Vanessa Prado dos Santos

Risk factors for primary major amputation in diabetic patients.

CONTEXT AND OBJECTIVE Diabetic patients present high risk of having to undergo minor or major amputation during their lifetimes, because of ischemia or infection. The aim of this study was to identify and quantify risk factors for major amputation in diabetic patients with foot infections. DESIGN AND SETTING Retrospective clinical-surgical trial at the Vascular Surgery Service of Santa Casa de São Paulo. METHODS Ninety-nine patients with diabetic foot infections who underwent 129 hospitalizations in the Vascular Surgery Unit were analyzed in accordance with a pre-established protocol to compare two groups of diabetic patients: one that underwent major amputations and the other that underwent minor amputations or debridements. The patients were predominantly male, in their sixth decade of life, and had type 2 diabetes mellitus. Chronic arterial insufficiency, age, diabetes mellitus duration, ascending lymphangitis, calcaneal lesions, Wagners classification, laboratory tests and different microorganisms in deep tissue cultures were the risk factors evaluated in all patients. RESULTS The statistically significant risk factors for major amputation included age, ascending lymphangitis (odds ratio, OR: 2.5), calcaneal lesions (OR: 10.5), Wagner grade 5 lesions (OR: 3.4), chronic arterial insufficiency without possibility of revascularization (OR: 5.4) and diabetes duration. Presence of Gram-positive microorganisms was associated with the need of major amputation. The serum urea, creatinine, glucose and white blood cell levels were not significant risk factors for major amputation. CONCLUSIONS The risk factors for major amputation were: age, ascending lymphangitis, calcaneal lesions, Wagner grade 5 lesions, arterial insufficiency, diabetes duration and Gram-positive microorganisms in cultures.

Atenção integral ao portador de pé diabético

Sao apresentadas, nessa separata, as principais orientacoes sobre a atencao as complicacoes do pe diabetico. A neuropatia, com suas diversas apresentacoes que acometem os membros inferiores dos diabeticos, as lesoes da doenca arterial obstrutiva periferica (DAOP), as multiplas apresentacoes da infeccao do pe diabetico, e, principalmente, os cuidados preventivos que possam impedir o estabelecimento ou a evolucao dessas complicacoes sao tratados de forma sistematica e simplificada, visando a atencao integral desses doentes. Especial cuidado e dado as orientacoes diferenciadas para os diversos niveis de atencao nos servicos publicos de saude, porta de entrada virtual de 80% dos infelizes portadores dessa complicacao. Sao aqui apresentados modelos de atencao e sugeridos protocolos que podem contribuir para a efetiva reducao do numero de amputacoes, internacoes e obitos de diabeticos com complicacoes nos membros inferiores.

Comparative histological study of atherosclerotic lesions and microvascular changes in amputated lower limbs of diabetic and non-diabetic patients

OBJECTIVE To perform a comparative analysis of atherosclerotic lesions and capillaries changes in diabetic and nondiabetic patients. METHODS Leg arteries and skin of 57 amputated lower limbs of diabetic (47.3%) and nondiabetic patients were histologically examined. The percentage of arterial stenosis of infrapopliteal arteries and the histological classification of atherosclerotic lesions were determined. Capillary thickening was classified into four categories. RESULTS Diabetic group showed more than 75% stenosis in 57% (vs. 56% in nondiabetic) of the anterior tibial; 78% (vs. 68%) of the posterior tibial; 58% (vs. 50%) of the peroneal leg arteries. Diabetic and nondiabetic patients have predominance of type VI atherosclerotic lesions. The comparison of both groups showed no significant differences in atherosclerotic lesions. Diabetic patients had significantly more PAS positive capillary thickening (63% vs. 23%). CONCLUSIONS There were no differences in histological characteristics of atherosclerosis between the two groups. Capillary thickening has been more observed in diabetics.

