUS).

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.