Formação médica na UFSB: I. Bacharelado interdisciplinar em saúde noprimeiro ciclo

Esta serie de artigos aborda diretrizes, estrutura curricular e estrategias pedagogicas de um novo modelo de curso de Medicina proposto pela Universidade Federal do Sul da Bahia (UFSB). Este artigo inicial apresentao Bacharelado Interdisciplinar em Saude como primeiro ciclo para a formacao medica. Em primeiro lugar, avaliam-se resultados de uma prospeccao de modelos avancados de formacao medica no cenario internacional e o potencial de sua aplicacao a realidade da educacao medica brasileira. Em segundo lugar, descrevem-se a estrutura e o funcionamento do Bacharelado Interdisciplinar como formacao geral em Artes, Saude, Humanidades e Ciencias. Em terceiro lugar, discute-se o BI-Saude como formacao especifica, com especial atencao para o conceito de Area de Concentracao, que pode funcionar como etapa propedeutica para o curso medico em regime de ciclos. Finalmente, avalia-se a formacao em Saude no primeiro ciclo como oportunidade de uma escolha vocacional mais madura, aprendizagem para o trabalho em equipe, atualizacao cientifica e pratica, uso consciente e critico de tecnologias de cuidado em saude, com base em valores eticos, politicos e humanisticos.

Fatores de morbimortalidade na cirurgia eletiva do aneurisma da aorta abdominal infra-renal: experiência de 134 casos

BACKGROUND: Conventional surgical treatment of infrarenal abdominal aortic aneurysm (AAA) can result in serious complications. To optimize treatment outcome it is important to identify patients at risk of having complications and implement prophylaxis. OBJECTIVES: To analyze early surgical mortality rate and postsurgical complications, and to identify risk factors related to morbidity and mortality. METHOD: A total of 134 patients with infrarenal AAA submitted to elective surgical correction from February 2001 to December 2005 were analyzed. RESULTS: The mortality rate (5.2%) was secondary mainly to acute myocardial infarction and intestinal ischemia. Heart-related complications were the most frequent, followed by lung and kidney complications. Presence of diabetes mellitus, congestive heart failure, coronary artery disease, and scintigraphy suggestive of ischemia were related to cardiac complications. Advanced age, chronic obstructive lung disease and reduced forced vital capacity were related to higher risks of atelectasis and pulmonary infection. Presence of renal failure, prolonged aortic clamping and high urea rates were related to acute renal failure. Smoking and advanced age were associated with lower limb ischemia. Presence of obstructive coronary insufficiency and prolonged aortic clamping and surgery time were associated with higher mortality rate. CONCLUSION: The morbidity and mortality rate was compatible with data found in the national and international literature, secondary to cardiac, pulmonary and kidney complications. Identified risk factors before and during the surgery were related to these complications.

Chlamydia pneumoniae and symptomatic carotid atherosclerotic plaque: a prospective study

OBJECTIVE To investigate the possible link between symptomatic carotid atherosclerotic plaque and Chlamydia pneumoniae. BACKGROUND Recently, several studies have demonstrated that there may be a possible link between Chlamydia pneumonia and carotid atherosclerosis, however the real role of Chlamydia pneumoniae is not completely understood. METHOD This is a prospective study with a total of 52 patients analyzed. All patients had been submitted to endarterectomy, and had suffered thrombotic ischemic stroke or transient ischemic attack up to 60 days prior to the surgery. Every patient presented carotid stenosis over 70%. The plaque was removed during the surgery and the laboratory exams were immediately done. Evaluation of Chlamydia pneumoniae DNA was done using polymerase chain reaction (PCR). RESULTS The PCR analyses of all 52 patients were negative for Chlamydia pneumoniae. CONCLUSION These initial results do not show a relationship between Chlamydia pneumoniae and symptomatic carotid atherosclerotic plaque.

Aneurisma da aorta abdominal infrarrenal: importância do rastreamento em hospitais do Sistema Único de Saúde na região metropolitana de Salvador - Bahia

BACKGROUND: Infrarenal abdominal aortic aneurysm (AAA) is a vascular disease requiring continuous attention both in terms of screening and therapeutic improvement. Infrarenal AAA is a major condition because of its high mortality rate due to AAA rupture, as opposite to the low mortality rate related to elective surgical repair conducted in specialized facilities. In the metropolitan area of Salvador there are no data concerning the identification of patients with infrarenal AAA. Such lack of information prompted this study. OBJECTIVE: (1) to determine the prevalence of infrarenal AAA in patients with risk factors; (2) to identify risk factors; and (3) to determine whether the population at risk should be routinely screened. METHODS: In a study for AAA screening conducted by the Department of Vascular Surgery of Hospital Geral Roberto Santos and Hospital Geral de Camacari from September 2008 to October 2009, 1,350 individuals aged 50 years or older with risk factors for aortic aneurysm were selected. Screening included completion of protocol and performance of color Doppler ultrasound. RESULTS: AAA prevalence in this sample was 3.9%. The most frequent risk factors associated with aneurysm were mean age of 72 years, male gender, smoking, and patients with peripheral obstructive arterial disease, coronary failure, and chronic obstructive lung disease. AAA screening should be considered in men aged over 65 years, mainly when one of these risk factors are present.

Embolização pré operatória no tratamento de paraganglioma abdominal: relato de caso

Paragangliomas is a pheochromocytoma of extra adrenal localization. The case report is a male, 55 years old who presented symptoms of adrenergic hyperstimulation associated to an abdominal mass diagnosed as paraganglioma by a biopsy. Because of its size, localization and vascularization, an aortography with embolization of the nutrient branches of the tumor was done pre-operatively. Four days later, a surgical ressection was performed, and the tumor was adhered to the duodenum, infra-renal aorta and inferior vena cava. We believe that an angiographic study pre-operatively with embolization makes possible an analysis of the anastomosis and arterial supplement, making the ressecability of the tumor safer, although it seems the surgical intervention should have been done earlier.

Ruptured abdominal aortic aneurysm: prognostic factors

OBJECTIVE: To analyze the prognostic factors related to the mortality of ruptured abdominal aortic aneurysm. METHOD: Seventy-two patients who suffered ruptured abdominal aortic aneurysm and were operated in the period between 1976 and 2000 by the Vascular Surgery Unit of the Santa Casa de Sao Paulo - School of Medical Sciences were retrospectively analyzed. RESULTS: The descriptive analysis of the data shows a mean age of 67.93 years, with a standard deviation of 11.58, 32% female and 68% male. Of the total number, 28% had a previous history of aneurysm and 72% were not aware of the disease. Mean systolic blood pressure during hospital admission was 96.53 mmHg. Pain was present in 100% of the patients, as well as throbbing abdominal mass. In 93% of the cases the location of the aneurysm rupture was the retroperitoneum, 4% in the duodenum, and 2% in the free peritoneum. CONCLUSION: The prognostic factors related to mortality and morbidity that demonstrated statistical significance were: age, initial blood pressure at hospital admission, diuresis during surgery, volume infused, and creatinine levels.

Arteriographic findings in diabetic and non-diabetic with critical limb ischemia

OBJECTIVE To compare angiographic findings of diabetic and non-diabetic patients with critical limb ischemia. METHODS We included 161 patients with infrainguinal critical limb ischemia (CLI). We evaluated the clinical and arteriographic (number and presence of opacification of leg arteries) of the two groups of patients. Statistical analysis was performed using EPI-INFO. RESULTS Most patients were category 5 of Rutherfords Classification and had femoropopliteal disease. Seventy-two percent of non-diabetic and 67% of diabetic had opacification of the fibular artery (p = 0.25), this is the most present artery in both groups. Diabetic patients had less opacification of the posterior tibial artery in the univariate analysis (29% vs. 47%, p = 0.008). But only female sex showed a significant risk for the absence of the posterior tibial artery in logistic regression (OR = 2.6; p = 0.01). CONCLUSION The peroneal artery was the most frequently artery in angiograms of diabetic and non-diabetic patients with CLI. Diabetic and non-diabetic patients did not differ in angiographic findings of the leg.